Maternal and Child Nursing
 Helping prevent complications from
Primary Goal of MCN
 Promotion and Maintenance of Optimal Family
Health
Goals of MCN
 Promote and maintain optimum family health.
 Extends from preconception to menopause
 Preconception health care
 Care of women during 3 trimesters of pregnancy
and the puerperium (weeks after birth)
 Care of infants during perinatal period (20 wks of
pregnancy – 4 weeks after birth)
 Care of children from birth through late
adolescent
 Care in variety of hospital and home care setting
Scope of Practice
1. Preconception Health Care
2. Care of women during the Three trimesters of
pregnancy and the puerperium (the 6 weeks post
childbirth. Sometimes referred to as the fourth
trimester)
3. Care of infants during the perinatal period (the
time span beginning at 20 weeks of pregnancy to 4
weeks or 28 days post birth)
4. Care of children from birth through late
adolescent.
5. Care in Hospital & Home Care setting
 Family Centered Approach is the preffered
nursing care
Philosophies of MCN
MCN is:
 Family-centered
 Community-centered
 Evidence-based
 Challenging role for nurses.
Nurse’s role:
 Advocate (protect the rights of all family
members)
 Educator
 Counselor
 Resource person
Phases of Health Care
 Health Promotion
 Educating parents and children to follow sound
health practices through teaching and role
playing
 Health maintenance
 Intervening to maintain health when risk of
illness is present
 Health Restoration
 Using conscientious assessment to be certain
that symptoms of illness are identified and
interventions are begun to return patient to
wellness most rapidly
 Health Rehabilitation
illness; helping a patient with residual
effects achieve an optimal state of
wellness and independence; helping a
patient to accept inevitable death
Health Promotion
 Educating parents and children to follow sound
health practices through teaching and role
modelling.
Example:
1. Teaching women the importance of rubella
immunization before pregnancy.
2. Providing preteens with information about safer
sex practices well before they are likely to
become sexually active
Health Maintenance
 Intervening to maintain health when risk of illness is
already present.
Example:
1. Encouraging women to be partners in prenatal
care.
2. Teaching parents the importance of
safeguarding their home by childproofing against
poisoning.
Health Restoration
 Using conscientious assessment to be certain that
symptoms of illness are identified and interventions
are begun to return the patient to wellness most
rapidly.
Example:
1. Caring for a woman during complications of
pregnancy such as GDM or a child during acute
illness such as pneumonia.
Health Rehabilitation
 Helping prevent complications from illness.
 Helping a patient with residual effects achieve an
optimal state of wellness and independence.
 Helping the patient accept inevitable death.
Example:
1. Caring for a woman during complications of
pregnancy such as GDM or a child during acute
illness such as pneumonia.
Sustainable Development Goals
The Concept of Family
A Family is defined as a householder and one or
more other people living in the same household who
are related by birth, marriage, or adoption.
Family Types
1. FAMILY OF ORIENTATION
 The Family one is born into.
2. FAMILY OF PROCREATION
 The Family one establishes.
1. The Childfree or Childless Family
Composed of two people living together without
children.
Positive Aspects: Companionship, possibly shared
resources.
Negative Aspects: Feelings of Guilt for the couple
who decided to delay a family and who then may
experience infertility issues.
2. The Cohabitation Family
Composed of couples, perhaps with children, who live
together but remain unmarried.
Positive Aspects: Companionship, possibly shared
resources, Financial Security
Negative Aspects: No long term financial security if
the couple will decide to end the relationship.
Custody and Financial care for children might be an
issue.
3. The Nuclear Family
The Traditional Family. Composed of two married
parents and their child or children.
Positive Aspects: Support for family members; sense
of security.
Negative Aspects: may lack support people in crisis
situation.
4. The Extended (Multigenerational) Family
Includes a nuclear family but also other members:
Grandparents, Uncles, Aunts, Cousins, and
Grandchildren.
Positive Aspects: Many people for child care and
member support.
Negative Aspects: Resources may be stretched thin
because of few wage earners.
5. The Single-Parent Family
Composed of Remarried or Reconstituted family. A
divorced or widowed person with children remarries
someone who also has children.
Positive Aspects: Increased security and resources.
Exposure to different customs and culture may help
children become more adaptable to new situations.
Negative Aspects: Rivalry or competition. Difficulty
adjusting to the concept of Stepparent.
6. The Blended Family
Composed of Remarried or Reconstituted family. A
divorced or widowed person with children remarries
someone who also has children.
Positive Aspects: Increased security and resources.
Exposure to different customs and culture may help
children become more adaptable to new situations.
Negative Aspects: Rivalry or competition. Difficulty
adjusting to the concept of Stepparent.
7. The LGBT Family
Composed of Lesbian, Gay, Bisexual, Transgender
couples living together as partners for companionship,
financial security, sexual fulfilment, or form the same
structure as a Nuclear Family. May have children from
previous heterosexual marriages or children from
adoption, surrogacy or foster parenthood.
Understanding Sexual Orientation
Development of Sexual Orientation
 Root of Development is Unknown.
 However, there are evidences that sexual
orientation is genetically determined or develops
due to the effect of estrogen or testosterone in
utero.
Factors in the Development of Sexual Orientation
1. Hormonal Effects in Utero
2. Childhood Developmental Changes
3. Environment
Sexual Orientation Terminology
1. Heterosexual
 Finds sexual attraction & fulfilment with a
member of the opposite sex. (STRAIGHT)
2. Homosexual
 Finds sexual attraction & fulfilment with a
member of the same sex. (GAY) (LESBIAN)
 MSM or WSW
3. Bisexual
 Finds sexual attraction & fulfilment with both
same sex and heterosexual relationships.
4. Transgender
 is an individual whose gender identity does
not match the sex assigned at birth.
5. Gender Dysphoria
 Is the realization that one’s physical sex and
gender are mismatched.
8. The Foster Family
Foster or substitute home by a child protection agency.
 Positive Aspects: Prevents children from being
raised in large orphanage setting.
Negative Aspects: Insecurity and inability to
establish meaningful relationships because of
frequent moves.
9. The Adoptive Family
Composed of any of the other types of Family plus an
adopted child or children.
Positive Aspects: Children grow up well cared for
and experiences a sense of love.
Negative Aspects: Divorce of adoptive parents can
be devastating if the child views himself as the cause
of separation or if the child is unable to find a secure
family for the second time.
Obstetrics & Gynecology Nursing
Obstetrics- the branch of medicine and surgery
concerned with childbirth and the care of women giving
birth.
Gynecology- the branch of physiology and medicine
which deals with the functions and diseases specific to
women and girls, especially those affecting the
reproductive system
Obstetric Nursing- Obstetrical nursing, also called
perinatal nursing, is a nursing specialty that works with
patients who are attempting to become pregnant, are
currently pregnant, or have recently delivered.
Maternal and Child Nursing- is nursing that works with
patients who are attempting to become pregnant, are
currently pregnant, or have recently delivered, The
Family of the Pregnant Woman, The newborn child, and
the child until adolescent.
Measurement of Maternal and Child Health
 An objective view of health through usage of
national or regional health statistics to describe the
degrees of illness.
DEMOGRAPHY- The science of population. Helps the
nurse find reasons or rationale why or how a particular
population or group is influenced by a variety of factors
resulting in vulnerability to diseases.
VITAL STATISTICS- Is the application of statistical
measures to vital events like births, deaths and common
illnesses. This is utilized to gauge the levels of health,
illness and health services of a community and the
country.
1. Birth Rate
The number of births per 1,000 population.
CBR = live births/population x 1000
2. Fertility Rate
The number of pregnancies per 1,000 women of
childbearing age.
General FR = Live Birth / 15 – 49 y/o x 1000
3. Fetal Death Rate
The number of fetal deaths (over 500g) per 1,000 live
births.
FDR = No. of FDU / LB x 1000
Reflects the overall quality of maternal health in the
community
4. Neonatal Death Rate
The number of deaths per 1,000 live births occurring at
birth or in the first 28 days of life.
NMR = <28 days / LB x 1000
5. Perinatal Death Rate
The number of deaths during the perinatal period
(beginning when a fetus reaches 500g, about 20 weeks
of pregnancy, and ending about 4-6 weeks after birth);
it is the sum of the fetal and neonatal rates
PDR = FDR + NMR
6. Maternal Mortality Rate
The number of maternal deaths per 100,000 live births
that occur as a direct result of the reproductive process.
MMR = Maternal Deaths / LB x 1000
7. Infant Mortality Rate
The number of deaths per 1000 live births occurring at
birth or in the first 12 months of life.
IMR = <1y/o / LB x 1000
Reflects the overall quality of general health in the
community
8. Childhood Mortality Rate
The number of deaths per 1000 population in children
aged 1 to 14 years.
