Maternity Nursing Lecture Presentation

MATERNITY NURSING Prepared by: Fely Rodriguez, RN, RM, MN

ANATOMY EXTERNAL  PUDENDA

/ VULVA- includes all structure visible externally from pubis to perineum that includes: 1. 2. 3. 4. 5. 6.

MONS PUBIS LABIA MAJORA LABIA MINORA CLITORIS VESTIBULE PERINEUM

INTERNAL



 

 

Measurement: 3 -4 inches between bladder and rectum function: ph 4.5 – 5.5 (acidic doderline bacilli rugae permits considerate stretching without tearing post vaginal canal vascular supply

Main: Internal Iliac Artery Upper third = cervicovaginal branches middle third = inferior vesical artery lower third = middle rectal and internal ppudendal arteries

•

VAGINA

 lymphatics   

or drains into:

upper- ileac nodes middle- internal ileac nodes lower- inguinal lymph nodes

•

VAGINA

Parts: 2 major unequal parts  

2. UTERUS the upper 2/3, triangular portion the lower 1/3, cylindrical portion

Layers 

endometrium/mucusal layer/DECIDUA myometrium/muscular layer



perimetrium/serosal layer



2. UTERUS •measurements: • NP- 3 inches long, 2 inches wide, one inch thick • Preg.- 32 cms, 24 cms., 20-24 cms •weight: NP= 50-60 gms • P= 1000 gms (immediately after delivery •capacity : 10 ml – 75 ml cavity {ave. of 30 ml} 5 L at term • 20 L- can hold at this maximum

2. UTERUS •Function: organ of menstruation organ of pregnancy/implantation labor power-powerful contract

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Size and Shape of uterus  

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original n-p shape –pear shape as pregnancy advances by 3rd lunar month-globular S. subsequently uterus   



2. UTERUS

increase rapidly by length decrease not width giving-ovoid shape end of 12 weeks-uterus becomes an abdominal organ for it become too large to remain in pelvis

vascular supply 

uterine and ovarian arteries

3. FALLOPIAN TUBES/OVIDUCTS

measurements: 8-14 cm./ 4 inches tube Parts: 1. interstitial-insertion in uterine wall 2. isthmus-narrowest portion 2-3 mm 3. ampulla-widest 5-8 mm 4. infundibulum- fimbrae, fingerlike projections Layers: outer longitudinal layer inner circular layer

3. FALLOPIAN TUBES/OVIDUCTS 

Function   



site of fertilization passageway of ovum from ovaries passageway of sperm from uterus

Note: 



5 minutes-sperm as quickly as this reach site of fertilization from time of ejaculation 12-24h average-mature ovum is capable being fertilized after ovulation

4. OVARIES

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FUNCTION 1. cardinal and primary function 2. endocrine PARTS 1. cortex 2. medulla Almond shape mittleschermz-pain during ovulation due to rupture of follicle, fluid and blood escape into peritoneum and irritates Lifetime history of germ cell maturation

Testis semineferous gland interstitial Epididymis-stores where it matures and it becomes motile vas deferens- passage of sperm prostate gland secret alkaline fluid for sperm to swim cm 2.5-3.5 glandular structure that surrounds the neck of bladder and urethra Bulburethra/ cowpers gland

72 hours- normal lifespan of sperm outside male’s body or after ejaculation to woman genital in normal men, semen volume and density decreases when ejaculation occurs more often than 48hrs right testis is lower than left because the large liver wide space to occupy and pushes it composition of semen 1. Sperm a. head b. body c. tail 2. secretions by seminal vesicle 3. prostate gland 4. cowper’s/bulbourethral gland

PHYSIOLOGY –MENSTRUATION – periodic discharge of bloody fluid from uterus occurring at more or less regular intervals during the life of a woman for puberty to menopause  Menstruation E  stim

and P low

Hypo to release GnRH {FSHRF&LHRF}

 release

FSHRF triggers

 APG-FSH

 acts

on follicles of ovary, but only one will grow and develop GF-growing and developing primoidial follicle called Graafian follicle  as



