OB Exam 1

Childbirth and Perinatal Education

-Goal is to assist individuals and family members to make informed and safe decisions about pregnancy, birth, and early parenthood Childbirth education programs -Pain management -Early classes- 1st trimester (will focus more of fetal growth and development and healthy nutrition, common discomforts) -Later classes- 2nd and 3rd trimesters (focus more on pain management, feeding option whether breastfeeding or formula, how to care for the baby, etc.)

Nutrient Needs Before Conception

-Healthy diet ensures adequate nutrients for developing fetus -First trimester is critical in terms of embryonic and fetal development (we try to get the mom at a healthy weight, etc. even before she is pregnant) -Folic acid intake (really recommended for women of child bearing age in general for healthy neural tube growth and development- 400 mcg/ day is recommended; once a women gets pregnant, we recommend they take 600 mcg/day) -Achieving desirable body weight before conception reduces maternal and fetal risks Weight gain -Varies among different women -Important to achieve weight in normal range for height before conception -Inadequate weight gain and pregnancy -Total: 25-35 lb wt. gain for women with normal BMI -it depends on what pre-pregnancy and BMI were (such as women who were underweight before pregnancy, we want them to. gain more weight and vise versa.) -weigh gain also depends on how many pregnancies she has had. (but we are talking about for 1 pregnancy) -women who are not gaining enough, they are at risk for low birth babies, preterm labor, IUGR, etc. -women who gain too much weight are at risk for having a really big baby, developing gestational diabetes, preeclampsia, gestational hypertension, increased risk of still birth, etc.) -we also want it to be a steady weigh gain with most of it occurring in the 2nd and 3rd trimester. Caloric intake -1st trimester: same as non pregnant -2nd trimester: ~350 calories more -3rd trimester: ~450 calories more Recommended ranges for weight gain -Underweight woman: 28-40 lb -Normal weight woman: 25-35 lb -Overweight woman: 15-25 lb -Obese woman: less than 15 lb -familiarize with BMI levels and numbers (underweight is under than 18.5, normal is 18.5 to 24.9, overweight is 25.0-29.9, obese is greater than 30.0) -someone having twins at a normal weight, we recommend gaining up to 50 pounds -a really large weight gain in a short period of time, you would think fluid retention (so you would have preeclampsia in the back of ur head) Pattern of weight gain -1st trimester: 3.5-5 lbs total Duration of pregnancy: -0.5 kg/week for underweight women -0.4 kg/week for normal weight (so about a pound a week) -0.3 kg/week (overweight) -0.2kg/week (obese) ex: 20 weeks pregnant, normal BMI (around 20)- she should have gained 12 pounds (bc 5 lbs by week 13 and for every week gaining a lb, so plus 7 is 12 lbs) Energy needs: Hazards of restricting adequate weight gain -Nutrition counseling -Overweight/obesity and weight gain -Quality of weight gain (from nutrient dense foods, not from empty bad foods) -remind them this is not fat gain is is the baby weight, increased blood volume, amniotic fluid, placenta, etc. -also can talk about breastfeeding, which can actually help the weight come off after birth bc if keeps the metabolism high -pregnancy is not a time for someone to lose weight Excessive weight gain -"Eating for two" -Can be difficult to lose postpartum Protein -Adequate protein intake is essential to meet demands of pregnancy (amino acids are the building blocks for tissue growth) so we need a lot more protein. Vegans are at risk for being deficient in protein. Fluids -8-10 glasses/day of water -Dehydration and pregnancy (there is an association with cramping and contractions with dehydration) -Caffeine (it is okay in moderation- the limit is 200 mg for pregnant women- maybe an association with low birth weight -Aspartame (women can have this and it is fine) Minerals and vitamins: Iron -30 mg/ day supplement starting at 12 weeks (or ASAP if possible) -they need more iron bc of the increase in blood volume in pregnancy and the increase of RBCs mean she needs more iron bc her body is pulling from the iron stores for all of the RBCs to be produced, so we need to replete that. In those that are not taking in enough iron or a twin pregnancy, if we deplete her, then she gets anemic -iron can also be gotten through food sources as long as they consume those that are higher in iron such as red meat. -we may need to add an additional iron supplement if a woman is already have a lower hemoglobin or having multiples- some may need even iron transfusions throughout the pregnancy to try to keep enough iron for them to not get anemic Counseling about iron supplementation -Increase Vitamin C to increase iron absorption -Take on an empty stomach to increase absorption -Take at bedtime to avoid GI upset (food helps with GI upset) -May cause stools to be black or green (and causes constipation) Calcium -1000 mg daily is sufficient for fetal bone and tooth development -as long as women consume dairy, they can get their calcium from their intake. -women who are either vegan or just don't drink milk or yogurt, they may need a calcium supplement Folate/folic acid -Pregnant women should consume 50% more than non pregnant women (600 mcg is recommended) -typically women don't get enough of it from food so they need a supplement. it is so important to take and is usually in a prenatal vitamin -*** know some food sources for iron, calcium, and folate Physical activity during pregnancy -Avoid sports with potential abdominal trauma or falls (can cause a placental abruption and can cause a dead mom and baby) -Avoid overheating (don't want them to get dehydrated) -STOP EXERCISING IF: vaginal bleeding, leaking fluid, decreased fetal movement, dizziness, HA, chest pain, calf pain, dyspnea -also make sure we are not going into a calorie deficit from the exercise (so add calories to account for the day if exercising and taking in extra fluid)

