NUR 321: Women's Health Exam 1 (Ch 2, 4, 6, 7, 12, 14, B ADU notes, PPTs, Book study guide Qs)

List four signs that suggest that the placenta has separated

(When the infant is born, the uterine cavity becomes much smaller. The reduced size decreases the size of the placenta site, causing it to separate from the uterine wall) 1. The uterus has a spherical shape 2. The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward 3. The cord descends further from the vagina 4. A gush of blood appears as blood trapped behind the placenta is released

Explain how each of the following fetal factors influences the FHR

*Autonomic Nervous System:* Sympathetic stimulation increases the HR and strengthens the heart contractions to increase cardiac output by releasing epinephrine and norepinephrine *Baroreceptors:* sense BP increases in the carotid arch and major arteries to slow the heart and reduce the blood pressure, thus reducing cardiac output. *Chemoreceptors:* chemoreceptors in the medulla oblongata, aortic arch, and carotid bodies sense changes in oxygen, carbon dioxide, and pH to increase the HR if hypoxia, hypercapnia, and acidosis, respectively, are not prolonged. *Adrenal glands:*secrete epinephrine and norepinephrine in response to stress and release aldosterone to cause retention of sodium and water, thus increasing the blood volume *Central Nervous System:* the fetal cerebral cortex causes the FHR to increase during fetal movement and decrease during fetal sleep; the hypothalamus coordinates the branches of the autonomic nervous system. The medulla oblongata maintains balance between forces that speed and slow the FHR

4 components to understanding a fetal monitoring strip

*B*aseline *A*ccelerations *D*ecelerations *U*terine Contractions -advanced nursing skill to become experts at fetal monitoring. Nursing students are responsible for understanding the various fluctuations in the FHR and nursing interventions associated with them. -5 things we look at are baseline, variability, accelerations, decelerations, and uterine contractions *Baseline HR:* -has to do with the average FHR usually over a 2 min period *Variability:* -The amplitude between beats. Is there a big difference b/w the height of the HR in a given time on the monitor *Accelerations:* -are a good thing, they are a sign of fetal oxygenation *Decelerations:* -are not good

Changes in Urinary System

*Bladder:* -Urinary frequency seen early in pregnancy and later in pregnancy due to compression of bladder from the growing fetus. *Kidneys and ureters:* -Size and shape of kidneys -Functional changes in kidneys: changes in kidneys due to increased demand

Maternal Cardiovascular System (During labor)

*Blood flow to the placenta:* -decreases during a contraction -The muscle fibers of the uterus constrict around the maternal spiral arteries, which supply the placenta; at no point is there mixing of the maternal and fetal blood -There is a relative increase in the woman's blood volume (as she contracts) -This temporary change increases her blood pressure slightly and slows her pulse rate -Vital signs are best assessed during the interval between contractions (also she is in pain during contractions which could influence her vitals) -Supine hypotension may occur during labor if the woman lies on her back completely (b/c the uterus can occlude the superior vena cava and put pressure on the major vessels there); The woman should be encouraged to rest in positions other than supine to promote blood return to her heart. She can feel a little lightheaded and dizzy if she is flat on her back

Female Reproductive Supportive Structures

*Bony Pelvis:* -Bony pelvis comes into play during labor and delivery Other Female Reproductive Support Structures:* -Lateral Support -Anterior Support -Posterior Support -Blood Supply -Nerve Supply

Describe common premonitory signs of labor. Note any dfferences between nullipara and a parous woman

*Braxton hick's contractions:* -irregular, mild contractions intensify near term; more noticeable to parous women *Lightening:* -descent of fetus toward pelvic inlet increases pressure on bladder but allows easier breathing; more noticeable in mulliparas *Increased vaginal secretions:* -with congestion of vaginal mucosa caused by fetal pressure *Bloody show:* -mixture of cervical mucus and blood as the mucus plug is released; seen earlier and in greater quantity in nulliparas. *Energy spurt:* -nesting *Weight loss:* -2.2-6.6 kg (1-3 lbs)occurs b/c altered estrogen and progesterone ratio causes excretion of some of the extra fluid that accumulates during pregnancy

Changes in Musculoskeletal System

*Calcium Storage:* -Affected during pregnancy as fetal demands for calcium increase -Moms need to increase their calcium intake and storage in order to help the fetus develop strong healthy bones *Postural changes:* -Can occur in preg women as her center of gravity shifts with the growing fetus -Changes are progressive *Abdominal Wall:* -Abdominal wall tissue can be compromised causes diastasis recti -Diastasis recti: separation of the abdominal wall. It is uncomfortable and makes pregnant women feel like their abdomen is not supporting their gestated uterus

Normal labor: Labor Mechanisms

*Cardinal Movements of Labor:* -Descent: fetal head descends; movement of fetus through birth canal; Descent is measured using stations (0 station is measured using the ischial spine) -Engagement: engages into the pelvis; fetal presenting part reaches 0 station (true pelvis) -Flexion: flexes by bringing its chin closer to its chest -Internal Rotation: turn to face mom's back when coming into side position (through the pelvis) -Extension: Extend their head underneath the pubic symphysis -External Rotation: during delivery -Expulsion: have a complete expulsion

Advanced Preparation for Maternal-Newborn Nurses

*Certified Nurse-Midwives (CNMs):* -RNs who have completed program of study and clinical experience -Provide complete care during pregnancy, childbirth, and the postpartum period -Counsel and support the childbearing family -Provide annual well-woman exams -Approach to childbirth is noninterventional and supportive *Nurse Practitioners:* -RNs with advanced preparation -Women's health nurse practitioners (WHNPs) provide wellness-focused, primary, reproductive, and gynecologic care of the life span, starting at adolescence -Family nurse practitioner (FNPs) provide preventive, holistic care for young and old family members -Neonatal nurse practitioners (NNPs) assist in the care of high-risk newborns in the immediate post-birth care or in a NICU -Pediatric Nurse Practitioners (PNPs) provide health maintenance care for infants and children not requiring the services of physicians

Describe and give the cause of each of the following changes in the cervix during pregnancy

*Chadwick's sign:* Increasing levels of estrogen cause hyperemia (congestion with blood) of the cervix, resulting in the characteristic bluish/purple color that extends to include the vagina and labia; one of the earliest signs of pregnancy! *Goodell's sign:* cervix is largely composed of connective tissue. Before pregnancy the cervix has a consistency similar to that of the tip of the nose. After conception the cervix feels more like the lips or earlobe. *Mucus Plug:* A less obvious change occurs as the cervical glands proliferate during pregnancy and the glandular walls become thin and widely separated. As a result the endocervical tissue resembles a honey comb that fills w/ mucus secreted by the cervical glands. The mucus which is rich in immunoglobulin, forms a plug in the cervical canal. It blocks the ascent of bacteria from the vagina into the uterus during pregnancy to help protect the fetus and uterine membranes from infection *Bloody Show:* The mucus plug remains in place until term when the cervix begins to thin and dilate allowing the mucus plug to be expelled. One of the earliest signs of labor may be "bloody show" which consists of the mucus plug and a small amount of blood. Bleeding is produced by disruption of the cervical capillaries as the mucus plug is dislodged when the cervix begins to thin and dilate

Other Nursing Roles

*Collaborator:* -Collaborates with other members of the health care team -Coordinates and manages a woman's or infant's care -Interdisciplinary approach *Researcher:* -Contributes to profession's knowledge base *Advocate:* -Speaks on behalf of another person *Manager and Teacher

Explain why each characteristic of uterine contractions is important during birth

*Coordinated:* -Important b/c they begin in the fundus and spread downward to the cervix to propel the fetus through the pelvis -Contractions must be stronger in the upper uterus than in the lower uterus to propel the fetus toward the outside *Involuntary:* -Women cannot consciously cause labor to start or stop; otherwise many infants would be born too early b/c the woman became tired of being pregnant or labor might be suspended when it became intense *Intermittent:* -Labor contractions are intermittent b/c it allows relaxation of the uterus and resumption of blood flow to and from the placenta (Intervals b/w contractions allows resumption of blood flow to the placenta to supply oxygen to the fetus and to remove waste)

At what point in gestation is it possible to hear fetal heart sounds with the following tools?

*Doppler:*detects heart motion and makes an audible sound by 9-12 weeks of gestation *Fetoscope:* by 18-20 weeks of gestation

What is the difference in the time when the immature female and male gametes are formed?

*Female gametes (ova):* -At birth the ovaries contain all the ova it will ever have (only occurs during prenatal life) *Male gametes (sperm):* -Sperm production begins at puberty and continues

Components of the Birth Process: Variations in the passenger

*Fetal Lie:* -Orientation of the long axis of the fetus to the long axis of the woman -relationship of fetal spine to maternal spine -In more than 99% of pregnancies, the lie is longitudinal and parallel to the long axis of the woman (so baby is in the vertex/head down presentation) -longitudinal or vertical is when fetus is parallel to mother's spine; transverse or horizontal if fetus is at right angle to mother's spine; oblique: the long axis of the fetus is at some other angle b/w longitudinal and transverse *Attitude:* -Relationship of fetal body parts to one another; normal fetal posture is completely flexed -Flexion or extension -Flexion: normal fetal attitude w/ the head flexed toward the chest and arms and legs flexed over the thorax; back is curved in C shape -Extension: abnormal fetal attitude, head extended and arms can be extended, not the typical C shape of the back -Occipital bones (back of baby's head) as landmarks. When we are assessing fetal position if we are feeling the occipital bones first (photo A) that baby's flexion (chin coming down to their chest) is the ideal position for birth (baby would face the floor initially when delivered) In photo B shows the extension of the fetal head, which would make labor and delivery more challenging. Using the occipital bones as a landmark it would be in a posterior presentation, more challenging for the baby to come through the passageway *Presentation:* fetal part that first enters the pelvis -Cephalic: vertex (head flexed and down), military (presenting chin a little more), brow (presenting forehead first), face (face first coming through the pelvis) -Breech: Frank breech (baby bottom first, legs are extended up across the abdomen toward shoulders), full breech (the head, knees, hips are flexed the way they would be in cephalic presentation except butt is presenting), footling breech: (bottom with one or both feet presenting into the pelvis) -Shoulder: No fetal head, it is more the shoulder presenting (not a position that's good for birth, C-section) *Position:* -Location of fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis -relationship of fetal reference point to one or four quadrants or sides of mother's pelvis -*Maternal Pelvis side:* Right or Left (is fetus tilted to the right, to the left?) -*Fetal Reference Points:* Occiput (O), Mentum (M), Sacrum (S) -*Maternal Pelvis Quadrant:* Anterior (A): closer to the top part of the pelvis itself, Posterior (P): closer to mom's sacrum, Transverse (T) *Station:* -Degree of engagement from presenting part to ischial spine. -Station 0 means at ischial spine -minus station (-1, -2, -3 etc) means above the ischial spines -plus station (+1, +2, +3 etc) means below the ischial spines

Explain how each of the following mechanisms allows the fetus to thrive in the relatively low-oxygen environment of the uterus

*Fetal hemoglobin and hematocrit levels:* -The fetal hemoglobin can carry 20-50% more oxygen than adult hemoglobin. The fetus has a higher oxygen carrying capacity b/c of a higher average hemoglobin level (14.5-22.5 g/dl) and hematocrit value (aaprox 48-69%) *Relative fetal and maternal blood carbon dioxide levels:* -Hemoglobin can carry more oxygen at low carbon dioxide partial pressure (PaCO2) levels than it can at high levels (Bohr Effect). Blood entering the placenta from the fetus has a high PaCO2, but CO2 diffuses quickly to the mother's blood, where the PaCO2 is lower, reversing the levels of CO2 in the maternal and fetal blood. Therefore, the fetal blood becomes more alkaline and the maternal blood becomes more acidic. This allows the maternal blood to release oxygen and the fetal blood to combine w/ oxygen readily (Fetal carbon dioxide quickly diffuses into the mother's blood, causing her blood to become more acidic and fetal blood to become more alkaline; this allows fetal blood to combine with oxygen more readily)

First Stage of Labor

*First Stage of Labor:* Onset of regular contractions to full dilation; 3 phases 1. Latent Phase: dilation is 0-3 cm; -duration is 10-30 seconds -interval is 5-30 mins -Intensity is mild to moderate -contractions come and go (labor might not be well established); a lot of variability 2. Active Phase: Dilation is 4-7 cm -duration is 30-40 sec -interval is 3-5 minutes -intensity is moderate to strong -labor becomes more established so mom can continue to dilate and efface the cervix; contractions become more rhythmic 3. Transition: dilation is 8-10 cm -duration is 45-90 seconds -Interval is 2-3 minutes -Intensity is strong -This is the phase seen in movies where women are screaming -she may vomit, and defecate, tremendous amount of pressure as baby moves down -typically shortest and most challenging part of labor *Nursing Care for 1st stage of labor:* -monitor VS and FHR every 15 minutes -Bed rest for ruptured membrane -Empty the bladder -Pain relief -Teach breathing techniques -Maintain safety

Describe events in each phase of the ovarian cycle

*Follicular phase:* -Period during which the ovum matures. Begins with the first day of menstruation and ends about 14 days later in a 28 day cycle. (The length of this phase varies more among women than the other phases). -Estrogen and progesterone secretion in ovaries decreases just before menstruation which stimulates secretion of FSH and LH by the anterior pituitary -As the FSH and LH levels rise slightly, 6-12 graafin follicles, each containing an immature ovum, begin to grow. Eventually one follicle outgrows the others to reach maturity. The mature follicle secretes large amounts of estrogen which depresses FSH secretion which blocks further maturation of other follicles. (Occassionally more than 1 follicle matures and releases ovum, resulting in multifetal pregnancies) -*Short version: estrogen and progesterone levels fall just before menstruation, causing increasing secretion of FSH and LH by the anterior pituitary; follicles mature with increasing estrogen secretion until one follicle outgrows all the others* *Ovulatory phase:* -Near the middle of the 28 day cycle 2 days before ovulation, LH secretion rises markedly (FSH also increases but to a lesser extent). The elevated LH and FSH cause a slight fall in follicular estrogen production and a rise in progesterone secretion, which stimulates final maturation of a single follicle and release of its ovum. Ovulation marks the beginning of the luteal phase and occurs 14 days before the next menstrual period. -At ovulation a blister-like projection (A stigma) forms on the wall of the follicle, the follicle ruptures and the ovum w/ its surrounding cells is released from the surface of the ovary, where it is picked up by the fimbriated end of the fallopian tube for transport to the uterus -*Short version: Marked increase in LH secretion, slight fall in follicular estrogen, and rise in follicular progesterone secretion; final maturation and release of the most mature ovum* *Luteal Phase:* -After ovulation and under the influence of LH, the remaining cells of the old follicle persist for about 12 days as a corpus luteum. The corpus luteum secretes estrogen and large amounts of progesterone to prepare the endometrium for a fertilized ovum. Levels of FSH and LH decrease in response to higher levels of estrogen and progesterone -If the ovum is fertilized, it secretes a hormone (hCG) that causes persistence of the corpus luteum to maintain an early pregnancy. -If the ovum is not fertilized, FSH and LH fall to low levels and the corpus luteum regresses. Decline of estrogen and progesterone levels along w/ corpus luteum regression results in menstruation as the uterine lining breaks down. A new reproductive cycle is initiated. -*Short version: The corpus luteum secretes progesterone to prepare the endometrium for a fertlized ovum; the corpus luteum will persist and continue to secrete progesterone if it receives a signal (hCG) from a fertilized ovum. Otherwise, progesterone secretion falls and menstruation occurs*

