NCM 107

MATERNAL AND CHILD HEALTH NURSING

Learning Packet 2

SAQA-1 Define the following key terms.

 Amnioinfusion- refers to the instillation of fluid into the amniotic cavity or injection of
solutions into the amniotic fluid, usually to induce abortion.
 Crowning- the appearance of the fetal scalp at the vaginal orifice in childbirth.
 Episiotomy- a surgical procedure for widening the outlet of the birth canal to facilitate
delivery of the baby and to avoid a jagged rip of the area between the anus and the vulva
(perineum). It is a cut (incision) made in the area between the vagina opening and anus
(perineum).
 lightening - refers to the sensation that a pregnant woman feels when the baby drops.
This is the time when the presenting (lowermost) part of the fetus descends into the
maternal pelvis.
 The process of your baby settling or lowering into your pelvis
 Pathologic retraction ring – abdominal indentation during difficult labor, also known as
Bandl's ring. It is the abnormal junction between the two segments of the human uterus,
which is a late sign associated with obstructed labor.
 ripening – refers to the softening of the cervix that typically begins prior to the onset of
labor contractions
 attitude – a posture or position of the body. It describes the degree of flexion a fetus
assumes during labor or the relation of the fetal parts to each other.
 dilatation – means that the cervix is open. It refers to the enlargement or widening of the
cervical canal from an opening a few millimeters wide to one large enough
(approximately 10cm) to permit passage of a fetus.
 Fetal descent - the passage of the presenting part of the fetus into and through the birth
canal.
 molding - the shaping of a baby's head to facilitate passage down the birth canal.
 Physiologic retraction ring - the demarcation between the upper, contracting portion of
the uterus in labor and the lower, dilating part.
 station - It is the relationship of the presenting part of the fetus to the level of the ischial
spines. It is the position of the baby’s head in relation to the pelvis.
 Breech presentation – fetal presentation in which either the buttocks or the feet are the
first body parts that will contact the cervix.
 Fetal presentation in which either the buttocks or feet are the first body parts to contact
the cervix
 effacement – shortening and thinning of the cervical canal. It means that the cervix
stretches and gets thinner.
 Leopold’s maneuvers – are a systematic method of observation and palpation to
determine fetal presentation and position and are done as part of a physical examination.
 passage – refers to the route a fetus must travel from the uterus through the cervix and
vagina to the external perineum.
 position - the orientation of the fetus in the womb, identified by the location of the
presenting part of the fetus relative to the pelvis of the mother.
 transition - passage from one condition or one part to another. In other words, it is the
change from one form, state, style, or place to another.
 Cephalic presentation – is the most frequent type of presentation, occurring as often as
96% of the time. With this type of presentation, the fetal head is the body part that first
contacts the cervix.
 engagement – refers to the settling of the presenting part of a fetus far enough into the
pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis. It is often
referred to as “baby dropping.” This means that the infant's head or buttocks have
settled into the pelvis prior to labor.
 lie – is the relationship between the long (cephalocaudal) axis of the fetal body and the
long (cephalocaudal) axis of a woman’s body. In other words, whether the fetus is lying
in a horizontal (transverse) or a vertical (longitudinal) position.
 passenger - a colloquial term for the fetus.
 powers- a colloquial term for the mechanical forces generated by the contractions of the
uterus that propel the fetus through the pelvis.
 Cardinal movements of labor- the mechanisms of labor. It involves changes in the
position of the fetus's head during its passage in labor.

