Maternal Midterms Reviewer PDF

**WEEK 7** Nursing care of a family during labor and birth. **[I. Definition of Labor:]** \>are the series of events by which uterine contractions and abdominal pressure expel a fetus and placenta from the uterus **[II. Theories of Labor]** \> Labor usually begins between 37 and 42 weeks of pre...

**WEEK 7** Nursing care of a family during labor and birth. **[I. Definition of Labor:]** \>are the series of events by which uterine contractions and abdominal pressure expel a fetus and placenta from the uterus **[II. Theories of Labor]** \> Labor usually begins between 37 and 42 weeks of pregnancy, when a fetus sufficiently mature to adapt to extra uterine life, yet not too large to cause mechanical difficulty with birth 1.The uterine muscle stretches from the increasing size of the fetus, which results in release of prostaglandins 2.The fetus presses on the cervix, which stimulates the release of oxytocin from the posterior pituitary 3\. Oxytocin stimulation works together with prostaglandins to initiate contractions 4.Changes in the ratio of estrogen to progesterone occurs, increasing estrogen in relation to progesterone, which is interpreted as progesterone withdrawal 5\. The placenta reaches a set age, which triggers contractions 6\. Rising fetal cortisol levels reduce progesterone formation and increase prostaglandin formation 7\. The fetal membrane begins to produce prostaglandins, which stimulate contractions **[III. The Components of Labor]** *[1.The passage]* Refers to the route a fetus must travel from the uterus through the cervix and vagina to the external perineum Known as the woman's pelvis Should be of adequate size and contour *[2. The passenger (the fetus)]* Should be of appropriate size and in an advantageous position and presentation The body part of the fetus that has the widest diameter is the head *[3. The powers of labor (uterine contractions)]* are adequate *[4. The psyche,]* or a woman's psychological state which may either encourage or inhibit labor. \> This can be based on her past life experiences as well as her present psychological state **IV. Difference Between True and False Contraction** FALSE CONTRACT TRUE CONTRACT --------------------------------------------------------------------- -------------------------------------------------------------- Begin & remain irregular begin irregular but become regular & predictable Felt first abdominally and remain confined to the abdomen and groin \>felt first in lower back and sweep @ the abdomen in a wave Often disappear with ambulation and sleep \> Continue no matter what the woman's level of activity Do not increase in duration, frequency & intensity \> Increase in duration, frequency and intensity **PASSENGER** -the fetus is the passenger -head is the widest part -the cranium, the upper most portion of the skull, is composed of eight bone. -frontal, occipital, 2 parietal -sphenoid, ethnoid and 2 temporal bones. ***[modling]***-overlapping of skull bones along the suture lines, which causes a change in the shape of the fetal skull to one long and narrow. **Fetal attitude** describes the position of specific parts of a fetus's body. -Degree of flexion a fetus assumes during labor. The ideal fetal attitude is when the fetus has its: Chin tucked into its chest. Arms and legs drawn into the center of its chest. But, there can be times the fetal attitude is irregular. For example, its chin is tilted back instead of tucked **Fetal lie** describes how the fetus's spine lines up with its birth parent's spine. Ideally, they line up vertically because the fetus's head is down in the birth canal. This is called longitudinal lie. If the fetus is sideways or horizontally across the uterus, it's in a transverse lie. **FETAL PRESENTATION** -Fetal presentation denotes the body part that will first contact to the cervix or to be born first and is determined by the combination of fetal lie and the degree of fetal flexion. -Normally, the presentation is vertex (head first), and the position is occiput anterior (facing toward the pregnant person\'s spine) and with the face and body angled to one side and the neck flexed. **Fetal position** -the relationship of the presenting part to a specific quadrant and the side of the pregnant persons pelvis. *[4 quadrant]* 1.Rigth anterior 2.Left anterior 3.Rigth posterior 4.Left posterior vertex presentation-occiput Face presentation- chin or mentum Breech presentation- sacrum Shoulder presentation- scapula or the acromion process. **Mechanisms (Cardinal Movements) of Labor** **Mechanisms (Cardinal Movements) of Labor** V. Mechanisms (Cardinal Movements) of Labor **[ENGAGEMENT]**-settling of the presenting part of a fetus far enough into the pelvis that rests at the level of the ischial spines, the midpoint of the pelvis. ***[1.Descent]*** \>The downward movement of the biparietal diameter of the fetal head within the pelvic inlet. Nulliparas: descent occurs during 2nd stage Multiparas: descent usually begins with engagement Occurs due to : 1.Pressure of amniotic fluid 2.Direct pressure on the breech by the fundus during contractions 3\. Bearing-down of maternal abdominal muscles ***[2.Flexion]*** As descent is completed, and the fetal head touches the pelvic floor, the head bends forward onto the chest, causing the smallest anteroposterior diameter Due to resistance from the cervix, pelvic walls, or pelvic floor Chin is brought towards the chest Shifts from longer occipitofrontal diameter (12cm) to shorter Suboccipito bregmatic diameter (9.5cm ***[3. Internal Rotation]*** As the head flexes at the end of descent, the occiput rotates so the head is brought into the relationship to the outlet of the pelvis. This movement brings the shoulders, coming next into the optimal position to enter the inlet ***[4.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. ***[5. External Rotation]*** -almost immediately after the head of the infant is born, the head rotates a final time back to the diagonal or transverse position of the early part of labor. -the anterior shoulder is born first, assisted perhaps by downward flexion of the infants head. ***[6. Expulsion]*** -once shoulder are born, the rest of the baby is born easily and smoothly because of its smaller size. -the end of the pelvic division of labor. ***[Cervical Changes]*** *a. Effacement* Is shortening and thinning of the cervical canal All during pregnancy, the canal is approx. 1-2 cm long During labor, the longitudinal traction from the contracting uterus shortens the cervix so much that the cervix virtually disappears *b. Dilatation* \> Refers to the enlargement or widening of the cervical canal from an opening a few millimeters wide to one large enough (approx.10cm) Effacement means that the cervix stretches and gets thinner. Dilatation means that the cervix opens. \> As labor nears, the cervix may start to thin or stretch (efface) and open (dilate). \>This prepares the cervix for the baby to pass through the birth canal (vagina). ***[VI. The Stages of Labor]*** - The first stage of dilatation, which begins with the initiation of true labor contractions and ends when the cervix is fully dilated - The second stage, extending from the time of full dilatation until the infant is born - The third or placental stage, lasting from the time the infant is born until after the delivery of the placenta - The first 1-4 hours after birth of the placenta is sometimes termed as the "fourth stage" to emphasize the importance of close maternal observation needed at this time ***[First Stage]*** Begins with the initiation of true labor contractions and ends when the cervix is fully dilated Takes about 12 hours to complete and divided into three segments: ***[a. Latent Phase]*** Also known as the early phase begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins Contractions are mild and short lasting - 20 to 40 sec. Cervical effacement occurs and the cervix dilates minimally ***[b. The Active Phase]*** Cervical dilatation occurs more rapidly Contractions grow stronger, lasting 40-60 sec and occur approx. every 3 to 5 minutes Show (increased vaginal secretions) and spontaneous rupture of the membranes may occur ***[c. The Transition Phase]*** \> Contractions reach their peak of intensity, occurring every 2 to 3 minutes With a duration of 60 to 70 sec. **[Nursing Management:]** - Encourage woman to be active participant by keeping active and assuming whatever position is most comfortable for her during this time - Lying flat on her back should be avoided during this time ***[c. The Transition Phase]*** - Contraction reach their peak of intensity; every 2-3 minutes with a duration of 60 to 70 seconds and a maximum cervical dilatation of 8 to 10 cm - Woman is experiencing an intense discomfort that is so strong - May accompanied with nausea and vomiting - With loss of control, anxiety, panic or irritability - The irresistible urge to push usually begins **[2. The Second Stage]** - The time span from full dilatation and cervical effacement to birth of the infant - A woman typically feels contractions change from the char. of crescendo-decrescendo pattern to an uncontrollable urge to push - As the fetal head pushes against the vaginal introitus, this opens and the fetal scalp appears at the opening to the vagina and enlarges from the size of a dime, to a quarter, then a half-dollar - This is termed as "crowning" **3. The Third Stage** *K*nown as the placental stage - Begins with birth of the infant and ends with the delivery of the placenta - After the birth of an infant, the uterus can be palpated as a firm, rounded mass just below the level of the umbilicus - After a few minutes of rest, uterine contractions begin again and the organ assumes a discoid shape - It retains this new shape until the placenta has separated, aprroximately 5 minutes after the birth of the infant. **[II. TWO PHASES INVOLVED]** 1.Placental separation 2.Placental expulsion **SIGNS OF PLACENTAL SEPARATION** \> Placing a clamp on the cord near the perineum makes it easier to appreciate this lengthening 1.Lengthening of the umbilical cord 2.Sudden gush of blood from the vagina 3.Placenta is visible at the vaginal opening 4\. Uterus contracts and feels firm again **PLACENTAL EXPULSION** The fetal side of the placenta is shiny because of the apposed amniotic membrane (Schultze mechanism) The maternal side of the placenta is dull and is subdivided into as many as 35 lobes (Duncan mechanism) PUERPERIUM-KNOWN AS THE POSTPARTAL PERIOD --REFERS TO THE 6-WEEK PERIOD AFTER CHILDBIRTH **[FOURTH STAGE ]** **[PSYCHE-EMOTIONAL STATE DURING BIRTH]** This aspect refers to supporting the pregnant client's psychological adaptation to labor. *Ways to support birthing clients with their frame of mind during labor include:* *[Education:]* childbirth classes, anticipatory guidance during labor *[Labor support]*: Continuous labor support increases vaginal birth rate. Build trust, frame labor pain as meaningful and productive, guide clients to their own decisions. *[Client]*-centered support: Respect cultural differences, respect client autonomy, and communicate effectively. **[Maternal Danger Signs of Labor]** *1.High or Low BP* A systolic pressure \> 140mmHg & a diastolic pressure \> 90mmHg or an increase in systolic pressure \> 30mmHg or in the diastolic pressure of \> than 15mmHg (the basic criteria for gestational hypertension) should be reported Falling BP should also be reported because it may be a sign of intrauterine hemorrhage *Others signs:* apprehension, increased PR and pallor- hypovolemic shock *[2.Abnormal Pulse]* Most women during pregnancy has a PR of 70-80 beats per minute Usually increased during the second stage of labor because of the exertion PR \> 100 beats per minute during labor is unusual- indication of hemorrhage 3*[. Inadequate or prolonged Contractions]* *[4.Abnormal Lower Abdominal Contour]* \> Full bladder is dangerous: 1.Bladder may be injured by the pressure of the fetal head 2.Pressure of the full bladder may not allow the fetal head to descend Nsg Mgt: Urge woman to void every 2 hours during labor 5\. Increasing Apprehension ***[Fetal Danger Signs of Labor]*** 1.Meconium Staining Green color in the amniotic fluid reveals the fetus has had a loss of rectal sphincter control, allowing meconium to pass into the amniotic fluid May indicate fetal hypoxia which stimulates the vagal reflex and leads to increased bowel motility. 