NATIONAL OPEN UNIVERSITY OF NIGERIA · 2020. 2. 10. · mons pubis in front to end at perineum....

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NSC501 PUBLIC-COMMUNITY HEALTH NURSING II

NSC501 PUBLIC-COMMUNITY HEALTH NURSING III

NATIONAL OPEN UNIVERSITY OF NIGERIA

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COURSE CODE: NSC501

COURSE TITLE: PUBLIC-COMMUNITY HEALTH NURSING III COURSE GUIDE

NSC501 PUBLIC-COMMUNITY HEALTH NURSING III

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Course Team DR NDIE ELKENAH (Course Writer/Developer and

programme leader)

NATIONAL OPEN UNIVERSITY OF NIGERIA

NATIONA OPEN UNIVERSITY OF NIGERIA, HEADQUATERS, UNIVERSITY VILLAGE CADASTRAL ZONE NNAMDI AZIKIWE EXPRESS WAY,JABI, ABUJA

1.0 Introduction NSC501 is a Five (5) credit unit course. It is a 500 level core course

available for Bachelor of Nursing Science (B.NSc) students. The goal is

to assist the individual, family and community in attaining their highest

level of holistic health in Maternal and child care

The main objective of Public-Community Health Nursing III is

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to provide optimum care to individual, and community through

maternal and child care. Services includes proper antenatal care, post-

natal, family planning nutritional assessment and education..

The course consist of two module and 10 units plus a course guide

which tells you briefly what the course is about, what course materials

you will use and how you can go through these materials with

maximum benefit. In addition the course Guide gives you guidance in

respect to your Tutor- marked Assignments (TMA) which will be made

available to you in assignment files in the study center. It is for your

best interest to attend the facilitation sessions.

Course Aim The course broad objective is to build in your ability to understand and

apply the principles, concepts and process of community health nursing

in providing maternal and child care contemporary society.

Course Objectives

In order to achieve the broad objectives, each unit has specific

objectives which are usually stated at the beginning of the unit. You are

expected to read these unit objectives before your study of the unit and

as you progress in your study of the unit you are also advised to check

these objectives. At the completion of each unit make sure you review

those objectives for self- assessment. At the end of this course, you are

expected to meet the comprehensive objectives as stated below. On

successful completion of the course you should be able to:

• Describe the structures, functions of reproductive organs.

• Define fertilizations and the foetal development.

• Describe maternal physiological adaptation to pregnancy.

• Discuss maternal psycho-social adaptation to pregnancy.

• Describe Sings and symptoms of pregnancy.

• Describe the care of minor disorders of pregnancy.

• Outline the antenatal care of pregnant mother.

• Discuss the stages of labour.

• Outline the role of a nurse in

management of labour

• Outline the care of new born

• Describe the characterist ics and special care of

childhood and adolescent.

D e s c r i b e f a m i l y p l a n n i n g

m e t h o d s

Discuss family health records

Working through the Course

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To complete the course, you are expected to study through the units, the

recommended textbooks and other relevant materials. Each unit has a

model questions which you are required to answer

Course Material

The following are the components of this course:

- The Course Guide

- Study Units

- Textbooks

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Study Units Module 1

Unit 1 Review of reproductive system

Unit 2 Pregnancy

Unit 3 Antenatal care

Unit 4 Labour management

Module 2

Unit 1 NEW BORN CARE

Unit2 CHILDHOOD

Unit 3 ADOLESCENCE

Unit 4 ANTHROPOMETRY

Unit 5 FANILY PLANNING

Unit 6 FAMILY RECORD

Tutor-Marked Assignments (TMAS) There will be 30 objective question from all the units of the course

materials. The questions will be divided into three tutor marked

assignments that will be uploaded to the NOUN website for you to

download and answer and the upload. It is computer marked. The value

is 30% of the total mark.

Final Examination and Grading The final examination for course NSC501 will be pen-on-paper and has

a value of 70% of the total course grade. The examination Pass mark is

50%.


Facilitation

There are hours of f a c i l i t a t i o n t o support this course material. You

will be notified of the dates, times and locations of these facilitation as well as

the names and phone numbers of your facilitator.


CONTENT MODULE 1 MATERNUTY NURSING

UNIT 1 REVIEW OF PRODUCTIVE SYSTEM

Unit 2 EMBROYOLOGY

UNIT 3 ANTENATAL CARE

UNIT 4 LABOUR

MODULE 2 NEW BORN, CHILDHOOD, ADOLESCENCE AND ANTHROPOMETRY

UNIT 1 NEW BORN

UNIT 2 CHILDHOOD

UNIT 3 ADOLESCENTCE

UNIT 4 ANTHROPOMETRY


MODULE 1 MATERNUTY NURSING

UNIT 1 REVIEW OF PRODUCTIVE SYSTEM

CONTENTS

1.0 Introduction

2.0 Objectives

3.0 Main Content

3.1 Anatomy and Physiology of Female and Male Reproductive System

3.1.1 External Organs

3.1.2 Internal Organs

3.1.3 Related Pelvic Organs

3.1.4 The Breasts

3.1.5 The Physiology of Female Reproductive System

3.2 Anatomy and Physiology of Male Reproductive System

3.2.1 Organs of Male Reproductive System

3.2.2 Physiology of Male Reproductive System

3.3 Obstetrical Anatomy

3.3.1 Pelvis

3.3.2 Foetal Skull

4.0 Conclusion

5.0 Summary


6.0 Tutor-Marked Assignment

7.0 References/Further Reading

1.0 INTRODUCTION

In the preceding units, you have learnt Family Health Care which included concepts and

principles of family health care, assessment of family needs, identification of risk

families, nursing intervention and family health records. In this module, we deal with

one of the important aspects of family health care i.e. Maternal and Child Health. In this

unit, you will review the anatomy and physiology of female and male reproductive

systems. You will also gain deeper understanding of female reproductive organs and the

importance of the related pelvic organs. We will also discuss, to some extent, the female

pelvis and foetal skull and their importance and relationship in obstetrics.

2.0 OBJECTIVES

In this unit you are going to learn about the anatomical structure of female and male

reproductive organs and their physiological functions.

After going through this unit you should be able to:

Identify the female reproductive organs

list the organs of female reproductive system

list the related pelvic organs of female reproductive system.

describe the physiology of female reproductive organs

list the male reproductive organs

describe the physiology of male reproductive system.

3.0 MAIN CONTENT

3.1 Anatomy and Physiology of Female Reproductive System

You know that the female reproductive system is divided into two groups - external and

the internal reproductive organs (genitalia). Let us discuss these external and inters

organs, and breasts and other accessory organs in the following sub-sections.


3.1.1 External Organs

The external reproductive female organs i.e. vulva (Pudendum) (the term which is

derived from the Latin word meaning covering) includes everything that is visible

externally from the lower margin of the pubis to the perineum. These structures are

shown in Fig. 1.1.

Mons Pubis (Mons Venaris): It is a firm cushion like formation. It covers the symphysis

pubis and is covered with hair. It constitutes the upper aspect of the vulva. is composed

of adipose tissue. It lies anterior to the vaginal and urethral openings.

Fig. 1.1: The External genitalia

Labia Majora (Singular-Labia Majus)

These are bilateral prominent cutaneous folds extended downwards on each side from

mons pubis in front to end at perineum. Each fold is 7-9 cm long, 2-4 cm wide. The labia

majora contains fatty areolar tissue, veno plexus and nonstriated muscle fibers with a

covering of stratified squamous epithelium of skin. The covering skin is hairy on outer

Mons veneris

Labium majus

Clitoris

Vestibule

Urethral meatus Labium minus

Vaginal orifice

Hymen

Fourchette

Central part of

perineum

Anus

http://vulva.is/


aspects of labia. Both inner and outer surfaces contain sebaceous and sweat glands.

Child birth trauma can cause vulval haematoma. Labia majora is homologous with

scrotum in male.

Labia Minora (Singular-Labia Minus)

The labia minora are two thin folds of cutaneous tissues lying between and parallel to

the labia majora. They are reddish in colour. Each fold is about 5 cm long, 0.5 - 1 cm

thick. The inner surfaces generally remain in contact with each other. Upper divisions of

each labia minus unite to form a hood like structure for the clitoris. This skin fold

hanging over the clitoris is termed as prepuce. The lower divisions unite to form frenum

of clitoris. Posteriorly they unite in the middle to form a thin ridge of skin called

fourchette. Labia minors contain two of nonkeratinized skin containing elastic tissue,

veins, a few smooth muscles, abundant; nerve endings, and sebaceous glands but no

hair follicles or sweat glands. They become erectile on sexual activity. They are

homologous to pineal urethra in male.

Clitoris

Ibis is a midline 2.5cm cylindrical erectile structure attached to the undersurface of

symphysis pubis by suspensory ligament. Clitoris lies 2.5 cm above external urinary

meatus and its body lies in front of symphysis pubis. Childbirth can cause tear around

clitoris and excessive hemorrhage. Clitoris is an analogue to penis in male.

Vaginal Vestibule

It is a triangular area between the labia minora laterally, from clitoris at the apex to

fourchette anteroposteriorly. There are four openings into the Vestibule:

i) External urethral opening

This is a midline anteroposterior slit with two lateral lips lying behind clitoris and just

in front of vaginal orifice. Paraurethral ductsspim (Skene's duct) opens on either side of

external urethral meatus or on its posterior wall inside the orifice.

ii) Vaginal orifice (introitus)

It is a median slit behind urethral opening. It is completely .guarded by a septum of

mucous membrane called hymen. In a virgin, hymen has a small eccentric opening not

usually admitting the finger tip. On coitus it gets ruptured. Following childbirth per


vagina hymenal tags carunculae myrtiformes. are visible. Hymen is composed of double

layer of stratified squamous epithelium with intervening vascular connective tissue.

Vaginal introitus gets dilated on coitus and child birth.

iii) Two openings of Bartholin gland ducts

Bartholin glands are pea sized mucus secreting oval glands. Each gland is situated

posterior to Vestibule. The duct is about 2 cm long and opens in the groove between

hymen and labia minus. The gland and duct are lined by single layer of columnar

epithelia, except for the duct opening which is lined with stratified squamous

epithelium. On sexual excitement, bartholin glands secrete alkaline mucus that

lubricates the vaginal introitus to facilitate coitus. The gland can become infected and

infection is termed as Bartholin abscess or Bartholinitis.

The vulva receives its blood supply from the pudendal arteries and nerve supply from

pudendal nerves.

Now we come to the important organs of reproduction i.e. pelvic floor and perinial

region.

The Pelvic Floor and Perinial Region: The pelvic floor is also known as pelvic diaphragm.

It is composed of two pairs of muscles, levator ani muscles and the coccygeus muscles.

The diagram of pelvic floor is given below in Fig. 3.2.

Fig. 1.2: The Pelvic Floor

Lachio-cavernosus Lachio-cavernosus

Clitoria

Lachio-cavernosus

Bulbo-cavernosus

Transverse perinei

Gluteus maximus

Urethral orifice

Vaginal orifice

Levator ani

& coccygeus muscles

Anal sphincter


The deeper layer is composed of three pairs of coccygeus muscles:

1. The Pubo Coccygeus Muscle 2. The Ilio Coccygeus Muscle 3. The Ischio Coccygeus Muscle The superficial layer is composed of fine muscles:

1. The external anal sphincter 2. The transverse perennial muscle 3. The bulbo cavernous muscle 4. The ischie cavernous muscle 5. The membraneous sphincter of the urethra. The functions of this region includes the following:

1. Supports the weight of the abdominal and pelvic organs 2. Its muscles are responsible for the voluntary control of micturition, defecation

and play an important part in sexual intercourse. 3. During childbirth it enhances passive movements of the foetus through the birth

canal. Perinial Body and Perineum

The perinial body is a wedge shaped mass of fibrous muscular tissue that extends

upwards from the perineum and occupies the area between the vagina and the rectum.

The base is called perineum. The perinial body is 4 cm in width and depth. Deep and

superficial muscles fuse in the centre of this body. The perinial body is stretched and

flattened when the vagina is distended as the foetus passes through birth canal during

delivery.

3.1.2 Internal Organs

The internal reproductive organs are contained in the true pelvic cavity and comprise

the uterus, vagina, ovaries and fallopian tubes.

Uterus

Uterus is a hollow muscular, pear shaped organ contained in the cavity of the true

pelvis. It is situated behind the urinary bladder and in front of rectum. It has a body

which has a rounded upper part called fundus and a lower part called neck or cervix. It

measures approximately 7.5 cm in length, 5 cm in width at its widest part and 2.5 cm in

thickness (in anterioposterior diameter). It weights approximately 60 gm. In it, the


fertilised ovum embeds, is nourished and protected for 40 weeks, until during labour,

the fetus is expelled by the powerful constructions of the uterine muscle.

The angle where the Fallopian tube is inserted is known as the Cornu or horn. The body

of the uterus gradually tapers downwards and the constricted area immediately above

the cervix is known as Isthmus which distends during pregnancy to form the lower

uterine segment.

The perimetrium is a layer of peritoneum; which covers the uterus except at the sides, beyond which it extends to form the broad ligaments. The perimetrium is firmly attached to the uterine wall except at the lower anterior part where, at the level of the isthmus, the peritoneum is reflected on to the bladder.

The myometrium, or muscle coat has very great expansile properties. It forms seven-eights of the thickness of the uterine wall and consists of three layers, an inner circular layer of fibres, a thick intermediate layer, the fibres of which form an encircling figure of eight arrangement surrounding the blood vessels, and by constricting them act as living ligatures to control, bleeding during the third stage of labour. The fibres of the outer muscle layer are arranged longitudinally and because they are four times more plentiful in the fundus the decreasing gradient plays a part in the expulsion of the fetus.

The endometrium lines the body of the uterus and consists of columnar epithelium glands, which produce an alkaline secretion, and stroma or connective tissue cells capable of the rapid regeneration necessary following menstruation. It is also a rich source of prostaglandins. The endometrium is richly supplied with blood and is about 1.5 mm thick. When embedding of the fertilised ovum occurs the endometrium is known as the decidua, because after labour it will be shed.


Fig. 1.3: The uterus and the left uterine tube and ovary

There are 4 pairs of ligaments which give additional support and maintain the uterus in

its forward inclination. These are:

1. The two broad ligaments-continuous structure that is formed by a fold of the peritoneum.

2. The two round ligaments, one on each side, are fibromuscular chords composed of muscles prolonged from the uterus and a small amount of connective tissue.

3. The two utero-sacral ligaments, again one on each side extend backward from the cervix, pass on each side of the rectum, and insert at the posterior wall of the pelvis.

4. The transverse cervical ligaments gives support to the uterus from below. The blood supply to the uterus is through the uterine artery which is a branch of

the internal iliac artery. The autonomous nerves (sympathetic and

parasympathetic) supply the uterus.

Vagina

Vagina is a muscular membraneous canal. It connects the internal and external

reproductive organs.

The vagina consists of:

a muscular layer

a loose connective tissue layer

the mucous layer which is arranged in folds called rugae.

Fundus

Uterine tube

Ligament of ovary

Ovary

Fimbria

5.0cm


During child bearing years of life the vaginal secretion is normally acidic, with a pH

ranging from 4.0 to 5.0 due to lactic acid resulting from breakdown of glycogen by

Doderlin bacilli.

The space between the cervix and vagina is termed as fornix (an archlike structure).

There are four fornices of vagina: the anterior, the posterior and two lateral fornices.

The posterior fomix is considerably deeper than the anterior because posterior wall of

vagina is larger. Anterior wall of vagina is 6.7 cm long whereas posterior vaginal wall is

8-y cm long. Fomices are important in pelvic examination.

Fallopian Tubes or Uterine Tubes or Oviducts

Fallopian tubes, are two slender muscular tubes, that extend laterally from the cornua

of the uterine cavity, one from each side. It consists of three layers:

Serous layer- the outer layer, made up of peritoneum covering

Muscular layer- the middle layer

Epithelial layer - the inner surface is lined by ciliated and nonciliated, secretory cells.

The length varies from 7 to 14 cm. and thickness also varies. The proximal end is very

small, but there is a slight gradual increase in width distally.

Each tube has four parts:

The interstitial portion - passes through the muscle wall

The Isthmus is immediately adjacent to the cornua of uterus

The Ampulla is the expanded lateral portion

The fimbriated end or infundibulum, is the wide distal funnel shaped opening Ovaries

The ovaries are the female sex glands (gonads). They are two small, flatten almond

shaped organs located one on each side of the uterus. Each ovary is attached the

posterior surface of the broad ligament by the mesovarian ligament. The ovaries the

fallopian tubes are supplied by the ovarian arteries.

An ovary is usually described as having the size and shape of an almond; each is about 4-

5 cm long, 2 cm wide, and 1 cm thick and weighs about 3 gm.

The ovary consists of two parts: central portion or medulla, and an outer layer or co The

medulla is composed of connective tissue, blood and lymph vessels and nerves. In the


cortex numerous minute follicles are embedded, each of which contains an ocyte, germ

cell of the female. These are produced during the first five to six months of foe life.

It is estimated that 200,000 ocyte are present in each ovary at birth. At the beginning

adolescence 500,000 ocyte are present, called primary ocyte. At mature stage during

reproductive period these are termed as graafian follicle. The ovaries perform two vital

functions:

i) they produce, mature and extrude ova

ii) they secrete hormones

Fig. 1.4: Life cycle of the Graafian follicle

The function of ovaries will be described in detail in subsection 1.2.5.

3.1.3 Related Pelvic Organs

We have already learnt about the external and internal reproductive organs of the

female. Now you will learn about the related organs such as bladder and rectum which

are situated in the pelvic cavity, and lie in close proximity to the reproductive organs.

We will learn in brief the structure, function and exact location of these organs. If

bladder or rectum is full, it interferes with satisfactory pelvic examination of woman.

Full bladder and rectum also cause delay in the progress of labour. Injuries to bladder

Fully developed corpus luteum

Ovarian ligament

Corpus albicans

Developing follicles

Ovulation


and rectum do occur sometimes at the time of childbirth. Let us discuss bladder and

urethra first and then talk of rectum.

Bladder and Urethra

The urinary bladder is a muscular membraneous sac. It is situated behind the symphysis

pubis and in front of the uterus and vagina. Urine is collected into the bladder by the

ureters. The ureters pass across the brim of the bony pelvis, to the posterior part of the

bladder, which they enter-somewhat obliquely at about the level of the cervix.

The bladder empties through urethra - a short passage/tube 3-8 cm long that terminates

in the urinary meatus. The meatus is a small opening situated in the middle of its

vestibule between the clitoris and vaginal orifice.

Rectum

The lowest segment of the intestinal tract is situated behind and to the left of the uterus

and vagina. The terminal inch of the rectum is called the anal canal. The anus is a deeply

pigmented, puckered opening situated 4-5 cm below the vaginal orifice. It consists of

bands of circular muscles, the internal and external sphincter ani muscle. Veins of the

lower rectum and anal canal sometimes become engorged and inflamed during

pregnancy, as a result of pressure exerted by greatly enlarged uterus. The distended

veins or enlargement of veins of lower rectum and anal canal are called hemorrhoids or

piles.

3.1.4 The Breasts

The breasts of the female may be regarded as accessory glands of the reproductive

system. These are two in number. Breasts are situated one on each side of the chest

between second and sixth ribs. The nipple and areola is covered by small elevations

known as the Tubercles of the Montgomery.

The breasts are compound secretory glands composed mainly of glandular tissue which-

is arranged in lobes, approximately 20 in number (see Fig. 1.5). Each lobe is divided into

lobules and consists of alveoli with secretory cells which produce milk. Small lactiferrous

ducts carrying milk from the alveoli of each lobe, unite to form 20 large ducts. These

ducts, before opening on the surface of the nipple widen to form ampulla which act as

temporary reservoirs for milk.


The nipple, composed of erectile tissue is covered with epittelium and contain plan

muscle fibres which has a sphincter like action in controlling the flow of milk.

Surrounding the nipple is an area of loose skin known as the areola.

In early puberty the breasts undergo extensive changes. Mammary growth is controlled

by hormones. The combined influence of the ovarian hormones (estrogen and

progesterone), the anterior pituitary hormones, somatotropin (growth hormone) and

prolactin bring about normal growth of the breast. At the end of puberty the breasts

reach a size that is characteristic for the individual woman. During pregnancy major

changes take place in the development of secretory tissue

Fig. 1.5: The Breast


As early as six weeks of pregnancy, the breasts become enlarged, tense and sometimes

tender. The growth of breasts continue throughout pregnancy. The nipple becomes

darker in colour and more erectile.

The primary areola

At 12 weeks there is darkening of the area around the nipple. this time a clear fluid can

be expressed from the breasts, but true clostrum does not appear until the 16th week.

Montgomery's tubercles

From the 8th week onwards, 12 to 13 small nodules appear on the primary areola. They

are the pouting mouths of sebaceous glands, and the sebum they secrete keep the

nipple soft and pliable.

The secondary areola: It is seen after the 16th week. It is a mottled zone of

pigmentation, extending beyond the primary areola and sometimes covering half of the

breasts. The breast pigmentation may persist for 12 months after childbirth.

3.1.5 The Physiology of Female Reproductive System

During childhood the reproductive system undergoes gradual growth, along with other

parts of the body, and becomes mature during adolescence. About the age of 9 to 11

years the reproductive organs begin to undergo rapid development. Given below is a

note on the physical changes of puberty; i.e. the usual sequence of sexual development

in girls and the average age at which these changes are first seen:

1. Before 8 years precocious sexual development 2. Appearance of secondary sex characteristics before the age of eight years in girls.

(Certain pathological conditions may stimulate the ovaries to premature activity) 3. 12-13 years - average age of sexual development 4. After 12-13 years-Delayed sexual development, physical changes, growth of bony

pelvis and widening of hips, 5. Certain changes in breasts also appear 6. Growth of public hair, auxiliary hair, growth of external genitalia 7. Acceleration of growth 8. The first menstrual period is termed as menarche. Menarche appears between 9

to 17 years. 9. Ovulation usually begins one or two years following menarche. Functions of the mature reproductive cycle


After the ability to reproduce has been attained, the reproductive organs of the female

go through a series of cyclic changes each month throughout child bearing period (like

menstruation) except during pregnancy, lactation and cessation of menstruation

(menopause). These changes involve two cycles:

i) Ovarian cycle

ii) Endometrial cycle or menstruation

Let us discuss ovarian cycle first.

3.1.5.1 The Ovarian Cycle

The ovarian cycle consist,-. of the series of changes in an ovary that are repeated at „

monthly intervals. Main phrase of the cycle includes of development of the-graafian

follicles, ovulation and formation. of corpus luteum.