SAQA -2 Describe the fetal positions that occur during the fetal
descent phase

POSITION DESCRIPTION
Internal Rotation During descent, the biparietal diameter of the fetal skull
was aligned to fit through the anteroposterior diameter of
the mother’s pelvis. As the head flexes at the end of
descent, the occiput rotates so the head is brought into the
best relationship to the outlet of the pelvis, or the
 anteroposterior diameter is now in the anteroposterior
plane of the pelvis. This movement brings the shoulders,
coming next, into the optimal position to enter the inlet, or
puts the widest diameter of the shoulders (a transverse
one) in line with the wide transverse diameter of the inlet.
Extension As the occiput of the fetal head is born, the back of the
neck stops beneath the pubic arch and acts as a pivot for
the rest of the head. The head extends, and the foremost
parts of the head, the face and chin, are born.
External Rotation In external rotation, almost immediately after the head of
the infant is born, the head rotates a final time (from the
anteroposterior position it assumed to enter the outlet)
back to the diagonal or transverse position of the early
part of labor. This brings the after coming shoulders into
an anteroposterior position, which is best for entering the
outlet. The anterior shoulder is born first, assisted perhaps
by downward flexion of the infant’s head.
Expulsion Once the shoulders are born, the rest of the baby is born
easily and smoothly because of its smaller size. This
movement, called expulsion, is the end of the pelvic
division of labor.

SAQA-3

A. Hilda, is a 25-year-old primipara who has completed natural child birth classes with
her coach, her husband. She is admitted at noon to the birthing room after 3 hours
of active labor at home. Her cervix is dilated 3 cm and is 80% effaced. Her sister is
with her, and she is concerned about causing her husband to miss time at work
needlessly early. He is a low-paid janitor, and they are a one income family.

1. What would you explain to Hilda about the progression of her labor, and how would
you advise her regarding contacting her husband?

Labor can be a very frightening experience for women, especially first births. I’ll explain
to her that each labor is different and can vary greatly from woman to woman, and that
she is experiencing the first stage of labor in its first phase or latent phase. Contractions
during this phase are mild and short, lasting 20 to 40 seconds. Cervical effacement
occurs, and the cervix dilates minimally. She will experience physical sensations ranging
from discomfort to severe pain, yet, she should focus on the positive aspects.
Moreover, I will encourage her to have a companion of her choice present during labor and
birth. However, encouraging the husband/partner to be more involved with the birth, where it is
acceptable, may also be beneficial for the whole family. Birth is a very emotional experience
and for some people especially the husband/partner, having more active involvement can make
the whole process particularly special. I will encourage her to talk to her husband about his
work and make a mutual decision as the father or partner of a woman’s child has traditionally
served as her chief support person in labor. Childbirth companion or social support during birth
has been found to improve the whole birth experience. Research shows that women who receive
good social support during labor and childbirth tend on average to have shorter labors, to
control their pain better and to have less need for medical intervention.

2. How could you support Hilda, or teach the family to support Hilda, if her husband
was not present during the 2ndstage of her labor?

The second stage of labor is the time span from full dilatation and cervical effacement to
birth of the infant. A woman typically feels contractions change from the characteristics
crescendo-decrescendo pattern to an uncontrollable urge to push or bear down with each
contraction as if to move her bowels. Helping Hilda to be as relaxed as possible and
aware of her situation can help minimize the physical pain and emotional distress of labor
and birth. Hilda can be helped with this by receiving adequate care, timely information,
comfort, support and reassurance during labor and birth. I can provide her emotional
support, such as companionship, eye contact, encouragement, distraction, reassurance;
physical comfort such as therapeutic touch and massage, nourishment, personal hygiene,
applications of heat or cold, hydrotherapy, position change; providing information,
offering advice, coaching in breathing, relaxation techniques and interpreting medical
jargon. I can support her with her decisions as well and translate her wishes to others.
Moreover, a support person plays a vital role during this time because all of the
preparations done up to this point may still not be enough to sustain a woman during
these final contractions unless she feels well supported. This participation also creates an
important sharing time later after the birth. I will talk to the childbirth companion, either
her family or someone, and either with the her present or alone, to understand their
feelings and wishes. Give them practical information about their role and offer advice on
things they can do to help Hilda. It can be useful to talk to them during pregnancy
especially at the onset of labor to find out how much they already know about labor and
birth, and to discuss with them what they might expect to see and what they are expected
to do. I should encourage them to give support using local practices which do not disturb
my work (and the rest of the health team) during labor or birth. The companion can also
help and encourage Hilda to move around freely as she wishes and to adopt the birthing
position of her choice.
ADVOCACY
Supporting the woman’s decisions
Translating the woman’s wishes to others
SUPPORT FOR FAMILY MEMBERS
Role model labor support
Providing opportunity for breaks
Encouragement

3. If labor failed to progress, what additional types of support might Hilda need? How
might these supports differ for a woman who has prior delivery by caesarean birth?

