MATERNAL AND CHILD

HEALTH NURSING
Prepared by:
Orlan Defensor Balano RN, MAN©
HUMAN SEXUALITY
CONCEPTS

A person’s sexuality encompasses the

complex behaviors, attitudes emotions and
preferences that are related to sexual self
and eroticism.
Sex – basic and dynamic aspect of life
During reproductive years, the nurse
performs as resource person on human
sexuality.
 DEFINITIONS RELATED TO SEXUALITY:

 Gender identity – sense of femininity or masculinity

 2-4 yrs/3 yrs gender identity develops.
 Role identity – attitudes, behaviors and attributes that
differentiate roles
 Sex – biologic male or female status. Sometimes referred to a
specific sexual behavior such as sexual intercourse.
 Sexuality - behavior of being boy or girl, male or female man/
woman. Entity life long dynamic change.
 developed at the moment of conception.
SEXUAL ANATOMY AND PHYSIOLOGY

A. Female Reproductive System

1. External value or pretender
a. Mons pubis/veneris - a pad of fatty tissues
that lies over the symphysis pubis covered by
skin and at puberty covered by pubic hair that
serves as cushion or protection to the symphysis
pubis.
 STAGES OF PUBIC HAIR DEVELOPMENT

Tannerscale tool - used to determine sexual maturity rating.

Stage 1 – Pre-adolescence. No pubic hair. Fine body hair
only
Stage 2 – Occurs between ages 11 and 12 – sparse, long,
slightly pigmented & curly hair at pubis symphysis
Stage 3 occurs between ages 12 and 13 – darker & curlier
at labia

Stage 4 – occurs between ages 13 and 14, hair
assumes the normal appearance of an adult but is
not so thick and does no appear to the inner
aspect of the upper thigh.
Stage 5 sexual maturity- normal adult- appear
inner aspect of upper thigh .
B. Labia Majora - large lips longitudinal fold, extends
symphisis pubis to perineum
C. Labia Minora – 2 sensitive structures
 clitoris- anterior, pea shaped erectile tissue with lots
sensitive nerve endings sight of sexual arousal (Greek-key)
 fourchette- Posterior, tapers posteriorly of the labia
minora- sensitive to manipulation, torn during delivery.
 Site – episiotomy.
 Vestibule – an almond shaped area that contains the
hymen, vaginal orifice and bartholene’s glands.
 Urinary Meatus – small opening of urethra, serves for
urination
 Skenes glands/or paraurethral gland – mucus secreting
subs for lubrication
 hymen – covers vaginal orifice, membranous tissue
  vaginal orifice – external opening of vagina
 bartholene’s glands- paravaginal gland or vulvo vaginal
gland -2 small mucus secreting subs – secrets alkaline
subs.
 Alkaline – neutralizes acidity of vagina
 Ph of vagina - acidic
 Doderleins bacillus – responsible for acidity of vagina
 Carumculae mystiformes-healing of torn hymen
Perineum – muscular structure – loc – lower
vagina & anus
Internal:
A. vagina – female organ of copulation,
passageway of mens & fetus, 3 – 4inches or 8 – 10
cm long, dilated canal
Rugae – permits stretching without tearing

B. uterus- Organ of mens is a hollow, thick walled
muscular organ. It varies in size, shape and
weights.
Size- 1x2x3
Shape: nonpregnant pear shaped / pregnant -
ovoid
Weight - nonpregnant – 50 -60 kg- pregnant –
1,000g
PREGNANT/ INVOLUTION OF UTERUS:

4th stage of labor - 1000g

2 weeks after delivery - 500g
3 weeks after delivery - 300 g
5-6 weeks after delivery - returns to
original, state 50 – 60
THREE PARTS OF THE UTERUS

fundus- upper cylindrical layer

corpus/body- upper triangular layer
cervix- lower cylindrical layer
* Isthmus lower uterine segment during
pregnancy
Cornua-junction between fundus &
interstitial
INTERNAL GENITALIA
 MUSCULAR COMPOSITIONS:

 1. Endometrium- inside uterus, lines the nonpregnant uterus. Muscle layer

for menstruation. Sloughs during menstruation.
 Decidua- thick layer.
 Endometriosis-proliferation of endometrial lining outside uterus.
Common site: ovary.
 S/sx: dysmennorhea, low back pain.
 Dx: biopsy, laparoscopy
 Meds: 1. Danazole (Danocrene) a. to stop mens b. inhibit ovulation
 2. Lupreulide (Lupron) –inhibit FSH/LH production
2. Myometrium – largest part of the uterus,
muscle layer for delivery process
Its smooth muscles are considered to be the
living ligature of the body.
Power of labor, resp- contraction of the uterus
3. Perimetrium – protects entire uterus
 C. ovaries – 2 female sex glands, almond shaped. Ext- vestibule int
– ovaries
 Function:
 1. ovulation
 2. Production of hormones
 d. Fallopian tubes – 2-3 inches long that serves as a passageway
of the sperm from the uterus to the ampulla or the passageway of
the mature ovum or fertilized ovum from the ampulla to the
uterus.
4 SIGNIFICANT SEGMENTS

1. Infundibulum
2. Ampulla
3. Isthmus
4. Interstitial
MALE REPRODUCTIVE SYSTEM
MALE REPRODUCTIVE ORGANS
1. EXTERNAL

 penis – the male organ of copulation and urination. It contains of

a body of a shaft consisting of 3 cylindrical layers and erectile
tissues. At its tip is the most sensitive area comparable to that of
the clitoris in the female – the glands penis.
 Scrotum – a pouch hanging below the pendulous penis, with a
medial septum dividing into two sacs, each of which contains a
testes.
 cooling mechanism of teste
 < 2 degrees C than body temp.
 Leydig cell – release testosterone
2. INTERNAL
INTERNAL GENITALIA
 PROCESS OF SPERMATOGENESIS