2.High or Low FHR 3\. Hyperactivity \> Sign of fetal hypoxia 4.Low O2 saturation \> Normal O2 saturation is 40% to 70% **[Fetal Heart Rate Patterns]** *1. Accelerations* \> Normal increases in FHR caused by fetal movement, a change in maternal position or administration of an analgesic. *2. Deceleration* \> Normal decreases in FHR resulting from pressure on the fetal head during contractions \> a transient decrease in heart rate that coincides with the onset of a uterine contraction, resulting in vagal stimulation and slowing of the heart rate. *3. Late Decelerations* Decelerations that are delayed after the onset of contractions that suggest decreased blood flow to the uterus gradual decrease in the fetal heart rate typically following the uterine contraction **Causes:** a\. uteroplacental insuffiency ( not enough oxygen to the baby), b\. amniotic fluid infection which can occur due to excessively long labor after the water has been broken c\. low maternal blood pressure *4. Prolonged Decelerations* - Decelerations that are a decrease from the FHR baseline of 15 beats per minute or more and last longer than 2 to 3 minutes but less than 10 minutes. *5. Variable Decelerations* Decelerations that occur at unpredictable times in relation to contractions that indicate compression of the umbilical cord 6*. The sinusoidal pattern* - In a fetus that is severely anemic or hypoxic, central nervous system control of heart pacing may be so impaired that the FHR pattern resembles a smooth, frequently undulating wave with a cycle frequency of 3 to 5 per minute and persisting 20 minutes or more. **WEEK 8** The nursing role in providing comfort during labor and birth **[I.Methods of Pain Management]** ***[1.The Bradley (Partner-Coached) Method]*** \>Stresses the important role of a woman's partner during pregnancy, labor, and the early newborn period \> During pregnancy, the woman performs muscle toning exercises and limits or omits foods rich in preservatives, animal fat ,or salty foods. \>The woman is encouraged to walk during labor ***[2.The Psychosexual(Kitzinger) Method]*** \>Includes conscious relaxation and levels of progressive breathing that encourages a woman to "flow with" uterine contractions ***[3.The Dick-ReadMethod]*** \>Premise is "fear leads to tension, tension leads to pain" \> Achieved through education and focus on abdominal breathing during contractions ***[4.TheLamazeMethod]*** ØBased on the "gating theory of pain control" \>Through stimulation response conditioning, women can learn to use controlled breathing to reduce pain during labor \> Also termed as psycho prophylactic method because it focuses on preventing pain in labor **Six major Concepts** 1.Labor should begin on its own, not be induced 2.Women should walk, move around and change positions throughout labor 3.Women should bring a loved one, friend or doula for continuous support. 4\. Interventions that are not medically necessary should be avoided. 5\. Women should be allowed to give birth in other positions than on their back and should follow their body's urges to push 6\. Mother and baby should be kept together after birth , it is best for the mother, the baby and for breastfeeding **Doula**-a woman, typically without formal obstetric training, who is employed to provide guidance and support to a pregnant woman during labor. ***[5.Conscious relaxation]*** - RELAXING BODY PARTS ***[6.BREATHING EXERCISES]*** a\. Cleansing breath \>Breathing in deeply and exhaling deeply b\. Consciously controlled breathing \>Set breathing patterns at specific rates, provides distraction as well as prevents the diaphragm from descending fully and putting pressure on the expanding uterus. **[LEVEL 1]**:slow deep chest breathing of comfortable but full respirations at a rate of 6-12 breaths per min \> Used for cervical dilatation: 0 and 3 cm **[LEVEL 2]**: lighter and more rapid breathing, rib cage expands but be so light that the diaphragm barely moves Ørate: up to 40 breaths/min ØCervical dilatation : 4 and 6 cm **[LEVEL 3]**: more shallow and more rapid breathing Ørate:50 to 70 breaths/min ØRespirations are faster but exhalation must be a little stronger to allow good air exchange and to prevent hypoventilation ØWoman should say "out" with each exhalation ØCervical dilatation:7 and 10 cm **[LEVEL 4]**: effective for transition contractions \>"PANT BLOW" pattern , or taking three or four quick breaths (in and out) then a force full exhalation \>Sounds like a train sound: breath-breath-breath-huff, and sometimes referred to as "choo-choo" or "hee-hee-hee-hoo" breathing **[LEVEL 5]**: continuous, very shallow panting at about 60 breaths/minute \> Can be used for very strong contractions or during the second stage of labor to prevent the woman from pushing before full dilatation **Comfort and Non pharmacologic Pain Relief Measures** ***[1.Doula]*** \> A woman who is experienced in childbirth and postpartum support \> Provides physical, emotional and informational support prenatally, during labor and birth and even at home in the postnatal period **2. Relaxation** **3.Focusing and imagery** **4. Breathing Techniques** **6. Herbal Preparations** **7. Aromatherapy and essential oils** ***[8. Heat or Cold Application]*** - Heat and cold can help some women during labor. - Heat can help the muscles relax, and both heat and cold can act as a nerve distractor because it provides a new sensation, which can reduce the perception of pain. ***[9. Bathing or Hydrotherapy]*** - is immersion in warm water during labor. - It can be used during any part of labor, including early labor and active labor, as well as the late ("pushing") phase. - Hydrotherapy is offered as a comfort measure, providing relaxation and pain relief. ***[10. Therapeutic Touch and Massage]*** Studies have shown that massage therapy performed during labor can significantly reduce pain.  Benefits: *[a. Releases Endorphins.]* Pregnancy massage stimulates the body's release of endorphins, which are chemicals produced by the pituitary gland. These act as a natural painkillers and provide welcome relief from labor pain, stimulating a positive outlook on the whole experience. *[b. Regulates Hormones]* Another of the benefits of pregnancy massage is that it produces and regulates neurohormones that make the labor experience less painful. Scientific evidence backs up the claims that it raises the levels of happy-brain chemicals while lowering stress-producing chemicals. [c. Relaxes Muscles] Labour raises anxiety levels. Even people who have never, or will never, experience labor, have some fear or anxiety surrounding it. So naturally, when you are actually going through it, you are going to feel all kinds of emotions. Labor is very much the rollercoaster woman describe it as being. *[d.Decreases the need for medical intervention]* - Research has shown that mothers who go through massage therapy are less likely to require medicinal in the course of labor because massage triggers the natural body processes required for a smooth childbirth experience. - When conducted by an experienced therapist, this type of massage stimulates contractions. That reduces the need an epidural or any other drug associated with labor induction. ***[11. Yoga and Meditation]*** \> can improve the outcomes of pregnancy and childbirth. They can be used as part of the care protocol along with childbirth preparation classes to reduce the complications of pregnancy and childbirth. ***[12. Reflexology]*** Reflexology techniques to stimulate the uterus and ovary reflexes as well the production of Oxytocin to help bring on labor naturally. ***[13. Hypnosis]*** \> Hypnobirthing is a birthing method that uses self-hypnosis and relaxation techniques to help a woman feel physically, mentally and spiritually prepared and reduce her awareness of fear, anxiety and pain during childbirth. **[14. Biofeedback]** -based on the belief that people have control over and can regulate internal events such as heart rate and pain responses. ***[15. Transcutaneous electrical nerve stimulation]*** -works to relieve pain by applying counterirritation to nociceptors. ***[16. Acupuncture and acupressure]*** -a form of complementary medicine that involves pricking the skin or tissues with needles, used to alleviate pain and to treat various physical, mental, and emotional conditions. -the application of pressure on specific points on the body to control symptoms **PHARMACOLOGIC MEASURES FOR PAIN RELIEF DURING LABOR** 1. **ANALGESIA**- reduces or decreases awareness of pain 2. **ANESTHESIA**- causes partial or complete loss of the pain sensation. **III.PHYSIOLOGIC CHANGES OF THE POSPARTAL PERIOD** Reproductive System Changes/Local Changes 1***[.Uterus-]***Uterine involution Immediately after birth- wt: 1,000g At the end of the 1st week- wt: 500 g Time involution is complete (6 weeks)- wt: 50g The uterus of a breastfeeding mother may contract more quickly because oxytocin stimulates uterine contractions Consistency of the post partal uterus- well contracted fundus feels so firm If soft and boggy in the first hour after delivery-uterine atony-post partum bleeding *Nursing Mgt*:check the bladder, massage the uterus, apply cold compress over the abdomen, Check the vital signs, administer Oxygen, notify the physician. **[2.The