OB Chapters 1-8

Joint Commission Five Core Measures

1. Decrease the rate of elective deliveries. 2. Decrease the rate of primary cesarean births. 3. Decrease rate of newborns with septicemia or bacteremia 4. Increase the rate of exclusive breastfeeding. 5. Increase rate of antenatal administration of steroids in preterm labor

Adolescent mother

19 years or younger. these mothers may have difficulty constructing their maternal identity regardless of developmental age, if they have a partner, living alone vs living with parents.

Autosomal dominant

A dominant gene on a non-sex chromosome. A single copy of the gene is enough to produce the trait. Males and females equally affected. Often appears in every generation. Usually heterozygous, normal gene on one chromosome and abnormal on other chromosome in the pair, if present on both they are affected more severely. Transmission: A parent with the trait has a 50% chance of passing it to each child. If mutation occurs after birth they can transmit it to future generations. Normal traits: Blood groups A and B, RH positive blood factor. Abnormal: Huntingtons, neurofibromatosis.

Justice

All people should be treated equally and fairly regardless of disease of social/economic status

Utilitarian model

Approaches ethical dilemmas by analyzing benefits and burdens of any course of action to find one that will result in the greatest amount of good. Consequences of actions are more important than the actions themselves. Ex: The end justifies the means, if the outcome is positive, the method of arriving at that outcome is less important.

Menarche

Approx. 2 - 2.5 years after breast development begins. Irregular and light at first, early cycles not usually fertile d/t ovulation occurring inconsistently , however they may still ovulate and be able to conceive if sexually active before first period.

Neonatal Nurse Practitioner (NNP)

Assist in care of high risk newborns in the immediate post birth care of in a NICU

Maternal Hyperthermia

Avoid deliberate exposure to heat sources like saunas and hot tubs. Important factor is how high the mothers body temp rises and for how long. Limit use to less than 10 minutes and keep head and chest out of water. Exposure to temperatures above 100F is not advised.

Preventing fetal exposure to teratogens

Avoid drugs, alcohol, infections and live vaccines, try to control some maternal medical conditions, avoid exposure to caffeine, tanning beds, and fish

Nonmaleficence

Avoiding risking or causing harm to others

Onset of puberty for females

Begin approx. 6 months - 1 year earlier in females than males. FSH & LH are secreted and stimulate secretion of estrogen and progesterone, resulting in maturation of reproductive organs, breasts, and secondary sex characteristics.

Human Rights model

Belief that each person has human rights. Nurse may find difficulty in the right of a person to refuse care.

Fatalism

Belief that events and results are predestined. May effect health care decisions.

Documentation

Best evidence that standard of care has been maintained. Charting should be accurate and objective.

Infant Mortality Rates

Caused by congenital malformations, premature birth and maternal complications of pregnancy. Infant is much higher in African Americans with no physiological reason, and is due to racial and ethnic disparities.

Reproductive cycle

Changes in anterior pituitary secretions, ovaries and endometrium to prepare for pregnancy. Driven by a feedback loop between anterior pituitary and ovaries (a change in the level of one secretion in response to the level of another secretion). Cycle is approx 28 days.

Ethical Issues in Reproduction

Conflicts between a mother and fetus occur when the mothers needs, behaviors or wishes may injure the fetus. Ex. Abortion, substance use, refusal to follow advice from caregivers. Nurses have no obligation to support a position they disagree with, but they must disclose this information before they are employed.

Cleanliness

Considered by some groups to be an American "obsession"

Primary Amenorrhea

Delayed onset of menstruation. Periods have not begun within 2 years after onset of breast development or by 16 years of age, or if the female is over 1 year older than mother/sisters were when their menarche occurred.

Decision making

Determine who makes decisions for the family(patient, partner, family member, authority figure). If decisions are made collectively or may be out of patients control, the decision makers should be included in the conversation.

Communication style

Differ among cultures. Nurse should validate understanding by asking patient to repeat information. Asians may nod and smiling meaning they hear you but does not indicate agreement or understanding. Hispanics engage in small talk before asking questions about care, this creates an atmosphere of trust(confianza) in the relationship. American Indian/Alaskan natives often converse in low tone that may be difficult to hear, they may dislike note taking and expect nurse to remember what was said.

