MATERNAL AND CHILD HEALTH NURSING

MATERNAL AND CHILD
HEALTH NURSING
BY: ROMMEL LUIS C. ISRAEL III
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It involves care of the woman and
family throughout pregnancy and
childbirth and the health
promotion and illness care for the
children and families.
Definition:

I. PHILOSOPHY
OF MATERNAL
AND CHILD
NURSING
BY: ROMMEL LUIS C. ISRAEL III 3

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• PHILOSOPHY OF MCN
• Family centered
• Community centered
• Research oriented
• Based on nursing theory
• Protects the rights of the family members
• Uses a high degree of independent functioning
• Places importance on health promotion
• Based on the belief that pregnancy or childhood illness are
stressful because they are crises
• Based on the belief that personal cultural and religious
attitudes and beliefs influence the meaning of illness and its
impact on the family
• A challenging role for the nurse
• A major factor in promoting high level wellness in families

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PRINCIPLES OF MCN
• The family is the basic unit of the society. It is
the structural unit of the society.
• Families represent racial, ethnic, cultural and
socio-economic diversity.
• Children grow both individually as a part of the
family.

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PHASES OF
CARE IN MCN
Health
– educating the
client to be aware
of healthy living
through teaching
and role modeling.
Health
– promptly
diagnosing and
treating illness
using
interventions that
will turn client to
wellness most
rapidly.
Health
Maintenance –
intervening to
maintain health
when risk of illness
is present.
Health
Rehabilitation -
preventing further
complications
from an illness
bringing ill client
back to optimal
state of wellness
for helping the
client accept
inevitable death.

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TRENDS IN MATERNAL AND CHILD HEALTH CARE
• Families are smaller in size than in previous
decades.
• Single parents are increasing in number.
• An increasing number of mothers work outside the
home.
• Families are more mobile than previously.
• Abuse is a more common than ever before.
• Families are more health conscious than previously.
• Health care must respect cost containment.

II. NURSING CARE OF THE
CHILD BEARING FAMILY
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A. REVIEW OF THE
REPRODUCTIVE ANATOMY AND
PHYSIOLOGY
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MALE REPRODUCTIVE SYSTEM

1. EXTERNAL ORGANS
a. PENIS
a. the male organ of copulation and urination
b. has the following parts:
i. shaft or body
ii. glans penis – the most sensitive part
iii. prepuce – a fo9ld of retractable skin
covering the glans and which is removes during
circumcision.
iv. urethral meatus – a slit-like opening
located at the tips of the penis which serves as a
passageway of both sperm and urine.
b. SCROTUM – is a sack-like structure containing the
testes that hang behind the penis; keeps the sperm viable.
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• 2. INTERNAL ORGANS
• TESTES
• a. are oval shaped organs lying within the abdominal cavity in the early
fetal life and descend to the scrotum after 34-38 weeks of gestation.
• b. male gonads (testicles) – made up of loops of 900 coiled
seminiferous tubules.
• c. principal function of the TESTES
• i. Hormone Production
• ii. Spermatogenesis – production of sperm.
• b. EPIDIDYMIS – is a long coiled tube, approximately 20 feet long at which
the sperm travels for 12 – 20 days
• c. VAS DEFERENS – the contractile power of this part of the duct system
propels the spermatozoa to the urethra during ejaculation.
• d. EJACULATORY DUCT – connects the seminal vesicle to the urethra
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• e. ACCESSORY GLANDS
• SEMINAL VESICLE – the pouch like organs that lie
behind the bladder and in front or the rectum.
• PROSTATE GLAND – main responsible in the production
of semen. – a conical body lying below the bladder
which secretes an alkaline fluid.
• COWPER’S / BULBOURETHRAL GLAND – pea size, a
small gland located below the prostate that secretes an
alkaline fluid which helps neutralize the acidic nature of
the semen.
• SEMINAL FLUID/SEMEN – are secretions from the
seminal vesicle, prostate gland, Cowper’s gland,
ejaculatory duct and spermatozoa.
• MALE FERTILITY TEST/SPERM ANALYSIS – can be
assessed by examining the semen.
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Characteristics of the semen which are analyzed for fertility
are:
a. VOLUME- 2.5 – 6 ml (average is 3.5 ml) after 3 days abstention.
b. SPERM COUNT – normal sperm count is 120 million sperms per
ml (1 teaspoon) after 3 days abstention.
c. SPERM MOTILITY
3 Grading System
1. Grade 1
a. sperm tends to remain only in one spot
exhibiting motion only of the tail
2. Grade 2
a. sperm move rapidly across microscopic field.
3. Grade 3
a. 60 % of sperm motility which is normal.
d. SPERM MORPHOLOGY – abnormal forms may be 2 headed
sperms, abnormally shaped heads and abnormal tails.
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FEMALE REPRODUCTIVE ORGAN

1. EXTERNAL ORGANS
a) MONS PUBIS/MONS VENERIS – lies over the symphysis pubis
covered by the skin and at puber5ty by short hairs; protects the
surrounding delicate tissues from trauma.
b) LABIA MAJORA – two folds of skin with fat underneath; contain
Bartholin’s glands
c) LABIA MINORA – two thin folds of delicate tissues; form an upper
fold encircling the clitoris (called the PREPUCE) and unite posteriorly
(called the FOURCHETTE).
d) GLANS CLITORIS – small erectile structure at the anterior junction
of the labia minora, which is comparable to the penis in its being
sensitive.
e) VESTIBULE – narrow space seen when the labia minora are
separated.
f) URETHRAL MEATUS – located on the anterior edge of the
vestibule and surrounded by the SKENE’S GLAND or the
paraurethral ducts which corresponds 6to the prostate in the male.
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VAGINAL ORIFICE / INTROITUS – external
opening of the vagina covered by a thin
membrane (HYMEN)
• h) PERINEUM (vulva) – area between the
mons pubis, buttocks and the thigh
externally. Perineal muscles are the
bulbocavernosus, ischiocavernosus,
“sphincter” of the urethra, superficial and
deep transverse perineal muscles and the
external sphincter of the anus.

2. INTERNAL ORGANS
a) VAGINA – a 3-4 inches long dilatable canal located between the
bladder and the rectum; contains rugae; organ of copulation;
passageway for menstrual discharges.
b) BARTHOLIN’S GLAND – these are located beneath the vestibule
on either side of the vagina and open at the lateral border of the
vagina.
c) UTERUS – hollow pear shaped fibromuscular organ, 3 inches
long, 2 inches wide, 1 inch thick, and weighing 50 grams in a non-
pr5egnant woman; organ of menstruation and implantation;
nourishes the products of conception.
d) FALLOPIAN TUBES/OVIDUCT/UTERINE TUBES – 4 inches
long from each side of the fundus; widest part (called AMPULLA)
spreads into finger like projections; fertilization takes place in its
outer third or outer half.
e) OVARIES – almond shaped, dull white sex glands near the
fimbrae, kept in place by ligaments.
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• OTHER STRUCTURES:
• Bones composing the
bony pelvis:
• Ilium
• Ischium
• Pubis
• Sacrum
• Coccyx

FOUR TYPES OF PELVIS
a) GYNECOID – female pelvis shaped found in approximately 50 % of
women; the anteroposterior and the transverse diameters are
relatively equal, with straight pelvic sidewalls; the ischial spines are
not usually prominent.
Shape: transversely rounded
b) ANDROID – male pelvic shape; characterized by convergent sidewalls,
prominent ischial spines, and a narrow pubic arch.
Shape: wedge shape or angulated
c) ANTHROPOID – heart-shaped pelvic characterized by the
anteroposterior diameter being greater than the transverse diameter.
Shape: heart or oval shape
d) PLATYPELLOID – is characterized by the transverse diameter being
greater than the anteroposterior diameter, with wide sidewalls.
Shape: flat in shape but with oval inlet.
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CONJUGATES – found in pelvic inlet
a) OBSTETRIC CONJUGATE – shortest
anteroposterior diameter between the sacral
promontory and the symphysis pubis; it can only
be measured radio graphically;
11 cm
b) DIAGONAL CONJUGATE – the distance between
the sacral promontory of the sacrum and the lower
margin of the symphysis pubis;
12.5 cm
c) TRUE CONJUGATE – conjugate vera; distance
between the sacral promontory of the sacrum to
the upper margin of the symphysis pubis;
11.5 cm
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OTHER RELATED STRUCTURES
LIGAMENTS OF THE UTERUS
1. BROAD LIGAMENTS – extend from the lateral margin of the
uterus to the pelvis; the uterine vessels and the uterus are
contained within the base of the broad ligaments.
2. ROUND LIGAMENT – connective tissue that extend from the
lateral uterine fundus to the upper portion of the labia majora.
3. UTEROSACRAL LIGAMENT – connective tissue that extends
from the inferior and posterior portion of the uterus and attach to
the fascia over the sacrum.
4. CARDINAL LIGAMENTS – connective tissue located at the base
of the broad ligament; provide most of the support to the uterus.
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B. COMPONENTS OF
HUMAN SEXUALITY
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•PUBERTY
– encompasses the physiologic changes leading to the
development of adult reproductive capacity; the process
includes maturation of the hypothalamus, pituitary glands
and gonads.
•ADOLESCENCE
- encompasses the physiologic, social and cognitive changes
leading to the development of adult identity.
•THELARCHE
- budding of the breast.
•ADRENARCHE
- development of axillary and pubic hair
•SEX
- act of copulation, coitus
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•SEXUALITY
- the sum of the physical, functional and psychological
attributes that are expressed by one’s gender identity
and sexual behavior, whether or not related to the sex
organs or to procreation.
•BIOLOGIC GENDER
- term used to denote a person’s chromosomal sex.
•GENDER/SEXUAL IDENTITY
- is the inner sense a person has of being male or
female.
•GENDER ROLE
- the expression of a person’s gender identity; the
image that a person presents to both himself/herself
and others demonstrating maleness/femaleness.
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SEXUAL DEVELOPMENT
(HUMAN SEXUAL CYCLE)
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1. EXCITEMENT
• vaginal lubrication and vasocongestion of the genitalia
• penile erection due to vasocongestion
• physical and psychological stimulus
• stimulation of the penis
• arterial dilation and venous constriction in the genital area
2. PLATEAU
• Formation of orgasmic platform due to prominent vasocongestion
• Generalized muscle tension, hyperventilation, increase BP, tachycardia in
the late plateau phase
• Reached first before orgasm
• WOMEN – formation of orgasmic platform, increased nipple engorgement
• MEN – full distension of the penis; pre-ejaculatory phase of life
spermatozoa

