1.

Growth spurt
NCM 107: MATERNAL AND CHILD
HEALTH
Reproductive and Sexual Health
Nursing Process: Promotion
Reproductive and Sexual Health
2. Increase in transverse diameter of
pelvis
3. Breast development
4. Growth of pubic hair
5. Onset of menstruation
of 6. Growth of axillary hair
7. Vaginal secretions

Assessment: Menarche:
1. Interview average age – 12.5 years
2. Physical Examination B. Males
- observation 1. Increase in weight
2. Growth of testes
Nursing diagnosis: 3. Growth of face, axillary and pubic hair
-Health-seeking behaviors related to 4. Voice changes
reproductive functioning 5. Penile growth
-Anxiety related to inability to conceive 6. Increase in height
after 6 months without birth control 7. Spermatogenesis
-Pain related to uterine cramping from
menstruation Reproductive Anatomy and
-Disturbance in body image related to Physiology
early development of secondary sex
characteristics Male reproductive system

Reproductive Development Pubertal A. External structures

development:
-Secondary sex changes begin Role of
androgen:
-Hormones responsible for muscular
development, physical growth, and the
increase in sebaceous gland secretions
in boys and girls
1. Scrotum
• Rugated, skin-covered, muscular
pouch suspended from the perineum
• Supports the testes and help regulate
the temperature of sperm

-Males – produced by adrenal cortex

and testes
-Females – produces by adrenal cortex
and ovaries

Role of Androgen:
-Development of testes, scrotum, penis,
prostate, and seminal vesicles
Appearance of pubic, axillary and facial
hair
-Laryngeal enlargement and voice
change Maturation of spermatozoa
-Closure of growth in long bones
Reproductive Development Role of
estrogen:
• Influences the development of the
uterus, fallopian tubes, and vagina;
• Fat distribution and hair patterns;
• Breast development;
• End to growth (closure of epiphyses
of long bones)
2. Testes
• 2 ovoid glands, 2 to 3 cm wide, lies in
the scrotum
• Encased by white fibrous capsule
• Composed of number of lobules
containing interstitial cells (Leydig’s
cells) and seminiferous tubules
Production of Spermatozoa:
Hypothalamus (GnRH)
Ant. Pituitary Gland (FSH and LH)
FSH – Androgen binding protein (ABP)
LH – testosterone

Secondary sex characteristics:

A. Girls (pubertal changes)
 Early Adolescence:
• Testicular self-examination
(tenderness and abnormal growth)
• Normal testes:
Firm, smooth and egg-shaped
3. Penis
• Composed of 3 cylindrical masses of
erectile tissue in the penis shaft:
a. Corpus cavernosa (2 masses)
b. Corpus Spongiosum
• Penile artery – branch of pudendal
artery
• Glans – bulging, sensitive ridge of
tissue at the distal end
• Prepuce – retractable casing of the
skin
2. Vas Deferens (Ductus Deferens)
• a hollow tube surrounded by arteries
and veins; protected by thick fibrous
coating
• Carries sperm from epididymis
through inguinal canal to abdominal
cavity, ending at the seminal vesicles
and ejaculatory ducts
Spermatic cord – blood vessels and vas
deferens Varicocele
Vasectomy

3. Seminal Vesicles
• two convoluted pouches; lie along the
lower portion of the posterior surface
of the bladder and empty into the
urethra secretes semen

4. Prostate gland
• chestnut-sized gland; lies below the
bladder
• secretes thin, alkaline fluid
Problem:

Benign Prostatic Hypertrophy (BPH)

B. Male internal structures

5. Bulbourethral Glands (Cowper’s
1. Epididymis Glands)
-Tightly coiled tube, approximately 20 ft. • two glands; lies beside prostate gland
long and empties into the urethra
- Stores some semen and produces • secretes alkaline fluid that helps
semen by its cells in the lining counteract action of the acid secretion
Problems: of the urethra
Aspermia; Oligospermia Semen is derived from:
Prostate gland (60%)
1: Epididymis Seminal vesicles (30%)
2: Head of epididymis Epididymis (5%)
3: Lobules of epididymis 4: Body of Bulbourethral glands (5%)
epididymis
5: Tail of epididymis
6: Duct of epididymis
7: Deferent duct (ductus deferens or vas
deferens
 6. Urethra
• hollow tube leading from the base of
the bladder, continues to the outside
through the shaft and glans of the
penis
• approximately 8 inches (18 to 20 cm)
lined with mucous membrane
Female reproductive system
A. External structures
1. Mons veneris
• Pad of adipose tissue over the
symphysis pubis
• Covered by a triangular coarse of hair
Purpose:
Protect the junction of the pubic bone
2. Labia Minora
two hairless folds of connective tissue
abundant with sebaceous glands
3. Labia Majora
two folds of adipose tissue covered by
loose connective tissue and epithelium
Purpose:
protects external genitalia and distal
urethra and vagina
Other External Organs:
Vestibule
• flattened smooth surface inside the
labia Clitoris
• small, rounded organ of erectile
tissue covered by prepuce
• sensitive to touch and temperature
Skene’s glands (paraurethral glands)
• located lateral to the urinary meatus,
on each side Bartholin’s glands
(vulvo-vaginal glands)
• located lateral to the vaginal opening
on both sides Fourchette
• ridge of tissue formed by the posterior
joining of 2 labia minor and major
Perineal muscle or body
• posterior to the fourchette
• Hymen
• tough, elastic semicircle of tissue
• covers the opening to the vagina in
childhood
Vulvar Blood Supply
• from pudental artery and a portion of
the inferior rectus artery
• venous return is through the pudendal
vein
Vulvar Nerve Supply
• from the ilioinguinal and genito-
femoral nerves (L1 level) – ant.
portion
• pudendal nerve (S3 level) – post.
portion
B. Female internal structures
1. Ovaries
• 4cm long by 2cm in diameter;
approximately 1.5cm thick
• Grayish-white; appear pitted with
minute indentations
• located close to and both sides of the
uterus in lower abdomen

Function:

a. Produce, mature, and discharge ova

b. Produce estrogen and progesterone
c. Initiates and regulates menstrual
cycles
d. Maturation and maintenance of
secondary sex characteristics
Three Principal Divisions:
1. Epithelium
2. Cortex
3. Central medulla
Maturation of Oocytes:
• lies in the ovary; surrounded by a
protective sac or thin layers of cells
(primordial follicle)
• Primordial follicle – underdeveloped
state

