MATERNAL AND CHILD HEALTH NURSING

REGIE A. BAUTISTA, RN, MN

MCH
one of the 10 elements of Reproductive Health.

Reproductive Health
the state of complete physical, mental, social and emotional well being and the absence of infirmity in all matters relating to the reproductive system and to its functions and processes. Vision: RH practice as a way of life for every man and woman throughout life.

Reproductive Health
Goals: >Achieve healthy sexual development and maturation >Achieve their reproductive intention >Avoid illness/disease, injuries, disabilities r/t sexuality and reproduction >Receive appropriate counseling and care of reproductive health problems

MCH
refer to mother and child relationship with consideration of the entire family as well as the culture and socio-economic environment as the framework of care.

Overall-goal Of MCH
Promotion and maintenance of optimal health of women and their fetuses/Newborn ensure children are not only physically, mentally and emotionally well born but also born well

Philosophy
Pregnancy, labor and delivery and the puerperium are part of the continuum of the total life cycle. Personal, cultural and religious attitudes and beliefs influence the meaning of pregnancy for individuals MCN is family centered and the father of child is as important as the mother.

Standards of MCH Nursing Practice Comprehensive Nursing care of Women and Newborns towards achievement of optimum health potential with in the framework of the Nursing Process Health Education is an integral part of comprehensive nursing care Written policies, procedures and protocols clarifies the scope of nursing practice and delineate the qualifications of personnel authorized to provide care Comprehensive nursing care is provided by nurses who are clinically competent and accountable

Association of Women s Health, Obstetrics and Neonatal Nurses

Standards of MCH Nursing Practice

Nursing care is conducted in practical settings that have qualified nursing staff in sufficient number Ethical principles guide the process of decision making Utilizes research findings, conduct nursing findings research and evaluate nursing practice to improve outcomes of care Quality and appropriateness of patient care are evaluated through a planned assessment program. program
Association of Women s Health, Obstetrics and Neonatal Nurses

Reproductive System
Its Structure and Function

Ovaries
Almond shaped Produce, mature and discharge ova Initiate and regulate menstrual cycle 4 cm long, 2 cm in diameter, 1.5 cm thick Produce estrogen and progesterone Estrogen: promotes breast dev t & pubic hair distribution prevents osteoporosis keeps cholesterol levels reduced & so limits effects of atherosclerosis

Fallopian tubes
Approximately 10 cm in length Conveys ova from ovaries to the uterus Site of fertilization Parts: interstitial isthmus cut/sealed in BTL ampulla site of fertilization infundibulum most distal segment; covered with fimbria

Uterus
Hollow muscular pear shaped organ uterine wall: endometrium; myometrium; perimetrium Organ of menstruation Receives the ova Provide place for implantation & nourishment during fetal growth Protects growing fetus Expels fetus at maturity Has 3 divisions: corpus fundus isthmus (most commonly cut during CS delivery) cervix

Uterine Wall

Endometrial layer formed by 2 layers of cells layer: basal layer closest to the uterine wall layerglandular layer inner layer influenced by estrogen and progesterone; thickens and shed off as menstrual flow Myometrium composed of 3 interwoven layers of smooth muscle; fibers are arranged in longitudinal; transverse and oblique directions giving it extreme strength

Vagina

Acts as organ of copulation Conveys sperm to the cervix Expands to serve as birth canal Wall contains many folds or rugae making it very elastic Fornices uterine end of the vagina; serve as a place for pooling of semen following coitus Bulbocavernosus circular muscle act as a voluntary sphincter at the external opening to the vagina (target of Kegel s exercise)

Pubertal Development Puberty: stage of life at which secondary sex changes begins; development and maturation of reproductive organs occurs (female 10-13 years; male 12-14 years) hypothalamus -the gonadostat or regulation mechanism set to turn on gonad functioning at this age

Reproductive Development
Readiness for child bearing begins during intrauterine life full functioning initiated at puberty -the hypothalamus releases the GnRF which triggers the APG to form and release FSH and LH. (FSH & LH initiates production of adrogen and estrogen ---> 2 sexual characteristics

Related terms
Adrenarche the development of pubic and axillary hair (due to androgen stimulation) Thelarche beginning of breast development Menarche first menstruation period in girls (early 9 y.o. or late 17 y.o.)

