DIVINE WORD COLLEGE OF BANGUED

SCHOOL OF HEALTH SCIENCES

Bachelor of Science in Nursing

A. Initial Prenatal Assessment

History
➢ History of family, individual. And partner with particular attention to:
- Chronic diseases such as asthma, diabetes, hypertension, or heart disease.
- Medications (prescribes or over the counter), complementary or alternative
therapies used, chemical dependency (including tobacco and alcohol use).
- Previous illnesses such as surgeries, episodes of sexually transmitted
diseases such as herpes.
- Occupation and workplace hazards, including exposure to teratogenic
substance.
➢ Reproductive history include:
- Menstrual and contraceptive history.
- *Gravida, para-, preterm births, living children, abortions, stillbirths.
- Type of births (vaginal or caesarean), hours of labor, condition and
weight of infant, complications of labor or postpartum.
Gravida and para
Gravida and para Two important components of a patient’s obstetric history are her
gravida and para status. Gravida represents the number of times the patient has been
pregnant. Para refers to the number of children above the age of 20 weeks’ gestation the
patient has delivered. The age of viability is the earliest time at which a fetus can survive
outside the womb, generally at age 24 weeks or at a weight of more than 400 g (14.1 oz).
These two pieces of information are important but provide only the most rudimentary
information about the patient’s obstetric history.
A slightly more informative system reflects the gravida and para numbers and includes
the number of abortions in the patient’s history. For example, G-3, P-2, Ab-1 describes a
patient who has been pregnant three times, has had two deliveries after 20 weeks’
gestation, and has had one abortion.
TPAL, GTPAL, and GTPALM
In an attempt to provide more detailed information about the patient’s obstetric history,
many facilities now use one of the following classification systems: TPAL, GTPAL, or
GTPALM. These systems involve the assignment of numbers to various aspects of a
patient’s obstetric past. They offer health care practitioners a way to quickly obtain fairly
comprehensive information about a patient’s obstetric history. In particular, these systems
offer more detailed information about the patient’s para history.
In TPAL, the most basic of the three systems, the patient is assigned a four-digit number as
follows:
▪ T is the number of pregnancies that ended at term (38 weeks’ gestation or later).
▪ P is the number of pregnancies that ended after 20 weeks’ gestation and before the
end of 37 weeks’ gestation.
▪ A is the number of pregnancies that ended in spontaneous or induced abortions.
▪ L is the number of children who are alive at the time the history is obtained. Note
that the patient’s gravida number remains the same, but the TPAL systems allow

1
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

subclassification of her para status. In most cases, a practitioner includes the

patient’s gravida status in addition to her TPAL number.
Here are some examples:
A woman who has had two previous pregnancies, has delivered two term children, and is
pregnant again is a gravida 3 and is assigned a TPAL of 2-0-0-2.
A woman who has had two abortions at 12 weeks (under the age of viability) and is pregnant
again is a gravida 3 and is assigned a TPAL of 0-0-2-0.
A woman who is pregnant for the sixth time, has delivered four term children and one
preterm child, and has had one spontaneous abortion and one elective abortion is a gravida
6 and is assigned a TPAL of 4-1-2-5.
In GTPALM, a number is added to the GTPAL to represent the number of multiple
pregnancies the patient has experienced (M). Note that a patient who hasn’t given birth to
multiple pregnancies doesn’t receive a number to represent M.
Here are some examples:
If a woman has had two previous pregnancies, has delivered two term children, and is
currently pregnant, she’s assigned a GTPAL of 3-2-0-0-2.
If a woman who’s pregnant with twins delivers at 35 weeks’ gestation and the neonates
survive, she’s classified as a gravida 1, para 2 and is assigned a GTPAL of 1-0-2-0-2. Using the
GTPALM system, the same woman would be identified as 1-0-2-0-2-1.
Physical Examination
➢ Vital signs, including auscultation of maternal heart sounds.
➢ Height, weight, and preconception weight.
➢ Inspection and palpation of the breast and abdomen.
➢ Palpation of fundus.
➢ Brachial and patellar reflexes for hyperreflexia, which suggests preeclampsia.
➢ Pelvic examination, including external and internal genitalia, cervical cultures, Pap
smear, and measurement of pelvic dimensions to estimate whether size seems
adequate for vaginal birth.
➢ Current pregnancy status including:
- Confirmation of pregnancy by presumptive, probable, and positive signs of
pregnancy.
- Confirmation of gestational age by noting (a) abdominal enlargement; (b)
measurement of fundal height; (c) sonography that can accurately
determine fetal age early in pregnancy.
- Fetal heartbeat that can detected with a doppler by 10 weeks of gestation
and much earlier by ultrasound examination.
- EDD based of LMP and confirmed by fundal height and sonography.
At about 12 to 14 weeks’ gestation, the uterus is palpable over the symphysis pubis as a firm
globular sphere. It reaches the umbilicus at 20 to 22 weeks, the xiphoid at 36 weeks, and
then, in many cases, returns to about 4 cm below the xiphoid due to lightening at 40 weeks.

