Purpose: (1)support fetal growth, (2)support and maintain maternal health, (3)prepare the body for childbirth, & (4)prepare the body for lactation

1. Presumptive: HIGHLY SUBJECTIVE. Ex. breast changes (earliest sign)
2. Probable: CAN BE DOCUMENTED BY HEALTHCARE PROVIDER. Ex. Pregnancy test
3. Positive: UNDENIABLE SIGN BY THE USE OF INSTRUMENT. Ex. Fetal heart movement

• 2 types of pregnancy test: (1) Laboratory test- detect presence of HCG in blood/urine, (2) Home pregnancy test- 97% accuracy if followed properly
• Quickening- fetal movement felt by woman (16-20 weeks)
• Melasma- dark line pigmentation
• Striae gravidarum- red streaks on the abdomen
• Chadwick's sign- change of color of the vagina. PINK to VIOLET
• Goodel's sign- softening of the cervix
• Hegar's sign- softening of the LUS
• Ballotement- fetus can be felt to rise against the abdominal wall
• Braxton-Hicks contraction- periodic uterine tightening
• Doppler UTZ- fetal heart is audible at 10-12 weeks
• Ordinary stethoscope- fetal heart is audible at 18-20 weeks

• LOCAL- confined to the reproductive organs
• SYSTEMIC- affecting the entire body

• RR: ↑by 1 or 2/minute
• Tidal volume: ↑ by 30-40%
• Vital capacity: no change
• Residual Volume: ↓ by 20%
• Plasma pCO2: ↓ by 27-32 mmHg
• Plasma pH: ↑ to 7.40-7.45
• Plasma pO2: ↑ to 104-108 mmHg

• Blood Volume: ↑ by 30% - 50% during the end of 3rd trimester up to 28th 32nd week
• Iron needs: ↑ by 350-400 mg, RBC- 400 mg
• Heart: CO ↑ by 25%-50%, HR by 10 bpm
• Blood pressure: ↓ slightly during the second trimester→ rises again to 1st trimester levels
• Peripheral Blood Flow: ↓ blood flow to extremities→ edema and varicosities of  vulva, rectum and legs
• Blood Constitution: ↑ up to to 50%

• Fluid retention: ↑ to 7.5L
• Ureter and Bladder changes: ↑ in diameter of ureters; bladder capacity to 1500 L
• Renal function: these includes the ff.

1. Glomerular Filtration Rate: ↑ by 50%
2. Renal plasma Flow: ↑ by 25%-80%
3. Blood Urea Nitrogen: ↓ by 25%
4. Plasma Creatinine level: ↓ by 25%
5. Renal threshold for sugar: ↓ to allow slight spillage
6. Bladder Capacity:↑ by 1,000mL
7. Diameter of ureters: ↑ by 25%
8. Frequency of Urination: ↑ 1st trimester, last 2 weeks of pregnancy to 10-12 times/day

• Presence of placenta: increases concentration of prostaglandins in the female reproductive tract
• Pituitary gland: ↑progesterone & estrogen, ↑production of growth hormone & melanoctye stimulating hormone
• Thyroid and parathyroid glands: enlarged thyroid gland, ↑BMR by 20%, iodine & thyroxine in blood serum
• Adrenal glands: ↑activity, corticosteriods & aldosterone production
• Pancreas: ↑Insulin level but is LESS effective

• Estrogen - prevents ovulation/FSH changes in reproductive organs and in development of your mammary gland
• Progesterone - prevents ovulation/LH; maintains the uterine lining, decrease progesterone leads to contraction = start labor
• HPL (Human Placental Lactogen) - similar to GH, makes INSULIN less effective -> makes glucose more available for fetal use
• HCG - during the start of pregnancy because it maintains your CL (corpus luteum) -> beginning of pregnancy
• Relaxin - relaxes smooth muscles/ligaments
• Progesterone - same as relaxin
• MSH - GH, lung maturity and may lead to hyperpigmentation
• Prolactin - lactation/milk production
• Oxytocin - uterine contraction, milk-let down

• 9-month long illness
• alone to a physician’s office for care
• Time of birth: separated from her family and
• admitted to a hospital

• a TIME OF HEALTH
• bring their families during prenatal care
• participate actively in the experience

• related to their cultural background
• their personal experiences, and the experiences of friends and relatives as taught by childbirth educators

• Teenage pregnancy affects about 6% of Filipino girls
• the second highest rate in Southeast Asia based on Save the Children’s Global Childhood Report from 2019
• an estimated 538 babies are born to Filipino teenage mothers EVERY SINGLE DAY, according to the Philippine Statistical Authority from 2017

• ask at prenatal visits if there is anything they believe should or should not be done
• Supporting these beliefs shows respect for the individuality of a woman and her knowledge of good health

• if she and her siblings were loved & seen as the pleasant outcome of a happy marriage
• pregnancy is natural and simple

• if she and her siblings were seen as intruders or were blamed for the breakup of a marriage
• women with disabilities may have specific concerns

• ability to cope with or adapt to stress
• relationship with people around
• “brides” as young, “mother” as old

1. 1st Trimester TASK: Accepting the Pregnancy – Ambivalence: feeling both pleased and not pleased about the pregnancy
2. 2nd Trimester TASK: Accepting the Baby – Narcissism and introversion: as they concentrate on what it will feel like to be a parent
3. 3rd Trimester TASK: Preparing for the Baby and End of Pregnancy - Preparing for Parenthood: Being ready for birth

1. Ambivalence: Interwoven feelings of wanting & not wanting that can exist at high levels
2. Grief: Not just a daughter anymore, a wife, a friend but a mother 
3. Narcissism: self-centeredness (early reaction)
4. Introversion vs Extroversion: turning inward to concentrate on oneself and one’s body VS more active, appear healthier than ever before and more
   outgoing
5. Body Image: way body appears to oneself
6. Body Boundary: zone of separation perceive between oneself and objects
7. Stress: difficult for a woman to make decisions, be as aware of her surroundings as usual or maintain time management
8. Couvade Syndrome: men are experiencing physical symptoms like N & V, backache to some degree or more
   intensely than partner
9. Emotional Lability: (1) Mood changes- manifestation of narcissism, (2) Mood swings- beginning with early pregnancy