GF grows and develop produces ESTROGEN

in response to increase estrogen 

lining of uterus starts to thicken



cervical glands produce sticky, cloudy, flaky mucus discharge giving a woman sticky sensation around the vagina

 as

GF full matures E is at its peak and man levels of estrogen

HYPO stop prod. FSHRF-APG-Stop FSH simultaneously produce LHRF-APG- LH 

2. 3.

 acts

on matured GF causing it to rupture and release  process

called ovulation

 the



ruptured follicle becomes a yellow body called CORPUS LUTEUM produces and release progesterone

 supports

 spongy,

further growth of endometrium becomes

very thick, rich in mucus and b.v (vascular and tortous) making is a perfect bed for possible implantation

P 

reach its peak and no fertilization stimu. – HYPO- to stop LHRF  APG

stops LH  Causes the CL to degenerate in 14 days as its normal life span,a drop in Pragesterone causes the  Shedding

or sloughing of endometrial lining= MENSTRUATION

Success of menstruation depends on different 4 body structure involved and its interaction 1. HYPO FSHRF & LHRF 2. APG FSH & LH 3. OVARY E/P 4. UTERUS

Phases of Menstrual Cycle 1. 2. 3.

A. UTERINE RESPONSE:

Menstrual Phase Proliferative Secretory phase

B. OVARIAN RESPONSE 1. 2.

FOLLICULAR PHASE LUTEAL PHASE

AMNIOTIC FLUID



 

COLOR – clear to cloudy Green Yellow Port wine stain Coffee Brown 1st nsg.action when BOW ruptures NITRAZINE TEST

N. Value: 500-1000cc  Associated Problem: Oligo –scanty amount of A.fluid less than 500cc which may result to fetal distress coz no enough fluid to equalize the pressure Polyhydramnios: excessive amount of A.fluid > 1500-2000cc w/c may result to preterm labor or uterine rupture 

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

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S/S: 1. abnormality in FHT 2. increase fetal thrushing/ movement 3. Meconium stained A.fluid TYPES: 1. F. Tachycardia 2. F. Bradycardia CAUSES: 1. Oligohydramnios 2. 3Cs-cord compressions, coil, prolapse 3. PIH,GDM 4. Bleeding 5. Abruptio placenta

 COMPOSITION:

3 vessels wharton’s jelly  Absence of pain receptors/ nerve endings  N.Lenght : 30-80 cms (ave. of 55cms)  Associated Problems: too short too long mechanical abruptio cord coil uterine inversion cord compression cord prolapse

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

 

FORMATION: formed by 8th wks develops/fxnal by 10-12th wks time bounded til 42 wks only FUNCTION: 1. respiratory 2. GIT 3. circulatory 4. endocrine 5. protects the fetus WEIGHT: 5OO gms, 5 cms thick, composed of 15-20 cotyledons. PARTS : 1. Maternal part / side 2. Fetal part / side

FETUS Summary:  1st

trimester  2nd trimester  3rd trimester

organogenesis fetal organ form development of fetal length rapid deposition of subcutaneous tissue

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1st Lunar Month  

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2nd lunar 

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Start deposition of the SC, disappearance of lanugo

9th lunar 

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alveoli

8th lunar 

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sensory receptors are well established

7th lunar 

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Vernix, Quickenning, FHT by stet, age of viability

6th lunar 

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Lanugo, FHT

5th lunar 

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Function

4th lunar 

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all organs formed is continued/ sex differentiation& formation/ placenta full development

3rd lunar 

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GERM layer differentiation VITAL ORGAN formation

