NCM 107 PADLET by Loise Anne Jarylle Soller

WEEK 1

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Lesson Module 1: Promoting Maternal & Child Health: Family-Centered Care

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Goal:

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“Promotion and maintenance of optimal family health to ensure cycles of optimal child bearing and childrearing.”

Key terms:

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• Obstare - "to keep watch"
• Pais - "child"
• Pre-conceptual healthcare -focuses on the health of the mother and father to ensure the health of a baby in the future.
• Antenatal or prenatal care - care of women during the entire pregnancy
1st trimester of pregnancy: 1 to 3 months
2nd trimester of pregnancy: 4 to 6 months
3rd trimester of pregnancy: 7 to 9 months
• Intrapartal-care - care of women during labor and birth
• Post-partal care - care of women after 6 weeks of giving birth (recovery)
• Perinatal period - the period from 6 weeks before conception to 6 weeks after birth.
• Puerperium - the period of about six weeks after childbirth during which the mother's reproductive organs return to their original nonpregnant condition

As nurses, we are expected to:

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^{Summary: As maternal and child health nurses, we are expected to provide holistic family-centered care which means that the care that we are to provide will not only limit to the patient alone, but will also include other family members involved. Moreover, in this area of nursing, the length of time that we are to provide care should not be confined to merely the time of pregnancy. It should also include care during the pre-conceptual period, puerperium period, perinatal period, and even from the child's birth through adolescence.

With all these, the goal of promoting and maintaining
optimal family health to ensure cycles of optimal childbearing and childrearing may be achieved.}

Principles

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▪ The family is the basic unit of the society.
▪ Families come in many different forms and sizes and represent racial, ethnic, cultural, and socioeconomic
diversity.
▪ Children grow both individually and as part of a family

Maternal and Child Health Nursing Framework

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^{During the childbearing and childrearing years of our patients, maternal and child health nurses can come up with a care that encompasses everything we know about nursing such as nursing process, nursing theory, and evidence-based practice.

This can be visualized within the framework above which shows four phases of health care:}^{Promotion
Maintenance
Restoration
Rehabilitation}

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Philippine Situation

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1. Declining live births
2. Increased births attended by health professionals
3. >50% born to unwed mothers
4. More babies born to adolescent mothers
5. Infant Mortality remains unchanged
6. Relatively Low Maternal mortality ratio

Indicators of Sustainable Development goal 3: Good Health & Well-being

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> Reduce child mortality
> Improve maternal health

LESSON MODULE 2: GROWTH AND DEVELOPMENT

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GROWTH AND DEVELOPMENT

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Factors such as (1) Genetic Inheritance and (2) Environmental Influences can influence or greatly affect growth and development.

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e.g. John is 6 years old. What body system is reaching its peak point of development at this time?
= Lymphatic system.

Principles of Growth and Development

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1. continuous processes from conception until death
2. proceed in an orderly sequence
3. Different children pass through the predictable stages at different rates
4. All body systems do not develop at the same rate
5. Development is cephalocaudal
6. Development proceeds from proximal to distal body parts
7. Development proceeds from gross to refined skills
8. There is an optimum time for initiation of experiences or learning
9. Neonatal reflexes must be lost before development can proceed
10. A great deal of skill and behavior is learned by practice

Patterns of Development

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• Cephalocadual: from head to toe
• Proximodistal: from the trunk to the tips of the extremities/inward to outward
• General to specific: from simple tasks to more complex tasks

Terminologies

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Theory
• a systematic statement of principles that provides
a framework for explaining some phenomenon
Developmental Theories
• provide road maps for explaining human
development
Developmental Tasks
• skill or a growth responsibility arising at a
particular time in an individual’s life
• the achievement of which will provide a foundation
for the accomplishment of future tasks

Theories of Development

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• Psychosexual Development – developing instincts or
sensual pleasure (Freud)
• Psychosocial Development – personality development
(Erickson)
• Moral Development – know right from wrong and
apply in real-life situations (Kohlberg)
• Cognitive Development – learn or understand from
experience, to acquire and retain knowledge to
respond to new situation and solve problems (Piaget)

Psychosexual Development

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Psychosocial Development

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Cognitive Development

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Sensorimotor: understands world through senses and actions
Preoperational: understands world through language and mental images
Concrete operational: understands world through logical thinking and categories
Formal operational: understands world through hypothetical thinking and scientific reasoning

Moral Development

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Stages
1: I do it so I don't get in trouble
2: I do it so I get something out of it
3: I do it so you like me
4: I do it because it is the law, and I respect the law
5: I do it because of a social contract we have with each other
6: I do it because it is the right thing to do

WEEK 2

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Lesson Module 3: Life with an Infant

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GROSS MOTOR DEVELOPPMENT

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Gross motor is the ability to accomplish large body movements

Examples of gross motor movements in infants are: Ventral Suspension Position, Landau Reflex, Parachute Reflex, Prone Position, Neck Righting Reflex, Sitting and Standing Position.

developments in these movements are seen over different certain period of time.

