MATERNAL & CHILD

HEALTH NURSING

ANTEPARTUM

Venice Joy Toledo - Malonzo, RN

1
Maternal and Child Health Nursing
involves care of the woman and
family throughout pregnancy and
child birth and the health promotion
and illness care for the children and
families.

2
Primary Goal of MCN
The promotion and maintenance of
optimal family health to ensure
cycles of optimal childbearing and
child rearing

3
 ANATOMY AND
PHYSIOLOGY OF
FEMAL REPRODUCTIVE
ORGANS

4
EXTERNAL
 Mons Pubis - pad of adipose tissue which
lies over the symphysis pubis covered by
skin and at puberty, by short hairs;
protecting the surrounding delicate tissue.

 Labia Majora -two folds of skin with fat

underneath; contain Bartholin’s gland.

 Labia Minora -two thin folds of delicate

tissues; form an upper fold encircling clitoris
called the prepuce; and unite posteriorly
called the fourchette. 5
 Clitoris - small, erectile structure at
the anterior junction of the labia minora

 Vestibule – narrow space seen when

the labia minora are separated.

 Urethral meatus – external opening of

the urethra; slightly behind and to side
are the opening of skene’s gland 6
 Vaginal orifice– external opening of
the vagina, covered by a thin
membrane called hymen.

 Perineum – area from the lower

border of the vaginal orifice to the anus

7
8
 INTERNAL
UTERUS
 A hollow pear shaped
muscular organ
 Serves various function
1. To receive ovum from
fallopian tube
2. To provide a place for the
ovum implant
3. To offer nourishment &
protection to the growing
fetus
4. To expel the fetus from the
mother’s body when mature
 It has 3 layers endometrium,
myometrium,perimetrium 9
VAGINA

 a 3-4 inches long dilatable canal

located between the bladder and the
rectum.
 it contains rugae which permit
considerable stretching without tearing
 passageway for menstrual discharges,
copulation and fetus.
10
OVARIES

 almond shaped,
dull white sex
glands near the
fimbrae, kept in
place by
ligaments.
 Produce mature
and expel ova
and manufacture
estrogen and
progesterone.
11
FALLOPIAN TUBES
 4 inches long from each side of
the fundus, widest part (called the
ampula) spreads into fingerlike
projections (called fimbrae).
 Responsible for transport of
mature ovum to the uterus.

12
13
Related Structure
 Pelvis - support and protect the reproductive
organ

14
 Types/ Variation of Pelvis
 Gynecoid – normal female pelvis. Inlet is
well rounded forward and back. Most ideal
for child birth.
 Anthropoid – transverse diameter is
narrow, AP diameter is larger than normal.
 Platypelloid – inlet is oval, AP diameter is
shallow
 Android – “male pelvis”. Inlet has a
narrow, shallow posterior portion and
pointed anterior portion. 15
Division of the Pelvis
False pelvis
 Part above the pelvic brim
 Serves to support the weight of the enlarged pregnant
uterus
 Directs the presenting fetal part into the true pelvis
Inlet: upper border of pelvis
 Pelvic cavity: Curved canal with a longer posterior than
anterior wall
 Outlet: Pelvic outlet is at the lower border of the true
pelvis

16
FIGURE 3–12 Female pelvis. A, The false pelvis is a shallow cavity above the inlet; the true pelvis is a
deeper portion of the cavity below the inlet.

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Pelvic Measurements
Pelvic inlet
Diagonalconjugate
Measure at least 11.5 cm

Obstetric conjugate - 10 cm or
more

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 A
FIGURE 10–5 Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which
extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the
anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of
the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior
measurements.

19
 B

FIGURE 10–5 (continued) Manual measurement of inlet and outlet. A, Estimation of the
diagonal conjugate, which extends from the lower border of the symphysis pubis to the
sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which
extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D,
Methods that may be used to check the manual estimation of anteroposterior
measurements. 20
 C

FIGURE 10–5 (continued) Manual measurement of inlet and outlet. A, Estimation of the
diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral
promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the
lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used
to check the manual estimation of anteroposterior measurements.
21
Pelvic Measurements

Pelvic outlet
Anteroposterior diameter
Should be 9.5 to 11.3 cm
Transverse diameter should
be 8 to 10 cm

22
FIGURE 10–6 Use of a closed fist to measure the outlet. Most examiners know the distance between their
first and last proximal knuckles. If they do not, they can use a measuring device.