2
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

If the woman is past 12 weeks of pregnancy, palpate fundus location, measure fundal height
(from the notch above the symphysis pubis to the superior aspect of the uterine fundus),
and plot the height on a graph. This information helps detect variations in fetal growth. If an
abnormality is detected, it can be further investigated with ultrasound to determine the
cause. After the examination, offer the patient premoistened tissues to clean the vulva.

FETAL HEART RATE

You can obtain an FHR by placing a fetoscope or Doppler ultrasound stethoscope on the
mother’s abdomen and counting fetal heartbeats. Simultaneously palpating the mother’s
pulse helps you to avoid confusion between maternal and fetal heartbeats.
A fetoscope can detect fetal heartbeats as early as 20 weeks’ gestation. The Doppler
ultrasound stethoscope, a more sensitive instrument, can detect fetal heartbeats as early as
10 weeks’ gestation and remains a useful tool throughout labor to determine the FHR at
fewer than 20 weeks’ gestation, place the head of the Doppler stethoscope at the midline of
the patient’s abdomen above the pubic hairline. After 20 weeks’ gestation, when fetal
position can be determined, palpate for the back of the fetal thorax and position the
instrument directly over it. Locate the loudest heartbeats and palpate the maternal pulse.
Count fetal heartbeats for at least 15 seconds while monitoring maternal pulse. Leopold
maneuvers can be used to determine fetal position, presentation, and attitude. However,
because the presentation and position of the fetus may change, most practitioners don’t
perform Leopold maneuvers until 32 to 34 weeks’ gestation.
Because FHR usually ranges from 110 to 160 beats/minute, auscultation yields only an
average rate at best. It can detect gross (but commonly late) signs of fetal distress, such as
tachycardia and bradycardia, and is thus recommended only for a patient with an
uncomplicated pregnancy.

3
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

B. Danger Signs of Pregnancy

The pregnant woman and at least one person must be instructed about signs that indicate a
problem that should be reported at once.
Danger Sign Possible Cause
Vaginal bleeding with or without Placental abnormalities, lesions of cervix or
discomfort vagina, “bloody show” (sign of labor onset)
Escape of fluid from vagina Premature rupture of membranes
Swelling of fingers or face Excessive edema
Continuous pounding headache Chronic hypertension or preeclampsia
Visual disturbances (blurred vision, Worsening preeclampsia
dimness, flashing lights, spots before the
eyes)
Persistent or severe abdominal or Ectopic pregnancy (if early), worsening
epigastric pain preeclampsia or abruptio placenta
Fever or chills Infection
Painful urination Urinary tract infection
Persistent vomiting Hyperemesis gravidarum
Change in frequency or strength of fetal Fetal compromise or death
movement
Uterine contractions, cramps, constant or Preterm labor
irregular low backache, pelvic pressure
before 38 weeks