Cervix]** Immediately after birth -- feels soft and malleable to palpation Internal and external os- open End of 7 days- the external os narrowed to the size of a pencil opening, feels firm and nongravid again **[3.The vagina]** After vaginal birth- feels soft, with few rugae,its diameter is greater than normal Hymen is permanently torn with small separate tags of tissue Takes the entire postpartal period for the vagina to involute (by contraction, as with the uterus) until it gradually returns to its prepregnancy state. A woman who is breastfeeding may have delayed ovulation and may continue to have thin-walled or fragile cells that cause slight vaginal bleeding during sexual intercourse until about 6 weeks Advice the woman to practice *kegel exercise* -- to strengthen the tone of the vagina ***[4. The Perineum]*** Immediately after birth -- edematous and tender due to the great amount of pressure experienced during birth *Eccymosis* patches from ruptures capillaries on the surface Labia majora and labia minora remain atrophic and softened after birth and never return to its prepregnancy state Advice the woman non pharmacologic comfort measures: cold compress within 24H after birth warm compress after 24 H after birth May sit on a soft pillow or doughnut pad Pharmacologic pain relievers as prescribed by the doctor: acetaminophen, ibuprofen. **b.Systemic Changes** ***[1.The Hormonal System]*** Decrease in pregnancy hormone as soon as the placenta is no longer present \*HCG and hPL-almost negligible by 24Hrs By week 1 -- progestin, estrogen and estradiol are all at prepregnancy levels (estriol may take an additional week before it reaches prepregnancy levels) FSH (Follicle Stimulating Hormone) remains low for about 12 days and begin to rise as a new menstrual cycle is initiated ***[2.The Urinary System]*** During pregnancy- 2,000-3,000ml of excess fluid accumulates in the body so extensive diaphoresis (excessive sweating) and diuresis (excess urine production) begin almost immediately after birth to rid the body of this fluid. Daily urine output-from a normal level of 1,500 to as much as 3,000ml/day during the 2nd to 5th day after birth This marked increase in urine production causes the bladder to fill rapidly. Advice: - reassure the mother that this is normal - Instruct the mother to continue to drink a healthy amount of fluids daily especially if she is breastfeeding There is a transient loss of tone together with the edema surrounding the urethra due to the pressure from the fetal head as it passed on the bladder's underside This leads to decreased woman's ability to sense when she has to void A woman who has had an epidural anesthesia can feel no sensation in the bladder area until the anesthetic has worn off Management: 1.Asess a woman's abdomen frequently in the immediate postpartal period *[Method: Palpation: ]* Findings: a full bladder is felt as a hard or firm area just above the symphysis pubis *[Method: Percussion:]* place one finger flat on the woman's abdomen over the bladder and tap it with the middle finger of the other hand Findings: Full bladder- sounds resonant in contrast to the thudding sound of non-fluid filled tissue Results: this pressure make a woman feel as if she has to void but unable to do so Inadequate or lack of contraction Management: \> Assist the woman to the bathroom to urinate ***[3.The Circulatory System]*** Presence of reduced blood volume accumulated during pregnancy Causes Diuresis (excess urine production) between 2nd and 5th day after birth Blood loss at birth Normal blood loss with vaginal birth -- 300-500 ml Cesarean delivery -- 500-1,000 ml A 4 point decrease in hematocrit (proportion of RBC to circulating plasma)and a 1 g decrease in hemoglobin occur per 250 ml of blood lost If the woman was anemic during pregnancy, she could be expected an anemic afterwards *[Management]*: advice woman to eat food rich in iron; administer iron prep as prescribed ***[4.The Integumentary System]*** After birth -- striae gravidarum still appear reddened and may be more prominent White woman -- will fade to a pale white over the past 3-6 mos Black woman---may remain slightly darker pigment melasma/chloasma, linea nigra -- become barely detectable by 6 weeks Diastasis recti (overstretching and separation of the abdominal musculature) -- appear as slightly indented bluish streak in the abdominal midline Management: Modified sit-ups to strengthen abdominal muscles and return abdominal support to its prepregnancy level Surgery may be required to correct diastasis recti ***[5.The Gastrointestinal System]*** Digestion and absorption begin to be active again soon after delivery unless the woman has had a cesarean delivery Hemorrhoids (distended rectal vein) that has been pushed of the rectum during pregnancy may be present Bowel sounds are active but passage of stool may be slow because of the still-present effect of relaxin ( a hormone which softens and lengthens the cervix and pubic --symphysis for preparation of the infant's birth Management: \> Advice the woman to eat high fiber diet and increase fluid intake **RETROGRESSIVE CHNAGES OF THE PUERPERIUM** Retrogressive - declining from a better to a worse state *[1.Exhaustion]* Experienced by the woman for the last several months of pregnancy" difficulty sleeping Working hard during labor Experiencing "sleep hunger" *[2.Weight Loss]* Due to rapid diuresis and diaphoresis during the 2nd to 5th days after birth Weight loss of 5 lbs (2 to 4 kg) Due to lochia flow-additional lost of 2 to 3 lb (1 kg) Influenced by the woman's nutrition, exercise and breastfeeding 3.If the infant refuses, instruct the mother to pump her breasts to maintain flow and to avoid clogged ducts), then offer the affected breast after 12-24 HRs 4.Once the mastistis is treated-infants will resume breastfeeding after 12-24Hrs **[b. Pulse]** Usually slower than usual during the postpartal period *[Causes:]* During pregnancy- the distended uterus obstructed the amount of venous blood returning to the heart After birth- to accommodate the increased blood volume returning to the heart, stroke volume increases that leads to reducing the PR between 6-70beats/min. By the end of the first week- PR will return to normal During the postpartal period- a rapid and thread pulse could be a sign of hemorrhage **[c.Blood Pressure]** A decrease may indicate bleeding An elevation above 140/90- may indicate postpartal hypertension Compare the woman's BP with her prepregnancy level rather than with standard blood pressure ranges *[Causes:]* Oxytocin administration during the postpartal period-to achieve uterine contraction, cause contraction of all smooth muscle, including blood vessels These can increase blood pressure *[Management:]* \> Always assess the BP before administering- if Bp \> 140/90mmHg, withhold the medication and notify the attending physician-to prevent hypertension and possible cerebrovascular accident **[Orthostatic Hypotension-]** major complication during postpartal period *[Cause]*: woman lost a considerable amount of blood with birth Dizziness that occurs on standing because of the lack of adequate blood volume to maintain nourishment of the brain cells **To assess:** Check the woman's BP and PR while she is lying supine Raise the head of the bed fully upright Wait for 2-3 minutes and recheck the BP and PR If PR is increased \> 20beats/min. and BP is \< 15 to 20mmHg than formerly- woman is positive for **Management**: 1.Inform the attending physician 2.Advice the woman to sit up slowly and "dangle" her legs on the side of her bed before attempting to stand and walk 3.If with obvious dizziness, support the woman to avoid falling incident 4.Advice the woman not to attempt to walk while carrying her newborn until her cardiovascular status adjusts to her blood loss. **B.PROGRESSIVE CHANGES OF THE PUERPERIUM** *[progressive]*- the building of new tissue Requires good nutrition; caution women against strict dieting that would limit cell-building ability during the first 6 weeks after childbirth **[1.Lactation]** Driven by hormones from the hypothalamus to the pituitary gland in order to secrete the lactation hormones This is identified by four phases of lactogenesis (human milk production) A retained placenta inhibit this process by causing continual circulation of progesterone -- inhibit prolactin and milk production **[FOUR PHASES]**: ***[LACTOGENESIS 1]*** -- milk synthesis Begins around 16 weeks gestation as the glandular luminal cells in the breast begin to secreting colostrum (thin, watery prelactation secretion) ***[LACTOGENESIS II]*** Triggered at birth by the delivery of the placenta, when the progesterone (prolactin is no longer inhibited) and other circulating pregnancy hormones suddenly decrease and oxytocin sharply increases as a result of the infant sucking. Oxytocin helps the uterus to shrink to its pre pregnancy size Some mothers feel uterine cramps initially when breast feeding until the uterus fully involutes. Often when mothers feel their "milk has come in" (engorgement)-occurs between birth to 5 to 10 days postpartum; termed as "transitional milk" **[LACTOGENESIS III]** occur from day 10 until weaning postpartum When the "mature milk" supply is driven by the circulating lactation hormones oxytocin and progesterone **[LACTOGENESIS IV]** Occurs after complete weaning and the breasts involute to their prelactation state Breast milk forms in response to the decrease in estrogen, and progesterone levels that follows delivery of the placenta This stimulates prolactin production and milk production and an increase in prolactin and oxytocin *[Signs and symptoms]*: breasts become fuller, larger and firmer as blood and lymph enter the area to contribute fluid to the formation of milk. Breasts distention, engorgement with feeling of heat or tenderness Engorgement phase: the breast tissue appear reddened- 3rd or 4th day after birth- primary engorgement Fades when infant begins effective latching and begins transferring colostrum followed by milk from the breasts **[Factors that Influence successful Breastfeeding:]** 1.infant's successful latch 2.Ability to suck 3.Transfer milk effectively 4\. Lactation support 5.Milk supply 6.Emplyment 7.Personal habits 8.mother's view about breastfeeding ***[3.Return of Menstrual Flow]*** After the delivery of the placenta production of placental estrogen and progesterone ends Rise in production of FSH Ovulation Return of Normal Menstrual Cycles \> woman not breastfeeding -- menstrual flow return 6-10 weeks after birth \> If breastfeeding- menstrual flow may not return for 3 or 4 months (lactational amenorrhea) **IV.Psychological Changes During the Post Partal period** ***[Phases of the Puerperium]*** *a. Taking-in phase* 2 to 3 days postpartum Woman is dependent and largely passive *b. Taking-hold phase* \> 3 days to 2 weeks Woman initiates actions and