MAJOR MILESTONES: SUMMARY

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Promoting Safety

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^{Infants are very prone to accidents. and so, these are one many things to look out for to ensure their safety:
• Falls
• Car safety
• Bathing & Swimming}

Promoting Nutritional Health

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- Offer new food one at a time
- Wait 5-7 days before introducing new items
- Introduce small amounts of new food: 1 or 2 teaspoonful at a time

Newborn: 30ml (2tbsp)
1 year: 240ml (1cup)

LESSON MODULE 3: FAMILY WITH A TODDLER

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addtl:
• Four times birth weight
• Bladder control during the day, sometimes at night
• Turns pages in book, and by age 3 draws stick people

Comparing type of play between infants, toddler, and pre-school
• infancy - solitary play
• toddler - parallel play
• pre-school - pretend play

Cognitive Development of Toddler

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Stage 5 (between 12 and 18 months)

^{• Tertiary Circular Reaction Stage
• “a little scientist”
• child experiments by trial and error methods}

Stage 6 (between 18 and 24 months)

^{• toddlers are able to try out various actions mentally rather than
having to actually perform them—the beginning of problem
solving or symbolic thought
• Deferred Imitation
• remember an action and imitate it later}

Preoperational Thought

^{• children deal much more constructively with symbols
• Assimilation
• change the situation (or how they perceive it) to fit their thoughts}

Psychosocial Development of Toddler

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• Freud — anal stage, toilet training is major focus
^{During this stage, sphincter control is to be expected to start at age 2. Therefore, a child should should be already be taught proper toilet training. However, in when toilet training, a caregiver should consider readiness and never punish the child.}
• Erikson — autonomy versus shame and doubt
^{It is during this stage that child develops sense of independence and it is a role of the child's primary caregiver to allow the child to explore the environment with encouragement and of course, with supervision as well. Always monitor safety.}

• Havighurst — tasks of learning to control elimination
process, learn sex differences, form concepts, learn
language, and distinguish right from wrong

Personality Traits

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• Negativism
• Ritualistic Behavior
• Slowness in carrying out requests/ambivalence
• Temper Tantrums

Role As A Nurse (Implementation)

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• teach parents a good rule is to think of a toddler as a visitor
from a foreign land who wants to participate in everything
the family is doing but does not know the customs or the
language
• teach parents not only how to approach a current problem
but also how to learn adequate methods for resolving
similar situations that are sure to arise in the future
• Health visits provide opportunities to help parents learn
healthy coping techniques
• demonstrating good communication skills with toddlers
can serve as a model for healthy communication behavior
with them

Nutrition

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^{Toddlers are more fussy eaters compared to infants and food jags are commonly experienced. To ensure proper nutrition, 6 small meals containing iron-rich food should be given, and nutritious snacks are offered. Hotdog, peanuts, and grapes should be avoided.}

Physical Growth of a Toddler

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LESSON MODULE 4: FAMILY WITH A PRE-SCHOOLER

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notes:
Pre-school stage is an important period of growth for parents. While cognitive growth and personality continues to grow at rapid rate, physical growth during this stage slows down.

Physiologic Development

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• Head is close to adult size by six years old
• Pulse rate decreases to about 85 beats per minute; blood pressure holds at about 100/60 mm Hg
• Bladder is easily palpable above the symphysis pubis
• voiding is frequent enough (9 or 10 times a day) that play must be interrupted
• Motor abilities include jumping, skipping, throwing a
ball, printing letters and numbers
• Full set of 20 deciduous teeth
• Weight gain is slight
• Average child gains only about 4.5 lb (2 kg) a year

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Psychosocial and Cognitive Development

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Erikson: Initiative Versus Guilt
^{If children are criticized or punished for attempts at initiative, they develop a sense of guilt for wanting to try new activities or have new experiences}Piaget: (1st phase) Preoperational → (2nd phase) intuitional thought (intuitive thought phase)

Emotional Development

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• Imitation
^{Watch adults and imitate behavior}
• Fantasy
^{Imaginative= imaginary playmates
Creative and curious = WHY, HOW}
• Oedipus and Electra Complexes
^{Each child competes with the same-sex parent for the love and attention of the other parent}
• Gender roles
^{“sex” – be honest’
Masturbation may be seen}
• Socialization
^{play with other children their age much more
Significant others now include grandparents, siblings, and preschool teachers (although parents remain central)}

Moral and Spiritual Development

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Pre-scholers can determine right from wrong based on their parents' rule. However, unless the parents were able to supply rationale of these rules, pre-schoolers might have difficulty in applying the rules they know to a new situation.

Pre-schoolers begin to have an elemental concept of God if they have been provided some form of religious training

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LESSON MODULE 5: CARE OF A FAMILY WITH A SCHOOL-AGE CHILD

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School Age (Middle Childhood)

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^{- 6 to 12 years
- time of}^slow^{physical growth}^{, but cognitive growth and development continue to proceed at}^{rapid rates
-}^{language and vocabulary is now more developed. six-year-olds begin to talk in full sentences.}

^{The school-age years can be a spectacular journey filled with}^{joys and successes}^{as the child
continues}^{to grow and mature.}^{It is also at this stage that the child begins to make truly}^{independent judgments.}^{Children of school age may be}^{more influenced by the attitudes of their friends}

Physiological Development

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By age 12,
Brain reaches 90% to 95% of adult size, nervous system almost mature, and so, motor abilities and coordination, compared to the previous ages, becomes more refined and developed already. All permanent teeth by this age will be present except for 2nd and 3rd molars

^{- The average child gains 28 teeth between 6 and 12 years of age: the central and lateral incisors; first,
second, and third cuspids; and first and second molars
- Sexual organs grow but are dormant until late in this period}

Physical Growth

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• annual average weight gain is approximately 3 to 5 lb (1.3 to 2.2 kg); the
• pulse rate decreases to 70 to 80 beats per minute; blood pressure rises to about 112/60mm Hg
• Maturation of the respiratory system leads to increased oxygen–carbon dioxide exchange
• increases exertion ability and stamina
• Scoliosis may become apparent for the first time in late childhood