1. 1st trimester: Decrease in libido due to nausea, fatigue and breast tenderness
2. 2nd trimester: As blood flow to pelvic area increases to supply the placenta, libido and sexual enjoyment rise markedly
3. 3rd trimester: Sexual desire remain high or may decrease 

1. Pre-embryonic Period (the OVUM): first 2 weeks, beginning with fertilization
2. Embryonic Period: weeks 3 through 8
3. Fetal Period: from week 8 through birth

• Ovum: From ovulation to fertilization
• Zygote: From fertilization to implantation
• Embryo: From implantation to 5–8 weeks
• Fetus: From 5–8 weeks until term
• Conceptus: Developing embryo or fetus and placental structures throughout pregnancy
• Age of viability: Earliest age at which fetuses could survive

1. equal maturation of both sperm and ovum
2. the ability of the sperm to reach the ovum
3. the ability of the sperm to penetrate the zona pellucida and cell membrane and achieve fertilization

• sperm makes contact with egg
• acrosome reacts with zona pellucida
• acrosome reacts with perivitelline
• plasma membranes of egg and sprem fuse
• sperm nucleus enters egg
• cortical granules fuse with egg plasma membrane, which renders the vitelline layer impenetrable to sperm

NOTE:
(1) THE FUNCTIONAL LIFE OF A SPERMATOZOON IS ALSO ABOUT 48 HOURS, POSSIBLY AS LONG AS 72 HOURS
(2) WHEN MATURE OVUM IS RELEASED, FERTILIZATION MUST OCCUR FAIRLY QUICKLY BECAUSE AN OVUM IS CAPABLE OF FERTILIZATION FOR ONLY 24 HOURS (48 HOURS AT THE MOST)

• Oocyte: an immature egg, usually undergo miosis
• Ampulla: widest part of fallopian tube

• Zona pellucida: membrane of ovum

• Zygote: fertilized ovum

• Morula: solid ball of cells resulting from division of zygote

• Blastocoel: fluid filled activity that causes the inner and outer form
• Blastocyst: fluid cavity in which differentiation of the cells

• Decidua capsularis: stretches/encapsulates the surface of the trophoblast
• Decidua vari: remaining portion of the uterine lining
• Decidua: the Latin word for “falling off”

• syncytiotrophoblast, or the syncytial layer: outer of the two covering layers 
• cytotrophoblast or Langhans’ layer: middle layer

• Metabolic gas exchange begins at 4 weeks
• Funic souffle soft blowing heard over umbilical cord: synchronous with fetal heartbeat, hearing bloodflow through vessel
• Uterine souffle heard just above mother’s pelvis: synchronous with maternal pulse

• Diffusion: area of higher concentration to the area of lower concentration 
• Facilitated Diffusion: ensure that a fetus receives sufficient concentrations of necessary nutrients, some substances cross the placenta
• Active Transport: process requires the action of an enzyme to facilitate transport
• Pinocytosis: absorption by the cellular membrane of microdroplets of plasma and dissolved substances

1. Forms a barrier between mother and embryo (blood is not exchanged)
2. Delivers nutrients and oxygen
3. Removes waste from embryonic blood
4. Becomes an endocrine organ (produce hormones)

• Human Chorionic Gonadotropin: first placental hormone produced; can be found in maternal blood and urine as early as the first missed menstrual period. Act as a fail-safe measure to ensure that the corpus luteum of the ovary continues to produce progesterone & estrogen
• Estrogen: referred to as the “hormone of women”
• Progesterone: the “hormone of mothers”
• Human Placental Lactogen (Human Chorionic Somatomammotropin): hormone with both growth-promoting and lactogenic (milk-producing) properties

• Chorion: Outer most membrane; Fingerlike projections, “villi”
• Amnion: Thin protective membrane; Contains amniotic fluid

• HYDRAMNIOS : Excessive amniotic fluid
• OLIGOHYDRAMNIOS : Reduction in the amount of amniotic fluid

• Protection
• Temperature regulation
• Protects the umbilical cord from pressure
• Protecting the fetal oxygen supply
• Aids in muscular development gives freedom of movement

• to transport oxygen and nutrients to the fetus 

ORIGIN OF THE BODY TISSUE
Ectoderm, Mesoderm, Endoderm

• One of the first systems to become functional in intrauterine life
• 16th day of life: simple blood cells joined to the walls of the yolk sac progress to become a network of blood vessels and a single heart
• 24th day: Heart beats
• 6th or 7th week: septum that divides the heart into chambers develops
• 7th week: heart valves begin to develop
• 10th to 12th week: heartbeat may be heard with a Doppler instrument
• 11th week: an electrocardiogram (ECG) may be recorded on a fetus

THREE SHUNTS IN THE FETAL CIRCULATION

1. DUCTUS ARTERIOSUS: protects lungs against circulatory overload
2. DUCTUS VENOSUS: fetal blood vessel connecting the umbilical vein to the IVC
3. FORAMEN OVALE: shunts highly oxygenated blood from right atrium to left atrium

• 3rd week of intrauterine life: the respiratory and digestive tracts exist as a single tube
• end of the 4th week: septum begins to divide the esophagus from the trachea
• Until the 7th week of life: the diaphragm does not completely divide the thoracic cavity from the abdomen

• begins to develop extremely early in pregnancy 3rd and 4th weeks of intrauterine life
• neural plate (a thickened portion of the ectoderm) is apparent by the 3rd week of gestation
• By 24 weeks, the ear is capable of responding to sound; the eyes exhibit a pupillary reaction, indicating that sight is present
• Brain waves can be detected on an electroencephalogram (EEG) by the 8th week
• Spinal cord disorders such as meningocele

• fetal adrenal glands : supply a precursor necessary for estrogen synthesis by the placenta
• fetal pancreas: produces insulin needed by the fetus
• thyroid and parathyroid glands: play vital roles in fetal metabolic function and calcium balance

• digestive tract separates from the respiratory tract at about the 4th week of intrauterine life and, after that, begins to grow extremely rapidly.