CMR = 1-14 / LB x 1000
Family
Family Roles
o Nurturer
o Provider
o Decision Maker
o Financial management
o Problem Solver
o Health Manager
o Culture Bearer
o Environmentalist
Family Tasks
 Physical Maintenance: provide basic needs
 Socialization of family members: allowing children
to socialize and be part of thecommunity
 Allocation of resources: prioritization of needs
 Maintenance of order: establishing rules and values
 Division of labor: evenly divide the workload
 Reproduction, recruitment and release of family
members:
 Placement of family members into larger society:
affiliations with the community
 Maintenance of motivation and morale: maintain
sense of unity and pride
Developmental Stages of the Family
Stage 1 (MARRIAGE)
Establish mutually satisfying relationship
Learn to relate to their families of orientation
Reproductive life planning
Stage 2 (EARLY CHILDBEARING FAMILY)
Integration of new family member
Making adjustments (financial, social adjustments
and etc)
Stage 3 (WITH PRESCHOOL CHILD)
Prevent unintentional injuries
Beginning socialization through play dates, child
care or nursery school
Stage 4 (WITH SCHOOL-AGE CHILD)
Promotes health through immunizations, dental
care and routine health assessment
encouraging socialization outside home (sports,
hobby activities, etc)
Encouraging a meaningful school experience
Stage 5 (WITH AN ADOLESCENT)
Loosening ties (enough freedom while staying safe)
Beginning to prepare adolescents for life on their
own
Stage 6 (lAUNCHING STAGE FAMILY: WITH A YOUNG
ADULT)
Changes of roles
Encourage independent thinking and adult-level
decision skills
Stage 7 (MIDDLE YEARS)
Adjusting to "empty nest" syndrome
Preparing for retirement
Stage 8 (RETIREMENT OR OLDER AGE)
Maintaining health by preventive care
Participating in social, political, and neighborhood
activities Reproductive and Sexual Health
Reproductive Development
Assessing Family Structure & Function INTRAUTERINE DEVELOPMENT- The sex of an individual
Genogram- diagram that details family structure and is determined at the moment of conception by the
provides information about the family's health history chromosome information supplied by the particular
and roles of various family members across several ovum and sperm that join to create new life
generations
Ecomap- a diagram of family and community
relationship

Female Male

Gonad
Female: Ovary
Male: Testes
Week 5:
 Mesonephric (Wolffian duct)
 Paramesonephric (Mullerian duct)
Week 7-8: (Males)
 early gonadal tissue begins formation of
testosterone
 Testosterone- mesophrenic duct develops into
reproductive organs
Week 10: (Females)
 Paramesophrenic duct becomes dominant and
develops into reproductive organs
  When Ovaries form, all of the oocytes (cells 2. low Estrogen level in the blood
that'll develop into eggs throughout the 3. Hypothalamus (GnRH - FSHRF)
woman's matuer years) are already present. 4. Anterior Pituitary Gland (FSH)
Pubertal Development 5. Ovaries (Estrogen)
- Puberty is the stage at which secondary sex changes prepares the endometrium to be thickened
begin facilitates growth of primodial follicle to
FEMALES: become graafian follicle
- Hypothalamus SECRETORY/ PROGESTATIONAL/ LUTEAL/
- GnRH (Gonadotropin RH) PREMENSTRUAL PHASE (DAY 15-26)
- Anterior Pituitary Gland 1. 13th day of menstrual cycle
- FSH & LH 2. high estrogen, low progesterone
3. Hypothalamus (GnRH - LHRF)
Androgen 4. Anterior Pituitary Gland (LH)
 muscular development follicle cells to produce lutein - rich in
 physical growth progesterone
 Male: testosterone is low until puberty (12-14) 5. Ovaries (Progesterone)
 Female: testosterone influences enlargement of further thickens the wall
labia majora, clitoris and formation of axillary and nourishes uterine wall
pubic hair hormone of ovulation and pregnancy
Estrogen fluid retention and decrease GI motility
 development of uterus, fallopian tubes and vagina 6. 14h day of menstrual cycle
7. high estrogen, high progesterone
Secondary Sex Characteristics 8. Rupture of Graafian follicle
Female: 8a1. Degenerate and becomes corpus luteum
o GROWTH SPURT 8a2. 24th day: Corpus Albicans
o INCREASE IN TRANSVERSE DIAMETER OF THE PELVIS 8b1. Release of ovum (fertile)
o BREAST DEVELOPMENT Ischemic Phase (Day 26)
o GROWTH OF PUBIC HAIR 1. 26th day of menstrual cycle
o ONSET OF MENSTRUATION 2. low progesterone
o GROWTH OF AXILLARY HAIR 3. endometrium begins to degenerate
o VAGINAL SECRETIONS 4. endometrium sloughs off
Male: Menstrual Phase
o INCREASE IN WEIGHT
o GROWTH OF TESTES Family Planning Methods
o GROWTH OF FACE, AXILLARY AND PUBIC HAIR A. Natural Family Planning Methods
o VOICE CHANGES 1. LAM (Lactating Amenorhea Method)
o PENILE GROWTH  1% to 5% Failure Rate
o INCREASE IN HEIGHT  When a woman is breastfeeding, there is
o SPERMATOGENESIS (PRODUCTION OF SPERM) suppression of both ovulation and
Menstruation.
Menstruation  Mens will return 6mos PP
4 Major Organs:  If Not lactating 2-3mos PP
 HYPOTHALAMUS 2. BBT (Basal Body Temperature) Method
 ANTERIOR PITUITARYGLAND  Just before the day of Ovulation, a woman’s
 OVARIES basal body temperature falls to about 0.5°F.
 UTERUS (ENDOMETRIUM)  At the time of ovulation, her BBT rises a full
Normal Menstrual Cycle: 0.2°C because of the rise in progesterone with
 INTERVAL: 28 DAYS ovulation.
 DURATION: 4-6 DAYS  Watch out for a slight dip and a sudden
 AMOUNT: 30-80 ML PER MENSTRUAL PERIOD increase.
(SATURATED PAD AFTER 1 HR IS HEAVY BLEEDING) 3. Billing’s (Cervical Mucus Method)
 COLOR: DARK RED (BLOOD, MUCUS, ENDOMETRIAL  predicts ovulation using the changes in
CELLS) cervical mucus that occur naturally with
 ODOR: SIMILAR TO MARIGOLD ovulation.
 Before Ovulation: Mucus is thick and does not
Physiology of Menstruation stretch when pulled between the Thumb and
PROLIFERATIVE/ ESTROGENIC/ FOLLICULAR/ Finggers.
POSTMENSTRUAL PHASE (DAY 1-14)  On the day of Ovulation, it becomes thin,
1. On the 3rd day of menstrual cycle
copius, watery and transparent. Feels slippery
 like egg white and stretches for about 1 inch 1. Coitus Reservatus (Sex S Ejaculation)
before breaking. C. Artificial Methods
1. Mechanical/Chemical Barriers
A. Condom
• Made of latex
• <sexual satisfaction
• Checks Holesm Protects from STI 99.9%
b. IUD
• Best time to insert, during menstruation or
After placental delivery
• Long term effect 5-10yrs
• Economical
• Insertion: Sever Cramping
• Monogamous Relationship
• Copper – Spermicidal
• If mother becomes pregnant, IUD must be
4. Symptothermal Method removed
 Combination of BBT Method and Billing’s C. Artificial Family Planning Methods
Method a. Mechanical/Chemical Barriers
 Checking of Temp in am to detect BBT. 1. Condom
 Assessing for Spinnbarkeit property of • Is a latex rubber or synthetic sheet that is
Cervical Mucus. placed over the erect penis before coitus to
5. Calendar Rhythm Method trap sperm.
 Continuous monitoring of Menstrual Cycle. • Protects from STI – 99.9%
 Needs 6mos data. Applicable only for women • Has 2% of Failure Rate
with regular menses. 28-32 days MC. 2. IUD (Intra-uterine Device)
 Formula: • An intrauterine device, is a small, often T-
 Longest = -11 shaped birth control device that is inserted
 Shortest = -18 into a woman's uterus to prevent pregnancy.
 DOO= No. of Days of the Menstrual Cycle – Among birth control methods, IUDs, along
14 with contraceptive implants, result in the
Family Planning Methods greatest satisfaction among users.
A. Natural FPM
1. LAM
• Mens will return 6mos PP
• If Not lactating 2-3mos PP
2. BBT
• Early in am b4 arising in bed, b4 doing anything
Contrain in:
1. Insomnia
2. Stress
3. On Diet
4. Infxn
3. Billing’s Method (Cervical Mucus Method)
• Spinnbarkeit test, clear, thin, stretchy, copious =
Fertile
• Cloudy, sticky, thick = infertile
Types of Infertility:
1. Primary = No preg at all
3. Diapragm
2. Secondary = difficult to conceive again
DOC: CLOMIPHENE CITRATE (CLOMID)  A diaphragm is a circular rubber disk that is
-Induces Ovulation placed over the cervix before intercourse to
B. Social Family Planning Methods mechanically halt the passage of sperm.
1. Abstinence Combination of a spermicidal gel increases
2. C. Interruptus rate of effectivity.
3. C. Reservatus
Family Planning Methods
B. Social Methods
• Least effective Method
1. Coitus Interruptus (withdrawal)
  Clitoris increases in size
 Appearance of mucoid fluid on vaginal wall
 Vagina widens and increases in length
 Breast nipples become erect.
Boys
 Penile erection
 Scrotal thickening and elevation of testes
Plateu
 Just before orgasm
 Girls:
 Clitoris is drawn forward
 Lower part of the vagina becomes extremely
4. Cervical Cap congested
 Is made of soft rubber shaped like a thimble,  Increased nipple elevation/ erection
which fits snugly over the uterine cervix. With  Boys:
high failure rate the same as of the  Further distention of penis
Diaphragm. Orgasm
 Shortest stage
 Intense pleasure
 “Climax”
Resolution
 30-minute period during which internal and
external organs return to unaroused state.
 Boys: refractory period
 Girls: none

5. Spermicidal Gel
 Spermicide is a contraceptive substance that
destroys sperm, inserted vaginally prior to
intercourse to prevent pregnancy.
 Contains Non-Oxinal 9 (Highly Acidic)
2. Physiologic Method
1. Depo-provera
Depot medroxyprogesterone acetate
• Given IM, do not massage
• Q 3mos
Lunelle
• Q 1 mos.
Ovulation will resume 6-12mos after D/C
2. Norplant
• 6 match like capsules containing progesterone
• Protects from pregnancy upto 5yrs
• +keloids the skin
• Ovulation will resume after removal
3. Pills
Missed Pills –
1st Day = 2 now, 1 tom
2nd Day = 2 now, 2 tom
Influence of Menstrual Cycle on Sexual Response
3rd Day = Throw Pack, restart cycle with new set
 During luteal phase – plateau stage is reach more
quickly – achieving orgasm more readily
Sexual Response Cycle
 Women may initiate during this time of the month
Excitement
Influence of Pregnancy on Sexual Response
 Stimulation
 Pregnancy - vasocongestion
 Foreplay
 Orgasm don’t cause a spontaneous miscarriage
 Parasympathetic nerve stimulation
 If with Hx of premature labor, sucking or massaging
 Vasoconstriction and arterial dilatation
breast is contraindicated
 Muscular tension
Girls
Types of Sexual Orientation
 Sexual gratification can be experienced in many
ways
 Heterosexuality (opposite sex)
 Safe sex practice
 Abstinence (100% guarantee)
 Choose your partner and ask his/her
lifestyle
 Inspect your partner
 Condom (best for prevention of infection)
 Homosexuality
 WWW
 If partner is bisexual, higher chances of
getting infected
 MWM
 Counselling for prevention of HIV and STIs
 Bisexuality (either)
 Bisexual x others = HIGHER RISK
 Transsexuality
 Feels as if he/she is of the opposite gender
 Gender affirmation surgery (synthetic vagina
and penis) = decreased over years
 Operations doesn’t change chromosomal
structure
Types of Sexual Expressions
1. Celibacy (abstinence)
- religious orders
- way of life for many adults
- fashionable among growing numbers of young
adults
- focus on giving and receiving love other than
through sexual expression; prevents pregnancy and
STD
2. Masturbation
- Self-stimulation
- Mutually done
- Sexual and anxiety release
- Women find masturbation to orgasm most
satisfying and use it more commonly than men
- Pre-schooler masturbation (without any attempt)
*Autoerotic asphyxia – extreme masturbation
associated with hanging for extreme sexual
experience = FATAL
Erotic Stimulation
 Use of visual materials for arousal
 - Adolescents: developmental and normal
 NI: respect this type of material when seen on pt’s
room.