Hilda, who is a first timer mom might be experiencing prolonged labor. If she’s still in
the first stage, this will rarely lead to complications though it can be extremely physically
and emotionally exhausting. However, if she is in the active stage, there can be cause for
this. It is important for a nurse to remind her that she did nothing wrong and that there are
varieties of reasons why this can happen, but it's not her fault. The greatest thing she can do
if she's in the latent phase is relax and wait for her cervix to develop. Walking, sleeping,
taking a warm bath, keeping in an upright position, or using a birth ball are all options for
her. Her medical team will also monitor the frequency and strength of her contractions if she
is in the active stage of labor. Or she'll be told to rest for a while. However, if the
contractions aren't powerful enough, they may consider using Pitocin (a medicine that helps
to speed up and strengthen contractions) to help things along. If the baby is already in the
delivery canal, your doctor or midwife will use a specific equipment to help pull the baby
out through the vaginal canal.

If it's determined that the baby is too big or the medication is not speeding up the
labor, a C-section (also known as a Cesarean section) may be something the doctor will
insist upon if she’s failing to progress. According to the American Pregnancy Association,
this issue accounts for about one-third of all c-sections.

B. Critical Thinking Exercise

1. Prepare a teaching plan for a woman in labor that addresses methods for maintaining a
maximum state of comfort during the first and second stages of labor.

Time
Intended Learning Fra Teaching-
Outcome (ILO) or Content me Resources Learning Assessment
Objective/s (Hou Activities
r)
At the end of 1 Brochure Interactive Directed
I. What is hour (large print Lecture Paraphrase
the lesson: labor? and well-
spaced One-to- Individual
 Woman II. Stages and
letter) with one- evaluation
should exhibit Duration
 pictures instruction Return
no signs of A. First Stage Demonstrati
bladder  Latent Phase Digital Video on
distention and (Early learning presentatio
have the Labor) resources n
ability to void  Active such as
every 2 hours. Labor Phase video, Actual
 Woman has a  Transition audio and Demonstrat
good to Phase images ion
tolerable level B. Second (well-
of pain. Stage modulated
 Woman can C. Third Stage sound and
express her III. Significant high
preferences events that definition
during labor. mark their quality)
 Woman has beginning
the ability to and end
understand IV. Pain
the usual management
process of a. What to do
labor. b. What to
 Woman expect
reports that c. When
her experiencing
environment contractions
is comfortable d. When water
and secure. breaks
 Woman (amniotic
would be able sac rupture)
to verbalize e. Tips for the
her feelings support
about her person
experiences V. Signs of true
during her labor
labor period. VI. False labor

2. Prepare a pain management plan for a woman in labor that includes two
nonpharmacologic pain relief measures and two medical pain relief methods, with nursing
implications for monitoring and prevention of drug-related complications.
Women's labor pain is influenced by a variety of physiological and psychosocial factors, and its
intensity varies substantially. The majority of women who are in labor seek pain
medication.Non-pharmacological therapies (to help women cope with pain during delivery) and
pharmaceutical interventions are two types of pain management techniques (that aim to relieve
the pain of labor).
Nurses play a key role in educating women and their support persons about the numerous
comfort and pain relief strategies. Nonpharmacologic measures may be employed as part of a
woman's comprehensive pain management program or to supplement pharmacologic
interventions in complementary and alternative therapies for pain alleviation. These may
include the use of acupressure, position changes, imagery, and other relaxation. The relaxation
approach prevents the abdominal wall from tensing, allowing the uterus to rise with
contractions without colliding with the hard abdominal wall. Although not evidence-based,
asking the woman to bring favorite music or aromatherapy to enjoy in the birthing room can aid
with relaxation. Because of the close oxygen outlets, no fragrant candles should be used.
Moreover, standing under a warm shower or soaking in a warm bath, jet hydrotherapy tub, or
whirlpool is another approach to relieve labor pain by applying heat according to Harper, 2014.
To avoid overheating (hyperthermia) in both the mother and the infant at birth, the water
utilized should be 37°C. Women should be reminded that plastic or porcelain baths are slick,
and they should ask for assistance entering and exiting them. It is not advisable to leave the
women unattended in a tub, as they may slip and struggle to keep their heads above water. If the
woman desires, a support person can join her in the tub or shower and continue with back
massage or other relaxing measures. Contraction timing, fetal heart rate auscultation, and
vaginal examinations can all be done without the mother leaving the water. Stark, Remynse, &
Zwelling on 2016, states that the birth environment, which may include the use of hydrotherapy
during labor, can aid in physiologic birth.

