Maternal Nursing

by

S. Mateo, RN, MD

- Contents Anatomy of the female reproductive tract

Physiology of Ovulation
Menstruation/Puberty/Menopause
Physiology of Pregnancy
Pre-natal Care
Fetal Presentation, Lie and Position
Fetal Surveillance

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MATERNAL NURSING

Anatomy of the Female

Reproductive Tract
Must Know:
parts of the internal & external

female reproductive organsblood supply to the uterus,

ovaries and tubes
ligaments of the uterus
course of the ureter
embryologic origin
homologous structures to male

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MATERNAL NURSING

External Female Genitalia

Vulva/ Pudenda

Mons pubis
Labia majora
Labia minora
Clitoris
Hymen
Vestibule
Urethral
opening
Skenes glands
Bartholins
glands

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MATERNAL NURSING

Internal Female Genitalia

Uterus
Fundus
cornu
isthmus
cervix
Ovaries
Fallopian tubes
Interstitial
isthmus
ampulla
infundibulum w/ the fimbriated end
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MATERNAL NURSING

Arterial Blood Supply

aorta --> common iliac--> internal

iliac (hypogastric) --> anterior

branch --> uterine a.---> medial to
uterine isthmus then branches to
two ( 2 cm lateral to endocervix
crosses over the ureter)
----->ascending branch
anastomoses w/ ovarian a.---->
descending branch supply the
cervix and the vagina

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MATERNAL NURSING

Arterial Blood Supply

Ovarian Artery. arises from the

aorta just below the renal vessels

It courses in the retroperitoneal
space,
crosses anterior to the ureter,
enters the infundibulo-pelvic
ligament to the ovary, and
anastomosis with the ascending
branch of the uterine artery.

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MATERNAL NURSING

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MATERNAL NURSING

Ligaments
Broad ligament - peritoneum covering

the fundus and part of the body

continuous laterally as the broad
ligament, draping the outstretched
fallopian tubes
Round ligament - begins anterior to
the interstitial portion of the tube
extends laterally to the pelvic sidewalls
to the deep inguinal ring to attach to the
skin of the labium major

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MATERNAL NURSING

Ligaments
Ovarian - attaches the ovary to the

uterus, posterior to the fallopian tube

Mesovarium - attaches the ovary to the
broad ligament
Mesosalpinx - part of the broad
ligament attached to the fallopian tube
Infundibulo-pelvic or Suspensory
lig of the ovary - arise from the pelvic
side wall to the lateral aspect of the
ovary, containing ovarian vessels

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MATERNAL NURSING

Ligaments
Uterosacral - from the upper portion

of the cervix it goes posteriorly to the

third sacral vertebra, serves as the
lateral border of the cul-de-sac
Cardinal or Mackenrodts - extends
from the lateral portion of the cervix
and vagina to the pelvic side walls. It is
the condensation of the broad lig
inferiorly. It is the main ligamentous
support of the uterus.

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MATERNAL NURSING

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MATERNAL NURSING

Course of the Ureter

Ureter enters the pelvis at the

bifurcation of the common iliac

artery, descends anterior to the
internal iliac artery, and crosses
inferior to the uterine artery.
At the level of the cardinal lig, the
ureter is about 1 to 2 cm. lateral to
the uterine cervix.

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MATERNAL NURSING

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MATERNAL NURSING

Embryology

Mullerian or Paramesonephric duct

forms the female reproductive tract

Fusion of the two Mullerian ducts in
the midline form the uterine canal
which later meets caudally with the
urogenital sinus.
Mullerian ducts form the Fallopian
tubes, uterus, and proximal part of
the vagina.

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MATERNAL NURSING

Physiology of Ovulation and

Menstruation

Must know:

Know the different hormones

and their respective actions
involved in ovulation, and
menstruation from the
hypothalamus, pituitary, ovary
and its effect on the
endometrium.

