MATERNITY NURSING

Prepared by: Fely Rodriguez, RN, RM, MN

ANATOMY EXTERNAL
PUDENDA

/ VULVA- includes all structure visible externally from pubis to perineum that includes:
1. 2. 3. 4. 5. 6.

MONS PUBIS LABIA MAJORA LABIA MINORA CLITORIS VESTIBULE PERINEUM

INTERNAL

Measurement: 3 -4 inches between bladder and rectum function: ph 4.5 5.5 (acidic doderline bacilli rugae permits considerate stretching without tearing post vaginal canal vascular supply

Main: Internal Iliac Artery Upper third = cervicovaginal branches middle third = inferior vesical artery lower third = middle rectal and internal ppudendal arteries

1. VAGINA

 lymphatics

or drains into:

upper- ileac nodes middle- internal ileac nodes lower- inguinal lymph nodes

1. VAGINA

Parts: 2 major unequal parts

2. UTERUS the upper 2/3, triangular portion the lower 1/3, cylindrical portion

Layers

endometrium/mucusal layer/DECIDUA myometrium/muscular layer perimetrium/serosal layer

2. UTERUS
measurements: NP- 3 inches long, 2 inches wide, one inch thick Preg.- 32 cms, 24 cms., 20-24 cms weight: NP= 50-60 gms P= 1000 gms (immediately after delivery capacity : 10 ml 75 ml cavity {ave. of 30 ml} 5 L at term 20 L- can hold at this maximum

2. UTERUS
Function: organ of menstruation organ of pregnancy/implantation labor power-powerful contract

Size and Shape of uterus

original n-p shape pear shape as pregnancy advances by 3rd lunar month-globular S. subsequently uterus

increase rapidly by length decrease not width giving-ovoid shape end of 12 weeks-uterus becomes an abdominal organ for it become too large to remain in pelvis uterine and ovarian arteries

2. UTERUS

vascular supply

3. FALLOPIAN TUBES/OVIDUCTS

measurements: 8-14 cm./ 4 inches tube Parts: 1. interstitial-insertion in uterine wall 2. isthmus-narrowest portion 2-3 mm 3. ampulla-widest 5-8 mm 4. infundibulum- fimbrae, fingerlike projections Layers: outer longitudinal layer inner circular layer

3. FALLOPIAN TUBES/OVIDUCTS

Function

site of fertilization passageway of ovum from ovaries passageway of sperm from uterus 5 minutes-sperm as quickly as this reach site of fertilization from time of ejaculation 12-24h average-mature ovum is capable being fertilized after ovulation

Note:

4. OVARIES

FUNCTION 1. cardinal and primary function 2. endocrine PARTS 1. cortex 2. medulla Almond shape mittleschermz-pain during ovulation due to rupture of follicle, fluid and blood escape into peritoneum and irritates Lifetime history of germ cell maturation

Testis semineferous gland interstitial Epididymis-stores where it matures and it becomes motile vas deferens- passage of sperm prostate gland secret alkaline fluid for sperm to swim cm 2.5-3.5 glandular structure that surrounds the neck of bladder and urethra Bulburethra/ cowpers gland

72 hours- normal lifespan of sperm outside males body or after ejaculation to woman genital in normal men, semen volume and density decreases when ejaculation occurs more often than 48hrs right testis is lower than left because the large liver wide space to occupy and pushes it composition of semen 1. Sperm a. head b. body c. tail 2. secretions by seminal vesicle 3. prostate gland 4. cowpers/bulbourethral gland

PHYSIOLOGY MENSTRUATION periodic discharge of bloody fluid from uterus occurring at more or less regular intervals during the life of a woman for puberty to menopause Menstruation
stim

E and P low

Hypo to release GnRH {FSHRF&LHRF}

release FSHRF triggers

APG-FSH

acts on follicles of ovary, but only one will grow and develop GF-growing and developing primoidial follicle called Graafian follicle

as GF grows and develop produces ESTROGEN

1. 2.

in response to increase estrogen

lining of uterus starts to thicken cervical glands produce sticky, cloudy, flaky mucus discharge giving a woman sticky sensation around the vagina

as GF full matures

E is at its peak and man levels of estrogen

1. 2.

HYPO

stop prod. FSHRF-APG-Stop FSH simultaneously produce LHRF-APG- LH

acts

on matured GF causing it to rupture and release

process called ovulation

the ruptured follicle becomes a yellow body called CORPUS LUTEUM

produces and release progesterone

supports further growth of endometrium becomes

spongy, very thick, rich in mucus and b.v (vascular and tortous) making is a perfect bed for possible implantation

P reach its peak and no fertilization stimu. HYPO- to stop LHRF

APG stops LH Causes the CL to degenerate in 14 days as its normal life span,a drop in Pragesterone causes the

Shedding or sloughing of endometrial lining= MENSTRUATION

Success of menstruation depends on different 4 body structure involved and its interaction 1. HYPO FSHRF & LHRF 2. APG FSH & LH 3. OVARY E/P 4. UTERUS

Phases of Menstrual Cycle

1. 2. 3.

