Review Of Concepts And Intrapartal Handout Mcn

MATERNAL AND CHILD NURSING Prepared by: Ma. Reina Rose D. Gulmatico, RN, MSN I. FEMALE REPRODUCTIVE ANATOMY AND A. External Reproductive Organs

PHYSIOLOGY

Mons Pubis (Mons Veneris) – (Mount of Venus) is a pad of fat lying over the symphysis pubis; covered with pubic hair from the time of puberty Labia Majora (Greater lips) – are two folds of fat and areolar tissue, covered with skin and pubic hair on the outer surface; arise in the mons veneris and merge into the perineum behind. Labia Minora (Lesser lips) - two folds of the skin between the labia majora; anteriorly, they divide to enclose the clitoris; posteriorly they fuse, forming the fourchette Clitoris - rudimentary organ corresponding to the male penis; extremely sensitive and highly vascular and plays a part in the orgasm of sexual intercourse Vestibule - area enclosed by the labia minora in which encloses the openings of the urethra and the vagina Vaginal orifice- also known as the introitus of the vagina and occupies the posterior two-thirds of the vestibule; partially closed by the hymen, a thin membrane that tears during sexual intercourse or during birth of the first child Skene’s Glands- either side of the meatus which are often involved in infections of external genitalia Bartholins Glands - are two small glands which open on either side of the vaginal orifice and lie on the posterior part of the labia majora. They secrete mucus which lubricates the vaginal opening. B. Internal Reproductive Organs THE VAGINA Structure: vaginal walls are pink in appearance and thrown into small folds called the rugae that stretches during intercourse and delivery. Functions: a passage that allows the escape of the menstrual flow receives the penis and the ejected sperm during sexual intercourse and provides an exit for the fetus during delivery

THE UTERUS Structure hollow, muscular, pear-shaped organ situated in the true pelvis the cervix forms the lower third of the uterus Functions to shelter the fetus during pregnancy contents

and following pregnancy it expels the

uterine

Parts of the Uterus Body or corpus – makes up the upper two-thirds of the uterus and is the greater part Fundus – domed upper wall between

the insertions of the uterine tubes

Cornua – are the upper outer angles

of the uterus where the uterine

Cavity – potential space between the

anterior and posterior walls

tubes join

Isthmus – narrow area between the cavity and the cervix that enlarges during pregnancy to form the lower uterine segment Cervix or Neck – protrudes into the vagina; supravaginal (upper half)- above the infravaginal portion (lower half)

vagina

Layers of the Uterus Endometrium - forms a lining of ciliated ephitelium (mucus membrane) on a base of connective tissue (stroma) Myometrium (muscle coat)- thick in the upper part of the uterus and is more sparse in the isthmus an cervix. Perimetrium D. UTERINE TUBES Functions •

The uterine tubes propels the ovum towards the uterus, receives the spermatozoa as they travel upwards and provides a site for fertilization. It supplies the fertilized ovum with the nutrition during its continued journey to the uterus.

Structure •

Each tube is 10 cm long. The lumen of the tube provides an open pathway from the outside to the peritoneal cavity. The uterine tube has four portions:

a) The interstitial portion – is 1.25 cm long and lies within the wall of the uterus. It’s lumen is 1 mm wide. b) The isthmus – is another narrow part which extends from 2.5 cm from the uterus. c) The ampulla – is the wider portion where fertilization usually occurs. d) The infundibulum – is the funnel shaped fringed end which is composed of many processes known as fimbriae. One fimbriae is elongated to form the ovarian fimbria which is attached to the ovary. E. THE OVARIES Functions •

The ovaries produce ova and the hormones estrogen and progesterone.

•

The ovary is composed of the medulla and cortex, covered with germinal epithelium.

Structure

F. THE FEMALE PELVIS Functions • • •

The primary function of the pelvic girdle is to allow movement of the body especially walking and running. It permits the body to sit and kneel. The woman’s pelvis is adapted to child-bearing, and because of its increased width and rounded brim, women are less speedy than men. The female pelvis, because of its characteristics, gives rise to no difficulties during in childbirth, provided that the fetus is of normal size.