 Testes – main reproductive organ

 Epididymis – 6 cm long; site or sperm maturation
 Vas deferens – Conduit or pathway of spermatozoa
 Seminal vesicle – secretes fructose, prostaglandin
 Ejaculatory duct
 Prostate gland
 Cowper’s gland
 Urethra
 MALE AND FEMALE
EQUIVALENCE
MALE FEMALE
Scrotum Labia minora
Glans penis Glans Clitoris
Penile shaft Clitoris Shaft
Testes Ovaries
Prostate Gland Skene’s gland
Cowper’s gland Bartholin’s gland
MALE FEMALE
FSH LH FSH LH
Maturation of Testosterone Maturation of Hormone for
sperm production ovum ovulation

Leydig’s cells Cortex of the

ovary
FUNDAMENTALS OF GENETICS AND
OBSTETRICS
 FUNDAMENTAL CONCEPTS

 DNA – carries genetic information

 Chromosomes – thread like strands composed of hereditary
materials
 Genes – small segment of DNA
 Normal ejaculated sperm: 3 – 5 cc or 1 tsp
 Ovum
 fertilized: 24 – 46 hours after ovulation
 Sperm
 48 – 72 hours or 2 – 3 days
Process of maturation of sperm is called:
Spermatogenesis – results in 4 sperms
Process of maturation of ovum
Oogenesis
Fomation of 2 haploids into diploid
Gametogenesis
Mitosis – cell division resulting in 46 chromosomes
MEIOSIS
Reproductive age: 15 – 35
High risk pregnancy: <18 and >35 years old
Ideal age of child bearing: 20 – 30
Phenotype
Karyotype
MENSTRUATION

Menstrual Cycle – beginning of mens to

beginning of next mens
Average Menstrual Cycle – 28 days
Average Menstrual Period - 3 – 5 days
Normal Blood loss – 50cc or ¼ cup
RELATED TERMINOLOGIES:

Menarche – 1st mens

Dysmenorrhea – painful mens
Metrorrhagia – bleeding between mens
Menorhagia – excessive during mens
Amenorrhea – absence of mens
Menopause – cessation of mens/ average : 51
years old
FUNCTIONS OF ESTROGEN AND PROGESTIN
 ESTROGEN
“HORMONE OF THE WOMAN”
 Primary function: development secondary sexual characteristic
female.
 Others:
 inhibit production of FSH ( maturation of ovum)
 hypertrophy of myometrium
 Spinnbarkeit & Ferning ( billings method/ cervical)
 development ductile structure of breast
 increase osteoblast activities of long bones
increase in height in female
causes early closure of epiphysis of long bones
causes sodium retention
increase sexual desire
 PROGESTIN/ PROGESTERONE
“ HORMONE OF THE MOTHER”

 Primary function: prepares endometrium for

implantation of fertilized ovum making it thick & tortous
(twisted)
 Secondary Function: uterine contractility (favors
pregnancy)
 Others: 1.inhibit prod of LH (hormone for
ovulation)
 2.inhibit motility of GIT
3. mammary gland development
4. increase permeability of kidney to
lactose & dextrose causing (+) sugar
5. causes mood swings in moms
6. increase BBT
THE PHYSIOLOGY OF
MENSTRUATION
MENSTRUAL CYCLE
MENSTRUAL CYCLE

4 phases of Menstrual Cycle

1. Phases of Menstrual Cycle:
1. Proliferative
2. Secretory
3. Ischemic
4. Menses

PARTS OF BODY RESPONSIBLE FOR MENS:

hypothalamus
anterior pituitary gland – master clock
of body
ovaries
uterus
Initial phase – 3rd day – decreased estrogen
13th day – peak estrogen, decrease
progesterone
14th day – Increase estrogen, increase
progesterone
15th day – Decrease estrogen, increase
progesterone
I. On the initial 3rd phase of menstruation ,
the estrogen level is decreased, this level
stimulates the hypothalamus to release
GnRH or FSHRF
II. GnRH/FSHRF – stimulates the anterior
pituitary gland to release FSH
Functions of FSH:
Stimulate ovaries to release estrogen
Facilitate growth primary follicle to become
graffian follicle (secrets large amt estrogen &
contains mature ovum.)
III. PROLIFERATIVE PHASE – PROLIFERATION OF
TISSUE OR FOLLICULAR PHASE, POST MENS
PHASE. PRE-OVULAROTY.

phase of increase estrogen.

 Follicular Phase – causing irregularities of
mens
Postmenstrual Phase
Preovulatory Phase – phase increase
estrogen
IV. 13th day of menstruation, estrogen
level is peak while the progesterone level
is down, these stimulates the
hypothalamus to release GnRF on LHRF
 Mittelschmerz – slight abdominal pain on L or RQ
of abdomen, marks ovulation day.
Change in BBT, mood swing
V. GNRF/LHRF STIMULATES THE ANT PIT
GLAND TO RELEASE LH.

Functions of LH:
(13th day-decreased progesterone)
LH stimulates ovaries to release
progesterone
hormone for ovulation
VI. 14th day estrogen level is increased
while the progesterone level is increased
causing rupture of graffian follicle on
process of ovulation.
VII. 15th day, after ovulation day, graafian
follicle starts to degenerate yellowish
known as corpus luteum (secrets large
amount of progesterone)
 Secretory phase-
 Lutheal Phase
 Postovulatory Phase Increased
progesterone
 Premenstrual Phase
IX. 24th day if no fertilization, corpus
luteum degenerate ( whitish – corpus
albicans)
 X. 28th day – if no sperm in ovum –
endometrium begins to slough off to
begin mens
 Cornix- where sperm is deposited
 Sperm- small head, long tail, pearly white
 Phonones-vibration of head of sperm to determine
location of ovum
 Sperm should penetrate corona radiata and zona
pellocida.
 Capacitation- ability of sperm to release proteolytic
enzyme to penetrate corona radiata and zona pellocida.
SECRETORY PHASE

 Endometrium increases in thickness

 Corpus luteum – secretes large amount of
progesterone.
 Graafian follicle that starts to turn yellow
 Phases with Elevated Progesterone
 Secretory phase
 Luteal phase
 Postovulatory phase
 Premenstrual phase
ISCHEMIC PHASE

