Maternal Book

PREFACE This book’s focus is fundamental on health, normally and wellness promotes an evidence-based interventional philosophy of care rooted in the concept that in most women birth is not a disease, but a natural event normally calling for little intervention. This book addresses the pregnant women’s changing situations from conception to during labor and birth, and through the early weeks after birth. This discus various issues of obstetric management drawn from obstetrical textbook, journals, and research detach chronologically order, as you would encounter them. When you understand what is happening in labor you will recognize each stage as it comes and fell more confident about trying different ways of coping. As you learn your own personal strength and resources for labor and birth, you will learn to trust your body and the enigma of the birth will be rediscovered. Remember, birth is a powerful experience of the unknown. Not a predetermined set of events. There is no right way to give birth. There is the birth you have. There is no right method just the need to be integrated into the physiological, psychological and emotional process of the intensely private experience of birth. This experience that is your own is an adventure in physical sensation and intense emotional discerning of your own inner power and strength. Labor is an awesome treadmill contracting incredible inner sensations. However difficult the labor may be, you are in your own space and discover your self the power to give birth with the same love and passion that created your baby. As the power of swing contractions spreads through your body, if the power of physicality of birth is respected, it allows you to use your body to bring forth life with strength and confidence. The care of the childbearing and childbearing family is a major focus of nursing practice. To have healthy children, it is important to promote the health of the childbearing woman her family from the time before the children are born to the time until they reach adulthood. Prenatal care and guidance are essential to the health of the woman and fetus and of the family’s emotional preparation for childbearing. Although the field of nursing typically divides all concerns for families during childbearing and childbearing into to two separate entities, maternity and child health, the full scope of nursing practice in the area is not true separate entities but one: MATERNAL AND CHILD NURSING BOOK.

INTRODUCTION Someone once said, “pregnancy begins at that unfelt, unknown moment of time when a single, wiggling sperm penetrates a mature ovum. Even though this momentous event of fertilization occurs without notice, the changes, which take place within the mothers’ body in the next nine months, are undeniable and amazing. Yeah, our coming to earth is really magical and we should thank our mothers for they sacrificed their lives just to give us our precious gift… our LIFE. Childbirth is a good metaphor for life. It begins at time of conception, when long gestation by hard labor to bring forth a new creation. Mixed passion and discomfort strike before fulfillment. For every person going through the process of birth, there is a possibility of transformation at the individual and the family level. That’s why everyone views birth as the most critical time, a hopeful time. In many ways, birth has become crucible in which modern woman is around and burned; it is our testing place. But there’s value in this work. True-births have often been difficult and painful, but pain can be essential part of growth. Maternal and child care is a philosophy based on the consideration of a mother and child in relation to each other and consideration of a whole family with each meaningful relationship as well as its cultural and socio-economic environment of the client. The overall trust of maternity care is to assist each mother throughout the stage of pregnancy, labor and delivery and the puerperium in such a way that minimal discomfort will be experienced and to ensure optimal health and well being for the mother and her newborn. Sure care must also meet the psychological needs of the mother and her partner and their contribution to satisfactory infant- maternal bonding following delivery.

NURSING PROCESS Nursing process is a systematic, rational method of planning and providing individualized nursing care. Its purpose is to identify a client’s health status, actual or potential health care problem or needs; to establish plans to meet the identified needs; and to deliver specific nursing intervention to meet those needs. The nursing process is cyclical; that is, the components of the nursing process follow a logical sequence, but more than one component may be involved at any one time.

CHARACTERISTICS OF NURSING PROCESS Cyclic and dynamic: nursing process is unique by properties that enables it to respond t the changing health status of the client. Client centered: the nurse organizes the plan of care according to client problems rather than nursing goals. In the assessment phase, the nurse collects data to determine the client’s habits, routines, and needs, enabling the nurse to incorporate client routines into the care plan as much as possible. Interpersonal and collaborative: to ensure the delivery of quality nursing care, the nurse must share concerns and problems and problems and participate in continuous evaluation of the care plan. This depends on open and meaningful communication and the development of rapport between the client and the nurse. To carry out the nursing process effectively and individualize approaches to each client’s particular needs, the nurse must collaborate with each individual, family, group, or community as required. Universally applicable: it can be used with client with any age. At any point of the wellness-illness continuum. Furthermore, it is useful in a variety of settings and across specialty areas. Problem - solving technique, It can be viewed as parallel to but separate from the medical process. Interpersonal skills: Nurses use a variety of interpersonal, technical, and intellectual skills in applying the nursing process. Technical skills: include using equipment and performing procedure. Intellectual skills: includes analyzing, problem solving, critical thinking, and making nursing judgments.

COMPONENTS OF NURSING PROCESS

ASSESSING: is collecting, organizing, validating, and recording data about a client’s health status. Data are obtained from a variety of sources and are the basis for actions and decisions taken in subsequent phases. No conclusions about the data are drawn in this phase. DIAGNOSIS: is a process, which results in a diagnostic statement or nursing diagnosis. In this phase, the nurse sorts, clusters, and analyzes the data and asks,” What are the actual and potential health problems for which the client needs nursing assistance?” and “What factors contributed to this problem? Responses to those questions establish the nursing diagnosis. PLANNING: involves series of steps in which the nurse and the client set priorities and goals or expected outcomes to resolve or minimize the identified problems of the client. In collaboration with the client, the nurse develops specific interventions for each nursing diagnosis. The product of the planning phase is a written care plan to coordinate the care provided by all the health team members. INTERVENTION: is putting the nursing care plan into action. During the implementation phase, the nurse carries out the prescribed nursing activities or delegates the care to an appropriate person, and validates the nursing care plan. This phase ends when the nurse records the care given and the client’s responses to care in the client record. EVALUATION: is assessing the client’s response to nursing interventions and then comparing the response to the goals or outcome criteria written in the planning phase. The nurse determines the extent to which the outcomes\goals of care phase been achieved. The care plan is reassessed in this phase, which may involve changes in any or all of the previous phases of the nursing process.

CONCEPT OF A FAMILY No social group has the potential to provide the save level of support and long - lasting emotional ties as one’s family. How well a family works The ability to provide for the physical, emotional, and spiritual needs of family members. The ability to be sensitive to the needs of family members. The ability to communicate thoughts and feeling effectively. The ability to provide support, security, and encouragement.

The ability to initiate and maintain growth - producing relationships. The capacity to maintains and deals constructive and responsible community relationships. The ability to grow with and through children. The ability to perform family roles flexibly. The ability to help oneself and to accept help when appropriate. The capacity for mutual respect for the individuality of family members. The ability to use a crisis experience as a means of growth. A concern for family unity, loyalty, and inter - family cooperation. Many types of families exist and a family type may change over time as it is affected by birth, work, death, divorce, and the growth of child health nursing, the following are the different types of families according to: Organization, structure or membership together and meets any crisis depends on its structure and function and how well the family can organize itself against potential threats. A family is a group people waked by blood, marriage, or adaptation. Spradly and Allender (1996) define the family in a much broader context as “two or more people who live in the name household (usually), share a common emotional bond, and perform certain interrelated social tasks.” This is a better definition for health care providers because it addresses the broad range of types of Families health care providers encounter. Like individuals, families manifest both wellness behavior and ------- behaviors. The following are lists of generally accepted behaviors indicating a well or functioning family: Nuclear. This is the primary or elementary type of family. It composed of a husband, wife, and children. An advantage of a nuclear family in its ability to provide support to family members because people feel genuine affection for each other. Extended. Sometimes called the multigenerational family, which includes not e stretched to accommodate all members. Single - Parent. This type increases today due to the high rate of divorce and also to the increasing practice of raising children outside marriage. Place of residence Patrilocal. The couple resides with the groom’s parents Matrilocal. The couple resides with the bride’s parents. Bilocal. The couple has the freedom to choose where to reside. Neolocal. The couple lives away from both parents. Awercolocal. The couple requires residing with the uncle of the groom.

Authority Patriarchal. In this type of family, the authority is vested on the oldest male or father. Matriarchal. In this fairly, authority is vested on the mother or mother’s kin. Equalitarian. In this family, there is an equal share of authority. Matricentric. In this type, the mother answers the highest authority while the father is away.

Terms of Marriage Monogamy. It includes one husband and 1 wife Polygamy. This also called plural marriage wherein there is two or more wives or husbands. Families tend to display characteristics of their culture and community. The types of families that live in communities tend to be culturally determined. According to Friedman, the role of the family is to meet the needs of its members while also meeting the needs of the society. A healthy family provides food, shelter, clothing, and health care for its members. And also prepares the children to live in community and interact with people outside the family. Because families work as a unit, unmet needs of any member can spread to become unmeet need of all family members.

RESPONSIBLE PARENTHOOD We affirm the principle of responsible parenthood. The family, in its varying forms, constitutes the primary focus of love, acceptance, and nurture, bringing fulfillment to parents and child. Healthful and whole personhood develops, as one is loved, responds to love, and in that relationship comes to wholeness as a child of God. Each couple has the right and the duty prayerfully and responsibly to control conception according to their circumstances. They are, in our view, free to use those means of birth control considered medically safe. As developing technologies have moved conception and reproduction more and more out of the category of a chance happening and more closely to the realm of responsible choice, the decision whether or not to give birth to children must include acceptance of the responsibility to provide for their mental, physical, and spiritual growth, as well as consideration of the possible effect on quality of life for family and society. To support the sacred dimensions of personhood, all possible efforts should be made by parents and the community to ensure that each child enters the world with a healthy

body and is born into an environment conducive to the realization of his or her full potential. When through contraceptive or human failure an unacceptable pregnancy occurs, we believe that a profound regard for unborn human life must be weighed alongside an equally profound regard for fully developed personhood, particularly when the physical, mental, and emotional health of the pregnant woman and her family show reason to be seriously threatened by the new life just forming. We reject the simplistic answers to the problem of abortion that, on the one hand, regard all abortions as murders, or, on the other hand, regard abortions as medical procedures without moral significance. When an unacceptable pregnancy occurs, a family-and most of all, the pregnant woman is confronted with the need to make a difficult decision. We believe that continuance of a pregnancy that endangers the life or health of the mother, or poses other serious problems concerning the life, health, or mental capability of the child to be, is not a moral necessity. In such cases, we believe the path of mature Christian judgment may indicate the advisability of abortion. We support the legal right to abortion as established by the 1973 Supreme Court decision. We encourage women in counsel with husbands, doctors, and pastors to make their own responsible decisions concerning the personal and moral questions surrounding the issue of abortion. We therefore encourage our churches and common society to: Provide to all education on human sexuality and family life in its varying forms, including means of marriage enrichment, rights of children, responsible and joyful expression of sexuality, and changing attitudes toward male and female roles in the home and the marketplace; provide counseling opportunities for married couples and those approaching marriage on the principles of responsible parenthood; Build understanding of the problems posed to society by the rapidly growing population of the world, and of the need to place personal decisions concerning childbearing in a context of the well being of the community; provide to each pregnant woman accessibility to comprehensive health care and nutrition adequate to ensure healthy children; make information and materials available so all can exercise responsible choice in the area of conception controls. We support the free flow of information about reputable, efficient, and safe nonprescription contraceptive techniques through educational programs and through periodicals, radio, television, and other advertising media. We support adequate public funding and increased participation in family planning services by public and private agencies, including church-related institutions, with the goal of making such services accessible to all, regardless of economic status or geographic location; make provision in law and in practice for voluntary