However, there are pharmacologic measures or medical pain relief methods for pain relief
during labor. Narcotics may be given during labor because of their potent effect, but all drugs in
this category cause maternal respiratory depression as well as fetal CNS depression to some
extent and so should be used cautiously (Brimdyr, Cadwell, Widstrom, et al., 2015). Timing the
administration of narcotics during labor is especially important as, if given too early (before
3cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver
takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours
after birth. For this reason, narcotics are preferably given when the mother is more than 3 hours
away from birth. This allows the peak action of the drug in the fetus to have passed by the time
of birth so the newborn breathes easily. Furthermore, additional drugs, such as tranquilizers,
may be administered during labor to reduce anxiety or potentiate the action of a narcotic. An
example of such a drug is hydroxyzine hydrochloride (Vistaril). These drugs do not relieve
pain, so the woman in labor needs pain management measures in addition to these drugs.

C. Joan has delivered her first child under general anesthesia by the caesarean method.
The nurse will need to monitor her closely for postpartal and postsurgical complications.
1. What position should Joan be placed in when she is brought to the recovery room?
Specify how you may help the patient maintain this position.

Joan should be placed flat on bed (supine position) when is brought to the recovery room.
During this time, the nurse will monitor the vital signs of Joan, check the firmness of the uterus,
urine output and the amount of vaginal bleeding.

2. Explain why Joan would be in jeopardy for an imbalance of fluid and electrolytes.
What important vital signs may alert you to this problem? What drug might be ordered
by the physician to ensure uterine contractions?

There are risks to the mother like Joan having a baby by C-section. Cesarean delivery is a major
abdominal surgery and is associated with a higher rate of injury to abdominal organs (bladder,
bowel, blood vessels). All surgical patients are at risk for fluid and electrolyte imbalances. This
risk increases when a patient undergoes abdominal surgery, because of the role of the
gastrointestinal system in providing the body with water and electrolytes. The gastrointestinal
tract plays an important role in the maintenance of fluid and electrolyte balance, and its diseases
cause disturbances in that balance. After surgery, the body usually retains large amounts of fluid
for several days, causing swelling of the body. Her body may have a hard time getting rid of
fluids. As a result, excess fluid builds up in the body. This is called fluid overload (volume
overload). This can lead to edema (excess fluid in the skin and tissues). Moreover, some risks
are associated with anesthesia. All operations under general anesthesia will undergo NPO
(Nothing per Orem) for 8 hours while flat on bed, meaning no food and no water by mouth. A
fluid imbalance may also occur when she loses more water or fluid than her body can take in.
As our body is constantly losing water through breathing, sweating, and urinating. If we do not
take in enough fluids or water, we become dehydrated. Furthermore, because of this risk, blood
pressure and heart rate should be kept an eye on. Oxytocin should be available for the
anesthesiologist to administer I.V. Oxytocin is in a class of medications called oxytocic
hormones. It is used to reduce bleeding after childbirth and works by stimulating uterine
contractions.