Division of Reproductive Cells

(Gametes): Oocytes:
• formed during first 5 months of
intrauterine life (2 million)
• Contains cell membrane, cytoplasm 2. Fallopian Tubes
and nucleus containing • arise from each upper corner of the
chromosomes uterine body Øsmooth, hollow tunnel;
• reproductive cells only have half the approximately 10cm in length
usual number of chromosomes
• Mitotic division (oocytes)- occurs in Fallopian tube
intrauterine life till puberty
• Meiosis (cell reduction division)
occurs:

Male – occurs just before spermatozoa

mature
Female – occurs before ovulation

Function:
a. Convey ovum from the ovaries to the
uterus
b. Place for fertilization of ovum and
sperm
Parts:

1. Interstitial
-1cm in length; 1 mm in diameter (lumen)

2. Isthmus
Ovum : - 2cm in length
• 22 autosomes and an X sex - Extremely narrow
chromosomes Spermatozoon:
• 22 autosomes and either an X or Y 3. Ampulla
sex chromosomes -Longest portion, 5 cm in length

4. Infundibular
-most distal segment; funnel shape; 2 cm
long
-covered by fimbria (small hairs) • prevents regurgitation of menstrual
flow holds internal cervical os closed
3. Uterus (pregnancy) Myomas or benign
• hollow, muscular, pear-shaped organ uterine tumors
• located in the lower pelvis, posterior
to the bladder and anterior to the 3. Perimetrium (connective tissue) -
rectum outermost layer
• 5 to 7 cm long, 5 cm wide, widest Function:
upper part is 2.5 cm deep; -add strength and support to the structure
approximately 60 g (non-pregnant
state) Uterine Blood Supply:
• 9 cm long, 3 cm thick, and 80 g in Large descending abdominal aorta
weight 2 iliac arteries hypogastric arteries
uterine arteries
Functions: supplies the uterus
a. Receive the ovum from the fallopian
tube Uterine Nerve Supply:
b. Place for implantation and -supplied by both efferent (motor) and
nourishment during fetal growth afferent (sensory) nerves
c. Protection to a growing fetus - Efferent – from T5 to T10 spinal ganglia
d. Expels fetus from woman’s body - Afferent – join the hypogastric plexus
and enter spinal column at T11 and T12
Divisions:
1. Corpus (Body) * Epidural Anesthesia
• Uppermost part; forms the bulk of the
organ Fundus: Uterine Supports:
• Amount of uterine growth
• Force of uterine contractions during 1. Posterior ligaments
labor • Douglas’ cul-de-sac
• Assess uterus to its non-pregnant • Culdoscopy or laparoscopy
state • Culdocentesis
2. Broad ligaments
2. Isthmus 3. Round ligaments
-short segment between the body and -acts as “stays” to steady the uterus
cervix
-1 to 2 mm in length (non-pregnant state) Uterine Deviations
• Bicornuate
-3. Cervix • Anteversion
lowest portion; represents one third of the • Retroversion
uterus • Anteflexion
-2 to 5 cm long • Retroflexion
Cervical canal – central cavity
Internal cervical os Bicornuate uterus
External cervical os

Uterine and Cervical Coats (layers);

1. Endometrium (mucous membrane)
2 layers: a. Basal layer
b. Glandular layer
Endocervix – mucous membrane lining of
the cervix Uterine Deviations

2. Myometrium (muscle fibers)

• muscle layer
• composed of 3 interwoven layers of
smooth muscles (fibers)
Functions:
• constrict tubal junctions
Breasts:
• Mammary glands, form from the
ectodermic tissue early in utero
• located anterior to the pectoral
muscle
• Consists of connective tissue and fat
deposits
• Glandular tissue remains
undeveloped till first pregnancy
begins
• milk glands is divided by connective
tissue partitions (20 lobes), which
produce milk by ACINAR cells
• delivers milk to the nipple via
Lactiferous duct
• Serves as reservoir for milk before BF
Nipple
• Has approximately 20 small openings
• Composed of smooth muscles,
surrounded by dark pigmented area
(AREOLA) approximately 4cm in
diameter
• Releases oxytocin
Areola
-Contains many sebaceous glands
(montgomery’s tubercle)
- Ampulla portion of the duct
-Located post. to the nipple
-Serves as reservoir for milk before BF
Pelvis:
• supports and protect the reproductive
and other pelvic organs
• formed by 4 united bones:
1. 2 innominate bones (flaring hip) –
anterior and lateral portion
2. Coccyx
3. Sacrum - forms the posterior aspect
A. Innominate bones divided into 3
parts:
1. Ilium – forms the upper and lateral
portion
Iliac crest
-Flaring superior border
- Forms the prominence of the hip
2. Ischium – forms the inferior portion
- 2 projections at the lowest portion:
Ischial tuberosities (important landmark
to determine pelvic width)
Ischial spines
• Small projections that extend from the
lateral aspects into the pelvic cavity
• Marks the midpoint of the pelvis, used
to assess the level to which the fetus
has descended into the birth canal
(station)
•
3. Pubis – forms the anterior portion
Symphysis pubis – junction of the
innominate bones at the front of the
pelvis
B. Sacrum – forms the upper posterior
portion
Sacral prominence
-marked anterior projection where it
touches the lower lumber vertebrae
-Landmark to identify when securing
pelvic measurements
C. Coccyx – below the sacrum,
composed of 5 very small fused bones
Sacrococcygeal joint
-Joint between the sacrum and coccyx
For Obstetric purposes: Pelvic
divisions:
1. False pelvis (superior half)
• Supports the uterus during late
months of pregnancy
• Aids in directing fetus into the true
pelvis for birth
• Divided from true pelvis by an
imaginary line (linea terminalis)
2. True pelvis (inferior half)
Other important terms:
1. Inlet
• Entrance to the true pelvis
• At the level of linea terminalis
• Appears heart-shape (ant. view)
• Wider transversely than anterior
posterior diameter
2. Outlet
Inferior portion of the pelvis
• Greatest diameter is the anterior
posterior diameter
3. Cavity
• Space between the inlet and the
outlet
• A curved passage (slow and control
the speed of birth)
• Compresses chest at birth (airway)
Types of Pelvis:
1. Android
-Male pelvis
2. Anthropoid
-Ape-like pelvis level of estrogen and some progesterone
3. Gynecoid at maximum size
-Normal female pelvis propelled towards surface of the ovary at
4. Platypelloid full maturity
-Flattened pelvis visible at the surface as clear water
blister (graafian follicle)
Menstruation
• Episodic uterine bleeding in response Day 14 (midpoint of typical 28 day
to cyclic hormonal changes cycle): ovum
• Menstrual cycle – ave. 28 days division
• Menstrual flow – ave. 4 – 6 days divided by mitotic
• Menarche – onset of 1st menstrual 1. primary oocyte
period 2. secodary oocyte
- early as age 8 or 9 or late as age 17 increase LH (from the pituitary)
releases prostaglandins
rupture graafian follicle (Ovulation)
Purpose:
1. Brings an ovum to maturity 2. Renews graafian follicle after discharge
uterine tissue bed (Ovulation) - 14th day
cells remain in the form of hollow, empty
CHARACTERISTICS: pit
FSH
the empty follicle (corpus luteum or
yellow body)
in amount while LH and acts on the
follicle cells causes
Production of lutein (bright-yellow fluid)
that fills