sterilization as an appropriate means, for some, for conception control and family planning; safeguard the legal option of abortion under standards of sound medical practice; make abortions available to women without regard to economic standards of sound medical practice, and make abortions available to women without regard to economic status; monitor carefully the growing genetic and biomedical research, and be prepared to offer sound ethical counsel to those facing birth-planning decisions affected by such research; assist the states to make provisions in law and in practice for treating as adults minors who have, or think they have, venereal diseases, or female minors who are, or think they are, pregnant, thereby eliminating the legal necessity for notifying parents or guardians prior to care and treatment. Parental support is crucially important and most desirable on such occasions, but needed treatment ought not be contingent on such support; understand the family as encompassing a wider range of options than that of the two-generational unit of parents and children (the nuclear family); and promote the development of all socially responsible and life-enhancing expressions of the extended family, including families with adopted children, single parents, those with no children, and those who choose to be single; view parenthood in the widest possible framework, recognizing that many children of the world today desperately need functioning parental figures, and also understanding that adults can realize the choice and fulfillment of parenthood through adoption or foster care; encourage men and women to actively demonstrate their responsibility by creating a family context of nurture and growth in which the children will have the opportunity to share in the mutual love and concern of their parents; be aware of the fears of many in poor and minority groups and in developing nations about imposed birth-planning, oppose any coercive use of such policies and services, and strive to see that family-planning programs respect the dignity of each individual person as well as the cultural diversities of groups.

ANATOMY AND PHYSIOLOGY Ovary, in anatomy, organ of female animals, including humans, that produces reproductive cells called eggs, or ova. In humans they are oblong, flattened, ductless glands, about 3.8 cm (about 1.5 in) long, on either side of the uterus, to which they are connected by the Fallopian tubes. Each ovary is composed of two portions: an external, or cortical, portion, and a deep, medullary portion. The cortical portion in the adult contains an enormous number of follicles, or sacs, varying in size. called Graafian follicles, they contain the ova, the female reproductive cells. The interior of the ovary is distinctly divided into an outer cortex, where the germ cells develop, and a central medulla occupied by the major arteries and veins. Each egg cell develops in its own fluid-filled

follicle and is released by ovulation. The ovary is supplied with an ovarian artery, ovarian veins, and ovarian nerves, which travel through the suspensory ligament. The ovary is held in place by the ovarian, suspensory, and broad ligaments as well as a peritoneal fold called the mesovarium. The ovary secretes hormones that, together with secretions from the pituitary gland, contribute to secondary female sexual characteristics and also regulate menstruation. The union of the male sperm cell with the ovum results in fertilization. The ovary may be the site of several disease conditions. It can be the site of acute and chronic inflammation; this may arise from injuries during labor, operations in the pelvic area, or gonorrheal infection spreading from the vagina. The ovary also may be the site of neoplasms (tumors) of several varieties. Some are fluidic enlargements of one or more Graafian follicles and may attain an enormous size; these are known as ovarian cysts. Other growths, of a solid nature, are known as dermoid cysts. These enlargements, usually benign, occasionally prove to be cancerous. Most species have male and female organisms. Each sex has its own unique reproductive system. They are different in shape and structure, but both are specifically designed to produce, nourish, and transport either the egg or sperm. Unlike its male counterpart, the female reproductive system is almost entirely hidden within the pelvis. It consists of organs that enable a woman to produce eggs (ova), to have sexual intercourse, to nourish and house the fertilized egg (ovum) until it is fully developed, and to give birth.

Females also have external organs collectively called the vulva (which means "covering"). Located between the legs, the outer parts of the vulva cover the opening to a narrow canal called the vagina. The fleshy area located just above the top of the vaginal opening is called the mons pubis. A thin sheet of tissue called the hymen partially covers the opening of the vagina. Two pairs of skin flaps, the labia (which means "lips") surround the vaginal opening. The clitoris, which is located toward the front of the vulva where the folds of the labia join, is a small cylindrical structure similar to the male penis; it also contains erectile tissue. Inside the labia are openings to the urethra (the canal that carries urine from the bladder to the exterior of the body) and vagina. The outer labia and the mons pubis are covered by pubic hair in the sexually mature female.

The female internal organs are the vagina, uterus, fallopian tubes, and ovaries. The vagina is a 3- to 6-inch-long tubular structure that extends from the vaginal opening to the uterus. It has muscular walls lined with mucous membrane, and it serves as the female organ of copulation (sexual intercourse) as well as the birth canal. It connects with the uterus, or womb, which houses the fetus during pregnancy. About 3 inches long and 2 inches wide and shaped like an inverted pear, the uterus is a muscular, expandable organ with thick walls At the lower part of the uterus is the cervix, which opens into the vagina. At the upper part, the fallopian tubes connect the uterus with the ovaries, two oval-shaped organs that lie to the right and left of the uterus. They produce, store, and release eggs through the fallopian tubes into the uterus. The ovaries also produce the hormones estrogen and progesterone. Also part of the reproductive system is the breasts. Mammary glands inside the breasts secrete milk after childbirth.

Normal Physiology The organs of sexual reproduction are the gonads, which are the ovaries in females and the testes in males. Females produce female gametes, or eggs; males produce male gametes, or sperm. Sexual reproduction is the fertilization of a female gamete by a male gamete. When a female is born, each of her ovaries has hundreds of thousands of eggs, but they remain dormant until her first menstrual cycle, which occurs during puberty. At this time, during adolescence, the pituitary gland secretes hormones that stimulate the ovaries to produce female sex hormones, including estrogen, which helps the female develop into a sexually mature woman. Also at this time, females begin releasing eggs as part of a monthly period called the menstrual cycle. Approximately once a month, during ovulation, an ovary discharges a tiny egg that reaches the uterus through one of the fallopian tubes. Unless fertilized by a sperm while in the fallopian tube, the egg dries up and is expelled about 2 weeks later from the uterus during menstruation. Blood and tissues from the inner lining of the uterus combine to form the menstrual flow, which usually lasts from 3 to 5 days. If a female and male have sexual intercourse within several days of ovulation, fertilization can occur. When the male ejaculates, about one tenth of an ounce of semen is deposited into the vagina. Between 200 and 300 million sperm are in this small amount of semen, and they "swim" up from the vagina through the cervix and uterus to meet the egg in the fallopian tube. It takes only one sperm to fertilize the egg. About a week after the sperm fertilizes the egg, the fertilized egg has become a multicelled blastocyst, a pinhead-sized hollow ball with fluid inside, now housed in the uterus. The blastocyst burrows itself into the lining of the uterus, called the endometrium. Estrogen causes the endometrium to thicken and become rich with blood, and

progesterone, another hormone released by the ovaries, maintains the thickness of the endometrium so that the blastocyst can attach to the uterus and absorb nutrients from it. This process is called implantation. As cells from the blastocyst take in nourishment, the embryonic stage of development begins. The inner cells form a flattened circular shape called the embryonic disk, which will develop into a baby. The outer cells become thin membranes that form around the baby. The embryonic cells multiply thousands of times, move to new positions, and eventually become the embryo. After approximately 8 weeks, the embryo is about the size of an adult's thumb, but all of its parts - the brain and nerves, the heart and blood, the stomach and intestines, and the muscles and skin - have formed. During the fetal stage, which lasts from 9 weeks after fertilization to birth, development continues as cells multiply, move, and differentiate. The fetus floats in amniotic fluid inside the amniotic sac. Its oxygen and nourishment come from the mother's blood via the placenta, a disk-like structure that adheres to the inner lining of the uterus and is connected to the umbilical cord. The umbilical cord attaches the embryo at its navel to the mother's uterus. The umbilical arteries in the cord carry blood from the fetus to the placenta, and an umbilical vein returns blood from the placenta to the fetus. The amniotic fluid and membrane cushion the fetus against bumps and jolts to the mother's body. Pregnancy lasts an average of 266 days. When the baby is ready for birth, its head presses on the cervix, which begins to relax and widen to get ready for the baby to pass into and through the vagina, which has enlarged to become the birth canal. The mucus that has formed a plug in the cervix loosens, and with amniotic fluid, comes out through the vagina when the mother's "water" breaks. When contractions begin, the uterine walls contract as they are stimulated by the pituitary hormone oxytocin. The contractions cause the cervix to widen and begin to open. After several hours of this widening, the cervix is dilated (opened) enough for the baby to come through. The baby is pushed out of the uterus, through the cervix, and along the birth canal. The baby's head usually comes first; the umbilical cord comes out with the baby and is cut after the baby is delivered. The last stage of the birth process involves the delivery of the placenta, which is now called the afterbirth. It has separated from the inner lining of the uterus, and through further contractions of the uterus it is expelled with its membranes and fluids.

MENSTRUATION

A menstrual cycle (also termed a female reproductive cycle) can be defined as episodic uterine bleeding in response to cyclic hormonal changes. It is the process that allows for conception and implantation of a new life. The purpose of a menstrual cycle is to bring an ovum to

maturity and renew a uterine tissue bed that will be responsible for its growth should it be fertilized. Menarche, the first menstrual period in girls, may occur as early as age 8- 9 or as late as 17 and still be within normal limits. Because menarche may occur as early as age 9 years, it is good to include health teaching information on menstruation to both girls and their parents as early as 4th grade as part of routine care. It is a poor introduction to sexuality and womanhood for a girl to begin menstruation unwarned and unprepared for the important internal function it represents. The length of menstrual cycle differs from woman to woman, but the accepted average length is 28 days (from the beginning of one menstrual flow to the beginning of the next). However, it is not unusual for cycles to be as short as 23 days or as long as 35 days. The length of the average menstrual flow is (termed menses) is 2 to 7 days although women may have periods as short as 1 day or as long as 9 days. Because there is such variation in length, frequency, and amount of menstrual flow and such variation in he onset of menarche, many women have questions about what is considered normal. Contact with health care personnel during the yearly health examination or prenatal visit is often the first opportunity some women have to ask question they have had for sometime.

