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
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