Framework for maternal and child health
nursing (MCN) focusing on at risk, sick client
Obstetrics– Care of woman during childbirth;
derived from Greek word“obstare”(to keep
watch)
Pediatrics– derived from Greek
word,“pais”(child)
Focus of MCN – Care of childbearing and
childrearing families.
Primary Goal of MCN– Promotion and
maintenance of Optimal Family Health.
Goals of MCN are broad b/c the scope of
practice or range of practice includes the ff:
1.Preconceptual Health Care
2.Care of women during 3 trimesters of
pregnancy
-1st trimester (1st – 3rd month)
-2nd trimester (4th – 6th month)
-3rd trimester (7th – 9th month)
3.Care of women during Puerperium or 4th
Trimester (6 weeks after childbirth)
4.Care of infants during Perinatal Period (6
weeks before conception and 6 weeks after
birth)
5.Care of children from birth to adolescence
-Neonatal (28 days of life); Infancy (1 – 12
months); Adolescence (after 18 y/o)
6. Care in settings as varied as the birthing
room, the PICU, and the home.
Philosophies of MCN
 MCN is Family Centered; assessment must
include both family and individual
assessment.
 MCN is Community Centered; health of
families depends on & influences the
health of communities.
 MCN is Evidence Based because critical
knowledge increases
 MCN includes independent nursing
functions because teaching & counselling
are major interventions.
 MCN Nurse, Advocate (protects the rights
of family members, including fetus)
 Health Promotion and Disease Prevention
to protect health of new generation.
 MCN is a challenging role for nurses
In all settings and types of care, keeping the
family at the center of care or considering
family as the primary unit of care is an essential
goal because the level of a family’s functioning
affects the health status of its members. A
family centered approach enables nurses to
better understand individuals and their effect
on others, and in turn, to provide holistic care
***
 Family – basic unit of society
Framework for MCN
1. Nursing Process (ADPIE)
2. Evidence Based Practice
3. Nursing Research
4. Nursing Theory
4 Phases of Health Care
1.Health Promotion
Educating clients to be aware of good health
through teaching and role modelling
Ex. Family planning, teach the importance of
safe sex practice, importance of immunizations
2.Health Maintenance
Intervening to maintain health when risk of
illness is present
Ex. Encourage prenatal care, importance of
safeguarding homes by childproofing it against
poisoning
3.Health Restoration
Diagnosing and treating illness using
interventions that will return client to wellness
fast
Ex. Care of child during illness, care of woman
during pregnancy complications
4.Health Rehabilitation
Preventing further complications from an illness
Bringing client back to an optimal state of
wellness
Helping client accept inevitable death
Ex. Encourage continuous therapies and
medications
Trends in Maternal and Child Health Nursing
Population
Client Advocacy – safeguarding and advancing
the interests of clients and their families.
 TRENDS NURSING Measuring Maternal and Child Health /
IMPLICATIONS Statistical Terms Used to Report Maternal and
Families are similar in Fewer family Child Health
size members are present
