MATERNAL AND CHILD HEALTH NURSING
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 & PHYSIOLOGY
Ovaries
o Almond shaped
o Produce, mature and discharge ova
o Initiate and regulate menstrual cycle
o 4 cm long, 2 cm in diameter, 1.5 cm thick
o Produce estrogen and progesterone
Estrogen: promotes breast dev’t & pubic hair
distribution prevents osteoporosis keeps
cholesterol levels reduced & so limits effects of
atherosclerosis
Fallopian tubes.
Approximately 10 cm in length
Conveys ova from ovaries to the uterus
Site of fertilization
Parts: interstitial
isthmus – cut/sealed in BTL
ampulla – site of fertilization
infundibulum – most distal segment; covered with
fimbria
Uterus -Hollow muscular pear shaped organ
-uterine wall layers: endometrium;
myometrium; perimetrium
-Organ of menstruation
-receives the ova
-Provide place for implantation & nourishment
during fetal growth
-Protects growing fetus
-Expels fetus at maturity
-Has 3 divisions: corpus – fundus , isthmus
(most commonly cut during CS delivery) and
cervix
Uterine Wall
-Endometrial layer: formed by 2 layers of cells
which are as follows:
basal layer- closest to the uterine wall
glandular layer – inner layer influenced by
estrogen and progesterone; thickens and
shed
off as menstrual flow
-Myometrium – composed of 3 interwoven layers
of smooth muscle; fibers are arranged in
longitudinal; transverse and oblique directions
giving it extreme strength
Vagina
-Acts as organ of copulation
-Conveys sperm to the cervix
-Expands to serve as birth canal
--Wall contains many folds or rugae making it
very elastic
Fornices – uterine end of the vagina; serve as a
place for pooling of semen following coitus
Bulbocavernosus – circular muscle act as a
voluntary sphincter at the external opening to the
vagina (target of Kegel’s exercise)
II. PUBERTAL DEVELOPMENT
Puberty: the stage of life at which secondary sex
changes begins the development and maturation
of reproductive organs which occurs in female 10-
13 years old & male at 12-14 yrs old the
hypothalamus serve as a gonad stat or regulation
mechanism set to “turn on” gonad functioning at
this age
Reproductive Development
Readiness for child bearing
-begins during intrauterine life
-full functioning initiated at puberty
-the hypothalamus releases the GRF which
triggers the APG to form and release FSH and LH.
(FSH & LH initiates production of androgen and
estrogen --->2°
Sexual characteristics
Role of Androgen
Androgenic hormones – are produced by the
testes, ovaries and adrenal cortex which is
responsible for: muscular development physical
growth inc. sebaceous gland secretions
Testosterone –primary androgenic hormone
Related terms
a. Adrenarche – the development of pubic and
axillary hair (due to androgen stimulation)
b. Thelarche – beginning of breast development
c. Menarche – first menstruation period in girls
(early 9 y.o. or late 17 y.o.)
d. Tanner Staging
-It is a rating system for pubertal development
-It is the biologic marker of maturity
-It is based on the orderly progressive
development of: breasts and pubic hair in
female’s genitalia and pubic hair in males
Body Structures Involved
1 Hypothalamus
2 Anterior Pituitary Gland
3 Ovary
4 Uterus
4. Menstrual Cycle
-Female reproductive cycle wherein periodic
uterine bleeding occurs in response to cyclic
hormonal changes
-Allows for conception and implantation of a new
life
-Its purpose it to bring an ovum to maturity;
renew a uterine bed that will be responsive to the
growth of a fertilized ovum
Menstrual Phases
• First: 4-5 days after the menstrual flow; the
endometrium is very thin, but begins to
proliferate rapidly; thickness increase by 8 folds
under the influence of increase in estrogenlevel
also known as: proliferative; estrogenic; follicular
and postmentrual phase
• Secondary: after ovulation the corpus luteum
produces progesterone which causes the
endometrium become twisted in appearance and
dilated; capillaries increase in amount (becomes
rich, velvety and spongy in appearance also
known as: secretory;progestational; luteal and
premenstrual
• Third: if no fertilization occurs; corpus luteum
regresses after 8 – 10 days causing decrease in
progesterone and estrogen level leading to
endometrial degeneration;
capillaries rupture; endometrium sloughs off ;
also known as: ischemic
• Final phase: end of the menstrual cycle; the
first day mark the beginning of a new cycle;
discharges contains blood from ruptured
capillaries, mucin from glands, fragments of
endometrial tissue and atrophied ovum.
Physiology of Menstruation
1. About day 14 an upsurge of LH occurs and the
graafian follicle ruptures and the ovum
is released
2. After release of ovum and fluid filled follicle
cells remain as an empty pit; FSH
decrease in Amount; LH increase continues to act
on follicle cells in ovary to produce
lutein which is high in progesterone ( yellow fluid)
thus the name corpus luteum or
yellow body
3. Corpus luteum persists for 16 – 20 weeks with
pregnancy but with no fertilization ovum
atropies in 4 – 5 days, corpus luteum remains for
8 -10 days regresses and replaced by white
fibrous tissue, corpus albicans
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
Associated Terms
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
Ovulation
1 Occurs approximately the 14th day before the
onset of next cycle (2 weeks before)
2 If cycle is 20 days – 14 days before the next
cycle is the 6th day, so ovulation is day 6
3 If cycle is 44 days – 14 days, ovulation is day
30.
4 Slight drop in BT (0.5 – 1.0 °F) just before day of
ovulation due to low progesterone
level then rises 1°F on the day following ovulation
(spinnbarkheit; mittelschmerz)
5 If fertilization occurs, ovum proceeds down the
fallopian tube and implants on the
endometrium
Menopause
o Mechanism- a transitional phase (period of 1 – 2
years) calledcl i macte ri c, heralds
the onset of menopause.
o Monthly menstrual period is less frequent,
irregular and with diminished amount.
o Period may be ovulatory or unovulatory -
advised to use Family planning method until
menses have
been absent for 6 continuous months
o Menopause is has occurred if there had been no
period for one year.
Classical signs: Vasomotor changes due to
hormonal imbalance
a. hot flushes
b. excessive sweating especially at night
c. emotional changes
d. insomnia
e. headache
f. palpitations
g. nervousness
h. apprehension
i. depression
j. tendency to gain weight more rapidly
k. tendency to lose height because of
osteoporosis (dowager hump)
l. arthralgias and muscle pains
m. loss of skin elasticity and subcutaneous fat in
labial folds
Artificial menopause / surgically induced
menopause
a. oophorectomy or irradiation of ovaries
b. panhysterectomy
III. PROMOTE RESPONSIBLE PARENTHOOD –
FAMILY PLANNING
A. Artificial Methods:
1. physiologic method: oral contraceptives ;
natural methods
2. mechanical methods
3. chemical methods morning or doing any activity to detect time of
4. surgical methods ovulation
Oral contraceptive 2 Ovulation is indicated by a slight drop of
Action: temperature and then rises
inhibits release of FSH no ovulation 3 Resume Sexual intercourse after 3 – 4 days
Types: 4 Recommended observation of BBT is 6
Combined ; menstrual cycle to establish pattern of
Sequential; fluctuations
Mini pill C. Mechanical Methods
Side Effects: due to estrogen and progesterone 1.
> nausea and vomiting Intrauterine Device - prevents implantation by
> Headache and weight gain non-specific cell
> breast tenderness inflammatory reaction
> dizziness inserted during menstruation (cervix is dilated)
> breakthrough bleeding/spotting SE:
> chloasma increased menstrual flow
Contraindications: spotting or uterine cramps
a. Breastfeeding increased risk of infection
b. Certain diseases: Note: when pregnancy occurs, no need to remove
o thromboembolism IUD, will not harm
o Diabetes Mellitus fetus 2.
o Liver disease Diaphragm
o migraine; epilepsy; varicosities oa
o CA; renal disease;recent hepatitis disc that fits over the cervix
c. Women who smoke more than 2 packs of of
cigarette per day orms a barrier against the entrance of sperms
d. Strong family Hx of heart attack o initially inserted by the doctor
Note: If taking pill is missed on schedule, take o
one as soon as remembered and maybe washed with soap and water is reusable
take next pill on schedule; if not done withdrawal o
bleeding occurs. when used, must be kept in place because
B. Natural Methods: sperms remains viable for 6 hrs.
a. Rhythm/Calendar/Ogino Knause Formula in the vagina but must be removed within 24
o Couple abstains on days that the woman is hours (to decrease risk of
fertile toxic shock syndrome)
o Menstrual cycles are observed and charted for 3.
12 months Condom
Standard Formula: 1 a rubber sheath where sperms are deposited
first day of the beginning of one cycle to the first 2 it lessens the chance of contracting STDs
day of the 3 most common complaint of users
next cycle interrupts sexual act when to apply
shortest cycle = minus 18 D. Chemical Methods
longest cycle = minus 11 These are spermicidals (kills sperms) like jellies,
Example: shortest cycle = 28 creams, foaming tablets,
longest cycle = 35 suppositories
Shortest cycle: E. Surgical Method
28 days – 18 = 10 a.