Occurs 27th to 28th day

On the 24th day, if no fertilization takes place,
Corpus Luteum degenerates and becomes whitish
known as Corpus Albicans
MENSTRUATION

Period of uterine bleeding and shedding of the

endometrium and lasts an average of 4 – 5 days
28th day, if no sperm visited the ovum;
endometrium begins to slough off
 MENSTRUAL CYCLE HORMONE
 Follicle Stimulating hormone
 stimulates growth of granulosa cells and induces the enzyme
which converts adnrogens and estrogen
 Leutenizing hormone
 Stimulates synthesis of prostaglandins to enhance follicle rupture
and ovulation
 Estrogen
 Androgens
 Inhibit FSH induction of LH receptors. Precursor of estrogen
 Progesterone
 GnRH/FSH -
RF

Anterior
Pituitary Gland
Facilitates the
growth of primary
follicle to become
Stimulates
ovaries to FSH graafian follicle,
which is the bag –
release like structure that
secretes large
estrogen amount of estrogen
and contains mature
ovum
 Decrease Progesterone

GnRH/LHRF

ANTERIOR PITUITARY

LH
Stimulate
ovaries to Hormone of
release ovulation
progesterone
 MENOPAUSE
Etiology: lack of estrogen
Average age: 51
Smokers: 2 years earlier
3 months of amenorrhea with elevation of
gonadotropins (FSH and LH)
Premature menopause: 30 to 40 can occur after
radiation therapy or surgical oophrectomy
 CLINICAL FINDINGS

 Amenorrhea
 Hot flushes
 Decreased vaginal secretion
 Increase urinary urgency,
frequency, nocturia and urge
continence
Mood alterations,
emotional lability,
sleep disorder,
depression
Osteoporosis –
decreased bone
density (prone to
pathologic fracture
 PREMENSTRUAL SYNDROME
SIDE EFFECTS:
 Fluid retention
 Autonomic changes
 Emotional symptoms
 Musculoskeletal complaints
TREATMENT
 B6
 Dietary modifications
 Exercise
STAGES OF SEXUAL RESPONSES (EPOR)
 Vasocongestion – congestion of blood vessels
 Myotonia – increase muscle tension

 1. Excitement Phase – (sign present in both sexes,

moderate increase in HR, RR,BP, sex flush, nipple
erection) – erotic stimuli cause increase sexual tension,
lasts minutes to hours.
 2. Plateau Phase – (accelerated V/S) – increasing &
sustained tension nearing orgasm. Lasts 30 seconds – 3
minutes.
Orgasm – (involuntary spasm throughout body,
peak v/s) involuntary release of sexual tension
with physiologic or psychologic release,
immeasurable peak of sexual experience. May last
2 – 10 sec- most affected are is pelvic area.
Resolution – (v/s return to normal, genitals return
to pre-excitement phase)
Refractory Period – the only period present
in males, wherein he cannot be restimulated
for about 10-15 minutes
 PHASES OF SEXUAL RESPONSE
Phase Vital Signs Characterized by Last from

Excitement Moderate Erotic stimuli cause Minutes to hours

increasing sexual
tension

Plateau Accelerated Increasing and 30 seconds to 3

sustained tension minutes

Orgasm Peak Immeasurable peak 2 to 10 seconds

of sexual
experience.

Resolution Returns to normal Sleepiness,

relaxation and
emotional outburst
HUMAN CONCEPTION AND FETAL
DEVELOPMENT
Fertilization
Fornix
Sperm
Prostaglandin and oxytocin
Capacitation
 PRE-EMBRYONIC STAGE

 Zygote
 is the fertilized ovum; it travels 3 – 4 days to reach the uterus
 46 chromosomes; 22 pairs of autosome and 1 pair of sex chromosomes
 Morula
 Mulberry like ball containing of 16 – 50 cells
 Balstocyst
 Enlarging cell forming a cavity that later becomes the embryo
 Trophoblast – covering of the blastocyst which later on will become the
placenta and membrane
Implantation or Nidation – occurs 7 – 10 days after
fertilization
Site: upper anterior or posterior of the uterus
Sign: slight vaginal spotting
Three Processes
Apposition
 BRUSH
Adhesion
 ATTACH
Invasion
 SETTLE DOWN
 DECIDUA

thickened endometrium ( Latin – falling off)

* Basalis (base) part of endometrium located
under fetus where placenta is delivered
* Capsularies – encapsulate the fetus
* Vera – remaining portion of endometrium.
CHORIONIC VILLI

10 – 11th day, finger life projections

3 vessels=
A – unoxygenated blood
V – O2 blood
A – unoxygenated blood
Wharton’s jelly – protects cord
Chorionic villi sampling (CVS) – removal of
tissue sample from the fetal portion of the
developing placenta for genetic screening.
Done early in pregnancy. Common
complication fetal limb defect. Ex missing
digits/toes.
SYNSITIOTROPHOBLAST

 synsitial layer – responsible

production of hormone
AMNION – INNER MOST LAYER

a. Umbilical Cord- FUNIS, whitish grey, 15 – 55cm,

20 – 21”. Short cord: abruptio placenta or inverted
uterus.
Long cord:cord coil or cord prolapse
b. Amniotic Fluid – bag of H2O, clear, odor
mousy/musty, with crystallized forming pattern,
slightly alkaline.

FUNCTION OF AMNIOTIC FLUID:

1. cushions fetus against sudden blows or

trauma
2. facilitates musculo-skeletal development
3. maintains temp
4. prevent cord compression
5. help in delivery process
normal amt of amniotic fluid – 500 to 1000cc
polyhydramnios, hydramnios- GIT
malformation TEF/TEA, increased amt of
fluid
oligohydramnios- decrease amt of fluid –
kidney disease
 DIAGNOSTIC TESTS FOR AMNIOTIC FLUID

 Amniocentesis empty bladder before performing the procedure.

