uUNIT V

Maternity Nursing

PYRAMID TERMSamniotic fluid Pale, straw-colored fluid in which the fetusfloats. It serves as a cushion against injury from sudden blowsor movements and helps maintain a constant body tempera-ture for the fetus. The fetusmodifies the amniotic fluid throughthe processes of swallowing, urinating, and movementthrough the respiratory tract.

ballottement Rebounding of the fetus against the exami-ner’s finger on palpation. When the examiner taps the cer-vix, the fetus floats upward in the amniotic fluid. Theexaminer feels a rebound when the fetus falls back.

Chadwick’s sign Violet coloration of the mucous membranesof the cervix, vagina, and vulva that occurs at about 4 weeksof pregnancy caused by increased vascularity. This is consid-ered a probable sign of pregnancy.

delivery Actual event of birth; the expulsion or extraction ofthe neonate.

embryo Stage of fetal development that lasts from day 15until approximately 8 weeks after conception or until theembryo measures 3 cm from crown to rump.

fertilization Uniting of the sperm and ovum, which occurswithin 12 hours of ovulation and within 2 to 3 days of insem-ination, the average duration of viability for the ovum andsperm.

Goodell’s sign Softening of the cervix that occurs at thebeginning of the second month of gestation. This is consid-ered a probable sign of pregnancy.

gravida A pregnant woman; called gravida I (primigravida)during the first pregnancy, gravida II during the second preg-nancy, and so on.

Hegar’s sign Compressibility and softening of the lower uter-ine segment that occurs at about week 6 of gestation. Thisis considered a probable sign of pregnancy.

implantation Embedding of the fertilized ovum in the uterinemucosa 6 to 10 days after conception.

infant A human born alive; also, a human from 28 days ofage until the first birthday.

labor Coordinated sequence of rhythmic involuntaryuterine contractions resulting in effacement and dilationof the cervix, followed by expulsion of the products ofconception.

lecithin-to-sphingomyelin (L/S) ratio Ratio of two compo-nents of amniotic fluid, used for predicting fetal lung matu-rity; normal L/S ratio in amniotic fluid is 2:1 or greaterwhen the fetal lungs are mature.

lochia Discharge from the uterus that consists of blood fromthe vessels of the placental site and debris from thedecidua; lasts for 2 to 6 weeks after delivery.

Nagele’s rule Determines the estimated date of birth basedon the premise that the woman has a 28-day menstrualcycle. Add 7 days to the first day of the last menstrualperiod; subtract 3 months and add 1 year. Alternatively,add 7 days to the last menstrual period and count forward9 months.

newborn A human from the time of birth to the twenty-eighthday of life; also called neonate.

parity Number of pregnancies that have reached viabilityregardless of whether the fetus was born alive or stillborn.

placenta Organ that provides for the exchange of nutrientsand waste products between the fetus and the motherand produces hormones to maintain pregnancy. The pla-centa develops by the third month of gestation and is alsocalled afterbirth.

quickening Maternal perception of fetal movement for thefirst time, occurring usually in the sixteenth to twentiethweek of pregnancy.

surfactant Phospholipid that is necessary to keep the fetallung alveoli from collapsing; amount is usually sufficientafter 32 weeks’ gestation.

uterus Organ located behind the symphysis pubis, betweenthe bladder and the rectum. It has four parts— fundus (upperpart), corpus (body), isthmus (lower segment), and cervix.

vagina Tubular structure located behind the bladder and infront of the rectum; it extends from the cervix to the vaginalopening in the perineum. It functions as the outflow tract formenstrual fluid and for vaginal and cervical secretions, thebirth canal, and the organ for coitus.

viability Capability of the fetus to survive outside the uterus;about 22 to 24 weeks of gestation or fetal weight more than500 g.

PYRAMID TO SUCCESS

The Pyramid to Success focuses on the physiological andpsychosocial aspects related to the experience of preg-nancy, delivery, and the postpartum period. PyramidPoints begin with the assessment and knowledge ofexpected findings of the pregnant client and fetus duringthe antepartum period. Instructing the pregnant client inmeasures that promote a healthy environment for themother and the fetus is included. The focus is on theimportance of antepartum follow-up, nutrition, andinterventions for common discomforts that occur duringpregnancy. Knowledge of the purpose of the commonlyprescribed diagnostic tests and procedures in the ante-partum period is also part of the Pyramid to Success.The focus is on disorders that can occur during preg-nancy, particularly gestational hypertension and diabe-tes mellitus. The labor and delivery process and theimmediate interventions for conditions in which thematernal or fetal status is compromised, such asprolapsed cord or altered fetal heart rate, is part of thePyramid to Success. Review of the fetus of a mother withhuman immunodeficiency virus or acquired immuno-deficiency syndrome or a substance-abusing mother isrecommended. The Pyramid to Success also includes afocus on the normal expectations of the postpartumperiod and the complications that can occur during thistime. The next Pyramid Point focuses on the normalphysical assessment findings and early identification ofdisorders in the neonate. The last Pyramid Point in thisunit focuses on maternity and newborn medications.

CLIENT NEEDS

Safe and Effective Care Environment

Consulting with other health care team membersDelegating client care activitiesEstablishing priorities of careHandling hazardous and infectious materials safelyMaintaining confidentialityManaging the health care environmentObtaining informed consent for diagnostic tests

and procedures

Providing continuity of client careUpholding client’s rightsUsing surgical asepsis when providing careUsing standard and transmission-based precautions

when providing care

Health Promotion and Maintenance

Assessing for growth and developmentDiscussing expected body image changes with the clientDiscussing family planning and birthing and parenting

issuesIdentifying at-risk clients during pregnancyIdentifying health and wellness concepts and providing

health care screeningIdentifying high-risk behaviorsIdentifying lifestyle choicesPerforming techniques of physical assessmentProviding antepartum, intrapartum, postpartum, and

newborn careTeaching regarding antepartum, intrapartum, and post-

partum careTeaching regarding care to the newborn

Psychosocial Integrity

Considering cultural, religious, and spiritual influencesregarding birth and motherhood

Discussing situational role changes in the familyEnsuring therapeutic interactions within the familyIdentifying available support systemsIdentifying coping mechanisms

Physiological Integrity

Providing nonpharmacological comfort interventionsand pharmacological pain management during labor

Identifying the action and contraindications for pre-scribed pharmacological agents

Monitoring for side effects and adverse effects related toprescribed pharmacological and parenteral therapies

Calculating medication dosages and administeringmedications safely

Monitoring for expected outcomes and effects relatedto pharmacological and parenteral therapies

Instructing the client about prescribed diagnostic testsand procedures

Providing interventions for unexpected events duringpregnancy

Monitoring the client during the labor and deliveryprocess

Monitoring for normal expectations during pregnancyTeaching the client about nutrition during pregnancy

and in the postpartum periodTeaching the client about the physiological changes

that occur during pregnancy

s252 UNIT V Maternity Nursing

u22Female Reproductive System

I. REPRODUCTIVE STRUCTURES (Fig. 22-1)

A. Ovaries1. Form and expel ova2. Secrete estrogen and progesterone

B. Fallopian tubes1. Muscular tubes (oviducts) approximate to the

ovaries and connected to the uterus2. Tubes that propel the ova from the ovaries to the

uterusC. Uterus

1. Muscular, pear-shaped cavity in which the fetusdevelops

2. Cavity from which menstruation occursD. Cervix

1. The internal os of the cervix opens into the bodyof the uterine cavity.

2. The cervical canal is located between the internalos and the external os.

3. The external cervical os opens into the vagina.E. Vagina

1. Muscular tube that extends from the cervix to thevaginal opening in the perineum

2. Known as the birth canal3. Passage between the cervical os and the external

environmenta. Passageway for menstrual blood flowb. Passageway for fetusc. Passageway for penis for intercourse

II. MENSTRUAL CYCLE (Box 22-1)

A. Ovarian hormones1. Ovarian hormones include follicle-stimulating

hormone (FSH) and luteinizing hormone (LH).2. The hormones are released by the anterior pituitary

gland.3. The hormones produce changes in the ovaries.4. Secretion of ovarian hormones leads to changes

in the endometrium.5. The menstrual cycle, the regularly recurring

physiological changes in the endometrium thatculminate in its shedding, may vary in length,with the average length being about 28 days.

B. Ovarian and uterine phases (see Box 22-1)

III. FEMALE PELVIS AND MEASUREMENTS

A. True pelvis1. Lies below the pelvic brim2. Consists of the pelvic inlet, midpelvis, and pel-

vic outletB. False pelvis

1. Is the shallow portion above the pelvic brim2. Supports the abdominal viscera

C. Types of pelvis1. Gynecoid

a. Normal female pelvisb. Transversely rounded or blunt

The gynecoid pelvis is most favorable for suc-cessful labor and birth.

2. Anthropoida. Oval shapeb. Adequate outlet, with a narrow pubic arch

3. Androida. Heart-shaped or angulatedb. Resembles a male pelvisc. Not favorable for labor and birthd. Narrow pelvic planes can cause slow descent

and midpelvic arrest.4. Platypelloid

a. Flat with an oval inletb. Wide transverse diameter, but short anteropos-

terior diameter,making labor andbirthdifficultD. Pelvic inlet diameters

1. Anteroposterior diametersa. Diagonal conjugate: Distance from the lower

margin of the symphysis pubis to the sacralpromontory

b. True conjugate or conjugate vera: Distancefrom the upper margin of the symphysispubis to the sacral promontory

c. Obstetric conjugate: The smallest front-to-back distance through which the fetal headmust pass in moving through the pelvic inlet

2. Transverse diameter: The largest of the pelvicinlet diameters; located at right angles to thetrue conjugate

253

3. Oblique (diagonal) diameter: Not clinicallymeasurable

4. Posterior sagittal diameter: Distance from thepoint where the anteroposterior and transverse

diameters cross each other to the middle of thesacral promontory

E. Pelvic midplane diameters1. Transverse diameter (interspinous diameter)2. Midplane normally is the largest plane and has

the longest diameter.F. Pelvic outlet diameters

1. Transverse (intertuberous diameter)2. Outlet presents the smallest plane of the pelvic

canal.

IV. FERTILIZATION AND IMPLANTATION

A. Fertilization1. Fertilization occurs in the ampulla of the fallo-

pian (uterine) tube.2. Fertilization occurs when sperm and ovum

unite.3. When fertilized, the membrane of the ovum

undergoes changes that prevent entry of othersperm.

4. Each reproductive cell carries 23 chromosomes.5. Sperm carry an X or a Y chromosome—XY,

male; XX, female.B. Implantation

1. The zygote is propelled toward the uterus.2. The zygote implants 6 to 8 days after

ovulation.

Fallopian tube

EndometriumOvary

Body Fundus

MyometriumPerimetrium(epimetrium)

Cervix

Vagina

Uterus

Rugae

Bartholin’sgland

Fimbriae

Infundibulum

Broad ligament

s FIGURE 22-1 Female reproductive organs. (From Herlihy, B., &Maebius, N. [2007]. The human body in health and illness [3rd ed.]St. Louis: Saunders.)

tBox 22-1 Menstrual Cycle

Ovarian ChangesPreovulatory PhaseHypothalamus releases gonadotropin-releasing hormone

through the portal system to the anterior pituitary system.Secretion of follicle-stimulating hormone (FSH) by the anterior

lobe of the pituitary gland stimulates growth of follicles.Most follicles die, leaving one to mature into a large graa-

fian follicle.Estrogen produced by the follicle stimulates increased

secretions of luteinizing hormone (LH) by the anteriorlobe of the pituitary gland.

The follicle ruptures and releases an ovum into the perito-neal cavity.

Luteal PhaseLuteal phase begins with ovulation.Body temperature decreases and then increases by 0.5! F

to 1! F around the time of ovulation.Corpus luteum is formed from follicle cells that remain in

the ovary after ovulation.Corpus luteum secretes estrogen and progesterone during

the remaining 14 days of the cycle.Corpus luteum degenerates if the ovum is not fertilized, and

secretion of estrogen and progesterone declines.Decline of estrogen and progesterone stimulates the ante-

rior pituitary to secrete more FSH and LH, initiating anew reproductive cycle.

Uterine ChangesMenstrual PhaseMenstrual phase consists of 4 to 6 days of bleeding as the

endometrium breaks down because of the decreasedlevels of estrogen and progesterone.

The level of FSH increases, enabling the beginning of a newcycle.

Proliferative PhaseProliferative phase lasts about 9 days.Estrogen stimulates proliferation and growth of the

endometrium.As estrogen increases, it suppresses secretion of FSH and

increases secretion of LH.Secretion of LH stimulates ovulation and the development

of the corpus luteum.Ovulation occurs between days 12 and 16.Estrogen level is high, and progesterone level is low.

Secretory PhaseSecretory phase lasts about 12 days and follows ovulation.This phase is initiated in response to the increase in LH

level.The graafian follicle is replaced by the corpus luteum.The corpus luteum secretes progesterone and estrogen.Progesterone prepares the endometrium for pregnancy if a

fertilized ovum is implanted.

s254 UNIT V Maternity Nursing

3. The blastocyst secretes chorionic gonadotropinto ensure that the corpus luteum remains viableand secretes estrogen and progesterone for thefirst 2 to 3 months of gestation.

V. FETAL DEVELOPMENT (Box 22-2)

A. Pre-embryonic period: First 2 weeks afterconception

B. Embryonic period: Beginning at day 15 throughapproximately the eighth week after conception

C. Fetal period: Beginning at the ninth week after con-ception and ending with birth

VI. FETAL ENVIRONMENT

A. Amnion1. Encloses the amniotic cavity

tBox 22-2 Fetal Development

Pre-embryonic PeriodFirst 2 weeks after conception

Embryonic PeriodBeginning day 15 through approximately week 8 after conception

Fetal PeriodWeek 9 after conception to birth

Week 1Blastocyst is free-floating.

Weeks 2 to 3Embryo is 1.5 to 2 mm in length.Lung buds appearBlood circulation begins.Heart is tubular and begins to beat.Neural plate becomes brain and spinal cord.

Week 5Embryo is 0.4 to 0.5 cm in length.Embryo is 0.4 g.Double heart chambers are visible.Heart is beating.Limb buds form.

Week 8Embryo is 3 cm in length.Embryo is 2 g.Eyelids begin to fuse.Circulatory system through umbilical cord is well established.Every organ system is present.

Week 12Fetus is 6 to 9 cm in length.Fetus is 19 g.Face is well formedLimbs are long and slender.Kidneys begin to form urine.Spontaneous movements occur.Heartbeat is detected by Doppler transducer between 10

and 12 weeks.Sex is visually recognizable.

Week 16Fetus is 11.5 to 13.5 cm in length.Fetus is 100 g.Active movements are present.Fetal skin is transparent.Lanugo hair begins to develop.Skeletal ossification occurs.

Week 20Fetus is 16 to 18.5 cm in length.

Fetus is 300 g.Lanugo covers the entire body.Fetus has nails.Muscles are developed.Enamel and dentin are depositing.Heartbeat is detected by regular (nonelectronic) fetoscope.

Week 24Fetus is 23 cm in length.Fetus is 600 g.Hair on head is well formed.Skin is reddish and wrinkled.Reflex hand grasp functions.Vernix caseosa covers entire body.Fetus has ability to hear.

Week 28Fetus is 27 cm in length.Fetus is 1100 g.Limbs are well flexed.Brain is developing rapidly.Eyelids open and close.Lungs are developed sufficiently to provide gas exchange

(lecithin forming).If born, neonate can breathe at this time.

Week 32Fetus is 31 cm in length.Fetus is 1800 to 2100 g.Bones are fully developed.Subcutaneous fat has collected.Lecithin-to-sphingomyelin (L/S) ratio is 1.2:1.

Week 36Fetus is 35 cm in length.Fetus is 2200 to 2900 g.Skin is pink and body is rounded.Skin is less wrinkled.Lanugo is disappearing.L/S ratio is greater than 2:1.

Week 40Fetus is 40 cm in length.Fetus is more than 3200 g.Skin is pinkish and smooth.Lanugo is present on upper arms and shoulders.Vernix caseosa decreases.Fingernails extend beyond fingertips.Sole (plantar) creases run down to the heel.Testes are in the scrotum.Labia majora are well developed.

s255CHAPTER 22 Female Reproductive System

2. Is the inner membrane that forms about the sec-ond week of embryonic development

3. Forms a fluid-filled sac that surrounds theembryo and later the fetus

B. Chorion1. Is the outer membrane2. Becomes vascularized and forms the fetal part of

the placentaC. Amniotic fluid

1. Consists of 800 to 1200 mL by the end ofpregnancy

2. Surrounds, cushions, and protects the fetus andallows for fetal movement

3. Maintains the body temperature of the fetus4. Contains fetal urine and is a measure of fetal

kidney function5. The fetus modifies the amniotic fluid through

the processes of swallowing, urinating, andmovement through the respiratory tract.

D. Placenta1. The placenta provides for exchange of nutrients

and waste products between the fetus and mother2. The placenta begins to form at implantation;

the structure is complete by week 12.3. It produces hormones to maintain pregnancy

and assumes full responsibility for the produc-tion of these hormones by the twelfth week ofgestation.

4. In the third trimester, transfer of maternalimmunoglobulin provides the fetus with passiveimmunity to certain diseases for the first fewmonths after birth.

5. By week 10 to 12, genetic testing can be done viachorionic villus sampling (CVS).

Large particles such as bacteria cannotpass through the placenta, but nutrients, drugs,antibodies, and viruses can pass through theplacenta.

VII. FETAL CIRCULATION

A. Umbilical cord1. It contains two arteries and one vein.2. The arteries carry deoxygenated blood and waste

products from the fetus.3. The vein carries oxygenated blood and provides

oxygen and nutrients to the fetus.B. Fetal heart rate (FHR)

1. FHR depends on gestational age; FHR is 160 to170 beats/min in the first trimester, but slows withfetal growth to 120 to 160 beats/min near or atterm.

2. FHR is about twice the maternal heart rate.C. Fetal circulation bypass (Fig. 22-2)

1. Fetal circulation bypass is present because ofnonfunctioning lungs.

2. Bypasses must close after birth to allow blood toflow through the lungs and the liver.

3. The ductus arteriosus connects the pulmonaryartery to the aorta, bypassing the lungs.

4. The ductus venosus connects the umbilicalvein and the inferior vena cava, bypassing theliver.

5. The foramen ovale is the opening between theright and left atria of the heart, bypassing thelungs.

The fetal heart rate is 160 to 170 beats/min inthe first trimester, but slows with fetal growth to120 to 160 beats/min near or at term. The physicianmust be notified if the fetal heart rate is outsidethese parameters.

VIII. FAMILY PLANNING

A. Description1. Involves choosing when to have children2. Includes contraception, prevention of preg-

nancy, and methods to achieve pregnancyB. Birth control

1. The focus of counseling on contraception mustmeet the needs and feelings of the woman andher partner.

2. Several factors should be considered whenchoosing a method of birth control, includingeffectiveness, safety, and personal preference.

3. The woman’s preferences are most important,and cultural practices and beliefs and religiousor other personal beliefs may affect the choiceof contraceptives.

4. Other factors that bear on selection of a con-traceptive method include family-planninggoals, age, frequency of intercourse, and theindividual’s capacity for compliance.

5. If planning goals have already been met, sterili-zation of either the male or female partner maybe desirable (it is important for the couple tounderstand that tubal reconstruction may beunsuccessful).

6. For women who frequently engage in coitus,oral contraceptives or a long-term method suchas implants or an intrauterine device (IUD)may be considered.

7. When sexual activity is limited, use of spermi-cide, condoms, or a diaphragm may be mostappropriate.

8. Because some methods have adverse effects, aninformed consent form may be needed.

9. For additional information on the use of contra-ceptives, see Chapter 55.

C. Infertility1. Infertility is the involuntary inability to conceive

when desired.

s256 UNIT V Maternity Nursing

2. Some factors contributing to infertility in meninclude abnormalities of the sperm, abnormalerections or ejaculations, or abnormalities ofthe seminal fluid.

3. Some factors that contribute to infertility inwomen include disorders of ovulation orabnormalities of the fallopian tubes or cervix.

4. Several diagnostic tests are available to deter-mine the probable cause of infertility and thetherapy recommended may depend on the causeof the infertility.

5. Infertility optionsa. Options include medication, surgical proce-

dures, or therapeutic insemination.b. Other therapies are available, such as in vitro

fertilization, surrogate mothers, or embryohosts.

c. Adoption may also be an option.6. The nurse needs to provide support to the cou-

ple in their decision-making process and duringtherapy.

MORE QUESTIONS ON THE CD!

Practice Questions201. A nursing student is preparing a prenatal class on

the process of fetal circulation. The nursinginstructor asks the student specifically to describethe process through the umbilical cord. Which ofthe following statements from the student iscorrect?1. “The one artery carries freshly oxygenated

blood and nutrient-rich blood back from theplacenta to the fetus.”

2. “The two arteries carry freshly oxygenatedblood and nutrient-rich blood back from theplacenta to the fetus.”

3. “The two arteries in the umbilical cord carrydeoxygenated blood and waste products awayfrom the fetus to the placenta.”

4. “The two veins in the umbilical cord carryblood that is high in carbon dioxide and

Placenta

Umbilicalarteries Urinary bladder

Internal iliac artery

To legs

Superior vena cavaAortic arch

Ductus arteriosus

Left atrium

Pulmonary veins

Noninflated lung

Right atrium

Foramen ovale (open)

Inferior vena cava

Liver

Umbilical vein

Aorta

Portal vein

Ductus venosus

Key to oxygensaturation of blood:

High

Medium

Low

Umbilical cord

Fetal circulation

s FIGURE 22-2 Fetal circulation. Three shunts (ductus venosus, ductus arteriosus, and foramenovale) allowmost blood from theplacenta to bypassthe fetal lungs and liver. (From McKinney, E., James, S., Murray, S., & Ashwill, J. [2009].Maternal-child nursing [3rd ed.]. St. Louis: Saunders.)

s257CHAPTER 22 Female Reproductive System