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3. ORGASM
• Strong rhythmic contractions of vagina and uterus
• In males, vas deferens, seminal vesicle, ejaculatory duct and prostate contract 3-4 times over a
few seconds causing pooling of seminal fluid in the prostatic urethra
• Rhythmic contractions in males occur at 0.8 seconds
• Discharge of accumulated sexual tension
• Shortest stage
4. RESOLUTION
• Rapid decline in pelvic vasocongestion
• External and internal organs return to an unaroused state
• Generally takes 30 minutes
5. REFRACTORY PHASE
• Only in males, the period during which no amount of stimulation can cause another erection
• Not manifested in females because females are multi-orgasmic
• This phase lengthens with age

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• M - utual
• C - onsent
• F - oreplay
• A - rousal
• P - lateau
• C - oitus
• O - rgasm
• R - esolution
• R - efractory
TANNER STAGING
• physical/Foreplay or Actual
• Psychological Stimulation
SEXUAL STIMULATION

C. MENSTRUAL CYCLE AND
FAMILY PLANNING METHODS
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HORMONES ENVOLVED
GnRH - Gonadotropin Releasing Hormone (APG- Anterior
Pituitary Gland)
- initiates the menstrual cycle.
FSH (Follicle Stimulating Hormone)
- stimulates the development of the primordial follicle (immature
follicle) into Graafian follicle (mature) follicles
LH- Luteinizing Hormone (ICSH)
- stimulates ovulation and development of corpus luteum (yellow
body); corpus albican (white body)
- thickens the endometrium
ESTROGEN
- hormone of women
- secondary sex characteristics
- female cervical mucus
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- maintains the endometrium
- stimulates uttering contraction
- inhibits the production of FSH
- causes hypertrophy of myometrium
- stimulates the development of ductile structures of the breast
- increases the pH and the quantity of the cervical mucus
PROGESTERONE
- hormone of mothers
- prepares the endometrium
- relaxes the myometrium
- increases the basal body temperature
- infertile mucus
- maintains pregnancy
- increases the fibrinogen, hematocrit and hemoglobin
- Inhibits the production of LH
- transport to the fertilized ovum (zygote) into the uterus
- increase uterine motility
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PHASES OF THE
MENSTRUAL CYCLE
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A. MENSTRUAL PHASE (1-5 DAYS)
•Extends from the first day of menstruation to the fifth day
•The first day of menses is considered the first day of the
cycle
•Characterized by desquamation of the superficial layers of
the endometrium caused by corpus luteum regression and
the consequent withdrawal of the progesterone and
estrogen
•About 2/3 of endometrium is shed off every menstrual
period
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B. PROLIFERATIVE PHASE (6-14 DAYS)
•From the 6th to day 15 of a 28 day cycle
•The very low estrogen level stimulates the hypothalamus to secrete
follicle stimulating hormone releasing factor (FSHRH). In a 28 day
cycle, estrogen level is lowest on the 3rd day before ovulation
•FSHRF stimulates the anterior pituitary gland to secrete follicle
stimulating hormone
•FSH stimulates the primordial follicle to develop into graafian
follicle
•As the graafian follicle develops, it produces large amount of
estrogen, while at the same time an ovum is maturing inside
•Estrogen promotes regeneration and proliferation of the cells of
endometrium and formation of new capillaries
Also called:
ESTROGENIC PHASE
FOLLICULAR PHASE
POST-MENSTRUAL PHASE
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C. SECRETORY PHASE (15-23 DAYS)
•From the 14th day to the 24th day or from the day of ovulation until about
3-4 days before the next menstruation
•The rising pituitary gland to secrete FSH, the very low progesterone level
triggers the hypothalamus to release LHRF
•LHRF stimulates the anterior pituitary gland to secrete Luteinizing
Hormone (LH)
•LH promotes ovulation. As the graafian follicles becomes overly
distended, with follicle fluid, it finally ruptures releasing the mature ovum
•After ovulation, the graafian follicle will be called corpus luteum
•The corpus luteum produce large amount of progesterone
•Progesterone is said to cause “opening of the uterus: as this hormone
further decreases the vascularity of endometrium and stimulates
endometrial glands to secrete mucin, nutrient and glycogen. As a result,
the lining of the uterus becomes soft, spongy and edematous, this occurs
in preparation for implantation and pregnancy
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•The corpus luteum has an average lifespan of about 8 days. If no fertilization occurs
at this time, it regresses resulting in withdrawal of estrogen and progesterone.
•If no fertilization occurs, the fertilized ovum or zygote implant between 7-10 days
after fertilization, the time when the corpus luteum is suppose to atrophy
•The secretion of human chorionic gonadotropin (HCG) by the trophoblast cells of
the zygote will prolong the life of the corpus luteum.
•The corpus luteum then will continue to produce estrogen and progesterone until
the third time or 12th week of pregnancy when the placenta is mature enough to
take over the function of hormone production
•The corpus luteum having accomplished its role after 12 weeks will now atrophy
•The secretory phase is the endometrial phase that proceeds nidation or
implantation
Also called:
PROGESTATIONAL PHASE
OVULATORY PHASE
LUTEAL PHASE
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D. ISCHEMIC/PREMENSTRUAL PHASE (24-28 DAYS)
•As mentioned earlier, the life of the corpus luteum is only 8-10
days, if fertilization does not take place, the corpus luteum shrivels
•Degeneration of the corpus luteum in withdrawal of estrogen and
progesterone
•Absence of progesterone results in arteriolar spasm and
vasoconstriction. Blood supply, then, to endometrium is cut off.
•Lack of blood vessels and endometrial sloughing
•The desquamated cells are discharge, thus menstruation occurs
•The onset of menstruation signals the beginning of another
menstrual cycle
Also called:
POST-OVULATORY PHASE
PREMENSTRUAL PERIOD
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FAMILY PLANNING
METHOD
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A. Natural Family Planning Methods
1. Techniques including checking the body
temperature or cervical mucus daily and
recording menstrual cycles on a calendar to
determine the days when the body is most
fertile.
2. Effectiveness 81%
3. Accepted by religions and inexpensive.
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B. Artificial Family Planning Methods
1. Spermicides
Chemicals in the form of foams, creams, jellies or suppositories
that are inserted into the vagina to kill the sperm before they can
enter the uterus.
Typical effectiveness 70%
Available over the counter and can be used with other methods
to improve effectiveness
2. Condoms
Male condom is a sheath of latex or animal tissue placed on
erect penis
 Female condom is a plastic sac with a ring on each end inserted
into the vagina.
Both may be used with a spermicide
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3. Birth Control Pills
Prescription drugs that contains the female hormones
(estrogen).
One pill is taken daily to prevent ovaries from releasing eggs and
thickens the cervical mucus to prevent sperm reaching egg.
4. Diaphragm
Shallow latex cup with flexible rim inserted into vagina over
cervix to prevent sperm from entering uterus with spermicide.
5. Intrauterine Device
small device inserted by a health care professional into the
uterus and prevents eggs from being fertilized and implanting
implanting in uterus.
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6. Cervical Cap
Thimble-shaped latex cap inserted into a vagina over cervix
to prevent sperm from entering uterus used with spermicide.
7. Hormonal Injection (Depo-Provera)
injection given by a health care professional in the arm
or buttocks every 12 weeks to prevent ovaries from
releasing an egg of thickened cervical mucus to keep
sperm from reaching the egg.
8. Hormonal Implant (Norplant)
Six small capsules inserted by a health care professional
under the skin of the upper arm that deliver small amounts of
hormone to prevent ovaries from releasing eggs.
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C. Permanent Methods of Reproductive Life
Planning
1. Tubal Ligation
surgical procedure to permanently block woman’s
fallopian tubes to prevent eggs from reaching by sperm.
2. Vasectomy
surgical procedure to permanently block the male’s vas
vas deferens to prevent sperm from reaching eggs.
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DIFFERENT
MENSTRUAL
CONCERNS
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AMENORRHEA – absence of menses
DYSMENORRHEA – painful, difficult menstruation
METRORRHAGIA – bleeding in between menses
MENORRHAGIA – excessive bleeding during regular menstruation
MENOPAUSE – cessation of menstruation
OLIGOMENORRHEA – markedly diminished menstrual flow,
nearing amenorrhea
POLYMENORRHEA – frequent menstruation occurring at intervals of
less than 3 weeks
OVULATION – monthly growth and release of mature, non-fertilized
ovum; usually occur in the middle of the menstrual cycle; the interval
between ovulation and menstruation is approximately 14 days.
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D. CONCEPTION AND
FETAL DEVELOPMENT
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Terminologies:
Fertilization- union of the sperm and the mature ovum in the outer third
or outer half of the fallopian Tube.
Implantation/ Nidation – immediately after fertilization, the fertilized
ovum or zygote stays in the fallopian tube for 3 days, during which time
rapid cell division (mitosis) is taking place.
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Zonapellucida- inner layer of zygote
•The thick, transparent, non-cellular membrane that encloses
encloses the mammalian ovum.
•It is secreted by the ovum during its development in the
ovary and is retained until nnear the time of implantation.
Corona Radiata- outer layer of zygote
•An aggregate of cells that surrounds the zona pellucid of
the ovum
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Morula- a solid, spherical mass od cells resulting from the cleavage of the
fertilized ovum in the early stages of embryonic development
- Represents an intermediate stage between the zygote and the
blastocyst.
Blastocyst- corpus luteum
- The embryonic form that follows the morula in human
development
- A spheric mass of cells having a central, fluid filled
cavity(blastocele) surrounded by two layers of cells.
- The outer layer (trophoblast) later forms the placenta, the inner
layer (embryoblast) later forms the embryo.
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Trophoblast or Trophectoderm
- Fingerlike projections form around the blastocyst and
this trophoblast are the ones which will implant high on
the anterior or posterior surface of the uterus.
- It is the layer of tissue that forms the wall of the
blastocyst in the uterine wall and in supplying nutrients to
the embryo.
- At implantation the cells differentiate into two layers, the
inner cytotrophoblast, which forms the chorion and the
syncitiotrophoblast, which developd into the outer layer of
the placenta.
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Terms to Denote Fetal Growth
Ovum- female germ cell extruded from the ovary at ovulation.
Zygote- the developing ovum from the time it is fertilized until, as
blastocyst, it is implanted in the Uterus.
Embryo (chick)- the stage of prenatal development between the time
of implantation of the fertilized ovum about 2 weeks after conception
until the end of the 7th or 8th week.
-The period is characterized by rapid growth, differentiation of
the major organ systems, and development of the main external
features.
Fetus- the human being in utero after the embryonic period and the
beginning of the development of the major structural features,
usually from the 8th week fertilization until birth.
Conceptus- the product of conception; the fertilized ovum and its
enclosing membranes at all stages of
intrauterine development, from implantation to birth.
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STAGES OF HUMAN PRENATAL
DEVELOPMENT
Zygote – first 12-14 days
Embryo- from 15th day up to the 8th week
Fetus- from 8th week up to time of birth
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DEVELOPMENT OF EMBRYONIC
AND FETAL STRUCTURES
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MILESTONES OF
FETAL GROWTH AND
DEVELOPMENT
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First Lunar Month
•Germ layers differentiate by the 2nd week
•Fetal membranes appear by the 2nd week
•Nervous system develops rapidly by the 3rd week
•FHR begins to form as early as the 16th day of life.
•Digestive and respiratory tract exist as a single tube
until 3rd week of life when they start to separate
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Second Lunar Month
•All vital organs are formed by the 3rd week;
placenta fully developed
•Sex organs are formed by the 8th week
•Meconium are formed in the intestines by the 5th –
8th week
Third Lunar Month
•Kidneys are able to function- urine is formed by
the 12th week.
•Buds of milk teeth form
•Beginning of bone ossification.
•Fetal swallows amniotic fluid
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Fourth Lunar Month
•LANUGO appears – fine tiny hairs
•Buds of permanent teeth form.
•FHR maybe audible with Fetoscope
•.
Fifth Lunar Month
•VERNIX CASEOSA appears
•Lanugo covers entire body
•QUICKENING felt.
Sixth Lunar Month
•Skin markedly wrinkled
•Attains proportions of full-termed baby
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Seventh Lunar Month
•Alveoli begins to form (28 weeks AOG)
Eight Lunar Month
•FETUS is viable
•LANUGO begins to disappear
•Nails extend to end of fingers
•Subcutaneous fat deposition begins
Ninth Lunar month
•LANUGO and VERNIX CASEOSA disappear
•Amniotic fluid volume somewhat decreases
Tenth lunar month
•All characteristics of the normal newborn
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ASSESMENT OF
FETAL GROWTH
DEVELOPMENT
60