Explain the factors that cause each of these fetal circulatory shunts to close after birth and the eventual outcome for each

*Foramen ovale:* -As the infant breathes and the lungs expand, blood flow to the lungs increases, pressure in the right side of the heart falls and the foramen ovale closes -(as the infant breathes, resistance to blood flow to lungs falls and the foramen ovale closes; tissue proliferation causes it to fill in the septum between the right and left atria.) *Ductus arteriosus:* -Constricts as the arterial oxygen level rises (persistent hypoxia may cause the ductus arteriosus to remain open for a prolonged period) -(Rising arterial oxygen levels cause constriction; becomes a ligament) *Ductus venosus:* -Constricts when flood of blood from the umbilical cord stops -(Cessation of umbilical cord blood flow with birth causes it to become non functional; becomes a ligament Notes: -Functional closure begins when the infant breathes and the cord is cut, removing the placenta from circulation. -Foramen ovale and ductus venosus are permanently closed as tissue proliferates in these structures. -The ductus venosus becomes a ligament (as do the umbilical arteries and vein) -Close functional after birth, but not closed permanently until several weeks or months later

Changes in Cardiovascular System:

*Heart:* -The muscles of the heart (myocardium) enlarge 10-15% during the first trimester (the blood volume in general increases and when we increase myocardium and blood volume it causes alterations in heart sounds -Alteration of heart sounds (some women develop benign murmurs *Blood Volume:* -Increase begins by week 6 of gestation -Can increase about 10-15% of volume during an entire gestation *Plasma Volume:* -Increases from 6-8 weeks until 32 weeks gestation *RBC Volume:* -Volume increases by about 20-30% -This shift of an increasing volume in the plasma and increasing RBCs can create a physiologic anemia, which is going to come into effect later on during pregnancy. Often times pregnant women have to take iron supplements or a prenatal vitamin with iron in order to compensate for the physiologic anemia *Cardiac Output:* -Output increases 30-50% b/c of the increased blood volume *Systemic Vascular Resistance:* -Decreases during pregnancy due to hormones causing the smooth muscle in vessels to relax *Blood Pressure:* -If our systemic vascular resistance is going to decrease it is likely going to decrease our BP -Effects of position: especially affected by position changes b.c of the increasing weight of the uterus, the increasing weight of the developing fetus. It can create some compression on the major vessels including the descending aorta and inferior vena cava, which can cause kind of a vagal response in mom (supine hypotension) -So be very cognizant of pregnant woman's position -Supine hypotension (this position will lead to this compression and hypotension) -Right lateral position (avoids the hypotension b/c uterus/fetus are not compressing the vessels) *Blood Flow:* -Altered due to the growing uterus to accommodate uteroplacental unit -Altered to include the uteroplacental unit (to accommodate fetal circulation, circulation to the placenta, so blood flow becomes highly impacted) -Renal plasma flow increases up to 30% -Skin requires increased circulation as it expands -Blood flow to the breasts increases -Expanding uterus partially obstructs blood return from veins in the legs, so this can cause some strain on the lower legs during pregnancy sometimes/often causing vascular changes, some numbness/tingling (if there is nerve compression) *Blood Components:* -Increased iron absorption -Increased clotting factors

List possible nursing or medical interventions to identify or correct the cause of a nonreassuring fetal monitor pattern

*Identify the cause:* -check BP to identify hypotension or hypertension, contractions to identify uterine hyperactivity, and recent maternal medications to identify sedative effects; perform vaginal examination to identify prolapsed cord; initiate internal monitoring to provide more accuracy *Increasing placental perfuson:* -Change position to reduce aortocaval compression; discontinue oxytocin or administer tocolytics to reduce uterine activity; increase nonadditive IV fluid to correct hypovolemia or vasodilation *Increasing maternal oxygen saturation:* -Administer 100% oygen at 8-10 l/min through a snug face mask *Reducing umbilical cord compression:* -reposition or perform amnioinfusion to reduce umbilical cord compression

Explain the importance of each type of uterine muscle (myometrial) tissue. Where is each type primarily located?

*Longitudinal fibers:* -Importance: they are designed to expel the fetus efficiently toward the pelvic outlet -Location:found mostly in the fundus (uppermost part of the uterus); make up the outer layer *Interlacing (figure 8) fibers:* -Importance: Figure 8 fibers contract after birth to compress blood vessels that pass between them to limit blood loss -Location: they make up the middle layer of the uterus *Circular fibers:* -Importance: Form constrictions where the fallopian tubes enter the uterus and surround the internal cervical os. Circular fibers prevent reflux of menstrual blood and tissue into the fallopian tubes. Promote normal implantation of the fertilized ovum by controlling its entry into the uterus, and retain the fetus until the appropriate time of birth -Location: where the fallopian tubes enter the uterus and surround the internal cervical os; inner layer

Explain how each of the following factors can reduce fetal oxygenation.

*Maternal hypotension:* Actual or relative reductions in the mother's circulating blood volume impair perfusion of the intervillous spaces w/ oxygenated maternal blood. Hemorrhage causes an actual decrease in the mother's blood volume. Relative reductions in maternal circulating blood volume involve altered distribution of blood volume w/o blood loss. Hypotension can result in reduction of placental blood flow. *Maternal hypertension:* -may reduce blood flow to the placenta b/c of vasospasm and narrowing of the spiral arteries *Maternal hypoxia:* -a lowered O2 level in the mother's blood reduces the amount available to the fetus. Maternal acid base alterations that accompany respiratory problems also can compromise exchange in the placenta. *Hypertonic uterine activity:* -Reduces the time available for exchange of oxygen and waste products in the placenta. Contractions may be too long or too frequent or have too short an interval. The uterus may not fully relax between contractions, applying continuous compression to the spiral arteries and reducing maternal-fetal exchange in the intervillous space. *Placental disruptions:* -When the placenta is disrupted (conditions such as abruptio placentae and infarcts) it reduces the placental surface area available for exchange *Umbilical cord blood flow compression:* -Blood flow through the umbilical cord may be reduced by compression between the fetal presenting part and pelvis by a nuchal cord, or by a knot in the cord. It may occur with oligohydramnios, it can also become entangled b/w fetal body parts or it may have inadequate wharton's jelly for cushioning. The thin walled umbilical vein is compressed initially resulting in a reduced flow of more highly oxyenated blood to the fetus. This results in initial hypoxia w/ hypotension. Baroreceptors and chemo receptors respond by accelerating the FHR. As cord compression continues the umbilical arteries are compressed resulting in hypertension. Baroreceptors respond by stimulating the vagus nerve, thus reducing blood pressure and slowing FHR. The FHR again accelerates as pressure is relieved on the umbilical arteries and then on the umbilical vein *Fetal bradycardia and tachycardia:* -Fetal cardiac is presumed to fail at rates lower than 60 bpm, but all factors from the fetal monitor stip must be evaluated. fetal tachycardia may reflect a recovery response from hypoxia or acidosis.

Mitosis vs meiosis

*Mitosis:* -Types of cells involved: somatic (body) cells -Number and type of chromosomes in each resulting cell: 46 chromosomes (22 pairs of autosomes (nonsex chromosomes) and 1 pair of sex chromosomes (XX or XY) *Meiosis:* -Types of cells involved: Gametes (reproductive/sex) cells -Number and type of chromosomes in each resulting cell: 23 chromosomes (22 autosomes and 1 sex chromosome; they are NOT paired

Describe monozygotic and dizygotic twinning in the following terms

*Monozygotic:* -Number of ova and sperm involved: 1 ovum, 1 sperm -Genetic component: identical genetic components -Gender: same gender -Hereditary tendency: no well established hereditary or racial components -Number of amnions and chorions: usually 2 amnions and 1 chorion (but can have 2 amnions and 2 chorions); vary according to the time when the inner cell mass divides in two *Dizygotic:* -Number of ova and sperm involved: 2 ova and 2 sperm cells -Genetic component: different genetic components (like any other siblings) -Gender: same or different gender -Hereditary tendecy: Can be hereditary (presumably b/c of an inherited tendency of the female to release more than one ovum per cycle); maternal age, and heredity and ethnic tendencies often found -Number of amnions and chorions: always 2 amnions and 2 chorions

What teaching is appropriate for these common discomforts of pregnancy?

*Nausea and vomiting:* -eat crackers, dry toast, dry cereal before rising in the morning, get out of bed slowly -prevent an empty stomach by eating a small amount of high carb, low fat foods every 2 hrs (total of 5-6 meals) -Eat a protein snack before bed -Suck on hard candy -drink fluids frequently, but separately from meals (avoid coffee) -avoid high fat, fried, greasy or spicy foods and those w/ strong odors (try bland food) -Open a window if cooking odors are bothersome -Experiment w/ dif foods that may be helpful (ginger, peppermint, tart and salty combos) -Take prenatal vitamins at bed time -use an acupressure band -nap and rest more frequently -check w/ provider before taking herbal remedies -Notify provider if severe nausea and vomiting or signs of dehydration *Heartburn:* -Eat small meals every 2-3 hrs and avoid fatty, acidic, or spicy foods -Eliminate smoking, drinking coffee, and carbonated beverages b/c stimulates acid formation in stomach -Avoid foods that increase symptoms (citrus fruits/juices, tomato products, chocolate, peppermint) -Try chewing gum, avoid bending over or lying flat, wear loose fitting clothes -Take deep breaths and sip water to help relieve burning sensation -Use antacids (but avoid those that are high in sodium and cause fluid retention (liquid antacids are great b.c coat esophagus) -Remain upright for 1-2 hrs after eating to reduce reflux and relieve symptoms -avoid eating or drinking for 2-3 hrs before bed time, might sleep with an extra pillow to elevate head *Backache:* -Maintain correct posture with head up and shoulders back -Avoid high heeled shoes b/c they increase lordosis and back strain -Do not gain excess weight; do not lift heavy objects (to pick up objects, squat rather than bend from the waist) -when sitting use foot supports, arm rests, and pillows behind back -Exercise: tailor sitting, shoulder circling, and pelvic rocking strengthen the back and help prepare for labor -application of heat or accupuncture may help- standing with one foot in front of the other and rocking back and forth may help *round ligament pain:* -use good body mechanics, and avoid very strenuous exercise -do not make sudden movements or position changes -do not stretch and twist at the at the same time. When getting out of bed , turn to the side first w/o twisting then get up slowly -bend toward the pain, squat or bring the knees up to the chest to relieve pain by relaxing the ligament -apply heat and and lie on the right side if discomfort persists *urinary frequency:* -restrict fluids in evening, nut have an adequate amount during the day -limit intake of natural diuretics such as coffee, tea, and other sources of caffeine -Perform kegel exercises to help maintain bladder control *varicosities:* -avoid constricting clothing and crossing the legs at the knees, which impedes blood flow from the legs -rest frequently w/ the legs elevated above the level of the hips and supported with pillows -apply support hose or elastic stockings that reach above the varicosities before getting out of bed in the morning (before blood has a chance to pool) -If working in one position for long periods, walk around for a few minutes at least 2 hrs to stimulate blood flow and relieve discomfort -walk frequently to stimulate circulation in legs -do foot circles and flex feet toward your head frequently if sitting for long periods *Constipation:* -Drink at least 8 glasses of fluids (not coffee, tea, or carbonated bevs b/c of diuretic effect-after one of these bevs drink a glass of water to counteract) -add foods high in fiber to diet (four pieces of fruit and a large salad = good fiber for a day) -restrict consumption of cheese -decrease consumption of sweets (causes gas) -ask provider about stool softeners -do not stop taking prescribed iron supplements -exercise stimulates peristalsis -establish a regular pattern by going at a consistent time each day -use a foot rest to decrease straining *hemorrhoids:* -avoid constipation to prevent straining that worsens hemorrhoids -to relieve existing hemorrhoids, take frequent tepid baths. Apply cool witch hazel compresses or anesthetic ointments -lie on your side with the hips elevated on a pillow -if pain or bleeding persist call provider *Leg cramps:* -to prevent cramps, elevate legs frequently to improve circulation -to relieve cramps, extend the affected leg, keeping the knee straight -avoid excessive foods high in phosphorous, such as soft drinks -check w/ your health care provider regarding the need for supplemental calcium, magnesium, or sodium chloride

How does average duration of labor vary between nulliparas and parous women for each stage of labor?

