MATERNAL AND CHILD NURSING

Human Sexuality
Human Sexuality-behavior of being a boy or a girl, female/male
An entity subject to a lifelong dynamic change
Developed at the time of birth
Involves emotions, attitudes, sexual self eroticism
Related concepts:
Sex- biologic male or female
Gender identity-sense of femininity or
musculinity
Developed between 2-4 years of age
Role identity- attitudes, behavior and attributes that differentiate role
EXTERNAL ORGANS
MONS PUBIS mound of fatty tissue over the symphysis pubis that cushion and
protects the bone.
LABIA MAJORA longitudinal folds of pigmental skin extending from the mons
pubis to the perineum.
LABIA MINORA soft longitudinal skin folds between the labia majora.

CLITORIS erectile tissue located at the upper end of the labia minora.
URETHRAL MEATUS small opening of the urethra. Located between the clitoris
and the vaginal orifice.
SKENE OR PARAURETHRAL GLANDS small mucus-secreting glands that
lubricate the vagina
VESTIBULE almond-shaped area between the labia minora containing the vaginal
introitus, hymen, and Bartholin glands.
VAGINAL INTROITUS external opening of the vagina.
HYMEN membranous tissue ringing the vaginal introitus.
BARTHOLIN OR VULVOVAGINAL GLANDS mucus-secreting glands located
on either side of the vaginal orifice.
PERINEUM area of tissue between the anus and vagina.

Pubic hair development: Tanners stages

Stage 1: Pre adolescent
No pubic hair except for fine body
hair
Stage 2:
11-12 y/o
sparse, long slightly pigmented and
curly hair that develop along the labia
INTERNAL ORGANS
VAGINA female organ of
copulation and also serves as the
birth canal. Lies between the
rectum and the urethra and bladder.

UTERUS hollow, muscular

organ with three muscle layers
(perimetrium, myometrium and
endometrium). Located between
the bladder and rectum. Consists of
the fundus, body(corpus) and
cervix.
UTERINE LIGAMENTS

Broad
and
Round
Ligaments provide
upper support for the
uterus.
Cardinal, Pubocervical,
and
Uterosacral
Ligaments suspensory
and
provide
middle
support.
Pelvic Muscular Floor
Ligaments provide
lower support.
FALLOPIAN TUBES extend
from the upper outer angles of the uterus and end near the ovary. Passageway for the
ovum to travel to the uterus.
OVARIES female sex glands located on each side of the uterus.
Stage 3: 12-13 y/o
hair becomes darker that develop along the pubic
symphysis
Stage 4: 13-14 y/o
hair assumes the normal appearance of an adult
but not
so thicked
doesnt appear in the inner aspect of the upper
thigh
Stage 5: Sexual maturity, hair assumes the normal
appearance of an adult
appears on the inner aspect of the upper thigh
PELVIS AND BREASTS
TYPES OF PELVES:

GYNECOID typical female pelvis with a ROUNDED INLET.

ANDROID normal male pelvis with a HEART-SHAPED INLET.

ANTHROPOID an APELIKE pelvis with an OVAL INLET.

PLATYPELLOID is a flat, female-type pelvis with a TRANSVERSE

OVAL INLET.

BREASTS:

Are specialized sebaceous glands that produce milk after childbirth.

Internal breast structures include glandular tissue, lactiferous ducts or

sinuses, Cooper ligaments and adipose and fibrous tissues.

External structures include the nipple, areola and Montgomery tubercles.

MENSTRUAL CYCLE AND HORMONES

MENARCHE (onset of menstruation) typically occurs between 10 and 13 years old.

MENSTRUAL CYCLE is a monthly pattern of ovulation and menstruation.

OVULATION is the discharge of a mature ovum from the ovary.

MENSTRUATION is the periodic shedding of blood, mucous, and

epithelial cells form the uterus (average blood loss is 50 ml)
HORMONES

ESTROGEN contributes to the characteristics of femaleness

PROGESTERONE (hormone of pregnancy) quiets or decreases the

contractility of the uterus.