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MATERNAL NURSING

Physiology of Ovulation

BRAIN

Hormone

Hypothalamus

GnRH

Anterior
Pituitary

FSH
LH

1/hrfollicular
1/ 2-3h luteal
granulosa
cells
theca cells

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MATERNAL NURSING

Physiology of Ovulation

OVARY

Hormone

Granulosa
cells

Estrogen

increase
granulosa
cells and

Theca cells

Androgens Estrogen

follicular
maturation

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MATERNAL NURSING

Physiology of Ovulation

OVARY

Hormone

Dominant follicle-
Mature follicle (18 22 mm) -
Ovulation --
Corpus luteum Progesterone

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MATERNAL NURSING

Physiology of Menstruation

Hormone

Ovary

Endometrium

Estrogen

Follicular
phase

Proliferative
phase

Progesterone Luteal phase Secretory

phase

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MATERNAL NURSING

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MATERNAL NURSING

Puberty
Must know:

- the proper sequence of physiologic changes

occurring in puberty

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MATERNAL NURSING

Puberty

Events occurring in chronologic

order:
1. Thelarhe - breast devt - 9 yrs.

old
2. Pubarche - appearance of pubic
hair - 10 yrs. old
3. Growth spurt - 12 yrs. old
4. Menarche - 12 1/2 yrs. old
5. Ovulation - 13 1/2 yrs. old

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MATERNAL NURSING

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MATERNAL NURSING

Menstrual Disorders

Must know:

Primary amenorrhea
Secondary amenorrhea
Dysfunctional Uterine
Bleeding

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MATERNAL NURSING

Primary Amenorrhea

The absence of menarche by age

16 years of age in the presence of

normal secondary characteristics
or by 14 years of age when there
is no visible secondary sexual
characteristic development.

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MATERNAL NURSING

Secondary Amenorrhea

Absence of menstruation for six

months in a previously
menstruating woman.
Most common cause of

physiologic secondary
amenorrhea is pregnancy
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MATERNAL NURSING

Dysfunctional Uterine Bleeding

Abnormal bleeding without an

obvious anatomic or organic

pathology.
Usually is anovulatory
secondary to a persistent
graafian follicle.
Estrogen is the predominant
hormone leading to
endometrial stimulation --->
endometrial hyperplasia.
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MATERNAL NURSING

DUB

Bleeding is caused by slight

withdrawal of estrogen,
unopposed by progesterone
leading to endometrial
shedding and irregular
bleeding.

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MATERNAL NURSING

DUB: Treatment

Medical:
Cyclic progesterone
Cyclic estrogen and
progesterone
Ovulation induction eg.
Clomiphene

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MATERNAL NURSING

DUB: Treatment

Surgical:

Fractional curettage

Endometrial ablation

Hysterectomy for recurrent DUB

cases unresponsive to medical
treatment

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MATERNAL NURSING

Menopause
Menopause is the absence of

menstruation for 6 to 12
months occurring on the
average at age 50 years.
Climacterium is the phase

preceding menopause
characterized by irregular
ovulation and menstruation
with subjective symptoms.
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MATERNAL NURSING

Menopause
Is the result of the gradual

decrease in secretion of ovarian

estrogen due to progressive
diminution in the number of
functional ovarian follicles.
Ovarian stromal cells continue to
secrete testosterone for a time
which is aromatized to estradiol in
fat and liver.
Adrenal and ovarian
androstenedione is likewise
aromatized to estrone.
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MATERNAL NURSING

Menopause

As estrogen and progesterone

production decreases, the

negative feedback to the
hypothalamus and pituitary is
reduced leading to increased
levels of FSH and LH.

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MATERNAL NURSING

Symptoms
Hot Flash - Sensation of intense

heat and flushing of the skin,

principally that of the head, face,
neck, chest, back followed by
profuse diaphoresis.
May last for a few seconds to a
few minutes.
Diminish in severity and
disappear in two years if
untreated.

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MATERNAL NURSING

Physical Changes

Atrophy of the reproductive

tract leading to Atrophic

vaginitis and later
dyspareunia and loss of
libido.
Amount of collagen in the
dermis decreases leading to
thinning of the skin and
wrinkling.
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MATERNAL NURSING

Physical Changes
Bone - resorption exceeds growth

leading to Osteoporosis (loss of

bone density).
Occurs more in White and
Oriental women than in black.
Exacerbated by smoking,
inactivity and use of
corticosteroids.
May be complicated by fractures
of vertebra, long bones and
femoral neck.
Treatment: ERT

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MATERNAL NURSING

Menopause

Cholesterol - There is an increase

in the level of low density

lipoproteins and decrease in the
level of high density lipoprotein.
This increases the incidence of

Atherosclerosis and the risk of

Myocardial Infarction in this age
group.