Peak of SC deposition, disappearance of vernix caseosa

10th lunar characteristics of a FT infant is achieved

DIAGNOSIS NORMAL

DURATION

SIGNS NORMAL

ADAPTATION

DIAGNOSIS OF PREGNANCY  Urine

examination  Uterine soufflé  Funic soufflé  ultrasound/quickening

NORMAL DURATION/LENGTH OF PREGNANCY  MONTHS: 10

lunar month 9 calendar month  WEEKS

: 38 – 42 Wks (ave. of 40 weeks )  DAYS : 280 days -singleton  260

days  247 days

twins triplets

Signs of Pregnancy Presumptive

Probable

Positive

1. amenorrhea

Vagina = Chadwick’s Cervix = Goodell’s sign Uterus = Hegar’s sign

FHT FETAL MOVEMENT FETAL OUTLINE

2. Urinary frequency

Enlarged abdomen

3. Am sickness

ballotement

4. Breast changes

Braxton Hick”s contraction

5. Skin pigmentation

(+) Pregnancy test

6. quickening

2 Common Problems  

leukorrhea alkaline envi  



GIT     

   

trichonomanas vaginalis Moniliasis AM sickness- due to progress Hyperemesis gravidarum constipation flatulence hemorrhoids Heartburn

Respiratory –shortness of breath Cardiovascular - 30-50% increase the cardiac volume results to physiologic anemia Renal urinary frequency,decrease threshold for sugar (coz of increase GFR), stasis in the urine Musculoskeletal - “pride of Pregnancy” – Lordosis Relaxin is increase causing wobbly joints

IV. PRE NATAL CHECK UP SCHEDULE COMPONENTS HEALTH

TEACHINGS

COMPONENTS OF PRENATAL I. Schedule A. B. C. D.

Every month - 1 to 8 months or from the time pregnancy is detected -32 weeks AOG Twice a month / every 2 weeks – 32 to37 wks Weekly 37weeks – birth or EDB 2X A Week for all Post term or > 42 wks

II. Components A. B. C.

Health history taking- G,P, OB Score, LMP assessment – VS, Wt.,LM, Pap Smear, Pelvimetry laboratory/ diagnostic procedure

A. History Taking 

includes: personal data; medical data; family history; OB-Gyne History 

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  

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Gravida- total number of pregnancy regardless of outcome parity- total number of pregnancy that has reach the age of viability whether dead or alive viability – ability of the fetus to live extrauterine life OB score T-P-A-L Past Pregnancy- method, where, whom, complication, risk Present pregnancy

IMPORTANT ESTIMATES OF AOG & EDB 





NAGELE’S RULE -3+7 if April – Dec +9+7 if Jan Feb & March Mc DONALDS RULE FH in cms X2 divided by 7 = AOG in mos. X8 = AOG in wks BARTHOLOMEW’S RULE Important landmarks : 1. symphysis pubis 2. umbilicus 3. xiphoid process

10 Danger signs 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

vaginal bleeding swelling of face and hands cont. HA dimness/blurring of vision flashes of lights before the eyes persistence of vomiting pain in abdomen chills/fever sudden escape of fluid from vagina (-) FHT/movement

TERMS  nulligravida-

never been pregnant  primigravida- pregnant for the 1st time  primipara-woman who deliveries only once of a fetus who has reached viability  multigravida- 2 or more successive  multipara-2 or more deliveries  grand multigravida- 6 or more pregnancy  grand multipara- 6 or more deliveries to viability

ASSESSMENT  VS  WEIGHT

: allowable weight gain : 20 – 25 lbs wt. distribution : 1st tri – 1 lb/mon 2nd & 3rd – 1 lb/wk pattern of wt. gain : a.3,5,12 b.5,5,12 c.3,12,12 d.5,12,12

ASSESSMENT  LEOPOLD’S

MANNEUVER LM1 - fundic grip LM2 – abdominal/umbilical grip LM3 – Pawlik’s grip LM4 - pelvic grip

ASSESSMENT  PATIENT

1. 2. 3. 4.

PREPARATION: Explain procedure Empty bladder Put patient on proper position Palpate with warm hands

ASSESSMENT  PAPANICOLAU

SMEAR – is a diagnostic cytological test for early detection of cervical cancer.  INDICATIONS: 1. All married women 2. single but sexually active 3. post partum women from 6 wks – 6 mos. 4. single not sexually active but more than 40 yrs old.