PHASES OF MENSTRUAL CYCLE 1. Proliferative Phase Immediately after a menstrual flow (occurring the first 4 or 5 days of a cycle), the endometrium, or lining of the uterus, is very thin, only approximately one cell layer in depth. As the ovary begins to produce estrogen (in follicular fluid, under the direction of the pituitary FSH), the endometrium begins to proliferate. This growth is very rapid and increases the thickness of the endometrium approximately eightfold. This increase continues for the first half of the menstrual cycle (from approximately day 5 to 14). This half of menstrual cycle is termed interchangeably the proliferative, estrogenic, follicular or post menstrual phase. 2. Secretory Phase After ovulation, the formation of progesterone in the corpus luteum (under the direction of the LH) causes the glands of the uterine endometrium to become corkscrew or twisted in appearance and dilated with quantities of glycogen and mucin, an elementary sugar and protein. The capillaries of the endometrium increase in amount until the lining takes on the appearance of rich, spongy velvet. This second phase of menstrual cycle is termed the progestational, luteal, premenstrual, or secretary phase.

3. Ischemic Phase If fertilization does not occur. The corpus luteum in the ovary begins to regrets after 8 to 10 days. As it regresses, the production of progesterone and estrogen decreases. With the withdrawal of progesterone stimulation, the endometrium of the uterus begins to degenerate (approximately day 24 or 25 of the cycle). The capillaries rupture, with minute hemorrhages, and the endometrium sloughs off. 4. Menses: Final Phase of Menstrual Cycle The following products are discharged from the uterus as the menstrual flow or menses: blood from ruptured capillaries; mucin from the glands, fragments of edometrial tissues, microscopic, atrophied and unfertilized ovum. Menses is actually the end of an arbitrarily defined menstrual cycle. Because it is the only external marker of the cycle, however, the first day of menstrual flow is used to mark the beginning day of a new menstrual cycle. Contrary to common belief, menstrual flow contains only approximately 30 to 80 ml of bloods, it may seem more because of the accompanying mucus and endometrial shreds. The iron loss during menstrual flow is approximately 11 mg, this is enough that many woman need to take daily iron supplement to prevent iron depletion during their menstruating years. In women who are going through menopauses, menses may typically be a few days of spotting before a heavy flow or heavy flow followed by a few days of spotting, because progesterone withdrawal is more sluggish or tends to “staircase” rather than withdraw.

TEACHING ABOUT MENSTRUAL HEALTH Exercise It’s good to continue moderate exercise during menses because it increases abdominal tone. Sustained excessive exercise, such as professional athletes maintain, can cause amenorrhea. Sexual Relations Not contraindicated during menses (the male should wear a condom to prevent exposure to body fluid). Heightened or decrease sexual arousal may be noticed during menses. Orgasm may increase menstrual flow. Activities of Daily Living Nothing is contraindicated (many people believed incorrectly that things like washing hair are harmful). Pain Relief

Any mild analgesic is helpful. Prostaglandin inhibitors such as ibuprofen (Motrin) are specific for menstrual pain. Applying local heat may also be helpful Rest More rest may be helpful if dysmenorrhea interferes with sleep at night. Nutrition. Many women may need iron supplementation to replace iron lost in menses. Eating pickles or cold food does not cause dysmenorrhea.

CHILD BEARING CYCLE Conception is the penetration of one ovum by one sperm resulting in a fertilized ovum called zygote. Sex of child is determined at the moment of conception by male gamete. If X-bearing male gamete unites with ovum, result is female child. If Y-bearing male gamete fertilize the ovum, result is male child. Nidation is the process of burrowing of the developing zygote into the endometrial lining of uterus. Usually take place 7-10 days after fertilization. Chorionic villi appear on surface of trophoblast and secrete human chorionic gonadotropin, which inhibit s ovulation during pregnancy by stimulating continuous production of estrogen and progesterone.

SPECIAL STRUCTURES OF PREGNANCY Fetal membranes Arise from the zygote Hold the developing fetus as well as the amniotic fluid Amniotic fluid Clear yellowish fluid surrounding the developing fetus Average amount 1000 ml Allows free movement Maintains temperature Provides oral fluid Umbilical cord Connecting link between fetus and placenta Contains 2 arteries and 1 vein supported by mucoid material(Wharton’s jelly) to prevent kinking and knotting There are no pain receptors in the umbilical cord Placenta Transient organ allowing passage of nutrients and water materials between mother and fetus also acts as an endocrine organ and as a protective barrier against some drugs and infectious agents

STAGES OF FETAL DEVELOPMENT In just 38 weeks, a fertilized egg matures from a single cell carrying all the necessary genetic material to a fully developed fetus ready to born. Fetal growth and development is typically divided into three periods. Pre- embryonic (First 2 weeks beginning with fertilization); embryonic (from 3 weeks through 8), and fetal (from week 8 through birth). Ovum Zygote Embryo Fetus Concept us

From ovulation to fertilization From fertilization to implantation From implantation to 5 - 8 weeks From 5 - 8 weeks until term Developing embryo or fetus and placental structures throughout pregnancy

MILESTONES OF FETAL GROWTH AND DEVELOPMENT The life of the fetus is generally measured from the time of ovulation or fertilization (ovulation age), but the length of pregnancy is generally measured from the first day of the last menstrual period (gestational age). Because ovulation and fertilization take place about 2 weeks after the last menstrual period, the ovulation age of the fetus is always 2 weeks less than the length of the pregnancy or the gestational age. Both ovulation and gestational age are also sometimes measured in lunar months (4 - week periods) or in trimesters (3- month-period) rather than in weeks. In lunar months, a pregnancy is 10 months (40 weeks or 280 days) long; a fetus grows in uteri 9.5 lunar months or three full trimesters (38 weeks or 266 days) End of 4 Gestation Weeks At the end of the 4th week gestation, the human embryo is rapidly growing formation of cells but does not resemble a human being yet. Length: 0.75 to 1 cm. Weight: 400 mg. The spinal cord is formed and fused at the midpoint. Lateral wings that will form the body are folded forward to fuse at the midline. Head folds forwards, becoming prominent, comprising about one third of the entire structure. The back is bend so the head almost touches the tip of the tail. The rudimentary heart appears as a prominent budge on the anterior surface.

Arms and legs are bud like structures. Rudimentary eyes, ears and nose are discernible. End of 8 Gestation Weeks Length: 2.5 cm (1cm). Weight: 20 g. Organogenesis is complete. The heart, with a septum and values, is beating rhythmically. Facial features are definitely discernible. Extremities have developed. External genitalia are present, but sex is not distinguished by simple observation. Primitive tail regressing. Abdomen appears large as the fetal intestine is growing rapidly. Sonogram shows gestational sac, diagnostic of pregnancy. End of 12 Gestation Weeks (First Trimester) Length: 7 to 8 cm. Weight: 45 g. Nail beds are forming on fingers toes. Spontaneous movements are possible, although usually too faint to be felt by the mother. Some reflexes, such as Babinski reflex are present. Bone ossification centers are forming. Tooth buds are present. Sex is distinguishable by outward appearance. Kidney secretion has begun, although urine may not be evident in amniotic fluid. Heartbeat is available by a Doppler End of 16 Gestation Weeks Length: 10 to 17 cm. Weight: 55 to 120 g. Fetal heart sounds are audible with an ordinary stethoscope. Lanugo (fine, downy hair on the back and arms of newborns, apparently serving as a source of insulation for body heart) is well formed. Liver and pancreas are functioning. Fetus actively swallows amniotic fluid, demonstrating an intact but uncoordinated swallowing reflex, urine is present in amniotic fluid. Sex can be determined by ultrasound. End of 20 Gestation weeks Length: 25 cm. Weight: 223 g. The mother can sense spontaneous fetal movements.

Antibody production is possible. Hair forms, extending to include eyebrows and hair on the head. Meconium is present in the upper intestine. Brown fat, a special fat that will aid in temperature regulation at birth, begins to be formed behind the kidneys, sternum and posterior neck. Fetal heart beat is strong - enough to be audible Vernix caseosa, a cream cheese -like substance produced by the sebaceous gland that serves as a protective skin covering intrauterine life, begins to form. Definite sleeping and activity patterns are distinguishable (the fetus has developed biorhythms that will guide sleep /wake patterns throughout life). End of 24 Gestation Weeks (Second Trimester) Length: 28- 36 cm. Weight: 550 g. Passive antibody transfer from mother to fetus probably begins as early as 20thweek of gestation, certainly by the 24th week of gestation. Infants born before antibody transfer has taken place have natural immunity and need more than the usual protection against infectious disease in the newborn period until the infant’s own store pf immunoglobulins can build up. Meconium is present as far as the rectum. Active production of lung surfactant begins. Eyebrows and eyelashes are well defined. Eyelids, previously fused since the 12th week, are now open. Pupils are capable of reacting to light. When fetuses reach 24 weeks or 601 g, they have achieved a practical low- end age of viability if they are cared for after birth in a modern intensive care facility. Hearing can be demonstrated by response to sudden sound. End of 28 Gestation Weeks Length: 35 to 38 cm. Weight: 1,200 g. Lung alveoli begin to mature, and surfactant can be demonstrated in amniotic fluid. Testes begin to descend into the scrotal sac from the lower abdominal cavity. The blood vessels of the retina are extremely susceptible to damage from high oxygen concentrations (an important consideration when caring for preterm infants who need oxygen). The eyes open. End of 32 Gestations Weeks

Length: 38-43 cm. Weight: 1,600 g. Subcutaneous fat begins to be deposited (the former is stringy “ Little old man” appearance is lost). Fetus is aware of sounds outsides the mothers body. Active Moro reflex is present. Birth position (vertex or breech) may be assumed. Iron stores that provide iron for the time during which the neonate will ingest only milk after the birth are beginning to be developed. Finger nails grow to reach the end of the fingertips. End of 36 Gestation Weeks Length: 42 to 49 cm. Weight: 1,900 to 2,700 g (5 - 6 lbs). Body stores of glycogen, iron, carbohydrate and calcium are augmented. Additional amounts of subcutaneous fat are deposited. Sole of the foot has only one or two crisscross crisscross creases compared with the full crisscross pattern that will be evident at term. Amount of lanugo begins to diminish. Most b babies turn into vertex or head - down presentation during this month. End of 40 gestation Weeks (Third Trimester) Length: 48 to 52 cm (crown to rump, 35 to 37 cm). Weight: 3,000g (7 - 7.5 lbs). Fetus kicks actively, hard enough to cause the mother considerable discomfort. Fetal hemoglobin begins its conversion to adult hemoglobin. The conversion is so rapid that, at birth about 20% hemoglobin will be adult in character. Vernix caseosa is fully formed. Fingernails extend over the fingertips. Creases on the soles of the feet cover at least two thirds of the surface.