Paraphilias
 - sexual arousal to objects, situation or individual
A. Fetishism
 Arousal from certain objects (leather, rubber,
shoes, feet)
B. Transvestism (hetero, homo or bisexual)
 Cross-dressing is sexually arousing for them
C. Voyeurism
 - Peeking tom
 - almost all children and adolescents pass
through this sexual expression
 - reflects insecurity or the inability to feel
confident enough
 D. Sadomasochism
 - inflicting or receiving pain for sexual
pleasure
E. Exhibitionism
 - exposing one’s own genitals to an
unsuspecting person
F. Frotteurism
- touching or rubbing against unconsented
person
G. Bestiality
- sexual relations with animals
H. Pedophilia
- interested in sexual encounters with children
Sexual Harassments
 - unwanted, repeated sexual advances, remarks or
behaviour toward another that is offensive to the
recipient
 - present to both genders
 - distressing that can lead to short-term or long-
term psycho consequences to the victim and its
family
 - Nurses should be aware of harassments
 1. Quid pro quo (equal exchange)
 2. Hostile work environment – employer makes
employee feel uncomfortable (honey, babe)
Disorders of Sexual Functioning
A. Failure to achieve orgasm
 Women: poor sexual technique, concentrating
too hard or negative attitude toward partner.
 DOC: Female Viagra (Pink Viagra)
B. Erectile Dysfunction (Impotence)
inability to produce or maintain erection
Causes: aging, atherosclerosis, or diabetes, S/E of
drugs (antidepressants) or after discontinuance of
Finasteride (BPH)
C.Premature Ejaculation
 - ejaculation before partner’s satisfaction has been
achieved.
 - unsatisfactory and frustrating
 Causes: psychological, masturbating to orgasm,
doubt of masculinity and fear of impregnating
partner
D. Persistent Sexual Arousal Syndrome (PSAS)
 Women: excessive and unrelenting arousal in the
absence of desire
 Factors: psychological, restless leg syndrome,
overactive bladder
 Ask pt’s if they are taking gingko biloba or
Finasteride (sex booster)
Restless Leg Syndrome
 Uncontrollable desire/urge to move your leg/s
 Common sensations:
 Crawling
 Creeping
 Pulling
 Throbbing
 Aching
 Itching - Prevents bone loss and the risk for bone
 Electric fracture
Characteristics:  Bisphosphonates (Alendronate, Zoledronic Acid)
 Starts after rest - Reduces bone thinning and risk of fracture
 Relieves with movement Contraception
 Commonly at night (nigh time leg twitching) Note:
Pain Disorder  Personal values
 Vaginismus – involuntary contraction of the  Ability to use method correctly
muscles (vagina) when coitus is attempted, which  If method will affect sexual enjoyment
prohibits penile penetration.  Financial factors
Factors:  If relationship is short term or long term
 Rape Hx  Prior experiences with contraception
 Early learning pattern (bad/ sinful)  Future plans
 Dyspareunia – pain during coitus Ideal Contraceptive should be:
Factors:  Safe
 Endometriosis – abnormal placement of  Effective
endometrial tissue  Compatible with religious beliefs and personal
 Vestibulitis – inflammation of the vestibules preferences
 Vaginal infection  Free of bothersome side effects
 Hormonal changes (menopause)  Convenient and easily obtainable
Menopause  Affordable and needing few instructions
 “Change of life” Do’s before using new method of contraception
 Cessation of menstrual cycle (40-55 yrs old)  Subjective assessment
 Smokers tend to have earlier menopause than  Vital signs
others  Pap smear
Perimenopausal – period which menopausal  Pregnancy test
changes is occurring (transition of 1-2 yrs)  Gonococcal and Chlamydial screening
Menopause – 12 months amenorrhea  Obstetric history (STIs, past pregnancies, failure
Postmenopausal – period after the final menses (12 of previously used method and compliance
months) history)
Maturation of Oocytes  Sexual practices
From utero: 5-7 million (most never develop and Hormonal Contraception
atrophy) Hormonal contraceptives are, as the name
At birth: 2 million implies, hormones that are taken orally, transdermally,
7 yrs old: 500,000 intravaginally, or intramuscularly.
22 yrs old: 200,000 Combination of Oral Contraceptive
 The point at which no functioning oocytes  Commonly known as pills, OCs, or COCs, are
remain in the ovaries composed of varying amounts of natural estrogen
 Due to follicular attrition, ovaries atrophy or synthetic estrogen combined with a small
resulting to decrease of estrogen level amount of progesterone
Physiological Changes:  If taken religiously, 99.9% effective
1. Breast and genital organs atrophy  If occasionally forgotten, and due to physiologic
2. Vaginal dryness (NI: Vaginal lubricant) differences there’s 5% failure
3. Osteoporosis (NI: Exercise (Weight-bearing, Estrogen - accts to suppress FSH and LH to suppress
strength training and aerobics)) ovulation.
4. Hot flashes (NI: relaxation technique) Progesterone – decreases permeability of cervical
5. Urinary incontinence (NI: provide pads, kegel mucus and so limits sperm motility and access to
exercise) ova.
6. Decrease in libido COC
7. Sleep disturbances  Typical pills are supplied with 28-pill dispensers (21
8. Headache active and 7 placebo pills) labelled with the day of
Medical Management the cycle.
 Hormone Therapy  Not effective for the first 7 days
- Used to be miracle drug that promotes  Caution women to take only pills in order or the
youthfulness progesterone level could be inaccurate and
- Pills, injectable or surgery ineffective for that day.
S/E: Increase risk of breast CA and blood clots  Prescribed by physician after examination
 Selective Estrogen receptor Modulator (SERMs) Oral Contraceptive Decreases:
 Dysmenorrhea (lack of ovulation)
 Premenstrual dysphoric syndrome and acne ● Failure rate is lesser than oral contraceptives. 1%
(increase in progesterone level) ● Won’t affect during breastfeeding
 Iron deficiency anemia (reduced amount of ● Con’s:
menstrual flow) ○ Weight gain
 Acute pelvic inflammatory disease (PID) ○ Irregular menstrual cycle
 Endometrial and ovarian cancer, cysts and ectopic ○ Possible infection to insertion site
pregnancies ● Contraindicated to women with undiagnosed
 Fibrocystic breast uterine bleeding
 Endometriosis, osteoporosis, rheumatoid arthritis IM Injection
When to Take Pills: ● Medroxyrogesterone acetate (Depo-Provera)
1. Sunday start: Take the first pill on the first Sunday ● IM every 3 months. Contains only progesterone
after the beginning of menstrual flow ● Educate to never massage the site after
2. Quick start: Begin pills as soon as they are administration to allow slow absorption from
prescribed (increase compliance) muscles.
3. First day start: begin pills on the first day of menses ● Not advisable for long term use (not over 2 yrs)
4. After childbirth: on any day (or Sunday) closest to 2 ● Cons:
wks after birth; after an elective termination of ○ Weight gain
pregnancy, she could begin on a chosen day after ○ headache
the procedure. ○ Depression
Progestin-only Pills ○ Irregular menstrual cycle for 1 yr
 Mini-pills ○ No menstrual bleeding after the 1st yr.
 Doesn’t allow development of endometrium, or ○ Higher risk for osteoporosis
sperm to freely access the cervix, fertilization and Emergency Postcoital Contraception
implantation won’t take place ● Morning-after pill
 Ovulation may occur ● Unprotected voluntary coitus or involuntary
Side Effects of Oral Contraception situations such as rape
 Nausea ● Types:
 Weight gain ○ High-dose progestin base
 Headache ○ IUD
 Breast tenderness ● 75% effectiveness is taken within 72 hrs
 Breakthrough bleeding
 Monilial vaginal infections (Candida albicans) Surgical Methods (Irreversible Procedure)
 Mild hypertension Vasectomy
 Depression ● The vas deferens on each side are pulled forward,
Symptoms of MI, Thromboembolic Complication: cut or tied and cauterized, blocking the passage of
 Chest pain (MI or pulmonary embolism) spermatozoa
 SOB ● Under local anesthesia
 Severe headache (CVA) ● Special consideration:
 Severe leg pain (thromboembolism) ○ 2 negative sperm reports (6-10 wks)
 Eye problem (HTN, CVA) ○ 10-20 ejaculations
Hormone Transderm patch ● COmplications:
● Efficiency is equal to COCs ○ Hematoma
● Applied each week for 3 weeks ○ Postvasectomy pain sydorme
● 4th week, patch free week, menstrual flow will
occur
● May be applied to ff areas:
○ Upper outer arm
○ Upper torso (front or back, excluding breast)
○ Abdomen
○ Buttocks
● Dont’s: Tubal Ligation
○ Areas where makeup, lotion or creams are ● Fallopian tubes are occluded by cautery, crushed,
applied clamped or blocked, preventing the passage of both
○ Waist (may lossen when bending) sperm and ova
○ Irritated skin or/with open lesions ● This is done after menstrual flow and before
Subdermal Hormone Implants ovulation
● Norplant ● s/sx S/P ligation
● 6 matchsticks like that contains progesterone ○ Abd discomfort
● 5 yrs of protection from pregnancy ○ Abd bloating (24 hrs)
 ○ Diaphragmatic & shoulder pain
● Extensive obesity may require full laparotomy
Elective Termination of Pregnancy
Elective Termination
● A procedure performed by a knowledgeable HCP to
end pregnancy before fetal viability.