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Concerns of Boys
• increasing genital size
• testicular development precedes penis growth
• gynecomastia: condition of overdevelopment or enlargement of the breast tissue in men or boys; can occur in prepuberty
• although they have pubic hair, they cannot yet grow
a beard or do not have chest hair
• nocturnal emissions: ejaculation during sleep

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Concerns of Girls
• Prepubertal girls are usually taller, by about 2 in (5cm) or more than preadolescent boys
• Change in pelvic contour and hips become broader
• Breast development (whether overdeveloped or underdeveloped)
• Supernumerary (additional) nipples may darken or increase in size at puberty
• Early preparation for menstruation
• Menarche (first menstruation): age 9-12

Begins puberty

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^{At this stage, puberty begins usually at 10-11 for girls, and 11-12 for boys. During this stage, there are significant changes in the body that will begin to appear. The following are some of these changes:}

Developmental Milestones of the School Age

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Psychological Development

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Erikson: Industry vs. Inferiority
^-^{child wants to}^{work and produce}^{, accomplishing and achieving tasks.
- focuses on}^{learning useful skills, self-identity emerges. However, i}^{f too much is expected of him, or if he feels unable to measure up to set standards, the negative attributes of}^{inadequacy and inferiority}^{may prevail}

Play

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Age 6: continues to be rough; but can discover reading and video games and can result to spending time alone, isolation or healthy sense of competition.
Age 7: decline in imaginative play
Age 8: develop skills for sorting and cataloging; collections may become increasingly structured
Age 9: children become very interested in rules and fairness in competitive play situations; Music and artistic expression; begins to discover Internet;

Cognitive Development

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Piaget's: Concrete Operational Stage
^{- In this stage, the level of thinking and reasoning of the child advances. Child already begin using}^{inductive reasoning, thinks logically.}^{(ACCOMMODATION)}^{- Child}^{develops concepts of measurement, classification systems,}^{(CLASS INCLUSION)
-}^Child^understands^{reversal of events.}^{(CONSERVATION)}^-^{Child also begins to develop}^{awareness of other’s feelings.}^{(DECENTERING)}

New Concepts Learned

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• Decentering
• Accommodation
• Conservation
• Class Inclusion

Emotional Development

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^{During the preschool age, child have already been able to quite observe and explore. And so, during this stage, which is now the school age, child is more likely to:}
- have the ability to trust others and with a sense of respect for their own worth
- have the ability to accomplish small tasks independently
- have practiced or mimicked adult roles
- have learned to share, and have discovered that learning is fun and an adventure

Moral and Spiritual Development

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Kohlberg’s: Conventional Level
^-^{Child behaves according to socially acceptable norms because an authority figure tells him to do so.
- However, at ages 11 to 12, when child begins to approach adolescence,}^{school and parental authority}^{is questioned and, occasionally, even challenged or opposed. There comes the massive influence of}^{peer group}^{in terms of}^{behavior standards and models}Spiritual
^{- Child begins to learn about the rituals and meaning behind their religious practices, so the}^{distinction between right and wrong}^{becomes more important}

Keys to health

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Being Healthy, remember PEDS

Proper nutrition
Exercise
Dental hygiene
Sleep

Nursing Process Implementation

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• Discover with the child the “hows” and “whys” of actions
• Give a satisfactory explanation of why it must be done, because child might not cooperate with the procedure.
• Maintain a positive because child will more likely to watch and see the nurses' actions in a given situation

LESSON 6: CARE OF FAMILY WITH ADOLESCENTS

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Physical and Physiological Growth

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Major milestone: Onset of puberty at 9 to 12 years of age and the cessation of body growth at 16-20 years of age

Adoloscence

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• THE PERIOD BETWEEN 13 AND 18 OR 20 YEARS
• TIME THAT SERVES AS A TRANSITION BETWEEN CHILDHOOD
AND YOUNG ADULTHOOD
• DEFINED NOT SO MUCH BY CHRONOLOGIC AGE BUT BY
PHYSIOLOGIC, PSYCHOLOGICAL, AND SOCIOLOGIC CHANGES

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• EARLY PERIOD (13 TO 14 YEARS)
• MIDDLE PERIOD (15 TO 16 YEARS)
• LATE PERIOD (17 TO 20 YEARS)

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^{FEMALE: estrogen}^{breasts and pubic hair grows, wide hips develop}^{MALE: testosterone}^{body hair grows, voice breaks, muscle growth increases}

Play or Recreation

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• Age 13: change from school-age activities of active games to more adult forms of recreation
• They learn they are strong and capable to take care of themselves and help less fortunate people
• These activities fulfill an adolescent’s need for satisfying interaction and are indications of maturity and willingness to accept adult roles.

Emotional Development

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^{Erik Erikson: Identity vs. Role Confusion}
^-^{Adolescents develop a sense of identity if their development is successful it leads to}

^{the development of an identity they are proud of. However, if unsuccessful there will be role confusion and a weak sense of identity.
If young people do not achieve a sense of identity, they develop a sense of role confusion.}^{4 main areas to achieve a sense of identity}¹^.^{Accepting their changed body image
2. Establishing a value system or what kind of person they want to be
3. Making a career decision
4. Becoming emancipated from their parents}^{2nd Developmental Task: Sense of Intimacy}^{• Once adolescents have achieved a sense of identity in early or mid-adolescence, they are ready to work on a second developmental task, that of achieving a sense of intimacy (Erikson, 1993).
• The ability to form intimate relationships is strongly correlated with the sense of trust, the first developmental task in infancy.
• Infants who are unable to form a sense of trust may be unable to relate to others on a deep enough level to form lasting and close relationships as adults.}

Cognitive Development

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Jean Piaget: Formal Operations
- being able to manipulate your mind