23
 Breast
 Consist of glandular,
fibrous, and adipose
tissue.
 Grow & Develop
from stimulation of
secretion from the
hypothalamus,
anterior pituitary and
ovaries.
 Provide nourishment
to the infant and
transfer maternal
antibodies during
breast feeding
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Menstrual
Cycle
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Female Reproductive Cycle
 Purpose:
To bring an ovum to maturity and renew the
uterine tissue bed that will be responsive to
its growth once it’s fertilized
 Menarche
First menstruation
May occur early as age of 7 or late as age 17

26
The menstrual cycle
 Varies from woman to woman

average length of cycle is 28 days from

the beginning of one menstrual flow to
the beginning of next.

aveverage length of the menses is 2 to

7 days
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 Initiated by the release of LUTEINIZING
HORMONE – RELEASING HORMONE, also
known as gonadotropin – releasing hormone
from the hypothalamus
 Under the influence of LHRH, the anterior
lobe of pituitary produces two hormone:
a. Follicle stimulating hormone
b. Luteinizing hormone

28
 Characteristics of Normal Menstruation
Period
1. Menarche – average onset 12 -13 years
2. Interval between cycles – average 28 days
3. Cycles 23 – 35 days
4. Duration – average 2 – 7 days; range 1 – 9
days
5. Amount – average 30 – 80 ml ; heavy
bleeding saturates pad in <1hour
6. Color – dark red; with blood; mucus; and
endometrial cells
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Phases of menstrual cycle
Menstrual phase (days 1-5)

 Estrogen and progesterone level

decrease
 FSH levels rise, and steady levels of LH
influence the ovary to secrete estrogen
 Menstrual flow begins

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Proliferative (follicular) phase (6-13 days)

 Estrogen production increases, leading

to proliferation of endometrium and
myometrium in preparation for possible
implantation of ovum
 Follicle secrete estradiol
 FSH stimulates graafian follicle
 FSH production decreases before
ovulation (around day 14)
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Secretory (Luteal) (days 14-25)

 The corpus luteum forms under the

influence of LH
 Estrogen and progesterone production
increases
 The endometrium id prepared for
implantation of fertilized ovum
32
Ischemic (days 26-28)

 The corpus luteum degenerates if

conception doesn’t occur
 Estrogen and progesterone levels
decline if conception doesn’t occur

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34
Associated Terms
1. Amenorrhea - temporary cessation of
menstrual flow
2. Oligomenorrhea - markedly diminished
menstrual flow
3. Menorrhagia - excessive bleeding during
regular menstruation
4. Metrorrhagia - bleeding at completely
irregular intervals
5. Polymenorrhea - frequent menstruation
occurring at intervals of less than 3 weeks
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
BEGINNING OF
PREGNANCY

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Process of Conception

Fertilization

1. Union of the ovum and spermatozoon

2. Other terms: conception, impregnation or fecundation
3. Normal amount of semen/ejaculation= 3-5 cc = 1 tsp.
4. Number of sperms: 120-150 million/cc/ejaculation
5. Mature ovum may be fertilized for 12 –24 hrs after
ovulation
6. Sperms are capable of fertilizing even for 3 – 4 days
after ejaculation (lifespan of sperms 72 hrs)
37
FIGURE Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a sperm are depicted
moving from top to bottom. B, Scanning electron micrograph of a human sperm surrounding a human ovum (750×).
The smaller spherical cells are granulosa cells of the corona radiata. Scanning electron micrograph used with38
permission from Nisson, L. (1990). A child is born. New York: Dell publishing.
FIGURE 7–2 (continued) Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a
sperm are depicted moving from top to bottom. B, Scanning electron micrograph of a human sperm surrounding a
human ovum (750×). The smaller spherical cells are granulosa cells of the corona radiata. Scanning electron
micrograph used with permission from Nisson, L. (1990). A child is born. New York: Dell publishing.(Photo
Lennart Nilsson/Albert Bönniers Folag AB) 39
Implantation

 Once implantation has taken place, the uterine

endometrium is now termed deciduas

 Occasionally, a small amount of vaginal bleeding

occurs with implantation due to breakage of
capillaries

 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. The developing cells now called blastomere
and when about to have 16 blastomere called
morula.
40
 Morula travels to uterus for another 3 – 4
days
 When there is already a cavity in the morula
called blastocyt finger like projections called
trophoblast form around the blastocyst, which
implant on the uterus
 Implantation is also called nidation, takes
place about a week after fertlization

41
FIGURE During ovulation the ovum leaves the ovary and enters the fallopian tube. Fertilization generally occurs
in the outer third of the fallopian tube. Subsequent changes in the fertilized ovum from conception to implantation
42
are depicted.
Placentation

 In placentation, the chronic villi invade

the decidua
 This becomes the fetal portion of the
future placenta

43
Stages of Fetal Development
Preembryonic period
 Begins with fertilization and lasts about 3
weeks
 As the zygote passes through the fallopian
tube, it undergoes a series of mitotic division,
or cleavage
 Once formed, the zygote develops into
morula and then blastocyst, eventually
attached to the endometrium.