Longest cycle: Tubal Ligation:
35 days – 11 = 24 Fallopian tubes are ligated to prevent passage of
Fertile pd: sperms
10th to 24th day of cycle = No sexual intercourse Menstruation and ovulation continue
b. Billings Method / Cervical Mucus b.
o woman is fertile when cervical mucus is thin Vasectomy:
and watery; may be extended Vas deferens is tied and cut blocking the passage
o Sexual Intercourse may be resumed after 3 – 4 of sperms
days Sperm production continues
c. Symptothermal Method / BBT Sperms in the cut vas deferens remains viable for
1 Requires daily observation and recording of about 6 months hence
body temperature before rising in couple
the needs to observe a form of contraception this
time to prevent pregnancy
IV. BEGINNING OF PREGNANCY
A.F e rti l i z ati on
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 (life
span of sperms 72 hrs)
B.Im pl antati on
General Considerations:
o Once implantation has taken place, the uterine
endometrium is now termed
decidua
o Occasionally, a small amount of vaginal
bleeding occurs with implantation due to
breakage of capillaries
o 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.
o Morula travels to uterus for another 3 – 4 days
o When there is already a cavity in the morula
called blastocyt
o finger like projections called trophoblast form
around the blastocyst, which
implant on the uterus
o Implantation is also called nidation, takes place
about a week after fertlization
C. Stages of human prenatal development
1.
Cytotrophoblast – inner layer
2.
Syncytiotrophoblast – the outer layer containing
finger like projections called chorionic villi which
differentiates into:
oL
angerhan’s layer – protective against Treponema
Pallidum,
present only during the second trimester
o bladder and urethra
Syncytial Layer – gives rise to the fetal
membranes, amnion and
chorion
D. Fetal Membranes
1. Amnion – gives rise to umbilical cord/funis –
with 2 arteries and 1 vein supported by
2. Wharton’s jelly
3. Amniotic fluid: clear albuminous fluid, begins to
form at 11 – 15th week of gestation, chiefly
derived from maternal serum and fetal urine,
urine is added by the 4th lunar month, near term
is
clear, colorless, containing little white specks of
vernix caseosa, produced at rate of 500 ml/day.
Known as BOW or Bag of Water
E. Amniotic Fluid
Purposes of Amniotic Fluid
Protection – shield against pressure and
temperature changes
Can be used to diagnose congenital abnormalities
intrauterine– amniocentesis
Aid in the descent of fetus during active labor
Implication:
Polyhydramios = more than >1500 ml due to
inability of the fetus to swallow the fluid
as in
trachoesophageal fistula.
Oligohydramnios = less than <500 ml due to the
inability of the kidneys to add urine
as in
congenital renal anomaly
F. Fetal Membranes
•Chorion - together with the deciduas basalis
gives rise to the placenta, start to form at
8th
week of gestation; develops 15 – 20 cotyledons
•Purpose of Placenta: respiratory; exchange of
nutrients and oxygen
•Renal system
•Gastrointestinal system
•Circulatory system
•Endocrine system: produces hormones (before
8th week-corpus luteum produces these
hormones) hCG keeps corpus luteum to continue
producing estrogen and progesterone
•HPL or human chorionic somatomammotropin
which promotes growth of mammary
glands for
lactation
•Protective barrier: inhibits passage of some
bacteria and large molecules
V. FETAL GROWTH AND DEVELOPMENT
First lunar month
•Germ layers differentiate by the 2nd week
1. endoderm – gives rise to lining of GIT,
Respiratory Tract, tonsils, thyroid (for basal
metabolism),
parathyroid (for calcium metabolism), thymus
gland (for development of
immunity),
2. Mesoderm – forms into the supporting
structures of the body (connective tissues,
cartilage, muscles and tendons); heart,
circulatory system, blood cells, reproductive
system, kidneys and ureters.
3. Ectoderm – responsible for the formation of the
nervous system, skin, hair and nails
and the
mucous membrane of the anus and mouth
1 month: 2nd week – fetal membranes
16th day – heart forms ; 4th week – heart
beats
2nd month: All vital organs and sex organs
formed; placental fully developed;
meconium formed (5th –8th wk)
3rd month: Kidneys function - 12th wk- urine
formed ; Buds of milk teeth form ; begin
bone ossification ; allows amniotic fluid ;
establishment of feto-placental exchange
4th month: Lanugo appears; buds of permanent
teeth form; heart beat heard by fetoscope
5th month: Vernix appears; lanugo over entire
body; quickening; FHR audible with
stethoscope
6th month: Attains proportions of full term but
has wrinkled skin
7th month: 28 weeks – lower limit of prematurity;
alveoli begins to form
8th month: 32 weeks – fetus viable; lanugo
disappears, subcutaneous fat deposition begins
9th month: Lanugo continue to disappear; vernix
complete; amniotic volume decrease
Focus of Fetal Development
First Trimester – period of organogenesis
Second Trimester – period of continued fetal
growth and development; rapid increase in
length
Third Trimester – period of most rapid growth and
development because of the deposition
of
subcutaneous fat
Assessing Fetal Well-being
Fetal Movement:
Quickening at 18 – 20 weeks , peaks at 29 -38
weeks
Consistently felt until term
a. Cardiff Method:
“Count to ten” - records time interval it takes for
10
- fetal movements to be felt usually occurs
in 60minutes
b. Contraction Stress Test:
Fetal Heart Rate (FHR) analyzed in conjunction
with
contractions
Nipple stimulation done to induce gentle
contractions
***3 contractions with 40 sec duration or more
must
be present
in 10 minutes window
Normal Result no fetal decelerations with
contractions
c. Non-stress Test:
Measures response of FHR to fetal movement
(10-
20mins.)
with fetal movement FHR increase by 15 beats
and
remain for 15 seconds then decrease to average
rate
(no increase means poor oxygen perfusion to
fetus)
d. Amniocentesis - done to determine fetal
maturity: Identify L/S ratio
16 wks – detect genetic disorder
30 wks – assess
1. Prior to the procedure, bladder should be
emptied; ultrasonography is used
to avoid
trauma from the needle to the placenta, fetus
2. Complications include premature labor,
infection, Rh isoimmunization
3. Monitor fetus electronically after procedure,
monitor for uterine contractions
4. Teach client to report decreased fetal
movement, contractions, or abdominal
discomfort
after procedure.
e. Ultrasound – transducer on abdomen transmits
sound waves that show
fetal image on screen
a. Done as early as five weeks to confirm
pregnancy, gestational age
b. Multiple purposes – to determine position,
number, measurement of fetus(es)
and other structures (placenta)
c. Client must drink fluid prior to test to have full
bladder to assist in clarity of
image
d. No known harmful effects for fetus or mother
e. Noninvasive procedure
VI. NORMAL ADAPTATIONS IN 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
Management: side lying hips elevated on pillow
modified knee chest position
e. Predisposition to blood clot formation
-due to increased level of circulating fibrinogen as b. Waddling gait
a protection from bleeding 1 due to increased production of hormone
implication: no relaxin, pelvic bones becomes more
massage movable
2. Gastrointestinal Changes 2 increasing incidence of falls
a. Morning sickness c. Leg cramps
2 nausea and vomiting in the 1st trimester due to 1d
HCG or due to increased acidity or ue to pressure of gravid uterus, fatigue, muscle
emotional tenseness, low calcium and
factors phosphorus intake
3 Management: dry toast 30 mins before get up 6. Endocrine Changes
in AM a. Addition of the placenta as an endocrine organ
b. Hyperemesis gravidarum producing HCG, HPL, estrogen
4 excessive nausea & vomiting which persists and progesterone
beyond 3 months causing dehydration, b. Moderate enlargement of the thyroid due to
starvation and acidosis increased basal metabolic rate
5 Management: hydration in 24 hrs; complete c. Increased size of the parathyroid to meet need
bed room of fetus for calcium
c. Constipation and Flatulence d. Increased size and activity of adrenal cortex
GI displacement slows peristalsis & gastric increasing circulating cortisol,
emptying time; inc progesterone aldosterone, and ADH which affect CHO and fat
d. Hemorrhoids metabolism causing
1 due pressure of enlarged uterus hyperglycemia.