Tanner Staging
It is a rating system for pubertal development It is the biologic marker of maturity It is based on the orderly progressive development of: breasts and pubic hair in females genitalia and pubic hair in males

Menstrual Cycle

Female reproductive cycle wherein periodic uterine bleeding occurs in response to cyclic hormonal changes Allows for conception and implantation of a new life Its purpose it to bring an ovum to maturity; renew a uterine bed that will be responsive to the growth of a fertilized ovum

Body Structures Involved

Hypothalamus Anterior Pituitary Gland Ovary Uterus

Physiology of Menstruation
About day 14 an upsurge of LH graafian follicle ruptures ovum is released After release of ovum FSH decrease in Amount; LH act on follicle cells in ovary to produce lutein high in progesterone Corpus luteum persists for 16 20 weeks with pregnancy no fertilization ovum atropies in 4 5 days, corpus luteum remains for 8 -10 days regresses and replaced by white fibrous tissue, corpus albicans

Menstrual Phases First: 4-5 days after the menstrual flow 4the endometrium is very thin, begins to proliferate rapidly; thickness increase by 8 folds under the influence of increase in estrogen level known as: proliferative; estrogenic; follicular and postmentrual phase

Menstrual Phases Secondary: after ovulation the corpus luteum produces progesterone endometrium become twisted in appearance and dilated; capillaries increase in amount (becomes rich, velvety and spongy in appearance known as: secretory; progestational; secretory; progestational; luteal and premenstrual

Menstrual Phases

Third: if no fertilization occurs; corpus luteum regresses after 8 10 days decrease in progesterone and estrogen level leading to endometrial degeneration; capillaries rupture; endometrium sloughs off known as: ishemic phase

Menstrual Phases
Final phase: end of the menstrual cycle; the first day mark the beginning of a new cycle; discharges contains blood from ruptured capillaries, mucin from glands, fragments of endometrial tissue and atrophied ovum.

Characteristics of Normal Menstruation Period

Menarche average onset 12 -13 years Interval between cycles average 28 days Cycles 23 35 days Duration average 2 7 days; range 1 9 days Amount average 30 80 ml heavy bleeding saturates pad in <1hour Color dark red; with blood; mucus; and endometrial cells

Ovulation Occurs approximately the 14th day before the onset of next cycle (2 weeks before) Slight drop in BT (0.5 1.0 F) just before day of ovulation due to low progesterone level then rises 1F on the day following ovulation (spinnbarkheit; mittelschmerz) If fertilization occurs, ovum proceeds down the fallopian tube and implants on the endometrium

Ovulation
If cycle is 20 days 14 days before the next cycle is the 6th day, so ovulation is day 6 If cycle is 44 days 14 days, ovulation is day 30.

Human Sexual Response Cycle

Promote Responsible Parenthood

Motivate use of family planning methods
Contraception Types: Abstinence or celibacy Sterilization Oral contraceptives Implant contraceptives Depo-provera Intrauterine device Mechanical Barriers Diaphragm Cervical cap Female condom Spermicide Male condom Practices Coitus interruptus Rhythm & natural method Types of Emergency Contraception Dosage of EstrogenProgestin Post-coital IUD Insertion

Physiologic Method
Oral contraceptive Action: inhibits release of FSH no ovulation Types: Combined Sequential Mini pill SE: due to estrogen and progesterone > nausea and vomiting > Headache and weight gain > breast tenderness > dizziness > breakthrough bleeding/spotting > chloasma

Oral Contraceptives
Contraindications: Breastfeeding Certain diseases: thromboembolism Diabetes Mellitus Liver disease migraine; epilepsy; varicosities CA; renal disease; recent hepatitis Women who smoke more than 2 packs of cigarette per day Strong family Hx of heart attack Note: If taking pill is missed on schedule, take one as soon as remembered and take next pill on schedule; if not done withdrawal bleeding occurs.

Mechanical Methods
Intrauterine Device prevents implantation by non-specific inflammatory reaction inserted during menstruation (cervix is dilated) increased menstrual flow spotting or uterine cramps increased risk of infection Note: when pregnancy occurs, no need to remove IUD, will not harm fetus SE: cell

 Diaphragm a disc that fits over the cervix forms a barrier against the entrance of sperms initially inserted by the doctor maybe washed with soap and water is reusable when used, must be kept in place because sperms remains viable for 6 hrs. in the vagina but must be removed within 24 hrs
decrease risk of toxic shock syndrome)

(to

 Condom

a rubber sheath where sperms are deposited it lessens the chance of contracting STDs most common complaint of users interrupts sexual act to apply

Chemical Methods
These are spermicidals (kills sperms) examples: jellies creams foaming tablets suppositories

Surgical Method
Tubal Ligation Ligation: Fallopian tubes are ligated to prevent passage of sperms Menstruation and ovulation continue Vasectomy Vasectomy: Vas deferens is tied and cut blocking the passage of sperms Sperm production continues Sperms in the cut vas deferens remains viable for about 6 months hence couple needs to observe a form of contraception this time to prevent pregnancy

VASECTOMY Ligation & transection of part of the vas deferens. No effect on sexual potency. No effect on production of male hormones. Does not provide protection against STD. Management: Cold compress, sitz bath. Advise that fertility remains for a varying time until sperms in the vas deferens have been evacuated.