4
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

Nursing Interventions
➢ Bathing
Recommended daily showers or tub baths; caution the pregnant woman to take
precautions to prevent falls during the third trimester, when her balance has
changed.
Suggest avoiding hot baths especially in early pregnancy because it is associated
with fetal anomalies. She should stay in a hot tub no more than 10 minutes and
keep her head and chest out of the water, a sauna no more than 15 minutes.
➢ Breast Care
Instruct patient to wash her breasts and nipples with clean water and to avoid
soap that removes natural lubricant.
Advise patient to wear a good support bra with wide straps that distribute the
weight evenly across the shoulders.
Emphasize avoidance of breast stimulation that may cause uterine contractions
if a history of preterm labor or signs of preterm labor are present.
➢ Exercise
Recommend moderate exercise 30 minutes or more daily but suggest to avoid:
▪ Beginning strenuous exercise or intensifying training.
▪ Exercise where there is a risk of falling or abdominal trauma.
▪ Vigorous exercise in hot or humid weather
▪ All exercise in supine position after the first trimester (increases risk of
supine hypotensive syndrome)
Emphasize the importance of taking adequate fluids before and after exercising
and to stop exercises that cause undue fatigue.
Stress the importance of following her health care provider’s advice about
taking her pulse during exercise and keeping it within certain range.
Instruct patient to stop exercise and seek medical advice if she has chest pain,
dizziness, headache, decreased fetal movement, or signs of labor.
Suggests patient to include warm-up and cool- down periods and stretching
exercises.
➢ Sleep and Rest
Instruct patient to use pillows to support the abdomen and back during the last
trimester.
Recommend patient to rest in a lateral position to prevent hypotension that
may occur as a result of lying in a supine position.
➢ Employment
Suggest patient to work out a schedule for frequent rest periods with her feet
elevated to prevent undue fatigue.
Assists patient to plan ways to change positions or to walk briefly to stimulate
circulation.
Recommend she avoid heavy lifting and curtail jobs that require balance during
the last trimester when the center of gravity shifts and is at greater risk for falls.

5
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

➢ Avoiding Teratogens
Advise the patient to investigate her specific situation to determine possible
exposure to toxic substances. Groups at risk include hairdressers, painters,
printers, nurses, and laundry and dry- cleaning workers.
Emphasize the ill effects of exposure to passive smoking. If patient is smoking,
help her to make a plan for smoking cessation and provide referral,
encouragement, and follow-up.
Explain the harmful effects of alcohol and illicit drugs.
➢ Over-the-counter drugs, complementary and alternative therapy
Advise patient to consult her healthcare provider before taking any over-the-
counter drugs or complementary and alternative therapy.
➢ Sexual Activity
Reassure the couple that sexual intercourse does no harm to the fetus or
healthy pregnant woman.
Suggest that they alter the position during the last trimester.
Advise them to curtail all sexual activity if the woman is at risk for preterm
labor, if the membranes have ruptured, or if there is vaginal bleeding.
➢ Immunizations
Remind her that live virus vaccines such as those for measles, rubella, and
mumps are contraindicated during pregnancy.
Counsel het to consult with her care provider before taking any
immunizations during pregnancy.
How to Overcome the Common Discomforts of Pregnancy
• Nausea and Vomiting
- Eat crackers or dry toast arising in the morning, then get out of bed slowly.
- Eat dry crackers every 2 hours to prevent an empty stomach rather than three
full meals.
- Drink fluids separately from meals.
- Avoid fried, high-fat, greasy, or spicy foods and foods with strong odors.
- Eat a protein snack at bedtime.
- Try ginger, peppermint, or tart and salty food combinations.
• Heart burn
- Avoid spicy or fatty foods
- Eat small, frequent meals; avoid overeating or eating at bedtime.
- Remain upright after eating to reduce reflux; sleep with an extra pillow.
- Avoid smoking and coffee, which increases acid.
- Breathe deeply and sip water to relieve burning sensation.
- Avoid antacids that are high in sodium.
• Backache
- Maintain correct posture with shoulders and neck straight, back flattened, and
pelvis tucked under.
- Avoid high-heeled shoes.
- Squat, rather than bend from the waist, to pick up objects.
- Use foot supports, arm rests, and pillows to support the back.

