Maternal and Child Nursing

THE FEMALE REPRODUCTIVE SYSTEM

I. External Genitalia
a. Mons pubis
b. Labia majora
 Nulliparous:
 multiparous:
c. Labia minora
d. Clitoris
 Sensitive to touch & temperature
 2 erectile tissue: corpus cavernosa
 Sexual intercourse:
 Clitoral congestion & erection
 Produce cheese-like secretion:
e. Vestibule
a.
b.
c.
d.
e.
II. Internal Genitalia
a. Vagina
 8-12 cm long
 Before puberty
 After puberty
b. Uterus
 Organ of:
 Layers:
 Parts:
 2.5-3 inches long
 2 inches wide
 50-70 gms
 Supporting ligaments:
1. Broad
2. Round
3. Posterior
c. Fallopian Tube
Parts:
 Interstitial
 Isthmus
 Ampulla
 Infundibulum
d. Ovaries
6-19 gms, 1.5-3cm wide, 2-5 cm long

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III. Accessory Structures

a. Mammary glands
S- W- D-
 Parts:
o Acini cells
o Lactiferous duct
o Lactiferous sinus
 Dilated portion behind the nipple
 Reservoir of milk
o Nipples
o Areola
 Montgomery tubercles
 Hormones
o Estrogen
 Stimulates dev’t of the ductile structures of the breast
o Progesterone
 Stimulates the dev’t of acinar structures of the breast
o Human Placental Lactogen
 Promotes breast dev’t during pregnancy
o Prolactin
 Stimulates milk production
 inhibited by estrogen
o Oxytocin
 Let down reflex
 inhibited by progesterone

THE MALE REPRODUCTIVE SYSTEM

I. External Genitalia
a. Penis
b. Scrotum
II. Internal Genitalia
a. Testes
 Descends in the scrotum at 28 week gestation
 4-5 cm long
 Parts
o Seminiferous tubules
 where spermatogenesis takes place
o Leydig’s/ interstitial cells
 Found around the semineferous tubules
o Sertoli cells
b. Epididymis
 Appx 20 feet long
 Passageway for the traveling sperm for 12-20 days

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c. Vas deferens
 Passageway of the sperm from the epdidymis in the testes to the urethra
d. Ejaculatory duct

The Process of Spermatogenesis

Testes


epididymis

Vas Deferens


Seminal Vesicle
(secreted: fructose form of glucose, nutritative value)

Ejaculatory Duct


Prostate Gland


Cowpers Gland


Urethra

III. Accessory structures

a. Seminal vesicles
b. Prostate gland
c. Bulbourethral gland
The Analogous
Male Female
Spermatozoa
Glans clitoris
Scrotum
Vagina
Testes
Fallopian tube
Prostate gland
Bartholin’s gland

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THE EVOLUTION OF LIFE

I. Prefertilization
a. Ovum moves to the ampulla by means of peristaltic movement
b. Sperm moves into the ampulla by means of their tail
c. Before sperm can penetrate the ovum, the cap must be removed
Capacitation- physiologic removal of the acrosome
d. Acrosome reaction-
Hyaluronidase- proteolytic enzyme released
Zona pellucid-protective covering of the ovum
Corona radiate-cells that encircle the zona pellucida
II. Conception/Fertilization
Zona reaction- ovum becomes impenetrable to other sperms
 Zygote
 Blastomere
 Morula
 Blastocyst
 Embryo
 Fetus
III. Implantation
 Trophoblast
o Placenta




o Fetal membrane
o Umbilical cord
o Amniotic fluid
 Embryoblast
o Germ Layers
 Ectoderm
 mucus membrane, acessories, nervous system
 Entoderm
 bladder, GIT, tonsils, thyroid gland, respiratory system
 Mesoderm
 kidneys, musculoskeletal, reproductive, cardiovascular
 Embryonic Membrane
a. Chorion - Outer membrane
b. Amnion - Inner membrane
c. Amniotic fluid
 Slightly yellow
d. Placenta
 Contains 30 separate (cotyledons)