*Nullipara:* -Latent phase: 7.3-8.6 hrs -Active phase: 8-10 hr (range: 8-16 hr) -Transition phase: 3.6 hr 2nd stage of labor: 50 min (range 30 min-3 hr) 3rd stage of labor: 5-10 min (up to 30 min) 4th stage of labor: 1-4 hrs after birth *Parous:* -Latent Phase: 4.1-5.3 hr -Active Phase: 6-7 hr (range 2-10 hr) -Transition phase: 0-30 min 2nd stage of labor: 20 min (range: 0-30 min) 3rd stage of labor: 5-10 min (up to 30 min; same as nulli) 4th stage of labor: 1-4 hrs after birth (same as nulli)

Gametogenesis

*Oogenesis:* -Formation of female gametes in ovaries -Begins during prenatal life -When the oocyte matures, 2 meiotic divisions reduce the chromosome number from 46 paired to 23 unpaired chromosomes *Spermatogenesis:* -Formation of sperm (male gametes in testes) -Each spermatogonium contains 46 paired chromosomes. -The first meiotic division forms 2 secondary spermatocytes and reduces the number to 23 unpaired chromosomes in each individual gamete -The gamete from a male determines the gender of the new baby

Oogenesis vs Spermatogenesis

*Oogenesis:* -Number and type of chromosomes in each mature gamete: 23 total (22 autosomes and 1 X chromosome) -Number of gametes resulting from each primary cell: one -When during life gametogenesis begins and ends: prenatal life (no others develop after about 30 weeks of gestation) *Spermatogenesis:* -Number and type of chromosomes in each mature gamete: 23 total (22 autosomes and 1 X or Y chromosome) -Number of gametes resulting from each primary cell: four -When during life gametogenesis begins and ends: begins at puberty and continues on

Female Reproductive Cycle: Ovarian Cycle and Endometrial cycle

*Ovarian Cycle:* -Follicular phase: how is it initiated? -Ovulatory phase: what does it mean for the cycle? -Luteal phase *Endometrial Cycle:* -Proliferative phase -Secretory phase -Menstrual phase *Understanding Menstrual Cycle:* -The average menstrual cycle usually occurs over 28 days, although the normal cycle may range from 22 to 34 days. The cycle is regulated by fluctuating hormone levels that, in turn are regulated by negative and positive feedback mechanisms *Menstrual (Preovulatory Phase):* -The cycle starts with menstruation (cycle day 1), which usually last 5 days -As the cycle begins, low estrogen and progesterone levels in the blood stream stimulate the hypothalamus to secrete gonadotropin-releasing hormone (GnRH) -In turn, this substance stimulates the anterior pituitary to secrete follicle stimulating hormone (FSH) and Luteinizing hormone (LH). When the FSH level rises, the LH output increases *Proliferative (Follicular) Phase and Ovulation:* -The proliferative phase lasts from days 6-14 of the cycle -During this phase, LH and FSH act on the ovarian follicle (mature ovarian cyst containing the ovum), causing estrogen secretion, which in turn stimulates the build up of the endometrium -Late in the proliferative phase, estrogen levels peak, FSH secretion declines, and LH secretion increases, surging at mid cycle (around day 14); *Huge rise in LH right before ovulation (LH = big full moon rises right before ovulation)* -Then estrogen production decreases, the follicle matures, and ovulation occurs -Typically one follicle matures during the ovulatory process and is released from the ovary during each cycle *Luteal (Secretory) Phase:* -During the luteal phase, which lasts about 14 days, FSH and LH levels drop -Estrogen levels decline initially, then increase along with progesterone levels as the corpus luteum (progesterone-producing, yellow structure that develops after the follicle ruptures) begins functioning -During this phase the endometrium responds to progesterone stimulation by becoming thick and secretory in preparation for implantation of a fertilized ovum -Between 10 and 12 days after ovulation, the corpus luteum begins to diminish as do estrogen and progesterone levels, until the hormone levels are insufficient to sustain the endometrium in a fully developed secretory state -Then the endometrial lining is shed (menses) -Decreasing estrogen and progesterone levels stimulate the hypothalamus to produce GnRH, and the cycle begins again Notes: -ruptured follicle turns into corpus luteum and produces progesterone -ovulation @ day 14 (most likely to get pregnant at day 14 of a 28 day cycle); egg survives for 24-48 hrs, and sperm survives for 72 hrs -Progesterone is pregnancy hormone!! -Corpus luteum produces progesterone for 3 months of pregnancy, until the placenta starts to produce it

Changes in Endocrine System

*Pituitary Gland:* -Very big hot spot for the hormones needed to support pregnancy. -Prolactin -Oxytocin: hormone that drives both pregnancy and labor *Thyroid Gland:* -Influenced during pregnancy due to a shift in hormones -Rise in total thyroxine (T4) and thyroxine-binding globulin -It's important that moms have their thyroid gland labs drawn and checked during pregnancy in order to assess for any hypothyroidism or hyperthyroidism *Parathyroid glands:* -also influenced during pregnancy -calcium homeostasis *Pancreas:* -Fluctuations in insulin production -Insulin resistance: can be caused by gestational diabetes; really important to have all prenatal testing done *Adrenal Glands:* -Cortisol: increasing or decreasing -Aldosterone *Changes caused by placental hormones:* -Human chorionic gonadotropin (hCG) -Estrogen -Progesterone -Human chorionic somatomammotropin (hCS) -Relaxin *Changes in metabolism:* -Motility decrease in GI system -Weight gain (uterus getting bigger etc, but also d/t metabolism) -Water metabolism (increased water retention) -Edema (can cause compression of certain organs and nerves, leads to carpal tunnel) -Carpal tunnel syndrome -Carbohydrate metabolism (used as quick energy)

Physiologic Effects of the birth process: Fetal Response

*Placental Circulation:* -Exchange of oxygen, nutrients, and waste products -Most placental exchange occurs during the interval between contractions *Cardiovascular System responds to stress:* -HR ranges from 110-160 bpm *Pulmonary System:* -Lungs produce fluid to allow normal development of the airways so it is important to assess the pulmonary system for the oxygenation status of the fetus

Changes in the pregnant woman's blood

*Plasma Volume:* -Change during preg: increases by 40-60% -Effect: transport nutrients and oxygen to placenta. Meet the demands of the expanded maternal tissue in the uterus and breast. Provide reserve to protect the preg woman from the adverse effects of blood loss that occurs during child birth *RBC Volume:* -Increased by about 20-30% *Leukocyte count:* -Increase during pregnancy and further increases during labor and early post partum *Clotting factors:* -Increase by 50% Effect: Protect from hemorrhage during child birth, but also puts woman at risk for thrombus formation

Preparation for conception

*Preparation for conception in the female:* -Release of the ovum -Ovum transport *Preparation for conception in the male:* -Ejaculation -Transport of the sperm

Teaching and Learning (Changing role of nurses)

*Principles:* -Readiness -Active participation -Repetition -Positive feedback -Role modeling -Address conflict and frustration -Simple to complex -Use of variety of methods -Small segments *Factors that influence Learning:* -Developmental level -Language -Culture -Previous experiences -Physical environment -Organization and skill of instructor -Early discharge

Describe events in each phase of the menstrual (endometrial) cycle

*Proliferative Phase:* -Occurs as the ovum matures and is released during the 1st half of the ovarian cycle. After completion of a menstrual period, the endometrium is very thin. THe basal layer of endometrial cells remain after menstruation. These cells multiply to form new endometrial epithelium and endometrial glands under the stimulation of estrogen secreted by the maturing ovarian follicles. -Endometrial spiral arteries and endometrial veins elongate to accompany thickening of the functional endometrial layer and nourish the proliferating cells. As ovulation approaches, the endometrial glands secrete thin, stringy mucus that aids entry of sperm into the uterus. *-Short version: Cells of the basal layer of the endometrium multiply; endometrial glands form; spiral arteries and endometrial veins elongate* *Secretory Phase:* -Occurs during the last half of the ovarian cycle as the uterus is prepared to receive a fertilized ovum. The endometrium continues to thicken under the influence of estrogen and progesterone from the corpus luteum, reaching its maximu thickness of 5-6 mm. The blood vessels and endometrial glands become twisted and dilated. Progesterone from the corpus luteum causes the thick endometrium to secrete substances to nourish a fertilized ovum. Large quantities of glycogen, proteins, lipids, and minerals are stored within the endometrium awaiting arrival of the ovum -*Short version: Endometrium continues to thicken; substances are secreted to nourish an embryo if one implants* *Menstrual phase:* -If fertilization does not occur, the corpus luteum regresses and its production of estrogen and progesterone falls. About 2 days before the onset of menstruation, vasospasm of the endometrial blood vessels causes the endometrium to become ischemic and necrotic. The necrotic areas of endometrium separate from the basal layer, resulting in the menstrual flow. Menstrual phase usually lasts 5 days. During a menstrual period, women lose about 40 ml of blood. Because of the recurrent loss of blood, many women are mildly anemic during their reproductive years -*Short version: Vasospasm occurs if the corpus luteum stops producing estrogen and progesterone, causing the endometrium to become necrotic. The necrotic layer separates from the basal layer to produce menstrual flow*

Other Changes in Body Systems

*Sensory Organs:* -Eyes (decrease in visual acuity -Ear *Immune System:* -Autoimmune conditions (can be exacerbated by changes in hormones during pregnancy) -Infection resistance

Changes in Integumentary System

*Skin:* -Hyperpigmentation can be seen in nipples, vaginal area due to changes in hormones -Melasma -Linea nigra: which is a line down the abdomen (hormone influenced) -Cutaneous vascular changes *Connective Tissue:* -Striae gravidarum: stretch marks occur as the abdomen continues to expand -Hair and nails: their growth can be affected

Components of the birth process: Passage

*The Bony Pelvis:* -Usually more important to the outcome of labor than the soft tissue -Bones and joints do not readily yield to the forces of labor *The linea terminalis (pelvic brim) divides the bony pelvis -False pelvis above the linea terminalis -True pelvis below linea terminalis: Most important in childbirth (Inlet, Midpelvis, Outlet) *Soft Tissues:* -Lower uterine segment, cervis, vagina, and introitus

General overview of a fetal monitoring strip

*Top Section:*line is reflecting a fetal HR. *Bottom section:* wave-like form reflects the uterine contractions. Looking at the amplitude of the wave. Hypertonic if high amplitude wave, hypotonic if low amplitude wave. Looking at the distance between the contractions to determine how frequently she is contracting. *Space between 2 thick red lines equals 1 minute. The 6 small boxes between the thick lines each represent 10 seconds.

Normal Labor: True vs False Labor

*True Labor:* -Increased Contractions (rhythmic- waves like the ocean) Increased discomfort (build on each other mild, then moderate then strong) -Cervical change: progressive effacement and dilation most important -True labor is defined by cervical change *False Labor:* -Contractions inconsistent (might have 4 contractions in one hr and then none for the next few hours) -Discomfort is more annoying than truly painful -Cervix does not change

Explain the umbilical cord structures and their functions

*Umbilical vein:* -carries freshly oxygenated and nutrient laden blood from the placenta back to the fetus *Umbilical arteries (two):* -carry deoxygenated blood and waste products away from the fetus to the placenta where these substances are transferred to the mother's circulation *Wharton's jelly:* soft substance that cushions the cord to prevent obstruction resulting from pressure; protects the cord vessels from stretching or pressure that would interrupt flow

Define the sounds heard when the uterus is auscultated during pregnancy, and specify the heart rate to which each sound corresponds

*Uterine souffle:* A soft blowing sound that can be auscultated over the uterus. This is the sound of blood circulating through the dilated uterine vessels and it *corresponds to the maternal pulse*. Therefore to identify it, the rate of the maternal pulse must be checked simultaneously *Funic souffle:* soft, whistling sound heard over the umbilical cord and it *corresponds to the fetal HR*

VEAL CHOP

*V:* variable decelerations *C:* cord compression *E:* early decelerations *H:* head compression *A:* accelerations *O:* oxygenation (okay!) *L:* late decelerations *P:* Placental insufficiency

Describe three methods that can be used during labor to clarify the fetal condition

*Vibroacoustic stimulation:* -Can be used as the initial method to stimulate the fetus or to supplement fetal scalp stimulation, or it may be used if scalp stimulation is contraindicated. An artificial larynx or vibroacoustic stimulator is applied to the mother's lower abdomen and turned on for up to 3 seconds. A reassuring response is an acceleration that peaks at 15 bpm for 15 seconds or more. An absent response however does not necessarily mean that the fetus is suffering from hypoxia or acidosis *Fetal Scalp Stimulation:* -Used to evaluate the response of the fetus to tactile stimulation. The examiner applies pressure to the scalp (or other presenting part) with a gloved finger or fingers and sweeps the fingers in a circular motion. A FHR acceleration is a reassuring response that says that the fetus is in normal oxygen and acid-base balance. The acceleration may be delayed instead of immediate. -Not used in certain cases: preterm fetus (may cause contractions), prolonged rupture of membranes (high risk of infection), chorioamnionitis (intrauterine infection), placenta previa (placenta overlies the cervix and hemorrhage is likely), maternal fever of unknown origin (b/c possibility of introducing microorganisms into uterus) *Fetal scalp blood sample:* -Occasionally the physician may obtain a sample of fetal scalp blood to evaluate the pH. Normal scalp pH is 7.25-7.35. Scalp sampling is less common b/c it's invasive and the results are not available immediately

Describe changes in maternal heart sounds that may occur during pregnancy

*When do the heart sound changes occur?* -First heard between 12 and 20 weeks and continue for 2-4 weeks after childbirth *Describe common changes in heart sounds:* -Splitting of the first heart sound -Systolic murmur heard at the left sternal border -3rd heart sound

Why should the nurse regularly check the woman's bladder at the following times?

*during labor:* -A full bladder increases pain and interferes with fetal descent (b/c takes up space in pelvis) *during early postpartum period:* -a full bladder interferes with the uterine contractions that compress open vessels to control bleeding

How does each of these factors affect the onset of labor?

*fetal hormone production:* the fetal membranes release prostaglandins in high concentrations during labor. In addition to fetal oxytocin secretion, large quantities of cortisol are secreted by the fetal adrenal glands, possibly acting as a uterine stimulation *Change in maternal progesterone and estrogen relationship:* higher estrogen levels make the uterus more sensitive to substances that stimulate it to contract, whereas lower progesterone levels allow it to be stimulated more easily; estrogen also increases the number of gap junctions (connections that allow the uterus to contract in a coordinated manner) *Oxytocin receptors:*Oxytocin receptors increase as labor begins, continue to increase during labor, and peak at delivery

What should the pregnant woman be taught about the following practices during pregnancy? How would you explain this to a woman if you were a nurse?