1. Age of gestation (AOG)
A. NAGALE’S RULE
•Calculation of expected date of confinement (EDC)
•Count back 3 months from the first day of the LMP then
add 7days. Substitute number for month for easy
computation
•For example: September 0 –
= 9 – 0 mo – 0 (JUNE)
= 0 + 7 days – 10
= EDC – JUNE 10
B. MCDONALDS METHOD
•Determine AOG by measuring from the fundus to the
symphysis pubis (in cm) then divide by 4-AOG in months
•Example
= Fundic height of 10cm / 4=4 months AOG= 10 weeks
AOG
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2. Measuring fundic Height
A. BARTHOLOMEW’S RULE
•Estimate AOG by the relative position of the uterus in the abdominal cavity
•By the 3rd lunar month, the fundus is palpable slightly above the symphysis
pubis
•On the 5th lunar month the fundus is at the level of the umbilicus
•On the 9th month, the fundus id below the xiphoid process
B. HAASE’S RULE
•Determines the length of the fetus in centimeters
•During the first half of pregnancy, square the number if the month
•(e.g. 1st lunar month 1x1 = 1cm)
•During the second half of the pregnancy, multiply the month by 5
•(e.g. 6th lunar month: 6x5 = 30 cm)
C. JOHNSON’S RULE
•Estimates the weight of the fetus in GRAMS
•FORMULA: fundic height in cm. n x k
•“K” is a constant, it is always 155
•“n” is = 12(if fetus is engaged) = 11(if fetus is not yet engaged)
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FOCUS OF FETAL DEVELOPMENT
1ST Trimester
Period of organogenesis.
2nd Trimester
Period of continued fetal growth and development, rapid
increase in fetal length.
3rd Trimester
Period of most rapid growth and development because of rapid
deposition of subcutaneous fat
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TERATOGENS
64

Maternal Risk factors:
1. German measles (Rubella)
•The risk of maternal & fetal or congenital infection is related
to the trimester of placental infection
•Maternal infection during the first 8 weeks of gestation
carries the highest rate of maternal & fetal infection
2. Sexually transmitted diseases
Syphilis
•My cross the placenta
•Usually leads to spontaneous abortions
•Incidence & mental abnormality
Genital herpes
•May cross placenta
•Fetus contaminated after membranes rupture
or with vaginal delivery
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Gonorrhea
•The fetus is contaminated at the time of delivery
•May result to postpartum infection
•Pneumonia
•Sepsis
Human Immunodeficiency Virus (HIV)
•The virus is transmitted through blood, blood
products, & other bodily fluids such as urine, semen &
vaginal fluid.
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3. Substance Abuse
•Many substances cross the placenta; therefore no drugs, including over
the counter medications should be taken unless prescribed by the
physician
•Substances commonly abused include alcohol, cocaine, crack,
marijuana, amphetamines, barbiturates, & heroin
•Substances abuse threatens normal fetal growth & successful term
completion of the pregnancy
•Substance abuse places the pregnancy at risk for fetal growth
retardation abruption placenta, & fetal bradycardia.
•Physical signs of drug abuse include dilated or constricted pupils,
fatigue, trace marks, skin abscesses, and inflamed nasal mucosa.
•Alcohol during pregnancy may lead to fetal alcohol syndrome & can
cause jitteriness, physical abnormalities, congenital anomalies, & growth
deficits
•Smoking causes vasoconstriction leading to low birth weight babies, a
higher incidence of birth defects & stillbirths
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•Drinking – in moderation is not contra indicated but when
excessive can cause transient respiratory depression in the
newborn and fetal withdrawal syndrome; besides, alcohol
supplies only empty calories.
•Drugs – dangerous to fetus especially during the first
trimester when the placental barrier is till incomplete and the
different body organs are developing
•Thalidomide – causes Amelia or phocomelia
•Steroids – can cause cleft palate and even abortion
•Iodine – causes enlargement of the fetal thyroid gland,
leading to tracheal ecompressin and dyspnea at birth
•Vitamin k – causes hemolysis and hyperbilirubinemia
•ASA and Phenobarbital – causes bleeding disorders.
•Streptomycin and Quinine – cause damage to the 8th cranial
nerve
•Tetracycline – cause staining and tooth enamel
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ADOLESCENT
PREGNANCY
69

Factors that result in adolescent pregnancy
include:
a.) The early onset of menarche
b.) changing sexual behaviors in this age group
c.) faulty family development
d.) poverty
e.) lack of knowledge of reproduction & birth
control
70

The major concerns related t adolescent pregnancy
includes:
1. Poor nutritional status
2. Emotional and behavioral difficulties
3. Lack of support systems
4. Increased risk of still birth
5. Increased risk of maternal complications: such as
hypertension, anemia, prolonge labor & infections
6. Low birth weight newborn infants
7. Fetal mortality
8. cephalopelvic disproportion
71

CAPACITATION – property of the sperm cell to transform
for fertilizing ovum
↓
Hyalorunidase – dissolves the corona radiate
↓
ACROSIN – sperm cell enters the ovum and nucleus 2
sex cells – fertilization
72