● AKA therapeutic, medical, or induced abortions.
● Reasons:
○ Threatens a woman’s life (Class IV heart dse)
○ Chromosomal defect in fetus
○ Unwanted
Medically Induced Termination
● Mifepristone
● Methotrexate (DOC for ectopic pregnancy)
● Misoprostol
Contraindications:
● Ectopic pregnancy
● IUD in place
● Serious medical conditions (Chronic adrenal
failure)
● Long-term systemic corticosteroid therapy
● Hemorrhagic d/o
Surgical Elective Termination
● Dilatation and Curettage
○ Cervix is dilated and uterus is scraped clean with
a curette
● Hysterotomy
○ Similar to cesarean birth
○ 20-24 weeks AOG
Subfertility
● the failure to achieve a clinical pregnancy after 12
months or more of regular unprotected sexual
intercourse.
● The major clinical challenge is to assess the
reproductive aging status of a given woman.
● Types:
○ Primary subfertility - no previous conception
○ Secondary - Previous viable pregnancy but
unable to conceive at present.
● Sterility - inability to conceive
Fertility Assessment
● Educate couples regarding variety of tests and
procedures
● Help client identify and express their feelings, how
far they are willing to go on in testing and
procedures
● Counsel clients about available
resources/alternatives when pregnancy cannot be
achieved.
Health History
● His general health
● Typical 24-hr food intake, drugs, herbs, alcohol and
tobacco use
● Congenital health problem (hypospadias or
cryptochidism)
● Previous exposure of his testes to radiation therapy,
xray or industrial accidents
● Previous operation done
● Current illness
● Sexual practices
● Contraceptives used
● Past pregnancies, miscarriages or abortions
● Hx of contraceptive use
● Reproductive infections
● Operations performed
● Hx of cancer and treatments
● Menstrual cycle
Factors of Subfertility in Men
● Disturbance in spermatogenesis
● Inadequate FSH and LH in the pituitary
● Obstruction in the seminiferous tubules, ducts, or
vessels, which prevent the movement of
spermatozoa
● Qualitative or quantitative changes in the seminal
fluid
● Development of autoimmunity
● Problems in ejaculation or deposition
● Chronic or excessive exposure to X-ray or
radioactive substance
Limited Sperm Count
● The number of sperm in a single ejaculation or in a
milliliter of semen. The minimum sperm count
consider normal has:
○ 33 t0 46 million sperm per milliliter of seminal
fluid, or 50 million per ejaculation
○ 50% of sperm that are motile
○ 30% that are normal in shape and form
Testing for Sperm Number
● Analysis of Pituitary Hormones
○ Whether adequate levels of FSH and LH
● Semen Analysis
○ After 2-4 days of sexual abstinence, a man
ejaculates by masturbation in a clean specimen
collector.
○ Specimen is examined for 1 hr
○ Average specimen 1.4-1.7 mL and should contain
33-46 million of sperms.
○ Required after 2-3 months (spermatogenesis)
○ 30-90 days before sperm matures
Therapy for Increasing Sperm Count and Motility
● If sperm are present but the total count is low, a
man may be advised to
○ Abstain from coitus for 7 to 10 days at a time to
increase the count.
○ Ligation of a varicocele (varicosity in spermatic
vein, if present)
○ Changes in lifestyle:
■ such as wearing loose clothing
■ avoiding long period of sitting
■ avoiding prolonged hot baths
Therapy for Sperm Disorders
● If the sperm are not able to pass through the vas
deferens because of obstruction, surgery to relieve
the obstruction is extensive, costly, and may not
have a positive outcome.
● Extracting sperm from a point above the blockage
and injecting it into the vagina or uterus of the
man’s partner by intrauterine insemination.
Ejaculation Problems
● Erectile Dysfunction or the inability to achieve an
erection, which may occur from psychological
problems, diseases such as a cerebrovascular
accident, diabetes, as well as the discontinuation of
finasteride, a drug used for male pattern baldness
may result in erectile dysfunction. This condition is
primary if the man has never been able to achieve
ejaculation and secondary if the man was able to
achieve ejaculation in the past but now has
difficulty.
Premature Ejaculation
● Another factor that may interfere with the proper
deposition of sperm.
● It is another problem often attributed to
psychological causes.
● Adolescents may experience it until they become
more experienced in sexual techniques.
Testing for Ejaculation Concern
Ejaculation concern are identified by a sexual
history. It may be difficult for a man to discuss his area
of his life, especially if a nurse is female, so skillful
patient interviewing technique is required.
Solution for erectile dysfunction include
psychological or sexual counseling as well as the use of
phosphodiesterase inhibitor, such as sildenafil (Viagra)
or tadalafil (Cialis).
Factors that Cause Female Subfertility
● Limited production of FHS or LH, which interfere
with ova growth
● Anovulation (failure or inadequate expulsion of ova)
● Uterine factors, such as rumors or poor endometrial
development
● Problems of ova transport through the fallopian
tubes to the uterus
● Cervical and vaginal factors, which immobilize
spermatozoa
● Poor nutrition, increased body weight, and lack of
exercise, which may compound these problems.
Ovulation Monitoring
The fastest way to investigate if ovulation is
occurring is to measure the woman’s serum
progesterone level during the luteal phase of her
menstrual cycle (about day 21 to day 28 of a typical
cycle). If this is elevated, it implies a corpus luteum has
formed or ovulation has occurred.
Anovulation Therapy
● Administration of GnRH is a possibility (this will
stimulate the pituitary to secrete more FSH and LH).
● Therapy with clomiphene citrate (CLomid,
Serophene) may also be used to stimulate
ovulation.
● In other women, ovarian follicular growth can be
stimulated by the administration of combination of
FSH and LH in conjunction with administration of
human chorionic gonadotropin (hCG) to produce
ovulation.
● If increase prolactin levels are identified,
bromocriptine (Parlodel) is added to the medication
regimen to reduce prolactin levels and allow for the
rise of pituitary gonadotropins.
Assisted Reproductive Techniques
Alternative Insemination
● Installation of sperm from specimen collected (male
partner or donor) into female reproductive tract.
● Sperm can be cryopreserved (frozen) in a sperm
bank
○ D/A: slower motility
● In preparation, Clomiphene or FSH is given 1 month
prior to stimulate ovulation.
● It takes 6 months or more to achieve
In Vitro Fertilization
● Fertilizing sperm and egg in a tube for 40 hrs, once
successful, the zygote (laboratory-grown fertilized
ova) is inserted to woman’s uterus.
● Overall pregnancy rate of IVF is as low as 30%-35%
for ages 35 and below, and 6%-10% for women
above 40 yrs old.
● Expensive and complication of infection can occur.
Alternatives to Childbirth
1. Surrogacy
2. Adoption
3. Child-free living
Genetic Pattern
Genetic D/O
● Incest
● Occupational hazards
Genes
● Basic unit of heredity that determine both the
physical and cognitive characteristics of people.
● Human cell is composed of 23 pairs or 46
chromosomes (44 autosomes and 2 sex
chromosomes)
Terminologies
● Allele - variant form of a gene
○ Dominant - exerts effects whenever present
○ Recessive - masked out when dominant is
present
● Phenotype - outward appearance or the expression
of genes (observable)
● Genotype - genetic makeup or composition
○ Homozygous - two healthy genes (HH) or 2
unhealthy genes
○ Heterozygous - one unhealthy, one healthy (hH)
Genetic Pattern
1. Autosomal Dominant Inheritance
a. h - healthy allele
b. D - dominant D/O
Characteristics in genogram:
- Sex is not important
- There’s a hx in other family member (vertical)
2. Autosomal Recessive Inheritance
a. h - healthy allele
b. d - recessive D/O
Characteristics in genogram:
- Both parents of a child with a d/o are free
- Fam hx of the disorder is not present (horizontal)
- Sex is not important
3. X-linked Dominant Inheritance
a. X - Dominant D/O
b. x & y - healthy alleles
Characteristics in genogram:
- All are affected
- All female children of affected men are also
affected; men are not
- Present in every generation (vertical)
- All children of homozygous affected women are
affected.
- 50% of the children of heterozygous affected
women are affected
4. X-linked Recessive Inheritance
a. x - recessive D/O
b. x & y - healthy alleles
Characteristics in genogram:
- Only males in the family have the disorder
- Sons of the affected man are not affected.
- The parents of affected children are not affected
(horizontal)
5. Y-linked Inheritance
Characteristics in genogram:
- Only males in the family have the disorder
6. Mitochondrial Inheritance
Characteristics in genogram:
- Females only pass mitochondrial d/os
Chromosomal Disorders
1. Nondisjunction D/O
- Cell division is uneven
- Ex. Down Syndrome (Trisomy 21)
2. Deletion D/O
- Part of chromosome breaks during cell division
- Ex: Cri-du-chat Syndrome (chromosome 5)
3. Mosaicism
- Nondisjunction d/o occurs after fertilization
- Causes: exposure to radiation
- Ex: Down Syndrome (near-normal intelligence)
4. Isochromosomes
- Horizontally separated.
- Ex: Turner syndrome.
Genetic Counselling and Testing
Counselling
● Provide concrete and accurate information about
the process of inheritance and inherited d/os.
● Allow them to have choices about future
reproduction.
● Allow families to begin preparation for a child with
special needs.
Diagnostic Test
1. Nuchal Translucency Screening
- Through sonogram (11-13 wks) detects unusual
fat or fluid deposit at the back of the fetal neck.
(DOwn and Turner Syndrome)
2. Karyotyping
- Process of pairing and ordering all chromosomes
3. Maternal Serum Screening
a. AFP (alpha Fetoprotein) - glycoprotein produced
by the fetal liver.
i. Elevated - Neural tube defects
ii. Decreased - chromosomal d/o
b. Unconjugated estriol - protein produced in the
placenta and in the liver
i. Decreased - High risk for Down Syndrome
c. HCG (human chorionic gonadotropin) - hormone
produced by the placenta
i. Elevated - presence of midline closure
anomaly
4. Chorionic Villi Sampling (CVS)
- Diagnostic technique that involves the retrieval
and analysis of chorionic villi from growing
placenta.
- Highly accurate but invasive.
- NI: Instruct signs of infection and abnormal
occurrence of bleeding (miscarriage).
