CARE OF MOTHER, CHILD, ADOLESCENT.pdf

[NUR C207-201N] CARE OF MOTHER, CHILD, ADOLESCENT Hildegard Peplau Interpersonal model L1: FRAMEWORK FOR MCHN...

[NUR C207-201N] CARE OF MOTHER, CHILD, ADOLESCENT Hildegard Peplau Interpersonal model L1: FRAMEWORK FOR MCHN Promote health through interpersonal process. GOALS AND PHILOSOPHIES OF MATERNAL Calista Roy’s Adaptation model AND CHILD HEALTH NURSING Theory Each person is a unified biopsychosocial system in constant interaction with FOCUS OF MCN changing environment. Dorothea Orem’s Self- care theory Care of childbearing and childrearing families. Theory Nurses have to supply care when the PRIMARY GOAL OF MCHN patients cannot provide care to themselves Promotion and maintenance of optimal family health. ROLES AND RESPONSIBILITIES OF A MCH NURSE considers the family as whole and as a partner in care. Goals of MCN are broad b/c the scope of practice or range of serves as an advocate to protect the rights of all family practice includes the following: members, including the fetus. demonstrates a high degree of independent nursing 1. Preconceptual Health Care functions. 2. Care of women during pregnancy (3 trimesters) promotes health and disease prevention. 3. Care of women during puerperium or 4th trimester serves as important resources for families during 4. Care of infants during perinatal period childbearing and childrearing. 5. Care of children from birth to adolescence respects personal, cultural and religious attitudes and 6. Care in various settings as in the birthing room, and at beliefs home. encourages developmental stimulation during both health and illness. assesses families for strength as well as specific needs or challenges. PHILOSOPHIES OF MCN encourages family bonding through rooming-in and family visiting in maternal and child health care settings. 1. MCN is Family Centered encourages early hospital discharge options to reunite 2. MCN is Community Centered families as soon as possible. 3. MCN is Evidence Based encourages families to reach out to their community so 4. MCN includes independent nursing functions the family can develop a wealth of support people they 5. MCN Nurse, Advocate can call on in a time of family crisis. 6. Health Promotion and Disease Prevention 7. MCN is a challenging role for nurses Family – basic unit of society THEORIES RELATED TO MCHN Florence Environmental theory Nightingale Give the client the best opportunity for recovery Faye Abdellah Identified 21 nursing problems Identify and correct the needs. Martha Rogers Unitary human beings To move the client toward optimal health. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 1  L2: REPRODUCTIVE AND SEXUAL HEALTH CONCEPT OF UNITIVE AND PROCREATIVE HEALTH TERMINOLOGY PROCREATIVE producing new life or offspring CHILDBEARING the process of giving birth to children CHILDREARING the process of bringing up a child or children REPRODUCTIVE addresses the reproductive processes, HEALTH functions and system at all stages of life REPRODUCTION biological process where a new individual is produced PROCREATIVE HEALTH GOALS FEMALE REPRODUCTIVE SYSTEM PARTS AND FUNCTIONS Promotion, maintenance of optimal family health to ensure cycles of optimal childbearing, childrearing The Breast Mammary glands (breasts) - located anterior to the Marital sexuality achieves two purposes. The Church affirms: pectoral muscle, HIGH estrogen at puberty produces a 1. its role in creating new human life, sometimes called the marked INCREASED in breasts size. procreative dimension of sexuality. - contains approx. 20 lobes. 2. sexual union expresses and deepens the love between - All glands in each lobe produce milk by acinar husband and wife. This is called the unitive, or relational, cells and deliver it to the nipple via lactiferous aspect of sexuality. duct. - Ampulla portion of the duct; reservoir for milk MALE AND REPRODUCTIVE SYSTEM before breastfeeding. REPRODUCTIVE system of organs for the Gynecomastia - in breast size at puberty in males. SYSTEM purpose of reproduction GYNECOLOGY study of the female reproductive organs THE MENSTRUAL CYCLE ANDROLOGY study of the male reproductive organs PELVIC CAVITY contains the reproductive organs and bladder Gonodotropin-Releasing Hormone (GnRH) stimulates the release of FSH and LH initiating puberty MAIN FUNCTION OF REPRODUCTIVE SYSTEM and sustaining menstrual cycle. Male - produce and deposit sperm. Female - produce egg cells and protect and nourish the Follicle-stimulating Hormone (FSH) offspring until birth. secreted by A. pituitary gland during the 1st half of menstrual cycle stimulate growth & maturation of graafian follicle before ovulation thins the endometrium Luteinizing Hormone (LH) secreted by the A. pituitary gland stimulates the final maturation of graafian follicle surge of LH about 14 days before next menstrual period causes ovulation stimulates transformation of graafian follicle into corpus luteum thickens the endometrium Estrogen secreted primarily by the ovaries, corpus luteum, adrenal cortex and placenta in pregnancy considered as the hormone of women TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 2  stimulates thickening of the endometrium; causes To renew a uterine tissue bed that will be responsive to suppression of FSH secretion and fetal growth stimulates uterine contractions To prepare the uterus for pregnancy responsible for the development of secondary sex characteristics TERMS DEFINITIONS Beginning Ave. age of onset, 12.4 years; ave. Progesterone (menarche) range, 9–17 years ecreted by the ovary, corpus luteum and placenta during Interval between Ave. 28 days; cycles of 23–35 days pregnancy cycles inhibits secretion of LH Duration of Ave. flow, 4–6 days; ranges of 2–9 days has thermogenic effect (increases body temperature) menstrual flow relaxes smooth muscles thereby decreases contractions Amount of ifficult to estimate; ave. 30–80 mL per of uterus menstrual flow menstrual period; saturating pad or causes cervical secretion of thick mucus, maintain tampon in < an hour is heavy bleeding thickness of endometrium and Color of menstrual Dark red; a combination of blood, mucus, prepares breasts for lactation. flow and endometrial cells allows pregnancy to be maintained = Hormone of Odor Similar to that of marigolds Pregnancy FEMALE REPRODUCTIVE CYCLE Oxytocin Controlled by monthly hormonal cycle from the secreted by the posterior pituitary gland hypothalamus, anterior pituitary gland and ovary. stimulates uterine contractions during birth and compress Monthly cycle of changes in ovary and uterus uterine blood vessels and control bleeding