Day before ovulation

-Basal body temperature drops slightly
by 0.5 – 1 °F
= caused by extremely progesterone
Physiology: = remains until day 24 of cycle
1. Hypothalamus
Releases GnRH or LHRH that initiates * Conception occurs, the corpus luteum
menstruation transmitted to the anterior remains approximately 16-20 weeks of
pituitary gland produce gonadotropic pregnancy
hormones (FSH & LH)
* No conception – ovum atrophies after
2. Pituitary Gland 4 or 5 days and
anterior lobe (adenohypophysis)
produces corpus luteum remains only for 8 – 10
2 hormones (FSH & LH) days
FSH: - Replaced by white fibrous tissue called
• Active early in cycle corpus albicans (white body)
• Responsible for maturation of ovum half of the cycle (day 5 – 14)
LH:
• Active at the midpoint of the cycle 4. Uterus Phases:
• Responsible for ovulation and growth 1. Proliferative (estrogenic, follicular,
of uterine lining during 2nd half of postmenstrual phase)
menstrual cycle immediately after the menstrual flow (1st
4 or 5 days of a cycle)
3. Ovary endometrium is very thin
primordial follicle is activated by FSH to ovary begins to produce estrogen,
begin to grow and mature endometrium begins to proliferate
as it grows (eightfold) till 1st
cells produce a clear fluid (follicular fluid)
containing
 2. Secretory (progestational, luteal,
premenstrual phase)
after ovulation
formation of progesterone in corpus
luteum
causes glands of endometrium become
corkscrew and dilated with quantities of
glycogen and mucin
capillaries in amount (like rich, spongy
velvet) endometrium slough off
3. Schematic
If no fertilization occurs, corpus luteum in
the ovary begins to regress after 8 – 10
days production of progesterone and
estrogen uterus degenerates (24th-25th
day of cycle)
capillaries rupture with minute
hemorrhages
4. Menses (Menstrual Phase)
• The end of menstrual cycle
• 1st day is used to a mark the
beginning day of new menstrual cycle
• Contains approximately 30 – 80 ml of
blood
• 11 mg iron loss during menses
Contains:
Blood
Mucin
Endometrial tissues Unfertilized ovum
Cervix:
1st half of cycle – cervical mucus is thick
and scant
Ovulation - estrogen level, cervical
mucus becomes thin and copious
2nd half of cycle - progesterone, cervical
mucus becomes thick
Cervical Changes (Fern Test)
Cervical Changes (Spinnbarkeit test)
Education
• Dispelling myths
• Menstrual disorders:
• Dysmenorrhea
• Menorrhagia
• Metrorrhagia
• Amenorrhea
• Polymenorrhea
• Oligomenorrhea
Menopause
-Cessation of menstrual cycles
1. Perimenopausal
2. Postmenopausal
Framework for Maternal and Child Health
Nursing
The care of childbearing and childrearing
families is a major focus of nursing practice,
because to have healthy adults you must have
healthy children. To have healthy children, it is
important to promote the health of the
childbearing woman and her family from the
time before children are born until they reach
adulthood. Both preconception and prenatal
care are essential contributions to the health of
a woman and fetus and to a family’s emotional
preparation for childbearing and childrearing.
• Preconception care consists of the healthcare
you receive before conceiving.
- to determine if there are conditions that can
affect your future pregnancy.
- Potential risks may be reduced or eliminated by
applying interventions such as medication or
lifestyle changes. Lifestyle changes that are
encouraged may include eating a healthy diet,
maintaining a healthy weight, taking
supplements that contain folic acid, receiving
pertinent vaccinations, getting mentally healthy,
quitting smoking and avoiding alcohol
consumption.
 • Most doctors recommend receiving
preconception care three to six months before
the time you intend to conceive.
• Prenatal care is healthcare you receive while
you are pregnant. It is important because it helps
improves your chances of having a healthy
pregnancy. Your visits with your doctor may
involve physical exams, imaging tests, blood
tests or screening tests to detect fetal
abnormalities.
As children grow, families need continued
health supervision and support. As children
reach maturity and plan for their families, a new
cycle begins and new support becomes
necessary. The nurse’s role in all these phases
focuses on promoting healthy growth and
development of the child and family in health
and in illness.
The specific objectives of MCH Care focuses on
the reduction of maternal, perinatal, infant and
childhood mortality and morbidity and the
promotion of reproductive health and the
physical and psychosocial development of the
child and adolescent within the family.
GOALS AND PHILOSOPHIES OF MATERNAL AND
CHILD HEALTH NURSING
The primary goal of maternal and child health
nursing care can be stated simply as the
promotion and maintenance of optimal family
health to ensure cycles of optimal childbearing
and childrearing.
Philosophy of Maternal and Child Health
Nursing
1. Maternal and child health nursing is family -
centered; assessment data must include a family
and individual assessment.
2. Maternal and child health nursing is
community - centered; the health of families
depends on and influences the health of
communities.
3. Maternal and child health nursing is research
oriented, because research is the means
whereby critical knowledge increases.
4. Both nursing theory and evidence-based
practice provide a foundation for nursing care.
5. A maternal and child health nurse serves as an
advocate to protect the rights of all family
members, including the fetus.
6. Maternal and child health nursing includes a
high degree of independent nursing functions,
because teaching and counselling are so
frequently required.
7. Promoting health is an important nursing role,
because this protects the health of the next
generation.
8. Pregnancy or childhood illness can be stressful
and can alter family life in both subtle and
extensive ways.
9. Personal, cultural, and religious attitudes and
beliefs influence the meaning of illness and its
impact on the family. Circumstances such as
illness or pregnancy are meaningful only in the
context of a total life.
10. Maternal and child health nursing is a
challenging role for a nurse and is a major factor
in promoting high-level wellness in families