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2 Functions:
a. Metabolic exchange
 produces nutrients needed by the embryo
 systhesis of glycogen, cholesterol & fatty acids
b. Endocrine Function
 HCG
 HPL
o Human chorionic somatomammotropin
o Promotes normal nutrition & growth of the fetus
 Estrogen
 Progesterone
e. Umbilical cord
IV. Fetal Development
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
10 months

ANTEPARTUM
I. Schedule of Visits

II. Classification of Pregnancy

 Gravida
 Para
 TPALM
III. Determination of Pregnancy
 Presumptive Sign
o Amenorrhea
o Breast changes
o Skin changes
o Quickening
o Chadwick’s Sign
 Probable Sign
o Goodell
o Hegar
o Piskacek

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 Positive Sign
o
o
o
IV. Physiologic Changes of Pregnancy
a.Breast
 Increase in size & nodularity
 Enlarged Montgomery’s tubercles
 Veins become prominent
 Colostrum
b. Uterus
 Increase in vascularity
 Presence of Hegar’s sign
c. Cervix
 Formation of mucus plug or operculum
 Presence of Goodell’s sign
d. Vagina
e. Gastrointestinal system
 Constipation
 Heartburn
 Hemorrhoids
 Morning sickiness
f. Urinary system
g.Musculoskeletal system
h. Intergumentary system
 Chloasma
 Linea nigra
 Striae gravidarum
i. Endocrine system
 Increase activity & hormone production
V. Antepartum Assessment
a. Nagele’s Rule

b. Fundal Height

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c. Leopold’s Maneuver




VI. Evaluation of Fetal Well Being
 Fundic Souffle
o Caused by blood rushing through the umbilical arteries. Synchronous with the
FHR.
 Uterine Souffle
o Caused by the sound of blood passing through the uterine vessels. Synchronous
with the maternal pulse.
 Amniocentesis
o TEST RESULTS: within 2-4 weeks
o Complication: Premature labor, Infection, Rh isoimmunization
 Electronic Fetal Heart Rate Monitoring
a. NST
o Tocodynamometer records fetal movements and Doppler ultrasound measures
fetal heart rate to assess fetal well-being after 28 weeks.
o 2 or more FHR accelerations of 15 seconds over a 20 minute interval, and return
of FHR to normal baseline.
b. Contraction Stress Test
o Late decelerations with at least 50% of contractions
o No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in
10 minute period.
 Fetal Activity
o Daily recording of fetal movements
o 3 or more movements felt in 1 hour
VII. Psychosocial Adaptation to Pregnancy
a. 1st Trimester
o acceptance of the biological fact of pregnancy
b. 2nd Trimester
o acceptance of the fetus as a distinct individual and a person to care for
c. 3rd Trimester
o prepare realistically for the birth and parenting of the child

INTRAPARTUM
I. Theories of Labor
a. Uterine Stretch Theory
b. Oxytocin Theory
c. Progesterone Deprivation Theory
d. Prostaglandin Theory
e. Theory of the Aging Placenta

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II. Factors Affecting Labor

A. Passageway
o Diagonal Conjugate- from lower border of symphysis pubis to sacral promontory
o Obstetric conjugate- distance between inner surface of symphysis pubis & sacral
promontory
o True conjugate or conjugate vera
o Tuber-ischial diameter/ Intertuberous diameter- measures the outlet between
the inner borders of ischial tuberosities
 Pelvic Divisions
o False
o True- Consists of the pelvic inlet, pelvic cavity, and pelvic outlet
o Linea Terminalis