stimulates let-down or milk-ejection reflex during breastfeeding OVARIAN CYCLE Prolactin Changes in ovary during and after maturation of the follicle and oocyte secreted by the anterior pituitary gland stimulates secretion of milk UTERINE CYCLE (MENSTRUAL CYCLE) Prostaglandins Preparation of the uterus to receive fertilized ovum. fatty acids’ categorized as hormones If implantation does not occur, the functional layer of produced by many organs of the body, including the endometrium is shed during menstruation endometrium affects menstrual cycle influences the onset and maintenance of labor TERMS DESCRIPTION MENARCHE first onset of menstruation MENOPAUSE cessation of menses AMENORRHEA absence of menstrual flow DYSMENORRHEA painful menstruation OLIGOMENORRHEA scanty menstruation POLYMENORRHEA too frequent menstruation MENORRHAGIA excessive menstrual bleeding METRORRHAGIA bleeding between periods of less than 2 weeks HYPOMENORRHEA abnormally short menstruation HYPERMENORRHEA abnormally long menstruation MENSTRUAL CYCLE periodic uterine bleeding in response to cyclic hormonal changes. HUMAN SEXUALITY MENSTRUATION periodic discharge of blood, mucus and epithelial cells from the uterus. SEXUALITY PURPOSE OF MENSTRUAL CYCLE a multidimensional phenomenon that includes feelings, To bring an ovum to maturity attitudes, and actions. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 3  it encompasses and gives directions to a person’s Transvestism form of fetishism, an individual dresses in physical, emotional, social, and intellectual responses the form of the opposite sex throughout life. Voyeurism obtaining sexual arousal by looking at another person’s body Sadomasochism involves inflicting pain (sadism) or receiving pain (masochism) to achieve sexual satisfaction Exhibitionism revealing one’s genitals in public Bestiality sexual relations with animals Pedophiles individuals who are interested in sexual encounters with children. STAGES OF SEXUAL RESPONSE 1. Excitement/arousal: Vasocongestion (increased blood flow that causes swelling in the genitals) stimulates male and female genital responses. 2. Plateau: Voluntary and involuntary muscle tensions increase. 3. Orgasm: Vasocongestion and muscle tension reach their peak, and rhythmic contractions occur through the genital regions. HUMAN SEXUALITY 4. Resolution: Muscle tension and congested blood subside Biologic Gender person’s chromosomal sex; male (XY) or female (XX) Gender Identity or personal view of oneself as male or as PROCESS OF HUMAN REPRODUCTION Sexual Identity female (self defined) Gender Role how maleness or femaleness is Ovum: Life = 24-28 hours expressed (socially defined) Spermatozoon: Life = 48-72 hours Sex biological aspects of being male or - Minimum sperm count as normal - 33-46 female. Sex differences are physical million/ml of seminal fluid or 50 differences million/ejaculation Gender psychological & sociocultural meanings added to biological sex Sexual Orientation the direction of one’s sexual interests can be toward members of the same gender, opposite gender or both genders. - heterosexual: attraction to opposite sex partner. - homosexual: primary attraction to and preference for sexual activity with people of the same sex; a) gay b) lesbian - bisexual: attraction to both same and opposite sex partners - transgender or transsexual: having a gender identity that does not match one’s biological sex. TYPES OF SEXUAL EXPRESSION Sexual abstinence separation from sexual activity (celibacy) Masturbation self-stimulation for erotic pleasure Erotic stimulation use of visual materials for sexual arousal TERMS USED IN FETAL GROWTH Fetishism sexual arousal from the use of certain Ovum from ovulation to fertilization objects, most common form of paraphilia (sexual arousal to objects, situations or Zygote from fertilization to implantation individuals) Embryo from implantation to 5-8 weeks Fetus from 5-8 weeks until term TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 4  Conceptus developing embryo and placental FETAL STRUCTURES structures throughout pregnancy. Age of viability earliest age for fetuses to survive is 24 Deciduas - endometrium of the gravid uterus. weeks or fetus weighs >500-600 g 1. Decidua basalis is the innermost portion of the layer, and will form the maternal portion of the placenta. 3-Time period of fetal growth and development 2. Decidua capsularis encapsulates the trophoblast’s surface. 3. Decidua vera becomes the remaining portion of the Pre-embryonic – first 2 weeks beginning with uterine linng and sheds as the lochias. fertilization. Embryonic – weeks 3 through 8. Chorionic Villi - microscopic, finger-like projections that contain Fetal – from week 8 through birth capillaries for blood to flow through and allow the transfer of nutrients from the mother's blood RESPONSIBLE PARENTHOOD to the fetus. Is the will and ability of parents to respond to the needs &aspirations of the family and children (Directional Plan of POPCOM). Is a shared responsibility of the husband and wife to determine and achieve the desired number, spacing, and timing of their children according to their own family life aspirations. Is the ability of a parent to detect the need, happiness and desire of the children and helping them to become responsible and reasonable children. QUALITIES OF RESPONSIBLE PARENTHOOD Marriage should be done at the right age. The size of a family should be decided by both parents together. Parents at the right age where both of them are physically Amniotic Membranes - forms the sac, and responsible for and mentally mature to start a family. producing the amniotic fluid and the phospholipids that triggers the Proper spacing between the births of children. formation of prostaglandins, the hormone that initiates uterine contractions. PRINCIPLES OF THE RESPONSIBLE PARENTHOOD 1. What you do matters 2. You cannot be too loving 3. Be involved in your child’s life 4. Adapt your parenting to fit your child 5. Establish and set rules 6. Foster your child’s independence 7. Be consistent 8. Avoid harsh discipline 9. Explain your rules and decisions 10. Treat your child with respect L3: PRENATAL CARE PART 1 THE PROCESS OF CONCEPTION Amniotic Fluid - protects the fetus from trauma or pressure to the mother’s abdomen. - regulates temperature for the fetus. - aids in muscular development allowing the fetus to move freely. - t protects the umbilical cord from trauma and pressure, thereby protecting the fetal oxygen supply. - Normal amount is 800 to 1,200 mL. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 5  FETAL BLOOD CIRCULATIONS Arms and legs have developed. External genitalia are forming, but sex is not yet During pregnancy, the fetal circulatory system works differently distinguishable by simple observation. than after birth: The primitive tail is regressing. The abdomen bulges forward because the fetal intestine 1. The fetus is connected by the umbilical cord to the is growing so rapidly. placenta, the organ that develops and implants in the An ultrasound shows a gestational sac, diagnostic of mother's uterus during pregnancy. pregnancy. 2. Through the blood vessels in the umbilical cord, the fetus receives all the necessary nutrition, oxygen and life END OF 12TH GESTATIONAL WEEK (FIRST TRIMESTER) support from the mother through the placenta. 3. Waste products and carbon dioxide from the fetus are Length: 7–8 cm Weight: 45 g sent back through the umbilical cord and placenta to the Nail beds are forming on fingers and toes. mother's circulation to be eliminated Spontaneous movements are possible, although they are usually too faint to be felt by the mother. Some reflexes, such as the Babinski reflex, are present. Bone ossification centers begin to form. Tooth buds are present. Sex is distinguishable by outward appearance. Urine secretion begins but may not yet be evident in amniotic fluid. The heartbeat is audible through Doppler technology. END OF 16TH GESTATIONAL WEEK Length: 10–17 cm Weight: 55–120 g Fetal heart sounds are audible by an ordinary stethoscope. Lanugo is well formed. Liver and pancreas are functioning. Fetus actively swallows amniotic fluid, demonstrating an intact but uncoordinated swallowing reflex; urine is NORMAL FETAL GROWTH present in amniotic fluid. Sex can be determined by ultrasound. MILESTONES OF FETAL DEVELOPMENT END OF 20TH GESTATIONAL WEEK The life of the fetus is commonly calculated from the time of ovulation or fertilization (ovulation age), but the Length: 25 cm Weight: 223 g duration of the pregnancy is usually calculated from the Spontaneous fetal movements can be sensed by the first day of the last menstrual period (gestational age). mother. Antibody production is possible. END OF 4TH GESTATIONAL WEEK The hair forms on the head, extending to include eyebrows. Meconium is present in the upper intestine. Length: 0.75–1 cm Weight: 400 mg Brown fat, a special fat that will aid in temperature The spinal cord is formed and fused at the midpoint. regulation at birth, begins to be formed behind the Lateral wings that will form the body are folded forward to kidneys, sternum, and posterior neck. fuse at the midline. Vernix caseosa begins to form and cover the skin. The head folds forward and becomes prominent, Passive antibody transfer from mother to fetus begins. representing about one-third of the entire structure. Definite sleeping and activity patterns are distinguishable The back is bent so that the head almost touches the tip of the tail. The rudimentary heart appears as a prominent bulge on END OF 24TH GESTATIONAL WEEK (SECOND TRIMESTER) the anterior surface. Arms and legs are budlike structures. Length: 28–36 cm Weight: 550 g Rudimentary eyes, ears, and nose are discernible Meconium is present as far as the rectum. Active production of lung surfactant begins. END OF 8TH GESTATIONAL WEEK Eyebrows and eyelashes become well defined. Eyelids, previously fused since the 12th week, now open. Pupils are capable of reacting to light. Length: 2.5 cm (1 in) Weight: 20 g When fetuses reach 24 weeks, or 601 g, they have Organogenesis is complete. achieved a practical low-end age of viability (earliest age The heart, with a septum & valves, is beating at which fetuses could survive if born at that time), if they rhythmically. are cared for after birth in a modern intensive care facility. Facial features are definitely discernible. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 6  Hearing can be demonstrated by response to sudden 3 trimesters sound. IMPORTANT ESTIMATED END OF 28TH GESTATIONAL WEEK NAGELE’S RULE Calculation of expected date of birth or EDC. Length: 35–38 cm Weight: 1200 g Count back 3 months then add 7 days Lung alveoli begin to mature, and surfactant can be from 1st day of LMP. Substitute number demonstrated in amniotic fluid. for months for easy computation. Testes begin to descend into the scrotal sac from the lower abdominal cavity. Ex: September 30, 2018 LMP The blood vessels of the retina are formed but thin and extremely susceptible to damage from high 9 - 30 - 18 O2 concentrations (an important consideration when -3 +7 +1 caring for preterm infants who need oxygen). _________ 6 - 37 - 19 +1- 30 _________ END OF 32ND GESTATIONAL WEEK 7 - 7 - 19 Length: 38–43 cm Weight: 1600 g MCDONALD’S Determine AOG by measuring the Subcutaneous fat begins to be deposited (the former METHOD height of the fundus to symphysis pubis stringy, “little old man” appearance is lost). (in cm.) Fetus responds by movement to sounds outside the mother’s body. Height of fundus in cm x 2/7 Active Moro reflex is present. = duration of pregnancy in lunar Iron stores, which provide iron for the time during which months the neonate will ingest only milk after birth, are beginning to be developed. Height of fundus in cm x 8/7 Fingernails grow to reach the end of fingertips = duration of pregnancy in wks END OF 36TH GESTATIONAL WEEK Height of fundus in cm /4 = duration of pregnancy in months Length: 42–48 cm Weight: 1800–2700 g (5–6 lb) Body stores of glycogen, iron, carbohydrate, and calcium are deposited. Additional amounts of subcutaneous fat are deposited. Sole of the foot has only one or two crisscross creases, compared with the full crisscross pattern that will be evident at term. Amount of lanugo begins to diminish. Most babies turn into a vertex (head down) presentation during this month END OF 40TH GESTATIONAL WEEK (THIRD TRIMESTER) Length: 48–52 cm (crown to rump, 35–37 cm) Weight: 3000 g (7–7.5 lb) BARTHOLOMEW’S Estimate AOG by the relative position Fetus kicks actively, hard enough to cause the mother RULE of the uterus in abdominal cavity. considerable discomfort. Fetal hemoglobin begins its conversion to adult 3rd lunar month (12-14 wks) hemoglobin. The conversion is so rapid that, at birth, = fundus is palpable slightly above the about 20% of hemoglobin will be adult in character. symphysis pubis. Vernix caseosa is fully formed. Fingernails extend over the fingertips. 5th lunar month,(20 -22 wks) Creases on the soles of the feet cover at least two thirds = fundus, at the level of umbilicus. of the surface. 9th lunar month, (36-38 wks) = fundus is below xiphoid process ESTIMATING EXPECTED DATE OF CONFINEMENT HAASE’S RULE Determines the length of the fetus in The duration of normal pregnancy: centimeters. 