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NCM 109: MATERNAL AND CHILD HEALTH NURSING
Chapter 07: NURSING CARE OF THE FAMILY
HAVING DIFFICULTY CONCEIVING A CHILD
STRUCTURE OF AN OVUM
NUCLEUS
o The hart of the egg cell;
o It contains most of the genetic material in
the form of chromosomes.
o This is where the genes are situated.
o An egg, like a sperm, contains half the
number of chromosomes as a normal cell,
i.e. 23 each.
CYTOPLASM
o A gel-like substance that holds all the cell’s
other internal structures, called organelles.
o It is in the cytoplasm that all the cell’s
activities take place to keep it alive and
functioning properly.
o Amongst the more important organelles
are structures called mitochondria, which
supply most of the energy for the cell.
ZONA PELLUCIDA
o An outer membrane of the egg.
o This structure helps the sperm to enter the
egg through its hard outer layers.
CORONA RADIATA
o Surrounds an egg
o Consists of two or three layers of cells from
the follicle.
o They are attached to the zona pellucida
Made by: The Insomniac
o Main purpose: to supply vital proteins to
the cell.
STRUCTURE AND FUNCTION OF A SPERM
o A normal sperm will have the following
characteristics:
 A smooth oval head
The head of the sperm measures
2.5 to 3.5 um in diameter and
4.0 to 5.5 um in length
(um=micrometers).
 They have a well-developed acrosome
that covers 40 to 70 percent of the oval
shaped head
 A slim middle section (body) that is
approximately the same length as the
head
 A thinner tail section that is about 45
micrometer in length
THE SPERM HEAD
o Nucleus – contains 23 chromosomes
o Acromosome
– involved in the recognition of the oocyte
o Contains:
a. Hyaluronidase – corona penetrating
enzyme
b. Acrosin – digests the zona pellucida
MIDPIECE
o Contains tightly packed mitochondria that
provide the energy requires for swimming.
CENTRIOLE
o Located between the head and the
midpiece.
Essential for movement of the pronuclear
for union with the female genome.

NCM 109: MATERNAL AND CHILD HEALTH NURSING
TAIL (FLAGELLUM)
o It is divided into several parts that include:
1.) Connecting Piece – this is the part that
connects the flagellum to the sperm
head
2.) Midpiece – contains mitochondria and
provides energy required for movement
3.) Principal Piece (Axial filament)
4.) End piece
o There have been no previous conceptions.
MOTILITY
o Two types of physiological motility:
ACTIVATED MOTILITY
o The type observed in the early stages of
motility (in the epididymis as well as freshly
ejaculated sperm).
o Gentle movement of the sperm's flagella
from one side to another as the cell moves
along what may appear to be a straight
path.
HYPERACTIVATED MOTILITY
(HYPERACTIVATION)
o This type of motility occurs is in the
female reproductive tract (site of
fertilization).
o Movement is more erratic and more
energy is used for movement.
o Serves to prevent the sperm cell from
getting trapped, propelling through the
reproductive tract (of the female) as well
as enhancing sperm penetration into the
egg (oocyte).
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INFERTILITY
o A term used to describe the inability to
conceive a child or sustain a pregnancy to
birth.
o A couple is said to be infertile if they have
not become pregnant after at least 1 year
of unprotected coitus.
SUBFERTILITY
o Term used rather than “infertility” because
it denotes that couple has a potential to
conceive.
o Affects 8% to 12% of couples desiring
children
o A lessened ability to conceive
PRIMARY SUBFERTILITY
SECONDARY SUBFERTILITY
o There has been a previous viable
pregnancy but the couple is unable to
conceive at present because of a known
condition.
STERILITY
o Inability to conceive due to known cause
such as absence of a uterus.
o The inability to create offspring (children)
as a result of a procedure such as tubal
ligation, hysterectomy, or vasectomy.
TUBAL LIGATION
o Also known as “getting your tubes tied,”
is a procedure in which a woman’s
fallopian tubes are blocked or partially
removed, preventing the chance for
sperm and eggs to meet.
VASECTOMY
o Similar to a tubal ligation, but for males
the tube that allows sperm to travel out
from the testicle is partially removed.

NCM 109: MATERNAL AND CHILD HEALTH NURSING
PREDISPOSING FACTORS: Subfertility
o PREDISPOSING FACTORS:
Age often increases Subfertility
the risk of infertility.
o Infertility can be caused by poor sexual or
lifestyle habits that are easily remedied.
For example: The couple may be using a sexual
lubricant that interferes with the
survival of the man's sperm.
PREDISPOSING FACTORS: Infertility
PREDISPOSING FACTORS: Subfertility
o Infertility can be caused by poor sexual or
lifestyle habits that are easily remedied.
- They may not be having sex often
enough.
- Heavy use of alcohol, tobacco or drugs.
- Starvation diets or anorexia in the
woman.
- Tight underwear or pants in men.
o Stress:
- In a woman, this may cause her periods
to be irregular.
- In a man, stress may reduce his sperm
count.
IMPACTS OF STRESS ON THE BODY
PREDISPOSING FACTORS:
DIGESTIVE Subfertility
SYSTEM
o Disturbed eating habits
o acid reflux
o Diarrhoea or constipation
o Obesity which is linked to a host of other
health problems.
o Extreme stress can also be associated
with diabetes.
o This is because excessive cortisol can
affect the activity of insulin.
o The body can also become resistant to
insulin. This can lead to diabetes.
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CIRCULATORY PROBLEM
o Cardiovascular diseases due to stress-
induced mechanisms are mediated
primarily through increased adrenergic
stimulation.
o Both adrenaline and cortisol (increased
during stress) affect heart and blood
pressure.
o Too much adrenaline makes blood
pressure to go up which in turn affects the
functioning of the heart since the heart has
to pump harder and faster.
o Cortisol also alters bone mineral density
thus affecting the development of new
bones in the body.
SUPPRESSION OF IMMUNE SYSTEM
o The high levels of stress hormones
suppress the release of cytokines
chemicals secreted by Th cells (T helper
cells- a type of T lymphocytes).
o Cytokines regulate both cell-mediated and
humoral immune response in the body.
REPRODUCTIVE SYSTEM (Men and Women)
o Chronic stress may decrease libido and
may even cause erectile dysfunction or
impotence in man.
o Testosterone levels can drop to an extent
that can interfere spermatogenesis (sperm
production).
o In women stress can affect menstrual
cycle.
o It can lead to irregular, heavier or more
painful periods.

