NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)

BSN 2 Y1-4 CALIWAG, ALLIAH H.

OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

■ Sperm moves through semen

RECAP FOR REPRODUCTIVE SYSTEM
to neutralize the acid in the
FEMALE REPRODUCTIVE SYSTEM vagina as semen is alkaline

VULVA (EXTERNAL) ● Cervix

● Mons-pubis ○ Neck of the uterus
○ Fatty pad that overlays the pubic ● Uterus
symphysis ○ Muscular body containing important
○ Front of the pubis layers
● Labia majora ○ It is where implantation takes place
○ Most external skin folds ■ Endometrium
○ Beginning in the mons pubis to ● Most internal layer
perineum that thickens when
women become
● Labia minora
pregnant
○ Most internal skin folds
■ Myometrium
○ Move from the clitoris to the vaginal
● Thick layer that
orifice
contract when the
● Vestibule baby is going to be
○ Sits within the skin folds of labia pushed out
majora ● Fundus
○ Top of the uterus
■ Clitoris
● extremely sensitive ● Uterine Tubes (Fallopian tubes)
and plays an ○ It is where fertilization happens
important roles in ○ Carry both sperm and egg
sexual arousal
■ Isthmus
■ External Urethral Orifice ● Thinnest portion
● where urine is
excreted ■ Ampulla
● Common area for the
■ Vaginal Orifice sperm to fertilize the
● important in egg
separating internal to
external environment ■ Infundibulum
of the female ● End portion of the
reproductive tract fallopian tubes that
contains the fimbriae
REPRODUCTIVE TRACT
- Vagina → cervix → uterus → fundus → ■ Fimbriae
isthmus → uterine (fallopian) tubes → ● Finger-like projections
ampulla → infundibulum → fimbriae → ovary that swells during
ovulation for the egg
● Vagina
to leave the ovary and
○ pH = acidic
moving it to the
■ In order to keep it clean
fallopian tubes
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

● Ovary ● Vas Deferens (Ductus Deferens)

○ Contains and ovulate the egg ○ Vasectomy — to cut the vas deferens
approximately every 28 days or every ○ Loops around the bladder
month ● Seminal Vesicle
○ Important in producing hormones ○ Produces ⅔ of the volume of the
semen (fructose - major component
■ Progesterone & Estrogen
as energy source)
● Important in
producing and ● Ejaculatory Duct
maintaining the ○ Merged with part of urethra and
thickening of the forms prostatic urethra
endometrial lining ● Prostate
MALE REPRODUCTIVE SYSTEM ○ Houses ejaculatory duct and urethra

SCROTUM ■ Prostatic hyperplasia

- A sac that houses the testes ● Prostate grows as
- Seminiferous tubules → Testes → Epididymis males ages that can
→ Vas deferens → Seminal vesicle → squeeze the urethra
Ejaculatory duct → Prostate → Urethra → which makes it hard to
Penis → Glans urinate
● Testes ● Urethra
○ Sperm production ● Penis
○ Made up of spongiform tissue
● Seminiferous tubules
○ Found in the lobes within the testes ■ Erection
○ Where sperm production begins ● Point =
Parasympathetic
■ Leydig cells
● Dilate blood vessel;
● Produce testosterone
blood filling the
● Stimulated by
spongiform tissue of
Luteinizing hormone
the penis
(LH)
■ Ejaculation
■ Sertoli cells
● Shoot = Sympathetic
● Produce androgen
● Contract smooth
binding protein —
muscle to push the
when bind with
sperm and semen
testosterone, sperm is
through
produced
● Glans
● Stimulated by Follicle
stimulating hormone
(FSH)
● Epididymis
○ Lines the outside of the testes
○ Store, mature, and transport sperm
into the vas deferens
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