 Types of Pelvis
 Android
 Anthropoid
 Gynecoid
 Platypelloid

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B. Passenger
a. Fetal Attitude
b. Fetal Presentation
c. Fetal Lie
d. Fetal Positions
C. Power- refers to the frequency, duration, and strength of uterine contractions to cause
complete cervical effacement and dilation
D. Placental factors
E. Psyche
III. Premonitory Signs of Labor
a. Lightening
b. Cervical changes
 Effacement
 Dilation
c. Regular Braxton Hick’s Contraction
d. Rupture of amniotic membrane
e. Nestling behaviors
f. Weight loss
IV. True vs False Labor
True Labor False Labor
Regular contractions
Decrease in frequency & intensity
Shorter intervals bet. contractions

Activity such as walking either has Activity such as walking, increases

no effect or decreases contraction contractions
Disappear while sleeping

No appreciable change in the cervix

V. Labor Contractions

VI. Fetal Monitoring

 Variability
o Irregular fluctuations in the baseline of FHR of 2 cycles per minute or greater
 Accelerations
o 15 bpm rise above baseline followed by a return to baseline
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 Decelerations-
o Fall below baseline lasting 15 seconds or more followed by a return to baseline
a. Type 1



b. Type 2



c. Type 3



VII. Labor
a. Stage 1
Latent Active Transition
Time

Cervix

Contraction

Intensity

Manifestations

b. Stage 2
 Cardinal Movement of Labor (Even Donna Failed In Easy English Exam)

c. Stage 3

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d. Stage 4

VIII. APGAR
A
P
G
A
R

POSTPARTUM
I. Uterine involution
II. Lochia
a. Rubra
b. Serosa
c. Alba
III. Post Partum Psychosocial Adaptation
a. Taking In
b. Taking Hold
c. Letting Go

TERATOGENS
– any drug or irradiation, the exposure to which may cause damage to the fetus

a. Streptomycin/Anti – TB –
b. Tetracycline
c. Vitamin K –
d. Iodides –
e. Thalidomides –
f. Steroids –
g. Lithium –

Substances Effects to Fetus

a. Alcohol LBW

b. Cigarette LBW

c. Caffeine LBW

d. Cocaine LBW

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TORCH – group of infections that can cross the placenta or ascend through the birth
canal and adversely affect fetal growth

T-
O-
R-
C-
H-
ANTEPARTUM COMPLICATIONS
I. Ectopic Pregnancy
Causes:
a.
b.
c.
Assessment Findings:

Complications:
 Hemorrhage/shock
 Peritonitis
Diagnostics:
 Culdocentesis
 Ultrasound
Management:

II. Abortion

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Causes:
a.
b.
c.
Assessment Findings:

Management:

III. Hydatidiform Mole

Types:
a. Complete

b. Partial

Assessment Findings:

Management:

IV. Incompetent Cervix

Assessment Findings:

Management:

V. Hyperemesis Gravidarum

VI. Anemia

VII. Placenta Previa

Perdisposong Factors:






Assessment Findings:

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VIII. Abruptio Placenta

Risk Factors:
 Uterine anomalies
 Multiparity
 Trauma to the abdomen
 Previous 3rd trimester bleeding
 Abnormally large placenta
Types:



Assessment Findings:

CHARACTERISTCS ABRUPTIO PLACENTA PLACENTA PREVIA

Onset 3rd Trimester 3rd Trimester

Bleeding
Pain & Uterine Tenderness
FHR
Presenting Part
Shock Moderate to severe Usually not present
Delivery Immediate delivery, usually Delivery maybe delayed,
by CS

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IX. Pregnancy Induced Hypertension

Incidence:
 Severe nutritional deficiencies
 < 15 years or > 35 years of age






Common Types:
 Gestational HTN

 Preeclampsia

 Eclampsia

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Assessment Findings:
a) Mild Pre-Eclampsia
 Increase systole > 30 mmhg (3 measurements)
 Increase diastolic 15 mmhg
b) Severe Pre-Eclampsia
 >160/110 mmhg or higher (2 occasions)
 Proteinuria 3-4+
c) Eclampsia
 Presence of convulsions
 Coma
Management:

 Hydralazie (Apresoline)
 Magnesium sulfate
 Magnesium sulfate
 Diazepam
 Phenobarbital
 Phenytoin