NCM 109: MATERNAL AND CHILD HEALTH NURSING
NURSING PROCESS OVERVIEW FOR A COUPLE
WITH SUBFERTILITY
PREDISPOSING FACTORS: Subfertility
ASSESSMENT
o Require many months and many tests, all
of which had the potential to interfere with
a couple’s self- image, self-esteem, and
lifestyle.
o Today, a subfertility investigation is usually
limited to only three assessments:
– Semen Analysis
– Ovulation Monitoring
– Tubal Patency
o Even with this more directed approach to
evaluation, a nursing assessment often
reveals that one or both partners feel
inadequate or angry and frustrated by what
has happened to them and their need to
undergo testing.
NURSING DIAGNOSIS
o Focus on psychosocial issues associated
with the inability to conceive and the
potentially nerve-wracking process of
fertility testing and management.
1. Fear related to possible outcome of
subfertility studies
2. Situational low self-esteem related to the
apparent inability to conceive
3. Anxiety related to what the process of
fertility testing will entail
4. Deficient knowledge related to measures to
promote fertility
5. Anticipatory grieving related to failure to
conceive or sustain a pregnancy
6. Powerlessness related to repeated
unsuccessful attempts at achieving
conception
7. Hopelessness related to perception of no
viable alternatives to usual conception
8. If required tests interfere with a couple’s
relationship (including sexual patterns),
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“sexual dysfunction related to command
performance of subfertility therapy” might
be applicable.
EXPECTED OUTCOMES AND PLANNING
o In establishing expected outcomes with a
couple undergoing fertility testing and
counseling, be certain the couple realizes
even after the reason for their subfertility is
identified, fertility may not be
instantaneous.
o In some instances, a couple may need to
change or modify their goals if tests begin
to show what they first wanted—to have a
child without medical intervention—is
impossible.
o Participation in a support group may allow
a couple to work through the stress fertility
testing places on their lives.
IMPLEMENTATION
o Fertility testing can be costly for a couple
because not all health insurance programs
provide reimbursement for these
procedures.
– Be certain couples are informed
beforehand of specific estimates of the
cost of testing or therapy so they can
budget and plan their resources and the
next steps they want taken.
o It also may help provide them with time for
sharing experiences and increasing
intimacy, helping to compensate for any
decreased enjoyment that comes from
“scheduled” sexual relations.
o Throughout testing, couples need thorough
education about the various procedures
being done.
o Make sure to review any specific
instructions about pre-procedural and
post-procedural care.
– Depending on their motivations, a
couple’s reaction to study results may
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vary from relief, to stoic acceptance, to CAUSES FOR FEMALE INFERTILITY
grief for children never to be born.
1. PELVIC INFLAMMATORY DISEASE (PID)
– Each partner may wonder whether the
o May also develop from bacteria that reach
other will be able to continue the
the reproductive organs through abortion,
relationship if he or she turns out to be
hysterectomy, childbirth, sexual
the subfertile one.
intercourse, use of an intrauterine (IUD)
OUTCOME EVALUATION contraceptive device or a ruptured
appendix.
o Examples of expected outcomes in this
area include:
1.) The patient rearranges work plans to
manage the schedule of fertility testing by
1month’s time.
2.) The couple verbalizes they understand
their individual subfertility problem after 2. POLYCYSTIC OVARY SYNDROME (PCOS)
preliminary testing.
o Symptoms:
3.) The couple demonstrates a high level of
 Excessive facial hair
self-esteem after fertility studies, even in
 Thinning hair
the face of disappointing study outcomes.
 Acne
4.) For a couple with the problem of
 Depression
subfertility, an evaluation is best if it is
 Unexplained weight gain
ongoing because, as circumstances
 Irregular or no periods
around them change, so may their goals
 High insulin or cholesterol readings
and desires.
o The exact cause of PCOS isn't known.
5.) Until they can accept an alternative method
Factors that might play a role include:
of having children—adoption or an assisted
1.) In PCOS, the ovaries produce high amounts
reproductive technique such as alternative
of male hormones, especially testosterone
insemination (deposition of sperm into a
resulting in hirsutism and acne.
woman’s cervix or uterus) or in vitro
2.) LH levels also remain abnormally high
fertilization (IVF; the union of sperm and
while FSH levels are abnormally low;
ovum under laboratory conditions)—former
 Thus, the follicles do not produce eggs.
plans to have children have been crushed.
Instead they form fluid-filled cysts that
6.) Continuing or future evaluations are also
eventually cover the ovaries.
important because a couple who decides at
3.) Excess Insulin
age 20 years to choose child-free living
 Insulin is the hormone produced in the
may change their minds at a later date.
pancreas that allows cells to use sugar,
7.) In the same way, a couple who chooses an
your body's primary energy supply.
assisted reproductive technique may
 If your cells become resistant to the
decide after a number of unsuccessful
action of insulin, then your blood sugar
attempts that they are no longer interested
levels can rise and your body might
in this method of conception.
produce more insulin.
8.) Keeping the evaluation as an ongoing
process allows such plans to be modified
as necessary.
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NCM 109: MATERNAL AND CHILD HEALTH NURSING
– Excess insulin might increase
androgen production, causing
difficulty with ovulation.
4.) Low-grade inflammation
 This term is used to describe white
blood cells' production of substances to
fight infection.
 Research has shown that women with
PCOS have a type of low-grade
inflammation that stimulates polycystic
ovaries to produce androgens, which
can lead to heart and blood vessel
problems.
5.) Heredity
 Research suggests that certain genes
might be linked to PCOS.
3. ENDOMETRIOSIS
o Refers to a condition in which sections of
the uterine lining implant in the vagina,
ovaries, fallopian tubes or pelvis.
o These implants eventually form cysts that
grow with each menstrual cycle, and may
eventually turn into blisters and scars.
– The scars can then block the passage
of the egg.
4. OVARY PROBLEMS
o Decreased production of any one of the five
hormones that regulate a woman's
reproductive cycle may result in infertility.
1.) GnRH or LHRH
2.) FSH
3.) LH
4.) Estrogen
5.) Progesterone
Phase FSH (IU/L) LH (IU/L)
Early follicular 3 - 10 2-8
Mid-cycle peak 4 - 25 10 - 75
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Phase Estradiol (pmol/L)
Early follicular 300 picomole/liter
Ovulatory surge 500 - 3000
Luteal surge 100 - 1400
PROGESTERONE (nanomole/liter)
0 – 6 nmol/L ovulation unlikely
7 – 25 nmol/L ovulation possible
> 25 nmol/L ovulation likely
o Problems within the ovaries may inhibit
reproduction as well. Instead of releasing
an egg, the ovarian follicle remains empty,
fails to rupture or traps the egg.
o Turner’s syndrome (hypogonadism)
– No ovaries to produce ova.
– It results from a hormonal imbalance
caused by a condition such as
hypothyroidism, which interferes with
hypothalamus-pituitary-ovarian
interaction.
o Ovarian tumors
o Excessive exposure to X-rays or
radioactive substances
5. IMMUNE SYSTEM PROBLEMS
o Women may develop antibodies or immune
cells that attack the man's sperm,
mistaking it for a toxic invader.
o Certain autoimmune diseases, in which the
woman's immune cells attack normal cells
in her own body, may also contribute to
ovarian problems.
6. LUTEAL PHASE DEFFECT
o In a luteal phase defect, a woman's corpus
luteum (the mound of yellow tissue
produced from the egg follicle) may fail to
produce enough progesterone to thicken
the uterine lining.