Pelvic Bones •

There are four pelvic bones: 1. two innominate (nameless) or hip bones – each innominate bone is composed of three bones:  The ilium  The ischium  The pubic bone 2. one sacrum 3. one coccyx

False Pelvis superior half formed by the ilia; offers landmarks for pelvic measurements; supports the growing uterus during pregnancy; directs the fetus into the true pelvis near the end of gestation True Pelvis- is the bony canal through which the fetus must pass during birth. It has a brim, a cavity and an outlet. inferior half formed by the pubes in sacrum and coccyx behind

front, the ilia and the ischia on the sides and the

1. Inlet entranceway to the true pelvis; transverse diameter is wider than its anteroposterior (AP) diameter * *

Transverse diameter – 13.5 cm. Anteroposterior (AP) diameter – 11 cm.

2. Outlet inferior portion/ lower border of the true pelvis of the pelvis anteroposterior diameter is wider than its transverse diameter 3. Cavity space between the inlet and the outlet contains the bladder and the rectum, with the uterus between them in an ANTEFLEXED position towards the bladder Variation/Types of Pelvis 1. Gynecoid – “normal” female pelvis that is most ideal for childbirth because it is well rounded forward and back 2. Anthropoid – transverse diameter is narrow, AP diameter is larger than normal 3. Platypelloid – inlet is oval, AP diameter is shallow 4. Android – “male” pelvis; inlet has a narrow shallow posterior portion and pointed anterior portion.

MENSTRUAL CYCLE A. KEY CONCEPTS 1. Hormones •Estrogen •Progesterone •Follicle Stimulating Hormone (FSH) •Luteinizing Hormone (LH) 2. Associated Terms • Amenorrhea • Menorrhagia • Metrorrhagia • Polymenorrhea • Oligomenorrhea

STAGES OF FETAL DEVELOPMENT I. FERTILIZATION Site: fallopian tube mature ovum + sperm = (zygote) Gamete: sex cell contains 23 chromosomes Sperm: contains X and Y chromosomes (XY) Ovum: contains X chromosomes (XX)

II. Implantation occurs 7 days post fertilization Fertilized zygote

migrates 3-4 days (uterus)

morulla

mitosis multiplication and floating in the uterine cavity (3 - 4 days)

+ mass of large cells (fluid space)

Blastocysts a. Trophoblast b. Erythroblast Post implantation: uterine endothelium

Apposition A. Adhesion (endometrium) B. Invasion

DECIDUA

Blastocysts a. Trophoblast (outer)- PLACENTA b. Erythroblast (inner)- EMBRYO TROPHOBLAST decidua (endometrium) chorionic villi “falling off” removed after delivery Cytotrophoblast Syncytiotrophoblast a. Basalis (maternal circulation) (inner) (outer) b. Encapsularis (trophobast) c. Vera (remaining portion) Langhan’s

Syncytial

protection for fetal membranes infection *present until 20th – 24th week

SYNCYTIAL

+

Decidua basalis

fetal membranes Amnion Umbilical cord

Chorion

Amniotic fluid

Placenta Fetal Development

A. Amniotic fluid 1. Protective function Shields the fetus against blows or pressures on the mother’s abdomen Protects the fetus against sudden changes in temperature Protects the fetus from infection “Injury, Temperature, Infection” 2. Diagnostic function Amniocentesis (chromosomal abnormalities) Meconium-strained amniotic (fetal distress) 3. Aids in the descent of the fetus during active labor B. Placenta 1. Provides oxygen to the fetus 2. Provisions of nutrients (diffusion through the placental tissues) 3. Feto-placental circulation (osmosis) 4. Excretion of waste products 5. Production of hormones HCG HPL Estrogen Progesterone 6. Protective – inhibits the passage of bacteria and large molecules to the fetus

