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Maternal Nursing care given by the
nurse to the expectant family before,
during, & following birth

Obstetrics branch of medicine that
pertains to the care of women during
pregnancy, childbirth, & the postpartum
Obstetrician = physician
Family-Centered Care
Recognizes the strength & integrity of the
family as the core of planning &
implementing health care
Nurse & family members need to be
Before the 1900s most babies born @

By 1960 more than 90% of births
occurred in hospitals

And Now???
Merging of the Maternity Unit
Used to be separate labor room, delivery
room, postpartum room, & newborn
Now combining labor, delivery, & recovery
(LDR) may still be transferred to a
postpartum unit, but baby usually rooms-in
Some facilities combine keep woman in
same area throughout her entire
experience (LDRP)
Lengths of Stay
Mandated by legislation

Vaginal delivery = 24-48 hrs.

Cesarean delivery = 72 hrs.
Statistics r/t Maternal Nursing:
Fertility rate
Fetal Mortality rate
Infant Mortality rate
Maternal Mortality rate
Neonatal Mortality rate
Perinatal Mortality rate
How are these statistics used?
To become aware of reproductive trends
To determine populations at risk
To evaluate the quality of prenatal care
To compare relevant information from
state to state & country to country
Male Reproductive System:

Male Reproductive System:
Penis deposits sperm into females vagina to
fertilize an ovum
Testes Manufacture sperm & secrete male sex
Semen seminal plasma & sperm together;
excreted during sexual intercourse
Testosterone most abundant male sex
muscle mass & strength
Promotes growth of long bones
basal metabolic rate
Enhanced production of RBCs
Produces enlargement of vocal cords
Affects distribution of body hair
Female Reproductive System:

Female Reproductive System:

Female Reproductive System:
Vagina tubular structure made of muscle &
membranous tissue
provides passageway for sperm to enter uterus
allows for drainage of menstrual fluids & other
provides passageway for infants birth
Cervix lower part of uterus
Lubricates vagina
Acts as a bacteriostatic agent
Provides alkaline environment for sperm
Produces mucus plug during pregnancy
Thins and dilates during labor

Female Reproductive System:
Uterus hollow muscular organ; site of
implantation of fertilized ovum & houses
developing fetus
Consists of 3 parts: cervix, corpus, & fundus
Begins a pelvic organ, becomes temporary
abdominal organ
Perimetrium outermost
Myometrium middle
Endometrium - innermost
Female Reproductive System:
Fallopian Tubes from uterus to ovary on each
Provide passageway in which sperm meet ovum
Site of fertilization
Safe nourishing environment for ovum
Means of transporting ovum to uterus
Ovaries almond-shaped glands
Produce estrogen & progesterone
Maturation of ovum during each reproductive cycle

Female Reproductive System
Breasts = accessory organs of reproduction;
produce milk after birth to provide
nourishment & maternal antibodies to
Follicle Stimulating Hormone (FSH):
Stimulates maturation of the follicle in the ovary that
contains a single ovum

Luteinizing Hormone (LH):
Stimulates final maturation & release of the ovum

Corpus Luteum empty follicle after ovum is
Produces increasing amounts of estrogen &
progesterone which lead to a build-up of the

Anterior pituitary secretes FSH & LH maturation of ovum

Ovulation occurs when mature ovum is released from follicle
~ 14 days before onset of next menstrual cycle

Corpus luteum turns yellow & secretes amounts progesterone

If no fertilization corpus luteum degenerates - amts.
estrogen & progesterone (after 12 days)

Endometrium breaks down menstruation occurs

Anterior pituitary secretes more FSH & LH beginning a new
cycle (refer to picture in book-pg 27)

Menarche beginning of menstruation
Climacteric period of years during which
womans ability to reproduce gradually
Menopause end of menstruation