*hot tubs and saunas:* -pregnant women should avoid activities that may cause hyperthermia (maternal hyperthermia during first trimester may be associated with fetal anomalies). Caution the woman not to be in a sauna for more than 15 minutes or a hot tub for than 10 and to keep her head, chest, shoulders, and arms out of the water *Douching:* -Douching is unnecessary at any time. It increases the risk of ectopic pregnancy, cervical cancer, STDs, pelvic inflammatory disease, and endometritis (bacterial vaginosis occurs more frequently in women who douche, and bacterial vaginosis is associated w/ spontaneous abortion, preterm birth, premature rupture of membranes, and chorioamnionitis. *Exercise:* -generally beneficial during pregnancy (can strengthen muscles, reduce backache and stress, and provide feelings of well-being) -Exercise tolerance is often decreased, but mild to moderate exercise is generally not a problem -Women w/o medical or obstetric complications should exercise in moderation for 30 minutes or more on most if not all days of the week. No contact sports or sports/exercise that has high risk of falls or abdominal trauma -Exercise in supine position should be discontinued after first trimester -Have to avoid getting overheated during exercise b/c heat is transmitted to fetus -Drink fluids to avoid dehydration during work out -Generally if woman cannot carry out a conversation while exercising, she is doing too much (walking is ideal exercise) -Get medical help is have chest pain, dizziness, headache, vaginal bleeding, decreased fetal movement, signs of labor while excercising *Working:* -try to reduce workload to minimize fatigue and stress -Women w/o complications can usually work up until labor but have to consider level of physical activity involved and the risk of exposure to environmental toxins and industrial hazards. -need frequent rest periods and to elevate feet, change positions *Use of a seatbelt:* -Fasten seatbelt snugly w/ the lap belt under her abdomen and across her thighs and the shoulder belt in a diagonal position across her chest and above the bulge of her uterus *Immunizations:* -live vaccines (MMR, varicella) are *contraindicated* during pregnancy -Inactivated vaccines are safe during preg (such as tetanus, hep b, influenza) -Advised that women who haven't previously been vaccinated against pertusis should receive the Tdap vaccine at any time during preg (best between weeks 27-36) *Over the counter drugs:* -consult w/ healthcare provider before taking any drugs -NSAIDS such as aspirin should be avoided (may increase bleeding) -Drugs taken during first trimester are of particular concern b/c of risk to developing fetal organs *Tobacco:* -make every effort to motivate expectant mothers to stop smoking and to avoid contact w/ others who smoke. -secondhand smoke increases the risk of preterm birth, respiratory distress syndrome, NICU admission, and other complications -5A approach to smoking cessation *Alcohol:* -Alcohol is a known teratogen, and maternal alcohol use is a leading cause of intellectual disability in the US -Can cause fetal alcohol spectrum disorders: cluster of developmental anomalies -No amount of alcohol consumed during pregnancy is known to be safe -Abstain from alcohol if pregnant or planning to become pregnant *Illegal drugs:* -harmful to fetus. -advise preg woman to seek help to discontinue all illicit drug use

What is the possible result of each of the following changes during pregnancy?

-*Increase in vascularity:* Causes the vaginal walls to appear bluish purple -*Softening of connective tissue:* allows the vagina to distend during childbirth -*Secretion of increased amounts of glycogen:* Causes rapid sloughing and increased thick, white, acidic vaginal discharge

Maternal Hematopoietic System (during labor)

-500 mL normal blood loss for vaginal delivery -800 to 1000 mL for c-section -Mom's increase their cardiovascular volume by 10-15% during pregnancy to accommodate for some of this blood loss as well -Levels of several clotting factors, esp fibrinogen are elevated during pregnancy and continue to be higher during labor and after delivery: provides protection from hemorrhage; increases the mother's risk for a venous thrombosis during preg and after brith (b/c of increased blood volume and b/c of elevated levels of several clotting factors) -Important to consider interventions to prevent DVT such as promoting use of sequential stockings to prevent risk of DVT

Function of human placental lactogen (hPL) (placental hormone)

-AKA human chorionic somatomammotropin; promotes normal nutrition and growth of the fetus as well as maternal breast development for lactation. This placental hormone decreases maternal insulin sensitivity and glucose use, making more glucose available for fetal nutrition

Accelerations (electronic fetal monitoring)

-Accelerations are defined as apparent, abrupt increases in the FHR above baseline -The increase from onset to the peak is < 30 seconds -*The peak must be > 15 bpm from the baseline and lasts > 15 seconds (at least 3x in 20 mins)* -Accelerations are highly desirable, sign of fetal well being, very reassuring to the nurse b/c we know that the fetus is well oxygenated and is maintaining proper acid-base balance

Describe the primary purpose of amnioinfusion. Describe how it is done and explain the basic nursing care involved

-Amnioinfusion increases the fluid around the fetus and cushions the cord. -Warm and sterile isotonic fluid (Lactated Ringers solution or NS) is infused into the uterus through IUPC. -The underpads must be changed regularly b/c fluid leaks out constantly. (nurse wants to keep woman dry as fluid leaks continuously from her vagina) -Possible complications include overdistention of the uterus, and increased uterine resting tone. These complications are relieved by releasing some of the fluid. -Amnioinfusion maybe used to wash out and dilute fluid that contains thick meconium to reduce chances that the infant will aspirate it at birth, but research has not found amnioinfusion effective for this purpose

Auxiliary structures: Fetal membrane and amniotic fluid

-Amnion: inner membrane -Chorion: outer membrane; if woman spikes fever during labor we assume it is d/t an infection of the chorion *Amniotic fluid:* -cushions against impacts to the maternal abdomen (extra barrier from baby to outside world -Maintains a stable temperature -Allows symmetric development -Prevents the membranes from adhering to developing fetal parts (prevents membranes of placenta from adhering) -Allows room and buoyancy for fetal movement (towards the end of gestation the fetus practices swallowing and breathing movements with this fluid)

Antepartum Assessment and Care: Objective

-Antepartum care is to ensure that pregnancy ends in the birth of a healthy infant w/o impairing the health of the mother *Antepartum Care: Preconception and Interconception:* -Ideally pt seen before conception -Identify problems -Provide education to help achieve a healthy pregnancy -History, vital signs, and physical examination -Screening -Medications and nutrition -Be able to adapt a plan of care that will fit that pt's needs

Changes in GI system

-Appetite b/c uterus can compress GI structures like the stomach, so appetite might fluctuate for a pregnant woman (1st trimester: possibly decreased appetite due to nausea and vomiting, 2nd trimester possibly increased appetite, 3rd trimester possibly decreased appetite and increased appetite (waxing and waning) due to compression -Mouth: woman can retain more fluid which can cause swelling in mouth, throat, esophagus, and cause a difficult airway -Esophagus -Large and small intestines -Liver and gallbladder -Motility decreases can affect the gallbladder

Application of the Nursing Process: Maternal-Newborn Nursing

-Assessment: Screening assessment, focused assessment -Analysis -Nursing Diagnosis -Planning -Setting Priorities -Establishing goals and expected outcomes -Developing interventions: For actual nursing diagnoses, for risk, for wellness -Implementing interventions -Evaluation -Individualized nursing care plans -Nursing process related to critical thinking

Baseline FHR (electronic fetal monitoring)

-Baseline FHR is the average FHR rounded to 5 bpm during a 10-min window (this does not include accelerations or decelerations) -There must be at least 2 min of identifiable baseline *Normal FHR:* 110-160 bpm (preterm fetus at 26-28 weeks is at higher end of this range b/c parasympathetic nervous system, which slows the rate, is immature) *Bradycardia:* FHR < 110 bpm (persisting for at least 10 min) *Tachycardia:* FHR > 160 bpm (persisting for at least 10 min)

Describe how passage of maternal immunoglobulin (IgG antibodies can be beneficial or harmful to the fetus

-Beneficial: b/c the newborn does not produce antibodies for several months after birth; provides newborn with temporary passive immunity to diseases to which the mother is immune -Harmful: If maternal and fetal blood types are not compatible, the mother may already have or may produce antibodies against fetal erythrocytes. (maternal blood type antibodies may cross the placenta and destroy incompatible fetal erythrocytes) The mother's antibodies may then destroy the fetal erythrocytes, causing fetal anemia or even death. This situation may occur if the mother is Rh-neg and the fetus is Rh-pos

What changes in carbohydrate metabolism and the production of, use of, and sensitivity to insulin occur during pregnancy? Why do these changes occur? How does the woman's body normally respond to these changes?

-Blood glucose levels are 10-20% lower than before pregnancy, and hypoglycemia may develop between meals and at night b/c the fetus continuously draws glucose from the mother -During the second half of pregnancy, maternal tissue sensitivity to insulin begins to decline because of the effects of hCS, prolactin, estrogen, progesterone, and cortisol. -The mother uses fatty acids to meet energy needs. Post prandial blood glucose level is higher than before pregnancy b/c of insulin resistance, making more glucose available for fetal energy needs. -In healthy women the pancreas produces additional insulin. In some women however insulin production cannot be increased and these women experience periods of hyperglycemia or gestational diabetes

Describe significant maternal changes that occur in a multifetal pregnancy

-Blood volume: blood volume increases significantly w/ multifetal pregnancies. With twins blood volume increases 500 ml more than the amt needed for a single fetus -Cardiac workload: this increase in blood volume increases the workload of the heart which may contribute to fatigue and activity intolerance -Respiratory effort: respiratory difficulty increases b/c the over distended uterus causes greater elevation of the diaphragm -Blood vessel compression: the uterus may also cause more compression of the large vessels, resulting in more pronounced and earlier supine hypotension -Ureter compression: Greater compression of the ureters can occur and maternal edema and slight proteinuria are common -Bowel: compression of the bowel makes constipation and hemorrhoids persistent problems

Normal Labor: Premonitory Signs

-Braxton Hicks contractions (also abdominal tightening) -Lightening (when the fetus kind of drops lower into the pelvis, this can improve maternal respiratory effort b/c the fetus is not pushing against the diaphragm anymore) -Increased vaginal mucus secretion --Energy spurt and weight loss (sometimes get a burst of energy and a little weight loss caused by diarrhea and vomiting); Way for the body to get rid of what it no longer deems necessary for the work of labor *Cervical Changes:* -Softening -Possible dilation -Bloody show (discharge of some blood mixed with vaginal mucus)

Female Puberty Changes

-Breast changes -Body contours -Body hair -Skeletal growth -Changes to reproductive organs -Menarche Notes: -breast and ovaries are primary sex characteristics, everything else secondary -Usually first menstrual period is similar to the timing of mother's. The development of breast buds is first and then usually get their period 1-2 yrs later (girls getting periods younger due to being overweight and hormones in food)

What breast changes occur during pregnancy?

-Breasts change in both size and appearance during pregnancy -Estrogen stimulates the growth of mammary ductal tissue, and progesterone promotes the growth of the lobes, lobules, and alveoli. -Breasts become highly vascular, with a delicate network of veins often visible just beneath the surface of the skin. -If increase in breast size is significant , stretch marks may develop -Nipples increase in size and become darker and more erect. Areolae become larger and more pigmented. -Sebaceous glands called tubercles of montogomery become more prominent during pregnancy and secrete a substance that lubricates the nipples. -Colostrum is also secreted as early as 16 weeks

Melasma

-Brownish discoloration of the face

Pinpointing

-Calling attention to differences or inconsistencies in statements -Ex. nurse talking to an 8 yr old child: "You said you didn't want your mother to spend the night with you, but you cry every night after she leaves. It can be scary being alone. I'll sit with you, and we can talk about asking your mother to stay tomorrow night"

Changes in Reproductive System: Cervix

-Chadwick's sign: bluish discoloration of the cervix/vaginal mucosa during pregnancy -Goodell's sign: Indication of pregnancy. It is a significant softening of the vaginal portion of the cervix due to increased vascularization during pregnancy. That vascularization is typically the result of hypertrophy and engorgement of the vessels below the uterus -Mucus plug: kind of like a cork in the center of the cervix which kind of seals that environment

Clarifying (therapeutic communication technique)

-Clearing up or following up to understand both content and feelings expressed, to check the accuracy of how the nurse perceives the message -"I'm confused about your plans. Could you explain?" -"Tell me what you mean when you say you don't feel like yourself" -"Are you saying that __________?" -"Tell me more about __________"

State when during the prenatal development each event occurs

-Closure of the neural tube: *4 weeks* -Heart contains four chambers: *6 weeks* -All abdominal organs are within the abdominal cavity: *10 weeks* -Eyes close at *10 weeks*, reopen at *26-28 weeks* -External ear development begins: *6 weeks* -Fetal gender apparent by external genitalia: *12 weeks* -Fetal movements felt by mother: *20 weeks* (possible at 16 weeks if woman has been preg before) -Surfactant production begins: *24 weeks* -Testes begin entry into scrotum: *26 weeks*

What maternal and fetal conditions can reduce fetal tolerance for the intermittent interruption in placental blood flow that occurs during contractions?

-Conditions associated with reduced placental function such as maternal diabetes and hypertension, and conditions associated w/ reduced fetal oxygenation capacity, such as fetal anemia -the placental circulation usually has enough reserve compared w/ fetal basal needs to tolerate the periodic interruption of blood flow, but not in the above situations

Behaviors that Block Communication

-Conveying lack of interest: looking away, fidgeting. Instead want to make eye contact, nod -Conveying sense of haste: checking the time, standing near door. Instead sit at bed side -Closed posture: arms crossed over chest, holding laptop computer in front of body. Instead want to lean forward with arms relaxed -Interrupting, finishing sentences: Woman- "I'm not sure how to.." Nurse- "We'll have a bath demonstration later" Instead: "go on" or "you were sayong" -Providing false reassurance: "You're going to be okay" Instead: "I sense you are concerned about how to care for the baby I will help you give the bath today" -Inappropriate self-disclosure: To woman in labor: "I was in labor for 12 hrs and then had a c-section" Instead: "What concerns you most about labor?" -Giving advice: "You should..." or "If I were you I would...." Instead: "How do you feel about that? What do you think is most important?" -Failure to acknowledge comments or feelings: Woman: "Being a parent is hard work. I never have time for myself" Nurse: It's going to get worse before it gets better" Instead: "Parenting is hard work. Let's talk about some ways that you might get a break"

Cultural considerations

-Culture often determines the health beliefs, values, and expectations of the family -Important to think about how a pt's culture may influence their pregnancy, their experiences, and value systems

Maternal GI system (during labor)

-Decreased gastric motility -Most women are not hungry but are thirsty and have dry mouths (not hungry b/c w/ decrease gastric motility it takes a lot longer for food to move down the GI tract) -Ice chips are commonly provided -Small amounts of clear liquids may be allowed -Solid food is usually withheld to prevent vomiting and aspiration in the event that general anesthesia is required

Decline in female fertility (as female maturation continues)

-Decreases during climacteric -Hormone production declines -Reproductive organs atrophy -Menopause *There is no distinct marker event in males

Male Puberty Changes

-Development of testes and penis (primary) -Nocturnal emissions: involuntary release of seminal fluid from the penis during sleep -Body hair -Body composition -Skeletal growth -Voice changes

What is meant by the term crossing over and what is its significance?

-Each chromosome (except for the x or y in the male) exchanges some material with its mate so that the new chromosome in the gamete contains material from the mother and some from the father. This is called crossing over and it allows variation in genetic material while keeping the total amount of chromosome material from generation to generation

Reproductive System: Cervical Changes

-Effacement (thinning and shortening); Cervix starts out kind of like a cone pointed a little toward the mom's rectum prelabor. The cone has to come forward toward the center of the vagina -Dilation (opening) -Effacement and dilation occur concurrently during labor but at different rates. *1st time moms will thin out their cervix before they start to dilate. Multiparous women usually dilate and efface at similar rates.* *Nulliparous:* -Woman who has not completed a pregnancy to at least 20 weeks of gestation -Completes most cervical effacement early in the process of cervical dilation *Parous:* -Woman who has given birth after a pregnancy of at least 20 weeks gestation -Cervix is usually thicker than that of a nullipara at any point during labor, women tend to move a little faster throughout labor

Questioning

-Eliciting information directly; using open-ended questions to avoid "yes" or "no" answers and to prevent controlling the answers Ex. "How do you feel about being pregnant?" instead of "Are you happy to be pregnant?"