makes her own decisions *c. Letting-go phase* \> Varied time frame \> Woman redefines her new role **[Maternal Concerns and Feelings in the Postpartal Period]** 1.Abandonment/Feeling overlooked/ forgotten 2.Disappointment/disillusionment 3.Postpartal Blues **[V.Discharge Planning]** The greatest need of a postpartal woman before discharge from a hospital is education to prepare her to care for herself and her newborn at home. Areas of Concern Before Discharge *[1.Rooming In]* -- keeping the infant with the parents To make the woman or parents to become acquainted with their child To make the parents more confident in their ability to care for their baby To form a mother-child relationship ***[2.Sibling Visitation]*** Reduces feelings that their mother cares more about the new baby than about them To relieve some of the impact of separation Help to make the baby a part of the family Check if siblings are free of contagious diseases Have them wash their hands **[Areas of concern]**: 1.How to bathe and breastfeed the baby 2.Care for the infant's cord and circumcision 3.A review of how much infant's sleep during 24 hours 4.Inform a woman that she must return to her physician for an examination 4-6 weeks after birth; take the baby to the primary care provider for an examination within the first 3 to 5 days postpartum. **[5.Maternal Immunizations]** Centers for Disease Control and Prevention (CDG) recommend that each pregnant woman receive a Tdap and seasonal influenza vaccine with each pregnancy. Tdap -- Tetanus, Diptheria & Pertussis Check if this was given prenatally to the women, if not, inform her physician and if applicable to be given prior to discharge Other close caregivers: partners, grandparents are also recommended to be up to date on their Tdap and influenza vaccines If the woman does not have adequate rubella antibody titer and anticipates further pregnancies , she should be asked if she wants a rubella immunization before discharge Women who are Rh negative and who have had an Rh-positive infant will receive Rh0 (D) immunoglobulin (RhIg) or Rh antibodies to prevent iso immunization concerns in a future pregnancy Inform the parents that many healthcare agencies have a community liaison person, ideally a nurse, who calls or makes a home visit to women after discharge This person helps the new mother assess her own health and that of her baby and answers questions from families who lose their instructions or unable to interpret them after they have returned home. Making telephone calls or visiting a family 24 Hours after discharge is another way to evaluate whether the family is able to continue self-evaluation and infant care ***[6.Postpartal Examination]*** Check up 4-6 weeks after birth (the end of the postpartal period) ***Areas of Concerns:*** Review of Post Partum Assessment Breast: check if the woman is breast feeding- she is free of nipple pain or damage and has established milk supply Abdomen/Uterus: check for tone and determine that the uterus involution is complete and the uterus is no longer palpable abdominally Returning to work or school Internal Examination-to be certain involution is complete and any lacerations sustained during birth have healed. **WEEK 9** Nursing care for the family in need of reproductive life planning. **1.REPRODUCTIVE LIFE PLANNING** *[IDEAL CONTRACEPTIVE SHOULD BE:]* - Safe, effective - Compatible with spiritual and cultural beliefs and personal; preferences of both the users and sexual partner - Free of bothersome side effects - Convenient to use and easily obtainable - Affordable and needing few instructions for effective use - Free of effects on future pregnancies Before a patients begins using a new method of contraception, information that should be obtained includes; - Vital signs, PT, and hemoglobin for detection of anemia - Papanicolaou pap smear test and STI screening - Obstetric history - Subjective assessment - Sexual practices **[Natural Family Planning]** ***[Abstinence]***- or refraining from sexual relations -has 0% failure rate and also the most effective way to prevent STI,s -sex education *[**Periodic Abstinence-**]* a method to avoid pregnancy by avoiding sex on the days conception may be possible. **Lactation Amenorrhea Method (LAM)** **-**safe birth control method **[Criteria]** An *[infant]* is: - Under 6 months of age - Being totally breastfed at least every 4 hours during the day and every 6 hours at night, and - Receiving no supplementary feedings *[Mother]* menses has not returned. **[Coitus Interruptus]** - The man withdraws his penis and ejaculates outside the vagina - One of the oldest known methods of contraception - Pre ejaculation **[POST COITAL DOUCHING]** -Douching following intercourse, no matter what solution is used, is ineffective as a contraceptive measure as sperm may be present in cervical mucus as quickly as 90seconds after ejaculation, long before douching could be accomplished. **FERTILITY AWARENESS METHODS** -Methods rely on detecting when a person will be capable of impregnation so they can use periods of abstinence during that time. ***[Calendar (Rhythm) Method]*** - Requires a couple to abstain from coitus on the days of a menstrual cycle when the woman is most likely to conceive. - The woman keeps a diary of about six menstrual cycles - To calculate "safe" days, she subtracts 18 from the shortest cycle she documented - This number predicts her first fertile day. - She then subtracts 11 from her longest cycle - This represents her last fertile day ***[Basal Body Temperatur]*e** - Before the day of ovulation, a woman's basal body temperature (BBT) falls about 0.5 degrees F - At the time of ovulation, her BBT rises a full Fahrenheit degree (0.2 degrees C) due to increase progesterone with ovulation - Serves as a basis for the BBT [Procedure:] Woman takes her temperature early in the morning before getting up from bed and without undertaking any activity Route: oral/tympanic membrane **[How to interpret:]** (+) ovulation -- if a slight dip in temperature followed by an increase No coitus for the next 3 days (the possible life of the discharged ovum) Sperm can survive from 3 to 5 days and rarely as many as 7 days in the female reproductive tract, calendar method and BBT are recommended to be combined **[Factors that can affect BBT:]** Increased temperature might be due to other illness-could be mistaken as a sign of ovulation-could mistake a fertile day with a safe one Changes in the woman's schedule **[Cervical Mucus Method (Billing's Method)]** - Before ovulation each month- cervical mucus is thick and does not stretch when pulled between the thumb and finger - Just before ovulation- mucus secretion increases - On the day of ovulation -- the peak day- becomes copious, thin, watery and transparent, feels slippery (like egg white) and stretches at least 1 inch before the strand breaks A property known as **[spinnbarkeit]** all the days the mucus is copious and for at least 3-4 days afterward- considered as fertile days **[Symptothermal Method]** - Combines the cervical mucus and BBT methods - Couple abstains from coitus until 3 days after the rise in temperature or the fourth day after the peak of mucus change - They also analyze their cervical mucus everyday and observe for other signs of ovulation such as *[mittelschmerz (midcycle abdominal pain)]* or if the cervix feels softer than usual. **STANDARD DAYS METHOD: CYCLE BEADS**  **[MARQUETTE MODEL]** - This method combines the use of ovulation detection with other signs of ovulation( cervical mucus, BBT, cervix position and softness) to avoid pregnancy during the fertile period. - Develop by nurses and doctors in the late 1990's at Marquette University in Wisconsin. - The Marquette Model brings 21st-century technology to NFP by using urine fertility biomarkers collected at home that measure hormone levels. - These biomarkers can be used in conjunction with cervical mucus or basal body temperature and an algorithm to confidently determine the woman\'s fertile window. - The purpose of using natural biological signs of fertility is to help women and couples to identify the day closest to ovulation and narrow the estimated fertile window. **[Hormonal Methods]** *[Oral contraceptives]* Commonly known as the pill OC4 (for oral contraceptive) COC4 (for combination oral contraceptives) Contain synthetic estrogen and progesterone suppressing ovulation **[estrogen]**- acts to suppress follicle stimulating hormone (FSH) and LH (Luteinizing Hormone) to suppress ovulation **[Progesterone]** -- causes & decrease in the permeability of cervical mucus and so limits sperm motility and access to ova. Interferes with tubal transport and endometrial proliferation to an extent the possibility of implantation is decreased. **[Benefits of oral Contraceptives:]** *Decreasing the incidence of:* - Dysmenorrhea because of lack of ovulation - Premenstrual dysphoric syndrome and acne because of the increased progesterone levels - Iron deficiency anemia because of the reduced amount of menstrual flow - Acute pelvic inflammatory disease (PID) and resulting tubal scarring - Endometrial and ovarian cancer, ovarian cysts, and ectopic pregnancies - Fibrocystic breast disease **PROGESTIN-ONLY PILLS (MINI PILLS)** - Containing only progestin\'s - Without estrogen content, ovulation may occur, but because the progestins have not allowed the endometrium to develop fully or sperm to freely access the cervix, fertilization and implantation will not take place. **[Subcutaneous Implants]** - Consist of 6 non-biodegradable implants filled with synthetic progesterone - Embedded just under the skin on the inside of the upper arm where it will slowly release progestin over a period of 3 years - Barely noticeable, appears as an irregular - crease on the skin, like a small vein - Implanted in a clinic under local anesthetic during - menses or no later than day 7 of a menstrual cycle - to be certain the woman is not pregnant **[Effects:]** Suppress ovulation, thicken cervical mucus, Change the endometrial lining making implantation difficult **[Transdermal patch/ ESTROGEN/PROGESTERONE]** - The small patch, worn on the skin, releases hormones into your bloodstream that thicken cervical mucus and suppress ovulation. - The birth control patch is a type of contraception that contains the hormones estrogen and progestin. - You wear the patch to avoid becoming pregnant. - The transdermal contraceptive patch is a safe and convenient birth control method that works really well if you always use it correctly. **[Intramuscular Injections]** Depo-Provera (single injection every 12 weeks) inhibits ovulation -advantage: long term reliability/ -disadvantage: weight gain, headache , depression , irregular menses, loss of bone mineral density. **[Intrauterine Devices]** A small T-shaped device that is inserted into the uterus through the vagina May contain copper or progesterone **[Barrier Methods]** Barrier method are forms of birth control that place a chemical or latex barrier between the cervix and advancing sperm so sperm cannot reach and fertilize an ovum. **SPERMICIDES** -An agent that causes the death of spermatozoa before they can enter the cervix. -often combination of other physical barrier methods **[Diaphragm]** - A circular rubber disk that is placed over the cervix before intercourse - Use of a spermicidal gel with a diaphragm combines a barrier and a chemical method of contraception **[Cervical Cap]** A soft rubber that fits snugly over the uterine cervix Use with a spermicidal gel  **[Male Condom]** Latex rubber or synthetic sheath that is placed over the erect penis before coitus begins **[Female Condom]** Latex sheaths made of polyurethrane and pre-lubricated with spermicide **[Surgical Methods]** *[Tubal Ligation]* Female sterilization Fallopian tubes are occluded, preventing passage of both sperm and ova **HYSTERECTOMY** -Removal of uterus or ovaries **FIMBIECTOMY** -Removal of fimbria at the distal end of the tubes **SALPINGECTOMY** -removal of the entire fallopian tube and fimbria **Laparoscopy technique-** surgical procedure where small incision is made in the abdomen for the purpose of viewing or performing surgery on the organs of the pelvis or abdomen. **TAH-BSO** **What is a total abdominal hysterectomy with a bilateral salpingo-oophorectomy?