11. Common Measures to Ensure Family-
Centered Maternal and Child Health Care
Principle
12. The family is the basic unit of society.
13. Families represent racial, ethnic, cultural, and
socioeconomic diversity.
14. Children grow both individually and as part of
a family. Nursing Interventions
15. Consider the family as a whole as well as its
individual members.
1. Encourage families to reach out to their
community so that family members are not
isolated from their community or from each
other.
2. Encourage family bonding through rooming-in
in both maternal and child health hospital
settings.
3. Participate in early hospital discharge
programs to reunite families as soon as possible.
1. Encourage family and sibling visits in the
hospital to promote family contacts.
1. Assess families for strengths as well as specific
needs or challenges.
2. Respect diversity in families as a unique quality
of that family.
3. Encourage families to give care to a newborn
or ill child.
1. Include developmental stimulation in nursing
care.
2. Share or initiate information on health
planning with family members so that care is
family oriented.
AmericanNurses Association/Society of
Pediatric Nurses Standards of Care and
Professional Performance
Standards of Care
Comprehensive pediatric nursing care focuses
on helping children and their families and
communities achieve their optimum health
potentials. This is best achieved within the
framework of family-centered care and the
nursing process, including primary, secondary,
and tertiary care coordinated across health care
and community settings.
Standard I: Assessment The pediatric nurse
collects patient health data.
Standard II: Diagnosis The pediatric nurse
analyzes the assessment data in determining
diagnoses.
Standard III: Outcome Identification The
pediatric nurse identifies expected outcomes
individualized to the child and the family.
Standard IV: Planning The pediatric nurse
develops a plan of care that prescribes
interventions to obtain expected outcomes.
Standard V: Implementation The pediatric nurse
implements the interventions identified in the
plan of care.
Standard VI: Evaluation The pediatric nurse
evaluates the child’s and family’s progress
toward attainment of outcomes.
Phases of Health Care:
HEALTH PROMOTION
Educating clients to be aware of good health
through teaching and role modelling.
Teaching women the importance of rubella
immunization before pregnancy; teaching
children the importance of safer sex practices
HEALTH MAINTENANCE
Intervening to maintain health when risk of
illness is present
Encouraging women to come for prenatal care;
teaching parents the importance of safeguarding
their home by childproofing it against poisoning
HEALTH RESTORATION
Promptly diagnosing and treating illness using
interventions that will return client to wellness
most rapidly
Caring for a woman during a complication of
pregnancy or a child during an acute illness
HEALTH REHABILITATION
Preventing further complications from an illness;
bringing ill client back to optimal state of
wellness or helping client to accept inevitable
death
Encouraging a woman with gestational
trophoblastic disease to continue therapy or a
child with a renal transplant to continue to take
necessary medications
Summary of Nursing Theories
Nursing theories offer frameworks that give
shape to the scope of nursing care and practice.
These consist of concepts, such as collaboration
or respect, descriptions of relationships, and
definitions. Nursing theories guide nurses in
their practice and give them a foundation to
make clinical decisions.
17 SDG’s
• The Sustainable Development Goals (SDGs)
are also known as the Global Goals. The SDGs are
new, universal set of goals, targets and indicators
that UN member states will be expected to use
to frame country agendas and policies over the
next 15 years. It consists of 17 goals, 169 targets
and 232 unique indicators.
• The 17 sustainable development goals
(SDGs) to transform our world:
• GOAL 1: No Poverty
• GOAL 2: Zero Hunger
• GOAL 3: Good Health and Well-being
• GOAL 4: Quality Education
• GOAL 5: Gender Equality
• GOAL 6: Clean Water and Sanitation
• GOAL 7: Affordable and Clean Energy
• GOAL 8: Decent Work and Economic Growth
• GOAL 9: Industry, Innovation and
Infrastructure
• GOAL 10: Reduced Inequality
•GOAL 11: Sustainable Cities and Communities
• GOAL 12: Responsible Consumption and
Production
• GOAL 13: Climate Action
• GOAL 14: Life Below Water
• GOAL 15: Life on Land
• GOAL 16: Peace and Justice Strong Institutions
• GOAL 17: Partnerships to achieve the Goal
•GOAL 1: NO POVERTY
•Economic growth must be inclusive to
provide sustainable jobs and promote
equality.
•GOAL 2: ZERO HUNGER
• The food and agriculture sector offers key
solutions for development, and is central for
hunger and eradication. The
agriculture sector solutions for development,
and is central for hunger and poverty
• 3 GOOD HEALTH AND WELL- BEING
•Ensuring healthy lives and promoting the well-
being for all at all ages is essential to sustainable
development.
Alternative Hybrid Education and
Asynchronous Distance Learning
•GOAL 4: QUALITY EDUCATION
•Obtaining a quality education is the foundation
to improving people’s lives and sustainable
development.
•GOAL 5: GENDER EQUALITY
•Gender equality is not only a fundamental
human right, but a necessary foundation for a
peaceful, prosperous and sustainable world.
•GOAL 6: CLEAN WATER AND SANITATION
•Clean, accessible water for all is an essential
part of the world we want to live in.
•GOAL 7: AFFORDABLE AND CLEAN ENERGY
•Energy is central to nearly every major
challenge and opportunity.
 •H
•Sustainable economic growth will require
societies to create the conditions that allow
people to have quality jobs.

•GOAL 9: INDUSTRY, INNOVATION, AND

INFRASTRUCTURE
•Investments in infrastructure are crucial to
achieving sustainable development.

•GOAL 10: REDUCED INEQUALITIES

•To reduce inequalities, policies should be
universal in principle, paying attention to the
needs of disadvantaged and marginalized
populations.

•GOAL 11: SUSTAINABLE CITIES AND

COMMUNITIES
•There needs to be a future in which cities
provide opportunities for all, with access to basic
services, energy, housing, transportation and
more.