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MATERNAL NURSING

Treatment:

ERT can lead to stimulation of the

endometrium and breast.

HRT- combination of estrogen and
progesterone, either cyclic or
continuous
SERM - selective estrogen
receptor modifiers has beneficial
effect on the bone and cholesterol
but does not stimulate the breast
and the endometrium, eg.
Raloxifene (Evista).
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MATERNAL NURSING

Fertilization and Implantation

Egg is released in the metaphase II

stage
Completion of second meiotic
division occurs with fertilization
(ampulla of FT)
After 3 to 4 days in the tube, it
enters the endometrial cavity as a
morula (12 -16 cell stage)
Six to seven days after
fertilization, implantation occurs
as a blastocyst.
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MATERNAL NURSING

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MATERNAL NURSING

Embryo and Fetus

embryo - from fertilization to 8 weeks from

ovulation ( 10 weeks by LMP)

- major
organ systems are formed
fetus - from 8 weeks ovulatory age ( 10
weeks by LMP) to term
differentiation and maturation of different
organs occur

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MATERNAL NURSING

Diagnosis of Pregnancy

Presumtive

Presumptive

signs

Sxs

nausea/vomiting
disturbance in
urination
fatigue
perception of
fetal movement
breast
tenderness

amenorrhea
anatomical
breast changes
changes in
vaginal
mucosa(Chadw
icks)
skin
pigmentation
thermal signs

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MATERNAL NURSING

Probable Evidence of Pregnancy

enlargement of

Braxton Hicks

the abdomen
changes in the
size, shape and
consistency of
the uterus
anatomical
changes in the
cervix

contraction
ballotement
physical
outlining of the
fetus
positive results
of endocrine
test

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MATERNAL NURSING

Positive Evidence of Pregnancy

Identification of fetal heart tones

perception of active fetal movements

by the examiner

recognition of the embryo or fetus by

ultrasound or radiologic tests

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MATERNAL NURSING

Maternal Adaptations to
Pregnancy
Uterus - capacity of 10ml to 5

liters
stretching and marked
hypertrophy of existing muscles
formation of new muscles
limited
first 3 months - uterine
enlargement due to estrogen
more than 3 months
enlargement due to effect of
pressure of the expanding fetus

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MATERNAL NURSING

Uterus/ Vagina
Chadwick sign - bluish

discoloration of the vagina and

cervix
softening of the cervix - 4 to 5
weeks
softening of the lower uterine
segment ( Hegars sign) - 6 weeks
Utero-placental blood flow 500ml/min

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MATERNAL NURSING

Ovaries

ovulation and maturation of new

follicles suspended
corpus luteum of pregnancy is the

main source of progesterone for

the first 6 to 7 weeks age of
gestation

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MATERNAL NURSING

Weight Gain

Total of 24 pounds (11 kg)

1st trim - 2 pounds ( 1kg)

2nd trim -11 pounds ( 5 kg)

3rd trim - 11 pounds ( 5 kg)

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MATERNAL NURSING

Blood Volume
Increase in blood volume marked

during the second trimester

Due to
- 40 % increase in plasma
volume
- 20 -30 % increase in RBC
mass
- there is hemodilution leading
to physiologic anemia of
pregnancy

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MATERNAL NURSING

Iron Requirements

Total Fe requirement is 1.0 gm.

- 300 mg to fetus and placenta

- 200 mg to obligatory loss
- 500 mg to formation of new RBCs
Second half of pregnancy - 6 to 7

mg of Fe required daily

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MATERNAL NURSING

Heart

Increase heart rate to 10 to 15 beats/min

heart displaced to the left and upward

Heart sounds:

exaggerated splitting of the 1st heart

sound
a loud third heart sound
Heart murmurs:
systolic murmur intensified on
inspiration

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MATERNAL NURSING

Pulmonary function

increase:

- tidal volume, minute ventilatory

volume, minute O2 uptake
mild increase inspiratory capacity
no change maximum breathing
capacity, vital capacity
decrease - residual volume

