Professional Documents
Culture Documents
Health Nursing
PART II
Maternal and Child
Health Nursing
Promoting Fetal
and Maternal Health
Breast Hypotension
tenderness Varicosities
Palmar erythema Hemorrhoids
Constipation Heart
Nausea, palpitations
vomiting and Frequent
pyrosis urination
Fatigue Abdominal
Muscle cramps discomfort
Leukorrhea
MARY LOURDES NACEL G. CELESTE, RN, MD 6
Health Promotion During Pregnancy
persistent headaches
Varicosities of extremities or vulva
related to uterine compression of
venous return, increased vein wall
distensibility from progesterone-
initiated relaxation, or inherited
tendency; suggest elevating legs
frequently, avoid sitting with legs
crossed, standing/sitting for long
periods of time, or wearing constrictive
clothing; support/elastic stockings may
be helpful.
MARY LOURDES NACEL G. CELESTE, RN, MD 14
DISCOMFORTS OF PREGNANCY
Assessment Nursing Considerations
May occur any time of day
Nausea and vomiting (morning
Eat dry crackers on arising
sickness)
Eat small, frequent meals
Bulk foods, fiber
Constipation, hemorrhoids
Generous fluid intake
Increase calcium intake
Leg cramps
Flex feet, local heat
Well-fitting bra
Breast soreness
Bra may be worn at night
Emphasize posture
Backache Careful lifting
Good shoes
Small, frequent meals
Antacids – avoid those containing phosphorous
Heartburn
Decrease amount of fatty and salty foods
Health Teachings
Schedule of clinic visits
Exercises
Dental hygiene
Clothing
Traveling
Bathing
Employment
Sexual relation
Immunization
Rupture of membranes
Excess energy
Uterine contractions
Calorie needs
Protein needs
Fat needs
Vitamin needs
(breathing patterns)
conditioned reflex
Passenger
Power
Left anterior
Right posterior
Left posterior
Placental separation
Placental expulsion
MARY LOURDES NACEL G. CELESTE, RN, MD 111
Friedman’s Division of
Labor
Stages of Labor:
First stage (dilating/ Cervical stage) – from onset of
regular contraction to full cervical dilation
AVE: 13-18 h for nulliparas
8-9 h for multiparas
Hyperactivity
Fetal acidosis
Dangersigns of labor -
maternal
Blood pressure
Abnormal pulse
Apprehension
MARY LOURDES NACEL G. CELESTE, RN, MD 124
MARY LOURDES NACEL G. CELESTE, RN, MD 125
Maternal and Fetal Assessment
Acoustic stimulation
Methods
1. Periodic auscultation of the fetal heart by
fetoscope (stethoscope adapted to amplify sound or
Doptone (ultrasound stethoscope) during contractions
and for 30sec beyond; best heard over fetal back
Electronic fetal monitoring (EFM) – continuous
monitoring providing audio and visual recordings as
well as tracing strips
External – indirect, noninvasive method using a
lubricated (water-soluble gel) ultrasound transducer
attached to the abdomen
Internal – small electrode attached to the fetal scalp;
indicated for high-risk maternity patient, problematic
labor, or with oxytocin use; requires ROM, cervical
dilation of at least 2 cm, and presenting part can be
reached
MARY LOURDES NACEL G. CELESTE, RN, MD 132
a. Alterations in fetal heart rate
use
Early deceleration Head compression :not None required
(deceleration begins and ominous
ends with uterine Vagal stimulation
contraction)
Late deceleration Fetal stress and hypoxia Change maternal position
(HR decreases after peak of Deficient placental Correct hypotention
Hypoxia
CNS anomalies
MARY LOURDES NACEL G. CELESTE, RN, MD 137
Nursing Care: First Stage
Respect contraction time
Change positions
Support
Pain management
Apgar scoring
Heart rate
Respiratory effort
Muscle tone
Reflex irritability
Color
coagulation
Stage 4
Monitor maternal blood pressure and
pulse; uterine contractility tone and
location; amount and color of lochia,
presence of clots; condition of
episiotomy every 15 min x 4
Monitor bladder function
Provide comfort
Evaluate parenteral interaction
MARY LOURDES NACEL G. CELESTE, RN, MD 158
FOURTH STAGE OF LABOR
First 1-2 h Nursing Considerations
Vital signs (BP, pulse) q 15 min Follow protocol until stable
q 15 min Position – even to 1 cm/finger breadth above the
umbilicus for the first 12 h, then descends by one
Fundus
finger breadth each succeeding day, pelvic usually by
day 10
q 15 min Lochia (endometrial sloughing) – day 1-3 rubra (bloody