44
Embryonic Period
 Begins with the 4th week of gestation and
ends with the 7th week
 The zygote now called an embryo, begins to
take on a human shape
 Germ layers develop, giving rise to organ
system
 The embryo is highly vulnerable to injury from
maternal drug use, certain maternal
infections, other factors

45
Fetal Period
 Begins with 8th week of gestation and
continues until birth
 During this period, the embryo now called
fetus, matures, enlarges, and grows heavier.
 The head of the fetus is disproportionately
larger than its body.
 The fetus also lacks subcutaneous fat

46
Embryonic & Fetal Structures
Decidua
 Refers to endometrial lining during pregnancy
 Provides a nesting place for the developing
ovum

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Fetal membranes
 The chorion is the fetal membrane closest to
the uterine wall:
- It gives rise to placenta
- It forms the outer wall of blastocyst
- Vascular projections, called chronic villi,
arise from its periphery

 Amnion is the thin, though inner fetal

membrane that lines amniotic sac, gives rise
to umbilical cord supported by Wharton’s
jelly
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Embryonic germ layers
Three layers develop during the embryonic
period
 Ectoderm – outermost layer
 Mesoderm – middle layer
 Endoderm – inner most layer; differentiation
of endoderm results in formation of epithelium
lining respiratory and digestive tracts

49
FIGURE Endoderm differentiates to form the epithelial lining of the digestive and respiratory tracts and associated
glands.
50
Amniotic sac
 Gradually increases in size and surrounds the
embryo
 Contains fluid, called amniotic fluid
 Purpose
1. Protection – shield against pressure and
temperature changes
2. Can be used to diagnose congenital
abnormalities intrauterine– amniocentesis
3. Aid in the descent of fetus during active labor
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Umbilical cord
 Serves as the lifeline from the embryo to the
placenta
 Measures from 30.5 – 90 cm in length & 2 cm in
diameter at full term
 Contains AVA (2 artery 1 vein)
artery – carries blood from fetus to placenta
vein – returns blood to the fetus from the
placenta
 Contains wharton’s jelly, jellatenous substance
that helps prevent kinking of the cord in utero
 Blood flows through the cord at about 400ml/min 52
Placenta
 A flat disk shaped structure formed from the
chorion, chronic villi, and adjacent decidua
basalis
 Contains 15-20 subdivison called cotyledons
 It supplies fetus with carbohydrates, water,
fats, protein, minerals & inorganic salts
 It transfer passive immunity via maternal
antibodies

53
Maternal portion
 Consists of deciduas basalis and its circulation
 Surface appears red and flesh-like

Fetal portion
 Consists of the chorionic villi and their
circulation
 The fetal surface of the placenta is covered by
the amnion
 Appears shiny and gray

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FIGURE Maternal side of placenta (Dirty Duncan).

55
FIGURE 7 Fetal side of placenta (Shiny Shultz).

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FETAL GROWTH &
DEVELOPMENT

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Fetus Growth & Development
 4 weeks: 4–6 mm, brain formed from
anterior neural tube, limb buds seen,
heart beats, GI system begins

 6 weeks: 12 mm, primitive skeletal

shape, chambers in heart, respiratory
system begins, ear formation begins

58
 12 weeks: 8 cm, ossification of skeleton
begins, liver produces red cells, palate
complete in mouth, skin pink, thyroid
hormone present, insulin present in pancreas

 16 weeks: 13.5 cm, teeth begin to form,

meconium begins to collect in intestines,
kidneys assume shape, hair present on scalp