FETAL CIRCULATION
73

Fetal Circulation
O2→ unbilical vein → ductusvenosus → Inferior vena cava →
atrum →forameovale → atrium → ventricle → ascending
Aorta → superior vena cava → RAtrum → pulmonary artery →
→ ductusarteriosisus → aorta →hypograstie artery →
placenta
74

STRUCTURE LOCATION
FUNCTION
1. Placenta attached to interus gas
exchange
during fetal life
2. umbilical arteries two arteries in a cord carry in
oxygenated
Blood from fetus
3. umbilical veins one vein in cord carry
oxygenated
Blood in fetus
4. foramen ovale opening in interatrial septum shunt blood
from r-hatrium
5. ductusvenosus accessory vein connecting supply
Umbilical vein into fetal blood to liver
Liver & IVC
6. ductusarteriosus connection between shunting
Fetal lungs & aorta larger portion
blood away
from lungs &
directly into aorta
75

AFTER BIRTH*
1. FO – connects atrium L+R → fossa ovalis
2. U.U – O2 blood fr. Placenta → ligamentumteres
3. UA - unoxygenated blood → umbilical
ligament Fr. Fetus
to placenta
4. DV – O2 blood from UV to IVC → ligament
umvenosum
5. DA – O2 blood from PA to aorta →
ligamentumarteriosum
76

MEDICATION
77

OXYTOTIC MED.
Description: smooth muscle stimulant promotes contraction to
uterus.
Uses: use to induce labor to promote milk let down
A/E: contradiction: initially hypotension leading to rebound HPN
ERGOT ALKALOIDS
•Ergonovine (ergotrate)
•Methylergovine (methergine)
• -after delivery placenta
Description:
↑ Forces & frequency uterine contraction
Use: it prevents post partrum hemorrhage
A/E: HPN / bradycardia
Input: monitor BP & HR
78

UTERINE RELAXANT (tocolytics)
•Ritodrvine (yutopar)
•Terbutaline sulfate
Description: it relaxes uteine muscles
Use: Tx for preferm labor
A/E: maternal tachycardia
Implication: monitor HR mother if ↑1306pm stop ritodrine
PROSTAGLANDINS
•Misoprostol (cytotec)
•Dinoprostone (cervidil)
Description: promotes cervical dilatation if enhances at 2nd
stage of labor
Applied as gel
79

Mg SO4
Description: CNS depressant, uterine relaxant laxative effect
Use: DOC for DIH (pregnancy include HPN)
A/E: toxicity calcium lactate
Antidote: calcium gluconate
Imp.: monitor Mg level, normal 4-7 mg/dl, monitor BP, UO, RR & patellar
reflex
•Pre elampsia- ↑BP, edema
•Eclampsia- ↑BP, anasarca(generalize edema), convulsion
MEPERIDINE HCL (Demerol)
- Narcotic analgesic
Use: ↓pain using labor
A/E: respiratory depression
Antidote: naloxone HCl / narcan
Implication: monitor RR
Teratogenicity cigarettes
Env’tl teratogens
80

E. SIGNS OF
PREGNANCY
81

DIAGNOSIS OF PREGNANCY:
Presumptive Signs – subjective
evidence
Probable Signs – objective
evidence
Positive Signs – absolute evidence
82

83
First
Trimester
PRESUMPTIVE PROBABLE POSITIVE
Amenorrhea
Morning
Sickness
Urinary
Frequency
Enlargement of
Uterus
Chadwick’s
sign
Goodell’s sign
Hegar’s sign
Positive HCG
Elevation of
BBT
Ultrasound
evidence –
12 weeks by
Doppler

SECOND TRIMESTER
PRESUMPTIVE PROBABLE POSITIVE
Quickening ( fetal Kick )
↑skin pigmentation
(chloasma and linea
nigra
Striae Gravidarum
Enlarged abdomen
Braxton Hicks Contraction
( false labor, a painless
uterine contraction)
Ballotement
Fetal Heart Tone – 18-20
weeks by auscultation
Fetal movements felt by
the Examiner at 20 weeks
Fetal outline on X-ray or
Sonography

F. PHYSIOLOGICAL
CHANGES OF
PREGNANCY
85

A. Reproductive Tract Changes:
• UTERUS
Weight increase to about 1000 grams at full term
Hegar’s sign – softening of uterine segment
Operculum – mucus plugs in the cervix that are produced to seal
out bacteria
Goodell’s sign - softening of the cervix
• VAGINA
Chadwick’s sign - bluish discoloration of the vagina
Leukorrhea – increase estrogen leads to ↑ vaginal discharge
Alkaline vaginal pH:
2 microorganisms which thrive in alkaline environment
•Trichomonas
•Candida Albicans
• OVARIES
No changes
No ovulation
Placenta take over the function which supervises estrogen and
progesterone
86

B. INTEGUMENTARY CHANGES:
•Linea Nigra – line running from navel to symphysis
•Melasma or Chloasma – “Mask of Pregnancy”
•Abdominal Wall
•Striae Gravidarum – pink or reddish streaks
C. BREAST CHANGES:
•COLOSTRUM IS FORMED (4th Month)
•Feeling of fullness and tingling sensation
•↑ in size and nipples more erect
•Montgomery gland become more bigger and
protuberant
•Areola becomes more darker and ↑ diameter
•Skin surrounding areola turns dark
87

D. SYSTEMIC CHANGES:
•Circulatory or Cardiovascular
Easy fatigability and SOB
Undue bleeding due to ↑ fibrinogen
Slight hypertrophy of the Heart
Systolic murmurs are common
Epistaxis, palpitation, bipedal edema
Vulva and rectal varicosities
E. GI CHANGES:
 Morning Sickness
 Hemorrhoids
 Heartburn or Pyrosis
 Constipation and flatulence
F. RESPIRATORY CHANGES:
Shortness of Breath
88

G. URINARY CHANGES
•Urinary frequency
• 1st Trimester
d/t ↑ blood supply to the kidneys and uterus rising out
of the pelvic cavity.
•3rd Trimester
d/t pressure of enlarged uterus on the bladder.
H. MUSCULOSKELETAL CHANGES:
•Lordosis – “Pride of Pregnancy”
I. ENDOCRINE CHANGES
•Placenta take over lactogen
•Slight hypertrophy / enlargement of Parathyroid Gland to
supply child calcium
•Slight ↑of the thyroid gland leads to ↑ activity of adrenal
cortex and ↑ production of cortisol anti-diuretic hormone leads
to hyperglycemia.
89

G. PSYCHOLOGICAL
TASKS OF PREGNANCY
90

•First Trimester
Accepting the Pregnancy
The Fetus is unidentified concept with great future
implications but without tangible evidence of reality
•Second Trimester
Accepting the baby
Fetus is perceived as a separate entity
•Third Trimester
Preparing for parenthood
Has personal identification with a real baby about to be
born and realistic plan for future childcare responsibilities
Let pregnant woman listen to the fetal heart sounds
91

H. NURSING CARE
DURING PREGNANCY
92

Health Assessment During First Prenatal Visit:
GRAVIDA – a pregnant woman
Nulligravida = who has never been pregnant
Primigravida = first time pregnancy
Multigravida = 2 or more pregnancies
Grandmultigravida = 5 or more pregnancies
PARTURIENT – woman in labor
PARTURITION/CONFINEMENT – process of labor and
delivery
VIABLE – capable of living, such as fetus that has reached a
stage of development, usually 20-28 weeks, which will permit to
live outside the uterus; dependent on level of technology
93

PARITY – the number of pregnancies in which the fetus have
reached viability, whether the fetus is born alive or its stillborn after
viability is reached does not affect parity
Nullipara = a woman who has not completed a
pregnancy with a fetus that has reached the age of
viability
Primipara = a woman who has completed one
pregnancy with a fetus that has reached the age of
viability
Multipara = a woman who has completed two or
more pregnancy with a fetus to the stage of viability
Grandmultipara = a woman who has completed at least
four pregnancies
94

OB SCORE:
•G – number of pregnancies
•P – number of pregnancies that reached the age of viability
•T – number of babies born at term
•P – number of preterm babies
•A – number of abortions
•L – number of children currently living
•M– number of multiple pregnancies
PRE-NATAL = before birth
PERINATAL = 20th or 28th week of gestation through the end
of the 28th day after birth
POST-NATAL = after birth
PREPARTUM = before delivery
INTRAPARTUM = labor and delivery
95

THE PRENATAL CLINIC:
•Consists of care and supervision given to the woman
throughout pregnancy to ensure the health and well-being of
both the mother and the baby by:
Ascertaining the patient’s general physical condition at
the beginning of the pregnancy.
Preparing the patient psychologically for pregnancy,
labor, delivery and infant care.
The term “antepartal” has been used by some to refer to the
mother and “antenatal” or “prenatal” to refer more
specifically to the fetus.
Prenatal Visits are Scheduled:
Once a month up to the 6th month (28th weeks)
Every two weeks from the 7th or 8th months (28-32 weeks)
Once a week from the 9th month until delivery.
96

97
INITIAL PRENATAL VISIT
• It includes both the diagnosis or verification of
pregnancy and the establishmenteof the data
base for ongoing prenatal care.