PROSTAGLANDINS regulate the reproductive process by stimulating the

contractility of uterine and other smooth muscles.
LEVELS OF THE MENSTRUAL CYCLE

CNS RESPONSE Follicle Stimulating Hormone (FSH) and Luteinizing

Hormone (LH)

OVARIAN RESPONSE Follicular phase (days 1 14) due to FSH; Luteal

phase (days 15 22) corpus luteum develops

ENDOMETRIAL RESPONSE
Menstrual phase (days 1 5) estrogen level is low
Proliferative phase (days 1 -14) estrogen level is high ovulation
occurs on day 14 of a 28-day cycle
Secretory phase (days 14 26) progesterone is high
Ischemic phase (days 27 28) estrogen and progesterone levels
recede menstruation begins

CERVIX AND CERVICAL MUCOUS RESPONSE

Before ovulation estrogen levels rise, high spinnbarkeit, excellent
sperm penetration
After ovulation progesterone levels rise, low spinnbarkeit, poor
sperm penetration
During pregnancy cervical circulation increases and a protective
mucus plug forms.
CLIMACTERIC PERIOD AND MENOPAUSE

Climacteric Period is a transitional period during which ovarian function

and hormonal production decline.

Menopause refers to a womans last menstrual period.

Menstrual problems
Dysmenorrhea- painful menstruation due to increase
prostaglandin
Amenorrhea- absence of menstruation
Metrorrhagia- bleeding in between menstruation
Menorrhagia- excessive bleeding during
menstruation
Menopause- cessation of menstruation
- 47 y/o average menopausal age
- decrease estrogen
osteoporosis
2. Plateau phase- increased congestion to sustained tension nearing orgasm
- Vs are high
- lasting 30 seconds to 3 minutes
3. Orgasmic phase- diminished sensory awareness
- involuntary release of sexual tension accompanied by physiologic & psychologic
release known as the peak of sexual experience
- VS peak
- 3-1o seconds
Sexual Responses
Initial Vasocongestion and Myotonia
muscle tension
Phases:
1. Excitement phase- Foreplay
- erotic stimuli increases sexual tension
- VS moderate
- may last from minutes to hours
4. Resolution phase- dangerous phase in cardiac patient

Bp suddenly returns to normal

5. Refractory phase- period where men cannot
be re stimulated within 10-15 minutes
Ejaculation
sperm deposited in the fornix of vagina
travel thru the uterus
FT
Ampulla
Fertilization of egg
FETAL STAGES OF DEVELOPMENT
ZYGOTE = union of ovum and sperm
MORULA = 16 50 cells; 3 4 days after fertilization
BLASTOCYST = enlarged cell w/ fluid filled structure; trophoblast ( becomes
placenta and membrane )
EMBRYO = 3 8 weeks; embryonic structures
FETUS = 2 months birth
PRENATAL PERIOD
FIRST, SECOND AND THIRD TRIMESTERS OF PREGNANCY
FIRST TRIMESTER OF PREGNANCY
The first trimester (from 0-12 Weeks) allows the pregnant womans body to undergo
many changes as it adjusts to the growing baby.
It is important to understand that these are all normal events and that most of these
discomforts will go way as the pregnancy progresses.
So included here are some of the symptoms experienced during pregnancy and how
best to deal with them:


Breast changes

Tiredness

Mood Changes

Nausea and Vomiting

Frequency of Urination

Gastrointestinal Symptoms

Dizziness

Varicose Veins and Hemorrhoids

Leg Cramps

Increased heart rate

SECOND TRIMESTER OF PREGNANCY
The second trimester (13-28 Weeks) is the most physically enjoyable for most women.
While some symptoms such as a morning sickness and nausea can abate, new ones can
begin.
What follows is a list of changes that could be seen in a pregnant womans body during
this trimester.