•GOAL 12: RESPONSIBLE CONSUMPTION

AND PRODUCTION
•Responsible Production and Consumption

•GOAL 13: CLIMATE ACTION

•Climate change is a global challenge that affects
everyone, everywhere.

•GOAL 14: LIFE BELOW WATER

•Careful management of this essential global
resource is a key feature of a sustainable future.

•GOAL 15: LIFE ON LAND

•Sustainably manage forests, combat
desertification, halt and reverse land
degradation, halt biodiversity loss.

•GOAL 16: PEACE, JUSTICE AND STRONG

INSTITUTIONS
•Access to justice for all, and building effective,
accountable institutions at all levels.

•GOAL 17: PARTNERSHIPS

•Revitalize the global partnership for sustainable
development.
Chapter 9
Psychological and Physiologic Changes of Psychological Tasks
Pregnancy

Nursing Process: Healthy Adaptation to

Pregnancy

Assessment:

- Begins before pregnancy (health status,

nutritional intake, lifestyle)
- Identify any potential problems
- Understanding and expectations of conception,
pregnancy and parenthood
- Establish trusting relationship Emotional responses
- Assess well being of fetus 1. Ambivalence
2. Grief
Nursing Diagnosis 3. Narcissism
- Anxiety related to unexpected pregnancy 4. Introversion vs extroversion
- Altered breathing pattern related to respiratory 5. Body image and boundary
system changes of pregnancy 6. Stress
- Disturbed body image related to weight gain 7. Couvade syndrome
with pregnancy 8. Emotional lability
- Deficient knowledge related to normal changes 9 .Changes in sexual desire
of pregnancy 10. Changes in the expectant family
- Imbalanced nutrition, less than body
requirements, related to morning sickness Diagnosis of Pregnancy

Outcome identification and Planning: Signs of Pregnancy

Planning nursing care concerning physiologic 1. Presumptive signs of pregnancy
and psychologic changes of pregnancy 2. Probable signs of pregnancy
3. Positive signs of pregnancy
Implementation:
Pre-natal visits Presumptive signs of pregnancy:
a. Breast changes
Outcome Evaluation b. Nausea and vomiting
- Client states she is able to continue her usual c. Amenorrhea
lifestyle throughout pregnancy d. Frequent urination
- Family members describes ways they have e. Fatigue
adjusted their lifestyles to accommodate the f. Uterine enlargement
mother’s fatigue g. Quickening (16 to 20 weeks) h. Linea nigra
- Couple states they accept the physiologic i. Melasma/Chloasma
changes of pregnancy as normal j. Striae gravidarum

Psychological Changes Uterine Enlargement:

a. Social
- Bring families
- Participate actively during birth
- Cultural background, personal experiences,
experiences of friends and relatives, current
public philosophy of childbirth

b. Cultural Linea Nigra

Cultural background (beliefs and taboos)

c .Family
- positive attitude towards pregnancy

d. Individual
-Ability to cope with or adapt to stress

Chloasma
:

Positive signs of pregnancy:

a. Fetal heart separate from the mother’s

- FHR- early as 6th to 7th week (UTZ)
-10TH To 12TH Week (Doppler)
- 5weeks (Echocardiography)
Striae Gravidarum: - 18 to 20 weeks (stethoscope)

b. Fetal movements felt by examiner

-20th to 24th week

c. Visualization of fetus by UTZ

d. Fetal outline felt by examiner/seen in X-ray

Physiologic Changes

a. Local Changes
Reproductive changes:
Probable signs of pregnancy
1. Uterine changes
a. Serum laboratory test - Increase in size (length, depth, weight, width,
- Urine or blood serum (hCG) wall thickness and volume)
- Home pregnancy tests length - 6.5 to 32 cm
: Depth - 2.5 to 22 cm
hCG: Width - 4 to 24 cm
- Serum
- 7 to 9 days after conception (measurable level; Weight - 50 to 1,000 g
50 mIU/mL) Wall thickness - 1 to 2 cm
- 60th and 80thday of gestation Volume - 2 mL to more than 1,000 mL
(peak;100mIU/mL) - Can hold a 7 lb (3,175 g) fetus plus 1,000 mL of
amniotic fluid; total of about 4,000 g.
Home pregnancy tests pack samples - Uterine blood flow increases - end of
pregnancy, expands to as much as 500 to 750
mL/min; 75% going to the placenta
- Hegar's sign

2. Amenorrhea

b. Chadwick’s sign 3. Cervical Changes

- More vascular and edematous (pink to violet
hue)
-Operculum - mucus plug in cervical canal
- Goodell's sign - softening of the cervix

4. Vaginal Changes
- White vaginal discharge throughout pregnancy
- Chadwick's sign - from light pink to deep violet
- From alkaline to acidic pH of vaginal secretions
c. Goodell’s sign
d.Hegar’s Sign 5. Ovarian Changes
e. Sonographic evidence of gestational sac - No ovulation

Changes in the Breast

- Feeling of fullness, tingling or tenderness
- Increase in size
- Areola darkens and increase in diameter
(3.5cm to 5 or 7.5cm)
- Blue veins become prominent
- Enlarged and protuberant Montgomery's
tubercle
f. Ballottement - Colostrum - 16th week of pregnancy
g. Braxton Hicks contractions
 4 Plasma Pco2 (carbon dioxide partial
pressure or tension) - the measure of the
b. Systemic Changes pressure exerted by small portion of total
carbon dioxide in the blood Value: Venous
1. Integumentary system blood - 41 to 51 mmHg
-Striae gravidarum - pink to reddish streaks Arterial blood - 35 to 45 mmg
sides of abdominal wall, sometimes thighs
-Strae albicantes or atrophicae - silvery-white Plasma pH - the measure of the acidity and
color streaks after birth alkalinity of the blood. Normal pH of human
-Diastasis - bluish groove (rectus muscle) of the arterial blood is approximately 7.40.
abdomen Normal range = 7.35 to 7.45
-Protruding umbilicus acidic - less than 7.35
alkaline - greater than 7.45

Plasma Po2 (oxygen partial pressure or tension)