 Purpose – obtain a sample of amniotic fluid by inserting a needle
through the abdomen into the amniotic sac; fluid is tested for:
 Genetic screening- maternal serum alpha feto-protein test
(MSAFP) – 1st trimester
 Determination of fetal maturity primarily by evaluating factors
indicative of lung maturity – 3rd trimester
 Testing time – 36 weeks
 decreased MSAFP= down syndrome
 increase MSAFP = spina bifida or open neural tube defect
 Common complication of amniocenthesis – infection
 Dangerous complications – spontaneous abortion
 3rd trimester- pre term labor
 Important factor to consider for amniocentesis- needle insertion site
 Aspiration of yellowish amniotic fluid – jaundice baby
 Greenish – meconium
 Amnioscopy – direct visualization or exam to an intact
fetal membrane.
 Fern Test- determine if amniotic fluid has ruptured or
not (blue paper turns green/grey - + ruptured amniotic
fluid)
 Nitrazine Paper Test – diff amniotic fluid & urine.
 Paper turns yellow- urine. Paper turns blue green/gray-
(+) rupture of amn fluid.
CHORION

 where placenta is developed

 Lecithin Sphingomyelin L/S
 Ratio- 2:1 signifies fetal lung maturity not capable for
RDS
 Shake test – amniotic + saline & shake
 Foam test
 Phosphatiglyceroli: PG+ definitive test to determine
fetal lung maturity
PLACENTA

(Secundines) Greek – pancake, combination

of chorionic villi + deciduas basalis. Size:
500g or ½ kg
-1 inch thick & 8” diameter
FUNCTIONS OF PLACENTA

Respiratory System – beginning of lung function

after birth of baby. Simple diffusion
GIT – transport center, glucose transport is
facilitated, diffusion more rapid from higher to
lower. If mom hypoglycemic, fetus
hypoglycemic
Excretory System- artery - carries waste
products. Liver of mom detoxifies fetus.
Circulating system – achieved
by selective osmosis
Endocrine System – produces
hormones
 Human Chorionic Gonadrophin – maintains corpus luteum alive.
 Human placental Lactogen or sommamommamotropin
Hormone – for mammary gland development. Has a
diabetogenic effect – serves as insulin antagonist
 Relaxin Hormone- causes softening joints & bones
 estrogen
 Progestin
 It serves as a protective barrier against some microorganisms –
HIV,HBV
 EMBRYONIC STAGE

Implanted ovum
Corpus luteum b – source of estrogen and progesterone
while placenta is not yet developed
EMBRYONIC CELLS
ECTODERM
MESODERM
ENDODERM
STAGES OF FETAL GROWTH AND DEVELOPMENT
FETAL GROWTH AND DEVELOPMENT
FIRST TRIMESTER
 FIRST MONTH
 Fetal heart tone begins
 CNS develops
 GIT and Respiratory tract remain a single tube
 On the second week, the differentiation of germ layer
 GERM LAYER
 ENDODERM – thyroid, parathyroid, liver, linings of respiratory tract
and GIT, Thymus
 MESODERM – heart, musculuskeletal system, reproductive organ,
Kidneys
 ECTODERM – CNS, 5 sense, skin, hair, nails, mucuous membrane
 FIRST TRIMESTER

Second month
All vital organs, are formed or
developed
Placenta is developed
Sex organs are formed
Corpus luteum will last until the end
of the 2nd month
 FIRST TRIMESTER

 THIRD MONTH
 Kidnesy are functional
 Fetus begins to swallow amniotic fluid
 Fetoplacental circulation is achieved by the
process of selective osmosis
 Sex is distinguishable
 FHT is audible by Doppler
 Placenta is complete
 Buds of milk teeth appear
 SECOND TRIMESTER
Fourth month
Lanugo begins to appear
Buds of permanent teeth
appear
FHT is audible by
fetoscope specifically 18
– 20 weeks
 SECOND TRIMESTER
 FIFTH MONTH
 Lanugo covers the body
 Quickening: 1st fetal movement
 Primigravida – 18 – 20 weeks
 Multigravida – 16 – 18 weeks
 FHT is audible without instrument
or by stethoscope
 Actively swallows amniotic fluid
 Fetus length: 19 – 25 cm
 SECOND TRIMESTER
SIXTH MONTH
Vernix caseosa, a white,
cheese like substance that
serves for lubrication
Eyelids open
Skin is red and wrinkled
THIRD TRIMESTER
SEVENTH MONTH
Surfactant develops
In males, testes descend to scrotum
In females, clitoris is prominent, labia
majora are small and do not cover labia
minora
THIRD TRIMESTER
Eight month
Lanugo begins to disappear
Subcutaneous fats deposit
Nails extend to fingers
THIRD TRIMESTER
Ninth month
Lanugo and vernix caseosa completely
disappear
Amniotic fluid somewhat decreases
Bone ossification of fetal skull begins
 TERRATOGENS- ANY DRUG, VIRUS OR
IRRADIATION, THE EXPOSURE TO SUCH MAY
CAUSE DAMAGE TO THE FETUS
 Drugs:
 Streptomycin – anti TB & or Quinine (anti malaria) – damage
to 8th cranial nerve – poor hearing & deafness
 Tetracycline – staining tooth enamel, inhibit growth of long
bone
 Vitamin K – hemolysis (destr of RBC), hyperbilirubenia or
jaundice
 Iodides – enlargement of thyroid or goiter
 Thalidomides – Amelia or pocomelia, absence of extremities
Alcohol – lowered weight (vasoconstriction
on mom), fetal alcohol withdrawal syndrome
char by microcephaly
Smoking – low birth rate
Caffeine – low birth rate
Cocaine – low birth rate, abruption placenta
TORCH
CHARACTERISTICS: group of infections caused by
organisms that can cross the placenta or ascend through
birth canal and adversely affect fetal growth and
development. These infections are often characterized by
vague, influenza like findings, rashes and lesions, enlarged
lymph nodes, and jaundice (hepatic involvement). In some
chases the infection may go unnoticed in the pregnant
woman yet have devastating effects on the fetus. TORCH:
Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes
simples virus.
Physiological
Adaptation of
the Mother to
Pregnancy
CARDIOVASCULAR SYSTEM

increase blood volume of mom (plasma

blood) 30 – 50% = 1500 cc of blood
easy fatigability, increase heart workload,
slight hypertrophy of ventricles, epistaxis –
due to hyperemia of nasal membrane
palpitation
Physiologic Anemia – pseudo anemia of pregnant
women
Normal Values
Hct 32 – 42%
Hgb 10.5 – 14g/dL
CRITERIA
1st and 3rd trimester.- pathologic anemia if
lower
HCT should not be 33%, Hgb should not be <
11g/dL
2nd trimester – Hct should not <32%
Hgb shldn't < 10.5% pathologic anemia if
lower
 PATHOGENIC ANEMIA

iron deficiency anemia is the most common

hematological disorder. It affects toughly 20% of
pregnant women.
Assessment reveals:
 Pallor, constipation
 Slowed capillary refill
Concave fingernails (late sign of progressive anemia)
due to chronic physio hypoxia
 NURSING CARE:

 Nutritional instruction – kangkong, liver due to ferridin

content, green leafy vegetable-alugbati,saluyot, malunggay,
horseradish, ampalaya
 Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if
improperly administered, hematoma.
 Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day)
empty stomach 1 hr before meals or 2 hrs after, black stool,
constipation
 Monitor for hemorrhage
ALERT:

Iron from red meats is better absorbed iron form

other sources
Iron is better absorbed when taken with foods
high in Vit C such as orange juice
Higher iron intake is recommended since
circulating blood volume is increased and heme is
required from production of RBCs
 Edema – lower extremities due venous return is
constricted due to large belly, elevate legs above hip
level.
 Varicosities – pressure of uterus
 use support stockings, avoid wearing knee high socks
 use elastic bandage – lower to upper
 Vulbar varicosities- painful, pressure on gravid uterus,
to relieve- position – side lying with pillow under hips or
modified knee chest position
THROMBOPHLEBITIS

 pregnant mom hyperfibrinogenemia

 increase fibrinogen
 increase clotting factor
 thrombus formation candidate
MANAGEMENT

 Bed rest
 Never massage
 Assess + Homan sign once only might dislodge thrombus
 Give anticoagulant to prevent additional clotting
(thrombolytics will dilute)
 Monitor APTT antidote for Heparin toxicity, protamine
sulfate
 Avoid aspirin! Might aggravate bleeding.
Respiratory system – common
problem SOB due to enlarged uterus
& increase O2 demand
Position- lateral expansion of lungs or
side lying position
 GASTROINTESTINAL – 1ST TRIMESTER
CHANGE
Morning Sickness – nausea & vomiting due to increase
HCG. Eat dry crackers or dry CHO diet 30 minutes before
arising bed. Nausea afternoon - small freq feeding.
Vomiting in preg – emesisgravida.
Metabolic alkalosis, F&E imbalance – primary med mgt –
replace fluids.
Monitor I&O
constipation – progesterone resp for
constipation. Increase fluid intake, increase fiber
diet
fruits – papaya, pineapple, mango, watermelon,
cantaloupe, apple with skin, suha.
Except guava – has pectin that’s constipating –
veg – petchy, malungay.
 exercise
mineral oil – excretion of fat soluble vitamins
 URINARY SYSTEM

 – frequency during 1st & 3rd trimester lateral expansion of

lungs or side lying pos – mgt for nocturia
 Acetic acid test – albumin in urine
 Benedicts test – sugar in urine
MUSCULOSKELETAL

Lordosis – pride of pregnancy

Waddling Gait – awkward walking due to
relaxation – causes softening of joints &
bones
Prone to accidental falls – wear low
heeled shoes
 Leg Cramps – causes: prolonged standing, over fatigue, Ca &
phosphorous imbalance(#1 cause while pregnant), chills,
oversex, pressure of gravid uterus (labor cramps) at lumbo sacral
nerve plexus
 Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or
3-4 servings/day. Cheese, yogurt, head of fish,
 Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster,
crab.
 Vit D for increased Ca absorption
 dorsiflexion
LOCAL CHANGES

Chadwick
Goodel’s
Hegar’s
LEUKORRHEA – whitish gray, mousy odor
discharge
ESTROGEN – hormone, resp for leucorrhea
OPERCULUM – mucus plug to seal out bacteria.
PROGESTERONE – hormone responsible for
operculum
PREGNANT – acidic to alkaline change to protect
bacterial growth (vaginitis)
PROBLEMS RELATED TO THE
CHANGE OF VAGINAL
ENVIRONMENT:
 VAGINITITS

S&Sx:
Greenish cream colored frothy irritatingly itchy with foul
smelling odor with vaginal edema
Mgt:
FLAGYL – (metronidazole – antiprotozoa).
Carcinogenic drug so don’t give at 1st trimester
treat dad also to prevent reinfection
no alcohol – has antibuse effect
VAGINAL DOUCHE – IQ H2O : 1 tbsp white
vinegar
MONILIASIS OR CANDIDIASIS

due to candida albecans, fungal infection.

Color – white cheese like patches adheres to walls
of vagina.
 Signs & Symptoms:
 Management – antifungal – Nistatin, genshan violet,
cotrimaxole, canesten
 Gonorrhea -Thick purulent discharge
 Vaginal warts- condifoma acuminata due to papilloma
virus
 Mgt: cauterization
Abdominal Changes – striae
gravidarium (stretch marks) due
enlarging uterus-destruction of sub Q
tissue – avoid scratching, use coconut
oil, umbilicus is protruding
Skin Changes – brown pigmentation
nose chin, cheeks –
chloasma melasma due to increased
melanocytes.
 Brown pinkish line-
linea nigra- symphisis pubis to
umbilicus
Breast Changes – increase hormones,
color of areola & nipple
pre colostrums present by 6 weeks,
colostrums at 3rd trimester
Breast self exam- 7 days after mens ––
supine with pillow at back
quadrant B – upper outer – common site
of cancer
Test to determine breast cancer:
1. mammography – 35 to 49 yrs once
every 1 to 2 yrs
 50 yrs and above – 1 x a yr
Ovaries – rested during
pregnancy
SIGNS & SYMPTOMS OF PREGNANCY