Appetite Increase

Increase belly size, stretch marks and skin changes

Abdominal and low back pain

Return to normal urination frequency

Nosebleeds and gum bleeds

Vaginal Discharge

Tingling and Itching

Continuation of other symptoms

THIRD TRIMESTER OF PREGNANCY
As your fetus continues to grow, preparation for the delivery of the baby should be at
hand. An uncomfortable feeling would arise as weight gain continues and your false
labor contractions continue.
Childbirth classes and breastfeeding classes around this time are started.
Included below is a list of some of the changes and symptoms this final trimester:

Increased temperature

The increased frequency of the bladder

Swelling

Hair

Breast tenderness and colostrum

Braxton Hicks contractions (false labor)

PRESUMPTIVE SIGNS OF PREGNANCY
First Trimester
B-reast changes
U-rinary frequency
F-atigue
A-menorrhea
( after 10 days)
M-orning Sickness
E- nlarged Uterus
Second Trimester
C -hloasma
L
-inea Nigra
I -ncreased skin pigmentation
Q uickening
S -triae gravidarum

PRESUMPTIVE SYMPTOMS
Subjective:

Client Need: Health promotion and maintenance

Nursing Intervention:
Instruct patient to eat dry crackers before arising
Recommend frequent rest if possible

Patient Teaching: Teach patient the differences and meaning of presumptive,

probable and positive signs.
PROBABLE SIGNS OF PREGNANCY
First Trimester
Chadwicks sign (vagina)
Goodells sign
( cervix )

Hegars sign ( uterus )

Elevated BBT

Positive HCG
Second Trimester
Ballottement
Enlarged abdomen
Braxton-Hicks contractions
PROBABLE SYMPTOMS
OBSERVABLE SYMPTOMS
Nursing Intervention:

Use first voided morning urine to identify HCG

Patient Teaching:

Linea nigra will disappear when pregnancy ends

Striae may not disappear; use cream or Vitamin A daily

Chloasma is related to hormonal changes

HCG in the urine is not diagnostic

EASY ASSOCIATION
UTERUS
- Hegars Sign
CERVIX
- Goodels Sign
VAGINA
- Chadwicks Sign
POSITIVE SIGNS OF PREGNANCY
Demonstration of fetal heart rate separate from the mother
Fetal movement felt by the examiner
( 20TH 24TH WKS AOG )
Visualization of the fetus by ultrasound

Transabdominal

Transvaginal Undeniable signs

Nursing Interventions:

Calculate EDC/ EDD

Calculate gestational age

Patient Teaching:

Avoid x ray during pregnancy, or protect abdomen as necessary.

DISCOMFORTS OF PREGNANCY
( 1 ) ANKLE EDEMA
Elevate feet when sitting or resting
Practice frequent dorsiflexion of feet
Avoid standing for a long period of time.

2 ) BACK ACHE
Practice good body mechanics
Practice pelvic tilt exercise
Avoid long standing, high heels, heavy lifting, over fatigue and excessive bending or
reaching
( 3 ) BREAST TENDERNESS
Wear a well fitting supporting bra
Decrease the amount of caffeine and carbonated beverages ingested.
( 4 ) CONSTIPATION
Increase fiber in the diet
Drink additional fluids
Have a regular time for bowel movement
Exercise
Use stool softeners as needed
( 5 ) FATIGUE
Plan a rest period regularly
Have a regular bedtime routine and use extra pillow for comfort
6 ) FAINTNESS
Arise and move slowly
Avoid prolonged standing
Remain in a cool environment; avoid crowded places
Lie on left side when lying down.
( ( 7 ) HEADACHE
Avoid eye strain
Rest with a cool cloth on the forehead
Report frequent and peristent headache to the doctor
( 8 ) HEARTBURN (PYROSIS)
Eat small, frequent meals
Avoid spicy, greasy foods
Refrain from lying down immediately after eating
Use low sodium antacids
( 9 ) HEMORRHOIDS
Avoid constipation and straining with BM
Take hot sitz bath, apply topical anesthetics, ointments, ice packs
10 ) LEG CRAMPS
Dorsiflex feet; Apply heat to affected muscle
Evaluate calcium to phosphorous ratio in diet.
( 11 ) NAUSEA
Avoid strong odors; drink carbonated beverages
Avoid drinking while eating
Eat crackers, avoid spicy and greasy food, eat small frequent meals
( 12 ) NASAL STUFFINESS
Use cool air vaporizer
Increase fluid intake, place moist towel on the sinuses; massage the sinuses
( 13 ) PTYALISM
Use mouthwash as needed
Chew gum or suck on hard candy.
( 14 ) ROUND LIGAMENT PAIN