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X. Gestational Diabetes Mellitus

Assessment Findings:

Diagnostics:
 FBS
 HbA 1cv
 Oral Glucose Tolerance Test
Management:

XI. RH Incompatibility

Management:
 Blood test early pregnancy


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XII. Multiple Gestation

Types:
 Monozygotic Twins

 Dizygotic Twins

Assessment Findings:
 Uterine size is greater than expected
 Palpation of three or more large parts
 Different FHT
Complications:
 Fetal malpresentation
 Uterine dysfunction due to over stretching
 Twin to twin transfusion

Management:
 Prenatal care
 Balanced diet
 Rest periods
 Anticipatory guidance & support

INTRAPARTUM COMPLICATIONS

I. Premature Rupture of Membranes

Amniotic fluid gushing from the vagina in the absence of contraction
Contributing Factors:
 Amniotic sac with weak structure
 Recent sexual intercourse
Diagnostics:
 Nitrazine test tape
Management:
 Monitored : infection / spontaneous labor
 Bed rest

 Tocolytic therapy
 Betamethasone (Celestone)

II. Cord Prolapse

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Etiology:
 Rupture of membranes with the fetal presenting part unengaged
 Hydramios

Assessment Findings:
 Cord protruding from the vagina
 Cord palpated in the vagina or cervix
 Fetal distress
Management:
 O2 therapy
 Push presenting part forward
 Deliver ASAP

III. Preterm Labor

Etiology:
 Incompetent cervix
 Placenta previa/Abruptio placenta
 Previous preterm labor
Management:
 Tocolytic therapy not needed if contractions stops
 Fetal and uterine contraction monitoring

 Ritodrine HCl (Yutopar)

 Terbutaline sulfate (Brethine)
 Magnesium Sulfate
 NSAIDS
 Indomethacin (Indocin)
 Betamethasone

IV. Post Term Labor

Assessment Findings:
 Weight loss and decreased uterine size

Management:
 Provide emotional and physical support

V. Induction of Labor
a. Amniotomy
- Initiated when the cervix is soft, partially effaced, slightly dilated,
presenting part is engaged
b. Prostaglandin

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- 8-12 hours after Prostaglandin E2 administration, pump infusion of

Oxytocin (Pitocin)
c. Oxytocin

 Dinoprostone (Prepidil)
 Prostin E2 suppository or gel
 OXYTOCIN (Pitocin, Syntocinon)

VI. Precipitate Labor

Complications:
a. mother

b. infant

Management:
- Support and guide fetal head through birth canal when birth occurs

VII. Uterine Rupture

Causes:
 Rupture of the scar from a previous CS
 Forceps delivery
 Use of oxytocin
 Fundal push
Management:
 IVF
 maintain patent airway

VIII. Episiotomy

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Assessment Findings:
R-
E-
E-
D-
A-
Management:
 Apply ice packs to perineal area for the first 12-24 hours after delivery.
 Sitz bath with either warm or cool water

IX. Lacerations
 1st Degree
 2nd Degree
 3rd Degree
 4th Degree

X. Forceps Delivery
Purpose:
 Prevents excessive pounding of the fetal head against the perineum
 Prevents exhaustion from a woman’s pushing effect
Assessment Findings:
 Cervix fully dilated before use of forceps
 Fetus in vertex presentation
 Bowel and bladder empty

XI. Cesarean Section

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Types:
a. Classical
Advantage
 Simple and rapid to perform

Disadvantage
 Potential for rupture of the scar with subsequent pregnancy

b. Pfannenstiel’s incision
Advantages
 Less chance of rupture of uterine scar during future deliveries
 Fewer postpartum complications
Disadvantages
 Longer to perform than classic incision