PRENATAL CARE Prenatal care, essential for ensuring the overall health of newborns and their mothers, is a major strategy for helping to reduce the number of low - birth - weight babies born yearly. When a woman inspects the she is pregnant, a woman should consult a physician to gain optimum care even during the early months of pregnancy. Since women are not certain that they will become

pregnant and after gestation have elapsed, the earliest prenatal care is always the responsibility of the woman herself. Her general health habits and physical condition before a physician is ever consulted are of considerable importance. When the diagnosis of pregnancy is established, provision for regular medical supervision and suitable plans for the baby’s arrival must be made. The term prenatal care refers to the planned examination, observation, and guidance of an expectant mother. It is well to remember that the extension of prenatal care is probably the primary factor in the improvement of maternal morbidity and mortality statistics. Society needs to appreciate its importance. The goals are as follows: A pregnant with minimum mental and physical discomfort and a maximum of gratification. A delivery under the best circumstances possible A normal, well baby The establishment of good health habits benefiting all the family A smooth, guided postpartum adjustment At the first visit, an extensive health history, a complex physical examination, including a pelvic examination, and blood and urine specimen for laboratory work are obtained. The first prenatal visit is a time to establish baseline data relevant to planning health promotion strategies now and with subsequent visit. A first prenatal visit not only cot only confirms a pregnancy but provides at time to assess client needs and to educate about pregnancy. Assessments consist of a health history, physical examination, and laboratory tests. The physical examination could include measurement of fundal weight and assessment of fetal heart sounds of the pregnancy is beyond 12 weeks, a pelvic examination (including pap smear test), and perhaps estimation of pelvic size. A first prenatal visit sets the tone for visits to follow. Maintaining a supportive manner is helpful in establishing rapport and allowing the woman to feel comfortable to return for future care. Sufficient time should be reserved for a first prenatal visit so it can be thorough, allowing enough time to set realistic goals and outcome criteria with both the woman and her partner, if desired. The purposes of prenatal care are to: Establish a baseline of present health Determine gestation age of the fetus Monitor fetal development Identify the woman at risk for complication Minimize the risk of possible complications by anticipating and preventing problems before they occur. Provide time for education about pregnancy and possible dangers.

The primary goal of maternal and child health nursing care can be stated simply as the promotion and maintenance of optimal family health to ensure cycles of optimal childbearing and childrearing. Remember that a family, not a woman alone, is having a baby and include family members in procedure and health reaching as derived. Nurses can be instrumental in helping achieve this goal by educating women and their families about the importance of prenatal care and by making sites of prenatal case receptive to women and families. Then aimed with information, the pregnant woman may make an appointment for her next visit. Before her return she can jot down questions that came up about which she needs to be reassured.

GENERAL HEALTH TEACHING 1. Pre-natal care Visits Blood pressure will be monitored each month. While low blood pressure is rarely a reason for concern, an abnormal increase may be sign of problems that can affect you and your baby. Weight is normal for your body to gain weight or experience a little ankle swelling due to water retention during pregnancy. Your doctor will advice you about how much weight gain is good for you. Urinalysis, bodily functions will be determined through this test. It will also detect diabetes, kidney and bladder infections, and early signs of many problems in pregnancy. Blood test, samples will be taken to determine blood type and Rh factor to check for anemia and other blood diseases, and to screen for potential birth defects. Ultrasound or sonograms, will be done to check for twins, baby’s position, and due date accuracy. Breast exam, may be done on your first pre-natal visit. Advice will be given on breastfeeding as well as nipple and breast preparation. Abdominal exam, the doctor will measure the size of your uterus, which shows the growth of you baby, as well as check the baby’s position. Pelvic exam, on your first prenatal visit, your doctor will perform a vaginal exam to evaluate the size of your birth canal. Unless absolutely necessary, this exam will not be repeated until just before the baby is due, when changes such as dilation and effacement of the cervix will be measured. 1st visit: 32 weeks: visit must be every 4 weeks 2nd visit: 32-36 weeks: visit must be every 2 weeks 3rd visit: 36-40 weeks: visit must be once every week 2. Work You can go to work, but take care not to strain yourself or subject yourself to stress. Avoid prolonged standing or sitting. Provide deep breathing, foot circling and relaxation. 3. Sleep Get plenty of bed rest. In the last months of your term, you may have some difficulty sleeping. Try to nap when you have the chance. 4. Exercise Moderate exercise, such as relaxed swimming, is allowed. Take care not to overheat.

Kegel’s exercise is recommended to strengthen the muscles around the reproductive organs and improve muscle tone. 5. Travel Routine travel, such as daily commute, is allowable. Airplane flights are possible usually until the last trimester of your pregnancy. Proper use of seatbelt and headrest and lap belts must be done. Avoid long trips especially on the 1st and 3rd trimester but can travel in 2nd trimester. Periods of activity and rest must be done fro 15 minutes. Every 2 hours for emptying of bladder. In high altitudes regions, lowered O2 mav cause hypoxia or fetal brain damage, it may be pressurized. 6. Nutrition Quality of your diet is essential. Your doctor may give you advice on a particular set of foods you can eat, given your condition. He may also prescribe vitamin and mineral supplements. Avoid salty, toosweet, and fatty foods. Drink 8-12 glasses of liquid a day, Juices may be included to lower the pH of urinary tract. Increase caloric intake to prevent maternal underweight. Eat variety of foods and maintain small, frequent feeding. 7. Hygiene Keep yourself clean always. Bathe regularly to keep your body cool. Do not use feminine washes or douches unless advised by your doctor. Do not use bathtub it can alter balance Do not bath if there is vaginal bleeding and rupture of membranes. Warm showers can be therapeutic, relax tensed tired muscles, helps counter insomnia, makes us feel fresh. Can swim but no diving to prevent traumatic injury. 8. Sexual activity Contrary to what some people say, sexual intercourse is not harmful to the baby. However, take care not to put too much weight on the abdomen. Try other position instead. If you have been exposed to any sexually transmitted disease, report it to your doctor immediately. Provide a safe, open, non-judgmental atmosphere, Provide comfortable environment, offer alternatives and show illustrations. Avoid sexual intercourse during the 1st and 3rd trimester. 9. Smoking

Stop! Smoking depletes much- needed oxygen and may cause birth defects. 10. Drinking Alcohol can harm your baby and should not be ingested during pregnancy. Avoid alcoholic beverages to prevent growth retardation and musculoskeletal deformities. 11. Caffeine Limit your intake or cut it altogether, it hinders the body absorption of certain nutrients like iron. 12. Medications/Drugs Self-treatment must be discouraged. All drugs, including aspirin should be limited and careful record of therapeutic agents used should be used. Consult your physician who undergone medications to reduce the cause of possible teratogenecity or fetal drug toxicity. 13. Immunizations Tetanus toxoid must be given to pregnant woman. Do not give medications such as measles, mumps and polio vaccine due to potential teratogenecity. 14. Dental care Adequate calcium and phosphorus in the teeth must be included on the diet. Dental tooth extraction is prohibited during pregnancy.

EXERCISES DURING PREGNANCY

KEGEL EXERCISES Are exercises designed to strengthen the pubococcygeal muscles? They should be done about 3 times a day. Exercises are as follows: Squeeze the muscles surrounding the vagina as if stopping the flow of urine. Hold for 3 seconds. Relax repeat 10 times. Contract and relax the muscles surrounding the vagina as rapidly as possible 10 to 25 times. Imagine that you are sitting in a bathtub of water and squeeze muscles as if sucking water into the vagina. Hold for 3 seconds. Relax Repeat 10 times. Push out with the vagina as if expelling something from it. Hold for 3 seconds. Relax Repeat 10 times. It may take as long as 6 weeks of exercise before, pubococcygeal muscles are strengthened. In addition to strengthening urinary

control and preventing stress incontinence, exercises can lead to increased sexual enjoyment because of the tightened vaginal muscles. PERINEAL AND ABDOMINAL EXERCISES 1. Tailor sitting - strengthens the things and stretches perineal muscles to make them suppler. A woman could use this position for TV watching, telephone conversations, or playing with an older child. It is good to plan on sitting in this position for at least 15 minutes. Should also practice this position for 15 minutes a day. 2. Squatting - stretches the perineal muscles. Should also practice this position for 15 minutes a day. For the pelvic muscles to stretch, the woman most keeps her feet flat on the floor. 3. Pelvic Floor Contractions - done during the course of daily activities as well. Perineal muscle - strengthening exercise will be helpful in the postpartum period as well as to promote perinea healing, to increase sexual responsiveness, and to help to prevent stress incontinence. 4. Abdominal muscles contractions - help strengthen abdominal muscles during pregnancy. Strong abdominal muscles can also contribute to effective second - stage pushing during labor and help to prevent constipation. Abdominal contractions can be done in standing or lying position along the pelvic floor contractions. The woman merely tightens here abdominal muscles, and then relaxes; she can repeat the exercise as often as she wished during the day. Another way to do the same thing is to practice blowing out a candle”. The women take a fairly deep inspiration, and then exhale normally. Holding her finger about 6 inches infront of herself, as if were a candle, she than exhales forcibly, pushing out residual air from her lungs. 5. Pelvic Rocking - helps relieve backache during pregnancy and early labor by making the lumbar spine more flexible. It can be done in a variety of positions. hand on knees, lying down, sitting or standing. The woman arches her back, trying lengthening or stretching her spine. She holds the position for I minutes, and then hallows her back. A woman can do this at the end of the day about five times to relieve back pain and make herself more comfortable for the night.

LEOPOLD’S MANEUVER First a. b. c. d.