Fertilization

-Entry: sperm enters the egg -Fusion: then there is mixing of cell nuclei and chromosomes of ovum and sperm, then fertilization is complete (embryo) -Fertilization occurs after the ovum is transported through the fallopian tube and then it implants in the uterine wall

Antepartum Assessment & Care: Initial Prenatal Visit

-Establish trust and rapport w/ family (want open and honest communication) -Verify or rule out pregnancy -Evaluate woman's physical health -Assess the growth and health of the fetus -Establish baseline data -Evaluate the psychosocial needs -Assess the need for counseling or teaching -Negotiate a plan of care -Laying down the foundation for a relationship that is really going to develop over the next several months *Obstetric history:* -Gravida, para (G: how many pregnancies, P: how many infants they delivered) -Length of previous gestations -Weight of infants at birth -Labor experiences -Anesthesia -Maternal complications (during pregnancy? delivery?) -Infant complications -Methods of infant feeding -Special concerns *Menstrual History & Estimated Date of Delivery (EDD):* -Nagele's rule -Gynecologic and contraceptive history -Medical and surgical history -Family history -Partner's health history -Psychosocial history -Important to get a thorough health history *Physical Exam:* -Vital signs -CV system -Musculoskeletal system -Neurological system -Integumentary system -Endocrine system -GI system -Urinary system -Reproductive system

Why are pregnant women more likely to develop gallstones?

-Estrogen and progesterone cause functional changes to the liver and gallbladder -The gallbladder becomes hypotonic, and emptying time is prolonged. -*The bile becomes thicker predisposing to the development of gallstones.* -Reduced gallbladder tone also leads to a tendency to retain bile salts, which can cause itching (pruritis)

What nasal changes are common during pregnancy? What causes them?

-Estrogen causes increased vascularity of the mucus membranes of the upper respiratory tract -As the capillaries become engorged, edema and hyperemia develop within the nose, pharynx, larynx, and trachea. This congestion may cause nasal and sinus stuffiness, epistaxis (nose bleed), and deepening of the voice

Changes in Reproductive System: Breasts

-Estrogen stimulates the growth of mammary ductal tissue (so can see an increase in breast tissue) -Progesterone promotes growth of the lobes, lobules, and alveoli which will be prepared in order to allow lactation -Characteristic changes -Colostrum is secreted, colostrum is the initial kind of golden in color milk that is secreted by mothers who will be lactating. It also can be secreted towards the end of pregnancy

Normal Labor

-Exact cause unknown but there are theories of onset -Labor is spontaneous *Factors that appear to have a role in starting labor:* -Progesterone withdrawal -Increased release of prostaglandins -Increased secretion of natural oxytocin in the brain -Increased oxytocin receptors in the uterus -Increased stretching and pressure of the uterus and cervix

Fetal Circulation Sequence

-Exchange of gases occurs in the *placenta*. Oxygenated blood is carried by the umbilical vein towards the fetal heart. -Through the umbilical vein, about 80% of oxygenated blood from the placenta travels through the *ductus venosus* away from the fetal liver (filitration of blood by the liver is unnecessary during the fetal life) and directly to the *inferior vena cava* and up into the *right atrium* -In fetal circulation most of the blood in the right atrium is directed by the *foramen ovale* (opening between the two atria) to the left atrium -The blood then flows from the *left atrium* to the *left ventricle* to the *aorta*. Most of the blood in the ascending aorta goes to the brain, heart, head, and upper body. -A portion of the blood that drained into the right ventricle passes to the *pulmonary artery*. As blood enters the *pulmonary artery* (carries blood to the lungs), an opening called the *ductus arteriosus* connects the pulmonary artery and the descending aorta. Hence, most of the blood will bypass the non-functioning fetal lungs and be distributed to the different parts of the body. A small portion of the oxygenated blood that enters the lungs remains there for fetal lung maturity. -The *umbilical arteries* then carry the non-oxygenated blood away from the heart back to the placenta for oxygenation

Baseline FHR

-FHR when the uterus is at rest

What is the difference between the fertilization age and gestational age?

-Fertilization age is calculated from the date of conception (full term ranges from 36 to 40 weeks of fertilization age) -Gestational age is calculated from the first day of the woman's last menstrual cycle (full term is 38-42 weeks of gestational age) -gestational age is approx 2 weeks longer than fertilization age

Fetal circulation

-Fetal circulation is different than adults or pediatric circulation b/c w a fetus have the placenta which is the main communication b/w mom and the baby. Also includes the umbilical cord -Umbilical cord has 3 vessels (AVA): two arteries carry deoxygenated blood away, and one vein carried oxygenated blood *Fetal circulatory circuit:* -Ductus venosus -Ductus arteriosus -Foramen ovale -These structures themselves play a role in bypassing the fetal lungs in the fetal circulatory system b/c the fetus isn't breathing in oxygen the way we do so they do not require the lungs to have the relationship they do in a fully developed human body -Changes in fetal circulation after birth (structures we needed in utero to bypass the lungs are no longer need as the baby starts to breathe oxygen in from the room. -Changes after birth: fetal circulatory shunts are not needed; oxygenates blood in the lungs (instead of through shunts); not circulating blood to the placenta

What are the changes in fetal lung fluid during pregnancy and labor and after birth?

-Fetal lungs produce fluid to allow normal development of the airways, but lung fluid must be cleared to allow normal air breathing after birth. -As term nears production of fetal lung fluid decreases by 65%. Labor speeds up the absorption of the fluid so only 35% of max amount remains at birth. -Some fluid is expelled from the upper airways as the fetal head and thorax are compressed during passage through the birth canal -Most of the remaining lung fluid is absorbed into the interstitial spaces of the newborn's lungs and then into the circulatory system

Quickening

-First fetal movements felt by the mother

Components of the Birth Process: Powers

-Forces acting to expel fetus; primarily by involuntary uterine contractions, secondarily by voluntary bearing down *Uterine Contractions:* -Primary force that moves the fetus through the maternal pelvis -functions of uterine contraction are effacement and dilation *Maternal Pushing Efforts:* -Woman feels an urge to push and bear down (with contractions) as the fetus descends her vagina and puts pressure on her rectum -She needs to be 10 cm dilated and 100% effaced to start exerting her pushing efforts

Third Stage of Labor

-From delivery of infant to delivery of placenta -5 to 30 min (but can be up to an hr) -sudden gush of blood -lengthening of the cord (sudden lengthening of the cord, blood rush -rising of the fundus -globular uterus *Nursing care for 3rd stage of labor:* -Assess for placental separation -inspection of placenta -monitor VS -initiate breast feeding -administer oxytocin and anti-lactation agents as ordered -Sending cord blood to lab if mother is O-positive or Rh-negative -allow bonding

Second Stage of Labor

-From full dilation to delivery of the fetus (30-60 minutes for primigravida and 20 minutes for multipara) -maternal effort/pushing stage 1. Phase one: station is 0 to +2; contraction is 2-3 minutes apart 2. Phase two: station is +2 to +4; contraction is 2-2.5 mins apart with urgency to bear down 3. Phase 3: station is +4 to birth; contraction is 1-2 minutes apart; fetal head visible, increased urgency to bear down *Nursing Care for Second Stage of Labor:* -Prepare for delivery 8-9 cm for multigravidas and full dilation for primiparas -Monitor VS and FHR -Prepare perineal area -Encourage pushing with contractions -Immediate newborn care

Sexual Development: Prenatal

-Genetic sex is determined at conception -Reproductive systems of males and females are similar for the first 6 weeks after conception and have similar reproductive organs during this development -Differentiation of the external genitalia is complete at about 12 weeks -Both ovaries and testes secrete their primary hormones (sex hormones)

What is the difference between gravida and para?

-Gravida refers to the number of pregnancies a woman has had (regardless of the length of the pregnancy) -Para refers to the number of pregnancies that have ended at 20 or more weeks, regardlesss of whether the infant was born alive or stillborn (para = # of deliveries at 20 or more weeks)

Critical Thinking

-Helps nurse make the best clinical judgements *Steps:* -Recognizing assumptions -Examining biases -Determining the need for closure -Becoming skillful in data management -Acknowledging emotions and environmental factors

Hormones of Pregnancy (From video)

-In the 3rd week of pregnancy, a few days after the fertilization of the egg cell, the embryo moves through one of the two fallopian tubes toward the uterus -The hormone progesterone prepares the lining of the uterus for the implantation of the embryo -The lining of the uterus becomes thicker in the ultrasound image. This thickening of the uterus lining, which is well supplied with blood, is clearly visible -The follicle is located in one of the ovaries. The egg was released about 1 week ago. In the meantime, the follicle has become the site of the production of progesterone. The fertilized egg itself is not visible with ultrasound b/c it is still too small -The implantation of the embryo in the lining of the uterus is a particularly critical phase of pregnancy. Immunologic incompatibilities for example may result in rejection of the embryo by the immune system of the mother. The embryo is passed off almost unnoticed. According to estimates this happens in the early stages of almost 60% of all pregnancies In the 5th week of pregnancy (2 weeks after fertilization) the embryo is implanted in the lining of the uterus. Now in its chorion it begins to produce the pregnancy hormone human chorionic gonadotropin (hCG). This hormone is secreted in the urine of the expectant mother. With modern methods a few drops of urine are sufficient to perform a pregnancy test. The test may indicate positive results as early as 1 week after having missed a menstrual period, that is in the 5th week of pregnancy. -A blastocyst with a diameter of 3-6 mm has formed around the embryo. Even now the embryo is not yet visible in an ultrasound exam. But its location is revealed by the developing blastocyst that has been created. A definite thickening of the uterine lining can be seen around it, a seam has formed -During this week the blastocyst reaches the size of approximately 1 cm. It is filled with fluid, and for that reason it appears dark on the ultrasound image -The embyro begins its development as an embryonic disk (in the video it is shown as blue). It is positioned between two liquid filled vessicles. The liquid filled vessicle on the left (shown in yellow) is the amniotic cavity. At first it is so narrow that it cannot be seen in the ultrasound image. However, the liquid filled vessicle on the right (the yolk sac on the side of the embryo which in the future will be the abdomen) is visible within the amniotic sac. It is surrounded by a thin membrane, which is shown in shadow on the ultrasound image. The diameter of the yolk sac can be measured by the ultrasound device. It is 3.3 mm -The disk shaped embryo is located between the yolk sac and the amniotic cavity. It is still too small to be detected by ultrasound, and thus remains invisible to us. During this phase of pregnancy, the first ultrasound examination is performed by the physician, he/she investigates whether the fertilized egg has been implanted in the uterus, or whether it has perhaps remained in the fallopian tube. -If the embryo is to be found in the uterine lining the probability of a tubal pregnancy is quite small, nevertheless in order to be certain the fallopian tubes are examined for swelling.

Female Breast: Function

-Inactive until puberty -Increased estrogen level stimulate growth *Pregnancy:* -High levels of estrogen and progesterone influence breast tissue -Prolactin secretion by anterior pituitary; Prolactin starts being made during pregnancy and is only secreted during lactation (post partum) -Active milk production occurs in response to the infant's suckling (can occur as well during the 2nd and 3rd trimesters) -Breast milk is made from mother's red blood cells -Milk travels from ducts --> lactiferous sinuses --> nipple and milk comes out (let down) -during this "let down" period mom feels tinging in ducts

Maternal Respiratory system (during labor)

-Increase depth and rate of respirations (makes sense b/c they've increased their cardiovascular volume, they've increased their weight, they have a larger organ, and they have a fetus to accommodate for) -Hyperventilation: It may occur with rapid and deep breathing; Respiratory alkalosis occurs as she exhales too much carbon dioxide; She may feel tingling of her hands and feet, numbness, and dizziness, light headed -The nurse should help her slow her breathing and breathe into a paper bag or her cupped hands to restore normal blood levels of carbon dioxide and relieve these symptoms. Encouraging that big deep inhale and slow exhale to restore the normal blood level of carbon dioxide

Changes in Respiratory System

-Increased oxygen consumption (makes sense b/c the uterus is requiring increased amounts of RBCs for the fetus to develop, will put a higher demand on oxygen) -Hormonal factors can influence the respiratory system: Progesterone & estrogen *Physical effects of the enlarging uterus:* -Causes temporary but uncomfortable compression -Lifting diaphragm (compression of the diaphragm, pushing it up) -Also can cause compression on lungs -Relaxation of the ligaments around the ribs can cause some undue chest pain during pregnancy. This relaxation of the ligaments is caused/influenced by a hormone called relaxin. Relaxin promotes stretchiness of the cartilage in these ligaments (relaxin works in the ligaments of the ribs and pelvis → in the pelvis it allows the baby to have a better fit in the pelvis) -Can cause some shortness of breath and chest pressure related to the uterus/growing fetus compressing the diaphragm

Which pregnancy-induced changes in pigmentation may occur in the following areas?

-Increased pigmentation from elevated levels of estrogen, progesterone, and melanocyte-stimulating hormone -Face:*Melasma*- (mask of pregnancy); areas of pigmentation include brown patches, involves the forehead, cheeks, and bridge of the nose -Breasts: areola become darker as pregnancy progresses -Abdomen: linea nigra- the line that marks the longitudinal division of the midline of the abdomen darkens

Changes in Reproductive System: Vagina and Vulva

-Increased vascularity: going to affect areas of high circulation such as vagina and vulva -The vaginal mucosa thickens -Vaginal rugae become more prominent (d/t vascularity) Increased production of lactic acid

Contraction Cycle

-Increment (period of increasing strength) -Acme (period during which the contraction is most intense) -Decrement (period of decreasing intensity as the uterus relaxes)

Amnioinfusion

-Infusion of a sterile solution into the amniotic cavity to reduce cord compression

Why is progesterone essential in pregnancy?