as support people in 1.Birth Rate – no. of births per 1000 population
times of crisis 2.Fertility Rate – no. of pregnancies per 1000
Role of Nurse: Fullfill women of childbearing age
the role 3.Fetal Death Rate –no. of fetal deaths
weighing more than 500 g or more per 1000 live
Increased Single Fewer financial births
Parents (most resources esp. woman 4.Neonatal Death Rate
common type of Role of Nurse: Inform  Neonatal Period – 1st 28 days of life; Infant
parent in US) parents of care is called Neonate
options and back – up  No. of deaths per 1000 live births occurring
opinion in the 1st 28 days of life.
5.Perinatal Death Rate
Increased mothers Healthcare must be  Perinatal Period – 6 weeks before
working outside home scheduled at times a conception and 6 weeks after childbirth
at least part-time working parent can  No. of deaths of fetuses weighing > 500g
(90%) care for her own self and within the first 28 days of life per 1000
or bring a child for birth.
care. 6.Infant Mortality Rate – no. of deaths per 1000
Role of Nurse: Discuss live births in the first 12 months of life.
selection of child care 7.Childhood Mortality rate – no. of deaths per
centers 1000 population in children; 1 – 14 y/o
8.Maternal Mortality Rate – no. of maternal
Families are more Good interviewing & deaths per 100,000 live births that occur as
mobile: Increased no. health monitoring are direct result of reproductive process.
Of homeless women necessary so health
and children database can be Trends in Health Care Environment
established and 1.Cost containment –reducing the cost of
continuity of care. health by closely monitoring the cost of
personnel, use and brands of supplies, length of
Child and Intimate Screening for child or hospital stays, no. of procedures carried out,
Partner Abuse intimate partner and no. of referrals while maintaining quality
abuse; Nurses must be care.
aware of legal 2.Increasing Alternative Settings and Styles for
responsibilities for Health Care
reporting abuse.  LDRP Rooms (Labor – Delivery – Recovery
– Postpartum) a more natural childbirth
Families are more Provide Health environment as a birthing room. Family
health conscious Education members are invited to stay to be a part of
childbirth.
Health care should Comprehensive care is  Retail Clinics or Emergent Care Clinics
respect cost necessary in primary located in shopping malls
containment care settings because  Ambulatory Clinics or at home to avoid
referral to specialists long hospital stays for women and
may no longer be an children.
option; Health 3.Including Family in Health Care
insurance is not 4.Increasing Intensive Care Units
available in all  NICU (Neonatal Intensive Care Unit) or ICN
families. (Intensive Care Nursery)
 PICU (Pediatric Intensive Care Unit)
5.Regionalizing Intensive Care – ex. Premature
infant transferred to regional hospital
6.Increasing the Use of Alternative Treatment
Modalities – alternative method of therapies
such as acupuncture and therapeutic touch;
herbal remedies.
7.Increasing Reliance on Home Care –
decreased hospital stay.
8.Increasing Use of Technology – use of
internet, charting in computer, using Doppler
9.Free birthing – women giving birth without
health care provider supervision; unassisted
birth
10.LAMAS – breathing techniques