Stages of human prenatal development: First 12-14 days – zygote From 15th day up to the 8th week – embryo From the 8th week up to the time of birth – fetus I. First Lunar month a. Germ layers: differentiate by the 2nd week 1. Endoderm – develops into the lining of the GIT, respiratory tract, tonsils, thyroids, parathyroid, thymus gland, bladder and urethra

system,

2. Mesoderm – forms into the supporting structures of the body (connective tissues, cartilage, bones, muscles and tendons); heart, circulatory system, reproductive kidneys and ureters 3. Ectoderm – responsible for the formation of the nervous system; the skin, hair and nails; and the mucous membrane of the mouth and anus

b. Fetal membranes (amnion and chorion): 2nd week c. Nervous system: 3rd week d. Fetal heart begins to form at 16th day of life II. Second lunar month a. All vital organs are formed: 8th week. b. Placenta develops c. Sex organs (ovaries/testes) are formed: 8th week Sex determination: conception Sex formation: 2nd lunar month d. Meconium formation: 5th-8th week. III. Third lunar month a. Urine formation: 12th week of pregnancy b. Fetus swallows amniotic fluid c. Feto-placental circulation begins through osmosis: no direct exchange between fetal and maternal blood IV. Fourth lunar month a. Lanugo appears b. Heart beats maybe audible with fetoscope

V. Fifth lunar month a. Vernix caseosa (cheesy covering on entire body to prevent drying of fetal skin) appears b. Lanugo covers entire body c. Quickening (fetal movements) is felt d. Fetal heart beats very audible VI. Sixth lunar month a. Skin markedly wrinkled b. Attains proportions of full term baby VII. Seventh lunar month a. Alveoli begin to form b. Production of surfactant VIII. Eight lunar month a. Fetus is viable b. Lanugo begins to disappear IX. Ninth lunar month a. Lanugo and vernix disappear b. Amniotic fluid volume somewhat

decreases

X. Tenth lunar month – has all characteristics of a normal newborn. FETAL CIRCULATION

NURSING CARE DURING LABOR AND DELIVERY Theories of labor Uterine Stretch theory – any hollow body organ when stretched to capacity contract and empty Oxytocin theory – production of oxytocin from posterior pituitary gland uterine contraction Progesterone Deprivation theory – progesterone inhibits uterine motility Decrease progesterone uterine contraction Prostaglandin theory:

increase prostaglandin synthesis

uterine contraction

Theory of Aging Placenta: decrease in blood supply to the placenta uterine contraction Premonitory/ Preliminary Signs of Labor 1. Lightening - the settling of the fetal head into the pelvic brim *Engagement occurs when the presenting part has descended into the pelvic inlet (station 0) 2. Loss of weight – about 2-3 lbs. 1 to 2 days before labor onset due to decrease progesterone resulting to decrease fluid retention 3. Increased activity level – due to increase in epinephrine level 4. Braxton Hicks contractions- irregular painless, “practice” contractions 5. Ripening of the cervix – Goodell’s sign 6. Rupture of the membranes Important Nursing Considerations: A. Ruptured BOW *Initial Nursing Action: Put her on the bed immediately, then take the FHT Instruct the client not to ambulate: FETAL CORD COMPRESSION

B. Cord Prolapse *Initial Nursing Action: Put her on Trendelenburg position to reduce pressure on the cord. (REMEMBER: Only 5 minutes of umbilical cord compression can already lead to CNS damage even death.) Apply a warm saline-saturated OS on the cord to prevent drying of the cord. 7. Show Sudden gush of blood (pinkish vaginal discharge) *Nursing Implication: Assess for the color of vaginal discharge GREENISH- meconium stained BRIGHT RED- vaginal bleeding SIGNS OF TRUE LABOR 1. Uterine contractions 2. Effacement/ Dilatation In primis, effacement occurs before dilatation (ED) In multis, dilatation proceeds effacement (DE) False vs True Labor Parameters for comparison: 1. Regularity 2. Location 3. Changes in contractions (FID) 4. Absence/ Presence of contractions during activity] 5. Cervical changes

FALSE LABOR PAINS

TRUE LABOR PAINS

Remain irregular

May be slightly irregular at first but predictable within regular and predictable within a matter of hours

Generally confined to the abdomen

First felt in the lower back and sweep around to the abdomen in a girdle-like fashion

No increases in duration, frequency and intensity

Increase in frequency, duration and intensity

Often disappears if the woman ambulates

Continue no matter what the woman’s level of activity is

Absent cervical changes

Accompanied by cervical effacement and dilatation (the most important difference)