Menstrual Phase Proliferative Secretory phase

A. UTERINE RESPONSE:

B. OVARIAN RESPONSE
1. 2. FOLLICULAR PHASE LUTEAL PHASE

AMNIOTIC FLUID COLOR clear to cloudy Green Yellow Port wine stain Coffee Brown 1st nsg.action when BOW ruptures NITRAZINE TEST N. Value: 500-1000cc Associated Problem: Oligo scanty amount of A.fluid less than 500cc which may result to fetal distress coz no enough fluid to equalize the pressure Polyhydramnios: excessive amount of A.fluid > 1500-2000cc w/c may result to preterm labor or uterine rupture

S/S: 1. abnormality in FHT 2. increase fetal thrushing/ movement 3. Meconium stained A.fluid TYPES: 1. F. Tachycardia 2. F. Bradycardia CAUSES: 1. Oligohydramnios 2. 3Cs-cord compressions, coil, prolapse 3. PIH,GDM 4. Bleeding 5. Abruptio placenta

 COMPOSITION:

3 vessels whartons jelly Absence of pain receptors/ nerve endings N.Lenght : 30-80 cms (ave. of 55cms) Associated Problems: too short too long mechanical abruptio cord coil uterine inversion cord compression cord prolapse

FORMATION: formed by 8th wks develops/fxnal by 10-12th wks time bounded til 42 wks only FUNCTION: 1. respiratory 2. GIT 3. circulatory 4. endocrine 5. protects the fetus WEIGHT: 5OO gms, 5 cms thick, composed of 15-20 cotyledons. PARTS : 1. Maternal part / side 2. Fetal part / side

FETUS Summary:
1st

trimester 2nd trimester 3rd trimester

organogenesis fetal organ form development of fetal length rapid deposition of subcutaneous tissue

1st Lunar Month

GERM layer differentiation VITAL ORGAN formation all organs formed is continued/ sex differentiation& formation/ placenta full development Function Lanugo, FHT Vernix, Quickenning, FHT by stet, age of viability sensory receptors are well established alveoli Start deposition of the SC, disappearance of lanugo Peak of SC deposition, disappearance of vernix caseosa

2nd lunar

3rd lunar

4th lunar 5th lunar 6th lunar 7th lunar 8th lunar 9th lunar 10th lunar characteristics of a FT infant is achieved

DIAGNOSIS NORMAL SIGNS NORMAL

DURATION ADAPTATION

DIAGNOSIS OF PREGNANCY
Urine

examination Uterine souffl Funic souffl ultrasound/quickening

NORMAL DURATION/LENGTH OF PREGNANCY

MONTHS:
10

lunar month 9 calendar month WEEKS

: 38 42 Wks (ave. of 40 weeks ) DAYS : 280 days -singleton

260

days 247 days

twins triplets

Signs of Pregnancy
Presumptive
1. amenorrhea

Probable
Vagina = Chadwicks Cervix = Goodells sign Uterus = Hegars sign

Positive
FHT FETAL MOVEMENT FETAL OUTLINE

2. Urinary frequency 3. Am sickness 4. Breast changes 5. Skin pigmentation 6. quickening

Enlarged abdomen ballotement Braxton Hicks contraction (+) Pregnancy test

2 Common Problems

leukorrhea alkaline envi

trichonomanas vaginalis Moniliasis AM sickness- due to progress Hyperemesis gravidarum constipation flatulence hemorrhoids Heartburn

GIT

Respiratory shortness of breath Cardiovascular - 30-50% increase the cardiac volume results to physiologic anemia Renal urinary frequency,decrease threshold for sugar (coz of increase GFR), stasis in the urine Musculoskeletal - pride of Pregnancy Lordosis Relaxin is increase causing wobbly joints

IV. PRE NATAL CHECK UP

SCHEDULE COMPONENTS HEALTH

TEACHINGS

COMPONENTS OF PRENATAL
I. Schedule
A. B. C. D.