2 Management: cold compress with witch hazel e. Gradual increase in insulin production but
and Epsom salts there is decreased sensitivity to
e. Heartburn insulin during pregnancy
1 due to increased progesterone and decreased 7. Weight Change
gastric motility causing regurgitation a. First Trimester 1.5 to 3 lbs normal weight gain
through gastric b. 2nd and 3rd trimester 10 – 11 lbs per trimester
sphincter is recommended
2 Management: pats off butter before meals c. Total allowable weight gain during throughout
avoid fried, fatty foods pregnance is 20 – 25 lbs or 10 –
sips of milk at intervals 12 kgs.
small, frequent meals taken slowly d. Pattern of weight gain is more important than
don’t bend on waist the amount of weight gained.
take antacids (milk of magnesia) 8. Emotional responses
3. Respiratory Changes a. 1st trimester: some degree of rejection,
a. Shortness of Breath disbelief, even depression because of its future
due to inc. oxygen consumption and production implication -> give health teachings on body
of carbon dioxide during the 1st changes and allow for expression of feelings
Trimester; b. 2nd trimester: fetus is perceived as a separate
and increased uterine size pushing the entity and fantasizes
diaphragm crowding chest cavity appearance
management: side lying position to promote c. 3rd trimester: best time to talk about layette,
lateral chest expansion and infant feeding method. To
4. Urinary Changes allay fear of death let woman listen to the FHT.
a. Urinary frequency VII. COMMON EMOTIONAL RESPONSES DURING
felt during the 1st trimester due to the increase PREGNANCY
blood supply to the kidneys •Stress –decrease in responsibility taking is the
and then on reaction to the stress of pregnancy not the
the 3rd trimester due to pressure on the bladder. pregnancy itself affects decision  making
b. Decreased renal threshold for sugar abilities
due to increased production of glucocorticoids •Couvade – syndrome – men experiencing
which cause lactose and nausea/vomiting, backache due to stress, anxiety
dextrose to spill and empathy for partner
into the urine; and inc. progesterone •Emotional labile – mood changes/swings occur
5. Musculoskeletal changes frequently due to hormonal changes
a. Pride of Pregnancy •Change in Sexual Desire – may increase or
1d decrease needs correct interpretation… not
ue to need to change center of gravity result to as a loss of interest in sexual partner
lordotic position VIII. LOCAL CHANGES DURING PREGNANCY
1. Uterus – wt increase to about 1000 grams at
full term due to increase in fibrous and elastic
tissues
a. Becomes ovoid in shape
b. Softening of lower uterine segment: Hegar’s
sign seen at 6th week
c. Operculum – mucus plug to seal out bacteria
d. Goodell’s sign – cervix becomes vascular and
edematous giving it consistency
of the earlobe
2. Vagina – increased vascularity occurs
a. Chadwick’s sign – purplish discoloration of the
vagina
b. Leukorrhea – increased amount of vaginal
discharges due to increased activity
of estrogen and of the epithelial cells.
a. Must not be itchy, foul smelling, excessive, nor
green/yellow in color.
b. Management: good hygiene
c. Under the influence of estrogen, vaginal
epithelium & underlying tissues
hypertrophic & enriched with glycogen
d. pH of vaginal secretions during pregnancy fall
•Microorganisms that thrive in an alkaline
environment:
a. Trichomonas – causes trichomonas
vaginalis/vagnitis or trichomoniasis
s/s: frothy, cream-colored, irritatingly itchy, foul
smelling discharges,
vulvar
edema
Management : Flagyl 10 days p.o. or
trichomonicidal cmpd
suppositories
(e.g. Tricofuron, Vagisec, Devegan)
Management:
1. treat male partner also with Flagyl
2. avoid alcohol to prevent SE
3. dark brown urine expected
4. Acidic vaginal douche (1 tbsp vinegar:1 qt
water or 15 ml: 1000 ml)
5. avoid intercourse to prevent reinfection
a.Candida Albicans - condition is called Moniliasis
or Candidiasis
6 it thrives in an environment rich in CHO and
those on steroid or
antibiotic
therapy
7 seen as oral thrush in the NB when transmitted
during delivery
8 s/s: white, patchy, cheese-like particles that
adhere to vaginal
walls, foul
smelling discharges causing irritating itchiness
Management :
1. Mycostatin/Nystatin p.o. or vaginal
suppositories 100,000 U BID x 15
days
2. Gentian violet swab to vagina
3. Acidic vaginal douche
4. Avoid intercourse
3. Ovaries
Inactive since ovulation does not take place
during pregnancy. Placenta produces
Progesterone and Estrogen during pregnancy
4. Abdominal Wall
1 Striae Gravidarum – due to rupture and atrophy
of connective tissue layers on the
growing abdomen
2 Linea Nigra
3 Umbilicus is pushed out
4 Melasma or Chloasma – increased pigmentation
due increased production of
melanocytes by the pitutitary
5 Unduly activated sweat glands
IX. SIGNS OF PREGNANCY
I.Pre gna ncy
1 Prenatal care is important for prevention of
infant and maternal morbidity and
mortality
2 Care is a cooperative action based on client’s
understanding of treatment modalities
3 Duration of normal pregnancy 266 – 280 days
of 38 – 42 weeks or 9 calendar months
or 10 lunar months.
4 Infant born < 38 weeks pre-term & 42 post
term)
5 Diagnosis: Urine examination – tests presence
of HCG (present from 40th –100th day,
peak 60 days) conduct test 6 weeks after LMP
2. Prenatal Visit
History Taking:
personal data
obstetrical data
gravida
para
TPAL
past pregnancies
present pregnancy: cc
LMP
medical data: hx of diseases/illnesses
3. Danger Signals of Pregnancy
1. Vaginal bleeding (any amount)
2. Swelling of face or fingers
3. Severe, continuous headache
4. Dimness or blurring of vision
5. Flashes of light or dots before eyes
6. Pain in the abdomen
7. Persistent vomiting
8. Chills and fever
9. Sudden escape of fluids from the vagina
10. Absence of FHT after they have been initially
heard on 4th or 5th month
4.As se ss me nt
a. Physical examination – review of systems
b. Pelvic examination (ask client to void)
c. IE –
determine Hegar’s, Goodell’s, Chadwick’s
d. Ballotement – on 5th month
e. Pap Smear
f. Pelvic measurements (done after 6th month or
2 wks before EDC)
g. Leopold’s Manuever: to determine fetal
presentation, position, attitude, est.
size and fetal parts
h. Vital signs
i. Blood studies: CBC Hgb, Hct , blood typing,
serological tests
j. Urinalysis: test for albumin, sugar & pyuria
5. Important Estimates:
a. Age of Gestation:
Nagele’s Rule: -3 calendar  months and +7 days
Ex. LMP= May 15, 2006 or 5-15-06
LMP:
51
5 cervix, deeply engaged presenting part
Formula:
-3+ 7
EDC:
2 22 or February 22, 2007
• is a gate that can be closed to ease pain felt.
McDonald’s Rule: Ht fundus/4 (AOG wks)
1. Measure in cms the length from the symphysis
to the
level of fundus
2. Lunar months: Fundal Height (cms) x 2/7
3. Weeks of pregnancy: Fundal height (cms) x 8/7
Ex. Fundal Height = 14 cms
Lunar Month: 14cms x 2 = 28 / 7 = 4 months
Weeks Pregnant: 14 cms x 8 = 112 / 7 = 16
weeks
AOG
• measures
Bartholomew’s Rule: based on position of fundus
in abdominal
cavity
3rd month = above symphysis
5th month = umbilical level
9th month = below xiphoid process)
b. Fetal Length:
1 f. Immunization: Tetanus Toxois (TT) =0.5 ml IM
Haase’s Rule: 1st half of pregnancy – square
number of
months
Example : 2 months = 2x2 = 4 cm
2nd half of pregnancy – number of months
multiplied
by 5
Example: 7 months x 5 = 35 cm
c. Fetal Weight:
1 Johnson’s Rule: Fundic Ht – n x k ( k=155; n =
11 not engaged/12
engaged)
Example for a not engaged fetus
Fundic Height given = 35 cms
n = 11 (standard for not engaged fetus)
k= 155 gms. (9 standard)
Solution: 35 cms – 11 = 24 x 155 =3,720 g
5. Health Teachings
a. Smoking – lead to LBW babies
b. Drinking – can cause respiratory depression in
the NB and fetal withdrawal
syndrome if
excessive; alcohol has empty calories
c. Drugs – may be teratogenic hence
contraindicated unless prescribed by Doctor
d. Sexual activity – allowed in moderation but not
during last 6 wks- high
incidence of post
partum infection noted.
♣
counseling is important on changes in desire and
positions

contraindication: bleeding, ruptured BOW,
incompetent
e. Prepared childbirth/Childbirth education
1 Based on Gate Control Theory: pain is
controlled in the spinal cord and
there
2 Information and breathing techniques help
minimize discomfort of labor
experience
3 Discomfort can be lessened if abdomen is
relaxed and allows uterus to
rise freely against it during contractions
Major Approaches to prepared childbirth
1 Teaching about anatomy, pregnancy, labor and
delivery, relaxation
techniques,
breathing exercises, hygiene, diet and comfort
Grant-Dick Read Method: Fear leads to tension
and tension leads to
pain
Lamaze Method: Psychoprophylactic method ;
based on S-R
conditioning;
concentration on breathing is practiced
for all pregnant women
shall be
given in 2 doses- 4 wks interval with 2nd dose at
least 3 wks
before delivery
= booster doses given during succeeding
pregnancies
regardless of interval.