XII. Uterine Inversion

Types:
a.Forced Inversion
Cause : excessive pulling of the cord , vigorous manual expression of the placenta or
clots from an atonic uterus
b. Spontaneous Inversion
Cause: due to increased abdominal pressure from bearing down, coughing, or sudden
abdominal muscle contraction
Predisposing Factors:
 Straining after delivery of the placenta
 Vigorous kneading of the fundus to expel the placenta
 Manual separation and extraction of the placenta
Assessment Findings:
 Extrusion of the inner uterine lining into the vagina
Management:
 Restore the uterus to its normal position
 use of general anesthesia and tocolytic therapy

POSTPARTUM COMPLICATIONS
I. Post Partum Hemorrhage

Management:
 Monitor BP and PR Q5-15 minutes
 Prepared for a possible D&C
 IV infusion, oxytocin, and BT

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 Oxytoxic methylergonovine maleate (Methergine)

II. Subinvolution
Delayed return of the enlarged uterus to normal size and function
Assessment Findings:
 Larger than normal uterus
 Prolonged lochial discharge
Management:
 Massage uterus, facilitate voiding
 Administer prescribed medications

III. Puerperal Infection

IV. Mastitis
Inflammation of the breast tissue caused by infection or stasis of milk in the ducts
Management:
 Administer antibiotics
 Breast feed frequently

V. Post Partum Mood Disorders

 Postpartum Blues

 Postpartum Depression

 Postpartum Psychosis

FAMILY PLANNING
Natural Method

 Abstinence
 Coitus interruptus (withdrawal)
80% effective with typical use

 Rhythm (Calendar method)

Ovulation occurs 14 days (plus or minus 2 days) prior to next menses
sperm viable for 5 days
ovum is capable of being fertilized for 24 hours
fertile period = shortest cycle minus 18 days and longest cycle minus 11 days
91% effective with perfect use; 75% effective with typical use
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 Basal body temperature (BBT)

Temperature drops just prior to ovulation, rises and fluctuates at higher
level until 2-4 days prior to next menses
basal thermometer – shows tenths of a degree
get temperature each AM prior to getting out of bed
avoid intercourse on the day temperature drops and for 3 days thereafter
97% effective with perfect use; 75% effective with typical use

 Cervical Mucus method (Billing’s, Ovulation)

Luteal Phase
- infertile period
- dominant hormone: progesterone
- vaginal characteristics:dry
- cervical mucus characteristics:
 scant
 cloudy, white to yellow
 beading – on microscope

Follicular phase – ovulation

- fertile period
- dominant hormone: estrogen
- vaginal characteristics: wet
- cervical mucus characteristics:
 profuse, clear
 thin, watery, slippery
 stretchable (spinnbarkheit)
 ferning – on microscope
assess cervical mucus daily
avoid intercourse when cervical mucus is first noted to become more
clear, stretchable and slippery and for about 4 days
effectiveness the same as basal body temperature

 Symptothermal Method
o Ovulation
o Menstrual calendar
o Effectiveness: 98% (perfect use), 75% (typical use)
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Mechanical Methods

 Male condom
Latex, plastic or natural membranes
effectiveness: 97% (perfect use); 86% (typical use)

 Female condom
Thin polyurethane sheath with flexible rings at each end
Cover the cervix, lines the vagina and partially shields the perineum
May be inserted up to 8 hours before intercourse
Effectiveness: 95% (perfect use); 79% (typical use)

 Spermicides
Kill spermatozoa before it reaches cervix
Make vaginal pH strongly acidic
Helps prevent STDs
Active ingredient: nonoxynol
Forms:
a. contraceptive foam
b. creams and jellies
c. spermicidal vaginal tablet
d. spermicidal condom
e. film
allergic reaction is possible
must be applied with each act of intercourse
onset of action varies

 Diaphragm
Circular rubber disc fitted over cervix to prevent entrance of sperm cells into
uterus
Of different sizes
Fitted by an obstetrician during:
a. first time of use
b. after every delivery/abortion
c. weight loss of at least 10lbs
largest size that fits is chosen
inspect for tears and holes by holding against the light
can be inserted 2 hours before intercourse but left for 6 hours after
intercourse
do not leave more than 24 hours
complication: toxic shock syndrome
a. elevation of temperature
b. diarrhea and vomiting
c. weakness and faintness
d. muscle aches
e. sore throat
f. sunburn type rash
effectiveness: 94% (perfect use), 80% (typical use)