\ **Hysterectomy is a surgery to remove the uterus and cervix. "Abdominal" is the surgical technique that will be used. This means the surgery will be done through an incision in your abdomen. A bilateral salpingo-oophorectomy is surgery to remove both of your ovaries and fallopian tubes. The hysterectomy and bilateral salpingo-oophorectomy will both be done during one procedure. This surgery will remove the uterus, cervix, ovaries, and fallopian tubes. After a hysterectomy you will no longer have periods or be able to become pregnant  **[Vasectomy]** *Male sterilization* The vas deferens are cut and occluded, blocking the passage of spermatozoa **WEEK 10** **[IMMEDIATECAREOFTHENEWBORN:]** - The period from birth to 28 days of life is called neonatal period and infant in this is termed as neonate or newborn baby. - The first week of life is known as early neonatal period and the late neonatal period extends from 7th day to 28 days of age. - Care given to newborn during neonatal period is known as new born care. **TYPES OF NEWBORN CARE:** 1.Immediate care of newborn--care of the baby that needs to be given at birth in the labor room 2.Later care of newborn --care of the baby that needs to be given in the postnatal ward and after discharge at home. **[Immediate Care of Newborn]** ***Objectives*** 1.Establishment of respirations and maintenance of a patent airway. \>Suction the newborn starting from the mouth and then nose. Do not start in nose since it can cause aspiration Suction gently and quickly Prolonged and deep suctioning of the naso pharynx during the first 5-10 minutes after birth will stimulate the vagus nerve (located in the esophagus) and cause bradycardia 2\. Position the baby in a Trendelenburg position inside the crib, except when there are signs of increased intracranial pressure: \> shrill, high pitched cry \> Vomiting \> Tensed, bulging anterior fontanel \* Quickly examine the infant for respiratory problems and abnormality 3.Maintain appropriate body temperature If temperature is below 35 degrees C, hypothermia occur Baby will chill and uses a lot of glucose leading to hypoglycemia Baby will also use the fats that leads to the release of fatty acids leading to respiratory acidosis **[Remember:]** The moment the baby is out, dry him The majority of heat loss occurs because of four separate mechanism: 1\. convection-air conditioner 2\. radiation-cold window/aircon 3\. conduction-warmed blanket 4\. evaporation-warm blanket/skin to skin contact **[4.Perform APGAR Scoring]** **[Apgar scoring]** The Apgar score helps find breathing problems and other health issues. It is part of the special attention given to a baby in the first few minutes after birth. The baby is checked at 1 minute and 5 minutes after birth for heart and respiratory rates, muscle tone, reflexes, and color. A baby who needs help with any of these issues is getting constant attention during those first 5 to 10 minutes. In this case, the actual Apgar score is given after the immediate issues have been taken care of. Each area can have a score of 0, 1, or 2, with 10 points as the maximum. Most babies score 8 or 9, with 1 or 2 points taken off for blue hands and feet because of immature circulation. If a baby has a difficult time during delivery and needs extra help after birth, this will be shown in a lower Apgar score. Apgar scores of 6 or less usually mean a baby needed immediate attention and care. +-------------+-------------+-------------+-------------+-------------+ | | **SIGNS** | **0 POINT** | **1 POINT** | **2 | | | | | | POINTS** | +=============+=============+=============+=============+=============+ | **A** | **Appearanc | Pale all | Pink body, | pink all | | | e: | over, | blue | over | | | Skin | | extremities | | | | Color** | blue-gray | | | +-------------+-------------+-------------+-------------+-------------+ | **P** | **Pulse | Absent | Below | Above | | | Rate** | | 100bpm | 100bpm | +-------------+-------------+-------------+-------------+-------------+ | **G** | **Grimace** | No Response | With slight | Sneezes, | | | | | grimace | coughs, | | | | | | pulls away | +-------------+-------------+-------------+-------------+-------------+ | **A** | **Activity: | Absent, | Arms and | Active | | | Muscle | Limp/ | legs flexed | movement | | | Tone** | flaccid | | | +-------------+-------------+-------------+-------------+-------------+ | **R** | **Respirati | Absent | weak/ | Good cry | | | on** | | irregular | | +-------------+-------------+-------------+-------------+-------------+ The intent of this scoring system is to help identify newborns at risks of complications ØA score is given for each sign at one minute and five minutes after birth ØIf there are problems with the newborn, an additional score is given at 10 minutes ØA score of 7-10 is considered normal Ø4-7-require some resuscitative measures ØA score of 3 and below-requires immediate resuscitation **[Birth weight]** A baby\'s birth weight is an important marker of health. Full-term babies are born between 37 and 41 weeks of pregnancy. The average weight for full-term babies is about 7 pounds (3.2 kg). In general, very small babies and very large babies are at greater risk for problems. Babies are weighed every day in the nursery to look at growth, and the baby's need for fluids and nutrition. Newborn babies may often lose 5% to 7% of their birth weight. This means that a baby weighing 7 pounds 3 ounces at birth might lose as much as 8 ounces in the first few days. Babies will usually gain this weight back within the first 2 weeks after birth. Premature and sick babies may not begin to gain weight right away. Most hospitals use the metric system for weighing babies. This chart will help you convert grams to pounds. **Converting grams to pounds and ounces:** 1 lb. = 453.59237 grams; 1 oz. = 28.349523 grams; 1000 grams = 1 Kg. **[Measurements]** The hospital staff takes other measurements of each baby. These include: ***[Head circumference]**.* The distance around the baby\'s head. ***[Abdominal circumference]***. The distance around the belly (abdomen). ***[Length]**.* The measurement from top of head to the heel. The staff also checks these vital signs: ***[Temperature]***. This checks that the baby is able to have a stable body temperature in normal room. ***[Pulse]***. A newborn's pulse is normally 120 to 160 beats per minute. ***[Breathing rate]***. A newborn's breathing rate is normally 40 to 60 breaths per minute. **[Physical exam]** A complete physical exam is an important part of newborn care. The healthcare provider carefully checks each body system for health and normal function. The provider also looks for any signs of illness or birth defects. Physical exam of a newborn often includes: **[General appearance]**. This looks at physical activity, muscle tone, posture, and level of consciousness. **[Skin.]** This looks at skin color, texture, nails, and any rashes. **[Head and neck]**. This looks at the shape of head, the soft spots (fontanelles) on the baby's skull, and the bones across the upper chest (clavicles). **[Face.]** This looks at the eyes, ears, nose, and cheeks. **[Mouth]**. This looks at the roof of the mouth (palate), tongue, and throat. **[Lungs.]** This looks at the sounds the baby makes when he or she breathes. This also looks at the breathing pattern. Heart sounds and pulses in the groin (femoral) **[Abdomen]**. This looks for any masses or hernias. **[Genitals and anus.]** This checks that the baby has open passages for urine and stool. **[Arms and legs]**. This checks the baby's movement and development. **[Gestational assessment]** The healthcare provider will check how mature the baby is. This is an important part of care. This check helps figure out the best care for the baby if the dates of a pregnancy are uncertain. For example, a very small baby may actually be more mature than he or she appears by size, and may need different care than a premature baby needs. Healthcare providers often use an exam called the Dubowitz/Ballard Examination for Gestational Age. This exam can closely estimate a baby\'s gestational age. The exam looks at a baby\'s skin and other physical features, plus the baby's movement and reflexes. The physical maturity part of the exam is done in the first 2 hours of birth. The movement and reflexes part of the exam is done within 24 hours after birth. The provider often uses the information from this exam to help with other maturity estimates. **[Physical maturity]** The physical maturity part of the Dubowitz/Ballard exam looks at physical features that look different at different stages of a baby\'s gestational age. Babies who are physically mature usually have higher scores than premature babies. Points are given for each area of assessment. A low of -1 or -2 means that the baby is very immature. A score of 4 or 5 means that the baby is very mature (postmature). These are the areas looked at: ***[Skin textures]***. Is the skin sticky, smooth, or peeling? *[**Soft, downy hair on the baby's body (lanugo)**.]* This hair is not found on immature babies. It shows up on a mature infant, but goes away for a postmature infant. ***[Plantar creases]***. These are creases on the soles of the feet. They can be absent or range up to covering the entire foot. *[**Breast**.]