SAQA-3
Multiple choice. Choose the letter that corresponds to the best answer for each question.
Give the rationale for your answers.

1.Leni has been experiencing regular, coordinated contractions with cervical dilation
moving from 4 cm to 6 cm in the last hour, and her membranes are still intact. Leni is is
which of the following stages of labor?

a. latent phase of the 2ndstage of labor

b. active phase of the first stage of labor
c. placental stage or the 3rdstage of labor
d. predelivery stage or the prelabor of labor

Answer:
b. active phase of the first stage of labor
Rationale:
Active Phase starts from 4 cm cervical dilatation to 7 cm cervical dilatation. During this phase,
contraction intensity is stronger, closer together, and regular.

2.When planning comfort measures to help the woman in active labor tolerate her pain,
the nurse must consider which of the following?

a. early labor contractions are usually regular, coordinated and very painful
b. if women are properly prepared, they will require no medication to manage their
pain
c. pain medication given during the latent phase of labor is not likely to impair
contractions
d. the active phase of labor can be a time of true discomfort and high anxiety

Answer:
b. if women are properly prepared, they will require no medication to manage their
pain
Rationale:
The amount of discomfort a woman experiences during contractions differs according to her
expectations of, preparation for labor; the length of her labor; the position of her fetus; the
presence of fear, anxiety, worry, body image, and self-efficacy; and the availability of
meaningful people around her to offer support. Women who believe they have control over their
situation (have self-efficacy) are more likely to report a positive birth experience than those
who do not. A better prepared woman is for childbirth and the more effective her support
person is, the less there is a need for analgesia and anesthesia.

3.Leila is admitted in active labor. The nurse locates fetal heart sounds in the upper left
quadrant of her abdomen. The nurse would recognize which of the following?

a. Leila will probably deliver very quickly and without problems

b. This indicates Leila will probably have a breech delivery
c. The fetus is in the most common anterior fetal position
d. This position is referred to as left anteropelvic

Answer:
b. This indicates that the fetus is probably in the breech position.
Rationale:
If the fetal heartbeat is found in the left upper quadrant of the mother's abdomen, the fetus is in
the breech presentation on the left side of the mother (left sacrum anterior)

4.When timing the length of contractions, the nurse would do which of the following?

a. ask the woman when the beginning of the contraction is felt, then time the interval
from this point until the woman states the contraction has subsided.
b. gently palpate the abdomen for the beginning of the tightening of the uterus; time
the interval from this point until the woman states the contraction has subsided.
c. lightly touch the abdomen and time the interval from the beginning of the uterine
tensing to the beginning of the next tensing.
d. note the upward slopes of the contraction on the monitor graph and measure from one
upward slope to the next upward slope.

Answer:
b. Gently palpate the abdomen for the beginning of the tightening of the uterus; time the
interval from this point until the uterine tightening subsides.
Rationale:
Frequency is measured from the start of one contraction to the start of the next contraction. The
duration of a contraction is measured from the beginning of one contraction to the end of that
same contraction. The intensity of two contractions is measured by comparing the peak of one
contraction with the peak of the next contraction. The resting interval is measured from the end
of one contraction to the beginning of the next contraction.

5.After the 3rdstage of labor, the nurse may have which of the following responsibilities?

a. administration of intramuscular oxytocin to facilitate contractility

b. monitoring for blood loss greater than 60 ml, which would indicate gross
haemorrhage
c. Noting if the placenta makes a Schultze presentation, which is a sign of gross
complications
d. Pushing down on the relaxed uterus to aid in the removal of the placenta.

Answer:
A
Rationale:

After completing all the stages of childbirth, woman will be monitored for the next few hours to
make sure that the uterus continues to contract and that bleeding is not excessive. Monitoring
the uterine contractions is an important nursing responsibility. Administering oxytocin helps
reduce bleeding after childbirth and works by stimulating uterine contractions.
6.What is the nursing action immediately after episiorrhaphy?

a. cleanse the woman’s anal area, then perineum and vulva, to remove any fecal
incontinence or vaginal secretions
b. monitor the woman for shaking and complaints of chill sensations, which may indicate
an adverse reaction to medication.
c. palpate the uterine fundus for size, consistency, and position, and take vital signs to
obtain baseline data.