Natural Method
Biological method Rhythm/Calendar/Ogino Knause Rhythm/Calendar/Ogino
Couple abstains on days that the woman is fertile Menstrual cycles are observed & charted for 12 months

Formula:

shortest cycle 18 longest cycle 11

shortest cycle = 28 longest cycle = 35 28 18 = 10 / 35 11 = 24 fertile pd: 10th to 24th day of cycle = No SI Example:

 Billings Method / Cervical Mucus cervical mucus is observed woman is fertile when cervical mucus is thin and watery; may be extended SI may be resumed after 3 4 days

 Symptothermal Method / BBT Requires daily observation and recording of body temperature before rising in the morning or doing any activity to detect time of ovulation Ovulation is indicated by a slight drop of temperature and then rises Resume SI after 3 4 days Recommended observation of BBT is 6 menstrual cycle to establish pattern of fluctuations

Beginning of Pregnancy: Fertilization

Union of the ovum and spermatozoon Other terms: conception, impregnation or fecundation Normal amount of semen/ejaculation= 3-5 cc = 1 tsp. Number of sperms: 120-150 million/cc/ejaculation Mature ovum may be fertilized for 12 24 hrs after ovulation Sperms are capable of fertilizing even for 3 4 days after ejaculation (life span of sperms 72 hrs)

Chromosomal Abnormalities
Occurrence 0.5 0.6% of NB infants Account for 10% of Neonatal deaths Spontaneous miscarriages = 61.5% Can occur in mitosis or meiosis Occur in autosomes or sex chromosomes

Autosomal Abnormalities
Involve differences in the number or structure of chromosomes unequal distribution of genetic material during gamete formation example: aneuploidy numerical deviation; not exact haploid set (monosomies and trisomies) - leading cause of pregnancy loss - leading cause of mental retardation

 Monosomy: normal gamete and gamete with missing chromosome have only 45 chromosomes (usually never survives) Trisomy : gamete with extra chromosome - 47 chromosomes - caused by nondisjunction during first meiotic division examples: Down s Syndrome trisomy 21 Edward s Syndrome - trisomy 18 Patau Syndrome trisomy 13 (with poor prognosis; child die from caridiac or respiratory complications within 6 months of birth.

 Mosaicism : due to nondisjunction during mitosis in early development mixture of normal and cells with missing or extra chromosomes

Abnormalities in chromosome structure

Translocation Deletion &/or addition as long as all genetic material is retained in the cell individual is unaffected but is a balanced translocation carrier if gamete has one of 2 normal chromosomes and fused version child will have extra copy of one of the chromosomes unbalanced translocation with clinical effects

Sex Chromosome Abnormalities

Caused by nondisjunction during gametogenesis in either prent. Example: Turner Syndrome have only X chromosome; affects females juvenile external genitalia; ovaries undeveloped; short stature, webbing of neck; impaired intelligence Klinefelter syndrome trisomyXXY; affects males; infertile; tall; effeminate; poorly developed secondary sexual characteristics and small testes.

Implantation General Considerations: Once implantation has taken place, the uterine endometrium is now termed decidua Occasionally, a small amount of vaginal bleeding occurs with implantation due to breakage of capillaries

Implantation Immediately after fertilization, fertilized ovum or zygote stays in the fallopian tube for 3 days, rapid cell division (mitosis) is taking place. The developing cells now called blastomere and when about to have 16 blastomere called morula. Morula travels to uterus for another 3 4 days

 When there is already a cavity in the morula called blastocyt finger like projections called trophoblast form around the blastocyst, which implant on the uterus Implantation is also called nidation, takes place about a week after fertlization

Stages of human prenatal development

Cytotrophoblast inner layer Syncytiotrophoblast the outer layer containing finger like projections called chorionic villi which differentiates into: Langhan s layer protective against Treponema Pallidum, present only during the second trimester Syncytial Layer gives rise to the fetal membranes, amnion and chorion

