OB Nursing: Fetal conception/development; Pregnancy Topics covered include: Changes during pregnancy, nutrition/weight gain, antenatal testing, prenatal care, bleeding during pregnancy

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Maternal Morbidity and Mortality: o US ranks 49th in list of rates of industrialized nations o US ranks 30/31 for infant mortality o Causes of maternal morbidity and mortality:  HTN  Emboli  Infx  Hemorrage o Neonatal/fetal morbidity and mortality:  Low birth weight  Congenital anomalies  Consequences of maternal disease  Prematurity Selected Anatomy and Physiology Review: o Caldwell-Molloy pelvic types:

Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97

OB Nursing: Fetal conception/development; Pregnancy 

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Gynecoid is ideal, others may present difficulties o Android: narrower midpelvis complicates travel o Antrhopoid: narrower inlet o Platypelloid: wider outlet Ischial spines: toughest part of birth passage Pubic crest can (and does) break Hormones: o Estrogens:  Estradiol: available only during reproductive years  Estriol: available only during pregnancy  Estrone: Estrogen of menopause o Progesterone: THE PREGNANCY HORMONE o Prostaglandins  PGe: vasodilation, smooth muscle relaxant  PGf: vasoconstriction, smooth muscle contraction The Female Reproductive Cycle o Highlights:  Cycle is comprised of (3) Main Phases: Follicular phase, Ovulation, and Luteal Phase  Because luteal phase is more regular (approx. 14 days), if we know length of cycle and it’s regularity we can predict ovulation.  By default this makes the follicular phase the more variable part of the cycle  During the follicular phase, estrogen is the predominant hormone and a surge of Luteinizing Hormone (LH) causes release of the ovum (egg) from the follicle. Following this, the follicle forms into the Corpus Luteum (CL) to support pregnancy. Progesterone becomes dominant hormone.  During this time, the uterine tissue is building up and preparing for implantation of the fertilized embryo (known as the secretory phase).  If there is no sustained pregnancy, the lining is shed through the menstrual phase, occurring at the end of the cycle (Important to know LAST KNOWN MENSTURAL PERIOD (the first day of bleeding) Can be used in determining cycle length, potential pregnancy)

Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97

OB Nursing: Fetal conception/development; Pregnancy 

Development of Pregnancy o Terminology:  Gestational age: Includes length of pregnancy + 2 Additional Weeks (1 Week for LMP, and preceding week)*ASSUMES A REGULAR 28 DAY CYCLE*  Pregnancy typically lasts 280 gestational days: o 40 weeks o 10 lunar months o 9ish calendar months  Fertilization: union of ovum and sperm in the ampulla of the fallopian tube  Cellular Multiplication:  Zygote (4 cell mass) differentiates into Morula (Day 3)  Morula further differentiates into Blastocyst and Trophoblast (by Day 5) o Blastocyst: inner cell mass which will become embryo, amnion, & yolk sac o Trophoblast: outer layer which becomes chorion and placenta

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Trophoblast IMPLANTS into endometrium between days 6-10 o Formation of Chorionic villi serves 2 functions:  Maintains estrogen/progesterone  Inhibits ovarian and menstrual cycles

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Differentiation of germ layers: ectoderm, endoderm, mesoderm o Ectoderm: Epidermis, hair, teeth, facial features, CNS o Endoderm: Dermis, muscles, bones, kidneys, ears, lymph, CV, spleen o Mesoderm: organs Embryonic membranes: chorion, amnion Amniotic fluid Yolk sacprimitive RBCs Umbilical cord

Cellular Differentiation:

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Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97

OB Nursing: Fetal conception/development; Pregnancy  

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First two weeks following conception= embryo is most likely to be damaged, most succepitble to teratogens Fetal developmental milestones: o 28 Days p conception: Heart beat o 4-6 weeks: Male differentiation BEGINS (not necessarily determinable) o 8-10 wks: all organs formed o 16 wks: Fetal respiration o 23 wks: Youngest preterm survivor Review of fetal circulation:

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Teratogens:  ETOH: no safe allowable level established  Caffeine: hard to determine effects, restrict until 2nd/3rd trimester and then limit intake  Drug classifications:  Category A: OK  B: No risk in anaimals  C: questionable risk

Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97

OB Nursing: Fetal conception/development; Pregnancy  

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D: Evidence of risk X: definite risk (i.e. ASPIRIN! BECAUSE IT CLOSES FETAL CIRCULATORY DUCTS)

Maternal changes during pregnancy o Familial changes:  Role crisis, perceived body image, financial concerns  Hensley’s rule: 1) Include the partner 2) Don’t assume gender of partner o Psychosocial adaptations:  1st Trimester: Surprise, ambivalence, focus on discomforts  2nd: Accept growing fetus, introversion  3rd: Preparation for birth, focus on physical discomforts, preparation of maternal role o Partner couvade: Unintentional taking on of symptoms by partner o Physical changes:  Signs of pregnancy (with differentials):  Presumptive: o Nausea (upset stomach, flu, food poisoning) o Fatigue (sleep deprivation) o Breast tenderness (fluctuates with cycle) o Vomiting (food poisoning, migraines) o Weight gain (sedentary lifestyle, diet) o Urinary frequency (UTI, cystitis) o Quickening (fluttering sensation: gas, ovulation)  Can be expected at 18-20 weeks o Ammenorrhea (low body weight, irregular cycle, contraceptive use) o Abdominal striae (weight/muscle gain)  Skin alterations attributed to estrogen  Probable: o Uterine souffle (uterine myomas)  soft bowing sound in sound with maternal pulse due to increased vascularization o Chadwick’s sign (intense intercourse)  “blue” vagina d/t incr vascularization o Ballotment (ghost pregnancy, ascities, polyps/fibroids)  Passive fetal movements elicited by palpating cervix o Goodell’s sign (hormonal contraception, intense intercourse)

Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97

OB Nursing: Fetal conception/development; Pregnancy

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 Softening of cervix Progressive enlargement of abdomen (obesity, ascities, pelvic tumors) Palpation of fetal outline (uterine myoma) Braxton-Hick’s contractions (soft myomas) Darkened areola (sun, hormonal contraception) Positive pregnancy test (false positive, inpropper use/interpretation, proteinuria) Linea negra (hormonal stimulation)

o  Positive o Fetal heartbeat per Doppler o Fetal heartbeat per fetoscope o Fetal movement per trained provider o Visualization of fetus on US Enlarging uterus has effects on:  Lungs, diaphragm: displacementdecr tidal volumeshortness of breath  Intestines: again displacement alters function  Bladder  Spine curvature o By 20 weeks, women experience an exaggerated lordosis, can be corrected by alternating legs on a stool o Altered center of gravity: PROBLEMATIC b/c more prone to falls  Round uterine ligaments o Late into pregnancy, sudden movement can pull on ligmanets causing “stabbing pain” Need to warn and teach to splint to decr pain HEENT  Bleeding gums, nose bleeds, sensitivity to tastes/smells Skin/Hair  Linea nigra, striae , acne vulagris, darkening areola, increased hair, palmar erythema  Melasma (Cholasma): appearance of gray/brown patches on face  Spider angiomas  Warn patients about cocoa butter and caffeine Breasts  Glandular hypertrophy, tenderness, nipple sensitivity, vein prominence, colostrum Resp  Respiratory alkalosis (breathing off CO2 through rapid exhalation)  Incr respiratory rate  20% increased oxygen consumption GI:  Decr GI motility and emptying

Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97

OB Nursing: Fetal conception/development; Pregnancy     

N/V Incr risk for gallstones Heartburn: progesterone “softens” cardiac sphincter Hemmoroids Elevated, benign alkaline phosphate

