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UNIT V

Maternity Nursing
PYRAMID TERMS

amniotic fluid Pale, straw-colored fluid in which the fetus

floats. It serves as a cushion against injury from sudden blows
or movements and helps maintain a constant body temperature for the fetus. The fetus modifies the amniotic fluid through
the processes of swallowing, urinating, and movement
through the respiratory tract.
ballottement Rebounding of the fetus against the examiners finger on palpation. When the examiner taps the cervix, the fetus floats upward in the amniotic fluid. The
examiner feels a rebound when the fetus falls back.
Chadwicks sign Violet coloration of the mucous membranes
of the cervix, vagina, and vulva that occurs at about 4 weeks
of pregnancy caused by increased vascularity. This is considered a probable sign of pregnancy.
delivery Actual event of birth; the expulsion or extraction of
the neonate.
embryo Stage of fetal development that lasts from day 15
until approximately 8 weeks after conception or until the
embryo measures 3 cm from crown to rump.
fertilization Uniting of the sperm and ovum, which occurs
within 12 hours of ovulation and within 2 to 3 days of insemination, the average duration of viability for the ovum and
sperm.
Goodells sign Softening of the cervix that occurs at the
beginning of the second month of gestation. This is considered a probable sign of pregnancy.
gravida A pregnant woman; called gravida I (primigravida)
during the first pregnancy, gravida II during the second pregnancy, and so on.
Hegars sign Compressibility and softening of the lower uterine segment that occurs at about week 6 of gestation. This
is considered a probable sign of pregnancy.
implantation Embedding of the fertilized ovum in the uterine
mucosa 6 to 10 days after conception.

infant A human born alive; also, a human from 28 days of

age until the first birthday.
labor Coordinated sequence of rhythmic involuntary
uterine contractions resulting in effacement and dilation
of the cervix, followed by expulsion of the products of
conception.
lecithin-to-sphingomyelin (L/S) ratio Ratio of two components of amniotic fluid, used for predicting fetal lung maturity; normal L/S ratio in amniotic fluid is 2:1 or greater
when the fetal lungs are mature.
lochia Discharge from the uterus that consists of blood from
the vessels of the placental site and debris from the
decidua; lasts for 2 to 6 weeks after delivery.
Nageles rule Determines the estimated date of birth based
on the premise that the woman has a 28-day menstrual
cycle. Add 7 days to the first day of the last menstrual
period; subtract 3 months and add 1 year. Alternatively,
add 7 days to the last menstrual period and count forward
9 months.
newborn A human from the time of birth to the twenty-eighth
day of life; also called neonate.
parity Number of pregnancies that have reached viability
regardless of whether the fetus was born alive or stillborn.
placenta Organ that provides for the exchange of nutrients
and waste products between the fetus and the mother
and produces hormones to maintain pregnancy. The placenta develops by the third month of gestation and is also
called afterbirth.
quickening Maternal perception of fetal movement for the
first time, occurring usually in the sixteenth to twentieth
week of pregnancy.
surfactant Phospholipid that is necessary to keep the fetal
lung alveoli from collapsing; amount is usually sufficient
after 32 weeks gestation.

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uterus Organ located behind the symphysis pubis, between

the bladder and the rectum. It has four parts fundus (upper
part), corpus (body), isthmus (lower segment), and cervix.
vagina Tubular structure located behind the bladder and in
front of the rectum; it extends from the cervix to the vaginal
opening in the perineum. It functions as the outflow tract for
menstrual fluid and for vaginal and cervical secretions, the
birth 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 than
500 g.

PYRAMID TO SUCCESS
The Pyramid to Success focuses on the physiological and
psychosocial aspects related to the experience of pregnancy, delivery, and the postpartum period. Pyramid
Points begin with the assessment and knowledge of
expected findings of the pregnant client and fetus during
the antepartum period. Instructing the pregnant client in
measures that promote a healthy environment for the
mother and the fetus is included. The focus is on the
importance of antepartum follow-up, nutrition, and
interventions for common discomforts that occur during
pregnancy. Knowledge of the purpose of the commonly
prescribed diagnostic tests and procedures in the antepartum period is also part of the Pyramid to Success.
The focus is on disorders that can occur during pregnancy, particularly gestational hypertension and diabetes mellitus. The labor and delivery process and the
immediate interventions for conditions in which the
maternal or fetal status is compromised, such as
prolapsed cord or altered fetal heart rate, is part of the
Pyramid to Success. Review of the fetus of a mother with
human immunodeficiency virus or acquired immunodeficiency syndrome or a substance-abusing mother is
recommended. The Pyramid to Success also includes a
focus on the normal expectations of the postpartum
period and the complications that can occur during this
time. The next Pyramid Point focuses on the normal
physical assessment findings and early identification of
disorders in the neonate. The last Pyramid Point in this
unit focuses on maternity and newborn medications.