Conception (Fertilization) sperm joins
with ovum
Physiology of Pregnancy
During sexual intercourse, the sperm carried
in the ejaculatory semen of the male enters
the vagina of the female.
Through flagellation, the sperm travel through
the mucus of the cervical canal, enter the
uterine chamber, and move into the ampulla,
the outer third of the fallopian tube.
If the timing is such that an ovum has been
produced and is also within the ampulla of the
tube, fertilization may occur.
Physiology of Pregnancy
Fertilization (continued)
Fertilization takes place when the sperm joins
or fuses with the ovum; this is called
Once fertilization has occurred, the new cell is
referred to as a zygote or fertilized ovum.
At the moment of fertilization, the sex of the
zygote and all other genetic characteristics
are determined and they do not change.
46 chromosomes- xx-girl xy-boy
Physiology of Pregnancy
The zygote moves through the uterine tube
through ciliary action and some irregular
peristaltic activity.
It requires about 3 or 4 days to enter the
uterine cavity.
During this time, the zygote is in a phase of
rapid cell division called mitosis; further
changes result in formation of a structure
called the morula.
The morula develops into a blastocyst.
Implantation (continued)
The condition of the uterine lining is critical if
implantation of the zygote is to occur.
Implantation usually occurs in the fundus of
the uterus on either the anterior or posterior
If uterine conditions are not suitable, it is
unlikely that implantation will occur.
If the intrauterine vascular or hormonal
conditions cannot sustain the implanted
embryo, a spontaneous abortion will occur;
usually during the first 8 weeks of pregnancy.
Implantation (continued)
After the blastocyst is free in the uterine cavity
for 1 or 2 days, the exposed cell walls of the
blastocyst (called the trophoblast) secrete
enzymes that are able to break down protein
and penetrate cell membranes.
These enzymes allow the blastocyst to enter
the endometrium and implant.
The action of the enzymes normally stops
short of the myometrium but may cause slight
bleeding; this is called implantation bleeding.
The bleeding may confuse some women who
think they had a very light and short menstrual
Physiology of Pregnancy
Implantation (continued)
Ectopic pregnancy, in which implantation
occurs outside of the uterine cavity, also
poses serious problems.
During the first few weeks after implantation,
primary villi appear; these villi are able to use
maternal blood vessels as a source of
nourishment and oxygen for the developing
Physiology of Pregnancy
Implantation (continued)
It is also during these first few weeks that the
first stages of the chorionic villi occur.
Chorionic villi secrete human chorionic
gonadotropin (hCG), a hormone that
stimulates the continued production of
progesterone and estrogen by the corpus
luteum; this is the reason that ovulation and
menstruation cease during pregnancy.
The chorionic villi become the fetal portion of
the placenta.
Is a disc-like endocrine organ that secretes HCG,
estrogen, & progesterone. Only present during preg.
Site of nutrient & waste exchange
Circulation thru to fetus is well established after 4
Able to block transfer of certain substances: placental
Meds such as Insulin & Ephedrine do not cross
Most bacteria do not cross (too large), some viruses able
to cross
Shiny Schultz fetal side, Dirty Duncan- maternal side

Amniotic Sac 2 layers: amnion (fetal
side) & chorion (outer layer); appears
fragile but strong enough to hold fetus &
amniotic fluid @ full term
Amniotic Fluid acts as cushion against
mechanical injury; helps regulate fetal
body temp., allows room for growth,
indicator of fetal well being & renal
Umbilical Cord joins embryo to placenta
20-22 long, <1 diameter
Whartons jelly major part of the cord
Vessels: (remember AVA)
1 vein carries oxygenated blood to fetus
2 arteries carries deoxygenated blood back to
No pain receptors
Can have knots, wrapped around fetus
Placental Hormones
Maintains uterine lining
uterine contractions
Prepares glands of breasts for lactation
Stimulates testosterone production in male
Stimulates uterine growth
blood flow to uterine vessels
Stimulates development of breast ducts to
prepare for lactation
Placental Hormones
Human Chorionic Gonadotropin (HCG)
Causes corpus luteum to persist & continue
production of estrogen & progesterone to sustain
Basis of most pregnancy tests
Human Placental Lactogen (HPL)
s insulin sensitivity & utilization of glucose by mother
making more glucose available to fetus. Is Insulin
Increases. Helps decrease contractions and remodel
collagen in cervix
Tissue Layers of the Zygote:

Tissue Layer

Gives rise to:
(Outermost layer)
Skin, nails, hair
(Middle layer)
Muscles, CT, bone,
blood, lymphoid tissue,
epithelial tissue, conn
(Innermost layer)
Lining of cavities &
passages, covering of
most internal organs
Stages of Prenatal Development
Germinal fertilization to implantation
Called Zygote, up to 2 weeks
Embryonic implantation (2
wk) thru 8
weeks, basic form of all major organs & systems
develop, simple heart beat, human appearance
Called Embryo
Fetal 9 weeks to birth (38-40 wks. considered
full term)
Called Fetus
Stages of Pregnancy

First: conception-12 weeks
Second: 13-27 weeks
Third: 28- delivery

3 weeks
4 weeks
8 weeks
12 weeks
16 weeks
Maternal-Fetal circulation
Fetal & Neonatal Circulation
Fetal Circulatory Shunts:
Ductus Venosus diverts some blood
away from the liver as it returns from the
placenta and goes to Rt atrium
Foramen Ovale diverts most of the blood
from the Rt. Atrium directly to Lt. Atrium,
rather than circulating to the lungs
Ductus Arteriosus diverts most of the
blood from the pulmonary artery into the
Fetal Circulation
blood goes to liver
via portal sinus
blood enters
Inferior Vena Cava thru
Ductus Venosus
Oxygenated Blood
Umbilical Vein

Small amt. blood to
Rt. Ventricle

Most blood passes into
Left Atrium via
Foramen Ovale
Blood in Inferior
Vena Cava
Right Atrium
Fetal Circulation
Fetal Circulation
Rest of blood from
Rt. Ventricle
Blood from Left
Join thru Ductus Arteriosus
Circulates thru fetal body
Returns to placenta thru Umbilical Arteries

Closure of Fetal Shunts:
Foramen Ovale pressure in Rt. side of heart
s as lungs become fully inflated & now is little
resistance to blood flow
Functional 2 hrs. post birth
Permanent by 3 months
Ductus Arteriosus blood O
level s
Functional 15 hrs. post birth
Permanent 3 weeks
Ductus Venosus flow from umbilical cord
Functional when umbilical cord is cut
Permanent 1 week

Conditions that impede full lung expansion
& decrease blood O
levels may cause the
Foramen Ovale &/or Ductus Arteriosus to
Example: Respiratory Distress Syndrome
Can give Prostaglandins to keep open
Can give Indomethacin to help close
Determination of Pregnancy
Presumptive Signs
Nausea and vomiting
Frequent urination
Breast changes
Changes in shape of the abdomen
Skin changes
Chadwicks sign: discoloration of cervix
Determination of Pregnancy
Probable Signs
Changes in the Reproductive Organs
Hegars sign: softening of uterus
Goodells sign: softening of cervix
Chadwicks sign: discoloration of cervix
Enlargement of uterus

Positive Pregnancy Test
Hegars Sign
Figure 25-5
Internal ballottement (18 weeks).
(From Wong, D.L., Perry, S.E., Hockenberry-Eaton, M.J. [2002]. Maternal-child nursing care. [2
St. Louis: Mosby.)
Determination of Pregnancy
Positive Signs
Visualization: ultrasound. <8 wks, vaginal. >8
weeks, abdominal.
Fetal movement detected by Healthcare
Auscultation of fetal heartbeat
Determination of Pregnancy
Determination of the Estimated Date of
Birth (EDB) (EDC)
Normal human pregnancy, counting from the
first day of the last menstrual period, is about
280 days, 40 weeks, or 10 lunar months
(slightly more than 9 calendar months).
Ngeles rule
Start with the first day of the womans last
menstrual period and count back 3 months; then
add 7 days.
Birth Date Calculator : Wheel
Determination of Pregnancy
Determination of the Estimated Date of
Birth (continued)
If the woman does not keep a menstrual
record, the primary care provider must then
rely on observations such as quickening,
estimation of fetal size by palpation, or
ultrasonic tests, all of which can be unreliable.
Determination of Pregnancy
Obstetric Terminology
Terms used to describe the number of times a
woman has been pregnant and given birth
Gravida: indicates a pregnant woman; # of
times woman has been pregnant including
present one
Primigravida: one pregnancy; 1
Nulligravida: no pregnancies
Multigravida: multiple pregnancies
Para: woman who has given birth to a
child/children who have reached 20 wks.
Primipara: given birth to 1
Nullipara: no births that have reached 20 wks.
Multipara: multiple births