 Presumptive – s/s felt and observed by the mother but

does not confirm positive diagnosis of pregnancy .
Subjective
 Probable – signs observed by the members of health
team. Objective
 Positive Signs – undeniable signs confirmed by the use
of instrument.
PLACENTAL GRADING – RATING/GRADE

o – immature
1 – slightly mature
2 – moderately mature
3 – placental maturity
PRESUMPTIVE

Breast changes Enlarged uterus

Urinary freq Cloasma
Fatigue Linea negra
Amenorrhea Increased skin
Morning sickness pigmentation
Striae gravidarium
Quickening
PROBABLE

 Goodel's- change of  Positive HCG or (+)preg test

consistency of cervix

 Chadwick’s- blue violet
 Ballottement – bouncing of
discoloration of vagina
fetus when lower uterine is
 Hegar's- change of tapped sharply
consistency of isthmus  Enlarged abdomen
 Elevated BBT – due to
 Braxton Hicks contractions –
increased progesterone
painless irregular
contractions
POSITIVE

 Ultrasound evidence (sonogram) full bladder

 Fetal heart tone
 Fetal movement
 Fetal outline
 Fetal parts palpable
PSYCHOLOGICAL ADAPTATION TO
PREGNANCY

First Trimester: No tanginal signs & sx,

surprise, ambivalence, denial – sign of
maladaptation to pregnancy. Developmental
task is to accept biological facts of
pregnancy
Focus: bodily changes of preg, nutrition
 Second Trimester – tangible S&Sx. mom identifies fetus
as a separate entity – due to presence of quickening,
fantasy. Developmental task – accept growing fetus as
baby to be nurtured.
 Health teaching: growth & development of fetus.
 Third Trimester: - mom has personal identification on
appearance of baby
 Development task: prepare of birth & parenting of child.
HT: responsible parenthood ‘baby’s Layette” – best time
to do shopping.
 Most common fear – let mom listen to FHT to allay fear
 Lamaze classes
PRE-NATAL VISIT:

 Frequency of Visit: 1st 7 months – 1x a month

 8 – 9 months – 2 x a month
 10 – once a week
 post term 2 x a week
 Personal data – name, age (high risk < 18 & >35 yrs old)
record to determine high risk – HBMR. Home base
mom’s record. Sex ( pseudocyesis or false pregnancy on
men & women)
 Couvade syndrome – dad experiences what mom goes
through – lihi)
 Address, civil status, religion, culture & beliefs with
respect, non judgmental
 Occupation – financial condition or occupational
hazards, education background – level knowledge
DIAGNOSIS OF PREGNANCY

 urine exam to detect HCG at 40 – 100th day. 60 – 70 day

peak HCG. 6 weeks after LMP- best to get urine exam.
 Elisa test – test for preg detects beta subunit of HCG as
early as 7 – 10days
 Home preg kit – do it yourself
Baseline Data: V/S esp. BP, monitor wt.
(increase wt – 1st sign preeclampsia)
WEIGHT MONITORING

First Trimester: Normal Weight gain 1.5 – 3 lbs

(.5 – 1lb/month)
Second trimester: normal weight gain10 – 12 lbs
(4 lbs/month) (1 lb/wk)
Third trimester: normal weight gain 10 – 12 lbs
(4 lbs/ month) ( 1lb/wk)
Minimum wt gain – 20 – 25 lbs
Optimal wt gain – 25 – 35 lbs
OBSTETRICAL DATA:

Nullipara – no pregnancy
Gravida- # of pregnancy
Para - # of viable pregnancy
 Viability – the ability of the fetus to live outside the
uterus at the earliest possible gestational age.
 Age of viability - 20 – 24 wks
 Term 37 – 42 wks,
 Preterm -20 – 37 weeks
 abortion <20 weeks
IMPORTANT ESTIMATES:

 Nagele’s Rule – use to determine expected date of

delivery
 McDonald’s Rule – to determine age of gestation IN
WEEKS
 FUNDIC HT X 7/8=AOG in WK
 Fr sypmhisis pubis to fundus 24 X 7 =21 wks
8
 Bartholomew’s Rule – to determine age of gestation by
proper location of fundus at abdominal cavity.
 Haases rule – to determine length of the fetus in cm.
 Tetanus immunizations – prevents tetanus neonatum
 -mom with complete 3 doses DPT young age considered as TT1
& 2. Begin TT3
 TT1 – any time during pregnancy
 TT2 – 4 wks after TT1 – 3 yrs protection
 TT3 – 6 months after TT2 – 5 yrs protection
 TT4 – 1 yr after TT3 – 10 yrs protection
 TT5 – yr after TT4 – lifetime protection
PHYSICAL EXAMINATION:

Examine teeth: sign of infection

Danger signs of Pregnancy
C - chills/ fever - infection
Cerebral disturbances ( headache – preeclampsia)
 A – abdominal pain ( epigastric pain – aura of impending convulsions
 B – boardlike abdomen – abruption placenta
 Increase BP – HPN
 Blurred vision – preeclampsia
 Bleeding – 1st trimester, abortion, ectopic pre/2nd – H mole, incompetent
cervix 3rd – placental anomalies
 S – sudden gush of fluid – PROM (premature rupture of membrane) prone
to inf.
 E – edema to upper ext. (preeclampsia)
Pelvic Examination – internal exam
empty bladder
universal precaution
PAP SMEAR

 Result:
 Class I - normal
 Class IIA – acytology but no evidence of malignancy
 B – suggestive of infl.
 Class III – cytology suggestive of malignancy
 Class IV – cytology strongly suggestive of malignancy
 Class V – cytology conclusive of malignancy
STAGES OF CERVICAL CANCER

Stage :
0 – carcinoma insitu
1 – cancer confined to cervix
2 - cancer extends to vagina
3 – pelvis metastasis
4 – affection to bladder & rectum
LEOPOLD’S MANEUVER