NCM 109: MATERNAL AND CHILD HEALTH NURSING
o Then the fertilized egg may be unable to
implant.
7. FIBROIDS
o Fibroids, or benign growths, may form in
the uterus near the fallopian tubes or
cervix.
o As a result, the sperm or fertilized egg
cannot reach the uterus or implant there.
o Fibroids in the uterus are very common in
women over age 30.
8. SURGICAL COMPLICATIONS
o Scar tissue (adhesions) left after
abdominal surgery can cause problems in
the movement of the ovaries, fallopian
tubes, and uterus, resulting in infertility.
o Frequent abortions may also produce
infertility by weakening the cervix or by
leaving scar tissue that obstructs the
uterus.
9. POOR QUALITY CERVICAL MUCOUS
o Sometimes a woman's mucous fails to thin
around the time of ovulation, and
consequently it prevents the sperm from
traveling through it.
o A cervical infection may also be the cause.
10. PREMATURE MENOPAUSE
o Some women may experience premature
menopause, when their ovaries stop
producing eggs.
o Cause:
– Excessive exercise or anorexia
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CAUSES FOR MALE INFERTILITY
o The most common cause for male infertility
is a problem with the sperm-either low
sperm count or sperm with poor quality.
o Some conditions that may contribute to
sperm problems include:
1. UNDER-DEVELOPED TESTES
o Usually arising after a mumps infection, a
hernia surgery, an injury or birth defect.
2. SWOLLEN VEINS IN THE SCROTUM
3. UNDESCENDED TESTES (CRYPTORCHIDISM)
o A problem often present from birth in which
the testes remain in the body cavity.
Normally they descend into the scrotum
before birth.
4. INFECTIONS, such as GONORRHEA or
TUBERCULOSIS
o Block the ducts through which the sperm
travel.
5. EXPOSURE TO METALS
o Such as leads, or chemicals such as
pesticides.
6. CERTAIN MEDICATIONS
o Such as
– Tagamet (cimetidine),
– Dilantin (phenytoin),
– Folex (methotrexate),
– Axulfidine (sulfasalazine),
– Corticosteroids and
– Chemotherapy drugs such as Cytoxan and
Neosar (cyclophosphamide).
7. INJURY TO THE TESTICLES
8. CHRONIC PROSTATE INFECTIONS

NCM 109: MATERNAL AND CHILD HEALTH NURSING
9. AUTOIMMUNITY
SEMEN ANALYSIS
o In which antibodies or cells of the man's
immune system attack sperm cells,
mistaking them for toxic invaders.
o The antibodies attach themselves to the
sperm and may cause them to stick
together, or may stop them from
penetrating the cervical mucous or the egg.
10. RETROGRADE EJACULATION
o In retrograde ejaculation the muscles of the
urethra do not force the sperm out.
o Instead, the sperm travel backward into the
bladder.
o Causes of retrograde ejaculation include:
 Drugs such as tranquilizers or high
blood pressure medicines.
 Diseases such as diabetes or multiple
sclerosis.
 Neck, bladder or prostate surgery.
 Spinal cord injury.
11. VARICOCELE or VARICOSITY
o Enlargement of the internal spermatic vein
o Can also increase temperature and
congestion within the testes, which may
slow and disrupt spermatogenesis.
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DIAGNOSTIC TESTS: MALE
o To determine sperm count & motility
o Must have 2 – 4 days of sexual abstinence
prior to the test.
o Average ejaculation: 2.5 – 5 ml
o Average normal sperm count:
50 – 200 million/ml
o The minimum sperm count considered
normal has:
– 33 - 46 million sperm/ml of seminal fluid,
or 50 million per ejaculation
– Fifty percent (50%) of sperm that are
motile
– Thirty percent (30%) that are normal in
shape and form
TIPS FOR ENSURING AN ACCURATE SEMEN
ANALYSIS
1.) Abstain from intercourse or masturbation
for about 2 – 4 days.
2.) Use a clean, dry plastic or glass container
with a secure lid to collect the sample.
3.) Avoid using any lubricants before you
collect the specimen.
4.) After you’ve collected the specimen in the
container, close it securely and write down
the time you collected it.
5.) Take the specimen to the laboratory or
healthcare provider’s office immediately so
it can be analyzed within 1 hour of
collection.
6.) Keep the specimen at body temperature
while transporting it. Carrying it next to
your chest is one way to do this.
ADDITIONAL TESTING FOR MEN, if warranted:
1.) Urinalysis
2.) A complete blood count
3.) Blood typing, including Rh factor
4.) Serologic test for syphilis
– a test for the presence of HIV
5.) Erythrocyte sedimentation
– An increased rate indicates
inflammation
6.) Protein-bound iodine
– A test for thyroid function
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NCM 109: MATERNAL AND CHILD HEALTH NURSING
– Hypothyroidism can cause poor o You're most fertile about two days before
semen quality, low sperm count, your basal body temperature rises, but
reduced testicular function, erectile sperm can live up to five days in your
dysfunction, and drop in libido. reproductive tract.
7.) Cholesterol level o If you're hoping to get pregnant, this is
– Arterial plaques could interfere with the time to have sex.
pelvic blood flow
8.) Follicle-stimulating Hormone (FSH),
Luteinizing Hormone (LH), and
testosterone levels (Niederberger, 2016)

DIAGNOSTIC TESTS: FEMALE

BASAL BODY TEMPERATURE (BBT)

o A fertility awareness-based method.
o A type of natural family planning.
o By tracking your basal body temperature
each day, you may be able to predict when
you'll ovulate.
o In turn, this may help you determine when
you're most likely to conceive.
o If you're hoping to get pregnant, you can
use the basal body temperature method to
determine the best days to have sex.

HOW TO USE THE BASAL BODY TEMPERATURE

(BBT) METHOD
1.) Take your basal body temperature every
morning before getting out of bed
o Use a digital oral thermometer or one
specifically designed to measure basal
body temperature.
o Make sure you get at least three hours of
uninterrupted sleep each night to ensure
an accurate reading.
o Always take your temperature using the
same method.
2.) Plot your temperature readings on graph
paper.
o Record your daily basal body
temperature and look for a pattern to
emerge.
o Your basal body temperature may
increase slightly— typically less than a
1/2 degree F (0.3 C) — when you ovulate.
o You can assume ovulation has occurred
when the slightly higher temperature
remains steady for three days or more.
3.) Plan sex carefully during fertile days.

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NCM 109: MATERNAL AND CHILD HEALTH NURSING
HYSTEROSCOPY
(Anovulatory Cycle)
CERVICAL MUCUS EXAM
o To determine elasticity for sperm motility.
CERVICAL MUCUS (SPINNBARKEIT)
o Once you notice that your CM has the
consistency of raw egg whites, you know
you're in your fertile period.
o If you hold it between two fingers, it can
stretch an inch or two without breaking in
the middle.
o This type of CM allows the sperm to swim
easily into the cervix.
PELVIC EXAM & ULTRASONOGRAPHY
o To identify obvious reproductive problems.
BLOOD HORMONE LEVELS & THYROID
FUNCTION TEST
o To measure levels of estrogen &
progesterone, and influence of thyroid
hormones.
SIMS-HUHNER TEST (Postcoital Cervical Mucus
Test)
o To determine pH of cervical mucus, effects
of hormones.
TUBAL PATENCY TEST
o Hysterosalpingogram (X-ray)
o Laparoscopic exam (direct visualization)
– To determine condition and patency of
fallopian tubes.
ENDOMETRIAL BIOPSY
o To determine condition of endometrium
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o Visual inspection of the uterus through
insertion of hysteroscope through the vagina,
cervix, and into the uterus.
NURSING IMPLICATIONS
1. Take careful lifestyle and sexual history of
both partners, chronic health problems,
medications, smoking, drug use, exposure to
chemicals, radiation.
2. Provide detailed explanation of all tests to
couple.
3. Know that process of assessment of fertility
and subsequent interventions may be
lengthy
INTERVENTIONS
o Therapy for Anovulation
 Important for adequate ova production:
– Nutrition
– Body Weight
– Exercise
 Are all important for adequate ova
production because they all influence the
blood glucose/insulin balance (Best &
Bhattacharya, 2015)
NURTRITION
o High glucose or Insulin Levels
– Can disrupt the production of FSH and
LH, leading to ovulation failure.
o Vitamin D
– May also be instrumental in maintaining
pituitary hormone levels (Shahrokhi,
Ghaffari & Kazerouni, 2016).
BODY WEIGHT
o Maintain a BMI of 18.5 to 24.9.
o Eat slowly digested carbohydrate foods
(e.g., brown rice, pasta, dark bread, beans)
and fiber-rich vegetables (e.g., asparagus,
broccoli)
– can not only increase fertility by keeping
insulin levels balanced but also may
prevent gestational diabetes when a
woman becomes pregnant (Sanabria-
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NCM 109: MATERNAL AND CHILD HEALTH NURSING
Martínez, García-Hermoso, Poyatos- o This second course may be
León, et al., 2015). repeated one more time.