Avoid twisting motions,

rise up slowly,
and bend forward to relieve pain
( 15 ) SHORTNESS OF BREATH
Proper posture; Use pillows under head & shoulders at night
(16) URINARY FREQUENCY
Void at least q 2 hrs; Avoid caffeine; Practice Kegel exercise
(17) LEUKORRHEA
Wear cotton underwear; bath daily; avoid tight panty hose
(18) VARICOSE VEINS
Walk regularly; rest with feet elevated; avoid long standing; dont cross legs; avoid
knee high stocking; wear support hosiery
DANGER SIGNS OF PREGNANCY
Chills and fever

Cerebral disorders (dizziness )

Abdominal pain
Boardlike Abdomen
Blood pressure elevation
Blurred Vision
Bleeding
Swelling
Scotoma ( blind spot on the retina )

Sudden gush of fluid

RISK CONDITIONS IN PREGNANCY
FACTORS THAT CATEGORIZE HIGH RISK PREGNANCIES
FACTORS THAT CATEGORIZE A PREGNANCY AS HIGH RISK
Psychological
Social
Physical
Prepregnancy
- Occupation involving handling- Visual or hearing impaired
- History of drugof toxic substances (including
- Pelvic
inadequacy
or
dependence
raidation and anesthesia gases)
malshape
(including
Environmental
- Uterine
incompetency,
alcohol)
contaminants at home
position or structure
- History of abusive
- Isolated
- Secondary major illness
behavior
- Lower economic level
(heart
disease,
- Survivor
of
Poor
access
to
hypertension,
battering
transportation for care
tuberculosis,
blood
- History of mental
- High altitude
disorder, malignancy)
illness
- Highly mobile lifestyle
Poor gynecologic or
- History of poor
- Poor Housing
obstetric history
coping
- Lack of support people
- History of previous poor
mechanisms
pregnancy outcome
- Cognitive
- History of child with
impairment
congenital anomalies
- Survivor
of
- Obesity
childhood sexual
- Pelvic inflammatory disease
abuse
(PID)

- History of inherited disorder

- Small stature
Potential
of
blood
incompatibility
- Younger than age 18 or
older than 35
- Cigarette smoker
- Substance abuser

Labor
Period
-

Pregnancy Period
- Loss of support
person
Illness of a
family member
Decrease in
self-esteem
Drug abuse
(including
alcohol
and
cigarette
smoking)
Poor acceptance
of pregnancy

-Refusal of or neglected
prenatal care
Exposure
to
environmental
teratogens
- Disruptive family incident
- Decreased economic
support
- Conception under 1 year
from last pregnancy
and pregnancy within
12 months of the first
pregnancy

- Subject to trauma
Fluid
or
electrolyte
imbalance
- Intake of teratogen such as a
drug
- Multiple gestation
- A bleeding disruption
- Poor placental formation or
position
- Gestational diabetes
- Nutritional deficiency of
iron, folic acid, or protein
- Poor weight gain
Pregnancy-induced
hypertension
- Infection
- Amniotic fluid abnormality
- Postmaturity

and

Delivery

Severely
frightened by labor
and
delivery
experience
Lack
of
participation due to
anesthesia
Separation of
infant at birth
Lack
of
preparation
for
labor
Delivery of infant
who
is
disappointing
in
some way
Illness in newborn

- Lack of support person

Inadequate home for
infant care
- Unplanned cesarean birth
Lack of access to
continued health care
Lack of access to
emergency personnel or
equipment
-

- Hemorrhage
- Infection
Fluid and electrolyte
imbalance
- Dystocia
- Precipitous delivery
- Lacerations of cervix or
vagina
- Cephalopelvic disproportion
- Internal fetal monitoring
- Retained placenta
-

LABOR AND DELIVERY

INTRAPARTAL NURSING CARE MANAGEMENT
THEORIES OF THE ONSET OF LABOR
UTERINE STRETCH - any hollow object when stretch to maximum will contract
and
empties.
OXYTOCIN - labor stimulates PPG to produce oxytocin that causes uterine
contraction.
PROSTAGLANDIN - labor causes release of arachidonic acid which in turn increases
the production of prostaglandin -> uterine contraction
AGING PLACENTA - decrease blood supply causes uterine contraction