Purpose: is done to determine the attitude, fetal

presentation lie, presenting part, degree of
descent, an estimate of the size, and number of
fetuses, position, fetal back & fetal heart tone
Prep mom:
Empty bladder
Position of mom-supine with knee flex (dorsal
recumbent – to relax abdominal muscles)
PROCEDURE:

 1st maneuver: place patient in supine position with knees

slightly flexed; put towel under head and right hip; with both
hands palpate upper abdomen and fundus. Assess size, shape,
movement and firmness of the part to determine presentation
 2nd Maneuver: with both hands moving down, identify the back
of the fetus ( to hear fetal heart sound) where the ball of the
stethoscope is placed to determine FHT. Get V/S(before 2nd
maneuver) PR to diff fundic soufflé (FHR) & uterine soufflé.
 Uterine soufflé – maternal H rate
 3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and
fingers.
 To determine degree of engagement.
 Assess whether the presenting part is engaged in the pelvis )Alert : if the head is
engaged it will not be movable).
 4th Maneuver: the Examiner changes the position by facing the patient’s feet.
With two hands, assess the descent of the presenting part by locating the cephalic
prominence or brow. To determine attitude – relationship of fetus to 1 another.
 When the brow is on the same side as the back, the head is extended. When the
brow is on the same side as the small parts, the head will be flexed and vertex
presenting.
ASSESSMENT OF FETAL WELL-
BEING
DAILY FETAL MOVEMENT COUNTING
(DFMC)
 begin 27 weeks
 Mom- begin after meal - breakfast
CARDIFF COUNT TO 10 METHOD

 (1) Begin at the same time each day (usually in the

morning, after breakfast) and count each fetal
movement, noting how long it takes to count 10 fetal
movements (FMs)
 (2) Expected findings – 10 movements in 1 hour or less
WARNING SIGNS

 a.) more then 1 hour to reach 10 movements

 b.) less then 10 movements in 12 hours(non-reactive-
fetal distress)
 c.) longer time to reach 10 FMs than on previous days
 d.) movement are becoming weaker, less vigorous
Movement alarm signals - < 3 FMs in 12 hours
4.) warning signs should be reported to
healthcare provider immediately; often require
further testing. Examples: nonstress test (NST),
biographical profile (BPP)
NONSTRESS TEST

 Postmaturity
 pregnancy induced hypertension (PIH), diabetes
 warning signs noted during DFMC
 maternal history of smoking, inadequate nutrition
PROCEDURE:

Done within 30 minutes wherein the mother is in

semi-fowler’s position (w/ fetal monitor); external
monitor is applied to document fetal activity;
mother activates the “mark button” on the
electronic monitor when she feels fetal
movement
ATTACH EXTERNAL NONINVASIVE FETAL
MONITORS
 1. tocotransducer over fundus to detect uterine
contractions and fetal movements (FMs)
 2. ultrasound transducer over abdominal site where most
distinct fetal heart sounds are detected
 3. monitor until at least 2 FMs are detected in 20 minutes
 if no FM after 40 minutes provide woman with a light snack or
gently stimulate fetus through abdomen
 if no FM after 1 hour further testing may be indicated, such as a CST
RESULT:

Noncreative Reactive
 Nonstress  Responsive is
 Not Good  Real Good
INTERPRETATION OF RESULTS

 Reactive result
 Baseline FHR between 120 and 160 beats per minute
 At least two accelerations of the FHR of at least 15 beats per minute,
lasting at least 15 seconds in a 10 to 20 minute period as a result of
FM
 Good variability – normal irregularity of cardiac rhythm representing
a balanced interaction between the parasympathetic (decreases FHR)
and sympathetic (increase FHR) nervous system; noted as an uneven
line on the rhythm strip.
 result indicates a healthy fetus with an intact nervous system
 Nonreactive result
 Stated criteria for a reactive result are not met
 Could be indicative of a compromised fetus.
HEALTH TEACHINGS

 a. Nutrition – do nutritional assessment – daily food intake

 High risk moms:
 Pregnant teenagers – low compliance to heath regimen.
 Extremes in wt – underweight, over wt – candidate for HPN, DM
 Low socio – economic status
 Vegetarian mom – decrease CHON – needs Vit B12 – cyanocobalamin –
formation of folic acid – needed for cell DNA & RBC formation.
(Decrease folic acid – spina bifida/open neural tube defect)
 How many Kcal CHO x4,CHON x4, fats x 9
 RECOMMENDED NUTRIENT
REQUIREMENT THAT INCREASES
DURING PREGNANCY
SEXUAL ACTIVITY

 should be done in moderation

 should be done in private place
 mom placed in comfy pos, sidelying or mom on top
 avoided 6 weeks prior to EDD
 avoid blowing or air during cunnilingus - air embolism
 changes in sexual desire of mom during pregnancy
CHANGES IN SEXUAL DESIRE:

 1st tri – decrease desire – due to bodily changes

 2nd trimester – increased desire due to increase estrogen
that enhances lubrication
 3rd trimester – decreased desire
CONTRAINDICATION IN SEX:

 1. vaginal spotting
 1st trimester -- threatened abortion
 2nd trimester– placenta previa
 2. incompetent cervix
 3. preterm labor
 4. premature rupture of membrane
EXERCISE – TO STRENGTHEN MUSCLES
USED DURING DELIVERY PROCESS
 Principles Of Exercise
 1.) Done in moderation.
 2.) Must be individualized
 Walking – best exercise
 Squatting – strengthen muscles of perineum. Increase
circulation to perineum. Squat – feet flat on floor
 Tailor Sitting – 1 leg in front of other leg ( Indian seat)
 Raise buttocks 1st before head to prevent postural
hypotension – dizziness when changing position
Kegel Exercise – strengthen pulococcygeal
muscles
- as if hold urine, release 10x or muscle
contraction
Abdominal Exercise – strengthens muscles of
abdominal – done as if blowing candle
CHILDBIRTH PREPARATION:

 Overall goal: to prepare parents physically and

psychologically while promoting wellness behavior that
can be used by parents and family thus, helping them
achieved a satisfying and enjoying childbirth experience.
PSYCHOPHYSICAL