EXERCISE
o Exercising 30 minutes per day by walking – abdominal discomfort
or doing mild aerobics also helps to – Distention
regulate blood glucose levels and – Bloating
increase fertility, – Nausea & vomiting
POSSIBLE
– Stress may play a role in limiting – breast tenderness
ADVERSE
ovulation as this may lower – vasomotor flushing
EFFECT
hypothalamic secretion of the – ovarian enlargement
gonadotropin-releasing hormone – ovarian overstimulation
(GnRH), which then lowers the – multiple births
production of LH and FSH, which – visual disturbances
leads to anovulation.
1. Ensure women have
DRUGS THAT AFFECT GONADAL FUNCTION & had a pelvic
FERTILITY examination and
baseline hormonal
studies before therapy.
ANDROGENS 2. Review medication
scheduling.
o To replace deficient male hormones 3. Urge women to use a
ESTROGENS calendar or some other
system to mark their
o To replace deficient hormones to control treatment schedule and
hormonal balance. also to determine and
plot ovulation.
CONCEPTION ENHANCERS 4. Remind patients that
timing intercourse with
OVULATORY STIMULANT ovulation is important
CLOMIPHENE CITRATE (Clomid) NURSING for achieving
o A follicle-maturing agent used during the IMPLICATIONS pregnancy.
5th – 10th day of menstrual cycle 5. Advice patient 24-hour
An estrogen agonist urine samples may be
ACTION commonly used to stimulate periodically necessary.
the ovary. 6. Caution patients to
o Initially, 50 mg/day orally report any bloating,
for 5 days (started anytime stomach pain, blurred
if no menstrual flow has vision, unusual
occurred recently or about bleeding, bruising, or
the fifth day of the cycle if visual changes.
menstrual flow is 7. Inform patients that
occurring). therapy can be repeated
DOSAGE
o If ovulation does not occur for a total of three
with this initial therapy, the courses; if no results
drug can be followed by a are obtained, therapy
prescription of 100 mg/day will be discontinued at
for 5 days started as early that point.
as 30 days after the initial
course of therapy.
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NCM 109: MATERNAL AND CHILD HEALTH NURSING
ASSISTED REPRODUCTIVE TECHNIQUES
OVULATORY STIMULANTS
o If ovulation, sperm production, or sperm
Inhibits release of motility problems cannot be corrected,
Bromocriptine
prolactin which can assisted reproductive strategies are the next
(Parlodel)
cause unovulation. step.
 Therapeutic insemination
Acts similarly to FSH – Alternative or IUI is the instillation of
Human Menopausal
or LH to stimulate sperm from a masturbatory sample
Gonadotropin
growth and maturation into the female reproductive tract
(Pergonal)
of ovarian follicles. by means of a cannula to aid
conception at the time of ovulation
Gonadotropin- Used when
releasing hormone clomiphene is  IVF
(GnRH) ineffective  Gamete intrafallopian transfer (GIFT)
 Zygote intrafallopian transfer (ZIFT)
 Surrogate embryo transfer
FOR HYPERPLASIA DEFECTS
THERAPY FOR INCREASING SPERM COUNT
o Reduces AND MOTILITY
endometrial 1. Abstain from coitus for 7 to 10 days at a
Danazol (Cyclomen) hyperplasia time to increase the count.
o Inhibits estrogen 2. Ligation of a varicocele (if present)
defects. 3. Avoid recreational marijuana use
4. Wear looser clothing
o Reduces adrenal 5. Avoid long periods of sitting, and
Prednisone
hyperplasia
6. Avoid prolonged hot baths

THERAPY FOR LACK OF TUBAL PATENCY THERAPY FOR SPERM TRANSPORT

1. Diathermy or steroid administration may be
1. If sperm are not able to pass through the
helpful to reduce adhesions.
2. Hysterosalpingography (instillation of a
contrast dye under X-ray monitoring) can
be attempted to see if the force of the dye
insertion will break adhesions.
3. Canalization of the fallopian tubes and
plastic surgical repair (microsurgery) are
other possible treatments.
4. Laparoscopy or Laser Surgery
– To remove peritoneal adhesions or
nodules of endometriosis that are
holding the tubes fixed and away from
the ovaries (Magos, 2012).
5. IVF is more commonly used today and more
apt to result in a viable pregnancy.
DISORDERS
vas deferens because of obstruction,
surgery to relieve the obstruction is
extensive, costly, and may not have a
positive outcome.
o A better solution can be extracting sperm
from a point above the blockage and
injecting it into the vagina or uterus of
the man’s partner by intrauterine
insemination (IUI)
o Today, sperm can be cryopreserved
(frozen) in a sperm bank before radiation
or chemotherapy and then used for
alternative insemination afterward
2. If the problem appears to be that sperm
are immobilized by vaginal secretions
due to an immunologic factor