Let's discuss briefly these three developments below:

Graafian Follicles

It is estimated that at birth each ovary contains two lacs of immature follicles.

Approximately fifty thousand are present in each ovary when puberty is reached. From

the time ovulation begins during puberty until the menopause, some of the primary

follicles, under the influence of follicle stimulating hormones (FSH) from the anterior

pituitary develop to full maturation. The structure of a fully mature graafian follicle (see

Fig. 1.6) shows the following structures.

Theca internal - inner layer

Theca external - external layer

Mendera ganulosa - cells lining the graafian follicle

Discus proligerous - mass of cells

Liquor follicle - fluid accumulates in the centre of the graafian follicle

Ocyte - enclose in discus proligerous.

Follicle beginning of

Antrum formation

Developing

Primary Follicle Germinal

Epithelium

Mature Follicle

Follicular Fluid

Ovum

Released Ovum

Raptured Follicle

Corpus albicans

http://repeated.at/


Fig. 1.6: Ovulation

3.1.5.2 Ovulation

When a graafian follicle, with its enclosed maturing ocyte, reaches the surface of the

ovary, its wall becomes thinner and it finally ruptures. The process of extrusion of a

matured ocyte from the ovary through rupture of graafian follicle is called ovulation.

The ovum is discharged near the fimbriated end of the fallopian tube. Ovulation is the

dividing period between the two phases of the ovarian and amenstrual cycle. The pre-

ovulatory period is termed follicular phase and post-ovulatory period termed luteal

phase.

The time of ovulation is approximately 10 days before the end of a cycle.

Several signs and symptoms may give evidence that ovulation will or has taken place.

These are:

1. Mid-cycle abdominal pain.

2. Mid-cycle vaginal bleeding amounting to no more than spotting.

3. A shift in basal body temperature. Body temperature is relatively higher during

post-ovulatory period. The basal body temperature shift is a useful clinical

method of determining the approximate time of ovulation. The woman is

instructed to take her oral temperature daily for six months immediately after


awaking in the morning and before getting out of bed to determine the time of

ovulation.

Corpus Luteum

After ovulation the cavity of the ruptured graafian follicle is replaced by a compact mass

of tissue termed as corpus Lueum (Yellow body), so named because it is of yellow

colour. The corpus luteum functions as an endocrine organ. It produces progesterone

and -sécretes the follicular hormone estrogen. Corpus luteum degenerates and forms

the corpus albicans. If pregnancy occurs, it is termed corpus luteum of pregnancy, and

continues approximately three months.

3.1.5.3 Ovarian Hormones

The ovaries produce two steroid hormones: estrogen and progesterone.

i) Estrogen: is a female sex hormone. It is responsible for the growth of female

reproductive organs and the mammary glands. Estrogen is also involved in a

number of systemic processes such as fluid, electrolyte balance and body

temperature. The functions of estrogen are as under:

a) Changes cervical mucus to favour migration of sperms.

b) It stimulates mobility of fallopian tubes to propel matured ova through

them.

c) It prepares endometrium for implantation of fertilized ovum.

d) It helps in the growth of uterus and breasts during pregnancy.

ii) Progesterone: The corpus luteum secrets progesterone in large amount and also

some estrogen. Progesterone is a progestational hormone. Its functions include

the following:

a) It prepares uterus for implantation of a fertilized ovum and maintenance

of pregnancy.

b) Progesterone along with estrogen causes cyclic changes in the

reproductive tract.

c) It is necessary for the complete development of the mammary glands.


d) It has some effect on metabolic process.

Ovarian hormones bring cyclic changes in the cervix and vagina.

Cervical Mucus

Varies considerably in its characteristics during the course of each cycle. Cervical mucus

can be examined and evaluated for its qualities to determine approximate time of

ovulation and to assess ovarian functions.

Vaginal Mucosa

Mucosal cells and the secretions of the vagina undergo regular changes during each

ovarian cycle. Vaginal smears may be used to estimate estrogen activity.

Now we will come to the discussion on endometrial cycle.

3.1.5.4 Endometrial cycle (menstrual)

As the ovary under goés cyclic changes, so the endometrial lining of the uterus also

undergoes a series of changes. The endometrial cycle can be described in three main

phases:

i) The Follicular Phase: This phase commences about two days after the cessation

of menstruation and lasts until ovulation takes place (14 days previous to next

menstruation period). Estrogens are responsible for the growth of the

endometrium which takes place at this time.

ii) The Luteal Phase: The premenstrual phase commences after ovulation, when

progesterône causes the endometrium, which has already been growing under

the influence of estrogens to hypertrophy still further. The endometrium glands

increase in size, the capillaries are distended with blood, and small haematoma

form under the epithelium producing red congested surface. This thick soft

vascular membrane is admirably prepared for the reception of the fertilised

ovum. Should fertilization not take place, the ovum dies, the corpus luteum

disintegrates, the secretion of estrogens and progesterone falls and

endometrium shows degenerative changes which are followed by desquamation

and bleeding.


iii) The Menstrual Phase: The menstrual phase, characterised by vaginal bleeding,

lasts for three or four days, and occurs every 28-30 days from puberty to the

menopause in the normal woman. This is the terminal phase of the menstrual

cycle. The superficial layer of the endometrium is shed, along with blood from

the capillaries. The unfertilised ovum is also discarded. As soon as menstruation

ceases the regeneration of the endometrium begins. The remaining glands and

stroma cells multiply and the effused blood is absorbed as in the healing of a

wound. The endometrium is reformed.

Certain signs and symptoms appear a few days before the onset of menstruation.

Collectively these signs and symptoms are called premenstrual syndrome.

Let us discuss the premenstrual syndrome.

3.1.5.5 Premenstrual Syndrome

A few days before bleeding begins, certain promontory signs are frequently noticed.

Common signs are abdominal distention, headache, backache, breastfullness, bladder

irritability, constipation and pre-menstrual tension characterised by depression or

anxiety These signs and symptoms should be considered as normal. It is believed that if

menstruation is accepted/regarded as a normal physiological process it often reduces

discomforts of menstruation such as dysmenorrhoea.

The Climacteric or Menopause

The cyclic changes of the reproductive organs of female continue during the child

bearing period. Beyond this period the function of the ovary gradually decreases and

ultimately stops. This period is called climacteric or menopause.

The climacteric, frequently termed as the menopause and sometimes called "the change

of life", is the period of life at which ovarian function gradually decreases and eventually

stops. Menopause means permanent cessation of menstruation. The climate occurs

between the age of 40 and 50, but there is considerable variation of time. As

menopause approaches menstruation often occurs irregularly. The flow sometimes

increases slightly, but usually begins to decrease in amount.

Vaso-motor changes - hot flushes - of the face and neck sweats and flashes of heat that

may involve the entire body are the most characteristic symptoms of climacteric.


3.2 Anatomy and Physiology of Male Reproductive System

In the foregoing section and subsections you have learnt about anatomy and physiology

of female reproductive organs. In this section we shall focus the anatomy and

physiology of male reproductive organs. The description of these organs is given below

in subsection 1.3.1.

3.2.1 Organs of Male Reproductive System

The male reproductive organs are:

1. Testes 2. Epididymis 3. Vas deferentia (Singuler -vas deferens) 4. Seminal Vesicles 5. Ejaculatory ducts 6. Prostate Gland 7. Bulbo Urethral Glands (Cowper's Glands) 8. Penis 9. Scrotum and Spermatic

Vas deference

Ductus

epididymis

Urethra

Bladde

Seminal vesicle

Ejaculatory duct

Prostate gland

Efferent ductule

Seminiferous

Tunica

Testes

Septu

Lobule

Penis


Fig. 1.7: Male reproductive organs

Let us discuss each of these organs.

3.2.1 Testes

The testes, the sex organs or gonads, of the male are two slightly flattened, ovoid,

glandular bodies. The testes are formed in the peritoneal cavity during foetal

development and then normally migrate through the inguinal canal into, the scrotum

during the eight or ninth month of pregnancy, or occasionally soon after birth. Descent

into the scrotum by the age of puberty is essential for normal spermatogenesis; which is

adversely affected by the relatively higher temperature within the body. Each testes has

a mass of narrow, coiled tubules, called semiferous tubules. These tubules are from 1 to

3 feet long. The combined length of many tubules in one testis equals almost one mile.

Epididymis

The epididymies are bilateral narrow bodies situated along the upper posterior part of

each testis. Each contain a narrow, tortuous tubule approximately 20 ft.in length. This

tubule serves as the area to which the spermatozoa that have been released into the

semiferous tubules are conveyed, and where they may remain for about three weeks.

Here they are retained until physiological maturation is complete and until they become

motile. As the tubule of the epididymis leaves the body, it becomes known as vas

deferens.

Vas deferentia

The vas deferentia are bilateral ducts, approximately 18 inches long, which continue

from each epididymis and then terminate in the bilateral ejaculatory ducts, which open

into the urethra. A vas deferens ascends from each testes through a spermatic cord,

passes through the inguinal canal, crosses the pelvic cavity, and after coursing upward

and medially, passes downward to the base of the bladder where it widens into an

ampulla. This terminal end joins with a duct from seminal vesicle, and they become the

ejaculatory duct. The vas deferens serves as a storage site for sperm.

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Seminal Vesicles: The seminal vesicles are two membraneous pouches, situated

between the lower part of the bladder and the rectum. Through a short duct each

vesicle joins the terminal end of a vas deferens and with it becomes an ejaculatory duct.

Ejaculatory Ducts

The ejaculatory ducts are paired, narrow, short tubes formed by the joining of the

terminal ends of the vas deferentia and the ducts from the seminal vesicles. These two

ducts descend between the lobes of the prostate gland and open into the urethra into

which they discharge sperm and secretions from the seminal vesicles and epididymis.

3.2.2 Prostate Gland

The prostate gland is located just below the bladder and surrounds the upper portion of

the urethra. It secretes a thin, complex fluid that is discharged into the urethra through

many small tubules that open into it.

Bulbo Urethral Glands (Cowper's Glands)

The bulbo urethral glands are two small pea sized bodies located below the prostate

gland within the pelvic floor. They secrete an alkaline, viscous fluid that is emptied into

the urethra, through a small duct from each gland.

3.2.3 Penis

The penis is the male organ of copulation. Semen is ejaculated through it into the vagina

of the female during intercourse, and the active spermatozoa in the semen can enter

the cervix and travel through the fallopian tubes where fertilization of an ovum may

take place. The penis is a cylindrical organ composed of three elongated masses of

erectile tissue. A slight enlargement at the end of the penis, called the glans penis,

contains urethral opening and many very sensitive nerve endings. The skin of the penis

extends over its end, covers the glans, and become folded upon itself. This is called the

prepuce or the foreskin and is the portion that is surgically removed when a

circumcision is performed.

Urethra

The male urethra, which extends from the neck of the bladder to the orifice in the glans

of the penis, serves two purposes. It conveys urine from the urinary bladder at urination

and transmits semen containing spermatozoa at copulation.


Scrotum and Spermatic Cord: The spermatic cords originate just above the inguinal

canal, pass through the canal, and down to the scrotum. Scrotum a pouch like double

chambered structure is made up of skin, fascia and muscle. The testes, epididymis, and

parts of the spermatic cords are enclosed.

3.2.4 Physiology of Male Reproductive System

Physical changes occur in puberty in boys. The earliest physical changes in boys are ,

testicular growth, and thinning and pigmentation of scrotal skin. The growth of genital

organs then continues.

Pubic hair begin to appear. Prostaatc growth and secretary activity begins. Breast also

enlarge slightly. Axillary hair grow. Fine hair appear on upper lip. Deepening of voice

occur at this time. Physical growth is accelerated and height production increases

rapidly.Boys continue to grow even beyond the age of 18 years. Fertility develops soon

after mid puberty in boys.

The mature reproductive organs of the male performs three major functions i.e. of

hormones, spermatogenesis and secretions from glands. The hypothalamus and

pituitary gland are closely inter-linked with function of the reproductive organs.

.Hormonal function is carried out by specialised cells of the testes called interstitial cells.

These cells secrete` the male hormone testosterone. Testosterone is necessary for

normal development and activity of male organs. Spermatogenesis also takes place in

the lining of seminiferous tubules. The secretions from the male accessory glands are as

follows:

1. The semen - produced and released from testes 2. The seminal fluid - the seminal vesicle secrete a yellow fluid 3. The secretion from the prostate gland the combined secretion from the seminal

glands provides a fluid that serves as a medium for sperm transport and as a favourable substance to sperm fertility.

The pH of semen varies 7.35 to 7.50. Semen is ejected from the male genital tract in an

average volume of 3 ml. Each milliliter of semen normally contains 50 to 150 million

spermatozoa.

So far we have discussed the anatomy and physiology of female and male reproductive

systems in general. Now we shall talk of obstetrical anatomy which is important from

the point of view of MCH care during pregnancy, child birth and postnatal care.


3.3 Obstetrical Anatomy

The internal organs of the female are contained in the pelvic cavity. The size and shape

of the pelvis is important because the foetus has to pass through it during labour.

There are three factors which are concerned during labour.

1. The passage - The pelvis (hard and soft parts) 2. The passenger - The foetal skull (the whole) 3. The powers - The uterine contractions (the general health of mother). The passage and passenger will be described here. The powers i.e. the uterine

constructions will be discussed in Section 2.4. Let us begin with passage i.e. pelvis fast.

3.3.1 Pelvis

Pelvis has been classified into four types according to the shape of the brim (Fig. 1.8).

Fig. 1.8: Characteristic inlet of the flour types of pelivs

1. The gynaecoid pelvis - or true pelvis, has a round brim 2. The android pelvis - has a heart shape brim 3. The anthropoid pelvis - has an oval brim, diameter 4. The platypelloid pelvis - or simple flat pelvis, has a kidney shaped brim, in the

anteroposterior diameter

Anthropoid

Android Gynaecoid

Platypelloid (flat)


We will discuss only gynaecoid pelvis here as it is of obstetric importance.

Gynaecoid pelvis

The gynaecoid pelvis is composed of:

i) Two innominate bones or hip bones composed of three parts:

Ilium

Ischium

OS pubis i) Sacrum ii) Coccyx There are three pelvic joints:

One symphysis pubic joint

Two sacroiliac joints

One sacrococcygealjoint There are five pelvic ligaments:

Interpubic ligament

Sacroiliac ligament

Sacrococcygeal ligament

Sacrotuberous ligament

Sacrospinous ligament The pelvis is divided into two parts:

False pelvis - The upper expanded part

True pelvis - The bony canal The true pelvis is divided into:

Pelvic brim or inlet

Cavity

Outlet The pelvic measurements are as follows:

Diameters of the pelvic brim or inlet

i) Anteroposterior diameters also called the obstetrical conjugate is 11 cm

i) Oblique diameters is 12 cm


iii) Transverse diameter is 13 cm

Diameters of the Cavity

Cavity is circular in shape. All the diameters are 12 cm.

Diameters of the outlet

The anteroposterior is 13 cm

The oblique diameter is 12 cm

The transverse diameter is 11cm

Fig. 1.9: The pelvic measurements

3.3.2 Foetal Skull

The foetal skull contains the delicate brain which may be subjected to great pressure,

during labour. It is large in comparison with the true pelvis. Head is the most difficult

part to deliver. Some adaptation between skull and pelvis must take place during

labour. Therefore the foetal skull is extremely important in obstetrics. See Figs. 1.10.

and 1.11.

Antero – posterior Obligue Transverse

Brim

Cavity

11 12 13

12 12 12

13 12 11

ANTERIOR FONTANELLE

OR BREGMA


Fig. 1.10: Foetal skull, showing regions and landmarks of obstetrical

The foetal head may be divided into vault, face and base

Bones of the vault of the foetal skull are:

occipital bone

two parietal bones

two frontal bones

Fig. 1.11: Diagrammatic representation of the vertex area of foetal skull showing sutures

and fontanelles

The Sutures

Are cranial joints. The important sutures in the foetal skull are:

The lambdoidal suture

The sagittal suture

The coronal suture

Lambdoidal Suture

Sagittal Suture

Coronal Suture

Frontal Suture

Posterior

Fontanelle

Anterior

Frontanelle

Occipital

L. Parietal R. Parietal

½ Frontal ½ Frontal


The frontal suture The Fontanelles

Where two or more sutures meet, a fontanelle is formed. Therg two important

fontanelle of foetal skull:

Posterior fontanelle, closes 6 weeks after birth

Anterior fontanelle, closes 18 months after birth Regions of the foetal skull

The occiput

The vertex

The sinciput or brow

The face The diameters of the foetal skull are given below:

Bitemporal 8.2 cms

Biparietal diameter 9.5 cms

Suboccipito bregmatic 9.5 cms

Suboccieito frontal 10.5 cm

Occieito frontal 11.5 cm

Mento vertical 13.5 cm

Submento vertical 11.5 cm

Submento bregmatic 9.5 cm Moulding is the change in shape of the foetal skull that takes place during the p through

the birth canal, due to overriding of bones because of sutures and fontanelle.

Diagnosis of presentation and position of foetus are ascertained by means of pal vaginal

examination, x-ray or ultrasound.

4.0 CONCLUSION

You have seen that female as well as male reproductive organs are important for

reproduction. Female reproductive external organs are collectively termed as vulva.

The internal organs are vagina, uterus, fallopian tubes and ovaries. The ovaries produce

female hormones and ovum. Under the influence of hormones- uterus becomes


prepared for pregnancy each month. When pregnancy does not take place, the

endometrium of the uterus sheds off in menstrual flow. These cyclic changes continue

throughout child bearing except in pregnancy and lactation. Related organs such as

bladder and urethra are also important because of their close proximity.

The breasts are accessory organs of reproduction. Their main function is to secrete milk

after child birth.

In male, reproductive organs and urinary organs, e.g. urethra, are together. Main

functions of mature reproductive organs of male are:

Hormonal

Spermatogenesis

Secretions from various glands

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Unit 2– PREGNANCY

CONTENT

1.0 INTRODUCTION

2.0 Objective:- At the end of this unit the students should

1. Discuss conception

2. Describe the maternal-foetal environment.

3. Describe maternal physiological adaptation to pregnancy.

4. Outline maternal psychological adaptation to pregnancy.

3.0 Maine Content

3.1. Conception

Fertilization

Definition of terms

Gametogenesis is a process in which germ cells are produced. The

female germ cells are produced. The female gamete (Ovum) is produced in

the grootion follide during oogenesis the male gamete is produced in the

seminiferous tubules of the testes during spermatogenesis.

MEIOSIS:- This is a special process of cell division in gometermy that

reduces the number of chromosomes in each gamete to half of the normal 46

to 23. Therefore, each fertilized ovum will have half of its genetic material

from the mother, and half from the father of the 23 chromosomes, one is a

sex chromosome. The sex chromosome from the mother will always be on X

chromosome. The sex chromosome from the father can be either on X or a Y

chromosome. Ovulation occurs 14 days before the beginning of the next

menstrual cycle – day 14 of a 28-day cycle and day 20 of a 34-day cycle.

Conception occurs when the ovum and sperm unit in the outer one third of

the fallopian tube. The fertilized ovum contains a total of 46 chromosomes

(22 pairs of matched chromosome and 2 sex chromosomes). The fertilized

ovum is called a zygote. A female zygot is created if a sperm carrying on x

chromosome fertilizes the ovum, which results in the zygote having the

female sex chromosomes of XX: a male zygot occurs when the ovum is

fertilized by a sperm carrying a Y chromosome, which result in the zygote

having the male sex chromosome of XY.


After the fertilization the zygote is transported through the fallopian tube by

a fluid current. The zygote changes through a process called cleavage. The

early cellular changes result in cells called the morale, to blastomere and

then the blastocyst. The developing fetus is called a pre-embryo for the first

2 weeks of gestation, and embryo from week 3 through week 8 and a foetus

until the time of birth.

3.1.2 Embryonic membranes and amniotic fluid: The embryonic membranes,

called the amnion and chorionic, are formed at the time of implantation. The

membranes surrounding the growing embryo and foetus contain amniotic

fluid which is slightly alkaline in nature. The volume of amniotic fluid

ranges from 500-1000ml after 20 weeks of gestation. The fluid is constantly

replaced. The foetus swallows approximately 400-500ml/day. The foetus

also “breaths” amniotic fluid in and out of the lungs. Substances contained in

the amniotic fluid include albumin, bilirubin, creatinine, fat, enzymes,

epithelial cells, lecithin and sphingomyelin.

Functions of amniotic fluid

The functions are

1. Provide a fluid cushion to prevent trauma

2. Allow the foetus to move with ease

3. Maintain the foetus at a uniform temperature

4. Promote development of foetal lung tissues

5. Provide fluid for the foetus to swallow

6. Protect the foetal head during labour.

3.1.3 PLACENTA

The placenta is an organ that provides metabolic and nutrients exchange

between the water and foetal systems. The placenta development and

circulation begin about 3 weeks after conception. The placenta fully formed

and functioning at 3 months of gestation.

At 40 weeks‟ gestation, the placenta contain 15-20 subdivision called

cotyledon and about 6-8 inches in diameter 1-1.2 inches thick and weighs

about one sixth the weight of the foetus. The maternal surface is red, and

flesh like while the foetal surface is shining and smooth.

The placenta produce four hormones

1. Progesterone which is essential for the pregnancy

- It stimulates development of decidedness

- It decreases contractility of uterus

2. Oestrogen or oestrus

- It stimulates proliferation of breast tissue and enlargement of uterus

- It stimulates uterine contractility


- Depends on essential precursors from foetal advenal glands and its

production.

3. Human placental lactogenic (HPL) that is also called human chorionic

semotomonimotropin.

- It enhances maternal metabolism

4. Human chorionic gonadotropin (HCG)

- It stimulates corpus lutein to secrete oestrogen and progesterone

- It exerts on effect on interstitional cells of lestes to produce testosterone in

the make foetus.

3.1.4 UMBILICAL CORD

The umbilical cord attaches the foetus to the placenta. It contains two

arteries and one vein. The umbilical vessels are surrounded by Wharton‟s

jelly, which protects the cord from pressure and kinking. The cord is

approximately 50-55cm in length. It is attached to the center of the foetal

side of the placenta. Occasionally it is attached to the edge of the placenta

and this is called Battledore insertion.

3.1.5 FOETAL CIRCULATION

The foetal circulation contain five unique structures

1. Umbilical vein: It carries oxygen and nutrients to the foetus.

2. Two umbilical atria: Which carry deoxygenated blood and waste product

from the foetus.