Fetal Membranes
Amnion gives rise to umbilical cord/funis with 2 arteries and 1 vein supported by Wharton s jelly amniotic fluid: clear albuminous fluid, begins to form at 11 15th week of gestation, chiefly derived from maternal serum and fetal urine, urine is added by the 4th lunar month, near term is clear, colorless, containing little white specks of vernix caseosa, produced at rate of 500 ml/day. Known as BOW

Amniotic Fluid
Purposes: protection shield against pressure and temperature changes Diagnosis amniocentesis Aid in the descent of fetus during active labor Implication: polyhydramios = > 1500 ml due to inability of the fetus to swallow the fluid as in trachoesophageal fistula. Oligohydramnios = <500 ml due to the inability of the kidneys to add urine as in congenital renal anomaly

Fetal Membranes
Chorion - together with the deciduas basalis gives rise to the placenta, start to form at 8th week of gestation; develops 15 20 cotyledons Purposes of Placenta: respiratory Renal system Gastrointestinal system Circulatory system Endocrine system: produces hormones (before 8th weekcorpus luteum produces these hormones) hCG keeps corpus luteum to continue producing estrogen and progesterone HPL or human chorionic somatomammotropin which promotes growth of mammary glands for lactation Protective barrier: inhibits passage of some bacteria and large molecules

Stages of Human Prenatal Development

First 12 14 days = zygote From 15th day up to 8th week = embryo From 8th week up to the time of birth = fetus

Fetal Growth and Development

First lunar month Germ layers differentiate by the 2nd week entoderm gives rise to lining of GIT, Respiratory 1. Tract, tonsils, thyroid (for basal metabolism), parathyroid (for calcium metabolism), thymus gland (for development of immunity), bladder and urethra Mesoderm forms into the supporting 2. structures of the body (connective tissues, cartilage, muscles and tendons); heart, circulatory system, blood cells, reproductive system, kidneys and ureters. 3. Ectoderm responsible for the formation of the nervous system, skin, hair and nails and the mucous membrane of the anus and mouth

Hallmarks of Fetal Development

1 mo. 2nd week fetal membranes 16th day heart forms 4th week heart beats 2 mo. - All vital organs and sex organs formed; placental fully developed; meconium formed (5th 8th wk) 3 mo. - Kidneys function - 12th wk- urine formed Buds of milk teeth form begin bone ossification Swallows amniotic fluid establishment of feto-placental circulation

Cont. Fetal Dev t

4 mos. -Lanugo appears; buds of permanent teeth form; heart beat heard by fetoscope 5 mos. - Vernix appears; lanugo over entire body; quickening; FHR audible with stethoscope 6 mos. - Attains proportions of full term but has wrinkled skin 7 mos. -28 weeks lower limit of prematurity; alveoli begins to form

Cont. Fetal Dev t 8 mos. - 32 weeks fetus viable; lanugo disappears, subcutaneous fat deposition begins 9 mos. - Lanugo continue to disappear; vernix complete; amniotic fluid volume decrease

Focus of Fetal Development

First Trimester period of organogenesis Second Trimester period of continued fetal growth and development; rapid increase in length Third Trimester period of most rapid growth and development because of the deposition of subcutaneous fat

Assessing Fetal Well-being

Fetal Movement: Quickening at 18 20 weeks Peaks at 29 -38 weeks Consistently felt until term

Assessing Fetal Well-being Cardiff Method: Count to ten records time interval it takes for 10 fetal movements to be felt usually occurs in 60 minutes

Assessing Fetal Well-being

Contraction Stress Test: FHR analyzed in conjunction with contractions Nipple stimulation done to induce gentle contractions 3 contractions with 40 sec duration or more must be present in 10 minute window Normal Result no fetal decelerations with contractions

 Nonstress Test: measures response of FHR to fetal movement (10-20mins.) with fetal movement FHR increase by 15 beats and remain for 15 seconds then decrease to average rate (no increase means poor oxygen perfusion to fetus)

Amniocentesis
done to determine fetal maturity: 16 wks detect genetic disorder 30 wks assess L/S ratio

Amniocentesis
Prior to the procedure, bladder should be emptied; ultrasonography is used to avoid trauma from the needle to the placenta, fetus Complications include premature labor, infection, Rh isoimmunization Monitor fetus electronically after procedure, monitor for uterine contractions Teach client to report decreased fetal movement, contractions, or abdominal discomfort after procedure.