CLIENT NEEDS
Safe and Effective Care Environment
Consulting with other health care team members
Delegating client care activities
Establishing priorities of care
Handling hazardous and infectious materials safely
Maintaining confidentiality
Managing the health care environment
Obtaining informed consent for diagnostic tests
and procedures

Providing continuity of client care

Upholding clients rights
Using surgical asepsis when providing care
Using standard and transmission-based precautions
when providing care

Health Promotion and Maintenance

Assessing for growth and development
Discussing expected body image changes with the client
Discussing family planning and birthing and parenting
issues
Identifying at-risk clients during pregnancy
Identifying health and wellness concepts and providing
health care screening
Identifying high-risk behaviors
Identifying lifestyle choices
Performing techniques of physical assessment
Providing antepartum, intrapartum, postpartum, and
newborn care
Teaching regarding antepartum, intrapartum, and postpartum care
Teaching regarding care to the newborn

Psychosocial Integrity
Considering cultural, religious, and spiritual influences
regarding birth and motherhood
Discussing situational role changes in the family
Ensuring therapeutic interactions within the family
Identifying available support systems
Identifying coping mechanisms

Physiological Integrity
Providing nonpharmacological comfort interventions
and pharmacological pain management during labor
Identifying the action and contraindications for prescribed pharmacological agents
Monitoring for side effects and adverse effects related to
prescribed pharmacological and parenteral therapies
Calculating medication dosages and administering
medications safely
Monitoring for expected outcomes and effects related
to pharmacological and parenteral therapies
Instructing the client about prescribed diagnostic tests
and procedures
Providing interventions for unexpected events during
pregnancy
Monitoring the client during the labor and delivery
process
Monitoring for normal expectations during pregnancy
Teaching the client about nutrition during pregnancy
and in the postpartum period
Teaching the client about the physiological changes
that occur during pregnancy

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22

Female Reproductive System

I. REPRODUCTIVE STRUCTURES (Fig. 22-1)

III. FEMALE PELVIS AND MEASUREMENTS

A. Ovaries
1. Form and expel ova
2. Secrete estrogen and progesterone
B. Fallopian tubes
1. Muscular tubes (oviducts) approximate to the
ovaries and connected to the uterus
2. Tubes that propel the ova from the ovaries to the
uterus
C. Uterus
1. Muscular, pear-shaped cavity in which the fetus
develops
2. Cavity from which menstruation occurs
D. Cervix
1. The internal os of the cervix opens into the body
of the uterine cavity.
2. The cervical canal is located between the internal
os and the external os.
3. The external cervical os opens into the vagina.
E. Vagina
1. Muscular tube that extends from the cervix to the
vaginal opening in the perineum
2. Known as the birth canal
3. Passage between the cervical os and the external
environment
a. Passageway for menstrual blood flow
b. Passageway for fetus
c. Passageway for penis for intercourse

A. True pelvis
1. Lies below the pelvic brim
2. Consists of the pelvic inlet, midpelvis, and pelvic outlet
B. False pelvis
1. Is the shallow portion above the pelvic brim
2. Supports the abdominal viscera
C. Types of pelvis
1. Gynecoid
a. Normal female pelvis
b. Transversely rounded or blunt

II. MENSTRUAL CYCLE (Box 22-1)

A. Ovarian hormones
1. 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 that
culminate in its shedding, may vary in length,
with the average length being about 28 days.
B. Ovarian and uterine phases (see Box 22-1)

The gynecoid pelvis is most favorable for successful labor and birth.