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MATERNAL NURSING

Urinary Tract

Increased GFR and RPF

Glucosuria not necessarily

abnormal
Proteinuria not occur normally
Hydronephrosis and hydroureter

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MATERNAL NURSING

GIT

decreased peristalsis leading to

pyrosis ( heartburn),
constipation
Hemorrhoids
predisposes to formation of gall

stones

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MATERNAL NURSING

Thyroid function

Test

Normal
pregnancy

Hyperthyroidism

BMR

Inc

Inc

Total T4

Inc

Inc

Thy binding
globulin

Inc

Not inc

Free T4

Not inc

Inc

Total T3

Inc

Inc

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MATERNAL NURSING

Estimation of AOG
Naegles Rule from LMP add 7 days,

subtract 3 months
Quickening 16 to 20 weeks
Height of Fundus

12 weeks above symp pubis

16 weeks halfway between sym pubis
and xiphoid
20 weeks level of umbilicus

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MATERNAL NURSING

Estimation of AOG

Ultrasound

- First Trimester: CRL +/1 week

- Second/Third Trim:
BPD, HC, AC, FL +/- 2-3
weeks

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MATERNAL NURSING

Initial Comprehensive
Evaluation

History
Physical Examination

Leopolds maneuver
First maneuver: fundal grip
Second maneuver: fetal back
Third maneuver: presenting part
(Pawlicks grip)
Fourth maneuver: cephalic
prominence
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MATERNAL NURSING

Prenatal Care

Paps smear
Pelvic Exam

Laboratory
Urinalysis
CBC, typing
HBSAg
VDRL
50 gms Glucose Challenge test

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MATERNAL NURSING

Frequency of Visits

First missed period

Every 4 weeks until 28 weeks
Every 2 weeks from 28 to 36

weeks
Every weeks from 36 weeks
WHO recommendation: 5
visits, minimum of 3 visits
with the 1st visit during the 1st
trimester
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MATERNAL NURSING

Nutrition in Pregnancy
Weight Gain
Pre-pregancy BMI

Recommended Total
Wt Gain in Kilogram
- Low (<19.8) 12.5 18
- Normal (19.8-26)11.5 16
- High (15-25)7 11.5
- Obese (>29) < 7

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MATERNAL NURSING

Recommended Dietary
Allowance (1989)

Folate and Iodine

supplementation

Safe level intake of Vit D and E

Proportionate intake of the

basic food groups

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MATERNAL NURSING

Calories

Additional 300 kcal/day for the 2nd

and 3rd trimesters

Proteins: 9 gms/day
Carbohydrates:
- 150 gms/day
- 1st trim 225 gms/day
- 3rd trim 50 100gms/day ave.
Fats 15 25 g/day
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MATERNAL NURSING

Iron

Required to replace losses and

for expansion of RBC mass

First trimester: no supplements

needed

Second and Third trimesters:

Supplementation needed Daily

required of 68 mg dietary Fe
- Ave. 41 mg / day

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MATERNAL NURSING

Lie, Presentation,
Attitude and Position

Fetal Attitude relation of the

fetal parts to one another

Fetal Lie relation of the long
axis of the fetus to the long axis
of the mother
- longitudinal
- transverse
- oblique
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MATERNAL NURSING

Presentation

Part of the fetus lying over the

pelvic inlet
- cephalic 95%
- breech 5%
- shoulder rare

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MATERNAL NURSING

Cephalic presentation

Vertex occiput presentation

- the occipital fontanel is

presenting
- full flexion
- shortest AP diameter:
Suboccipitobregmatic 9.5
cm

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MATERNAL NURSING

Cephalic Presentation

Sinciput Military Attitude

- bregma or anterior
fontanel presenting
- partially flexed head
- occipitofrontal
diameter 12.5 cm
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MATERNAL NURSING

Cephalic Presentation

Brow - brow is presenting

partially extended
- occipitomental diameter
13.5 cm (longest)
Face

- chin presenting
- marked extension
- submentobregmatic
diameter 9.5 cm
Notes:
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MATERNAL NURSING