Trisomy 21

Downs syndrome. Has an extra 21 chromosome. 47(total number of chromosomes) XX or XY(female or male) +21 (the number of the extra chromosome). Ex. 47,XY,+21. Characteristics: Reach developmental milestones more slowly than other children, delayed intellectual development.

Body composition

Due to testosterone, males develop a greater muscle mass than females, approx. 50% more.

Drugs / Substances

Fetal blood levels of drugs remain high because fetus swallows amniotic fluid containing the substance, even after eliminated from mothers body. If therapeutic drugs are required, provider may be able to prescribe alternative drug with lower risk.

Breast changes

First noticeable change of puberty in females. Begins at approx. 8 - 13 years old. Glandular and ductal tissue growth, fat deposited. Breasts often develop at different rates, lopsided appearance until one catches up with other.

Individualism

Freedom of action for an individual, self reliant / independent. Conflicts with values of many cultural groups

Touch

Hinduism/Islamic: Touch by woman other than wife is offensive. Hispanics more likely to appreciate touch, viewed as a sign of sincerity. Nurses should remain sensitive to response of patient being touched and refrain from touching if patient indicates it is not welcomed.

Nuclear or conjugal family

Husband, wife, and children living in the same household

Ovarian Cycle

In response to gnRH from hypothalamus, the anterior pituitary secretes FSH and LH to stimulate ovaries to release a mature ovum and additional hormones. Three phases: Follicular, Ovulatory and Luteal.

Circular fibers

Inner layer of myometrium. Prevent the reflux of menstrual blood and tissue into the fallopian tubes, promote normal implantation of fertilized ovum by controlling its entry into the uterus and retain the fetus until appropriate time of birth.

Reproductive organs (female)

Internal and external grow/fat deposited. Mucosa changes to resist trauma and infection.

Parts of fallopian tube

Isthmus: Narrow part adjacent to uterus. Ampulla: Wider area of tube lateral to the isthmus. This is site where fertilization occurs. Infundibulum: Wide funnel shaped terminal at end of tube, surrounded by fingerlike projections called fimbriae.

Ligaments of pelvis

Maintain internal reproductive organs and their nerve and blood supplies.

Nurses role in preventing abuse

Make it clear that patient owns their body and has the right to decide how it should be treated. Increase patients control over situation and make them feel supported. Let them remained clothes when meeting health care provider before undressing for exam. Screen for IPV at every visit without partner in the room, observe for signs of abuse, give resources and help develop a safety plan.

Beneficence

Making decisions that produce the greatest good or least harm

Spirituality and religiosity

Many patients have deeply held religious and spiritual practices/beliefs and may be reluctant to share these with nurses. Thai clients describe adherence to practices associated with beliefs about three essences: The Body, Mind-Heart and Energy.

Onset of male puberty

May begin as early as 9.5 years old. LH & FSH stimulate secretion of testosterone and cause reproductive organ development, spermatogenesis and secondary sex characteristics. First outward sign is growth of testes, penile growth begins approx. 1 year later.

Malpractice

Negligence by professionals. Four elements must be present to provide negligence: Duty, Breach of duty, Damage or harm as a result of breach of duty and Proximate cause.

Ionizing radiation

Nonurgent radiologic procedures may be done during first 2 weeks after menstrual period begins, before ovulation occurs. In emergencies, lower abdomen should be shielded with a lead apron and radiation dose is kept as low as possible. Ultrasounds and MRI's are preferred for pregnant women.

Blended family

One or more parents bring into the union children from previous relationships

Longitudinal fibers

Outer layer of myometrium, Found mostly in fundus, expel fetus efficiently towards pelvic outlet during birth

Requirements of Informed Consent

Patients competence to consent Full disclosure of information needed Patients understanding of information Patients voluntary Consent.

Time

Preoccupation with time is a major conflict with those who mark time by different standards

Causes of Amenorrhea

Primary & Secondary: Thin, Too little body fat to produce enough sex hormones to stimulate ovulation/menstruation(Eating disorders or athletes). Inadequate pituitary stimulation of ovary or failure of ovary to respond. Excessive androgenic hormones from the adrenal glands which has a masculinizing effect.