Lochia with fleshy odor; may be clots); day 4-9 serosa
(color, volume) (pink/brown with fleshy odor); day 10+ alba (yellow-
white); at no time should there be a foul odor
(indicates infection)
Urinary Measure first void May have urethral edema, urine retention
Bonding Encouraged interaction Emphasize touch, eye contact
perineum
Types of Episiotomy
Median – rare faulty healing,
easier to make and repair
Mediolateral – tearing in the anus
and rectum is rare
2.Forceps delivery
forceps - two doubled-curved,
spoonlike articulated blades used to
extract the fetal head; indicated if
mother cannot push fetus out or
compromised maternal/fecal status in
late second stage; contraindicated in
cephalopelvic disproportion (CPD)
Complications
Maternal – lacerations
fetal – neonatal – soft tissue
compression or cranial injury
MARY LOURDES NACEL G. CELESTE, RN, MD 166
MARY LOURDES NACEL G. CELESTE, RN, MD 167
2. Vacuum extractor – delivery with
use of suction device that is
applied to the fetal scalp for
traction; used in prolonged second
stage; contraindicated in CPD and
face/breech presentation
Indications:
Prolonged second stage (most
common)
Non reassuring EFM strip
Avoiding maternal pushing
Breech presentation
MARY LOURDES NACEL G. CELESTE, RN, MD 168
Complications
Maternal – lacerations
fetal – neonatal –
cephalhematoma and scalp
laceration, subgluteal hematoma
and intracranial hemorrhage
(>10min)
Relaxation
Focusing and imagery
Breathing
Herbal preparations
Regional anesthesia
Comfort measures
Positioning
Childbirth method
Morphine sulfate
Anesthesia- includes analgesia, amnesia,
and relaxation; abolishes pain
perception by CNS depression
Spinal anesthesia
MARY LOURDES NACEL G. CELESTE, RN, MD 178
Medication for Pain Relief:
Birth
Local anesthesia
Local infiltration
Pudendal nerve block
General anesthesia
Preparation
Aspiration of vomitus
MARY LOURDES NACEL G. CELESTE, RN, MD 179
MARY LOURDES NACEL G. CELESTE, RN, MD 180
MARY LOURDES NACEL G. CELESTE, RN, MD 181
Timing of administration
1. Before 5 cm (latent phase) – may
retard or stop labor
From 5 to 7 cm (early active phase) –
may aid relaxation
After 8 cm (transition phase) – may
result in respiratory depression
requiring resuscitative measures in
sedated neonate
- Because most medications cross the
placental barrier, FHR is taken
frequently before and after
administration of medication
MARY LOURDES NACEL G. CELESTE, RN, MD 182
Obstetrical analgesia – functions
through alleviation of sensation of pain
or enhancement of threshold for pain
Sedatives/hypnotics – used less
frequently than previously because of
incidence of side effects
Narcotics
– Morphine sulfate – used rarely because of
adverse reactions
– Meperidine hydrochloride (Demerol) –
most commonly used; mother and infant
interaction may be limited in immediate
postpartum period because infant may still
be sluggish and less alert
– Alphaprodine (Nisentil) – may be given
IV/SC but never IM because of
unpredictability by this route
MARY LOURDES NACEL G. CELESTE, RN, MD 183
– Mixed narcotic agonist-antagonist
compounds (Stadol [IM/IV/SC], Talwin
[IV/IM] but not SC, which can cause severe
tissue damage) – analgesia while
decreasing side effects but can still
produce respiratory depression, nauseas
and vomiting, light-headedness
– Narcotic antagonist (Narcan) – counteracts
respiratory depressant effects; may be
administered to mother IM/IV 5-15 min
prior to delivery or to neonate IV via
umbilical vein immediately after birth
Note: Narcotic antagonist given to a
woman who is addicted to narcotics
may cause immediate withdrawal
symptoms. MARY LOURDES NACEL G. CELESTE, RN, MD 184
Analgesic potentiator/ataractic
(Phenergan, Largon, Vistaril,
Sparine) – tranquilizing effect,
decreasing apprehension and
anxiety as well as the nausea and
vomiting associated with many
analgesics; fetal and neonatal
problems are rare
MARY LOURDES NACEL G. CELESTE, RN, MD 185
Anesthetics
Inhalation
– Nitrous oxide and oxygen – used
intermittently with each
contraction; patient is able to
cooperate in bearing down;
increased danger of neonatal
depression with continued use
after 15-20 min
– Trilline/Penthine – self-