• first 2 weeks of fetal life, cartilage prototypes provide position and support
• Ossification of this cartilage into bone begins at about the 12th week

• child’s sex is determined at the moment of conception by a spermatozoon carrying an X or a Y chromosome and  can be ascertained as early as 8 weeks by chromosomal analysis
• 6th week of life, the gonads (ovaries or testes) form

• rudimentary kidneys are present as early as the end of the 4th week of intrauterine life,
• Urine is formed by the 12th week and is excreted into the amniotic fluid by the 16th week of gestation.

• skin of a fetus appears thin and almost translucent until subcutaneous fat begins to be deposited at about 36 weeks

• Immunoglobulin G ((gG) maternal antibodies cross the placenta into the fetus as early as the 20th week and certainly by the 24th week of intrauterine life to give a fetus temporary passive immunity against diseases for which the mother has antibodies

• The Process by which the Products of Conception will be expelled from the body

1. Lightening- descent of the fetal presenting part into the pelvis; occurs 10-14 days before labor begins
2. Braxton-Hicks Contractions- begin and remain irregular; Felt first abdominally & remain confined to the abdomen & groin
3. Nesting Instinct- increase in epinephrine release – prepares a woman’s body for the work of labor ahead
4. Ripening of the cervix- an internal sign seen only on pelvic examination: Goodell’s sign – all throughout pregnancy, cervix has the same consistency as the earlobe (( at term it becomes still softer & described as “butter-soft”))
5. Weight loss 
6. Bloody show
7. Rupture of membranes

PRELIMINARY SIGNS
• SUBTLE SIGNS
• INDICATES IMMINENT LABOR
• MUST EDUCATE PATIENTS FOR THEM TO DETECT THESE SIGNS

• Primipara: 14 hours-20 hours
• Multipara: 8-14 hours

• Primipara: 1st effacement then dilation
• Multipara: Both processes occur at the same time

1. The Passage or the woman’s pelvis: should be adequate in size & contour
2. The Passenger or the fetus: should be appropriate in size & in an advantageous position presentation
3. The Powers of labor or uterine factors: should be adequate
4. A woman’s Psyche is preserved: should be preserved, so that afterward labor can be viewed as

• CEPHALIC: most frequent type, 95%; 4 types: vertex, face, brow & mentum presentation
• BREECH: buttocks or feet are the first body parts that will contact the cervix, 3% of births; 3 types: complete, frank, footling.
• SHOULDER: fetus lie horizontally (transverse) in the pelvis – longest fetal axis is perpendicular to that of the mother, 1% of births

• GOOD ATTITUDE: advantageous for birth because it helps the fetus present the smallest AP diameter of the skull to the pelvis
• COMPLETE FLEXION: The most common attitude; most favorable for vaginal birth; Skull smallest diameter to the bony pelvis: Sub-occiptobregmatic

• Ischial spines→ 0 station “engaged”
• Above ischial spines→ negative
• Below ischial spines→ positive
• +3-+4 crowning

• LOA: most common and favorable for birthing position

• DESCENT: A continuous process from engagement until birth
• FLEXION: Nodding of the fetal head toward the chest.
• INTERNAL ROTATION: Occipitotransverse to the occipito anterior position while descending
• EXTENSION: Begins when the head crowns to head passing under the symphysis pubis
• EXTERNAL ROTATION (RESTITUTION): Realignment of the fetal head with the body after the head emerges.
• EXTERNAL ROTATION (SHOULDER ROTATION): Shoulders externally rotate after the head emerges and restitution occurs
• EXPULSION: Birth of the entire body

1. UPPER PORTION: becomes thicker & active, preparing to exert strength to expel the fetus when the expulsion phase is reached.
2. LOWER PORTION: becomes thin-walled, supple & passive to easily push the fetus out of the uterus.

1. FIRST: active labor to full cervical dilation
2. SECOND: full cervical dilation to delivery of infant
3. THIRD: delivery of infant to delivery of placenta
4. FOURTH: delivery of placenta to 1-4 hours

• Modified Ritgen’s
• Support the head & (suction secretions?)
• Dry the baby
• Initiate skin to skin interaction
• Wait for pulsation to stop
• When there is still birth, let the mother see the baby

1. Involuntary Uterine Contractions or Primary Powers: Muscular contractions which lead to dilation and effacement in the First Stage of Labor
2. Voluntary Uterine Contractions or Secondary Powers: Abdominal muscles assist in the Second Stage with pushing.

• Uterine contractions: primary force moving fetus thru maternal pelvis during 1st stage of labor
• Maternal Efforts: woman adds voluntary pushing force to force of contractions during 2nd stage of labor to propel fetus thru pelvis

1. INCREMENT: building up of the contraction
2. ACME: peak or highest intensity
3. DECREMENT: descent or relaxation of the uterine muscle fibers

• CONTRACTION: exhibits a wavelike pattern that begins slowly climbing (increment) to a peak (acme), and decreases (decrement)
• DURATION: beginning of one contraction to the end of the same contraction (from 20 to 30 sec to a range of 60 to 90 sec)
• FREQUENCY: from beginning of one contraction to the beginning of another contraction
• INTERVAL: Resting time between contractions for placental perfusion, from 10 minutes early in labor to only 2 to 3 minutes

• INTERVAL: early labor: 10 to 20 minutes between contractions; late labor: 3 to 5 minutes between contractions
• DURATION: early labor: 20 second long contraction; late labor: 40 to 80 second long contraction
• QUALITY: early labor: Uterus can be dented (poor quality); late labor: Uterus is hard (good quality)