-It maintains pregnancy. Helps suppress contractions of the uterus and may also help prevent tissue rejection of the fetus -Progesterone is produced first by the corpus luteum and then by the placenta

Multifetal pregnancy

-More than one zygote developing and implanting -Monozygotic: single ovum and sperm, with later division -Dizygotic: two ova that are fertilized by different sperm (so they are individual zygotes) -Multifetal pregnancies are higher risk

Confirmation of Pregnancy: Presumptive Indicators

-Most, but not all, presumptive indicators are subjective changes that are experienced and reported by the woman. These changes are the least reliable indicators of pregnancy b/c they can be caused by conditions other than pregnancy -Amenorrhea -Nausea and vomiting -Fatigue -Breast and skin changes -Vaginal and cervical color changes (probable?) -Fetal movement

Common discomforts of Pregnancy

-Nausea and vomiting -Heartburn (d/t decreased GI motility) -Backache (b/c center of gravity changes) -Round ligament pain (compression of nerves in pelvis) -Urinary frequency -Varicosities: thickening of vascularity esp in lower extremities -Constipation -Hemorrhoids -Leg cramps

Antepartum Assessment & Care: Multifetal Pregnancies

-Now taking care of 3 or more pts depending on how many fetuses have implanted -Maternal physiological changes are greater w/ multiple fetuses → important to assess -There is an increased workload for the heart -Respiratory difficulty increases -Early diagnosis if possible -Special antepartum classes -More frequent visits and ultrasounds -Teach signs of preterm labor → multifetal preg at higher risk for preterm labor -May be at higher risk for diabetes, preeclampsia, hypertension in pregnancy

How can nursing measures help increase a woman's sense of control during labor?

-Nursing measures that promote relaxation and reduce anxiety and fear as well as provide information allows the woman to maintain a sense of control during labor. Having a sense of control during labor increase the woman's sense of satisfaction with her birth experience.

Confirmation of Pregnancy: Probable Indicators

-Objective findings that can be documented by an examiner. They are primarily related to physical changes in the reproductive organs. Although these signs are stronger indicators of pregnancy, a positive diagnosis cannot be made b/c they may have other causes -Abdominal enlargement w/ a gravid uterus -Cervical softening (goodell's sign) -Chadwick's sign -Changes in uterine consistency (thickens early on, thins later on) -Ballottement -Braxton Hicks Contractions: dress rehearsal of labor (uterus contracts and relaxes) -Palpation of the fetal outline -Uterine souffle -Pregnancy tests will be positive

Ovaries and fallopian tubes (internal female reproductive organs)

-Ovaries and fallopian tubes are organs that play a major role in conception and fetal development Notes: -Ovaries are not attached to fallopian tubes. Fallopian tubes have finger-like projections off of them that move and helps collect the egg from the ovary -Uterine artery and vein are blood supply to the fetus **Fertilization of the ovum takes place in the AMPULLA (outer 1/3rd of tube) of the fallopian tube

Changes in Reproductive Body System: Uterus

-Physical growth -Pattern of growth as the fetus continues to grow and uterus gets larger, specific pattern that mimics gestational weeks -Contractility: the uterus is able to contract, soften, and then contract in order to be able to deliver the baby -Uterine blood flow changes significantly during pregnancy *Uterus Growth:* -Before pregnancy: 50-70 g (1.8-2.5 oz), capacity: 10 ml volume -36 weeks (late preterm) 800-1200 g (1.8-2.6 lb), capacity: 5000 ml volume -Growth is due to hyperplasia and hypertrophy -1st trimester: estrogen stimulation -Wall thickens during early pregnancy -Wall thins during late pregnancy (can palpate fetal parts) *Measure Fundal Height to determine patterned growth of the uterus:* -The numbers that are midline indicate fundal height typically at that weeks gestation

Antepartum Assessment & Care Review

-Preconception visit -Initial prenatal visit: history, vital signs, physical exam -Subsequent assessments: warning signs, multifetal pregnancies, common discomforts of pregnancies, cultural considerations

Confirmation of Pregnancy

-Presumptive indicators -Probable indicators -Positive indicators

What mechanism prevents onset of puberty before the proper time?

-Production of even tiny amounts/quantities of sex hormones by the young child's ovaries or testes inhibits secretions of the hypothalamus (GnRH), preventing premature onset of puberty -An unknown area of the brain prevents the young child's hypothalamus from responding to estrogen and testosterone secretion by the ovaries or testes. W/o GnRH from the hypothalamus, further estrogen or testosterone secretion ceases

Changes in Reproductive System: Ovaries

-Progesterone must be present in adequate amounts (one of the hormones that drives pregnancy itself) -Corpus luteum of the ovaries secretes progesterone -Ovulation ceases during pregnancy b/c focus is on developing fetus

Therapeutic Communication (changing role of nurses)

-Purposeful, goal directed, and focused *Guidelines:* -Restful setting -Introductions and clarification of the nurse's role -Focused and directed toward meeting the family's needs -Nonverbal behaviors of family -Attending behavior that conveys interest -Cultural awareness -Clarifying communication -Reflect emotion -Techniques to facilitate communication: clarifying, paraphrasing, reflecting, silence, structuring, pinpointing, questioning, directing, summarizing -Behaviors that block communication: conveying lack of interest, conveying sense of haste, closed posture, interrupting, finishing sentences, providing false reassurance, inappropriate self-disclosure, giving advice, failure to acknowledge comments or feelings

Maternal Urinary System (during labor)

-Reduced sensation of a full bladder (esp as fetal head begins to compress the bladder itself) -Full bladder can inhibit fetal descent -Occupies space in the pelvis -So mom's are encourage to empty their bladder at least once per hour during labor to increase space in the pelvis

Sexual development: Sexual Maturation

-Reproductive organs become functional at puberty -Primary and secondary sex characteristics are also developed during this period of sexual maturation *Initiation of Sexual maturation:* -Puberty occurs in an orderly sequence. Hypothalamus is responsible for helping to initiate this sequence -Hypothalamus secretes gonadotropin-releasing hormone (GnRH); GnRH from hypothalamus leads to cascade b/c hypothalamus controls pituitary so GnRH leads to FSH being released to the ovaries and GnRH leads to pituitary producng LH -Anterior pituitary secretes follicle stimulating hormone (FSH) and Luteinizing hormone (LH) -Ovaries and testes increase production of sex hormones (they are the driving force of the sex hormones) -Gametes mature in response to higher levels of FSH and LH -Secondary sex characteristics develop (due to sex hormones)

Summarizing

-Reviewing the main themes or issues that were discussed -"You had two major concerns today", "We have talked about breastfeeding and how to bathe the baby today"

Why is pregnancy risk assessment not a one time evaluation?

-Risk assessments must be updated throughout pregnancy b/c risk factors change throughout pregnancy; risk factors that were not apparent early in pregnancy can appear later on in preg

Leydig cells

-Secrete testosterone in the male

Sexual development: Childhood

-Sex glands are inactive during infancy and childhood (even though hypothalamus and sex organs are present) -The hypothalamus stimulates gonads to produce hormones at sexual maturity and that is what kick starts the active part of sexual development

Why are the sutures and fontanels of the fetal head important during birth?

-Sutures and fontanels of the fetal head are important during birth b/c they permit slight movement of the bones in the fetal head during birth so that it can adapt to the size and shape of the pelvis by molding

What changes in the urinary system make the pregnant woman more susceptible to infection?

-The bladder mucosa becomes congested w/ blood, and the bladder walls become hypertrophied as a result of stimulation from estrogen. -Decreased drainage of blood from the base of the bladder results in edema of its tissues and renders the area susceptible to trauma and infection during childbirth

What factors contribute to a woman's sense of dyspnea?

-The enlarging uterus lifts the diaphragm about 4 cm. The ribs flare, the substernal angle widens, and the transverse diameter of the chest expands by about 2 cm to compensate for the reduced space. They result from the hormone relaxin, which causes relaxation of the ligaments around the ribs. Breathing becomes more thoracic rather than abdominal adding to the dyspnea. -Progesterone along with prostaglandins are responsible for the heightened awareness of the need to breathe experienced by many women during pregnancy

Why must the fetal head and shoulders undergo rotation within the pelvis?

-The fetal head begins descent with the sagittal suture oriented in a transverse (Crosswise) or oblique orientation to the woman's pelvis. As the head descends, it rotates so that the head is oriented with the sagittal suture in an anterior-posterior orientation to the woman's pelvis. After the fetal head is born, the fetal shoulders are then transverse in the pelvis and must rotate to pass under the pubic arch and be born

Components of Birth process: interrelationship of the four Ps

-The four Ps are actually an interrelated whole -The nurse can act as an ADVOCATE for the laboring woman and her support person to increase their sense of control and mastery of labor, which often REDUCES ANXIETY AND FEAR and helps them ACHIEVE THEIR DESIRED BIRTH -Really considering the RN's role as facilitator for the labor and birth, advocate for a good labor and birth experience, helping to influence that psyche

What causes the heartburn that often occurs in pregnancy?

-The lower esophageal sphincter tone decreases during pregnancy, primarily b/c of the relaxant activity of progesterone on the smooth muscles. These changes along with upward displacement of the stomach, allow gastroesophageal reflux of the acidic stomach contents into the esophagus and produces heartburn (pyrosis)

Components of the Birth Process: Passenger

-The passenger is the fetus, membranes, and placenta (anything that is a product of conception and needs to make its way out after delivery) -Several fetal anatomic and positional variables influence the course of labor -If the baby is in position where they're facing up at the ceiling and the occiput is in the posterior part of the pelvis, it'll make for a more challenging labor process *Fetal Head:* -Cephalic presentation (vertex presentation): For vaginal delivery we need baby to be head first typically esp in first time moms -Sutures the two frontal bones on the forehead: We use the sutures of the two frontal bones on the forehead as landmarks to assess fetal position; Two parietal bones at the crown of the head; Occipital bone at the back of the head -Fontanels: Wider spaces at the intersections of the sutures connecting skull bones, helps the fetal bones to overlay eachother a little to get through the passageway; Anterior fontanel: diamond shape; Posterior fontanel: triangular shape -Fetal Head Diameters (allows fetal head to kind of mold and shape- sometimes cone shape) so it can get through the passageway for a vaginal delivery

What must the nurse consider when evaluating intrauterine pressures from a solid catheter vs a fluid catheter

-The pressures from a solid intrauterine pressure catheter are slightly higher than those of the fluid-filled catheter. A fluid-filled catheter is sensitive to the height of the catheter tip in relation to the transducer

What changes allow the woman to obtain the increased oxygen needed during pregnancy?

-The tidal volume (volume of gas moved into or out of the respiratory tract with each breath) increases by 30-40%. -To compensate for the increased need, progesterone causes the woman to hyperventilate slightly by breathing more deeply, although her respiratory rate remains unchanged

Electronic Fetal Monitoring

-The top band (pink) will measure the frequency and duration of uterine contractions -The bottom band (blue) will monitor the FHR. It is placed on the maternal abdomen dependent upon the fetus's position in utero

Reproductive System: Uterine Body

-The upper two thirds of uterus contracts actively to push the fetus down (creates pressure on the cervix and helps push the baby down, creating that pressure on top of the cervix also helps to thin out (effacement of) the cervix, also helps to promote dilation) -The lower one third of the uterus remains less active -The cervix is also passive

Describe the differences in how the upper and lower parts of the uterus contract during labor. Why is it important that the parts have dif contraction characteristics?

-The upper uterus contracts actively to push the fetus downward, whereas the lower uterus is more passive (remains less active) to reduce resistance to fetal passage into and through the pelvis (promotes downward passage of the fetus) -Any other pattern would be ineffective at pushing the fetus out -The opposing characteristics of contractions in the upper and lower uterine segments changes the shape of the uterine cavity, which becomes more elongated and narrow as labor progresses. This change in uterine shape straightens the fetal body and efficiently directs it downward into the pelvis

Why is it important for the uterus to remain firmly contracted after birth?

-The uterus must contract firmly and remain contracted after the placenta is expelled to compress open vessels at the implantation site. Inadequate contraction after birth may result in hemorrhage.

Fourth Stage of Labor

-Time from delivery of placenta to homeostasis (first 4 hrs after delivery of the placenta) -Allow baby/mom to bond -May initiate breast feeding -not a lot of teaching b/c they're on cloud 9; need to bond *Nursing care for 4th stage of labor: -monitor VS every 15 mins -take fundal height, position and consistency -assess for lochia -check perineum -perform perineal care from front to back -post partum care *Labor is a coordinated sequence of involuntary contractions resulting in effacement and dilation of cervix followed by expulsion of conception

Nursing research

-To improve client outcomes -To be cost effective -Evidence-based guidelines promote application of the best available scientific evidence

Vagina (Internal female reproductive organs)

-Tube of muscular and membranous tissue -Lining has multiple folds -Lubricated by secretions of the cervix and bartholin glands *Major Functions of the Vagina:* -Allows discharge of menstrual flow -Female organ of coitus -Allows passage of the fetus to outside the mother's body during childbirth

Directing

-Using nonverbal responses or succinct comments to encourage the person to continue -Ex. nodding. "um-mm", "you were saying?", "Please go on"

When during pregnancy does each of these markers in fundal height occur?

-Uterus can first be palpated above symphysis pubis: *12 weeks* -Fundus can be palpated about halfway between symphysis pubis and umbilicus: *16 weeks* -Fundus is at level of umbilicus: *20 weeks* -Fundus is at xyphoid process: *36 weeks* -At *40 weeks* descent of the fetal head into the pelvic cavity, called lightening, causes the uterus to sink to a lower level, so fundal height will be a little lower than it was at 36 weeks.

Why is variability an important component of fetal heart pattern evaluation? Under what circumstances might variability be minimal? Why?

-Variability reflects normal function of the autonomic nervous system, which helps the fetus adapt to the stress of labor. Minimal variability might be normal in prematurity or fetal sleep or after maternal narcotics or sedative administration b/c these conditions do not reflect reduced nervous system oxygenation. Fetal sleep would be temporary, and variability should reappear when the fetus awakens, usually in approximately 40 minutes at term. Narcotic effects would last longer but would still be temporary

Reflecting

-Verbalizing comprehension of what the patient said and what she seems to be feeling. It is important to link content and feeling and to reflect the woman as a mirror reflects a person. The opinion, values, and personality of the nurse should NOT be in the reflected image Ex. Woman: "Idk what to do. My husband doesn't think a c-section is needed, but the doctor says the baby is showing some stress" -Nurse: "You're confused and frightened b/c they don't agree?"

Variable deceleration (electronic fetal monitoring)

-Visually apparent abrupt decrease in FHR -At least 15 bpm below the baseline, lasting at least 15 seconds and less than 2 min in duration Notes: -Variable decelerations fall somewhere between early and late decelerations. -They are usually caused by cord compression, therefore very quickly the FHR drops and then recovers very quickly. -Usually in the shape of a V, W, or sometimes a U. It is a very obvious drop in FHR with a very quick recovery. -Some are related to contractions and some aren't (but not a consistent pattern always matching contractions) *Nursing Interventions for variable decelerations:* -Understanding that a variable deceleration is caused by cord compression, the first nursing intervention would be a *change of position in the client*, however if the variable decelerations do not change after repositioning we would notify the provider. -Many variable decelerations right/correct themselves with a change in position of the mom. Either the baby is lying on the cord, or perhaps the cord is caught between the baby's arm and leg, usually can resolve itself with position change, but if not notify provider.