- reflects the amount of oxygen gas dissolved in
the blood; measures the effectiveness of the
lungs in pulling oxygen into the blood stream
from the atmosphere.
Normal Value = 75 - 100 mmHg

g. Resp. minute volume (minute ventilation or

flow of gas) - the volume of air which can be
inhaled or exhaled from a person's lungs in one
1 Linea nigra minute.
2 Melasma (chloasma) How to calculate:
• Vascular spiders (small, fiery-red branching RMV = tv × RR
spots) Result:
◦ Increase perspiration the higher the MV, the more CO2 the person is
◦ Palmar erythema (redness and itching) releasing and vise versa
◦ Increased scalp hair growth Normal value = 5 - 8 L/min
2. Respiratory System
• Marked congestion "stuffiness" of h. Expiratory Reserve Volume (ERV) - the
nasopharynx amount of additional air that can be pushed out
> Acute sensation of shortness of breath late in after the end expiratory level of normal
pregnancy breathing.
Normal Value:
Male - 1.2 L
Female - 0.93 L

а. Vital Capacity (VC) - the maximum amount of
air a person can expel from the lungs after filling
to maximum extent and then expiring to
maximum extent.
Value:
Male - 4.6 L
Female - 3.6 L
b. Tidal Volume (Vt) - the amount of air
breathed in and out during normal respiration
Value:
Male - 500 mL
Female - 390 mL
3 Residual Volume (RV) - the amount of air
left in the lungs after a maximal exhalation
Value: Male - 1.2 L Female - 0.93 L
3. Temperature:
• Slight increase in body temperature (early
pregnancy)
4. Cardiovascular system:
Increased total circulatory blood volume (30% -
50%)
Normal amount = 4.7 and 5 L (adult)
Increase plasma volume than BC production
causing pseudoanemia early in pregnancy
Blood loss:
◦ Vaginal birth - 300 to 400 mL
Cesarean birth - 800 to 1,000 mL
Iron needs
Importance:
a. Essential for making hemoglobin
b. Helps maintain healthy immune system
c. Needed for growing placenta and baby
- Fetus - 350 to 400 mg of iron
- Mother - additional 400 mg of iron
- Total iron need - 800 mg
Iron supplement is needed; containing 30 mg of
iron
Folic acid needs: (vit. B9 or Folacin
Importance:
For periods of rapid cell division and growth
Produce healthy RBC and prevent anemia
Vitamins containing folic acid/eat foods high in
folic acid
Inadequate folic acid:
megalohemoglobinemia - mother
neural tube disorders in fetuses
Most Common Neural Tube Defect:
1.Spina bifida - incomplete closure of spinal
cord and spinal column
2. Anencephaly – severe underdevelopment of
the brain
3. Encephalocele - brain tissue protrudes out to
the skin from an abnormal opening in the skull
Heart:
• Increase cardiac output by 25% to 50%
- Increase HR by 10 bpm
- Functional (innocent) heart murmur
- Occasional palpitations
Blood Pressure:
" BP does not normally increase during
pregnancy
BP: 120/80 mmHg
Peripheral Blood Flow:
-Impaired blood flow leading to edema and
varicosities of vulva, rectum and legs
Supine Hypotension Syndrome:
-Decrease in blood return to the heart,
decreased cardiac output and hypotension
-Can cause fetal hypoxia
-Symptoms: lightheadedness, faintness and
palpitations
Blood constitution:
- Increase fibrinogen (factor 1) to 50%
- Factors VII, VIII, IX and X and platelet count
increase
- Slight increase in WBC (20,000 cells/mm®)
- Decrease total protein level
- Increase blood lipids by 1/3
- Increase cholesterol serum level by 90% to
100%
5. Gastrointestinal System
-Slow peristalsis and emptying of stomach
leading to heartburn, constipation and
flatulence
- Hemorrhoids
- Decreased gastric motility - release of relaxin
- Nausea and vomiting (morning sickness)
- Decreased emptying of bile from the
gallbladder leading to reabsorption of bilirubin
in maternal bloodstream (subclinical jaundice)
- Increased tendency to gallstones (cholesterol
level)
- Hypertrophy of gum-lines and bleeding of
tissue
- Hypertyalism - increased saliva formation
6. Urinary System
Causes:
- Effects of high estrogen and progesterone
level
- Compression of bladder and ureters
- Increased blood volume
- Postural influences
Alterations:
a. Fluid Retention - total body water increases
to provide sufficient fluid volume for placental
exchange
- increase to 7.5 L
c. Ureter and Bladder Function
- Increased bladder capacity by 1,500 mL
- Increased diameter of ureters by 25%
- Increased frequency of urination at 1st and
last 2 weeks of pregnancy (10-12 times/day)
Pressure on the right ureter may lead to:
◦ Urinary stasis
◦ Pyelonephritis
◦
Pressure on urethra may lead to:
a. Poor bladder emptying
b. Bladder infection (cystitis)
7. Skeletal System
- Gradual softening of pelvic ligaments and
joints
-Wide separation of the symphysis pubis (3 to 4 9. Immune System
mm by 32 weeks) -Decrease immunologic competency
- Lordotic position causing backache - Decreased IgG production
- Increase in WBC
8. Endocrine System
a. Placenta LEOPPOLD’S MANEUVER
-Produce estrogen and progesterone Systematic method of observation and palpation
to determine fetal presentation and position.
Effect:
Uterine and breast enlargement, fat deposits
Increased blood coagulation, sodium and water
retention

> Relaxin increased

Effect:
Softening of the cervix and collagen of joints

> hPL is produced

Effect:
Increase glucose available for fetus
Decrease utilization of protein for energy,
increasing protein available for fetal growth
Process of Conception
b. Pituitary Gland Preparation for Conception in the Female:

> Decreased FSH and LH A. Release of the ovum

Effect: mature ovum (contained in graafian follicle)
Anovulation ruptures
release the mature ovum to the surface of the
> Increased Prolactin ovary follicle is transformed into corpus luteum
Effect:
Prepare breast for lactation B. Ovum Transport

> Increased melanocyte-stimulating hormone

Effect:
Increased skin pigmentation

c. Thyroid gland
- Slight enlargement
Preparation for Conception in the Male:
Effect: A. Ejaculation
Increased basal metabolism rate -40 – 250 million of sperm (suspended in 2 to 5
ml of seminal fluid)
> Increased thyroid hormone production - 50 – 90 % are morphologically normal
Effect: - Deposited at the upper vagina and over the
Increased oxygen consumption cervix

d. Parathyroid gland B. Transport of sperm in the female

> Slight enlargement, increased parathyroid
hormone production
Effect:
Better utilization of calcium and vitamin D
reproductive tract
- tails of the spermatozoa propels through the
cervix, uterus and fallopian tubes
- Uterine contraction enhances movement of the
sperm towards the ovum

e. Pancreas C. Preparation of sperm for fertilization

> Early in pregnancy, decreased insulin
production; increased insulin production after
1st trimester