= 3 booster doses is equal to lifetime immunity
g. Clinic Visits for Pre-natal check-up
2 First 7 lunar months – every month
3 On 8th and 9th lunar month – every week
4On 10th lunar month – every week until labor
X. LABOR AND DELIVERY
1. THEORIES OF LABOR ONSET
Uterine stretch theory
Oxytocin theory
Progesterone Deprivation theory
Prostaglandin theory
2. FOUR P’S OF LABOR
a. Power - the uterine contraction
b. Passenger – the fetus
c. Passageway – the maternal pelvis
d. Psyche – the mental and emotional aspect of
the woman
a. POWER -Uterine Contractions:
a.1. Frequency – the beginning of one contraction
to the beginning of the next contraction
a.2. Interval – pattern which increases in
frequency and duration
a.3. Duration – the beginning of one contraction
to the end of the same contraction
a.4. Intensity – strength of contraction, measured
through a monitor or through touch of
a fingertip
on the fundus (mild, moderate or strong)
b. PASSENGER -Fe t us
b.1. Fetal Skull:
a. largest part of the fetus - most frequent
presenting part; least compressible
Bones: sphenoid, ethmoid, temporal, frontal,
occipital, parietal
Suture lines: sagittal/ coronal, lamboidal
b.2. Fontanels - membrane covered spaces at the
junction of the main suture lines
anterior fontanel: larger, diamond shaped; closes
at 12 – 18 months
posterior fontanel: smaller, triangular shaped,
closes at 2 – 3 months
b.3. Fetal Lie – relationship of the cephalocaudal
axis of the fetus to the cephalocaudal
axis of the
mother.
Measurements:
b.4. Fetal Attitude – fetal position
Pelvis is divided into 6 areas: Anterior, Posterior,
Transverse Left,
Transverse
Right, Posterior Left, Posterior Right
Fetal landmarks: Occiput (O); mentum (M),
sacrum (S), and scapula (Sc)
b.5. Presentation –the part of the passenger that
enters the pelvis is the presenting part
a. Cephalic – Vertex (occiput) ; Brow (sinciput);
Face (mentum)
b. Breech – Complete (sacrum) ; Frank; Footling
c. Shoulder
b.6. Movement of Passenger upon birth or
descent:
d. Descent
e. Flexion
f. Internal Rotation
g. Extension
h. External rotation/ restitution
c. PASSAGEWAY – maternal pelvis
c.1. Divisions
a.
False Pelvis -supports the growing uterus during
pregnancy
-directs the fetus into the true pelvis near the end
of gestation
b.
True Pelvis: the bony canal through which the
fetus will pass during delivery formed by the
pubis
in front, the iliac and ischia on the sides and the
sacrum and coccyx behind
c.2. Significant Pelvic Measurements
a. External – Suggestive only of pelvic size
> External Conjugate/ Baudelaocque’s Diameter
- the distance between the anterior aspect of the
symphysis pubis and the
depression
below lumbar 5 (Average: 18 – 20 cm)
b. Internal – the actual diameters of the pelvic
inlet and outlet
> Diagonal Conjugate
- the distance between the sacral promontory and
inferior/lower margin of the
symphysis pubis
- widest AP diameter at outlet estimated on
vaginal/pelvic exam (Average:
12.5 cm)
>Obstetrical Conjugate
- the distance from the inner border of the
symphysis pubis to the sacral
prominence
- most important pelvic measurement
- shortest AP diameter of the inlet through which
the head must pass
- 1.5 to 2 cm or less than the diagonal conjugate
>True Conjugate/Conjugate Vera
- the distance between the anterior surface of the
sacral promontory and superior
margin
of the symphysis pubis
- diameter of the pelvic inlet (10.5 -11 cm)
>Bi-Ischial/ Tuberiischial Diameter
- the distance between the ischial tuberosities
- narrowest diameter of the outlet
- transverse diameter of the outlet (Average: 11
cm)
D.PSYCHE- the emotions of the mother
Factors that may increase a woman’s chance of
depression:
1 History of depression or substance abuse
2 Family history of mental illness
3 Little support from family and friends
4 Anxiety about the fetus
5 Problems with previous pregnancy or birth
6 Marital or financial problems
7 Young age (of mother
Signs and Symptoms of Post-partum depression:
1 Feeling restless or irritable
2 Feeling sad, hopeless, and overwhelmed
3 Crying a lot
4 Having no energy or motivation
5 Eating too little or too much
6 Sleeping too little or too much
7 Trouble focusing, remembering, or making
decisions
8 Feeling worthless and guilty
9 Loss of interest or pleasure in activities
10 Withdrawal from friends and family 12 bradycardia
11 Having headaches, chest pains, heart 13 fetal thrashing
palpitations (the heart beating fast 14 meconium stained amniotic fluid in non-
and breech presentation
feeling like it is skipping beats), or b.4. Monitor and inform patient of progress of
hyperventilation (fast and shallow labor
breathing) b.5. Monitor progress – fetal
3.PRELIMINARY/PRODROMAL SIGNS OF LABOR a) during labor check FHR
a. Lightening b) manage fetal distress
b. Increased activity level- “nesting behavior” 5. Analgesia/anesthesia during childbirth
c. Loss of weight ( 2-3 lbs) 5.1. Analgesia – relieves pain and its perception
d. Braxton Hick’s Contractions 5.2. Anesthesia – produces local or general loss of
e. Cervical Changes – effacement sensation ;
- Goodell’s sign – ripening of the cervix - usually regional anesthesia (e.g. spinal)
f. Increase in back discomfort o
g. Bloody Show - pinkish vaginal discharge Relieve uterine and perineal pain
h. Rupture of Membranes– labor expect in 24 o
hours Usually safe for the fetus (potential for maternal
i. Sudden burst of energy hypotension)
j. Diarrhea o
k. Regular Contractions - phases: Types of Anesthesia:
increment,acme,decrement a. Paracervical block
- characteristics: intensity, frequency, interval, b. Peridural block: Epidural/caudal
duration c. Intradural: spinal/saddle block
False Labor Pains d. Pudendal block
True Labor Pains e. Local anethesia
o1 Remain irregular o Regional Anesthesia is mostly preferred
o2 Confined to abdomen because it does not enter
o3 No increase in duration, frequency, maternal circulation nor affect fetus
intensity o Xylocaine is used (NPO with IV infusion)
o4 Disappears on ambulation > allows to be awake and participate in process;
o5 No cervical changes > can increase incidence of maternal
o6 Becomes regular and predictable hypotension and fetal
o7 Radiates in girdle like fashion bradycardia
o8 Increase in duration, frequency, intensity 5.3. Analgesics:
o9 Continue regardless of activity 5.3.1 Narcotics (Demerol)
o10 Effacement and dilatation occurs op
o11 Signs of True labor roduces sedation/relaxation
Effacement od
Dilatation epresses NB’s respiration
1 Uterine Changes– upper and lower segments; og
physiologic retraction ring iven in active labor
2 Bandl’s pathologic retraction ring- a danger o
sign of impending rupture of the Special Considerations:
uterus if obstruction is not relieved Demerol is most commonly used
1. Nursing Interventions of Woman in Labor: Has sedative and antispasmodic effect
a. Assessment – history and physical assessment Dose is usually 25 –100 mg depends on body
a.1. Personal data weight
a.2. Obstetrical data Not given early in labor due to possible effect on
1 determine EDC contractions
2 obstetrical score Not given too late (1 hr before delivery) can
3 amount/ character of show cause
4 status of the BOW respiratory depression in the newborn
5 general physical examination Given if cervical dilatation is 6 – 8 cms.
6 Leopold’s Maneuver: presentation 5.3.2. Narcotic Antagonist: Narcan; Nalline
7 Internal examination: 6. Nursing Care before administration of
effacement ; dilatation; station anesthesia/analgesia
b. Monitoring and Evaluating Progress of Labor 1.1.Assess pain status
b.1. Blood pressure 1.2.Explain the action of drugs
b.2. Fetal Heart Tone 1.3.Check vital signs of mother and fetus
b.3. Observe for signs of fetal distress 1.4.Observe safety measures
Evaluate allergies - from delivery of the newborn to
Provide siderails – have call bell ready the delivery of the placenta
NPO (anesthesia) Still with mild contractions until the
Check time last medication was given placenta is expelled.
1.5.Nursing Care after administration of Usually, placenta is expelled within 30
anesthesia/analgesia minutes.