• Onset of true labor to complete dilation = 10 cm.
• primipara: 6-18 hrs (12H)
• multipara: 2-10 hrs (7H)

• latent or preparatory phase
• begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins
• Contractions: mild and short, irregular, lasting 20 to 40
• seconds

• Contractions: more rapidly, stronger, lasting 40 to 60 seconds, and occur approximately every 3 to 5 minutes
• Cervical effacement: cervix dilates from 4 to 7 cm

• contractions reach their peak of intensity
• Contractions: every 2 to 3 minutes with a duration of 60 to 90 seconds
• Cervical effacement: maximum cervical dilatation of 8 to 10 cm

1. Labor should begin on its own, not be artificially induced
2. Women should be able to move about freely throughout labor, not be confined to bed.
3. Women should receive continuous support during labor
4. No interventions such as intravenous fluid should be used routinely.
5. Women should be allowed to assume a non-supine (e.g.,upright, side-lying) position for birth.  
6. Mother and baby should be together after the birth, with unlimited opportunity for breastfeeding

• Slow chest: 6-12 “easy” breaths/min. Used in early labor.
• Combination: quicker, lighter breaths Used during active
• labor; one slow breath in beginning & quicker breaths to follow.
• Pant-Blow: 3 - 4 quick breaths, with forceful exhalation.
• Used @ end of 1st stage when contractions strongest

• period from full dilatation and cervical effacement to birth of the infant
• Primipara: up to 1 hr. (50 min) or ~ 20 contractions
• Multipara: 20 min. or ~ 10 contractions
• Cardinal movements
• Most difficult & uncomfortable part of labor
• Crowning occurs at +4 -+5 station

CARE OF A WOMAN DURING THE SECOND STAGE OF LABOR
• Assess fetal heart sounds at the beginning of the second stage of labor to be certain that the start of the baby’s passage into the birth canal is not occluding the cord and interfering with fetal circulation

• Multipara: convert a birthing room into a birth room by opening the sterile packs of supplies on waiting tables when the cervix has dilated to 9 to 10 cm.
• Primipara: can be delayed until the head has crowned to the size of a quarter or half-dollar

1. lateral or Sims’ position
2. dorsal recumbent position (on the back with knees flexed)
3. semi-sitting
4. squatting

• begins with the birth of the infant and ends with the delivery of the placenta
• 5 - 30 min (if not: uterine atony)

1. placental separation
2. placental expulsion

• Normal: 300 to 500 mL.
• Up to 30 minutes for placental separation

• Dirty: Duncan
• Shiny: shultze

• Placenta out; mother recovers in “LDR” “Labor, delivery, & recovery”
• Lasts ~ 1 hr. unless complications arise
• Then pt. transferred to PP unit

• uterus may be so exhausted from labor that it cannot
• maintain contraction, there is a high risk for hemorrhageduring this time
• woman often is so exhausted that she may be unable toassess her own condition or report any changes
• specific assessments done during this time are continued throughout the postpartal period

• 6 week period after birth; Considered as the fourth trimester
• Time for maternal changes (retrogressive and progressive)

• Formation of breast milk (lactation)→increase breast tissue
• 2nd day: SOFT AND NON TENDER
• Primary engorgement: On the 3rd day, breast feels tender, fuller
• Breast may appear reddened: MASTITIS- appear on 1 side of the breast

• Assess woman’s breasts: Inspect & palpate for breast size, shape & color
• Note for a firm nodule. Take note of location & report

• Undergoes INVOLUTION: contraction of uterus to go back to pre-pregnancy state
• Uterine contraction begins immediately after birth
• After 24 hrs: FIRM. MIDLINE, AT THE LEVEL OF UMBILICUS

• Position the patient supine: Assess for contour, striae & diastasis; measure width & length in fingerbreadths
• Ask the patient to empty bladder
• If the uterus is boggy/not contracted: Massage gently

• Extensive diuresis & urine output increases to 3,000mL (2nd-5th PPD)
• Transient loss of bladder tone+ edema surrounding the urethra (4 weeks) + effect of anesthesia= decrease ability to sense fullness of bladder

• Assess the bladder for fullness frequently & encourage regular voiding habits
• Full bladder may cause uncontracted uterus

• Bowel sounds are active
• The woman feels hungry & thirsty immediately after giving birth
• Hemorrhoids are often present
• (+) constipation: presence of relaxin & pain d/t episiotomy or hemorrhoids

• Stool softeners, suppositories or an
• enema given as ordered.
• Bowel movements do not occur for a few days (2-3 days PP)

• Composed of blood, fragments of decidua, white blood cells, mucus & some bacteria
• It takes 6 weeks for the placental implantation site to be cleansed & healed

• Check perineal pad and evaluate lochia for character, amount, color, odor, and presence of any clots
• Perineal pad soaked within 1 hr: COULD BE DANGEROUS
• Instruct on hygiene
• X tampons

1. Lochia rubra: red; 1-3 PPD; Blood, fragments of decidua & mucus
2. Lochia serosa: pink/brownish; 3-10 PPD; Blood, mucus & invading leukocytes
3. Lochia alba: white; 10-14--6 wks; Largely mucus, leukocyte count is high

• Small amount: <4 inch stain on peripad
• Moderate amount: <6 inch stain on peripad
• Heavy amount: saturated pad within 1hr (could be DANGEROUS)

• Ask the woman to turn on her side (Sim’s position)
• Labia majora & minora remain atophic & softened
• R-ednessE-demaE-pisorapphyD-ischargedA-approximation
• Usually 1-2 inches long: inspect for laceration & clotted lochia

• Striae lightens or becomes slightly darker (reddened) over 3-6 months
• Chloasma and linea nigra will be barely detectable in 6 weeks
• Diastasis recti will appear as slight indentation or a bluish area