A. INTERVIEW
Probability of pregnancy with symptoms noted
Menstrual History
Menarche
Duration and amount of flow
LMP
Obstetric History
OB Scoring
Estimation of AOG based on LMP
Fundic Height
Ultrasonography
Computation of EDC
Outcomes of previous pregnancies
Contraceptive History
Previous major illness
Current health problems and all medications being used
Reaction to pregnancy
98

FETAL HEART TONE
Cephalic presentations, fetal heart sounds are heard loudest midway
between the umbilicus and the anterior superior iliac spine.
In LOA and LOP positions they are heard loudest in the Left Lower
Quadrant; and in ROA and ROP positions they are heard loudest in the
Right Lower Quadrant.
In breech presentation, the fetal heart sounds are heard loudest at the
level of the umbilicus or above.
The normal fetal heart rate is 120 – 160 bpm regular.
PELVIC EXAMINATION
Its purpose is to permit visual and digital examination of the internal
and external genitalia and the pelvic contour.
Nursing Responsibilities:
•Give psychological care.
•Help the mother relax during the procedure.
•Maintain woman in Lithotomy Position. Drape her accordingly and
avoid unnecessary exposure.
•When the examination is complete, assist the mother into sitting
position and then stand.
•Provide wipes for the removal of lubricant.
99

PELVIC MEASUREMENTS
Done only two weeks before EDC
X – ray Pelvimetry – is the most effective method of diagnosing
Cephalopelvic Disproportion (CPD)
URINE EXAMINATIONS
Routine Analysis –to determine pyuria.
Pregnancy test
Analysis for glucose albumin
Heat and Acetic acid test – to determine albuminuria. Albumin
the urine should be reported immediately because it is a sign of
toxemia.
Benedict’s Test – glycosuria, a sign of possible gestational
diabetes.
BLOOD STUDIES
Hemoglobin and hematocrit
Venereal Disease Research Lab (VDRL) or Rapid Plasma Reagin
Test (RPR)
Blood typing and Rhesus factor
Antibody titer for Rubella
Blood sugar
100

PAPANICOLAU SMEARS (CYTOLOGIC EXAMINATION)
To detect abnormalities of cell growth by examining cells and secretions
from the cervix and vagina and to diagnose Cervical Carcinoma/
Classification of Findings:
Class 1 – absence of atypical or abnormal cells
Class 2 – atypical or abnormal cytology but no evidence of
malignancy
Class 3 – cytology suggestive malignancy
Class 4 – cytology strongly suggestive malignancy
Class 5 – conclusive of malignancy
CLINICAL STAGES:
Reflect localization or spread of malignant and cervical changes
Stage 1 – CA confined to cervix
Stage 2 – CA extends beyond the cervix into the vagina, but
not into the pelvic wall or l lower 1/3 of the vagina.
Stage 3 – metastasis to the pelvic wall
Stage 4 – metastasis beyond pelvic wall into the bladder and
rectum.
Speculum placement
101

PHYSICAL EXAMINATION
Vital Signs
Height and Weight
Breast examination
Abdominal examination
Contour of uterus, fundal height
Leopold’s Maneuver
Fetal Heart Rate, if applicable
Vaginal or bimanual examination for changes consistent
with pregnancy
Pap’s smear – done during 1st prenatal visit and 1st
postpartum visit.
LABORATORY TEST
Pregnancy test
CBC
Urine exams for glucose and protein
102

103
• DANGER SIGNS TO BE REPORTED IMMEDIATELY:
• Vaginal Bleeding
• Swelling of the face, fingers and legs
• Severe continuous headache
• Dizziness or blurring of vision
• Flashes of light or dots before eyes
• Abdominal or chest pain
• Persistent vomiting
• Chills and fever
• Sudden escape of vaginal fluids

COMMON
DIAGNOSTIC
PROCEDURES IN MCN
104

1. Assessment of Lochia
To detect the presence of infection and bleeding (side-lying position).
The normal color of lochia is as follows:
•Lochia Rubra (Reddish) – 1 to 3 days postpartum
•Lochia Serosa (Brownish) – 4 to 10 days
•Lochia Alba (Whitish) – 10 to 14 days
The longest possible time for the patient to have lochial discharge can be up to 3 weeks
to sixty days postpartum.
2. Alpha – Protein Levels
Assesses presence of neural tube defects and Dawn’s Syndrome.
3. Amniocentesis
Assesses fetal growth and maturity, determine genetic disorders and sex of fetus.
4. APGAR Scoring
Appearance, pulse, grimace, activity and respiration. At first, it detects the
cardiorespiratory nervous functioning, and the second is used for planning nursing care.
•0 – 3 Poor ( needs resuscitation )
•4 – 6 Fair (needs suctioning and oxygenation )
•7 – 10 Good ( needs only admission care )
105

5. Chorionic Villi Sampling
Determine some genetic aberrations.
6. Contraction Stress Test ( Oxytocin Challenge Test )
Indicates uteroplacental insufficiency and identifies pregnancies at risk
•NEGATIVE RESULT – indicates absence of abnormal deceleration
with all contractions.
•POSITIVE RESULT – indicates FHR abnormal deceleration with all
contractions.
7. Non – Stress Test (NST)
Assess fetal activity and well being .
Types:
•Reactive Test – acceleration of FHR > 15 bpm lasting for 15
seconds and more.
•Non – Reactive Test – acceleration of FHR < 15 bpm may indicate
fetal jeopardy.
8. Coomb’s Test
•Direct – used to test antibodies on patient’s erythrocytes.
•Indirect – used to test antibodies on patient’s serum.
106

9. FHR Monitoring
Assess FHR abnormalities.
•Early Decelerations – indicate fetal head compression, reflects mirror image in
the monitor and no treatment required.
•Late Decelerations – placental insufficiency, reverse mirror image in the
monitor Tx: Administer oxygen.
•Variable Decelerations – cord compression, reflects V/W shape image in the
monitor.
Tx: Change the patient’s position to Left Lateral Recumbent
Position and Administer oxygen.
10. Guthrie Capillary Blood Test
Used to screen Phenylketonuria or PKU
Normal level is 2mg/dl
Provide the patient a high protein diet, 24 – 48 hours before the test.
11. Hysterosalpingography
Determines patency of the fallopian tube and to detect pathology in the uterine
cavity.
12. Laparoscopy
Evaluates pelvic pain and infertility, and treats endometriosis lesions.
NPO before the procedure.
107

13. Mammography
Detects the presence of breast tumor.
14. Self – Breast Exam
Best done a week after the menstruation.
15. Pelvic Ultrasound
Detects abnormalities of the organs in the abdomen.
The patient should ↑ Oral Fluid Intake 30 mins. – 1 hour before the test to
distent the bladder to promote visualization of organs.
16. Percutaneous Umbilical Cord Blood Sampling (PUBS)
Cardiocentesis or Funicentesis
Removal of blood from Umbilical vein using an amniocentesis technique for
analysis
RhoGam is given to Rh negative women to prevent sensitization, since there
is a possibility that the fetal blood could enter the maternal circulation.
The fetus is monitored by NST before and after the procedure.
108

CONDITIONS ASSOCIATED
WITH FIRST TRIMESTER
BLEEDING
109

A. Spontaneous Miscarriage
Spontaneous interruption of pregnancy
Early Miscarriage – before week 16 of pregnancy
Late Miscarriage – between week 16 – 24
TYPES:
•Threatened Miscarriage
•Imminent Miscarriage
•Complete Miscarriage
•Incomplete Miscarriage
•Missed Miscarriage
Early pregnancy failure: Recurrent Pregnancy Loss d/t
•Defective Spermatozoa or Ova
•Endocrine Factors
•Deviations of the Uterus
•Infection and autoimmune disorders
110

B. PREGNANCY
Implantation occurs outside the uterine cavity.
The most common site is in the Fallopian Tube.
Causes:
•Obstruction
•PID
•Smoking
•Use of IUD
C. Abdominal Pregnancy
The placenta continues to grow in the fallopian tube,
spreading perhaps into the uterus for a better blood
supply, or it may escape into the pelvic cavity and
implant on an organ such as intestine.
111

WITH SECOND TRIMESTER
BLEEDING
112

A. Gestational Trophoblastic Disease/
Hydatidiform Mole
Abnormal proliferation and degeneration of the
trophoblastic villi.
B. Premature Cervical Dilatation
Incompetent cervix
Refers to a cervix that dilates prematurely and therefore
cannot hold a fetus until term.
113

WITH THIRD TRIMESTER
BLEEDING
114

A. Placenta Previa
Low implantation of the placenta, a painless vaginal
bleeding.
Low-lying Placenta – implantation on the lower rather than
in the upper portion of the uterus.
Marginal Implantation – the placenta edge approaches
that of the cervical os.
Partial Placenta Previa – implantation that occludes a
portion of the cervical os.
Total Placenta Previa – implantation that totally obstructs
the cervical os.
Causes:
•↑ Parity
•Advanced maternal age
•Past cs birth
•Past uterine curettage
•Multiple gestation
115

B. Abruptio Placenta
Detachment of placenta from the uterus and a painful
vaginal bleeding.
Apparent Hemorrhage – partial separation
Concealed Hemorrhage – complete separation
C. Disseminated Intravascular Coagulation ( DIC )
An acquired disorder of blood clotting in which the
fibrinogen level fails to below effective limits.
It occurs when there is such a extreme bleeding and so
many platelets and fibrin from the general circulation rush to
the site that not enough are left in the rest of the body fur
further clotting.
The high thrombin level continues to encourage
anticoagulation.
116

PROMOTION OF NUTRITIONAL HEALTH DURING
PREGNANCY
•Nutrition
•Women who need special attention
•Pregnant teenagers
•Extremes in weighing scale – low pregnant weight and
obese
•Low income women
•Successive pregnancies
•Vegetarians
Nutritional Assessment is based on taking a diet
history first:
•Food preferences or eating habits
•Cultural or Religious Influences
•Educational or Occupational
117