Breech Presentation
Frank

- thighs are flexed on the fetal

abdomen with the legs
extended
Complete
- thighs are flexed and the
legs are flexed
Incomplete
- one or both thighs are extended,
one or two feet/knee and are below
the breech
Notes:
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MATERNAL NURSING

Breech Presentation

Shoulder presentation

- shoulder or an acromion is
presenting in transverse lie
Compound presentation

- prolapse of fetal hand

together with the head or
breech
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MATERNAL NURSING

Position

Position the relation of a chosen

portion of the presenting part of

the fetus as to the right or left side
of the maternal birth canal:
- right or left

Notes:
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MATERNAL NURSING

Variability

Relation of a chosen portion of

the presenting part of the fetus

as to anterior, transverse or
posterior portion of the
maternal pelvis
- transverse
- anterior
- posterior

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MATERNAL NURSING

 Points of reference

O Occiput
M Mentum
S Sacrum
A Acromion
In shoulder presentation the side of
the mother towards which the
acromion is directed determines if it
is right or left.
Direction of the fetal back
determines if dorsoanterior or
dorsoposterior
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MATERNAL NURSING

Diagnosis of Presentation
and Position

Leopolds maneuver

Vaginal Examination
Sonography

Notes:
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MATERNAL NURSING

Fetal Surveillance

Inspection
Palpation

Size and shape of growing

uterus
Observe and feel gross fetal
movements

Notes:
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MATERNAL NURSING

Fetal Surveillance

Fetal Movement

- first perceived at quickening

- increases as pregnancy progresses
- daily fetal movement count in high
risk pregnancies advocated

Notes:
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MATERNAL NURSING

Fetal Surveillance
Contraction Stress Test or Oxytocin

Challenge Test

- mimic uterine contractions of

labor
- three contractions (40-60
secs) in ten minutes

- observe fetal heart pattern on

Electronic Fetal Monitor
Notes:
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MATERNAL NURSING

Oxytocin Challenge Test

Negative - No decelerations
Positive - Persistent Late

Decelerations (> half)

Suspicious - Late Dec. but < half
Hyperstimulation
Excessive uterine contractions
Unsatisfactory
No adequate contractions

Notes:
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MATERNAL NURSING

Fetal Surveillance

Nonstress Testing

- records FHR acceleration in

response to Fetal Movement
- test of fetal condition
- easier to perform

Notes:
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MATERNAL NURSING

Nonstress Test

Reactive Nonstress Test

- increase of FHR of 15
beats/min for longer than 15
secs. after fetal movement

Non-reactive Nonstress test

- no increase in FHR

Notes:
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MATERNAL NURSING

Fetal Surveillance

Biophysical Profile

- Fetal Breathing
- Fetal Movements
- Fetal Tones
- Fetal Heart Reactivity
- Amniotic fluid Volume

Notes:
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MATERNAL NURSING

Biophysical Profile
Score 2

Fetal breathing 1.
30 secs FB in 30
min
2.
2. Fetal Movements
- 3 or > gross BM
3. Fetal Tone 1
3.
limb flexionextension- flexion
1.

Score 0
Less than 30 sec
FB movements
Two or < gross
BM
Limb in
extension or
semi-extension
no or slow
return to flexion

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MATERNAL NURSING

Biophysical Profile

4. No or < 2 FH
4. Fetal Heart
accelerations
Reactivity- 2 or >
FH accelerations
5. AFV 2 pockets 5. Largest pocket < 1
of AF at least 1 cm cm
each

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MATERNAL NURSING

Biophysical Profile
10/10 or 8/8
8/10 normal AF

Normal

6/8, 8/10
decreased AF

Chronic fetal
asphyxia

6/8 normal AF
4/8
0-2

Possible asphyxia
Probable asphyxia
Certain of fetal
asphyxia

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MATERNAL NURSING

External intrapartum
assessment
2 transducers
Involves the use of a fetal monitor

Uses the Doppler principle

- fetal heart rate

- uterine activity (contractions)

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MATERNAL NURSING

Electronic Fetal Monitoring

Serve as a screening test for

severe asphyxia
Diagnose fetal distress
Decrease incidence of fetal
morbidity and mortality