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NCM 109: MATERNAL AND CHILD HEALTH NURSING
o the response can be reduced by
abstinence or condom use for about 6
months
o The administration of corticosteroids
to a woman may have some effect in
decreasing sperm immobilization
because it reduces her immune
response and antibody production.
THERAPY FOR EJACULATION CONCERNS
1. Psychological or sexual counseling
2. use of a phosphodiesterase inhibitor,
such as sildenafil (Viagra) or tadalafil
(Cialis)
3. Dapoxetine, a short-acting selective
serotonin reuptake inhibitor, is a drug
that has been developed especially for
the treatment of premature ejaculation
and shows good results when taken
about 1 hour before planned coitus (Yue,
Dong, Hu, et al., 2015).
THERAPY FOR UTERINE CONCERNS
1. LUTEAL PHASE DEFECT
o This can be corrected by progesterone
vaginal suppositories begun on the
third day of a woman’s temperature
rise and continued for the next 6
weeks (if pregnancy occurs) or until a
menstrual flow begins.
2. MYOMA (FIBROID TUMOR) OR
INTRAUTERINE ADHESIONS
o A myomectomy, or surgical removal of
the tumor and adhesions, can be
scheduled (Bailey, Jaslow, & Kutteh,
2015).
o If the growth is small, this can be done
by a hysteroscopic ambulatory
procedure.
o the woman may be prescribed
estrogen for 3 months as another
method to prevent adhesion formation
o an intrauterine device (IUD) may be
inserted to prevent the uterus from
touching and forming new adhesions
– Be certain she has a good
explanation of the IUD’s purpose
and that it can be easily removed in
about 1 month’s time.
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3. ABNORMAL UTERINE FORMATION
(SEPTATE UTERUS)
o Surgery is also available. However,
these defects are usually related to
early pregnancy loss, not initial
subfertility.
4. ENDOMETRIOSIS
o Can be treated both medically and
surgically
TREATMENT: ENDOMETRIOSIS
1. PAIN MEDICATION
o Nonsteroidal anti-inflammatory drugs
(NSAIDs) ibuprofen (Advil, Motrin IB, others)
or naproxen sodium (Aleve) to help ease
painful menstrual cramps.
2. HORMONE THERAPY
HORMONAL CONTRACEPTIVES
o Birth control pills, patches and vaginal rings
help control the hormones responsible for
the buildup of endometrial tissue each
month.
o Using hormonal contraceptives — especially
continuous-cycle regimens — may reduce or
eliminate pain in some cases.
GONADOTROPIN-RELEASING HORMONE (Gn-RH)
AGONISTS AND ANTAGONISTS
o These drugs block the production of ovarian-
stimulating hormones, lowering estrogen
levels and preventing menstruation.
o This causes endometrial tissue to shrink.
o Because these drugs create an artificial
menopause, taking a low dose of estrogen or
progestin along with Gn-RH agonists and
antagonists may decrease menopausal side
effects, such as hot flashes, vaginal dryness
and bone loss.
o Menstrual periods and the ability to get
pregnant return when you stop taking the
medication.
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NCM 109: MATERNAL AND CHILD HEALTH NURSING
THERAPY FOR VAGINAL AND CERVICAL together, these become sufficient to create
CONCERNS subfertility.
1. If sperm do o A woman may be prescribed o It is obviously discouraging for couples to
not appear to low-dose estrogen therapy complete a fertility evaluation and be told
survive in to increase mucus their inability to conceive cannot be
vaginal production during days 5 to explained.
secretions 10 of her cycle. o Offer active support to help the couple find
because o Conjugated estrogen
alternative solutions at this point, such as
secretions (Premarin) is a type of
continuing to try to conceive, using an
are too scant estrogen prescribed for this
or tenacious purpose. assisted reproductive technique, choosing
to adopt, or agreeing to a child-free life.
2. If a vaginal o The infection will be treated
infection is according to the causative
present organism based on culture ASSISTED REPRODUCTIVE TECHNIQUES
reports.
o If ovulation, sperm production, or sperm
o Vaginal infections such as
trichomoniasis and mobility problems cannot be corrected,
moniliasis tend to recur, assisted reproductive strategies are the
requiring close supervision next step for a couple to consider.
and follow-up.
BEFORE BEGINNING ANY OF THESE
o If the woman’s sexual
PROCEDURES:
partner is the source of
1. Urge a woman to be in excellent health by
infection, and is therefore
discontinuing smoking or recreational drug
reinfecting her, the partner
behaviors
needs antibiotic therapy as
2. Ingesting a diet high in protein
well.
3. A BMI within a normal range of 18.5 to 24.9.
o Caution women who are
4. Tests for HIV and hepatitis C
prescribed metronidazole
5. A hormone profile including levels of FSH,
(Flagyl) for a Trichomonas
LH, estrogen, and progesterone to test for
infection;
ovarian reserves (whether ovaries have the
– Although no studies have
capacity to produce multiple oocytes)
shown fetal
6. Intravaginal sonogram to visual usual
malformations after its
structures.
use, it may be teratogenic
7. Consider the budget
early in pregnancy and
8. Availability of health insurance because the
therefore should not be
couple may not be able to afford these
continued if the woman
therapies
suspects she has
9. Consider their religion or cultural beliefs
become pregnant.
because they may find these unacceptable
procedures. LGBT couples may also feel
uncomfortable seeking reproductive advice.
UNEXPLAINED SUBFERTILITY 10. In all instances, culturally sensitive care is
required by the nurse
o In a small percentage of couples, no known
cause for subfertility can be discovered.
o It may be that the problem of one partner
alone is not significant, but when combined
with a small problem in the other partner,

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NCM 109: MATERNAL AND CHILD HEALTH NURSING
ALTERNATIVE INSEMNATION
o The instillation of sperm from a
masturbatory sample into the female
reproductive tract by means of a cannula
to aid conception at the time of ovulation
(Kop, van Wely, Mol, et al., 2015).
o The sperm can either be instilled into the
cervix (intracervical insemination) or
directly into the uterus (IUI) at the time of
predicted ovulation.
– BBT charting, mucus analysis, or
urinary test kits for LH can be used
to detect the day of ovulation
(Hamilton, 2012).
o Either the male partner’s sperm (alternative
insemination by male partner) or donor
sperm (alternative insemination by donor)
can be used.
o Indication:
1.) The male partner has no sperm or an
inadequate sperm count
2.) A woman has a vaginal or cervical factor
that interferes with sperm motility
3.) A woman has hormonal issues affecting
fertility.
4.) Donor insemination can be used if the
man has a known genetic disorder he
does not want to be transmitted to
children
5.) A woman does not have a male partner.
6.) It is also a useful procedure for men who
underwent a vasectomy but now wish to
have children
o Today, sperm can be cryopreserved
(frozen) in a sperm bank before radiation
or chemotherapy and then used for
alternative insemination afterward
ALTERNATIVE INSEMINATION (IUI)
Preparation:
o A woman receives an injection of
clomiphene (Clomid) or FSH 1 month
prior to the insemination
– So follicle growth of ova is stimulated
– Ovulation can be predicted.
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Procedure:
1.) On the selected day of insemination
(confirmed by a serum analysis of
progesterone), the sperm sample is
instilled next to her cervix using a device
similar to a cervical cap or diaphragm, or
sperm are injected directly into the
uterus using a flexible catheter.
2.) Donors for alternative insemination are
volunteers who have no history of
disease and no family history of possible
inheritable disorders.
3.) The blood type, or at least the Rh factor,
can be matched with the woman’s to
prevent incompatibility.
4.) Sperm can be selected according to
desired physical or mental
characteristics if desired.
5.) If FSH was used to stimulate follicle
growth, caution women that the chance
for a multiple birth (twins or triplets)
increases so she can be prepared for this
(Trew & Lavery, 2012).
IN VITRO FERTILIZATION (IVF)
o Overall Live Birth Rate by IVF:
– 41% to 43% per treatment cycle for
women under 35 years
– It is as low as 13% to 18% for woman
age 40 years (American Pregnancy
Association, 2015).
– About 25% of pregnancies end in
spontaneous miscarriage (the same
rate as for natural pregnancies).
– COST: $12,000 to $17,000 per cycle
Indications:
1.) Woman has obstructed or damaged
fallopian tubes
2.) Man has oligospermia or a very low
sperm count.
3.) Absence of cervical mucus prevents
sperm from entering the cervix or
antisperm antibodies cause
immobilization of sperm
4.) Couples with unexplained subfertility of
long duration