Teen pregnancy

-Pregnancy in which the mother is between 15 and 19 years of age Increased risk of adverse outcomes for both mother and infant -Maternal death -Risk for STIs -Greater risk of cephalopelvic disproportion (CPD) -Less likely to receive prenatal care -More likely to have PTB and LBW infant

Pics of breach options

*understand these -complete means i am in a complete general flexion ("completely correct", i am just flipped and bottom first -frank means, while my hips are flexed, my knees forgot to bend (think frank forgot to flex) -footling means you can have single or double and the leg is coming through first -shoulder presentation is where the shoulder is coming out first and this will have to be a c- section

1st Trimester warning signs

-Abdominal cramping or vaginal bleeding (could be signs of miscarriage) -Chills or fever (signs of infection) -Burning on urination (signs of infection) -Uncontrolled vomiting (when the mom is now losing weight, dehydrated, etc.) -Diarrhea (electrolyte imbalances)

Health Risks in the Childbearing Years

-Age (too young and too old- 20 or less, older than 35) -Socioeconomic status and culture -Substance use and abuse -Nutrition -Lack of exercise -Stress -Sexual practices -Medical conditions (esp. HTN and diabetes) -Gynecologic conditions (such as STIs, endometriosis, etc.) -Environmental and workplace hazards (ex: radiation) -Violence against women

Obstetrical History Terminology

-Antepartum: pregnancy, before birth -Intrapartum: during birth, labor patients -Postpartum: after birth

Genetics and Cancer

-Certain inherited gene mutations predispose people to cancer -Hereditary mutations thought to be major factor in in about 5-10% of all cancers -Tumor suppressor genes (limit cell growth) and oncogenes (promote cell growth and development) Cancers caused by genetic mutations: -if you have a mutation, it will severely increase your chance of having the cancer, etc. Hereditary breast and ovarian cancer -BRCA1 and BRCA2 Colon cancer -Several predisposing genes -HNPCC (Hereditary nonpolyposis colon cancer)-type of hereditary colon cancer -At risk patients can be offered a prophylactic colectomy -most cancers are caused by environment such as smoking, too much sun exposure, drinking too much, etc.

Maternal mortality

-Death associated with problems related to pregnancy and childbirth Maternal Mortality rate -# maternal deaths divided by total # live births -Most deaths are preventable -the younger maternal age (younger than 20) and older moms (over the age of 35) and not having prenatal care are big reasons of higher maternal mortality rates and racial/ethic groups, etc. -there are also more African American women dying due to having more risk factors 3 major causes: -Hypertensive disorders -Infection -Hemorrhage -the maternal morality rates are increasing in the U.S

Frequency of Prenatal Visits in Normal Pregnancy

-Every 4 weeks for the first 28 weeks (once a month) -Every 2 weeks to week 36 (we will see them more often starting in the 3rd trimester bc complications with pregnancy either first appear of worsen in the 3rd trimester such as gestational hypertension or preeclampsia so we want to have increased surveillance) -Weekly from week 36 to birth -there are better outcomes when women have good and consistent prenatal care. -if we do discover a complication, we may see them more often that this above, bc this timeline is only for those that are having a normal pregnancy

Barriers to Seeking Health Care

-Financial issues: not being able to get care -Cultural issues: such as not wanting to de-robe at the OBGYN -Gender issues: gender of the provider and the women only wanting a female doctors, transgender, and lesbian individuals and their fear of judgement and not wanting to disclose their sexual orientation

U.S Health Care system and Maternity nursing

-Fragmented structure High cost of health care -Low birth weight infants in NICU and preemies Limited access: -Inability to pay- due to not having insurance (most significant issue that influences the lack of access) -Transportation -Child Care- if have other kids, they can't find someone to care for them so they can't make their appointments -Lack of Providers- there may not be enough providers who actually can take medicaid or no insurance at all because after it runs out the doctors won't take them -a lack of prenatal care is tied and associated to poor outcomes!