267-280 days 40 weeks 1st half of pregnancy, square the 9 calendar months number of months 10 lunar months. Ex: 3rd month x 3 = 9 cms TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 7  Obstetrical history – GTPAL 2nd half of pregnancy, multiply the # Review of system – subjective information (head to toe) months by 5 Physical examination and Pelvic examination Ex: 6th month x 5 = 30 cms. Baseline height/weight and vital sign measurement Measurement of fundal height and fetal heart sounds JOHNSON’S RULE Estimates the weight of the fetus in grams. OBSTETRICAL HISTORY Formula: height in cm – n x k Last Menstrual Period (LMP) - 1st day of onset of k = is constant, it is always 155 menstrual flow. n = is 12 if fetus is engaged Expected Date of Confinement (EDC) - date of = 11 if fetus is not yet engaged expected delivery. Gestational age (AOG) - the age of a fetus, calculated from the mother’s last menstrual period to the date of ASSESSMENT OF FETAL GROWTH AND DEVELOPMENT birth. TERMINOLOGY Pregnancy Status (OB Score) Para/parity # of previous pregnancies that reached G – gravida viability, regardless of the P - para, divided into: # of fetuses whether the fetus was ○ T - # of full-term infants born born alive or not ○ P - # of pre-term infants born ○ A - # of abortions Nullipara a woman who has never delivered a ○ L - # of living children viable infant. ○ M - # of multiple pregnancy Primipara / a woman who has delivered a viable Primiparity infant NUTRITIONAL STATUS DURING PREGNANCY Multipara / a woman who has delivered 2 or more Multiparity viable infants Grandmultipara / a woman who has had more than six Grandmultiparity deliveries Gravida / Gravidity woman who is or has been pregnant Nulligravida woman who is not or has never been pregnant Primigravida woman pregnant for the 1st time Multigravida woman who has 2 or more pregnancies PURPOSES AND OBJECTIVES OF CARE 1. To establish a baseline of present health. 2. To determine the gestational age of the fetus. 3. To monitor fetal development. 4. To identify the woman at risk for complications. 5. To minimize the risk of possible complications by anticipating & preventing problems before they occur. 6. To provide time for education about pregnancy possible dangers HEALTH HISTORY COMPONENTS Demographic Data Chief Concern Family Profile – marital status, educational level & lifestyle. History of past illnesses History of family illnesses Day history/social profile - woman’s current nutrition, exercise, hobbies,tobacco, alcohol & drug consumption, Recommended weight gain, distribution of pounds medicine and herbal therapy and intimate partner through: violence. ○ Fetus: 7.5 lbs (3.4 kgs) Gynecologic history – menstrual history, perineal & ○ Placenta: 1.5 lbs (0.6 kg) breast-self examination, past surgery, reproductive ○ Amniotic fluid: 2 lbs. (0.9 kg) planning, sexual history and stress incontinence. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 8  ○ Uterus: 2.5 lbs. (1.1 kg) PHYSICAL EXAMINATION ○ Blood Volume: 4 lbs. (1.8 kg) ○ Breast: 1.5 - 3 lbs. (0.6 – 1.3 kg) Measure a woman’s weight and height (cms.) ○ Body fluid: 4lbs. (1.8 kg) ○ underweight before pregnancy - at risk for LBW ○ Body fat: 7 lbs. (3.8 kgs) infants and pregnancy loss. ○ Obese before pregnancy - at risk for increased Components of healthy nutrition (Dietary Reference perinatal mortality, delivery complications, LGA Intake) infants, pre-eclampsia & diabetes. ○ Calorie needs – 2500 cal / day (CHO – cereals Measure vital signs & grains) ○ BP: sudden increase is a danger sign of PIH ○ Protein needs – 71g / day ○ Temp: increase temperature suggests ○ Fat needs – for cell growth (vegetable oil) dehydration or infection ○ Vitamin needs – support growth of new fetal ○ PR : tachycardia is associated w/ anxiety, cells hyperthyroidism & infection. Sudden increase ○ Mineral needs – for new cell building may suggests bleeding. ○ Calcium, phosphorus – for bone formation ○ RR: tachypnea may indicate respiratory infection Iodine – for formation of thyroxine for or cardiac disease. the proper functioning of thyroid gland Assessment of system (head to toe - IPPA) (DRI =250 ug/day). Measurement of fundal height and fetal heart sounds Iron – to build an increase red cell ○ average fundic ht = 35cms > FHT = 120 to 160 volume & protect from iron lost in blood bpm at birth (DRI = 15 mg/day). Pelvic examination and estimating pelvic size Fluoride – aids in formation of teeth Sodium – electrolyte that acts to maintain fluid in the body. Zinc – for the synthesis of DNA & RNA , deficiency maybe associated with preterm birth. Fluid needs – promote kidney function. Fiber needs – to prevent constipation PELVIC INLET DIAMETERS PELVIC INLET ○ entrance to the true pelvis DIAGONAL CONJUGATE (NARROWEST) ○ anterior posterior diameter of pelvic inlet MATERNAL ANDFETAL HEALTH ASSESSMENT ○ normal: 12.5 cm – 13 cm TRANSVERSE DIAMETER Estimating Fetal Growth ○ normal: 13.5 cm or greater McDonald’s rule - symphysis-fundal height TRUE CONJUGATE/ CONJUGATE VERA measurement. ○ normal: 1.5 to 2cm less than DC OBSTETRIC CONJUGATE Fetal Movement ○ normal: less than 1.5 cm to DC Quickening occurs at approximately 18 to 20 weeks of pregnancy. A fetus normally moves a minimum of twice DIAGNOSTIC AND LABORATORY FINDINGS every 10 minutes or an average of 10–12 times an hour. Fetal Heart Rate Laboratory Tests to Confirm Pregnancy - A missed menstrual Fetal hearts beat at 120 to 160 beats per minute period is usually the 1st sign of pregnancy. throughout pregnancy. Fetal heart sounds can be heard 1. Home test kit – a typical kit includes special paper that is and counted as early as the 10th to 11th week of sensitive to the presence of βhCG in urine. pregnancy by the use of an ultrasonic Doppler technique. 2. Urine test – the doctor can test the urine for βhCG. 3. Blood test – a test of the βhCG levels in the blood can be accurate within a week. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 9  4. Ultrasonography - to confirm pregnancy length and document healthy fetal growth if the date of LMP is unknown. Blood Studies - Blood studies obtained at first prenatal visit: 1. Complete Blood Count (CBC) - determine the presence of anemia, infection & to estimate clotting ability. 2. Genetic screen - for common inherited diseases 3. Serologic test for syphilis (VDRL or Rapid Plasma Reagin test). For detection of syphilis & gonorrhea. 4. Blood typing (including Rh factor). Blood type is documented to detect the possibility of Rh isoimmunization. 