NCM 109: MATERNAL AND CHILD HEALTH NURSING
Preparation:
1.) 1 month before the procedure, the
woman is given FSH to stimulate oocyte
growth.
2.) Beginning about the 10th day of the
menstrual cycle, the ovaries are
examined daily by sonography to assess
the number and size of developing
ovarian follicles.
3.) When a follicle appears to be mature, a
woman is given an injection of hCG,
which causes ovulation in 38 to 42
hours.
Procedure:
1.) One or more mature oocytes are
removed from a woman’s ovary by
laparoscopy and fertilized by exposure to
sperm in a laboratory.
2.) The oocytes chosen are incubated for at
least 8 hours to ensure viability.
3.) The male partner or donor supplies a
fresh or frozen semen specimen.
4.) A donor ovum, rather than the woman’s
own ovum, can be used for a woman who
does not ovulate or who carries a sex-
linked disease she does not want to pass
on to her children.
Procedure:
5.) Young women who had extensive
ovarian radiation or ovaries removed
before surgery for ovarian cancer can
have oocytes cryopreserved before
surgery and used for IVF (Brezina, Ding,
Ke, et al., 2015).
6.) The sperm cells and oocytes are mixed
and allowed to incubate in a growth
medium.
7.) About 40 hours after fertilization, the
laboratory-grown fertilized ova (now
zygotes) are inserted into a woman’s
uterus, where, ideally, one or more of
them will implant and grow.
8.) Genetic analysis to reveal chromosomal
abnormalities or the potential sex can be
completed at this point.
9.) Progesterone or LH may be prescribed to
a woman following IVF
10.) A routine serum pregnancy test as early
as 11 days after transfer will be done
– Proof that zygote has implanted
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GAMETE INTRAFALLOPIAN TRANSFER
o In gamete intrafallopian transfer (GIFT)
procedures, ova are obtained from ovaries
exactly as in IVF.
o Instead of waiting for fertilization to occur
in the laboratory, however, both ova and
sperm are instilled, within a matter of
hours, using a laparoscopic technique,
into the open end of a patent fallopian
tube.
o Fertilization then occurs in the tube, and
the zygote moves to the uterus for
implantation.
ZYGOTE INTRAFALLOPIAN TRANSFER
o Zygote intrafallopian transfer (ZIFT) is
similar to IVF in that the egg is fertilized
in the laboratory,
o The fertilized egg is transferred by
laparoscopic technique into the end of a
waiting fallopian tube.
SURROGATE EMBRYO TRANSFER
o Surrogate embryo transfer is an assisted
reproductive technique for a woman who
does not produce ova.
1.) The oocyte is donated by a friend,
relative, or an anonymous donor (Check,
Wilson, Levine, et al., 2015).
2.) The menstrual cycles of the donor and
recipient are synchronized by
administration of gonadotropic
hormones.
3.) At the time of ovulation, the donor’s
ovum is removed by a transvaginal,
ultrasound-guided procedure.
4.) The oocyte is then fertilized in the
laboratory by the recipient woman’s
partner’s sperm (or donor sperm) and
placed in the recipient woman’s uterus
by embryonic transfer.
5.) Once pregnancy occurs, it progresses the
same as an unassisted pregnancy.

NCM 109: MATERNAL AND CHILD HEALTH NURSING
ALTERNATIVES TO CHILDBIRTH
1. SURROGATE MOTHERS
o A surrogate mother is a woman who
agrees to carry a pregnancy to term for a
subfertile couple or an LGBT couple (Dar,
Lazer, Swanson, et al., 2015).
o The surrogate may provide the ova, which
is then impregnated by the man’s sperm in
the laboratory.
o In other instances, the ova and sperm both
may be donated by the subfertile couple; in
a third technique, both donor ova and
sperm are used.
o Surrogate mothers are often friends or
family members who assume the role out
of friendship or compassion, or they can be
referred to the couple through an agency or
attorney and receive monetary
reimbursement for their expenses.
o The subfertile couple can enjoy the
pregnancy as they watch it progress in the
surrogate.
o A number of ethical and legal problems
arise if the surrogate mother decides at the
end of pregnancy that she has formed an
attachment to the fetus and wants to keep
the baby despite the pre-pregnancy
agreement she signed.
o Court decisions have been split on whether
the surrogate or the subfertile couple has
the right to the child.
o Another potential problem occurs if the
child is born imperfect and the subfertile
couple then no longer wants the child.
o Who should have responsibility in this
instance?
o For these reasons, the couple and the
surrogate mother must be certain they
have given adequate thought to the
process and to what will be the outcome
should these problems occur before they
attempt surrogate mothering.
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2. ADOPTION
o Adoption is an alternative for subfertile and
LGBT couples, those individuals who have
genetic-related health conditions or health
conditions that would make pregnancy high
risk.
3. CHILD-FREE LIVING
o Child-free living is another option available
to both fertile and subfertile couples.
o A couple in the midst of fertility testing may
begin to reexamine their motives for
pursuing pregnancy and may decide
pregnancy and parenting are not worth the
emotional or financial cost of future
treatments.
o They may decide the additional stress of
going through an adoption is not for them
either, or they may simply decide children
are not necessary for them to complete
their family unit.
o Child-free living can be as fulfilling as
having children because it allows a couple
more time to help other people and
contribute to society through personal
accomplishments.
o It has advantages for a couple in that it
also allows time for both members to
pursue careers.
o They can travel more or have more time
and money to pursue hobbies or continue
their education.
o If a couple still wishes to include children
in their lives in some way, many
opportunities are available to do this
through family connections (most parents
welcome offers from siblings or other
family members to share in childrearing),
through volunteer organizations (such as
Big Brother or Big Sister programs), or
through local schools and town
recreational programs.
o Many couples who believe overpopulation
is a major concern choose child-free living
even if subfertility is not present.
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NCM 109: MATERNAL AND CHILD HEALTH NURSING
o Parents who choose child-free living
typically rate their marriage as happier
than for those with children probably
because of the decreased expense involved
and the availability of more free time, which
allow them greater freedom in life (Avison
& Furnham, 2015).

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NCM 109: MATERNAL AND CHILD HEALTH NURSING
Chapter 20: NURSING CARE OF THE FAMILY
HAVING DIFFICULTY CONCEIVING A CHILD
INTRODUCTION
o A high-risk pregnancy
– Concurrent disorder, pregnancy-
related complication, or external
factor jeopardizes the health of the
mother, the fetus, or both.
o Both the mother & the fetus can be at risk
for complications because either the
pregnancy can complicate the disease, or
the disease can complicate the pregnancy.
o A thorough history and physical
examination must be obtained at the first
prenatal visit to establish a baseline of
information on the condition
o Documentation of any medication being
taken for a secondary condition is also
necessary to protect against adverse drug
interactions and the possibility of
teratogenic action on the fetus.
o Teaching is an important nursing
intervention because a woman with a
preexisting illness must make
modifications in her usual therapy to adjust
to pregnancy.
o Pregnancy often stimulates women to
learn more about their primary disease as
well.
o Nursing care focuses on:
– Preventing such disorders from
affecting the health of the fetus.
– Helping a woman regain her health
as quickly as possible.
– Helping a woman learn more about
her chronic illness so she can
continue to safeguard her health
during her child- rearing years.
HIGH-RISK PREGNANCY: CARDIOVASCULAR
SYSTEM
o Cardiovascular disease complicates only
1% of pregnancies but accounts for 5% of
maternal deaths.
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o Blood volume and cardiac output increase
up to 50%% during pregnancy (peaks at 28
to 32 weeks).
NURSING PROCESS: Care of a High-Risk
Woman
ASSESSMENT
o Understanding of the course of a normal
pregnancy.
o Signs & symptoms of illnesses
o Assessment techniques include:
1.) Baseline V/S
2.) Extent of edema
3.) Level of exhaustion
o Woman to assess her own health in
relation to objective parameters.
NURSING DIAGNOSIS
o Examples of possible Nsg. Dx:
– Ineffective tissue perfusion
(cardiopulmonary) r/t poor heart
function 2° MVP during pregnancy
– Social isolation r/t prescribed bed
rest during pregnancy 2° to
concurrent illness
– Ineffective role performance r/t
increasing level of daily restrictions
2° to chronic illness and pregnancy.
– Knowledge deficit r/t normal
changes of pregnancy vs illness
complications
– Fear regarding pregnancy outcome
r/t chronic illness
– Health-seeking behaviors r/t the
effects of illness on pregnancy
– Situational low esteem r/t illness
during pregnancy
OUTCOME IDENTIFICATION AND PLANNING
o Expected outcomes established are
realistic in light of a woman’s pregnancy
and the health restrictions.
o Give the woman the available alternatives.
o Allow a woman to choose among the
alternatives.