Answer:
a. cleanse the woman’s anal area, then perineum and vulva, to remove any fecal
incontinence or vaginal secretions
Rationale:
Perineal care will help your perineum heal faster, feel better, and help prevent infection.

7.Which of the following outcome criteria would be appropriate for the woman in labor
without a support person?

a. reuniting with her child’s father before labor is complete

b. verbalizing that she felt supported during the labor process
c. indicating that she was comfortable going through labor alone
d. stating the labor process was a smooth, rewarding experience

Answer:
b. verbalizing that she felt supported during the labor process
Rationale:
A woman who brings no support person with her needs a supportive nurse to remain with her
continuously during labor. If this happens, she can verbalize that she felt supported during the
labor process

8.Which of the following signs could indicate maternal distress?

a. heart rate of 90-100beats/minute during labor
b. less, frequent, less intense uterine contractions
c. reports of feeling the need to have a bowel movement
d. uterine relaxation between 69 second contractions

Answer:
c. reports of feeling the need to have a bowel movement
Rationale:
The thought of having a bowel movement in labor terrifies many women. Women often describe the pelvic pain
and pressure as feeling the urge to have a bowel movement.
9.When planning comfort measures to help the woman in active labor tolerate her pain,
the nurse must consider which of the following?

a. early labor contractions are usually regular, coordinated and very painful
b. if women are properly prepared, they are more likely to require less medication to
manage their pain
c. pain medication given during the latent phase of labor is not likely to impair
contractions
d. the acceleration phase of labor represents a time of minimum pain and discomfort

Answer:
b. if women are properly prepared, they will require no medication to manage their
pain
Rationale:
The amount of discomfort a woman experiences during contractions differs according to her
expectations of, preparation for labor; the length of her labor; the position of her fetus; the
presence of fear, anxiety, worry, body image, and self-efficacy; and the availability of
meaningful people around her to offer support. Women who believe they have control over their
situation (have self-efficacy) are more likely to report a positive birth experience than those
who do not. A better prepared woman is for childbirth and the more effective her support
person is, the less there is a need for analgesia and anesthesia.

10.What the basic physiologic and psychological factors that may predispose a client who
has experienced a caesarean procedure to a complicated surgical outcome?

a. poor nutritional status

b. age variations
c. marital status
d. poor general health
e. religious preference
f. fluid and electrolyte imbalances
g. fear
Answer:

RELATED LEARNING EXPERIENCE ACTIVITY (RLEA) 1

1.Prepare a checklist of the priority assessments and related nursing actions for managing
pain in each stage of labor.

NURSING CARE DURING THE STAGES OF LABOR

Nursing Care of the Mother
1. Care of the Woman During the First Stage
Stage Profile: Marked by duration and stress of labor

Phase 1: Early labor (Latent)

Priority Assessments:
 Effacement is occuring
 Cervix dilates from 1 to 4 cm* and thins
 Contractions are mild and short, lasting 20 to40 seconds
 Cervix dilates minimally
 Takes 8-12 hours of the 1st stage

Related Nursing Actions

 Provide privacy and reassurance during admission
 Determine effacement and dilatation
 Determine the presenting part, type of presentation, position, station, attitude
 Monitor and evaluate important aspects such as contractions, duration, interval,
frequency and intensity
 Encourage woman to continue to walk about and make preparations for birth, such as
doing last minute packing for her stay at the hospital or birthing setting
 Give instructions to the person who will take care of them
 If desired, advise alternative methods of pain relief such as aromatherapy, distraction, or
acupressure
 If arrived at the birthing setting early, encourage her to continue to be active and to use
any pharmacotherapeutic measures she finds effective