Maneuver (Upper uterine segment or the uterine fundus) Nurse faces woman's head Palpate uterine fundus Determine the height the uterine fundus Determine what fetal part is in the uterine fundus

e. Palpation of the Uterine Fundus Will usually indicates the fetal part situated in the fundus; usually a fetal head; infrequently a fetal breech. Place hands on either side of the fundal area so that the fingers of both hands almost tough each other (face the woman's head). A somewhat hard and roundish shape, which when moved back and forth between the finger pads, also moves the entire fetus usually indicates a fetal breech. Press gently and firmly with finger pads. A very hard round well defined shape which can be moved back and forth (balloted) usually indicates a fetal head. Second Maneuver (Determines small parts and back of fetus along the sides of maternal abdomen) a. Examiner faces woman's head b. Palpate with one hand on each side of abdomen c. Palpate fetus between two hands d. Assess on which side is the fetal back or spine and which side has small parts or extremities Third Maneuver (Lower uterine segment or uterine pole) a. Face the woman's head and spread your hands widely apart b. Grasp the uterine contents just above the symphysis pubis (firmly but gently) c. Hold presenting part between index finger and thumb d. Assess for cephalic versus Breech Presentation e. Move the fetal presenting part gently back and forth in your hand Fetal head will shift more easily back and forth Fetal breech will move the whole body Fourth Maneuver (pelvic palpation of the uterus - assess the presenting part) a. Provides information about the presenting part: breech or head, attitude (flexion or extension), and station (level of descent of the presenting part). b. Examiner faces woman's feet c. Place hands on either side of the lower abdomen with finger pads at the lower uterine pole (bikini line) and thumbs directed toward the umbilicus. d. Carefully move fingers of each hand towards each other in a downward and inward manner using gentle pressure. The nurse's thumbs should point towards the woman's umbilicus. If there is a head palpated in the pelvis, the fetal presentation is referred to as a cephalic or vertex presentation. e. Assess if a prominence on one side of the abdomen can be palpated higher than a prominence on the other side. The first prominence felt indicates the occiput (forehead) of the infant and is

on the same side as the fetal small parts. Therefore, the occiput is on the side opposite the fetal back. The prominence felt further down the pelvis is the fetal occiput back of the head) and is on the same side as the fetal back. This maneuver provides information related to fetal descent into the pelvis. How much of the fetal head can be palpated above the pelvic brim? Is the head fixed into pelvis? Can the head be easily moved from side to side? When moved from side to side does the presenting part move by itself back and forth (balloted)? Does the whole fetal body move when palpating the presenting part side to side?

Findings from Leopold's Maneuver Movement of the fetal part in the fundus moves the entire fetus. This part is firm and roundish (the 1st Leopold's maneuver). There is a long firm smooth area which covers most of one side of the maternal far right abdomen. The flat smooth surface is felt deep on the right lateral side (the 2nd Leopold's maneuver). "Walking the fingers" across the uterus finds many large and small dips and contours on the maternal left lateral margin. The lower uterine pole contains a round small, hard object. This object can be moved slightly from side to side (the 3rd Leopold's maneuver). In the pelvis, the prominence which is higher is found on the maternal left side (the 4th Leopold's maneuver)

Estimate Fetal Growth Nagele’s Rule To calculate the date of birth by this rule, count backward 3 calendar months from the first day of the last menstrual period and add seven days. Eq: 06 - 22 - 03 -03 +7 + 01 03 - 29- 04 Mc Donald’s Rule: Measurement of the height of the fundus using a tape measure. The distance from the symphisis pubis to the level xyphoid process. Used to calculate the AOG. Eq:

Fundic height (cm) x 2/7 = AOG in lunar months Fundic height (cm) x 8/7 = AOG in weeks. Bartolomew’s Rule: Height of fundus is used to determine the AOG. Fundic height is used to determined by palpation and by relating it to the different landmark in the abdomen: umbilicus: symphisis pubis and xiphoid process. 12 wks - level of syphisis pubis 16 wks - halfway between umbilicus and symphisis pubis 20 wks - level of umbilicus 24 wks - 2 finger breaths above umbilicus 30 wks - midway between umbilicus and xiphoid process 34 wks - just below xiphoid process 36 wks - at the level of xiphoid process 40 wks - at 34 wks level due to lightening

Johnson’s Rule: Used to calculate the fetal weight in grams. Fundic height in (cm) - N x K = weight of the fetus K= 155 (constant) N- 12 (engaged) 11 (not engaged) Eq: 30 - 12 x 155 = 18 x 155 = 2790 gms. Haase’s Rule: Is used to determine length of fetus A. During the first half of pregnancy, square the number of months B. During the second half of pregnancy, multiply the number of months by five.

Beliefs and Practices Belief and Practices Prenatal Do not eat twin banana Do not eat dark foods Avoid hiding of foods Always have a garlic on your pocket Do not see a dying person Intrapartal Nobody should stay on the door or near the stair. Member of the family should give ‘atang’ to the anitos to help the woman in labor Let the mother eat soft boiled egg and drink lard

Rationale

Clinical Significance

So that the mother will not give birth to a twin baby The baby’s skin will have dark complexion So that the baby will came out naturally Protection from “aswang” The baby will come out grasping from breath and may die

No scientific basis

For easy delivery

Doorsteps or stairs has no connection with the progress of labor. Has nothing to do with the progress of labor

‘Atang’ are the ones they offer to the spirits to help the people who are kind to them To make the mother’s birth canal slippery thus facilitate easy delivery of the baby

Kick every corner of To facilitate easy the house during labor delivery Post Partal

No scientific basis No scientific basis No scientific basis No scientific basis but may affect the mother emotionally.

No scientific basis because the birth canal will surely give way to the baby to be delivered No scientific basis

Mother should not take a bath for 9 days after delivery Mother should wear thick clothes and confine to bed after delivery

To prevent post partal complications

Keep the baby’s first cut hair and finger nails

To make the baby intelligent

So that mother will not get sick

Taking a bath is very important to promote good hygiene Mother should have exercise and can work as long as she can for early wound healing and peristalsis No Scientific basis

LABOR AND DELIVERY Labor is the series of events by which uterine contractions and abdominal pressure expel the fetus and placenta from the woman’s body. Regular contractions cause progressive dilatation of the cervix and sufficient muscular force to allow the baby to be pushed to the outside. It is a time of change, both an ending and beginning, for the woman, the fetus, and the family. Labor and birth require the woman to use all the psychological and physical coping methods she has available. Labor and birth are enormous emotional and physiologic accomplishments not only for a woman but her support person as well. For this reason, support persons should be treated with respect and be included in all phases of the process, wherever possible. Labor normally begins when a fetus is sufficiently mature to cope with extra uterine life, yet not too large to cause mechanical difficulties why labor begins, it is believed that labor is influenced by a combination of factors form the mother and fetus. These factors include: Uterine muscle stretching Pressure on cervix Oxytocin stimulation Change in ratio of estrogen and progesterone Placental age Rising fetal Cortisol level Fetal membrane production of prostaglandin Seasonal and time influences Assessment of a woman in labor must be done quickly yet thoroughly and gently. Before labor, woman after experiences subtle signs that can signal the onset of labor. All pregnant women should be taught how to recognize the preliminary signs and true signs of labor.

The following are the preliminary signs of labor:

Lightening In primiparas, it is the descent of the fetal presenting part into the pelvis, occurs approximately 10 to 14 days before the labor begins. This changes the woman’s abdominal contour as the uterus becomes lower and more anterior. Lightening gives the woman relief from diaphragmatic pressure and shortness of breath however abdominal pressure increases. Increase in Level of Activity This increase in activity is due to an increase in epinephrine release that is initiated by a decrease in progesterone produced by the placenta. Braxton Hicks Contraction This is sometimes called the false labor contractions, which begins and remain irregular. Contraction is felt first abdominally and remain confined to the abdomen and grown which do not increase in duration, frequency, or intensity. Ripening of the Cervix Ripening of the cervix is an internal sign seen only on pelvic examination. At term, the cervix becomes till softer, until can be described as “butler - soft,” (Goodells’ sign) and tips forward. This ripening, and internal announcement that labor is chose at hand. Signs of true labor involve uterine and cervical changes. The more women know about true labor signs, the better. This is helpful both in preventing preterm birth and being able to feel secure during labor.

TRUE SIGNS OF LABOR Uterine Contraction The surest sign that labor has begun is the initiation of effective, productive, involuntary uterine contractions. This is felt in lower back and sweep amount to the abdomen in a wave. Show As the cervix softens and ripens, the mucus plug that filled the cervix canal during pregnancy is expelled. The blood, mixed with mucus, takes on a pink tinge and is referred to as “show” or “bloody show.” Rupture of the Membane Labor may begin with rupture of the membranes, experienced as either as sudden gush or scanty, slow seeping of clear fluid from the vagina. The two main risks associated with ruptured membranes

include intrauterine infection and possible prolapsed of the umbilical cord, which can cut off the oxygen supply to the fetus. A successful labor depends on three integrated concepts: The woman’s pelvis (passage) is of adequate size and contour. The passage refers to the route the fetus must traverse from the uterus through the cervix and vagina to the external perineum. In most instances, if a disproportion between the fetus and pelvis occurs, the pelvis is the structure at fault. The fetus (passenger) is a appropriate size and in an advantageous position and presentation. The body parts of a fetus that has the widest diameter is the head, it is important to understand fetal presentation and position. Complete flexion is the normal fetal position, which is advantageous for birth because it helps \ the fetus presents the smallest antercoposterior diameter of the skull to the pelvis. Cephalic presentation means that the head is the part that first contacts the cervix. It is the most common type of presentation. The uterine factors (powers of labor) are adequate. The powers of labor, supplied by the fundus of the uterus, are implemented by then expulsion of the fetus from the uterus. After full dilation of the cervix, the primary power is supplemented by the use of the abdominal muscles. It is important for women to understand they should not bear down with their abdominal muscles until the cervix is fully dilated. Doing so will impede the primary force or could cause fetal or cervical damage. The fourth “P” (Psyche) refers tot eh psychological scale of feelings that women bring into labor with them. For many women, this is a feeling of apprehension or fright. For almost everyone, it includes a sense of excitements or awe. Women who manage best in labor typically are those who have a strong sense of self - esteem and a meaningful support person. In nursing literature, labor is traditionally divided into three stages: a first stage of dilatation, beginning with true labor contraction an ending when the cervix is fully dilated; a second stage, from the time of full dilatation until the infant is born; and a third or placental stag, from the time the infant is born until after the delivery of the placenta. The fist 1 to 4 hours after birth of the placenta are sometimes termed the “fourth stage” to emphasize the importance of the close observation needed at this time. The table below (Table 1.1) shows the average length of labor both in primipara and multipara. This varies depending upon the individual. (1.1) AVERAGE LENGTH OF LABOR STAGE PRIMIPARA Stage 1 Stage 2 Stage 12 - 13 hours 1 hour

MULTIPARA 8 hours 20 minutes 4

3 Stage 4

3 - 4 minutes 1 - 2 hours

- 5 minutes 1 - 2 hours

Length of labor depends on the following: Effectiveness/consistency of contraction Amount of resistance: baby must overcome to adapt to the pelvis Stretching ability of soft tissue Preparation and relaxation client