Legal Considerations of MCN Practice

1.Identifying and Reporting Child Abuse
2.Child can bring a lawsuit when they reach
legal age
3.Informed Consent for invasive procedure and
any risk that may harm the fetus
4.In divorced or blended families, nurse has the
right to give consent.

Ethical Considerations of Practice

1.Conception Issues
 In Vitro Fertilization
 Embryo Transfer
 Cloning
 Stem Cell Research
 Surrogate Mothers
2. Abortion
3.Fetal Rights vs Rights of the Mother
4.Use of Fetal Tissue for Research
5.Resuscitation
6.No. of procedures or degree of pain that a
child should asked to achieve better health
7.Balance between modern technology and
quality of life.
INTRAPARTUM COMPLICATIONS
OBSTETRIC PROCEDURES
-ARE PROCEDURES USED TO PREVENT
COMPLICATIONS DURING BIRTH, TO AID THE
PREGNANT CLIENT DELIVER SAFELY THE FETUS,
OR TO PROMOTE A POSITIVE OUTCOME FOR
THE MOTHER AND FETUS WITH
COMPLICATIONS
AMNI0INFUSION
 INJECTION OF WARMED SALINE OR
LACTATED RINGERS SOLUTION INTO THE
UTERUS VIA AN INTRAUTERINE PRESSURE
CATHETER DURING LABOR AFTER THE
MEMBRANES HAVE RUPTED
 IT CAN BE ADMINISTERED AS A ONE TIME
BOLUS FOR 1 HOUR OR AS CONTINUOUS
INFUSION
PURPOSE:
 To replace the amniotic fluid
 500 ml for an hour
INDICATION:
 OLIGOHYDRAMNIOS
 UMBILICAL CORD COMPRESSION
RESULTING FROM LACK OF AMNIOTIC
FLUID
-REPLACES THE “CUSHION” FOR THE
UMBILICAL CORD AND RELIEVES THE VARIABLE
DECELERATIONS THAT MAY OCCUR DURING
CONTRACTIONS WHEN DECREASED AMNIOTIC
FLUID IS PRESENT
 REDUCTION OF RECURRENT VARIABLE
DECELERATIONS IN THE FHT
 DILUTION OF MECONIUM-STAINED
AMNIOTIC FLUID
NURSING CARE:
 CONTINOUS MONITORING OF UTERINE
ACTIVITY AND FHT
 CHANGE THE UNDERPADS ON THE BED AS
NEEDED TO MAINTAIN PATIENT COMFORT.
 DOCUMENT COLOR, AMOUNT, AND ANY
ODOR OF THE FLUID EXPELLED FROM THE
VAGINA
AMNIOTOMY
 IS THE ARTIFICIAL RUPTURE OF
MEMBRANES (AROM) BY USING A STERILE
SHARP INSTRUMENTS.
 The membranes may be ruptured using a
specialized tool, such as an amnihook or
amnicot, or they may be ruptured by the
proceduralist's finger.
There are four main reasons for performing an
amniotomy:
1. To induce labor or augment uterine
activity. 
2. To enable the doctor or midwife to
monitor the baby's heartbeat internally
3. To check the color of the fluid.
4.  To avoid having the baby aspirate the
contents of the amniotic sac at the
moment of birth. Most often, the amniotic
sac will break of its own accord, most often
by the beginning of the second stage of
labor.
COMPLICATIONS:
PROLAPSE OF THE UMBILICAL CORD
 May occur if the cord slips downward with
the gush of amniotic fluid
INFECTION  Before the labor is inducted it is important
 May occur because the membranes no that fetal maturity is confirmed by
longer block vaginal organisms from ultrasound or amniotic fluid analysis, and
entering the Uterus the status of cervix is determined

ABRUPTIO PLACENTA BISHOP SCORING SYSTEM

 Likely to occur if the uterus is overly
distended with amniotic fluid when the
membranous rupture
 The uterus becomes smaller with the
discharge of amniotic fluid, but the
placenta stays the same size and no longer
fits its implantation site.
 Used to assess the status of the cervix and
the success of induction of labor
 A score of 6 above is recommended before
induction of labor
 A high score is predictive of a successful
labor induction