administered by mother with
inhaler (under supervision); may
cause maternal and fetal narcotic
depression
MARY LOURDES NACEL G. CELESTE, RN, MD 186
Regional blocks – allow mother to be awake
and participate in process; can increase
incidence of maternal hypotension and fetal
bradycardia; need for forceps delivery,
prolonged labor or uterine atony, necessity
for catheterization, and sometimes post
spinal headache
1. Lumbar epidural block –affects the entire pelvis by
blocking impulses at level of T12 through S5; may
be administered continuously through tubing left in
place; incidence of maternal hypotension may be
minimized if 500-1000 ml of IV fluids is infused at a
rapid rate prior to administration and mother is
maintained in side-lying position
There must be vigilant monitoring of maternal
BP and FHR every 1-2 min x 15 min and every
10-15 min thereafter
MARY LOURDES NACEL G. CELESTE, RN, MD 187
Treatment of maternal hypotension includes
– Mild/Moderate – place mother in left
lateral position, increase the rate of IV
fluid; administer oxygen by mask
– Severe/prolonged – place mother in
Trendelenburg position for 2-3 min
2. Caudal – administered during second stage
just before delivery; not commonly used
3. Subarachnoid block/ “saddle block” (nerves
from S1 to S4) – anesthetizes perineum,
lower pelvis, and upper thighs; diminishes
pushing efforts; high incidence of maternal
hypotension and potential for fetal hypoxia
Currently
26% of births
Indications:
Cephalopelvic disproportion
Fetal malpresentation
non reassuring EFM strip
Visceral injury
Thrombosis
Preterm birth
- Birth before the end of the 37th
week of gestation
MARY LOURDES NACEL G. CELESTE, RN, MD 210
Factors predisposing to preterm
labor and birth
- History of preterm birth
- PROM premature rupture of
membranes
- Multiple gestation
- Bacterial vaginosis
- Intraamniotic infection
- Bleeding
- Uterine/ cervical abnormalities
MARY LOURDES NACEL G. CELESTE, RN, MD 211
If contractions are continuing and
cervical changes are occurring,
tocolytic agents may be prescribed.
Tocolytic agents – medications that
inhibit contractions
- Ritodrine, Terbutaline, Magnesium
sulfate
Corticosteroid may also be given to
accelerate fetal lung maturation
If contractions subside and cervical
dilatation and effacement remain the
same, client may be discharged with
instructions to limit activities and
medication to prevent labor.
MARY LOURDES NACEL G. CELESTE, RN, MD 212
Premature Rupture of Membranes
- Spontaneous rupture of membranes
before the onset of labor characterized
by fluid leak in the cervix and pooling
in the posterior fornix of the vagina,
(+)nitrazine test, (+)ferning under
microscopic exam; possible protrusion
of membranes or presenting part,
prolapsed cord
MARY LOURDES NACEL G. CELESTE, RN, MD 213
Prophylactic antibiotic therapy –
to decrease the occurrence of
chorioamnionitis
Tocolysis
corticosteroid
Umbilical cord
- length:55 cm at term
- 1 vein (carries oxygenated blood to the fetus)
- 2 arteries (carry deoxygenated blood from
fetus to placenta)
- Wharton’s jelly, gelatinous substance
- Cord extends from the fetal surface of the
placenta to the fetal umbilicus
MARY LOURDES NACEL G. CELESTE, RN, MD 226
Placenta succenturiata
Placenta has 1 or
more accessory
lobes connected
to the main
placenta by
blood vessels
Cocaine
Amphetamines
Marijuana and hashish
Phencyclidine
Narcotic agonists
Inhalants
Alcohol
MARY LOURDES NACEL G. CELESTE, RN, MD 261
MARY LOURDES NACEL G. CELESTE, RN, MD 262
CHILDBEARING –
MATERNAL
COMPLICATIONS
- Characterized by:
unilateral lower quadrant pain after 4-6
weeks of normal signs and symptoms of
pregnancy (amenorrhea, (+) pregnancy test
bleeding may be gradual oozing to frank
bleeding
may be palpable unilateral mass in adnexa
low HCG levels
rigid and tender abdomen
signs and symptoms of hemorrhage
MARY LOURDES NACEL G. CELESTE, RN, MD 281
– Necessary to be alert for signs and symptoms
– investigate risk factors especially PID,
multiple sexual partners, recurrent episodes
of gonorrhea, infertility
Management
– prepare for surgery
– Shock monitoring and management
– postoperatively, monitor for infection and
