Chapter 1 MCN

The care of childbearing and childrearing families is a major focus of nursing

practice, because to have healthy adults you must have healthy children. To have
healthy children, it is important to promote the health of the childbearing woman
and her family from the time before children are born until they reach adulthood.
Both preconceptual and prenatal care are essential contributions to the health of a
woman and fetus and to a familys emotional preparation for childbearing and
childrearing. As children grow, families need continued health supervision and
support. As children reach maturity and plan for their families, a new cycle begins
and new support becomes necessary. The nurses role in all these phases focuses
on promoting healthy growth and development of the child and family in health and
in illness. Although the field of nursing typically divides its concerns for families
during childbearing and childrearing into two separate entities, maternity care and
child health care, the full scope of nursing practice in this area is not two separate
entities, but one: maternal and child health nursing

GOALS AND PHILOSOPHIES OF MATERNAL AND CHILD HEALTH NURSING

The primary goal of maternal and child health nursing care can be stated
simply as the promotion and maintenance of optimal family health to ensure cycles
of optimal childbearing and childrearing. Major philosophical assumptions about
maternal and child health.

The goals of maternal and child health nursing care are necessarily broad because
the scope of practice is so broad. The range of practice includes

Preconceptual health care

Care of women during three trimesters of pregnancy and the puerperium (the 6
weeks after childbirth, sometimes termed the fourth trimester of pregnancy

) Care of children during the perinatal period (6 weeks before conception to 6

weeks after birth)

Care of children from birth through adolescence

Care in settings as varied as the birthing room, the pediatric intensive care unit,
and the home child health nursing is always family-centered; the family is
considered the primary unit of care. The level of family functioning affects the
health status of individuals, because if the familys level of functioning is low, the
emotional, physical, and social health and potential of individuals in that family can
be adversely affected. A healthy family, on the other hand, establishes an
environment conducive to growth and health-promoting behaviors that sustain
family members during crises. Similarly, the health of an individual and his or her
ability to function strongly influences the health of family members and overall
family functioning. For these reasons, a family-centered approach enables nurses to
better understand individuals and, in turn, to provide holistic care.

Philosophy of Maternal and Child Health Nursing

Maternal and child health nursing is familycentered; assessment data must

include a family and individual assessment. Maternal and child health nursing is
communitycentered; the health of families depends on and influences the health of
communities.

Maternal and child health nursing is researchoriented, because research is the

means whereby critical knowledge increases.

Both nursing theory and evidence-based practice provide a foundation for nursing
care.

A maternal and child health nurse serves as an advocate to protect the rights of
all family members, including the fetus.

Maternal and child health nursing includes a high degree of independent nursing
functions, because teaching and counseling are so frequently required.

Promoting health is an important nursing role, because this protects the health of
the next generation. Pregnancy or childhood illness can be stressful and can alter
family life in both subtle and extensive ways.

Personal, cultural, and religious attitudes and beliefs influence the meaning of
illness and its impact on the family. Circumstances such as illness or pregnancy are
meaningful only in the context of a total life.

Maternal and child health nursing is a challenging role for a nurse and is a major
factor in promoting high-level wellness in families.

Common Measures to Ensure Family-Centered Maternal and Child Health Care

Principle

The family is the basic unit of society.

Families represent racial, ethnic, cultural, and socioeconomic diversity.

Children grow both individually and as part of a family. Nursing Interventions

Consider the family as a whole as well as its individual members.

 Encourage families to reach out to their community so that family members are
not isolated from their community or from each other.

Encourage family bonding through rooming-in in both maternal and child health
hospital settings.

Participate in early hospital discharge programs to reunite families as soon as

possible. Encourage family and sibling visits in the hospital to promote family
contacts.

Assess families for strengths as well as specific needs or challenges.

Respect diversity in families as a unique quality of that family.

Encourage families to give care to a newborn or ill child. Include developmental

stimulation in nursing care.

Share or initiate information on health planning with family members so that care
is familyoriented.

A FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING CARE

Maternal and child health nursing can be visualized within a framework in

which nurses, using nursing process, nursing theory, and evidence-based practice,
care for families during childbearing and childrearing years through four phases of
health care:

Health promotion

Health maintenance

Health restoration

Health rehabilitation

MATERNAL AND CHILD HEALTH NURSING TODAY At the beginning of the 20th
century, the infant mortality rate in the United States (i.e., the number of infants
per 1,000 births who die during the first year of life) was greater than 100 per
1,000. In response to efforts to lower this rate, health care shifted from a treatment
focus to a preventive one, dramatically changing the scope of maternal and child
health nursing. Research on the benefits of early prenatal care led to the first major
national effort to provide prenatal care to all pregnant women through prenatal
nursing services (home visits) and clinics. Today, thanks to these and other
community health measures (such as efforts to encourage breast-feeding, increased
immunization, and injury prevention), as well as many technological advances, the
U.S. infant mortality rate has fallen to 6.9 per 1,000 (National Center for Health
Statistics [NCHS], 2005). Medical technology has contributed to a number of
important advances in maternal and child health: childhood diseases such as
measles and poliomyelitis are almost eradicated through immunization; specific
genes responsible for many inherited diseases have been identified; stem cell
therapy may make it possible in the next few years to replace diseased cells with
new growth cells; new fertility drugs and techniques allow more couples than ever
before to conceive; and the ability to delay preterm birth and improve life for
premature infants has grown dramatically. In addition, a growing trend toward
health care consumerism, or self-care, has made many childbearing and
childrearing families active participants in their own health monitoring and care.
Health care consumerism has also moved care from hospitals to community sites
and from long-term hospital stays to overnight surgical and ambulatory settings.
Even in light of these changes, much more still needs to be done. National health
care goals established in 2000 for the year 2010 continue to stress the importance
of maternal and child health to overall community health (Department of Health and
Human Services [DHHS], 2000). Although health care may be more advanced, it is
still not accessible to everyone. These and other social changes and trends have
expanded the roles of nurses in maternal and child health care and, at the same
time, have made the delivery of quality maternal and child health nursing care a
continuing challenge.

FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY I. The External Reproductive

Organ (Figure 1)

a.

Mons Pubis or Veneris

pad of fats which lies over the symphysis pubis covered by skin and at puberty, by
short hairs, protects the surrounding delicate tissues from trauma. b.

Labia Majora

 Two folds of skin with fat underneath: contain Bartholin glands (believed to secrete
a yellowish mucus which acts as a lubricant during sexual intercourse). The
openings of

the Bartholins glands are located posteriorly on either s

ide of the two vaginal orifice. c.

Labia Minora

two thin folds of delicate tissues: for an upper fold encircling the clitoris (called
forchette, which is highly sensitive to manipulation and trauma that is why it is
often torn during

womens delivery).

d.

Glans Clitoris

small, erectile structure at the anterior junction of the labia minora, which is
comparable to the penis in its being extremely sensitive. e.

Vestibule

narrow space seen when the labia minora are separated. f.

Urethral Meatus

external opening of the urethra: slightly behind and to the side are the openings of
the Skene glands (which are often involved in infections of the external genitalia). g.

Vaginal orifice/Introitus


External opening of the vagina, covered by a thin membrane (called hymen) in

virgins. h.

Perineus

area from the lower border of the vaginal orifice to the anus; contains the muscles
(e.g., pubococcygels and levator ani) which support the pelvic organs, the arteries
that supply blood and the pudendal nerves which are important during delivery
under anesthesia.

II. The Internal Reproductive Organs (Figure 2) a. Vagina

a 3-4 inch long dilatable canal located between the bladder and the rectum;
contains rogue, (which permit considerable stretching without tearing): passageway
for menstrual discharges, copulation and fetus.

b. Uterus

hollow pear-shaped fibromuscular organ. 3 inches long, 2 inches wide, 1 inch thick,
and weighing 50

60 grams in a non-pregnant woman held in place by broad ligaments from sides of

the uterus to pelvic walls; also hold Fallopian tubes and ovaries in place) and round
ligaments (from sides of uterus to mons pubis); abundant blood supply from uterine
and ovarian arteries; composed of 3 muscle layers (perimetrium, ayometrium, and
endometrium). Consists of three parts: corpus (body)

upper portion with triangular part called fundus; isthmus

area between corpus and cervix which forms part of the lower uterine segment;
and cervix

 lower cylindrical portion. (1) Organ of menstruation, (2) site of implantation and (3)
retainment and nourishment of the products of conception.

c. Fallopian Tubes

4 inches long from side of the fundus; widest part (called empala) spreads into
fingerlike projections (called pimbrige). Responsible for transport of mature ovum
from ovary to uterus; fertilization takes place in its outer third or outer half.

d. Ovaries

almond-shaped, dull white sex glands near the fimbriae, kept in place by ligaments.
Produce, mature and expel ova and manufacture estrogen and progesterone.

III. The Pelvis (Figure 3)

although not a part of the female reproductive organs but of the skeletal system. Is
the very important body part of pregnant woman. A. Structure 1.

Os Coxae/Innominate

bones

made up of a.

Ilium

upper, extended part; curved upper border is the Illiac crest.

b. Ischium

 under part; when sitting, the body rests on the ischial tuberositis: ischial spines are
important landmarks.

c. Pubis

front part; join to form an articulation of the pelvis called the symphysis pubis.

2. Sacrum

wedge-shaped, forms at the back part of the pelvis. Consists of 5 fuse vertebrae,
the first having a prominent upper margin called the sacral promontory. Articulates
the ilium, the sacroiliac joint.