Moral and Spiritual Development

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^{- In adolescence, an}^{idealistic sense of social justice and fairness develops}^{. They more likely have a need to have choices and make personal decisions, and a desire to make a difference in the world and in the lives of others.}

Common Health Problems

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• Hypertension
• Poor Posture
• Body Piercings and Tattoos
• Fatigue
• Acne
• Obesity

Common Concerns

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• Sexual Behaviors
• Stalking
• Hazing
• Drug or Substance Abuse
• Depression
• Suicide
• Runaway

LESSON 7: YOUNG AND MIDDLE-AGED ADULT

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Adulthood

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Three phases:
1. Young Adulthood: 20 to 40 years old
2. Middle Adulthood: 40 to 65 years old
3. Late Adulthood

Three very different generations
1. Baby Boomers: (born in years 1945–1964)
2. Generation X: (birth years 1965–1978)
3. Generation Y or the Millennials: (birth years 1979–2000)

Young Adults

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• adult depends on how adulthood is described in the
social context of the individual, and this defining age is
changing
• Another criterion of adulthood is financial independence,
which is also highly variable
• boomerang kids have evolved, as young adults have
moved back into their parents’ homes after an initial
period of independent living
• factors contributing to this trend include high housing
costs, high divorce rates, high unemployment rates, and
the problems resulting from substance abuse
and maladaptive behaviors

Middle-Aged Adults

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• The middle years, from 40 to 65, have been called the years of stability and consolidation
• For most people, it is a time when children have grown and moved away or are moving away from home
• Thus, partners generally have more time for and with each other and time to pursue interests they may have deferred for years
• Maturity is the state of maximal function and integration or the state of being fully developed
• Mature individuals are guided by an underlying philosophy of life
• They take many perspectives into account and are tolerant of the views of others
• A comprehensive philosophy allows a person to make sense out of life and thus helps that person maintain a sense of purpose and hope in the face of human tragedies.

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^{HEALTH RISKS:
Young Adult}^{Injury and Violence
Suicide
Hypertension
Substance Abuse
Sexually Transmitted Infections
Eating disorder
Malignancies}^{Middle Adulthood:}^{Injury
Cancer
Cardiovascular Disease
Obesity
Alcoholism
Mental Health Alterations}

LESSON 8: PROMOTING HEALTH IN OLDER ADULTS

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Stages of Growth and Development

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• Older Adulthood: 65 – 74 years
• Middle Old: 75 – 84 years
• Old-old: 85 and over

Gerontological Nursing

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Gerontology
– is the study of aging and older adults
– is multidisciplinary and is a specialized area within various
disciplines such as nursing, psychology, and social work

Geriatrics
– is associated with the medical care (e.g., diseases and
disabilities) of older adults

Roles of Gerontological Nurse

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• provider of care
• Teacher
• Manager
• Advocate
• research consumer

Care Settings for Older Adult

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• Acute Care Facilities
• Long-Term Care Facilities
• Hospice
• Rehabilitation
• Community

Normal Physical Changes Associated with Aging

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^{Neuromuscular:}^{Sarcopenia, Kyphosis (humpback of the upper spine), Osteoporosis}^{Sensory-Perceptual:}^{Presbyopia, Presbycusis, Loss of peripheral vision, atrophy of lacrimal glands resulting in dry eyes, difficulty in discriminating similar colors, age-related macular degeneration (ARMD), glaucoma, diabetic retinopathy (Miller, 2012)}

Psychosocial Aging

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Erik Erikson: Ego Integrity versus Despair^{– People who attain ego integrity view life with a sense of wholeness and derive satisfaction from past accomplishments
– They view death as an acceptable completion of life
- People who develop integrity accept “one’s one and only life cycle” (Erikson, 1963, p. 263)
- By contrast, people who despair often believe they have made poor choices during life and wish they could live life over}

Cognitive Abilities and Aging

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^Piaget:^{-Phases of cognitive development end with the formal operations phase. However, considerable research cognitive abilities and aging is currently
being conducted
- Intellectual capacity includes perception, cognitive agility, memory, and learning}

Moral Reasoning

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^{Kohlberg: moral development is completed in the early adult years}

^•^{Older person at the preconventional level:}^{obeys rules to avoid pain and the displeasure of others
•}^{Older adults at the conventional level:}^{follow society’s rules of conduct in response to the expectations of others}

^{Moral reasoning does not decline in old age}

Spirituality and Aging

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^{- Older adults can contemplate new religious and philosophical views and try to understand ideas missed previously or interpreted differently
- The older person may derive a sense of worth by sharing experiences or views
- In contrast, the older adult who has not matured spiritually may feel impoverishment or despair as the drive for economic and professional
success lessens}

Health Problems

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• Injuries
• Chronic disabling disease such as hypertension and arthritis
• Drug abuse and misuse, alcoholism, dementia, and mistreatment

Goals of Nursing Care

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• Promote independent function
• Support individual strengths
• Prevent complications of illness
• Secure a safe and comfortable environment
• Promote return to health

LESSON 9: ASSESSING MATERNAL AND FETAL HEALTH

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Maternal

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Pregnancy

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Early Term: 37-38 weeks
Full Term: 39-40 weeks
Late Term: 41 weeks
Post Term: 42 weeks

Changes in Pregnancy

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• Systemic: all systems except reproductive system
• Local: reproductive system including the breast

Trimester

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• 1st trimester: 1-3 mos
• 2nd trimester: 4-6 mos
• 3rd trimester: 7-9 mos

3 Classifications of Pregnancy

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3P's:
Presumptive
Probable
Positive