PHASES OF PREGNANCY ○ Possible for normal delivery but is to

- 9 months risky for both the patient and her
GERMINAL STAGE baby
- Shortest stage ○ Recommended delivery is through
- Matured eggs starts to come out of the ovary cesarean section
- It is when the egg cell and sperm cell meets QUESTIONS TO CONSIDER
resulting fertilized egg (zygote)
● Is the fundal consistent with the fetal or
EMBRYONIC STAGE maturity?
- When zygote travels from the fallopian tube ● Is the baby lying transverse ( —; horizontal ),
to the uterus longitudinal ( |; vertical), or oblique ( / or \)?
- Forms two structure: ● Is the presentation cephalic or breech?
● Fetus ● If cephalic, is the attitude vertex or facial?
● Placenta (provides nutrients to the ● What is the position of the denominator?
fetus) ● Is the vertex engaged?

FETAL STAGE OBSERVATION OF ABDOMEN SHOULD GIVE

- Longest stage DATA ABOUT
- The time when the fetus grows ● Longest diameter in appearance
LEOPOLD’S MANEUVER ○ Fundal height
■ Always use the cm
- Method of observing and palpating fetal
○ Axis
position, presentation, lie, and attitude
■ Length of the fetus
- Preferably performed after 24 weeks (6
● Location of apparent fetal movement
months)
○ Most likely reflect the position of the
PURPOSE feet
● To identify the position of the baby in the
CARDINAL RULE
utero
● Instruct woman to empty bladder
● To identify the expected presentation during
○ To promote comfort and allow for
labor and delivery
more productive palpation so fetal
● To provide information about fetal
contour will not be obscured by
presentation (cephalic or breech), position,
distended bladder
presenting part (lie, attitude, and descent)
● To aid in location of the fetal heart rates ● Place woman in dorsal recumbent position
● To aid in assessment of fetal size (supine with knee flexed)
● To identify single or multiple gestation (one ○ To relax abdominal muscles. Pillow
baby, twins, etc.) underhead for comfort
○ To avoid hypotension
PRESENTATION
● Drape properly to maintain privacy
● Cephalic Presentation
○ Candidate for normal spontaneous ● Explain procedures to gain patient’s
delivery cooperation
○ Head of the baby is presented in the
vaginal canal of the pregnant woman ● Warm hands especially palm
● Breech Presentation ○ Cold hands may stimulate uterine
○ Feet of the baby is presented in the contractions
vaginal canal of the pregnant woman
● Use the palm not fingers in palpating
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

● During the first 3 maneuvers stand facing ● Purpose

the patients ○ To assess the fetal heart rate of the
baby
● When doing the last maneuver, stand facing
○ To locate fetal back
patient’s feet
● Procedure
LEOPOLD’S MANEUVER STEPS ○ One hand is used to steady the uterus
on the side while the other hand move
FUNDAL GRIP (FUNDUS PART)
in circular motion (gentle but deep
● 1st maneuver
pressure) from to to lower segment to
● Purpose
feel the fetal back and small fetal
○ To determine presentation (Cephalic
parts
or Breech)
● Findings
● Procedure
○ Fetal back
○ Use both hands to feel fetal part lying
■ Smooth, hard, and resistant
in the FUNDUS
surface
● Findings
■ Important to easily identify
○ Head
the heartbeat of the baby
■ If firm, hard, and round is
palpated in the fundus ○ Knees and Elbows
(Breech presentation) ■ Numerous angular
modulation
○ Breech ●

■ If less defined and moves only ● PAWLIK’S GRIP

in conjunction with the body ● 3rd maneuver
(Vertex presentation) ● Purpose
● Points to Consider ○ To determine engagement of
○ Relative consistency presenting part
■ Head is firmer > breech ● Procedure
○ Use thumb and finger to grasp and
○ Shape press lightly the lower portion of the
■ Head abdomen above the symphysis pubis
● round & hard, and gently move from side to side
transverse groove of ● Findings
neck maybe felt ○ Engaged
■ Breech ■ Not movable, relatively fixed,
● no groove and more and knoblike part
angular ● Head will be firm
● Breech feels softer
○ Mobility
and irregular
■ Head
● move independently ○ Not engaged
■ Breech
■ Movable, round ballotable and
● moves in conjunction
easily displaced
with the body
● ■ Gently pushed back and forth
● UMBILICAL GRIP
●