3. Coccyx

lowest part of the spine; degree of movement between sacrum and coccyx, made
possible by the third articulation of the pelvis called

sacroccygeal joint

which allows room for delivery of the fetal head. B.

Divisions

set apart by the linea terminalis, an imaginary line from the sacral promontory to
the iliac on both sides to the superior portion of the symphysis pubis.

1. False pelvis

superior half-formed by the iliac. Offers landmarks for pelvic measurements;

supports the growing uterus during pregnancy; and directs the fetus into the true
pelvis near the end of gestation.
2. True pelvis

inferior half formed by the pubis in front, the iliac and the ischium on the sides, and
the sacrum and coccyx behind. Made up of three parts:

a. inlet

entranceway to the true pelvis. Its transverse diameter id wider than its

anteroposterior diameter. Transverse diameter

13.5 cm Anteroposterior diameter

11 cm Right and left oblique diameter

12.75 cm.

b. Cavity

space between the inlet and outlet

c. Types/variations

1.

Gynecoid

normal female pelvis. Inlet is well rounded forward and

back. Most ideal for childbirth. 2.

Anthropoid

transverse diameter is narrow, AP diameter is larger than normal. 3.

Platypelloid

inlet is oval, AP diameter is shallow. 4.

Android

male pelvis. Inlet has a narrow, shallow posterior portion and

pointed anterior portion.

d. Measurements 1. External

suggestive only of pelvic size.

a. Intercristal

distance between the middle points of the iliac crests. Average

28 cm.

b. Interspincus

distance between the anterosuperior iliac spines. Average

25 cm.

c. Intertrochanteric

distance between the trochanters of the femus. Average

31 cm.

d.

External conjugate/baudelocques

the distance between the anterior aspect of the symphysis pubis and depression
below Ls. Average

18-20 cm.

2. Internal

give the actual diameter of the inlet and outlet.

a. Diagonal conjugate

distance between sacral promontory and inferior margin of the symphysis pubis.
Average

12.5 cm.

b. True conjugate/conjugata vera

distance between the anterior surface of the sacral promontory and the superior
margin of the symphysis pubis. Very important measurement because it is the
diameter of the pelvic inlet. Average

10.5-11 cm.

c. Bi-schial diameter/tuberishii

transverse diameter of the pelvic outlet. Is measured at the level of the anus.
Average

11 cm.

IV. Mechanism of Menstruation A. General Considerations

1. 300,000

4000,000 immature cocytes per ovary are present at birth (where formed during
the first 5 months of intrauterine life), many, however, degenerate and atrophy
(process called atresia). About 300

400 mature during the entire reproductive cycle of women. 2. Ushered in by

Menarche, (first menstruation in girls) and ends with menopause (permanent
cessation of menstruation; no more functioning cocytes in the ovaries). Age of onset
and termination varies widely, depending on heredity, racial background, nutrition
and climate. 3. Normal period (days when there is menstrual flow) last for 3

6 days; menstrual cycle from first day of menstrual period to the first day next
menstrual period. Average menstrual cycle

24-36 days to 28 days acceptable. 4. An ovulatory states after menarche not

unusual because of immaturity of feedback mechanism. a. Pregnancy b. Lactation

c.

Related disease conditions

5. Associated terms:

a. Amenorrhea

temporary cessation of menstrual flow.

b.Oligomenorrhea

markedly diminished menstrual flow, nearing amenorrhea.

c.Menorrhagia

excessive bleeding during regular menstruation.

d.Metrorrhagia

bleeding at completely irregular intervals.

e.Polymenorrhea

frequent menstruation occurring at intervals of less than 3 weeks.

6. Body structures involved: a. Hypothalamus b. Anterior pituitary gland c. Ovary d.

Uterus 7. Hormones which regulates cyclic activities: a. Follicle

Stimulating Hormone (FSH) b. Luteinizing Hormone 8. Effects of estrogen in the

body a. Inhibits production of FSH b. Causes hypertrophy of the myometrium c.
Stimulates growth of the ductile structures of the breasts. d. Increases quantity and
pH of cervical mucus, causing it to become thin and watery and can be stretched to
a distance of 10

13 cm. (Spinnbarkheit test of ovulation). 9. Effects of progesterone in the body: a.

Inhibits production of LH b. Increases endometrial tortuosity c. Increases
endometrial secretions d. Inhibits uterine motility e. Decreases muscle tone of
gastrointestinal and urinary tracts f. Increases musculoskeletal motility g. Facilitates
transport of the fertilized ovum through the fallopian tubes h. Decreases renal
threshold for lactose and dextrose i. Increases fibrinogen levels; decreases
hemoglobin and hematocrit j. Increases body temperature after ovulation. Just
before ovulation, basal body temperature decreases slightly (because of low of
progesterone level in the blood) and then increases slightly a day after ovulation
(because of the presence of progesterone).