5. Maternal serum for alpha-fetoprotein (AFP) (MSAFP) - elevated if a neural tube or abdominal defect is present in the fetus; decreased if a chromosomal anomaly is present. 6. Indirect Coombs’ test - determination if Rh antibodies are present in an Rh- negative woman. 7. Antibody titers for rubella & hepatitis B (HBsAg) - DIAGNOSIS OF PREGNANCY determine whether a woman is protected against rubella if exposure should occur during pregnancy and whether a Pregnancy is officially diagnosed based on symptoms newborn will have a chance of developing hepatitis B. reported by the woman and the signs elicited by a health 8. HIV screening; Enzyme-Linked ImmunoSorbent care provider. Assay (ELISA) If this is positive, the finding is confirmed by a second test (a Western blot). All women can be CLASSIFICATION OF SIGNS AND SYMPTOMS asked, and those at high risk for contracting HIV infection PRESUMPTIVE least indicative of pregnancy, cannot be should be asked, whether they want to be screened for (SUBJECTIVE) documented by an examiner this disease early in pregnancy. PROBABLE objective signs, can be documented by 9. Oral Glucose Tolerance Test. If a woman has a family (OBJECTIVE) an examiner history of diabetes, has had babies who were LGA, is Laboratory tests obese, or has glycosuria. Home pregnancy tests POSITIVE signs of pregnancy OTHER DIAGNOSTIC TESTS: (DOCUMENTED) Urinalysis - test for proteinuria, glycosuria, and pyuria. Tuberculosis Screening - purified protein derivative (PPD) tuberculin test to screen for tuberculosis. Any woman who has a (+) reaction would then require a chest radiograph for further diagnosis. Screening for tuberculosis early in pregnancy is important because it is a chronic and debilitating disease that increases the risk of miscarriage. L4: CARE OF THE PREGNANT MOTHER AND PREPARATION FOR CHILDBIRTH MATERNAL ADAPTATION PSYCHOLOGICAL CHANGES PSYCHOLOGICAL CHANGES SOCIAL INFLUENCES - personal experiences, REPRODUCTIVE SYSTEM experiences of friends and relatives, as well as that ovaries, uterus, vagina & breasts taught by childbirth educators. CULTURAL INFLUENCES - certain beliefs may place restrictions on her behavior and activities. Ovaries - ovulation stops FAMILY INFLUENCES - family in which a woman was Uterus - (2 5 lbs) raised can be influential to her beliefs about pregnancy o Increase in size: 12th week above the symphysis because it is part of her cultural environment. INDIVIDUAL INFLUENCES - ability to adapt to being a pubis. mother without needing mothering, to loving a child as o Lightening descend of the fetal head into the pelvis well as a husband, to becoming a mother of each new o "Hegar's sign: softening of the lower uterine segment child-depends on her basic temperament. o Braxton Hicks contractions: false labor/uterine tightening. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 10  Pressure on the urethra results in poor emptying of the ▪ Effleurage: circular motion done with hands - bladder which can cause UTI leading to kidney problems relieve contractions or preterm labor Cervix o Goodell's sign: softening of the cervix due to relaxing RESPIRATORY SYSTEM hormone. o Operculum/mucus plug: acts as a barrier Vaginal Hyperventilation as the fetus is developing, everything is o Chadwick's sign: purplish color of the vaginal wall. moving upward & pushes the diaphragm up. Breasts - changes due to the effects of estrogen & Shortness of breath progesterone production which prepare the breast for Nasal stuffiness due to increased estrogen levels lactation. o Fullness, tingling or tenderness ENDOCRINE SYSTEM o Darkened areola and prominent blue veins maybe seen o Secretion of colostrums by the 16th week pituitary glands secretes prolactin and oxytocin, BMR increases INTEGUMENTARY SYSTEM Thyroid enlargement causes increased BMR. (woman feels hot) Parathyroid slight enlargement allows for better use of Striae gravidarum (stretch marks), turns silvery after Calcium and vitamin D pregnancy. Pancreas in the 1st trimester decreased insulin Diastasis - separation of abdominal muscle. Loose tone. production, allowing for more glucose availability for fetal A dimple in between can be seen on abdomen. growth. Chloasma/melasma - increase pigmentation on the face. Pituitary increased secretion of prolactin that prepares Linea negra (linea alba) - dark line from symphysis breast for lactation. pubis to umbilicus. Adrenals increased glandular activity results in elevated corticosteroid and aldosterone level which suppresses CARDIOVASCULAR SYSTEM inflammatory action and promotes sodium reabsorption. MUSCULOSKELETAL SYSTEM Cardiac output increases, 30-50% increase in total blood volume, increased clotting factors, increased chance of thrombophlebitis. Softening of pelvic ligaments & joint due to increased Supine hypotension/vena caval syndrome - feeling of relaxin, this aids the birth process. lightheaded and palpitations Lordosis is due to pregnant posture and gait causing Increase cardiac load, cause palpitation due to increase backache. in blood vol. B/P decreases in 2nd trimester due to lowered peripheral EMOTIONAL RESPONSES TO PREGNANCY resistance. Decreased regional blood flow causes edema and varicosities Common reactions include: grief GASTROINTESTINAL SYSTEM narcissism (self centeredness) introversion or extroversion body image and boundary concerns Heartburn, constipation, flatulence; due to couvade syndrome (somatic experiences of father during displacement of the stomach and slowed intestinal pregnancy simulating those of the pregnant mother) peristalsis. stress Nausea & vomiting; caused by increased HCG & emotional lability - mood swings progesterone levels. changes in sexual desire > changes in expectant family Hyperptyalism; cause by increased estrogen levels. DANGER SIGNS OF PREGNANCY RENAL/URINARY SYSTEM Chills and fever - infection Escape of fluid from vagina - PROM frequency of urination Persistent vomiting beyond 3rd month = Hyperemesis Glomerular filtration rate increases sometimes resulting in Gravidarum glycosuria. Abdominal pain Greater than a trace or 1+ is suspicious. o Early pregnancy - cramps with bleeding abortion Glycosuria: spill/glucose in urine, 1+ means glucose o Low quadrant pain radiating to shoulder - ectopic amount in urine. Pressure of the uterus & fetus on the ureters causes pregnancy urinary stasis. o Hard, boardlike painful abdomen - abruption placenta o Sudden, sharp abdominal pain - uterine rupture TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 11  Vaginal bleeding o rest in Sims' position or on back with the legs raised o 1st trimester - Abortion against the wall