● DEEP PELVIC GRIP

● 2nd maneuver
● 4th maneuver; last
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

● Purpose ● Inaccurate during the 3rd trimester of

○ To identify degree of flexion of fetal pregnancy as the fetus is growing more in
head weight than in height
○ To determine attitude or habitus ○ When measuring, the tape measure
● Procedure must be in between index and middle
○ Face the feet part of the patient. finger
Using both hand palpate fetal head ○ For example, if the measurement is
pressing downward, 2 inches above 28cm the patient is pregnant for 28
inguinal ligament. weeks
● Findings ● FORMULA in getting duration in lunar
○ Good Attitude months:
■ Brow correspond to the 2nd 𝑀𝑒𝑎𝑠𝑢𝑟𝑒𝑚𝑒𝑛𝑡 𝑖𝑛 𝑐𝑚
○ 3.5
maneuver
28 𝑐𝑚
■ Nakabow si baby ■ 3.5
= 8 𝑚𝑜𝑛𝑡ℎ𝑠 (3𝑟𝑑);
○ Poor Attitude ● 2nd and 3rd trimester, fundal height (cm) =
■ If there is obstruction on the fetus age in weeks
fetal back, palpate the infant's ● 16th week, fundus is approximately halfway
anteroposterior position. between symphysis pubis and umbilicus
■ If brow is easily palpated, ● 20th - 22nd week, fundus is at umbilicus
infant is at posterior position ● 36th week, fundus is at the xiphoid process
● Hyperextended head
○ Nakatingala si
baby

ESTIMATING FETAL GROWTH

MCDONALD’S RULE
● symphysis-fundal height (SFH) measurement
● To assess the fetal growth during pregnancy
● Distance from the fundus to the symphysis
pubis in cm = week of gestation between the ● Fundal height much greater than the
20th and 31st pregnancy standard suggests:
○ Multiple pregnancy
○ Miscalculation of due date
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

■ Patient does not know when is ■ LMP: May 27, 2023

her last menstruation
○ Large for gestational age infant
○ Hydramnios
■ Increased amniotic fluid
volume
○ Possibly hydatidiform mole
● EDD is 280 days from the LNMP
● How to get Last Menstruation Period (LMP)
● Patient must have regular cycles for the
○ 1st day of menstruation
results to be accurate
○ Example, August 3 - August 10, the
● Accuracy is up to 50% within 7 days on either
LMP is August 3
side
GESTATIONAL AGE & ESTIMATION OF DUE ● Inaccurate in patients with the following
DATES circumstances:
○ Oligomenorrhea
NAEGELE’S RULE
■ Irregular cycles
● Named after Franz Karl Naegele (1778-1851)
○ Bleeding in the first trimester of
○ A German obstetrician who devised pregnancy
the rule ■ Implantation bleeding
○ Born on July 12, 1778 ○ Pregnancy following the use of oral
○ Published Lehrbuch der Geburtshilfe contraceptive
with 14 editions for midwives ○ Pregnancy after postpartum period
(6-8 weeks)
● Standard way to calculate the due date for
■ once done na yung 6 weeks
a pregnancy
meron ng ovulation meaning
● It estimates the Expected Date of Delivery
may possibility na ulit
(EDD) by +1 year, -3 months, and +7 days to
mabuntis si patient
the patient’s LMP
■ Lactational amenorrhea
○ January to March
■ (+) 9 months and 7 days MCDONALD’S RULE
○ April to December ● Estimation of the duration of pregnancy
■ (-) 3 months, and (+) 7 days & ● FORMULA
1 year ○ Weeks gestation
○ Examples ■ 𝐹𝑢𝑛𝑑𝑎𝑙 ℎ𝑒𝑖𝑔ℎ𝑡 (𝑐𝑚) ×
8
7
■ LMP: January 5 2023
8
■ 28𝑐𝑚 × 7
224
■ 7
= 32 𝑤𝑒𝑒𝑘𝑠
○ Duration in Months
2
■ 𝐹𝑢𝑛𝑑𝑎𝑙 ℎ𝑒𝑖𝑔ℎ𝑡 (𝑐𝑚) × 7
■ LMP: April 6, 2023 2
■ 28𝑐𝑚 × 7
56
■ 7
= 8 𝑚𝑜𝑛𝑡ℎ𝑠