Genetics vs. genomics

-Genetics: study of individual genes and their effect on gene disorders -Genomics: study of all the genes in the human genome Recent advances -Human Genome Project -Increased interest in personalized genomic information -Direct-to-consumer genetic testing (23 and Me, etc.) -Complex ethical, legal, and social issues (such as a couple that can't have a baby so they have genetic testing on embryos if they do IVF and they can figure out if an embryo has a chromosome abnormality, etc. and gives gender, etc. and it causes issues bc the mom may decide to terminate the pregnancy after that)

Scheduled Laboratory Tests

-Hgb/Hct we repeat this at around 28 weeks (beginning of 3rd trimester to see how it has been affected, or if mom has become anemic. Remember, we do expect a slight decrease but if more is at like a 7 or 8, we may have to get them to take some iron to try to fix the issue before birth) -Quad Screen(15-20 weeks) -tests for trisomy 13, 18, and 21 -remember, bc they are screening tests, they aren't 100% accurate -if something comes up positive, we would offer more testing for mom such as an amniocentesis -Maternal serum alpha feta protein (MSAFP) -Included in the Quad Screen -can be done by itself or with the other 3 things -mainly tests for neural tube defects and abdominal wall defects -Blood type and Antibody Screen -Rhogam given at 28 weeks to Rh (-) mothers -we want the screen to come back negative bc we don't want any antibodies -all Rh - moms will get Rhogam at 28 weeks. (bc things can be problematic when we have a Rh- mom with a Rh+ baby and we don't know what the baby's blood type is until it is born so we do this as a preventative measure) -Group B Strep (GBS) Screen (35 - 37 weeks) patient has to be placed in lithotomy position bc it is a rectum and vaginal swab. It is not a problem for mom (its not a STI or anything), but can make the newborn very sick and they baby could actually die bc they could develop GBS sepsis, pneumonia, etc. that their immune system can not handle -sometimes there is a mom in labor and she is a GBS unknown because either she has not had prenatal care or she came in in preterm labor, so hospitals have protocols and if the mom is GBS positive, they are treated with ampicillin x4hrs in labor. Hospitals also have protocols for GBS unknown as well. -Urinalysis: every visit -Glucose, protein, nitrites, and leukocytes (nitrites and leukocytes in the urine are signs of infections so UTI- we treat UTIs very aggressively bc it can cause preterm labor) -One-Hour Glucose Tolerance Test (GTT) (24- 28 weeks) -If abnormal, 3-hour GTT -this is the gestational diabetes screen -for all women, pregnancy is an insulin resistant state already, and some women with risk factors and obesity, pregnancy can push them over the edge and -the pregnant women will do the glucose tolerance test after drinking a really sugary drink, and after the hour is up, they test the glucose and if the the blood sugar is over 140, they will retest and do a 3 hour test and that test will confirm gestational diabetes (if it was under 140 after the 1 hr test, they are good)

Factors leading to Infant mortality

-Limited maternal education- such as only a high school degree -Young maternal age- teen pregnancy -Unmarried status -Poverty -Lack of prenatal care -Smoking -Poor nutrition -Alcohol use -Poor overall maternal health

Prematurity and Low birth weight

-Low birth weight (LBW)-weight less than 5.5 pounds, or 2,500 grams -Very low birth weight (VLBW)- weight less than 3.3 pounds, or 1,500 grams -Preterm birth (PTB)- live infant birth before 37 weeks -the lower the birth weight and the more premature the baby is, the more complications there will be Risks associated with PTB and LBW -Social causes (such as living in poverty, being in a minority group, being unmarried, not having access to care) -Behavioral causes (such as tobacco, drugs, alcohol, extreme stress) -Physiologic causes (such as medical problems like a chronic illness the mother may have) -Poor Nutrition (either being malnourished or obesity) -Teen Pregnancy (bc they are often associated with the social factors listed above)

What Is Maternity and Women's Health Nursing in the 21st Century?