Effect:
Additional glucose is available for fetal growth

Fertilization:
A. Entry of one spermatozoon into the ovum
entry has 3 results: 1. zona reaction
2. cell membranes (ovum and sperm) fuse and
break down, allowing sperm head to enter
3. the ovum completes meiosis
Ø Mature ovum now contains 23 chromosomes
in its nucleus
B. Fusion of the nuclei of sperm and ovum
Stages of Fetal Development
B. Entry of zygote into the uterus:
blastocyst (contains approximately 100 cells)
enters
uterus (lingers another 2 – 4 days before
implantation)
endometrium (decidua) 3 separate areas of
decidua:
1. Desidua basalis – lies under the embryo
2. Desidua capsularis – stretches and
encapsulates surface of thophoblast
3. Desidua vera – remaining portion of lining
C. Implantation in the Decidua:
-Nidation
-Occurs between 6th to 10th or 8th to 10th days
after conception
D. Maintaining the Decidua:
-Supply of estrogen and progesterone
-Zygote secretes hCG to signal woman’s body
that pregnancy has begun persistence of corpus
luteum and secretion of estrogen and
progesterone
E. Location of Implantation:
- upper uterus (often on posterior wall than
anterior)
3 Reasons:
1. Richly supplied with blood
2. Lining is thick in the upper uterus
3. Limits blood loss after birth because of strong
interlacing muscle fibers
conceptus is fully embedded within decidua by
10 day
during implantation, a small amount of bleeding
may occur at the site (“spotting”)
*implantation bleeding
F. Mechanism of Implantation
enzymes (conceptus)
erodes decidua
tapping maternal sources of nutrition
primary chorionic villi (decidua basalis), lies
between the conceptus and wall of the uterus
Chorionic villi – forms the fetal side of the
placenta Decidua basalis – forms the maternal
side of the
EMBRYONIC PERIOD and FETAL STRUCTURES:
-from the third week through the eight week
after conception Chorionic Villi:
implantation
thophoblast begins to mature rapidly
11th or 12th day
chorionic villi reached the endometrium
central core of chorionic villi, surrounded by
double layer of trophoblast cells contains fetal
capillaries
syncytial layer (syncytiotrophoblast) produces
hormones
hCG, hPL, estrogen and progesterone
Langhans’ layer (cytotrophoblast) – present at
12 AOG but disappears between 20th to 24th
week of AOG
The Placenta:
-arise from the trophoblast
-15 to 20 cm in diameter; 2 to 3 cm in depth at
term
Function:
Fetal lungs, kidneys and gastrointestinal tract
and separate endocrine organ
A. Circulation:
-12th day of pregnancy
-maternal blood collects in the intervillous
space of endometrium surrounding chorionic
villi
-3rd week
-oxygen and other nutrients diffuse from
maternal blood to the capillaries
-transports
nutrients to the embryo
 -placental osmosis
-substances able to cross into fetal circulation
Placental Circulation
-increase number of chorionic villi
-Intervillous space grow larger and larger,
separated by partitions or septa
-Mature placenta – cotyledons (30)
-about 100 maternal uterine arteries supply
mature placenta
-at term, placenta weighs 400 to 600 grams (1 lb)
Endocrine Function:
Hormones produced by the syncytial layer of
chorionic villi:
1. Human Chorionic Gonadotropin
Purpose:
-act as fail-safe measure to ensure corpus luteum
to continuously produce estrogen and
progesterone
-suppress maternal immunologic response so
placenta will not be rejected
2. Estrogen
Purpose:
- development of mammary gland
- Stimulates uterine growth
3. Progesterone
Purpose:
-necessary to maintain endometrial lining
-reduce contractility of uterine musculature
during pregnancy (premature labor)
4. Human Placental Lactogen Purpose:
-promotes growth of mammary glands for
lactation
-regulates maternal glucose, protein, and fat
levels
Umbilical Cord:
-From fetal membranes (amnion and chorion)
-Provides circulatory pathway
-Contains one vein and two arteries
- length – 53 cm; 2 cm thick
-Wharton’s jelly - gelatinous
mucopolysaccharide
- no nerve supply
-Nuchal cord – loop of cord around fetal head
Function:
1. Transport oxygen and nutrients to fetus from
placenta
2. Return waste products from the fetus to the
placenta
Amniotic Membranes:
medial surface of chorionic villi of trophoblast
gradually thin, smooth
chorionic membrane (chorion) - supports the
sac containing amniotic fluid
amniotic fluid
amniotic membrane (amnion) – supports and
produces
Amniotic Fluid:
-Never stagnant
- 800 to 1,200 ml (at term)
-Hydramnios (more than 2,000 ml/pockets
larger than 8cm)
- Oligohydramnios (less than 300 ml, no
pocket larger than 1 cm)
-Serves to protect fetus
-Shields against pressure
-Protects from temperature changes ØAids
muscular development ØProtects umbilical cord
ORIGIN AND DEVELOPMENT OF ORGAN
SYSTEMS
A. Stem Cells
zygote (1st 4 days of life) – totipotent stem cells
embryo (another 4 days) – pluripotent stem cells
another few days – multipotent
B. Zygote growth
cephalocaudal development
Ø Body organs develops from specific tissue
layers (germ layers)
C. Primary Germ Layers
blastocyst (2 cavities of inner structure)
amniotic cavity (lined with ectoderm cells) yolk
sac (lined with entoderm cells)
-Supply nourishment until implantation
- source of RBC
third layer of primary cells (mesoderm)
implantation
•The three germ layers of the embryo develop
into:
•Ectoderm: most nervous tissue and skin
epidermis.
•Mesoderm: connective tissue and muscle.
•Endoderm: epithelial lining of gut.
Embryonic Shield:
3 cells layers meet
8 weeks gastation – all organs (organogenesis)
are complete in a rudimentary from
Cardiovascular System:
-network of blood vessels and single heart tube
– forms at 16th day of life and beats at 24th day
-septum – develops at 6th or 7th week
-HB – may be heard as early as 10th to 12th week
(doppler)
- 28th week – HR has variability of about 5 bpm
on a strip
Fetal Circulation:
1. Oxygenated blood enters the umbilical vein
from the
placenta
2. Enters ductus venosus
3. Passes through inferior venacava
4. Enters the right atrium
5. Enters the foramen ovale
6. Goes to the left atrium
7. Passes through left ventricle
8. Flows to ascending aorta to supply
nourishment to the brain and upper extremeties
9. Enters superior vena cava
10. Goes to right atrium
11. Enters the right ventricle
12. Enters pulmonary artery with some blood
going to the lungs to supply oxygen and
nourishment
13. Flows to ductus arteriosus
14. Enters descending aorta ( some blood going
to the lower extremeties)
15. Enters hypogastric arteries
16. Goes back to the placenta
Special Structures in Fetal Circulation:
a. Placenta – Where gas exchange takes place
during fetal life
b. Umbilical Arteries – Carry unoxygenated
blood from the fetus to placenta
c. Umbilical vein – Brings oxygenated blood
coming from the placenta to the fetus
d. Foramen Ovale – Connects the left and right
atrium. It pushes blood from the right atrium to
the left atrium so that blood can be supplied to
brain, heart and kidney
e. Ductus Venosus - Carry oxygenated blood
from umbilical vein to inferior vena cava,
bypassing fetal liver
Estimating EDD/EDB:
Nagele’s Rule:
-first day of the last menstrual period
-count three months backwards and add 7 days
ASSESSMENT OF FETAL GROWTH &
DEVELOPMENT:
A. Health History
- nutritional intake
- personal habits and lifestyle
B Estimating Fetal Growth
McDonald’s Rule – symphysis – fundal height
measurement
Fundic Height Measurement:
ASSESSING FETAL WELL-BEING:
A. Fetal Movement
Quickening - begins 18 to 20 weeks of pregnancy
- peaks at 28 to 38 weeks of pregnancy
- more than 10 times a day
Methods:
1. Sandovsky Method
- 2 every 10 minutes or 10 to 12 times an hour 2.
Cardiff Method
- Count – to – ten
B. Fetal Heart Rate
-120 to 160 bpm
-heard and counted as early as 10th to 11th week
(doppler)
Rhythm Strip Testing:
-Semi-fowler’s position
-external fetal heart rate and uterine contraction
are monitor
-recorded for 20 minutes
Baseline - average rate of the FHB per minute
Short-term variability (beat-to-beat variability) –
small changes in rate occur from second to
second
-Long-term variability – difference in HR occur
over a 20-minute time period
Nonstress Testing:
-measures FHR to fetal movement
-no increase in FHB – poor oxygen perfusion
-done 10-20 minutes
-performed after the 28th week Non-reactive:
- no accelerations occur with fetal movement
- no fetal movement
- low short term FHR variability (less than 6 bpm)
Vibroacoustic Stimulation:
-acoustic stimulation (acoustic stimulator)
Contraction Stress Testing:
-FHR analyzed with contractions
-stimulation of breast (oxytocin)
-3 contractions of 40 seconds duration or longer
must be present in 10 minutes
Result:
negative (normal) – no FHR decelerations are
present with contractions
Positive (abnormal) – 50% or more of
contractions cause late deceleration
Ultrasonography: Purposes:
-diagnose pregnancy (6 weeks)
- confirm presence, size, and location of placenta
and amniotic fluid
-establish that fetus is growing and has no gross
anomalies
- establish sex
- establish presentation and position of the fetus
- predict maturity by measuring biparietal
diameter of the head
- discover complications of pregnancy and fetal
anomalies and fetal death
Ultrasound
Measuring Biparietal Diameter: Øused to
measure fetal maturity
-8.5cm or greater – infant weigh more than 2,500
g (5.5 lb) 40 weeks AOG
Head circumference:
34.5 cm – 40 weeks AOG
3 – placenta is 38 weeks (mature)
Doppler Umbilical Velocimetry:
-measures velocity at which RBC in the uterine
and fetal vessels are traveling
-Placental Grading – Placental grades are
number values assigned to a placenta on the
basis of its appearance on an ultrasound
examination
Graded as:
0 – placenta is 12 to 24 weeks 1 – placenta is 30
to 32 weeks 2 – placenta is 32 t0 36 weeks
Fetal ECG:
- early as 11th week
- BUT, inaccurate before 20th week
MRI:
- diagnose ectopic pregnancy or trophoblastic
disease
1. Obtain biopsy samples of fetal tissue and fetal
blood samples
Fetal endoscope
Biophysical Profile: (fetal apgar)
-combines five parameters (fetal re-activity, fetal
breathing movements, fetal body movement,
fetal tone, and amniotic fluid volume)
-has 5 components: 4 ultrasound (US)
assessments and a nonstress test (NST)
-each scores 2 (10 as the highest possible score)
-8-10 = maximal score
6 = suspicious; 0-4 = severe fetal compromise;
delivery indicated