Length of Normal labor: Primis- 14 hours Multis- 8 hours 5 P’s of Labor 1. Passenger (Fetus) 2. Passageway (Pelvis) Shape and measurement of maternal pelvis and distensibility of birth canal Engagement: fetal presenting part enters true pelvis (inlet) Primi: two weeks before labor Multi: beginning of labor Soft tissue (cervix, vagina): stretches and dilates under the force of contractions to accommodate the passage of the fetus

3. Power A. Uterine Contractions (involuntary): fingers should be spread lightly over the fundus 1. Frequency: from the BEGINNING of one contraction to the beginning of the next contraction (A-C) 2. Interval: from the END of one contraction to the BEGINNING of the next contraction (B-C) 3. Duration: from the BEGINNING of one contraction to the END of the same contraction (A-B) 4. Intensity: strength of a contraction should be measured during the acme of contraction a. mild b. moderate c. strong A

B

C

B. Voluntary Bearing Down Efforts: use of ABDOMINAL MUSCLES to help expel fetus thru CONTRACTION OF LEVATOR ANI MUSCLES 4. Placenta 5. Psychological response “A positive attitude during labor yields a positive outcome.” A woman who is: relax, aware and participating in the birth process: shorter, less intense labor A woman who is: fearful has high levels of adrenaline which slows uterine contractions

STAGES OF LABOR 1st - Stage of Dilatation 1st - Stage of dilatation: from onset of labor until full dilatation of cervix Phases: Latent phase: 3-4 cm Active phase: 4-8 cm Transition phase: 8-10 cm 1. Latent Phase Duration: 6 hours Cervical dilatation: 3-4 cm Uterine contractions: every 15-30 minutes; short duration; mild intensity Women’s Attitude: excited with some degree of apprehension Support Measures 1. Establish rapport 2. Breathing exercise 3. Encourage ambulation 4. Offer ice chips or fluids 5. Encourage voiding of the client 2. Active/Accelerated Cervical dilation: 4-8 cm Uterine Contractions: every 3-5 minutes; 30-60 seconds duration; moderate intensity Women’s Attitude: afraid of losing control of herself Support Measures 1. Encourage breathing exercise 2. Provide a quiet environment 3. Provide reassurance, encouragement and support 4. Provide comfort (back massage, assisting positioning, support with pillows 5. Provide ice chips for dry mouth

Nursing management/ Health Teaching During Stage 1 1. Ambulation (+) Ambulation – during the LATENT PHASE *to shorten the first stage of labor BUT (-) Ambulation- RUPTURED BOW 2. Diet “No food or fluid please!” On NPO Solid or liquid foods are to be avoided because: Digestion is delayed during labor A full stomach interferes with proper bearing down May vomit resulting to ASPIRATION 3. Enema administration NOT a routine procedure Purposes: A full bowel hinders the progress of labor Expulsion of feces during second stage of labor- INFECTION of the mother and baby Full bowel predisposes to postpartum discomfort Procedure: Enema solution: soapsuds or Fleet enema Optimal temperature of the solution: 105°F to 115°F (40.5 °C-46.1°C) Patient on side-lying position NURSING IMPLICATION DURING ENEMA: (+) RESISTANCE during insertion of rectal catheter: withdraw the tube slightly while letting a small amount of solution enter (+) CONTRACTION: clamp rectal tubing

IMPORTANT NURSING ACTION: Check FHR AFTER enema administration to determine any FETAL DISTRESS Contraindications: Vaginal bleeding Premature labor Abnormal fetal presentation or position Ruptured membranes Crowning 4. Voiding “Please empty my bladder” Should void every 2-3 hours Offer the bedpan if BOW has ruptured because: A full bladder retards fetal descent Urinary stasis can lead to urinary tract infection A full bladder can be traumatized during delivery 5. Breathing Technique DO NOT PUSH OR BEAR DOWN DURING CONTRACTIONS because it leads to: unnecessary exhaustion AND cervical edema (due to repeated strong pounding of the fetus against the pelvic floor); thus interfering with dilatation and prolonging the length of labor ABDOMINAL BREATHING should be encourage to reduce tension and prevent hyperventilation “No to pushing, Yes to breathing!” 6. Position “I need to lie on my side!” Sim’s position SINCE: It favors anterior rotation of the fetal head It promotes relaxation between contractions It prevents Supine Hypotensive Syndrome/Vena Cava Syndrome