-Maternity care: taking care of women in the whole child bearing process such as pregnancy, labor and delivery, and postpartum period (4-6 weeks after birth)) -Women's health care: more broad, includes maternity care but also caring for women across the lifespan and their reproductive things such as menstruel problems, menopause- ex: NICU, labor and delivery, postpartum, antepartum, high risk OB floors, clinics and birthing centers, and home visits -Role of nurses in women's health care: educating patients- teaching about pregnancy, the labor and birth process, about recovery, how to take care of new baby. Also being an advocate and agents of change and in that we we can notice trends and trying to take it and improve women's health outcomes such as healthcare costs, mortality, and morbidity rates. They have a lot of influence over communities and populations because of the influence for pregnant moms and their babies

Common Discomforts of First Trimester of Pregnancy

-Nausea and vomiting: seen in 85% of pregnancies -Increased hCG -you can tell patient to eat small and frequent meals and whatever they tolerate, etc. -Urinary frequency: -Due to pressure from enlarging uterus on bladder -Fatigue -Unexplained cause -Could be related to incr. in hormones, may be aggravated by nocturia -Breast changes -Increased estrogen and progesterone -wear a supportive bra, etc. -Increased vaginal discharge -Results from the hyperplasia and hyperproductivity of vaginal mucosa -Nasal stuffiness and epistaxis -Elevated estrogen levels that produce edema and increased vascularity in nasal passages -Ptyalism -Mood swings -go in the book and include teaching points for mom and how to help these signs

Implantation

-Occurs 6-10 days after fertilization (ex: in a normal 28, fertilization would occur at day 14 where fertilization could occur. So at around day 21-25, implantation is occuring) -The outer trophoblast (blastocyst burrows itself into the endometrium) adheres to the endometrium -hCG begins production (once implantation occurs, immediantly the trophoblast secretes this pregnancy hormone- so the women may not have even missed her period yet since this hCG starts immediately with implantation -Blastocyst buries itself into the endometrium- at this time the woman may have implantation bleeding and they have a little bit of spotting -we want implantation to occur in the top part of uterus (fundus area)

The bottom line

-Preconception care (such as getting mom on meds if he needs and meds that are healthy for pregnancy) AND prenatal care are pivotal to promoting health of women and their infants -We must improve the "related to" factors before we will see improvement in infant and maternal mortality rates, PTB, and LBW infants -We must take an "upstream approach" to illness and disease (looking at the risk factors more to try to fix the root of the problems) -Look at root causes of problems to ultimately improve the health of the community and nation

Initial Prenatal Assessment

-Pregnancy Test (either urine or blood test, and we will do this even is the chief complaint is a positive pregnancy test) -Menstrual history (finding out first day of LMP bc it helps us to come up with a due date and figure out how far along in her pregnancy she is) -Signs and symptoms of pregnancy (presumptive signs- it is actually a good thing that they are having these signs because it shows their hormones are at a high level and things are good, so it can actually be concerning if they have no symptoms at all) Calculation of due date -EDD: Estimated date of delivery -EDC: Estimated date of confinement -EDC and EDD mean the same thing- the women's due date. There are a few ways we can calculate due date -Ultrasound: have to do one to confirm the pregnancy, making sure it is viable, and this first trimester ultrasound is extremely accurate to measure the embryo (best in the first trimester, bc after that measurements may be off due to genetics for the baby and pretty much all embryos are created the same size in the first trimester- this is the best way for those with really irregular periods) -Nägele's rule: a formula we use to calculate due date and all we need is the first day of hr LMP so taking that first day of LMP, adding 7 days to it, and subtracting 3 months. (its really only accurate for women who have really regular menstruel cycles and requires that they remember the date) -Gestational wheel: you would line up the first day of LMP with the date it was and then you would follow around the circle to where the 40 weeks is and that is the estimated due date. If the mom only knows her due date, we can figure out how many weeks she is currently with the wheel by putting the arrow on the due date, then looking at the actual date and it will tell how many weeks along she should be. (for women with very irregular menstruel cycles, you may not be able to use the wheel, so the ultrasound is the most accurate way)

Expanded roles in genetics for maternity nurses

-Prenatal screening and testing -Carrier testing during pregnancy (such as to see if they are a sickle cell carrier) -Newborn screening (all newborns have newborn metabolic screen done when they are about 24 hrs old which is a heel stick) -Palliative care for infants with lethal genetic conditions and families -Care of women with genetic disorders during pregnancy -Cystic fibrosis, Factor V Leiden (blood clotting disorder) -Identification and care of individuals with genetic conditions and families

