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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. MONS PUBIS
2. LABIA MAJORA
3. LABIA MINORA
4. CLITORIS
5. VESTIBULE
6. 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
• VAGINA
 lymphatics or drains into:
 upper- ileac nodes
 middle- internal ileac nodes
 lower- inguinal lymph nodes

• 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
2. UTERUS
 decrease not width giving-ovoid shape
 end of 12 weeks-uterus becomes an
abdominal organ for it become too large to
remain in pelvis
 vascular supply
 uterine and ovarian arteries
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
 Note:
 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
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 male’s 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. cowper’s/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

E and P low

 stim 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

 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

HYPO

2. stop prod. FSHRF-APG-Stop FSH


3. 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
A. UTERINE RESPONSE:
1. Menstrual Phase
2. Proliferative
3. Secretory phase

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

 COLOR – clear to  N. Value: 500-1000cc


cloudy  Associated Problem:
Green Oligo –scanty amount of
Yellow A.fluid less than 500cc
Port wine stain which may result to fetal
distress coz no enough
Coffee Brown fluid to equalize the
 1st nsg.action when pressure
BOW ruptures Polyhydramnios:
 NITRAZINE TEST 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
wharton’s 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 organogenesis fetal organ form
 2nd trimester development of fetal length
 3rd trimester rapid deposition of subcutaneous

tissue
 1st Lunar Month
 GERM layer differentiation
 VITAL ORGAN formation
 2nd lunar
 all organs formed is continued/ sex differentiation& formation/ placenta
full development
 3rd lunar
 Function
 4th lunar
 Lanugo, FHT
 5th lunar
 Vernix, Quickenning, FHT by stet, age of viability
 6th lunar
 sensory receptors are well established
 7th lunar
 alveoli
 8th lunar
 Start deposition of the SC, disappearance of lanugo
 9th lunar
 Peak of SC deposition, disappearance of vernix caseosa
 10th lunar
characteristics of a FT infant is achieved
DIAGNOSIS
NORMAL DURATION
SIGNS
NORMAL ADAPTATION
DIAGNOSIS OF PREGNANCY

 Urine examination
 Uterine soufflé
 Funic soufflé
 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 twins
 247 days triplets
Signs of Pregnancy
Presumptive Probable Positive
1. amenorrhea Vagina = Chadwick’s FHT
Cervix = Goodell’s sign FETAL MOVEMENT
Uterus = Hegar’s sign FETAL OUTLINE

2. Urinary frequency Enlarged abdomen

3. Am sickness ballotement

4. Breast changes Braxton Hick”s


contraction
5. Skin pigmentation (+) Pregnancy test

6. quickening
2 Common Problems
 leukorrhea
 alkaline envi
 trichonomanas vaginalis
 Moniliasis
 GIT-
 AM sickness- due to progress
 Hyperemesis gravidarum
 constipation
 flatulence
 hemorrhoids
 Heartburn
 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. Every month - 1 to 8 months or from the time
pregnancy is detected -32 weeks AOG
B. Twice a month / every 2 weeks – 32 to37 wks
C. Weekly - 37weeks – birth or EDB
D. 2X A Week - for all Post term or > 42 wks
II. Components
A. Health history taking- G,P, OB Score, LMP
B. assessment – VS, Wt.,LM, Pap Smear, Pelvimetry
C. laboratory/ diagnostic procedure
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

 NAGELE’S 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
 BARTHOLOMEW’S RULE
Important landmarks :
1. symphysis pubis
2. umbilicus
3. xiphoid process
10 Danger signs
1. vaginal bleeding
2. swelling of face and hands
3. cont. HA
4. dimness/blurring of vision
5. flashes of lights before the eyes
6. persistence of vomiting
7. pain in abdomen
8. chills/fever
9. sudden escape of fluid from vagina
10. (-) 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
 LEOPOLD’S MANNEUVER
LM1 - fundic grip
LM2 – abdominal/umbilical grip
LM3 – Pawlik’s grip
LM4 - pelvic grip
ASSESSMENT

 PATIENT PREPARATION:
1. Explain procedure
2. Empty bladder
3. Put patient on proper position
4. 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 - normal
CLASS II - atypical cell is present
CLASS III - suggestive of malignancy
CLASS IV- strongly suggestive of
malignancy
CLASS V - conclusive of malignancy
STAGES:

Stage I - confined in the cervix


Stage II - invades the vagina
Stage III - diffuses on the entire
reproductive
Stage IV - metastasis on the anterior
bladder & posterior rectum
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 causes
 iron
 CHON
 Vitamin C
 Caloric
 Folate/Folic acid
 Iodized salt
 Minerals
IMMUNIZATION
DRUG CATEGORY INTERPRETATION

A. Shows no risk to fetus


B. no evidence of risk to humans (both
animal and human finding at risk)
C. risk cannot be ruled out
E. (+) evidence of risk (research/studies
shows)
x. Shows risk & teratogenic effects on fetus
 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 Inhibitors - 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


HEALTH TEACHINGS cont.
 Avoid Smoking=LBW  EXERCISE
 No ROH intake= MR 2. Pelvic Rock=low
 Avoid radiation exposure = backache
Abortion 4. Kegel’s = pelvic
 Sex pressure / congestion
 Employment = role 6. Walking
modification, identification of 7. Modified Knee Chest
occupational risk exercise = relieves
discomforts of hemorrhoids,
cramps in the thighs &
buttocks
9. Squatting/Tailor Sitting –
strenghtens perineal muscles
For CGFNS : NST vs CST, AMNIOCENTESIS, RUBELLA
TITIER

 NST or FAD TEST - determines fetal


fetal response to every fetal
movement. An increase of 15 bpm
is expected @ each movement
means REACTIVE result. Mothers
who has been sedated or was not able
to take a good meal prior to the
NST may yield a false Non Reactive
result & not necessarily mean a Non re
assuring fetal well being.
DIFFERENCE OF FALSE LABOR From TRUE LABOR PAINS

Assessment tool/criteria” Irregular u.c. in terms Becoming regular w


1. Uterine contraction of duration, interval& increasing intensity
freq.

2.Location of pain Confined in the Radiates at the


abdomen lumbosacral region
(back)

3.ambulation Decreases uterine Worsens uterine


contraction contraction

4. Sedation Relieves of the pain No amt of sedation


can relieve the pain
only anesthesia
(+) c.dilatation and
5.IE No progression of
cervical dilatation & effacement
effacement
Dilatation Expulsion Placental Recovery
stage Stage Stage Stage
Def Def Def Def
Ambulation N.Duration N. Duration Degrees
 4Ps of Labor Episiotomy S/S of
Passageway Mod Placental of
Ritgen’s
Power
manneuver Separation laceration
Passenger Brandt
Mech. Of  location
Psyche Andrews
Labor
 Phases of Manneuver of fundus
Labor Types of  lochia
Medications
Placental
Anesthesias Delivery
Monitoring Medications
TYPES OF PELVIS
1. ANDROID
2. ANTHROPOID
3. GYNECOID
4. PLATYPELLIOD
POWER
 SOURCE:

Primary = uterine  MONITORING:


contractions Duration- beginning to
Secondary = end of the same
abdominal muscle contraction.
during the bearing Interval – end of one
down contraction to the
 INTENSITY: beginning of the next
Mild, Moderate,Strong Frequency – beginning
 PHASES: of one to the beginning
1. INCREMENT of the next contraction
2. ACME
3. DECREMENT
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
 Measurements
3. anteroposterior diameters
 occipito mental = 13 cms
 occipitofrontal = 12cms
 suboccipitopregmatic = 9-9.5 cms

4. Transverse Diameter
a. biparietal D. = 9-9.5 cms
b. Bitemporal D. = 8 cms
c. Bimastoid D. = 7 cms
Phases of labor
PHASES IE INTENSITY ACTIVITY

LATENT 0-3 cms Mild talkative

ACTIVE 4-7 cms Moderate Fear of


losing ctrl
TRANSI 8-10 cms uncontrolla
TIONAL ble
SECOND STAGE OF LABOR
Known as the
 Normal Duration: Primi = 80 mins

Multi = 3o mins
 Modified Ritgen’s 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 as the
 Normal 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:

CALKIN’S SIGN – the earliest sign


 Types of Placental Separation:
Medications of 3rd stage of labor
Difference Oxytocin Methergin

Mechanism of Action Rhythmic uterine Sustained uterine


contraction contraction

Route of Continous IV drip IM


Administration (incorporation)

Side effects Hypotension hypertension


Water intoxication
Nursing Check BP – X if 90/60 Check BP –X if 130/90
Responsibilities Given after bb out Given only after
placental delivery
Possible Uterine rupture Placental entrapment
Complications 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.
PPD10 - (-) Palpate coz its behind the symphysis pubis
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