• Same high level of fibrinogen during the 1st postpartal weeks
• Pain on dorsiflexion

1. Taking In Phase (DEPENDENT PHASE): time for reflection where the woman is largely PASSIVE; Encourage to talk about the birth 
2. Taking Hold (DEPENDENT TO INDEPENDENT PHASE): Begins to initiate action; Give brief demonstration of baby care & praise efforts
3. Letting Go (INTERDEPENDENT PHASE): new role and gives up old role; Extended and continues during the child’s growing years

• ABANDONMENT: Feeling less important/jealous; Allow verbalization of feelings
• DISAPPOINTMENT: Difficult for parents to feel positive immediately about the child (does not meet their expectations); should handle the child warmly and comment on the child’s good points
• POST PARTAL BLUES: burst into tears easily/feel let down/irritable; Reassure the woman and family and allow to verbalize feelings & low to make decisions --> can lead to postpartal depression (overwhelmed feeling of sadness that extends beyond 2 wks)

• Exhaustion: sleep hunger
• Weight loss: 5lbs for diuresis + 2-3 lb for lochial flow + 12 lb at birth= 19 lbs

• Temperature: slight increase 1st 24 hours
• Increased in Temp = infection
• Pulse: Usually slightly slower
• (+) Thready & rapid pulse, decreased in BP, hypotension, tachypnea = could be signs of hemorrhage
• Blood Pressure: monitor for increased & decreased

• PROLACTIN – stimulates milk Production
• OXYTOCIN – initiates the let-down reflex with milk ejection as the baby suckles
• Menstruation – 6 weeks after birth in non-nursing moms; 24 weeks in nursing moms

• Plotted in conjunction with height and head circumference to highlight disproportionate measurements
• A newborn loses 5% to 10% of birth weight (6-10 oz) during first few days after birth because

• Measured using a tape measure drawn across the center of the forehead around the occiput

• usually about 2 cm less than head circumference and is measured at the level of the nipples 

• Newborns lose heat by 4 mechanisms

1. Convection – flow of heat from newborn’s body surface to cooler surrounding air 
2. Conduction – transfer of body heat to cooler solid object in contact with the baby 
3. Radiation – transfer of body heat to cooler solid object not in contact with the baby 
4. Evaporation – loss of heat through conversion of a liquid to vapor

> Increased Metabolism -> Increased O2 demand -> (without O2) Anaerobic catabolism will occur -> Acidosis

• irregular, transient murmurs, coarctation of aorta

• Rate may be irregular, with short periods of apnea

1. Drying or clamping of umbilical cord and stimulation of cold receptors 
2. Increased PCO2 and decreased PO2 And increasing acidosis

First Breath
Increased PO2 <- Decreased pulmonary artery pressure -> Closure of Foramen Ovale
-> Closure of Ductus arteriosus --> Closure of ductus venosus and umbilical vein and arteries 

• BV: 80-110 ml per kg of BW (300 ml)
• NB: increased erythrocyte count, increased hemoglobin and hematocrit; increased erythrocyte count, increased hemoglobin and hematocrit; increased WBC in response to the trauma of birth and is nonpathogenic

• newborn’ s intestine is sterile at birth, it has no flora needed to synthesize Vitamin K; Vitamin K is administered intramuscularly

• Within 10 minutes after birth, newborns have established good residual volume; 
• 10-12 hours: vital capacity is established

• NB: GI tract is sterile ; limited ability to digest fat and starch because of deficient pancreatic enzymes
• immature cardiac sphincter -> causing regurgitation
• Stools : meconium within 24 hours, transitional stool by 2nd -3 rd day of life
• NOTE: Breast fed – light yellow, sweet smelling stool, Fed on formula – bright yellow with more noticeable odor, Clay colored stool, Black tarry stool, Loose watery stool 

• NB: voids within 24 hours after birth; 15 ml/single voiding; Daily urine output in first 1 -2 days is about 30-60 ml. By week 1, total volume rises to about 300 mL
• urine light colored and odorless

• They have passive antibody from the mother (IgG) that crossed the placenta 

• REFLEXES: Blink, Rooting, Rooting, Sucking, Swallowing, Extrusion, Palmar Grasp, Step – in Place, Placing, Plantar Grasp, Tonic Neck, More, Babinski, Landau, and Deep Tendo

1. Hearing – able to hear even before birth
2. Vision – see as soon as they are born
3. Touch – well developed at birth
4. Taste – taste buds developed and functioning at birth
5. Smell – present as soon as nose is clear of mucus

• Resting Period – 90 minutes: Baby sleeps 
• Second Period of Reactivity – 2 to 6 hours of life: Baby wakes again, alert and responsive to surroundings

• Color – Term baby has ruddy complexion
• Cyanosis, mottling of skin is common 
• Acrocyanosis – blueness of hands and feet (24-48 hrs) 
• Central cyanosis – indicates decreased oxygenation
• Hyperbilirubinemia – leads to jaundice; RBC breakdown

1. Physiologic jaundice – 2nd to 3rd day of life
2. Pathologic jaundice - first 24 hrs (DANGEROUS)

• Cephalhematoma - collection of blood under the periosteum of the bone
• Kernicterus - permanent neurologic damage caused by build up of indirect bilirubin (MGT: phototherapy)
• (-) Pallor - Maybe caused by excessive blood loss, inadequate perfusion, fetal –maternal transfusion, low iron stores, blood incompatibility
• (-) Harlequin sign - nb who has been lying on his side appears red on the dependent side and pale on the upper side

• Hemangiomas- dilated cappilaries; vascular tumors of skin

• Nevus flammeus – macular purple/dark red lesion

1. Port-wine stain – tend to fade
2. stork’s beak marks - do not fade

• Strawberry hemangiomas - elevated immature capillaries and endothelial cells
• Cavernous Hemangiomas – dilated vascular spaces; they do not disappear