Initial Visit: Prenatal History

-Reason for seeking care (usually bc they are having a positive pregnancy test, missed period, or spotting, etc.) -Assessment of current pregnancy (assess how she feels about the pregnancy, any presumptive signs and symptoms such as nausea, breast tenderness, etc., know when was the date of her first day of the LMP -Assessment of past pregnancies (assess her G&P's- gravity and pregnancy and account for all of that, know what kind of delivery she had if she has had previous kids, what the weight of her babies have been, did she have any complications with her past pregnancies) -Gynecological history (such as any gyn surgeries, concerns such as hx of STIs, also going into more hx of menstruel cycles -Current and past medical/surgical history (anything that could affect the pregnancy, any mental problems such as anxiety or depression, postpartum depression, etc. Ask about prescription, OTC, herbal or anything we want to make sure it is safe for the pregnancy, ask about allergies. It is also a time to make sure mom is up to date on all the immunizations, etc. bc for some women, these 9 months are the only time they get care from a doctor) -Drug use (smoking, alcohol, vaping, illicit drugs that can all pass onto the baby) -Family medical history -Father's family history of genetic conditions -Social and occupational history (since a lot of social risk factors are associated with baby outcomes. Ask about her work, education level, income, housing, support system, is the father of the baby involved, etc.) -History of abuse/Intimate partner violence (pregnancy is actually a time where the likelihood of abuse increases so make sure we are screening women for abuse at a minimum of once per trimester and then again at her postpartum visit- making sure we are asking this privately)

Nutrient Needs During Lactation

-Similar to those during pregnancy (because you have a baby that is rapidly growing over the first year that her body is supporting so metabolism stays really high, etc. -Needs for energy, protein, vitamins, minerals are greater than non pregnant needs (protein needs stay really high for tissue growth, etc.) -Consumption of at least 1800 calories/day is recommended -About 500 calories above pre-pregnant levels (so similar to the third trimester) -most women will notice a steady weight loss when breastfeeding so that is an incentive for a lot of moms to breastfeed -in order to breastfeed, it is a lot of fluid so they need additional fluid intake (as long as they are drinking to their thirst, that should be good but they just need to make sure they are not getting dehydrated bc it can affect their milk supply -smoking also affects milk supply so definitely need to avoid that bc it decreases the production and supply -caffeine levels can build up in infants in an instant so mom needs to keep an eye on the caffeine intake when breastfeeding -alcohol intake can adversely affect the baby's growth and development, so nursing women don't need to constantly be drinking alcohol and breastfeeding. It is okay to drink and breastfeed (some woman do pump and dump after they drank but if the mom is not really feeling it, the baby is not really feeling it and as long as a few hours have elapsed before breast feeding, they do not need to pump and dump. -sometimes a baby will have sensitivities to things that the mom has eaten such as dairy and that can mess up the baby's stomach so it can be a process of elimination to get rid of the things the baby is having sensitivity to.

Pregnancy: trimesters

-Spans 9 calendar months Trimesters -First: weeks 1-13 -Second: weeks 14-26 -Third: weeks 27-40