ASSESSMENT CLASSIFICATION: CLASS I CLASS II CLASS III CLASS IVCLASS V -

normal atypical cell is present suggestive of malignancy strongly suggestive of malignancy conclusive of malignancy

STAGES: Stage I Stage II Stage III

-

Stage IV -

confined in the cervix invades the vagina diffuses on the entire reproductive metastasis on the anterior bladder & posterior rectum

C. Labs & Diagnostic procedures  CBC

Hgb , Hct – 0.35 – 0.45  Blood typing  Urinalysis – (+) albumin = PIH (+) sugar = GDM (+) Pus = UTI  Gram stain – presence of yeast cells & hyphae -- pres. Of gm(-) diplococci -- presence of T. vaginalis



Ultrasonography: 1. AOG 2. Sex of baby 3. amount of amniotic fluid 4. locates the placenta 5. Ectopic pregnancy,H-mole 6. Gyne: tumors, cyst,myomas 7. limited congenital anomalies

HEALTH TEACHINGS  NUTRITION  IMMUNIZATION  DRUGS  EXERCISE  SMOKING,

ALCOHOL INTAKE, RADIATION EXPOSURE  SEX  EMPLOYMENT

Nutrition  malnutrition

causes

 iron  CHON  Vitamin

C

 Caloric  Folate/

Folic acid  Iodized salt  Minerals

IMMUNIZATION DRUG CATEGORY INTERPRETATION A. Shows no risk to fetus B. no evidence of risk to humans (both animal and human finding at risk) C. risk cannot be ruled out E. (+) evidence of risk (research/studies shows) x. Shows risk & teratogenic effects on fetus

 Tetracycline

staining of the teeth & long bones  Streptomycin damages CN8= conge nital deafness  Chloramphenicol- Gray Baby Syndrome  Safest:

-

Penicillin, Erythromycin

 Salicylates/Aspirin

-Bleeding tendencies, Abortion  Acetamenophen – premature closure of PDA  Safest antipyretic/analgesic: Paracetamol

 ACE

Inhibitors

-

conginatal renal anomaly  Steroids/Phenobarbital- cleft lip & palate  Iodides - enlargement of the thyroid  DES or Diethylstilbestrol – CA of the repro ductive organ later in adult life

HEALTH TEACHINGS cont.     

Avoid Smoking=LBW No ROH intake= MR Avoid radiation exposure = Abortion Sex Employment = role modification, identification of occupational risk

 2. 4. 6. 7.

9.

EXERCISE Pelvic Rock=low backache Kegel’s = pelvic pressure / congestion Walking Modified Knee Chest exercise = relieves discomforts of hemorrhoids, cramps in the thighs & buttocks Squatting/Tailor Sitting – strenghtens perineal muscles

For CGFNS : NST vs CST, AMNIOCENTESIS, RUBELLA TITIER  NST

or FAD TEST - determines fetal fetal response to every fetal movement. An increase of 15 bpm is expected @ each movement means REACTIVE result. Mothers who has been sedated or was not able to take a good meal prior to the NST may yield a false Non Reactive result & not necessarily mean a Non re assuring fetal well being.

DIFFERENCE OF FALSE LABOR

From

TRUE LABOR PAINS

Assessment tool/criteria” 1. Uterine contraction

Irregular u.c. in terms of duration, interval& freq.

Becoming regular w increasing intensity

2.Location of pain

Confined in the abdomen

Radiates at the lumbosacral region (back)

3.ambulation

Decreases uterine contraction

Worsens uterine contraction

4. Sedation

Relieves of the pain

5.IE

No progression of cervical dilatation & effacement

No amt of sedation can relieve the pain only anesthesia (+) c.dilatation and effacement

Dilatation stage Def

Expulsion Stage Def

Placental Stage Def

Ambulation

N.Duration

N.

4Ps of Labor Passageway Power Passenger Psyche  Phases of Labor Medications Anesthesias Monitoring

Episiotomy



Mod

Ritgen’s manneuver Mech. Of Labor

Duration S/S of Placental Separation Brandt Andrews Manneuver Types of Placental Delivery Medications

Recovery Stage Def Degrees of laceration  location of fundus  lochia

TYPES OF PELVIS 1. 2. 3. 4.