BARTHOLOMEW’S RULE
● Determines Age of Gestation depending on
the height of the fundus
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

● Knuckle rule:

● Solving:
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

PERINEAL CARE SAFETY

- Washing external genitalia and its - Always wear clean glove due to risk of
surrounding with soap and water, water-only, contact with infectious microorganisms
or commercially prepared peri-wash - Assess water temperature. Make sure it is
- Also called as perineal genital care, which mild to avoid or minimize irritation
involves cleaning private areas of the - Avoid using excessive force when cleansing
patient as it is prone to infection - Avoid placing tension on catheter if present
● Women are more prone as their - Wash from pubic area down the rectum to
urethra is more closer to the prevent vagina and urethral meatus to be
environment contaminated
- Done daily and if patient is suffering from - Report signs of impaired skin integrity to
incontinence it must be done more nurse in charge or health care provider

PURPOSE BEFORE PROCEDURE

- To prevent infection, odor, and promote - Assess the presence of excessive bleeding,
healing odor, pain, discomfort, presence of indwelling
- Remove secretion catheter and recent episiotomy (incision to
- Provide comfort open vagina larger for childbirth) and
episiorrhaphy (repairing vulva injury by
PRINCIPLES
suturing)
- To clean perineum from cleanest to less
clean area PROCEDURE
● Inner to outer; vagina outwards ● Introduce self and verify client’s identity
- Follow standard precautions (Figure of 7 ○ Ask for Full name and Birth date
strokes) ● Explain procedure to the client
- Maintain patient privacy ● Perform hand hygiene and observe infection
- Proximal level of function control procedures
● Provide privacy
INDICATIONS
● Prepare client
● Patient unable to do self care
○ Fold gown to expose only the genital
● Patient with genito-urinary infection
area
● Patient with incontinence of urine stool
○ Place towel under client’s hip
● Patient with indwelling catheter
● Position the client in dorsal recumbent
● Postpartum patients
● Drape the patient
● Patient with injury, ulcer, and surgery
● Wear gloves
CONTRAINDICATIONS ● Wash & dry upper inner thighs
- Perineal malformation ● Clean labia majora then folds then labia
● Genital abnormalities minora
- Inflammatory bowel disease ● For washcloth, use separate quarters for
each stroke.
MATERIALS
○ If menstruating and postpartum
● Bedpan
patient, use clean wipes
● Sterile gloves
● Rinse area well by placing client on bedpan
● Towel
and using PeriWash solution
● Perineal wash
● Inspect orifices for intactness
● Canister with dry cotton, normal saline, or
● Clean between buttocks
betadine
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

● For postpartum and menstruating patients,

apply pad as needed from front to back
● Remove and discard gloves
● Perform hand hygiene
● Document procedure and findings
○ Unusual findings
■ Redness, excoriation, skin
breakdown, discharge, or
vaginal bleeding
○ For Postpartum patients
■ Amount, color, and odor of
bleeding (unused pad weight
– used pad weight; 1 gram = 1
mL blood loss)
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