or elevated on a footstool for 15 to o 3rd trimester - Placenta previa 6. Dysuria with 20 mins 2x/day. burning sensation - UTI o exercise to alleviate varicosities. Severe, persistent headache with vomiting o break up long periods of sitting or standing with a Swelling of hands and face "walk break" at least 2x / day. > vitamin C may be Dimness, blurring and doubling of vision (#7, 8, and 9 = helpful in reducing the size of varicosities because it signs of PIH) is necessary for the formation of blood vessel Marked change in intensity & frequency of fetal collagen & endothelium. movement or absence of movement (6-8 hours) after Hemorrhoids (varicosities of the rectal veins) quickening - fetal distress o because of pressure on these veins from the bulk of the growing uterus. NURSING DIAGNOSIS INVOLVING CHANGES THAT OCCUR o daily bowel evacuation to relieve constipation W/ PREGNANCY o resting in a modified Sim's position daily are both helpful. Anxiety related to unexpected pregnancy o assuming knee-chest pos. for 10-15 mins - reduce Altered breathing pattern related to respiratory system pressure on rectal veins. changes of pregnancy o stool softener such as docusate Na (Colace) may be Disturbed body image related to weight gain with recommended for a woman who already has pregnancy hemorrhoids. promote comfort - sitz bath, warm Deficient knowledge related to normal changes of compress pregnancy o avoid spices. Imbalanced nutrition, less than body requirements, Heart Palpitations related to early morning nausea o probably due to circulatory adjustments necessary to accommodate her increase blood supply during pregnancy. PREGNANCY NEEDS AND DISCOMFORT o reassure women that palpitations are normal and to be expected occasionally FIRST TRIMESTER o gradual, slow movements help prevent heart palpitations frequently. Abdominal Discomfort Breast Tenderness o pregnant women stand with their arms crossed in o wear a bra with a wide shoulder strap for support. front of them because the weight of their arms o dress warmly to avoid cold drafts if cold increases resting on their abdomen relieves this discomfort. the symptoms. Frequent Urination Palmar Erythema or Palmar Pruritus o due to the pressure of the growing uterus on the o probably caused by increase estrogen levels. anterior bladder. o explain that this type of itching in early pregnancy is o occasional stress incontinence (involuntary loss of normal. urine on coughing/sneezing) - do Kegel's exercises o increase amount of fiber in diet (alternately, contracting and relaxing perineal o increase OFI, (8-oz glasses of water / day). muscles) helps strengthen urinary control, directly Nausea, Vomiting, and Pyrosis (heartburn) strengthens perineal muscles for birth and decrease Fatigue possibility of stress incontinence. o because of increased metabolic requirements. o increase fluids to replace losses except bedtime o encourage increase amount of rest and sleep o wear perineal pads to absorb leakage Muscle Cramps o report burning sensation o cause by low serum calcium levels, increase serum Leukorrhea phosphorus levels and possibly, interference with o whitish, viscous vaginal discharge or an increase in circulation. the amount of normal vaginal secretions due to high o hyperextend involved leg and dorsiflex the foot/toes. estrogen levels and increase blood supply to the o take magnesium citrate or aluminum hydroxide gel vaginal epithelium and cervix in pregnancy. (Amphojel) - to lower the circulating phosphorus o daily bath/shower and proper hygiene level. o wearing cotton underwear can be helpful to reduce o increase calcium in the diet moisture o avoid 1 position for a long time, elevate lower o do not use tampons because this could lead to stasis extremities frequently to improve circulation. of secretions and subsequent infection. Hypotension (Supine hypotension) o report abnormal color, odor & burning sensation o woman experiences an irregular heart rate & feeling leukorrhea of apprehension. o avoid douche o turn woman onto her side o always rest or sleep on their side not their back. MIDDLE TO LATE TRIMESTER Varicosities or Tortuous Leg Veins o due to weight of distended uterus, puts pressure on the veins returning blood from the lower extremities. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 12  Backache TYPES OF TERATOGENS o lumbar lordosis develops & postural changes to 1 PHYSICAL AGENTS maintain balance leads to backache. 2 METABOLIC CONDITIONS o wear comfortable shoes (low to moderate heels) to 3 INFECTION reduce the amount of spinal curvature. 4 DRUGS AND CHEMICALS o encourage a woman to walk with her pelvis tilted forward (putting pelvic support under the weight of the fetus) is also helpful. TERATOGENIC DRUGS o use a firm mattress during sleep. o do exercises: squatting, pelvic rock - helps prevent Two principles governing drug intake during pregnancy: and relieve backache. Any drug or herbal supplement, under certain Headache circumstances, may be detrimental to fetal welfare. o apparently due to expanding blood volume, which A woman of childbearing age & ability should not take puts pressure on cerebral arteries. any drug other than one prescribed by a physician or o resting with cold towels on their forehead and taking nurse-midwife to avoid exposure to a drug should she usual adult doses of acetaminophen usually become pregnant. furnishes adequate relief. o continuous sharp headache may be a danger sign of TIMING high BP during pregnancy. Dyspnea The effect of teratogens depends upon the timing of o expanding uterus places pressure on the diaphragm, exposure. lung compression and shortness of breath result. The first trimester of pregnancy is the critical period of o notice primarily at night if lying flat & definitely notice organ and limb development in the fetus. on exertion. The fetal brain develops throughout pregnancy and can o advise to sleep with head and chest elevated so the be affected at any time. weight of the uterus falls away from her her diaphragm SENSITIVITY DURING ORGANOGENESIS o caution her to limit her activities during the day to prevent exertional dyspnea. Ankle Edema The probability of a structural defect is greatest during o probably caused by general fluid retention and organogenesis. 15-25 days after conception, the brain is most vulnerable. reduced blood circulation in the lower extremities due 20-40 days after conception, the heart is most vulnerable. to uterine pressure. 