• Mongolian spots - Collection of melanocytes that appear slate gray patches in sacrum or buttocks
• Vernix caseosa - White cream cheese like substance that serves as lubricant
• Lanugo – fine downy hair, disappears by 2 weeks of age
• Desquamation – Newborn’s skin becomes
  extremely dry.
• Milia – A pinpoint white papule
• Erythema Toxicum (Flea bite rash) - Caused by newborn’s eosinophils reacting to the environment as the immune 
• Forceps Mark – A circular or linear contusion matching the rim of the blade of the forcepssystem matures
• Skin Turgor - Newborn’s skin should feel resilient and elastic

• Fontannels

1. Anterior – diamond shaped, closes at 12-18 mos.
2. Posterior – triangular, closes by end of 2nd month
3. Indented fontannel – a sign of dehydration
4. Bulging fontannel – a sign of increased ICP

• Sutures – The separating lines of the skull

1. Wide separation – suggests hydrocephalus, subdural bleeding
2. Fused suture lines – prevents head growth expansion

• Molding – The part of the infant’s head that engages the cervix is molded to fit the cervix contours
• Caput Succedaneum – Edema of the scalp at the presenting part of the head
• Cephalhematoma – Collection of blood between the periosteum of a skull bone and the bone itself
• Craniotabes – Localized softening of the cranial bones caused by pressure of fetal skull

1. (-) Ophthalmia neonatorum (gonorrheal conjunctivitis)
2. (-) Subconjunctival hemorrhage
3. (-) Periorbital edema
4. (-) Congenital glaucoma
5. (-) Congenital cataract

• Tongue appears large and prominent in the mouth
• The frenulum membrane is attached close to the tip of the tongue
• Epstein’s pearls – small round, glistening, well
• circumscribed cysts as a result of extra load of Calcium deposited in utero
• Thrush – a Candida infection
• Natal teeth

• Congenital torticollis – injury to the sternocleido mastoid muscle
• Nuchal rigidity – suggests meningitis

• Retractions – drawing in of the chest wall w/ inspiration
• Rhonchi – air passing over mucus
• Grunting – suggests respiratory distress syndrome
• Crowing – suggests stridor or immature trachea

• Scaphoid / sunken – suggests missing abdominal contents or diaphragmatic hernia
• Bowel sounds present within 1 hour
• Liver must be palpable 1-2 cm below right costal margin
• Spleen must be felt 1-2 cm below left costal margin 
• Right kidney is located lower than the left; Umbilical stump must have 1 vein, 2 arteries

• Cryptorchidsm - undescended testes
• Agenesis – absence of an organ
• Ectopic testes – testes cannot enter scrotum because the opening in scrotal sac is closed

• Epispadias – urethral opening is on the dorsal surface of the glans
• Hypospadias – urethral opening is on the ventral surface of the glans

• Hips- Both can be flexed and abducted 180 degrees

1. Hip subluxation- shallow and poorly formed acetabulum
2. Ortolani’s Sign - can be heard
3. Barlow’s sign – can be felt

• < 4 – needs resuscitation
• 4 – 6 - guarded, clear airway, O2 support
• 7-10 - good

• 0 – no resp. distress
• 4-6 –moderate
• 7-10 – severe

• Height and weight- Weighed nude once a day, same time everyday

• Heel stick tests - Anemia, ploycythemia, hypoglycemia (<40mg / 100 ml)

1. Ballard’s Physical Maturity Assessment 
2. Ballard’s Neuromuscular Maturity Assessment

• Necessary equipment includes: Radiant heat table, warmer bassinet, warm soft blanket, equipment for O2 administration, resuscitation, suction, eye care, identification and weighing of newborn
• Newborn Identification and registration: ID band with permanent locks and built in sensor
• Birth record documentation

• Keep newborn warm
• Promote adequate breathing pattern and prevent aspiration
• Record the first cry
• Inspect and care for umbilical cord
• Administer eye care
• General infection precautions

• Initial feeding - Do best on demand schedule
• Bathing - In hospitals, nb receive a complete bath to wash away vernix caseosa in an hour after birth ; Pattern should be from cleanest to most soiled areas – eyes, face – trunk – extremities – diaper area (“football hold”)
• Sleeping Position : Sudden Infant death syndrome (SIDS) – cause is unknown. But placing infants in supine position has decreased the incidence of the syndrome.
• Diaper Area Care – To prevent diaper dermatitis, wash area with clean water and dry well
• Metabolic Screening Tests - Tests PKU, hypothyroidsm, cystic fibrosis, galactosemia
• Hepatitis B vaccination – Given in 12 hours after birth, then after a month, then at 6 months (0-1-6)
• Vitamin K Administration – NB are risk for bleeding, vitamin K is administered intramuscularly
• Circumcision – Is the surgical removal of the foreskin of the penis

• Daily home care - Parents should offer a degree of consistency ; Satisfy the infant
• Sleep patterns - Infant sleeps 16 hours of every 24 hours, average 4 hours at a time. By 4 months, sleeps 15 hours through the night
• Crying – Infants typically cry for 2 hours of every 24 hours
• Parental concerns related to breathing – Stuffy nose, snoring noises, sneeze frequently, periods of apnea are all normal for newborns
• Continued health maintenance for a newborn – Make appointments with primary care provider (2-6 wks)
• Car safety – Child placed in car seat, at the back seat facing the back of the car

• MISCONCEPTIONS: Tub bath are restricted because water can enter the vagina and cervix and contaminate the uterine contents; It may also initiate labor
• FACT: Daily baths are recommended to cleanse the mother from excessive perspiration and vaginal discharge
• CAUTION: WOF risk of slipping due to difficulty in maintaining balance; Not recommended when there is vaginal bleeding or ROM
• HEALTH EDUCATION: Change to sponge bath/showering if with problem in balance