* The provider looks at the thickness and size of breast tissue and the darker ring around each nipple (areola). ***[Eyes and ears]***. The provider checks to see if the eyes are fused or open. He or she also checks the amount of cartilage and stiffness of the ears. ***[Genitals, male]***. The provider checks for the testes and how the scrotum looks. It may be smooth or wrinkled. ***[Genitals, female]***. The provider checks the size of the clitoris and the labia and how they look. **[Maturity of nerves and muscles]** The healthcare provider does 6 checks of the baby\'s nerves and muscles. A score is given to each area looked at. Typically, the more mature the baby is, the higher the score. These are the areas checked: **[Posture]**. This looks at how the baby holds his or her arms and legs. **["Square window."]** This looks at how far the baby\'s hands can be flexed toward the wrist. **[Arm recoil]**. This looks at how much the baby\'s arms \"spring back\" to a flexed position. **[Popliteal angle]**. This looks at how far the baby\'s knees extend. "**[Scarf sign."]** This looks at how far the baby's elbows can be moved across the baby\'s chest. **[Heel to ear.]** This looks at how near the baby\'s feet can be moved to the ears.  When the physical assessment score and the nerves and muscles score are added together, the healthcare provider can estimate the baby's gestational age. Scores range from very low for immature babies to very high scores for mature and postmature babies. All of these exams are important ways to learn about your baby\'s well-being at birth. By finding any problems, your baby\'s doctor can plan the best possible care. **[Physiologic Function Changes in the newborn at birth]** **[LUNGS, HEART, AND BLOOD VESSELS]** The mother\'s placenta helps the baby \"breathe\" while it is growing in the womb. Oxygen and carbon dioxide flow through the blood in the placenta. Most of it goes to the heart and flows through the baby\'s body. This allows for the baby to have the proper amount of these chemicals in their body. At birth, the baby\'s lungs are filled with fluid. They are not inflated. The baby takes the first breath within about 10 seconds after delivery. This breath sounds like a gasp, as the newborn\'s central nervous system reacts to the sudden change in temperature and environment. *Once the baby takes the first breath, a number of changes occur in the infant\'s lungs and circulatory system:* Increased oxygen in the lungs causes a decrease in blood flow resistance to the lungs. Blood flow resistance of the baby\'s blood vessels also increases. Fluid drains or is absorbed from the respiratory system. The lungs inflate and begin working on their own, moving oxygen into the baby\'s bloodstream and removing carbon dioxide by breathing out (exhalation). **[BODY TEMPERATURE]** A developing baby produces about twice as much heat as an adult. A small amount of heat is removed through the developing baby\'s skin, the amniotic fluid, and the uterine wall. After delivery, the newborn begins to lose heat. Receptors on the baby\'s skin send messages to the brain that the baby\'s body is cold. The baby\'s body creates heat by burning stores of brown fat, a type of fat found only in fetuses and newborns. Newborns are rarely seen to shiver. **[LIVER]** In the baby, the liver acts as a storage site for sugar (in the form of a chemical called glycogen) and iron. When the baby is born, the liver has various functions: It produces substances that help the blood to clot. It begins breaking down waste products such as excess red blood cells. It produces a protein that helps break down bilirubin. If the baby\'s body does not properly break down bilirubin, it can lead to newborn jaundice. **[GASTROINTESTINAL TRACT]** A baby\'s gastrointestinal system doesn\'t fully function until after birth. In late pregnancy, the baby produces a tarry green or black waste substance called meconium. Meconium is the medical term for the newborn infant\'s first stools. Meconium is composed of amniotic fluid, mucus, lanugo (the fine hair that covers the baby\'s body before birth), bile, and cells that have been shed from the skin and intestinal tract. In some cases, the baby passes stools (meconium) while still inside the uterus. **[URINARY SYSTEM]** The developing baby\'s kidneys begin producing urine by 9 to 12 weeks into the pregnancy. After birth, the newborn will usually urinate within the first 24 hours of life. The kidneys become able to maintain the body\'s fluid and electrolyte balance. The rate at which blood filters through the kidneys (glomerular filtration rate) increases sharply after birth and in the first 2 weeks of life. Still, it takes some time for the kidneys to get up to speed. Newborns have less ability to remove excess salt (sodium) or to concentrate or dilute the urine compared to adults. This ability improves over time. **[IMMUNE SYSTEM]** The immune system begins to develop in the baby, and continues to mature through the child\'s first few years of life. The womb is a relatively sterile environment. But as soon as the baby is born, they are exposed to a variety of bacteria and other potentially disease-causing substances. Although newborn infants are more vulnerable to infection, their immune system can respond to infectious organisms. Newborns do carry some antibodies from their mother, which provide protection against infection. Breastfeeding also helps improve a newborn\'s immunity by continuing to supply antibodies from the mother to the baby. **[SKIN]** Newborn skin will vary depending on the length of the pregnancy. Premature infants have thin, transparent skin. The skin of a full-term infant is thicker. ***Characteristics of newborn skin:*** A fine hair called l*[anugo]* might cover the newborn\'s skin, especially in preterm babies. The hair should disappear within the first few weeks of the baby\'s life. A thick, waxy substance called **[vernix]** may cover the skin. This substance protects the baby while floating in amniotic fluid in the womb. Vernix should wash off during the baby\'s first bath. The skin might be cracking, peeling, or blotchy, but this should improve over time. **[Neuromuscular System]** -term newborns demonstrate neuromuscular function by moving their extremities, attempting to control head movements, exhibiting a strong cry, and demonstrating newborn reflexes. **The blink reflex** -a blink reflex in a newborn serves the same purpose as it does in an adult-to protect the eye from any objects coming near it by rapid eyelid closure. It may be elicited by shinning a strong light such as a flashlight into an eye. **[The rooting reflex]** -The rooting reflex in babies is a basic survival instinct. This reflex helps your baby find and latch onto a bottle or your breast to begin feeding. When you gently stroke the corner of your baby\'s mouth with your nipple, they should instinctively turn their head toward it to nurse. **[The sucking reflex]** -When the roof of the baby\'s mouth is touched, the baby will start to suck. This reflex doesn\'t start until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this. -newborns lips are touched, the baby makes a sucking motion. -begin to diminish at about 6 months of age. **[The swallowing reflex]** -It is integrated by 12-18 months. Swallowing Reflex: The swallow is initiated when food, liquid, or saliva reaches your baby\'s throat. Your baby comes under control of this reflex by 18 months and it continues as an important reflex throughout our lives. -Swallowing reflex serves as a defensive airway reflex. Any procedures that disturb the coordination of respiration and swallowing may increase the chance of pulmonary aspiration. **[The extrusion reflex]** -When your baby pushes solid food out of their mouth using their tongue, it\'s called the extrusion reflex (it\'s also referred to as tongue-thrust reflex). While it may seem discouraging that your baby doesn\'t want to try new textures, this reflex is a primitive instinct to protect them. -fades at 4months **[The palmar grasp reflex]** -The palmar grasp reflex is present at birth and persists until 4 to 6 months of age. When an object is placed in the infant\'s hand, the fingers close and tightly grasp the object. The grip is strong but unpredictable. \--fades about 6 weeks to 3 months of age; after it fades, a baby begins to grasp meaningfully. **[The step(walk)-in-place reflex]** -newborns who are held in a vertical position with their feet touching a hard surface will take a few quick, alternating steps. -disappears by 3 months of age. **[The placing reflex]** -elicited by touching the anterior lower leg against a surface such as the edge of a table. The newborns makes few quick lifting leg motions, as if to step onto the table. **[The plantar grasp reflex]** -the lateral surfaces of the foot bend as if to make a cup out of the plantar surface -disappears at 8 to 9 months **[The tonic neck reflex]** -Tonic neck reflex or \"fencing"or boxer posture You may notice that when your baby\'s head turns to one side, his corresponding arm will straighten, with the opposite arm bent, as if he\'s fencing. -disappears on the 2^nd^ and 3^rd^ months of life. **[The moro reflex]** -The Moro reflex is a normal reflex for an infant when he or she is startled or feels like they are falling. The infant will have a startled look and the arms will fling out sideways with the palms up and the thumbs flexed. Absence of the Moro reflex in newborn infants is abnormal and may indicate an injury or disease. -strong for the 1^st^ 8 weeks of life and then fades by the end of the 4^th^ or 5^th^ month. **[The Babinski reflex]** -When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age. **[The magnet reflex]** -if pressure applied to the sole of the feet of a newborn lying in a supine position, they push back against the pressure. -this and the two following reflexes are test of spinal cord integrity. **[The crossed extension reflex]** -if the sole of baby\'s foot is stimulated and the lower limb is held in extension, baby should extend his other leg and bring it closer to the stimulated one as if to ward off \"the tickle\". **[The trunk incurvation reflex]** -Truncal incurvation or Galant reflex The Galant reflex is tested by holding the baby face-down in one hand while using the other hand to stroke the baby\'s skin along either side of the spine. -The baby\'s spine should curve in response, causing the head and feet to move towards the side being stroked. **[The landau reflex]** -The Landau is an important postural reflex and should develop by 4 to 5 months of age. -When the infant is suspended by the examiner\'s hand in the prone position, the head will extend above the plane of the trunk. -The trunk is straight and the legs are extended so the baby is opposing gravity. **[The deep tendon reflex]** -The first thing is to use a reflex hammer, not a finger or a stethoscope. Ideally, the baby is in a quiet alert state with the head in the