6
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

- Strengthen the back by doing exercises such as tailor sitting, shoulder circling,
and pelvic rocking.
- A maternity back binder may be helpful.
- Round Ligament Pain
- Avoid stretching and twisting at the same time.
- Bend toward the pain, squat, or flex the knees to the chest to relax the
ligament.
- Use a heating pad.
• Urinary Frequency and Loss of Urine
- Void when the urge occurs.
- Maintain daytime fluid intake.
- Use Kegel exercises (contracting the muscles around the vagina for 10
seconds, relaxing 10 seconds) 30 times daily.
• Varicosities
- Avoid constricting clothing or crossing the legs at the knees, which impedes
blood return from the legs.
- Take frequent rest periods with legs elevated above the level of the hips.
- Wear support hose or elastic stockings to prevent blood pooling in the legs.
- Walk for a few minutes at least every 2 hours to stimulate circulation and
relieve discomfort.
• Hemorrhoids
- Avoid straining when having a bowel movement.
- Drink plenty of water, eat high-fiber foods, and exercise regularly.
- Take frequent, tepid baths; apply cool witch hazel compresses or use
anesthetic ointments to relieve existing hemorrhoids.
- Lie on the side with the hips elevated on a pillow to promote drainage of
blood from swollen hemorrhoids.
- Push hemorrhoids back into the rectum if necessary. Use a clean glove and
lubricate the index finger. Maintain pressure for 1 to 2 minutes.
- Notify physician or midwife if there is persistent pain or bleeding.
• Constipation
- Establish a regular pattern of bowel elimination.
- Drink at least 8 glasses of water each day in addition to any caffeinated drinks.
- Consume foods high in fiber, such as unpeeled fresh fruit, whole grain cereals
and bread, and vegetables.
- Restrict consumption of cheese, which can cause constipation, ad sweets,
which increase bacterial growth in the intestine and cause flatulence.
- Continue iron supplementation and consult health provider if constipation
persists. If constipation still persists, a stool softener may be prescribed.
- Walk briskly for at least 1 mile daily to stimulate peristalsis.
• Leg Cramps
- Dorsiflex the foot and extend the leg to relieve cramp.
- Elevate the legs frequently to improve circulation.
- Avoid excessive intake of phosphorus; ask provider about supplemental
calcium or magnesium.

7
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

C. NUTRITION FOR PREGNANCY AND LACTATION

Nutritional needs must also be addressed as a
part of prenatal care. A pregnant woman’s
nutritional intake—including calories, protein,
fat, vitamins, minerals, and fluid—needs to be
increased to provide sufficient nutrients for her
growing fetus. In most cases, the patient
doesn’t have to increase the quantity of food
she eats; she simply needs to increase the
quality of the food she eats.
A pregnant woman’s food choices should be
based on the food guide pyramid. When
discussing nutrition with the patient, refer to
servings of food rather than milligrams or
percentages.

SUPLLEMENTATIONS
➢ Supplementations should not be used
as a substitute for eating good diet
because supplements do not contain
nutrients needed during pregnancy.
➢ Iron (30 mg per day) is often prescribed
for women during the second and third trimesters because it is difficult to obtain
adequate amounts through normal food intake. The dose higher (60 mg to 120 mg
per day) for women who have been diagnosed with iron deficiency anemia.
Recommend that these women:
- Take iron with food, if necessary, to decrease the nausea that some
women experience.
- Eat food high in fiber (fresh fruits and vegetables) and drink at least 8
glasses of water a day to prevent constipation.
- Avoid taking iron with calcium supplements, milk, tea, coffee, or antacids,
which interfere with iron absorption.
- Get plenty of vitamin C (in citrus fruits, tomatoes, melons, and berries) and
heme iron (in meals) to increase absorption of iron.
- Expect stools to be black or dark green, a side effect of iron
supplementation.
➢ Folic acid (400 mcg per day) is recommended for all women of childbearing age to
prevent neural tube defects in the fruits. Intake during pregnancy should be 600 mcg
daily.
➢ Additional prenatal vitamins and minerals are recommended when there is reason
to believe that diet may not be adequate.