 Blood Incompatibility An antigen-antibody reaction which causes excessive destruction of fetal red blood cells Mother is Rh negative and the fetus in Rh positive (because the father is either a homozygous or heterozygous Rh positive) Mother is type O and the fetus is either Type A or Type B (because of the father s blood type)

Ultrasound

transducer on abdomen transmits sound waves that show fetal image on screen

Done as early as five weeks to confirm pregnancy, gestational age Multiple purposes to determine position, number, measurement of fetus(es) and other structures (placenta) Client must drink fluid prior to test to have full bladder to assist in clarity of image No known harmful effects for fetus or mother Noninvasive procedure

Biophysical Profile (Fetal Apgar) Assessment of biophysical variables to detemine fetal wellness perfect score of 2 per criteria Criteria: Fetal heart reactivity (NST) Fetal tone Gross body movement Fetal breathing Amniotic fluid volume

Normal Adaptations in Pregnancy

Systemic Changes Cardiovascular/ circulatory changes: Physiologic anemia of pregnancy -30-50% gradual increase in total cardiac volume (peak 6th month) causing drop in Hemoglobin and Hematocrit values (inc only in plasma volume)

Consequences of increased cardiac volume: 1. easy fatigability & shortness of breath due increase cardiac workload 2. slight hypertrophy of the heart 3. systolic murmurs due to lowered blood viscosity 4. nosebleeds may occur due to congestion of nasopharynx

 Pregnancy & Heart Disease Classification of Heart Disease Class I no physical limitation Class II slight limitation of physical activity Ordinary activity causes fatigue Palpitation, dyspnea, or angina Class III moderate to marked limitation of physical activity; less than ordinary activity causes fatigue Class IV unable to carry on any activity without experiencing discomfort

 Prognosis: Classes I & II normal pregnancy & delivery Classes III & IV poor candidates S/S: heart murmur due to inc. total cardiac volume Cardiac output decreased nutritional and oxygen requirements not met Incomplete emptying of the left side of the heart Pulmonary edema and HPN (moist cough in Gravidocardiacs danger sign)

 Management: depends on cardiac functional capacity Bed rest especially after 30th week of gestation Diet gain enough (consider effect on cardiac workload) Medications: Digitalis Iron preparations not placed in lithotomy position Avoid increasing venous return (place in semi-sitting position)

Not allowed to bear down; low forceps Ergotrate and other oxytoxics, scopolamine, diethylstilbestrol and oral contraceptives contraindicated cause fluid retention and promote thromboembolism Most critical period: immediate postpartum period when 30 50% increased blood volume is reabsorbed back in 5 10 minutes and the weak heart needs to adjust

Cont. Circulatory changes

Palpitations caused by the SNS stimulation during early part of pregnancy; increased pressure of the uterus against the diaphragm during the second half of pregnancy Edema of the lower extremities & varicosities due to poor circulation caused by the pressure of the gravid uterus on the blood vessels of the lower extremities

Cont. circulatory changes

Vaginal and rectal varicosities due to pressure on blood vessels of the genitalia mgnt: side lying hips elevated on pillow modified knee chest position Predisposition to blood clot formation due to increased level of circulating fibrinogen as a protection from bleeding implication: no massage

Gastrointestinal Changes Morning sickness nausea and vomiting in the 1st trimester due to HCG or due to increased acidity or emotional factors mgnt: dry toast 30 mins before get up in AM Hyperemesis gravidarum excessive nausea & vomiting which persists beyond 3 months causing dehydration, starvation and acidosis mgnt: hydration in 24 hrs; cbr Constipation and Flatulence GI displacement slows peristalsis & gastric emptying time; inc progesterone

Cont. GI changes
Hemorrhoids due pressure of enlarged uterus mgnt: cold compress with witch hazel Epsom salts Heartburn due to inc. progesterone and dec. gastric motility causing regurgitation through gastric sphincter
mgnt: pats off butter before meals avoid fried, fatty foods sips of milk at intervals small, frequent meals taken slowly don t bend on waist take antacids (milk of magnesia)

and

Respiratory Changes Shortness of Breath due to inc. oxygen consumption and production of carbon dioxide during the 1st Trimester; and inc. uterine size pushing the diaphragm crowding chest cavity mgnt: side lying position to promote lateral chest expansion

Urinary Changes

Urinary frequency felt during the 1st trimester due to the increase blood supply to the kidneys and then on the 3rd trimester due to pressure on the bladder. Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine; and inc. progesterone