PERILIGHT APPLICATION/EXPOSURE - (Psychology) nurse explains purpose ot

- Application of dry heat to the perineal area treatment for cooperation
for comfort - (Sociology) cooperation of patients
- Increases blood circulation and hasten BEFORE PROCEDURE
wound healing
- Check client’s condition and all electrical
- More on for those who undergo episiotomy
equipments fot defects
IMPORTANCE OF PERI LIGHT EXPOSURE - Always handle equipment with dry hands
- Relief pain and muscular spasm - Check physician's order for area to be treated
- Provides comfort and duration of therapy
- Relaxes muscles and capillaries to make pain - Do perineal flushing
tolerable DURING PROCEDURE
- Increases blood circulation
● It should be given 24 hours before delivery
- Hastens wound healing
● Position client comfortably
- Increases oxygen and nutrient supply
● Position lamp at safe distance from where it
- Releases dry heat and help reduce edema
is to be applied (18 - 24 inches)
and soreness
● Inspect skin. Make sure it is clean and dry
INDICATIONS before applying heat
● Patients who have rectal or perineal surgery ● Place bed cover over lamp but avoid it from
● Postpartum patient with episiotomy wounds touching the bulb
● Patients with vaginal inflammation/bladder ● Check skin every 5 minutes
spasm ● Monitor any untoward response
● Patients with painful or local irritation from AFTER PROCEDURE
hemorrhoids
● Assist and monitor client
CONTRAINDICATIONS ● Do after care
● Patients with cardiovascular condition ● Record on client’s chart
● Presence of cyst ○ Time started
● Patients with open wound with hemorrhage ○ Patient reaction
● Patients with burns or fracture at lower limbs ○ Perineum’s condition
● Pressure ulcer care ○ Inspect sutures, episiotomy, and the
condition of part being treated
PRINCIPLES
- (AnaPhy) Due to the connections they make GUIDELINES
with nerves and blood vessels of the skin all ● Review doctor’s order
parts of the body maybe influenced by the ● Gather equipment and check for safety
application of heat factors
- (Microbiology) heat application on open ● Bring lamp to the patient’s room
wounds or lesions may cause it to rapture ● Greet and Identify patient
and demand sterile technique ○ Full name and Birth date
- (Body Mechanics) Patient is positioned in ● Explain procedure and instruct the patient to
dorsal recumbent to properly expose the area void first
to be treated ● Handle equipment with dry hands
- (Physics) it employs physical agents (heat, ● Place patient in a dorsal recumbent position
water, and light). Heat can be transferred by ● Provide privacy during procedure
radiation (heat exposure) and convection ● During exposure, keep lamp away at 20-50
(hot sitz bath) cm
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

● Check any discomfort and untoward

reactions
● Instruct the patient not to change position
nor touch the lamp during procedure
● After 15 minutes, removed the lamp or as per
doctor’s order
● Perilite exposure should be repeated 3-4
times a day
● Reposition the patient for comfort
● Wipe the washable parts of the lamp with
antiseptic solutions before putting it back to
the storage area or using it with another
patient
● Document procedure
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

NORMAL SPONTANEOUS DELIVERY Active

● Duration
LABOR AND DELIVERY ○ Nullipara — 3 hours
FOUR STAGES OF LABOR ○ Multipara — 2 hours
❖ Cervical Dilation ● Duration of Contractions
❖ Fetal Delivery ○ 40-60 seconds
❖ Placental Delivery ● Interval of Contractions
❖ Postpartum ○ 3-5 minutes
GESTATION TERMS ● Cervical Dilatation
❖ Preterm/Premature (before 37 weeks) ○ 4-7 cm
❖ Full term (37-42 weeks) ● Psyche
❖ Postmature (after 42 weeks) ○ Frightened, Anxious, Irritable,
CERVICAL DILATION but still can comprehend
● Pagbuka ng cervix ni pregnant woman since
ready na lumabas si baby Transition (8-10 cm)
● When measuring cervix insert 2 fingers inside ● Duration
the vagina, spread then measure, if cervix is ○ Nullipara —
10 cm then it is ready for delivery ○ Multipara —
● Duration of Contractions
○ 60-90 seconds
● Interval of Contractions
○ 2-3 minutes
● Cervical Dilatation
○ 8-10 cm
● Psyche
○ Loss of control
● Nakalabas na ulo ni baby (Crowning)

