MATERNAL AND CHILD NURSING

Prepared by: Ma. Reina Rose D. Gulmatico, RN, MSN

I. FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY A. External Reproductive Organs

Mons Pubis (Mons Veneris) – (Mount of Venus) is a pad of fat lying over the symphysis pubis; covered with pubic hair from the time of puberty

Labia Majora (Greater lips) – are two folds of fat and areolar tissue, covered with skin and pubic hair on the outer surface; arise in the mons veneris and merge into the perineum behind.

Labia Minora (Lesser lips) - two folds of the skin between the labia majora; anteriorly, they divide to enclose the clitoris; posteriorly they fuse, forming the fourchette

Clitoris - rudimentary organ corresponding to the male penis; extremely sensitive and highly vascular and plays a part in the orgasm of sexual intercourse

Vestibule - area enclosed by the labia minora in which encloses the openings of the urethra and the vagina

Vaginal orifice- also known as the introitus of the vagina and occupies the posterior two-thirds of the vestibule; partially closed by the hymen, a thin membrane that tears during sexual intercourse or during birth of the first child

Skene’s Glands- either side of the meatus which are often involved in infections of external genitalia

Bartholins Glands - are two small glands which open on either side of the vaginal orifice and lie on the posterior part of the labia majora. They secrete mucus which lubricates the vaginal opening.

B. Internal Reproductive OrgansTHE VAGINA Structure: vaginal walls are pink in appearance and thrown into small folds called the rugae that stretches during intercourse and delivery.

Functions: a passage that allows the escape of the menstrual flowreceives the penis and the ejected sperm during sexual intercourse and provides an exit for the fetus

during delivery

THE UTERUSStructure

hollow, muscular, pear-shaped organ situated in the true pelvis

the cervix forms the lower third of the uterus

Functionsto shelter the fetus during pregnancy and following pregnancy it expels the uterine

contents Parts of the UterusBody or corpus – makes up the upper two-thirds of the uterus and is the greater part

Fundus – domed upper wall between the insertions of the uterine tubes

Cornua – are the upper outer angles of the uterus where the uterine tubes join

Cavity – potential space between the anterior and posterior walls

Isthmus – narrow area between the cavity and the cervix that enlarges during pregnancy to form the lower uterine segment

Cervix or Neck – protrudes into the vagina; supravaginal (upper half)- above the vaginainfravaginal portion (lower half)

Layers of the UterusEndometrium - forms a lining of ciliated ephitelium (mucus membrane) on a base of connective

tissue (stroma) Myometrium (muscle coat)- thick in the upper part of the uterus and is more sparse in the isthmus

an cervix.  Perimetrium  

D. UTERINE TUBES

Functions The uterine tubes propels the ovum towards the uterus, receives the

spermatozoa as they travel upwards and provides a site for fertilization. It supplies the fertilized ovum with the nutrition during its continued journey to the uterus.

Structure Each tube is 10 cm long. The lumen of the tube provides an open pathway from

the outside to the peritoneal cavity. The uterine tube has four portions:

a) The interstitial portion – is 1.25 cm long and lies within the wall of the uterus. It’s lumen is 1 mm wide.

b) The isthmus – is another narrow part which extends from 2.5 cm from the uterus.c) The ampulla – is the wider portion where fertilization usually occurs.d) The infundibulum – is the funnel shaped fringed end which is composed of many

processes known as fimbriae. One fimbriae is elongated to form the ovarian fimbria which is attached to the ovary.

E. THE OVARIES

Functions The ovaries produce ova and the hormones estrogen and progesterone.

Structure The ovary is composed of the medulla and cortex, covered with germinal

epithelium.

F. THE FEMALE PELVIS

Functions The primary function of the pelvic girdle is to allow movement of the body

especially walking and running. It permits the body to sit and kneel. The woman’s pelvis is adapted to child-bearing, and because of its increased

width and rounded brim, women are less speedy than men. The female pelvis, because of its characteristics, gives rise to no difficulties

during in childbirth, provided that the fetus is of normal size.