Late deceleration (electronic fetal monitoring)

-Visually apparent usually symmetrical gradual decrease and return of FHR associated with a uterine contraction -Delayed in timing, in most cases, the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction respectively. Notes: -Late Decelerations: not okay to be late; Highly UNDESIRABLE! -Something is going on with the baby to cause a decrease in fetal HR and the baby is unable to recover from whatever is going on. -Late deceleration is usually a really gradual decrease and return to FHR caused by a lack of blood flow during a uterine contraction. -However, in terms of timing, the onset, nadir, and recovery of the deceleration occurs after the contraction is over (whereas with early deceleration we see a mirror like relationship between the contraction and FHR.) but with late decelerations the contraction is completely over and then we see the gradual decrease in FHR. -You can go up the contraction (increment, acme) and then the decrement down and the contraction ends, but the decrease in FHR is continuing. This pattern continues throughout these contractions. The FHR has not recovered even though the contraction has ended. *Nursing Students need to know what to do:* -Late decelerations are a sign of poor oxygenation and several nursing interventions are required. -In no particular order nurse wants to *change the pt's position, apply oxygen by face mask, turn off the Pitocin if it is running, and also notify the provider.* This is an *emergency situation* that needs to be tended to immediately.

Early deceleration (electronic fetal monitoring)

-Visually apparent usually symmetrical, gradual decease and return of the FHR associated with a uterine contraction -In most cases, the onset, nadir, and recovery of the deceleration are coincident with the beginning, peark, and ending of the contraction, respectively, Notes: -Early decelerations are okay! "It's okay to be early for dinner but it's not okay to be late!" -Early decelerations are expected during labor b/c when mom is contracting regularly the pressure of the mother's uterus on the baby's head during a contraction causes a subtle decrease in the fetal HR which exactly mirrors the length of a contraction. -As the contraction begins you will see a very subtle decrease in the fetal HR that will match what is happening with the uterine contraction. Visualize the contraction as a mountain, going up the left side is the increment of the contraction, the top is the acme, and then the decrement of the contraction. In most cases the onset, nadir, which is the peak of the deceleration, and the recovery of the deceleration coincide exactly with the increment, acme, and decrement of the contraction *Document early decelerations as a normal finding*

Silence

-Waiting and allowing time for the pt to continue. Verbal communication need not be constant Ex. the nurse waits quietly for the pt to continue

Why might a man who usually wears very tight underwear have a problem w/ infertility?

-Wearing very tight underwear could cause the testes to held closer to the body which would cause them to be very warm. If too warm, it could suppress normal sperm production, causing infertility issues

Primipara

-Woman who has given birth once after a pregnancy of at least 20 weeks

Changing Role of Nurses

-Work in a variety of highly specialized areas -Assume primary responsibility for independent functions -Teach, counsel, and intervene for a wide variety of nonmedical problems -Interpersonal skills: Communication, Effective teaching, Critical thinking

Uterine contractions (electronic fetal monitoring)

-assessment of uterine contractions looks at the number of contractions during a 10 minute window, averaged over 30 minutes -Normal: < 5 contractions in 10 minutes *Hypertonic uterine contractions:* can be very strong and very close together. -Very difficult for the mother to manage and dangerous for the fetus. -Want to make sure the mother is given a rest period between the contractions, because it is at this time (between contractions) when blood is sent to the fetus. -The rest time between contractions, is also the best time to assess mother's vital signs, esp blood pressure, b/c it is when she is at rest. -Knowing what you do about how to read the fetal monitoring strip with the thick red lines being 1 minute. How we measure the distance between contractions if we are to document something like "contractions are occurring every 2-3 minutes". -When we measure the frequency of contractions we measure from the beginning of one contraction to the beginning of the next contraction.

Nuchal cord

-cord around the fetus's neck

Tocolytic

-drug that reduces the uterine muscle contractions

3 types of decelerations (electronic fetal monitoring)

-early decelerations -late decelerations -variable decelerations

List factors that might decrease variability

-fetal sleep (usually lasting 40 min or less at term, but may last up to 2 hrs) -narcotics or other sedative drugs such as magnesium sulfate given to the woman -alcohol/ilicit drugs -fetal sepsis -fetal tachycardia -extreme prematurity -fetal anomalies that affect CNS regulation of the HR such as anencephaly -Hypoxia that is severe enough to affect the CNS -Abnormalities of the CNS, heart, or both -Maternal acidemia or hypoxemia (reduced blood O2 or low PO2)

variability

-fluctuations in the baseline FHR

Components of the Birth Process: Psyche

-how the maternal experience can influence/impact labor and birth -response to labor, perceptions and beliefs, pre-natal care and education, support systems and communication skills -Anxiety -Culture and expectations -Birth as an experience -Support (is mom supported or no? Does she have people in the room to help?) -Impact of Technology

Brown fat (fetal structures/substances)

-special heat-producing fat deposited during this period that helps the newborn maintain temperature stability after birth. It is located on the back of the neck, behind the sternum and around the kidneys

Periodic FHR changes

-temporary recurrent changes in the fetal HR

Nagele's rule

-to calculate the EDD -subtract 3 months from the date the last menstrual period began and add 7 days and then correct the year if necessary -Ex. if last menstrual period started on Feb 4th, 2018 --> Nov 4th + 7 days = Nov 11th, 2018 -Ex. Aug 2, 2018--> May 2 + 7 days = May 9, 2019

Which anatomic reference point is used for each presentation or position when stating fetal position?

-vertex: occiput (O) -Face: mentum/chin (M) -Breech: sacrum (S)

Check yourself Questions ch 7

1. A preg women expects to give birth to her first baby in approximately 1 week. She asks the nurse whether she has a bladder infection b/c she urinates so much, even though urination causes no discomfort. The nurse should explain to her that b. her fetus is probably lower in her pelvis, and this puts more pressure on her bladder 2. The nurse will be concerned about anemia that is not physiologic if a woman in her 2nd trimester has a hemoglobin level less than 10.5 g/dl (11 g/dl if 1st or 3rd trimester) 3. Slight hyperventiliation during pregnancy enhances the d. transfer of fetal carbon dioxide to maternal blood 4. A preg woman is prone to urinary tract infection primarily b/c b. nutrients that enhance bacterial growth are excreted by her rkidneys 5. A preg woman complains that her hands become numb at times. Neither hand is inflamed or discolored. The nurse should explain to the woman that d. increased tissue fluid is causing compression of a nerve 6. A preg woman has a glucose challenge test at 26 weeks of gestation. The result is 128 mg/dl. The nurse should expect that: a. no additional glucose testing will be needed (140 or higher need the 3 hr test) 7. Mrs. J tells you that she occasionally has a sharp pain in her right side. The pain does not last long but worries her c. she should bend toward the pain or sharply flex her leg to relax the round ligament 8. A pregnant woman asks the nurse about skin changes during her pregnancy. The nurse tells her that a. the striae will fade to silvery lines

Check Yourself Questions

1. An important purpose of seminal fluid is to c. protect sperm from the acidic vaginal environment 2. Fertilization is complete when a. fusion of the sperm and ovum nuclei occurs 3. The embyro is fully implanted in the uterus on which day after conception? c. 10 4. Which fetal circulatory structure carries blood with the highest oxygen concentration? b. umbilical vein 5. What substance is the primary energy source for the fetus? a. glucose 6. What is the significance of a fetal hemoglobin level of 13 g/dl and a hematocrit value of 39%? d. anemia reduces the oxygen carrying capacity of the fetal blood

State three functions of amniotic fluid

1. Cushions against impacts to the maternal abdomen 2. Maintains a stable temperature 3. Promotes normal prenatal growth and development by the following actions: a. allowing symmetric development as the major body surfaces fold toward the midline; b. preventing the membranes from adhering to the developing fetal parts; c. allowing room and buoyancy for fetal movement

List the three germ layers and the structures that develop from each

1. Ectoderm: brain and spinal cord, peripheral nervous system, pituitary gland, sensory epithelium of eye, ear, nose, epidermis, hair, nails, subcutaneous glands, mammary glands, tooth enamel 2. Mesoderm: cartilage, bone, connective tissue, muscle tissue, heart, blood vessels, blood cells, lymphatic system, spleen, kidneys, adrenal cortex, ovaries, testes, reproductive system, lining membranes (pericardial, pleural, peritoneal) 3. Endoderm: lining of GI and respiratory tracts, tonsils, thyroid, parathyroid, thymus, liver, pancreas, lining of urinary bladder and urethra, lining of ear canal

Check yourself Questions Ch 14

1. Firm contractions that occur every 2-2.5 min and last 100 seconds (1 min and 40 secs) may reduce fetal oxygen supply b/c they c. reduce time for oxygen exchange in the placenta 2. The expected response of the fetal HR of a term fetus to movement is b. acceleration of 15 or more bpm for 15 seconds 3. The nurse notes a pattern of variable decelerations to 75 pbm on the fetal monitor. The initial nursing action should be to a. reposition the woman 4. The woman who uses cocaine is more likely to have which pattern on the electronic fetal heart monitor d. late decelerations 5. The tocotransducer should be placed b. in the fundal area 6. The nurse should respond to incomplete uterine relaxation b/w contractions by c. contacting the physician for a tocolytic order 7. A woman is admitted in possible labor at 34 weeks of gestation. She is monitored with the external fetal monitor while on her left side. The nurse should periodically assess the contractions by palpation, primarily b/c d. the tocotransducer is not accurate for actual intensity and uterine resting tone 8. Choose the important precaution to be taken when a solid intrauterine pressure catheter is used to monitor uterine contractions during labor a. the pressure reflects the pressure of the fluid above, as well as the pressure of the contraction 9. The nurse notes a pattern of decelerations on the fetal monitor that begin shortly after the contraction begins and returns to baseline just before the contraction is over. The correct nursing response is to d. continue to observe and record the normal pattern

Four Major Factors that Interact During Normal Childbirth: 4Ps (Components of the Birth Process)

1. Powers: Maternal power of effort (pushing) & uterine contractions 2. Passage: birth canal (vagina) 3. Passenger: fetus 4. Psyche: Maternal outlook & experience of labor & delivery *Interrelationship of these components

List three reasons why the fundus is the best area for implantation

1. The fundus (uppermost part of the uterus) has *rich blood supply* for optimal fetal gas exchange, nutrition, and waste elimination 2. The *uterine lining is thick in the fundus*, preventing the placenta from attaching too deeply into the uterine muscle and facilitating easy expulsion of the placenta after full term birth 3. Implantation in the fundus *limits blood loss* after birth because strong interlacing muscle fibers in the area compress open endometrial vessels after the placenta detaches

Check yourself Questions

1. The gender of an infant will be female unless: b. the short arm of the Y chromosome is received from the father 2. The primary purpose of GnRH is to stimulate the: d. secretion of FSH and LH from the anterior pituitary gland 3. The first outward change of puberty in girls is: b. enlargement and development of the breasts 4. Choose the girl who is most likely to have secondary amenorrhea b. Brittney, 17 yrs old, who is preparing for a national gymnastics tournament 5. Males are usually taller than females when they reach their adult height because: d. the puberty growth spurt begins later and continues for a longer time 6. The layer of uterine muscle that is most active during labor is composed of fibers is which of the following? a. longitudinal 7. The layer of uterine tissue that responds to cyclic changes in hormones secreted by the pituitary gland is the: c. endometrium 8. Conditions that cause the fallopian tubes to be narrower than normal may result in: d. implantation of a fertilized ovum within the tube 9. Extra follicles that remain after ovulation: d. are never active in another reproductive cycle 10. Menstruation occurs because the: a. hormone stimulation from the corpus luteum ceases 11. Milk is manufactured within the ____________ of the breast. b. alveoli 12. The primary purpose of the cremastor muscle is to c. keep the testes cooler than the rest of the body 13. Erection of the penis occurs when a. blood is trapped within the organ's spongy tissue

What are the major events that occur immediately after fertilization?

1. The zona pellucida (surrounding the ovum) prevents other sperm from entering 2. The cell membranes of the ovum and sperm fuse and break down, allowing the contents of the sperm head to enter the cytoplasm of the ovum 3. The ovum (which has been suspended in the middle of its second meiotic division since just before ovulation) completes meiosis. This results in a nucleus w/ 23 chromosomes and the expulsion of a second non functioning polar body. The mature ovum now contains 23 unpaired chromosomes in its nucleus

Check yourself Questions ch 12

1. When assessing a laboring woman's BP, the nurse should b. check the blood pressure between two contractions 2. A woman is admitted in active labor. Her leukocyte count is 14,500/mm3. Based on this info the nurse should d. record the expected results in the woman's chart 3. The most appropriate time for the nurse to assist a laboring woman to push is c. during the second stage of labor 4. The abbreviation LOA means that the fetal occiput is: b. in the left front part of the mother's pelvis 5. Choose the most reliable evidence that true labor has begun: b. change in the amount of cervical thinning 6. The nurse should note how long the interval b/w contractions lasts because c. most exchange of fetal oxygen and waste products occurs at this time 7. What is the primary benefit of the stress of labor to the newborn? a. it stimulates breathing and elimination of lung fluid 8. Choose the abbreviation that represents the fetal presentation and position that is most favorable for vaginal birth a. LOA 9. A station of +1 means that the d. fetal presenting part is 1 cm below the mother's ischial spines

List the 5 factors that affect fetal oxygenation

1. normal maternal blood flow and volume to the placenta 2. normal oxygen saturation in maternal blood 3. Adequate exchange of oxygen and carbon dioxide in the placenta 4. An open circulatory path between the placenta and the fetus through vessels in the umbilical cord 5. Normal fetal circulatory and oxygen carrying functions

Girls usually experience their first menstrual period..

2-2.5 yrs after the first outward change associated with puberty

Puberty begins in girls at an average age range of

8-13

What routine urine testing is done during prenatal visits?

A clean catch midstream urine sample is tested for urinary tract infection and substances that may indicate a problem -protein: although a trace amount of protein may be present in the urine, the amount should not increase. Its presence may indicate kidney disease, preeclampsia, or contamination by vaginal secretions -Glucose: small amounts of glucose may indicate physiologic "spilling" that occurs during normal pregnancy -ketones: ketones may be found in the urine after heavy exercise or as a result of inadequate intake of food and fluid -Bacteria: increased bacteria in urine is associated w/ urinary tract infection, which is common during pregnancy

vernix caseosa (fetal structures/substances)

A fatty, cheese-like secretion of the fetal sebaceous glands, covers the skin to protect it from constant exposure to amniotic fluid

Surfactant (fetal structures/substances)

A surface active lipid that makes it easier for the baby to breathe after birth. Surfactant reduces surface tension in the lung alveoli and prevents them from collapsing w/ each breath; a surface active lipid substance that helps alveoli remain slightly open between breaths to ease the work of air breathing

Hydramnios

Abnormally large quantity of amniotic fluid

Oligohydramnios

Abnormally small quantity of amniotic fluid

Why does the preg woman's bone mass remain stable, even though the fetus requires calcium for skeletal development?