8
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

D. POSTPARTUM ASSESSMENT

Patient history

Your postpartum patient history should focus on the patient’s pregnancy, labor, and birth
events. You should be able to find much of this information on the medical record. For

example, the medical record should contain information about:

• problems experienced, such as gestational hypertension or gestational diabetes

• time of labor onset and admission to the birthing area

• types of analgesia and anesthesia used

• length of labor

• time of delivery

• time of placenta expulsion and appearance of the placenta

• sex, weight, and status of the neonate.

You’ll need this information to plan the mother’s care and promote maternal-neonate
bonding.

9
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

Don’t rely on the medical record as your sole source of information. Always ask the mother
to describe the events and fill in the details in her own words. This is also a good way to find
out her emotions and feelings about pregnancy and childbirth. Also ask the mother about
her family and lifestyle, including support systems, other children, other people living in the
home, her occupation, her community environment, and her socioeconomic level. This
informa tion can help you determine whether additional support, follow-up, or education
about self-care and neonatal care are needed.

PHYSICAL EXAMINATION
In many cases, you won’t need to do a complete physical examination in the postpartum
period because the mother already had a complete assessment early in the labor process.
However, you should complete review of systems, covering the following areas:

• general appearance

• skin

• energy level, including level of activity and fatigue

• pain, including location, severity, and aggravating factors, such as sitting and walking

• gastrointestinal (GI) elimination, including bowel sounds, passage of flatus, and

hemorrhoids

• fluid intake

• urinary elimination, including the time and amount of first voiding

• peripheral circulation.

In addition, you’ll need to assess these four critical areas:

• breasts

• uterus

• lochia

• perineum

10
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

BREASTS
Inspect and then palpate the breasts, noting size, shape, and color. At first, the breasts
should feel soft and secrete a thin, yellow fluid called colostrum. However, as they fill with
milk—usually around the third postpartum day—they should begin to feel firm and warm.
Between feedings, the entire breast may be tender, hard, and tense on palpation. A low-
grade temperature (under 101° F [38.3° C]) isn’t uncommon between days 2 and 5, but it
shouldn’t last for more than 24 hours.

UTERUS
During your examination, palpate the uterine fund us to determine uterine size, degree of
firmness, and rate of descent, which is measured in fingerbreadth above or below the
umbilicus. Unless the practitioner orders otherwise, perform fundal assessments every 15
minutes for the first hour after delivery, every 30 minutes for the next hour or two, every 4
hours for the rest of the first postpartum day, and then every shift until the patient is
discharged. Fundal assessment will need to occur more frequently if complications are
noted. Pain at the incision site makes fundal assessment especially uncomfortable for the
patient who has had a cesarean birth. In such cases, provide pain medication beforehand as
ordered.

Before palpating the uterus, explain the procedure to the patient and provide privacy. Wash
your hands and then put on gloves.

Also, ask the patient to void. A full bladder makes the uterus boggier and deviates the
fundus to the right of the umbilicus or 1 or 2 above the umbilicus. When the bladder is
empty, the uterus should be at or close to the level of the umbilicus.

Next, lower the head of the bed until the patient is lying supine or with her head slightly
elevated. Expose the abdomen for palpation and the perineum for inspection. Watch for
bleeding, clots, and tissue expulsion while massaging the uterus.

Performing palpation

To palpate the uterine fundus, follow these steps:

11
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

• While supporting the lower segment of the uterus with a hand placed just above the
symphysis, gently palpate the fundus with your other hand to evaluate its firmness.

• Note the level of the fundus above or below the umbilicus in centimeters or
fingerbreadths.

• If the uterus seems soft and boggy, gently massage the fundus with a
circular motion until it becomes firm. Without digging into the abdomen,
gently compress and release your fingers, always supporting the lower
uterine segment with your other hand. Observe the vaginal drainage during
massage.

• Massage long enough to produce firmness but not discomfort. You may also
encourage the patient to massage her fundus for 10 to 15 seconds every 15
minutes. This is usually necessary only for a few hours.

