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ANTEPARTUM Venice Joy Toledo - Malonzo, RN
Maternal and Child Health Nursing
involves care of the woman and family throughout pregnancy and child birth and the health promotion and illness care for the children and families.
Primary Goal of MCN
The promotion and maintenance of optimal family health to ensure cycles of optimal childbearing and child rearing
ANATOMY AND PHYSIOLOGY OF FEMAL REPRODUCTIVE ORGANS
Mons Pubis - pad of adipose tissue which
lies over the symphysis pubis covered by skin and at puberty, by short hairs; protecting the surrounding delicate tissue.
Labia Majora -two folds of skin with fat
underneath; contain Bartholin’s gland.
Labia Minora -two thin folds of delicate
tissues; form an upper fold encircling clitoris called the prepuce; and unite posteriorly called the fourchette.
Clitoris - small, erectile structure at
the anterior junction of the labia minora
Vestibule – narrow space seen when
the labia minora are separated.
Urethral meatus – external opening of
the urethra; slightly behind and to side are the opening of skene’s gland
Vaginal orifice– external opening of
the vagina, covered by a thin membrane called hymen.
Perineum – area from the lower
border of the vaginal orifice to the anus
UTERUS A hollow pear shaped muscular organ Serves various function
1. 2. 3.
To receive ovum from fallopian tube To provide a place for the ovum implant To offer nourishment & protection to the growing fetus To expel the fetus from the mother’s body when mature
It has 3 layers endometrium,
a 3-4 inches long dilatable canal
located between the bladder and the rectum. it contains rugae which permit considerable stretching without tearing passageway for menstrual discharges, copulation and fetus.
dull white sex glands near the fimbrae, kept in place by ligaments. Produce mature and expel ova and manufacture estrogen and progesterone.
FALLOPIAN TUBES 4 inches long from each side of the fundus, widest part (called the ampula) spreads into fingerlike projections (called fimbrae). Responsible for transport of mature ovum to the uterus.
Pelvis - support and protect the reproductive
Types/ Variation of Pelvis
Gynecoid – normal female pelvis. Inlet is
well rounded forward and back. Most ideal for child birth. Anthropoid – transverse diameter is narrow, AP diameter is larger than normal. Platypelloid – inlet is oval, AP diameter is shallow Android – “male pelvis”. Inlet has a narrow, shallow posterior portion and pointed anterior portion.
Division of the Pelvis
Part above the pelvic brim Serves to support the weight of the enlarged pregnant uterus Directs the presenting fetal part into the true pelvis Pelvic cavity: Curved canal with a longer posterior than anterior wall Outlet: Pelvic outlet is at the lower border of the true pelvis
Inlet: upper border of pelvis
FIGURE 3–12 Female pelvis. A, The false pelvis is a shallow cavity above the inlet; the true pelvis is a deeper portion of the cavity below the inlet.
conjugate Measure at least 11.5 cm
Obstetric conjugate - 10 cm or
FIGURE 10–5 Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.
Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior 20 measurements.
FIGURE 10–5 (continued)
FIGURE 10–5 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.
diameter Should be 9.5 to 11.3 cm Transverse diameter should be 8 to 10 cm
FIGURE 10–6 Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal knuckles. If they do not, they can use a measuring device.
Consist of glandular,
fibrous, and adipose tissue. Grow & Develop from stimulation of secretion from the hypothalamus, anterior pituitary and ovaries. Provide nourishment to the infant and transfer maternal antibodies during breast feeding
Female Reproductive Cycle
To bring an ovum to maturity and renew the uterine tissue bed that will be responsive to its growth once it’s fertilized Menarche First menstruation May occur early as age of 7 or late as age 17
The menstrual cycle
Varies from woman to woman
average length of cycle is 28 days from the beginning of one menstrual flow to the beginning of next. aveverage length of the menses is 2 to 7 days
Initiated by the release of LUTEINIZING
HORMONE – RELEASING HORMONE, also known as gonadotropin – releasing hormone from the hypothalamus Under the influence of LHRH, the anterior lobe of pituitary produces two hormone: a. Follicle stimulating hormone b. Luteinizing hormone
Characteristics of Normal Menstruation Period
1. Menarche – average onset 12 -13 years 2. Interval between cycles – average 28 days 3. Cycles 23 – 35 days 4. Duration – average 2 – 7 days; range 1 – 9 days 5. Amount – average 30 – 80 ml ; heavy bleeding saturates pad in <1hour 6. Color – dark red; with blood; mucus; and endometrial cells
Phases of menstrual cycle
Menstrual phase (days 1-5)
Estrogen and progesterone level
decrease FSH levels rise, and steady levels of LH influence the ovary to secrete estrogen Menstrual flow begins