1.6.Monitor: vital signs – BP and FHR (be alert for Fourth Stage
bradycardia) - the first hour after complete
1.7.Record properly delivery until the woman becomes
1.8.Provide comfort measures physically stable
1.9.Remember that the use ofF orce ps is needed Uterine cramping
in delivery of patient under Rubra with small clots
anesthesia due 2. Principles of Postpartum Care
to loss of coordination in bearing down during a. Promote healing and the process of involution
2nd stage b. Provide emotional support
1.10. Side effects: c. Prevent postpartum complications
a. postspinal headaches – place flat on bed for 12 d. Establish successful lactation
hrs and increase e. Promote responsible parenthood (FP)
fluid intake 3. Nursing Care of the Woman in First & Second
b. common side effect is hypotension (xylocaine – Stage Labor
vasodilator): a. Monitor discomfort/exhaustion/pain control –
Nursing Intervention: support client in choice of pain
turn to side control
elevate legs b. Relaxation techniques taught during
administer vasopressor and oxygen as ordered pregnancy where breathing is taught as a
Fetal bradycardia relaxed
Decreased maternal respirations response to contraction
(Observe for bulging of the perineum) c. Low back pain – massage of sacral area
XI. STAGES OF LABOR d. Use different breathing techniques during the
1. Stages of Labor different phases of labor
Stage e. Encourage rest between contractions
Characteristics f. Keep couple informed of progress
First Stage g. Administer analgesic : side effects-may prolong
- the stage of true labor until the labor; local/ block/ general
complete cervical dilatation 4. Nursing Care of Woman in the 3rd Stage of
a. Latent Phase Labor
b. Active Phase a. Principle Of Watchful Waiting
c. Transitional b. Use Brandt Andrews Maneuver
Phase c. Note Time Of Delivery (20 Minutes After
Extent: Delivery Of The Baby)
Primigravida – 3.3.-19.7 hrs d. Check Bp; Injects Oxytocin (Methergin 0.2
Multigravida – 0.1 - 14.3 hrs Mg/Ml Or Syntocinon 10 U/Ml Im)
0-4 cms. cervical dilatation e. Inspect Cotyledons For Completeness
Interval: 15-20 mins interval f. Check Uterus For Contraction
Duration: 10-30 seconds g. Check Perineum For Lacerations -Give perineal
5-7 cms. cervical dilatation care; apply perineal pads
Interval: 3-5 mins h.
Duration: 30-60 seconds Change gown
8-10 cms cervical dilatation i.Place flat on bed
Interval: 2-3 mins. j.Keep warm – provide extra warm blanket
Duration: 50-90 seconds k.
Second Stage Give initial nourishment – warm milk, tea
- begins with complete dilatation of the cervix l.Allow to rest/ sleep
until the birth of the newborn 5. Nursing Care of Woman in Fourth Stage
Duration: a. Lactation: promote lactation by encouraging
Primigravida – 30 mins. - 2 hrs. early breastfeeding to stimulate
Multi-gravida- 20 mins – 1 hr. milk
Contractions- 2-3 mins for 50-90 secs production
Mother is exhausted and has urge to *** Those mothers who cannot breastfeed:
push suppressing agents are given – estrogen-
Third Stage androgen preparations given
first hours Nursing Care:
post partum to prevent milk production. These 
drugs tend to increase Explain to client cause of pain
uterine 
bleeding and retard involution. (e.g. Do not apply heat
diethylstilbestrol, Parlodel or 
deladumone) Administer analgesics as prescribed
b. Rooming-in-concept 3. Genital Changes/ Discharges
provides opportunity for developing positive - Presence of Lochia: uterine discharges
family relationship consisting of blood, decidua, WBC and some
promotes maternal infant bonding bacteria
releases maternal caretaking responses - Characteristics:
c. Assess vital signs, fundus and flow every 15 pattern should not reverse –
minutes. 1-3 days – rubra - - - bright red with no or minimal
d. Hydration and elimination clots
e. May ambulate 4-9 days – serosa- - - thinner, serous sanguinous
Puerperium - the 6 weeks period following blood
delivery 10- 3 to 6 wks pp – alba - - - whitish discharge
Involution- time period for the return of the same amount as menstrual flow, decreased if
reproductive organs to return to its with breastfeeding , increased
prepregnant with activity
state with fleshy odor; never foul smelling
8. Categories of Lacerations 4. Perineal Pain
8.1. First degree – involves vaginal mucous Nursing Care:
membrane and perineal skin 
8.2. Second degree – involves the perineal Place in Sim’s position – lessens strain on the
muscles, vaginal mucous membrane suture line
and 
perineal skin Expose to dry heat or warm Sitz bath
8.3. Third degree – involves all in the 2nd degree 
lacerations and the external Application of topical analgesics or oral
sphincter of analgesics as ordered
the rectum 
8.4. Fourth degree – involves all in 3rd degree Provide/ encourage perineal care
lacerations and the mucus 5. Sexual Activity
membrane of the 1 sexual stimulation may be decreased due to
rectum emotional factors and hormonal
XII. PROMOTING HEALING AND INVOLUTION changes
DURING POST-PARTUM 2 it may be resumed if bleeding has stopped and
1. Vascular Changes episiorrhaphy has healed by
- Reabsorption of the 30-50% increase in cardiac the 3rd or
volume within 5 – 10 minutes after 4th week
the thirdstage of labor. 6. Menstruation
- WBC increases to 20,000 – 30,000/mm³ 1 Breastfeeding influences return of the
- Activation of the clotting factor menstrual flow.
- All blood values are back to prenatal levels by 2 Breastfeeding – menses return in 3 – 4 months;
3rd or 4th week o some do not menstruate throughout lactation
2. Location of the Fundus period
- Uterine involution is measured by determining o ovulation is also possible with lactational
the level of the fundus in relation to amenorrhea
the 3 Non-Breastfeeding Mothers – menstrual flow
umbilicus return within 8 weeks
- Nursing care: 7. Urinary Changes
 o marked diuresis occurs within 12 hours
Assess condition and level of the fundus postpartum to eliminate excess tissue
 fluids during pregnancy
Position in prone or knee chest o frequent urination in small amounts may be
1 Occurrence of afterpains – it is an indication of experienced by some
uterine contractions and are o others have difficulty of urination
normal. Usually Nursing Care:
lasts up to 3 days after birth 
Explain cause of urinary changes 4 Oral contraceptives decrease milk supply and
 are contraindicated in lactating mothers
Assist to promote voiding utilizing appropriate 5 Afterpains are felt more by breastfeeding
measures (encouraging mothers due to oxytocin production; have
voiding, let client listen to sound of flowing water, less lochia and rapid involution
etc.) 12. Advantages of Breastfeeding
8. Gastrointestinal Changes Mother: faster involution
- Change is more on the delay of bowel less incidence of CA
evacuation; constipation economical- time, effort, cost
- Cause: Infant: bonding with the mother
decreased muscle tone protection against common illness
lack of food intake less incidence of GI diseases
dehydration always available
fear of pain 13. Health Teachings
-Nursing Care: encourage early ambulation a. Hygiene
increase fluids Wash breasts daily
increase fibers in the diet No soap; No Alcohol for cleaning
9. Vital Signs Handwashing
o Temperature: may increase because of Insert clean OS squares/ absorbent cloth in
dehydration on the first 24 hours pp. brassiere for breast discharges
o CR 50 – 70 beats/min (bradycardia) is common b. Feeding Techniques
for 6 - 8 days pp. c. Nutrition: 3000 calories daily; 96 grams protein
o RR – no change is expected d. Contraindications:
o Weight = 10 – 12 lbs is expected to be Drugs – oral contraceptives, atropine,
immediately lost. This corresponds to the anticoagulants, antimetabolites,
weight of the fetus, placenta, amniotic fluid and cathartics,
blood. Diaphoresis will tetracyclines.