The placenta

-Structure: begins to form at implantation (it does take some time to form and grow- it is usually later in the first trimester until the placenta is ready to do all of its functions- completely formed by 12-14 weeks). There is still circulation between mom and baby right after their first heartbeat. It gets wider and thicker as the pregnancy progresses and will eventually take up about half of the uterus. -baby and mom have their own circulation and it is important to know that their blood never mixes or should never mix, but their blood do come very close to each other and they are only separated by a thin membrane.** -2 sides: maternal side and fetal side (in the pic, A is the maternal side which is bumpy and lumpy, and is adhered to the uterine wall. B is the fetal side and is smooth and shiny which is shiny because of the amnion. It has he umbilical cord attached to it. the third pic is showing the membrane. Functions: "Endocrine gland" -Human chorionic gonodotropin (hCG)- tells the corpus luteum to hang around and keep secreting hormones. Starts to be produced right at implantation. It is normal for the hCG levels to rise very rapidly (doubles every other day) throughout the first trimester. Right around the end of the first trimester, it begins to level off and that is about the same time the placenta takes over. We think that the hCG levels have an association with nausea and sickness with first trimester because that gets better at the end of first trimester. -Progesterone: helps support the pregnancy and to maintain the endometrium, also helps keep the uterus relax and prevents it from contracting. It is also involved in breast development and getting it ready for lactation -Estrogen: also contributes to breast development and getting it ready to produce milk. It also increases the vascularity to the uterus and placenta -if pregnancy does occur, we need the corpus luteum to hang around for a while (bc if there is no pregnancy that occurs, it just degenerates and causes the hormones to plummet and that is what signals us to start our period again) -once the placenta is fully developed, it completely takes over hormone production and we no longer need the corpus luteum to do it. Metabolic functions: -Respiration: working as the baby's lungs and does it for the baby until the baby is born -Nutrition: gives baby nutrition as long as it is functioning properly -Excretion: gets rid of waste products (functions like the kidneys and will bring it to the mom and then mom will get rid of all those waste products) -Storage: can store certain nutrients such as bigger things like iron and calcium (calcium will be needs as baby's teeth and bones begin to ossify and harden. Iron will be needed for RBC production. -it is a good thing that the membrane between mom and baby is so thin for all the respiration, nutrition, etc. listed above but can also be a bad thing because bad things can cross also such as the teratogens like drugs, meds, viruses, etc. getting to the baby Maternal blood pressure and placental function: -By term: 10% of maternal cardiac output goes to the uterus -Hypertension: if you have widespread vasoconstriction in moms circulation and placenta, that will interfere with baby's blood flow (there will be a problem if he have a chronic interruption to blood flow). Also nicotine in cigarettes cause widespread vasoconstriction so that also has an impact on thee placenta and baby and that is why most of those babies are much smaller. Also moms who use cocaine cause very small babies. -Hypotension/decreased cardiac output: decreased blood flow and CO will interfere with perfusion for mom and baby -Supine hypotension -> "Vena Cava Syndrome"- this occurs in pregnant women, more towards thee thtird trimester of pregnancy, usually when the uterus is larger. when pregnant women lie flat on their back, they uterus presses on the inferior vena cava, decreasing the amount of blood comes to the heart and that adversely impacts perfusion. It can get bad and cause mom to become light headed, meaning it is definitely compromising perfusion to placenta and baby. The way to fix this is to flip them on their side and it usually resolves pretty quick. -mom needs to have an adequate blood pressure and cardiac output to ensure good perfusion to the placenta, because if there is a problem with that, there will be a problem with nutrients, etc. for the baby. -a decent amount of mom's cardiac output will go to the placenta for baby. -we can have an acute interruption of blood flow (such as Vena Cava Syndrome or a knot in the cord) and we would see fetal distress on a monitor with an abrupt problem, but it would not cause the baby to stop growing. -or a chronic interruption and issues of blood flow (more like moms with uncontrolled hypertension, or chronic smoking). This chronic problems will cause babies to not grow well and be small.

2nd and 3rd Trimester warning signs

-Sudden leakage of fluid from vagina prior to 37 weeks -Vaginal bleeding with or without abdominal pain -Chills, fever, burning on urination, flank pain -Decreased fetal movement -Increased pressure, uterine contractions, or cramping < 37 weeks (signs of preterm labor) -Visual disturbances or severe headaches (ex: seeing spots, double vision) -Swelling in face and/or fingers (generalized edema) -Abdominal pain, epigastric pain -the last 3 points are signs of severe gestational hypertension or preeclampsia

Fallopian Tubes & Ovaries

-Two fallopian tubes, two ovaries arise from the side of uterus -Ovum (egg) released from ovary during ovulation and fertilized in the fallopian tube. -provide a Warm, nourishing environment as zygote (fertilized egg) moves to uterus to implant -28 days is an average period cycle, generally the luteal phase is pretty constant (14 days), but the follicular phase is the one that has variation in length

The Family in a cultural context

-Women with a minority racial/ethnic affiliations share poorer health outcomes -Understanding culture provides insight into how a person reacts to illness, pain, and medical procedures, and expression of emotion -Health-seeking behaviors are greatly influenced by culturally related health beliefs -Development of cultural competence promotes good health outcomes Childbearing beliefs and practices -Prenatal care (people approach on prenatal care and whether or not they get it may be due to culture) -Communication -Use of Interpreters (you really want to use a hospital approved interpreters esp. for legal reasons so no information is misinterpreted, we try not to use children, and a male interpreter may cause embarrassment bc of some of the things we have to ask the patient. Make sure if you are using one you want to talk to the patient and not just be staring at the interpreter) -Family roles (role of the father may be different and may not be present in the room with their wife, etc.) -Circumcision -dietary measures may also be very different with culture such as the hot and cold foods (yin and yang) esp. in the Chinese culture bc they are trying to restore balance -don't make any assumptions, just ask if the patient has cultural preferences