Musculoskeletal changes
Pride of Pregnancy due to need to change center of gravity result to lordotic position Waddling gait due to increased production of hormone relaxin, pelvic bones becomes more movable increasing incidence of falls Leg cramps due to pressure of gravid uterus, fatigue, muscle tenseness, low calcium and phosphorus intake

Endocrine Changes

Addition of the placenta as an endocrine organ producing HCG, HPL, estrogen and progesterone Moderate enlargement of the thyroid due to increased basal metabolic rate Increased size of the parathyroid to meet need of fetus for calcium

Endocrine Changes
Increased size and activity of adrenal cortex increasing circulating cortisol, aldosterone, and ADH which affect CHO and fat metabolism causing hyperglycemia. Gradual increase in insulin production but there is decreased sensitivity to insulin during pregnancy

 Gestational Diabetes Mellitus characterized by marked hyperglycemia Effects of pregnancy abnormalities in glucose tolerance develop decreased renal threshold for sugar due to inc. estrogen, inc. production of adenocorticoids, adenocorticoids Anterior Pituitary hormones, and thyroxin affect CHO concentration in blood (hyperglycemia) rate of insulin secretion is increased but insulin sensitivity is decreased

 Risks associated with GDM:

Toxemia Infection Hemorrhage Polyhydramnios Spontaneous abortion because of vascular complications which affect placental circulation Acidosis because of nausea and vomiting Dystocia due to large baby

GDM Screening
High risk are screen at initial visit and again at 24 28th weeks of gestation (ADA) 50 gram glucose load followed by plasma glucose determination at 1 hour after (glucose challenge test) 135-140 mg/dl positive OGTT done: 2 hr PG using 75 gram or 3 hour 100 gram glucose load

OGTT using100 gram Glucose Load

Avoid caffeine No smoking 12 hrs before test 3 days unrestricted diet Overnight fasting Fasting blood glucose determined 100 gram glucose load given Blood glucose levels taken at 1,2 and 3 hrs after positive for GDM if 2 or more levels are met or exceeded: fasting < 95, 1 hr < 180; 2 hr < 155; 3 hr < 140mg/dl

 Management: Diet - highly individualized - adequate glucose intake (1,800 2200 calories) to prevent intrauterine growth retardation Insulin requirements individualized Increased need for 2nd and 3rd trimester because of more pronounced effect of hormones Postpartum Period more difficult to control BG because of hormonal changes

Weight Change First Trimester 1.5 to 3 lbs normal weight gain 2nd and 3rd trimester 10 11 lbs per trimester is recommended Total allowable weight gain during throughout pregnancy is 20 25 lbs or 10 12 kgs. Pattern of weight gain is more important than the amount of weight gained gained.

Local Changes
Uterus wt increase to about 1000 grams at full term due to increase in fibrous and elastic tissues Becomes ovoid in shape Softening of lower uterine segment: Hegar s sign seen at 6th week Operculum mucus plug to seal out bacteria Goodell s sign cervix becomes vascular and edematous giving it consistency of the earlobe

Vagina increased vascularity occurs Chadwick s sign purplish discoloration of the vagina Leukorrhea increased amount of vaginal discharges due to increased activity of estrogen and of the epithelial cells. must not be itchy, foul smelling, excessive, nor green/yellow in color. management: good hygiene Under the influence of estrogen, vaginal epithelium & underlying tissues hypertrophic & enriched with glycogen pH of vaginal secretions during pregnancy fall

Cont. Local Changes: vagina Microorganisms that thrive in an alkaline environment: Trichomonas causes trichomonas vaginalis/vagnitis or trichomoniasis s/s: frothy, cream-colored, irritatingly itchy, foul smelling discharges, vulvar edema mgnt: Flagyl 10 days p.o. or trichomonicidal cmpd suppositories (e.g. Tricofuron, Vagisec, Devegan) Special Consideration: treat male partner also with Flagyl avoid alcohol to prevent SE dark brown urine expected Acidic vaginal douche (1 tbsp vinegar:1 qt water or 15 ml: 1000 ml) avoid intercourse to prevent re-infection

 Candida Albicans condition is called Moniliasis or Candidiasis it thrives in an environment rich in CHO and those on steroid or antibiotic therapy seen as oral thrush in the NB when transmitted during delivery s/s: white, patchy, cheese-like particles that adhere to vaginal walls, foul smelling discharges causing irritating itchiness mgnt: Mycostatin/Nystatin p.o. or vaginal suppositories 100,000 U BID x 15 days Gentian violet swab to vagina Acidic vaginal douche Avoid intercourse

Cont.