Proliferative (follicular) phase (6-13 days)
Estrogen production increases, leading
to proliferation of endometrium and myometrium in preparation for possible implantation of ovum Follicle secrete estradiol FSH stimulates graafian follicle FSH production decreases before ovulation (around day 14)
Secretory (Luteal) (days 14-25)
The corpus luteum forms under the
influence of LH Estrogen and progesterone production increases The endometrium id prepared for implantation of fertilized ovum
Ischemic (days 26-28)
The corpus luteum degenerates if
conception doesn’t occur Estrogen and progesterone levels decline if conception doesn’t occur
1. Amenorrhea - temporary cessation of menstrual flow 2. Oligomenorrhea - markedly diminished menstrual flow 3. Menorrhagia - excessive bleeding during regular menstruation 4. Metrorrhagia - bleeding at completely irregular intervals 5. Polymenorrhea - frequent menstruation occurring at intervals of less than 3 weeks
BEGINNING OF PREGNANCY
Process of Conception
1. Union of the ovum and spermatozoon 2. Other terms: conception, impregnation or fecundation 3. Normal amount of semen/ejaculation= 3-5 cc = 1 tsp. 4. Number of sperms: 120-150 million/cc/ejaculation 5. Mature ovum may be fertilized for 12 –24 hrs after ovulation 6. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation (lifespan of sperms 72 hrs)
FIGURE Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a sperm are depicted moving from top to bottom. B, Scanning electron micrograph of a human sperm surrounding a human ovum (750×). The smaller spherical cells are granulosa cells of the corona radiata. Scanning electron micrograph used with38 permission from Nisson, L. (1990). A child is born. New York: Dell publishing.
FIGURE 7–2 (continued) Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a sperm are depicted moving from top to bottom. B, Scanning electron micrograph of a human sperm surrounding a human ovum (750×). The smaller spherical cells are granulosa cells of the corona radiata. Scanning electron micrograph used with permission from Nisson, L. (1990). A child is born. New York: Dell publishing.(Photo 39 Lennart Nilsson/Albert Bönniers Folag AB)
Once implantation has taken place, the uterine endometrium is now termed deciduas Occasionally, a small amount of vaginal bleeding occurs with implantation due to breakage of capillaries Immediately after fertilization, the fertilized ovum or zygote stays in the fallopian tube for 3 days, during which time rapid cell division (mitosis) is taking place. The developing cells now called blastomere and when about to have 16 blastomere called morula.
Morula travels to uterus for another 3 – 4
days When there is already a cavity in the morula called blastocyt finger like projections called trophoblast form around the blastocyst, which implant on the uterus Implantation is also called nidation, takes place about a week after fertlization
FIGURE During ovulation the ovum leaves the ovary and enters the fallopian tube. Fertilization generally occurs in the outer third of the fallopian tube. Subsequent changes in the fertilized ovum from conception to implantation 42 are depicted.
In placentation, the chronic villi invade
the decidua This becomes the fetal portion of the future placenta
Stages of Fetal Development
Preembryonic period Begins with fertilization and lasts about 3 weeks As the zygote passes through the fallopian tube, it undergoes a series of mitotic division, or cleavage Once formed, the zygote develops into morula and then blastocyst, eventually attached to the endometrium.
Embryonic Period Begins with the 4th week of gestation and ends with the 7th week The zygote now called an embryo, begins to take on a human shape Germ layers develop, giving rise to organ system The embryo is highly vulnerable to injury from maternal drug use, certain maternal infections, other factors
Fetal Period Begins with 8th week of gestation and continues until birth During this period, the embryo now called fetus, matures, enlarges, and grows heavier. The head of the fetus is disproportionately larger than its body. The fetus also lacks subcutaneous fat
Embryonic & Fetal Structures
Decidua Refers to endometrial lining during pregnancy Provides a nesting place for the developing ovum
Fetal membranes The chorion is the fetal membrane closest to the uterine wall: - It gives rise to placenta - It forms the outer wall of blastocyst - Vascular projections, called chronic villi, arise from its periphery
Amnion is the thin, though inner fetal
membrane that lines amniotic sac, gives rise to umbilical cord supported by Wharton’s jelly
Embryonic germ layers
Three layers develop during the embryonic period Ectoderm – outermost layer Mesoderm – middle layer Endoderm – inner most layer; differentiation of endoderm results in formation of epithelium lining respiratory and digestive tracts
FIGURE Endoderm differentiates to form the epithelial lining of the digestive and respiratory tracts and associated glands.