7. Monitoring Contractions Vital Signs (Temperature/ BP) A. Temperature: sign of infection due to early RUPTURE OF MEMBRANE B. Blood pressure (q 30 minutes) Should be taken midway/between contractions BECAUSE BP INCREASES during contraction (-) blood going to the uterus (+) blood in the periphery Danger Signals Signs of Fetal distress Signs of Maternal Distress FHT/ FHT Variability NORMAL Fetal heart rate: 120/160 BPM Should be taken midway/between contractions BECAUSE FHT DECREASES during contraction (AS A RESULT vagal stimulation due to fetal head compression by the contracting uterus) Should not be mistaken for UTERINE SOUFFLÉ which synchronizes maternal heart/pulse rate Should be taken: every hour - latent phase every half hour - active phase every 15 minutes – transition INITIAL NURSING ACTION FOR ABNORMAL FHT: Change the mother’s position

Acceleration: visually apparent abrupt INCREASE in FHR; increase of 15 beats per minute or greater and lasts 15 seconds or more; with return to baseline less than 2 minutes a. Periodic: usually encountered with BREECH PRESENTATION Remember: Pressure of the contraction applied to A. Fetal buttock- ACCELERATION B. Fetal head- DECELERATION b. Episodic: increase FHR during fetal movement NORMAL FINDING Deceleration: dominance of PARASYMPATHETIC response described in relation to the ONSET and end of a CONTRACTION and by their SHAPE a. Early- HEAD COMPRESSION visually apparent decrease in an return to baseline FHT normal and benign finding Characteristic: uniform shape early onset due to RISE in INTRAAMNIOTIC PRESSURE as the uterus contracts occurs during the first stage when cervix is dilated to 4 to 7 cm

COMPARISON BETWEEN ACELERATION AN DECELERATION PARAMETERS ACCELERATION DECELERATION DESCRIPTION

transitory increase of fhr transitory decrease of fhr above above baseline baseline

SHAPE

resembles shape of uterine uniform, MIRROR IMAGE OF contraction UTERINE CONTRACTION

early in contraction phase bfore ONSET onset to peak : 30 seconds peak orocurs during contraction end of uterine contraction RECOVERY less than 2 minutes HEAD COMRESSION COMMON CAUSE SPONTANEOUS FETAL MOVEMENT b. Late- UTEROPLACENTAL INSUFFICIENCY occurs after the start of contraction lowest point of decelertion: after peak does not return to baseline until after the contraction is over CAUSE: maternal supine hypotensive syndrome Effect: fetal hypoxia c. Variable: UMBILICAL CORD COMPRESSION decrease is > 15 bpm; lasts at least 15 seconds; returns to baseline in less than 2 minutes from the time of onset SHAPE: U, V , W COMPARISON BETWEEN LATE AN VARIABLE DECELERATION

PARAMETERS

LATE DECELERATION GRADUAL decrease

VARIABLE DECELERATION ABRUPT decrease

SHAPE

uniForm, MIRROR IMAGE OF UTERINE CONTRACTION

U, V, W

ONSET

Late in contraction; after Beginning of the depth < peak of contraction 30 sec; duration of ≥ 15 sec; decrease in FHR is ≥ 1 BPM

RECOVERY

After end of contraction < 2 minutes from onset less than 2 minutes

DESCRIPTION

COMMON CAUSE Uteroplacental Insufficiency

Umbilical Cord Compression

8. Administration of Analgesics (Demerol) Drug of choice: DEMEROL Indication: analgesic, sedative and antispasmodic (CNS DEPRESSION) IMPLICATION TO NURSING CARE: Do not give A. early in labor: Retards progress of uterine contractions B. if delivery is only an hour away : Respiratory depression in the newborn occurs Give if cervical dilatation is already 6-8 cm