Every month - 1 to 8 months or from the time pregnancy is detected -32 weeks AOG Twice a month / every 2 weeks 32 to37 wks Weekly 37weeks birth or EDB 2X A Week for all Post term or > 42 wks Health history taking- G,P, OB Score, LMP assessment VS, Wt.,LM, Pap Smear, Pelvimetry laboratory/ diagnostic procedure

II. Components
A. B. C.

A. History Taking

includes: personal data; medical data; family history; OB-Gyne History

Gravida- total number of pregnancy regardless of outcome parity- total number of pregnancy that has reach the age of viability whether dead or alive viability ability of the fetus to live extrauterine life OB score T-P-A-L Past Pregnancy- method, where, whom, complication, risk Present pregnancy

IMPORTANT ESTIMATES OF AOG & EDB

NAGELES RULE -3+7 if April Dec +9+7 if Jan Feb & March Mc DONALDS RULE FH in cms X2 divided by 7 = AOG in mos. X8 = AOG in wks BARTHOLOMEWS RULE Important landmarks : 1. symphysis pubis 2. umbilicus 3. xiphoid process

10 Danger signs
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

vaginal bleeding swelling of face and hands cont. HA dimness/blurring of vision flashes of lights before the eyes persistence of vomiting pain in abdomen chills/fever sudden escape of fluid from vagina (-) FHT/movement

TERMS
nulligravida-

never been pregnant primigravida- pregnant for the 1st time primipara-woman who deliveries only once of a fetus who has reached viability multigravida- 2 or more successive multipara-2 or more deliveries grand multigravida- 6 or more pregnancy grand multipara- 6 or more deliveries to viability

ASSESSMENT
VS WEIGHT

: allowable weight gain : 20 25 lbs wt. distribution : 1st tri 1 lb/mon 2nd & 3rd 1 lb/wk pattern of wt. gain : a.3,5,12 b.5,5,12 c.3,12,12 d.5,12,12

ASSESSMENT
LEOPOLDS

MANNEUVER LM1 - fundic grip LM2 abdominal/umbilical grip LM3 Pawliks grip LM4 - pelvic grip

ASSESSMENT
PATIENT

1. 2. 3. 4.

PREPARATION: Explain procedure Empty bladder Put patient on proper position Palpate with warm hands

ASSESSMENT
PAPANICOLAU

SMEAR is a diagnostic cytological test for early detection of cervical cancer. INDICATIONS: 1. All married women 2. single but sexually active 3. post partum women from 6 wks 6 mos. 4. single not sexually active but more than 40 yrs old.

ASSESSMENT
CLASSIFICATION: CLASS I CLASS II CLASS III CLASS IVCLASS V normal atypical cell is present suggestive of malignancy strongly suggestive of malignancy conclusive of malignancy

STAGES: Stage I Stage II Stage III confined in the cervix invades the vagina diffuses on the entire reproductive metastasis on the anterior bladder & posterior rectum

Stage IV -

C. Labs & Diagnostic procedures

CBC

Hgb , Hct 0.35 0.45 Blood typing Urinalysis (+) albumin = PIH (+) sugar = GDM (+) Pus = UTI Gram stain presence of yeast cells & hyphae -- pres. Of gm(-) diplococci -- presence of T. vaginalis

Ultrasonography: 1. AOG 2. Sex of baby 3. amount of amniotic fluid 4. locates the placenta 5. Ectopic pregnancy,H-mole 6. Gyne: tumors, cyst,myomas 7. limited congenital anomalies

HEALTH TEACHINGS
NUTRITION IMMUNIZATION DRUGS EXERCISE SMOKING,

ALCOHOL INTAKE, RADIATION EXPOSURE SEX EMPLOYMENT

Nutrition
malnutrition iron CHON Vitamin Caloric Folate/

causes

Folic acid Iodized salt Minerals

 Tetracycline

staining of the teeth & long bones Streptomycin damages CN8= conge nital deafness Chloramphenicol- Gray Baby Syndrome
Safest:

Penicillin, Erythromycin

 Salicylates/Aspirin

-Bleeding tendencies, Abortion Acetamenophen premature closure of PDA Safest antipyretic/analgesic: Paracetamol

 ACE

conginatal renal anomaly Steroids/Phenobarbital- cleft lip & palate Iodides - enlargement of the thyroid DES or Diethylstilbestrol CA of the repro ductive organ later in adult life

Inhibitors

HEALTH TEACHINGS cont.

Avoid Smoking=LBW No ROH intake= MR Avoid radiation exposure = Abortion Sex Employment = role modification, identification of occupational risk

1. 2. 3. 4.

5.

EXERCISE Pelvic Rock=low backache Kegels = pelvic pressure / congestion Walking Modified Knee Chest exercise = relieves discomforts of hemorrhoids, cramps in the thighs & buttocks Squatting/Tailor Sitting strenghtens perineal muscles

DIFFERENCE OF FALSE LABOR

From

TRUE LABOR PAINS Becoming regular w increasing intensity Radiates at the lumbosacral region (back) Worsens uterine contraction No amt of sedation can relieve the pain only anesthesia (+) c.dilatation and effacement

Assessment tool/criteria Irregular u.c. in terms of duration, interval& 1. Uterine contraction freq. 2.Location of pain Confined in the abdomen Decreases uterine contraction Relieves of the pain

3.ambulation

4. Sedation

5.IE

No progression of cervical dilatation & effacement

Dilatation stage Def

Ambulation

Expulsion Stage Def

N.Duration Episiotomy Mod

Placental Stage Def

N.