Amniotic sac Gradually increases in size and surrounds the embryo Contains fluid, called amniotic fluid Purpose 1. Protection – shield against pressure and temperature changes 2. Can be used to diagnose congenital abnormalities intrauterine– amniocentesis 3. Aid in the descent of fetus during active labor
Umbilical cord Serves as the lifeline from the embryo to the placenta Measures from 30.5 – 90 cm in length & 2 cm in diameter at full term Contains AVA (2 artery 1 vein) artery – carries blood from fetus to placenta vein – returns blood to the fetus from the placenta Contains wharton’s jelly, jellatenous substance that helps prevent kinking of the cord in utero Blood flows through the cord at about 400ml/min
Placenta A flat disk shaped structure formed from the chorion, chronic villi, and adjacent decidua basalis Contains 15-20 subdivison called cotyledons It supplies fetus with carbohydrates, water, fats, protein, minerals & inorganic salts It transfer passive immunity via maternal antibodies
Consists of deciduas basalis and its circulation Surface appears red and flesh-like
Consists of the chorionic villi and their circulation The fetal surface of the placenta is covered by the amnion Appears shiny and gray
FIGURE Maternal side of placenta (Dirty Duncan).
FIGURE 7 Fetal side of placenta (Shiny Shultz).
FETAL GROWTH & DEVELOPMENT
Fetus Growth & Development
4 weeks: 4–6 mm, brain formed from
anterior neural tube, limb buds seen, heart beats, GI system begins
6 weeks: 12 mm, primitive skeletal
shape, chambers in heart, respiratory system begins, ear formation begins
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
FIGURE The fetus at 20 weeks weighs 435 to 465 g and measures about 19 cm. Subcutaneous deposits of brown fat make the skin a little less transparent. “Woolly” hair covers the head, and nails have developed on the fingers and toes. Use with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing. (Photo Lennart Nilsson/Albert Bönniers Folag AB)
20 weeks: 19 cm, myelination of spinal cord
begins, suck and swallow begins, lanugo covers body, vernix begins to protect the body 24 weeks: 23 cm, respiration and surfactant production begins, brain appears mature 28 weeks: 27 cm, nervous system begins regulation of some functions, adipose tissue accumulates; nails, eyebrows, and eyelids are present; eyes are open 36 weeks: 35 cm, earlobes soft with little cartilage, few sole creases
40 weeks : 40 cm, adequate surfactant,
vernix in skin folds and lanugo on shoulders, earlobes firm, sex apparent
Weight about 3,000 to 3,600 g (6 lb., 10 oz. to 7 lb., 15 oz.) Varies in different ethnic groups Skin has a smooth, polished look Hair on head is coarse and about 1 inch long Body and extremities are plump
Focus of Fetal Development
First Trimester – period of organogenesis Second Trimester – period of continued fetal
growth and development; rapid increase inlength Third Trimester – period of most rapid growth and development because of the deposition of subcutaneous fat
FIGURE 7 The actual size of a human conceptus from fertilization to the early fetal stage. The embryonic stage 64 begins in the third week after fertilization; the fetal stage begins in the ninth week.
Fetal Development: What Parents Want to Know
Fetal Blood Circulation
The fetus is connected by the umbilical cord to the placenta, the organ that develops and implants in the mother's uterus during pregnancy. Through the blood vessels in the umbilical cord, the fetus receives all the necessary nutrition, oxygen, and life support from the mother through the placenta. Waste products and carbon dioxide from the fetus are sent back through the umbilical cord and placenta to the mother's circulation to be eliminated.
Placenta ▼▼▼ Umbilical vein (composed of two arteries and one vein – AVA) ▼▼▼ Liver ▼▼▼ Ductus Venosus (First Shunt)
▼▼▼ Inferior Vena Cava ▼▼▼ Right Atrium ▼▼▼ Foramen Ovale (Second Shunt) ▼▼▼ Left Atrium ▼▼▼ Left Ventricle
▼▼▼ Aorta ▼▼▼ ▼▼▼ To upper half of the fetal body only Upper Extreme Brain Heart Pulmonary Upper part of the GUT
▼▼▼ ▼▼▼ Then this blood is recollected ▼▼▼ with less oxygen and then it ▼▼▼ goes to the ▼▼▼ Superior Vena Cava
▼▼▼ Right Atrium ▼▼▼ Right Ventricle ▼▼▼ Pulmonary Artery (but lungs are collapsed; Surfactant inadequate and amniotic fluid is present) ▼▼▼ Ductus Arteriosus
▼▼▼ Descending Aorta ▼▼▼ Supply the lower half of the fetal body ▼▼▼ ▼▼▼ Blood is recollected ▼▼▼ Hypogastric Artery ▼▼▼ Umbilical Artery ▼▼▼ Placenta
SHUNTS When the baby is delivered, the shunts are normally removed
Venosus Foramen ovale
Two (2) types of Closure Functional Closure Anatomic Closure
FORAMEN OVALE Closed functionally immediately after birth or IMMEDIATELY AFTER CORD IS CLAMPED Anatomically, it can persist up to one (1) year after delivery
in auscultation in twenty-eight (28) day
There is a MURMUR This is Normal This is NOT A PATHOLOGIC MURMUR It is a SYSTEMIC / INNOCENT MURMUR
PHYSIOLOGIC MURMUR IN NEONATES
DUCTUS ARTERIOSUS Functional Closure
to ninety-six hours (10 – 96 hrs) after birth or approximately four (4) days to three months (2 – 3 mos.)