2. Anthropoid
a. Oval shape
b. Adequate outlet, with a narrow pubic arch
3. Android
a. Heart-shaped or angulated
b. Resembles a male pelvis
c. Not favorable for labor and birth
d. Narrow pelvic planes can cause slow descent
and midpelvic arrest.
4. Platypelloid
a. Flat with an oval inlet
b. Wide transverse diameter, but short anteroposterior diameter, making labor and birth difficult
D. Pelvic inlet diameters
1. Anteroposterior diameters
a. Diagonal conjugate: Distance from the lower
margin of the symphysis pubis to the sacral
promontory
b. True conjugate or conjugate vera: Distance
from the upper margin of the symphysis
pubis to the sacral promontory
c. Obstetric conjugate: The smallest front-toback distance through which the fetal head
must pass in moving through the pelvic inlet
2. Transverse diameter: The largest of the pelvic
inlet diameters; located at right angles to the
true conjugate

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3. Oblique (diagonal) diameter: Not clinically
measurable
4. Posterior sagittal diameter: Distance from the
point where the anteroposterior and transverse
Infundibulum
Body

Ovary

Fundus

Endometrium
Myometrium
Perimetrium
(epimetrium)
Cervix
Vagina

Fallopian tube

Fimbriae
Broad ligament
Uterus
Rugae

Bartholins
gland
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.)

diameters cross each other to the middle of the

sacral promontory
E. Pelvic midplane diameters
1. 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. Fertilization
1. Fertilization occurs in the ampulla of the fallopian (uterine) tube.
2. Fertilization occurs when sperm and ovum
unite.
3. When fertilized, the membrane of the ovum
undergoes changes that prevent entry of other
sperm.
4. Each reproductive cell carries 23 chromosomes.
5. Sperm carry an X or a Y chromosomeXY,
male; XX, female.
B. Implantation
1. The zygote is propelled toward the uterus.
2. The zygote implants 6 to 8 days after
ovulation.

Box 22-1 Menstrual Cycle

t
Ovarian Changes
Preovulatory Phase

Uterine Changes
Menstrual Phase

Hypothalamus 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 graafian follicle.
Estrogen produced by the follicle stimulates increased
secretions of luteinizing hormone (LH) by the anterior
lobe of the pituitary gland.
The follicle ruptures and releases an ovum into the peritoneal cavity.

Menstrual phase consists of 4 to 6 days of bleeding as the

endometrium breaks down because of the decreased
levels of estrogen and progesterone.
The level of FSH increases, enabling the beginning of a new
cycle.

Luteal Phase
Luteal 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 anterior pituitary to secrete more FSH and LH, initiating a
new reproductive cycle.

Proliferative Phase
Proliferative 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 Phase
Secretory 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.

CHAPTER 22 Female Reproductive System

3. The blastocyst secretes chorionic gonadotropin
to ensure that the corpus luteum remains viable
and secretes estrogen and progesterone for the
first 2 to 3 months of gestation.
V. FETAL DEVELOPMENT (Box 22-2)
A. Pre-embryonic
conception

period:

First

B. Embryonic period: Beginning at day 15 through

approximately the eighth week after conception
C. Fetal period: Beginning at the ninth week after conception and ending with birth
VI. FETAL ENVIRONMENT

weeks

after

A. Amnion
1. Encloses the amniotic cavity

Box 22-2 Fetal Development

t
Pre-embryonic Period
First 2 weeks after conception

Embryonic Period
Beginning day 15 through approximately week 8 after conception

Fetal Period
Week 9 after conception to birth

Week 1
Blastocyst is free-floating.

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

Week 5
Embryo 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 8
Embryo 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 12
Fetus is 6 to 9 cm in length.
Fetus is 19 g.
Face is well formed
Limbs 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 16
Fetus 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 20
Fetus 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 24
Fetus 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 28
Fetus 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 32
Fetus 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 36
Fetus 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 40
Fetus 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.

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2. Is the inner membrane that forms about the second week of embryonic development
3. Forms a fluid-filled sac that surrounds the
embryo and later the fetus
B. Chorion
1. Is the outer membrane
2. Becomes vascularized and forms the fetal part of
the placenta
C. Amniotic fluid
1. Consists of 800 to 1200 mL by the end of
pregnancy
2. Surrounds, cushions, and protects the fetus and
allows for fetal movement
3. Maintains the body temperature of the fetus
4. Contains fetal urine and is a measure of fetal
kidney function
5. The fetus modifies the amniotic fluid through
the processes of swallowing, urinating, and
movement through the respiratory tract.
D. Placenta
1. The placenta provides for exchange of nutrients
and waste products between the fetus and mother
2. 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 production of these hormones by the twelfth week of
gestation.
4. In the third trimester, transfer of maternal
immunoglobulin provides the fetus with passive
immunity to certain diseases for the first few
months after birth.
5. By week 10 to 12, genetic testing can be done via
chorionic villus sampling (CVS).
Large particles such as bacteria cannot
pass through the placenta, but nutrients, drugs,
antibodies, and viruses can pass through the
placenta.

VII. FETAL CIRCULATION

A. Umbilical cord
1. 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 to
170 beats/min in the first trimester, but slows with
fetal growth to 120 to 160 beats/min near or at
term.
2. FHR is about twice the maternal heart rate.
C. Fetal circulation bypass (Fig. 22-2)
1. Fetal circulation bypass is present because of
nonfunctioning lungs.

2. Bypasses must close after birth to allow blood to

flow through the lungs and the liver.
3. The ductus arteriosus connects the pulmonary
artery to the aorta, bypassing the lungs.
4. The ductus venosus connects the umbilical
vein and the inferior vena cava, bypassing the
liver.
5. The foramen ovale is the opening between the
right and left atria of the heart, bypassing the
lungs.
The fetal heart rate is 160 to 170 beats/min in
the first trimester, but slows with fetal growth to
120 to 160 beats/min near or at term. The physician
must be notified if the fetal heart rate is outside
these parameters.

VIII. FAMILY PLANNING

A. Description
1. Involves choosing when to have children
2. Includes contraception, prevention of pregnancy, and methods to achieve pregnancy
B. Birth control
1. The focus of counseling on contraception must
meet the needs and feelings of the woman and
her partner.
2. Several factors should be considered when
choosing a method of birth control, including
effectiveness, safety, and personal preference.
3. The womans preferences are most important,
and cultural practices and beliefs and religious
or other personal beliefs may affect the choice
of contraceptives.
4. Other factors that bear on selection of a contraceptive method include family-planning
goals, age, frequency of intercourse, and the
individuals capacity for compliance.
5. If planning goals have already been met, sterilization of either the male or female partner may
be desirable (it is important for the couple to
understand that tubal reconstruction may be
unsuccessful).
6. For women who frequently engage in coitus,
oral contraceptives or a long-term method such
as implants or an intrauterine device (IUD)
may be considered.
7. When sexual activity is limited, use of spermicide, condoms, or a diaphragm may be most
appropriate.
8. Because some methods have adverse effects, an
informed consent form may be needed.
9. For additional information on the use of contraceptives, see Chapter 55.
C. Infertility
1. Infertility is the involuntary inability to conceive
when desired.

CHAPTER 22 Female Reproductive System

Aortic arch

Superior vena cava

Ductus arteriosus

Noninflated lung
Right atrium

Left atrium

Foramen ovale (open)

Pulmonary veins

Inferior vena cava

Ductus venosus
Aorta
Liver
Key to oxygen
saturation of blood:

Portal vein

High
Medium

Umbilical vein

Low

To legs
Umbilical cord

Placenta
Internal iliac artery
Umbilical
arteries

Urinary bladder

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

2. Some factors contributing to infertility in men

include abnormalities of the sperm, abnormal
erections or ejaculations, or abnormalities of
the seminal fluid.
3. Some factors that contribute to infertility in
women include disorders of ovulation or
abnormalities of the fallopian tubes or cervix.
4. Several diagnostic tests are available to determine the probable cause of infertility and the
therapy recommended may depend on the cause
of the infertility.
5. Infertility options
a. Options include medication, surgical procedures, or therapeutic insemination.
b. Other therapies are available, such as in vitro
fertilization, surrogate mothers, or embryo
hosts.
c. Adoption may also be an option.
6. The nurse needs to provide support to the couple in their decision-making process and during
therapy.

MORE QUESTIONS ON THE CD!

Practice Questions
201. A nursing student is preparing a prenatal class on
the process of fetal circulation. The nursing
instructor asks the student specifically to describe
the process through the umbilical cord. Which of
the following statements from the student is
correct?
1. The one artery carries freshly oxygenated
blood and nutrient-rich blood back from the
placenta to the fetus.
2. The two arteries carry freshly oxygenated
blood and nutrient-rich blood back from the
placenta to the fetus.
3. The two arteries in the umbilical cord carry
deoxygenated blood and waste products away
from the fetus to the placenta.
4. The two veins in the umbilical cord carry
blood that is high in carbon dioxide and

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