Variable 0 1 2 3
Dilatation
of cervix 0 1-2cm 3-4cm 5-6cm

Consisten
cy of firm medium soft
cervix

Cervical
effacemen >2cm 1-2cm 0.5- <0.5cm
t 1cm

Position of
cervix 0-30% 40-50% 60- 80%
NURSING CARE:
70%
GOAL: observing for complications
Station of
1. FHT is recorded for at least 1 minute after
presenting
amniotomy
part
 Rates outside the normal range for a term
related to -3 -2 -1 +1,+2
fetus suggest a prolapsed umbilical cord
ischial
2. Record the color, amount, characteristics,
spine
and odor of amniotic fluid
 The fluid should be clear, possibly with
flecks of vermix, and should not have a bad
odor
 Cloudy, yellow, or malodorous fluid INDICATION:
suggests infection  Gestational hypertension
 Green fluid means that the fetus has  Ruptured membranes without
passed meconium spontaneous onset of labor
3. Monitor temperature every 2 hours  Infection with the uterus
Goal: promoting comfort  Medical problems in the woman that
 Change underpads as often as needed to worsen during pregnancy
keep woman dry.  Fetal problems, such as slowed growth,
prolonged pregnancy, or blood
INDUCTION OR AUGMENTION OF LABOR: compatibility
 Placental insufficiency
 INDUCTION OF LABOR – is the initiation of  Fetal death
labor before it begins naturally.  Convenience for the family or health care
 AUGMENTION OF LABOR – is the provider is not an indication for inducing
stimulation of contractions after they labor
have begun naturally.
CONTRAINDICATIONS:
 Placenta previa
 Umbilical cord prolapse
 Abnormal fetal presentation
 High station of the fetus, which suggest a
preterm fetus or a small maternal pelvis
 Active herpes infection in the birth canal,
which the infant can acquire during birth
 Abnormal size or structure of the mother’s
pelvis
 Previous classic cesarean incision
TECHNIQUES:
-Pharmacological methods to stimulate
contraction, include:
CERVICAL OPENING
 Induction is easier if the woman’s cervix is
soft, partially effaced, and beginning to
dilate
 Methods to hasten cervical ripening is
done before induction of labor because
oxytocic drugs have no effect on the cervix
 Prostaglandin in the form of gel or
commercially prepared vaginal insert is
used
 Laminaria – an alternative to prostaglandin
- a narrow cone of a substance that
absorbs water and swells the cervix
LAMINARIA STICK
OXYTOCIN
 Most common method
 Oxytocin is diluted in an IV infusion
 Begins at a very low rate and is adjusted
upward or downward according to how
fetus responds to labor and to the
woman’s contractions
 Monitor closely rate of infusion and
maternal and fetal condition to prevent
complications
Nonpharmacological methods to stimulate
contractions, include:
Walking
 Stimulates contractions, eases the
pressure of the fetus on the mother’s back,
and adds gravity to the downward force of
contractions
Nipple stimulation
 Causes the posterior pituitary gland to
secret natural oxytocin
COMPLICATIONS:
 Fetal compromise ( changes in FHT )
because blood flow to the placenta is
reduced if contractions are excessive
-Placental exchange of oxygen , nutrients,
and waste products occurs between
contractions
-These exchange is likely to be impaired if
the contractions are too long, too frequent, or
too intense
 Uterine rupture because of too much
stimulation ( tetanic contractions )
 Water intoxication sometimes occurs
because oxytocin inhibits excretion of
urine and promotes fluid retention.
NURSING CARE:
 Monitor uterine activity and FHT before
and during procedure
 Recording of I & O identifies potential
water intoxication
 Oxytocin is discontinued if:
-Contractions are more frequent than
every 2 minutes
-Contraction during exceeds 75-90 seconds
-Uterus does not relax; remains contracted
and tetanic
-Fetal distress occurs
In addition to stopping, measures to
correct complications are instituted, which
includes:
 Increasing the non-medicated IV solution
 Changing the woman’s position, avoiding
supine position
 Giving oxygen by face mask
VERSION
 A method of changing the fetal
presentation, usually from breech to
cephalic
 There are two methods: external ( more
common )and internal
 A successful version reduces the likelihood
that the woman will need a cesarean
delivery