Pelvic Bones There are four pelvic bones:

1. two innominate (nameless) or hip bones – each innominate bone is composed of three bones:

The ilium The ischium The pubic bone

2. one sacrum

3. one coccyx

False Pelvissuperior half formed by the ilia; offers landmarks for pelvic measurements; supports the

growing uterus during pregnancy; directs the fetus into the true pelvis near the end of gestation

True Pelvis- is the bony canal through which the fetus must pass during birth. It has a brim, a cavity and an outlet.

inferior half formed by the pubes in front, the ilia and the ischia on the sides and the sacrum and coccyx behind

1. Inlet entranceway to the true pelvis; transverse diameter is wider than its anteroposterior (AP)

diameter

* Transverse diameter – 13.5 cm.* Anteroposterior (AP) diameter – 11 cm.

2. Outlet inferior portion/ lower border of the true pelvis of the pelvis

anteroposterior diameter is wider than its transverse diameter

3. Cavity space between the inlet and the outlet

contains the bladder and the rectum, with the uterus between them in an ANTEFLEXED position towards the bladder

Variation/Types of Pelvis1. Gynecoid – “normal” female pelvis that is most ideal for childbirth because it is well rounded forward and back2. Anthropoid – transverse diameter is narrow, AP diameter is larger than normal3. Platypelloid – inlet is oval, AP diameter is shallow4. Android – “male” pelvis; inlet has a narrow shallow posterior portion and pointed anterior portion.

MENSTRUAL CYCLE

A. KEY CONCEPTS1. Hormones

•Estrogen•Progesterone•Follicle Stimulating Hormone (FSH)•Luteinizing Hormone (LH)

2. Associated Terms• Amenorrhea• Menorrhagia • Metrorrhagia • Polymenorrhea • Oligomenorrhea

 

 

 

STAGES OF FETAL DEVELOPMENT

I. FERTILIZATIONSite: fallopian tubemature ovum + sperm = (zygote)Gamete: sex cell

contains 23 chromosomes Sperm: contains X and Y chromosomes (XY) Ovum: contains X chromosomes (XX)

II. Implantationoccurs 7 days post fertilization

Fertilized zygote migrates 3-4 days (uterus)

morulla mitosis

multiplication and floating in the uterine cavity (3 - 4 days)

+

mass oflarge cells

(fluid space)

Blastocysts Apposition a. Trophoblast A. Adhesion b. Erythroblast (endometrium)

B. Invasion

Post implantation: uterine endothelium DECIDUA

Blastocystsa. Trophoblast (outer)- PLACENTAb. Erythroblast (inner)- EMBRYO

TROPHOBLAST

decidua (endometrium) chorionic villi “falling off”

removed after delivery Cytotrophoblast Syncytiotrophoblasta. Basalis (maternal circulation) (inner) (outer)b. Encapsularis (trophobast)c. Vera (remaining portion)

Langhan’s Syncytial

protection for fetal membranes infection

*present until 20th – 24th week

SYNCYTIAL + Decidua basalis

fetal membranes

Amnion Chorion

Umbilical cord Amniotic fluid Placenta

Fetal Development

A. Amniotic fluid1. Protective function

Shields the fetus against blows or pressures on the mother’s abdomenProtects the fetus against sudden changes in temperature Protects the fetus from infection

“Injury, Temperature, Infection”

2. Diagnostic functionAmniocentesis (chromosomal abnormalities)

Meconium-strained amniotic (fetal distress)

3. Aids in the descent of the fetus during active labor

B. Placenta1. Provides oxygen to the fetus2. Provisions of nutrients (diffusion through the placental tissues)3. Feto-placental circulation (osmosis)4. Excretion of waste products5. Production of hormones

HCGHPLEstrogenProgesterone

6. Protective – inhibits the passage of bacteria and large molecules to the fetus

Stages of human prenatal development:First 12-14 days – zygote

From 15th day up to the 8th week – embryo

From the 8th week up to the time of birth – fetus

I. First Lunar montha. Germ layers: differentiate by the 2nd week

1. Endoderm – develops into the lining of the GIT, respiratory tract, tonsils, thyroids, parathyroid, thymus gland, bladder and urethra

2. Mesoderm – forms into the supporting structures of the body (connective tissues, cartilage, bones, muscles and tendons); heart, circulatory system, reproductive

system, kidneys and ureters

3. Ectoderm – responsible for the formation of the nervous system; the skin, hair and nails; and the mucous membrane of the mouth and anus

b. Fetal membranes (amnion and chorion): 2nd week

c. Nervous system: 3rd week

d. Fetal heart begins to form at 16th day of life

II. Second lunar montha. All vital organs are formed: 8th week.b. Placenta developsc. Sex organs (ovaries/testes) are formed: 8th week

Sex determination: conceptionSex formation: 2nd lunar month

d. Meconium formation: 5th-8th week.