4Ps of Labor Passageway Power Passenger Psyche Phases of Labor Medications Anesthesias Monitoring

Ritgens manneuver Mech. Of Labor

Duration S/S of Placental Separation Brandt Andrews Manneuver Types of Placental Delivery Medications

Recovery Stage Def Degrees of laceration location of fundus lochia

TYPES OF PELVIS
1. 2. 3. 4.

ANDROID ANTHROPOID GYNECOID PLATYPELLIOD

POWER
SOURCE:

Primary = uterine contractions Secondary = abdominal muscle during the bearing down INTENSITY: Mild, Moderate,Strong

PHASES: 1. INCREMENT 2. ACME 3. DECREMENT

MONITORING: Duration- beginning to end of the same contraction. Interval end of one contraction to the beginning of the next Frequency beginning of one to the beginning of the next contraction

POSITION

IS THE RELATIONSHIP OF THE FETAL PRESENTING PARTS TO THE FIXED QUADRANTS OF THE MATERNAL PELVIS POINT OF REFERENCE/ COMMON DENOMINATOR: VERTEX = OCCIPUT FACE = MENTUM BREECH = SACRUM TRANSVERSE = ACROMIUM

Cranial bones 1. frontal 2. occiput 3. parietal Membrane spaces/suture lines - important they allow bones to move and overlap and change shape to fit in birth canal called molding 1. sagittal suture-membranes interspace which join 2 parietal bones 2. coronal suture- frontal bone and 2 parietal bones 3. lamboidal- occiput and parietal Fontanelles- membrane covered spaces at the junction of the main suture line

 1.

Measurements anteroposterior diameters a. occipito mental = 13 cms b. occipitofrontal = 12cms c. suboccipitopregmatic = 9-9.5 cms Transverse Diameter
a. b. c.

2.

biparietal D. = 9-9.5 cms Bitemporal D. = 8 cms Bimastoid D. = 7 cms

Phases of labor
PHASES LATENT ACTIVE TRANSI TIONAL IE 0-3 cms 4-7 cms 8-10 cms
INTENSITY

ACTIVITY

Mild

talkative

Moderate Fear of losing ctrl uncontrolla ble

SECOND STAGE OF LABOR

Known as the Normal Duration: Primi = 80 mins Multi = 3o mins Modified Ritgens Manneuver is the forward upward pressure applied in the perineum with the main purpose of preventing laceration as well as promote flexion of the head in brow presentation.

MECHANISM OF LABOR
Occurs

in chronological order of : EDE FIRE ERE 1. engagement 5. descent 2.flexion 6. internal rotation 3. extension 7. expulsion 4. external rotation A.1234567 c. 1526347 b. 1357246 d. 1425367

THIRD STAGE OF LABOR

Known
Normal

as the

Duration: 3 20 mins. Average: 10 mins Maximum : 2 hrs Placenta Accreta is an abnormally adherent placenta,managed by manual exploration and hysterectomy. S/S of Placental separation: CALKINS SIGN the earliest sign Types of Placental Separation:

Medications of 3rd stage of labor

Difference Mechanism of Action Route of Administration Side effects Nursing Responsibilities Possible Complications Oxytocin Rhythmic uterine contraction Continous IV drip (incorporation) Hypotension Water intoxication Methergin Sustained uterine contraction IM hypertension

Check BP X if 90/60 Check BP X if 130/90 Given after bb out Given only after placental delivery Placental entrapment Uterine rupture leads to massive bleeding

4 Stage of Labor
th
Known

as the Degrees of Laceration: 1st vaginal skin (Fourchette) 2nd vag.skin muscles, & mucosa 3rd 2nd degree + extends into the external anal sphincter 4th - 2nd degree + rectal mucosa

 LOCATION

OF FUNDUS:

Immediately after delivery

- slightly above the level of umbilicus 1st 24 hrs (12-24 hrs)- @ the level of umbilicus PPD1 - 1 fingerbreadth below the umbilicus The involution of the uterus subsides @ 1 fingerbreadth per day. - (-) Palpate coz its behind the symphysis pubis

PPD10

LOCHIA
COMPOSITION:
All but one is a normal composition of lochia: a. shreds of decidua b. small clotted blood with mucus c. WBC d. bacteria e. amniotic fluid

PATTERN

: 1. RUBRA - 1ST 3 DAYS POST PARTUM(shreds decidua) 2. SEROSA - 4th-10th day post partum(brownish vag.disch) 3. ALBA -10th day- 6th wk (whitish yellowish non foul
smelly vaginal discharges