contribute to further weight loss Certain disease conditions – TB
10. Provision of Emotional Support because of close contact during feeding
Post-partum Psychological Phases (TB germs are not transmitted thru breast milk)
1. Taking – in : First 1 – 2 days; mother focuses on XIII. ASSOCIATED PROBLEMS
herself and her experience 1. Engorgement
2. Taking – hold: mother starts to assume her role breast becomes full, tense and hot  with
3. Letting go throbbing pain
Postpartum Blues – overwhelming sadness that expected to occur on the 3rd post partum day
cannot be accounted for. Could be due accompanied by fever (milk fever)last 
to for 240 due to increased lymphatic and venous
hormonal changes, fatigue or feelings of circulation
inadequacy. Nursing care:
Nursing Care: Encourage verbalization; crying is o encourage breastfeeding
therapeutic, explain that it is normal o advise use of firm-supportive brassiere
11. Establish Successful Lactation o (if not going to breastfeed – apply cold
Physiology of Lactation: compress; no massage; no breast
Estrogen & progesterone levels stimulates APG to pump; apply
produce  Prolactin acts on breast binder)
acinar cells to 2. Sore Nipples
produce foremilk stored in collecting tubules -> Nursing care:
infant sucking stimulates encourage to continue BF
PPG to expose nipples to air for 10 – 15 minutes after
produce oxytocin causes contraction of smooth feeding
muscles of collecting tubules (alternative) exposure to 20 watt bulb placed 12 –
milk  18 inches away promotes
ejected forward (milk ejection reflex or let down vasodilation
reflex hindmilk is produced and therefore promote healing
Implications of lactation: do not use plastic liners
1 Breast milk will be produced postpartum use nipple shield
2 Lactation do not occur during pregnancy due to 3. Mastitis -
levels of estrogen and progesterone inflammation of the breast
3 Lactation suppressing agents are to be given Signs & Symptoms: pain, swelling, redness,
immediately after placental delivery to be lumps in the breasts, milk becomes
effective scanty
Nursing Care: Sources/ Cause:
Ice compress 1. Endogenous/primary sources - normal bacterial
Supportive brassiere , empty breast with pump flora
Discontinue BF in affected breast 2. Exogenous sources - hospital personnel,
Apply warm dressing to increase drainage excessive obstetric manipulations
Administer antibiotics as prescribed breaks in aseptic techniques, coitus late in
*** Postpartum Check-up: 6th week postpartum pregnancy
to assess involution premature rupture of membranes
XIII. HIGH RISK PREGNANCY CONDITIONS General symptoms: malaise, anorexia, fever,
1. Infections chills and headache
2. Bleeding / Hemorrhage/ PIH Management:
3. Diabetes Mellitus Complete Bedrest
4. Heart Disease Proper Nutrition
5. Multiple Pregnancy Increased Fluid Intake
6. Blood Incompability Analgesics
7. Dystocia Antipyretics and antibiotics as ordered
8. Induced Labor 1.3. Infection of the perineum
9. Instrumental Deliveries Signs & Symptoms: pain, heat, feeling of
1. INFECTIONS pressure,
1.1.Syp hi l i s inflammation of suture line with 1 –2 stitches
Cause: sloughed off
Treponema pallidum - a spirochete transmitted temperature elevation
thru sexual Management: drain area & resuturing ; sitz bath
intercourse & warm compress
Treatment: 1.4.End o me t ri ti s
2.4 – 4.8 million units of Penicillin (or 30 – 40 gms - An infection/inflammation of the lining of the
Erythrocin) uterus
x 10 days Signs & Symptoms: Abdominal tenderness
readily cross placenta thus prevent congenital Uterus not contracted and
syphilis painful to touch
Untreated: Dark brown
Cause mid-trimester abortion Foul smelling lochia
Cause CNS lesions Management: Oxytocin administration
Can cause death Fowler’s position to drain out lochia
1.2. TORCH test series Prevent pooling of discharges
TOxoplasmosis (protozoa) 1.5.Thro mb o p hl e b it i s
avoid eating uncooked meat and handling cat -infection of the lining of a blood vessel with
litter box formation of clots, usual an
Others: Syphilis, Varicella/ Shingles extension of
Hepatitis B; Hepatitis A; AIDS endometritis
Rx – Signs & Symptoms:
Zoster Immune Globulin ,Penicillin o1
RUbella Pain
Effect: if contracted early, slows down cell o2 Stiffness and redness in the affected part of
division during organogenesis causing the leg
congenital defects NB can carry and transmit o3 Leg begins to swell below the lesion because
the virus for about 12 – 24 months after birth venous circulation
CYtomegalovirus has been blocked
(CMV) (DNA virus) o4 Skin is stretched to a point of shiny whiteness,
Herpes type 2 called milk leg
Group of maternal systemic infections that can of
cross the placenta or by ascending Phlegmasia alba dolens
infection(after rupture of membranes) to the o5 Positive Homan’s sign: calf pain on dorsi-
fetus. flexing the foot
Infection early in pregnancy may produce fetal Specific Management:
deformities, whereas late infections 1b
may result in ed rest with affected leg elevated
active systemic disease and/or CNS involvement 2a
causing severe neurological nticoagulants (e.g. Dicumarol or Heparin) to
impairment or prevent
death of newborn formation or extension of a thrombus
Side effect of Anticoagulant: hematuria, - Occurs anytime after the 24th wk of gestation
increased lochia up to 2 wks PP
Considerations: - Develops during pregnancy and resolves during
1 discontinue breastfeeding postpartum period
2 monitor prothrombin time Predisposing Factors:
3 have Protamine Sulfate at bedside to counter a. large fetus
act severe bleeding b. Older than 35, younger than 17
4 analgesics are given but not ASPIRIN because it c. primigravida
prevents d. multiple pregnancy or H mole
prothrombin formation e. poor nutrition
which may lead to hemorrhage f. Hx of DM, renal and vascular disease
2. HEMMORRHAGE/ BLEEDING g. Morbid obesity or weight less than 100 lb
Definition: blood loss more than 500 cc. ( normal h. Family history
blood loss 250- 350 cc) Diagnosis:
*** Leading cause of maternal mortality Roll – over test : Assess the probability of
associated with childbearing developing toxemia when done
2.1. Early Post-partum hemorrhage – first 24 hrs between the
after delivery 28th and 32nd week of pregnancy.
2.2. Late Postpartum Hemorrhage Procedure of Roll-over test:
Early Post-partum hemorrhage 1 Patient in lateral recumbent position for 15
Late Postpartum Hemorrhage minutes until BP Stable
Cause 2 Rolls over to supine position
Uterine Atony – uterus is not 3 BP taken at 1 minute and 5 minutes after roll
well contracted, relaxed or boggy over
(most frequent cause) 4 Interpretation: If diastolic pressure increases 20
Lacerations mmHg or more,
Hypofibrinogenemia patient is prone to Toxemia
Clotting defect Types of Pregnancy Induced Hypertension (PIH):
Retained Placental Fragments a. Transient hypertension - without proteinuria or
Management edema
Bleeding in Pregnancy b. Pre-eclampsia, mild
blood transfusion o BP of 140/90 mmHg or increase of 30/15mmHg
D & C (Dilatation and o 2+ to 3+ proteinuria
Curettage o begins past 20th week
Predisposing factor: o slight generalized edema may be present,
Overdistension of the uterus (multiparity, large weight gain of 1- 5
babies, polyhydramnios, lbs/wk
multiple pregnancies) c. Pre-eclampsia, severe
Cesarean Section o BP of 150-160/100-110 mmHg
Placental accidents (previa or abruptio) o 4+ proteinuria (5 gm/L or more in 24 hrs
Prolonged and difficult labor o Headache and epigastric pain(aura to
Management: Massage –first nursing action convulsions)
Ice compress o Oliguria of 400 ml or less in 24 hrs. (normal
Oxytocin administration UO/day 1500 ml)
Empty bladder o Cerebral or visual disturbances
Bimanual compression to explore retained d. Eclampsia - Obstetrical Emergency
placental fragments o HPN
Hysterectomy (last alternative) o Proteinuria
2.3.He mat o ma o Convulsions
- Due to injury to blood vessels in the perineum o Coma
during delivery Immediate Intervention for Eclampsia:
Incidence: Commnon in precipitate delivery and a. Maintain IV line with large-bore needle
those with perineal b. Monitor fluid balance
varicosities c. Minimize stimuli
Treatment: d. Have airway and oxygen available
1 Ice Compress in first 24 hours e. Give medications as ordered (e.g Magnesium
2 Oral Analgesics as prescribed sulfate, Apresoline,
3 Site is incised and bleeding vessel ligated Valium)
2.4. Pregnancy Induced Hypertension (PIH) f. Prepare for possible delivery of fetus
- A vascular disease of unknown cause g. Monitor fetal status
h. Type and cross match for blood
i. Postpartum- monitor vital signs and watch for o with Disseminated Intravascular Coagulation –
seizure anticoagulant
Management for Eclampsia: therapy
a. Digitalis (with Heart Failure) o Monitor blood pressure for 48 hours
Increase the force of contraction of the heart Diagnosis:Roll – over test : Assess the probability
decrease heart of developing toxemia when done
rate between the 28th and 32nd week of pregnancy.