Computation of Caloric Equivalents:
•CHO x 4
•CHON x 4
•Fats x 9
Food Sources:
•Protein Rich Foods
•Vitamin A
•Vitamin D
•Vitamin E
•Vitamin C
•Vitamin B
•Folic Acid
•Calcium or Phosphorus
•Iron
118

Weight Gain during Pregnancy:
•1st Trimester – 1.5 – 3 lbs is normal
•2nd and 3rd Trimester – 10 – 11 lbs per Trimester is
recommended
•Total allowable weight gain during entire pregnancy – 20- 25
lbs ( 10 – 12 kgs )
Distribution of Weight Gain during Pregnancy:
•Fetus - 7 lbs
•Placenta - 1lb
•Amniotic Fluid - 1 ½ lb
•↑ Uterine weight - 2 lbs
•↑ Blood Volume - 1 lb
•↑ Breast weight - 1 ½ - 3 lbs
•Additional Fluid - 2 lbs
•Fat and Fluid Accumulation - 4 - 6 lbs
•TOTAL = 20 – 25 lbs
119

MALNUTRITION
•Results in prematurity; pre-eclampsias, absorption, low birth
weight babies, congenital defects or even stillbirths.
Normal Pre-pregnancy BMI:
•Underweight = under 18.5
•Normal weight = 18.5 – 24.9
•Overweight = 25 – 29.9
•Obese = above 30
120

COMMON DISCOMFORTS IN
PREGNANCY:
121

First Trimester
Breast Tenderness
Palmar Erythema
Constipation
Nausea, vomiting, and pyrosis
Fatigue
Muscle cramps
Hypotension
Varicosities
Hemorrhoids
Palpitations
Frequent urination
Abdominal discomfort
Leukorrhea
Second and Third Trimester
Backache
Headache
Dyspnea
Ankle edema
Braxton Hicks Contraction
122

HEALTH PROMOTION
DURING PREGNANCY
123

124
• Self-care needs:
• Dental care
• Perineal care
• sexual activity
• Exercise such as Kaegel’s Exercise
• Taylor Sitting

Preparations for Childbirth and Parenting:
“ Gate Control of Pain”
Premises:
-Discomforts during labor can be minimized if the
woman comes into labor informed about what is happening
and prepared with breathing exercises to use during labor.
- Discomforts during labor can be minimized if the
woman’s abdomen is relaxed and the uterus is allowed to rise
freely against the abdominal wall during contractions.
125

Major approaches to Prepared Childbirth
Grantly – Dick Read Method
- Fear leads to tension and tension leads to pain
- Breathing techniques
Lamaze
•Psychoprophylactic Childbirth
•Based on stimulus response conditioning. To be effective, full
concentration on breathing exercises during labor should be
observed, mouthing silently words or songs with rhythmical
tapping of fingers.
Leboyer Method
•the contrast of uterine environment and the external world
causes infant to suffer psychological shock at the time of delivery
•relaxing the craniosacral axis.
126

I. LABOR AND
DELIVERY
127

Theories of Labor Onset
Uterine Stretch Theory – any hollow body organ when stretched
to capacity will necessarily contract and empty.
Oxytocin Theory – labor, being considered a stressful event
stimulates the hypophysis to produce oxytocin from the posterior
pituitary gland. Oxytocin causes contraction of the smooth muscles
of the body.
Progesterone Deprivation Theory – progesterone, being the
hormone designed to promote pregnancy, is believed to inhibit
uterine motility. Thus, if its amount decreases labor pain occurs.
Prostaglandin Theory – initiation of labor is said to result from the
release of arachidonic acid produced by steroid action on lipid
precursors. Arachidonic acid is said to increase prostaglandin
synthesis, which in turn causes uterine contractions.
Theory of Aging Placenta – because of the decrease in blood
supply, the uterus contracts.
128

SIGNS OF LABOR
129

Preliminary Signs/ Prodromal Signs of Labor
1. Lightening – refers to the settling of the fetal head into the pelvic
brim. It results in increase in urinary frequency, relief of abdominal
tightness and diaphragmatic pressure, shooting pains down the legs
because of pressure on the sciatic nerve.
2. Engagement – occurs when the presenting part has descended into
the pelvic inlet.
3. Increase activity level
4. Loss of weight
5. Braxton Hicks Contraction – painless, irregular practice contractions.
6. Ripening of the Cervix – from Goodell’s sign, the cervix becomes
“butter- soft”.
7. Rupture of the Membranes – BOW ruptured, integrity of the uterus is
already destroyed.
8. Show – due to pressure of the descending presenting part of the fetus
which causes rupture of minute capillaries in the mucus membrane of
the cervix. It is only Pinkish Vaginal Discharge.
130

Uterine Contractions
 The surest sign that labor has begun is the initiation of
effective, productive uterine contractions
Phases:
•INCREMENT – first phase which the intensity of
contraction increase, also known as CRESCENDO.
•ACME – the height of the uterine contraction; also known
as APEX
•DECREMENT – last phase during which intensity of
contraction decreases; also known as DECRESCENDO.
131

False Labor Pains True Labors
1. Remain irregular of
uterine contraction.
1. Maybe slightly irregular at first but become regular and
predictable in a matter of hours. (3-4 contraction every 2hours)
2. Generally confined to
the abdomen.
2. First felt in the lower back and sweep around to the abdomen in a
girdle-like fashion.(circle movement)
3. No increase in
duration, frequently and
intensity
3. Increase in duration, frequency and intensity.
4. Often disappears if the
woman
ambulates/walking.
4. Continue no matter what the woman’s level of activity is being
done.
5. Absent cervical
changes
5. Accompanied by cervical effacement and dilatation. (thinning of
the cervical)
Effacement
•Shortening and thinning of the cervical canal as district from the uterus.
Dilatation
•Enlargement of the external cervical os up to 10cm primarily as a result of uterine contractions and
secondarily as a result of pressure of the presenting part and the BOW.
Differences between False and True Labor Pains
132

LENGTH
OF
NORMAL
LABOR
Stage of Labor Primis Multis
First Stage 12 ½
hours
7 hours,
20
Second Stage 80
minutes
30
minutes
Third Stage 10
minutes
10
minutes
TOTAL 14
minutes
8 hours

COMPONENTS OF LABOR
Passage
Passenger
Power
134

STAGES OF LABOR
135

A. First Stage (Stage of Dilatation)
begins with true labor pains and ends with complete
dilatation of the cervix.
Power/ Forces: involuntary uterine contractions
3 PHASES (LAT)
•Latent – early in time labor
•Cervix dilates only 3-4cm. Contractions are of short
duration and occur regularly 5-10 minutes apart.
•Active/ Accelerated
•Cervical Dilatation reaches 4-8cm. Rapid increase n
duration, frequency and intensity of constractions.
•Transition Period
•When the mood of the women suddenly changes and
the nature of the contractions intensify.
136

B. Second Stage (Stage of Expulsion)
Begins with complete dilatation of the cervix and ends with
the delivery of the baby.
Power/ Forces: Involuntary uterine contractions and
contraction of the diaphragmatic and abdominal muscles.
Mechanisms of Labor/ Fetal Position Changes (ED FIRE ERE)
•Engagement
•Descent – maybe preceded by engagement.
•Flexion – as descent occurs, pressure from the pelvic floor
causes the chin to bend forward onto the chest.
•Internal Rotation – from AP to transverse, then AP to AP.
•Extension – as head comes out, the back of the neck stops
beneath the pubic arch. The head extends and the forehead,
nose, mouth and chin appear.
•External Rotation (also called as the Restitution) – anterior
shoulder rotates externally to the AP position.
•Expulsion – delivery of the rest of the body.
137

•C. Third Stage (Placental Stage)
begins with the delivery of the baby and ends with the
delivery of the placenta.
•Signs of Placental Separation
•Calkin’s Sign – the earliest sign of placental separation.
•Sudden gush of blood from the vagina.
•Lengthening of the cord.
•Types of Placental Delivery
Schultz – if placenta separates first at its center and last at its
edges, it tends to fold on itself like an umbrella and presents
the fetal surface which is shiny (SHINY for SCHULTZ), 80% of
placentas separate in this manner.
Duncan – if placenta separates first at its edges, it slides
along the uterine surface and presents with the maternal
surface, which is raw, red, beefy and dirty (DIRTY for DUNCAN).
Only about 20% placentas separate this way.
138

D. FOURTH STAGE
•First 1 – 2 hours after delivery, which is
said to be the most critical stage for the
mother because of unstable VS.(Blood
Pressure)
139

First Stage
•Station – relationship of the fetal presenting part
to the level of the ischial spines
•Station 0 – at the level of the ischial spines,
synonymous to engagement
•Station -1 – presenting part above the level of
the ischial spines.
•Station +1 – presenting part below the level of
the ischial spines.
•Station +3 or +4 – synonymous to crowning
encircling of the largest diameter of the fetal
head by the vulvar ring.
140

PRESENTATION
•Relationship of the long axis of the mother to the long axis of
the fetus; Also known as LIE
1. VERTICAL
•Cephalic – head is the presenting part
•Vertex – head is sharply flexed, making the parietal bones the
presenting parts.
•In poor flexion – face, brow, chin (MENTUM)
•Breech – buttocks are the presenting parts.
•Complete – thighs are flexed on the abdomen and legs are on
the thighs.
•Frank – thighs are flexed and legs are extended, resting on the
anterior surface of the body.
Footling
Single – one leg unflexed and extended; one foot presenting.
Double – legs unflexed and extended; feet are presenting.
141