Abortion: termination of pregnancy before 20
wks. gestation; spontaneous or induced
Gestational Age: prenatal age of developing
fetus calculated from 1
day of LMP
Age of Viability: stage where fetus is capable
of living outside of the uterus; usually 20 wks.
Maternal Physiology
Hormonal Changes
Estrogen and progesterone levels remain
elevated for the first 8 weeks of pregnancy as
a result of hCG.
After this time, the placenta takes over
production and maintains necessary levels.
As long as these levels are high, follicle-
stimulating hormone (FSH), luteinizing
hormone (LH), and ovulation are suppressed,
as is menstruation.
Maternal Physiology
The uterus enlarges during pregnancy as a
result of hormonal stimulus, increased
vascularity, hyperplasia, and hypertrophy.
The nonpregnant uterus is pear-shaped and
weighs about 2 oz. & has a capacity of 10ml.;
@ term weighs 2.2# & has a capacity of
In a nonpregnant state, it is a pelvic organ;
when the pregnancy reaches completion, the
superior aspect of the uterus will be located at
the level of the xiphoid process.
Cervix color & consistency change;
produces mucus plug; thins & dilates near
onset of labor & mucus plug is expelled

Ovaries do not ovulate; corpus luteum
persists until placenta takes over hormone
production (6-7 weeks)

Vagina - d blood supply bluish color;
rugae become prominent; mucosa
thickens; d secretions; pH becomes
more acidic
Hypertrophy of the mammary glandular tissue and
increased vascularization, pigmentation, size, and
prominence of nipples and areola.
Sebaceous glands secrete lubrication for nipples

Respiratory System
d O
consumption (15%)
Depth increases, slight increase in rate
Dyspnea until fetus descends into pelvis
Swollen mucous membranes; nasal stuffiness; nose
bleeds; voice changes
Cardiovascular System
Heart displaced up & to left by uterus
Blood volume s by 45%
HR (10-15 bpm) & cardiac output s
Vascular resistance s
Vena Cava Syndrome
Orthostatic hypotension
Dilutional anemia
Vericose veins
in clotting factors & WBC
Gastrointestinal System
Stomach & intestines displaced
appetite & thirst
d acidity of gastric secretions
d gastric emptying & intestinal motility
Cardiac sphincter of stomach relaxes
Alteration in glucose metabolism (GDM)
Urinary System
GFR s d/t maternal & fetal waste excretion
Renal tubules reabsorption
Bladder capacity s, lead to urinary stasis
Skeletal System
Posture changes; rounded shoulders; back ache
Waddling gait
Joint instability d/t softening of ligaments
Evaluating Fetal Well-being
A variety of technologic and assessment tools
can be used to evaluate fetal well-being.
These tools are used to evaluate maternal and
fetal health problems, fetal congenital
anomalies, and fetal growth and maturity.
Ultrasonography:<8 wk, vaginal. >8wk, abd.
Maternal serum alpha-fetoprotein screening
Chorionic villus sampling
Lecithin-Sphingomyelin Ratio
Nonstress test
Contraction stress test
Magnetic resonance imaging
Biophysical profile
Fetal kick count
Figure 25-3
Transabdominal amniocentesis.
(Courtesy of Marjorie Pyle, RNC, LifeCircle, Costa Mesa, California.)
21 week fetus diagnosed with spina bifida undergoing surgery
while still in the womb.
Antepartal Assessment
General Physical Assessment
Ideally, the woman has been receiving regular
medical attention and is already known by the
health care provider.
On the first visit, demographic data, such as
age, occupation, marital status, and insurance
information, are obtained; this helps the
primary care practitioner identify potential
areas of concern.
A basic family and personal medical history is
obtained; it should include genetic diseases.
Antepartal Assessment
Lifestyle patterns
Basic physical examination
Psychosocial history
Cultural practices & health beliefs that affect
Prenatal labs: Blood type, Rh, Rubella, Hepatitis B,
Syphilis, H&H, HIV, Urinalysis, Urine culture.
New Test: RHD Test- only for Rh- moms, test mom
serum for Rh of infant and infant sex. Mom must be
12wks or > preg.
Antepartal Assessment
Obstetric Assessment
Information about the womans gynecological,
menstrual, and obstetric history is obtained.
The number of pregnancies and their
outcomes are discussed.
Gynecological Examination
The gynecological examination is also
performed at this time. Pap, GC, Chlamydia
The nurse is often called on to prepare the
necessary equipment and assist with this
Antepartal Care
Health Promotion
Pregnancy is a time in life when most women
see the importance of regular medical
supervision and are more willing to make
changes in their habits than any other time.
Once pregnancy is diagnosed, prenatal care
is instituted.
Early in pregnancy, the woman often begins
to seek information and make choices
regarding how and where she wishes to give
Health Promotion (continued)
Routine care during pregnancy begins with the initial
examination and history.
Appointments are recommended once a month
through the seventh month (28 wks), once every 2
weeks for the next month (29-36 wks), and then once
every week until delivery(36-40 wks).
Smoking, doing drugs, and drinking alcoholic
beverages during pregnancy are contraindicated.
Taking any medications during pregnancy, including
over-the-counter drugs, should be taken only under
the direction of a doctor.
Danger Signs During Pregnancy
Visual disturbances
Rapid weight gain
Signs of infection
Vaginal bleeding or drainage
Persistent vomiting
Muscular irritability or convulsions
Absence or decrease in fetal movement once
Nursing Action:
Stress to the pregnant
woman to contact her
care provider
promptly if she
develops any of these
Maternal Nutrition:
Benefits of optimal nutrition during pregnancy:
risks of complication
premature deliveries
rate of low-birth weight babies

Nurse must teach pregnant women that
nutrient needs increase more than calorie
needs (select nutrient-dense foods)
Pregnant woman additional 300 calories
Lactating woman additional 500 calories (from
prepregnant intake)
All women of childbearing age should be
encouraged to consume a healthy diet &
use care in the consumption of alcohol &
caffeine because:
Many women are unaware of the pregnancy
during the 1
few weeks after conception
Most women dont attend prenatal information
classes until the later months of their
Intake = 60 g.
Importance = metabolism, growth & repair
of maternal & fetal tissues
Sources = meat, fish, poultry, dairy
Intake = 1200 mg.
Importance = bones, proper nerve &
muscle function
Sources = dairy products, enriched cereal,
legumes, green leafy veggies, broccoli,
dried fruits, canned salmon & sardines
Intake = 30 mg.
Importance = d production of RBCs,
fetus must store iron supply to meet needs
for 1
3-6 months
Sources = red & organ meats, whole
grains, dark green leafy veggies, dried
fruit, fortified cereals & breads
Folic Acid
Intake = 400 mcg.
Importance = incidence of neural tube
defects; formation & maturation of RBCs
& WBCs
Sources = liver, lean beef, kidney & lima
beans, potatoes, fresh dark green leafy
veggies, whole wheat bread, peanuts,
fortified cereals, dried beans
Fluids during Pregnancy
Drink 8-10 glasses (8oz.) per day
Most of fluid intake should be water
Limit caffeinated & high-sugar drinks
Recommended weight gains:
Women of normal weight: 25-35 #
Underweight women: 28-40 #
Overweight women: 15-25 #

Distribution of weight gain:
Uterus = 2.5# Breasts = 1.5-3#
Fetus = 7-7.5# Blood volume = 3.5-4#
Placenta = 1-1.5# Extravascular fluid = 3.5-5#
Amniotic Fluid = 2# Maternal reserves = 4-9.5#
This is the craving and eating of substances that
are not normally considered edible.
Substances such as clay or laundry starch are
commonly ingested.
They are not toxic but may interfere with iron
absorption, resulting in anemia.
Large amounts of clay may cause constipation.
Common Discomforts of
Ptyalism(Excessive salivation)
Hyperemesis gravidarum
Pyrosis (heartburn)
Urinary Frequency
Common Discomforts (cont.)
Varicose veins
Leg cramps
Nasal stuffiness
Skin Changes during Pregnancy
Linea nigra: dark line midline of abdomen
Chloasma: the mask of pregnancy
Striae gravidarum: stretch marks
Spider nevi: dilated capillaries on the skin
Palmar erythema: reddened palms
Hirsutism: excessive body hair
Hygiene Practices
Bathing and showering during pregnancy
should continue as part of routine hygiene.
Increased perspiration is common, and good
personal hygiene is important to prevent body
Some primary care practitioners restrict tub
baths in the last month, because the cervix
may have dilated. No bath once ROM.
Most primary care practitioners recommend
that women avoid using hot tubs, sauna
baths, and spas during pregnancy.
Normal activity should continue throughout an
uncomplicated pregnancy discuss exercise
routine with healthcare provider.
Fatigue is common pace activities, dont
overdo it.
Avoid high-risk activities or those requiring a
great deal of coordination or balance.
exercise 4 wks. before due date.
Avoid becoming overheated.
Stop exercising if develop SOB, dizziness,
numbness, tingling, abd. pain, or vaginal
bleeding & contact provider immediately.

Early in pregnancy, few changes in sleep
patterns are experienced.
As the size of the abdomen increases, it may
become increasingly difficult for the woman to
find a position of comfort.
The supine position is not recommended as a
woman approaches her due date; this may
cause excessive pressure on the aorta and
vena cava and may result in decreased
circulation for the fetus.
Rest periods during the day with the feet
elevated should be encouraged.
Figure 25-7
During third trimester, pillows supporting abdomen and back provide
a comfortable position for rest.
(From McKinney, E.S., James, S.R., Murray, S.S., Ashwill, J.W. [2005]. Maternal-child nursing. [2
Philadelphia: Saunders.)
Sexual Activity
Unless there are complications in the
pregnancy or the bag of water has ruptured,
there is no physiological reason to limit sexual
activity during pregnancy.
Many women experience a decrease in desire
as a result of hormonal changes and the
multiple discomforts that may be occurring.
Discussion of various coital positions and
sexual activity that does not include
intercourse is appropriate.
Fears & concerns normal partners need to
communicate these concerns.
Vaginal Bleeding
Vaginal bleeding at any time during pregnancy
should be reported to the physician at once.
Sexual activity should cease until the cause of
the bleeding is determined and should be
resumed only when the physician determines
that no danger exists.
Coping/Stress Tolerance
All of the physical and hormonal changes of
pregnancy place additional stress on the
Mood swings and ambivalence are common
as the woman works through her fears and
comes to grip with the reality of pregnancy
and how the pregnancy will affect her life.
Listening and allowing the woman adequate
time to verbalize her fears can also help
reduce anxieties.
Pregnancy introduces a totally new role, that
of a mother & father.
Culture will have much to do with how the
woman will define her role.
Dynamics also change between the woman
and the babys father, particularly with the first
pregnancy. The woman is no longer just a
wife or girlfriend; she is also a mother.
Women will look to family & friends as role
Rapid changes in body shape and size can
lead to changes in self-image.
Many women feel that they are not attractive
when they are pregnant.
They may also feel a loss of control related to
the changes taking place.
Impact of Pregnancy
Older couple
Single parents
Preparation for Childbirth
Cultural Variations in Prenatal Care
It is imperative that the practitioner
determine and explore cultural practices
and beliefs with the patient.

African American
Southeast Asian
Preparation for Childbirth
Prenatal Education special classes offered to help the
childbearing family understand & prepare for the
demands of pregnancy, labor, the newborn, &
Review reproductive A&P
Discuss changes during pregnancy
Fetal growth & development
Danger signs
Discussion of analgesia & anesthesia during labor
Care of the newborn
Sibling preparation & changing family dynamics

Preparation for Childbirth
Childbirth Preparation Classes
Some classes are general in nature, whereas
others are targeted toward specific groups
such as adolescents, those having cesarean
or vaginal birth after cesarean delivery,
siblings, or grandparents.
Common methods of prepared childbirth
Figure 25-8
Entire family participating in a childbirth preparation course.
(From Lowdermilk, D.L., Perry, S.E. [2004]. Maternity & womens health care. [8
ed.]. St. Louis:
Nursing Process
Nursing Diagnoses
Body image, disturbed
Nutrition: less than body requirements
Injury, risk for
Activity intolerance
Incontinence, stress urinary
Sleep pattern, disturbed
Nursing Process
Nursing Diagnoses (continued)
Knowledge, deficient
Family processes, interrupted
Parenting, risk for impaired