Nursing Considerations: Check CR prior to Procedure on Roll-over test:
administration ( do 5 Patient in lateral recumbent position for 15
not give if minutes until BP Stable
CR <60/min) 6 Rolls over to supine position
b. Potassium supplements – prevent arrhythmias 7 BP taken at 1 minute and 5 minutes after roll
c. Barbiturates – sedation by CNS depression over
d. Analgesics; antihypertensives, antibiotics, 8 Interpretation: If diastolic pressure increases 20
anticonvulsants, mmHg or more, patient
sedatives is prone to Toxemia
e. Magnesium Sulfate – drug of choice Management:
Action: CNS depressant ; Vasodilator a. Digitalis (with Heart Failure)
Antidote: Calcium Gluconate- given 10% IV to Increase the force of contraction of the heart 
maintain decrease heart rate
Cardiac and vascular tone Nursing Considerations: Check CR prior to
Earliest sign of MgSO4 toxicity disappearance of administration ( do not give if
knee CR <60/min)
jerk/patellar reflex b. Potassium supplements – prevent arrhythmias
Method of delivery – preferably Vaginal but if not c. Barbiturates – sedation by CNS depression
possible CS d. Analgesics; antihypertensives, antibiotics,
Prognosis: the danger of convulsions is present anticonvulsants, sedatives
until 48 hrs e. Magnesium Sulfate – drug of choice
postpartum Action: CNS depressant ; Vasodilator
f. Cathartic – cause shift of fluid from the extra Antidote: Calcium Gluconate- given 10% IV to
cellular spaces into the maintain Cardiac and
intestines from where the fluid can be excreted vascular tone
Dosage: Earliest sign of MgSO4 toxicity disappearance  of
10 gms initially –either by slow IV push over 5 – knee jerk/patellar
10 minutes or reflex
deep IM, Method of delivery – preferably Vaginal but if not
5 gms/buttock, then an IV drip of 1 gm per hour possible CS
(1 gm/100 ml Prognosis: the danger of convulsions is present
D10W), until 48 hrs
Check first the ff. before administration: postpartum
1 Deep tendon reflexes are present f. Cathartic – cause shift of fluid from the
2 Respiratory rate = 12 / min extracellular spaces into the
3 UO = at least 100 ml / 6 hrs. intestines from where the fluid can be excreted
Nursing Intervention: Dosage:
a. 10 gms initially –either by slow IV push over 5 –
Advised bedrest, left lateral 10 minutes or
bb deep IM,
. 5 gms/buttock, then an IV drip of 1 gm per hour
. (1 gm/100
Encourage a well-balanced diet ml D10W),
c. May administer if :
Weigh daily, keep daily log 4 Deep tendon reflexes are present
dd 5 Respiratory rate = 12 / min
. 6 UO = at least 100 ml / 6 hrs.
. 3. DIABETES MELLITUS
Education on self – assessment a.
e. Chronic hereditary disease characterized by
Diversion marked hyperglycemia
f. b.
Family support Due to lack or absence of insulin
e.Post-delivery PIH abnormalities in CHO, fat and protein
metabolism Effect on Infant:
c. a.
Effects of pregnancy – may develop abnormalities Typically longer and weighs more due to:
in glucose tolerance decreased excessive supply of
renal threshold for sugar due to increased glucose from the mother
estrogen, inc. production of b.
adenocorticoids, Anterior Pituitary hormones, and Increased production of growth hormone from
thyroxin which affect CHO maternal pituitary
concentration in blood (hyperglycemia) gland
d. c.
Rate of insulin secretion is increased but Increased secretion of insulin from the fetal
sensitivity of the pregnant body to insulin pancreas
is decreased d.
Pregnancy Risks: Increased action of adrenocortical hormone that
1 favor the passage
Toxemia of glucose from mother to fetus congenital
2I anomalies are often
nfection seen
3 e.
Hemorrhage Cushingoid appearance (puffy, but limp and
4 lethargic)
Polyhydramnios f.Born premature more often – RDS common
5 g.
Spontaneous abortion – because of vascular Greater weight loss because of loss of extra fluid
complications h.
which affect placental circulation Prone to hypoglycemia (BG <30 mg%)
6 Signs and symptoms of Diabetic Babies/
Acidosis – because of nausea and vomiting Hypoglemic Infant:
7 a.
Dystocia – due to large baby Shrill, high pitched cry
Diagnosis : Glucose Tolerance Test (GTT) b.
Procedure for GTT: Listlessness/jitteriness/tremors
NPO after midnight c.
2 ml of 50% glucose / 3 kg of pre-pregnant body Lethargy/poor suck
weight given IV (oral glucose not d.
advisable due to decreased gastric motility and Apnea/cyanosis
delayed e.
absorption of sugar during pregnancy) Hypotonia; hypothermia
Interpretation of Results: ***Consequence of hypoglycemia: untreated
a. If less than 100 mg% = normal hypos brain damage  and even death
b. If 100 – 120 mg% possible GDM ***Management: feed with glucose water earlier
c. If more than 120 mg% - overt gestational than usual, or administer IV of glucose
diabetes 4. HEART DISEASE
Management: Classification:
a. Class I
Diet - highly individualized- adequate glucose - no physical limitation
intake (1,800 – Class II
2200 calories) to prevent intrauterine growth - slight limitation of physical activity
retardation - Ordinary activity causes fatigue, palpitation,
b. dyspnea, or angina
Insulin requirements – individualized; increased Class III
during 2nd - moderate to marked limitation of physical
and 3rd trimester because of more pronounced activity; less than ordinary
effect of activity causes fatigue
hormones Class IV
c. -unable to carry on any activity without
Method of Delivery – Cesarian Section experiencing discomfort
d. Prognosis: Classes I & II – normal pregnancy &
Postpartum Period – more difficult to control delivery
Blood Glucose Classes III & IV – poor candidates
because of hormonal changes Signs & Symptoms:
Heart murmur due to increased total cardiac
volume
Cardiac output decreased nutritional and
oxygen requirements not
met
Incomplete emptying of the left side of the heart
Pulmonary edema
and HPN (moist cough in Gravidocardiacs
danger sign)
Congestion of liver and other organs due to
inadequate venous return increased venous
pressure fluid escapes through the walls of
engorged capillaries and cause edema and
ascites CHF is a high probability due to increased
CO during pregnancy dyspnea,
exhaustion, edema, pulse irregularities, chest
pain on exertion and cyanosis of
nailbeds are obvious
Management: (depends on cardiac functional
capacity)
a. Bed rest – especially after 30th week of
gestation
b. Diet – gain enough (consider effect on cardiac
workload)
c. Medications: Digitalis, Iron preparations
d. Avoid lithotomy
position to avoid increase in venous return, place
in semisitting
position
e. Not allowed to bear down; Birth is via low
forceps or Cesarean section
f. Anesthetic choice – caudal anesthesia
g. Ergotrate and other oxytoxics, scopolamine,
diethylstilbestrol and oral
contraceptives –
h. contraindicated can cause fluid retention and
promote thromboembolism
i. Most critical period: immediate postpartum
period when 30 – 50% increased
blood volume
j. is reabsorbed back in 5 – 10 minutes and the
weak heart needs to adjust
5. MULTIPLE PREGNANCY
Risks: Increased Blood Loss
Small for Gestational Age Infants
Premature Birth
Dystocia
Management:
a. Monitor FHT, VS, weight
b. Cesarean Section
c. Health Teaching on importance of regular pre-
natal check-up visits
d. Educate regarding proper nutrition and
exercise
6. BLOOD INCOMPATIBILITY
- An antigen-antibody reaction which causes
excessive destruction of fetal red blood
cells
Mother
Fetus
Rh- negative
Rh Positive (Father is homozygous
or heterozygous Rh positive)
BloodType O
Either Type A or B (From father)
7. DYSTOCIA - broad term for abnormal or difficult
labor and delivery
Uterine Inertia – sluggishness of contractions
Cause:
Inappropriate use of analgesics
Pelvic bone contraction
Poor fetal position
Overdistention – due to multiparity, multiple
pregnancy,
polyhydrmanios or excessively large baby
Management: Stimulation of labor by oxytocin
administration or amniotomy
7.1. Precipitate Delivery
- labor and delivery that is completed in < 3
hours due to multiparity or
followingoxytocin administration or amniotomy
Effects: Extensive lacerations
Abruptio placenta
Hemorrhage due to sudden
Release of pressure shock
7.2. Prolonged Labor - Usually occurs in primi
gravida
- Labor lasting more than 18 hrs and in
multigravidas, more
than 12 hours
Effects: Maternal exhaustion
Uterine atony
Caput succedaneum
7.3. Uterine Inversion - fundus is forced through
the cervix so that the uterus is
turned inside out
- Insertion of placenta at the fundus, so that as
fetus is
rapidly delivered, fundus is pulled down
- Strong fundal push, attempts to deliver the
placenta before
signs of separation
-Management: Hysterectomy
8. INDUCED LABOR
- Stages of labor and birth occurs due to chemical
or mechanical means which is
usually performed to save the mothe or fetusr
from complications which may cause death
Indications:
Maternal – toxemia
Placental accidents
Premature Rupture Of Membrane
Fetal: DM – terminated at about 37 wks AOG if
indicated
Blood incompatibility
Excessive size
Postmaturity
Prerequisites to Induce Labor :
No Cephalo- Pelvic Dislocation
Fetus is already viable >32 weeks AOG
Single fetus in longitudinal lie and is engaged
Ripe cervix – fully or partially effaced; Cervical o Fetal Distress
Dilatation at least 1=2 cm o Previous classic CS – done prior to onset of
Procedure for Induced labor: labor pains; scheduled birth
1. Oxytocin Administration; 10 IU of Pitocin in Types:
1000 ml of D5W at a slow rate of 8 1. Low Segment – the method of choice.
gtts/min given initially no fetal distress in 30 Incision is made in the lower uterine segment,
minutes   rate 16 -20 gts/min which is the thinnest and most
2. Amniotomy – done with Cervical Dilatation = 4 passive
cm ; Check FHR and quality of amniotic Part during active labor.