• FACT: A woman should wear a firm, supportive bra with wide strap to spread the weight across the shoulders
• CAUTION: Constant moisture next to the nipple can cause nipple excoriation, pain and fissuring;  Place gauze pad or breast pad inside the bra if necessary
• HE: Inform that colostrums may be discharged from the breast at 16 week; Instruct to wash breasts with clear tap water daily then dry nipple by patting

• MISCONCEPTIONS: Dental care is not part of prenatal care
• FACT: Gingival tissue tends to hypertrophy during pregnancy; Dentist should be seen for routine examination and cleaning
• CAUTION: X-ray for dental purposes can be done as long as the woman wears a lead apron
• HE: Encourage the woman to brush teeth regularly; Encourage to snack on nutritious food such as fresh fruits and vegetables; If sweets are unavoidable, ask to eat sweets that can easily dissolve in the mouth

• FACT: Douching is not recommended because it can enter the cervix and lead to infection; Douching alters the vaginal pH

• FACT: Women should avoid garters, extremely firm girdles with panty legs and knee high stockings because these may impede LE circulation
• HE: Encourage to wear shoes with a moderate to low heel to minimize pelvic tilt and possible backache

• MISCONCEPTIONS: Coitus on expected date of her period will initiate labor; Orgasm will initiate labor but participating in sexual relations without orgasm will not; Coitus during the fertile days of a cycle will cause a second pregnancy or twins; Coitus might cause ROM
• CAUTION: Women with history of miscarriages;Women with ROM and vaginal bleeding; Oral-genital sex could cause air embolism
• HE: Assure that coitus is not harming the child;A side by side or woman in a superior position may be comfortable; Use of water soluble lubricant maybe necessary

• MISCONCEPTIONS: Exercise is contraindicated in pregnancy
• FACT: important to prevent circulatory stasis in the LE.; Offer well-being
• CAUTION: For HR pregnant women, they need to be cautioned to restrict; Make sure the woman has consulted her physician
• HE: A woman should exercise everyday for 30 consecutive minutes with 5-min warm up 20- min active and 5-min cool-down; Exercise that focus on large muscle groups such as walking is recommended

• FACT: Women need enough sleep during pregnancy for fetal growth and because of increased BMR
• CAUTION: Avoid lying flat on bed or with knees sharply bent
• HE: Advise to drink a glass of milk if there is difficulty of sleeping; Relaxation exercises may also be effective; Modified Sim’s position is a good resting position

• MISCONCEPTIONS: Women should not work during pregnancy
• FACT: Only women who are exposed to work hazards that might affect pregnancy should not continue work (toxic substances, lifting, etc)
• CAUTION: Preterm birth may occur more frequently in women who work at strenuous jobs or those who stand for a prolonged period
• HE: Counsel women to reserve periods during the day for rest and to eat a healthy diet than telling them to resign from their jobs

• FACT: There are no restrictions early in pregnancy; Pregnant women can drive as long as they are comfortable and use seat belts
• CAUTION: Regardless of the AOG, the pregnant woman must be familiar with the nearest health care facility; Vaccines may be necessary if traveling
• HE: Educate not to eat raw fruits, vegetables and meat or drink unpurified water;Advise a woman taking a long trip by automobile to plan for frequent rest or stretch periods every hour or 2 hours

• Encourage to wear bra that provides support
• Dress warmly
• Rule out other conditions if persistent

• Explain Calamine lotion may be soothing

• Discuss preventive measures
• Reinforce the need for Iron even if it may cause constipation
• Advise not to use mineral oil
• Recommend avoiding gasforming food
• Avoid enema and use of laxatives

• Advise to side-lying eat dry crackers
• Dry CHO diet
• Wait 30 minutes before arising from bed

• Relieve by rest and sleep
• Advise one short rest period per day
• Advise to elevate legs

• Advise to lie on the back momentarily, extend the leg and dorsiflex the foot
• May also advise to decrease milk intake

• Assume left to side-lying

• Assume the Sim’s position or on the back with legs raised against a wall or elevated on a footstool for 15-20 minutes
• Caution not to cross legs 
• Avoid wearing knee-high hose/garters
• Apply TEDS
• Walk break 2x/day
• Exercise
• Vitamin C and fruits

• Daily bowel evacuation
• Resting in modified Sim’s position
• Assume a knee-chest position for 10- 15minutes
• Cold compress
• Gentle finger pressure
• Stool softeners
• PREVENTION

• Reassure that it is normal
• Report if they occur very frequently or continuously or if accompanied by pain
• Advise gradual/slow movements

• Decrease coffee intake
• Explain that voiding frequently is normal
• Advise to perform Kegels’ exercises to decreases stress incontinence and strengthen perineal muscles

• Advise to rise slowly
• Evaluate description of the pain carefully

• Advise daily bath/shower
• Wearing cotton underwear and sleeping at night w/o one
• May wear perineal pads but not tampons
• Advise to consult when there are changes in discharge
• Advise not to douche
• Avoid tight underpants and pantyhose

• Advise to wear lowheeled shoes to reduce the amount of spinal curvature
• Encourage to walk with pelvis tilted forward
• Apply local heat
• Advise to squat rather than bend to pick up objects
• Hold objects close to the body when lifting
• Perform pelvic tilt/rocking
• Detailed account of women’s symptoms
• Caution not to self medicate

• Resting with cold towels on forehead
• Taking usual dose of acetaminophen
• Caution that if HA is unusually intense or continuous, they should report it; It may be a danger sign of high BP

• Advise to sleep upright
• May require 2 or more pillows
• Caution to limit her activities during the day

• Advise to assume left-lateral position
• Sitting with legs elevated 2x/day for 30 min
• Avoid wearing constrictive clothing
• Reassure
• Assess for other signs of PIH

• Educate about these types of contraction
• Some women might be anxious
• Report to the primary care provider for evaluation
• Observe for rhythmic pattern of even very light contractions