24-36 days after conception, the legs are most vulnerable o ankle edema is a normal occurrence of pregnancy 24-40 days after conception, the eyes are most (w/o proteinuria & hypertension). vulnerable. o rest in a left side-lying position to increase the kidney's glomerular filtration rate and also allows good venous return. SENSITIVITY DURING THE FETAL PERIOD o avoid standing/sitting in one position for long periods o encourage frequent leg elevation Exposure is less likely to cause anatomical defects. o avoid wearing constricting clothing such as panty Exposure is more likely to stunt growth. girdles or knee-high stockings because these impede Exposure is more likely to create problems in organ lower extremity circulation and venous return. functioning. Braxton Hicks Contractions o Beginning as early as the 8th to 12th week of EFFECTS OF THE MEDS, DRUGS, SUBSTANCES pregnancy, the uterus periodically contracts and then relaxes again. Interfering with normal fetal development and damaging o By middle or late pregnancy, the contractions the baby's organs. become stronger, and a woman who tenses at the Damaging the placenta and putting the baby's life at risk. sensation may even experience some minimal pain, Bringing on premature labour and increasing the risk of similar to a hard menstrual cramp, women should miscarriage. inform their primary care provider about them so that they can be evaluated. EFFECTS OF THE MEDS, DRUGS, SUBSTANCES COMMON TERATOGENS AND THEIR EFFECTS The potential for harm to the pregnancy and unborn baby depends on a range of factors including: TERMS DEFINITIONS o type of drug/medication taken and how it is TERATOLOGY field of study that investigates the causes taken of birth defects. o the dose of the drug/medication and how often it TERATOGEN any substances that may produce is taken, whether it is used alone or in physical or functional defects in the combination with other drugs/medications. human embryo or fetus. o gestational age of the baby. o other factors, such as maternal health and diet. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 13  Harmful Drugs, Substances and Medications; Detrimental to growth because it interferes with cell o Medicines metabolism, can occur from saunas, hot tubs, or tanning o illicitly used prescription drugs beds, from a work environment next to a furnace, such as o Tobacco in welding or steel making, or from a high maternal fever o alcohol early in pregnancy (4-6 weeks). o Caffeine Women who use a hot tub at 40° C should not stay in it o illegal drugs for longer than about 10 minutes at one time. o substances used as drugs TERATOGENIC MATERNAL STRESS SMOKING AND ALCOHOL DURING PREGNANCY An emotionally disturbed pregnancy could produce physiologic changes through its effect on the sympathetic SMOKING division of the autonomic nervous system. o increases risk of miscarriage and stillbirth, If the anxiety is prolonged, the constriction of uterine greater risk of low birth weight, prematurity and vessels could interfere with the blood and nutrient supply sudden unexpected death in infants. to a fetus. ALCOHOL Illness or death of one's partner, marital discord & illness o frequent and heavy use of alcohol during or death of another child are examples of stressful pregnancy has been associated with situations that might provoke excessive anxiety. miscarriage, babies who are small for gestational age and intellectual impairment in children (known as fetal alcohol syndrome). CAFFEINE o heavy use (greater than 7cups of coffee/day) may be associated with an increased risk of low birth weight. ILLEGAL DRUGS AMPHETAMINES o increased risk of LBW, birth defects, prematurity. SCHEDULE FOR PRENATAL VISIT CANNABIS o increased risk of growth retardation, sleep problems, behavioural problems COCAINE o increased risk of miscarriage, pre-term birth, growth retardation, stillbirth and birth defects (brain, heart, genitals and urinary system) HEROIN o increased risk of LBW, prematurity, fetal distress, stillbirth, blood-borne viral disease (hepatitis), infant withdrawal after birth. INHALANTS o increased risk of miscarriage, LBW, birth defects, and SUDI. RADIATION Produces a range of malformations depending on the stage of development of the embryo/fetus & the strength & length of exposure. Most damaging time for exposure and subsequent damage is from implantation to 6 weeks after conception. If exposure occurs before implantation, the zygote apparently killed. The nervous system (brain) and retinal innervation are most affected. PREPARATION FOR CHILDBIRTH CLASSES Radiation of the pelvis should be avoided all during pregnancy. Focus mainly on explaining the birth process rather than pregnancy and ways to prevent or reduce the pain of HYPERTHERMIA childbirth. Common goals of preparation are to: TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 14  o prepare a woman and her support person for the o Pain perception can be altered by distraction childbirth experience. techniques or by the gating control theory of o help women reduce and manage pain with both pain perception. pharmacologic and non- pharmacologic methods. THE BRADLEY (PARTNER-COACHED) METHOD o Help increase a couple's overall enjoyment of and satisfaction with the childbirth experience. by Robert Bradley o Include several exercises to ready the body for woman's partner should play an important role during labor, as well as methods of pain prevention or pregnancy, labor and the early newborn period. relief in labor. reduces pain in labor by abdominal breathing. encouraged to walk during labor. PRENATAL EXERCISES THE PSYCHOSEXUAL METHOD Prenatal Yoga o aimed at helping a woman to relax and manage by Sheila Kitzinger in England stress. includes a program of conscious relaxation and levels of o focus on gentle stretching and deep breathing. progressive breathing that encourage a woman to "flow o Yoga breathing techniques can be used in labor with" rather than struggle against contractions. to help both relaxation and pain management. Perineal and Abdominal Exercises o strengthen pelvic and abdominal muscles and THE DICK-READ METHOD make these muscles stronger and more supple. o Do not exercise if any danger signs of Grantly Dick-Read, English physician. pregnancy are present, and never exercise to a the premise is that fear leads to tension which leads to point of fatigue. pain. reduced fear through education about childbirth & ▪ Tailor Sitting - stretches perineal muscles relaxation. without occluding blood supply to the lower reduced pain by focusing on abdominal breathing during legs. contractions ▪ Squatting - stretches perineal muscles, can be a useful position for 2nd stage LAMAZE PHILOSOPHY labor. popularized by a French physician, Ferdinand Lamaze. ▪ Pelvic