Estrogen (males)

Produced by sertoli cells in testes and liver in males, necessary for normal sperm formation

Body hair (females)

Pubic hair first grows as downy hair and becomes thicker as puberty progresses. Axillary hair appears near time of menarche

Body hair (males)

Pubic hair growth begins and approx. 2 years later axillary hair begins.

Technology

Reliance on technology may be intimidating

Lateral support ligaments

Stabilize uterus and ovaries laterally and keep them midline. Right and Left cardinal ligaments provide support to lower uterus and vagina. Infundibulopelvic ligament connects lateral ovary wall and distal fallopian tubes pelvic walls.

Proliferative phase

Stage 1 endometrial cycle. Occurs as ovum matures and releases during first half of ovarian cycle. Basal cells of endometrium multiply to form epithelium and glands under stimulation of estrogen. Arteries and veins elongate to nourish the proliferating cells. Glands secrete thin stringy mucus to aid sperm entry.

Ischemic and Menstrual Phase

Stage 3/4 of endometrial cycle. If fertilization doesn't occur, corpus luteum regresses and estrogen and progesterone fall. Endometrium becomes necrotic and shed, resulting in menstruation, which lasts about 5 days.

Pelvis

Support structures of pelvis. Bony pelvis supports and protects the lower abdomen and internal reproductive organs. Posterior wall formed by sacrum. Side and anterior are composed of three fused bones: Ilium, Ischium and pubis. Linea terminalis(pelvic brim/iliopectineal line) is a imaginary line dividing upper(false) pelvic from lower (true) pelvis. False pelvis provides support, the true pelvis is most important during birth.

Foster / Adoptive families

Take responsibility for children who were not born to them. May include children from another country or of another cultural, ethnic or racial group.

Belief that optimal health is a right

The belief that optimal health is a right conflicts with beliefs in many cultures in which health care is not a major expected right

Anterior support ligaments

These ligaments maintain uterus in its normal anteflexed position and help direct the fetal presenting part against the cervix during labor

X-Linked Traits effects

Usually effects males because their only X chromosome has the abnormal gene on it. Only one copy of the gene is needed to cause the disorder in males. Females are carriers but aren't usually affected. Transmission: Males who have the disorder transmit the gene to 100% of their daughters and none of their sons. Sons of carrier females have a 50% chance of being affected or unaffected, Daughters of carrier females have a 50% chance of being carriers, or 50% chance of not being carriers. Examples: Colorblindness, duchenne muscular dystrophy, hemophilia A.

X Linked Recessive Effects on Females

Usually effects males(XY) because their only X chromosome has the abnormal gene on it. One of the two X chromosomes in females(XX) is inactivated and the active X chromosome provides adequate cell function. Females can show the full disorder in two uncommon circumstances: 1. If a female has a single X chromosome(Turner syndrome) 2. If a female child is born to an affected father and carrier mother.

Posterior support ligaments

Uterosacral ligaments provide posterior support and contain sympathetic and parasympathetic nerves of autonomic nervous system.

Eye Contact

White & AA consider eye contact important. AI/AN believe avoiding eye contact is a sign of respect. Latino believe in mal ojo(evil eye) where a sudden unexplained illness occurs when individual with special powers admires a child too openly. Eye contact between man and woman in middle eastern cultures is considered seductive.

Nurses role in maternity nursing

Work in variety of specialized areas. Assume primary responsibility for independent function. Teach, counsel and intervene for a wide variety of nonmedical problems. Interpersonal skills(communication, teaching, critical thinking) Collaborator, Researcher, Advocate.

Single parent

a person bringing up one or more children without a partner.

deontologic model

determines what is right by applying ethical principles and moral rules. It does not vary the solution according to the individual situations. Example: Life must be maintained at all costs and in all circumstances.

Extended family

nuclear family plus other relatives living together

Same gender family

two adults of the same sex living together, some with children

Autosomal Recessive

two copies of an abnormal gene must be present in order for the disease or trait to develop. Autosomal recessive genes are uncommon due to probability of two unrelated people sharing same abnormal genes, Consanguinity and isolated groups increase risk. Transmission: Unaffected parents are carriers, children of carriers have 25% chance of receiving both copies of abnormal gene and having the disorder. 50% chance of receiving one copy and being unaffected carriers. 25% chance of receiving both copies of normal gene and are neither carriers nor affected. Normal traits: Blood type O, RH-negative blood factor. Abnormal: Tay-Sachs disease, sickle cell disease, cystic fibrosis.

