Framework for Maternal and Child Health Nursing


Obstetrics – Care of woman during childbirth

“obstare” (to keep watch)
Pediatrics – “pais” (child)
Focus of MCN – Care of childbearing and childrearing families.
Primary Goal of MCN – Promotion and maintenance of Optimal Family
Health.

Goal and Scope of MCN

1. Preconceptual Health Care
2. Care of women during 3 trimesters of pregnancy
3.Care of women during Puerperium or 4thTrimester (6 weeks after childbirth)
4.Care of infants during Perinatal Period (6 weeks before conception and 6
weeks after birth)
5. Care of children from birth to adolescence
Neonatal (28 days of life); Infancy (1–12 months); Adolescence (after 18 y/o)
6. Care in settings as varied as the birthing room, the PICU, and the home

Philosophies of MCN
1. MCN is Family Centered - assessment must include both family and
individual assessment.
2. MCN is Community Centered - health of families depends on and
influences the health of communities.
3.MCN is Evidence Based - because critical knowledge increases
4.MCN includes independent nursing functions
because teaching & counseling are major interventions.
5.MCN Nurse, Advocate - protects the rights of family members, including
fetus
6. Health Promotion and Disease Prevention - to protect health of new
generation.
7. MCN is a challenging role for nurses.


Millennium Development Goals (MDGs)

- to eradicate extreme poverty and hunger;
- to achieve universal primary education;
- to promote gender equality and empower women;
- to reduce child mortality;
- to improve maternal health;
- to combat HIV/AIDS, malaria, and other diseases;
- to ensure environmental sustainability; and
- to develop a global partnership for development.

WHO’s 17 Sustainable Development Goals


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

CHANGING CONCEPTS IN MATERNAL-HEALTH CARE

- Maternity care has changed dramatically through out the years as attitudes
and opinions have altered.
- Historically, maternity care was a function of lay midwives, and most birth
occurred in the home setting.
- As knowledge increased about birth interventions and physicians develop
methods of infection prevention, the family physician become the provider of
choice for prenatal care and hospitals instead of homes, became the
accepted place to give birth.
- In today’s society, as the health care consumer has become more
knowledgeable, two different trends can be noted on one hand, as lawsuits
have become more common with large judgments being leveled against
practitioners, maternity care has become increasingly specialized.
- Obstetricians often provide routine prenatal and delivery care.
- The at-risk clients is frequently followed by a perinatologist, a physician who
specializes in the care of women with high-risk pregnancies.
- Neonatologist provide expert with specialized care to at-risk newborns.
- On the other hand, the consumer movement has pushed for birth to be
viewed as a natural process in which little intervention is required.
- Therefore, the midwife has once again come to be accepted as a provider of
maternity care, and some women elect to deliver at home or in birthing
centers, which provide a home-like atmosphere.

MATERNAL-CHILD HEALTH TODAY

- One way to measure health status of a nation is to determine mortality rates
of childbearing women, infants and children.
- Mortality rates are statistics recorded as the ratio of deaths in a given
category of the population.
- The statistics that are of interest to the maternity and pediatric nurse are
maternal, fetal, neonatal, perinatal (the period surrounding birth from
conception throughout pregnancy and birth), infant and child mortality rates.
- Morbidity refers to the number of persons afflicted with the same disease
condition per certain number of population.

Statistical Terms Used to Report Maternal and Child Health

- Birth rate: Number of births per 1000 population.
- Fertility rate: Number of pregnancies per 1000 women of childbearing age.
- Fetal death rate: Number of fetal deaths (weighing more 500 g) per 1000 live
births.
- Neonatal death rate: Number of deaths per 1000 live births occurring at birth
or in the first 28 days of life.
- Perinatal death rate: Number of deaths of fetuses weighing more than 500 g
and within the first 28 days of life per 1000 live births.
- Maternal mortality rate: Number of maternal deaths per 100,000 live births
that occur as a direct result of the reproductive process.
- Infant mortality rate: Number of deaths per 1000 live births occurring at birth
or in the first 12 months of life.
- Childhood mortality rate: Number of deaths per 1000 population in children, 1
to 14 years of age.

THE NURSES CHANGING ROLE IN MATERNAL-CHILD

HEALTH CARE
- The image of nursing has changed, and the horizons and responsibilities has
broadened tremendously in recent years.
- The primary thrust of health care is towards prevention.
- In addition in the treatment of disease and physical problems, modern
maternal-child care addresses prenatal care, growth and development and
anticipatory guidance on maturational and common health problems.
- Teaching also is an important aspects of caring for the child bearing and child-
rearing family.
- Clients are educated on a variety of topics from follow up and immunization to
other more traditional aspects of health.
- Nurses at all levels are legally accountable for their actions and assume new
responsibilities and accountability with every advance in education.
- Nurses practicing in maternity and pediatric settings at all levels must keep
up to date with education and information on how to help their patients and
where to direct families for help when other resources are needed.
- When the nurse functions as a teacher, adviser and resource person, it is
important that the information and advice provided be correct, pertinent and
useful to the person in need.
- Health teaching is one of the most important aspects of promoting wellness.
- Nurses are often in a position to do incidental teaching, as well as more
organized formal teaching.
- Nurses also must be aware that they serve as role models to others in
practicing good health habits.

Unitive and Procreative Health

Where Does Human Life Begins.

Secondary Sex Characteristics in Girls

- Growth spurt
- Increase in the transverse diameter of the pelvis
- Breast development
- Growth in pubic hair
- Onset of menstruation
- Growth of axillary hair
- Vaginal secretions
 Secondary Sex Characteristics in Males
- Increase in weight
- Growth of testes
- Growth of face, axillary, and pubic hair
- Voice changes
- Penile growth
- Increase in height
- Spermatogenesis

Role of Androgen
- Responsible for muscular development, physical growth, and the increase in
sebaceous gland secretions.
- In males, it is produced by the adrenal cortex and the testes.
- In females, by the adrenal cortex and the ovaries.
- It influences the development of the testes, scrotum, penis, prostate and
seminal vesicles; the appearance of male pubic, axillary and facial hair;
laryngeal enlargement and its accompanying voice change; maturation of
spermatozoa; and closure of growth in long bones.
- In girls, it influences enlargement of the labia majora and clitoris and the
formation of axillary and pubic hair.

- ADRENARCHE
Role of Estrogen
- When triggered at puberty by FSH, ovarian follicles in females begin to
excrete high level of the hormone estrogen.
- Composed of three compounds; estrone (E1), estradiol (E2), and estriol (E3).
- It influences the development of the uterus, fallopian tubes and the vagina;
typical female fat distribution and hair patterns; breast development; and an
end to growth because it closes the epiphyses of long bones.

- THELARCHE
MALE EXTERNAL STRUCTURES
PENIS
- The penis is composed of three cylindrical masses of erectile tissues, two
termed corpus cavernosa, and a third termed corpus spongiosum, contained
in the shaft.
- With sexual excitement, contraction of the ischiocavernosus muscle at the
penis base occurs.
- This causes venous congestion in the three sections of the erectile tissue,
leading to distention and erection of the penis.
- At the distal end of the organ is bulging sensitive ridge of tissue, the glans.
- A retractable casing of skin or prepuce protects the nerve-sensitive glans at
birth.
- The penile artery, a branch of the pudendal artery, provides the blood supply
for the penis.
- Penile erection is stimulated by parasympathetic nerve innervation.

SCROTUM
- The scrotum is a rugated skin-covered muscular pouch suspended from the
perineum.
- It contains the testes, epididymis, and the lower portion of the spermatic cord.

TESTES
- The testes are two ovoid glands 2 to 3 cm wide that lie in the scrotum.
- Each testis is encased by a protective white fibrous capsule and is compose
of a number of lobules, each lobule containing interstitial cells (Leydig’s cells)
and a seminiferous tubule.
- Seminiferous tubules produce spermatozoa.
- Leydig’s cells are responsible for the production of testosterone.

MALE REPRODUCTIVE ORGAN

 MALE INTERNAL STRUCTURES
EPIDIDYMIS
- The seminiferous tubule of each testis leads to tightly coiled tube, the
epididymis. Because the epididymis is so tightly coiled, its length is extremely
deceptive.
- The epididymis is responsible for the conduction of sperm from the testis to
the vas deferens, the next step in the passage to the outside.
- Some sperm are stored in the epididymis , and a part of the fluid that
surrounds sperm (semen, or seminal fluid) is produced by the cells lining the
epididymis.

VAS DEFERENS (Ductus Deferens)

- The vas deferens is an additional hallow tube surrounded by arteries and
veins and protected by thick fibrous coating.
- It carries sperm from the epididymis through the inguinal canal into the
abdominal cavity where it ends at the seminal vesicles and the ejaculatory
ducts.
- The blood vessels and vas deferens together are referred to as the spermatic
cord.

SEMINAL VESICLES
- The seminal vesicles are two convoluted pouches that lie along the lower
portion of the posterior surface of the bladder and empty into the urethra by
the way of the ejaculatory ducts.
- These glands secrete a viscous portion of the semen, which has a high
content of a basic sugar and protein and is alkaline in ph.
- Sperm become increasingly motile with this added fluid because it surrounds
them with nutrients and more favorable ph.

EJACULATORY GLANDS
- The two ejaculatory ducts pass through the prostate gland.
- They join the seminal vesicles with the urethra.

PROSTATE GLAND
- The prostate gland lies just below the bladder.
- The urethra passes through the center of it, like the hole of the doughnut.
- The prostate gland secretes a thin alkaline fluid. When added to the secretion
from the seminal vesicles and the accompanying sperm from the epididymis,
this alkaline fluid further protects sperm from being immobilized by the
naturally low ph level of the urethra.
 URETHRA
- The urethra is a hollow tube leading from the base of the bladder, which, after
passing through the prostate gland, continues to the outside through the shaft
and glans of the penis.
- It is approximately 8 inches long. As with other urinary tract structures, it is
lined with mucous membrane.

BULBOURETHRAL GLANDS
- Two bulbourethral, or Cowper’s glands, lie beside the prostate gland and by
short ducts empty into the urethra.
- Like the prostate gland and seminal vesicles, they secrete an alkaline fluid
that helps counteract the acid secretion of the urethra and ensures the safe
passage of spermatozoa.

MALE REPRODUCTIVE ORGAN

FEMALE EXTERNAL STRUCTURES

MONS VENERIS
- The mons veneris is a pad of adipose tissue located over the symphysis
pubis, the pubic bone joint.
- It is covered by a triangle of coarse, curly hairs.
- The purpose of the mons veneris is to protect the junction of the pubic bone
from trauma.
 LABIA MINORA
- Just posterior to the mons veneris spread two hairless folds of connective
tissue, the labia minora.
- Normally, the folds of the labia minora are pink, the internal surface is covered
with mucous membrane, the external surface with skin.

LABIA MAJORA
- The labia majora are two folds of adipose tissue covered by loose connective
tissue and epithelium; they are positioned lateral to the labia minora.
- Covered by pubic hair, the labia majora serves as protection for the external
genitalia, the urethra, and the distal vagina.

OTHER EXTERNAL ORGANS

- The vestibule is the flattened, smooth surface inside the labia. The opening to
the bladder and the uterus both arise from the vestibule.
- The clitoris is a small (approximately 1 to 2 cm) rounded organ of erectile
tissue at the forward junction of the labia minora. It is covered by a fold of
skin, the prepuce. When the ischiocavernosus muscle surrounding it contracts
with sexual arousal, the venous outflow for the clitoris is blocked, leading to
clitoral erection.
- Two Skene’s glands (paraurethral glands) are located just lateral to the
urinary meatus, one on each side. The ducts open into the urethra. Secretions
from them help to lubricate the external genitalia during coitus. Bartholin’s
glands (vulvovaginal glands) are located just lateral to the vaginal opening on
both sides. Their ducts open into the distal vagina. These glands lubricate the
external vulva during coitus. The alkaline ph of their secretions helps to
improve sperm survival in the vagina.
- The fourchette is the ridge of tissue formed by the posterior joining of the two
labia minora and labia majora. This is the structure that is sometimes cut
before birth of the child to enlarge the vaginal opening.
- Posterior to the fourchette is the perineal muscle or the perineal body.
Because this is a muscular area, this is easily stretched during childbirth to
allow for the enlargement of the vagina and passage of the fetal head.
- The hymen is a tough but elastic semicircle of tissue that covers the opening
of the vagina in childhood. It is often torn during time of the first sexual
intercourse.
 Female Reproductive Organ

VULVAR BLOOD SUPPLY

- PUDENDAL ARTERY
- INFERIOR RECTUS ARTERY

VENOUS RETURN PUDENDAL VEIN

 VULVAR NERVE SUPPLY
Anterior Vulva
- Ilioinguinal (L-1 level)
- Genitofemoral (L-1 level)

Posterior Vulva
- Pudendal Nerve (S-3 level)

FEMALE INTERNAL STRUCTURES

OVARIES
- The function of the two ovaries (the female gonads) is to produce, mature,
and discharge ova (the egg cells).
- The ovaries are approximately 4 cm long by 2 cm in diameter and
approximately 1.5 cm thick, or the size and shape of almonds. They are
grayish white in color and appear pitted or with minute indentations on the
surface. An unruptured, glistening, clear, fluid-filled graafian follicle (an
ova about to be discharged) or a miniature yellow corpus luteum (the
structure left after the ovum has been discharged) often can be observed
on the surface of the ovary.

Ovaries are formed with three principal division:

- A protective layer of surface epithelium.
- The cortex filled with the ovarian and graafian follicles. Here the immature
(primordial) follicles mature into ova and produce large amounts of
estrogen and progesterone.
- The central medulla containing the nerves, blood vessels, lymphatic
tissue and smooth muscle tissue.

FALLOPIAN TUBES
- The fallopian tubes arise from each upper corner of the uterine body
and extend outward and backward until each opens at the distal end
next to an ovary. Fallopian tubes are approximately 10 cm in length in
a mature woman. Their function is to convey the ova from the ovaries
to the uterus and to provide a place for fertilization of the ova by sperm.
- Although a fallopian tube is one smooth hallow tunnel, it is
automatically divided into four separate parts:
- The interstitial portion, is that part of the tube that lies within the uterine
wall. This portion is only approximately 1 cm in length; the lumen of the
tube is only 1 mm in diameter at this point.
 - The isthmus is the next distal portion. It is, like the interstitial tube,
extremely narrow. The segment is approximately 2 cm in length. It is
the portion of the tube that is cut or sealed in a tubal ligation or tubal
sterilization procedure.
- The ampulla is the third and also the longest portion of the tube. It is
approximately 5 cm in length. It is in this ampullar portion that
fertilization of an ovum usually occurs.
- The infundibular portion is the fourth most distal segment of the tube. It
is approximately 2 cm long and is funnel shaped. The rim of the funnel
is covered by fimbria (small hairs) that help to guide the ova into the
fallopian tube.
o *The lining of the entire fallopian tube is comprise of mucous
membrane, which contains both mucous-secreting and ciliated
(hair-covered) cells. Beneath the mucous lining is connective
tissue and a circular muscle layer.
o *The muscle layer of the tube produces peristalic motions that
conduct the ova the length of the tube. This migration of the ova
is further aided by the action of the ciliated lining and the mucus,
which acts as a lubricant.
o *The mucus produced may also act as a source of nourishment
for the fertilized egg because it contains protein, water, and
salts.

UTERUS
- The uterus is a hollow, muscular, pear-shaped organ located in the lower
pelvis, posterior to the bladder and anterior to the rectum. During
childhood, it is approximately the size of an olive, and its proportions are
reserve from what they are later on, the cervix being the largest portion of
the organ. At approximately age 8 years, an increase in the size of the
uterus begins. The maximum increase in size occurs by approximately
age 17 years.
- With maturity, a uterus is approximately 5 to 7 cm long, 5 cm wide, and in
its widest upper part 2.5 cm deep. In a nonpregnant state, it weighs
approximately 60 g. The function of the uterus is to receive the ova from
the fallopian tube; provide a place for implantation and nourishment
during fetal growth; furnish protection to a growing fetus; and at maturity
of the fetus, expel it from the woman’s body.
Anatomically, the uterus consists of three divisions:
- The body or corpus
- The isthmus
- The cervix
 - The body of the uterus is the upper most part and forms the bulk of the
uterus. The lining cavity is continuous with that of the fallopian tubes,
which fused at its upper aspects (the cornua). The portion of the uterus
between the points of attachment of the fallopian tubes is the fundus.
During pregnancy, the body of the uterus is the portion of the structure
that expands that contain the growing fetus.
- The isthmus of the uterus is a short segment between the body and the
cervix. In the nonpregnant uterus, it is only 1 to 2 mm in length. During
pregnancy, this portion also enlarges greatly to aid in accommodating
the growing fetus.
- The cervix is the lowest portion of the uterus. It represents
approximately one third of the total uterus size, or is approximately 2 to
5 cm long. Approximately half of it lies above the vagina; half extends
into the vagina. The cavity is termed the cervical canal. The junction of
the canal at the isthmus is the internal cervical os; the distal opening to
the vagina is the external cervical os.

UTERINE AND CERVICAL COATS

- The uterine wall consists of three separate coats or layers of tissue:
- An inner one of mucous membrane (the endometrium)
- A middle one of muscle fibers (the myometrium)
- An outer one connective tissue (the perimetrium)
o The mucous membrane lining of the cervix is termed the endocervix.

VAGINA
- The vagina is a hollow musculomembranous canal located posterior to
the bladder and anterior to the rectum. It extends from the cervix of the
uterus to the external vulva. Its function is to act as an organ of
intercourse and to convey sperm to the cervix so sperm can meet with the
ovum in the fallopian tube. With childbirth, it expands to serve as birth
canal.
FEMALE INTERNAL REPRODUCTIVE ORGAN

FEMALE INTERNAL
REPRODUCTIVE ORGAN
 UTERINE BLOOD SUPPLY
Descending abdominal aorta

Two Iliac arteries

Uterine arteries

Uterine Nerve Supply

- Afferent nerve – sensory
o T11 and T12
- Efferent nerve – motor
o T5 – T10
Epidural Anesthesia

Uterine Support
- The uterus is suspended in the pelvic cavity by several ligaments that also
help support the bladder and is further supported by a combination of fascia
and muscles.
- If its ligaments become over stretched during pregnancy, they may not
support the bladder well afterward, and the bladder can then herniate into the
anterior vagina ( a cystocele).
- If the rectum pouches into the vaginal wall, a rectocele develops.
- A fold of peritoneum behind the uterus forms the posterior ligament. This
creates a pouch (Douglas’ cul-de-sac) between the rectum and the uterus.
 UTERINE SUPPORT

Position Deviations of the Uterus

- Anteversion – a condition in which the entire uterus is tipped far forward.
- Retroversion – a condition in which the entire uterus is tipped backward.
- Anteflexion – a condition in which the body of the uterus is bent sharply
forward at the junction with the cervix.
- Retroflexion – a condition in which the body is bent sharply back just
above the cervix.
Pelvis
- The pelvis serves to support and protect the reproductive and other pelvic
organs.
- It is a bony ring formed by four united bones: the two innominate bones
that form the anterior and lateral portion of the ring, and the coccyx and
sacrum, which compose the posterior aspect.
- Each innominate bone is divided into three parts:
o Ilium
o Ischium
o Pubis

- Ilium – forms the upper and lateral portion. The flaring superior border of
this bone is what forms the prominence of the hip (the crest of the ilium)
- Ischium is the inferior portion. At the lowest portion of the ischium are two
projections : the ischial tuberosities. This is the portion of bone on which a
person sits.
 These projections are important markers used to determine lower
pelvic width.
 The ischial spines are small projections that extend from the lateral
aspects into the pelvic cavity. They mark the midpoint of the pelvis.

- Pubis – is the anterior portion of the innominate bone. The symphysis

pubis is the junction of the innominate bones at the front of the pelvis.

SACRUM
- The sacrum forms the upper posterior portion of the pelvic ring. There is a
marked anterior projection of this bone at the point where it touches the
lower lumbar vertebrae, the sacral prominence. This landmark must be
identified when securing pelvic measurements.

COCCYX
- The coccyx, just below the sacrum, is composed of five very small
bones fused together.
- Although it is stiff, there is a degree of movement possible in the joint
between the sacrum and the coccyx.

PELVIC ARTICULATIONS
- Sacroiliac
- Sacrococcygeal
- Symphysis pubis
 TYPES OF PELVIS
1. Android
- “male pelvis”
2. Anthropoid
- “ape-like” pelvis
3. Gynecoid
- “normal” female pelvis, the inlet is well rounded forward and
backward.
4. Platypelloid
- “flattened” pelvis

DIVISION OF PELVIS
 FEMALE BREAST
- Milk glands of breasts are divided by connective tissue partitions into
approximately 20 lobes.
- All the glands in each lobe produce milk by acini cells and deliver it to the
nipple by a lactiferous duct.
- The nipple has approximately 20 small openings through which milk is
secreted.
- An ampulla portion of the duct just posterior to the nipple serves as a
reservoir for milk before breastfeeding.

- A nipple is composed of smooth muscle that is capable of erection on

manual or sucking stimulation.
- On stimulation, it transmits sensation to the posterior pituitary gland to
release oxytocin.
- Oxytocin acts to constrict milk gland cells and push milk forward into the
ducts that lead to the nipple.

- The nipple is surrounded by a darkly pigmented area of epithelium

approximately 4cm in diameter termed the areola.
- The areola appears rough on the surface owing to many sebaceous
glands, called Montgomery’s tubercles.
 - The blood supply to breasts is profuse because it is formed by the thoracic
branches of the axillary, internal mammary and intercostal arteries.

FEMALE BREAST

Human Sexuality
- Sexuality is a multidimensional phenomenon that includes feelings, attitudes
and actions. It has biologic and cultural components. It encompasses and gives
direction to a person’s physical, emotional, social and intellectual responses
throughout life.
- Biologic gender is the term used to denote chromosomal sexual development:
male (XY) or female (XX).

- Gender or sexual identity is the inner sense a person has of being male or
female, which may be the same as or different from biologic gender.
- Gender role is the behavior a person conveys about being male or female,
which again, may or may not be the same as biologic gender or gender
identity.
Development of Gender Identity
- The amount of testosterone secreted in utero may affect this characteristics. A
process termed sex typing.
- How appealing parents or other adult role models portray their gender roles may
also influence how a child envisions himself or herself.
- Gender role is also culturally influenced. Women have in the past been viewed
as kind and nurturing, with sole responsibility for childbearing and homemaking.
- Men were viewed as financial providers for the family.
- Fortunately, gender roles today are more interchangeable than they once were.
Women pursue all kinds of jobs and careers without loss of femininity; men
participate with childbearing and household duties without loss of masculinity.
- As individual’s sense of identity develops throughout an entire lifespan, and the
stage is set by expectations even before a child is born.
- Although parents usually respond to the question, “Do you want a boy or a girl?’
with the answer, “It doesn’t matter as long as its healthy”. Many parents actually
have strong preferences for a male or female child.