Ovaries inactive since ovulation does not take place during pregnancy. Placenta produces Progesterone and Estrogen during pregnancy

Abdominal Wall Striae Gravidarum due to rupture and atrophy of connective tissue layers on the growing abdomen Linea Nigra Umbilicus is pushed out Melasma or Chloasma increased pigmentation due increased production of melanocytes by the pitutitary Unduly activated sweat glands

Breast all changes are due to increased estrogen Increased in size Feeling of fullness and tingling sensation Nipples more erect (prepare for BF) Montgomery glands bigger Areola darker and increased diameter Colostrum formed by 4th month (precursor of breast milk)

Emotional responses
1st trimester: some degree of rejection, disbelief, even depression because of its future implication -> give health teachings on body changes and allow for expression of feelings 2nd trimester: fetus is perceived as a separate entity and fantasizes appearance 3rd trimester: best time to talk about layette, and infant feeding method. To allay fear of death let woman listen to the FHT.

Common Emotional Responses

Stress decrease in responsibility taking is the reaction to the stress of pregnancy not the pregnancy itself affects decision making abilities Couvade syndrome men experiencing nausea/vomiting, backache due to stress, anxiety and empathy for partner Emotional labile mood changes/swings occur frequently due to hormonal changes Change in Sexual Desire may increase or decrease needs correct interpretation not as a loss of interest in sexual partner

Signs of Pregnancy
Stage First Trimester Presumptive Breast changes Urinary frequency Fatigue Amenorrhea Morning sickness Enlarging uterus Chloasma Linea negra Inc. skin pigmentation Striae gravidarum Quickening
BUFAME - CLISQ

Probable Goodells Chadwicks Hegars Elev. BBT Positive HCG

Positive Ultrasound evidence

Second Trimester

Ballotement Enlarged abdomen Braxton Hicks

FHT Fetal movement felt by an Examiner Xray of fetal outline

U - FFFF

GCHEP-BEB GCHEP-

Pregnancy
Prenatal care is important for prevention of infant and maternal morbidity and mortality Care is a cooperative action based on client s understanding of treatment modalities Duration of normal pregnancy 266 280 days of 38 42 weeks or 9 calendar months or 10 lunar months. Infant born < 38 weeks pre-term & > 42 post term Diagnosis: Urine examination tests presence of HCG (present from 40th 100th day, peak 60 days) conduct test 6 weeks after LMP

Prenatal Visit
Components:
Historypersonal data obstetrical data gravida para TPAL past pregnancies present pregnancy: cc LMP medical data: hx of diseases/illnesses

Assessment
Physical examination review of systems Pelvic examination (ask client to void)
IE determine Hegar s, Goodell s, Chadwick s Ballotement on 5th month Pap Smear Pelvic measurements (done after 6th month or 2 wks before EDC) Leopold s Manuever: to determine fetal presentation, position, attitude, est. size and fetal parts

Vital signs Blood studies: CBC Hgb,Hct , blood typing, tests Urinalysis: test for albumin, sugar & pyuria

serological

Important Estimates:

Age of Gestation: Nagele s Rule -3 months +7 days Rule: McDonald s Rule: Ht fundus/4 Rule (AOG wks) Bartholomew s Rule: based on position of Rule fundus in abdominal cavity (3rd / 12 wks above symphysis; 5th /20 wks umbilical level; 9th / 36 wks below ziphoid process)

Important Estimates

Fetal Length: Haase s Rule: 1st half of pregnancy Rule square number of months ( 2 months = 2x2 = 4 cm) 2nd half of pregnancy number of months multiplied by 5 (7 months x 5 = 35 cm) Fetal Weight: Johnson s Rule: Fundic Ht n x k ( k=155; Rule n = 11 not engaged/12 engaged) (35 11 x 155 =3,720 g)

Danger Signals of Pregnancy

Vaginal bleeding (any amount) Swelling of face or fingers severe, continuous headache Dimness or blurring of vision Flashes of light or dots before eyes Pain in the abdomen Persistent vomiting Chills and fever Sudden escape of fluids from the vagina Absence of FHT after they have been initially heard on 4th or 5th month

Nursing Management

Nutrition who need special attention: teenager under/over weight; low income; successive pregnancies; vegetarians basis of nutritional assessment: food ways preferences; culture influence; work and educational level