STAGES OF LABOR FIRST STAGE OF LABOR The first stage of labor is divided into three phases: the latent, the actives, and the transition phases. Latent Phase The latent or preparatory phase begins of the onset of regularly perceive uterine contractions and ends when rapid cervical dilatation begins. Contractions during this phase are mild and short, lasting 20 40 seconds. Cervical effacement occurs, and the cervix dilates from 0 to 3 cm. This phase may be prolonged if a cephalopelvic disproportion (CPD) exists. Active Phase During the active phase of labor, cervical dilatation occurs more rapidly, going form 4 cm to 7 cm. Contractions are stronger, lasting 40 to 60 seconds and occurring approximately every 3 to 5 minutes. Show and perhaps spontaneous rupture of the membrane may occur. Transition Phase During this phase, maximum dilatation of 8 to 10 cm occurs, and contractions reach their pear of intensity, occurring every 2 to 3 minutes with duration of 60 to 90 seconds. Dilatation continues at a rapid rate. If the membranes have not previously ruptured or been ruptured by amniotomy, they will rupture as a rule at full dilatation (10 cm). SECOND STAGE OF LABOR The second stage of labor is the period from full dilatation and cervical effacement to birth of the infant. Contractions change form the characteristics crescendo - decrescendo pattern to an overwhelming, uncontrollable urge to push or bear down with contractions as if she were moving her bowels. As the fetal head touches the internal side of the perineum, the perineum begins to bulge and appear tense. The anus of the woman may appear averted. As the fetal head is pushed still tighter against the perineum, the vaginal introitus opens and the fetal scalp becomes visible at the opening to the vagina. At first, this is a slit like opening, which then becomes oval, then circular. The circle enlarges from the size of a dinel to that of a quarter to that of a half dollor. This is called crowning. As the woman pushes, using her abdominal muscles and the involuntary uterine contractions, the fetus is pushed out of the birth canal. THIRD STAGE OF LABOR

The third stage of labor, or the placental stage, begins with the birth of the infant and ends with the delivery of the placenta. CARDINAL MOVEMENTS OF LABOR Passage of the fetus through the birth canal involves a number of different position changes to keep the smallest diameter of the fetal head (in cephalic presentation) always presenting to the smallest diameter of the birth canal. These positions are termed the mechanisms or cardinal movements of labor. The following are the mechanisms of labor: Decent This is the downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. Full descent occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor. The pressure of the fetus on the social nerves causes the mother to experience a pushing sensation. Descent occurs because of the pressure on the fetus by the uterine fundus. Full descent may be aided by abdominal muscle contraction. Flexion As descent occurs, pressure from the pelvic floor causes the fetal head to bend forward onto the chest. The smallest anteroposterior diameter the suboccipitobugnatic diameter) is the one presented to the birth canal in this flexed position. Internal Rotation The head flexes as it touches the pelvic floor, and the occupant intake until it is superior, or just below the symphisis pubis, bringing the head into the best diameter for the outlet coming next, into the optimum position to enter the inlet or puts the widest diameter of the shoulders in line with the wide transverse diameter of the inlet. Extension As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head thus extends, and the foremost parts of the head, the face and chin, are born. External Rotation In external rotation, almost immediately after the head of the infant is born, the head rotates back to the diagonal shoulders are thus brought into an anteroposterior position, which is best for entering the outlet. The anterior shoulder is delivered first, assisted perhaps by downward flexion of the infant’s head.

Expulsion Once the shoulders are delivered, the rest of the baby is delivered easily and smoothly because of its smaller size. This is expulsion and is the end of the pelvic division of labor.

THE DELIVER OF THE PLACENTA After birth of the infant, the uterus can be palpated as a firm, round mass just inferior to the level of the umbilicus. After a few minutes shape, It retains this new shape until the placenta, ahs separated, approximately 5 minutes after birth of the infants. The two separate phase involved in the delivery of the placenta are: Placental Separation Placental separation occurs automatically as the uterus resumes contractions. As the uterus contracts down on an almost empty interior, there is such ad disproportion between the placenta and the contracting wall of the uterus that folding and separation of the placenta occurs. Active bleeding on the maternal surface of the placenta begins with separation; the bleeding helps to separate the placenta still further by pushing it away form its attachment site. As separation is completed the placenta sinks to the lower uterine segment or the upper vagina. The following signs indicate that the placenta has loosened and is ready to deliver: a. Lengthening of the umbilical cord b. Sudden gush of vaginal blood, or c. Change in the shape of the uterine If the placenta separates first at its center and last at its edges, it tends to fold on itself like an umbrella and will present at the vaginal opening with the fetal surface evident. Appearing shiny and glistering from the fetal membranes, it is called a Schultze’s Placenta. If, however, the placenta separates first at its edges, it slides along the uterine surface and presents at the vagina with the maternal surface evident. It looks raw, red, and irregular with the ridges or cotyledons that separate blood collection spaces showing, and is a Duncan Placenta. Bleeding occurs as part of the normal consequence of placental separation, before the uterine contracts sufficiently to seal maternal sinuses. The normal blood loss is 300 to 500 ml. Placental Expulsion The placenta is delivered either by the natural braving - down effort of the mother or by gentle pressure on the contracted uterine fundus by the physician or nurse midwife. Pressure must never be applied to a uterus in a noncontracted station the uterus may event and hemorrhage. This is a grave complication of birth, because the maternal blood sinuses are open and gross hemorrhage occurs.

If the placenta does not deliver spontaneously, it can be removed morally. With the delivery of the placenta, the third stage of labor is over. The placenta is carefully inspected to be sewing that it is whole. If pieces remain within the uterus, it cannot clamp down completely, and serious hemorrhage may result.

CARE OF NEWBORN What is newborn care? Caring for a brand new baby can be overwhelming and tiring. It includes adjusting to round-the-clock diaper changes and feedings. Ideally, new mothers should receive significant support from partners, other family members, and friends. The new mother's partner can and should participate in most aspects of newborn care. Even during breastfeeding, partners can help to ensure that the mother is comfortable and receiving adequate nourishment. Some basics of newborn care include: 1. Infants need breastmilk or formula only. Breastfeeding offers many advantages to both infants and their mothers, and breastmilk is the best source of food for your baby's health and development. However, a major brand of formula is sufficient if the mother chooses not to breastfeed. Newborn babies do not need any other food. 2. Infants need to be warm and comfortable. Babies should be dressed appropriately for the weather. If parents are wearing shorts, then baby can wear shorts too. Babies should not be overdressed, since this can cause irritability and elevated body temperature. 3. Diapers should be changed as soon as they are wet or soiled. Failure to change diapers when wet or soiled can lead to discomfort and skin irritation. Cloth diapers are better than plastic ones, and diapers should be free of chemicals and fragrances. Should a rash occur, exposing the affected skin to air is excellent treatment? 4. Infants need to be clean. Babies twice weekly shampoo with a product like Sebulex. 5. The umbilical cord should be cleaned every 4-6 hours with rubbing alcohol and cotton. 6. Infants need sleep. Babies sleep many hours throughout the day, and sleep patterns differ from one baby to the next. During the first few weeks, babies should sleep in the parents' room. Babies should be placed on their backs. Sleeping on the abdomen has been related to SIDS (sudden infant death syndrome). 7. Infants need stimulation.

Appropriate stimulation includes talking to, singing to, and holding the baby. 8. Infants cry. Crying is how babies "talk" to their parents, and babies often cry up to several hours each day. Babies cry when they are hungry, sick, angry, in pain, or have a wet diaper. Whenever a baby cries, the caretaker should consider these reasons first. Sometime, babies also cry for no apparent reason, except that they may be irritable. Babies who cry during most of their waking hours are called "colicky." Colic usually disappears after a few months. If this occurs, you can try: Holding the baby closely Holding the baby more often during periods when s/he is not crying Gently rubbing the abdomen Burping the baby more often during feedings Changing the diet (avoiding cow milk formula) Gently rocking or swinging the baby 9. Infants need regular preventive medical visits. A good time to find a pediatrician is before the baby is born. During "well-baby visits" with a health care provider, infant growth and development will be monitored. In addition, providers will screen for common childhood conditions and provide immunizations

APGAR The APGAR scoring provides a valuable index for assessing the newborn’s condition at birth. The APGAR Score standardizes infant evaluation and serves as a baseline for future evaluations. Using the APGAR system, the infant is assessed at one minute and 5 minutes after birth. An infant whose total score is under 4 is in serious danger and needs resuscitation. A score of 4 to 6 means that the condition is guarded and the baby may need clearing of the airway and supplementary oxygen. A score of 7 to 10 is considered good. The highest score is 10. Sign Heart Rate Respiratory Effort

0 Absent Absent

Muscle Tone

Flaccid

Reflex Irritability

No Response

1 Slow <100 Slow, irregular, weak cry Some flexion of extremities Grimace

2 >100 Good strong cry

Score 2 2

Well flexed

2

Cry and withdrawal

2

Color

Blue pale

Body pink, extremities blue

of foot Completely pink

2 10

Implication: The baby had a total score of 10. She was in good condition.

PUERPERIUM Postnatal Care and Puerperium Introduction: Throughout pregnancy, you were center stage: your partner, your family, your doctor and you yourself were concentrating on various aspects of your health and care in pregnancy and labour. The foetus growing inside you was a secondary patient. Now that you have delivered, the focus of everybody’s attention, including your own seems to have shifted suddenly from you to the little bundle of joys (well, most of the time joy, sometimes trouble!) next to you. This is but natural, and we are sure you will take it in your stride. However, there are many things about your body that are still going to change. This post delivery period is extremely important, and to recover to your prepregnancy health (if not better) you need to pay attention to yourself too.

Phases of Puerperium:

Taking - In Phase The taking -in phase, the first phase experienced, is a time of reflection for a woman. During this period, the woman is largely passive. She prefers having a nurse minister to her to get her a bath towel or a clean night gown, and make decisions for her rather than doing these things herself. This dependence is due partly to her physical discomfort from possible perineal stitches, afterpains, or hemorrhoids; partly to her uncertainty in caring for newborn; and partly from the extreme exhaustion that follows childbirth. Taking - Hold Phase After the time of passive dependence, a woman begins to initiate action. She prefers to get her own washcloth and to make her own decisions. Women who give birth without anesthesia may reach this second phase in a mater of hours after birth. During the taking - in period, a woman may have expressed little interest in caring for her child. Now, she begins to take a strong interest, as a rule therefore, it is always best to give the woman brief demonstration of baby care and then allow her to care for the child herself with watchful guidance. Although a woman’s action suggest strong independence during this time, she often stills feels insecure about her ability to care for her new

child. She needs praise for the things she does well to give her confidence. Do not rush a woman through the phase of taking - in or prevent her from taking hold when she reaches that point. For many young mothers, learning to make decisions about their child’s welfare is one of the most difficult phases of motherhood. It helps if the woman has practice in making such decisions in a sheltered setting rather than first taking on that level of responsibility when she is on her own. Letting - Go Phase In this 3rd phase, called letting go, the woman finally refines her new role. She gives up fantasize image of her child and accept that real one; she gives up her old role of being childless or the mother of only one or two. This process requires some grief work and adjustment of relationships similar to what occurred during pregnancy. It is extended, and continues during the child’s growing years. A woman who has reached this phase is well into her new role.