59
FIGURE The fetus at 20 weeks weighs 435 to 465 g and measures about 19 cm. Subcutaneous deposits of
brown fat make the skin a little less transparent. “Woolly” hair covers the head, and nails have developed on
the fingers and toes. Use with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.
(Photo Lennart Nilsson/Albert Bönniers Folag AB)
60
 20 weeks: 19 cm, myelination of spinal cord
begins, suck and swallow begins, lanugo
covers body, vernix begins to protect the
body
 24 weeks: 23 cm, respiration and surfactant
production begins, brain appears mature
 28 weeks: 27 cm, nervous system begins
regulation of some functions, adipose tissue
accumulates; nails, eyebrows, and eyelids
are present; eyes are open
 36 weeks: 35 cm, earlobes soft with little
cartilage, few sole creases 61
 40 weeks : 40 cm, adequate surfactant,
vernix in skin folds and lanugo on shoulders,
earlobes firm, sex apparent
 Weight about 3,000 to 3,600 g (6 lb., 10 oz. to
7 lb., 15 oz.)
 Varies in different ethnic groups
 Skin has a smooth, polished look
 Hair on head is coarse and about 1 inch long
 Body and extremities are plump

62
Focus of Fetal Development

 First Trimester – period of organogenesis

 Second Trimester – period of continued fetal
growth and development; rapid increase
inlength
 Third Trimester – period of most rapid growth
and development because of the deposition
of subcutaneous fat

63
FIGURE 7 The actual size of a human conceptus from fertilization to the early fetal stage. The embryonic stage
64
begins in the third week after fertilization; the fetal stage begins in the ninth week.
Fetal Development: What Parents
Want to Know

65
66
 Fetal Blood Circulation

The fetus is connected by the umbilical cord to the

placenta, the organ that develops and implants in the
mother's uterus during pregnancy.

Through the blood vessels in the umbilical cord, the

fetus receives all the necessary nutrition, oxygen, and life
support from the mother through the placenta.

Waste products and carbon dioxide from the fetus are

sent back through the umbilical cord and placenta to the
mother's circulation to be eliminated.
67
68
Placenta
▼▼▼
Umbilical vein (composed of two arteries and
one vein – AVA)
▼▼▼
Liver
▼▼▼
Ductus Venosus (First Shunt)

69
▼▼▼
Inferior Vena Cava
▼▼▼
Right Atrium
▼▼▼
Foramen Ovale (Second Shunt)
▼▼▼
Left Atrium
▼▼▼
Left Ventricle
70
▼▼▼
Aorta
▼▼▼
▼▼▼
To upper half of the fetal body only
 Upper Extreme
 Brain
 Heart
 Pulmonary
 Upper part of the GUT
71
▼▼▼
▼▼▼ Then this blood is recollected ▼▼▼
with less oxygen and then it ▼▼▼ goes to
the
▼▼▼
Superior Vena Cava

72
▼▼▼
Right Atrium
▼▼▼
Right Ventricle
▼▼▼
Pulmonary Artery (but lungs are collapsed;
Surfactant inadequate and amniotic fluid is
present)
▼▼▼
Ductus Arteriosus

73
▼▼▼
Descending Aorta
▼▼▼
Supply the lower half of the fetal body
▼▼▼
▼▼▼ Blood is recollected
▼▼▼
Hypogastric Artery
▼▼▼
Umbilical Artery
▼▼▼
Placenta
74
SHUNTS
 When the baby is delivered, the shunts are
normally removed
 DuctusVenosus
 Foramen ovale

75
 Two (2) types of Closure
 Functional Closure
 Anatomic Closure

76
FORAMEN OVALE
 Closed functionally immediately after birth or
IMMEDIATELY AFTER CORD IS CLAMPED
 Anatomically, it can persist up to one (1) year
after delivery

77
 Therefore, in auscultation in twenty-eight (28) day
old baby
 There is a MURMUR
 This is Normal
 This is NOT A PATHOLOGIC MURMUR
 It is a SYSTEMIC / INNOCENT MURMUR
A PHYSIOLOGIC MURMUR IN NEONATES

78
DUCTUS ARTERIOSUS
 Functional Closure
 Ten to ninety-six hours (10 – 96 hrs) after birth
or approximately four (4) days
 Anatomically
 Two to three months (2 – 3 mos.)