3. Ductus Venous: This shunts the umbilical vein to the inferior vena cava, by

passing the liver and organs of digestion.

4. Foramen Ovale: This shunts blood from right atria to left atria, by passing

the ventrides and lungs

5. Dustus arferiosus: This shunt blood from pulmory artery to aota, bypass the

lungs.

See fig 1

3.2 MATERNAL PHYSIOLOGICAL ADOPTATIONS TO PREGNANCY.

3.2.1: Cardiovascular System:

The maternal blood volume increases progressively during pregnancy until it is

about 45% above prepregnant levels. A 30%-50% increase in blood volume is due

to increases in both plasma and red blood cells. The pulse may increase to about 10

beats/minutes. The maternal blood pressure is lowered in the second trimester and


gradually increased in the third trimester but should not exceed prepregnancy level.

The total RBC increased by 20% while cardiac output increases by 20%-30%. The

haemoglobin may decrease to 10.5g/dL because of the haemodilution. This is

called physiologic anaemia. Iron supplementation is not needed unless the

haemoglobin falls below 10.5g/dL.

White blood cell (WBC) production increases as blood volume increase.

The fibrin level of blood increases by about 40%.

3.2.2 Respiratory System

Pregnancy induces small increase hyperventilation in the mother which causes a

mild respiratory alkalosis. Oxygen consumption increases by about 15%-20%

between 16th and 40

th week of gestation. Vital capacity increases slightly. The

respiratory rate remains unchanged.

3.2.3 Gastrointestinal System

The gastrointestinal symptoms of nowzia and vomiting are common in first

trimester due to secretion of HCG. There is alteration in taste and small are

common. The gum tissue may become soft, swollen and bleeds easily. Gastric

emptying time and intestinal mobility is delayed which leads to bloating and

constipation. Haemorrhoid may occur at late pregnancy due to increase venous

pressure.

3.2.4 Urinary Tract

Urinary frequency occur in the first trimester due to pressure of enlarging uterus on

the bladder near the end of the pregnancy, the weight of the uterus once again

comes pressure on the bladder, resulting in urinary frequency. Dilution of the

kidney, renal pelvis and ureters may occur especially on the right side because of

the elevated progesterone levels and pressure of the enlarged uterus. The

glomerular filtration rate and renal plasma flow increase early in pregnancy.

Glycosuria may occur because of increased glomerular filtration. Clearance of

creatinine and urea increases due to increased renal function.

3.2.5 Endocrine System:-

The thyroid gland has increased vascularity and hyperplasia which is associated

with increased circulating oestrogens. The based metabolic rate rises to +50% in

late pregnancy. The increase is associated with the demands of foetus and uterus

and with oxygen consumption increase. The size of parathyroid increases. The

increase parallels foetal calcium need. The pituitary glands enlarge slightly.

Circulating cortisol levels are increased because of increased oestrogen levels. The

cortisol levels regulates carbohydrate and protein metabolism.

3.2.6 Reproductive System


3.2.6.1 Uterus

The uterus enlarges primarily as a result of an increase in size of myometrial cells.

The size and number of blood vessels and hypnotics increase during pregnancy.

Irregular contractions called Braxton Hicks sign occur throughout pregnancy, but

may not be noticed by the pregnant woman until the third trimester. These

contractions must be differentiated from regular contractions which result in

cervical dilution.

3.2.6.2 Cervix

The endocervical glands secrete a thick, tenacious mucus plug. The plug is

expelled from the endocervical canal when cervical dilation begins. Increased

vascularization causes softening of the cervix, which is called Goodell‟s sign. This

softening also causes easy flexion of the uterus against the cervix called

McDonald‟s sign. The cervix takes on a blue-purple coloration and also caused by

increase vascularization which is called Chadwick‟s sign.

3.2.6.3 Ovaries

The ovaries cease to produce ovum. The corpusluteum persists until the 10th-12

th

week of pregnancy.

3.2.6.4 Vagina and Labia:-

Hypertrophy of vaginal epithelium occurs. There is also increased vascularization

and hyperplasia. The vaginal cells contain higher levels of glycogen, which

redispose pregnant woman to vaginal yeast infection. The vaginal secretions which

are thick, white and acidic are increased.

3.2.7 BREAST

The breast size increases. The superficial veins become prominent. The nipples

become more erectile. Hypertrophy of Montgomery‟s tubercles occurs and

colostrum may leak from the breasts in the last trimester.

3.2.8 SKIN

There is increased level of melanocyte-stimulating hormone that lead to increased

pigmentation. The pigmentation of skin may increase in areola, the nipples, the

vulva, the perenial area, and limen Alba. The increase in pigmentation of the line

from the umbilical to the pubis is called lineanigra 70% of women develop

pigmentation over the forehead, cheeks, and nose. This is called chloasma Striace

(reddish purple stretch marks) may occur on the abdomen, breasts, thighs and

upper arms.

3.3. MATERNAL PSYCHOLOGICAL ADOPTATION TO PREGNANCY


3.3.1 Psychological response to pregnancy:- Pregnancy is viewed as a

developmental stage. The woman‟s response varies according to her own

emotional makeup, her sociocultural background, her support system and her

acceptance or rejection of the pregnancy. The psychological responses include.

- Ambivalence:- This feeling occurs early in pregnancy and is common even

when the pregnancy is planned.

- Acceptance:- This is when the woman accepts the pregnancy. She tends to

display happiness and pleasure and experience fewer physical discomforts.

- Introversion:- A turning inward is common to pregnant women as they

attend to planning for and adjusting to the new baby.

- Mood swings:- The extent of mood swings ranges from ecstasy to great

despair. Mood swings are more prevalent in early pregnancy as hormone

levels increase.

- Body image changes:- Pregnancy is associated with marked changes in a

woman‟s body. These physical changes affect how a woman views herself

as well as how she perceives others to view her.

3.3.2 Maternal tasks of pregnancy; There are four maternal tasks of pregnancy

as the pregnant woman forms a relationship with her foetus and rearranges

family relationship.

a) Seeking safe passage:- This is the most important task for the woman. It is

the process of ensuring the safety of herself and her foetus through

pregnancy and birth by obtaining prenatal care and following the traditional

practices of her culture as they relate to pregnancy, birth and the postpartum

period.

b) Securing Acceptance:- The woman try to secure acceptance of the

pregnancy and body from other family members including reworking family

relationship so that the woman‟s new role as a mother and the new body is

welcomed as a family members.

c) Learning to give of self:- This is a task that must be learned by a pregnant

woman. This process starts when the woman learn she is pregnant and

allows the foetus to grow and develop within her body. Pregnant women

learn to give by both giving and receiving.

d) Committing herself to the unborn child:- This maternal task of pregnancy is

also known as developing attachment to the foetus. This is the only maternal

task that starts in the first trimester and does not end until the end of the new

born period. This task is called “binding in” to pregnancy. The events that

make it more real include feeling foetal movement or heavy the foetal heart

beat. The woman feels protective of her foetus and has increased feeling of

vulnerability. She starts to take please in thinking about her new role as a

mother.


UNIT 3 ANTENATAL CARE

CONTENT

1.0 INTRODUCTION

2.0 Objectives

At the end of this unit the student will be able to (i) Calculate the expected date of delivery

(ii) Discuss the history taking in antenatal clinic

(iii) Conduct abdominal palpation on pregnant mother

(iv) Identify at risk pregnancy

(v) Describe nutritional needs in pregnancy

3.0 MAIN CONTENT

3.1 Estimating the Probable Date of Delivery (EPD) or Expected Date of Delivery (EDD)

Now after knowing the signs and symptoms, you need to estimate the probable date of

delivery. The exact duration of pregnancy can be ascertained. The duration of pregnancy

is generally 280 days or 40 weeks or ten lunar months. The approximate date of delivery

may be estimated by adding seven days to the first day of the list menstrual period and

counting forward nine calendar months.

Other methods are:

i) By measuring the height of uterus with tape measure in centimeters

ii) By palpating the uterus


iii) Estimating the duration of pregnancy by counting forward 22-24 weeks from the

day on which the expectant mother fast feels foetal movement

iv) Dates when pregnancy tests are positive in relation to last menstrual period

v) When foetal heart is first heard by an ordinary foetoscope.

3.2 Maternal Care During Pregnancy

The antepartum (antenatal) period extends from conception until the onset of labour.

Pregnancy is a normal biological event. But it is an unusual one in the life of a woman

and as such requires special attention for promotion of her health and that of her

foetus: For the promotion of maternal and foetal health, the pregnant woman has

several needs. To initiate these needs maternal care during pregnancy is given below.

3.2.1 Initiating Antepartum Care

As soon as a woman suspects herself to be pregnant, she should make an appointment

with the clinic/health workers. The health worker should also identify pregnant woman

during routine home visiting.

The first antepartum contact should be primarily one of the assessment for both the

woman and health professionals. The main purpose of the antepartum contact is to

determine the physiological and psychological responses of the woman to pregnancy by

means of thorough assessment. Three methods of data collection for assessment are

explained below: i) the health history, ii) the physical examination and iii) laboratory

screening procedures. Further assessment of high risk factors and mother-foetal

physiological status are also discussed in this subsection.

i) The Health History

Taking the health history is the most important method of data collection. The history

has to be recorded under the following headings:

a)Menstrual history Age of menarche Regularity, interval, and duration of flow Dysmenorrhoea or other complications Date of first day of, last menstrual period

b) Obstetrical history


Past pregnancy

Date

Courses of pregnancy labour and postpartum period

Sex, name, birth weight and gestational age of infant

Present health of the child c) Present pregnancy

Planned vs Unplanned

Subjective signs and symptoms d) Medical History

Family

Personal d) Social history

Education of woman and her husband

Occupation of the couple

Marital and sexual history

General health habits, regarding rest and sleep, nutrition, elimination and recreation

ii) The Physical Examination

a) General Examination -Weight, height; blood pressure, temperature, pulse, respiration etc.

b) Obstetrical examination - Examination of breasts, abdominal palpation vaginal examination (if necessary)

iii) Laboratory Screening Procedure

The following laboratory screening tests are done during pregnancy, depending on

individual needs of the woman:

Haematocit haemoglobin

White blood cell count and differential white cell count

Blood grouping

Antibody screening

Urine analysis

Serological examination

Cervical smear

Papanicolaou smear

Blood sugar examination 3.2.2 Assessment of Perinatal Risk or High Risk Factors


After completing the history, physical examination and laboratory examination, are

analysed to determine risk factors.

Factors of "high risk" pregnancy

Age-under 15 or above 30

Multigravida

Short statured primi (140 cm and below)

Mal-presentation, multiple pregnancies

Anaemia (Hb 50 per cent and below)

Pre-eclampsia and eclampsia,

Antepartum haemorrhage

Previous still births, Intra-uterine deaths, Instrumental delivery, Caesarian section

Prolonged pregnancy (14 days + after expected date of delivery)

Twins, hydraminios

Pregnancy associated with general disease, viz. cardiovascular disease, diabetes, kidney disease, etc.

3.2.3 Assessment of mother-foetal physiological status

Monitoring of the physicalphysiological changes of pregnancy and the growth and

development of the foetus is achieved by a series of visits by the mother to the clinic at

intervals, throughout gestation. A typical schedule for these visits is as follows:

Once a month for the first 30 weeks

Every two weeks until the 36th week

Every week until the onset of labour

Organising an Antepartum Visit

Determine the purpose of visit

Renew the present plan of care

Collect subjective data

Collect objective data i.e., to check weight, blood pressure, urine testing and haemoglobin testing

Obtain necessary assessment

Modify plan of care based on obtained informations

Give appropriate teaching/counselling i.e. on diet, rest, exercises, etc.


3.3 Management of General Health during Pregnancy

Pregnancy is a time of rapid and dramatic physical changes which makes the woman

feel, as well as look, more feminine and attractive.

An increased interest in health awareness is to be created. Advice on the following

aspects should be given to all pregnant women in general and particularly to

primigravida.

Grooming and personal hygiene A daily bath or shower is ideal

Clothing Pregnant mother should be advised to wear loose and attractive cloths.

Footwear Shoes with 4-5 cm heel having a broad base should be worn. Narrow high heels cause

fatigue in maintaining good posture.

Care of breasts and nipples An uplifting brassier should be worn. The brassier should not be tight to depress the

nipples.

Exercise and recreation Outdoor exercise is ideal and pregnant women need to be encouraged to continue with

such outdoor recreation as they have been accustomed to, so long as it does not cause

jolting. Games should not be strenuous. As good brisk walk is excellent. House-work

brings many, but not all muscles into play, so exercises have been devised to keep the

muscles to be used during labour in good trim and the pelvic joint flexible. The pregnant

women should not lift heavy weights, as this may predispose to abortion in susceptible

cases. The woman should not climb to reach high shelves, because of the likelihood of

over balancing and her tendency to faint.

Sexuality In woman who have a history of abortion, coitus should be prohibited during the early

months of pregnancy.

Teeth Soft bristle tooth brush should be used to clean teeth as there may be greater tendency

for gums to bleed.


Use of drugs during pregnancy It is generally believed that most drugs cross the placenta. Drugs taken during

pregnancy exert their effect in many ways. Women should be advised not to take any

medication without the prescription of a doctor.

Smoking Smoking during pregnancy is associated with a significant increase in low birth weight

baby. It is a good health teaching practice to encourage women to stop or at least cut

down smoking.

Fresh air and sunshine The pregnant woman should spend two hours a day in the fresh air, if possible away

from busy streets and preferably walking or sitting in the garden or park.

Safe work environment Woman should not work around ionizing radiation or chemical hazards.

Travel During the first three months the jarring and the excitement may induce abortion in

susceptible women. Industries should consider reassignment of work for the pregnant

woman.

Preparation for infant A room, or area with-in a room is designated as the "baby care unit" and a crib or

bassinet is installed. If there are other children in the family these preparations can be

one way of helping them realise that an infant is coming and allows them to participate

in the fun of anticipation. Some parents, because of their cultural background, may

consider it bad to purchase baby clothe prior to birth of the baby. In these cases the

relatives or neighbour usually have old baby cloths ready. About three weeks before her

due date, the woman should organise her belonging that she plans to take to hospital.

Arrangement should be made for the care of older children.

3.4 Common Discomforts during Pregnancy

Many minor discomforts may be present during pregnancy. They are not serious and

require home remedial measure. When any symptom is severe or persists longer,

medical intervention is indicated. These discomforts are listed below:


i) Gastro-intestinal symptoms are nausea, vomiting, heart-burn, flatulence and

constipation

ii) Pressure symptoms are edema, varicosities, hemorrhoids, muscle cramps and

dysponea

iii) Back-ache, pulling pain in lower abdomen

iv) Fatigue

v) Insomnia

vi) Vaginal Discharge

vii) Itching

3.5.1 PALPATION

Palpation is examination by touch using the fingers. It is done to determine

the normalcy of foetal growth in relations gestational age, position and

presentation of the foetus.

Purpose

1. To measure the abdominal girth

2. To determine fundal height

3. To determine abdominal muscle tone

4. To determine the foetal lie, presentation, position engagement of the

head

5. To determine the position location of the foetal height tone

6. To observe signs of pregnancy

7. To detect deviation from normal

Requirements

1. Couch


2. Screen

3. Fetoscope

4. Measuring tape

5. Pelvimeter

6. Patients wrapper

Procedure

1. Explain procedure to client

2. Instruct patient to empty her bladder

3. Provide privacy

4. Assist client to lie on the couch or examination table, relax her

abdominal muscle by bending her knee slightly

5. Wash hands thoroughly with soap and dry

6. Rub hands together to generate warmth before beginning to palpate

7. Rest your hands on the mother’s abdomen lightly while giving

explanation about procedure

8. Use flat of the palm and not fingers tips

9. Keep fingers of hands together and apply deep pressure as firm is

necessary to obtain accurate findings.

10. Perform fundal height estimation to determine gestational age

11. Perform the first manoeuve (fundal palpation) to determine

presentation

12. Face the woman’s head, place your hand on the side of the fundus

and curve the finger around the lap of the uterus

13. Palpate for size, shape, consistency and mobility of the foetal part in

the fundus


14. Do the second manoeuvre (lateral Palpation continue to face the

woman’s head, place your hands on both sides of the uterus about

midway between the symphysis pubis and the fundus.

15. Apply pressure with one had against the side of the uterus pushing

the foetus to the other side or stabilizing it there.

16. Palpate the other side of the abdomen with the examining finger from

the midline to the lateral and from the fundus using smooth pressure

or rotatory movement.

17. Third manoeuvre (Pawlik’s grip) continue to face the woman’s head,

ensure the woman’s knees are bent.

18. Grip the portion of the lower abdomen immediately above the

symphysis between the thumbs and middline finger of one of your

hand.

19. Fourth Manoeuvre (pelvic palpation) Turn and face the woman’s feet

(ensure the woman’s knees are bent).

20. Place your hands on the side of uterus, with the part of your hand just

below the level of the umbilicus on your finger directing the

symphysis pubis.

21. Press deeply with your fingertips into the lower abdomen and move

them towards the pelvic inlet, the hand covering around the

presenting part when the head is not engaged.

22. The hands will diverge away from the presenting part and there will

be no mobility if the presenting part engaged.

NOTE:

1. Fundal palpation is done to know the gestational age, presentation at

the fundus e.g Breech or cephalic.


2. Pelvic palpitation is to know whether presenting part is engaged and

determined presentation

3. Lateral palpitation is to identify position of back and foetal limbs

4. Estimate weeks by using birth calculator or tape measure

5. Take fundal height it cm by tape measurement

6. Determine the fundal height using ulnar side of the palm at:

a. 12weeks - Level of the symphysis pubis

b. 16weeks - Midway between symphysis pubis and umbilicus

c. 22weeks - One- two finger breaths below the umbilicus

d. 24weeks - level of umbilicus

e. 28weeks - Five- six finger breaths above the umbilicus

f. 32weeks - Halfway between umbilicus and xiphoid process

g. 36weeks - Level of xiphoid process

h. 40week - Two- three finger breaths below the xiphoid process if lighting has occurred.

3.5.2 Measuring fundal Height using tape method:

1. By using measuring tape, place zero line of the tape measure on the

superior border of the symphysis pubis

2. Stretch the tape across the contour of the abdomen to the top of the

fundus along the midline

3. The number of centimeter measure should be approximately equal to

the weeks of gestation at 22 to 24 weeks

4. Measure the abdominal girth by encircling the woman’s abdomen

with a tape measure at the level of the umbilicus

5. Document findings


3.6 AUSCULTATION

To listen to foetal heart and record the rate.

Procedure

1. Place stethoscope over the convex portion of the foetus, closest to the

anterior uterine wall. Foetal heart sounds are heard over foetal back in

vertex scapular in breech presentations and over the chest in face

presentation

2. Inform the mother of your findings

3. Make her comfortable

4. Replace equipment

5. Document findings

3.7 SUBSEQUENT VISITS

Mother craft talks should be given accordingly on every clinic visit taking

one topic at a time.

Note: clients should have at least 4 antenatal visits before delivery and feel

free to visit the clinic at any time they are or have complaints.

3.7.1 Clinic Routine

1. Mother craft talks

2. Collect card

3. Urine and Haemoglobin estimation

4. (Haemoglobin should be done monthly)

5. Blood pressure estimation

6. Weight

7. Examination, appointments date for next visit given


8. Refer clients/patients to doctor if necessary

9. Collect drugs

Tetanus Toxoid (IT) injections to be given when due

3.8.1 Nutritional Care during Pregnancy and Lactation

The human embryo and foetus can obtain nutrient only from mother through the

placenta. If mother is undernourished, adequate growth nutrients may not be available

and intrauterine growth retardation may occur. Both science and folklore have

recognised the important relationship between food and pregnancy. It is necessary to

obtain dietary history along with health history of antepartum mother.

Factors affecting food intake are:

Daily activity

Cultural, religious and family food, customs

Socio-economic status

Psychological factors

Pregnancy symptoms Optimum maternal nutrition and adequate daily food intake are essential during

pregnancy.

The nutritional requirement of non pregnant, pregnant and lactating mother are given

in 2.1.

Calories

Minerals

Protein

Vitamins

Fat

Water

Carbohydrate These are necessary for utilization of energy and synthesis of metabolite-enzymes,

hormones etc.

Table 2.1: Dally Nutritional Requirements of Mothers


Nutrients Non Pregnant Late Pregnant Lactating

Calories 2200 2200 + 300 (2500) 2200 + 700(2900)

Protein 50 gm 50 gm + 10 = 60 gm 50 gm + 20 = 70 gm

(1 gm per kg body wt.) 10 = 60 gm 20-70 gm

Fat 50 gm 50 gm 60 gm

(1 gm per kg body wt.)

Carbohydrate 395 gm 395 + 65 = 460 gm 395 + 155 = 550 gm

Iron 20 mg 40 mg 30 mg

Calcium 500 mg 1 gm 1 grn

Vitamin A 3000 kg 3000 mg 4600 mg.

Vitamin B 1.1 kg 1.3 mg 1.5 mg

Folic acid 100 kg 150-300 kg 150 mg

Vitamin B12 0.1 kg 1.5 kg 1.5 mg

Vitamin C 50 kg 50 kg 80 mg

Vitamin D 200 kg 200 kg 200 mg

During late pregnancy, energy requirement will increase due to demands of foetus,

placenta, uterus and breasts. Additional daily energy requirement of about 20%

becomes necessary during second half of pregnancy amounting to 300 calories. Energy

requirement of moderately active non pregnant adult woman is about 40 cal/kg body

weight. Energy requirement increases throughout pregnancy. During lactation, for the

production of milk additional 700 calories are required.

Intake of protein is essentially necessary to build tissue protein and is not utilised for

energy purpose. One half of protein must be given as protein of high biological value.

The daily protein requirement of a non-pregnant woman is 1 mg per kg. body weight.

For a woman whose weight is 50 kg., the protein requirement is 50 gms. Protein

requirement of a pregnant woman is 50 gms. plus 10 gms i.e. 60 gms. During lactation,

protein requirement increases to 20 gm.in addition to normal requirement. i.e 70 gm.

http://gm.in/


Minerals, and sodium chloride requirements during pregnancy is 5-10 gm. It is taken as

common salt and also is present in water, milk and all ordinary articles of diet. During

pregnancy, overloading of salt over 10 gm causes oedema and raises blood pressure.

Daily water requirement is 2.5 litres, since 1 ml is needed for every caloric food intake,

6-8 glasses of water is needed daily.