5. Amniocentesis
- Withdrawal and analysis of amniotic fluid.
- NI: Instruct signs of infection and abnormal
occurrence of bleeding (miscarriage).
- Lower risk of miscarriage than CVS.
6. Fetal imaging
- MRI and UTZ are used to assess fetal size and
structural d/os.
7. Fetoscopy
- endoscopic procedure during pregnancy to allow
surgical access to the fetus, the amniotic cavity,
the umbilical cord, and the fetal side of the
placenta.
8. Newborn Screening
- Newborns are tested for a number of d/os
1. Congenital Hypothyroidism
2. COngenital Adrenal Hyperplasia
3. Phenylketonuria
4. G6PD (glucose 6- phosphate dehydrogenase
deficiency)
5. Galactosemia
6. Maple syrup Urine Dse
Female Reproductive System
External Structures
1. Mons Veneris- A pad of adipose tissue located 7. Hymen – is a tough but elastic semicircle of
above the symphysis pubis, pubic bone joint. tissue that covers the opening to the vagina
Covered by a triangle of coarse, curly hairs. Protects during childhood.
the pelvis from trauma.
2. Labia Minora
- Two hairless folds of connective tissue.
- The folds are normally pink in color. The internal
surface is covered with mucous membrane and the
external surface is covered with skin.
3. Labia Majora
- Two folds of tissue, fused anteriorly but separated Excision of an imperforate hymen- to allow menstrual
posteriorly, positioned lateral to the minora and blood to escape in a female who has reached puberty
composed of loose connective tissue covered by
epithelium and pubic hair. Female Internal Structure
- Shields the outlets to the urethra and vagina Ovaries
 Approx. 3cm long and 2cm in diameter and 1.5cm
thick. Equivalent to the size and shape of an
Almond. They are grayish-white and appear pitted,
with minute indentions on the surface.
 Are solid, avoid structures positioned in the upper
pelvic cavity on both sides of the uterus. They are
slightly larger than an almond
 Normally, they lie so low they cannot be located by
abd palpation. Only if an abnormality exists, such as
an enlarging ovarian cyst, can the resulting
4. Other external organs
tenderness and enlargement be evident on the LLQ
1. Vestibule – flattened, smooth surface inside the
or RLQ.
labias. The orifice of the Urethra and vagina arise
 -Function: To produce, mature, discharge ova.
from this membrane.
Produce Hormones and regulate Menstrual Cycle.
2. Clitoris- small rounded organ of erectile tissue at
the forward junction of the labia Minora. The  The Ovaries are held suspended by three strong
Center of sexual arousal and orgasm in a woman ligaments to both the uterus and pelvic wall.
3. Skene Glands – located on each side of the
urinary meatus. Their ducts open into the
urethra.
4. Bartholin’s Glands – located on each side of the
vaginal opening. Their ducts open into the
proximal vagina near the labia minora and
hymen. Both glands help lubricate the vagina
during coitus and maintains alkalinity.
5. Fourchette – is the ridge of tissue formed by
the posterior joining of the L.Min. & L.Maj. This
 Because they are suspended and not firmly fixed, an
is the structure that sometimes lacerates during
abnormal tumor or cyst growth that can easily
birth or is cut during Episiotomy.
enlarge twice its size before pressure on the
6. Perineum – a muscular area that stretches
surrounding organs leads to signs and symptoms.
during childbirth to allow enlargement of the
Fallopian Tubes
vagina and passage of the fetal head.
 Approx. 10cm long in a mature woman. Their
function is to convey the ovum from the ovaries to
the uterus and to provide a place for fertilization of
the ovum by the sperm.
 Parts of the Fallopian Tubes
1. Interstitium – part of the tube that lies within
the Uterine Wall.
2. Isthmus – Site for Tubal Ligation
3. Ampulla – Longest Part. Site of Fertilization
4. Infundibulum – Funnel Shaped. Covered by
Fimbria that helps guide the ovum into the
fallopian Tube.
 Because the fallopian tubes are open at their distal
ends, a direct pathway exists from the external
organs to the peritoneum. This can lead to infection
of the Peritoneum. For this reason, clean technique
must be used during pelvic exams. And Sterile
Technique during vaginal exams, labor and birth.
Uterus
 Is a hollow, muscular, pear shaped organ located in
the lower pelvis, posterior to the bladder and
anterior to the rectum.
 5-7cm long, 5cm wide, 2.5cm deep. Weighs 60g in
non-pregnant women.
 Function – to receive ovum from FT, provide place
for implantation and nourishment, furnish
protection to a growing fetus, and at maturity of the
fetus, expel it from the woman’s body. After
pregnancy, the uterus never returns exactly to its
non-pregnant state but remains 80g in weight.
 Is a thick-walled muscular organs shaped like an
inverted pear. It is where an egg normally implants
 Provides a site for implantation of the pre-embryo,
nourishes the developing embry/fetus, expels the
fetus at birth and sheds its inner lining every month
if pregnancy does not occur
 Division of the Uterus
1. Fundus – The Portion that can be palpated
abdominally to determine the amount of uterine
growth during pregnancy, to measure the force
of uterine contractions during labor, and to
assess if the uterus is returning to its non-
pregnant state.
Bartholomew’s Rule
 To determine the AOG base on the fundic
height
 Tape measure is placed in the fundus of the
Uterus
 3mos: Above SP
 5mos: Level of Umb.
 8mos: Level of Xyphoid Process
 9 mos: Below Xyphoid Process
2. Corpus/Body – Forms the Bulk of the organ.
The portion of the uterus that expands to
contain the growing fetus.
3. Isthmus – The portion of the uterus where
incision is made during caesarean birth.
4. Cervix – The lowest portion of the uterus.
Contains Different Parts:
a) Cervical Canal – The Central Cavity
b) Internal Cervical Os – the internal opening at
the junction of the Isthmus of the Uterus
c) External Cervical Os – Distal opening to the
vagina
Uterine & Cervical Coats
 The uterine wall consists of three different layers:
1. Endometrium – Inner layer of mucous
membrane. The one that sheds off during
menstruation
a. Basal Layer – remains stable, uninfluenced by
Hormones.
b. Glandular Layer – Dramatically
influenced by Estrogen &
Progesterone. Becomes so
thickened each month under
the influence of hormones that
it becomes capable of
supporting pregnancy. This is
the layer that sheds off as
menstrual flow.
- The layer that later on
becomes the Decidua during
Pregnancy.
Decidua - the thick layer of
modified mucous membrane
which lines the uterus during
pregnancy and is shed with
placenta afterbirth.
2. Myometrium – The Layer of Muscle Fibers.
Responsible for Uterine Contractions.
3. Perimetrium – outer layer of connective Tissue.
Adds further strength and support to the organ
 3 Major Types:
1. Shape
2. Position
3. Flexion
 When a woman lies on her back, the course of the
vagina goes inward and downward. The Posterior
Fornix serves as a place for the pooling of semen
after coitus. This allows for a large amount of sperm
to remain close to the cervix.
Stages of Fetal Development
Terms to Describe Fetal Growth
1. Ovum – Ovulation to Fertilization
2. Zygote – Fertilization to Implantation
3. Embryo – Implantation to 5-8 weeks
4. Fetus – 5-8 weeks to term
5. Neonate – 1st 28 days
6. Infant – 29th days to 1 year
In 38 weeks, a fertilized ovum matures from a single
cell to a fully developed fetus.
3 Periods of Fetal Growth & Development
1. Pre-Embryonic Stage
o From fertilization to 2 weeks
2. Embryonic Stage
o From week 3 to week 8
3. Fetal Stage
o From Week 8 to birth
Fertilization: The beginning of Pregnancy
Fertilization
o conception or impregnation
o Is the union of an ovum and a spermatozoa.
o The ovum is extruded from the Graaffian Follicle of
an ovary and is surrounded by a ring of
mucopolysaccharide fluid (zona pellucida) and a
circle of cells (corona radiata)
o Hyaluronidase is released by sperm and dissolves
the corona radiata and zona pellucida that protects
the ovum.
o Immediately after penetration of ovum, the
chromosomal material of the ovum and
spermatozoa fuse to form a zygote.
o Bec. Sperm and ovum each carry 23 chromosomes
(22 autosomes and 1 sex) chromosome the zygote
has 46 chromosomes in total. If an x carrying sperm
penetrates the ovum = 2 X chromosomes = assigned
female at birth. If a Y carrying sperm penetrates the
ovum = 1 X and 1 Y chromosome = assigned Male at
birth.
Fertilization depends on 3 separate factors:
1. Equal Maturation of both sperm and ovum
2. Ability of sperm to reach ovum
3. Ability of sperm to penetrate the ovum cell
membranes
Implantation
 Mitotic cell division begins.
 First division occurs about 24 hrs, then succeeding
division continuous every 22 hrs
 Over the next 3 or 4 days, Blastocyst is formed.
 Cells in the outer ring is termed as Trophoblast. This
will later form the placenta and membranes
 The cell inner mass, embryoblast, is the portion of
the structure that will later form the embryo.
Embryonic and Fetal Structures
Umbilical Cord
 Develops from amnio
Body stalk attaches embryo to yolk sae, fuses
with embryonic portion of placenta
Provides pathway from chorionic villi to embryo
 Contains two arteries and one vein; surrounded by
Wharton’s jelly to protect vessels
Wharton’s jelly: specialized connective tissue
Protects blood vessels
 Function of umbilical cord: provides circulatory
pathway to embryo
Placenta
 Placental development
Begins at third week of embryonic development
Develops at site where embryo attaches to
uterine wall
 Function: metabolic and nutrient exchange between
embryonic and maternal circulations
 Placenta has two parts
Maternal
Fetal
 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
 Theoretically, there is no exchange of blood cells
between the embryo and the mother during
pregnancy. However, fetal cells do cross into the
maternal blood stream as well as fetal enzymes
such as Alpha-fetoprotein (AFP) produced by the
fetal liver. This allows testing of fetal cells for
genetic analysis as well as the level of AFP in
maternal blood.
 Braxton Hicks contractions, the barely noticeable
uterine contractions present from about the 12th
week of pregnancy.
 Uterine perfusion and placental circulation are most
efficient when the mother lies on her left side. This
position lifts the uterus away from the inferior vena
cava.