PROGESTERONE DEPRIVATION decrease causes uterine contraction

PRELIMINARY SIGNS OF LABOR
1. LIGHTENING
Descent of fetal presenting part; 10 14 days before labor onset
2. INCREASE IN LEVEL OF ACTIVITY
Due to increase epinephrine as a result of decrease progesterone
3. BRAXTON HICKS CONTRACTION
Painless uterine contraction; few days or weeks before labor onset
4. RIPENING OF THE CERVIX
Internal sign seen in pelvic examination; buttersoft ( softer than Goodells
Sign )
SIGNS OF TRUE LABOR
1. PRODUCTIVE UTERINE CONTRACTION
longer duration, greater intensity, regular
2. BLOODY SHOW ( PINKISH )
Due to expulsion of the mucus plug(operculum)mixed with ruptured
capillaries as cervix softens
3. RUPTURE OF THE MEMBRANE
Gush or seeping

 Risk for intrauterine infection and cord prolapse

CHARACTERISTICS OF TRUE LABOR
Contractions occur at regular intervals
Contractions start in the back and sweep around to the abdomen, increase in intensity
and duration, and gradually have shortened intervals
Walking intensifies contractions
Bloody Show
Cervix becomes effaced and dilated
Sedation does not stop contractions
CHARACTERISTICS OF FALSE LABOR
Contractions occur at irregular intervals
Contractions are located chiefly in the abdomen, the intensity remains the same or is
variable, and the intervals remain long
Walking does not intensify contractions and often gives relief
Bloody Show usually is not present; if present, usually brownish rather than bright
red
There are no cervical changes
Sedation tends to decrease the number of contractions
COMPONENTS OF LABOR
4 Ps OF LABOR:
1. PASSAGEWAY adequacy of the womans pelvis and birth canal in
allowing fetal decent
2. PASSENGER ability of the fetus to move through the passageway

3.
4.

POWERS - frequency, duration, and strength of uterine contractions to

cause complete cervical effacement and dilation
PSYCHE psychological state, available support systems, preparation for
childbirth, experiences, and coping strategies

THE POWERS
Uterine Contractions
Phases:
a. Increment or Crescendo
b. Acme or Apex
c. Decrement or Decrescendo
Important Aspects:

Duration = beginning to end of same

Early labor = 20 30 secs; late: 60 70 secs.
Interval = end of one contraction to beginning of one
Early labor: 40 45 mins.; late: 2 3 mins.
Frequency = beginning to beginning
Time 2 3 contractions to come up with clearer view
Intensity = strength of contractions

STAGES OF LABOR
FIRST STAGE

Latent Phase: onset of contractions; effacement and dilation of cervix at 3 to

4 cms

Active Phase: dilation continuous from 3 to 4 to 7 cms; contractions are

stronger

Transition Phase: cervix dilates from 8 to 10 cms; irresistible urge to push

SECOND STAGE (EXPULSIVE STAGE)

Cardinal Movements or Mechanisms

Engagement

Descent
Flexion
Internal Rotation
Extension
External Rotation (Restitution)

Expulsion
THIRD STAGE (PLACENTAL STAGE
Placental Separation
Signs of Placental Separation:
Uterus becoming globular
Fundus rising in the abdomen
Lengthening of the cord
Increased bleeding (trickle or gush)
Placental Expulsion
FOURTH STAGE (RECOVERY AND BONDING)

First 1 to 4 hours after birth

Mother and newborn recover from physical process of birth

Maternal organs undergo initial readjustment

Newborn body systems begin to adjust to extrauterine life and stabilize

Uterus contracts in the midline of the abdomen with the fundus midway
between the umbilicus and symphysis pubis
FETAL PRESENTATION AND POSITION
ATTITUDE

degree of flexion of head, body, extremities; Complete Flexion

ENGAGEMENT

settling of the presenting part

the presenting part ( widest diameter ) has pass through the pelvic inlet
STATION

relationship of fetal presenting part with the ischial spine of the mother

FETAL LIE

relationship of long axis of mother with long axis of fetus

FETAL STATION
Relationship of the presenting part to ischial
spine
-1: 1 cm above ischial spine
-3: needs therapeutic rest
0: level of ischial spine, ENGAGEMENT