midline. -The head turned to one side can reinforce the tone and reflexes on that side. I usually start with the knee jerk because is the easiest to obtain. -Take control of the leg with the hand under the knee and the leg at about a 90 degree angle at the knee. -Then strike the patellar tendon with the reflex hammer using a pendular action rather a chopping action. - Reposition the leg and try several times if you have trouble getting a knee jerk. - Absence of deep tendon reflexes is a much more important finding than hyperreflexia in the newborn. A normal newborn can have hyperreflexia and still be normal, if the tone is normal, but absent reflexes associated with low tone and weakness is consistent with a lower motor neuron disorder. ***[The senses of a newborn]*** Babies are born with all 5 senses---sight, hearing, smell, taste, and touch. Some of the senses are not fully developed. The newborn\'s senses are as described below. **[Sight]** Over the first few months, babies may have uncoordinated eye movements. They may even appear cross-eyed. Babies are born with the ability to focus only at close range. This is about 8 to 10 inches, or the distance between a mother\'s face to the baby in her arms. Babies are able to follow or track an object in the first few weeks of life. Focus improves over the first 2 to 3 years of life to a normal 20/20 vision. Newborns can detect light and dark but can\'t see all colors. This is why many baby books and infant toys have distinct black and white patterns. **[Hearing]** During pregnancy, many mothers find that the baby may kick or jump in response to loud noises and may quiet with soft, soothing music. Hearing is fully developed in newborns. Babies with normal hearing should startle in response to loud sounds. These babies will also pay quiet attention to the mother\'s or father\'s voice. And they will briefly stop moving when sound at a conversational level is begun. Newborns seem to prefer a higher-pitched voice (the mother\'s) to a low sounding voice (males). They can also tune out loud noises after hearing them several times. Newborns will have their hearing screened while still in the hospital. **[Smell]** Studies have found that newborns have a strong sense of smell. Newborns prefer the smell of their own mother, especially her breastmilk. **[Taste]** Babies prefer sweet tastes over sour or bitter tastes. Babies also show a strong preference for human milk and breastfeeding. This is especially true if they are breastfed first and then offered formula or a bottle. **[Touch]** Babies are comforted by touch. Placing a hand on your baby\'s belly or cuddling close can help him or her feel more secure. Wrapping your baby snugly in a blanket (swaddling) is another technique used to help newborn babies feel secure. You can buy a special swaddling blanket designed to make swaddling easier. **[Nutritional Allowances for newborn]** **For newborns** *Breast milk* is ideal for newborns up until 6 months (and can be continued up until the mother and their child have mutually understood that breastfeeding can stop). However, babies older than 6 months can still breastfeed along with eating solid food. *Breastfeeding* should start immediately after birth Breast milk provides all of the nutrients that a growing baby needs. For mothers who are not able to breastfeed, formula milk can be an alternative. However, exclusive breastfeeding is still recommended by doctors. Please consult your doctor/pediatrician first before starting formula milk It is important to note that not all formula milk is created equal. When choosing the right formula milk for your baby, always consult your doctor. **COLOSTRUM**- a thin watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies. **[Solid food]** Soft/Solid food is not a replacement for Breastfeeding/Breast milk... it is only a "complement" for breastmilk. Introduce soft, solid foods slowly. Wait 3-4 days before giving your child another solid food. Use a small spoon when feeding your baby, and feed them only small amounts to avoid choking. Don't force your baby to finish their food, especially if they are already full. At 6 to 8 months old, start with soft, mushy foods that are easily digestible. For babies who are 8 to 10 months old, be sure to cut up any big chunks of food into small pieces. Avoid using salt or sugar when preparing your child's food. **[Key Nutrients for Growth and Development]** Here is a list of the essential nutrients that can fulfill the nutritional requirements of babies 0-12 months old. **[Carbohydrates]** Carbohydrates are important because they provide energy that a growing baby needs. It functions as the primary energy source for babies, and it is important to make sure that they get enough carbohydrates to support their growth and development. Newborn babies get enough carbohydrates from breast milk, but older babies can get it from rich food sources such as rice, bread, and sweet potato. **[Protein]** Protein is an essential nutrient that helps fulfill the nutritional requirements of babies 0-12 months old. It functions as the building blocks of muscles, and also helps build and repair tissues for the eyes, skin, heart, lungs, brain, and other organs. Protein is also responsible for the production of hormones that are necessary for normal growth and development of babies. Foods rich in protein include breast milk, eggs, legumes, lean meat, chicken, and fish. **[Fat]** For most adults, fat would not necessarily be a part of a healthy diet. But for babies, fat is an essential part of their nutrition. Fat helps supply babies with energy, allows the absorption of fat-soluble vitamins, and also helps with brain development. For the most part, breast milk and infant milk can provide the fat necessary for a baby's growth and development. However, other sources of fat include, butter, vegetable oil, and fatty fish such as tuna and salmon. However, it is important to limit the fat intake of babies, since it can cause problems if eaten in large amounts. **[Vitamins A, D, E, C]** **[Vitamins A, D, E, and C]** are all important vitamins that help regulate body functions, and promote normal growth and development in babies. **[Vitamin A]** helps with proper vision, healthy skin, and a healthy immune system. **[Vitamin D]** helps with bone formation, and proper absorption of calcium and phosphorus in the body. **[Vitamin E]** helps protect vitamin A in the body, and helps prevent the breakdown of tissues. **[Vitamin C]** helps form collagen that is essential in the development of bones, cartilage, blood vessels, and other connective tissue. It also helps with wound healing, strengthens the immune system, and helps the body absorb iron better. These vitamins are found in breast milk, as well as fruits and vegetables. Ideally, your baby should be eating more fruits and vegetables in order to get the vitamins and minerals that they need to grow. **[B Vitamins]** B vitamins include vitamin B1,B2,B6,B12, niacin, thiamine, and folate. These vitamins are essential for regulating body functions, as well as brain development. They also help promote cell health and cell metabolism. Just like the other vitamins, B vitamins can be found in breast milk as well as fruits and vegetables. **[Calcium]** Calcium helps with healthy bone and tooth development, blood clotting, and maintenance of the nerves and muscles. The best sources of calcium for babies are from breast milk or infant formula. **[Iron]** Iron is a vital nutrient that is important when it comes to the production of red blood cells. Iron also helps prevent iron-deficiency anemia in babies. It can be found in breast milk, formula milk, red meat, fish, liver, and legumes. It would be best to obtain iron from these sources, rather than from supplements, because they are more readily absorbed by the body. **[Zinc]** Zinc is a nutrient that helps promote wound healing, blood formation, and formation of protein in the body. In addition, it also helps support a growing baby's immune system. Good sources of zinc are breast milk, red meat, and fish, eggs, and liver. **[Sodium]** Sodium is a mineral that helps maintain the balance of water in the body, regulates blood volume, as well as ensures the function of cells and cell membranes. For the most part, breast milk and formula milk can provide all of the sodium that a growing baby needs. While sodium is indeed found in salt, it would be best to avoid adding salt to your baby's food as they do not need to eat a lot of salt at a young age. **[Water]** Lastly, water is an essential nutrient that your baby's body needs. It helps regulate kidney function, metabolism, as well as the transportation of nutrients around the body. It also helps with regulating body temperature. For babies aged 0-4 months old, all of the water they need can be found in breast milk. However, as babies start to eat solid food, they also need to drink water as part of their meals. **WEEK 11** **COMPONENTS OF GROWTH AND DEVELOPMENT** Physiologic- physical appearance, body built, weight, height of an individual Cognitive- result of interaction between individual and the environment It deals on how people learn to think, reason and use of language Theory: Cognitive Theory by Piaget c.Moral -- identifying right from wrong \> Theory: Kohlberg's Theory d\. Psycho -- Social -- refers to the development of personality \> Theory: Freud's, Erickson's e\. Spiritual -- refers to individual's understanding of their relationship with the universe and their perceptions about the direction and meaning of life \> Theory: Fowler Westerhoff **PRINCIPLES OF GROWTH AND DEVELOPMENT** Growth and Development are continues, orderly, sequential processes influenced by maturational, environmental and genetic factors. All humans follow the same pattern of growth and development. 3.The sequence of each stage is predictable, although the time of onset, the length of the stage and the effects of each stage vary with the person 4.Learning can either help or hinder the maturational process, depending on what is learned 5\. Each developmental stage has its own characteristics 6\. Growth and Development occur in a cephalo-caudal direction, that is, starting at the head and moving to the trunk, the legs and the feet.  7\. Growth and Development occur in the proximodistal direction, that is from the center of the body outward. 8\. Development proceeds from simple to complex or from single act to integrated acts. 9\. Development becomes increasingly differentiated 10\. Certain stages of G. and D. are more critical than others. 