Floor Contractions (Kegel originally termed as psycho-prophylactic method - Exercises) - perineal muscle- focuses on preventing pain in labor by use of the mind. strengthening exercise, can help in the women can learn to use controlled breathing to reduce postpartum period to reduce pain and pain during labor. promote perineal healing. Labor should begin on its own, not be artificially induced. ▪ Pelvic Rocking - helps relieve backache Women should be able to move about freely during labor, not be confined to bed. during pregnancy and early labor by Women should receive continuous support during labor. making the lumbar spine more flexible. No routine interventions (IVF) are needed. ▪ Abdominal Muscle Contractions - help Women should be allowed to assume a non-supine position for birth. strengthen abdominal muscles during Mother and baby should be housed together following pregnancy. birth, with unlimited opportunity for breastfeeding. ▪ Strong abdominal muscles can also contribute to effective 2nd-stage pushing during labor. Ex: practice "blowing out a Premises related to the gating control method of pain relief candle." A woman takes a fairly deep o Familiarization with what will happen during inspiration then exhales normally. labor & the nature of contractions can decrease tension. o Concentration on breathing patterns, use METHODS FOR MANAGING PAIN IN CHILDBIRTH imagery or focusing on a specified object to block incoming pain sensations. Discomfort during labor can be minimized; o Conditioned reflexes in response to a stimulus to o if they are informed about what is happening displace pain during labor. and prepared with breathing exercises to use during contractions. o if the abdomen is relaxed and the uterus is GETTING THEORY OF PAIN CONTROL allowed to rise freely against the abdominal wall with contractions. gate control mechanisms in the substantia gelatinosa, capable of halting an impulse at the level of spinal cord TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 15  so the impulse is never perceived at the brain level as Separation of the family for pain. at least one night Mother may not feel as much in control of the THE LAMAZE METHOD childbirth experience as she may wish. Conscious Relaxation Care may be fragmented, o learning to relax body parts so that a woman particularly if a woman's does not remain tense physician is not present o place a comforting hand on the tense body area during the entire labor & or tell her to relax that area to achieve complete birth or if labor nurses relaxation. change shifts in the middle Cleansing Breath of labor. o woman breathes in deeply & then exhales deeply. o limits the possibility of either hyperventilation or ALTERNATIVE BIRTHING CENTERS (ABCS) hypoventilation, that could happen with rapid breathing patterns. wellness-oriented childbirth facilities at least within an Consciously Controlled Breathing easy distance of a hospital. o provides distraction as well as prevents the The birth attendants tend to be nurse-midwives. diaphragm from descending fully and putting Women are encouraged to express her own needs & pressure on the expanding uterus. wishes during the labor process. Effleurage Women remain in an ABC from 4 to 24 hours after birth. o French for "light abdominal massage," done with just enough pressure to avoid tickling. Serves as distraction technique and helps limit local ADVANTAGES DISADVANTAGES discomfort. A woman is encouraged to Extended high-risk care is Focusing or Imagery (sometimes called "sensate be prepared to control the not immediately available. focus") discomfort of labor. A woman may be fatigued o A photograph, graphic design or just something A woman is encouraged to after birth because of a brief that appeals to her. She concentrates on it be knowledgeable about health care setting stay. during contractions. the labor process. She must independently o Other women use imagery by imagining they are A woman is encouraged to monitor her postpartal status breastfeed. because of brief health care in a calm place. Family integrity can be setting stay. Second-Stage Breathing maintained because family o suggest that women breathe any way that is members may accompany natural for them, except holding their breath a woman to the birthing during this stage of labor. center. A woman is attended by PREPARATION FOR LABOR AND DELIVERY skilled professionals during labor & birth. THE BIRTH SETTING Emergency care is immediately available. Extended high-risk care is easily arranged. CHOOSING THE APPROPRIATE SETTING HOME BIRTHS uncomplicated pregnancies, hospitals, birthing centers , homes. high-risk pregnancies - hospitals where immediate May be supervised by a physician, but nurse-midwives emergency care will be available. are the more likely choice as birth attendants in this setting. They choose home birth so that they CHOOSING A BIRTH ATTENDANT AND SUPPORT PERSON o can have their baby close by after birth. o can have more control over the childbirth HOSPITAL BIRTH experience. o can give birth in familiar, low-cost surroundings. Receive accurate and up-to-date information about the benefits and risks of all procedures, drugs, and tests ADVANTAGES DISADVANTAGES suggested for use during pregnancy, birth, and the Woman is encouraged to be Adequate equipment is postpartum period, with the rights to informed consent knowledgeable on birth unavailable and informed refusal. process. Abrupt change of goals is Woman has the greatest necessary if hospitalization ADVANTAGES DISADVANTAGES freedom for expressing her is required. individuality. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 16  There is no separation of A woman and support the family at birth. person may become A skilled professional can exhausted because of the attend the birth. responsibility placed on them. A woman must independently monitor her postpartal status. ALTERNATIVE BIRTHING METHODS LEBOYER METHOD Frederick Leboyer, French obstetrician. the birthing room is darkened & kept pleasantly warm soft music is played or at least harsh noises are kept to a minimum. Infant is handled gently, the cord is cut late and the infant is placed immediately after birth into a warm-water bath. HYDROTHERAPY AND WATER BIRTH Birthing centers allow women to labor in warm showers or give birth in spa tubs of warm water. Baby is born underwater then immediately brought to the surface for a first breath. RISKS: o uterine infection in the mother o aspiration of contaminated bath water by a newborn maternal chilling when leaving the water. TRANSCRIBED BY: JOSHUA MATTHEW CAYABAN & NAOMI ASHLEY JOSE 17