RISK AND CONTRAINDICATIONS:
 Few maternal an fetal risks are associated
with version, especially external version
 Version is not indicated if there is any
maternal or fetal reason why vaginal birth
should not occur, because that is its goal
 The following are maternal or fetal
conditions that are contraindications for
version:
 Disproportion between the mother’s pelvis
and fetal size
 Abnormal uterine or pelvic size or shape
 Abnormal placental placement
 Previous cesarean birth with a vertical
uterine incision
 Active herpes virus infection
 Inadequate amniotic fluid
 Poor placental function
 Multifetal gestation
 Version may not be attempted in a woman
who has a higher risk for uterine rupture
 Not usually attempted if the fetal
presenting part is engaged in the pelvis.
 The main risk to the fetus is that it will
become entangled in the umbilical cord,
thus compressing the cord.
Technique:
EXTERNAL VERSION
 Done after 37 weeks AOG but before the
onset of labor
 Begins with a nonstress test or biophysical
profile to determine if the fetus is in good
condition and if there is adequate amniotic
fluid to perform version
 The woman receives a tocolytic drug to
relax her uterus
 Using ultrasound to guide, the physician
pushes the fetal buttocks upward out of
the pelvis while pushing the fetal head
downward toward the pelvis in either a
clockwise or a counterclockwise turn
 The fetus is monitored frequently during
the procedure
 The tocolytic drug is discontinued after the
external version is completed
 RH negative woman receive a dose of
RhoGam.
INTERNAL VERSION
 Is an emergency procedure
 The physician usually performs interval
version during a vaginal birth of twins to
change fetal presentation of the second
twin.
NURSING CARE:
 Assist in the procedure and observing the
mother and fetus afterwards for 1 to 2
hours
 Baseline maternal vital signs and FHT are
taken before version
 Vaginal leaking of amniotic fluid suggest
that manipulating the fetus caused a tear
in the membranes and this is reported
 Uterine contraction usually decrease or
stop shortly after the version, the physician
is notified if they do not
 Review signs of labor with the woman
because version is performed near term,
when spontaneous labor is expected
EPISIOTOMY AND LACERATIONS
EPISIOTOMY – is the surgical enlargement of
the vagina during birth
LACERATION – is an uncontrolled tear of the
tissues that results in a jagged wound
 Both are treated similarly
 Perineal lacerations and often episiotomies
are described be the amount of tissue
involved
-First degree – involves the superficial
vaginal mucosa or perineal skin
-Second degree – involves the vaginal
mucosa, perineal skin and deeper tissues of the
perineum
-Third degree – same as second degree
plus involves the anal sphincter
-Fourth degree – extends through the anal
sphincter into the rectal mucosa

 Woman with third and fourth degree
lacerations may have more discomfort
postpartum if they are constipated after
birth
 A high- fiber diet and adequate fluids help
to prevent constipation that might result in
breakdown of the perineal area where the
laceration was sutured
 Cold packs should be applied to the
perineum for atleast the first 12 hours
( leave in place at 20 mins intervals ) o
reduce pain, swelling and bruising
 After 12-24 hours of cold application,
warmth in the form of heat packs, peri
light ( 20 minutes, 3 to 4 times per day ) or
sitz bath increase blood circulation,
enhancing comfort and healing
 Mild oral analgesics are usually sufficient
for pain management
-Extreme pain may indicate hematoma or
abscess formation
 Teach importance of perineal cleansing
-Front to back direction
-Change perineal pad after each
elimination

FORCEPS & VACUUM EXTRACTIONS BIRTHS

-Used to provide traction and rotation to the
fetal head when the mother’s pushing efforts
 Routine episiotomy has been challenged are insufficient to accomplish a safe delivery.
by several recent studies that do not
support many of it’s supposed benefits
 Perineal massage and stretching exercises
before labor are becoming popular
techniques to decrease the need for
episiotomy during birth