FETAL DELIVERY
● Delivering the Baby
● Mechanism of Labor/ Cardinal Movement
of Labor
ED FIRE ERE
STAGES OF CERVICAL DILATION
Early/Latent ○ Engagement, Descent,
● Duration ○ Flexion, Internal Rotation, Extension,
○ Nullipara — 6 hours ○ External Rotation, and Expulsion
○ Multipara — 4.5 hours
● Duration of Contractions
○ 20-40 seconds
● Interval of Contractions
○ 5-10 minutes
● Cervical Dilatation
○ 0-3 cm
● Psyche
○ Excited and Still can
communicate
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

- So that it faces either the lower back

(tailbone) or front of the mother’s
pelvic
- Kusa mag rorotate si baby, we will
just catch its head in a L-shape hand

EXTENSION
- Lalabas head, face, chin ni baby as he/she
extends
- Dito palang lalabas neck

EXTERNAL ROTATION
- Lalabas na shoulders ni baby
- From the anterior part to posterior part
- Down first then Up

EXPULSION
- When both shoulders are out, the body will
ENGAGEMENT
flow freely
- Not movable na si baby
● DO INC IN THE 1ST 30 SECONDS
● Before the next stage make sure to
cut the umbilical cord
● Para matutong huminga si baby
need paiyakin by TAPPING HEEL /
RUBBING BACK
● AVA- 2 arteries and 1 vein

PLACENTAL DELIVERY
● Before doing the delivery look for placental
separation first
○ SIGNS OF PLACENTAL
SEPARATION
■ Sudden gush of blood
DESCENT ■ Lengthening of umbilical
- Bababa na head ni baby sa pelvic floor cord
■ Presentation of placenta on
FLEXION vaginal opening
- Accommodating the narrow part of the head ■ Firm Fundus
(crown) ● Do this delivery while mommy and baby are
- Time of doing the episiotomy as needed skin-to-skin
- Due to resistance from pelvic floor ● If there is resistance, don’t force it as the
- Usually gumagamit ng baby oil separation may not be done
- SANITEX ○ BRANDT ANDREW MANEUVER
- Sasaluhin with middle and index finger ■ ↓ ↑ → ← twist
■ Pasalong kukunin yung
INTERNAL ROTATION placenta
- Rotation of the head ● Fetal side = Baby
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

○ Shultz — Shiny - Constipation can cause the wound to open so

● Maternal side = Mother it is advisable to have an DIET HIGH IN
○ Duncan — Dirty FIBER
○ Cotyledons
● MAKE SURE ALL COTYLEDONS ARE 5. LOCHIA
REMOVED - Normal discharges expelled after delivery
○ In case na may matira, kunin with THREE TYPES
the use of sanitex, as left placental ● LOCHIA RUBRA
fragments can cause bleeding ○ 1 - 3 days red
■ Normal blood loss is 300-500 ○ 7 days brown
● LOCHIA SEROSA
mL when it exceeds it will
○ 7 -14 days pink to yellow
cause HEMORRHAGE →
● LOCHIA ALBA
ANEMIA → HYPOVOLEMIC
○ 14 - 28 days white to clear
SHOCK → DEATH
■ Do fundal massage to push
6. EPISIOTOMY/EPISIORRHAPHY
excess placental fragments
● Tomy — to cut; Rhaphy — suture/repair
■ Use ice packs to lessen
ASSESS FOR INFECTION
bleeding as it constrict blood REEDA
vessels ❖ REDNESS
POSTPARTUM ❖ EDEMA
● First 4 - 24 hours after delivery ❖ ECCHYMOSIS
WHAT TO ASSESS DURING THIS STAGE? - pasa
BUBBLE HE ❖ DISCHARGE
❖ APPROXIMATION OF SUTURE
1. BREAST - If mali it can prolong healing
- Assess for engorgement (pamamaga) or Vernix Caseosa
mastitis - helps in thermoregulation of the body
- Assess if ready for breastfeeding
● Prolactin — responsible for lactation
● Progesterone — inhibits the release of 7. HEMORRHOIDS/HOMANS SIGN
milk - Extend knees (dorsiflexion) if there is pain in
the calves it is (+)Homan’s Sign — Deep Vein
2. UTERUS Thrombosis (blood clot)
- Dapat FIRM
- Pag soft and boggy it can cause bleeding 8. EMOTIONAL RESPONSE
- Rubin’s Phase
3. BLADDER ● Taking in
- Ask if nakaihi na or kailan yung last nag pag ○ Mommy is still dependent sa
ihi caregiver
- Since patients went into surgery, some think ○ mommy
that it will be painful to void. We must ● Taking hold
encourage her to void. ○ Unti-unti inaaccept yung
responsibility
4. BOWEL
○ Sometimes independent
- Ask if nakapoop na or nagflatulate na si
○ Mommy and Baby
patient
● Taking out
- Check bowel movement is back to normal
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