Zygote

-Zygote: fertilized ovum -Morula: 3 days after fertilization (16 cell sphere) -Blastocyst: day 5 (distinct inner and outer cell mass with fluid in between) -Embryoblast (inner mass of cells in the blastocyst): develops into amnion and embryo -Trophoblast (outer cells in the blastocyst): develops into chorion and the placenta

Follow up Prenatal visits

-a lot quicker than the first visit -Interview interval history, just to figure out if there are any changes from the last visit -Physical examination a lot more focused and abbreviated (vital signs, weight, do a urinalysis to look at the protein, glucose, signs of UTI, measure fundal height) Fetal assessment -Fetal movement or "quickening" (by 20 weeks, they should start to feel the fetal movements but it just depends on the mom and their size, etc. Moms perception of fetal movement is the best indicator for fetal well being bc they know the baby's habits and know how the baby knows so it is important to teach them to notify any decrease in fetal movement because that would not be normal) -Listening for fetal heart tones with the doppler (can be dopplered usually around 10-12 weeks) -Comparing fundal height and gestational age -Review appropriate trimester warning signs (pg 314)

Chapter 15: Maternal and Fetal Nutrition

-nutrition is associated with birth outcomes on both ends of the spectrum (bad outcomes with either malnutrition or too much unhealthy food)

Formation of the membranes

-the embryo of zygote is surrounded by: Chorion and Amnion: -2 layers of membranes surround developing embryo -Chorion-develops from the trophoblast, contains chorionic villi on its surface that will tap into the maternal circulation and pick up oxygen and nutrition for the baby, and will exchange and get rid of waste products as well for baby (the outer membrane) -Amnion- develops from the inner layer or membrane of the blastocyst surrounding embryo and fetus -these 2 layers will fuse together by the time of birth Chorionic villi -part of the fetal side of the placenta -Finger like projections that form from the trophoblast -Obtain oxygen and nutrients from the maternal bloodstream -Dispose of waste products in maternal blood Amniotic Cavity: contains amniotic fluid -Volume -starts out kind of small, but Increases weekly (700 -1000 mL present at term) -Amount changes continuously bc there are different things that affect the fluid level since the baby is continually swallowing and consuming the amniotic fluid and then peeing it back out and it is also moving in and out of the fetal lungs -Oligohydramnios: not enough or low amniotic fluid (can be a bad sign, seen especially in late pregnancy or could be a warning sign for the fetal kidneys) -Polyhydramnios: too much amniotic fluid (may see this with gestational diabetes - when you have mom has too much blood sugar, you drink and pee a lot and so is baby, also could mean some GI anomalies such as esophageal atresia, and also neuro anomalies) -by birth and the water breaking, you will have about a liter of amniotic fluid -amniotic fluid includes fetal DNA which is why they may get an amniocentesis

pic of vernix caseosa and lanugo

-these both appear around 20 weeks of pregnancy and for the most part, have disappeared by term. -the skin itself is very thin, sticky, and transparent- in a 24 week baby you can see the blood vessels straight through and it is not unless the third trimester that they develop adipose and cutaneous tissue. If they are really young, they may have to turn on humidity since the preemie can lose their insensible losses and moisture from their skin very easily.

Passenger- station and engagement

-we look at the Ischial spines. Everything as far as engagement and stations, etc. have to do with where the baby is in the relation to the ischial spines. -when doing an exam, you go to find the baby's head and. spread fingers apart -if baby's head is even with the ischial spine- that is called a 0 station. Anything back, is negative (we don't go past -5, and they may even just chart OOP meaning it is out of the pelvis and not even in it yet), and anything farther coming out is positive numbers such as +2. -usually if it is a first time mom, those baby's start to engage in the pelvis usually before labor starts. After that first baby the 2nd, 3rd, etc. baby becomes engaged at the same time that the mom is in labor. in the engagement pic, the baby one left is not engaged -the right pic means the baby is engaged and is at a 0 station.

Pregnancy Tests

Human chorionic gonadotropin (hCG) is earliest biochemical marker for pregnancy -Production begins as early as day of implantation -Can be detected as early as 7 to 10 days after conception -when the hCG is not doubling every other day like it should be, that is a sign of an abnormal pregnancy and could be an atopic pregnancy or one likely to end in miscarriage -an abnormally high level, that can be if the fetus is affected with Down syndrome, a molar pregnancy, and multiples -recommended to do urine test if pregnant early in the morning bc the hCG levels are highest in the morning.