3.8.2 Mineral requirement during pregnancy and lactation

Iron and calcium requirement increase during pregnancy and lactation. Iron

requirement in pregnancy is 40 mg compared to 20 mg in non pregnant woman and 30

mg in lactation. Similarly, calcium requirement increases to 1 gm in pregnancy and

lactation as compared to 500 mg in non pregnant yeoman. All animal foods e.g. meat,

liver, egg; vegetables e.g. peas, lentils, green leaves and fruits are rich sources of iron.

Milk, egg, cheese and green vegetables are the chief sources of calcium.

Other trace elements necessary for metabolic processes are zinc, copper, magnesium.

3.8.3 Vitamin requirement during pregnancy and lactation

Daily intake of most of the vitamins need to be enhanced during pregnancy. Water

soluble B vitamins, particularly foliate and vitamin B12 are important. Foliate is necessary

for DNA synthesis in growing tissue and red cell formation. Vit B12 is necessary for

haemopoiesis, storage and secretion of milk. Adequate amounts of milk, fruits and

vegetables can supply all necessary vitamins and folic acid. Rich source are fresh green

leafy vegetables, liver and kidney. Lesser amounts are-present in fish, cereals and

muscle meat.

Vitamin B12 is rich in animal food, liver, and muscle meat. It is in lesser amount in fish,

egg, cheese and milk. Fruits particularly lemon and amla are rich (Vitamin C) sources.

Other sources include tomato, sprouted gram and leafy vegetables.

Vitamin A

Animal Source - Codliver oil, milk butter, egg, fish, vegetables such as carrots, spinach,

green leaves and yellow fruits like mango, papaya, banana.

Vitamin D


Codliver oil, butter, milk, egg.

Other B complex Vitamin

Cereal, pulses, green vegetables, egg yolk.

UNIT 4 LABOUR

CONTENT

1.0 Introduction

A pregnant woman in labour is admitted to the labour room for observation,

treatment, care and safe delivery, which can be in the community or

hospital. This marks the beginning of intra-natal care.

2.0 Objectives; At the end of this unit the student should be able to

1. Prepare the woman for safe delivery

2. Monitor feto-maternal conditions

3. Ensure immediate care of the new-born

4. Prevent infection to mother and child

3.0 Main content

3.1 Principles of labour management

1. Foetal heart rate should be listened to and counted in between

contractions


2. Apply sanitary pad when patients is draining liquor

3. No vaginal examination should be done when patient is bleeding

4. Partograph chart should be used for eligible patients

5. Confine patient with liquor drainage to bed to avoid cord prolapsed.

3.2.1 Requirement (Trolley)

Top shelf

1. Delivery kit/pack

2. Sterile gloves

Bottom Shelf

1. Patients charts/Partograph

2. Fetoscope

3. A tray for TPR/B/P

4. Enema tray

5. Kidney dish

6. Razor blade (optional)

3.2.2 Procedure

1. Welcome client and relations

2. Admit her into the first stage room

3. Reassure relations and allow them to wait

4. Take history of labour

5. Obtain clients antennal card to sort out antenatal records if booked or

registered

6. Encourage client to change into labour gown

7. If not booked take full history e.g social, medical/ surgical, past and

present obstetric history


8. Obtain urine specimen and test

9. Measure height and record

10. Take and record vital signs/foetal heart rate

11. Carry out general examination and palpation

12. Shave vulva (optional)

13. Perform vaginal examination noting the state of the vulva,

vaginal, cervix, cervical dilation, membranes and position of

presenting part

14. Open partograph chart

15. Document findings in patients admission folder

16. Give enema (optional)

17. Continue observation in the first stage room

18. Inform relatives to stay around until labour is completed

19. Inform doctor immediately or refer if any complication is

suspected.

3.3 MANAGEMENT IN THE FIRST STAGE OF LABOUR

3.3.1 Observation

Temperature - 4hourly, if no pyrexia

Pulse - 2 hourly, hourly as labour Progresses

Respiration - 2 hourly, hourly as labour Progresses

Blood Pressure - 4 hourly if normal, hourly if Abnormal

Contractions - Hourly, ½ hourly, every 10 Minutes as labour

progresses.


(Note the strength, frequency, duration and record)

Foetal heart rate - ½ hourly throughout labour

(Note rhythm, volume and rate)

1. Bladder – encourage to empty as often as possible, measure amount

and test for protein or acetone

2. General Condition- Note if client rests well between contractions or is

distressed

3. Give copious glucose drinks for hydration and rehydration

4. Note progress in descent of presenting part especially if not engaged

on admission

5. Diet- in early labour, give light diet e.g pap or tea

6. Encourage client to move around if desired as long as she is

comfortable and embrances are intact

7. Give arm bath if permissible

8. Change perineal pad when necessary

9. Vagina Examination – Every 4 hours, note progress in cervical

dilation, position of presenting part, degree of effacement, condition

of cervix (thin or thick), intact or ruptured membranes. In rupture of

membranes, note colour, odour and amount of liquor amnii. Normally,

liquor is clear with a characteristics odour. Abnormally, it may be

meconium or blood stained, offensive odour .

Note: degree of moulding and descent of presenting part

3.3.2 Full Cervical Dilatation:

Transfer to delivery bed


Set sterile delivery trolley

Position client and encourage her to bear down

Pain in labour can be relieved through the following measures:

1. Breathing exercise (Encourage patients to breath in and out during

contractions)

2. Viewing of television

3. Reading interesting magazines

4. Give psychotherapy

5. Administration of recommended analgesic depending on the stage of

dilation.

THE PARTOGRAPH

Introduction

The partograph is a useful tool for effective monitoring and management of all

the events of labour or progress of labour. It is labour records form designed to

record the patients profile and time of admission and plot salient features such

as the maternal and foetal conditions and progress of labour in a graphic form

after each vaginal examination. It provides the opportunity for early

identification of deviation from normal or prolonged labour and appropriate

action. WHO modified partograph, making it simpler to use as plotting now

begins from the active stage when the cervical dilatation is 4cm.

Contra-Indication to the Use of Partopgraph

Women who are not eligible for Partograph include:

Cervical dilation of 1-3 or 9-10cm

Elective Caesarean Section

Emergency Caesarean Section on admission

Gestational age less than 30 weeks

Ante-Partum Haemorrhage

Severe Pregnancy induced Hypertension (PIH) e.g. Severe Pre-Elcampsia

Mal-presentation and abnormal lie e.g. breech, face, brow, and transverse

lie

Confirmed Cephalo-Pelvic Disproportion (CPD)

USE OF PARTOGRAMPH (recording and charting)


Record patient’s information: full name, gravida, parity, hospital number,

date and time of admission at the top of the graph/form. The actual time of

the day if recorded as „zero-time‟ below the hour line.

Locate the right hour line/column and record maternal vital signs:

- Temperature and respiration in the spaces provided

- BP as a plus sign (+)

- Pulse as a dot sign (.) in the block between the time lines and

- Connect the dot using a ruler or straight edge

Record urinary data as: Volume in mls, Protein 0 to 4+; Ketones 0 to 4+

Record drugs and rehydration fluids including oral and intravenous in the

space provided (if given).

Record Oxytocin given in a separate column above the column for fluids and

drugs.

Plot FHR with a dot(.) in each square and on the time line and conntect the

dots using a ruler or straight edge

Record findings on amniotic fluid as:

I: Membranes intact OR A: Liquor is absent

R: Membranes ruptured

C: Membranes ruptured; clear fluid/liquor

M: Meconium stained fluid/liquor

B: Blood stained fluid/liquor

Record and plot findings on moulding in the corresponding time hour as:

- “O: no moulding

- +: mild ++@moderate +++: severe

Plot finding on cervical dilatation in the corresponding time hour as a cross

(x) beginning from 4cm

Plot findings on uterine contractions (frequency and duration) in the

corresponding time hour as a cross (X) beginning from 4cm.

Plot findings on uterine contractions (frequency and duration) in the

corresponding time hour as:

(Dots) Mild Uterine contractions of less than 20 seconds duration per

10 minutes

(Diagonal lines) Moderate contractions of 20 to 40 seconds duration

(Solid colour) Strong contractions of longer than 40 second duration.

Note:

All observations on the maternal and foetal conditions are to be

recorded on the time line at which the observations are made at the


bottom of the partograph every 4 hours during the latent phase and 2

hourly during the active phase.

Encourage the mother to empty her bladder every 2 hours


3.5 VAGINAL EXAMINATION

It is the examination done vaginally to ascertain the state of the

vagina and cervix, diagnose and assess the progress of labour,

Purpose

1. To ascertain onset labour

2 Monitor cervical dilatation

3. Identify fetal presentation

4. Ascertain if membranes hove ruptured

5. Identify risk for cord prolapse

6. Assess progress in labour

7. Confirm full dilatation

8 Assess status of head and degree of moulding

Requirements

A sterile vaginal examination tray containing.

1. 2 Gaillipots

2. 1 Kidney dish

3. 3 dressing towels

4. 2 perineal pads

5. Kocker’ (Artery forceps)

6. 1 Cusco’s or Sims vaginal speculum (optional)

7. Sterile gloves

8. Face mask

9. 2 urethral catheters

10. Hibitane cream (lubricant)

1 1 . Lotion for swabbing e.g. savlon 1:200


1 2. Screen

Procedures


2. Encourage client to empty the bladder

3. Emphasize the need for cooperation during the procedure

4. Read the patient’s chart for Previous findings

5. Set requirement on the trolley

6. Screen the bed to provide privacy

7. Position the woman in a lithotomy position

8 Drape the patient

9 Do surgical hand washing

10 Wear sterile gloves

11. Observe the external genitalia

1 2. Clean the vulva and perineal area with cotton swab.

13. Lubricate the index and middle fingers with hibitane cream

1 4. lnsert examining fingers into the vagina, explore and note the

following:

15. If the vaginal walls are moist or dry; warm or hot, feel for scar from

previous perineal wound, cystocele or rectocel

16. Examine the cervix and locate the OS

17. Asses the cervix for: effacement, dilatation, consistency (thick or thin)

18. Assess the level of presenting part in relationship to maternal ischial

spines

l9. Identify the presentation by feeling the hard bones of the vault of the

skull, fontanels and sutures

20. Assess moulding by feeling amount of over lapping of the skull


bones

21 . Remove your fingers from the vagina and observe the colour of

secretion and amniotic fluid

22. Make client comfortable

23. Explain your findings to client

24 Document all your findings on the partograph

Point to note on Vaginal Examination

1. Vulva- Any signs of infection, discharge, Oedema, varicose veins and

circumcision scar

2. Perienum – Any scar

3. Condition of membrane- intact or ruptured. If ruptured note colour,

odour and amount of amniotic fluid

4. Vagina – warm and moist, hot or dry

5. Cervix- Effacement and application to presenting part, consistency

(soft, thin or thick and unyielding)

6. Cervical OS- Degree of delatation

7. Presentation- station of presenting part, position as determined by

sutures and fontanelles, presence of caput or excessive moulding

8. Adequacy of pelvis – Inability to reach the sacral promontory, none

prominence of the ischial spines.

a. Accommodation of 4 knuckles of a clenched fist

between the buttocks and the two Ischial

tuberosities

b. Admission of two stretched fingers under the pubic

arch.


3.6.1 MANAGEMENT OF THE SECOND STAGE OF LABOUR

This is the period from full dilatation of the cervical OS to the delivery of the

baby. More frequent observations should be made of both mother and

baby.

Observations

1. Mother

a. Contractions:

i. Frequency

ii. Strength

iii. Duration

iv, Character – Bearing down or expulsive

b. Pulse: Check every 1 5 minutes and record.

c. Blood Pressure: Check and record as directed b Midwife in charge.

d. Bladder: Check and see that bladder is empty if not catheterise to empty

it.

e. Note Signs of Second stage:

i. Advancement of presenting part

ii. Bearing Down urge

iii. Gapping of the anus, etc.

iv. Confirm 2 stage by vaginal examination transfer to delivery bed

f. Note general condition of mother: whether between contractions or

exhausted.

g. Give oral glucose drinks

2 Foetus

a. Foetal heart rate

i Check after each contraction


ii Record every 5 minutes

b Observe and report abnormalities e.g.

i. Meconium stained liquor (except in breech)

ii Rapid slow foetal heart rate

3.6.2 Mechanism of LOA and ROA

Definition: Mechanism of labour is the series of pas’vt movements of the

fetus during its passage through t) maternal pelvis during labour.

Principles of Mechanism of Labour:

1. Descent takes place through-out labour

2. Whichever part leads and first meets the resistance of the pelvic floor

will rotate forward until it comes under the symphysis pubis.

3 Whatever emerges from the pelvis will pivot around the pubic bone.

LEFT OCCIPITO ANTERIOR (LOA)

Lie : Longitudinal

Presentation : Vertex

Position : LOA

Attitude: Flexion

Denominator: Occiput

Presenting part: Posterior port of the right parietal bone.

Engaging diameter:sub-occipito bragmatic (9.5cm)

• Descent

Descent takes place due to forceful uterine contraction c retraction, rupture

of membranes, complete dilatation.

Flexion

When the head meets the resistance flexion is increased.


The increased flexion will decrease the presenting diameter of sub

occipito-frontal (10cm) to a smaller diameter suboccipito-bregmatic

(9.5cm).

The occiput becomes the leading part.

Internal rotation of the head

The occiput leads and reached the pelvic floor first and rotates

anteriorly 1/8th of the circle to come under the symphysis pubis.

The anteroposterior diameter of the head now lies in the

anteroposterior diameter of the pelvic outlet.

Crowning

The occiput slips beneath the subpubic arch and crowning occurs

when the head no longer recedes back between the contractions and

the widest transverse diameter (biparietal) is born.

Extension of the head

The fetal head pivots around the pubic bone while the sinciput, face

and chin sweep the perineum and head is born by the movement of

extension.

Restitution

The twist in the neck of the fetus that resulted from internal rotation is

now corrected by a slight untwisting movement.

The occiput moves 1/8th of the circle towards the side from which it

started.

23. Explain your findings to client

24 Document all your findings on the partograph

Point to note on Vaginal Examination


9. Vulva- Any signs of infection, discharge, Oedema, varicose veins and

circumcision scar

10. Perienum – Any scar

11. Condition of membrane- intact or ruptured. If ruptured note

colour, odour and amount of amniotic fluid

12. Vagina – warm and moist, hot or dry

13. Cervix- Effacement and application to presenting part,

consistency (soft, thin or thick and unyielding)

14. Cervical OS- Degree of delatation

15. Presentation- station of presenting part, position as determined

by sutures and fontanelles, presence of caput or excessive moulding

16. Adequacy of pelvis – Inability to reach the sacral promontory,

none prominence of the ischial spines.

c. Accommodation of 4 knuckles of a clenched fist

between the buttocks and the two Ischial

tuberosities

d. Admission of two stretched fingers under the pubic

arch.

3.7.1 ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR

(According to WHO)

1. Give Oxytocin 10 units IM within one minute of the birth of the baby

after checking for a second baby

2. Controlled cord traction to deliver placenta. Wait for strong uterine

contractions (2 -3 minutes). Assist delivery of the placenta by

controlled cord traction while holding the uterus up

3. Massage uterus: massage the uterus immediately after delivery of the

placenta for 1 5 seconds


Note:

Oxytocin is given within one minute of the baby’s birth (after checking

for a second baby)

do not wait for separation instead:

feel the top of the uterus for a contraction

wait for the uterus to contract

apply controlled cord traction while holding the uterus up

Placenta delivers by controlled cord traction while holding the uterus

up. Mother does not push

Massage the uterus immediately after the placenta delivers

3.7.2 Controlled Cord Traction

1. On completion of delivery, take pulse, note colour and keep client

comfortable.

2 Place end of cord with clamp into a sterile kidney dish and place

between the client’s thighs.

3. With hand above pubic bone, apply pressure in an upward direction

(towards the woman’s head) to apply counter traction and stabilize

the uterus

4. At the same time with the other hand, pull with steady tension on the

cord in a do5 Receive placenta with cupped hands and gently

ease the membranes out.

6 Place placenta in the kidney dish and leave at the bottom of the

trolley.

7 Check for firmness of the uterus

8. Clean the vulva, separate labia and inspect vaginal wall for

laceration.


9 Check perineum for laceration or extension episiotomy (laceration or

episiotomy is to be repaired within an hour of delivery).

10. Check uterus again and expel blood clots.

11. Collect clots and add to previous loss.

12. Clean client up, apply vulva pad and make client comfortable.

1 3. Take and record vital signs.

14. Offer something to drink or eat

1 5. Wheel out delivery trolley to the sluice room:

a. Examine placenta and membranes completeness and weigh

b. Measure blood loss.

c. Discard all other things on the trolley.

16. Record findings and complete labour charts.

17 Weigh baby and record.

1 8. Leave mother and baby to rest but they must 4 observed closely.

19. After one hour, detailed examination of the baby is carried out. The

cord is shortened and temperature recorded.

20. If baby’s condition is satisfactory, clean baby and warm.

21 Bathe mother, allow her to pass urine, check uterus, check blood

loss, take and record vital signs.

22. Inform postnatal word staff, and

23. Transfer mother and baby to the postnatal ward.

3.7.3 EXAMINATION OF THE PLACENTA

There should be a thorough inspection and examination of the placenta

and membranes, soon after expulsion for its completeness. The

management of the third stage of labour is not considered ended until the


placenta and its membranes have been examined and found to be

complete.

Purpose

1. Ensure that the entire placenta and membrane hove been

expelled and no part has retained.

2. Make sure that placenta is of normal size, shape, consistency and

weight

3. Ascertain the health of the cord, number of blood vessels and site

of the insertion of the cord

4. Check weight of placenta and measure length of cord.

5. Assess abnormality such as infarctions or additional lobes or

additional lobes

Requirements

1. Placenta in a bowl

2. A washable surface to lay the placenta for examination

3. Weighing scale

4. Kidney dish

5. Pair of clean gloves

procedure

1. Examine the placenta under running tap

2. Using gloved hands to hold the placenta by the allow the

membrane to hang (twisting the cord twice around the fingers will

provide a firm grip)

3. Identify the opening through which the baby was delivered.

4. Hold the cord with the placenta and membranes hanging down to

check for


completeness membranes.

5. Insert hand through the opening and spread fingers to view the

membranes and blood

vessels.

6. Remove the hand from inside the membranes and lay the placenta

on a flat surface with

the foetal surface up. Identify the site of cord insertion.

7. Examine the two membranes, (amnion and chorion for

completeness and presence of

abnormality indicating succenturiate lobe

8. Invert the placenta, expose the maternal surface and remove clots

present.

9. Examine the maternal surface by spreading it in palms of your two

hands and placing the cotyledon in close approximation.

Note: any missing lobe or fragments.

10. Assess for presence of abnormalities such as infarctions,

calcifications or succenturiate

lobes.

11 . lnspect the cut end of the umbilical cord for presence of three

umbilical vessels.

12. The placenta is weighed, and important facts regarding if are

recorded in the chart.

13. The blood loss, including clots, is poured into a measuring jug and a

good estimate of the spiIIed blood is made and recorded (Blood loss above

500mls within 24 hours of delivery is considered primary PPH).

NOTE: The examination of the placenta is a very important duty of the

midwife because of the danger of a cotyledon or fragment of membranes


being retained. If the placenta is normal and the doctor has not requested

that if should kept for inspection, it is disposed of by burying if possible.

It is important to report to the doctor immediately if it is thought that a piece

of placenta tissue or membrane has been retained.

The midwife must not leave her patient, for she may have a severe

haemorrhage at any time while it remains in the uterus

3.7.4 Vulva swabbing (Perineal care)

Introduction

Perineal care involves cleaning of the genitalia with antiseptic lotion.

principle

Clean from the cleanest to the less clean area

Introduction

- Patients who are unable to carry out self care

- Patients with indwelling catheters

- Patients with surgical interventions

Requirements (trolley procedure):

Top shelf:

- Bowl with cotton balls

- Long artery forceps in a receiver

- Receiver for used swabs

- Sterile gloves

- Clean linen


- Perineal Pads

Bottom shelf:

• Mackintosh

• Bedpan

• Lotion for swabbing e.g savlon 1:200

Extra requirement

• Screen

Procedure

- Greet client and introduce self

- Explain the procedure lo the client and obtain consent

- Provide privacy

- Encourage client to empty bladder

Position and drape client

- Wash hands and put on gloves

- Hold swabs with forceps and clean from top to bottom

- Use one swab once and discard

- Clean the perineal region and anus thoroughly

- Remove the equipment

- Make client comfortable

- Wash hands

- Document findings


Non-Pneumatic Anti Shock Garment (NSAG)

The non-pneumatic anti shock garment (NSAG) also known as “Life Wrap” is a

first-aid device that reverses hypovolemic shock and decreases obstetric

haemorrhage. It was recommended by WHO in 2012 as a life saving device for the

treatment of life threatening post-partum haemorrhage and hypovolemic shock in

low referral facilities and treatment delays pending clients transfer for definitive

management. It is easy to apply after a brief training. It is no replacement for

standard definitive care, protocol should be followed. It is made up of washable,

reusable light weight neoprene close tightly with Velcro. It is about 1.5kg in

weight, cuts into segments labelled 1,2,3,4,5, and 6 which contain a foam ball for

extra pressure and adaptable to a wide range of women. Each segment of the

device is wrapped in sequence around the legs, pelvis and to the navel region and

looks like a lower half of wet suit or “a trouser”. It is applied as soon as a signs of

shock are identified with three segments on each leg, one segment over the pelvis

and another, over the abdomen. T is contraindicated in patient with heart diseases.

It is designed to give easy access to other interventions such as vaginal procedures,

perineum and episiotomy repair, as well as surgical procedures by removing

segments 5 & 6. It comes in different colours including blue, green, black and

brown. It must be applied by a single person except in an unconscious mother.

MECHANISM OF ACTION

The NASG act by ensuring circumferential compression of the abdomen and legs

reduces total vascular volume (container size) while expending the central

circulation.

Purpose

- To control postpartum haemorrhage

- To treat shock

- To resuscitate, stabilize and prevent further bleeding

NASG APPLICATION PROCEDURE

Position patient in a lying position on a flat surface

Wear a pair of glove

Open the NASG and place under the woman ensuring that the part labelled 5

matches the patient‟s navel, if the patient is unconscious, two people can roll

her onto her side placing the garment underneath her, similar to making an

occupied bed.

Stretch and fasten the garment tightly, starting with the ankle labelled

segment 1


Continue with segment 2 below the knees and segment 3 on the thighs (for

shorter women, fold segment 1 into segment 2 before starting to ensure that

segments 1 & 2 are below the knees).