• Notify the practitioner immediately if the uterus fails to contract and heavy
bleeding occurs. If the fundus becomes firm after massage, keep one hand on
the lower uterus and press gently toward the pubis to expel clots.

 When assessing the uterine fundus, also assess for bladder distention. A
distended bladder can impede the downward descent of the uterus by
pushing it upward and, possibly, to the right side. If the bladder is
distended and the patient is unable to urinate, you may need to
catheterize her.

LOCHIA
After birth, the outermost layer of the uterus becomes necrotic and is
expelled. This vaginal discharge—called lochia —is similar to menstrual flow
and consists of blood, fragments of the decidua, white blood cells

(WBCs), mucus, and some bacteria.

Assessing lochia flow

Lochia is commonly assessed in conjunction with fundal assessment. (See Three types of
lochia .) Help the patient into the lateral Sims position. Be sure to check under the patient’s
buttocks to make sure that blood isn’t pooling there. Then, remove the patient’s perineal
pad and evaluate the character, amount, color, odor, and consistency (presence of clots) of
the discharge. Before removing the perineal pad, make sure that it isn’t

sticking to any perineal stitches. Otherwise, tearing may occur, possibly increasing the risk of
bleeding.

Here’s what to look for when assessing lochia:

• Amount—

— Although it varies, the amount of lochia is typically comparable to the amount during
menstrual flow. A woman who’s breast-feeding may have less lochia. Also, a woman who
has had a cesarean birth may have a scant amount of lochia; however, lochia shouldn’t be
absent. Lochia should be present for at least 3 weeks

12
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

postpartum. Lochia flow increases with activity; for example, when the patient gets out of
bed the first several times (due to pooled lochia being released) or when she lifts a heavy
object or walks upstairs (due to an actual increase in the amount of lochia). If your patient

saturates a perineal pad in less than an hour, this is considered excessive flow, and you
should notify the practitioner.

• Color—

— Lochia typically is described as lochia rubra, serosa,or alba, depending on the color of the
discharge. Lochia color depends on the postpartum day. A sudden change in color— for
example, from pink back to red— suggests new bleeding or retained placental fragments.

• Odor—

— Lochia should smell similar to menstrual flow. A foul or offensive odor suggests infection.

• Consistency—

— Lochia should have minimal or small clots, if any. Evidence of large or numerous clots
indicates poor uterine contraction and requires further assessment.

Perineum and rectum

The pressure exerted on the perineum and rectum during birth

results in edema and generalized tenderness. Some areas of the perineum may be
ecchymotic, caused by the rupture of surface capillaries. Sutures from an episiotomy or
laceration may also be present. Hemorrhoids are also commonly seen. Assessment of the
perineum and rectum mainly involve inspection and is performed at the same time that you
assess the lochia. Help the patient into the lateral Sims position. This position provides
better visibility and causes less discomfort for the patient with a mediolateral episiotomy. A
back-lying position can also be used for patients with midline episiotomies. Make sure you
have adequate light for inspection.

13
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

Lift the patient’s buttocks and observe for intactness of skin, positioning of the
episiotomy (if one was performed), and appearance of sutures (from episiotomy
or laceration repair) and the surrounding rectal area. Keep in mind that the edges
of an episiotomy are usually sealed 24 hours after delivery. Note ecchymosis,
hematoma, erythema, edema, drainage or bleeding from sutures, a foul odor, or
signs of infection. Also observe for the presence of hemorrhoids.

PERINEAL CARE
Perineal assessment also includes perineal care. The goals of postpartum
perineal care are to relieve discomfort, promote healing, and prevent infection
by cleaning the perineal area. Assist and teach the patient how to perform
perineal care in conjunction with a perineal assessment. Perineal care should be
performed after the patient voids or has a bowel movement. Two methods of
providing perineal care are generally used: a water-jet irrigation system or a peri
bottle. In either case, help the patient walk to the bathroom or place her on a
bedpan; then wash your hands and put on gloves.