III. Third lunar montha. Urine formation: 12th week of pregnancyb. Fetus swallows amniotic fluidc. Feto-placental circulation begins through osmosis: no direct exchange between fetal and maternal

blood

IV. Fourth lunar montha. Lanugo appearsb. Heart beats maybe audible with fetoscope

V. Fifth lunar montha. Vernix caseosa (cheesy covering on entire body to prevent drying of fetal skin) appearsb. Lanugo covers entire body

c. Quickening (fetal movements) is feltd. Fetal heart beats very audible

VI. Sixth lunar montha. Skin markedly wrinkled

b. Attains proportions of full term baby

VII. Seventh lunar montha. Alveoli begin to form

b. Production of surfactant

VIII. Eight lunar montha. Fetus is viableb. Lanugo begins to disappear

IX. Ninth lunar montha. Lanugo and vernix disappearb. Amniotic fluid volume somewhat decreases

X. Tenth lunar month – has all characteristics of a normal newborn.

FETAL CIRCULATION

NURSING CARE DURING LABOR AND DELIVERY

Theories of labor Uterine Stretch theory – any hollow body organ when stretched to capacity

contract and empty

Oxytocin theory – production of oxytocin from posterior pituitary gland uterine contraction

Progesterone Deprivation theory – progesterone inhibits uterine motility Decrease progesterone uterine contraction

Prostaglandin theory: increase prostaglandin synthesis uterine contraction

Theory of Aging Placenta: decrease in blood supply to the placenta uterine contraction

Premonitory/ Preliminary Signs of Labor1. Lightening - the settling of the fetal head into the pelvic brim

*Engagement occurs when the presenting part has descended into the pelvic inlet (station 0)

2. Loss of weight – about 2-3 lbs. 1 to 2 days before labor onset due to decrease progesterone resulting to decrease fluid retention

3. Increased activity level – due to increase in epinephrine level

4. Braxton Hicks contractions- irregular painless, “practice” contractions

5. Ripening of the cervix – Goodell’s sign

6. Rupture of the membranes Important Nursing Considerations:A. Ruptured BOW

*Initial Nursing Action: Put her on the bed immediately, then take the FHT

Instruct the client not to ambulate: FETAL CORD COMPRESSION

B. Cord Prolapse*Initial Nursing Action:

Put her on Trendelenburg position to reduce pressure on the cord.

(REMEMBER: Only 5 minutes of umbilical cord compression can already lead to CNS damage even death.)

Apply a warm saline-saturated OS on the cord to prevent drying of the cord.

7. ShowSudden gush of blood (pinkish vaginal discharge)

*Nursing Implication:Assess for the color of vaginal discharge

GREENISH- meconium stainedBRIGHT RED- vaginal bleeding

SIGNS OF TRUE LABOR

1. Uterine contractions 2. Effacement/ Dilatation

In primis, effacement occurs before dilatation (ED)In multis, dilatation proceeds effacement (DE)

False vs True LaborParameters for comparison:1. Regularity2. Location3. Changes in contractions (FID)4. Absence/ Presence of contractions during activity]5. Cervical changes

FALSE LABOR PAINS TRUE LABOR PAINS

Remain irregular

Generally confined to the abdomen

No increases in duration, frequency and intensity

Often disappears if the woman ambulates

Absent cervical changes

May be slightly irregular at first but predictable within regular and predictable within a matter of hours

First felt in the lower back and sweep around to the abdomen in a girdle-like fashion

Increase in frequency, duration and intensity

Continue no matter what the woman’s level of activity is

Accompanied by cervical effacement and dilatation (the most important difference)

Length of Normal labor:

Primis- 14 hoursMultis- 8 hours

5 P’s of Labor 1. Passenger (Fetus)

2. Passageway (Pelvis)

Shape and measurement of maternal pelvis and distensibility of birth canal

Engagement: fetal presenting part enters true pelvis (inlet)Primi: two weeks before labor Multi: beginning of labor