PRELIMINARY SIGNS OF LABOR

1. LIGHTENING: Settling of the fetal head into the inlet of the true pelvis
2. EXCESS ENERGY: Feeling extremely energetic
3. UTERINE CONTRACTIONS: True contractions
4. SHOW: beginning of cervical dilatation
5. RUPTURE OF THE MEMBRANE: Sudden gush of clear fluid from the vagina

1. Vaginal Bleeding
2. Sudden Escape of clear fluid from the vagina
3. Persistent vomiting
4. Abdominal or chest pain
5. Pregnancy-induced HTN
6. Increase/decrease Fetal movement
7. Chills and Fever

• Can either be sexually transmitted or systemic infections
• Organisms cause the placental barrier (viral, bacterial, protozoan)
• Maybe subclinical but still injure a fetus
• Common diseases that cross the placenta and cause fetal harm: – TORCH (Toxoplasmosis, Other Infections, Rubella, Cytomegalovirus, Herpes Simplex virus)

• MOT: Handling raw meat, cat litter, or soil contaminated with cat feces; Eating inadequately prepared meat and animal products; Eating inadequately washed vegetables that have come in contact with contaminated soil
• EFFECT: CNS damage, hydrocephalus, microcephaly, intracerebral calcification, retinal deformities

• EFFECTS: Deafness, mental and motor challenges, cardiac defects, dental and facial clefts

• MOT: By contact with contaminated saliva, respiratory secretions, urine, semen, breastmilk, blood, cervical-vaginal secretions
• EFFECTS: Hemolytic anemia, jaundice, hydrocephalymicrocephaly, pneumonitis, mental retardation

• MOT: Contact with contaminated genital secretions; Transplacentally especially during a primary infection; Contact with active lesions and contaminated secretions during passage
• EFFECTS: 1st trimester: severe congenital anomalies or spontaneous miscarriages; 2nd-3rd trimester: premature labor, intrauterine growth restrictions, and continuation of infection

• EFFECTS: Congenital anomalies, extreme rhinitis, syphilitic rash; Presence of Hutchinson teeth (oddly shaped)

• MOT: Tick bites 
• EFFECTS: Spontaneous miscarriage or severe congenital anomalies

• MOT: Not teratogenic to fetus but are harmful at birth

• Live virus vaccines cannot be administered during pregnancy
• They may transmit viral infection to a fetus
• Live virus vaccines include:
  – Measles
  – Mumps
  – Rubella
  – Poliomyelitis

• Women should be cautious in taking any type of drug, whether it be over-the-counter, herbal or prescription drugs
• Recommendations: – Women (pregnant or child-bearing age) should not take any drugs or supplements not specifically prescribed or approved by their physician
• A common teratogenic drug is THALIDOMIDE. can cause amelia/phocomelia when taken between 34th -45th day of pregnancy
• Recreational drugs are also harmful for fetus:
  – Narcotics and heroin: causes intrauterine growth
  restriction
  – Marijuana: unstudied
  – Cocaine: compromises fetal blood flow, spontaneous
  miscarriage, preterm labor, meconium staining and
  intrauterine growth restriction
  – Inhalants: limit oxygen supply

• A: Risk during 1st trimester; No evidence for risk in last trimester. (Ex: Thyroid hormone)
• B: Adverse effect on fetus on animal studies but not on pregnant women. (Ex: Insulin)
• C: Adverse effect on the fetus on animals but not on humans. No adequate studies. Unknown pregnancy risk. (Ex: Docusate sodium (Colace))
• D: There is evidence risk to human fetus but maybe acceptable because of potential benefits. (Ex: Lithium citrate)
• X: Show abnormalities in humans and animals. Risk outweighs the benefits. (Ex: Isotretinoin (Accutane))

• Alcohol from the mother is passed on to the fetus through the placenta
• Fetus cannot remove breakdown products of alcohol→ causes Vitamin B deficiency→ neurologic damage
• Can cause fetal alcohol syndrome→ baby becomes SGA and may be cognitively challenged
• The infant is characterized by craniofacial deformity

• Fetus experiences growth restriction
• Infants are at greater risk for sudden infant death syndrome and they are born with LBW due to limited blood supply to the fetus during pregnancy

• Women are exposed to this at home or at work
• Can be classified into:
  – Metal and chemical hazards: includes pesticides, carbon monoxide, lead, paints, etc
  – Radiation: destroys rapidly growing cells; all women should only be exposed to x-ray during the first 10 days of menstruation; pregnancy test should be done before x-ray
  – Hyperthermia & hypothermia: It interferes with cell
  metabolism

• Emotionally disturbed pregnant woman can cause physiologic changes through its effect on sympathetic division of the Autonomic Nervous System
• It may cause constriction 
• It is not caused though by normal anxiety but by long-term, extreme stress

• Elective participation
• Signed informed consent
• Results must be interpreted correctly yet provided as quickly as possible
• Confidentiality of results
• Free and individual decision on action to be taken

REMEMBER!
> Allelles are different forms of a gene
> We inherit one allele from each parent

• Autosomal
• X-linked

• Dominant
• Recessive

• Huntington’s Disease
• Osteogenesis Imperfecta
• Marfan Syndrome
• Achondroplasia
• Retinoblastoma

• Cystic Fibrosis
• Sickle Cell Anemia
• Fancone’s Anemia
• Galactosemia
• Phenylketonuria
• Albinism
• Limb –girdle Muscular Dystrophy
• Adrenogenital Syndrome
• Rh-factor Incompatibility
• Tay Sach’s Disease

BIG IDEA!
> Both parents must be a carrier for the disease to be transmitted
> There must be 2 recessive diseased genes for the disease to be manifested

• Alport’s syndrome

• Christmas Disease
• Color Blindness
• Baldness
• Duchenne Muscular Dystrophy
• Fragile X syndrome

BIG IDEA!
> Females can only be carriers & only males will have the disorder
> Sons of affected man are unaffected
> The parents of affected children don’t have the disease

1. Numerical
2. Deletion

1. Monosomy
2. Trisomy
3. Tetrasomy