Normal Adaptation to Pregnancy
1. Cardiovascular/ Circulatory changes
a. Physiologic anemia of pregnancy 30-50% gradual increase in total cardiac
volume (peak 6th month) causing drop in Hemoglobin and Hematocrit values (inc only in plasma volume)
Consequences of increased cardiac volume:
1. easy fatigability & shortness of breath due increase cardiac workload 2. slight hypertrophy of the heart 3. systolic murmurs due to lowered blood viscosity 4. nosebleeds may occur due to congestion of nasopharynx
b. Palpitations caused by the SNS stimulation during early part of pregnancy; increased pressure of the uterus against the diaphragm during the second half of pregnancy c Edema of the lower extremities & varicosities due to poor circulation caused by the pressure of the gravid uterus on the blood vessels of the lower extremities
d. Vaginal and rectal varicosities due to pressure on blood vessels of the genitalia e. Predisposition to blood clot formation due to increased level of circulating fibrinogen as a protection from bleeding implication: no massage
2. Gastrointestinal Changes
a. Morning sickness
nausea and vomiting in the 1st
trimester due to HCG or due to increased acidity or emotional factors b. Hyperemesis gravidarum excessive nausea & vomiting which persists beyond 3 months causing dehydration, starvation and acidosis
c. Constipation and Flatulence GI displacement slows peristalsis & gastric emptying time; inc progesterone
d. Hemorrhoids due pressure of enlarged uterus
e. Heartburn due to increased progesterone and decreased gastric motility causing regurgitation through gastric sphincter
3. Respiratory Changes
a. Shortness of Breath due to inc. oxygen consumption and production of carbon dioxide during the 1st Trimester; and increased uterine size pushing the diaphragm crowding chest cavity
4. Urinary Changes
a. Urinary frequency felt during the 1st trimester due to the increase blood supply to the kidneys and then on the 3rd trimester due to pressure on the bladder. b. Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine; and inc. progesterone
5. Musculoskeletal changes
a. Pride of Pregnancy due to need to change center of gravity result to lordotic position b. Waddling gait due to increased production of hormone relaxin, pelvic bones becomes more movable increasing incidence of falls c. Leg cramps due to pressure of gravid uterus, fatigue, muscle tenseness, low calcium and phosphorus intake
d. Increased size and activity of adrenal cortex increasing circulating cortisol, aldosterone, and ADH which affect CHO and fat metabolism causing hyperglycemia. e. Gradual increase in insulin production but there is decreased sensitivity to insulin during pregnancy
6. Endocrine Changes
a. Addition of the placenta as an endocrine organ producing HCG, HPL, estrogen and progesterone b. Moderate enlargement of the thyroid due to increased basal metabolic rate c. Increased size of the parathyroid to meet need of fetus for calcium
7. Weight Change
a. First Trimester 1.5 to 3 lbs normal weight gain b. 2nd and 3rd trimester 10 – 11 lbs per trimester is recommended c. Total allowable weight gain during throughout pregnance is 20 – 25 lbs or 10 –12 kgs. d. Pattern of weight gain is more important than the amount of weight gained.
8. Emotional responses
a. 1st trimester: some degree of rejection, disbelief, even depression because of its future implication -> give health teachings on body changes and allow for expression of feelings b. 2nd trimester: fetus is perceived as a separate entity and fantasizes appearance c. 3rd trimester: best time to talk about layette, and infant feeding method. To allay fear of death let woman listen to the FHT.
COMMON EMOTIONAL RESPONSES DURING PREGNANCY
Stress –decrease in responsibility
taking is the reaction to the stress of pregnancy not the pregnancy itself affects decision making abilities
Couvade – syndrome – men
experiencing nausea/vomiting, backache due to stress, anxiety and empathy for partner
Emotional labile – mood
changes/swings occur frequently due to hormonal changes
Change in Sexual Desire – may
increase or decrease needs correct interpretation… not as a loss of interest in sexual partner
Appropriate Relief Measures
Increase fluid intake during day Decrease fluid intake in the evening
Fatigue: Plan rest periods and ask for help
from family or support persons Breast tenderness: Wear well supporting bra
Common Obstetric Terminology (cont’d)
Nullipara: Woman who has had no births at
more than 20 weeks’ gestation Primipara: Woman who has had one birth at more than 20 weeks’ gestation Multipara: Woman who has had two or more births at more than 20 weeks’ gestation Stillbirth: Infant born dead after 20 weeks’ gestation Multigravida: Woman in second or any subsequent pregnancy
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