79
Normal Adaptation to Pregnancy

Systemic
Changes

80
1. Cardiovascular/ Circulatory changes

 a. Physiologic anemia of pregnancy

 30-50% gradual increase in total cardiac
volume (peak 6th month) causing drop in
 Hemoglobin and Hematocrit values (inc only
in plasma volume)

81
 Consequences of increased cardiac volume:
1. easy fatigability & shortness of breath due
increase cardiac workload
2. slight hypertrophy of the heart
3. systolic murmurs due to lowered blood
viscosity
4. nosebleeds may occur due to congestion of
nasopharynx

82
b. Palpitations
 caused by the SNS stimulation during early
part of pregnancy; increased pressure of the
uterus against the diaphragm during the
second half of pregnancy
c Edema of the lower extremities & varicosities
 due to poor circulation caused by the
pressure of the gravid uterus on the blood
vessels of the lower extremities

83
84
d. Vaginal and rectal varicosities
 due to pressure on blood vessels of the
genitalia
e. Predisposition to blood clot formation
 due to increased level of circulating fibrinogen
as a protection from bleeding implication: no
massage

85
 2. Gastrointestinal Changes
a. Morning sickness
 nausea and vomiting in the 1st
trimester due to HCG or due to
increased acidity or emotional factors
b. Hyperemesis gravidarum
 excessive nausea & vomiting which
persists beyond 3 months causing
dehydration, starvation and acidosis

86
c. Constipation and Flatulence
 GI displacement slows peristalsis &
gastric emptying time; inc
progesterone

87
d. Hemorrhoids
 due pressure of enlarged uterus

88
e. Heartburn
 due to increased progesterone and
decreased gastric motility causing
regurgitation through gastric sphincter

89
3. Respiratory Changes
a. Shortness of Breath
 due to inc. oxygen consumption and
production of carbon dioxide during the 1st
Trimester; and increased uterine size pushing
the diaphragm crowding chest cavity

90
4. Urinary Changes
a. Urinary frequency
 felt during the 1st trimester due to the
increase blood supply to the kidneys and then
on the 3rd trimester due to pressure on the
bladder.
b. Decreased renal threshold for sugar
 due to increased production of
glucocorticoids which cause lactose and
dextrose to spill into the urine; and inc.
progesterone
91
5. Musculoskeletal changes
a. Pride of Pregnancy
 due to need to change center of gravity result
to lordotic position
b. Waddling gait
 due to increased production of hormone
relaxin, pelvic bones becomes more movable
increasing incidence of falls
c. Leg cramps
 due to pressure of gravid uterus, fatigue,
muscle tenseness, low calcium and 92

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

93
6. Endocrine Changes
a. Addition of the placenta as an endocrine
organ producing HCG, HPL, estrogen and
progesterone
b. Moderate enlargement of the thyroid due to
increased basal metabolic rate
c. Increased size of the parathyroid to meet
need of fetus for calcium

94
7. Weight Change

a. First Trimester 1.5 to 3 lbs normal weight

gain
b. 2nd and 3rd trimester 10 – 11 lbs per
trimester is recommended
c. Total allowable weight gain during throughout
pregnance is 20 – 25 lbs or 10 –12 kgs.
d. Pattern of weight gain is more important than
the amount of weight gained.

95

 8. Emotional responses
a. 1st trimester: some degree of rejection,
disbelief, even depression because of its
future implication -> give health teachings on
body changes and allow for expression of
feelings
b. 2nd trimester: fetus is perceived as a
separate entity and fantasizes appearance
c. 3rd trimester: best time to talk about layette,
and infant feeding method. To allay fear of
death let woman listen to the FHT.
96
 COMMON EMOTIONAL
RESPONSES DURING PREGNANCY
 Stress –decrease in responsibility
taking is the reaction to the stress of
pregnancy not the pregnancy itself 
affects decision making abilities

 Couvade – syndrome – men

experiencing nausea/vomiting,
backache due to stress, anxiety and
empathy for partner
97
 Emotional labile – mood
changes/swings occur frequently due to
hormonal changes

 Change in Sexual Desire – may

increase or decrease needs correct
interpretation… not as a loss of interest
in sexual partner
98
Appropriate Relief Measures
 Urinary frequency
 Increase fluid intake during day
 Decrease fluid intake in the evening

 Fatigue: Plan rest periods and ask for help

from family or support persons
 Breast tenderness: Wear well supporting bra

99
Common Obstetric Terminology
(cont’d)
 Nullipara: Woman who has had no births at
more than 20 weeks’ gestation
 Primipara: Woman who has had one birth at
more than 20 weeks’ gestation
 Multipara: Woman who has had two or more
births at more than 20 weeks’ gestation
 Stillbirth: Infant born dead after 20 weeks’
gestation
 Multigravida: Woman in second or any
subsequent pregnancy
100