Secure the pelvic segment 4 tightly at the level of the symhpysis pubis

Apply segment 5 over the umbilicus (navel) and close by securing the two

flaps of segment 6 over segment 5 (do this one at a time on each side).

If the woman experiences difficulty in breathing, slightly loosen-but do not

remove the abdominal segment..

Monitor the patients pulse rate and BP every 15 minutes until stable

Monitor the urinary output hourly.

Resuscitate the patient with IV fluids and/or blood as required (give 3mls of

fluid for every 1ml of blood loss).

If NASG application does not result in prompt increase systolic blood

pressure (SBP) and decreased pulse, check for adequate tightness and give

additional IV fluids.

Determine the cause of haemorrhage

Refer patient to the nearest higher facility while still on NASG (between 12-

36hours) if there is no improvement in the condition of the patient.

NASG REMOVAL

The NASG must be removed only under skilled supervision in a setting

where vital signs can be monitored and there are adequate IV fluids.

The NASG should not be removed until the woman has been

haemodynamically stable for at least 2 hours with blood loss 50ml/hour,

pulse 100BPM and SBP 100mm Hg.

To safely remove NASG, with the ankle segments and proceed upwards.

Allow 15 minutes between opening each segment for the redistribution of

blood, then check vital signs.

If SBP falls by 20mm Hg or the pulse increase by 20BPM, rapidly replace

all segments and consider the need for more saline or blood transfusions.

If there is recurrent bleeding, replace the NASG and determine the source of

bleeding.

Clean the garment in .01% chlorine solution and store in a cool dry place

after removal.


MODULE 2 CHILD CARE

UNIT 1 CARE OF NEW BORN

UNIT 2 CHILDHOOH

UNIT 3 ADOLESCENT

UNIT 4 ANTHROPOMERY

UNIT 5 FAMITY PLANNING

UNIT 6 FAMILY RECORD

UNIT 1 CARE OF NEW BORN

CONTENT

1.0Introduction

2.0 Objectives

3.0 Main Content

3.1 Delivering the baby

1.0 CARE OF THE NEWBORN AT BIRTH

1.1 Delivering the baby

THE HEAD

1. As head is delivered, the midwife quickly picks a gauze swab and

wipes mouth, nose and face using a swab at a time.


2. Give a gentle handling.

THE BODY

1. The body is delivered over the mother’s abdomen

2. Clamp and cut cord

3. Record time of birth and Apgar score at birth, 5 minutes and 10

minutes

4. Clean eyes and apply 0.4% terramycin eye ointment or erythromycin

eye ointment (when medically indicated)

5. Dry body, wrap and keep warm

6. Note sex of baby, show sex to mother

7. Apply name tag on baby’s wrist

8. Quickly examine baby from head to toe

9. Put baby to breasts

3.2 SIMPLE RESUSCITATION

This is carried out when the Apgar Score at birth is between 7 to 10

Requirements

1. Mucus extractor/ catheter (or improvise)

2. Clean gauze

3. Clean dry cloth to keep baby warm

4. Oxygen giving set (cylinder nasal catheter or face

mask or Ambubag

Procedure

This is for healthy baby with Apgar 7:

1. Keep baby warm with a dry cloth

2. Clean nose and mouth

3. Look to see if the baby is breathing

4. Place your hand on the chest over the heart


5 Feel how regular, strong and fast the heart is beating

6. Look at baby’s Colour

7. Dry baby quickly and keep baby warm

8. Handle baby gently

9. Place baby on mother’s chest if no problem

10. Cover both mother and baby with cloth.

3.3 Physical Examination of New born

A good examination of the baby is normally Carried about one hour after

birth and before the bath ( hour) when the temperature is stable. A general

physical examination of the new-born is done systematically to detect any

abnormality

Requirement

A tray Containing the following

1. A gallipot with swabs

2. Another gallipot with sterile water

3. Kidney dish for soiled swabs

4. Rectal thermometer in its container or kidney dish with a lubricant

5. Measuring tape

6. Weighing scale

Procedure 1. Do a general examination from head to toe

2. Check Patency of anus using rectal thermometer

3. Measure length, head circumference and baby

4 Treat the cord with 7.1 percent chlorhexidine

5 Re-clamp the cord and cut

6 Keep baby warm with cloths


7 Put baby in warm cot

7 Transfer baby with mother to Postnatal warm

Procedure

1. Prepare a flat Surface preferably a table(cover surface with a clean

sheet)

2. Take tray to the prepared table

3. Wash hands thoroughly

4. Bring the baby out from the cot, Unwrap and qui weigh the baby if the

was not done at

birth

5. Take the following measurement

a. Length: grasp the baby’s feet and gently turn baby upside down.

Measure from the heels to the vertex.

b. Head circumference. Measure from the sinciput through the Occipital

protuberance round the head

The Head

The head is examined for the following:

1. Excessive moulding

2. The width of the sutures and size of the fontanelles.

3. Large caput formation

4. The size of the head whether too large or too small

5. Any abnormal growth

6. Bruises on the head

The Eyes

Examine the eyes for:

1. Presence of the eye balls

2. Discharges


3. Sub-conjunctival haemorrhage

4. The setting of the eyes: too closely set or wide apart

5. Yellowish discolouration

Nose:

1. Take note of the presence of the nostrils

2. Any discharge

Mouth:

The mouth is examined with a good light taking note of:

1. Any tongue tie

2. Presence of teeth

3. Harelip and cleft palate

The Ears

1. Examine the ears for the lobes

2. The setting

3. The openings

4. Discharges

The Neck

The length —whether it is too long or short, presence of any congenital

growth.

The Chest

1. Shape and size of the chest

2. Type and rate of respiration, note any abnormality

The Abdomen


Take note of the size of the abdomen to identify any abnormality such as:

1. Hydropsfefalis and exomphalus

2. Check the cord for any bleeding

3. Check for femoral or inguinal Hermia or hydrocele

External Genitalia

1. The sex of the baby should be identified

2. In the male, the scrotum and testes should be for any abnormality

3. In the female, check size of the labia majora and minora.

4. Check to make sure that the two openings are (Vaginal and urethral

openings)

5. Check for position of urethra in the penis

6. Any abnormality should be noted,

1. Pick Anal thermometer, shake down and wipe it with a wet swab.

2. Lubricate and insert into the anus to determine whether it is

perforated or

3. Take the temperature at once and record.

The Back

1. Inspect the back for presence of spinal bifida and any discontinuity in

the vertebrae.

2. The Hip: The hip is examined for any abnormalities

e.g. congenital dislocation of the hip.

3. For this, Barlow’s or Ortolani’s test is done. The thighs flexed and

abducted through 90 degree. A clicking sound, denotes an

abnormality.

The Extremities


The upper and lower extremities are examined accordingly

1. Equality

2. Mobility

3 Fracture

4 Extra and webbed digits

5 Talipes of the legs

At the end of the examination, any abnormality detected should be

recorded and reported for Prompt action to be taken. The baby is then

given the first bath and dressed up.

3.4 SUBSEQUENT CARE OF THE NEWBORN

Daily Bathing of Baby

The baby needs daily baths.

A trolley with the following:

Requirements

A trolley with the following:

Top Shelf

A tray Containing.

A. Bathing Soap in a Soap dish

B. Talcum Powder

C. Chlorhexidine gel

D. Olive oil

E. Vaseline

F Baby lotion (optional)

G. Sterile Swabs in gallipot

H. Comb and brush

I. Kidney dish Containing Sterile Scissors


J. Sterile water in gallipot

K. Extra ligature

L. 2 jugs-one Containing cold water and the other Water

Bottom Shelf

a) Baby Clothing

b) Face flannel

c) Large towel

d) Kidney dish for used swabs

e) A bath, thermometer

f) A large basin or plastic bowl on a stand

9) A bucket for used water

Procure

1. Assemble requirement

2. Close nearby doors, windows and turn off fans to

avoid draught

3. Put on water-proof apron and wash hands

4. Prepare the bath water to a temperature of 37.20c (the

temperature of the water can be determined with the

bath thermometer or by using the elbow)

5. The baby is wrapped with a large towel to avoid chills.

6. Clean the face and head with warm water, using each swab once

only.

7. Swab eyes from inside out with cotton wool

8. Clean face and dry with face flannel

9. The head is washed by supporting the baby’s neck in the left hand


10. The body may be tucked under the Midwife’s arm or supported on the

lap. The head is dried with a towel

using the flat of a hand.

11. Change water

12. The towel is unwrapped.

13. Remove venix-caseosa if present with swab dipped in warm olive oil,

and soap the baby paying particular attention to the skin folds.

14. The baby is immersed in the bath, the head and shoulders supported

on the Midwife’s left arm while

she washes off the soap with her right hand.

15. The baby is lifted out and placed face downwards on the towel.

16. The back is dried and baby turned over to dry the front

17. Wash your hands and treat cord with chlorhexidine gel.

18. Should the cord bleed or is longer than normal should be re-ligatured

and shortened with scissors.

19. Vaseline is applied to the buttocks and the diaper (e.g pampers) put

on.

20. The baby is dressed; hair combed, and wrapped in a shawl and lay

on its side in the cot.

3.5 SUBSEQUENT CARE OF THE CORD

The umbilical cord is treated twice daily.

Requirements

A tray containing:

1. Chlorhexidine gel

2. Sterile cotton wool swabs in a sterile bowl or dressing pack can be

used.

3. Gauze bandage and dressing if needed


4. A receiver for used swabs.

Procedure

Care of the cord is usually carried out along with bathing the child or when

the napkin is completely soiled.

1. Assemble the requirements and wash your hands clean

2. In some hospital a cord dressing pack is used

3. Expose the cord and clean with 7.1 percent chlorhexidine gel.

4 One stroke at a time from the cord end, for the first dressing.

Subsequently, start from the stump to the end of the cord.

5. After cleaning, expose to air (open method)

6. Apply napkin below the umbilicus and make baby comfortable

7. Cleaning is done at least twice daily or more often when the napkin is

soiled

8. Note and record abnormalities such as redness, offensive odour or

bleeding.

9. Report to doctor when any of such abnormalities arise.

1 0. When the cord falls off and there is no inflammation, clean stump with

chlorhexidine as

often as - possible.

NOTE: Cord usually falls off between the 4 -10th day.

3.6 KANGAROO MOTHER CARE

Requirement

Baby in socks, nappy and a cap

Front-open top


Baby shawl

2 bowl with clean and Soapy water

Hands towel

Procedure

Explain the procedure to the mother

Gather necessary equipment

Wash hand with soap and water and dry

Ensure warm and clean environment

Observe baby’s general condition, including the vital signs to ensure

fitness

Dress the baby in socks, napkin and a cap

Place the baby between the mother’s breast

Secure the baby on the mother’s chest with a cloth

Put a blanket or shawl on top for additional warmth

Instruct the mother to put on a front opened top to maintain an

effective skin to skin contact

Instruct mother to keep baby up right when walking or sitting

Counsel the mother on the importance of having the baby in a

continuous skin to skin contact twenty four hours daily

Advice the mother to sleep in half sitting position in order to maintain

the baby in vertical position.


UNIT 2: CHILDHOOD

CONTENTS

1.0 Introduction

2.0 Objectives

3.0 Main Content

3.1 The Neonate

3.1.1 Pre-natal Development

3.1.2 Physiological Status of Neonate

3.1.3 Assessment of the Neonate and Nursing Management

3.1.4 Common Health Problems of Neonate

3.2 The Infant

3.2.1 Growth and Development

3.2.2 Health Promotion

3.2.3 Common Health Problems

3.3 The Toddler


3.3.2 Promoting Optimum Development

3.4 The Pre-Schoolage


3.4.2 Psychosocial Development and Play

3.5 The Schoolage Child



3.5.2 Mental and Psychosocial Development


4.0 CONCLUSION

5.0 Summary



1.0 INTRODUCTION

The child has to pass through various stages of growth and development. Safe childhood

and adolescence are the essence of child survival and family welfare in primary health

care. In this Unit you will learn about prenatal development of the foetus, care of the

neonate and study the growth and development of infant and toddler. Growth and

development of preschool and school age will be explained. You will be made familiar

with the health problems of the child at various stages of development, and their

prevention. Finally you will study the physical and intellectual development of the

adolescent both male and female.

2.0 OBJECTIVES

In this unit you will learn various developmental stages of a child in order to give the

child a safe childhood and adolescence.

After going through this Unit you should be able to:

Describe physiological status of new-born

Advise on care of new-born

Describe the growth and development of infant

Explain the procedure of infant weaning

Explain the growth and development of pre-school and school-age child

List the common health problems of various stages of development

Advise on their prevention.

3.0 MAIN CONTENT


3.1 The Neonate

The neonatal period is from birth to 28 days. The neonate after birth has to make

physiological adjustment to extra uterine environment. Health status of newborn

depend; on pre-natal development. The pre-natal development, physiological status,

assessment and common problems of neonate are briefly described in the following

subsections.

3.1.1 Pre-natal Development

Development from zygote to fully mature infant is due to two process:

1. Growth that result when cells divide and synthesize.

2. Differentiation by which these cells are systematically organised to form all the

tissues necessary to assure an organised, coordinated individual.

The development process is as follows:

Embryogenis

Soon after fertilization, the zygote changes into morula stage, and followed by

blastocyst stage. The outside layer of blastocyst is called trophoblast. The collection of

cells inside the blastocyst is called inner cell mass. Implanation occurs on the 9th day.

Villous structure at the point of attachment forms the placenta and chorion. Embryonic

cells form the amnion.

Foetal Growth

Foetal growth is accomplished by two processes - Hyperplasia and Hypertrophy. Most

rapid linear growth takes place: during mid-foetal life. The most rapid gain in weight

occurs in late foetal life.

Environmental Factors

Before birth unfavourable maternally imposed environment may produce long range

health problems in the infant or child. These factors are maternal age, chemicals,

infections, radiations and mechanical factors.

3.1.2 Physiological Status of Neonate


New-born period or neonatal period is the first 28 days after birth. The first 24 hours of

birth are the most critical period during which respiration is initiated. Heat loss can also

occur through conduction and convection and neonate has to adjust to extra uterine

life.

The physiological status of new-born is given below:

Respiratory system: Respiration in new-born is abdominal. The rate is generally 30-50

breaths per minute.

Haemopoietic system

The average red blood cells count of the new-born is 5 million/ mm 3. The average

hemoglobin value at birth is 16-18 g/100 ml of blood. The levels of serum bilirubin from

the breakdown of red blood cells rises due to immaturity of liver of new-born.

Fluid and electrolyte balance

The infant has higher ratio of extracelluler fluid than the adult and higher level of total

body sodium chloride and a lower level of potassium.

Thermoregulation

The major sources of body heat are heart, liver and brain. There is an additional source

unique to neonate, that is brown fat. It has a greater capacity for heat production.

Gastro-intestinal system

The stomach has a capacity of 90 ml. The intestines are longer in relation to body size.

Regurgitation is common due to immature cardiac sphincter. Enzymes are adequate to

handle digestion. The liver is most immature.

Renal system

All the structural components are present in the renal system. But their functional

deficiency exists in the kidneys.

Integumentary system

All the structures within the skin are present but many of the functions are immature.

The protective function of the skin is fairly efficient.


Musculoskeletal system: Contains larger amounts of cartilage than ossified bones. The

process of ossification is rapid during the first year.

Defences against infection

The infant is born with several defences against infection and is protected against major

neonate diseases.

Endocrine system

Is adequately developed. Maternal sex hormone causes engorgement of infant breast

which secretes milk during the first few days of life. Female new-born may have pseudo

menstruation due to sudden drop of the level of oestrogen and progesterone.

Neurological system

At birth, the nervous system is incompletely integrated. Most of the neurological

functions are primitive reflexes.

Sensory functions

1. Taste

The lips and tongue are very sensitive. The sense of taste is not very well developed, but

babies seem to prefer sweeter food.

2. Hearing

Loud noises cause the baby to cry, but the ability to discriminate between sounds is not

developed for two or three months.

3. Sight

True vision is not present at birth, but at one month the baby looks towards bright light.

The eyes do not focus properly for some weeks.

3.1.3 Assessment of the Neonate and Nursing Management

The assessment includes physical and neurological assessment as given below. We shall

briefly discuss this here. The physical assessment

1. Head circumference: 33 to 35.5 cm


2. Chest circumference: 30.5 to 33 cm 3. Crown to rump length: 31 to 35 cm 4. Head to feet length is 48 to 53 cm 5. Weight 2700 to 4000 g. Vital signs

1. Temperature: 35.5°C to 37.5°C 2. Pulse: 100 to 140 beats per minute 3. Respiration: 30-50 breaths per minute. General appearance

Posture

Is one of flexion, a result of inutero position.

Colour

The infant becomes red when crying.

Skin

The skin is smooth and puffy. The skin is covered with vernix caseosa, lanugo is present

on the skin.

Milia as tiny white papules appear on the cheeks. Several colour changes may be noted

on the skin.

Head

The nurse palpates the skull for all patent sutures and fontanelle noting the size, shape,

moulding and for any presence of Caput succedaneum and cephalohaematoma.

Eyes, ears and nose

Are examined to detect abnormalities.

Mouth

The nurse inspects the mouth and looks for cleft lip and palate.

Neck, chest, abdomen, genitalia, lower extremities and back are examined to locate.

congenital abnormalities especially for imperforated anus.


Neurological Assessment

Several reflexes such as sucking, gaging, resting, corneal and papillary reflexes are

usually observed during physical examination. Several other reflexes are seen such as

moros reflex, tonic neck and startle reflex.

Nursrng Care of the Neonate

We have discussed the physical and neurological assessment of the new-born. Now we

shall talk briefly of nursing management of neonate.

The objectives/principles of care of the new-born include:

1. Establishment and maintenance of air way 2. Maintenance of stable body temperature 3. Protection from infection 4. Provision of adequate nutrition 5. Promotion of infant parent attachment (child-parent bond) Nursing care of neonate can be divided into two periods: immediate care and delayed

care.

Immediate care includes the following:

Vital signs

Temperature, heartbeat and respiration should be observed after every 15 minutes

immediately after birth, for the first hour; then 2 hourly for the next S hours and every 4

hourly until 24 hours of age. Rectal temperature is preferable to axillary temperature.

Observe colour, muscle tone and reflexes

Apgar Scoring chart may be used to evaluate the condition of the new-born for the first

minute and 5 minutes after birth.

Bathing

Should be done after 24 hours after the vital signs are stabilized. Bathing time is an

excellent time for observations of infant behaviour such as irritability, state of arousal,

alertness and muscular activity.

Umbilical cord: The umbilical cord separates through the process of drying and usually

falls off between 7-10 days. The umbilical stump is an excellent medium for bacterial


growth. Therefore, it should be kept clean and dry. Instruct parents regarding proper

umbilical care.

Infant nutrition

Although heredity determines the infant's growth but nutrition influences the

attainment of the growth. Hence optimum nutrition during foetal life and infancy should

be the goal for each child. In general, two methods of infant feeding are used: that is,

breast feeding and artificial feeding. Breast milk is the best and most perfect food for

infant nutrition.

Identification and registration of the neonate.

3.1.4 Common Health Problems of Neonate

The neonate can have following problems after birth.

Hyperbilirubinaemia

Hyperbilirubinaemia may occur due to physiological jaundice and Rh or ABO

incompatibility.

Neonatal hypoglycaemia

This condition of low blood glucose (less than 30 mg/100 ml.) Commonly occurring

during the first 48 hours of life, is a hazardous state that must be recognised and dealt

with at once. Early feeding of babies has reduced the incidence of hypoglycaemia.

Hypothermia

The normal baby's temperature may fall to 35.5°C or less within one hour of birth,

unless precautions are taken to avoid chilling, the new born may go into hypothermia

with the temperature falling below 35.5°C.

Sepsis

Within few hours of birth, staphylococci generate colonies on the baby's skin and in the

nasal passages: the umbilicus becomes infected, more readily then nostrils and skinfolds

such as axilla and groin. Any person suffering from respiratory infection or diarrhea, or

one who has any septic focus should not be allowed to come in contact with babies.


Eye infections

The baby's eyes may be infected during his passage through the birth canal, or later by

the mother's hands. A number of cases of neonatal conjunctivitis are due to the B-

Proteus and staphylococci which produces a yellow discharge. Pneumococci and

streptococci are sometimes found but gonococcal infection is the most dreaded

infection.

Oral thrush

Oral thrush is characterised by white patches in the mouth. The causal organism is the

Candid albicans which is present in the vagina of some women.

3.2 The Infant

We have discussed the care of the new-born. Now we shall learn about the physical

growth of the infant, its health promotion and health problems. Here we shall discuss

the preventive and promotive aspect in the care of an infant, the growth and

development aspect will be discussed in detail in course NSS 511 (Paediatric

Nursing).


The first year of life is characterized by rapid changes in body size, proportion and

function. The infant increases in length dramatically during the first year. By the end of

the first year the infant's increase in length is 50 per cent greater than at birth. The birth

weight trebles. Physiological changes occur in all the systems of the body. Intellectual

growth takes place gradually. The child starts interacting with his environment. Few

teeth appear the child crawls, sits and tries to stand.


Health promotion during first year includes the following aspects: i) nutrition guidance,

ii) immunisation, iii) safety and security.

i) Nutrition guidance: Infant nutrition and feeding habits or ways are highly

individualised. Breast milk or cow's milk are excellent sources of nutrition for the

infant for the first three months of life. While giving supplementary milk, teach

methods to develop the habit of using cup and spoon and not to use feeding


bottle. Supplementation of mineral or vitamins is dependent upon the type of

formula given. After three months, milk does not meet the nutritional

requirement of the infant, so solid foods should be introduced as discussed

below.

a) Introduction of solids: The main purpose of initiating the feeding of solid

foods to the infant is to provide adequate iron; cereal is an excellent

source of iron. The type of iron added to the commercial formula is better

absorbed. Solid foods facilitate adequate chewing and digestion of foods

in later life. Cereal is introduced first because of its high iron content.

Preparing food at home is simple and inexpensive. Spoon should be used

to feed the child. New foods should be introduced to small amounts and

singly at intervals of 4-7 days. The introduction of the infant to solid foods

is called weaning.

b) Weaning: is the process of giving up one method of feeding for another. It

is psychologically significant because the infant is required, to give up a

major source of pleasure and gratification. There is no fixed time or

weaning, but most children show signs of readiness at the age about five

to six months. Over-feeding should be avoided. Obesity in infancy may

predispose to obesity in later life.

ii) Immunisation: Primary schedule of immunization begins during infancy and is

completed during early childhood with the exception of booster doses. The

discussion on childhood immunizations for diphtheria, tetanus, pertussis, polio,

measles, mumps and rubella will be presented in Unit 11.

iii) Safety and Security: Accidents are a major cause of death during infancy.

Common accident hazards are suffocation, falls, burns, poisoning, aspiration of

foreign object, road accidents and drowning etc. You must be aware of possible

causes of injury and plan anticipatory preventive teaching for the parents.

Teething, thumb sucking, sleep etc. are some of the concerns of parents requiring

extension of guidance to them.

3.2.3 Common Health Problems:The infant's immature physiological system

predisposes him/her to several potential health problems during the first year. Some of

the important problems are listed as under.


i) Nutritional Deficiencies

a) Iron deficiency anaemia

b) Protein calorie deficiencies - Kwashiorkor - Marasmus

c) Vitamin deficiencies like night blindness, scurvy, rickets

ii) Allergy

Is an adverse reaction to a foreign substance or an antigen. During infancy eczema,

nutritional allergies and seborrheic dermatitis can occur.

iii) Colic

Colic is described as paroxysmal abdominal pain or cramping that is manifested by loud

crying. It is more common in the infant under the age of three months. Causative factors

may be too rapid feeding, over-eating and swallowing excessive air. Colic is considered a

mild ailment but can have an intense emotional impact on a colicky infant.

iv) Failure to thrive

Is also referred to as maternal deprivation syndrome. There is lack of physical growth

due to lack of emotional and sensory stimulation from the mother.

v) Sudden infant death

Syndrome is also referred to as crib death between the ages of 2 weeks to 1 year. The

airway gets blocked at the level of vocal cords from laryngospasm. There are many

theories regarding the etiology of sudden infant death. Parents should be explained that

it cannot be predicted or prevented.

vi) Diarrhea

Infant diarrhea is common due to unhygiene feeding habits and drinking unsafe water.

viii) Acute respiratory infection

This is common where the child is unprotected from the natural elements of

environment such as, cold, heat, rain, wind etc. It becomes serious if immediate care is

not given.


3.3 The Toddler

The "terrible twos" has been.used to describe the toddler's years from 12 months to 24

months of age. It is a time of intense exploration of the environment. You must

understand the dynamics of behaviour in order to help parents to deal effectively with

the tasks of this age. The growth and development pattems.of toddler are given below.


The growth and development of the toddler has been explained as under:

i) Development Tasks

The toddler is faced with the mastering of several important tasks. Toddler period builds

on previously acquired needs and acquired completion of tasks. The toddler has the

need for self esteem - the desire to feel important, in control, competent in his/her own

way. The toddler's ability to control his/her environment is greatly enhanced by his/her

increased motor skills and energy. The birth of a new sibling has special significance for

the toddler in his/her quest for autonomy. There is development of ego which may be

thought of as reason or common sense. It is evident that the child is able to tolerate

delayed gratification. There is also rudimentary beginning of super ego. Within the

psychosexual framework the anal zone becomes the center of child's physical,

emotional and psychological activities. Pleasure comes from moving his bowels.

Cleanliness of toileting should not be over-emphasised as this may make the toddler

tense.

ii. Biological development

Biological development and maturation of body systems is less dramatic during early

childhood. Physical growth slows considerably in toddlers as compared to the infant.

iii) Neurological development

By the end of the first year all the brain cells are present but they continue to increase in

size. Visual ability is fairly developed by the end of the first year and undergoes

refinement until the age of 6 years. The senses of hearing, smell, taste and touch

become increasingly well developed.

iv) Musculoskeletal system


Bone growth continues to be rapid. More than 25 ossification centres appear during the

second year. Growth in height is mainly due to elongation of legs, the feet develops

normal arches.

Dentition

By one year of age most children have between six and eight temporary teeth -- the

upper and lower central and lateral incisors: 'Dental hygiene can be started when the

fast tooth erupts.

The defense mechanism is much more efficient in the toddler than in infant.

v) Adaptive behaviour

Gross and fine motor behaviour: The major gross motor skill during the toddler period is

the acquisition of locomotion. Fine motor development is demonstrated in increasingly

skillful manual dexterity.

vi) Language behaviour

Increasing levels of comprehension develop. By the end of two years the child acquires

300 words. The child uses multi-word sentences.

vii) Intellectual development:

By the beginning of the second year the toddler 'thinks' and 'reasons', things out. There

is deliberate trial and error experiment to produce certain results. The mental abstracts

of time, space and causality begin to have meaning.

3.3.2 Promoting Optimum Development

As a health care provider, you have to teach parents how to ensure the optimum

development of their child according to the following guidelines.

i) Developing a sense of autonomy

Give children opportunity to assert themselves. Appropriate limit setting and discipline

are essential. Discipline is a positive, necessary component of child rearing. A child's

wants and needs may be restricted. Unrestricted freedom is a threat to their security

and safety.


ii) Temper Tantrum

Children may assert their independence by violently objecting to discipline. It is best to

investigate temper tantrums and other forms of indiscipline which can occur during

such as meal times, bedtime and toilet training. Sibling rivalry is a crisis for even the best

prepared toddler.

iii) Health Promotion during the Toddler Years

Nutritional requirement: Calorie requirement for toddler is 100 Kcl/kg; Protein 2.0

gm/kg; Fluid 125 ml/kg. Vitamins requirement remains the same as in the case of the

infant. The need for minerals, iron, calcium and phosphorous is still high. Health

Hazards. You should also teach the parents about the prevention of common accidents

to the toddler. These can be:

1. Road accidents 2. Drowning 3. Bums 4. Poisoning 5. Aspiration and asphyxia 6. Cuts and abrasions

3.4 The Pre-Schoolage

Pre-schoolers are emerging as creative persons. This is also a time for changes in the

parent-child relationship. Growth and development, psychosocial development and play

is described in the following subsections.


1. Biological growth

Children in the pre-school years grow relatively slowly, they become taller and thinner.

Weight and height

The pre-schooler gains approximately 1.8 kg per year. Growth and height occur at a

fairly steady pace. Sex related differences in weight and height are insignificant in the

pre-school period.

Body proportions: A pre-schooler looks like an adult because of skeletal maturation.


Dentition

Changes in dentition are few during the pre-school years. Dental carries are most

common during the pre-school period.

Integumentary system

Dry skin continues to be a problem because of the minimal amount of serum

production. The hair continues to become courser, darker and straighter.

Blood value

During pre-school years, fat replaces the red bone marrow of the long bones.

Respiratory system

When respiratory tract infections occur, they are localised in the upper tract. Tonsils and

adenoids remain large and should not be removed.

Immune system

Adult level-immunoglobin A (1gA) are reached during the preschool years.

Nervous system

Cerebral dominance is achieved. Co-ordination and the ability to voluntarily control

movements is increased significantly.

Sensory development

The development of auditory structures is complete by the end of pre-school years. The

other senses of taste, smell and touch continue to develop. In addition, children

experience pleasurable feelings associated with touching their bodies.

ii) Cognitive Development

Mental powers develop rapidly between 3-6 years. At the beginning of pre-school, they

remain in the pre-conceptual phase. They devote a great deal of time to imitation and

symbolic play. During this period children are very rigid in their demands. They have

great difficulty in disentangling an object from its background, a problem that has been

termed field dependency. From the age of 4 years children are in the stage of mental

development which is described as intuitive phase. Children use numerous concepts.


Children's attention span, . level of interest and ability to communicate and interact

with the environment to facilitate rapid acquisition of concepts and knowledge,

increases. Pre-school children become involved in the formation of new concepts. They

tend to define objects according to their use, e.g., a bed to sleep. Perception of time and

space is fairly good in the pre-school child. Reasoning and generalisation in their own

thinking is also developed.

Memory is influenced by the levels of perceiving and conceptualizing, modes of

attending and capacity for extracting meaning from the situation. The memory of pre-

school children can be improved through the intervention of parents, teachers or

nurses. Language development proceeds at a fast pace during the pre-school years. At

the age of two years the child has a vocabulary of about 300 words. At the age of six this

has grown to 8000-14000 words. There is also a steady increase in the number of words

used in a sentence.

3.4.2 Psychosocial Development and Play

Interdependency in all spheres of development is again demonstrated in the pre-school

child. Intelligence and reason play a large part in the development and maturing of the

capacities of the ego. With the increase of mental and physical powers, the ego is

assisted in its function of testing reality through interaction with and exploration of the

environment. A child's ego becomes strengthened through relationships with children

and adults.

The areas of psychosocial development are described below.

i) Identification with parents

Identification refers to the process whereby a pre-school child begins to behave like the

parent of the same sex. Identification is facilitated by dependency on parents and by

conscious awareness of parental expectations related to cultural standards of behaviour

and sex role identity. Identification is also furthered by acquisition of attributes or skills

currently defined masculine and feminine behaviour; children's perceptions that others

regard them as possessing a particular sex role; experiencing the parents as powerful

and significant nurturants who are in command of the desired goal such as power and

love.


ii) Conscience development: Through identification, the child may come to

resemble not only what the parent is, but also what the parent wishes the child to

become. Parents' standards and ideals become internalized in the child's character, so

that the child is no longer as dependent on the parents for behaviour regulation. With

the development of conscience or superego, older children are able to resist

temptations in the absence of parents. They begin to feel guilt for their misdeeds.

iii) The internalization of moral standards involves three different components.

Behavioural

Emotional

Judgmental The child's conscience becomes modified in later stages of development, though

meeting and adapting to the standards and conversions of his or her group, peers,

teachers and eventually the wider community. Development of Moral Judgment: As

children begin to interact with others and acquire increasing cognitive capacity to define

situations, their reasoning for moral action becomes more mature. During the pre-

school and early school years, children view rules passed down by their parents as fixed

and absolute. As children's experiences increase, their moral judgements progress

toward more internal and subjective values.

iv) Socialization and Social relationships

During the pre-school period, children identify with their own particular culture and

adopt its value, belief and norms. Family structure, educational institutions and child

rearing practices vary among societies. The culture in which children grow up

determines both the content and the methods of socialization of its members.

During pre-school period parents continue to act as the major agents of socialization of

children. In school, children can learn to become more independent and to express

feelings with greater freedom because relationships to other adults are less emotionally

charged than the relationship with parents. In a group, children's potentials for

socialisation can unfold, and the teacher can help them to turn to playmates for release

of affectionate feelings. When children succeed in making friends with other children in

the group, disappointment over family relationships becomes more tolerable. For many

children, a pre-school experience provides the first opportunity to interact with children

from different socioeconomic, cultural, ethnic and religious backgrounds. Optimum

health is also vital to children beginning a new experience. Health problems have a


direct bearing on the child's capacity for adjustment and ability to handle this new

experience constructively.

Adjustment to pre-school experience is usually gradual. Children have different method

of coping with the unfamiliar situation. Some children plunge into new situation

aggressively and others are passive at first and need to survey the situation from a

distance before entering into group activity.

v) Development of sex role

As the child begins to behave like the parent of the same sex, he or she begins to

experience some of the emotions as the parent. For example, while cuddling a doll the

girl may feel warmth, happiness, and pride the emotions her mother felt while caring for

her. The boy may experience pride when he learns to throw a ball like his father and

receives praise for his accomplishment.

Gender role of sex typing is important to most parents in the socialization of their

children. From the time of birth they may have given differential treatment to their child

according to sex, so that the child learns, throughout early childhood that particular

behaviours and mannerisms are expected of sex role identity in a particular culture.

Older sibling and peers also influence the child's sex role training, and can act as models.

For instance, boys with older sisters are more likely to exhibit greater feminine

characteristics whereas the reverse is true for girls with brothers.

vi) Development of body image:

When children begin to distinguish themselves as separate persons, they begin to, form

a mental image of themselves and their bodies. They also begin to recognise and

respond to parental pride or disappointment in their appearance and abilities. Vision

plays a part in the developing body image. When first viewing themselves in a mirror,

babies may shriek with distress. Later, however, they are able to recognise the image as

the self and to incorporate the external image into the concept of the body. If parents

register, disapproval of exploration of body parts during care taking activities, a child

may develop long lasting disgust. Natural curiosity about the body may be transformed

into guilt and anxiety.

At this age, children develop an image of their bodies as attractive or unattractive, and

normal or 'different' as a reflection of the opinions of others particularly those of


parents. We discussed about psychosocial development now we become to the next

part i.e. play as given below.

Play is the principal business of early childhood. Play provides an outlet for their needs

for self-expression. In dramatic play, children practice before one another the roles they

may play as parents.

Purposes of play

Play develops creativity in children.

Children develop cognitive map of the environment with patterns of time and space.

Play relieves tension, stress and painful experiences.

Through play children learn social interaction. Enhancing play activities

In the home, neighbourhood and in pre-school, adults should be sensitive to children's

needs for play. Play area should be checked for hazards. The play equipment should be

checked frequently to prevent accidents. Children should be dressed appropriately for

play. Parents interference should be kept to a minimum. They should not be left

unattended. Play articles should be selected according to the physical and mental

development of each child. They should be colourful and harmless.

3.5 The School age Child

The period of life from age 6-12 years (school age) has been given a series of labels. This

age is also called the "gang age" as the child gives more importance to peers during this

period. This is also the stage of industry and complexes. Between 6-12 years the child

achieves intellectual development and mastery of concrete operations. Let us discuss

the physical and mental development of the school age child.


During the school years the child shows progressively slower growth in height and a

rapid growth in weight. General growth is slow until the growth spurt just before

puberty. Muscular co-ordination improves steadily. Posture is good. The lymphatic

tissues reach its maximum growth. During this period there is eruption of permanent

teeth. The temperature, pulse and respiration approach the adult norms.


3.5.2 Mental and Psychosocial Development

In school the child has an opportunity to widen his social contacts as he develops his

mental abilities. Let us first talk of mental development and then we shall discuss

psychosocial aspects of development.

Mental Development

During school age the child gives up, to a large extent, his earlier pre-operational

egocentricity. He is able to function at a higher level in terms of his mental abilities.

Therefore he is able to learn in school. The school age child is able to arrange things or

concrete objects according to their size and relationship to other things. The child is able

to classify objects in a more complex manner. He can solve problems because he can

manipulate symbols. As regards the concept of time, the child not only thinks about the

present but of the past and future. The child's ability to speak and play becomes

socialized and cooperative during school age.

Psychosocial Development

Sense of industry

Between the ages of six and twelve years the child develops a sense of industry and a

desire to engage in tasks in the real world. The child enjoys doing socially useful tasks

for others which will yield a sense of worth. He learns how to cooperate with others.

The kind of school a child attends is important to his developing a sense of industry.

Relation with family, siblings and friends

More time is spent with other children but the family still provides security and a place

to relax. Children of large families find adjusting to peers and sharing with the group

easier than an only child. The school child's jealousy of younger and older siblings

increases as he/she attempts to keep ahead of a younger child and in pace with an older

one. Scholastic ability is a principal cause of sibling jealous among school children,

particularly in a child who is mentally inferior. School children often prefer to be with

their friends rather than their siblings.

Body image

The body image of school children is constantly changing because they are changing

physically, emotionally and socially. Modesty appears at about 9 years of age and at 10


years investigation of their own sexual organs begins. The pubescent years bring rapid

changes in body image.

Gang or groups

They form close friendships and ultimately form a group with other children. It may be a

secret society or an antisocial gang. Girls also form their own groups and discuss their

problems. Towards the end of the school period children learn to compete, compromise

and cooperate. Parents should understand and accept the activities of their children.

Children still need the continued love, interest and support of both parents.

Psycho-sexual development

Between 8 and 11 years, children begin to perceive sex roles in a near adult fashion.

Boys and girls (as they approach puberty) should be informed about the reproductive

cycle and their respective role. Both male and female sexual changes should be

discussed by parents.

Spiritual development

During these years children are learning the specifics of their religion that will later

develop into religious philosophy.

Play and work

Today school age children are increasingly interested in the type of play and work

usually associated with those of the opposite sex i.e. the girls may be interested in

participating in team sports traditionally reserved for boys. Boys may be interested in

learning to bake and. cook. Play serves as a learning tool for children and their play

changes with development needs. Children participate in more organised sports.


The health of the school child is influenced by the health supervision received from the

family physician, nurse practitioner, the dentist, health instructions given by parents,

teachers, school and school nurse, the home and school environment. As a health care

provider you have to play the role of school health nurse as given below.

The Role of School Health Nurse Practitioner


The role of school health nurse practitioner or school health nurse is changing from

being child centred to being family centred. Health fairs present the concepts (if health

and well-being to school children. Hospital tours. can also be arranged by the school

health nurse to familiarise the children with a hospital and prepare them for possible

hospitalisation. The school health nurse should give health education in the' following

areas.

Areas of Health Education

Nutrition

School children usually eat well and have fewer food fads than pre-school children.

Eating problems relate more to the time of eating. Milk and fruits are preferable to

candy and cookies. As a school health nurse you have to ensure that the diet of the child

should contain all the nutrients in proper adequate proportion and advise the child and

parents on a balanced diet to prevent nutritional deficiency.

Eating habits

Meal time should be pleasant. There should be resting period in the day, but some

parents do not keep it so because of over emphasis on manners. The child’s eating

habits improve as he grows older. A friendly atmosphere and enjoyment of the meal are

the best aids to appetite. Your responsibility as a school health nurse is to ensure and

advise the child and parents regarding healthy eating habits such as washing hands

before and after eating and eating in clean surroundings.

Dental problems

Dental health is of particular importance during this stage of development. Ideally,

children should receive regular preventive dental care and supervision in daily hygiene

from the time the teeth begin to erupt. Inadequate dental care results in dental caries,

malocclusion and trauma. These conditions have harmful long range effects on

children's health. The most effective means of preventing dental problems is to provide

information to the child and parents regarding brushing of teeth and washing of mouth

in both early morning and after taking food.

Sleep and rest: The amount of sleep and rest required during childhood is a highly

individual matter and unique to every child. During school age children usually sleep 11-

12 hours.


Exercise and activity

Exercise is essential for developmental progress in a number of areas such as the

following muscle development and tone, refinement of balance and co-ordination,

gaining strength and endurance, and stimulating body functions and metabolic

processes. Children need ample space to run, jump, skip and climb and safe equipment

to use inside and outside the home or school. Most children need little encouragement

to engage in physical activity. They have so much energy that they seldom know when

to stop.

Sex education

Evidence, indicates that many children experience some form of sex play during or prior

to preadolescence as a response to normal curiosity; not from love or sexual urge.

Children are experimentalists by nature, and this play is incidental and transitory. You,

as a school health nurse, can provide information on human sexuality to both parents

and children.

Prevention of accidents

As in all other age groups, the most common cause of serious accident, injury and death

in school age children is motor vehicle accidents - either as pedestrians or passengers.

Physically active, school age children are highly susceptible to cuts and abrasions,

fractures, strains and sprains. The most effective means of prevention is education of

the child and family regarding hazards of risk taking and improper use of equipment.


UNIT 3 THE ADOLESCENT

CONTENT

3..1 Physical Growth

3..2 Psychosocial and Emotional Development

3..3 Health Promotions and Anticipatory Guidance

INTRODUCTION

Achieving. independence from the family is an important goal of adolescence. The time

period extends from 10-12 years to 18 years. This period is also called the teenager. The

adolescent period has three stages i.e. Prepubescent or pre-puberty period is refers to

the period of rapid physical growth when secondary sex characteristics appear.

Objectives

After going through this Unit you should be able to:

Describe physiological status of adolescent

Describe the growth and development of adolescent

Explain the growth and development of adolescent

List the common health problems of various stages of development

Advise on their problem prevention

4.0 CONCLUSION

5.0 Summary



3.1 Puberty


This is the age at which girls begin to menstruate and the boys to produce spermatozoa.

Adolescence begins when the secondary sex characteristics appear and when somatic

growth is completed. The individual now is psychologically mature, capable of becoming

a contributory member of society.Let us discuss the growth and development of

puberty first and then talk of adolescence.

3.1.1 Physical Growth

Puberty is a period of rapid physical change and personality growth. Girls begin their

pre-adolescent growth spurt at about 10 years of age and boys at 12 years of age.

The physical characteristics of puberty are given below.

Weight and height Rate of growth in height tends to decrease each year from birth but with the onset of

puberty there is a rapid increase, or spurt, and the child becomes tall. Gain in weight is

proportionately greater than gain in height during early adolescence.

Body proportion The skeletal system grows faster than its supporting muscles. This tends to cause

clumsiness, poor posture, and lack of co-ordination. The extremities, hands, and feet

grow out of proportion to the rest of the body and cause more co-ordination problems.

Dentition The number of permanent teeth increase.

Physiological development It is believed that due to changes in hypothalamus with resultant neuro-hormonal and

pituitary gland, stimulation development of secondary sex characteristics occurs.

Physical changes in boys include in order of appearance Increase in size of genitalia; swelling of the breast, growth of pubic, axillary, facial and

chest hair; voice changes; and production of spermatozoa. Boys grow rapidly in shoulder

breadth from about the age of 13 years. Boys can become disturbed by nocturnal

emissions and the loss of seminal fluid during sleep. If they have not been told that this

is normal they may regard it as a disease or as a punishment because of masturbation or

thinking too much about sex. They may also believe it is devitalizing. Nocturnal emission

is due to the activities of glands, and occasional release of spermatic fluid during sleep

should cause no concern.


Physical changes in girls in order of appearance Include increase in the transverse diameter of the pelvis; development of the breasts;

change in the vaginal secretions; and growth of pubic and axillary-hair. Menstruation

begins. Average age of menarche (time of first menstruation) is 12.5 to 12.8 years. A

girl's hips begin to broaden from about the age of 12 years. Because of lack of adequate

information, girls may have misconceptions about menstruation. Children should be

well oriented to the anatomic and functional differences between the sexes. Girls

should have clear understanding about ovulation, fertilization, pregnancy and birth.

Menstruation is a normal physiological phenomenon, so women need not curb their

normal activities during it.

Integumentary system The sebaceous glands of the face, back and chest become more active. If the pores are

too small, sebaceous material cannot escape. It collects beneath the skin and produces

pimples or acne; perspiration is increased. Vasomotor activity produces blushing.

Cardiovascular and respiratory system

Heart and lungs grow more slowly than the rest of the body. The supply of oxygen may

be inadequate, causing the pubescent to feel constantly tired. So far we have discussed

the physical characteristics of puberty. Now we shall talk of adolescence.

3.1.2 Physical characteristics of Adolescence

After the pubescent years growth slows and the changes in the body proportion occurs

more gradually. The stages of puberty and adolescence are on a continuum. Stress and

anxiety may occur with these physical, emotional, social and intellectual changes in the

young maturing person. Usually by 15 to 16 years secondary sex characteristics have

developed fully, and adolescents are capable of reproduction. At the end of

adolescence, young persons appear physically like adults. The head is approximately one

eighth of body length.

3.2 Psychosocial and Emotional Development

Children become increasingly more adaptable, approaching their peer group and

problem situations at home and at school, with greater confidence. Parents become

aware that during pubescence the hostility that previously existed between boys and

girls gradually disappears.


The sense of identity and the sense of intimacy:

Adolescence is a period of stress for young people and their parents. Adolescents must

know who they are and must modify their conscious thought of their adult role in life.

Adolescents today are faced with many pressures; rapid rate of social change, the threat

of nuclear war, the increase in speed of travel and technological progress and access to

mind-altering drugs, pose problems. Although sense of identity is difficult to achieve,

young persons must gain it, in order to be saved from emotional turmoil. After

developing a sense of identity during early adolescence, they should be able to develop

a sense of intimacy between themselves with persons of both sexes.

If individuals have weak egos, and are uncertain of self, they will not be able to form

close ties of friendship or love with other people. Close relations between boys and girls

begin during pubescence; these are not intimate relations and serve only as settings for

discussion, on what they think and feel. During late adolescence these relations serve

another purpose. While a healthy adolescent is establishing a sense of intimacy, a

struggle with sexual feelings, may be experienced. As a result peers become very

important.

Achievement of independence from parents

Adolescent-parent separation is part of the natural course of the life cycle. The

adolescent may also adopt the alternative styles of dress, philosophic view points, and

goals of the peer group. The rules of the house set by parents are no longer acceptable

to the adolescence. They begin to internalize the qualities of their parents, if they are

perceived as valuable. These values may be constructive or destructive.

Emotional-Social needs

Adolescence is characterized by mood swings and extremes in behaviour. Friendships

are important to adolescents. Groups of friends are important during early adolescence,

but with maturity older adolescents pick and choose their friends. Peers influence

greatly the adolescent's sense of identity.

Due to rapid body growth, there are changes in body image. To integrate these changing

body image into their self-concepts, adolescents spend a great deal of time in body

hygiene, grooming, and select clothing. Some individuals achieve emotional maturity

during the later stages of adolescence whereas others may achieve it during adulthood.


Psycho-sexual Development: Masturbation: Masturbation is a central concern in early

adolescence, especially in boys. Girls may indulge in it to a lesser degree. Adolescents

should be informed that masturbation is a normal response to increased sexual

development.

Factors influencing decisions about sexual behaviour:

Value and ethics

Value and ethics come from family, religion and peers and society.

Intellectual or Cognitive Development

Formal operational stage (11-15 years): Children progress from concrete to formal

operations during early adolescence. Adolescents can make use of assumptions while

thinking, formulating hypotheses,, and constructing theories. They can use hypothetical

deductive reasoning. They may reject the authority if they are not satisfied with the

rationale and logic.

School

School subjects become more complex. Adolescents experience a period of rapid

increase in vocabulary and language development. Mental growth is not correlated with

increase in size. Adolescents may face some difficulties in adjustment to school. They

may spend more time in extra curricular activities. Adolescents' academic abilities and

interest vary greatly. Besides academic preparation for adult life, high school offers

adolescents an opportunity for extra-curricular activities to satisfy their needs for

security, recognition and success. Parents should continue to take interest in the school

life of the adolescent.

3.3 Health Promotions and Anticipatory Guidance

The adolescent girls and boys should be advised on the following general points.

1. Physical examination

- Personal hygiene

- Nutrition

- Exercise and sports


- Dental health

- Accident prevention

- Prevention of addictive behaviour

- Sex education

2. Health concerns of girls

- Menstruation

- Pre-menstrual syndrome

- Dysmenorrhoea

- Amenorrhoea

- Breast size and shape

3. Health concern of boys

- Size of genitalia

- Gynecomastia

- Muscle development

- Acne

- Growth of secondary sex characters.

4.0 CONCLUSION

5.0 SUMMARY

Adolescent years are important for the family and the community. We have seen that

growth and development start right from the time of conception. The health of foetus

depends on maternal environment. The neonate period is most critical. The newborn

has to make physical adjustments to service. During the first year of life growth is very

rapid. In addition to this other developmental changes begin. Toddlers are more difficult

to manage. They need to be prevented from accidents. During pre-school and school

age, the child is exposed to different kind of environment. Infections are common


among these children. Physical examination of these children is to be carried out by the

school health nurse. Adolescents are unique. Teachers and parents should understand

their needs and problems.

6.0 TUTOR-MARKED ASSIGNMENT


UNIT 4 ANTHROPOMETRIC MEASUREMENT

CONTENT

3.1 Introduction

3.2 Objectives

3,1 Growth monitoring

3.1.2 Height measurement

3.2.1 Nutritional assessment

3.2.2 Mid-upper-arm circumference

3.3 Body Mass Index

3.4 Infant and young children feeding

3.5 Malnutrition management

1.0 Introduction

Growth Monitoring is a simple prevent way to identify the child is growing. It is

used at the time growth is fastest which is first 36 months of life. Growth

monitoring refers to regular assessment of the growth of children through weighing

in the presence of the mother/caregiver from birth to five years to detect deviation

from normal growth and the application of appropriate interventions.

2.0 Objectives

After the completion of this unit you should be able to

i) Describe growth development and monitoring

ii) Discuss nutritional assessment

iii) Determine Body Mass Index

iv) Discuss management of malnutrition

3.0 Main Content

3.1 GROWTH MONITORING

Growth monitoring begins immediately after birth by taking the birth weight. The

birth weights form the base line for growth monitoring. It shows underweight,

overweight and or normal weight gain. This is done on a regular basis using road-

to health chart. It is used until the child is five years (i.e. pre-school age). As a

child grows, he gains weight so long as he remains healthy. Malnutrition and

diseases disrupt this process of growth and can abnormally increase or decrease the


weight. The kind of scale used depends on the age of the child. For example, for

infants and young children 0-24 months, hanging scales is used in the rural areas

where there is no Salter bowl type scale. For older children, bathroom type scale

can be used.

IMPLIMENTATION OF GROWTH MONITORING

Before a child is weighed, correct and accurate age to the nearest months of birth

(birth month) should be determined from birth records. The growth charts were

designed for mothers and families as means of communication between them and

the health workers. It is a home-based records that need to be brought along with

her to the health facilities whenever she has an appointment.

- Weights of children are taken on regular (monthly) intervals and plotted

against the age (in moths) by joining the monthly Dot(.) made on the growth

chart.

- The month is written in full (i.e. November, October)

- He chart is for use during the first five years of the child‟s life

- The graph has two weights-for-age curves or lines.

- The Upper one represents the 50th centile (for boys) and lower, the 3

rd centile

(for girls).

- The space between the two is called the “ROAD TO HEALTH” which most

healthy children are expected to follow.

- In addition to the two standard curves described, some graphs may have a

third curve, the 97th

centile.

- The shape of the curve of the normal healthy child‟s growth line is similar to

that of the reference lines on the growth chart. The slope of the growth line

is then compared with the normal average growth curve already printed on

the card.

There are three shapes or three reference curve directions for growth

monitoring which must be recognised and their implications understood.

(a) Upward direction : Good. The child is gaining weight and growing well

(normal development). The mother should be commended.

(b) Horizontal or flat line : Warning sign. Child is not gaining weight (static).

Growth has flattered. Something is wrong and requires investigation.


(c) Downward line: Very dangerous. Weight does not rise above the lower line.

Child is losing weight. Very abnormal and urgent action must be taken. As

and check for infection (treat if present). Breastfeeding and complimentary

foods, personal and environmental hygiene are advised as appropriate.

As a guide, weight between 80-100% of the standard reference is good.

Weights between 60-80% are referred to as underweight and such a child is

said to be at risk of malnutrition. If a child‟s weight is < 60% of normal

standard weight, he is said to be malnourished. He is either suffering from

marasmus or kwashiorkor.

To be able to get the above percentage (%) is used

Actual age of the child x100

Standard Weight

3.1.2 HEIGHT MEASUREMENT

It is used to estimate the rate of growth of the individual and correlate the relation

of height with general health.

The implementation include the following

Inform the mother about the procedure and gain consent

Lay the child on a flat even surface like table

Hold the head and heel firmly

Place two books or any flat non injurious objects one each at the head and

heel level.

Instruct the mother to remove the infant

Place a measuring tape between the two blocks and measure height

Record the height and inform the mother

To measure school children and adults

Inform the client about the procedure and gain consent

Instruct the client to stand against a wall on a flat surface or against the

height rod with his feet together, arms and hands down, head erect and eyes

straight, without footwear, feet parallel and heels, buttocks, shoulders and

back of head touching the wall.

Place the ruler on top of the head level and mark the area with pencil where

the ruler touches the head.


Instruct the client to move away from the area marked.

Measure from ground level to the marked area with a measuring tape or if a

height is used, read the measurement that appears at the point where the

ruler touches the head.

3.2.1 NUTRITIONAL ASSESSMENT

Nutrition is the provision of energy and essential nutrients to maintain optimal

growth and development. An adequate diet contains all kinds of food in the right

proportion. To remain healthy, an individual (child, adolescent and adult) must

have the right amount and kind of food. Inadequate diet may result in under

nutrition, overweight or obesity (mal nutrition) there are four elements of

nutritional assessment. These include the following:

Biochemical data such as Hb, PVC and urinalysis

Clinical data such as information about individual‟s medical history which

include acute and chronic illness, diagnostic procedures or treatment which

can increase or decrease nutrients.

Dietary data taken during a nutritional interview about the meal taking

during previous day previous twenty four hours. Estimating portion or size

of food is difficult.

Anthropometric measurement such as weight, height, write circumference,

skinfold thickness, mid upper arm circumference, chest and head

circumference are carried out for assessing the level of malnutrition in

children while the body mass index (weight and height2) in adolescents and

adults.

3.2.2MEASURING THE MID-UPPER ARM CIRCUMFERENCE (MUAC)

Mid-Upper Arm Circumference is age independent measurement to assess the

nutritional status or to screen malnutrition in children between ages one and five

years. Measuring the mid-upper arm circumference is one of the direct

anthropometric techniques of assessing the nutritional status of children between 1-

5 years of age. It is one of the cheapest, easiest and quickest techniques. The

MUAC changes with about 1cm or less from 1-5 years regardless of the sex of the

child. At birth, it is between 7 and 9 centimetres and increases minimally in


diameter between the first and fifth birthdays in healthy normal children. Any child

whose MUAC is below 14.6centimeters within 1-5 years of age is undernourished.

The device for the measurement of MUAC is called SHAKIR strip (named at the

developer) or MUAC tape. MUAC strip can be made from old X-ray films

(previously washed). At its simplest form, the strip has a zero mark and three areas

marked by colours green, yellow and red. “Green” signifies healthy baby, colour

“yellow” indicates caution/warning and that the child is not getting enough and not

growing well. The colour “red” is generally noted for danger.

The three colours of the strip can be effectively used as nutrition educational tool

for mothers. The colour “green” can be used to give information to the mothers on

locally available food stuffs and encourage the mothers to give green leafy

vegetables, yellow colour signifies the need to give food and fruits such as

pawpaw, mangoes, pineapple, banana, yellow yam, oranges, and other yellowish

fruits. Reds colour indicates the need for reddish foods such as palm oil, tomatoes,

as good sources of carotene.

IMPLEMENTATION

Nurses implementation include:

Collect appropriate requirements needed including Shorka‟s strip

Greet and explain to the mother the reasons for using the MUAC strip/tape

Ensure mother is well seated with the child on her laps

Give the MUAC tape/strip to the child to examine or hold before applying it

Push up clothing from the left arm

Allow arm to hang freely

Locate the middle point by measuring the length between the tip of the

should (acromion) and the elbow (olecranon) of the left arm using non-

stretchable fibre tape as the arm hangs freely.

Place the MUAC tape/strip round the middle of the upper arm at the marked

spot (i.e.mid-way).

Put the end of the tape through the small slot in the wide of the tape

Pull the tape/strip firm but not too tight that it pinches or pull the skin

Read and record the colour where the tape/strip intercepts the original

marked line on the strip (in-between the arrows)


Counsel the mother accordingly to the result of the MUAC Tape (Nutrition

Education).

Green-Normal (commend good efforts)

Yellow-Warning sign (child requires attention)

Red – Danger sign (child needs immediate attention with follow-up instructions

on nutrition, personal and environmental hygiene and immunization.

3.3 BODY MASS INDEX

Body Mass Index (BMI) can be described as a reliable indicator that measures

generalized body fatness for adult adolescents and children. It is calculated by

dividing the weight (kg) by height (m) squared. The average normal BMI for

men and women is 24.99kg/m2. Anything above 25kg/m

2 but less than 30.0 is

regarded as overweight and when it is above 30 but less than 40, regarded as

morbid obesity. The BMI for children and young adults‟ age 2 t0 20 years is

expressed in percentiles. Regardless of gender when the BMI falls below the

5th

, it is referred to as underweight, when it is between the 5th percentile and less

than 85th percentile, it is within healthy weight. When it is within 85

th but less

than the 95th percentile the classification is overweight and when the BMI for

boys and girls 2 to 20 years can be numerically classified.

BOYS 2 T0 20 years Girls 2 to 20 years

<14.8- Underweight <14.4 – Underweight

14.8 – Healthy weight 14.4 – 18.0 Healthy weight

18.4 – 19.2 Overweight 18.0 – 19.0 Overweight

>19.4 – Obese >19.0 – Obese

BMI Formula = Weight in kilogrammes

Height in metres2

The interpretation is as follows:

Less than 20 - Inadequate nutrition

20 – 24 - Normal

25 – 29 - Overweight. Possibly obese


30 – 39 - Moderately obese

40 and above - Grossly obese

3.4 INFANT AND YOUNG CHILD FEEDING

Infant and young child feeding (IYCF) encompasses the set of feeding practices

needed to prevent malnutrition. These practices are essential for the nutrition,

growth, development and survival of infants and young children. Breast feeding

should be initiated within 30 minutes of delivery and infants should be exclusively

breastfed for the first six months of life and thereafter breastfeeding should

continue up to two years and beyond while safe complementary foods are

introduced at six months after delivery.

Inappropriate breastfeeding practices are a major factor contributing to infant and

child mortality in Nigeria. Children from 0-6 months who are not breastfed have

five and seven times higher risk of dying from pneumonia and diarrhoea

respectively. In addition, these children are at higher risk of developing non

communicable diseases in adulthood promotion of Exclusive Breast Feeding (EBF)

for six months and continued breastfeeding with adequate complementary foods

until 24 months and beyond constitutes the most effective preventive interventions

reducing child morbidity and mortality.

Skilled behaviour change counselling and support for infant and you child nutrition

should be integrated into all points of contact between mothers and health service

providers during pregnancy and the first two years of life of a child. Community

based support networks are needed to help support appropriate infant and young

child feeding (IYCF) at all levels.

Table 1: Interventions Focusing on Infant and Young Child Feeding. (Pls. correct

the font/or use this

Intervention Description Target

Population

Potential Dietary

Platform Breast feeding promotion

and support, taking into

account policies and

recommendations of HIV

and infant feeding.

Early initiation of

breast feeding within

30 minutes of delivery

EBF for 6 months and

continued

breastfeeding until 2

years of age and 12

months for HIV

exposed infants.

Pregnant mothers

and parents of

infants under 6

months of age

Health Facilities

Community

structures

Campaigns/Outreac

hes. Home Visits

Complementary feeding Behaviour change Pregnant mothers Health Facilities


promotion promotion to follow

international best

practices Provision of

CIYCF counselling

provision of nutrient

dense complementary

foods for children

under two.

and parents of

infants and young

children under

two years of age.

Community

structures

Campaigns/Outreac

hes Home Visits

Strengthening of optimal

feeding of a sick child

during and after illness

and exceptional

circumstances

Encouragement of

breastfeeding increase

frequency of eating

during and after illness.

Pregnant mothers

and parents of

infants and young

children under 5

years of age.

Health Facilities

Community

Structures

Campaigns/Outreac

hes. Home Visits

Advocacy for monitoring

and strengthening

enforcement of the

international code of

marketing of breast milk

substitutes

Advocate for increased

monitoring and

enforcement that

supports breast feeding

promotion

Legislators Health Facilities

Community

structures

campaigns/outreach

es. Home Visits

Sources: Nutritional policy- National strategic plan of action for nutrition in

Nigeria (2014-2019)

3.5 MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN

CHILDRENT UNDER FIVE YEARS

Health workers who have contact with infant and young children should be

oriented on the early signs and dangers of under nutrition. They should know how

to identify the underlying causes of under nutrition, be able to recognize poor child

caring practices and advices caregivers on corrective action and be equipped with

screening tools for acute under nutrition and appropriate information for referral

and follow up. Children with acute malnutrition are at higher risk of dying

particularly those with (SAM) Severe Acute Malnutrition and require feeding with

appropriate treatment.

TABLE 2

Intervention Description Target

Population

Potential Dietary Plat

Form

Prevention and

management of

moderate under

nutrition in

children 0-23

months of age

Population with

high prevalence

of children 0-23

months of age

with weight for

age

Health Facilities

Community structures

Campaigns/Outreaches.

Home Visits


Treatment of

Severe

malnutrition

Identification of

SAM and

subsequent

treatment

Children 6-59

months of age

with weight to

height (with or

without oedema)

or with

MUAC<110cm

Health Facilities



Source: Nutritional policy – National strategic plan of action for nutrition in

Nigeria (2014-2019)

Micro Nutrient Deficiency Control

Vitamin A and mineral deficiencies contribute to morbidity and mortality among

children by impairing immunity, impeding cognitive development and growth

thereby reducing physical capacity and work performance in adulthood.

Micro nutrient deficiencies of public health importance in Nigeria include Vitamin

A, Zinc, Iron, Folic acid and iodine. Multiple strategies are needed to control these

deficiencies.

Table 3: Intervention Focusing on Micronutrient Deficiency Control (PI. Use this

format)

Intervention Description Target Population Potential Delivery

Platform

Vitamin A

Supplementation

Bi-annual doses for

children. Used in

the management of

measles infection

Children 6-59

months

Health Facilities

Community Structures

Campaigns/Outreaches

Zinc

Supplementation

As part of

diarrhoea

management

Children 6-23

months of age

Health Facilities



Multiple Micro

nutrient powders

Micronutrient

powders for in-

home fortification

of complementary

foods

Children 6-23

months of age

Health Facilities

Community Structures


Deworming Two rounds of

treatment per year

Children 12

months-59 months

of age

Health Facilities



Nutrition Education

on Bio-fortified

foods

Promote

consumption of

fortified foods.

Parents and

caregivers

Health Facilities




Sources: Nutritional policy-National strategic plan of action for nutrition in

Nigeria (2014-2019).

Diet Related Non Communicable Diseases (DRNCD)

diet related non communicable diseases (DRNCD) such as obesity, diabetes

mellitus and cardiovascular diseases are increasing in public health importance in

Nigeria. Researchers have empirically identified the link between non-

communicable diseases and globalization, urbanization, demographics, lifestyle

transition socio-cultural factors, poverty, poor maternal, foetal and infant nutrition.

Table 4: Intervention focusing on DRNCD (PI. Use this format)

Intervention Description Target Population Potential Delivery

Platform

Awareness of

DRNCD

Identify risk factors

providing

education and

increasing service

for DRNCD

General population Health Facilities



Sources: Nutritional policy – National strategic plan of action for nutrition in

Nigeria (2014-2019)

4.0 Conclusion 5.0 Reference


Unit 5 FAMILY PLANNING 1.0 Introduction The current population of Nigeria is 200,000,000 with annual increase of population of 3.5%. This is about the highest rate of increase in the world. This unit enables you to understand the needs of family planning, the methods and the roles of the public-community health nursing in the implementation of family planning. 2.0 Objectives

This unit will enable you (1) Outline the importance of family planning (2) State different types of planning methods (3) Discuss the mode of action of the method (4) Discuss the roles of public-community health nurses in family planning implementation.

3.0 MAIN CONTENT 3.1 Family Planning refers to practices that help individuals or couples to attain the following objectives including to: i). Avoid unwanted birth ii). Bring about wanted birth iii). Regulate intervals of pregnancy Iv). Control the time of birth in relation to age of the parents v). Determine the number of children in the family Family planning is basic human right. The scope involved sterility, sex education, screening for pathological conditions related to reproductive system and marriage counseling. The eligibility couples are defined as currently married wherein the wife is in reproductive age of 15-45years who need family planning servicecs. 3.2 CONTRACEPTIONS These are methods designed to prevent conception. There is no ideal contraception suitable for all couples. Each has advantages and disadvantages that must be put into consideration when making recommendation. It is the duty of the Public-community health nurse to provide the information to the couples to make informed choice on utilization of family planning. The conventional contraception include the following

1. Spacing method


Barrier method- This include physical, chemical and combined methods

Intra-uterine devices

Hormonal contraceptions

Post-conraceptional method 2. Terminal Method

Vasectomy (male sterilization)

Tubectomy (female sterilization) PHYSICAL METHOD:

1) Condom: This is the most common and widely used by men all over the world. It also protects individuals from sexually transmitted diseases. It is for a single use and is worn on the erected penis before coitus. When it is correctly used is effective. Currently there is female condom that is also effective.

2) DIAPHRAGM: It is made of synthetic rubber and is used by wemen. It is cup-like with a rim that is strengthened by a spring. It is inserted into the vaginal canal before coitus and it is left in place six hours after intercourse.

3) CHEMICAL METHODS: The chemical methods include foam tablets, foam aerosol, creams and Jellies and pastes. These products contain spermicides.

4) NTRAUTERINE DEVICE (IUD) It is the introduction of a specially designed device into the uterine cavity of a fertile woman who desires to prevent conception/ pregnancy for specific period of time. This is classified into

First generation IUCD: They are made up of inert materials from polyethylene. Lippes loop is S-shaped with a thread attached at the end that help to identify it and aids the removal.

The second generation is made of metallic copper. It is a T-shape.

The third generation IUCD are with progestogen which is released slowly into the uterus


The mode of action of IUCD is to cause biochemical changes in the uterus that alter the mucus secretion and impair the survival of the sperm in the vagina.

Purpose: 1. To ovoid unwonted pregnancy 2. To space pregnancy

Requirements: Trolley Procedure

Top Shelf

A Sterile Pock Containing the following:

1. 2 gallipots for iodine and swabs

2. 1 Artery forceps curved 81/2 long

3 Uterine forcepts

4. 1 single or multiple toothed vulselum (Tenaculurn)

5. 1 pair dressing forceps

6 1 Pair of sponge forceps

7 1 I.U.D removal forceps (Alligator fang type 8’-I

8 1 Curette for biopsy

9. Sterile Scissors size 8’

1 0. Uterine sound

11 . Vaginal speculum (CUSCOs) medium and large

12 .Sterile water.