Endocrine Function in Pregnancy
 The outer layer of the Chorionic Villi develops into a
separate and important hormone-producing
system.
 Hormones produced by the Chorionic Villi.
1. HCG
2. Progesterone
3. Estrogen
4. HPL
HCG (Human Chorionic Gonadotropin)
 The 1st placental hormone produced.
 Can be found in maternal blood and urine as early
as the first missed menstruation
 See Pregnancy Test Kits.
- The pregnant woman’s blood will be completely
negative for HCG within 1 to 2 weeks after birth.
Finding no serum HCG after birth can be used as
proof that placental tissue is no longer present
in-utero.
 The purpose of HCG is to act as a fail-safe measure
to ensure that the corpus luteum of the ovary
continues to produce progesterone and estrogen so
the endometrium of the uterus is maintained.
Progesterone
 The Hormone of pregnancy
 Necessary for maintaining the endometrial lining of
the uterus during the entire duration of gestation.
Estrogen
 Primarily Estriol
 Contributes to the woman’s mammary gland
development in preparation for lactation
 Stimulates uterine growth to accommodate the
developing fetus.
Human Placental Lactogen
 Promotes Mammary Gland (breast) growth in
preparation for lactation in the mother.
 Serves an important role in regulating the maternal
glucose during pregnancy.
The Amniotic Membranes
- The Chorionic Villi on the medial surface of the
thropoblast gradually thin until they become the
 Chorionic Membrane, the outermost fetal o Two embryos develop with separate amniotic
membrane. sacs
- The Amniotic Membrane, forms beneath the o Sacs will eventually be covered by a common
chorionic membrane chorion
- Is a dual walled sac composed of the Chorion and o Monochorionic-diamniotic placenta
the Amnion.  If amnion already developed, division approximately
- The two fuse together as the pregnancy continues, 7 to 13 days after fertilization
and by term, they appear to be a single sac. o Two embryos with common amniotic sac and
- The Amniotic membrane not only offers support to common chorion
the amniotic fluid but actually produces fluid. o Monochrionic-monoamniotic placenta
The Amniotic Fluid o Occurs about 1% of the time
- The Amniotic fluid never becomes stagnant because Fraternal Twins
it is constantly being newly formed and absorbed by  Also referred to as dizygotic
direct contract with the fetal surface of the o Arise from two separate ova fertilized by two
placenta. separate spermatozoa
- N Color: Clear Straw Colored o Two placentas, two chorions, and two amnions
 Yellow: RH Incom o Sometimes placentas fuse and appear to be one
 Brown: Infxn  Fraternal twins
 Green: Meconium Stained o No more similar to each other than singly bom
 Red: Abruptio Placenta siblings
- N PH = 7.25 slightly alkaline o May be of same or different sex
- N Odor: Odorless, Slightly sweet, bleach like smell
- Nitrazine Paper Test Origin and Development of Organ Systems
Results: Zygote Growth
 if paper turns blue= Amniotic Fld  Development proceeds in a cephalocaudal
 If paper turns red/yellow=URINE direction.
- Fern’s Test Primary Germ Layers
 + Ferning Image  Body organ systems develop from specific tissue
- N Volume: 500 – 1000ml layers called germ layers.
 <500 = oligohydramnios Ectoderm - gives rise to the skin, hair, nails, the
o Fetus cannot urinate nervous system, sense organs, mucous
o Renal Anomaly membranes of anus, nose and mouth, mammary
 >1000ml = polyhydramnios glands.
o Fetus in unable to swallow Mesoderm - specifies the development of
o S/ of trachea-esophageal Fistula several cell types such as bone, muscle, and
- 3cs of TEF connective tissue. Reproductive system,
 Choking cardiovascular system, upper portion of urinary
 Cough system
 Cyanosis Endoderm - cells become the linings of the
Functions of Amniotic Fluid digestive and respiratory system, and form
- Cushions the baby, protects from trauma organs such as the liver and pancreas. Lower
- Maintains Temp urinary system.
- Promotes Fetal Movement Cardiovascular System
 16th day of life - blood vessels and single heart tube
Twin Pregnancies is already present and beats as early as the 24th
Identical Twins day,
 Develop from single fertilized ovum  6th-7th week - septum that divides the heart
 Of same sex and have same genotype chambers develop
 Identical twin usually have common placenta;  7th week - heart valves develop
monozygosity is no affected by environment, race  10th-12th week - heart sound can be heard with a
physical characteristics, or fertility doppler instrument
 Both fetus are same sex with same characteristics  20th week - accurate ECG conduction can be
 Single placenta recorded
 28th week - consistent heartbeat of 110-16-bpm
 Number of amnions and chorions present depends
Fetal Circulation
on timing of division
 Placenta - umbilical vein - ductus venosus - inferior
 Division within 3 days of fertilization; two embryos,
vena cava - right side of the heart - right atrium -
two amnions, and two chorions will develop
foramen ovale - left atrium - left ventricle -
 Division about 5 days after fertilization
ascending aorta - other parts of the body
 Placenta - umbilical vein - ductus arteriosus -
inferior vena cava - right side of the heart - right
atrium - right ventricle - pulmonary artery - lungs
(small amt) and ductus arteriosus - descending
aorta - umbilical arteries – placenta
Respiratory System
 3rd week - respiratory and GI tract exist as one tube
 End of 4th week - septum divides the two and lung
buds appear.
 24th week - surfactant is formed and excreted by
the alveolar cells of the lungs.
 Surfactant - prevents alveolar collapse and improves
infant’s ability to maintain respiration once
delivered in the outside environment.
 Has two components:
Lecithin (L)
Sphinogomyelin (S)
Ratio: 2:1
Nervous System
 8th week - brain waves can be detected thru
Electroencephalogram
 24th week - ear is capable of responding to sound.
 Food intake of the mother is important for brain
development (Folic acid)
 Lack of folic acid - neural tube defects
(meningocele, spina bifida)
Digestive System
 4th week - separation of GI and respiratory tract
 6th-10th week - intestines becomes too large that it
is pushed into the base of the umbilicus.
 Meconium - collection of cellular waste, bile, fats
and etc. Sticky and appears black or dark green.
 GI tract is sterile. There is no presence of good
bacteria inside the intestine that’s why Vit. K is
routinely given at birth.
Musculoskeletal System
 First 2 weeks - cartilage prototypes provide support
to the growing fetus.
 11th week - fetus can be seen to move thru UTZ
 20th week - Quickening (fetal movement)
Reproductive Sytem
 8th week - sex can be determined thru
chromosomal analysis
 Testes first form in the abdominal cavity until 34-
38th weeks.
 Cryptochidism (undescended testes) - surgical
intervention
Urinary System
 End of 4th week - kidney is present
 12th week - urine is formed
 16th week - excretion of urine in amniotic fluid.
Integumentary System
 36th week - subcutaneous fat begins to deposit
underneath the skin
 Lanugo - soft downy hair (preserves warmth)
 Vernix Caseosa - cream-cheese like (lubrication and
prevents maceration)
Milestones of Fetal Growth and Development
 Trimesters: 3 Trimesters
 Calendar Months: 9 Months
 Calendar Weeks: 38 Weeks
 Calendar Days: 266 Days
End of 4th Week AOG
 Spinal Cord is Formed and fused at midpoint
 Rudimentary Heart appears as a prominent bulge
on the anterior Surface
 Arms and Legs are bud-like structures; Rudimentary
eyes, ears, and nose are discernible.