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 Cervical Cap
Resembles a diaphragm but smaller with taller dome
Insert at least 20 minutes but no longer than 4 hours prior to intercourse
May be left in place for 48 hours

Hormonal Methods

 Contraceptive Pills
Consist of estrogen and progesterone
inhibit ovulation by suppressing FSH and LH
cause thickening of cervical mucus
alter motility of fallopian tubes
2 types of packets:
a. 21 day pill – rest day of 7 days
b. 28 day pill – last 7 pills either iron supplement or lactose
Forms of OCP
a. Combination Oral Contraceptives
- contain both an estrogen and a progestin
- formulations:
1. monophasic
 contains fixed amount estrogen and progestin
 e.g.: cyproterone/ethinylestradiol,
Desogestrel/ethinylestradiol
2. biphasic
 fixed or variable amount of estrogen
 progestin increases in the 2nd half of the cycle
 e.g.: desogestrel/Ethinyldestradiol
 7 tabs 25 mcg progestin/40mcg estrogen
 15 tabs 125mcg progestin/30mcg estrogen
3. Triphasic
 amount of estrogen may be fixed or variable while amount
of progestin increases in 3 equal phases
 e.g., Levonorgestrel/Ethinyldestradiol
 6 tabs 30 mcg progestin/50mcg estrogen
 5 tabs 40 mcg progestin/75mcg estrogen
 10 tabs 30mcg progestin/75mcg estrogen
- effectiveness: 99.1% (perfect use), 95% (typical use)
b. progestin-only pills (POPs)
- “mini-pills”
- contain low doses of progestins
- considered in women seeking a highly effective, reversible and
coitally independent method of contraception
- action:
a. prevents ovulation
b. thickens cervical mucus and suppresses the endometrium
- effectiveness with perfect use: 95.5%
- with typical use: 95%

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- warning signs and symptoms

(ACHES)
A – abdominal pain
C – chest pain,cough
H – headache, dizziness

 Norplant (Subdermal Implant)

- six silastic capsules containing progestin
- implanted subdermally
- upper inner arm
- first 7 days of menstrual cycle
- action:
a. prevent ovulation
b. stimulate production of thick cervical mucus

 Long Acting Progestin Injections

- medroxyprogesterone acetate (Depo-Provera) 150mg IM every 3 months
starting with 1st 5-7 days of the menstrual cycle
- blocks LH surge
- action:
a. suppress ovulation
b. thickens cervical mucus
- effectiveness: 97.7%

 Combination transdermal contraceptive patch

- Norelgestromin/ethinylestradiol
- 150mcg/20mcg per 24 hr patch
- apply 1 patch weekly x 3 weeks followed by 1 week patch free period.
- Women >90kg may find patch less effective
- Patch applied to clean, dry, hair-free skin on: buttock, abdomen, upper outer
arm or upper torso
- Avoid irritated or broken skin, breasts or skin in contact with tight
clothing/cosmetic

 INTRAUTERINE DEVICE
- Contraception achieved by immobilizing sperm and impeding travel from cervix
to fallopian tube
- Types:
a. Progesterone T (progestasert)
 for women allergic to copper
b. Copper T380A (ParaGard)

 for women with at least 1 child

 can be left in place x 10 years
c. Levonorgestrel
 Suited for women with heavy menstruation
 Inserted in uterus during 1st 7 days of menstrual cycle
 Effective x 5 years

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- warning signs & symptoms (PAINS)

P – period late, abnormal spotting

A – abdominal pain, pain with
intercourse
I – Infection exposure abnormal
Discharges
N – not feeling well, fever
S – string missing

Surgical Methods

a. vasectomy
b. tubal ligation

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