○ Kaya na akuin yung IMMEDIATE NEWBORN CARE

responsibility 1. Assemble all the materials needed making
○ Letting go sure the delivery area is draft-free
○ Thinking of family ● Blanket
○ Family ● Drying blanket
● 1cc syringe for vitamin K and Hepa B
● Cotton balls
● Weight scale
● Tape measure

2. Regulate the room temperature to 25-28°

3. Hand hygiene then double gloves

● 2 sterile or 1 sterile 1 clean

4. Call baby out

● Baby boy out at 3:45 pm or 15: hours

5. Dry baby and do APGAR SCORING

● Appearance
○ 0 — Pale/cyanosis
○ +1 — Acrocyanosis (bluish
extremities which is normal
for newborn since hindi agad
nasusuplyan yung mga
extremeties uunahin yung
nasa center since nandon
mga pinaka important na
organs)
○ +2 — Pinkish
● Pulse
○ 0 — No pulse
○ +1 — < 100 bpm
○ +2 — > 100 bpm
● Grimace
○ 0 — no response
○ +1 — minimal response
○ +2 — response with
stimulation
● Activity
○ 0 — no activity / flaccid
○ +1 — minimal flexion
○ +2 — full flexion
● Respiration (Cry)
○ 0 — no respiration
○ +1 — minimal cry
○ +2 — vigorous cry
NCMA 217: CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENT)
BSN 2 Y1-4 CALIWAG, ALLIAH H.
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
1st SEMESTER│A.Y.: 2023-2024

6. Change the wet blanket into a dry one then ● Commonly done to check is open ba
put a bonnet on the baby yung anus ni baby

7. Skin-to-skin contact 19. Keep baby properly dressed or dress warmly

● Diaper (make sure hindi tatakpan
8. Put Identification bracelet pusod ni baby para iwas infection)
● Clothes
9. After positioning the baby for cord clamping
● Mittens
REMOVE 1ST SET OF GLOVES
20. Transfer baby in crib with drop light for
10. Palpate cord if there is still pulsation.
monitoring if it may not yet be roomed-in
11. When pulsation stops, clamp (plastic) the with mother
cord 2 CM AWAY FROM THE BASE and 5 CM
21. Remove gloves then Do handwashing
AWAY FROM THE BASE with instrument
clamp 22. Document procedure

12. Cut near the plastic clamp.

13. Maintain skin-to-skin contact of the mother

and child. Nudge the baby to the breast of
the mother

14. Administer ophthalmic ointment

● Discard 1st bead then apply it inner to
out
● It is to prevent neonatal conjunctivitis

15. Administer Vitamin K

● 0.1 solution and 0.9 sterile water
● Promote blood clotting to prevent
bleeding

16. Administer Hepatitis B vaccine

● 0.5 through Intramuscular at the
upper outer leg of the baby or the
vastus lateralis to prevent hitting the
sciatic nerve (back of the leg)

17. Perform ANTHROPOMETRIC measurement

● Head (33-35 cm)
● Chest (31-33 cm)
● Abdomen (Usually same with chest
which is 31-33 cm)
● Weight (2500 - 3400 g = 2.5 - 3.4 kg)
● Length — contour of the baby (44-55
or 47-52)

18. Check rectal temperature