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MATERNAL NURSING

 Recognition of early asphyxia so

that timely obstetric intervention

can be instituted

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MATERNAL NURSING

Notes:
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MATERNAL NURSING

Notes:
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MATERNAL NURSING

Variability

Fluctuations in baseline FHR of 2

cycles/minute or greater
Fluctuations are irregular in
amplitude and frequency
Normal: 6-25 bpm

Notes:
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MATERNAL NURSING

Variability
Short-term variability

- beat to beat fluctuations in

FHR
Long-term variability
- amplitude excursions
- visually determined
approximate amplitude range of
the fluctuations

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MATERNAL NURSING

Notes:
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MATERNAL NURSING

Acceleration

Abrupt increase in fetal heart rate

of at least 15 bpm, at least 15

seconds, less than 2 minute
duration in a 10 minute tracing
Prolonged acceleration: 2-10
minutes
If acceleration > 10 minutes,
already a baseline rate change

Notes:
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MATERNAL NURSING

Deceleration

Early (type I)

Late (type II)

Variable (type III)

Notes:
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10
0

MATERNAL NURSING

Deceleration

Transient episode of slowing of the

fetal heart rate below the baseline

level of more than 15 bpm and
lasting 15 seconds or more
If rate is below 110 bpm and

duration is > 10 minutes,

bradycardia
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MATERNAL NURSING

Early deceleration

usually associated with head

compression
generally seen in active labor
between 4 and 7 cm dilatation
not associated with fetal hypoxia,
acidemia or low Apgar scores

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MATERNAL NURSING

Notes:
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MATERNAL NURSING

Late Decelerations

smooth, gradual symmetrical

decrease in FHR beginning at or

after the peak of the contraction
return to baseline after the
contraction has ended
usually but not invariably
pathological

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MATERNAL NURSING

Late Deceleration

magnitude not more than 30-40

bpm
in milder cases, can be a reflex to
CNS hypoxia
in more severe cases, may be the
result of direct myocardial
depression

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MATERNAL NURSING

Notes:
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MATERNAL NURSING

Variable Deceleration

Onset of deceleration varies with

successive contractions
Due to umbilical cord
compression
Reflex that reflects BP changes
due to interruption of umbilical
blood flow or changes in
oxygenation

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MATERNAL NURSING

Notes:
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MATERNAL NURSING

Variable Deceleration

appearance of the dip is variable

in duration, depth and shape
from contraction to contraction
usually abrupt in onset and
cessation
described as severe when the
decelerations are below 70 bpm
and longer than 60 seconds in
duration

Notes:
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MATERNAL NURSING

Other Intrapartum Fetal Assessment

Techniques

Fetal scalp blood sampling

Scalp stimulation

Vibroacoustic stimulation
Fetal pulse oximetry
Intrapartum Doppler velocimetry

Notes:
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MATERNAL NURSING

Fetal scalp blood sampling

pH of fetal scalp blood measured

Fetal acidosis
pH > 7.25

observe labor
pH 7.20-7.25 repeat testing
pH < 7.20
immediate
delivery

Notes:
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MATERNAL NURSING

Notes:
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MATERNAL NURSING

Color Flow Doppler

Uses Doppler Principle in measuring

vessels supplying the fetus

Trophoblastic proliferation losses the
muscular layer of vessels of the
uterus
Leads to decrease in resistance to
flow of blood

Notes:
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MATERNAL NURSING

Color Flow Doppler

Normal Pregnancy

- decrease in resistance at 20-24

weeks
- good systolic and diastolic flow
Utero-Placental Insufficiency

- increase in resistance at 20 24
weeks
- decreased, absent to reversed
flow during diastole
Notes:
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114

MATERNAL NURSING

Color Flow Doppler

Resistance Index
Pulsality Index
Systolic/Diastolic Ratio

Notes:
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MATERNAL NURSING

ACKNOWLEDGMENT OF RECEIPT

Student Copy

ACKNOWLEDGMENT OF RECEIPT

I hereby acknowledge the receipt of this Student Handbook.

__________________________
(Signature of Client)
____________
Date

---------------------------------------------FNCC Copy

ACKNOWLEDGMENT OF RECEIPT
I hereby acknowledge the receipt of this Student Handbook.
__________________________
(Signature of Client)
____________
Date

FNCC in partnership with UV

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MATERNAL NURSING