+3, 4, 5: crowning (2nd stage of labor)

PRESENTATION/FETAL LIE
Longitudinal

Cephalic
Vertex: face, brow, chin

Breech
Complete
Incomplete: frank, footling, kneeling

Shoulder
Transverse

Horizontal or perpendicular

Complete
breech

Single
Footling

Shoulder acromium
Frank
Breech

MECHANISM OF LABOR
Engagement

Descent

Flexion
Internal Rotation
Extension
External Rotation
Expulsion

NURSING CONSIDERATIONS: FIRST STAGE OF

LABOR
Bath patient as necessary
Monitor patients Vital Signs, especially Blood
Pressure

If patients has the same BP rest

If elevated BP notify immediate

attending physician
Place patient on Nothing Per Orem (NPO)
Encourage mother to void
Do perineal preparation or cleansing
Administer Enema (as per hospital policies)

Cleanse bowel to prevent infection

Place patient in Lateral Sidelying (Sims)

Position, elevated enema can to about 12-18
inches, insert catheter slowly and pull out
slowly if with resistance to allow water flow
to rectum

Clamp rectal tube if (+) contraction

Check FHT before and after (120-160, irregular)

SECOND STAGE OF LABOR
Fetal stage or Expulsion Stage
Primigravida: transfer at 10 cm dilatation
Multigravida: transfer at 7 - 8 cm dilatation
Lift legs simultaneously ( Lithotomy )
Bulging of perineum best sign of delivery initiation
Pant and blow breathing, push with open glottis
DELIVERY
Support head and remove secretions
Check for cord coil

 Maintain temperature
Put on abdomen of mother to facilitate contractions
Clamp cord, dont milk, wait for the pulsation to stop the cut cord
Administration of vitamin K and tetracycline eye ointment
Proper identification
THIRD STAGE: BIRTH TO EXPULSION OF PLACENTA (PLACENTAL STAGE)
First sign: fundus rises Calkins sign
Signs of placental separation

Fundus becomes globular and rises

Gush of blood

Cord descends several inches out of vagina

TYPES OF PLACENTAL DELIVERY
Shultz (Shiny)

From center to edges

Presents fetal side that is shiny

Duncan (Dirty)

from edges to center

Presents maternal side that is beefy red and dirty

NURSING CONSIDERATIONS
Check Placenta (cotyledons) for completeness
Assess firmness of fundus
Monitor patients blood pressure
Administer Methergine as ordered by physician
Administer Oxytocin as ordered by physician
Check for laceration
Check on patients Episiorrhapy for any signs of bleeding
Do proper aftercare of equipments and delivery room after delivery
NURSING CONSIDERATIONS: RECOVERY ROOM
Maintain patient flat on bed until instructed otherwise in order to prevent dizziness
Monitor patients vital signs, if with chills provide additional warm blanket to prevent
hypothermia
Keep patient properly oxygenated
Give nourishment as ordered:

Clear liquids

Full liquids

Soft diet

Regular diet
FOURTH STAGE: RECOVERY AND BONDING
Maternal observations: monitor for body system (reproductive system changes,
cardiovascular system changes, respiratory system changes, etc.) stabilization
Placement of the Fundus: shoulde be at the level of the umbilicus

Check bladder, assist in voiding

Check for uterine atony as this may lead to hemorrhage

10 to 14 days is the period of involution

Perineum: check for REEDA

Redness, Edema, Ecchymoses, Discharges, Approximation

Monitor vital signs every 15 minutes
Pain Management

Psychological state (postpartum blues )

Bonding or Rooming-in of Baby

Strict 24 hours with mother

Partial with mother during the morning, at nursery during the afternoon
Check for Lochia:

Lochia Rubra is the dark red discharge occurring in the first 2 to 3 days
Lochia Serosa is pink to brownish discharge, occurring from 3 to 10 days
after delivery
Lochia Alba is an almost colorless to creamy yellowish discharge occurring
from 10 days to 3 weeks after delivery