 With Marked C-Shape and Rudimentary Tail
Fetus Growth and Development
 4 weeks 4-6 mm, brain formed from anterior
neutral tube, limb bud seen, heart beats, GI system
begins
 6 weeks: 12 mm, primitive skeletal shape, chambers
in heart, respiratory system begins, ear formation
begins
End of 8th Week AOG
 Organogenesis is Complete
 The Heart beats rhythmically
 Facial Features are discernible
 External Genitalia are forming but sex is not yet
distinguishable
 The Abd bulges forward because of intestinal
growth
 Sonogram shows gestational Sac
Fetus Growth and Development
 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
End of 16th Week AOG
 Fetal Heart Sounds are audible by ordinary
stethoscope
 Lanugo is well formed
 Both Liver and pancreas are functioning
 Fetus actively swallows amniotic fluid showing
uncoordinated swallowing reflex
 Urine is present in amniotic fluid
 Sex can be determined thru UTZ
End of 20th Week AOG
 Spontaneous Fetal movements can be sensed by
the mother
 Antibody Production is Possible
 Hair including eyebrows begin to form on the head;
vernix caseosa begins to cover the skin
 Meconium is present in the upper intestine
 Brown fat begins to form
 Sleeping patterns are distinguishable
End of 24th Week AOG
 Active Production of Lung Surfactant Begins
 Eyelids begin to open and pupil is now reactive to
light
 Hearing can be demonstrated by response to
sudden sound
 If fetus reaches 500-600g they have achieved low- o 8mos: Level of Xyphoid Process = 32 - 36
end AOV and can be cared for in a NICU. weeks
End of 28th Week AOG 9 mos: Below Xyphoid Process = 36 - 38 weeks
 Lung Alveoli are almost mature; surfactant can be - McDonald’s Rule
demonstrated in amniotic fluid Months:
 Testes begin to descend into the scrotal sac from = FH (cm) x 2
lower abd cavity 7
 The blood vessels of the retina are formed but thin Weeks:
and extremely susceptible to damage from high = FH (cm) x 8
oxygen concentrations 7
End of 32nd Week AOG
 Sub-Q Fats begin formation, Little old man Obstetric History
appearance is Lost Terms Related to Pregnancy Status
 Fetus responds by movement to sounds outside the 1. GRAVIDA – The number of Pregnancies regardless if
mother’s body Delivered and Regardless if Dead or Alive
 Active Moro Reflex is present 2. PARITY – The No. of Deliveries that have reached
 Fingernails reach the end of fingertips viability, regardless if dead or alive
End of 36th Week AOG 3. PRIMIGRAVIDA – A Woman who is pregnant for the
 Most Fetuses turn into a vertex (Head Down) first time
presentation during this month 4. PRIMIPARA - A woman who gave birth to one child
 Types of Presentations past age of viability
1. Cephalic 5. MULTIGRAVIDA – A Woman who has been
 Vertex pregnant previously
 Sinciput 6. GRANDMULTIGRAVIDA – A woman who has been
 Occiput pregnant many times
 Mentum (Chin) 7. MULTIPARA – A Woman who has carried two or
 Face more pregnancies to viability
 Brow 8. NULLIGRAVIDA – A Woman who has never been
2. Breech and is not currently pregnant
 Footling (feet) Classification of Para
 Frank Breech T – Term: 38Weeks
 Complete Breech P- PreTerm: <38 Weeks
 Incomplete Breech A- Abortion: <20 Weeks
 Transverse L- Living: Alive
1. Acromion (Shoulder) M: Multiple: Twins
End of 40th Week AOG Pre-Natal Visits
 Fetus kicks actively, sometimes strong enough to  At Least 4 visits in Total
cause considerable discomfort 1st- Anytime on 1st Trimester
 Fingernails extend over fingertips 2nd- 20 – 24 weeks (Age of Viability)
 Vernix starts to decrease and is more prominent in 3rd- 28 - 32 weeks
body creases 4th- 36 weeks

Obstetric Assessment The Confirmation of Pregnancy

Determination of Estimated Birth Date 3 Classification of Signs and Symptoms
- Naegele’s Rule Presumptive Signs
Used to Determine EDC/EDD/EDB o Subjective Data
 Requires LMP o Felt by the Mother
 LMP = First day of last menstrual period. 1st Day o Least Indicative
of Bleeding of the Last Menstrual Cycle  Breast Changes
Formula:  Freq Ux
 Jan – Mar = +9 +7  Fatigue
 Apr – Dec = -3 +7 +1  Amenorrhea
- Bartholomew’s Rule  Morning Sickness
 To determine the AOG  Enlargement of ABD
 Tape measure is placed in the fundus of the  Melasma
Uterus  Linea Nigra
o 3mos: Just Above the SP = 12 weeks  Leukorrhea
o 5mos: Level of Umbilicus = 20 weeks  Striae Gravidarum
 Quickening
 Probable Signs  Striae Gravidarum
o Objective Signs  Striae Albicans
o Felt by the Examiner  Linea Nigra From Umbilicus – Symp. Pubis
o More Reliable 4. Respiratory System
 +PT Test  ^Nasal & Pharyngeal Congestion
 Hegar’s S/ 5. Musculo-Skeletal System
 Goodel’s S/  Changes in the center of Gravity
 Opperculum  Lordosis
 Chadwick’s S/  N Ca in Blood 8-10 mg/dl
 Osiander’s S/  4.5-5.5meq/l
 Ballotement  ^ Oral Ca intake
 Braxton Hick’s  Calcium supplement
 Gestational SAC thru UTZ 6. GIT System
Positive Signs  Morning Sickness
o Objective Signs  N&V N during 1st Tri
o Felt by the Examiner  1st tri= Hyperemesis Gravidarum
o Confirmatory Signs  MOC: Dry Toast Crackers b4 arising in bed
 Fetal Heart Tone-  Ice Chips- removes stimulants
10-12 weeks = Doppler  Avoid Fatty & Spicy Food
14-16 weeks= Fetoscope Hemorrhoids
>20 weeks= Stethoscope  Dt ^ Rectal pressure of the expanding uterus
 Fetal Movement MOC:
- ^ Fiber in Dt.
Must be Felt by Examiner
- ^OFI
10x/hr
- Regular Bowel Habits
 Fetal Skeleton
Heartburn
By UTZ
 Due to ^ Estrogen and Progesterone & HCG in
Normal Adaptation to Pregnancy
1st Tri
1. Reproductive System
MOC:
A. Breast:
- Avoid Lying in Bed after Meals
 Nipple & Areola Darken
- Give decaf Coffee
 Feeling of Fullness
7. Renal System
 Tension & Sensitivity
 UX Frequency dt:
 Production of Colostrum by 2nd trim
 ^ Blood Volume in kidneys
B. Uterus
 + Glucose Test
 Hegar’s S/
8. Neurologic
 Braxton Hick’s Contractions
 ^Pressure on Sciatic Nerve
 Uterus Rises in Pelvic Cavity of the Abd.
 Varicosities
 Amenorrhea
 DVT
C. Cervix:
 MOC: Anti-Embolic Stockings
 Goodel’s S/
 Best Time- B4 arising in Bed
 Opperculum
 Best Type: Panty Hose
 Seals out bacteria
9. Endocrine System
 Mucus Plug
 ^ HCG = + PT
 Produced by Progesterone
 ^^HCG= +H.Mole
D. Vagina
 Slight Hypertrophy of the Thyroid and
 Chadwick’s S/ due to estrogen Vasodilator
parathyroid Gland
 pH 4-5
Nutrition
2. Cardiovascular System
 Best Diet- ^CHON ^Kcal ^Vit,^E.Acid, ^Minerals
 ^Plasma Volume
o Folic Acid
 +Palpitations
o Iron
 Slight Hypertrophy of the Heart
o Taurine
 <HGB = Physiologic Anemia
o DHA
 DOC: Fe So4 20-40 or 30mg/day
 Optimal for Brain Development
 ^Clotting Factors = DVT & Thrombophlebitis
Optimal Weight Gain of Gravid
 Decrease protein & ^WBC
 25-35lbs
 Slightly < BP on 2nd Trimester but returns to
 Twin Pregnancy- 40-45lbs
Normal on 3rd Tri
3. Integumentary System  1st Tri = 1lbl/Mos.
 Melasma / Chloasma (MSH)  2nd Tri = 1 lbl/wk
 3rd tri= 1lbl/wk The individual performing the maneuver first
o Non Pregnant: 2,200kcal/day grasps the lower portion of the abdomen just
o Pregnant: additional 300kcal/day above the symphysis pubis with the thumb and
o Total: 2500kcal/day fingers of the right hand
o Lactating: Additional 500kcal/day  Pe – Pelvic Grip
High Risk Mothers The health care provider faces the woman’s feet,
 Teenage Mothers as he or she will attempt to locate the fetus’
 Prone to Non-compliance brow
o PICA- Consumption of Non edible- non nutritious To determine the degree of flexion of the fetal
food head
o MOC: Offer Ice Chips to stop cravings The fingers of both hands are moved gently
o Effects of PICA: down the sides of the uterus towards the pubis
o Under Nourishment, Overnourishment o P-Presentation
o SGA, GDM o B- Back & Lie
o E- Engagement
Leopold’s maneuver o Attitude
 F- Fundal Grip  Good Attitude- if brow correspond to the side
First Maneuver that contained the elbows and knees
to determine the presenting part at the fundus  Poor Attitude- if examining fingers will meet
While facing the woman, palpate the woman's an obstruction on the same side as fetal back
abdomen with both hands.
Often done to determine the size, consistency, The Components of Labor
shape, and mobility of the form that is felt. 5Ps of Labor
The FETAL HEAD is hard, firm, round, and moves 1. Passageway – The Maternal Pelvis
independently of the trunk  The Passageway of Pregnancy is the Maternal
The BUTTOCKS feels softer, is symmetric, and Pelvis.
has small bony prominences; it moves with the  Refers to the route a fetus must travel from the
trunk uterus through the cervix and vagina, and to the
Types of Presentation external perineum.
1. Cephalic Terms relating to the Maternal Pelvis:
 Vertex 1. Pelvic Inlet: The Entrance to the True Pelvis
 Sinciput  The Upper ring of bone through which the
 Occiput fetus must pass to be born vaginally
 Mentum (Chin) 2. Pelvic Outlet: The Inferior portion of the Pelvis
 Face  The portion bounded in the back by the
 Brow coccyx.
2. Breech 3. The Pelvic Cavity: is the Space between the Inlet
 Footling (feet) and the Outlet
 Frank Breech  Curved space to slow and control and the
 Complete Breech speed of birth.
 Incomplete Breech  The Snugness serves to compress the chest of
 Transverse the fetus and to expel lung fluid and mucus
1. Acromion (Shoulder) and thereby prepare the lungs for better
 U- Umbilical Grip aeration.
2. Passenger – Fetus & Placenta
The maneuver attempts to determine the
 The Pax of Pregnancy is the Fetus and Placenta
location of the fetal back
 The body part of the fetus that has the widest
Facing the woman, the health care provider
diameter is the Head.
palpates each side of the abdomen with gentle
 The Head is the part that is least likely to pass
but deep pressure using the tips of his or her
through the pelvic ring
hands
3. Power – Ability to Push
The fetal back is firm and smooth, hard, resistant
4. Position – Position during labor
surface
5. Psyche – Emotion of the Mother
Fetal extremities feels like small irregularities Molding
and protrusions  Is the overlapping of skull bones along the suture
 Pa – Pawlick’s Grip lines, which causes a change in the shape of the
Determine what fetal part is lying above the Fetal skull to one long and narrow, a shape that
inlet, or lower abdomen facilitates passage through the rigid pelvis.
 Molding is caused by the force of Uterine
contractions as the vertex of the head is pressed Mechanism (Cardinal Movements) of labor
against the not yet dilated cervix. E- Engagement
Fetal Presentation and Position D- Descent
 Fetal Attitude: describes the degree of flexion a F- Flexion
fetus assumes during labor I- Internal Rotation
 The relation of the fetal parts to each other E- extension
 Types E- External Rotation
1. Good Flexion: Complete Flexion E- Expulsion
 Spinal Cord is bowed forward The Powers of Labor
 Head is Flexed forward - Refers to the ability of the Mother to push
 Chin touches the sternum True False
 Arms are flexed and folded on the chest 1. Contractions Regular Irregular
 Thighs are flexed into the abdomen 2. Discomfort Pain from back Abd only
2. Moderate Flexion: to abd
 Chin does not touch the chest 3. Effect on Pain ^by Pain < by
 Can be seen in Sinciput Presentation walking walking walking
3. Partial Extension 4. Dilatation & Present Absent
 Moderate Flexion Effacement
5. Bloody Present Absent
 Brow of the head is present in the birth canal
Show
 Can be seen in Brow Presentation
Effacement
4. Complete Extension
 Refers to the Shortening and thinning of the cervical
 The back is arched
canal
 The neck is extended
 Effacement First before Dilatation
 This unusual presentation is too wide for vaginal
birth  Fully Effaced Cervix = 98 – 100%
Fetal Lie: Dilatation
 Is the relationship between the long axis of the fetal  Refers to the enlargement or widening of the
body and the maternal long axis. cervical canal
 Transverse of Longitudinal  Fully Dilated Cervix = 10cm
 Longitudinal Lies are further Classified into Cephalic  After Dilation, there is an increase in the amount of
or Breech. vaginal secretions due to rupture of capillaries and
Fetal Position release of the Mucus Plug
 Is the relationship of the presenting part to a  Bloody Show
specific quadrant and side of a woman’s pelvis. The Position of Labor
 In Vertex Presentation, the Occiput is the Point =  Refers to the position of the Mother during labor
(O) and delivery
 In Face Presentation, Chin = (M)  Best Poxn: Any poxn as long as the mother is
 In Breech Presentation, Sacrum = (Sa) comfortable
 In Shoulder Presentation, scapula = (A)  Desired: Lithotomy Poxn
ROA & LOA  If With Heart Problems: High Fowler’s
 Favourable Fetal Position Psyche
 Faster Delivery  Refers to emotion of the mother during labor.