• Presumptive: highly subjective (e.g. breast tenderness, enlarged uterus felt by the pregnant woman)
• Probable: (+) signs and symptoms but can be indicative of other health conditions (e.g. false positive pregnancy)
• Positive: undeniable sign; confirmed
^{3 signs of positive:
- fetal outline in UTZ
- fetal heart tone
- fetal movement felt by examiner}

Age of Gestation (AOG)

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^{- term used to describe how far along the pregnancy is.}

Measuring AOG

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Bartholomew's Rule of Four
measuring the height of the fundus of the uterus above the pubic symphysis.
• above symphysis fundus: 12 weeks
• above umbilicus: 20 weeks
• in between symphysis fundus and ambilicus: 16 weeks
• above xiphoid process: 36 weeks
• fundus descend (lightening): 38 weeks

McDonald's Rule
measuring the height of fundus in centimeters (cm)
e.g. 36 cm = 36 weeks

assessment: position the pregnant woman in a supine position (slightly flexed with small pillow behind the right pelvis)

Expected symptoms

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CARDIOVASCULAR SYSTEM
• heart rate + 20 bpm; increased cardiac output
• palpitations
• mild hypertrophy (goes away after pregnancy)
• presence of extra heart sounds (s3)
*disclaimer: refer to physician if accompanied with DOB, chest pain
• blood pressure may decrease
• varicose veins
• edema on lower extremities only

URINARY SYSTEM
• high urinary frequency
• increased urine output

RESPIRATORY SYSTEM
• decreased RR; shortness of breath without DOB
• nasal stuffiness
• sinus congestion
• nose bleeds

GI SYSTEM
• constipation
• bloating
• morning sickness
• gastric reflux/heartburn

REPRODUCTIVE SYSTEM
• breast development
• increase in melanocyte: results to hyperpigmentation/darkening of skin
• melasma
• linea nigra: line from the symphysis pubis to umbilicus

ENDOCRINE
• increased thyroid activity
• increased metabolic needs
• slight enlarged thyroid

Fetal

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Biophysical Profile

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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

Fetal Heart Rate

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Assessing Fetal Well-Being

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• Biophysical Profile

• A L O N E

Amniocentesis
L/S Ratio
Oxytocin test
Non stress testing
Estriol Level

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200106c — 2021-09-22 15:15:23 UTC

MIDTERM

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LESSON 2: PHYSIOLOGIC & PSYCHOLOGICAL CHANGES IN PREGNANCY

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PHYSICAL CHANGES

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Pregnancy Hormones

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1. HCG (Human chorionic gonadoprotin)
- secreted during first trimester
- sustaining the corpus luteum
*corpus lutuem: secretes estrogens & progesterone during first 2 months of pregnancy

2. Estrogen
- comes from the androgens inside the adrenal cortex that comes from the fetus

3. Progesterone
- comes from the mother
- inhibits GnRH, LH, FSH, release, preventing LH surge

PLACENTA: hormone secreting organ

Pregnancy Tests

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1. Laboratory tests - detects HCG

* HcG - found in blood or urine
- important in secreting estrogen and progesteron

2. Home pregnancy tests - 97% accuracy if done properly
* medications such as anti-depressants can give false positive result

Cryptic pregnancy
- unconsciously aware of pregnancy

3F's Positive Signs

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Fetal Outline in UTZ
Fetal heart tone
Fetal movement felt by examiner

*note- Fetal Outline is only a probable sign if it's only felt by examiner

Signs in Pregnancy

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Presumptive Signs

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NOTES
• breast changes is one of the earliest signs of pregnancy apart from amenorrhea
• By the 12th week, the uterus rises above the
symphysis pubis.
• On the 18th week, quickening, a term used to describe fetal movement felt by the mother is present at this time.
• all the signs under presumptive may be signs of other conditions aside from pregnancy and are highly subjective.

MsH promotes lung maturity

Probable Signs

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NOTES:
• Ballottement is done by tapping the lower uterine segment
• Braxton-Hicks contraction are also known as practice contractions (not a true contraction)
- prepares for labor contraction

TRUE CONTRACTION
- cervix opens

Positive Signs

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NOTES:

The fetal heart is audible by the 10th to 12th week using a doppler

The fetal heart is audible by by
the 18-20th week using a ordinary stethoscope

• 120-160 bpm: normal FHT
• fetal back: where FHT is best heard at and determined by performing the Leopold’s maneuver

Importance of hormones during pregnancy

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- to support fetal growth
- maternal health

Local Changes (Reproductive System)

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UTERUS

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• ↑ size (volume, length, width, depth, wall thickness)
•↑ uterine blood flow
• decidua: endometrium of pregnant woman (thick, highly vascularized)
• hegar's sign
• ballottement
• braxton hicks
• amenorrhea

OVARY

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• ovulation stops
• ↑ corpus luteum

OPERCULUM: mucus plug; coating of mucus fills the cervical canal: prevents ascending infection to uterus/vagina

VAGINA

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• chadwick's sign
• vaginal secretion changes (from alakaline (7 pH) to acidic (4-5 pH))

LEUKORRHEA: white vaginal discharge
abnormal: change in color and odor, and excessive amount

BREAST

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• colostrum: earliest breastmilk production; happens at 12th to 18th weeks

MONTGOMERY'S TUBERCLE: small bumps around dark area of nipple
: lubricates and keeps germs from breast

Consistency of Vaginal Discharge

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Nonpregnant - tip of nose
Pregnant - earlobe
Term - soft as butter; "ripening"

Systemic Changes

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INTEGUMENTARY

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• striae
• melasma

RESPIRATORY

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there is an increased amount of oxygen needed, and an increased amount of CO2 to be eliminated

• ↑ increased RR
• ↑ increased tidal volume
• no change vital capacity
• ↓ by 20% residual volum
• ↓ to about 27-32 mmHg plasma CO2
- to allow movement of CO2 from fetus to mom through diffusion
• ↑ plasma pH
• ↑ plasma PO2

FETAL: 40-45 mmHg
MOTHER: 20-30 mmHg

CARDIOVASCULAR

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↑ increased by 30-50% blood volume
----may cause pseudo-anemia (false OR physiologic anemia)

• pseudo-anemia
- compensated by increased RBC
- near levels by 2nd trimester

• anemia
- low hemoglobin
- low RBC to carry oxygen

PSEUDO-ANEMIA: anemia during late 1st trimester to early 2nd trimester

ANEMIA: early 1st and late 2nd-3rd trimester
- (Hgb < 11.5g/100mL)/Hct < 300%

PSYCHOLOGICAL CHANGES

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Attitude towards pregnancy

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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

Social Influences

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- knowledge
- personal experiences
- cultural experiences

pregnancy is viewed as:
before: 9-month long illness
present: a time of health

Influences in Pregnancy

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•Cultural Influences: beliefs and practices
• Family Influences: positive or negative influence
• Individual Influences: coping mechanism, social relationships

Changes in Sexual Desire

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1st trimester: decreased in libido due to nausea, vomiting
2nd trimester: libido and sexual enjoyment rise markedly
3rd trimester: sexual desire may remain high or may decrease due to uncomfortabileness

Common Psychological Effects

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1st trimester: ambivalence
2nd trimester: narcism and introversion; role playing and day dreaming
3rd trimester: clothes preparation and arrangement of sleep; being ready for birth

Tasks during pregnancy

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1st trimester: Accepting the pregnancy
2nd trimester: Accepting the baby
3rd trimester: Preparing for the baby and end of pregnancy

Changes in Sexual Desire

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Emotional responses

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ambivalence
grief
narcissism
introversion
body image and boundary
stress
emotional lability

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

LESSON 3: FETAL GROWTH & DEVELOPMENT

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Period of Fetal Growth and Development

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Pre-embryonic Period (the OVUM)
• begins at first 2 weeks, fertilization
• ends at day 7 post-conception, implantation
• pre-differentiation of organs
• conceptus: ovary through the oviduct → uterine
cavity

Embryonic Period
• 3-8 weeks
• begins with blastogenesis (i.e., formation of germ layers)
• organ differentiation (organogenesis)

Fetal Period
• week 8 through birth
• post-differentiation of organs

Teratogens

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Pre-embryonic Period
teratogen: “all” or “none” law

Embryonic Period
teratogen: most dangerous period

Fetal Period
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

FERTILIZATION AND IMPLANTATION

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Embryonic and Fetal Structures

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Embryonic and Fetal Structures

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Chorionic villi
- early as 11-12 weeks
- functional layer of placenta
- resembles finger probing

Layer of Trophoblast Cells

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syncytiotrophoblast, or the syncytial layer
- outer of the two covering layers
- produces various placental hormones

cytotrophoblast or Langhans’ layer
- middle layer
- present 12 days’ gestation; disappears between the 20th and 24th weeks
-function early in pregnancy to protect the growing embryo and fetus from certain infectious organisms such as the spirochete of syphilis

Placenta - "Pancake"

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smaller placenta: circulation to the fetus may have been inadequate.
larger placenta: circulation to the fetus was threatened

fetus from diabetic mother: may develop a larger-than-usual placenta from excess fluid collected between cells

Mechanisms by Which Nutrients Cross the Placenta

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Functions of the Placenta

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• 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

Endocrine Function (The Placenta)

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^{Human Chorionic Gonadotropin}^{- first placental hormone produced
- a fail-safe measure to ensure that the corpus luteum of the ovary continues to produce progesterone and estrogen
- suppresses the maternal immunologic response}^Estrogen^{- “hormone of women”
- contributes to the woman’s mammary gland development in preparation for lactation and stimulates uterine growth to accommodate the developing fetus}^Progesterone^{- “hormone of mothers”
- necessary to maintain the endometrial lining of the uterus during pregnancy
- appears to reduce the contractility of the uterus during pregnancy, preventing premature labor}^{Human Placental Lactogen (Human Chorionic Somatomammotropin)}^{- a hormone with both growth-promoting and lactogenic (milk-producing) properties
- promotes mammary gland ((breast) growth in preparation for lactation in the mother
- 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}

Embryonic Membranes

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Chorion
- Outer most membrane
- Fingerlike projections, “villi”

Amnion
- Thin protective membrane
- Contains amniotic fluid

Amniotic Fluid

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Functions/Purpose
^{- Protection
- Temperature regulation
- Protects the umbilical cord from pressure
- protecting the fetal oxygen supply
- aids in muscular development
- gives freedom of movement}

The Umbilical Cord

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Function
^{- to transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta}

A. THE GROWING FETUS

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B. ORIGIN AND DEVELOPMENT OF ORGAN SYSTEMS

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Stem Cells

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Totipotent Stem Cells
- first 4 days of life; zygote
- undifferentiated cells

Pluripotent Stem Cells
- another 4 days; embryo
- cell differentiation → loses ability to become any body cell. iNstead, they become specifc body cells (i.e. nerve, brain, skin cells, etc)

Multipotent Stem Cells
- another few days
- more specific cells; set a sure course towards boy organ they'll create

Types of Cloning

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Reproductive Cloning
- adult's nucleus is transferred into an oocyte

Therapeutic Cloning
- pluripotent cells are removed and grown in lab/incubator

Zygote Growth

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- pattern: cephalocaudal (head to tail)
- body organ systems develop from specific tissue layers calls germ layers

Primary Germ Layers

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Ectoderm
- amniotic cavity

Entoderm
- yolk sac
- supplies nourishment only until implantation; after, it only provides RBC until hematopoietic system matures

Mesoderm
- between ectoderm and entoderm

^{Embryonic shield
- when 3 layers meet
- time when embryo will begin to develop}

NOTE:
each germ layers develop into specific body system.

Cardiovascular System

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- one of the first systems to develop

^{Day 16:}^{network of blood vessels and single heart tube}^{Day 24:}^{beats of blood vessels and single heart tube}^{Week 6-7:}^septum^{Week 7:}^{heart valves}^{Week 10-12:}^{heartbeat heard with doppler instrument}^{Week 11:}^{ECG recorded; however, not too accurate}^{Week 20:}^{ECG becomes more accurate}^{Week 28}^{: fetal heartbeat; atleast 5 bpm}

Cardiovascular System (CONT.)

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Fetal Circulation
- nutrients are exchanged in placenta
Week 3: exchanging nutrients across the chorionic villi
umbilical vein → ductus venosus → inferior vena cava → foramen ovale

Fetal Hemoglobin

Fetal: 2 alpha and 2 gamma chains

- more concentrated; greater oxygen affinity
- ↑ hemoglobin level: 17.1 g/100 mL
- ↑ hematocrit level: 53%

Adult: 2 alpha, and 2 beta chains

Respiratory System

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Day 3: respiratory and digestive tract exist as one

NOTE: Until week 7, lungs and abdomen does not fully divide. Hence, lungs buds down to abdomen.

Diaphragmatic hernia: happens when diaphragm fails to close completely

At the end of week 4:
- septum divides esophagus from trachea
- lung buds appear on trachea

3 months of gestation: spontaneuous respiratory practice movement
Week 24-28: alveoli and capillaries
Week 24: surfactant

Respiratory System (CONT.)

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Surfactant
- formed and secreted by alveolar cells; decreases surface tension upon expiration

2 component of surfactant:
lecithin (L)
sphingomyelin (S)

ratio: 2:1

sphingomyelin (S): chief component during early surfactant formation
lecithin (L): chief component about 35 weeks

Nervous System

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- develops early; begins at 3-4 weeks

3 weeks gestation: neural plate present; differentiated into:
i. neural tube - CNS
iii. neural crest - peripheral nervous system

24 weeks: hearing capability, responsive to sound; pupillary reaction, sight is present
8 weeks: brain waves detected on EEG

Meningocele:
birth defect where there is a sac protruding from the spinal column; lack of folic acid

Endocrine System

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- function begins as soon as endocrine organs mature

precursor: produced by adrenal glands; for estrogen synthesis
estrogen: produced by pancreas
thyroid and parathyroid glands: for metabollic function and calcium balance

Digestive System

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4 weeks: separates from respiratory system; begins to grow rapidly
6 weeks; intestine becomes too large. hence, a portion is pushed into the base of umbilicus until abdominal cavity grows large enough

volvulus of umbilicus: happens when there is inadequate mesentery attachment because intestine fails to rotate 180 degrees
omphalocele: congenital anomaly; intestine remains outside of abdomen
gastroschisis: same condition with omphalocele; incomplete midline fusion

Week 16: accumulation of meconium
Week 36: ability of GI tract to secrete enzymes of carbohydrate and protein digestion

Hypoglecemia & Hypobiliburinemia
- 2 conditions that may appear 24 hours after birth; due to immature liver at birth

Reproductive System

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Sex
- determined at 8 weeks by chromosomal analysis
- spermatozoon (X or Y chromosome)

Week 6: gonads (ovaries or testes) are formed

TESTES produces testosterone
→ intersex or pseudo-hermaphroditism: deficient testosterone production from testes; both mullenium (female) duct and wolffian (male) duct develops

Testes
- first formed in abdominal cavity; does not descend into scrotal sac until 34-38 weeks
- preemies: born with undescended testes
- undescended testes: associated with poor sperm production and testicular cancer

Urinary System

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- kidneys aren't essential before birth since placenta clears waste from fetus

Week 12: urine is formed
Week 16: urine is excreted into amniotic fluid

- kidney function is still not mature at birth; it gradually develops
- patent urachus: discovered at birth by the persistent drainage of a clear, acid pH fluid (urine) from umbilicus; happens when open lumen between urinary bladder and umbilicus fails to close

Integumentary System

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Fetal skin: thin, almost translucent until 36 weeks

36 weeks: subcutaneous fat begins to deposit

Skin is covered by:
i. soft downy hairs (lanugo): serves as insulation to preserve warmth in utero
ii. vernix caseosa: cream-cheese like substance; for lubrication and for keeping the skin from macerating

Immune System

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Week 20-24: IgG (maternal bodies) cross from placenta into fetus to give temporary passive immunity against diseases
- infants born before this period have no natural immunity

Term birth: IgG in babies is at peak (passive)
Over the next 8 months: IgG starts to decrease

2 months after birth: passive IgG starts to decline; typically, immunization begins at this time
12 months after birth: measles vaccine

passive antibodies last for more than 1 year

Trimesters in Pregnancy

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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

MILESTONES OF FETAL GROWTH AND DEVELOPMENT

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Key Factors

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Factors Influencing Fetal Development