paralytic ileus
– Provide support for emotional distress
– RhoGam for Rh- negative woman
– monitor Hgb and Hct
– ultrasound for adnexal mass/ gestational sac
in tube
– culdocentesis (indicated by nonclotting blood)
– laparoscopy and/or laparotomy
– adequate blood replacement (type and X
match, IV withMARYlarge-bore needle)
LOURDES NACEL G. CELESTE, RN, MD 282
2nd Trimester Bleeding
Classification
Type I – insulin-dependent (IDDM)
Type II – non insulin-dependent
(NIDDM)
Gestational diabetes (GDM)
Impaired glucose tolerance (IGT)
MARY LOURDES NACEL G. CELESTE, RN, MD 299
MARY LOURDES NACEL G. CELESTE, RN, MD 300
Effects of diabetes on pregnancy
Maternal
Postpartum bleeding
Hydramnios glucose
Stress Management
Macrosomia (large Try diet first; then Insulin:
fetus)
usually short acting
Possible PIH, (regular) insulin combined
moniliasis with immediate acting
NO ORAL HYPOGLYCEMIC
AGENT! –passes through the
placenta and can be
teratogenic
MARY LOURDES NACEL G. CELESTE, RN, MD 307
Hypertension disorders
Preexisting hypertension (HTN) – diagnosed
and treated before pregnancy; requires strict
medical and obstetrical management
Pregnancy-induced hypertension (PIH) – no
prior incidence, develops during pregnancy
and resolves during postpartum period
Pre-eclampsia (synonymous with PIH) – may
progress from mild, which can usually be
managed as outpatient, to severe, which
requires hospitalization; triad of
symptomatology:
Hypertension (vascular effect)
Edema (interstitial effect)
Proteinuria (kidney effect)
Mild
Severe
MARY LOURDES NACEL G. CELESTE, RN, MD 308
Pregnancy-Induced
Hypertension
Vasospasm occurs during
pregnancy
Symptoms
Hypertension
Proteinuria
Edema
Mild preeclampsia
Severe preeclampsia
Eclampsia
Gestational hypertension
Nursing management
Remain with patient; do not attempt to prevent birth
Prepare sterile or clean environment
Support infant’s head; apply slight pressure to control
delivery
Slip nuchal cord, if present, over head
Deliver shoulders, trunk, holding head downward to
facilitate drainage
Dry baby and place on mother’s abdomen
Hold placenta as delivered
Wrap infant in blanket and put to breast
Check for bleeding and fundal tone
Comfort mother and family; arrange transport to
hospital MARY LOURDES NACEL G. CELESTE, RN, MD 326
CARDIAC DISEASE
Assessment
Monitor vital signs and do EKG as heart lesion
(especially those of the mitral valve) may become
aggravated by pregnancy
Chest pain
Dyspnea
Treatment of heart disease in pregnancy is
determined by the functional capacity of the heart,
and type of delivery will be influenced by the
mother’s status and the condition of fetus
Nursing Management
Encourage rest
Encourage moderation in physical activity
Explain importance of avoidance of upper
respiratory infections
Be alert for signs of heart failure: increase of
dyspnea; tachycardia
Monitor activity level
MARY LOURDES NACEL G. CELESTE, RN, MD 327
Cardiac Disease
Left-sided heart
failure
Right-side heart failure
Dyspnea,
Orthopnea Distended liver and
Paroxysmal spleen
nocturnal dyspnea Ascites
(PND) Peripheral edema
Rales, cough hepatomegaly
Chest pain, cardiac
arrhythmia,
syncope during or
after exertion
Extreme fatigue,
pallor cyanosis
MARY LOURDES NACEL G. CELESTE, RN, MD 328
Common Nursing Diagnoses:
Potential for decreased cardiac
output
Activity intolerance
MOTHER FETUS
A B
B A
O A, B, AB
Tuberculosis
Neither the disease nor the treatment is
threatening to the mother or newborn
Late afternoon fevers, nightsweats, weight
loss, malaise
Sputum Microscopy / Chest X-ray with
abdomnal shield
TB drugs : Rifampicin, Izoniazid,
Pyrazinamide, Ethambutol (RIPE)
Breastfeeding is not affected by the
medications of TB
MARY LOURDES NACEL G. CELESTE, RN, MD 340
Rubella (German Measles)
Virus crosses the placenta and had deleterious
effects on 50-90% of the fetus in the 1st trimester
(deafness, psychomotor prolems, microcephaly)
S/S: 3-day rash which disappears upon pressure
on the skin; fever; lymphadenopathy
Rubella immunization during childhood
Women immunized should NOT be pregnant for at
least 3 months following vaccination
Immune serum globulin for maternal symptoms;
does not alter fetal outcome