 Shorter Labor  If there is negative psychological outlook, provide
 Less Painful Delivery Support Person
 Check FHT below Umbilicus Support Person during Labor:
ROP & LOP o Mother of the Pregnant Woman
 Painful Delivery o Any Female Relative
 Prolonged Labor o Female Friend
 Difficult to check FHT o Husband
 At Level of Umbilicus or above umbilicus
Engagement Stages of Labor
 Refers to the settling of the presenting part of the 1. Dilatational Stage
fetus far enough into the pelvis that it rests at the  From onset of contraction to the full dilatation of
level of the ischial Spine. the cervix
 Engaged Fetus is at Station 0 Progress of Cervical Dilatation
Fetal Stations Primis: 1cm/hr
 Refers to the relationship of the fetal presenting Multi G: 1.5 cm/hr
part to the maternal ischial spine When to bring to DR:
 Primis: 10cm
Multi G: 7-8 cm
3 Segments of Dilatational Stage
a. Latent
 Mother is happy & excited, able to
communicate.
 Contractions are tolerable
 Cervical Dilatation: 0-3cm
 Duration of Contractions: 20-40secs
 Frequency: q 5-15mins
 Intensity: Mild
NX MGT:
 Encourage the mother to ambulate
 Encourage the mother to void
 Bathing
 Provide small frequent feedings
 Elimination
Pain Management During Childbirth
 Gating theory of pain control
a) Cutaneous stimulation - rubbing the area
(effleurage massage)
b) Distraction - singing, walking, deep
breathing, etc.
c) Reduction of anxiety - teach the woman
on what to expect.
 Bradley Method
a) Robert Bradley - formulated this method
b) Happy thoughts and diet (low salt, low fat
(animal) and no preservatives) to prepare
for muscle-toning exercises.
 Psychosexual Method
a) Conscious relaxation and progressive
breathing techniques
b) “Go with the flow”
 Dick-Read Method
a) Grantly Dick-Read - physician
b) Fear - tension - pain.
c) Health teaching
 Lamaze Method
a) Ferdinand Lamaze - physician
b) Psychoprophylactic - prevents pain in
labor by use of the mind
c) Lamaze classes - last trimester
6 major concepts:
- Labor should not be induced
- Free to walk and move around during
labor
- Women can bring loved one or friend for
continuous support
- Avoid unnecessary medical interventions
- Women should be allowed to give birth in
other positions than on their back and
follow their body’s urges to push
- Mother and baby should be kept together
after birth.
Lamaze Exercises:
 Conscious relaxation
- Relaxing one part of the muscle, then
another, until the entire body is relaxed.
- This could be done with a partner as an
emotional support
 Cleansing breath
- Before starting and ending all breathing
techniques, breathe in and breathe out
DEEPLY.
 Consciously controlled breathing
- Level 1: slow deep breathing (full) (6-12
bpm) (0-3 cm)
- Level 2: Lighter and more rapid (40 bpm)
(4-6 cm)
- Level 3: more shallow and rapid (50-70
bpm) (7-10 cm)
- Level 4: “pant-blow” pattern 3-4 breathing
then forceful exhalation
- Level 5: continuous rapid and shallow
breathing (60 bpm)
 Effleurage
- Light abdominal massage
 Focusing or Imagery
- Focusing intently on an object
- cone
b. Active
 Mother is apprehensive with ^ Anxiety
 Best time to admit in Labor room
 Cervical Dilatation: 4-7cm
 Duration of Contractions: 40-60secs
 Frequency of Contractions: 3-5mins
 Intensity: Moderate
NX MGT:
 Anticipate Physical Needs
 Provide Comfort and I&O
 Monitor FHT = N 120-160
 Admin. Certain Medications
c. Transitional
 Most Painful Part
 Mother is Screaming and in panic - hysteria
 BOW Ruptures
 Anus is Pouting
 Cervical Dilatation: 8-10cm
 Duration of Contractions: 60-70secs
 Frequency of Contractions: Q 2-3mins
 Intensity: Strong
NX MGT:
 Admit to DR
 Deliver the baby
2. Expulsive Stage
 From full dilatation of the Cervix to the delivery of
the baby
 Positioning – Lithotomy Position on padded Stirrups
Lift Legs at the same time. Only for < 1 hr.
Contra In mothers with Heart conditions
 Monitor Contractions & FHT q 5-15mins
 Perineal Cleaning
Episiotomy
 Best time is during the peak of a contraction
 Shortens 2nd stage of labor
 PRN
2 Types:
 1. Median Duncan- Maternal Side-Dirty
2. Medio-Lateral Retained Placental Fragments
Median: Faster Healing Rate MOC: D&C
 Less Painful Maneuver for Placental Delivery
 Less Bleeding
Medio-Lateral: More Painful a. Crede’s Maneuver
 More Bleeding  Pushing the Uterus Downwards
 Slow Healing  Never Done in a contracted uterus
 Hard to repair 4. Recovery Stage
Episiorraphy- Surgical Repair of Episiotomy  1st 4 hours Post Partum
MOC: Priority:
 1st 24hr Monitor S/ of Hemorrhage
- Cold Compress to prevent bleeding N blood loss:
 Post 24hrs NSD: 300- 500ml
- Heat, Perineal Lamp, Hot Sitz Bath to CS: 800- 1000ml
promote healing process Vital Signs Monitoring:
- Oral Analgesics 1st Hour
- Health Teaching Kegel’s Exercise  Check VS Q 15mins
Addendums:
2nd Hour
 Instruct Mother not to push anymore if  Check VS Q30mins
head is crowning
Check Umbilical Cord
 Palpate for cord coiling
 AVA 2 Arteries, 1 vein
 Initiate unang yakap protocol SUA – Single Umbilical Artery
Unang Yakap Protocol
Congenital Anomaly
Updated AO 0025 EINC, ENC
Heart Defects
a. Immediate Thorough Drying for 30 secs
Kidney Problem
b. Early SSC
NX MGT:
c. Properly timed cord clamping &
Cutting Weigh the Pad- 1grm = 1cc
d. Early breastfeeding Fully soaked Pad = 25-50cc
AO 0025 Addendums as of 2018 Assessment of Fundus
- *Suctioning - prn Immediately After Placental Del: Uterus, should
- *Pacifier – not needed be firm, midline bet. Umbilicus & SP
- *no Water with Glucose 1st Day Post Delivery Level of umbilicus (24H)
- Hepa B, Vit. K, Crede’s given Succeeding days- <1cm, 1 fingerbreadth
- Vernix Caseosa – Spread down/day
- *no Trendelenburg 10th day - nonpalpable
- *no Foot Slapping Puerperium = 6wks duration
- *no Foot Printing = Skin allergy Involution – Return to N
- * Milking of Cord Subinvolution- Not all returned to N
- * Covering of Cord Soft Fundus, Boggy, Non contracted are S/ Of
- * Application of Alcohol/Iodine on Uterine Atony
stump Hard Fundus= Contracted Uterus
- Washing Delayed for 6 hours High, Deviated to the L or R = FULL BLADDER
Omphalitis - infected cord Lochia
- DOC: Gentian Violet 3 Types:
3. Placental Stage Rubra 1-3 (Dark Red)
 From delivery of baby to delivery of placenta
Serosa 4-9 (Pinkish Brown)
 Max time for placental del = 30 mins
Alba 10-21 (White) (Creamy White) Upto 6
 If Placenta is intact > 1 hr. remove manually
weeks
S/ of Placental Seperation:
Shouldn’t have:
Calkin’s Sign (Earliest S/)
Cont. Trickling of Blood
Uterus Rises in ABD
Bright Red Blood
Sudden Gush of Blood
Should not have Foul odor or large clots
Lengthening of Cord (Surest S/)
Length of Cord = Length of Baby Normal Expected Postpartum Changes
Mechanism of Delivery N Post-Partum Changes
Schultz- Fetal Side-Shiny 1. 1st 24 hours:
  ^ in Temp due to DHN
 24 hours Fever = SEPSIS/Puerperial Infxn
2. ^ WBC Count upto 30,000/mm3
3. Diaphoresis

Maternal Post-Partum Adaptation

3 Phases by Dr. Reva Rubin
1. Taking In Phase – 1-3 days PP
o Mother is self-centered
o Inactive, dependent, cannot decide
o With poor decision making
o Narcissistic
o Tells stories about birth experience
2. Taking Hold Phase 4-14 days PP
o Mother is active, independent, can decide
o Best Time to insert Family Planning
o Mother Starts to take care/hold baby
o Encourage Breastfeeding
a. Postpartum Blues – N on 1st 2 weeks Because of
Hormonal Imbalance
 Give health Teaching
b. Postpartum Depression – >2 weeks
 Overwhelming Sadness
 Refer: COUNSELOR
c. Postpartum Psychosis
 Overwhelming Sadness + Psychological
Disturbance
 Hallucination, Illusion, Delusion
MOC:
o Acknowledge First
o Present Reality
o Verbalize
Auditory Hallucination=Most Common
Refer: PSYCHIATRIST
3. Letting Go Phase
 3rd – 4th week
 Mother Redefines herself as a parent
 Moves on, goes on
 Ignores Fantasy Baby
 Accepts the true form of real baby