fluidNursing Considerations: Advantages:Minimal blood loss
Monitor uterine contractions potential for Incision is easier to repair
rupture Lower incidence of post partum infection
Monitor flow rate regularly No possibility of uterine rupture
Turn off IV with any abnormality in FHR or 2. Lower vertical incision – recommended in:
contractions Bladder or lower uterine segment
Watch out for complications: HPN, Antidiuresis Adhesions from Previous operations
Prostaglandin administration: Route: oral or IV Anterior Placenta Previa
(never IM causes irritation); Transverse lie
effect is slower than oxytocin Preoperative Care
9. INSTRUMENTAL DELIVERIES a.
a. Forceps Delivery The patient is both a surgical and an OB patient
- Use of metal instruments to extract the fetus b.
from the birth canal, when at +3 / +4 and sagittal Check vital signs, uterine contractions, and FHR
suture line is in an AP position in relation to the c.
outlet (e.g. Simpson, Elliot, Piper for breech Physical examination; routine laboratory tests;
presentation) blood typing and cross
Purposes: matching
shorten second stage of labor because of fetal d.
distress; maternal exhaustion; Abdomen is shaved from the level of the xiphoid
maternal disease – cardiac, pulmonary process below the
complication nipple line,
ineffective pushing due to anesthesia extending out to the flanks on both sides up to
prevent excessive pounding of fetal head against the upper thirds of the
perineum (low forceps for thighs
prematures) e.
poor uterine contraction or rigid perineum Retention catheter is inserted to constant
Prerequisites: drainage to keep the bladder
Pelvis adequate, no disproportion away from
Fetal head is deeply engaged the operative site
Cervix is completely dilated and effaced f.Preoperative medication is usually only atropine
Membranes have ruptured sulfate.
Vertical presentation has been established No narcotics are given causes respiratory 
The rectum and bladder are empty depression in the NB
Anesthesia is given for sufficient perineal Postoperative Care
Relaxation and to prevent pain a.
Types: Deep breathing, coughing exercises, turning from
Low or Mid Forceps Delivery side to side
Complications: b.
Forceps marks – noticeable only for 24 – 48 hrs Ambulate after 12 hours
Bladder or rectal injury c.
Facial paralysis Monitor vital signs
Ptosis d.Watch for signs of hemorrhage – inspect lochia;
Seizures feel fundus (if
Epilepsy boggy, massage
Cerebral Palsy with proper abdominal splinting and give
a. Cesarean Section – birth through a surgical analgesics as ordered)
incision on the abdomen e.
Indications: Breastfeeding should be started 24 hrs after
o Cephalo-pelvic disproportion (CPD) delivery
o Severe Toxemia f. Most common complication: Pelvic thrombosis
o Placental Accidents 10. OTHER RISK FACTORS:
10.1.Ag e : ri
- Maternal and infant mortality rates tend to be is
high in age below 15 so
and older om
than 40 years my
Adolescent pregnancy y2
Advanced age 21
Most common problems: 1 (associated
Toxemia with menopause)
A precipitating factor in: 10.2.Pari t y – first pregnancy is the period of high
Placental accidents risk
Iron-deficiency anemia Multiparity G5 and above and age is over 40
Toxemia 10.3. Birth Interval – 3 months from previous
Uterine atony or inertia delivery or more than 5 years
Varicosities; hemorrhoids 10.4. Weight
Low birth weight babies Pre-pregnant weight < 70 lbs or > 180 lbs
C Ch Weight gain < 10 lbs LBW babies
hr Weight gain > 30 lbs = sign of toxemia; DM; H-
ro mole; polyhydramnios;
om multiple
mo pregnancy
os 10.5. Height
so Short stature < 4 feet, 10 inches = contracted
om pelvis or CPD
ma XIV. MATERNAL COMPLICATIONS
al 1. Spontaneous Abortion
lA Termination of pregnancy spontaneously at any
Ab time before the fetus has attained
bn viability
no Assessment:
or 1. Persistent uterine bleeding and cramplike pain
rm 2. Laboratory finding – negatively or weakly
ma positive urine pregnancy test
al 3. Obtain history, including last
li menstrual period
it 2. Ectopic Pregnancy
ti - Any gestation outside the uterine cavity
ie Causes of Ectopic Pregnancy:
es a. Pregnancy Induce Hypertension
sl b. Previous tubal surgery
li c. Congenital anomalies of the fallopian tubes
ik Signs & Symptoms:
ke 1
eD Severe, sharp, knife-like stabbing pain
Do 2
ow Rigid abdomen
wn 3
n’ Positive Cullen’s sign (bluish umbilicus)
’s 4
s Excruciating pain on IE
S 5
Sy Signs of shock
yn Management: Ruptured Ectopic Pregnancy is an
nd emergency requiring immediate
dr intervention
ro Salpingostomy – if Fallopian tube can still be
om replaced and preserved,pregnancy
me is terminated
e/ Saphingectomy – removal of FT and BT
/T Nursing Interventions:
Tr 1
Help woman to combat shock 2
2 Bedrest side-lying or Trendelenberg position for
Elevate foot of the bed at least 72
3 hrs.
Maintain body heat 3
4 Ultrasound to locate placenta
Prepare for surgery 4
5 No vaginal, rectal exam unless delivery would not
Monitor for shock preoperatively and be a problem (if necessary must be done in OR
postoperatively under sterile conditions)
6 5
Provide emotional support and expression of grief Amniocentesis for lung maturity; monitor for
7 changes in
Administer Rhogam to Rh negative women bleeding and fetal status
8 6
Discharge teaching Daily Hgb and Hct
3. Hydatidiform Mole (H-Mole) 7
-Degenerative anomaly of chorionic villi Two units of crossmatched blood available
Signs & Symptoms: 8
1. Elevated hCG levels marked  nausea & Monitor amount of blood loss
vomiting 9
2. Uterine size greater than expected for dates Send home if bleeding ceases and pregnancy is
3. No FHR maintained
4. Minimal dark red/brown vaginal bleeding with 10
passage of grapelike clusters Limit activity
5. No fetus by ultrasound 11
6. Increased nausea and vomiting and associated No douching, enemas, coitus
with PIH 12
Management: Monitor fetal movement
1. Curettage to completely remove all molar 13
tissue that can become malignant NST at least every 1 – 2 weeks
2. Pregnancy is discouraged for 1 year 14
3. hCG levels are monitored for 1 year (if Monitor complications
continue to be elevated, may require 15
hysterectomy and chemotherapy) Delivery by cesarean if evidence of fetal maturity,
4. Contraception discussed; IUD not used excessive
4. Incompetent Cervical Os bleeding, active labor, other complications
One that dilates prematurely 7. Abruptio Placenta
Chief cause of habitual abortion ( 3 or more) Signs & Symptoms:
Causes: 1. Painful vaginal bleeding
1 2. Abdomen (uterus) is tender, painful, tense
Congenital Developmental Factors (couvelaire uterus)
2 3. Possible fetal distress
Endocrine factors 4. Contractions
3 (Occurrence increased with maternal HPN and
Trauma to the cervix cocaine abuse; sudden release of
Signs & Sypmtoms: amniotic fluid; short cord; advanced age;
1 Presence of show and uterine contractions multiparity; direct trauma;
2 Rupture of membranes, Painless cervical hypofibroginemia)
dilatation Management:
5. Incompetent Cervix a. Monitor maternal and fetal progress
6. Placenta Previa – the placenta is the presenting b. Blood loss seen may not match symptom
part c. Could have rapid fetal distress
1. First and second trimester spotting d. Prepare for immediate delivery
2. Third trimester bleeding that is sudden, e. Monitor for post partal complications
profuse, painless Predisposing Factors:
3. Ultrasonography – classified by degree of b. Disseminated intravascular coagulation
obstruction c. Pulmonary emboli
Management: d. Infection
1 e. Renal failure
Hospitalization, initially f. Transfusion hepatitis
Nursing Intervention:
Bedrest
Vital signs, FHT
Monitor intake and output
Seizure precautions
Medications (Magnesium sulfate, Apresoline,
Valium)
8. Uterine Rupture -occurs when the uterus
undergoes more straining than it is capable of
sustaining
Cause: Scar from previous CS
Unwise use of oxytocins
Overdistention
Faulty presentation
Prolonged labor
Signs & Sypmtoms:
Sudden severe pain
Hemorrhage and clinical signs of shock
Change in abdominal contour (two swelling on
the abdomen due to retracted
uterus and the extrauterine fetus)
Management: Hysterectomy
9. Amniotic Fluid Embolism – (Obstetric
Emergency)
– occurs when amniotic fluid is forced into an
open maternal uterine flood sinus
through some defect in the membranes or after
partial premature separation of the
placenta. Solid particles in the amniotic fluid
enter maternal circulation and reach the
lungs as emboli
Signs and symptoms: Dramatic
Sudden inability to breathe, sits up, grasps chest
and sharp chest pain
Turns pale then  bluish gray color