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Incr renal blood flow Renal stasis in pelvicies (risk for UTI) Incr GFR: So increased, it may cause filtrate to slip through showing benign proteinuria or glycosuria

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Increase in stroke volume, heart rate, cardiac output, and blood volume (HUGE) o Incr in HR by 10-15 beats  Decrease in blood pressure (systemic vasodilation)  Systolic murmur d/t fluid overload  Incr in clotting factors  Hematologic  Physiologic anemia of pregnancy: dilutional anemia due to incr blood volume o Monitor, treat at 11  Vena Cava Syndrome  Implications for prenatal/labor  Decr venous return when laying supine Complaints of discomforts in pregnancy are ALWAYS treated as serious until proven benign o ALWAYS serious until proven benign o Infections:  S/sx: itching, increase in purulent (white) d/c, smell or not, dysuria  Problematic: Incr risk for preterm labor o PROM (Premature Rupture of membranes)  Miconium (greenish tinged fluid): aspiration risk for fetus, potential sign of fetal stress  Mucus plug (clear, snot-like) o Pre-eclampsia (Wil be discussed later)  S/sx: sudden onset of swelling, HA, “floaters” o Hyper-emesis gravidum  Unknown cause (potentially hCG)  Concern if last PO was over 12 hours o Pre-term labor  Sometimes sneaky “back labor”

Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97

OB Nursing: Fetal conception/development; Pregnancy 

At-risk pregnancies o Hypertensive disorders of pregnancy  Chronic Hypertension  Pre-pregnancy BP > 140/90 OR  BP is > 140/90 before 20 weeks gestation without proteinuria  TX: >160/105 with labetalol, nifedipine, methyldopa o Goal is 120-160/80-105 o More frequent Prenatal visits o IOL recommended at 38 weeks  Need to be concerned with aggressive treatment, if decrease supply to placenta can late decelerations  Preeclampsia  HTN that occurs AFTER 20 WEEKS accompanied by: o Proteinuria OR  >300 mg/dL on 24 hr urine, urine dipstick of at least 1+ o New onset of 1 severe feature  Severe HTN (SBP >190, DBP >110)  Thrombocytopenia (plt cnt 30 mL/hr  Serum level: 4-7 mEq/mL  Effects on contraction, immediate postpartum, CLE administration  Complications: o Eclampsia: seizure in woman with preeclampsia which can’t be attributed to another cause  Superimposed preeclampsia  Onset of severe feature or proteinuria in pt with chronic htn  Gestational Hypertension TORCH Viral Infections:  Toxoplasmosis  Blindness, deafeness, retardation in fetus  Other: varicella, parovirus (“fifth’s disease), syphilis, listeria, coxsackie  Varicella: maternal death d/t pneumonia, limb hypoplasia, contractures, CNS involvement  Fifth’s: fetal death, fetal hydrops  L&C: miscarriage, fetal death, encephalitis  Rubella  Cataracts, sensorineural deafness, congenital heart defects, mental retardation, cerebral palsy  CMV  Fetal death, SGA, micro/hydrocephaly, cerebral palsy, mental retardation  HSV

Other infections:  STI’s  Chlamydia: ophthalmic neonatorum, PNA  Tuberculosis:  Active TB: no direct contact with newborn until non-nfectious  Inactive: May breastfeed, treatment delayed until post-partum

Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97

OB Nursing: Fetal conception/development; Pregnancy

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 GBS discussed in L&D Diabetes:  In early pregnancy, placenta stimulates insulin production  In later pregnancy, pregnancy hormones lead to insulin resistance allowing for greater access to fetus  Different diagnoses:  TIDM  TIIDM  A1GDM (Diet controlled gestational diabetes)  A2GDM (Medication required gestational diabetes)  Screening:  Pre-exisiting are not screened  Low risk: screened with 1 hr gtt  High risk: early 1 hr gtt before universal screen at 24-28 weeks  Normal value is