Maternal Serum Alpha-Fetoprotein: Parameter

- assessed at 15th week NST/Reactive FHR
AFP – produced by amniotic fluid and maternal US: Fetal breathing movements
serum US: Fetal activity / gross body movements
- open spinal of abdominal defect US: Fetal muscle tone
- chromosomal defects US: Qualitative AFV

Chorionic Villi Sampling:

-biopsy and chromosomal analysis of chorionic
villi
-done at 10 to 12 weeks

Amniocentesis:
- aspiration of amniotic fluid from the pregnant
uterus for examination
- done 14th and 16th weeks; 15 ml of fluid
Complications:
1. Hemorrhage from penetration of the placenta
2. Infection of the amniotic fluid
3. Puncture of the fetus
4. Premature labor
How:
- empty the bladder
- supine position (folded towel under buttock) Ø
attach fetal monitors/guided by UTZ +CARE OF FETUS PPT

Amniocentesis:

Percutaneous Umbilical Blood Sampling:

-cordocentesis or funicestesis
-aspiration of blood from the umbilical vein for
analysis

Kleihauer-Betke test:
- used to measure the amount of fetal
hemoglobin transferred from a fetus to a
mother's bloodstream.

Amnioscopy:
- Visual inspection of the amniotic fluid through
the cervix and membranes
with amnioscope
- Detect meconium staining

Fetoscopy:
- visualization of fetus through a fetoscope
- 16th or 17th week
Purpose: