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Cervix remains slightly open - forming a slit-like or star-shaped

Vagina - returns to its pre-pregnant state

Perineal pain: Sim’s position and cold compress

Episiorrhaphy pain: heat lamp for NOT more than 15 minutes

Uterus - intermittent contractions enhance involution. Analgesics for after pains (3D)

Uterine involution: assess by measuring the fundus by fingerbreadths.

Menstruation

6 weeks after birth in non-nursing moms 24 weeks in nursing moms

Breasts – lactation begins

PROLACTIN - stimulates milk Production
OXYTOCIN - initiates the let-down reflex with milk ejection as the baby suckles

Women may ovulate without menstruating, so breastfeeding should not be considered a form of birth control.

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Most critical period in mothers – the 1st few minutes after delivery.

30-50% increase in total cardiac volume

Nursing care: Monitor vital signs

WBC normally increases = Significant sign of infection 24⁰ postpartum

Increase in plasma fibrinogen: protective measure against hemorrhage

Nursing care:

*Encourage early ambulation (4-8H)

*Encourage exercise*

Dangle legs for 10-15 minutes prior to walking: prevent dizziness

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Temperature: slight increase 1st 24 hours

Pulse: Usually slightly slower

***Thready & rapid pulse = signs of hemorrhage

Blood Pressure: monitor for increased & decreased

Profuse sweating (Diaphoresis) may occur

Clients are usually hungry after delivery

Hyperpigmented areas begin to fade but not completely return to pre-pregnant state

Weight loss of 10 lbs. occurs immediately after delivery

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ABANDONMENT

Feeling less important/jealous

Allow verbalization of feelings and make infant care a shared responsibility

DISAPPOINTMENT

Difficult for parents to feel positive immediately about the child who does not meet their expectations.

Nurses should handle the child warmly and comment on the child’s good points

POST PARTAL BLUES

They burst into tears easily or feel let down or irritable

May be caused by hormonal changes or a response to dependence and low self-esteem

Can lead to postpartal depression

Reassure the woman and family and allow to verbalize feelings & low to make decisions

Effects of retrogressive changes

Exhaustion: may have “sleep hunger”

Weight loss: 5lbs for diuresis + 2-3 lb for lochial flow + 12 lb at birth = 19 lbs

Dependent on pregnancy weight gain

The weight a woman achieves in 6 week s becomes her baseline postpartum weight

All clients should be assessed for depression during pregnancy and in the postpartum period.

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Taking In Phase

A time for reflection where the woman is largely PASSIVE

Encourage to talk about the birth and help integrate it into life experiences

Taking Hold

Begins to initiate action

Learning to make decisions and to do things well

Give brief demonstration of baby care

Praise efforts

Letting Go

Redefines new role and gives up old role

Extended and continues during the child’s growing years

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Same high level of fibrinogen during the 1st postpartal weeks

Pain on dorsiflexion ; used in the diagnosis of deep venous thrombosis.

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Striae lightens or becomes slightly darker (reddened) over 3-6 months

Chloasma and linea nigra will be barely detectable in 6 weeks

Diastasis recti will appear as slight indentation or a bluish area

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Ask the woman to turn on her side (Sim’s position)

Perineum develops edema & generalized tenderness, ecchymosis from rupture capillaries/hematoma, intactness of suture & presence of drainage/bleeding

Labia majora & minora remain atophic & softened

Usually 1-2 inches long; inspect for laceration & clotted lochia

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Layer adjacent to the uterine cavity becomes necrotic & is cast off as uterine discharge similar to a menstrual flow

Composed of blood, fragments of decidua, white blood cells, mucus & some bacteria

It takes 6 weeks for the placental implantation site to be cleansed & healed

Nursing Consideration

Check perineal pad and evaluate lochia for character, amount, color, odor, and presence of any clots once every 15 minutes for the 1 st hour

A constant trickle of vaginal flow or soaked perineal pad every 60 minutes is not the normal amount of blood loss.

Instruct on hygiene: perineal hygiene, handwashing and use of personal equipment ✓ Encourage frequent changes of perineal pads to prevent infection and to hasten wound healing.

Educate not to use tampons until she returns for postpartal check-up and to distinguish the normal type and amount of lochia

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Bowel sounds are active

The woman feels hungry & thirsty immediately after giving birth

If without GA, patient can eat without difficulty from nausea or vomiting

Hemorrhoids are often present

May develop constipation because of presence of relaxin & pain d/t episiotomy or hemorrhoids

Urinary retention may occur or diuresis can occur (within 12 hours)

Bowel movements do not occur for a few days (2-3 days PP)

Stool softeners, suppositories or an enema given as ordered.

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Extensive diuresis & urine output increases to 3,000mL (2nd-5th PPD)

Transient loss of bladder tone + edema surrounding the urethra (4 weeks) + effect of anesthesia = decrease ability to sense fullness of bladder

Increases the possibility of permanent bladder damage & urinary tract infection

Nursing Consideration

Assess the bladder for fullness frequently & encourage regular voiding habits

What to expect?

If bladder is full: Hard or firm above the symphysis pubis, resonant on percussion, displaces the uterus. Ask the patient to void

Increase nitrogen and lactose levels

***Full bladder may cause uncontracted uterus

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Undergoes involution

Area where placenta was implanted is sealed off

Organ is reduced to pre-pregnant size (approximately)

Uterine contraction begins immediately after birth

Fundus of the uterus may be palpated at certain areas/levels at a specified time to determine contraction

Uterine involution maybe delayed in several conditions

***Uterus of a breast-feeding mother may contract more quickly. Involution will occur most dependably if a woman is well nourished & who ambulates early

Nursing Consideration

Position the patient supine: Assess for contour, striae & diastasis; measure width & length in fingerbreadths

What to expect?

Uterus is firm/ contracted (if relaxed—uterine atony)

At a specific location

Uterus is in midline

Presence of after pains maybe normal

The 1st hour after birth is potentially the most dangerous.
Ask the patient to empty bladder.

If the uterus is boggy / not contracted, what will be the nursing action?

Massage gently using gentle rotating motion

Administer oxytocin as ordered / place the infant on the woman’s breast to suck

Assess the uterine fundus every 10 to 15 minutes

Assess for height less frequently after 1 hour

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Formation of breast milk (lactation) → increase breast tissue

Primary engorgement: On the 3rd day, breast feels tender, fuller , enlarged & tensed as milk forms within breast ducts (the ducts becomes dilated); feeling of heat/throbbing pain

Breast may appear reddened

***Breast milk production depends on the sucking (oxytocin for contraction & let-down)

Nursing Consideration

Assess woman’s breasts: Inspect & palpate for breast size, shape & color

What to expect?

Soft - 1st-2nd PPD

Firm & warm, reddened, with taut, shiny skin (engorgement)– 3rd/4th PPD; hard, tensed & painful on palpation.

***If only one area of the breast is reddened or warmed, suspect for mastitis/inflammation/infection.

Note for a firm nodule. Take note of location & report.

Assess breast nipples—erect/inverted, cracks/fissures/presence of caked milk. Do not squeeze or manipulate nipples unnecessarily.

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B — breast

U — uterus

B — bowel

B — bladder

L — lochia

E — episiorrhaphy / episiotomy

S — skin

H — homan’s sign/hemorrhage

E — emotions

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6 week period after birth

Considered as the fourth trimester

Time for maternal changes (retrogressive and progressive)

Post-partal care can influence her health for the rest of her life

Also considered as the transition phase

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First 1-2 hours or first 4 hours after placental delivery

Observation/monitoring

1st hour - q 15 minutes

2nd hour - q 30 minutes, once it’s stable, check every 4 hours

Assess placement of fundus must be midline, during the first 24 hours, should be at the level of the umbilicus, firm and well-contracted (empty bladder)

Lochia - 30-40 cc/ml fully saturated

Perineum (REEDA)

check perineum for

R - redness

E - episiotomy/episiorrhaphy

E - ecchymosis/bruising

D - discharge

A - approximation (the closure is intact)

Flat on bed (epidural-given), if went through normal vaginal delivery = ambulate to prevent other complications like thrombosis or clog formation

If with chills, give blanket (epidural-given) side effect of anesthesia, blood loss, dehydration

Give nourishment (progression of meals)

Clear liquid - juice, gelatins

FL - milk, ice cream

SD

RD

Check VS/Pain

Psychological state (taking-in passive in caring for the child, taking hold partially participating in the care of the NB, letting go mother fully care for the NB)

Bonding (MBFH)

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Up to 30 minutes after delivery

Signs of Placental Separation

Calkin’s sign - the fundus rises (the shape of the abdomen changes from discoid to ovoid; it means that the placenta has already separated from the uterus)

Cord lengthens

Sudden gush of blood

Brandt-Andrews Maneuver - the up and down motion while delivering the placenta; controlled cord traction (you must be trained or else there’s a risk for uterine prolapse

Schultz (shiny; fetal side)  vs.    Duncan (dirty; maternal side)

PLACENTAL EXPULSION

Natural (bearing-down)

Gentle pressure (Crede’s maneuver) - must be trained or else, uterine prolapse

Check completeness (check which side came out first because it will tell you how the placenta separated ; shiny or dirty), completeness of the cotyledon (divided into lobes/divisions) should be 15-20 cotyledons (not important to count)

As long as there are no spaces in-between or depressions on the cotyledons for it to be complete. Check because if there are fragments left in the uterus, there will be bleeding/hemorrhage (anything that will impair or prevent the uterus from contracting could lead to bleeding) and must be manually removed by the midwife

Check fundus (has to be firm = contracted like a grapefruit really hard at the level of umbilicus; soft/boggy = non-contracted, perform fundal massage)

BP Check

Methergine, methylergonovine maleate (IM) - used to prevent or treat bleeding from the uterus that can happen after childbirth or an abortion like oxytocin.

Oxytocin IV if methergine is not present

Check perineum for lacerations

Assist in episiorrhaphy - repair of episiotomy

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Complete effacement and dilation to birth

Marked by crowning

Lithotomy - put legs at the same time if the doctor advises

Birthing Position: depends on the position of choice (upright, squatting, laying on the back, or left-side lying)

Bulging of the perineum is the surest sign that delivery is starting

Pant & blow breathing - during labor, when doing this breathing, monitor her for signs and symptoms of respiratory alkalosis (increased RR, light-headedness, tingling sensation, carpopedal spasm, circumoral numbness

Respiratory Alkalosis - excess carbon dioxide is being blown off the body which will change the acid-base balance

It is normal for the fetal heart rate to change during contractions; however, it must go back to the normal range immediately after the contractions and before the beginning of the next contraction. If it doesn’t, you have to monitor it for the next 3 contractions to see if it is persistent because it might mean that there is fetal distress

Episiotomy - prevent laceration; not done routinely

2 types: median, mediolateral (most preferred, less painful, less bleeding)

Complication: Urethroanal fistula

Modified Ritgen's Maneuver - Support the perineum to prevent laceration; also controls the speed of delivery (dominant hand on the perineum, non-dominant hand on the occiput, chin if head is out)

Nursing management during the 2nd stage of labor:

Modified Ritgen’s

Support the head & (suction secretions? No longer recommended unless there is a sign of fetal distress)

Dry the baby

Initiate skin to skin interaction

Wait for pulsation to stop

*When there is stillbirth, let the mother see the baby

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Other nursing measures during the first stage of labor:

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Other nursing measures during the first stage of labor:

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Small snacks and sips of water as allowed by the OB

Encourage to urinate every 2 hours

Bathing is encouraged for comfort and relaxation

Perineal preparation (antiseptic, no shaving = entrypoint for microorganisms)

Left side-lying = to prevent supine hypotension syndrome

Monitor for fetal thrashing (increase in the fetal movement; a sign of oxygen deprivation)

For pain:

Demerol @ 6-8 cm (active phase), WOF Respiratory Depression since it is a narcotic analgesic (for both the mother and the fetus); there should be an antidote prepared if there’s respiratory depression

Epidural - WOF Hypotension; remain a supine position for a few hours after labor and WOF for signs of headache, allergy and assess for sensation of the lower extremities

X NPO (unless the woman could possibly undergo C-section), X Enema (intends to augment labor) X Shaving

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8-10 cm

2-3 minutes

40-90 seconds

Strong

Hyperesthesia (mother is very irritable; very sensitive to touch)

Sacral pressure
T- tired
I - inform them of the progress of labor
R - restless
E - emotional support
D - discomfort

Breathing Techniques

Cleansing / organizing breath - deep breath through nose; do this at the beginning and end of each contraction

Pant and Blow (hee-ha!) / Variable Breathing - fast type of breathing wherein you breathe 5 times for every 10 seconds (3 fast breaths and the 4th-5th will be a blow); done when the woman is exhausted

Expulsive Breathing - a type of breathing when there is already a strong urge to push; breathe in and when there is a strong urge to push, the woman will hold her breath and bear down)

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4-8 cm

3-5 minutes

30-60 seconds

Moderate

Medications ready (pain-relieving medications ; anesthesia)

Anesthesia is ideally given during the active phase. If you give it early, it can further slow down the progress of labor

Assess:

➡️ VS (before and after contractions not during)

➡️ cervical dilatation

➡️ fetal status (continuous fetal monitor attached to the mother to determine the heart rate of the fetus; must be 120-160 bpm) taken every 30 min.

Internal examination is done every 4 hours

Dry lips = provide oral care, dry linens

Breathing Techniques

Cleansing / organizing breath - deep breath through nose; do this at the beginning and end of each contraction

Light Accelerated Breathing - woman breathes 1 breath per second during contractions.

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0-3 cm dilatation

Every 5-10 minutes

20-40 second duration

Mild intensity

Mother is excited, apprehensive, but can communicate.

We want to shorten the latent phase by:

Encourage walking Encourage to void 2-3 hours

Breathing Techniques

Cleansing / organizing breath - deep breath through nose; do this at the beginning and end of each contraction

Slow Breathing - for mild to moderate contractions; done during contractions

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DANGER SIGNS

In terms of duration: Contractions should not last for more than 90 seconds. Because the longer the contractions are, the less blood flow / oxygen the fetus will receive.

In terms of interval: it should not be less than 1 min.

= could lead to fetal distress

Labor

Duration of Labor

Primi -14 hours-20 hours

Multi - 8-14 hours

4 stages. First stage is the longest.

Only go to the hospital if the cervix is at least 5cm or if the contractions is less than 3 min. apart. Although you can consider the 5cm dilatation as an active phase.

1cm dilation per hour is not expected especially if the cervix has not reach 5cm

It’s okay if the dilatation is slow. You can expect it to speed up when it reaches 5cm (active phase)

The rate of cervical dilatation does not automatically indicate whether augmentation is required

Augmentation of labor - you want the labor to speed up IF there is fetal & maternal distress

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Fetal Position

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How far the presenting part descended into the pelvis.

Ischial spines → 0 station “engaged”

Above ischial spines → negative

Below ischial spines → positive

+3-+4 crowning

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Fetal attitude: Degree of Flexion Relationship of the fetal body parts to one another.

Complete flexion

The most common attitude; most favorable for vaginal birth; Skull smallest diameter to the bony pelvis: Sub-occipito bregmatic.

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1. The Passage
or the woman’s pelvis
Should be adequate in size & contour

Pelvic Shape: Gynecoid

True Pelvis: The bony passageway through which the fetus must pass during delivery

Obstetric/True Conjugate: The most important measurement of the inlet because it has the smallest diameter (at least N-11 cm)

For the pelvic outlet (below the ischial spine), AP > T, transverse is measured

Measurement is the ischial tuberosity = at least 10 cm

2. The Passenger
or the fetus
Should be appropriate in size (good attitude = baby is fully flexed, chin is touching the chest, thigh is drawn up to the abdomen) & in an advantageous position (vertical lie) & presentation (cephalic)

Most Important: Bony Pelvic Ring

AP: 9.5 cm ; Transverse: 9.25

Fontanelle spaces compress during birth to aid in molding of the fetal head

3. The Powers of labor
or uterine factors

4. A woman’s Psyche
Should be preserved, so that afterward labor can be viewed as a positive experience

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Uterine Contractions

Begin irregular but become regular & predictable

Sweeps around to the abdomen

Continue no matter what

Increase in duration, frequency & intensity

Achieve cervical dilatation

Show

Mucus plug that filled the cervical canal is expelled

“Bloody show” exposed capillaries seep blood and mixed with mucus resulting to pink-tinged color

Rupture of the Membranes

Sudden gush or a scanty, slow seeping of clear fluid from the vagina

Early rupture is advantageous if it causes the fetal head to settle snugly into the pelvis, resulting to short labor

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​​Lightening

Occurs 10-14 days before labor begins (primiparous women, 2 weeks before)

Relief of shortness of breath from the lungs but now presses more on the bladder

Braxton-Hicks Contractions

Felt first abdominally & remain confined to the abdomen & groin

Often disappear with ambulation & sleep

Nesting Instinct

It is related to an increase in epinephrine release – prepares a woman’s body for the work of labor ahead

Do not encourage, they must not expend their energy, rest instead (conserve)

Ripening of the cervix

Goodell’s sign - all throughout pregnancy, cervix has the same consistency as the earlobe

At term, it becomes still softer & described as “butter-soft”

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What could be more beautiful than bringing life into this world?

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Unclear in Humans

Attributed to Progesterone withdrawal in animals

Multiple Theories

Uterine Muscle Stretching Releasing Prostaglandins

Cervical Pressure Causing Release of Oxytocin

Oxytocin and Progesterone Balance

Placental Aging

Fetal Cortisol and Prostaglandin

Progesterone - prevent uterine contractions; during the end, it decreases to induce contractions, less hormones.

Placental Aging - it ages, so the tendency of the body is to take it out through uterine contractions.

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Milestones of Fetal Growth and Development

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Milestones of Fetal Growth and Development

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Ovulation Age

Life of the fetus is typically measured from the time of ovulation or fertilization.

Gestational Age

The length of a pregnancy is more commonly measured from the first day of the last menstrual period.

Both ovulation and gestational age are typically reported in lunar months (4-week periods) or in trimesters (3-month periods) rather than in weeks

Normal Length of Pregnancy

Days : 267 – 280 days

Weeks: 40

Lunar months: 10

Calendar months: 9

Trimesters: 3

1st trimester - Period of organogenesis, teratogens are highly damaging

2nd trimester - Most comfortable for the mother with continued fetal growth

3rd trimester - Rapid deposition of fats, periods of rapid growth with rapid iron and calcium deposits

End of 4th gestational week
Length: 0.75 – 1cm, weight: 400 mg

All systems in rudimentary form: beginning formations of eyes, nose, heart chambers formed, heart beating (14 days), with arm and leg buds.

End of 8th gestational weeks

Length: 2.5 cm, weight: 20 g

Organogenesis is complete

End of 12th gestational week (1st trimester)

Length: 7-8 cm, weight: 45 g

Nail beds are forming

End of 16th gestational week

Length: 10-17 cm, weight: 55-120g

FHT by stethoscope

Lanugo is well formed

Liver and pancreas are functioning

Sex can be determined by ultrasound

End of 20th gestational week

Length: 25cm, weight: 223 g

Hair forms including eyebrows and on the head

Meconium is present in the upper intestine

Vernix caseosa begins to form and cover the skin

End of 24th gestational week (Second Trimester)

Length: 28-36cm, weight: 550g

Meconium is present as far as the rectum

Active production of lung surfactant begins

End of 28th gestational week

Length: 35–38 cm; Weight: 1200 g

Lung alveoli begin to mature and surfactant can be demonstrated in amniotic fluid

End of 32 gestational week

Length: 38–43 cm; Weight: 1600 g

Subcutaneous fat begins to be deposited

Little old man appearance is lost

Fetus responds by movement to sounds outside the mother's body

End of 36th gestational week

Length: 42-48 cm, weight: 1800-2700g

Body stores of glycogen, iron, carbohydrate, and calcium are deposited

Additional amounts of subcutaneous fat are deposited

End of 40th gestational week (Third Trimester)

Length: 48–52 cm (crown to rump, 35–37 cm); Weight: 3000 g (7–7.5 lb)

Kicks hard enough that causes discomfort to the mother

Fetal hgb to adult hgb so rapid that about 20% of hgb is adult in character

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Stem Cells

Totipotent Stem Cells - cells that are so undifferentiated they have the potential to form a complete human being

Pluripotent Stem Cells - cells begin to show differentiation and lose their ability to become any body cell – become specific body cells, such as nerve, brain, or skin cells

Multipotent - cells grow so specific that they have set a sure course toward the body organ they will create

Reproductive Cloning - nucleus is removed from an oocyte and the nucleus of an adult cell is transferred into the oocyte, an embryo has the potential to grow into an infant who is identical to the adult donor

Therapeutic Cloning - pluripotent stem cells are removed and allowed to grow in the laboratory, these have the potential to be able to supply a type of body cell needed by the adult donor

Zygote Growth

development proceeds in a cephalocaudal (head-to-tail) direction

Continues after birth - infants are able to lift up their heads approximately 1 year before they are able to walk

as a fetus grows, body organ systems develop from specific tissue layers called germ layers

Primary Germ Layers

1. The ectoderm gives rise to the nervous system and the epidermis, among other tissues.

2. The mesoderm gives rise to the muscle cells and connective tissue in the body.

3. The endoderm gives rise to the gut and many internal organs.

Main Purpose of the Yolk Sac:

to provide a source of red blood cells until the embryo’s hematopoietic system is mature enough to perform this function

yolk sac then atrophies and remains only as a thin white streak discernible in the cord at birth

Rubella infection (German measles) is so serious in pregnancy – the virus is capable of infecting all three germ layers or causing congenital anomalies in a myriad of body systems.

8 weeks’ gestation

(the end of the embryonic period)

all organ systems are complete, at least in a rudimentary form

This early time of organogenesis (organ formation)

the growing structure is most vulnerable to invasion by teratogens

factor that adversely affects the fertilized ovum, embryo, or fetus

Cardiovascular System

16th day of life - simple blood cells joined to the walls of the yolk sac progress to become a network of blood vessels and a single heart

24th day - Heart beats

6th or 7th week - the septum that divides the heart into chambers develops

7th week - heart valves begin to develop

10th to 12th week - heartbeat may be heard with a Doppler instrument

11th week - an electrocardiogram (ECG) may be recorded on a fetus – although the accuracy of such ECGs is in doubt until about the 20th week of pregnancy when conduction is more regulated

Heart rate of a fetus is affected by oxygen level, activity, and circulating blood volume.

After the 28th week of pregnancy, when the sympathetic nervous system has matured = 5 beats per minute on a fetal heart rate rhythm strip.

Fetal Circulation

3rd week of intrauterine life

fetal blood begins to exchange nutrients with the maternal circulation across the chorionic villi.

Gas exchange in the placenta.

Anatomy and Physiology

Fetus depends on placenta to meet Oxygen needs while organs continue formation

Oxygenated blood flows from the placenta to the fetus via the umbilical vein

Umbilical Circulation

Umbilical cord consist of:

2 umbilical arteries: carry or return deoxygenated blood, fecal waste, CO2 from the fetus to the placenta

1 umbilical vein: brings oxygenated blood and nutrients from the placenta to the fetus

The Placenta

Facilitates gas and nutrient exchange between maternal and fetal blood

respiratory center for the fetus

water, glucose, amino acids, vitamins, and inorganic salts freely diffuse across the placenta along with oxygen

* The blood itself does not mix

Three Shunts in the Fetal Circulation

1. Ductus arteriosus - protects lungs against circulatory overload; allows the right ventricle to strengthen

2. Ductus venosus - fetal blood vessel connecting the umbilical vein to the IVC

3. Foramen ovale - shunts highly oxygenated blood from right atrium to left atrium

Surfactant - a phospholipid substance, is formed and excreted by the alveolar cells at about the 24th week of pregnancy

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Pre-embryonic Period (the OVUM)

First 2 weeks, beginning with fertilization

Ends at implantation, which occurs on day 7 post-conception

Period of pre-differentiation of organs

Includes fertilization, cleavage of oocyte, and formation of blastocyst

The conceptus is transported from the ovary, through the oviduct, into the uterine cavity

When exposed to a teratogen, “all” or “none” law applies

Ovum is damaged and is out in spontaneous abortion or

Not affected at all and continues to grow normally

Embryonic Period

Weeks 3 through 8

Begins with blastogenesis (i.e., formation of germ layers)

Period of organ differentiation (organogenesis)

Most dangerous period

A teratogen introduced may result in severe organ malformation and dysfunction

Fetal Period

From 8 weeks to birth

Period of post-differentiation of organs

When exposed to teratogen: malformation is least likely to occur

If ever the fetus is affected, the effects will be most likely be alteration in size or function

Terms Used to Denote Fetal Growth
Ovum - From ovulation to fertilization
Zygote - From fertilization to implantation
Embryo - From implantation to 5-8 weeks
Fetus - From 5-8 weeks until term
Conceptus - Developing embryo or fetus and placental structures throughout pregnancy
Age of viability - earliest age at which fetuses could survive if they were born at that time ; generally accepted as 24 weeks or fetuses weighing more than 400 g.

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FERTILIZATION: The Beginning of Pregnancy

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FERTILIZATION: The Beginning of Pregnancy

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When mature ovum is released, fertilization must occur fairly quickly because an ovum is capable of fertilization for only 24 hours (48 hours at the most)

The functional life of a spermatozoon is also about 48 hours, possibly as long as 72 hours

Capacitation is a final process that sperm must undergo to
be ready for fertilization

Hyalurodinase (a proteolytic enzyme)

If an X-carrying spermatozoon entered the ovum, the resulting child will have two X chromosomes and will be female (XX)
If a Y-carrying spermatozoon fertilized the ovum, the resulting child will have an X and a Y chromosome and will be male (XY)

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MORULA (from the Latin word morus, meaning “mulberry”) -
bumpy outward appearance attaches to the uterine endometrium.

late blastocyst implants in the wall of the uterus (by day 14)

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lies directly under the embryo (or the portion where the trophoblast cells establish communication with maternal blood vessels) ; stretches or encapsulates the surface of the trophoblast.

DECIDUA (Latin word for “falling off”)

Layer of Trophoblast Cells

Syncytiotrophoblast, or the syncytial layer

Outer of the two covering layers

Layer of cells produces various placental hormones, such as hCG, somatomammotropin (human placental lactogen [hPL]), estrogen, and progesterone

Cytotrophoblast or Langhans’ layer

Middle layer

Present as early as 12 days’ gestation

Function early in pregnancy to protect the growing embryo and fetus from certain infectious organisms such as the spirochete of syphilis

Disappears, however, between the 20th and 24th weeks

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PLACENTA - “pancake,” 15 to 20 cm in diameter and 2 to 3 cm in depth, covering about half the surface area of the internal uterus at term.

At term, the placental circulatory network has grown so extensively that a placenta weighs 400 to 600 g (1 lb), one/sixth the weight of the baby.

If a placenta is smaller, circulation to the fetus may have been inadequate.

If placenta is larger, circulation to the fetus was threatened, because it suggests that the placenta was forced to spread out in an unusual manner to maintain a sufficient blood supply

The fetus of a woman with diabetes may also develop a larger-than-usual placenta from excess fluid collected between cells

Placental Circulation

Metabolic gas exchange begins at 4 weeks

Funic souffle soft blowing heard over umbilical cord – synchronous with fetal heartbeat, hearing bloodflow through vessel

Uterine souffle heard just above mother’s pelvis – synchronous with maternal pulse

Uterine perfusion, and thus placental circulation, is most efficient when the woman lies on her left side

This position lifts the uterus away from the inferior vena cava, preventing blood from being trapped in the woman’s lower extremities

If the woman lies on her back and the weight of the uterus compresses the vena cava, placental circulation can be so sharply reduced that supine hypotension (very low maternal blood pressure and poor uterine circulation) occurs

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Mechanisms by which Nutrients cross the Placenta

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Mechanisms by which Nutrients cross the Placenta

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DIFFUSION
Substances of correct molecular weight cross the membrane from the area of higher concentration to the area of lower concentration.

Example: Oxygen, carbon dioxide, sodium, and chloride cross the placenta by this method

Facilitated Diffusion
To ensure that a fetus receives sufficient concentrations of necessary nutrients, some substances cross the placenta guided by a carrier so move more rapidly or easily than would occur if only simple diffusion were operating.

Example: Glucose

Active Transport
This process requires the action of an enzyme to facilitate transport ; The process ensures that a fetus will have adequate amino acid concentrations for fetal growth.

Example: Essential amino acids and water-soluble vitamins cross the placenta by this process

Pinocytosis
Absorption by the cellular membrane of micro droplets of plasma and dissolved substances ; Unfortunately, viruses that then infect the fetus can also cross in this manner.

Example: Gamma globulin, lipoproteins, and phospholipids

Functions of the Placenta

Forms a barrier between mother and embryo (blood is not exchanged)

Delivers nutrients and oxygen

Removes waste from embryonic blood

Becomes an endocrine organ (produces hormones) and takes over for the corpus luteum

Estrogen

Progesterone

Other hormones that maintain pregnancy

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Human Chorionic Gonadotropin

First placental hormone produced

Can be found in maternal blood and urine as early as the first missed menstrual period (shortly after implantation has occurred) through about the 100th day of pregnancy

A false-negative result from a pregnancy test may be obtained before or after this period

Blood serum will be completely negative for hCG within 1 to 2 weeks after birth

Testing for hCG after birth can be used as proof that placental tissue is no longer present

Purpose of hCG

Act as a fail-safe measure to ensure that the corpus luteum of the ovary continues to produce progesterone and estrogen

Play a role in suppressing the maternal immunologic response so that placental tissue is not detected and rejected as a foreign substance

The structure of hCG is similar to that of luteinizing hormone of the pituitary gland, if the fetus is male, it exerts an effect on the fetal testes to begin testosterone production

Presence of testosterone causes maturation of the male reproductive tract

8th week of pregnancy, the outer layer of cells of the developing placenta begins to produce progesterone, making the corpus luteum

The production of hCG, which sustained the corpus luteum, begins to decrease

Estrogen

Primarily estriol

Produced as a second product of the syncytial cells of the placenta

Contributes to the woman’s mammary gland development in preparation for lactation and stimulates uterine growth to accommodate the developing fetus

Referred to as the “hormone of women”

Progesterone

The “hormone of mothers”

Necessary to maintain the endometrial lining of the uterus during pregnancy

Present in serum as early as the fourth week of pregnancy, as a result of the continuation of the corpus luteum

After placental synthesis begins (at about the 12th week), the level of progesterone rises progressively during the remainder of the pregnancy

Appears to reduce the contractility of the uterus during pregnancy, preventing premature labor

Reduced contractility is probably produced by a change in electrolytes (notably potassium and calcium), which decreases the contraction potential of the uterus

Human Placental Lactogen (Human Chorionic Somatomammotropin)

hPL is a hormone with both growth-promoting and lactogenic (milk-producing) properties

Produced by the placenta beginning as early as the sixth week of pregnancy, increasing to a peak level at term

Can be assayed in both maternal serum and urine

Promotes mammary gland (breast) growth in preparation for lactation

Serves the important role of regulating maternal glucose, protein, and fat levels so that adequate amounts of these nutrients are always available to the fetus

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The placenta also produces several plasma proteins.

The function of these has not been well documented, but it is thought that they may contribute to decreasing the immunologic impact of the growing placenta through being part of the complement cascade.

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Membranes with embryo lying within amniotic sac

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Embryonic Membranes
Chorion

Outer most membrane

Fingerlike projections, “villi”

Amnion

Thin protective membrane

Contains amniotic fluid

As embryo grows, amnion comes in contact with chorion and forms fluid filled sac.

The amniotic membrane actually produces the fluid.

Produces a phospholipid that initiates the formation of prostaglandins

Can cause uterine contractions and may be the trigger that initiates labor

Occasionally, fibrous amniotic bands that can constrict an arm or leg of the fetus form in utero

Can close off the blood supply to the distal extremity and cause growth of the extremity to halt at that point

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constantly being newly formed and reabsorbed by the amniotic membrane, so it never becomes stagnant

Functions/Purpose

Protection

Temperature regulation

Protects the umbilical cord from pressure

Protecting the fetal oxygen supply

Aids in muscular development

Gives freedom of movement

Amniotic fluid is slightly alkaline, with a pH of about 7.2

Checking the pH of the fluid at the time of rupture helps to
differentiate it from urine, which is acidic (pH 5.0–5.5).

Major method of absorption

The fetus continually swallows the fluid

In the fetal intestine, it is absorbed into the fetal bloodstream --> it goes to the umbilical arteries and to the placenta, and it is exchanged across the placenta

At term, the amount of amniotic fluid has increased so
much it ranges from 800 to 1200 cc

HYDRAMNIOS

Excessive amniotic fluid

More than 2000 mL in total, or pockets of fluid larger

Than 8 cm on ultrasound

-  Esophageal atresia or anencephaly
- Diabetes

OLIGOHYDRAMNIOS

Reduction in the amount of amniotic fluid

Less than 300 cc, no pocket on ultrasound larger than 1 cm

Disturbance of kidney function

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formed from the fetal membranes (amnion and chorion)
and provides a circulatory pathway that connects the
embryo to the chorionic villi of the placenta

Function:

To transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta

About 53 cm (21 in) in length at term and about 2 cm
(3⁄4 in) thick

Bulk of the cord is a gelatinous mucopolysaccharide
called Wharton’s jelly ; gives the cord body and prevents pressure on the vein and arteries that pass through it
- outer surface is covered with amniotic membrane

1% to 5% of infants are born with only a single vein and artery
chromosomal disorders or congenital anomalies,
particularly of the kidney and heart.

Assess and record the number of vein and arteries in the cord at birth.

Rate of blood flow through an umbilical cord is rapid (350 mL/min at term) ; it is unlikely that a cord will twist or knot
enough to interfere with the fetal oxygen supply.

20% of all births, a loose loop of cord is found around the fetal neck (nuchal cord) at birth ; If this is removed before the newborn’s shoulders are born, there is no traction in it, the oxygen supply to the fetus remains unimpaired.

Adequacy of blood flow (blood velocity) can be determined by ultrasound examination during pregnancy

Blood can be withdrawn from the umbilical vein or transfused into the vein during intrauterine life for fetal assessment or treatment (termed percutaneous umbilical blood sampling [PUBS]).

Walls of the umbilical cord arteries are lined with smooth muscle

Constriction of these muscles after birth contributes to hemostasis and helps prevent hemorrhage of the newborn

Because the umbilical cord contains no
nerve supply, it can be cut at birth
without discomfort to either the child or
woman

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In this section, the development of the fetus which is a complex phenomenon, originates from the union of the ovum and the sperm. When united, the ovum and the sperm form a single cell called the zygote.

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A woman’s attitude toward a pregnancy depends a great deal on psychological aspects:

the environment in which she was raised

the messages about pregnancy her family communicated to her as a child

the society and culture in which she lives as an adult

whether the pregnancy has come at a good time or less than a good time in her life

PAST

9-month long illness

alone to a physician’s office for care

Time of birth: separated from her family and admitted to a hospital

hospitalized in seclusion from visitors and even from the new baby for a week afterward …

PRESENT

a TIME OF HEALTH

bring their families during prenatal care

participate actively in the experience

COUPLES VIEWED PREGNANCY:

related to their cultural background

their personal experiences, and the experiences of friends and relatives

as taught by childbirth educators

the current public philosophy of childbirth

Teenage pregnancy affects about 6% of Filipino girls.

Nurses can help make pregnancy and childbirth more enjoyable for clients and their families, continuing to work with other health care providers to “demedicalize” childbirth, informing women about their new health care options.

CULTURAL INFLUENCES

Ask at prenatal visits if there is anything they believe should or should not be done to make the pregnancy successful and keep the baby healthy

Supporting these beliefs shows respect for the individuality of a woman and her knowledge of good health

FAMILY INFLUENCES

Positive and Negative Influences
“People love as they have been loved”

INDIVIDUAL INFLUENCES

Ability to cope with or adapt to stress

Relationship with people around

Common Psychosocial Changes / Tasks that occur with Pregnancy

1st Trimester

TASK: Accepting the Pregnancy

Ambivalence - feeling both pleased and not pleased about the pregnancy.

Recovering from the shock of learning about pregnancy and concentrating on the feeling of being pregnant.

2nd Trimester

TASK: Accepting the Baby

Narcissism and introversion as they concentrate on what it will feel like to be a parent

Role playing and increased dreaming

3rd Trimester

TASK: Preparing for the Baby and End of Pregnancy (Preparing for Parenthood)

Emotional Responses to Pregnancy

Ambivalence - interwoven feelings of wanting and not wanting that can exist at high levels

Provide outlet to discuss concerns and other parenting information at prenatal visit

Grief - not just a daughter anymore, a wife, a friend but a mother

Narcissism - self-centeredness (early reaction)

dressing is time-consuming, mirror studying procedure

change activity level

criticize husband’s driving

Introversion vs Extroversion

turning inward to concentrate on oneself and one’s body (common)

versus

more active, appear healthier than ever before and more outgoing

Body Image and Boundary

Body Image - way body appears to oneself

basis for narcissism and introversion

Body Boundary - zone of separation perceive between    oneself and objects or other people

Protect self from harm

Stress - difficult for a woman to make decisions, be as aware of her surroundings as usual or maintain time management with her usual degree of skill

Couvade Syndrome

men are experiencing physical symptoms like N & V, backache to some degree or more intensely than partner

due to stress, anxiety and empathy

Emotional Lability

Mood changes

as a manifestation of narcissism

partly because of hormonal changes

Mood swings

beginning with early pregnancy

Changes in sexual desire

1st trimester - Decrease in libido due to nausea, fatigue and breast tenderness

2nd trimester - As blood flow to pelvic area increases to supply the placenta, libido and sexual enjoyment rise markedly

3rd trimester - Sexual desire remain high or may decrease because of difficulty finding comfortable position and increasing abdominal size

Changes in Expectant Family

Reassure preschool and school age children periodically that a new baby will be an addition to the family and will not replace them in their parents’ affection.

Emotional Changes

During pregnancy, the birth of your baby and the postnatal period, changes in the hormones in your body will have an effect on your emotions.

It’s a good idea for you and your partner to spend a bit of time thinking about the positive and negative emotions that may arise

Work out some strategies that will help you if feelings become overwhelming

ANGER IN PREGNANCY

You might also be troubled by the changes in your body shape and might worry that you look unattractive. You may feel strange, even unrelated to the body in which you find yourself.

Don't worry about your shape
See your roundness as ripeness, and glory in your body's fertility. Feel confident and proud of your shape.

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Pregnancy is a period of health.

There are even more changes happening within for the following purpose:

1. Support fetal growth

2. Support and maintain maternal health

3. Prepare the body for childbirth

4. Prepare the body for lactation

Psychological changes may be a result of bodily changes such as presence of hormones or by the actual physical changes that may lead to changes in a woman’s ability to function or in their self-perception.

Officially diagnosed on the basis of the SYMPTOMS reported by the woman and the SIGNS elicited by the healthcare team.

Serves to date the diagnosis of birth and helps predict the existence of a high-risk status.

Diagnosing pregnancy early on is important in order to ensure and secure the safety of both the mother and the growing fetus.

Early diagnosis allows women to change their lifestyle—so that health promotive behavior can be assumed early on.

TRIVIA: The phenomenon whereby women do not become consciously aware of their pregnancy until the last week of pregnancy or birth is called CRYPTIC PREGNANCY.

There are 3 classifications of “pregnancy signs''.

Presumptive

least indicative of pregnancy; could indicate other conditions; HIGHLY SUBJECTIVE

Probable

more reliable than presumptive, they still are not positive or true diagnostic findings; CAN BE DOCUMENTED BY A HEALTHCARE PROVIDER

Positive

undeniable signs confirmed by the use of instrument

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PREGNANCY TESTS

1. Laboratory test: detects the presence of hCG (human chorionic gonadotropin) in blood or urine - present as early as 24-48 H after implantation; measurable at 7-9 days after conception;

2. Home Pregnancy Test: 97% accuracy if followed properly

Can detect as little as 35mIU/mL

Advise to wait until the day of the missed menstrual period to test

There maybe a FALSE POSITIVE result

The most common way to diagnose pregnancy is the presence of HCG in the blood or urine.

HCG or human chorionic gonadotropin is a hormone produced by the cells surrounding the growing fetus (trophoblast) at the early stage of pregnancy before the placenta is fully formed. After which, the placenta takes over.

HCG maintains the corpus luteum which secretes large amounts of progesterone necessary for pregnancy to continue.

The best time to take a pregnancy test is on the day of the missed menstrual period.

If the result comes out negative, the procedure may be repeated 1 week after. Accuracy of pregnancy test may be altered by certain medications, and medical conditions among others.

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Here are changes that serve as signs of pregnancy and the corresponding time they appear.

Breast changes are one of the earliest signs of pregnancy apart from amenorrhea.

Frequent urination as an early sign is caused by an increase in the levels of HCG and not by the weight of the uterus.

On the 18th week, quickening, a term used to describe fetal movement felt by the mother is present at this time.  Quickening is only a presumptive sign because fluttering may be caused by other conditions such as presence of gas or flatus.

Highly subjective.

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Uterine blood flow increases from 50ml/minute to 1L/minute or more at term. The weight of the uterus increases from 50g (nonpregnant) to 1200g (full term).

It rises above the symphysis pubis at 12 weeks and the umbilicus at 20 weeks.

Estrogen promotes growth of muscle fibers to accommodate the growing fetus

Progesterone prevents uterine contraction and at the same time maintains the uterine wall (endometrium) making it thick and tortuous (highly vascularized) to maintain the pregnancy, and is now called decidua.

Hegar’s sign - extreme softening of the lower uterine segment

Ballottement - the fetus can be felt to rise against the top examining hand after being tapped sharply

Braxton-Hicks contraction - known as “practice contractions”; felt by women as waves of hardness or tightening across her abdomen

Amenorrhea

Occurs because of suppression of FSH

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Increase in estrogen and progesterone inhibit ovulation. As such, menstrual cycle will not occur.

Since there is an increased blood flow going to the uterus, the cervix and other reproductive organs like the vagina will become more vascular, thus resulting in a change in color called Chadwick’s sign.

At the same time, the increase in Estrogen will cause the cervix to soften (Goodel’s sign) in order to aid in ease of birth.

The consistency of the cervix becomes softer as time of birth is approaching.

An operculum or mucus plug is present in the cervix that serves as a protective mechanism against ascending infection.

Estrogen also causes increased vaginal discharge. This is considered to be normal. Pregnant women must however watch out for excessive vaginal discharge that is continuous and clear, or has foul smelling odor.

The environment of the vagina also becomes acidic to prevent the proliferation of microorganisms. However, this environment is more favorable to fungal infections thus, perineal hygiene should be practiced.

Consistency of the cervix

Nonpregnant - tip of the nose

Pregnant - earlobe

Term - soft as a butter (this is termed as ripening)

Colostrum is the earliest breast milk produced by the 12th-18th week of pregnancy; clear yellowish fluid is continuously produced for the first few weeks after birth. The Montgomery tubercle is present to lubricate the nipples.

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Skin changes are brought about by the stretching of the skin causing breakdown of the elastin and collagen that supports it.

There is also hyperpigmentation of the skin resulting from an increase production of MSH melanocyte stimulating hormones by the APG, as well as increase in Estrogen and Progesterone.

Increased pigmentation is actually a protective mechanism against UV radiation. The appearance of vascular spiders (tiny red veins on the face, neck and arms) and increased activity of the sweat glands are also caused by the increased estrogen.

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Remember that there is an increased need for Oxygen and an increased amount of CO2 that needs to be eliminated!

The major factor that results in a mild alteration in breathing is the pressure exerted by the growing uterus on the lungs. The woman’s lungs, although displaced upward, compensates by extending laterally.

The residual volume on the other hand decreases because of the extra “push” the uterus is exerting on the lungs that results in a fewer amount of air left in the lungs during exhalation.

It is the placenta that has the full responsibility for the transfer of Oxygen and Carbon Dioxide. The pCO2 of a pregnant woman decreases to about 27-32mmHg from the usual 35-45mmHg in a nonpregnant individual; to allow the pCO2 from the fetal blood to diffuse going to the maternal blood where it can be excreted by the mother.

The maternal pH is also slightly increased in order to increase oxygen affinity and at the same time improved placental exchange.

Pregnant women may also exhibit mild hyperventilation in an attempt to prevent acidosis from developing.

Marked congestion or stuffiness which is considered to be a normal effect of the increased ESTROGEN levels. There is no medication required. If accompanied by other symptoms such as fever or change in the color of discharge, advise to seek consultation.

If a woman complains of acute shortness of breath especially when in a supine position, advise to assume a lateral position to take the weight off the lungs.

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The increase in blood volume is necessary for adequate uteroplacental circulation. The peak of increased blood volume usually occurs during the 20th week of pregnancy.

Hence, pseudoanemia may be present up to the early part of the 2nd trimester.

Another factor that may lead to PSEUDOANEMIA or PHYSIOLOGIC anemia is the delayed increase in RBC in proportion to the increase in blood volume. Once the RBC production matches up to the blood volume which also happens during the early part of the 2nd trimester, anemia should no longer be present. However if anemia persists beyond this time, this may be attributed to iron deficiency and is considered PATHOLOGIC or TRUE ANEMIA.

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For the heart to push out the increased blood return, the heart rate increases by 10bpm. This may also be affected by the increased metabolic demands in pregnancy. May pose a risk to women with cardiac disease depending on the extent of the condition. Heart murmurs are innocent unless accompanied by other symptoms.

BP decreases slightly during the 2nd trimester as the circulatory system expands with addition of the uteroplacental circulation.

The BP of a pregnant woman should not change significantly more so should not increase. An increase in BP during pregnancy above the normal (presence of protein in the urine, upper extremity edema) may be a sign of preeclampsia.

A common change that occurs in pregnancy is the presence of edema. Presence of edema may be caused by impaired blood flow going to the lower extremity.

Dependent edema - decrease in protein (attracts water)
osmotic/oncotic pressure - pulling pressure will decrease in comparison to your hydrostatic pressure.

Dilation of the veins in the vulva, rectum and legs or otherwise known as varicosities.

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Supine Hypotension syndrome is when a woman’s blood pressure drops while in a supine position.

The weight of the uterus compresses the vena cava, decreasing the venous return to the heart. This leads to a decrease in cardiac output, with hypotension as the result.

Assuming the left side-lying position will relieve the pressure off the vena cava.

Prolonged compression of the vena cava may result in decreased uteroplacental blood flow and thus may result in fetal hypoxia.

Clotting factors and platelet count increases in order to prevent bleeding. WBC increases in order to protect the woman against infection despite the decreases in IgG to prevent fetal rejection.

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Common in pregnancy are constipation and vomiting.

It is normal for a pregnant woman to experience vomiting during the first 3 months (first trimester) of pregnancy, an effect of the hormone HCG.

However after that, the condition is called hyperemesis gravidarum and can be dangerous due to fluid and electrolyte loss.

Vomiting in the first trimester may be attributed to reflux resulting from the relaxation of the gastroesophageal sphincter as an effect of the hormone, Relaxin. Aside from this, reflux may also be brought about by the pressure of the growing uterus on the stomach.

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Common concern raised by pregnant women is increased frequency of urination. This is considered normal and not a sign of any other condition, except if accompanied by other signs and symptoms.

Increased urinary frequency may be attributed to the presence of HCG in the 1st trimester, and compression of the bladder by the growing uterus in the 3rd.

Some women will consider limiting their fluid intake but this practice is wrong.

Fluids are necessary to increase the blood volume for better placental perfusion.

Also, it is important to maintain the normal amount of amniotic fluid.

A woman is more prone to infection during pregnancy because of the obstruction of the urine flow due to bladder and ureter compression.

There is a risk for retention of urine. The urine is also less acidic and contains more proteins, sugar and hormones. These factors increase the risk of UTI.

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Several changes in the pregnant woman’s body can be attributed to the presence of hormones produced in increased amounts such as estrogen and progesterone. Apart from this, new hormones are being produced by an organ that is present only during pregnancy—the placenta.

HPL or Human placental lactogen has a function similar to that of the growth hormone. It also contributes to the development of the mammary gland.

Relaxin is a hormone that relaxes smooth muscles which leads to symptoms such as reflux, constipation and waddling gait.

The sustained increased levels of estrogen and progesterone in pregnancy halts the release of FSH and LH thus stopping the ovarian cycle.

Melanocyte is increased that results in darkening of some areas of the skin.

Melasma or mask in pregnancy

Oxytocin is important late in pregnancy for effective uterine contraction and prolactin to promote lactation.

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Thyroid hormones are critical for the development of fetal and neonatal brain, as well as many other aspects of pregnancy and fetal growth.

Can be attributed to the increased amount of estrogen and the presence of HCG.

Each hormone has an effect in the thyroid gland that will increase its activity. Thus, it may cause some women to experience transient hyperthyroidism.

In general, all because of the increased metabolic requirements to support a growing fetus.

The adrenal gland also has increased activity.

Corticosteroid which is a steroid hormone involved in stress and immune response, has anti-inflammatory actions that are beneficial in preventing the woman’s body from fetal rejection.

It has an effect of making insulin less effective, making more glucose readily available for fetal use.

Glucose is the main energy source for intrauterine growth and is continuously being transmitted from the mother to the fetus.

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IgG is the most common antibody in the blood and body fluids that protects against bacteria and viral infections.

IgG production is decreased to avoid the initiation of an immune response that would cause the mother’s body to attack the fetus.

WBC is increased as protection.

For the skeletal system, the pelvic joints and ligaments relax and become more pliable in order to prepare the body for childbirth.

This increased pliability leads to the separation of the symphysis pubis, causing pain on walking, backache and change in posture of lordosis (an excessive inward curve of the spine).

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Good health is a cycle that starts before conception.

This section will serve as a basis for identifying any deviations from normal and at the same time a basis for opportunities in improving health through health education.

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Make prenatal care a good experience!

Educate

Emphasize the importance

Ensure privacy and comfort

Engage and involve

Frequency of Visit

1-7: once a month

8-9: twice a month

10 month: weekly

Post-term: twice a week

Components

Health history

Physical exam

Diagnostic test

Health education

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Set up and plan the interview well

Guide the client in answering

Verify information

Complete information

Regular prenatal check up

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Naegele’s Rule

→ standard method used to predict the length of pregnancy

Month    Day      Year

-3         +7        +1

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Baseline height/weight and vital signs measurement

Normal weight gain all throughout pregnancy is 30-35 lbs

Sudden increase in BP and weight gain is a danger sign of HYPERTENSION

Sudden increase in PR or RR may suggest BLEEDING

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Bartholomew’s Rule - fundus reaches typical milestone measurements.

Mcdonald’s Rule - measuring the fundic/uterine height.

measurement (cm) from FUNDUS → SYMPHYSIS PUBIS = week of gestation

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Fetal Movement

▪ Consistent

▪ Should be at least 10x a day

Fetal Heart Tone

▪ 120-160 bpm

▪ 10-12 weeks by DOPPLER, 18-20 weeks ORDINARY STETH

→ best heard at the fetal back

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Detecting if the pelvis is adequate for the fetus to pass through its center.

Done during the first pregnancy

Must be done by the 24th week because at this time, there is a danger that the fetal head will reach a size that will interfere with safe passage.

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Pelvic Examination

Internal and external reproductive organs

Prepare needed equipment

Help the patient to relax

Position the woman correctly: lithotomy position with pillow under her head and ask to void

DRAPE and ask to remain in the same position for a short time after the procedure

Allow support people

If desired, allow to watch the pelvic examination

Pap Smear

3 sites for smear:

Endocervical

Cervical os

Vaginal pool

Cervicograms (photograph of the cervix)

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Gives the actual diameters of the inlet and outlet through which the fetus must pass.

1. True conjugate

10.5 cm - 11 cm

2. Diagonal conjugate

> 12.5 cm

3. Ischial Tuberosity

11 cm

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to confirm general health and rule out sexually transmitted infection that could injure the growing fetus.

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1. Complete Blood Count
Hemoglobin or Hematocrit & Red Cell Index - to determine the presence of anemia.
White Blood Cell Count - to determine infection
Platelet count - to estimate clotting ability

2. A genetic screen
for common ethnically inherited diseases.

African American women for sickle cell trait or disease and glucose6-phosphate dehydrogenase (G6PD)

Asian and Mediterranean women for beta-thalassemia

Jewish ancestry for Tay-Sachs disease

Caucasian women for cystic fibrosis

3. A serologic test for syphilis (VDRL or rapid plasma reagin test)
If syphilis is present, it must be treated early in pregnancy before fetal damage occurs.
A blood sample for a serologic test for gonorrhea may
be drawn as well.

4. Blood typing (including Rh factor)

Blood type is documented because blood may have to be made available if a woman has bleeding during pregnancy.

To detect the possibility of Rh isoimmunization.

5. Maternal serum for alpha-fetoprotein (AFP) (MSAFP)

Elevated if a neural tube or abdominal defect is present in the fetus.

Decreased if a chromosomal anomaly is present

Done at 16 to 18 weeks of pregnancy

Level in serum is expressed as “multiples of the mean” (MOM).

Normal value is 2.5 MOM

If elevated or decreased, an ultrasound or amniocentesis will be ordered to assess for a fetal disorder.

6. An indirect Coombs’ test
(determination if Rh antibodies are present in an Rh-negative woman).

Generally repeated at 28 weeks of pregnancy.

If the titers are not elevated, an Rh negative woman will receive RhIG (RhoGAM) at 28 weeks of pregnancy and after.

Any procedure that might cause placental bleeding, such as amniocentesis or external version.

7. Antibody titers for rubella and hepatitis B (HBsAg)
determine whether a woman is protected against rubella if exposure should occur during pregnancy and whether a newborn will have a chance of developing hepatitis B.

HBsAg testing may be repeated at about 36 weeks

Antibodies for varicella (chickenpox) may also be assessed.

Vaccine against these diseases can then be offered in the postpartum period.

8. HIV screening
All women can be asked, and those at high risk for contracting HIV infection should be asked whether they want to be screened for this disease early in pregnancy.

High-risk:

who have used or are using intravenous drug

have engaged in sex with multiple partners

have had sexual partners who are infected

Bisexual

intravenous drug abusers

Hemophiliacs

women who received a blood transfusion between 1977 and 1985

Screening is done by an enzyme-linked immunosorbent assay (ELISA) on a blood sample.

If this is positive, the finding is confirmed by a second test (a Western blot)

Testing for HIV early in pregnancy allows a woman who is found to be HIV antibody positive the opportunity to begin therapy with zidovudine (AZT) - can decrease the risk of her infant acquiring the virus

9. If a woman has a history of previously unexplained fetal loss, has a family history of diabetes, has had babies who were large for gestational age (9 lb or more at term), is obese, or has glycosuria, she will need to be scheduled for a 50-g oral 1-hour glucose loading or tolerance test toward the end of the first trimester to rule out gestational diabetes.

If not, she will have this done routinely at the 24th to 28th week to evaluate insulin-antagonistic effects of placental hormones, which can register a noticeable effect at this time.

Unless a problem is developing, the plasma glucose level should not exceed 140 mg/dL at 1 hour.

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performed to test for proteinuria, glycosuria, and pyuria.

All three of these can be done by means of test strips or microscopic examination of the urine.

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incidence of tuberculosis is on the rise, related to the HIV epidemic.

More people with lowered immune system function (i.e., those with HIV infection) are contracting tuberculosis and then spreading it to others.

Physician or nurse-midwife may order a purified protein derivative (PPD) tuberculin test for a woman to screen for tuberculosis.

– (+) = chest radiograph

If a woman has a history of tuberculosis or has received a bacillus Calmette-Guérin (bCG) vaccine for

tuberculosis, a tuberculin skin test should not be given because the reaction would be extreme.

To assess a woman’s current disease status, a chest radiograph will be ordered instead.

A woman is often reluctant to have this done because she knows radiation is harmful to a growing fetus.

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If the date of the last menstrual period is unknown, a woman will be scheduled for an ultrasound to confirm the pregnancy
length and document healthy fetal growth.

Be certain that women know an ultrasound done this early in pregnancy will show only the presence of a gestation sac, not a moving, kicking fetus so their expectations of what they will see are realistic.

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Assessment of Fetal Maturity and Well-Being

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Assessment of Fetal Maturity and Well-Being

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Assessment of fetal well-being is designed to identify fetuses at risk for “in utero death” or asphyxia-mediated damage and affect expeditious and safe delivery.

Using the biophysical profile score, a 60-70% reduction in stillbirth rates has been shown in tested populations.

Perinatal fetal hypoxemia leads to irreversible tissue damage and is related to a myriad of problems for the neonate, child, and adult.

Fetal asphyxia → cerebral palsy, learning disability, adult-onset hypertension and cardiovascular disease.

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fetal movements or “kick counts” may be evaluated daily by the pregnant woman to provide reassurance of fetal well-being.

Can be felt by the mother (quickening), occurs at approximately 18 to 20 weeks of pregnancy and peaks in intensity at 28 to 38 weeks.

Healthy fetus moves with a degree of consistency or at least 10 times a day.

Fetus not receiving enough nutrients because of placental insufficiency has greatly decreased movements.

Asking a woman to observe and record the number of movements the fetus is making offers a gross assessment of fetal well-being.

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Protocols Have Been Developed by Different Institutions

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Protocols Have Been Developed by Different Institutions

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Sandovsky Method

Lie in a left recumbent position after a meal and record how many fetal movements over the next hour.

Fetus normally moves a minimum of twice every 10 minutes or an average of 10–12 times an hour.

If less than 10 movements occur within an hour, repeat the test for the next hour.

CALL her health care provider if she feels fewer than 10 movements (half the normal number) during the chosen 2 hours.

“Count-to-Ten” (the Cardiff method)

The woman records the time interval it takes for her to feel 10 fetal movements.

Usually, this occurs within 60 minutes.

Assure a woman that fetal movements do vary, especially in relation to sleep cycles of the fetus, her activity and the time since she last ate.

Fetal movements are best assessed after meals, after or with light abdominal massage, or after short walks, and if she has not smoked for the last 2 hours.

Instruct patient that the fetus can sleep for up to 40 minutes.

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combines five parameters (fetal reactivity, fetal breathing, fetal body movement, fetal tone, and amniotic fluid volume) into one assessment.

Fetal heart and breathing record measure short-term central nervous system function; the amniotic fluid volume helps measure long-term adequacy of placental function.

More accurate in predicting fetal well-being.

May be done as often as daily during a high-risk pregnancy
If the fetus score on a complete profile:
8-10, normal, low risk for chronic asphyxia
4-6 suspected chronic asphyxia
0-2 strong suspicion of chronic asphyxia

For simplicity, some centers use only two assessments (amniotic fluid index and a non-stress test) for assessment

Referred to as a modified biophysical profile this predicts short-term viability by the non-stress test and long-term viability by the AFI.

A healthy fetus should show a reactive non-stress test and an AFI range between 5 and 25 cm.

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Fetal hearts beat at 120 to 160 beats per minute throughout pregnancy.

Fetal heart sounds can be heard and counted as early as the 10th to 11th week of pregnancy by the use of an ultrasonic Doppler technique.

Indicator of oxygen perfusion to the fetal brain, heart, and adrenals.

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assessment of the fetal heart rate for whether a good baseline rate and a degree of variability are present.

Semi-Fowler’s position (either in a comfortable lounge chair or on an examining table or bed with an elevated backrest) to prevent the uterus from compressing the vena cava and causing supine hypotension syndrome during the test.

Attach an external fetal heart rate monitor abdominally.

Record the fetal heart rate for 20 minutes.

Baseline Reading refers to the average rate of the fetal heartbeat per minute.

Variability refers to small changes in rate that occur if the fetal parasympathetic and sympathetic nervous systems are receiving adequate oxygen and nutrients.

Categories:
absent (none apparent)
minimal (extremely small fluctuations)
moderate (amplitude range of 6–25 beats per minute)
marked (amplitude range over 25 beats per minute)

Rhythm strip testing requires a woman to remain in a fairly fixed position for 20 minutes.

Keep her well informed of the purpose of the test, how it is interpreted, and the meaning of results after the test.

The more she understands about the process, the better she can cooperate to make it successful.

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NCLEX Tutor: EKG strips for the NCLEX & beginners

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measures the response of the fetal heart rate to fetal movement.

Position and attach to both a fetal heart rate and a uterine contraction monitor.

Instruct to push a button attached to the monitor (similar to a call bell) whenever the fetus moves.

This will create a dark mark on the paper tracing at these times.

no increase in beats per minute on fetal movement = POOR OXYGEN PERFUSION

Non-stress test usually is done for 10 to 20 minutes.

Reactive if two accelerations of fetal heart rate (by 15 beats or more) lasting for 15 seconds occur after movement within the chosen time period.

Non-reactive if no accelerations occur with the fetal movements.

The results can be interpreted as non-reactive if no fetal movement occurs or if there is low short-term fetal heart rate variability (less than 6 beats per minute) throughout the testing period.

If a 20-minute period passes without any fetal movement, it may mean only that the fetus is sleeping.

Other reasons for lessened variability are maternal smoking, drug use, or hypoglycemia. If you give the woman an oral carbohydrate snack, such as orange juice, it can cause her blood glucose level to increase enough to cause fetal movement.

Fetus also may be stimulated by a loud sound to cause movement.

Both rhythm strip and non-stress testing are non-invasive procedures and cause no risk.

Can be used as screening procedures in all pregnancies.

Can be done at home daily as part of a home monitoring program for the woman who is having a complication.

If a nonstress test is non-reactive, additional fetal assessment, such as a contraction stress test or a biophysical profile test, will be scheduled.

NURSING ALERT ⚠️ Monitor tracings become part of the neonate’s and mother’s chart and are legal documents. They may be used in litigation if certain health problems develop in years to come.

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For acoustic (sound) stimulation, a specially designed acoustic stimulator is applied to the mother’s abdomen to produce a sharp sound of approximately 80 decibels at a frequency of 80
Hz, startling and waking the fetus.

During a standard non-stress test, if a spontaneous acceleration has not occurred within 5 minutes, apply a single 1-to-2-second sound stimulation to the lower abdomen.

Can be repeated again at the end of 10 minutes if no further spontaneous movement occurs, so that two movements within the 20- minute window can be evaluated.

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Fetal heart rate is analyzed in conjunction with contractions.

Source of oxytocin for contraction stress testing currently is achieved by nipple stimulation.

Gentle stimulation of the nipples releases oxytocin in the same way as happens with breastfeeding.

With external uterine contraction and fetal heart rate monitors in place, the baseline fetal heart rate is obtained.

Next, the woman rolls a nipple between her finger and thumb until uterine contractions begin, which are recorded by a uterine monitor.

Three contractions with a duration of 40 seconds or longer must be present in a 10-minute window before the test can be interpreted.

The test is negative (normal) if no fetal heart rate decelerations are present with contractions.

It is positive (abnormal) if 50% or more of contractions cause a late deceleration (a dip in fetal heart rate that occurs toward the end of a contraction and continues after the contraction).

After a contraction stress test, encourage a woman to remain in the health care facility for about 30 minutes, to be certain that contractions have quieted and preterm labor is not a risk.

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Lecithin and sphingomyelin are the protein components of the lung enzyme surfactant that the alveoli begin to form at the 22nd to 24th weeks of pregnancy.

After amniocentesis, the L/S ratio may be determined quickly by a shake test (if bubbles appear in the amniotic fluid after shaking, the ratio is mature) or sent for laboratory analysis.

An L/S ratio of 2:1 is traditionally accepted as lung maturity.

Infants of mothers with severe diabetes may have false-mature readings of lecithin because the stress to the infant in utero tends to mature lecithin pathways early.

Some laboratories interpret a ratio of 2.5:1 or 3:1 as a mature indicator in infants of women with diabetes.

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Measures feto-placental well being.

Specimen:
Serum or 24H urine (most commonly used)

Results:

Normal: gradual increase which is 12 – 50 mg/day at term.

Abnormal: sudden drop of < 50% of the previous level = fetal distress.

Persistent low level = fetal well being is compromised.

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Ultrasonography is a noninvasive, safe technique that uses reflected sound waves as they travel in tissue to produce a picture.

In the abdominal approach, a clear gel is applied to the woman’s abdomen or to the transducer and the transducer is moved along the abdomen by the examiner.

Images are produced onto a screen.

During the early weeks of gestation, when the uterus remains a pelvic organ, a full bladder may be necessary to facilitate visualization.

In the endovaginal approach, a lubricated transducer probe is inserted (either by the woman or by the examiner) into the vagina.

No full bladder is necessary.

Especially useful during the early weeks of pregnancy or when cervical evaluation is important (ie, for assessment of preterm labor).

Uses of UTZ

Diagnose pregnancy as early as 6 weeks’ gestation.

Confirm the presence, size, and location of the placenta and amniotic fluid.

Establish that a fetus is growing and has no gross anomalies, such as hydrocephalus, anencephaly, or spinal cord, heart, kidney, and bladder defects.

Establish sex if a penis is revealed.

Establish the presentation and position of the fetus.

Predict maturity by measurement of the biparietal diameter of the head.

1. Uses in the first trimester of pregnancy include:

Early confirmation of pregnancy and determination of the estimated date of confinement

Diagnosis of an ectopic pregnancy

Detection of an intrauterine device

Evaluation of placental location

Diagnosis of a multiple gestation

Guidance for CVS

2. Uses in the second and third trimester include:

Evaluation of fetal growth, weight, and gestational age

Evaluation of the placenta for placenta previa or separation associated with vaginal bleeding

Evaluation of fetal presentation and position

Evaluation of fetal abnormalities

Evaluation of fetal viability

Determination of the Biophysical Profile (BPP) Score

Evaluation of amniotic fluid volume.

Guidance for amniocentesis or fetal blood sampling.

Secondary survey for pregnant trauma patient

Type or mode of process

B-mode scanning allows patterns to merge and form a still picture, similar to a black-and-white snapshot (called gray-scale imaging).

Real-time mode involves the use of multiple waves that allow the screen picture to move.

Fetal heart can be seen to move, and even movement of the extremities, such as bringing a hand to the mouth to suck a thumb.

A parent who is in doubt that her fetus is well or whole can be greatly reassured by viewing a real-time ultrasound image.

Three- and four-dimensional (3-D and 4-D) ultrasonography

Evaluates major and superficial vessels of the placenta, including the cord; fetal physiologic development; and fetal behavior.

Advantages to 3-D and 4-D ultrasonography over Doppler velocimetry.

Decreased time of fetal exposure to ultrasound beam (2 to 5 minutes for 3-D versus 15 to 30 minutes for velocimetry).

* off-line image processing

Identification of placental anastomoses

Other Uses of UTZ

Discover complications of pregnancy, such as the presence of an intrauterine device, hydramnios or oligohydramnios, ectopic pregnancy, missed miscarriage, abdominal pregnancy, placenta previa, premature separation of the placenta, coexisting uterine tumors, multiple pregnancy, or genetic disorders such as Down syndrome.

Fetal anomalies such as neural tube disorders, diaphragmatic hernia, or urethral stenosis.

Fetal death can be revealed by a lack of heartbeat and respiratory movement.

After birth, an ultrasound may be used to detect a retained placenta or poor uterine involution in the new mother.

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How Ultrasound Works Animation - Ultrasound Scan During Pregnancy Video - USG Medical Imaging

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In 80% of pregnancies in which the biparietal diameter of the fetal head is 8.5 cm or greater, it can be predicted that the infant will weigh more than 2500 g (5.5 lb) or is at a fetal age of 40 weeks.

Two other measurements commonly made by ultrasound to predict maturity are head circumference (34.5 cm indicates a 40-week fetus) and femoral length.

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Doppler flow study, also known as Doppler Velocimetry

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Doppler flow study, also known as Doppler Velocimetry

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Noninvasive way to analyze uteroplacental blood flow within the umbilical, uterine and cerebral arteries.

Focuses on placental analysis to identify patients at risk for increased perinatal mortality.

Systolic and diastolic ratios are measured within the arteries.

If the ratios rise above normal, it means that blood flow to the placenta is decreased.

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Measures the velocity at which red blood cells in the uterine and fetal vessels travel.

Assessment of the blood flow through uterine blood vessels is helpful to determine the vascular resistance present.

In women with diabetes or hypertension of pregnancy and whether resultant placental insufficiency is occurring.

Because it will limit the number of nutrients that can reach the fetus, decreased velocity is an important predictor of poor neonatal outcome.

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1. Explain the purpose and procedure to patient, emphasizing the need to remain still.

2. Inform patient of the need for a full bladder, if indicated, before the procedure.

3. When indicated, instruct patient to drink three to four glasses of water if the bladder is not full.

4. Instruct patient not to void until the procedure is over.

5. Remove the lubricant from patient’s abdomen after the procedure or provide perineal cleaning products, as needed.

Note: Nurse can perform ultrasound if credentialed.

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also called aortoaval compression or vena cava syndrome.

Occurs if woman lies flat on her back.

Allows heavy uterus to compress inferior vena cava.

Reduces blood returned to her heart.

Can lead to fetal hypoxia.

Symptoms

1. Fainteness

2. Light-headedness

3. Dizziness

4. Agitation

Turning to one side relives pressure on inferior vena cava, preferable the left side.

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Based particularly on the amount of calcium deposits in the base of the placenta, placentas can be graded by ultrasound as:
0 (a placenta 12–24 weeks),
1 (30–32 weeks),
2 (36 weeks), and;
3 (38 weeks).

Because fetal lungs are apt to be mature at 38 weeks, a grade 3 placenta suggests that the fetus is mature.