Bottom Shelf

1. A jar with cheatle forceps

2. Disinfectant

3. Mask

4. Receiver for soiled swabs


5. Angle poise lamp

Procedure

1. Explain procedure to the client to allay anxiety

2. Assemble requirements on the trolley

3. Put the client in lithotomy position in the insertion room and

screen the client

4. Put-on mask

5. Swab vulva

6. Perform bimanual examination (vaginal examination)

7. Apply vaginal speculum, leave it in situ and inspect the cervix

excluding any

abnormality

8. Stabilize the cervix with tenaculum clamping at 10cm or 2pm

direction to prevent

haemorrhage

9. Use uterine sound gently to determine the depth of the uterus.

1 0. The bloody discharges leaves a mark of the depth on the uterine

sound, but if done after

the menstrual flow, apply a small quantity of contraceptive cream

or jelly on its tip

before inserting. (Correct sounding, should not be painful).

11 . After sounding, withdraw gently and note the depth of the uterus.

a. For uterine depth less than 4.5cm or type of IUD. 4.5-6.5cm (copper

T, or small’ T-coil

6.5- 9.9cm) most IUD are acceptable type).

b. For uterine depth 10cm or more, use large with a backup.

12, Load the device appropriately into its tube following the makers


guideline

13. Place the loaded tube alongside the uterine s and adjust the tube to

the appropriate

depth of the uterus using the adjuster for Copper T.

14. Lippies loop, may not need an adjuster because its firmly

attached to the body of the barrel (Not in use in Nigeria).

I5. Select the correct size of the lippes loop or saf T.coil that

corresponds with the parity and

depth of the uterus and load (Do not load and keep for a long

otherwise the device will

lose its memory). Copper T need no selection.

16. HoIdIng the tenaculum, apply a gentle outward pressure to

strengthen the cervix

17. lnsert, using proper technique of pushing in for lippies loop or

withdrawal for copper T.

That is, for lippies loop push in to release the device.

18. For Copper T, hold the piston stationary, and retract the barrel (vice

versa)

1 9. After inserting the device, withdraw the tube and piston

20. Unclamp the cervix

21 . Trim the string and swab the cervix

22. Remove the vaginal speculum and push the string i the anterior or

posterior fornix of the

vagina.

23. Move the client backward and disengage the legs from the stirrups

24. Clean her buttocks and make her comfortable

25. Remove all equipment for washing and sterilization


26. Record the findings and the device into the client chart

27. instruct the client accordingly on how to check for the string

28. For checking the string, she is advised to wash her hands clean, in

squatting position r

lying down position, she should carry out a self vaginal examination

usually before and

after menses

29. No intercourse for 2days after the insertion.

30. Analgesic can be given for pain and the need for personal hygiene

stressed

31. For follow-up next appointment is 6 weeks. 2 appointment in 3

months, 3rd

appointment in 6 months.

32. Client should report early if she has pelvic pain, persistent painful

intercourse, vaginal

discharge, unusual vaginal bleeding or fever.

33. Appointment card with necessary information should be given to the

client.

NOTE: Methods for disinfecting instruments and IUDs:

1. Instruments are boiled for 5 minutes, if not soaked in disinfectant.

2. Do not use salvon (cetrimide) for sterilization as it is a weak

disinfectant.

3.3 INSERTION AND REMOVAL OF JADELLE

(LEVONORGESTREL IMPLANT)

It is a long-acting reversible contraceptive implant design to prevent

pregnancy. It is a two-rod implant developed in the 1 980s by the


Population Council for five years of continuous use (population council

2010) Jadelle acts by preventing the release of the ovum and also

thickening the cervical mucus thereby blocking the sperm.

Purpose

1. To avoid unplanned pregnancy

2. To enhance child spacing (pregnancy)

Requirement

1. Examination table or couch

2. Sterile surgical drapes

3. Sterile gloves

4. Antiseptic lotion (povidone iodine or spirit)

5. Sterile maker (optional)

6. Local anaesthetic agent(1% lignocaine) epinephrine free

7. Needles & syringes,

8. Sterile gauze

9. Adhesive bandage (plaster)

10. Pressure bandage (crepe)

11 . An applicator with the following parts:

i. Needle shield/needle

ii. Applicator seal

iii Cannulo

iv. Obturator support

v. Obturator

12. Sharp proof container (Injection Safety Box)

1 3. Leak-proof container or plastic bag

14. Pregnancy test strip


Procedure

Pre — Insertion Task


2. Encourage client to ask questions

3. Provide privacy

4. Check to ensure that her arm is thoroughly washed if not, swab the

area of insertion with spirit or iodine swab

5. Wash hands, dry and don gloves

6. Place the sterile drape under the arm to be inserted with the

Jadelle rod

7. Mark area of insertion 6 — 8cm above the elbow fold in a ―V‖

pattern

8. Clean area with high level disinfectant e.g. povidone iodine

9. Change hand gloves and replace with another sterile gloves

1 0. Instruct assistant to hold the lignocaine vial

11 . Draw up 2mls of 1% Lignocaine without epinephrine (local

Anaesthetic)

1 2. lnject under skin (subdermal) and raise small wheal

13. Advance needle about 4cm and injects 1mL of local anaesthetic in

each of two sub-dermal tracks

14. Wait for 2minutes before checking for Anaesthetic effect

1 5. Start skin incision if anaesthetic effect is present

Insertion Task

1. Using the new sharper disposable trocar, insert directly sub-dermally

2. While tenting the skin, advances trocar and plunger to mark (1)

nearest hub of trocar


3. Remove plunger and load first rod into trocar with forceps (preferably)

or with gloved fingers

4. Reinserts plunger and advance it until resistance is felt

5. Hold plunger firmly in place with one hand and slide trocar out of

incision until it reaches plunger handle

6. Withdraw trocar and plunger together until mark (2) nearest trocar tip

(do not remove trocar from skin)

7. Move tip to trocar away from end to the rod and hold rod out of the

path of trocar

8. Redirect trocar about 150 and advance trocar and plunger to mark (1)

9. Insert second rod using same technique

10. Palpate rod to ensure that two rods have been inserted in a V-shaped

distribution

11. Palpate to check that all rods are at least 5mm clear of insertion (if

rod is protruding through point of insertion remove and reinsert)

12. Remove trocar only after insertion of the last rod

Post Insertion task

1. Remove drape and wipe client skin with antiseptic

2. Apply pressure dressing with bandage

3. Dispose implant trocar, needle, sypringe in a sharp box before you

remove gloves

4. Dispose waste materials (gauze, cotton wool etc). into a leak proof

container or plastic bag.

5. Immerse both glove hands. 0.5% chlorine solution

6. Remove by turning inside out and place in leak proof container or

plastic bag.


7. Wash hands thoroughly and dry

8. Complete client records (jadelle) card including drawing position of

rods

REMOVAL OF JADELLE IMPLANT

Jadelle implant is a Long Acting Reversal Contraceptive method of

family planning inserted to last for duration of five (5) years. The implant

may be removed at an time of the menstrual cycle for personal or medical

reasons.

Requirement for Removal of Jadelle implant

1. Local anaesthetic

2. Needle and syringes

3. Puncture prove container

4. Scalpel

5. Two different types of forceps (mosquito and Crile

6. Gauze

7. Antiseptic lotions

8. Gallipot

9. Kidney dishes

10. Adhesive

11. Cotton wool

Procedure

1. Explain procedures to patients

2. Obtain consent

3. Provide privacy

4. Provide lamination


5. Palpate to locate implant

6. Clean skin using forceps and sterile cotton wool soak into antiseptic

control end

7. Wait for effect of aneasthetic

8. Make an incision of about 2 – 4mm with the scalpel below the end or

bottom of the V

9. Crippen the end of the implant at the point when visible incision with

the mosquito artery forceps

10. Remove the implant very gently (this take time more than inserting

the implant may be nicked, cut or broken off during removal).

11. If removal prove difficult, the patient can be ask to return for a second

visit after the incision have healed

12. Repeat same procedure for the 2nd rod

13. If patient wishes to continue with a new set of implant may be

inserted using the same incision or use of opposite direction or hand

14. Tidy the equipment

3.5 INSERTION AND REMOVAL OF IMPLANON

It is a single thin, flexible and long-acting reversible contraceptive implant. It

is about the size of a match stick and approved for 3 years of continuous

use. It acts by preventing ovulation and thickening of cervical mucus to

block the sperm.

Requirements

1. Examination couch

2. Sterile surgical drapes

3. Sterile gloves

4. Antiseptic solution


5. Sterile marker (optional)

6. Local anaesthetic (1% Lignocaine eprephine free)

7. Sterile gauze

8. Adhesive bandage

9. Applicator with the following parts:

(a) Needle shield

(b) Applicator seal

(c) Needle

(d) Cannula

(e) Obturator support

(f) Obturator

(g) Pregnancy test strip

Prior to Insertion

Prior to insertion, carefully read the instruction for insertion and removal as

well as the full prescribing information.

NOTE:

1. Proper implanon insertion facilitaes removal

2. Correct timing of insertion is important

3. Take history and perform physical examination including a

gynaecological examination before implanon insertion

4. Ensure that the patient understands the risks and benefits of

implanon before insertion

5. Provide the patients with a copy of the patient labeling included in

package

6. Have the patient review and complete a consent form

7. Exclude pregnancy before insertion


Checklist for the implanon Insertion. Getting Reading

1. Check to be sure client has thoroughly washed and rinsed her entire

non-domination arm

2. Tell client what is going t be done and encourage her to ask

questions

3. Position woman’s arm and place clean, dry cloth under her arm

4. Mark position on arm for insertion of rod 6cm to 8cm above the target

insertion point

5. Determine that required sterile or high level disinfected instrument

implanon trocar with one rod is present.

Pre- Insertion Tasks

1. Wash hands thoroughly and dry with clean personalized towel or air

dry

2. Put on sterile gloves on both hands (if powered, remove powder from

gloves fingers)

3. Prepare insertion site in a radial manner with antiseptic solution

4. Place sterile or high level disinfectant drape with a central hole over

arm (optional)

Insertion Tasks

1. Draws 2cc of local anaesthetic (1% lignocaine without epinephrine

and/or adrenaline) and inject just under skin to raise a small wheal

2. Advance needle towards the second marked point (4cm) and inject

about 1ml of local anaesthetic in one sub-dermal track

3. Place used needles and sharps in container

4. Wait for 2 minutes and then check for anaesthetic effect before

marking and then check for anasethetic


5. Remove the sterile disposable applicator carrying implanon from

buster pack

6. While keeping the shield on the needle, visually verify the presence of

the implants is not seen. Tap the top of the needle shield against a

firm surface to bring the implant into the needle

7. Following the visual conformation of the presence of the implant, the

implant is lowered back into the needle

8. Remove the plastic needle shield

9. Stretch the skin around the insertion site with thumb and index finger

10. Insert the tip of the needle at about 200 angle

11. Release the skin

12. Lower the applicator to a horizontal position

13. Lift the skin with the tip of the needle, keeping the needle in the sub-

dermal connective tissue

14. While lifting the skin, gently inserts the entire needle in the direction

of the 2nd marked point keep the applicator paralle to the skin

15. Break the seal of the applicator

16. Turn the rounded end of the obturator a quarter turn, about 900

17. Hold the abturator against the client arm with one hand and with the

other hand, slowly draw the needle out of the arm, never pushing

against the obturator

18. Check the needle to make sure the implant is absent,, after retraction

of the cannula, the grooved tip of the obturator should be visible

19. Verify the presence of the implant by palpating the skin. Check to

make sure that the lower end of the implant is at least 5cm from the

insertion point


20. Check the insertion site of bleeding (if bleeding put pressure with

gauze)

21. Apply a sterile gauze to insertion point and hold in place with surgical

tape

22. Wrap the arm with pressure bandage

Post Insertion Tasks

1. Before removing gloves, disposed of the applicator, needles, syringe

in a sharp box and any used instrument (Gallipot, bowl, kidney dish

etc) in 0.5% chlorine solution for 10minutes

2. Dispose other waste materials e.g cotton wool, gauze, etc. by placing

in a leak proof containers or plastic bag.

3. Immerse both gloved hands in 0.5% chlorine solution, Remove

gloves, by turning inside, out and place in a leak- proof container of

plastic bag

4. Wash hands thoroughly and dry

5. Fill out the implanon user and give it to the client

6. Complete client record including noting in which arm the implanon

was inserted.

REMOVAL OF IMPLANON

1. Receiver with swabs

2. A cured mosquito artery forceps

3. Surgical blade

4. Lignocaine

5. Syringe and needle

6. Antiseptic lotion e.g Savlon


7. Sterile dressing

8. Adhesive

9. Sterile gloves

Procedure

1. Welcome client and make her comfortable

2. Explain the procedure to the client

3. Help her to adopt a comfortable position

4. Put on sterile gloces after washing and drying hands

5. Clean the point of insertion with antiseptic lotion using sterile swabs

6. Using your sterile hands, gentle push the implanon towards the

incision until the tip is visible

7. Then grasp the implant with forceps (curve mosquito artery forceps)

and pull it out gently

8. If it encapsulated, make an incision using a sterile with 1mI lignocaine

into the tissues sheath

9. Then remove the implanon with the forceps

10. Apply pressure on the incision site with sterile swabs

11. Dress the wound with sterile dressings and apply plaster

12. Make the patient comfortable

13. Advice on care of the wound

14. Return your use equipment and dispose the waste as

directed above.


UNIT 6 FAMILY HEALTH RECORDS

CONTENT

1.0 Introduction

2.0 Objectives

3.0 Main Content

3.1 Family Records and Purposes

3.1.1 Purposes

3.1.2 Criteria for Recording in Family Health Records

3.1.3 Types of Family Health Records

3.2 Filing and Storage of Records

4.0 CONCLUSION

5.0 Summary



1.0 INTRODUCTION

In Unit 4 you have learnt about the Family Nursing Intervention which focuses on

assessing the health needs, planning, implementing and evaluating the care. So once

you have done this, you would like to record the case. How do you do it? This is

explained in Unit 5. In this Unit, you will learn about health records; types of health

records which are maintained for family health; what type of information is recorded

and criteria for recording. This would also help you in filing and storing health records.

2.0 OBJECTIVES

In this unit you will learn about family health records and evaluation of family health

service. After going through this unit, you will be able to:


explain what family health record means

list the purposes of maintaining family health records

write up in family health records keeping in mind the criteria for recording identify different family health records maintained in the agency you are working

evaluate the importance of information included in family records for further health care planning

arrange family records as per filing and storage system of records in the agency you are working

decide on the type of records which you wish to maintain for the family under your care.

3.0 MAIN CONTENT

3.1 Family Records and Purposes

Maintenance of family health records is one aspect of the total records system of a

health agency. In most of the agencies the record system comprises a mixture of

prescribed and standard forms often identical to those of other agencies, which can be

designed or modified to meet the needs of particular agency. Use of common forms for

records facilitates inter-agency and inter-unit comparisons and makes reporting of

service data easier. Even if these forms are supplemented or modified still they retain

enough similarity to provide a base for comparison.

Maintenance of family health records and evaluation of the family health service are

complementary to each other. Records are necessary for continuation of delivery of

family health care services and its evaluation. And evaluation of family health services is

necessary to identify now and continuing family health needs.

Family records include information based on factual events, observation results or

measurements taken, like height, weight, body circumference or investigations carried

out like hemoglobin, urine test, stool test and sputum examination depending upon the

problem of the family. These also have records of immunization, nutritional status,

medical prescriptions and curative procedures carried out. Demographic data and

individual personal history is also included in the family folders. We shall now discuss

about purposes of records, criteria for recording in family health records and types of

family health records in the following subsections. Let us begin with purposes.

3.1.1 Purposes

Purposes of family health records are:


1. to serve as guides to nursing care, 2. to provide the practitioner or community health nurse with data that is required

for improvement of family health care, 3. to provide the staff, administrator or governing body with documentation of

services that have been rendered, and 4. to provide data that are essential for programme planning and evaluation. The purposes of documenting family health history, which is an important component of

family health records, are:

1. to provide facts that are necessary for evaluating health situation of the family; it should also describe the nature and impact on health threat. It should describe the health condition and interacting forces within the family in their daily living,

2. to afford an opportunity for mutual exploration of the health situation by the nurse and by the family so that they can explain to each other their concerns, expectations and probable actions,

3. to provide baseline and periodic data from which to estimate the long-term changes, services provided and response of the family to these changes and services.

Family health records should represent a comprehensive, systematically organised data

and information that are essential for nursing care decisions. The community health

nurse must assure adequate records support for her actions. It is the grassroot level

workers who write most of the family history and progress record. You as a community

health nurse and other grassroot level workers have much to gain if these records are

comprehensive, available and relevant to service needs.

Though each agency has its own system of recording, the community health nurse can

find her own ways of adapting family history and progress record to her own practice,

style and informational needs. Her records may be a valuable resource when agency

records are being revised or the system is being reorganised.

The community health nurse may need to build into the records, methods for

incorporating information necessary for case planning and assessing health service

utilization.

3.1.2 Criteria for Recording in Family Health Records

The criteria should reflect both the purpose and process of community health nursing

practice.


1. Record should concentrate on the family and community as focus of care. It should reflect not only the health of the members of the family but also the ways in which the functioning of the family as a unit has an impact on the health of the family as a whole. It should also specify the ways in which family functions within its physical and social environment.

2. Family health cords should serve as guides for comprehensive care. These should include health threats and health behaviours that have significance for family health. For example, an adequately immunized family may have a health threat from emotionally immature and impulsive parents.

3. An apparently healthy family may have poor nutritional habits and poor house keeping practice inviting accidents. It is important that records show the problem as it develops so that the change can be identified.

4. The record should indicate the expected outcomes and also the degree to which outcomes are achieved. This means that the goals of care to a family are also defined in the records.

5. The family health record should have specific actions planned for the family actions actually taken and distribution of responsibility to family and other community resources so that necessary activities are carried out. Action taken should be recorded in such a way that it can be easily located and future planning can be done.

6. The family record should indicate family response to nursing action. 7. Since initial planning and implementation can redefine a problem the record

must show revision in the status of the problem so that further planning can be done accordingly.

8. Record systems should possess sufficient uniformity to make recording, tabulation. and collection easy and to permit inter-unit in-service comparisons and easy reference.

9. Maintenance of records should require minimal amount of time. Unimportant and irrelevant data reading may also require more time and lengthy records may result in errors.

10. Family records should be quickly available to the user. Accessibility is not always easy to achieve. Compiled individual and family records can be made available at a central location for easy reference, only for professional use.

11. Family records require reasonable storage space. As number of individuals are added, the records also increase and require more storage space and facilities.

12. Depending upon the number of years records should be retained, according to agency policies and storage space will be required.

13. Family record system should provide confidentiality of record content. For example, sometimes a mother in the family may not like information about family planning methods she has adopted to be shared with other members of


the family or her neighbourhood women. There should be provision for such confidential information and sometimes official records in the agency do not have provisions for such recording. The community health nurse must find her own ways to incorporate such summarization into her recording so that priority needs can be attended to first.

3.1.3 Types of Family Health Records

Different family health records which are commonly used are grouped in different ways.

These may be grouped according to:

Age of family member for whom records are used such as:

1. Newborn care 2. Road to health card 3. Toddler card 4. Adult card 5. Old age or elderly card 6. Mother-child link card Health care requirement cards as per health conditions and morbidity status

Pregnant women or antenatal card

Intranatal care card or labour record

Person with illness: for example - Tuberculosis record

- Diabetic record

- Hypertension care card

- Malaria record.

Drug addicts or alcoholics record

Any chronic care record

Immunization record. Records used in the

Clinic

Home


Head Office. These records are in the form of

Cards

Folders

File

Charts, etc. Usually for family health services a family folder including different cards is maintained.

This includes socio-demographic information, children health status (including height,

weight, immunization and feeding habits, etc.) maternal records, morbidity records and

observations -of general health status of family and the environment of the family.

These records have individual formats and styles of recording which is prescribed for

each agency. The method of recording is usually a standard one and general instructions

are provided. Examples of records for infant, toddler, antenatal women, immunization

and family planning are shown in Appendices 1 to.3 (which is given at the end of this

block) and, similar kind of record you may find in the agency where you are working.

3.2 Filing and Storage of Records

We have discussed about the purposes, criteria and types of records. Let us discuss how

these records are filed, as given below.

To have quick access to records for efficient use of records, a proper filing system must

be adopted. In a primary health care set up in community health nursing this aspect

needs special attention. Filing will depend upon the type of records. If it is a family

folder, it is filed as per geographical location or as per house number in the area. These

family folders may be filed as per the name of the head of family. If community

members and the health worker is familiar with house numbers, it is as per house

number in the area. In a rural community where a family is known by the name of the

head of the family, the folder is filed as per the name and arranged alphabetically. Since

these records are preserved for a long period of time and needs frequent handling, they

should be kept in the pro; filing space or in a shelf with labels so that a file can be easily

traced when a family member is visiting the health centre or a family visit is to be

planned.

At a health centre, when cards are maintained as per age groups or type of morbidity

conditions, these may be filed under these headings.The record system requires

reasonable space for storage. The proliferation of records as! well as increase in number


of people under care, may create a serious problem or r storage. The period for which

records are maintained is usually the agency's policy; often the period of retention is as

low as five years. A short retention period does save space but it also presents

problems, since community health needs and methods are changing and the period over

which care is provided to the family is likely to be more prolonged.

4.0 CONCLUSION

In order to assemble in one place the comprehensive family information needed by a

community nurse providing general family care, it is necessary to have a record system

that permits quick and easy transfer of information among the care providing team

members. The individual practitioner on the community health team must be able to

assure adequate record support for her own actions. It is mostly the grassroot level

practitioner who writes most of the family history and progress record. It is she who has

most to gain if records are comprehensive, available and relevant to service needs.

Using of family history and progress records is as important as developing and

maintaining them. It is important to find and read the record as a basis for planning and

taking nursing action for the family. Thus the nurse who uses records can value and

monitor her own recording programme.

6.0 TUTOR-MARKED ASSIGNMENT

7.0 REFERENCES/FURTHER READING

NATIONAL OPEN UNIVERSITY OF NIGERIA · 2020. 2. 10. · mons pubis in front to end at perineum....

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