Cont. Nutrition

Include in teaching food sources Special considerations concerning food: iron should be given with vitamin C for better absorption; given after meals to prevent gastric irritation; found in liver; internal organs, camote tops; ampalaya, malunggay, etc. Caloric requirements: 2300 2400 calories Malnutrition: can result in prematurity; preeclampsia; low birth wt, congenital defects and still births

Health Teachings
Smoking lead to LBW babies Drinking can cause respiratory depression in the NB and fetal withdrawal syndrome if excessive; alcohol has empty calories Drugs may be tetratogenic hence contraindicated unless prescribed by Doctor Sexual activity allowed in moderation but not during last 6 wks- high incidence of pp infection noted. counseling is important on changes in desire and positions contraindication: bleeding, ruptured BOW, incompetent cervix, deeply engaged presenting part

Health Teachings
Employment take rest periods walk to promote Employment: circulation; avoid exposure to hazardous substances; lifting; emotional strain Traveling restrictions only during last trimester; on Traveling: long rides have 15 20 minutes stop/rest periods q 2-3 hrs. Exercise aim to strengthen muscles used in Exercise: labor and delivery squatting; pelvic rock; walking; modified knee chest; shoulder circling; Kegel

Nursing Management

Prepared childbirth/Childbirth education based on Gate Control Theory: pain is controlled in the spinal cord and there is a gate that can be closed to ease pain felt. information and breathing techniques help minimize discomfort of labor experienced discomfort can be lessened if abdomen is relaxed and allows uterus to rise freely against it during contractions

Major Approaches to prepared childbirth

Teaching about anatomy, pregnancy, labor and delivery, relaxation techniques, breathing exercises, hygiene, diet and comfort measures Grant-Dick Read Method: Fear leads to tension and tension leads to pain. Goal is to decrease fear. Lamaze: psychoprophylactic method based on S-R conditioning; concentration on breathing is practiced. Use of distractions to reduce pain perception.

Major Approaches to prepared childbirth Bradley Method husbands are encouraged to participate in labor as coach. During pregnancy muscle toning exercises are done and omits food with preservatives, animal fat and high salt content in the diet. Kitzinger method emphasis on body awareness, innovative relaxation techniques & special breathing patterns. This is a program of conscientious relaxation and levels of progressive breathing.

Theories of Labor Onset Uterine stretch theory Oxytocin theory Progesterone Deprivation theory Prostaglandin theory

3 P s of Labor
Power Passenger Passageway

Power
Uterine Contractions: ______ _______ A B C Frequency: Interval: Duration: Intensity _______ D

Passenger
Fetal Skull: largest part of the fetus most frequent presenting part least compressible

Bones: sphenoid, ethmoid, temporal frontal, occipital, parietal Suture lines: sagittal/ coronal, lambdoidal

Fetal Skull
Fontanels membrane covered spaces at the junction of the main suture lines anterior fontanel larger, diamond fontanel: shaped; closes at 12 18 months posterior fontanel smaller, triangular fontanel: shaped, closes at 2 3 months in its Measurements wider AP diameter than transverse diameter
Transverse: biparietal 9.25; bitemporal 8 cm bimastoid 7 cm Anteroposterior: suboccipitobregmatic 9.5 cm narrowest diameter occipiotofrontal 12 cm, occipitomental 13.5 cm widest AP diameter

Divisions:
False Pelvis supports the growing uterus Pelvis: during pregnancy directs the fetus into the true pelvis near the end of gestation True Pelvis the bony canal through which Pelvis: the fetus will pass during delivery formed by the pubes in front, the iliac and ischia on the sides and the sacrum and coccyx behind

Significant Pelvic Measurements Internal the actual diameters of the pelvic inlet and outlet > Diagonal Conjugate distance between the Conjugate: sacral promontory and inferior/lower margin of the symphysis pubis widest AP diameter at outlet estimated on vaginal/pelvic exam (Ave. 12.5 cm)

Significant Pelvic Measurements

>Obstetrical Conjugate: distance from the inner border of the symphysis pubis to the sacral prominence most important pelvic measurement shortest AP diameter of the inlet through which the head must pass 1.5 to 2 cm or less than the diagonal conjugate

Significant Pelvic Measurements

>True Conjugate/Conjugate Vera True Vera: distance between the anterior surface of the sacral promontory and superior margin of the symphysis pubis diameter of the pelvic inlet (10.5 -11 cm) BiDiameter: >Bi-Ischial/ Tuberiischial Diameter distance between the ischial tuberosities narrowest diameter of the outlet transverse diameter of the outlet (ave. 11 cm)