2. HORIZONTAL
•Transverse Lie
•Shoulder Presentation
142

POSITION
•Relationship of the fetal presenting
presenting part to a specific
quadrant in the mother’s pelvis.
143

POSSIBLE FETAL
POSITIONS
144

Vertex
LOA – left oxipitoanterior – most
favorable
LOP – left oxipitoposterior
LOT – left oxipitotransverse
ROA – right oxipitoanterior
ROP – right oxipitoposterior
ROT – right oxipitotransverse
BREECH
LSA – left sacroanterior
RSA – right sacroanterior
LSP – left sacroposterior
RSP – right sacroposterior
LST – left sacrotransverse
RST – right sacrotransverse
FACE
LMA – left mentoanterior
LMP – left mentoposterior
LMT – left mentotransverse
RMA – right mentoanterior
RMP – right mentoposterior
RMT – right mentotransverse
SHOULDER
LADA – left acromiodorsoanterior
LADP – left
acromiodorsoposterior
RADA – right
acromiodorsoanterior
RADP – right
acromiodorsoposterior
145

NURSING CARE DURING LABOR
Monitoring and evaluating important aspects like uterine
contraction (duration, interval, frequency and intensity), BP,
FHT.
Emotional support is provided for the women in labor.
Health Teachings – Bath, Ambulation, NPO, Enema
Encourage the mother to void every 2 – 3 hours by offering
the bedpan.
Perineal prep done aseptically and perineal shave.
Encourage Sim’s Position.
Woman in labor should not be allowed to push or bear
down unnecessarily during contractions of the first stage.
Abdominal Breathing
Administer analgesics as ordered.
Assist in administration of original anesthesia.
146

Transition Period
•Nursing Actions are primarily comfort measures.
•Sacral Pressure relieves discomfort from contractions.
•Proper bearing techniques.
•Controlled chest breathing during contractions.
•Emotional support.
Second Stage
•When positioning legs on lithotomy, put them up at the
same time to prevent injury to the uterine ligaments.
•As soon as the fetal head crowns, instruct mother not to
push, but to pant (rapid and shallow breathing to prevent
rapid expulsion of the baby).
•Assist in episiotomy (incision made in the perineum primarily
to prevent lacerations).
147

Types of Episiotomy
•Median – from middle portion of the lower vaginal border directed toward the anus.
•Mediolateral – begun in the midline but directed laterally away from the anus.
•Often done because it prevents 4th degree laceration should it occur despite
episiotomy.
Natural Anesthesia
Apply the Modified Ritgen’s Maneuver
Immediately after delivery, the newborn should be held below the level of the mother’s
vulva for a few minutes to encourage flow of blood from the placenta to the baby.
The infant is held with his head in a dependent position to allow for drainage of secretions.
Wrap the baby in a sterile towel to keep him warm. Chilling increases the body’s need for
oxygen.
Put the baby on the mother’s abdomen. The weight of the baby will help contract the
uterus.
Cutting the cord is postponed until the pulsations have stopped because it is believed that
50 – 100ml. of blood is flowing from the placenta to the baby at this time. After cord
pulsations have stopped, clamp it twice, an inch apart and then cut in between.
Show the baby to the mother, inform her of the sex and time of delivery then give the baby
to the circulating nurse.
148

Third Stage
Do not hurry the expulsion of the placenta by forcefully pulling out the cord or
doing vigorous fundal push as this can cause uterine inversion.
Tract the cord slowly, winding it around the clamp until the placenta spontaneously
comes out, slowly rotating it so that no membranes are left inside the uterus, a
method called BRANDT – ANDREWS MANEUVER.
Take note of the time of placental delivery.
Inspect for completeness of cotyledons; any placental fragment retained can also
cause severe bleeding and possible death.
Palpate the uterus to determine degree of contraction.
Inject oxytocin (Methergin=0.2mg/ ml or Syntocinon=10U/ ml) IM to maintain
uterine contractions, thus preventing hemorrhage. NOTE: OXYTOCIN are not given
before placental delivery.
Inspect the perineum for lacerations.
Make mother comfortable by perineal care and applying clean sanitary napkin
snugly to prevent its moving forward from the anus to the vaginal opening.
Position the newly delivered mother flat on bed without pillows to prevent
dizziness due to decrease in intra abdominal pressure.
The newly delivered mother may suddenly complain of chills due to decreased BP,
fatigue or cold temperature in the delivery room.
NSG. INTERVENTION: Provide addition blankets to keep her warm.
May give initial nourishment.
Allow patient to sleep in order o regain lost energy.
149

Fourth Stage
•Assessment of the fundus, lochia, bladder, perineum, BP
and PR.
•Lactation - suppressing agents, estrogen, androgen
preparations given within the first hours postpartum to
prevent breast milk production on mothers who will not
breastfeed.
•Rooming – In Concept (Giving the baby to the mother)
•Lochia Assessment
150

J. PUERPERIUM
151

Terminologies:
Puerperium/ Postpartum
a) Refers to the 6 week after delivery of the baby.
b) Involution – return of the reproductive organs to their
pregnant state.
PHASES OF PUERPERIUM
a) Taking in phase (2 – 3 days)
• “Woman is largely passive”
• Is a time reflection
• A time when the new parent review their pregnancy,
labor and birth.
b) Taking Hold Phase
• “Woman initiates action”
c) Letting Go Phase
• “The woman finally redefines her new role”, she gives
up the fantasized image of her child and accepts the
real one. She gives up her old role of being childless
152

MATERNAL NEWBORN ATTACHMENT
Bonding – breast feeding
Mother – “claiming”
En face position
Father – “engrossment”
Rooming – In
Sibling visitation
A chance to visit the hospital and see the new baby
and their mother, reduces feeling that their mother cares
more about the new baby.
It helps relieve from impact of separation.
153

MATERNAL CONCERNS AND FEELINGS IN THE
POSTPARTAL PERIOD
Abandonment
Disappointment
Postpartum blues
Labile mood and affect
Crying spells
Sadness
Insomnia
Anxiety
154

PHYSIOLOGIC CHANGES DURING PUERPERIUM
1. Systemic changes
2. Reproductive System Changes
155

a. Vascular Changes
30%-50% increase in cardiac volume for 5-10 minutes after
placental delivery
Activation of the clotting factors, which encourages
THROMBOEMBOLIZATION
*massage is not advisable
156

b. Genital Changes
Uterine involution- measure the fundus using fingerbreath
Knee-chest position
Afterpains/ afterbirth pain- abdominal pain for large baby, twin delivery, etc.
•For breastfeeding mothers, it last for not more than 3 days
•Heat packs- not advisable
Lochia- blood, residues, bacteria, mucous
-Increase activity= increase lochia
- breastfeeding= decrease lochia
•Pattern of Lochia
a) Lochia Rubra- red, 1-3 days, moderate amount
b) Lochia Serosa- 4-6 days, lower amount than in lochia rubra
c) Lochia Alba- 10-14 days or up to 6 weeks, minimal amount
Characteristics of Lochia:
•Pattern should not reverse.
•It should approximate menstrual flow.
•It should not have any offensive odor.
•It should not contain large clots.
•It should never be absent regardless of method of delivey.
•Pain in the perineal region may be relieved by Sim’s position.
157

c. Urinary Changes
Marked dieresis within 12 hours postpartum
Frequent urination- small amount/ scanty
d/t urinary retention overflow
d. GI Changes
Decreased muscle tone
Lack of food + enema during labor
Dehydration
Fear of pain from perineal tenderness
e. Vital Signs
Temperature may be increased
Bradychardia is common for 6-8 days
There’s no change in the respiratory rate.
158

NURSING CARE DURING THE PUERPERIUM
•Promote healing and return to normal (involution) of
different parts of the body
•Provide emotional support
•Prevent postpartum complication
159

POSTPARTUM COMPLICATION:
1. PP Hemorrhage- blood loss of more than 500 cc during delivery
*normal: 250-350 cc
a.early- 1st 24 hours
•Causes: uterine atony, laceration, hypofibrinogenemia
•Uterine Atony- boggy/relaxed uterine
CAUSES:
1. CS
2. Over distention of the uterus
3. Placental accidents
4. Prolonged/difficult labor
NURSING ACTIONS:
1. Massage the fundus (milking massage)
2. Ice compress (abdominal area)
3. Oxytocin administration
4. Empty the bladder
5. Bimanual compression
6. Hysterectomy
•Hypofibrinogenemia- d/o of clotting factors
*administer BT
160

2. PP Infection
Establish successful lactation
161

K. IMMEDIATE CARE OF
THE NEWBORN
162

Suctioning- 5-10 seconds to prevent hypoxia
- mouth first before nose to prevent vagal stimulation that
leads to bradychrdia
Establish and Maintain Patency of Airway- cover nostril one at a time
Positioning- slight trendelenburg, side lying but avoid prone position
(promotes drainage,prevents increase ICP, promotes closure of
foramen ovale and ductus arteriosus, prevents aspiration)
*Signs of Increased ICP:
•High pitch, high shrill cry
•Spontaneous vomiting
•Bregma and Lambda are bulging and very dense
•Increased BP
•Decreased CR & RR
•Widening of pulse pressure
Maintain Appropriate Temperature- normal temp is 36.4˚C -37.2˚C
*Temperature is unstable but stabilizes in 6-8 hours
163