NCM 109: MATERNAL AND CHILD HEALTH NURSING
IMPLEMENTATION
o For pregnant woman with chronic illness
– Focus on teaching her new or
additional measures to maintain
health.
o For women who developed a new illness
– Provide an opportunity to talk about
the event after her initial care is
complete to identify concerns.
OUTCOME EVALUATION
o If the expected outcome is not met,
reassessment, analysis & planning need to
be done.
o Make evaluation ongoing to ensure
whether interventions are successful.
o Examples of outcomes:
– Client states she rests for 2 hrs
morning and afternoon; dependent
edema remains at 1+ or less at next
prenatal visit.
– Family member state they are all
participating in an exercise program
since mother developed gestational
diabetes.
– Client reports no burning on
urination or flank pain at next
prenatal visit.
– Client states she understands the
importance of taking daily thyroid
medicine for total length of
pregnancy.
IDENTIFYING THE HIGH-RISK PREGNANCY
o A concurrent disorder, pregnancy-related
complication, or external factor
jeopardizes the health of the mother, fetus
or both
o The cardiovascular disorders that most
commonly cause difficulty during
pregnancy are:
1.) Valve damage concerns caused by
rheumatic fever or Kawasaki disease
2.) Congenital anomalies such as atrial
septal defect or uncorrected
coarctation of the aorta (Gordon,
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Jimenez-Fernandez, Daniels, et al.,
2014).
CARDIAC DISEASE
o Cardiovascular disease complicates only
1% of pregnancies but accounts for 5% of
maternal deaths.
o Blood volume and cardiac output increase
up to 50% during pregnancy (peaks at 28 to
32 weeks), which places stress on a
compromised heart.
LEFT-SIDED HEART FAILURE
WOMAN WITH L-SIDE HEART FAILURE
o Mitral valve stenosis & mitral
insufficiency
– Mitral valve thickening which
becomes rigid, it cannot be fully
opened.
o Aortic Coarction
o The inability of the MV to push blood
forward causes:
1.) Back pressure on the pulmonary
circulation causing it to be distended
2.) Systemic Bp decreases
3.) Pulmonary hypertension
– Pressure in pulmonary vein
reaches 25 mmHg, fluid begins to
pass from pulmonary capillary
membranes into the interstitial
spaces surrounding the alveoli
and then into the alveoli
(pulmonary edema)
4.) Pulmonary edema
5.) Pulmonary capillaries rupture

NCM 109: MATERNAL AND CHILD HEALTH NURSING
o Because of limited O2 exchange, women
with pulmonary hypertension are at
extremely high risk for:
 Spontaneous miscarriage
 Preterm labor
 Maternal death
SIGNS AND SYMPTOMS
1. Increased RR
2. Increased fatigue, weakness & dizziness
3. Systemic decrease in Bp
PATHOPHYSIOLOGY OF LEFT HEART FAILURE
LEFT-SIDE HEART FAILURE MED. MGT:
o If MV stenosis is present, thrombus
formation can occur from non-circulating
blood.
 Adm. Anticoagulant
– Heparin (does not cross the
placenta) for early pregnancy
– Warfarin (Coumadin) can be used
after 12 wk. but returned to heparin
during the last month of pregnancy
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– Balloon valve angioplasty
o If complications result in impaired blood
flow to the uterus, the following events can
occur:
 Poor placental perfusion
 IU growth restriction
 Fetal mortality
o Woman needs serial U/S and non-stress
tests done after wks. 30 – 32.
RIGHT-SIDED HEART FAILURE
RIGHT-SIDE HEART FAILURE
o Common causes:
 Pulmonary valve stenosis
 Atrial & ventricular septal defects
 Eisenmenger syndrome
– R to L atrial or ventricular
septal defect with pulmonary
stenosis.
o Occurs when:
 Output of the RV is less than the
blood volume received by the RA
from the vena cava
 Back-pressure results in:
– congestion of the systemic
venous circulation
– Decreased cardiac output to
the lungs
 Bp decreases in the aorta
 High pressure in the vena cava
 Jugular venous distention
 Increased portal circulation
– Liver & spleen become
distended
 Distention of abdominal vessels can
lead to exudate of fluid from the
vessels into the peritoneal cavity
(ascites).

NCM 109: MATERNAL AND CHILD HEALTH NURSING
RIGHT-SIDE HEART FAILURE MED. MGT.:
o Those with uncorrected anomaly of this
type (Eisenmenger syndrome) may be
advised not to get pregnant.
PERIPARTUM HEART DISEASE
WOMAN WITH PERIPARTUM HEART DISEASE
PERIPARTAL CARDIOMYOPATHY
o Can originate in pregnancy in women
with no previous history of heart disease
(Desplantie, Tremblay-Gravel, Avram, et
al., 2015).
o Cause: unknown
o May occur because of the stress of the
pregnancy on the circulatory system.
o The mortality rate = 50%.
Signs and Symptoms
 Shortness of breath
 Chest pain
 Nondependent edema
 Her heart increases in size (i.e.,
cardiomegaly).
For Therapy:
1. She must sharply reduce her physical
activity
2. Diuretic
3. An arrhythmia agent, and digitalis
therapy to maintain heart function
4. Low–molecular-weight heparin may be
administered.
5. Immunosuppressive therapy
(Corticosteroids)
o If the cardiomegaly persists past the
postpartum period
– It is generally suggested a woman not
to attempt any further pregnancies
because the condition tends to recur
or worsen in additional pregnancies.
– Oral contraceptives are
contraindicated because of the danger
of thromboembolism that these can
create.
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CLASSIFICATION OF HEART DISEASE
o To predict a pregnancy outcome, heart
disease is divided into four categories
based on criteria established by the New
York Heart Association.
CLASS DESCRIPTION
Class 1 Uncompromised. Ordinary physical activity
causes no discomfort. No symptoms of
cardiac insufficiency and no anginal pain.
Class 2 Slightly compromised. Ordinary physical
activity causes excessive fatigue,
palpitation, and dyspnea or anginal pain.
Class 3 Markedly compromised. During less than
ordinary activity, woman experiences
excessive fatigue, palpitations, dyspnea, or
anginal pain.
Class 4 Severely compromised. Woman is unable to
carry out any physical activity without
experiencing discomfort. Even at rest,
symptoms of cardiac insufficiency or
anginal pain are present.
CARDIAC DISEASE
ASSESSMENT
1. A thorough health history to document pre-
pregnancy cardiac status.
2. Woman’s level of exercise performance.
3. Ask if she normally has a cough or edema
– Coughing could be a sign of pulmonary
edema.
– The usual innocent edema of
pregnancy must be distinguished from
the beginning of edema from heart
failure (serious).