Soft tissue (cervix, vagina): stretches and dilates under the force of contractions to accommodate the passage of the fetus

3. Power

A. Uterine Contractions (involuntary): fingers should be spread lightly over the fundus 1. Frequency: from the BEGINNING of one contraction to the beginning of the

next contraction (A-C) 2. Interval: from the END of one contraction to the BEGINNING of the next

contraction (B-C)3. Duration: from the BEGINNING of one contraction to the END of the

same contraction (A-B)

4. Intensity: strength of a contraction should be measured during the acme of contraction

a. mild b. moderatec. strong

A B C

B. Voluntary Bearing Down Efforts: use of ABDOMINAL MUSCLES to help expel fetus thru CONTRACTION OF LEVATOR ANI MUSCLES

4. Placenta

5. Psychological response“A positive attitude during labor yields a positive outcome.”

A woman who is: relax, aware and participating in the birth process: shorter, less intense labor

A woman who is: fearful has high levels of adrenaline which slows uterine contractions

STAGES OF LABOR

1 st - Stage of Dilatation 1st - Stage of dilatation: from onset of labor until full dilatation of cervix

Phases:Latent phase: 3-4 cmActive phase: 4-8 cmTransition phase: 8-10 cm

1. Latent PhaseDuration: 6 hours Cervical dilatation: 3-4 cmUterine contractions: every 15-30 minutes; short duration; mild intensityWomen’s Attitude: excited with some degree of apprehension

Support Measures1. Establish rapport2. Breathing exercise3. Encourage ambulation4. Offer ice chips or fluids5. Encourage voiding of the client

2. Active/AcceleratedCervical dilation: 4-8 cmUterine Contractions: every 3-5 minutes; 30-60 seconds

duration; moderate intensityWomen’s Attitude: afraid of losing control of herself

Support Measures1. Encourage breathing exercise2. Provide a quiet environment3. Provide reassurance, encouragement and support4. Provide comfort (back massage, assisting positioning,

support with pillows5. Provide ice chips for dry mouth

Nursing management/ Health Teaching During Stage 11. Ambulation

(+) Ambulation – during the LATENT PHASE

*to shorten the first stage of labor

BUT

(-) Ambulation- RUPTURED BOW

2. Diet

“No food or fluid please!”

On NPOSolid or liquid foods are to be avoided because:

Digestion is delayed during laborA full stomach interferes with proper bearing downMay vomit resulting to ASPIRATION

3. Enema administrationNOT a routine procedure

Purposes:A full bowel hinders the progress of labor Expulsion of feces during second stage of labor- INFECTION of the

mother and babyFull bowel predisposes to postpartum discomfort

Procedure:Enema solution: soapsuds or Fleet enemaOptimal temperature of the solution: 105°F to 115°F (40.5 °C-46.1°C)Patient on side-lying position

NURSING IMPLICATION DURING ENEMA:(+) RESISTANCE during insertion of rectal catheter: withdraw the tube slightly while letting a small amount of solution enter

(+) CONTRACTION: clamp rectal tubing

IMPORTANT NURSING ACTION: Check FHR AFTER enema administration to determine any FETAL DISTRESS

Contraindications:Vaginal bleedingPremature laborAbnormal fetal presentation or positionRuptured membranesCrowning

4. Voiding“Please empty my bladder”

Should void every 2-3 hours

Offer the bedpan if BOW has ruptured because:A full bladder retards fetal descentUrinary stasis can lead to urinary tract infectionA full bladder can be traumatized during delivery

5. Breathing TechniqueDO NOT PUSH OR BEAR DOWN DURING CONTRACTIONS because it leads to: unnecessary exhaustion AND cervical edema (due to repeated strong pounding of the fetus against the pelvic floor); thus interfering with dilatation and prolonging the length of labor

ABDOMINAL BREATHING should be encourage to reduce tension and prevent hyperventilation

“No to pushing, Yes to breathing!”

6. Position“I need to lie on my side!”

Sim’s positionSINCE:

It favors anterior rotation of the fetal headIt promotes relaxation between contractionsIt prevents Supine Hypotensive Syndrome/Vena Cava Syndrome

7. MonitoringContractionsVital Signs (Temperature/ BP)

A. Temperature: sign of infection due to early RUPTURE OF MEMBRANE

B. Blood pressure (q 30 minutes)Should be taken midway/between contractions

BECAUSE

BP INCREASES during contraction

(-) blood going to the uterus(+) blood in the periphery

Danger SignalsSigns of Fetal distressSigns of Maternal Distress

FHT/ FHT VariabilityNORMAL Fetal heart rate: 120/160 BPM

Should be taken midway/between contractions BECAUSE FHT DECREASES during contraction (AS A RESULT vagal stimulation due to fetal head compression by the contracting uterus)

Should not be mistaken for UTERINE SOUFFLÉ which synchronizes maternal heart/pulse rate

Should be taken:every hour - latent phase every half hour - active phaseevery 15 minutes – transition

INITIAL NURSING ACTION FOR ABNORMAL FHT: Change the mother’s position

Acceleration: visually apparent abrupt INCREASE in FHR; increase of 15 beats per minute or greater and lasts 15 seconds or more; with return to baseline less than 2 minutes

a. Periodic: usually encountered with BREECH PRESENTATION

Remember: Pressure of the contraction applied to

A. Fetal buttock- ACCELERATIONB. Fetal head- DECELERATION

b. Episodic: increase FHR during fetal movementNORMAL FINDING

Deceleration: dominance of PARASYMPATHETIC responsedescribed in relation to the ONSET and end of a CONTRACTION and by their SHAPE

a. Early- HEAD COMPRESSIONvisually apparent decrease in an return to baseline FHT

normal and benign finding

Characteristic: uniform shape

early onset due to RISE in INTRAAMNIOTIC PRESSURE as the uterus contracts

occurs during the first stage when cervix is dilated to 4 to 7 cm

COMPARISON BETWEEN ACELERATION AN DECELERATIONPARAMETERS ACCELERATION DECELERATION

DESCRIPTION

SHAPE

ONSET

RECOVERY

COMMON CAUSE

transitory increase of fhr above baseline

resembles shape of uterine contraction

onset to peak : 30 seconds orocurs during contraction

less than 2 minutes

SPONTANEOUS FETAL MOVEMENT

transitory decrease of fhr above baseline

uniform, MIRROR IMAGE OF UTERINE CONTRACTION

early in contraction phase bfore peak

end of uterine contraction

HEAD COMRESSION

b. Late- UTEROPLACENTAL INSUFFICIENCYoccurs after the start of contraction

lowest point of decelertion: after peak does not return to baseline

until after the contraction is over

CAUSE: maternal supine hypotensive syndrome

Effect: fetal hypoxia

c. Variable: UMBILICAL CORD COMPRESSION

decrease is > 15 bpm; lasts at least 15 seconds; returns to baseline in less than 2 minutes from the time of onset

SHAPE: U, V , W

COMPARISON BETWEEN LATE AN VARIABLE DECELERATIONPARAMETERS LATE

DECELERATIONVARIABLE

DECELERATIONDESCRIPTION

SHAPE

ONSET

RECOVERY

COMMON CAUSE

GRADUAL decrease

uniForm, MIRROR IMAGE OF UTERINE CONTRACTION

Late in contraction; after peak of contraction

After end of contractionless than 2 minutes

Uteroplacental Insufficiency

ABRUPT decrease

U, V, W

Beginning of the depth < 30 sec; duration of ≥ 15 sec; decrease in FHR is ≥ 1 BPM

< 2 minutes from onset

Umbilical Cord Compression

8. Administration of Analgesics (Demerol)Drug of choice: DEMEROLIndication: analgesic, sedative and antispasmodic (CNS DEPRESSION)

IMPLICATION TO NURSING CARE:Do not give

A. early in labor: Retards progress of uterine contractions

B. if delivery is only an hour away : Respiratory depression in the newborn occurs

Give if cervical dilatation is already 6-8 cm

9. Administration of AnestheticsAnesthetic of choice: Xylocaine

NURSING CONSIDERATION:On NPO with IV to prevent aspiration and dehydration

Types of anesthesia:A. Paracervical – transvaginal injection into either side of the cervix

B. Pudendal - through the sacrospineous ligament into the posterior areolar tissues

Side effect: (+) ecchymosis to the right of the perineum

Ice bag application to the area on the first day to reduce swelling or bleeding

C. Low spinal1. Epidural (caudal) - local anesthetic injected at the lumbar level 2. Saddle block - injection into the 5th lumbar space

(+) Anesthesia: perineum, upper thighs and lower pelvisPosition: sitting or side-lying position with back aligned

NURSING IMPLICATIONS: TYPE of delivery: Forceps delivery (due to loss of coordination in

second stage pushing)

Adverse effect: POSTSPINAL HEADACHES (due to the leakage of anesthetic into the CSF or injection of air at the time of needle insertion)

Management:Increase fluid intake FLAT ON BED without pillows for the first 12 hrs after

delivery

Common side effects of regional anesthesia1. Hypotension - due to vasodilator effects of xylocaine

Management: Turn to side; prompt elevation of legs; administration of vasopressors as ordered and

oxygen2. Fetal bradycardia3. Decreased maternal respiration

3. TRANSITION PHASE

A. Cervical Dilatation: 8-10 cm

B. Characteristics:1. changes in the mood and intensity of contraction2. rupture of membrane

if (-) ROM: AMNIOTOMY to prevent aspiration of fetus from amniotic fluid

CONSIDERATION:“(-) AMNIOTOMY for STATION (-)”

to prevent cord compression

3. Prominent SHOW

4. Uncontrollable urge to push during contraction

Nursing management: 1. Breathing technique

Controlled chest (costal) breathing during contractions

2. Avoidance of Bearing Down

3. Emotional Support

4. Comfort measures (Sacral pressure)

2 nd - Stage of Expulsion

begins with complete dilatation of the cervix and ends with the delivery of the baby

Mechanisms of Labor /Fetal Position Changes (D FIRE ERE)

DescentFlexionInternal RotationExtensionExternal RotationExpulsion

Nursing management1. PositioningLITHOTOMY

When positioning legs onto the stirrups, put them up at the same time in order to prevent injury to the uterine ligaments

2. Bearing Down technique/ Mc Robert’s maneuverHead crowning: instruct mother NOT TO PUSH, BUT TO PANT (rapid and shallow breathing), so as to prevent rapid expulsion of the baby.

Mc Robert’s Maneuver: To prevent shoulder dystocia (+) delivery of the head BUT (-) delivery of the anterior

shoulder in the pubic arch

Position: woman’s legs are flexed apart with her knees on her abdomen

Mc Robert’s Maneuver

SACRUM straightens SYMPHYSIS PUBIS rotates PELVIC INCLINATION decreased

freeing the shoulder

3. Breathing Technique4. EpisiotomyIndications:

MAIN- TO PREVENT LACERATIONS

Prevent prolonged and severe stretching of muscles supporting the bladder and rectum

Reduce duration of second stage of labor

Enlarge outlet in breech presentations or forceps delivery

Types of episiotomyA. Median – from middle portion of the lower vaginal border directed towards the anus

B. Mediolateral – begun in the midline but directed laterally away from the anus

5. Modified Ritgen’s ManeuverApply PRESSURE AGAINST THE RECTUM using sterile towel; drawing it DOWNWARD to aid in flexing the head as the back of the neck catches under the symphysis pubis

Apply UPWARD pressure from the coccygeal region to extend the head during the actual birth (to protect the musculature of the perineum)

6. Handling of NewbornImmediately after delivery

A. Infant Position: 1. head lower than the rest of the body to allow drainage of

secretions

2. NEWBORN is held below the level of the mother’s vulva for a few seconds to allow placental blood to enter the infant’s body through gravity flow

B. Provide warmth by 1. Wrapping the baby in a sterile diaper to keep him warm.

C. Place the baby on the mother’s abdomen. The weight of the baby will help contract the uterus.

7. Cutting of CordCutting of the cord- until the pulsations have stopped because 50-100 ml. of blood is still flowing from the placenta to the baby at this time

Then, clamp twice, an inch apart and cut between.

8. Initial ContactAfter newborn care,

Show the baby to the mother, inform her of the sex and time of delivery

Encourage the mother to start breastfeeding of the child.

3 rd - Placental Stage

4 th - First 2 hours after delivery