SECOND PERIOD OF REACTIVITY
•Immature hypothalamus
•Inadequate brown fat
•Shivering mechanism is underdeveloped
*Babies are born wet (more heat loss)
Evaporation
Radiation
Convection
Conduction
Nursing Care:
Dry once
Wrap
Expose to drop light
Encourage the mother to cuddle and embrace the baby
Complications:
•Hypoglycemia- d/t use of glucose
•Metabolic acidosis
164

FIRST PERIOD OF REACTIVITY
•Methods:
1. Breastfeeding- best method
Other Purpose:
i. Colostrum- first milk
- high protein-LACTOGLOBULIN, high
antibody-IgA, high WBC, macrophages and Lactoferin
- these protect infant against bacterial
and viral infections of the respiratory and GI systems
- high levels of vitamins ABCDE, low levels
of CHO and COOH
ii. Promotes uterine contraction
iii. Prevents physiologic jaundice- ICTERUS
NEONATORUM d/t stimulation of gastrocolic reflex
*bilirubin- responsible for jaundice
165

Rooming-in:
a) Complete- mother and child are together 24 hour a
day
b) Partial- infant remains in the woman’s room for most
of the time (8AM-9PM) but he/she is taken to a small
nursery near the woman’s room for the night
3. Senses stimulation:
a) Touch and hearing- highly developed
b) Sight and smell- least developed but one of the best
methods to promote bonding
166

ASSESSMENT:
•APGAR Scoring Test by Virginia Apgar
Assess general condition of infant
Done twice at 1 & 5 mins.
Determine the degree of acidosis and the need for CPR
To evaluate ability of the NB to adjust extrauterinely and the
prognosis
Score Interpretation
•0-3: poor, serious or severely depressed; needs immediate CPR
•4-6: fair, guarded or moderately depressed; needs further
observation and suctioning
•7-10: good of healthy
**therefore: the higher the Apgar score, the better
167

IDENTIFICATION
•Best accomplished before transfer to
the nursery ( footprints, ID bands,
birthmarks )
168

CARE OF THE NEWBORN IN THE NURSERY
•Recheck ID
•Take the temperature initially- per rectum to determine
anal patency (primary reason)
•Complications related to frequent rectal temperature
taking:
• Perforation of the mucous membrane
• Vagal stimulation
•Special initial care:
a. Initial bath- best done with temperature of the NB
stable or at least 37˚C
Water with non-alkaline soap- prevent the
destruction of the acid mantle of the skin
Oil- appropriate in case vernix caseosa is plenty
Anti-microbial solution- most preferred in NB of
mothers with infections in the vaginal canal:
Trichomoniasis, Candidiasis, STD, Gonorrhea
169

b. Cord dressing
Done with strict aseptic technique practices
Include application of CORD CLAMP- prevent
OMPHALANGIA (bleeding)
Include application of ANTISEPTIC SOLUTIONS:
•Povidone Iodine- Betadine (prevents Tetanus
Neonatorum
•Alcohol 70%- prevents Omphalitis
Inspect the blood vessels (2 arteries and 1 vein), in case 1
of the arteries is absent indicates a congenital disorder of
possibly the GIT, CV % GUT
**Cord falls on 7th-10th day
c. Credes Prophylaxis- Ophthalmic Ointment
-Prevent or prophylactic treatment against
OPHTHALMIA NEONATORUM
170

MEDICATIONS:
•Ophthalmic drops- Silver Nitrate 1%
•Ophthalmic ointment
Teramycin- most common
Erythromycin- Chlamydia infections, 4 days
Vit. K injection- left vastus lateralis, prevent bleeding
PHYTONADIONE- Aquamephyton
PHYTOMENADIONE- Konakion
Full term- 1 mg
Preterm- 0.5 mg
Amt- 0.05-0.1 ml
Route- IM
Site- Vastus Lateralis (prevent injury to sciatic nerve
that may lead to paralysis
171

ANTHROPOMETRIC MEASUREMENTS:
Birth weight- normally 2.5 kg to 3.4 kg or 5.5 lbs to 7.8 lbs
Birth length- normally 47.5 to 53.75 cm
Like the BW the BL:
Increases by 50% at age of 1 year
Doubles at 2 years (length at 2 years is half of adult height)
Average of 50 cm at birth
***Note: children under 24 mos- take the RECUMBENT HEIGHT in supine
Children over 24 mos- take height in standing position
Head circumference- 33-35 cm or 13-14 inches
HC < 32 cm- Microcephaly
HC > 37 cm- Macrocephaly
No fetal skull- Anencephaly
Chest circumference- 31-33 cm or 12-13 inches
Abdominal circumference- 29-31 cm or 11-12 inches
172

PHYSICAL ASSESSMENT
•Vital signs- PR/CR & RR
*RR: 30-60/min; 80/min at birth
> rapid, irregular with normal physiologic apnea of less than 15 seconds
Note: observe signs and symptoms of respiratory distress
•Tachypnea
•Bradypnea
•Nasal flaring
•Retractions
•Expiratory grunt
*PR: 120-160/min; at birth- 180/min
Characteristics:
Rapid, irregular
Increases with activity & as low as 100/min when asleep
SITES:
•Apical pulse- most preferred for children under 3 y/o
•Brachial pulse- site to check pulsation in case CPR is necessary
•Femoral pulse
•Pedal pulse
•Radial pulse- common site for children over 3 y/o
173

*Temperature: at birth 36.4- 37.2˚C
Characteristics:
Unstable
Stabilize between 6-8 hours known as the 2nd
period of reactivity
*Blood Pressure: at birth- 80/46 mmHg; at 10th day
100/50 mmHg
Methods:
•Doppler
•Flush- normally 60 mmHg
174

Head- largest part of the body & ¼ of the total length.
Assess the following:
Fontanels (soft spot):
normally 6 in number
2-paired: Anterolateral & Posterolateral
2 single: Anterior (Bregma) & Posterior (Lambdoid)
a) Anterior- closes between 12 mos- 18 mos, diamond
shaped, 3-4 cm long and 2-3 cm wide. *if >5cm: sign of
Cretinism/ Congenital Hypothyroidism.
b) Posterior- triangular shaped, center of the 3 sutures,
closes between 6 weeks- 12 weeks or 3-4 months,
measures 1x1 cm
Assess further for:
a) Bulging- increased ICP
b) Depressed- dehydration
c) Craniostenosis or Craniosynostosis
Complications:
•Increase ICP
•Mental Retardation
175

Other Structures:
Caput Succedaneum
Affects both hemisphere
Swelling of the sculp
Disappears on or before 3rd day
Cephalhematoma
Collection of blood
Caused by increase pressure of birth
Rupture of periosteal capillaries
Disappears in 3-4 weeks
Craniotabes
 Localized softening of cranial bones
 Caused by early lightening (2wks for primis and 1 day for
multis)
 Disappears in 6 wks
Eyes- NB usually cry tearlessly, because their lacrimal ducts do not
mature until about 3 months of age.
176

L.
BREASTFEEDING

Physiology of Breastmilk Production
•Estrogen and progesterone levels after placental
delivery- stimulates APG to produce PROLACTIN-
acts on acinar cells to produce foremilk- stored in
collecting tubules.
•When infant sucks- PPG is stimulated to produce
OXYTOCIN- causes contraction of smooth muscles
of collecting tubules- milk ejected forward, LET-
DOWN /MILK EJECTION REFLEX- hindmilk is
produced.
178

Patient teaching:
Line bra with soft cotton, never use plastic lining.
Let nipples air dry 5-15 mins before replacing bra
Wash breasts with water, if soap is used, rinse completely
Use well fitting supportive bra
Avoid using harsh cleanser
Use a breast pump
A tingling sensation is often felt just before leakage begins.
Well balanced diet
It takes about two days for the infant to establish a sucking pattern.
Colostrums will be secreted initially and the infant should be encouraged to
take it.
Milk appears 48-96 hours after delivery.
Teach positions for burping the baby, upright, across lap, or on shoulder
Fluid intake of at least 3000 ml/day
Teach the mother to bring the infant to breast, not pulling the breast to the
infant
Teach mother to support the infant’s head while feeding such as the cradle or
the football hold.
179

Associated Nursing Diagnosis
•Anxiety
•Breastfeeding, ineffective
•Infant feeding pattern, ineffective
•Knowledge deficit
•Breastfeeding, effective
•Nutrition: Less than body requirements, altered
Associated Problems
•Engorgement- feeling of tension on the breasts during the 3rd
postpartum day sometimes accompanied by fever.
•Sore nipples
Associated problems:
•Mastitis- localized pain, swelling and redness, lamps in the
breast and milk becomes scanty.
•Nutrition
Lactating mothers should take 3000 calories daily and should
have larger amounts of CHON (96 g/day), Ca, Fe, Vit. A, B & C.
180

BREASTFEEDING
•Best for babies
•Reduces the incidence of allergies
•Economical
•Antibodies, greater immunity
•Stool inoffensive
•Temperature is always ideal
•Fresh milk never goes off
•Emotional bonding
•Easy once established
•Digested easily with 2-3 hours
•Immediately available- no mixing req’ts
•Nutritionally optimal
•Gastroenteritis greatly reduced
Additional notes:
•Ambulation
a) 4-8 hours after NSD
b) 24 hours after CS
•Return of sexual activity: 3rd-4th week postpartum
•Menstruation returns: 8th week
181

MATERNAL AND CHILD HEALTH NURSING

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