Immediate Puerperium: The first 24 hours after birth, or the immediate puerperium, is a critical stage. This is the time when your uterus has to contract well, in order to stop the bleeding from the site of placental attachment. It is also the initiation of breastfeeding and bonding. Occasionally, this is the time that most life threatening complications of delivery manifest. These include postpartum excessive bleeding, collapse of the circulation, cardiac failure, etc. These are not common, but even with normal vaginal birth there is a risk of death of about 1 in 10,000 women. This risk may be more in women with pre-existing medical conditions like anaemia, hypertension or heart diseases. It is also more with operative deliveries. Hence you will be advised to stay in hospital for at least 24 hours following childbirth.

Early Puerperium: This refers to the 2<sup>nd to 7<sup>th day post delivery where major changes start in your genital tract. This is probably also the time of maximum adjustment when you come to terms with your new role as ‘mother’. You will also be going home with your baby in this period. There are many relatively minor, yet significant bodily changes you should be aware of. These include:

Lochia / Vaginal discharge:

This term refers to the discharge from the vagina, coming mainly from shedding of the inner lining of the uterus. For the first 4 days, there is fresh bleeding, like a heavy menstrual flow (Lochia rubra). You may need to use 2 pads at a time, changing 3 - 4 times a day. However, if you find it very heavy, or large clots keep coming out, you must inform your doctor. Usually by the 5<sup>th day the flow

becomes much less, and may now be more of a blood stained yellowish-brown discharge. You may still require sanitary protection, about 2 - 3 pads a day. This discharge called ‘lochia serosa’ usually stops by the end of the second week after which it becomes a plain white discharge. Good hygiene and care of episiotomy will prevent infection. Any foul smell in the discharge should be reported to your doctor.

Urination:

The first day you must pass urine at least 2 - 3 hourly, despite pain in the stitches. This is because the bladder may become overfull without you realize it, which can cause problems, especially infections later. During the first week, you may notice that you seem to be passing a lot of urine. This is because your body is removing some of the excess water and salt that was retained in pregnancy.

Stools:

You may not have a good bowel motion for the first 2 days following delivery, for various reasons. One is that you have not eaten much during labor, you are exhausted and sleepy. Secondly you may be having pain in the stitches of the episiotomy It is important to take a high fiber diet and plenty of liquids to prevent hard stools. You may need a mild laxative for a few days.

Breast:

The first day you will have only a watery, yellowish discharge, not looking like ‘real’ milk coming from the breasts. This is called colostrum and it is rich in many nutritive factors that are needed by your baby. You must feed your baby at this time. By the third day, the milk flow increases a lot, due to hormonal changes in your body. Regular feeding is important to prevent engorgement. Link to engorged breast in Breastfeeding.

After - Pains: The delivery is over. You have borne with labor pains. So now you may be worried that you are still getting a cramping lower abdominal pain off and on. Don’t worry, there is nothing left inside! This is a normal phenomenon, which occurs due to the uterus contracting in response to oxytocin, a natural body hormone. This is more marked when you are breastfeeding. Link to letdown reflex in breastfeeding. It is nature’s way of getting your uterus back to the normal size. If the pain is severe, or you are having other symptoms like fever or excess bleeding, you need to inform your doctor.

POST PARTAL EXERCISES MUSCLE STRENGTHENING EXERCISE

1. Abdominal Breathing - abdominal breathing maybe started on the first day postpartum, because it is a relatively easy exercise. Lying flat on her back on sitting, a woman should breath slowly and deeply in and out 5 minds, using her abdominal muscles. 2. Chin - to chest - chin to chest exercise is excellent for the second day. Lying on chin forward on her chest without moving any other part of her body while exhaling. She should start this gradually, repeating it no more than 5 times the first time and then increasing it to 10-15 times in succeeding. The exercises can be done 3 to 4 times a day. She will feel the abdominal muscles pull and tighten if she is doing it correctly. 3. Perineal Contraction - If a woman is not already if she is doing it correctly. Of alleviating perineal discomfort, it is a good one to add on the third day. She would tighten and relax her perineal muscles 10-15 times in succession as if the trying to stop voiding. She will feel her perineal muscles working if she is doing it correctly. 4. Arm Raising. Arm raising helps both the breasts and the abdomen return to good time is a good exercise to add on the fourth day. Lying on back, arms at her sides, a woman moves arms out from her sides until they are perpendicular to her body. She time raises them over her body until they are perpendicular to her body. She then raises them over her body until her hands touch and lowers them slowly to her sides. She should rest a moment, then repeat the exercise 5 times. 5.Abdominal Crunches. It s advisable to wait until to 10th and 12th day after delivery before attempting abdominal crunches. Lying flat on her back with knees bent a woman folds her arms across her chest and raises herself to a sitting position. This exercise expenses a great deal foe effort and tires a postpartum woman easily. She should be cautioned to begin it very gradually and work up slowly to doing it 10 times in a row.

Post Partum Blues: There are many changes, which have happened to you in the past 9 months, and even more are happening now. You may be feeling a little left out or dissociated from your surroundings. Link to introduction of puerperium the swings in your hormone levels are maximum in the first week. Your baby may be keeping you awake all the time, your breasts feel sore, and your stitches are hurting. Many things add up to make you feel down. Many women feel low or depressed soon after delivery - in fact, it is so common that there is a medical team for it, called ‘fifth day blues’! Talk to your partner, your friends, an older relative or your health care persons. Ask for help with the baby if you are tired. Have a good cry. Take a break, sleep for a

while and you will feel better. If this feeling of depression does not settle in a few days, then perhaps you should see your doctor for help, Sometimes an underlying hormonal problem like low thyroid function may be causing these feelings. Remember that these feelings are not uncommon. You are not the only mother who is not feeling ‘100% maternal love’ all the time, particularly soon after delivery. Be good to yourself, pamper yourself also, and talk about what you feel. Soon, you too will feel on ‘top of the world’!

Resuming Activities: As discussed earlier, it takes up to 6 weeks for your body to recover from the changes of pregnancy. So, be patient with you. Listen to your body and do as much as you feel up to, Different women have different abilities to deal with their health changes. However, in most cases, after a normal vaginal delivery, you will be able to resume your daily personal care activities within a day, and your household routine within a week, don’t overexert yourself - This is the time you need to devote to yourself and your baby. Take help; involve your partner, Link to Father’s role, and others available to make your life easier. After a complicated childbirth, or after a caesarean delivery your recovery may take twice as much time, so be patient.

Postnatal Exercises:. Sexual Activity is best avoided in the early post delivery period. This is because your stitches may be raw or painful, and your genital tract is prone to infection, particularly in the 1<sup>st week. Complete restoration of the lining of the uterus, including the placental site, is not complete. Hence traditionally some advise abstinence till 6 weeks following delivery. However, if you have had an uncomplicated birth, and are not having any problems, you could resume your sexual life earlier. You and your partner may have been deprived of each other, particularly in the last month of pregnancy. Hence, it is not unusual to feel the need to renew your sex - life. Until you feel comfortable for actual penetrative sexual intercourse, other displays of caring and affection can suffice. Hugging, kissing, petting or touching is not forbidden at anytime during pregnancy or post-delivery.

Lactational Amenorrhoea: Link to lactation amenorrhoea in preventing pregnancy. While you are exclusively breastfeeding, Link to exclusive breastfeeding in Breastfeeding, the hormonal changes is your body act on the genital tract to suppress ovulation and menstruation. Link to female reproductive, tract, ovulation, and menstruation. You may not get your periods for a few months. Some women do not start menstruating for up to a year, depending on the pattern and frequency of breastfeeding. Timing No lactation If lactation established Menstruation 6 - 12 weeks 36 weeks (average) Earliest ovulation 4 weeks 12 weeks Average time for ovulation. 8 - 10 weeks 17 weeks (variable) Does this mean you cannot get pregnant? The answer is NO. About 5% of women get pregnant before they start menstruating, postdelivery. Lactation amenorrhoea (absence of periods) does protect you from pregnancy to some extent. However, you can rely completely on Lactational amenorrhoea as a method of preventing pregnancy ONLY IF ALL 3 preconditions listed below are satisfied:

Contraception: If you are relying on lactational amenorrhoea. If not, that brings us to the important question: Are you ready for another pregnancy? You need to give your body time to recover; your baby time to grow up and yourself time to adjust to the new role of ‘mother’. Of course, it is a question of personal choice but a minimum gap of 2 years is recommended between successive pregnancies. So, how can you prevent pregnancy during the post-delivery period? There are many methods available. During the post partum period, however, certain factors need to be kept in mind:

Others: Condoms Condoms are a good, locally acting method, which are reliable if used correctly and consistently. They have no side effects and are useful for couples with less frequent sexual intercourse. IUCDs or ‘loops’: These are a very reliable method, requiring one visit to the doctor for insertion, which can be done easily without anaesthesia. They are effective for average 3 - 5 years (depends on the device) and are independent of the sexual act, unlike condoms. This is a very popular method for women with one or more children. Infact, can be used as an option to permanent procedure. The IUCD can be inserted at the first postnatal visit. Link (6 weeks from childbirth) or later, even if you do not have periods, provided your internal checking is normal. Oral Contraception pills: These are a type of hormonal contraception. During the period of exclusive breastfeeding the combined Oral Contraception pills (containing Estrogen + Progesterone) may reduce the breast milk flow. Hence are not popularly recommended. Once weaning is begun, there can be used safely. Sterilization: This is a permanent method, which can be opted for after you have completed your family. This is a procedure which can be done easily immediately post-delivery (puerperial sterilization) or at the time of caesarean section. For both these options, you need to discuss the pros and cons with your doctor and spouse before delivery, ideally in one early antenatal period. Some prefer to wait until the youngest child is older, preferably above 1 year old, before doing this permanent procedure. As an interval procedure, 6 weeks or more after delivery, it is usually done by laparoscopy. First Postnatal Visit: You and your baby have been through a lot. After you go home, and you recover from childbirth, your doctor will need to see you at least once to confirm that your recovery is complete. The first check up is usually 6 weeks from delivery. It may be earlier, about 3 weeks, if you have needed special care or had any problem in delivery. At the first visit, your doctor will check You may need to do some tests. You need to discuss the following issues with your doctor

ESTABLISH SUCCESSFUL LACTATION In most of the hospital they require the mothers who delivered there to breast reed as soon as possible because the baby will receive colostrums that contains gamma globulins. Advantages of breath feeding to the mother are: It is economical in terms of money and effort, more rapid involution, loss incidence of cancer of the breast. For the baby: closer mother infant relationship, contains antibodies that protect against common illness, less incidence of gastrointestinal diseases and always available at the right temperatures.