Phase 2: Active Labor

Priority Assessments:
 Cervical dilatation occurs more rapidly
 Cervix dilates to *4 to 7 cm and thins
 Contractions will be noticeably stronger and longer (45 to 60 seconds) every 3 to
5 minutes
 Lasts about 4 to 8 hours
Related Nursing Actions:
 Provide comfort (non-pharmacological and pharmacology).
 Encourage frequent urination
 Monitor vitals of mother
 Monitor fetal heart rate
  Observe for signs of fetal distress
 Emotional support
 Health teachings
 Administer analgesic as ordered

Phase 3: Transition

Priority Assessments:

 Contractions reach their peak, every 2-3 min with a duration of 60-90 sec
 Cervix dilates to 8 to 10 cm and thins

Related Nursing Actions:

 Comfort measures such as providing support

 Inform patient on progress of her labor
 Assist patient with plan-blow breathing
 Monitor mother’s vitals and fetal heart rate every 30 minutes-1hour, or depending on the
doctor’s order (esp. during contractions, and before, and after)
 When perineal bulging is noticeable, prepare for delivery.
 Check room temperature (25-280C and free of air drafts)
 Notify staff and prepare necessary supplies and equipment, including resuscitation
machine
 Perform handwashing and double gloving

2. Care of the Woman During the Second Stage

Priority Assessments:

 complete dilatation of the cervix

 strong and intense contractions like in the transition period (60-90 seconds length every
2-3 minutes)
 fetus starts descending into the birth canal
 perineum begins to bulge and appear tense
 head crowning

Related Nursing Actions:

  Provide client support
 Assess and record v/s, FHR, uterine contractions
 Prepare place of birth in advance
 Convert the labor room to birth room
 Make the client select positioning for birth
 Promote second stage pushing
 Clean perineum with warm antiseptic before birth
 As soon as head is about 8cm across:
- Perform the Ritgen’s maneuver
-Encourage the woman to continue pushing until the occiput of fetal head is firmly a the
pubic arch
-Once head is delivered
-Note time of birth, announce sex of infant
-Cut and clamp the cord
-Introduce infant to initiate parent child relationship

3. Care of the Woman in the Third and Fourth Stages of Labor

Priority Assessments:

 Placental separation and delivery

Related Nursing Actions: (Third Stage)

 Administer oxytocin (IM or IV

 Inspect delivered placenta
 Monitor vital signs (q 15 minutes)
 Palpate fundus
 Observe character and amount of lochia
 Coach in relaxation for delivery of placenta.
 Congratulate on delivery of baby.
 Encourage skin-to-skin contact to facilitate bonding and early breastfeeding.
 Ask patient whether placenta is important to them before it is destroyed. For those who
want to take it home, ensure that they understand and follow standard infection
precautions and hospital policy.
 Make mother comfortable
 Position the mother flat on bed
 Provide warmth to the mother
 Nourishment
 Rest
Related Nursing Actions: (Fourth Stage)

 Transfer the patient from the delivery table.

 Provide care of the perineum.
 Transfer the patient to the recovery room.
 Ensure emergency equipment is available in the recovery room for possible
complications.
 Monitor lochia flow
 Observe the mother for chills
 Monitor the patient’s vital signs and general condition
 Observe patient’s urinary bladder for distention
 Evaluate the perineal area for signs of developing edema and/or hematoma
 Observe for signs of hemorrhage
 Assess for ambulatory stability
 Observe C-section patients
 Instruct the patient in the proper perineal care
 Discontinue IV on a normal patient once she is stable and the physician has ordered
removal
 Complete notes and transfer the stable patient to the ward (on normal vaginal delivery–
others require physician clearance).

2.Give an overview of the DOH Program, Maternal, Neonatal and Child Health and
Nutrition

OVERVIEW OF THE MATERNAL AND CHILD CARE PROGRAMS

Maternal, Newborn, Child Health & Nutrition (MNCHN) program focuses on crucial supports
to enable populations to both survive and thrive. Our work spans the value chain from discovery
to delivery, and use science and evidence to drive approach and efforts to achieve impact.
The program provides core technical support and expertise to enable communities to survive
and thrive by focusing on three broad, intersecting areas of work:
 Strengthening maternal and newborn care;
 Expanding nutrition policies, programs, and innovation; and
 Integrating early childhood development into the broader MNCHN environment.