Strict isolation during the disease
May breastfeed after the disease
Candidiasis
Thrush in newborn
Diagnostics:
Elevated BUN, Crea
Elevated AST, ALT, total bilirubin
Decreased platelets
Management:
IV fluids, fluid and electrolyte replacement
Antibiotics
renal dialysis
Client education – change tampons 3-6 hours, avoid tampons
6-8 wks after childbirth, do not
MARY LOURDES NACEL leave
G. CELESTE, RN, MDdiaphragms>48357
hours
Pelvic inflammatory disease (PID)
– local infection, usually gonorrhea
and/or chlamydia, spreads/ ascends to
the fallopian tubes, ovaries, and other
organs
-Characterized by lower abdominal
pain and tenderness, malaise, fever,
leukocytosis, and purulent vaginal
discharge
-Potential to cause adhesions that
produce sterility and contribute to
ectopic pregnancy
-Management includes noting amount,
color, and odor of drainage; systemic
antibiotics; warm douches to increase
circulation and promote drainage; rest
and comfort measures; STD prevention
MARY LOURDES NACEL G. CELESTE, RN, MD 358
Chlamydia
Increased yellowish vaginal discharge,
painful and frequent urination, bleeding
between periods, mucopurulent cervicitis,
(+) culture and antigen detection test
Tx: erythromycin (tetracycline not used
during pregnancy)
Associated with premature rupture of
membranes, preterm labor and
endometriosis, low birth weight and
perinatal mortality due to placental
transmission
Can lead to infertility, ectopic pregnancy
and endometritis
nipple is relocated
Cancer of the breast – rapidly
growing tumor
Assessment – small, mobile,
painless lump; rash, or in more
advanced cases, change in color,
puckering or dimpling of skin,
pain and/or tenderness, nipple
retraction or discharge; axillary
adenopathy; detection by
mammography
MARY LOURDES NACEL G. CELESTE, RN, MD 366
Risk Factors:
Age, female, family hx, HRT > 5 yrs,
overweight after menopause, alcohol, no
history of pregnancy or 1st pregnancy after
age 30, never breastfeeding, early
menarche, late menopause, radiation, upper
socioeconomic areas, geographic location
Risk Factors:
coitus at an early age
Multiple sexual partners
Sex partner with a history of numerous sexual
partners
Exposure to STD
HPV infections
Chemotherapy
Contraceptive use>5 yrs
Smoking
Antenatal exposure to DES
History of dysplasia
MARY LOURDES NACEL G. CELESTE, RN, MD 375
Diagnostics:
Pap smear
Colposcopy
Endocervical curettage
Management:
Surgery
intravaginal radiation implants to deter
tumor growth and metastatic invasion
or hysterectomy
Management:
TAHBSO
counseling
Management includes internal and
sometimes external radiation therapy;
surgery; chemotherapy in advanced
cases
MARY LOURDES NACEL G. CELESTE, RN, MD 380
Problems related to the ovaries
Benign Ovarian masses
Manifestations
Sensation of fullness, cramping, dyspareunia, irregular
bleeding
Diagnostics:
USG
Management:
OCP to suppress ovarian function
MARY LOURDES NACEL G. CELESTE, RN, MD 381
Surgery
Ovarian cancer – leading cause of death from female
reproductive malignancies because of rapid growth and
spread and lack of early symptoms
Assessment – family history of ovarian cancer, client
history of breast, bowel, endometrial cancer, nulliparity,
infertility, heavy menses, palpation of abdominal mass
(late sign); diagnosis by ultrasound, CT, x-ray, IVP
Risk Factors:
Increased age (mean age 59 yrs old)
Fertility drugs
Early menarche or late menopause
Asbestos and talc exposure
Manifestations
Pelvic pain – dull/cramping, related to
menstruation
Dyspareunia
Abnormal uterine bleeding
Fixed tender retroverted uterus
MARY LOURDES NACEL G. CELESTE, RN, MD 383
Palpable nodules in the cul de sac
Risk Factors
Retrograde menstrual flow of
endometrium
Physiologic disruption after
gynecologic surgery or cesarean birth
Hereditary
Possible immunologic effect
Management
OCP-combination contraceptives to induce amenorrhea
Analgesics
NSAIDS
Danazol – antiprogesterone; suppresses GnRH, low estrogen
and high androgens to suppress ovulation, promotes
amenorrhea and decreases endometrial support
GnRH agonists ie leuprolide suppresses the menstrual cycle
through estrogen antagonism
Progestins ie Medroxyprogesterone – antiendometrial effect