Choices in birth settings

1. Hospitals (LDR/LDRP rooms): Most common, support people can stay in room. 2. Birth Centers: Maternity care for low risk patients. Provides classes and follow up care for 6 weeks after birth for mother and baby. Less expensive, home like setting, not equipped for obstetric emergencies. 3. Home Birth: Keeps family together in its own environment throughout birth experience. Bonding with infant is uninterrupted and patient controls each detail of birth. Low risk patients only, time required to transfer to hospital incase of emergency may be an issue, patient must provide care for themselves and infant without immediate help.

Time Orientation

AI/AN, middle eastern and H/L's emphasize present moment rather than future. If patients do not view keeping appointments as important they may encounter frustration from health care workers which leaves them ashamed and unlikely to return for care.

Secondary Amenorrhea

Absence of menstruation for at least 3 cycles after regular cycles have been established for 6 months. Pregnancy is a cause of secondary amenorrhea.

Self sufficiency and financial success

Admiration for self sufficiency and financial success may conflict with beliefs of other societies that place less value on wealth and more value on less tangible factors such as spirituality

Nurse Practitioner (NP)

Advanced practice RN. Prenatal and newborn care, does not perform deliveries. Includes: WHNP, FNP, NNP and PNP.

Certified Nurse Midwife (CNM)

Advanced practice Registered Nurse trained in nursing and midwifery, have completed a program of study and clinical experience. Cares for women who have low risk for complications through pregnancy, birth and postpartum and refers them to a back up physician if problems develop. Counsels and supports family, provides annual well woman exams, approach to childbirth is noninterventionist and supportive.

Democracy

Cultural value that may not be shared by families who think decisions should be made by the family, religious figures or higher authorities in their cultural group.

Cultural values

Culture is the sum of beliefs and values that are learned, shared and transmitted from generation to generation. Cultural values guide thinking, decisions, and actions of a group, particularly during events such as child birth and parenting.

Infections

For infections that cannot be prevented by immunization, avoid situations where getting infection is likely. Rubella may result in severe damage to fetus. MMR immunization 28 days before conception eliminates risk of infection.

Communal family

Group of unrelated people who choose to live together, with the children becoming the responsibility of the group.

Skeletal growth (female)

Grow in response to estrogen stimulation. Growth spurt begins approx. 1 year after breast development begins. Estrogen also causes epiphyses(growth plate) to unite with bone shafts to stop growth in height. Growth starts and ends sooner than in males.

Testes

Male gonads, serve as endocrine gland to produce testosterone and produce male gametes (sperm). Spermatogenesis occurs within seminiferous tubules of testes, leydig cells support tubules and secrete testosterone. Sertoli cells within the tubules respond to FSH by nourishing sperm as they mature.

Differing cultures and lack of understanding of cultures (between nurse and childbearing family)

May create communication difficulties related to communication style, decision making, touch, spirituality and religiosity, and time orientation.

Intimate partner violence

May start or escalate during pregnancy. Causes maternal/child complications, may start prenatal care late, increased risk for uterine rupture, placental abruption, preterm birth, low birth weight, maternal and fetal death, STD's and perinatal depression.

Interlacing figure-8 fibers

Middle layer of myometrium. These fibers contract after birth to compress blood vessels that pass between them to limit blood loss.

Teratogens from maternal disease

Mother with diabetes should keep blood sugar levels normal and stable. Phenylketonuria (PKU): Mother should return to phenylalanine free diet before conception to prevent fetus damage. Consuming folic acid before and during pregnancy decreases risk of neural tube defects, 0.4m daily is recommended. For patients who have delivered a baby with neural tube defects, increase to 4mg.

Patient advocate

Nurses are ethically and legally bound to act as the patient advocate. They should follow the chain of command and document their efforts to seek help for patients.

Refusal of care

Patients have the right to refuse care and can withdraw agreement to treatment at any time. Make provider aware of decision and document notification accordingly. Verify patient understands the treatment and consequences of refusal. Every effort should be made to obtain written refusal from patient indicating they have been informed of all risks and benefits. If it poses an ethical dilemma, referral may be made to ethics committee.