9. Administration of Anesthetics Anesthetic of choice: Xylocaine

NURSING CONSIDERATION: On NPO with IV to prevent aspiration and dehydration Types of anesthesia: A. Paracervical – transvaginal injection into either side of the cervix B. Pudendal - through the sacrospineous ligament into the posterior areolar tissues Side effect: (+) ecchymosis to the right of the perineum Ice bag application to the area on the first day to reduce swelling or bleeding C. Low spinal 1. Epidural (caudal) - local anesthetic injected at the lumbar level 2. Saddle block - injection into the 5th lumbar space (+) Anesthesia: perineum, upper thighs and lower pelvis Position: sitting or side-lying position with back aligned NURSING IMPLICATIONS: TYPE of delivery: Forceps delivery (due to loss of coordination in second stage pushing) Adverse effect: POSTSPINAL HEADACHES (due to the leakage of anesthetic into the CSF or injection of air at the time of needle insertion) Management: Increase fluid intake FLAT ON BED without pillows for the first 12 hrs after delivery Common side effects of regional anesthesia 1. Hypotension - due to vasodilator effects of xylocaine Management: Turn to side; prompt elevation of legs; administration of vasopressors as ordered and oxygen

2. Fetal bradycardia 3. Decreased maternal respiration 3. TRANSITION PHASE A. Cervical Dilatation: 8-10 cm B. Characteristics: 1. changes in the mood and intensity of contraction 2. rupture of membrane if (-) ROM: AMNIOTOMY to prevent aspiration of fetus from amniotic fluid CONSIDERATION: “(-) AMNIOTOMY for STATION (-)” to prevent cord compression 3. Prominent SHOW 4. Uncontrollable urge to push during contraction Nursing management: 1. Breathing technique Controlled chest (costal) breathing during contractions 2. Avoidance of Bearing Down 3. Emotional Support 4. Comfort measures (Sacral pressure)

2nd - Stage of Expulsion

begins with complete dilatation of the cervix and ends with the delivery of the baby Mechanisms of Labor /Fetal Position Changes (D FIRE ERE) Descent Flexion Internal Rotation Extension External Rotation Expulsion Nursing management 1. Positioning LITHOTOMY When positioning legs onto the stirrups, put them up at the same time in order to prevent injury to the uterine ligaments 2. Bearing Down technique/ Mc Robert’s maneuver Head crowning: instruct mother NOT TO PUSH, BUT TO PANT (rapid and shallow breathing), so as to prevent rapid expulsion of the baby. Mc Robert’s Maneuver: To prevent shoulder dystocia (+) delivery of the head BUT (-) delivery of the anterior shoulder in the pubic arch Position: woman’s legs are flexed apart with her knees on her abdomen Mc Robert’s Maneuver SACRUM straightens SYMPHYSIS PUBIS rotates PELVIC INCLINATION decreased

freeing the shoulder

3. Breathing Technique 4. Episiotomy Indications: MAIN- TO PREVENT LACERATIONS Prevent prolonged and severe stretching of muscles supporting the bladder and rectum Reduce duration of second stage of labor Enlarge outlet in breech presentations or forceps delivery Types of episiotomy A. Median – from middle portion of the lower vaginal border directed towards the anus B. Mediolateral – begun in the midline but directed laterally away from the anus 5. Modified Ritgen’s Maneuver Apply PRESSURE AGAINST THE RECTUM using sterile towel; drawing it DOWNWARD to aid in flexing the head as the back of the neck catches under the symphysis pubis Apply UPWARD pressure from the coccygeal region to extend the head during the actual birth (to protect the musculature of the perineum) 6. Handling of Newborn Immediately after delivery A. Infant Position: 1. head lower than the rest of the body to allow drainage of secretions 2. NEWBORN is held below the level of the mother’s vulva for a few seconds to allow placental blood to enter the infant’s body through gravity flow

B. Provide warmth by 1. Wrapping the baby in a sterile diaper to keep him warm. C. Place the baby on the mother’s abdomen. The weight of the baby will help contract the uterus. 7. Cutting of Cord Cutting of the cord- until the pulsations have stopped because 50-100 ml. of blood is still flowing from the placenta to the baby at this time Then, clamp twice, an inch apart and cut between. 8. Initial Contact After newborn care, Show the baby to the mother, inform her of the sex and time of delivery Encourage the mother to start breastfeeding of the child. 3rd - Placental Stage 4th - First 2 hours after delivery