Water-jet system

If you’re using a water-jet irrigation system, follow these steps:

• Insert the prefilled cartridge containing the antiseptic or medicated solution into the
handle, and push the disposable nozzle into the handle until you hear it click into place.

• Help the patient sit on the toilet or bedpan.

• Place the nozzle parallel to the perineum and turn on the unit.

• Rinse the perineum for at least 2 minutes from front to back.

• Turn off the unit, remove the nozzle, and discard the cartridge.

• Dry the nozzle and store as appropriate for later use.

Peri bottle

If you’re using a peri bottle for perineal care, follow these steps:

• Fill the bottle with cleaning solution (usually warm water).

• Help the patient sit on the toilet or bedpan.

• Tell her to pour the solution over her perineal area.

• After completion, help the patient off the toilet or remove the bedpan.

• Pat the perineal area dry, and help the patient apply a new perineal pad.

14
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

During perineal care, note if the patient complains of pain or tenderness. If she does, you
may need to apply ice or cold packs to the area for the first 24 hours after birth. This helps
reduce perineal edema and prevent hematoma formation, thereby reducing pain and
promoting healing.

Cold therapy isn’t effective after

the first 24 hours. Instead, heat is
recommended because it increases
circulation to the area. Forms of
heat include a perineal hot pack
(dry heat) or a sitz bath (moist
heat).

For extensive lacerations, such as

third- or fourth-degree lacerations,
the practitioner may order a sitz
bath to aid perineal healing,
provide comfort, and reduce
edema. Because of shortened
hospitalization time, you may need
to teach the patient how to use a
sitz bath at home.

ELIMINATION
Assess the patient’s urinary elimination. The patient should void within 6 to 8 hours after
delivery. If she doesn’t, help her urge to void by administering analgesics as ordered, pouring
warm water over the perineum, placing the patient’s hands in warm water, or running water
for the patient to hear (the sound may encourage the urge to void). If all attempts fail, the
patient may need to be catheterized. Finally, assess bowel function. Elimination is typically a
good indicator of bowel function. The patient should have a bowel movement 1 to 2 days
after delivery to avoid constipation. However, a patient who has eaten nothing by mouth for
12 to 24 hours and then has a cesarean birth may not have a bowel movement for several
days. In these cases, flatus may be a better indicator of bowel function. Encourage the
patient to drink plenty of fluids and eat high-fiber foods to prevent constipation. If
necessary, the practitioner may order stool softeners or laxatives. If the patient has
hemorrhoids, cool witch hazel compresses may be helpful. Don’t use suppositories if the
patient has a third- or fourth-degree laceration.

15
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited
 DIVINE WORD COLLEGE OF BANGUED
SCHOOL OF HEALTH SCIENCES
Bachelor of Science in Nursing

Assignment….

Calculate the EDD and GTPALM of the following. 5 pts. each

1. Maria, who is at 20 weeks gestation went to the clinic to have her prenatal check-up.
She had 2 sons, the older was born 40 weeks while her second son was born 34
weeks. Her LMP is May 30, 2020.
2. Clara, who is at 12 weeks gestation went to the clinic complaining excessive nausea
ad vomiting and now diagnosed with Hyperemesis Gravidarum by her OB-Gyne. She
has a history of abortion at 8 weeks. Her LMP is January 1, 2021.
3. Tina, who is at 28 weeks gestation went to her OB- Gyne for pre-natal check- up. She
had 1 set of twins born at 32 weeks, 1 born at 39 weeks but died shortly after
because of hydrops and 1 daughter born at 42 weeks. Her LMP is March 29,2019.
4. Grace, who is at 40 weeks gestation rushed by her husband to the hospital because
her BOW was ruptured and complaining of uterine contractions for every 2 minutes.
Her LMP is June 19, 2022.

Note:

Pls. write your answers in 1 yellow sheet of paper and pls pass on September 15, 2022.

Thank you!

16
NCM 109 Care of Mother and Child at Risk or with Problems Prepared by: Mariel Anne B. Tiples, RN
This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any
retrieval system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited