Handout Maternal Nursing

Maternal Child Nursing

I. Family
A group of two or more persons who lives together in the same household, perform certain interrelated social tasks and share an emotional bond

II. Types:
a. Nuclear
i. Husband, wife, children ii. Provide support and feel affection to family members
b. Cohabitation family
i. Heterosexual couple living together But NOT married ii. Short or long term
c. Extended or Multigenerational family
i. Nuclear family + other family members ii. May experience financial problems since the family’s income must be stretched to accommodate other people
d. Single Parent Family
i. 50-60% of the population ii. Financial issues are a concern iii. Lack of family support for childcare
e. Blended family
i. Two separate families joined as one as a result of marriage ii. Jealousy, friction between members may occur iii. Children may adapt more to the new situation
f. Communal Family
i. Group of people who have chosen to live together who are not necessarily related by blood or marriage. ii. Related by social or religious values
g. Gay or Lesbian Family
h. Foster Family
i. Adoptive Family

Anatomy and Physiology
Female Anatomy
I. External

There are seven openings in the female external genitalia Vagina Anus
Bartholin’s Duct (2)
Urethra
Skene’s Duct (2)

Sexual Maturity Begins at 10 years of age in Girls / 12 years of age in boys Thelarche Adrenarche Menarche

II. Internal Organs
a. Vagina
i. Female organ for copulation ii. Divided into 3 parts: upper, middle, lower iii. pH 4-5 iv. pH from infancy to prepubertal and menopause pH is 7.5
v. Normal bacterial flora cells lactobacilli - Doderlein bacillus and the vaginal epithelial environment vi. Cells contain glycogen vii. Rugae - permits stretching without tearing

b. Uterus
i. Hollow muscular organ ii. Shape
1. non pregnant - pear shaped
2. pregnant - ovoid iii. Weight
1. non pregnant – 50 -60 g
2. pregnant – 1,000g iv. Pregnant/ Involution of uterus: 4th stage of labor - 1000g 2 weeks after delivery - 500g 3 weeks after delivery - 300 g 5-6 weeks after delivery - 50 – 60g
v. Ligaments of the uterus
1. Upper portion - broad and round ligaments
2. Middle portion – cardinal pubocervical and uterosacral ligaments
3. Lower portion – pelvic muscle floor vi. Cervix
1. Narrow neck of the uterus
2. It is lined with columnar epithelium
3. Highly elastic due to its high fibrous and collagenous content

c. Fallopian Tubes
i. Otherwise known as the Oviducts or uterine tubes ii. Parts of the FT (from inside to out) –
In-Is-A-If
1. Interstitium
a. uterine portion
2. Isthmus
a. narrow and straight, site of sterilization
3. Ampulla
a. central portion, site of fertilization
4. Infundibulum or the fimbriae
a. fingerlike projection to the ovaries, longest of which is the fimbriae ovarica, site of Ectopic pregnancy iii. Functions
1. Provide transport for the ovum
2. Provide site for fertilization
3. Nourishes the zygote
d. Ovaries
i. 3 to 4 cm long, 2 to 3 cm wide and 1 to 3 cm thick ii. Almond shape iii. From pubertal dull white to pitted gray organ iv. Held in place by infundibulopelvic ligaments
v. No peritoneal covering – easy spread of malignant cells vi. Source of primary hormones – estrogen and progesterone

III. Bony Pelvis
a. Support and protect the pelvic contents
b. Made up of 4 bone
i. Innominate bones ii. Sacrum iii. Coccyx
c. Lined with fibro cartilages and held together by ligaments

IV. Muscular floor of the bony pelvis
a. Provides stability and support for surrounding structures
b. Levator ani muscle makes up most of the major portion of the floor and comprises by:
i. Iliococcygeus ii. PuboCoccygeous iii. Puborectalis iv. Pubovaginalis

V. Pelvic Types
a. Gynecoid
i. Normal female pelvis. Transversely rounded or blunt, most favorable for vaginal birth
b. Android
i. Oval shape. Adequate outlet, with a normal or moderately narrow pubic arch
c. Anthropoid
i. Wedge shaped or angulated, usually seen in males, not a favorable for vaginal birth
d. Platypelloid
i. Flat with an oval inlet. Wide transverse diameter but short AP dm, making the inlet inadequate

VI. Physiology of Menstruation
a. Average menstrual cycle
i. 28 to 30 days
b. Average blood loss
i. 30 to 80 mean of 50 cc
c. Duration
i. 4 – 6 days
d. Menarche
i. 1st menses
e. Dysmenorrhea
i. painful menses
f. Amenorrhea
i. absence of menses for 3 months
g. Menometrorrhagia
i. prolonged uterine bleeding at irregular intervals
h. Menorrhagia
i. prolonged menses at regular intervals (hypermenorrhea)
i. Metrorrhagia
i. irregular but frequent menses
j. Polymenorrhea
i. regular intervals of less than 21 days
k. Menopause – cessation of menstruation within 12 months
i. Mean age 45- 55 ii. Premature menopause may occur before age 45
l. Perimenopause or the Climacterium - gradual decline of ovarian functions
i. May occur 8 – 10 years before menopause

Phases of Menstruation
Ischemic phase
Mentrual Phase
Proliferative Phase
Secretory Phase

VII. Breast
a. Each breast is composed of glandular, fibrous and adipose tissues
b. Contains 15 – 20 lobes clustered acini cells
c. Cooper’s ligament support the breast
d. Montgomery’s tubercle - sebaceous glands
1. Produce sebum
2. Lubricates the areola and nipple

Male Reproductive System
I. External
a. Penis
i. Elongated cylindrical structure ii. Body and shaft iii. Composed of
1. 2 corpora cavernosa
2. central bulbous spongiosa iv. Erection is secondary to parasympathetic stimulation
b. Scrotum
i. Pouch like structure hanging in front of the anus ii. Composed of the skin and the Dartos muscle iii. Highly pigmented and with scattered hairs iv. Contains 2 compartments
v. Less than 2C than the body temp

II. Internal
a. Gonads –
i. Testicles
b. Ducts –
i. epididymis, ii. vas deferens iii. ejaculatory ducts iv. urethra and other accessory glands
III. Sperm
a. Head made up of acrosomes and nucleus, carries the haploid chromosome of the male, enters the ovum during fertilization
b. Tail or flagellum is for motility

Male/Female Homologues
Male Female
Penis Clitoris
Testes Ovaries
Prostate Gland Skene’s Gland
Cowper’s GlandBartholin’s Gland ScrotumLabia Majora
Stages of Sexual Response
Excitement Phase
Erotic stimuli cause increase sexual tension, lasts minutes to hours.
Plateau Phase
Nearing orgasm. Lasts 30 seconds – 3 minutes
Orgasm
May last 2 – 10 sec
Most affected are is pelvic area.
Resolution
V/S return to normal, genitals return to pre-excitement phase
Refractory Period The only period present in males, wherein he cannot be restimulated for about 10-15 minutes

Fertilization - Union of the sperm and ova
I. Ovum – from ovulation to fertilization
II. Zygote – from fertilization to implantation
III. Blastocyst – 32 cell stage zygote
IV. Embryo – from implantation to end of 7 wks
V. Fetus – from 8 weeks until term
VI. Conceptus – developing embryo or fetus and placental structures throughout pregnancy

Signs of Implantation Hartman’s Sign – vaginal bleeding on implantation
Process of Implantation Apposition Adhesion Invasion
Decidua – Endometrium of Pregnancy
Decidua basalis
Part under the embryo, communicates with maternal blood vessels
Decidua capsularis
Encapsulates the surface of the trophoblast
Decidua Vera Remaining portion
Trophoblast
o has finger like projections o serves to attach the Blastocyst in the walls of the endometrium o It also has a role in nutrition of the forming cells and maintenance of pregnancy o 2 layers;
• Amnion - Funis
• Chorion - secundines
Chorionic villi o trophoblastic layer of the Blastocyst forming miniature villi at 11 – 12th day o with the following areas
Central Core – contains fetal capillaries
Outer covering has 2 layers:
Syncytiotrophoblast (hCG, HPL, E and P), Cytotrophoblast (protects from viral infection, disappears at 20 – 24th week)

Embryonic Germ Layers
Ectoderm Mesoderm Endoderm
CNS (brain/spinal cord) peripheral nervous system skin, hair, nails sebaceous glands sense organs mucous membranes of the anus, mouth, nose tooth enamel mammary glands supporting structures
(bones, muscle, tendons) dentin of teeth kidneys & ureters reproductive system heart, circulatory system lymph vessels lining of pericardial, pleural, peritoneal cavities lining of GIT, Respiratory Tract, tonsils, parathyroid, thyroid, thymus lower GUT (bladder, urethra)

Fetal Developmental Milestones

End of 4th week Presence of rudimentary heart, central nervous system development
End of 8th week End of organogenesis; external genitalia present but not discernible
End of 12th week Heart beat audible by Doppler
End of 16th week Heart beat audible by stethoscope, lanugo present,
End of 20th week Quickening, vernix caseosa forming,
End of 24th week Start of fetal viability, passive antibody transfer from mother to fetus
End of 28th week Surfactant demonstrable in the AF
Testis descend into the scrotal sac
End of 32nd week Delivery position is assumed
End of 36th week Amount of lanugo diminish, sole of the foot with creases
End of 40th weeks Vernix caseosa well form, term pregnancy

Pregnancy Divided into trimesters 1st – missed period to 12 weeks 2nd – 13th – 24th weeks 3rd – 25th weeks – onwards 266 days – 294 days 38 weeks – 42 weeks average of 40 weeks 9 calendar months and 10 lunar months Start of the period of viability – 24 weeks Estimate the date of confinement: Naegelle’s Rule - +7 days (-) 3 months from the LMP Example: LMP: December 15, 2006 12 15 2006 - 3 + 7 9 22 2007 Mc Donald’s Rule Fundic height is equal to weeks of gestation from 20-32 weeks 20 cm = 20 weeks 32 cm = 32 weeks Bartholomew’s Rule
To determine age of gestation bydividing the abdomen from the symphysis pubis to the xyphoid process into area of fourths

3 months – ½ from umbilicus to symphysis pubis 4 months – ¾ from umbilicus to symphysis pubis 5 months – level of umbilicus 6 months – ¼ from umbilicus to xyphoid 7 months – ½ from umbilicus to xyphoid 8 months – ¾ from the umbilicus to xyphoid 9 months – just the xyphoid process 10 months – level of 8 months due to lightening

Signs of Pregnancy
Probable Presumptive Positive
Breast changes
Nausea, vomiting
Amenorrhea
Frequent urination
Fatigue
Uterine enlargement
Quickening
Linea nigra
Melasma
Striae gravidarum Serum laboratory tests, (+) hCG
Chadwick’s sign – bluish discoloration of vagina and cervix
Goodell’s sign – softening of the cervix
Hegar’s sign – softening of the lower uterine segment
Ballottement – fetus noted to bounce or rise against the examining hand
Braxton-Hick’s sign – irregular painless contractions of the uterus, false labor Sonographic evidence of fetal outline

Fetal heart audible

Fetal movement felt by examiner

Pre Natal Check Up Missed period to 32 weeks - 1 each month 33 – 36 weeks – every 2 weeks 36 weeks onwards – weeks Iron Supplementation – begins at 20 weeks to 2 months postpartum 100 – 200 mg OD for 210 days Antimalarial drugs – Chloroquine 150 mg 2 tabs every 7 days in Malarial infested areas Goiter – may add iodized salt in the diet Laboratory Examinations: Coombs Test – in Rh negative mother at 28 wks AOG
Group B Streptococcus test – rectal and vaginal swab
TORCH test Toxoplasmosis – if mother takes care of cats
Others – Hepatitis A, B Syphilis – Screen with VDRL in the first Prenatal check up, repeat at 36th wks in Patients with multiple sexual partners
Rubella – German measles – Titer 1:8, suggest immunity
12 cpm
3. U.O. > 30 cc/h
VI. Iron Deficiency Anemia
a. Low red cell count due to malnutrition and chronic blood loss may be underlying condition
b. May or may not be exacerbated by physiologic hemodilution of pregnancy
c. Most common medical disorder of pregnancy
d. Client is pale, tired, short of breath, dizzy
e. Hemoglobin is lower than 11 gms/dl
f. Nursing care
i. Instruct client to take the prenatal multivitamins, ii. Monitor patient’s CBC, vital signs iii. Assess dietary habits iv. Evaluating for signs and symptoms of decreased perfusion to vital organs

VII. Multiple Pregnancy
a. Gestation involving more than one fetus
b. Can be monozygotic (single ova) or dizygotic ( multiple ova)
c. Client may experience increased fatigue and backache
d. Can put the client at risk for developing many complications of pregnancy like preterm labor, Premature Rupture Of Membranes (PROM) And Intrauterine Growth Retardation (IUGR)
e. During delivery there should be one nurse to one neonate
f. Nursing Care
i. Close follow up of the client ii. Encourage rest and put the client on left lying position iii. Assess FHT and FH every visit iv. Explain danger signs and symptoms and report them immediately

VIII. Premature Rupture of Membranes (PROM)
a. Spontaneous break or tear in the amniotic sac before the onset of regular contractions
b. Maternal complications include amnionitis, endometritis, and septic shock
c. Fetal complications include asphyxia, pulmonary hypoplasia, malpresentation and cord prolapse
d. Predisposing factors include lack of proper prenatal care, poor nutrition and hygiene, maternal smoking and incompetent cervix
e. Diagnosis is confirmed by the following
i. Nitrazine paper test – blue stained bodies present fetal epithelial cell, orange stain may conclude urine or other discharges ii. Ferning test – a smear of the fluid placed on the slide allowed to dry or heat under denature alcohol. If with Ferning pattern this indicates amniotic fluid
f. Nursing Care:
i. Provide sterile gloves and sterile lubricating jelly during examination ii. Reassure the client iii. Perineal prep before and after the examination iv. Watch for signs and symptoms of maternal infection
v. Anticipate giving of antimicrobial to the patient
IX. IsoImmunization
a. AKA Rh Incompatibility
b. Mother is Rh negative, fetus is Rh positive
c. Nulliparous woman doesn’t exhibit any signs of the disorder. Subsequent pregnancies and fetus are affected though
d. First prenatal check up, anti D antibody titer should be determined. A titer of 1:16 indicates Rh sensitization
e. Treatment focuses on prevention, hence may give RhoGAM as soon as possible after the birth of a Rh positive neonate
f. Nursing care
i. Assess the client for possible Rh incompatibility ii. Administer RhoGAM to Rh negative woman at 28 weeks as ordered iii. Prepared the woman for planned delivery iv. May also give RhoGAM within 72 hrs after delivery, spontaneous abortion to prevent complications in subsequent pregnancies
X. Premature labor
a. Uterine contractions that produces cervical changes after period of fetal viability before fetal maturity
b. Causes include PIH, PROM, multiple pregnancy, Placenta previa, abruption placenta, trauma
c. History of uterine contractions
d. Treatment include suppression of the contraction
e. May also give corticosteroid to enhance lung maturity
f. Nursing Care
i. Closely observe client ii. Maintain on bed rest iii. Ensure adequate hydration iv. Observe fetal responses through fetal monitoring

INTRAPARTUM COMPLICATIONS
I. Malpresentation
a. Breech presentation
i. Types
1. Frank breech
2. Footling Breech
3. Complete Breech ii. Risk
1. cord prolapse
2. traumatic injury
3. Spinal fracture
4. PROM
5. Meconium aspiration
II. Ineffective uterine force
a. Hypertonic uterine contractions
i. Intensity of uterine contractions are severe but ineffective to dilate the cervix ii. Painful but not observed in the electronic fetal monitor iii. Promote rest and analgesia
b. Hypotonic uterine contractions
i. Frequency of uterine contractions are low increasing the hours of labor ii. Leads to ineffective contraction increasing postpartum hemorrhage complications iii. Lack of labor progression iv. May augment labor with Oxytocin administration
c. Uncoordinated Contractions
i. Contractions occurring erratically ii. Treated by Oxytocin administration
III. Umbilical Cord prolapse
a. A loop of cord slips down in front of the presenting part
b. May lead to immediate cord compression
c. Management is aimed towards alleviating pressure on the cord
d. Nursing Care
i. Anticipate cesarean delivery ii. Place the client in knee chest or Trendelenburg position iii. Cover the exposed cord with sterile wet os
IV. Amniotic Fluid Embolism
a. Amniotic fluid is forced into the open maternal blood sinuses after membranes ruptured or placental separation
b. Risk factors
i. Oxytocin administration ii. Abruptio placenta iii. Polyhydramnios
c. Patient sits up and grasp her chest suddenly indicating air hunger
d. Can not be prevented since it can not be predicted
e. Prognosis is poor
f. Quick emergency resuscitation should be given POSTPARTUM COMPLICATIONS
I. Postpartum hemorrhage
a. Any blood loss from the uterus exceeding 500 ml in NSD and 1000 Ml in operative delivery
b. Can be caused by uterine atony, perineal lacerations retained placenta and disseminated intravascular coagulation (DIC)
c. Uterine atony or relaxation is the usual culprit in early postpartum period
i. There is doughy boggy uterus ii. Uterus is not contracted
d. Lacerations may result in profuse bleeding and usually occurs immediately after delivery of the placenta
i. Uterus is firm but bleeding persist
e. Retained placenta can be partial or complete
i. Bleeding is slow trickle of blood, oozing or frank hemorrhage
f. Nursing care
i. Assess the uterine fundus ii. Initiate uterine massage to increase uterine tone and contractility iii. Weigh perineal pads
1. 1 gm of weight is = 1 ml of fluid iv. Turn patient to her side and inspect buttocks for pooling of blood
v. Assess VS to include urine output
II. Puerperal Infection
a. Can be due to Group A, B hemolytic streptococcus, Chlamydia and other coagulase negative staphylococci
b. Fever occurs at day 1-10 postpartum except the first 24h and last for 2 consecutive days
i. Assess the client’s episiotomy site
Redness
Erythema and echymosis
Edema
Drainage or discharge
Approximation of wound edges
c. Diagnosis can be confirmed by Blood culture and sensitivity
d. Treatment includes antimicrobial treatment, pain management, isolation of the client
e. Supportive care includes bed rest, hydration and reduction of fever
f. Nursing care
i. Monitor VS ii. Place client in high Fowler’s or semi fowlers position for drainage iii. Strictly CBR iv. High caloric, high protein diet
v. Encourage client to void frequently
III. Mastitis
a. Inflammation of the breast tissue disrupting lactation
b. Infection usually comes from the neonate’s mouth and nares
i. Staphylococcus aureus ii. Group B hemolytic streptococcus
c. Begin 7 to 28 days postpartum, with high grade fever
d. Should be differentiated with breast engorgement which typically occurring 2-5 days after initiation of lactation
e. Treatment includes antimicrobial therapy
f. Nursing Care
i. Infection control with proper hand washing and universal precaution ii. Assess and record the cause and amount of discomfort iii. May continue with lactation with the following
1. offer the affected breast first to promote complete emptying and prevention of milk stasis
2. if there is abscess formation, may use breast pump BUT DISCARD breast milk
3. continue to breastfeed on the Unaffected side
4. wear supportive bra
5. empty the breast as completely as possible iv. ensure adequate hydration
IV. Uterine Rupture
a. Usually occurs when the uterus undergoes more strain than it can sustain
b. Can be caused by
i. Prolonged labor ii. Malpresentation iii. Multiple gestation iv. Use of oxytocin
v. Obstructed labor vi. Traumatic maneuvers
c. Presence of Pathologic Retraction Ring
i. Bandl’s Ring – seen at the junction of upper and lower uterine segment ii. Constriction Ring – can occur at any point of the myometrium
d. Signs and symptoms
i. Severe abdominal pain ii. Halt in contractions iii. Absent FHT iv. Possible vaginal bleeding
v. Hypotension vi. Thready pulses
e. Nursing Care
i. Hydration ASAP! ii. Prepare the client for possible laparotomy followed by hysterectomy
V. Uterine Inversion
a. Rare phenomenon
b. Uterus turns inside out
c. Can be due to
i. Excessive cord traction ii. Excessive fundal pressure
d. Diagnoses
i. Large sudden gush of blood from the vagina ii. Inability to palpate the fundus in the abdomen iii. Hypotension, dizziness, diaphoresis iv. Signs of shock
e. Nursing Care
i. Never attempt to replace the inversion without anesthesia - it may cause severe bleeding ii. Be ready for possible blood transfusion iii. Oxytocin is administered after manual replacement of the uterus iv. Antibiotic therapy

FAMILY PLANNING
I. Ensures planned and wanted pregnancies thus assuring the love and care of the family
II. Three Methods
a. Natural family Planning or Fertility awareness method
i. Rely on periods of temporary abstinence and requires an understanding of the changes that occur in a woman’s Ovulatory cycle
1. Calendar Method
a. Requires a couple to abstain from coitus on the days of a menstrual cycle when the woman is most apt to conceive
b. 3- 4 days before and after ovulation
c. In menstrual cycle more than 30 days monitor the menstrual cycle for 6 months and subtract 18 – shortest = first fertile day and 11 – longest = last fertile day
2. Basal Body temperature
a. A woman’s basal body temperature falls about one degree on ovulation because of progesterone
3. Symtothermal/Cervical Mucus
a. Use the changes in cervical mucus that occur naturally with ovulation
b. Just before ovulation (peak day)
i. Mucus becomes thin, watery, transparent, feels slippery, stretches at least one inch before the strand breaks
b. Artificial Method
i. Oral Contraceptive Pills
1. Use of Combination Oral Contraceptives (COC’s) or Progestin only pills
2. Side effects include
a. nausea
b. Monilial vaginal infection
c. Weight gain
d. headache
e. Breast tenderness
f. Break through bleaching
g. Mild hypertension and depression
3. Contraindication
a. History of CVA
b. Woman who smoke
c. > 35 y/o
d. obese
e. High serum level of liver enzymes
f. High blood pressure
g. Deep vein Thrombosis
4. Discontinue with the presence of:
A – abdominal pain
C – chest pain
H - headache
E – eye problems
S – Severe leg cramps

ii. Intrauterine Devices
1. Small plastic object inserted into the uterus through the vagina where it remains in place
2. insertion should be done on Day 7 -9 of the menstrual cycle
3. contraindicated in patient’s with Wilson’s disease (inability to metabolize copper), clients with active, recent or recurrent PID
4. increase the risk for Ectopic pregnancy
5. Health teaching includes checking of the string every month, advice the client to submit for pap smear every year and early treatment of vaginal and cervical infection iii. Barrier method
1. Includes condoms, diaphragm, female condom and cervical cap
2. Inexpensive and doesn’t require a visit to the health worker
3. It should be inserted 15 min to 1h prior to coitus thus it may embarrass the client and it is messy
4. health teaching should include hygiene and checking of holes in the condom before use
c. Surgical Method
i. Vasectomy
1. Vas deferens is cut and tied
2. Out patient procedure and 99% effective
3. testes continue to produce sperm but can’t pass the vas deferens
4. advice client that additional form of contraception should be used until two negative sperm count report have been obtained ii. Tubal Ligation
1. it is a mini laparotomy incision
2. performed after menses and before ovulation or after a delivery or an abortion, 99.6% effective
3. tubes are ligated cut and severed
4. it should be viewed as irreversible though reversal is successful in around 70% of cases but it is a difficult process and may cause Ectopic pregnancy

References:
1. Adelle Pilliteri, Maternal & Child Health, care of the Childbearing and ChildRearing Family, 5th Ed, Lippincott, Williams & Wilkins, Vol 1 & 2
2. Cunningham et al, Williams Obstetrics, 21st Edition, Lippincott, Williams & Wilkins 2004
3. Ladewig,London, Davidson, A Look At Contemporary Maternal-Newborn Nursing Care, 6th Edition, Pearson Education South Asia PTE Ltd
4. Baja-Panlilio et al, Textbook of Obstettrics (Physiologic & Pathologic) 2nd Edition, APMC Philippines
5. Aurilio, L, Chatham C, et al Maternal-Neonatal Nursing Made Easy, Lippincott, Williams & Wilkins, 2003

References: 1. Adelle Pilliteri, Maternal & Child Health, care of the Childbearing and ChildRearing Family, 5th Ed, Lippincott, Williams & Wilkins, Vol 1 & 2 2. Cunningham et al, Williams Obstetrics, 21st Edition, Lippincott, Williams & Wilkins 2004 3. Ladewig,London, Davidson, A Look At Contemporary Maternal-Newborn Nursing Care, 6th Edition, Pearson Education South Asia PTE Ltd 4. Baja-Panlilio et al, Textbook of Obstettrics (Physiologic & Pathologic) 2nd Edition, APMC Philippines 5. Aurilio, L, Chatham C, et al Maternal-Neonatal Nursing Made Easy, Lippincott, Williams & Wilkins, 2003