NCM 109: MATERNAL AND CHILD HEALTH NURSING
o BASELINE VITAL SIGNS
– At future health visits, always obtain
these in the same position for the most
accurate comparison.
– Making comparison assessments for
nail bed filling (should be <5 seconds)
and jugular venous distention can also
be helpful throughout pregnancy.
o LIVER SIZE
– If a woman’s heart disease involves
right-sided heart failure, assess liver
size at prenatal visits.
o ECG
– An electrocardiogram (ECG) or an
echocardiogram may be done at
periodic points in pregnancy.
– ECG merely measures cardiac
electrical discharge and so cannot
harm her fetus in any way.
– Echocardiography uses ultrasound
and, likewise, will not harm her fetus.
o FETAL ASSESSMENT
– At the point that maternal blood
pressure becomes insufficient to
provide an adequate supply of blood
and nutrients to the placenta, fetal
health can be compromised.
– This can result in preterm labor
– If the placenta is not filling well, a fetus
may not respond well to labor
(evidenced by late deceleration
patterns on a fetal heart monitor).
– Cesarean birth may be necessary (an
increased risk for both the mother and
fetus).
NURSING DIAGNOSES
NURSING DIAGNOSIS
o Deficient knowledge regarding steps to
take to reduce the effects of maternal
cardiovascular disease on the pregnancy
and fetus.
OUTCOME EVALUATION
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o Patient identifies danger signs such as
angina pain and steps to take when they
occur;
o Maternal blood pressure is maintained
above 100/60 mmHg and fetal heart rate at
110 to 160 beats/min.
o Be certain that goals and outcomes
established with a woman with heart
disease are realistic.
– Not all women with heart disease, for
example, will be able to complete a
pregnancy successfully
– However, there are positive actions a
woman with heart disease can take to
reduce or eliminate complications
during pregnancy, such as increasing
periods of rest to strengthen heart
action.
RELATED INTERVENTIONS
1. Promote Rest
o As a rule, women with cardiac
disease need two rest periods a day
(fully resting, not getting up
frequently) and a full night’s sleep
(not tossing and turning) to obtain
adequate rest.
o Women should plan activities so they
stop exercising before the point when
cardiac output becomes insufficient
to meet systemic body demands
causing peripheral and
uterine/placental constriction.
o Some women, for example, may need
to discontinue employment early in
pregnancy rather than work until the
end.
o A prescription to allow “normally
heavy” housework may mean nothing
more strenuous than dusting to
some women.
o To others, it may mean washing
windows, turning mattresses, and
shoveling snow.

NCM 109: MATERNAL AND CHILD HEALTH NURSING
2. Promote healthy nutrition
o She must not gain so much weight
that her heart and circulatory
system become overburdened.
o Be certain she is remembering to
take her prenatal vitamins.
o Prevent Anemia
o Sodium-restricted diet may be
continued during pregnancy; but not
severely restricted
3. Educate Regarding Medication
o Women taking cardiac medication,
such as digoxin, before pregnancy
may need to increase their
maintenance dose because of their
expanded blood volume during
pregnancy.
o Digoxin – can be administered to
the woman to slow the fetal heart if
fetal tachycardia is present.
o Antihypertensive and arrhythmia
agents such as adenosine, β-
blockers, and calcium channel
blockers to reduce hypertension
o Nitroglycerin, a compound often
prescribed for angina (a category C
drug), is also considered safe
(Karch, 2015).
o A woman who was taking penicillin
prophylactically because she had
rheumatic fever as a child (which is
often taken for 10 years after the
occurrence of rheumatic fever, or at
least until age 18 years) should
continue to take this drug during
pregnancy because penicillin is not
known to be a teratogenic (a
category B drug).
o Close to the anticipated day of birth,
some primary care providers
prescribe an additional course of
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ampicillin, amoxicillin (Amoxil), or
clindamycin (Cleocin) to prevent
streptococci bacteria from invading
the denuded placental site on the
uterus.
4. Educate Regarding Avoidance of Infection
o A systemic infection can increase
her cardiac output as her
metabolism increases.
o Caution women with heart disease
to avoid visiting or being visited by
people with infections and to alert
healthcare personnel at the first
indication of an upper respiratory
tract infection or urinary tract
infection (UTI)
o Antibiotic therapy can begin early in
the course of the infection.
o Monthly screening for bacteriuria
with a clean-catch
o Urine test at prenatal visits should
help detect UTIs.
NURSING INTERVENTIONS DURING LABOR
AND BIRTH
1. Frequently assess a woman’s blood
pressure, pulse, and respirations
2. Monitor fetal heart rate to assess fetal
well-being.
3. Monitor uterine contractions during labor
for women with heart disease to be certain
their circulatory system is not failing and
the placenta is filling adequately.
4. Advise a woman to assume a side-lying
position during labor to reduce the
possibility of supine hypotension
syndrome.
5. May need oxygen administered during
labor because of the need for extra oxygen
due to the exertion of labor;
6. Continuous hemodynamic monitoring such
as by a Swan-Ganz catheter to monitor
heart function may be prescribed.

NCM 109: MATERNAL AND CHILD HEALTH NURSING
7. Many women with heart disease should not
push with contractions, as pushing
requires more effort than they should
expend.
– That makes epidural anesthesia the
anesthetic of choice for women with
heart disease.
8. Because of the lack of pushing, low forceps
or a vacuum extractor may be used for
birth.
NURSING INTERVENTIONS DURING
POSTPARTUM
1. Assess for heart failure
– The period immediately after birth is a
critical time for a woman with heart
disease.
– After birth, the increase in pressure
takes place within 5 minutes, so the
heart must make a rapid and major
adjustment (Easterling & Stout, 2012).
2. A woman may need a program of
decreased activity
3. Anticoagulant and digoxin therapy until her
circulation stabilizes.
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4. Antiembolic stockings or intermittent
pneumatic compression (IPC) boots may
be prescribed to increase venous return
from the legs.
5. Prophylactic antibiotics should be started
immediately after birth to discourage
subacute bacterial endocarditis caused by
the introduction of microorganisms
through the placental site.
6. Stool softener can be prescribed to prevent
straining with bowel movements.
7. Oxytocin (Pitocin), should be used with
caution because they tend to increase
blood pressure, which necessitates
increased heart action.
8. Kegel exercises are acceptable for perineal
strengthening immediately
9. Postpartum exercises to improve
abdominal tone until her primary care
provider approves them.
10. Assess baby
– Acrocyanosis is normal in newborns,
so the woman does not interpret her
baby’s peripheral cyanosis as cardiac
inadequacy.