11\. The pace of growth and development is uneven **III. Theories Related to Growth and Development** **1. SIGMUND FREUD -The Father of Psychoanalysis** Described the concepts of the unconscious mind, defense mechanism, and the id, ego and superego Unconscious mind- is the part of the person's mental life that the person is unaware of **[THREE ASPECTS OF PERSONALITY]** Id-resides in the unconscious and operating on the pleasure principle, seeks immediate pleasure and gratification. Ego -- operating on the reality principle, balances the gratification demands of the id with the limitations of social and physical circumstances The methods the ego uses to fulfill the needs of the id in a socially acceptable manner are called ***[DEFENSE MECHANISM OR ADAPTIVE MECHANISM]***, also these are the results of conflicts between the id's impulses and the anxiety that attends these conflicts due to environmental restrictions 3\. Superego- contains the conscience and the ego idea Also contains the DONT'S of society **[FIXATION]** -- is the immobilization or the inability of the personality to proceed to the next stage because of anxiety  **[DEFENSE MECHANISM]** *[1.Compensation]* -- Covering up weaknesses by emphasizing a more desirable trait or by overachievement Example: a high school student too small to play basketball becomes the star long distance runner for the track game. \> Allows a person to overcome weakness and achieve success *[2. Denial]* -- an attempt to screen or ignore unacceptable realities by refusing to acknowledge them Example: a woman though told her father has metastatic cancer, continues to plan a family reunion 18 mos in advance. Use/Purpose:  temporary isolate the person from the full impact of a traumatic situation 3\. *[Displacement]*- the transferring or discharging of emotional reactions from one object to another object or person. Example: a husband and wife are fighting and the husband becomes so angry, he hits a door instead of his wife Use/Purpose:  allows for feelings to be expressed through or to less dangerous objects or people 4*[. Identification]* -- an attempt to manage anxiety by imitating the behavior of someone feared or respected. Example: a new graduate suddenly left in charge emulates her faculty role model. Use/Purpose: Helps a person avoid self devaluation *[5. Intellectualization]* -- a mechanism which an emotional response that normally would accompany an uncomfortable or painful incident is evaded by the use of rational explanations that remove from the incident any personal significance and feeling Example: the pain over a parent's sudden death is reduced by saying: " He wouldn't have wanted to live with disability"  Use/Purpose:  Protects a person from pain and traumatic events 6*[. Rationalization]* -- justification of certain behaviors by faulty logic and ascribing motives that are socially acceptable but did not in fact inspire the behavior Example: a mother spank her child too hard and say it was alright because he couldn't feel it through the diaper anyway Use/Purpose:  helps a person cope with the inability to meet goals or certain standards *[7. Projection]* -- a process in which blame is attached to others or the environment for unacceptable desires, thoughts, shortcomings, and mistakes Example: a mother was told her child must repeat a grade in school and she blames this on the teacher's poor instruction Use/Purpose: allows the person to deny the existence of shortcoming and mistakes; protects self image  8*[. Reaction Formation]* -- a mechanism that causes people to act exactly opposite to the way they feel. Example:  an executive resents his bosses for calling in a consulting firm to make recommendations for change in his department but verbalizes complete support of the idea and is exceedingly polite and cooperative Use/Purpose:  aids in reinforcing repression by allowing feelings to be acted out in amore acceptable way 11*[. Sublimation]* -- displacement of energy associated with more primitive sexual or aggressive drives into a socially acceptable activities Example: a person with excessive sexual drives invests psychic energy into a well-defined religious value system Use/Purpose:  protects a person from behaving in irrational, impulsive ways 12*[. Substitution]* -- the replacement of a highly valued, unacceptable or unavailable object by a less valuables, acceptable, or available object Example: a woman wants to marry a man exactly like her dead father and settles for someone who looks a little bit like him. Use/Purpose : helps a person achieve goals and minimizes frustration and disappointment *[13. Undoing]* -- an action or words designed to cancel some disapproved thoughts, impulses or acts in which the person relieves guilt by making reparation Example:  a father spanks his child and the next evening brings home a present for his child Use/Purpose:  allows a person to appease guilty feelings and atone for mistakes **2. ERICKSON'S  DEVELOPMENTAL  MODEL** **[PSYCHOSOCIAL DEVELOPMENT THEORY]** **[1. TRUST VS MISTRUST (INFANCY])** In infancy, the central task is to develop a sense of trust that basic needs are met. As these needs are met, infant learned that world is safe to live in. **[2. AUTONOMY VS SHAME AND DOUBT]** (TODDLER) Learning to trust begins to test his environment Autonomy develops as toddler explores and learns control of self and environment **[3. INITIATIVE VS GUILT (PRE-SCHOOLER]**) As a pre-schooler tries to be assertive during interactions with others and environment, approval from others fosters initiative. When preschoolers action are not permitted or disapproved by others, the child develops sense of guilt **[4. INDUSTRY VS INFERIORITY (SCHOOL AGE)]** Child directs energy towards knowledge and skills applicable in real world.  A child who receives satisfaction from those efforts continues to be industrious A child who has difficulty and whose efforts go unrewarded may feel inferior or inadequate 5**[. IDENTITY VS ROLE DIFFUSION (ADOLESCENCE)]** During this stage the individual searches  for current and future identities This is an attempt to integrate life experiences into a sense of self to master identity  The adolescent must feel an internally consistent self image It must agree with others' view The adolescent who is unable to integrate life experiences and self-image into a consistent identity experience role diffusion. Feeling of lost and confusion occur. **[6. INTIMACY VS ISOLATION (YOUNG ADULT)]** Seeks relationship with others to acquire a sense of sharing, caring and intimacy. An individual who is unable to share close relationship and feel comfortable in intimate relationship may have a sense of isolation from friends or family member **[7. GENERATIVITY VS STAGNATION (ADULTHOOD]**)  Primary task is satisfaction with productivity  This includes work, family, house, citizenship 3. **Cognitive Theory by Jean Piaget** **[Sensorimotor (birth to about age 2)]** 1\. The child learns about himself and his environment through motor and reflex actions. Teaching for a child in this stage should be geared to the sensorimotor system Examples: modifying behavior by using the senses, a frown or soothing voice 2**. Preoperational (begins about the time the child starts to talk to about age 7)** The child begins to use symbols to represent objects The child is now better able to think about things and events that are not immediately present - Oriented to the present, the child has difficulty conceptualizing time - His thinking is influenced by fantasy-the way he'd like things to be and he assumes that others see situations from his viewpoint **[Implications:]**  teaching must take into account the child's vivid fantasies and undeveloped sense of time Using neutral words, body outlines and equipment a child can touch gives him an active role in learning **3.Concrete (about first grade to early adolescence)** During this stage accommodation increases The child develops to think abstractly and to make rational judgments about concrete or observable events Implications: Giving the child the opportunity to ask questions and to explain things back to you allows him to mentally manipulate information **4. Formal Operations (adolescence)** This stage brings cognition to its final form. This person no longer requires concrete objects to make rational judgments, At this point, he is capable of hypothetical and deductive reasoning Teaching for the adolescent may be wide ranging because he'll be able to consider many possibilities from several perspectives **[Moral Theory by Kohlberg ( TABLE 28.7 PAGE786)]** **[a. Level 1 (Pre-Conventional]**) Stage 1. Obedience and punishment orientation (How can I avoid punishment?) common in children, although adults can also exhibit this level of reasoning Reasoners at this level judge the morality of an action by its direct consequences individuals focus on the direct consequences of their actions on themselves. For example, an action is perceived as morally wrong because the perpetrator is punished.  \"The last time I did that I got spanked so I will not do it again.\"  The worse the punishment for the act is, the more \"bad\" the act is perceived to be.\[ **[Stage 2. Self-interest orientation]** (What\'s in it for me?) right behavior is defined by whatever the individual believes to be in their best interest  shows a limited interest in the needs of others (Paying for a benefit)-\"You scratch my back, and I\'ll scratch yours.\" mentality. b\. **Level 2: Conventional ** \> **Stage 3: The good boy/girl attitude/golden rule** moral reasoning is typical of adolescents and adults To reason in a conventional way is to judge the morality of actions by comparing them to society\'s views and expectations. an individual obeys rules and follows society\'s norms even when there are no consequences for obedience or disobedience. Adherence to rules and conventions is somewhat rigid **Stage 4: Authority and social-order maintaining orientation(Law and order morality)** it is important to obey laws  because of their importance in maintaining a functioning society. Most active members of society remain at stage four, where morality is still predominantly dictated by an outside force.  Ten commandments **c. Level 3: Post-Conventional** **Stage 5: social contract driven**  \> the world is viewed as holding different opinions, rights and values Such perspectives should be mutually respected as unique to each person or community Laws are regarded as social contracts rather than rigid edicts. Those that do not promote the general welfare should be changed when necessary to meet "the greatest good for the greatest number of people **[Stage 6: Universal ethical principles(Principled conscience)]** moral reasoning is based on abstract reasoning using universal ethical principles  Laws are valid only insofar as they are grounded in justice, and a commitment to justice carries with it an obligation to disobey unjust laws This involves an individual imagining what they would do in another's shoes  the individual acts because it is right, and not because it avoids punishment, is in their best interest, expected, legal, or previously agreed