Indications:
 Better control over where and how much
the vaginal opening is enlarged
 An opening with a clean edge rather than
the ragged opening of a tear
Risks:
 Infection is the primary risks
 Extention of the episiotomy with a
Indications:
laceration into or through the rectal
 A woman is unable to push with
sphincter
contractions in the pelvic division of labor
Technique:
such as might happen with a woman who
Episiotomy is performed with a blunt-tipped
receives regional anesthesia or has a spinal
scissors just before birth
cord injury.
One of the following two directions is chosen:
 Cessation of descent in the second stage of
 Median ( midline ) – extending directly
labor occurs.
from the lower vaginal border toward the
 A fetus is in abnormal position or is
anus
immature.
-Is easier to repair and heals neatly
 A fetus is in distress from a complications
 Mediolateral – extending from the lower
such as a prolapsed cord.
vaginal border toward the mother’s right
or left
-Provides more room, but greater scarring
CONTRAINDICATIONS:
during healing may cause painful sexual
 Cannot substitute for Cesarean birth if the
intercourse.
maternal or fetal condition requires a
quicker delivery.
Nursing Care:
 Not done if they would be more traumatic
 Assess for bleeding, swelling, redness, or
that cesarean birth, such as the fetus is
any discharges
 too high in the pelvis or too large for a
vaginal delivery.
RISKS
 Trauma to maternal or fetal tissues is the
main risk
-Mother may have laceration or hematoma
in the vagina
-Infant may have bruising, facial or scalp
lacerations or abrasions, cephal
hematoma, -or intracranial hemorrhage
-Chignon – circular edema on the
infant’sscalp where vacuum extractor is applied
TYPES:
 Low or outlet forceps
-Fetal head has reached the perineal floor
 Mid-forceps
-Head is at or below the level of the ischial spine
 Piper forceps
-Used in breech deliveries
Techniques:
 The health care provider catheterizes the
woman to prevent trauma to her bladder
and to make room in her pelvis.
 Forceps delivery
-Forceps are applied then the physician
pulls in line with the pelvic curve
-An episiotomy is usually done
-After the fetal head is brought under the
mother’s symphisis, the rest of the birth
occurs in the usual way
 Vacuum extractor
-Follows a similar sequence as forceps
delivery
-The physician applies the cup over the
posterior fontanelle of the fetal occiput
Nursing Care:
 Provide physician with the type of forceps
or extractor required and place it on the
sterile instrument table
 Monitor FHT
 Explain procedure to couple and provide
emotional support
 After birth, care is similar to that for
episiotomy
 Infant’s head is examined for lacerations,
abrasions, or bruising
 Mild facial reddening and molding of the
head are common and require no
treatment
 Cold application is not used on neonates
because they would cause hypothermia
 Pressures from forceps may injure the
infants facial nerve as evident by facial
assymetry ( different appearance of right
and left sides ) which is most obvious
when the infants cries
CESAREAN BIRTH
-Surgical delivery of the fetus through incisions
in the mother’s abdomen and uterus

INDICATION:
MATERNAL:
 Uterine dystocia ( difficulty giving birth )
 Preexisting maternal diseases – heart
disease, diabetes, genital herpes,
gonorrhea
 Severe pre eclampsia and eclampsia
 Previous cesarean birth of surgery in the
uterus
 Tumors of the uterus
 Post term pregnancy
 Placenta previa and abruption placental
FETAL
 Fetal distress
 Prolapsed umbilical cord
 Fetal abnormalities e.g ( hydrocephalus )
CONTRAINDICATIONS:
 Fetus is dead or too premature to survive
 Mother has abnormal blood clothing
TYPES OF INCISION:
SKIN INCISION
 Done in either a vertical or a transverse
direction
 A vertical incision allows more room if a
large fetus is being delivered, and it is
usually needed for an obese woman
 In an emergency situation, the vertical
incision can be done more quickly
 The transverse, or Pfannensteil, incision is
nearly invisible when healed but cannot
always be used in obese women or in
women with large uterus
UTERINE INCISION
 LOW-SEGMENT TRANSVERSE INCISION
-Preferred and most common method
-Decreased blood loss; less chance of
uterine rupture with subsequent
pregnancy as incision is made into lower
uterine segment
-VBAC is possible
-It may not be an option if the fetus is
large or if there is a placental previa in the
area where the incision would be made
-Fewer complications – peritonitis and
postoperative adhesions
 LOW- SEGMENT VERTICAL INCISION
-Produces minimal blood loss and allows
delivery of a large fetus
-It is more likely to rupture during another
birth, although less so than the classic
Incision
 CLASSIC INCISION
-Involves more blood loss
-Most likely of the three types to rupture
during another pregnancy
-May be the only choice if the fetus is in
transverse lie or if there is scarring or a
placental previa on the lower anterior uterus
NURSING CARE:
 Preoperative care is similar to
any abdominal surgery
 Includes both normal
abdominal postoperative care
and postpartum care.