Absorption of calcium from the intestines doubles during pregnancy, calcium is stored for use during the third trimester when fetal needs peak. Although 28-30 g of calcium from maternal bone stores is transferred to the fetus, this amount is small in comparison with total maternal stores and does not deplete the maternal bone density.

What causes physiologic anemia of pregnancy?

Both RBC volume and plasma volume increase, but the increase in plasma volume is more pronounced and occurs earlier. The resulting dilution of RBC mass causes a decline in maternal hemoglobin and hematocrit, which is called physiologic anemia of pregnancy, because it reflects dilution of RBCs in the expanded plasma volume, rather than an actual decline in the number of RBCs, and does not indicate true anemia (which is why it is also called pseudo anemia of pregnancy

Function of estrogen (placental hormone)

Cause enlragement of the woman's uterus, enlargement of the breasts, growth of the ductal system of the breasts, and enlargement of the fetal external genitalia. Estriol is the most plentiful estrogen produced during pregnancy

Function of human chorionic gonadotropin (hCG) (placental hormone)

Causes the corpus luteum to persist for the 1st 6-8 weeks of pregnancy and secretes estrogens and progesterones. Placenta eventually takes over this function and the corpus luteum regresses. -When a Y chromosome is present in the male fetus, hCG also causes the fetal testes to secrete testosterone (necessary for normal male reproductive structures)

Feedback loop

Change in the level of one secretion in response to a change in the level of another secretion

Cervical Changes During Female Reproductive Cycle

Changes in cervical mucus are noted: -Cervical mucus can become scant, thick, and sticky signifying differences in a woman's cycle -Just before ovulation: cervical mucus becomes thin, clear, and elastic -*Spinbarkeit:* the elasticity of cervical mucus which creates a hospitable environment for sperm to survive

Vulva

Collective term for all the female external reproductive organs

Characteristics of Contractions

Contractions are essentially the flexion and release/relaxation of a muscle *Coordinated:* -Frequency: beginning of one uterine contraction to the beginning of the next; Can be several intervals. At the beginning of labor contractions might be every 10-20 minutes, then as labor progresses might be every 2-3 minutes -Duration: beginning of a uterine contraction to the end of the same contraction -Intensity: strength of a contraction (mild, moderate, strong) *Involuntary:* -nothing the pt is doing is cause them to happen *Intermittent:* -In a spontaneous labor situation -As labor progresses contractions get stronger and closer together in interval

Structuring

Creating guidelines or setting priorities -"You said you don't know how to take care of the baby and also that you're afraid of getting pregnant again. What should we talk about first?"

Lightening

Descent of the fetus into the pelvis, reducing pressure on the diaphragm

Myoepithelial cells

Discharge milk into the ductal system of the breast

Function of progesterone (placental hormone)

Essential for normal continuation of pregnancy: -Causes secretory changes in the endometrium, providing nourishment as the conceptus enters the uterus (before placenta is established) -Causes changes in endometrial cells that convert them into the larger and thicker cells of the decidua, which characterize pregnancy -Reduces muscle contractions of uterus to prevent spontaneous abortions -May induce some immune tolerance in the mother's body for the conceptus (so mother's immune system tolerates fetus better) -Acts w/ estrogens and other hormones to cause growth of the breasts, budding of the alveoli that will secrete milk, and development of secretory characteristics in the alveolar cells of the breast

Preembryonic period

Fertilization to 2 weeks -Cell division: cells are rapidly dividing -Entry of the zygote into the uterus -Implantation into the decidua -Maintaining the decidua -Location of implantation -Mechanism of implantation

Ballottement

Fetal rebound in the amniotic fluid when the cervix is tapped

What changes occur in blood flow during pregnancy?

Five major changes in blood flow during pregnancy: 1. Blood flow is altered to include the uteroplacental unit 2. Renal plasma flow increases up to 30% to remove the increased metabolic wastes generated by the mother and the fetus 3. The woman's skin requires increased circulation to dissipate heat generated by increased metabolism during pregnancy 4. Blood flow to the breasts increases resulting in engorgement and dilated veins 5. The weight of the expanding uterus on the inferior vena cava and iliac veins partially obstructs blood return from veins in the legs. Blood pools in the deep and superficial veins of the legs causing venous distention. Prolonged engorgement of the veins of the lower legs may lead to varicose veins of the legs, vulva, or rectum

Linea terminalis

Imaginary line dividing the upper (false) pelvis from the lower (true) pelvis

Detailed Obstetric Notation

In an obstetrical history the gravida (G) and para (P) status of a woman is often written in abbreviated form. Where: Gravida is the number of pregnancies a woman has had. A multiple gestation counts as a single pregnancy. Para is the number of completed pregnancies beyond 20 weeks gestation (whether viable or nonviable). A multiple gestation counts as a single birth. For example a woman who has been pregnant 3 times (where one pregnancy was a set of triplets delivered at 36 weeks) had one term delivery, one preterm delivery (of her triplets), and one termination at 16 weeks would be described as: G 3 P 2 Expanded obstetric notation gives more detail: G- T-P-A-L = G=Gravida (Total number of pregnancies) T= Term births (Delivery at 37 or greater weeks gestation). P=Preterm births (Delivery at 20 to 36 6/7 weeks gestation). A=Abortions (Delivery before 20 weeks' gestation (elective or spontaneous)). L=Living children (Children who lived beyond the neonatal period). In expanded form the woman with triplets from the previous example would be described as G 3, T 1, P 1, A 1, L 4 indicating 3 pregnancies, 1 term delivery, 1 preterm delivery, 1 miscarriage or termination of pregnancy, and 4 living children.

Goodell's sign

Indication of pregnancy. It is a significant softening of the vaginal portion of the cervix due to increased vascularization during pregnancy. That vascularization is typically the result of hypertrophy and engorgement of the vessels below the uterus

Striae gravidarum

Irregular reddish streaks caused by tears in connective tissue (stretch marks)

Uterus (internal female reproductive organs)

Layers of the uterus: -Inner layer: circular fibers -Middle layer: figure 8 fibers -Outer layer: longitudinal fibers

Skene's glands

Lubricate the female's urethra

Uterine resting tone

Muscle tension when the uterus is not contracting

Sertoli cells

Nourish sperm during their formation within the testes

Family Responses to physical changes of pregnancy

Oftentimes moms are accompanied by a family member or partner. So important to include them in: -Assessment -Nursing diagnosis -Expected outcomes -Interventions -Teaching lifestyle changes -Teaching signs of possible complication (partner/fam member can help) -Providing resources -Evaluation -How does partner/family member affect the pt in general? Consider them in all of these

Confirmation of Pregnancy: Positive Indicators

Only three signs are accepted as positive confirmation of pregnancy: 1. Auscultation of fetal heart sounds 2. Fetal movements felt by examiner 3. Visualization of the fetus (ultrasound)

Auxiliary Structures: Placenta

Placenta is the communication between the baby and the mother (communication meaning circulation, nutrients, removing waste products, etc) -Placenta is about the size of a dinner plate -If there is an issue with the placenta we worry about the fetus surviving *Maternal component:* -Embedded in the uterus -Development: develops w/ the fetus (grows w/ the fetus) in order to support circulatory needs -Circulation in the maternal side *Fetal component:* -Fetal side -Development -Circulation in fetal side -Metabolic functions (bringing nutrients, taking out waste products *Transfer functions:* -gas transfer -nutrient transfer -waste removal -antibody transfer -transfer of maternal hormones (from mother-baby) -endocrine functions -After delivery placenta is sent to pathology where they analyze it to determine if there are any lobes that didn't come out. Important b/c if there are other parts still in the mom it can cause bleeding -Normal placenta: w/ insertion of umbilical cord near center and branching of fetal umbilical vessels over the surface -Placenta w/ cord inserted near margin of placenta -Placenta w/ a small accessory lobe -Velamentous insertion of umbilical cord: cord vessels branch far out on membranes when membranes rupture, fetal umbilical vessels may be torn and fetus can hemorrhage (cord branches out in own membrane, causes issues in circulation with both mom and baby. It is not a solid implantation)

Perineum

Posterior part of external female reproductive organs; provides support for female pelvic structures

Blastocyst

Preembryonic structure that has an outer cell layer and an inner cell mass

Acinar Cells

Produce milk from substances extracted from blood

Bartholin glands

Promote lubrication of the vagina for coitus

Why do the pregnancy induced changes in fibrinogen levels and other clotting factors have a protecting effect but also a risk?

Protective effect because protect against hemorrhage during childbirth b/c there are more clotting factors -But they also increase the risk of blood clots (thrombus formation)

Scrotum

Regulate temperature of testes to promote normal sperm formation

Paraphrasing

Restating in words other than those used by the woman; what she seems to express; a form of clarification Ex. Woman: "My boyfriend won't even come into the room for the birth. I am furious with him." Nurse: "You seem to be angry because he won't be here" Ex. Woman: "My baby cries all the time. We aren't getting any sleep" Nurse: "You say that you're exhausted, and it seems like your baby cries a great deal. What is a typical day like?"

Antepartum Assessment & Care: Subsequent Assessments

Schedule for uncomplicated pregnancy: -Conception to 28 weeks: appt every 4 weeks -29-36 weeks: every 2 weeks -37 weeks to birth: weekly Subsequent Assessments Include: -Vital signs -Weight -Urine -Fundal height -Leopold's maneuvers: health care provider puts hands on gravid abdomen to assess position, size -FHR -Fetal activity -Signs of labor → educating pt -Ultrasound screen -Glucose screen -Isoimmunization: assess which immunizations are needed, would fetus be at risk? -Pelvic examination

Montgomery's tubercles

Secrete a substance to keep nipples soft during breast feeding

Rugae

Small ridges or folds of tissue in the female vagina and on the male scrotum

Hegar's sign

Softening of the lower uterine segment

What factors cause the average male to be taller than the average female at physical maturity?

Testosterone causes boys to undergo a rapid growth spurt (esp in height). A boy's linear growth begins 1 yr later than girls, and lasts into their twenties. Testosterone (in males) and estrogen (in females) eventually causes the union of the epiphysis w/ the shaft of long bones, but the height limiting effect of testosterone is not as strong as that of estrogen's, so boys grow for longer *Male's greater average height is due to beginning growth spurt at a later age and continuing it for a longer time.

Puberty

The period of maturation of reproductive organs

Fetal Period

Week 9-term (term begins at 37 weeks, full gestation is 40 weeks) -Weeks 9-12: heart beat, determine gender at 12 weeks; most susceptible to teratogens (teach about nutrition, prenatal vitamins, avoid teratogens) -Weeks 13-16: rapid growth, quickening (fetal movements) -Weeks 17-20: fetal movement is a regular occurrence, baby develops hair. At this point viability is unlikely b/c of lack of lung maturity -Weeks 21-24: surfactant is being produced. It is a longshot at 21-24 weeks, but could keep them alive if born during this time (betamethasone: an IM injection in mom to increase production of surfactant if she has to give birth at this point) -Weeks 25-28: baby starts to move into head-down position (vertex) so she might start to feel kicking under the ribs; at 28 weeks lungs are mature so viability is much better, but still need some help -Weeks 29-32: Skin pigment, viability is significantly better, they do very well. At 32 weeks baby is fully developed, after that they're just adding fat -Weeks 33-38

Embryonic Period

Weeks 2 through 8 -Differentiation of cells (weeks 2-3) -Weeks 2 through 8 have more development from a zygote to more of a fetus that we can see -Start to see the development of the eyes , ears, umbilical cord, umbilical cord is adjacent to where the placenta is going to implant as well into the uterus -As the weeks of pregnancy continue to evolve the fetus itself continues to develop and we can see a more/better developed eye in 6-8 vs week 4.

What is supine hypotension syndrome, and what signs and symptoms might a woman with this syndrome display? What should the nurse do to prevent or relieve it?

When preg woman is in the supine position (esp during late pregnancy) the weight of the gravid uterus partially occludes the vena cava and the aorta. The occlusion diminishes return of blood from the lower extremities and consequently reduces cardiac return (reduces cardiac output up to 25-30%). -Collateral circulation developed during pregnancy generally allows blood flow from the legs and pelvis to return to the heart when the woman is in supine position. -Supine hypotension syndrome symptoms: lightheadedness, dizziness, nausea, or syncope. -Blood flow through the placenta decreases if the woman remains in the supine position for a prolonged period, which could result in *fetal hypoxia* -Turn to a lateral recumbent position alleviates the pressure and corrects supine hypotension. (Women should lay in side lying position) -If they must lie in supine position, a wedge or pillow under one hip may be effective in decreasing supine hypotension.

How does each of the following differ when a woman has a multifetal pregnancy?

With multifetal pregnancies women are larger than expected for the weeks of gestation, have more fetal movements, and gain more weight -Uterine size: with multifetal pregnancies the uterus may achieve a volume of 10L or more and weigh more than 9 kg (20 lbs) -Fetal movements: there are more fetal movements -Weight gain: they gain more weight to meet nutritional needs of more than one fetus. Women with a normal pre-pregnancy weight are advised to gain 17-25 kg (37-54 lbs) during a twin pregnancy

Penile development occurs..

approximately 1 yr after growth of testes (male sexual maturity complete at 16.5 yrs old)

Chadwick's sign

bluish discoloration of the cervix/vaginal mucosa during pregnancy

The first outward change of puberty in girls is

breast development

Corpus luteum

cells that remain after ovum formation and secrete estrogen and progesterone

Molding

change in the shape of the fetal head during birth

physiologic retraction ring

division between the upper and lower uterine segments

Corpus cavernosum and corpus spongiosum

enable erection of the penis for coitus

Hyperemia

excess blood in a body part

Lanugo (fetal structures/substances)

fine, downy hair that covers the fetal body and helps the vernix adhere to the skin

The first outward change of reproductive maturation in boys is

growth of testes (as early as 9.5 yrs old)

relaxin

hormone that causes cartilage to soften

Mucus plug

kind of like a cork in the center of the cervix which kind of seals that environment

catecholamines

maternal substances secreted in response to stress

station

measurement of descent of the fetal presenting part into the pelvis

Polar body

nonfunctional form that carries away extra chromosomes during oogenesis

Autosome

nonsex chromsome

Dilation

opening of the cervix

Somatic cell

ordinary body cell

afterpains

post birth uterine contractions

Gamete

reproductive cell

Effacement

thinning of the cervix

Decidua

uterine endometrium during pregnancy