 1. Bradley Method – Dr. Robert Bradley – advocated

active participation of husband at delivery process.
Based on imitation of nature.
 Features:
 1.) darkened rm
 2.) quiet environment
 3.) relaxation tech
 4.) closed eye & appearance of sleep
Grantly Dick Read Method – fear leads to tension
while tension leads to pain
PSYCHOSEXUAL

Kitzinger method – preg, labor & birth & care of

newborn is an impt turning pt in woman’s life
cycle
- flow with contraction than struggle with
contraction
PSYCHOPROPHYLAXIS – PREVENTION OF
PAIN
Lamaze: Dr. Ferdinand Lamaze
 req. disciple, conditioning & concentration. Husband is
coach
 Features:
 Conscious relaxation
 Cleansing breathe – inhale nose, exhale mouth
 Effleurage – gentle circular massage over abdominal to
relieve pain
 imaging – sensate focus
DIFFERENT METHODS OF DELIVERY:

 birthing chair – bed convertible to chair – semifowlers

 birthing bed – dorsal recumbent pos
 squatting – relives low back pain during labor pain
 leboyers – warm, quiet, dark, comfy room. After
delivery, baby gets warm bath.
 Birth under H20 – bathtub – labor & delivery – warm
water, soft music.
INTRAPARTAL NOTES
THEORIES OF THE ONSET OF LABOR

 1.) uterine stretch theory ( any hallow organ stretched, will always contract &
expel its content) – contraction action
 2.) oxytocin theory – post pit gland releases oxytocin. Hypothalamus produces
oxytocin
 3.) prostaglandin theory – stimulation of arachidonic acid – prostaglandin-
contraction
 4.) progesterone theory – before labor, decrease progesterone will stimulate
contractions & labor
 5.) theory of aging placenta – life span of placenta 42 wks. At 36 wks degenerates
(leading to contraction – onset labor).
THE 4 P’S OF LABOR
PASSENGER
. PASSENGER

 a. Fetal head – is the largest presenting part – common

presenting part – ¼ of its length.
 Bones – 6 bones S – sphenoid F – frontal - sinciput
 E – ethmoid O – occuputal - occiput
 T – temporal P – parietal 2 x
Measurement fetal head:
transverse diameter – 9.25cm
biparietal – largest transverse
bitemporal 8 cm
bimastoid 7cm smallest transverse
Sutures – intermembranous spaces that
allow molding.
sagittal suture – connects 2 parietal bones (
sagitna)
coronal suture – connect parietal & frontal
bone (crown)
lambdoidal suture – connects occipital &
parietal bone
 MOLDINGS: THE OVERLAPPING OF THE
SUTURES OF THE SKULL TO PERMIT PASSAGE
OF THE HEAD TO THE PELVIS
Fontanels:
 Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm –
hydrocephalus), 12 – 18 months after birth- close
 Posterior fontanel or lambda – triangular shape, 1 x 1 cm. Closes – 2 – 3 months.
 4.) Anteroposterior diameter -
 suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
 occipitofrontal 12cm partial flexion
 occipitomental – 13.5 cm hyper extension submentobragmatic-face
presentation
2. PASSAGEWAY
Mom
1.) < 4’9” tall
2.) < 18 years old
3.) Underwent pelvic dislocation
4 MAIN PELVIC TYPES

 1. Gynecoid – round, wide, deeper most suitable (normal

female pelvis) for pregnancy
 2. Android – heart shape “male pelvis”- anterior part
pointed, posterior part shallow
 3. Anthropoid – oval, ape like pelvis, oval shape, AP
diameter wider transverse narrow
 4. Platypelloid – flat AP diameter – narrow, transverse –
wider
 PELVIS
 2 hip bones – 2 innominate bones
 3 Parts of 2 Innominate Bones
 Ileum – lateral side of hips
 - iliac crest – flaring superior border forming prominence of hips
 Ischium – inferior portion
 - ischial tuberosity where we sit – landmark to get external measurement
of pelvis
 Pubes – ant portion – symphisis pubis junction between 2 pubis
 1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis
 1 coccyx – 5 small bones compresses during vaginal delivery
 IMPORTANT MEASUREMENTS

 1. Diagonal Conjugate – measure between sacral promontory and inferior

margin of the symphysis pubis.
 Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC –
11.5 cm=true conjugate)
 2. True conjugate/conjugate vera – measure between the anterior surface of
the sacral promontory and superior margin of the symphysis pubis.
Measurement: 11.0 cm
 3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more.
 Tuberoischi Diameter – transverse diameter of the pelvic outlet. Ischial
tuberosity – approximated with use of fist – 8 cm & above.
POWER
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. PSYCHE/PERSON
– psychological stress when the mother is
fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
PRE-EMINENT SIGNS OF
LABOR
 S&SX:

 - shooting pain radiating to the legs  4. Ripening of the Cervix – butter soft
 - urinary freq.  5. decreased body wt – 1.5 – 3 lbs
 1. Lightening – setting of presenting part  6. Bloody Show – pinkish vaginal
into pelvic brim - 2 weeks prior to EDD discharge – blood & leukorrhea
 * Engagement- setting of presenting part  7. Rupture of Membranes – rupture of
into pelvic inlet water. Check FHT
 2. Braxton Hicks Contractions – painless
irregular contractions
 3. Increase Activity of the Mother- nesting
instinct. Save energy, will be used for
delivery. Increase epinephrine
 DIFFERENCE BETWEEN TRUE LABOR AND
FALSE LABOR
False Labor True Labor
 Irregular contractions  Contractions are regular
 No increase in intensity  Increased intensity
 Pain – confined to  Pain – begins lower back radiates to
abdomen abdomen
 Pain – relived by walking  Pain – intensified by walking
 No cervical changes  Cervical effacement & dilatation * major sx
 of true labor.
DURATION OF LABOR

Primipara – 14 hrs & not more than 20 hrs

Multipara – 8 hrs & not > 14 hrs
NURSING INTERVENTIONS IN EACH
STAGE OF LABOR

2 segments of the uterus

1. upper uterine - fundus
2. lower uterine – isthmus