ANDROID ANTHROPOID GYNECOID PLATYPELLIOD

POWER  SOURCE:

Primary = uterine contractions Secondary = abdominal muscle during the bearing down  INTENSITY: Mild, Moderate,Strong 

PHASES: 1. INCREMENT 2. ACME 3. DECREMENT



MONITORING: Duration- beginning to end of the same contraction. Interval – end of one contraction to the beginning of the next Frequency – beginning of one to the beginning of the next contraction

POSITION 



IS THE RELATIONSHIP OF THE FETAL PRESENTING PARTS TO THE FIXED QUADRANTS OF THE MATERNAL PELVIS POINT OF REFERENCE/ COMMON DENOMINATOR: VERTEX = “OCCIPUT” FACE = “ MENTUM” BREECH = “ SACRUM ’’ TRANSVERSE = “ ACROMIUM”

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Cranial bones 1. frontal 2. occiput 3. parietal Membrane spaces/suture lines - important they allow bones to move and overlap and change shape to fit in birth canal called molding 1. sagittal suture-membranes interspace which join 2 parietal bones 2. coronal suture- frontal bone and 2 parietal bones 3. lamboidal- occiput and parietal Fontanelles- membrane covered spaces at the junction of the main suture line

 3.

4.

Measurements anteroposterior diameters  occipito mental = 13 cms  occipitofrontal = 12cms  suboccipitopregmatic = 9-9.5 cms Transverse Diameter a. b. c.

biparietal D. = 9-9.5 cms Bitemporal D. = 8 cms Bimastoid D. = 7 cms

Phases of labor IE

INTENSITY

ACTIVITY

LATENT

0-3 cms

Mild

talkative

ACTIVE

4-7 cms

Moderate

TRANSI TIONAL

8-10 cms

PHASES

Fear of losing ctrl uncontrolla ble

SECOND STAGE OF LABOR Known as the  Normal Duration: Primi = 80 mins Multi = 3o mins  Modified Ritgen’s Manneuver – is the forward upward pressure applied in the perineum with the main purpose of preventing laceration as well as promote flexion of the head in brow presentation.



MECHANISM OF LABOR  Occurs

in chronological order of : “EDE FIRE ERE”  1. engagement 5. descent 2.flexion 6. internal rotation 3. extension 7. expulsion 4. external rotation  A.1234567 c. 1526347 b. 1357246 d. 1425367

THIRD STAGE OF LABOR  Known  Normal

as the

Duration: 3 – 20 mins. Average: 10 mins Maximum : 2 hrs  Placenta Accreta – is an abnormally adherent placenta,managed by manual exploration and hysterectomy.  S/S of Placental separation: CALKIN’S SIGN – the earliest sign  Types of Placental Separation:

Medications of 3rd stage of labor Difference Mechanism of Action Route of Administration Side effects

Oxytocin Rhythmic uterine contraction Continous IV drip (incorporation)

Methergin Sustained uterine contraction IM

Hypotension Water intoxication

hypertension

Nursing Responsibilities

Check BP – X if 90/60 Given after bb out

Possible Complications

Uterine rupture

Check BP –X if 130/90 Given only after placental delivery Placental entrapment leads to massive bleeding

4 Stage of Labor th

 Known

as the  Degrees of Laceration: 1st – vaginal skin (Fourchette) 2nd – vag.skin muscles, & mucosa 3rd – 2nd degree + extends into the external anal sphincter 4th - 2nd degree + rectal mucosa

 LOCATION

OF FUNDUS:

Immediately after delivery

- slightly above the level of umbilicus 1st 24 hrs (12-24 hrs)- @ the level of umbilicus PPD1 - 1 fingerbreadth below the umbilicus

PPD10

The involution of the uterus subsides @ 1 fingerbreadth per day. - (-) Palpate coz its behind the symphysis pubis

LOCHIA  COMPOSITION: All but one is a normal composition of lochia: a. shreds of decidua b. small clotted blood with mucus c. WBC d. bacteria e. amniotic fluid

 PATTERN

: 1. RUBRA - 1ST 3 DAYS POST PARTUM(shreds decidua) 2. SEROSA - 4th-10th day post partum(brownish vag.disch) 3. ALBA -10th day- 6th wk (whitish – yellowish non foul smelly vaginal discharges