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• Quality of ovum or sperm
• Adequacy of uterine environment
• Teratogens “agent/substance which cause
malformation”; 1-8wks most vulnerable to induced
malformations
• Maternal environment
Nutrition, Hyperthermia

Naegele's rule

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- a standard way of calculating the due date for a pregnancy.
- The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman's last menstrual period (LMP).
- The result is approximately 280 days (40
weeks) from the LMP

Parikh's Formula

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- a calculation method that considers cycle duration
- EDD is calculated using Parikh's Formula by adding 9 months to LMP, subtracting 21 days, then adding duration of previous cycles
- In modern practice, calculators, reference cards, or sliding wheel calculators are used to add 280 days to LMP

LABOR AND BIRTH

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Stages of Labor and Birth

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Stage 1: 12-19H
: beginning of 2 contractions until complete dilatation of cervix

Stage 2: 20m-2H
: full cervical dilatation until delivery of baby

Stage 3
: birth of baby until delivery of placenta

Stage 4
: recovery stage

Stage 1

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- baby descends to cervix
- contraction: 9-18 mins → back pain
- water breaks
- transfer pt to delivery room
- (+) preliminary signs of labor: bloody show, rupture of membrane

Stage 2

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- 10cm dilation
- cervical opening to birth canal
- "crowning fetal head"
- encourage mom to push in conjunction with contractions
- active upper part: pushes
- active lower part: allows passage
- navigates its way through birth canal (cardinal movements of labor)

7 cardinal movements, namely engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.

MOULDING (head): bones of skull overlap over the sutures in order to decrease the diameter of the skull; resolves its own

CROWNING: when largest circumference of head is shwoing on the vaginal opening

Episiotomy

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- incision made in the perineum during childirth
Mediolateral (diagonal): less painiful; moe preferred
Medial (straight): may go straight to the anus

Stage 3

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- mild contractions
- mother-baby relationship → SSC & breastfeeding
- delivery of placenta: 13 mins after

Stage 4

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- recovery stage

4 Components of Labor

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ideal and favorable characteristic in order to facilitate an effective labor

4P's
Passenger
Passageway/Passage
Power
Psyche/Psychological state

4 Components of Labor

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Passenger
: baby should assume good position and size (flexion and attitude)
: moulding; presenting part is decreased to fit pelvis

Passageway/Passage
: pelvis/ring
: pelvic ring (shape and size) should be adequate

Power
: coordinated uterine contractions
: enough to push baby and for uterine changes

Psyche
: the more the mother is prepares, the easier the process

Onset of Labor

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Theory
a result of changes in the ff. hormones → contractions
i. decrease in progesterone: in contrary, ↑ progesterone inhibits contraction
ii. release of oxytocin
iii. production of prostaglandins

Theory
placenta aging
if placenta ages, body responds to removing it by resulting to contractions

Preliminary Signs of Labor

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- subtle signs; prompt woman to consult
- indicates imminent labor
- educate pt to detect signs

Lightening
Nesting or increased in level of activity
Braxton-Hicks Contractions
Ripening of Cervix

Lightening

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- early signs of labor; 10-14 days
- primigravida: 2 weeks before labor (earlier)
- multigravida: right before labor
- gives relief from diaphragmatic pressure and DOB
- cause shooting leg pains, ↑ vaginal discharge
- > pressure on upper part of body, < pressure on lower

Nesting (increased in level activity)

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- before actual labor or before term week for some
- desire of woman to be in full energy
- surge of epinephrine or adrenaline
- epinephrine release → prepares body for labor ahead

Braxton-hicks contractions

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- begins and remain irregular
- felt first abdominally and remain confined to abdomen and groin
- do not achieve dilation

Ripening of cervix

200106c — 2021-11-10 22:57:16 UTC

- butter soft cervix to allow dilations and childbirth
- internal announcement that labor is near

Signs of True Labor

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more imminent than the preliminary signs

Uterine contraction
Bloody show
Rupture of membrane

Uterine contraction

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True contraction: achieves dilation

^{- becomes irregular but becomes regular and predictable
- felt first in lower back and sweep around to abdomen in wave
- continues no matter what the woman's level of activity
- ↑ duration, frequency, intensity}

DURATION: from start of contraction to end of the same contraction; 60-90s; ↑ as labor progresses

FREQUENCY: end of contraction to beginning of next (interval; how often); interval shortens, contractions more frequent; 3-5m

INTENSITY: strength or power of contractions

Bloody show

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- mucus plug that filled the cervical canal is expelled
- exposed capillaries seep blood and mixed with mucus resulting to pink-tinged color

Rupture of membranes

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- sudden gash or as scanty, slow seeping of clear fluid from vagina
- advantageous if it causes the fetal head to settle shugly into pelvis → short labor
- immediately bring to HCPs; ↑ risk for infection and lack of support for baby and the umbilical cord to grape since amniotic fulid should be adequate

Duration of Labor

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Primi: 14h-20h
Multi: 8h-14h

Effacement: thinning of cervix; 100% effaced
Dilation: opening of cervix; 10cm

True Pelvis

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- below pelvic groin
- where fetus will pass

2 parts
i. pelvic inlet: T>AP
ii. pelvic outlet: AP>T

Obstetric/True Conjugate

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- smallest diameter of pelvic inlet (AP diameter)
- 11 cm
- <11 cm: pelvic opening not adequate

Bi-ischial diameter

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- measurement between the ischial tuberosity
- smallest diameter of pelvic outlet (transverse diameter)
- 10cm

Diagonal conjugate

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- measurement from pubic bone to symphysis pubis or sacral promontory
- 13 cm
- diagonal conjugate (-) 1.5-2cm = 11-11.5cm