Muscles of pelvis

Pelvic fascia supports pelvic organs. Levator ani is a collection of three pairs of muscles, pubococcygeus(pubovaginal muscle), puborectal and iliococcygeus. Ischialcavernosus muscle extends from clitoris to ischial tuberosities. Two transverse perineal muscles extend from and stabilize perineum.

Body contours

Pelvis widens for childbirth. Fat deposited in hips.

Autonomy

People have the right to self determination, right to respect, privacy and information necessary to make decisions based on their personal values and beliefs.

Follicle Stimulating Hormone (FSH)

Produced by anterior pituitary gland, targets ovaries and testes. Action in females: Stimulates maturation of follicle. Stimulates growth and maturation of graafian follicles before ovulation. Action in males: Stimulates leydig cells of testes to secrete testosterone.

Luteinizing Hormone (LH)

Produced by anterior pituitary, targets ovaries and testes. Action in females: Stimulates maturation of follicle, surge of LH approx. 14 days before next menstrual period causes ovulation. Stimulates transformation of graafian follicle into corpus luteum which continues secretion of estrogens and progesterone for about 12 days if ovum is not fertilized. If fertilized, placenta gradually assumes function. Action in males: Stimulates leydig cells of testes to produce testosterone

Gonadotropin releasing hormone (GnRH)

Produced by hypothalamus, targets anterior pituitary. Action in females: Stimulates release of FSH and LH, initiating puberty and sustaining female reproductive cycles. Action in males: Stimulates release of FSH and LH, initiating puberty.

Estrogen (females)

Produced by ovaries and corpus luteum and placenta(pregnancy), targets reproductive organs and breasts. Action in females: Maturation of reproductive organs, stimulates endometrium before ovulation. Breast growth. Stimulates growth of long bones and fusion of epiphyses. Stimulates growth of uterus, breast tissue, relaxes pelvic ligaments and inhibits milk production

Pediatric Nurse Practitioner (PNP)

Provide health maintenance care for infants and children not requiring services of physicians

Family Nurse Practitioner (FNP)

Provide preventative, holistic care for young and old family members.

Women's Health Nurse Practitioner (WHNP)

Provide wellness focused, primary, reproductive and gynecological care over the lifespan starting at adolescence

Nurses role in genetic counseling

Providing counseling after additional education. Guiding parent through prenatal diagnosis. Supporting parents as they make decisions after diagnosis. Helping family deal with emotional impact of birth defect. Assisting parents with child with birth defect locate services and support. Coordinating serves of other professionals. Helping families find support groups

Follicular Phase

Stage 1 of ovarian cycle. Ovum matures, begins on first day of last menstrual cycle and ends approx. 14 days later. FSH and LH levels rise slightly and cause 6-12 graafian follicles containing ovum to grow. The follicles secrete estrogen which accelerates maturation. One mature follicle is released and estrogen rises, FSH decreases to block other follicles from maturing.

Secretory Phase

Stage 2 of endometrial cycle. Occurs during last half of ovarian cycle. Estrogen and progesterone from corpus luteum causes endometrium to thicken and vessels to dilate. Progesterone causes endometrium to secrete and store glycogen, protein, lipids and minerals to nourish a fertilized ovum.

Ovulatory Phase

Stage 2 of ovarian cycle. Approx. day 14. 2 days before ovulation. LH increases significantly and FSH increases slightly. These will decrease estrogen and increase progesterone, which stimulates final maturation of follicle, which ruptures and releases ovum and is picked up by fimbriated end of fallopian tube for transport to uterus. Ovulation marks beginning of luteal phase and occurs 14 days before menstrual period.

Luteal Phase

Stage 3 of ovarian cycle. Remains of follicle become the corpus luteum which secretes estrogen and large amounts of progesterone to prepare endometrium for implantation. If fertilized: Chorionic gonadotropin is released to cause corpus luteum to persist. If not fertilized: FSH and LH fall, corpus luteum breaks down, estrogen and progesterone falls, resulting in menstruation.

Skeletal growth (males)

Testosterone causes a rapid growth spurt, begins 1 year later than in females and may continue into their 20's. Testosterone causes union of epiphysis with long bone shafts but the height limiting effect is not as strong as females, male growth begins at slightly later age but for a longer time.

Nocturnal Emissions

Wet dreams, spontaneous ejaculation of seminal fluid during sleep. Commonly occurs in teenage years