The maternal and child care programs include pre-pregnancy services, antenatal, delivery,
postpartum care; also newborn care, immunization, breastfeeding, maternal and child nutrition
through micronutrient supplementation and food fortification, and integrated management of
common childhood illnesses, among others (DOH 2000).
Although all these services are provided by public providers, there is a parallel provision of
these services by the private sector, particularly those involving personal maternal and child
health care like antenatal, assisting in delivery, and management of common childhood
illnesses. Public health interventions like immunization and micronutrient supplementation are
mostly provided by the public sector. Thus, the financing of maternal and child care services
come from mixed sources, mostly public financing for those services provided at the public
facilities and, until recently, private financing for those services provided by the private
providers. In 2000, the Philippine Health Insurance Corporation (PhilHealth), the government’s
health insurance system, developed a package for maternal care service which was enhanced in
2003 to cover the LAVADO AND LAGRADA 55 continuum of maternal care services
including prenatal care, normal delivery, newborn care, postpartum care, and family planning
counseling that can be provided by both accredited hospital and nonhospital facilities.
Under this current health delivery system, there are several combinations of utilizing the
different maternal and child care services. For example, a woman utilizes family planning
services at the health center without cost (if free family planning commodities are available at
that facility), goes to the health center for prenatal care when she gets pregnant, delivers her
baby at home with the family paying out-of-pocket to whoever assisted in the delivery, and goes
back to the health center again for postpartum and postnatal care for her baby. In another
scenario, a woman may utilize all these services through the private sector and be financed
through private sources.
The first example may be the reason for the 2003 Demographic and Health Survey (DHS)
report that while 86 percent of pregnant women access antenatal care (ANC) services from a
health professional, only 60 percent of them are assisted by a medical professional during birth.
Although the quality of antenatal care, measured as a composite of antenatal care from DHS
2003 data (Lavado et al. 2008), is negatively correlated with maternal mortality rate (MMR)
and under mortality rate (U5MR), facility-based delivery is still critical in ensuring safe
delivery.
The Family Planning Survey in 2004 shows that both the nonpoor and the poor deliver at the
health facility, with higher proportion among the non-poor (56.2% versus 17.4%). Moreover,
both of these groups utilize public health facilities more than the private ones, with 34.8 percent
of the nonpoor and 14.9 percent of the poor utilizing public health facilities.
These different scenarios of delivering and financing maternal and child care services in the
country provide the background that emphasizes the three major gaps in the health care delivery
system that increase the risk of dying among mothers and children (DOH 2009).

These include:
1) gaps in the delivery of services, which may be breaks in the provision of continuum of
services across various stages of life cycle;
2) gaps in the utilization of these services, which occur when clients do not avail of
recommended services owing to lack of information, poor capacity to pay and poor geographic
access, and personal beliefs;
and 3) gaps resulting from weaknesses in the health system itself, which arise when the capacity
to deliver services is lacking, financing is inadequate, regulations fail, and governance is weak.
To address these gaps, the DOH through the years has taken innovative strategies to protect
mothers and children—from adopting the Safe Motherhood Initiative in 1988 to ensure that
childbirth will be safe and will not carry with it.
A composite measure of quality ANC is developed by assigning 1 point for the following
antenatal care-related questions asked in the DHS 2003: (1) weigh checked; (2) height checked;
(3) blood pressure is taken; (4) urine examination performed; (5) blood sample examination
performed; (6) told about pregnancy complications; (7) told where to go for pregnancy
complications; (8) received tetanus toxoid injection; and (9) received iron supplementation.
Levels of quality of care are classified as no antenatal care, poor quality ANC (1-3 points), fair
ANC (4-6 points) and very good ANC (7-9 points).

3.Awoman recently become aware of her pregnancy. Discuss alternative settings for the
birth and emphasize the advantages and disadvantages.