BREASTFEEDING Breast milk is preferred method of feeding a newborn because it provides numerous health benefits to both the mother and the infant. It remains the ideal nutritional source for infants through the first year of life. Nurses can play a major role in teaching women about the benefits of breastfeeding and providing anticipatory guidance for problems that may occur by implementing steps such as: Educating all pregnant woman about the benefits and management of breastfeeding. Helping women initiate breastfeeding within half an hour of birth. Assisting mothers to breast-feed and maintain lactation even if they should be separated from their infant. Not giving newborns food or drink other than breast milk unless medically indicated. Not giving pacifies to breastfeeding infant. Practicing rooming- in (allow mothers and infants to remain together) 24 hours a day. Encouraging breastfeeding on demand. Fostering the establishment of breastfeeding support groups and referring mothers to them on discharge from the birthing center or hospital. The mother gains several physiologic benefits from breast feedings, such as: breastfeeding may serve as a protective function in preventing breast cancer, the released of oxytocin from the posterior pituitary aids uterine involution and successful breastfeeding can have an empowering effect because it is a skill only woman can master. Breastfeeding also reduces the cost of feeding and preparation time. Many women feel that breastfeeding enhances the formation of a true symbiotic bond with their child. Breastfeeding has major physiologic advantages for the baby. Breast milk contains secretary immunoglobulin A, which binds large

molecules of foreign proteins, including viruses and bacteria and keeps them from being absences to the GIT into the infant.

Prolactin An anterior pituitary hormone, acts on the acinar cells of the mammary gland to stimulate the production of milk. In addition, when infant’s sucks at the breast, nerve impulses travel from the nipple to the hypothalamus to stimulate the production of prolactin releasing factor.

Colustrum The acinar breast cells starting in the 4th month of preganancy secrete a thin watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies. Lactoferin Is an iron binding protein in breast milk that interferes with growth of pathogenic bacteria? Lysozyme In breast milk apparently actively destroys bacteria by lying their cell membranes, possibly increasing the effectiveness of antibodies. Leukocytes In breast milk provide protection against common respiratory infections invaders. L bifidus Interferes with the colonization of pathogenic bacteria, in GIT. the incidence of diarrhea. Breast milk also contains ideal electrolyte and mineral composition for human infant growth.

Advantage of breastfeeding Little controversy exist about breastfeeding as the best nutrition for human infants, but the decisions to breastfeed depends on what would please the woman the most and make and make her most comfortable. If she is comfortable and pleased with what she is doing, her infant will be comfortable and pleased, will enjoy being fed, and will thrive.

Breastfeeding is contraindicated circumstances, such as:

in

only

a

few

An infant with galactosemia (such infant cannot digest the lactose in milk Herpes lesions on the mother’s nipples Mother is on restricted nutrient diet that prevents quality milk production Mother is receiving medications that are inappropriate for breastfeeding, such as lithum or methotrexate. Maternal exposure to radioactive compounds, as could happen during thyroid testing

Advantage for the mother A woman gains several physiologic benefits from breastfeeding, including: Breastfeeding may serve a protective function in preventing breast cancer The release of oxytocin from the posterior pituitary gland aids in uterine involution Successful breastfeeding can have an empowering effect because it is a skill only woman can master. Breastfeeding also reduces the cost of feeding and preparation time. Many women feel that breastfeeding provides the best opportunity to enhance the formation of a true symbiotic bond with their child. Although this does occur readily with breastfeeding, a woman who holds her baby to bottle- feed can form this bond equally well. Some woman believes that breastfeeding is a foolproof contraceptive technique. Some feel breastfeeding will help them lose their weight gained during pregnancy. This also is not true, and women who arebreastfeeding need to concentrate on eating a well balance diet to ensure that her milk is rich in nutrients. Some woman are reluctant to breastfeed because they fear that having to be available to feed the baby every 3 or 4 hours will tie them down.

Advantage for the Baby Breastfeeding has many physiologic advantages for the baby. Breast milk contains contains immunoglobulin A (IgA), which binds large molecules of foreign proteins, including bacteria and viruses. Thus keeping them from being absorbed through the gastrointestinal tract into the infant. Lactoferin is an iron binding protein in breast milk that interferes with growth of pathogenic bacteria. Lysozyme in breast milk apparently actively destroys bacteria by lying their cell membranes, possibly increasing the effectiveness of antibodies.

Leukocytes in breast milk provide protection against common respiratory infections invaders. L bifidus interferes with the colonization of pathogenic bacteria, in GIT. the incidence of diarrhea. Breast milk also contains ideal electrolyte and mineral composition for human infant growth. Breast milk contains more linoleic acid, an essential amino acid for skin integrity, and less sodium, potassium, calcium and phosphorous than do many formulas. Breast milk also has a better balance of trace elements, such as zinc, than formulas do. These levels of nutrients are enough to supply the infants needs, yet they spare the infant’s kidneys from having to process a high renal solute load of unused nutrients. One disadvantage of breast milk is that it may carry microorganisms such as hepatitis B and cytomegalovirus, although the risk to infant is small. HIV is carried at a high enough level in breast milk that women who are HIV positive are advised not to breast-feed.

Preparing for Breastfeeding Ask all women during pregnancy whether they plan to breastfeed or formula feed their newborn. Thinking about feeding in advance allows couples to make informed choices. Some fathers experience jealousy at the thought of breastfeeding. Physical preparation such as nipple rolling, advised in the past as a way of making the nipple more protuberant is no longer advised. This is unnecessary because few women have inverted or non-protuberant nipples, plus oxytocin, released by this maneuver, could lead to preterm labor (nipple rolling is used to create uterine contractions for stress test). Practicing breast massage to move the milk forward in the milk ducts (manual expression of milks) maybe helpful. This can help a woman who feels hesitant about handling her breast to grow accustomed to doing so, allowing her to assist with milk production in the first few days after birth. Manual expressions consists of supporting the breast firmly, then placing the thumbs and forefinger on the opposite sides of the breast just behind the areolar margin, first pushing backward toward the chest wall and then downward until secretion begins to flow. Teach woman not to used soap on their breasts during pregnancy because soap tends to dry and crack nipples. The occasional woman who has inverted nipples may need to wear a nipple cup (a plastic shell) to help the nipples become more protuberant.

BEGINNING BREASTFEEDING

Breastfeeding should begin as soon as possible, ideally while the woman is still in the delivery or birthing room and while the infant is in the first reactivity period. This practice has several advantages infant suckling stimulates release of oxytocin which in turns stimulates uterine contracts to prevent hemorrhage, promotes closer maternal and infant relationship, prevents breast engorgement: If it is not possible to start breastfeeding right after delivery, initiate breastfeeding, then, after 4 to 8 hours when the mother has already rested on her condition and stable.

HOW TO FEED 1. Instruct mother to relax first before feeding, anxiety and fatigue interferes with the let down reflex 2. Wash hands and assumes a comfortable position. The mothers can breastfeed lying down or sitting, which ever is comfortable for her and her baby. 3. If the baby is asleep or sleepy talking or rubbing baby’s soles will gently wake him or wake up breastfeeding is more effective if the baby is awake. 4. Guide baby to the breast by stimulating rooting reflex, touch the cheek nearest the breast. The baby will respond by turning his head and opening his mouth. 5. Press the breast away from the nose with a finger if the breast blocks the baby’s nose. 6. Let the baby’s mouth grasp both the nipple and areola. 7. Feed the baby for only 2 to 3 minutes during the first time, then, increase feeding time by one minute each day until the infant is fad for ten minutes on each breast 8. When removing the baby from the breasts, pull the chin down or place a finger in the corner of the mouth to break the suction. Pulling the baby from the breasts is painful and can cause sore nipple. 9. On the next feeding, place infant on the breast where she or he last fed during the previous feeding. 10. Instruct mother to burp infant after feeding by placing baby on her lap on a prone position or positioning him or her in sitting upright. 11. Signs of proper feeding: the baby’s mouth group both nipple and areola. the other breast flows with milk. Infant sucking stimulates release of oxytocin, which in form stimulates milk let down reflex. the mother feels after pains or uterine cramping while breastfeeding, this is due to release of oxytocin.

12. It is not unusual to haves scanty milk supply during the first few days after delivery. There is no need to offer milk formula to the infant. Placing infant regularly on the breasts will stimulate milk production. Maintenance of successful lactation requires that breasts are completely emptied at each feeding so that they will completely fill again. The more the baby suckles, the more milk is produced. 13. Instruct the mother to avoid: Smoking Oral contraceptives because they decrease milk supply Drugs passed to infant via breast milk.

Problems of breastfeeding: 1. Breast Engorgement Breast engorgement usually occurs during the 3rd to 4th day after delivery. The mother complains of pain and tenderness, the breast are reddish, tense, shiny, hot to touch and feels firm and nodular. Breast engorgement is not cause by milk or infection but by lymphatic and venous congestion. When the breast are engorged, the infant will not be able to grasp the nipple effectively and pain can cause the mother to avoid or refused breastfeeding. Management: Give analgesics before feeding to provide pain relief Give breast more often to empty breast with milk and prevent further engorgement Initiate breastfeeding as soon as possible after delivery to prevent engorgement. Let warm water run over the breast or apply warm compress to improve circulation and promote comfort if the mother plans breastfeed. If the mother does not plan to breastfeed, apply ice packs. Reassure mother that engorgement is temporary and it will subside after 24 hours. 2. Sore and Crack Nipples Causes: Forceful pulling of the infant after feeding Improper sucking - infant grasping only the nipple during feeding Breastfeeding too long Nipple remaining moist for a long time due to leakage of milk

Management: Expose to air after feeding to let nipples dry Use of loose fitting clothing and leaving bra unsnapped to let air circulate in the breast for a few minutes Limit amount of time of feeding to allow nipple to healed Use of nipple shield Express milk usually or by breast pump if breastfeeding causes too much pain to maintain milk supply Sore nipples are not contraindication to breastfeeding unless the mother cannot tolerate the discomfort caused by infant suckling. She can express milk from her breasts and give it to infant using feeding bottle.

ACKNOWLEDGEMENT The author acknowledges with profound gratitude and appreciation to all those were behind her in the pursuit of her work for without them she should not have succeeded. Special mention to: Ms. Maria Elena Figuerroa RN, for her suggestion and guidance in accomplishment of this study. Kathleen and numerous true friends for their voluntary services, support and care; Her parents, brothers for the prayer and encouragement and who are always at her price. Above all to God for countless blessings showered to the writer.

DEDICATION To my parents who gave me the unconditional love from the time I saw the light and for what I am now; To my brothers who added inspiration though their assistance and moral support, To my ever loyal and closest friend and relatives. This humble work is heartily dedicated