Essential Nursing Competencies for genetics

1. Constructs a pedigree from family history utilizing standard symbols and terminology 2. Develops a plan of care that incorporates genetic and genomic assessment information 3. Provides credible, accurate, appropriate, and current genetic information and resources that facilitate decision-making 4. Recognizes when one's own values/attitudes r/t genetics may affect patient care 5. Assess patient knowledge 6. Facilitates appropriate referrals/resources

Sex Chromosome Abnormalities- Klinefelter syndrome

Klinefelter syndrome -Trisomy XXY (47 XXY) -they have an extra X instead of just 1 and because there is a Y, it will be a boy -Affects males only -Usually very tall -Underdeveloped secondary sex characteristics -Small testes, usually infertile -Learning disabilities

Variations in Prenatal Care

Age differences: Adolescents -Less likely than older women to receive adequate prenatal care -more likely to have poor nutrition, to smoke, etc. -higher risk for complications so bc of these things, we need to increase our surveillance of adolescent moms. Women older than 35 years -Incidence -Age related medical risks -Prenatal Care (will prob have more of these visits than normal pregnancies) -Genetic screening and amniocentesis (we see more birth defects, down syndrome, low birth weight, etc.) -Ultrasounds (will prob have more of these bc of the risk fo complications) -for different reasons, we are seeing more older moms

Female Reproductive System

Breasts -Change in size and nodularity in response to cyclic ovarian changes -right before your period cycle the alveoli stretch, blood flow increases in the breast, and the increasing levels of estrogen and progesterone (hormones) also cause fluid retention which is why we feel the heavy feeling right before our period -Physiologic alterations in breast size reach minimal level 5 to 7 days after menstruation stops and breast self-examination (BSE) best carried out during this phase of menstrual cycle (regardless, do it at the same time every month) Self Breast Exam Best time: no tenderness or swelling -5-7 days after the period has ended -Teaching guidelines: pg. 52 -use pads of fingers and either do up and down approach or a circular approach and make sure you cover all of the breast tissue -tell obese patients to check collarbone to ribs and arm pits to sternum to make sure they are checking all of the breast tissue -50% of cancers are in the upper outer part of the breast -also get them to look and check for symmetry and contour of the breast, dimpling, nipple changes such as all of the sudden inverting inwards, discharge, etc.

Physiological Changes of Pregnancy

Cardiovascular system Blood volume: -Increases by 1500 mL (about 50%) -Protective mechanism (bc once women give birth, they bleed and some more than others if they have postpartum hemorrhage.) -she needs more blood circulating to get to the baby Blood composition: -Increase in RBC production and plasma: since RBCs carry oxygen and that helps provide oxygen for the baby. They also need to take an iron prenatal vitamin to help make the red blood cells. All of this is even more pronounced when women are having multiples so that means this women will need even more iron. There is actually a greater increase of plasma than the RBC and that kind of waters it down a little bit which can make them develop a physiologic anemia and it is normal to note a drop in hemoglobin because of this change. (normal hemoglobin is 12-16 and in pregnant women, we see the greatest drop in the 2nd trimester so we let the mom get to 10.5 before we start to get concerned. but, in 1st and 3rd trimester, our cut off is about 11 and anything below, we get a little more worried then. -Physiologic anemia Circulation and coagulation times: -Tendency for blood clots b/c of increase in clotting factors -women who are pregnant are at an increased risk (like 5-6x) for blood clots r/t the estrogen bc it increases the number of clotting factors. The risk is not over once they have their baby and it extends for the 6 weeks of postpartum.

The process of conception

Conception -The process involving the union of a single egg and sperm Occurs as a sequential process (3 things have to happen) -Ovulation: egg needs to be released -Fertilization: which occurs in the fallopian tube (outer portion of the tube) -Implantation in the uterus: after it is fertilized and turns into a zygote, it will burrow and implant itself in to the thick endometrium. -Ovum: when a ovum is released, it is viable for about 24 hrs once it is released -Sperm: viable in the reproductive tract for about 24-72 hours (so there is about a 3-4 day window that conception can occur.) -if the egg is not fertilized, it just degenerates and will be reabsorbed by the body. Fertilization: takes place in the outer third of the uterine or fallopian tube (called Ampula) -Sperm head contains enzyme and the enzymes will be released that allow it to penetrate an egg (enables it to enter ova) -After one sperm enters and penetration of that egg occurs, cellular change occurs (called the cortical reaction) in ovum which makes it impenetrable to other sperm (this happens and the egg closes itself off to other sperm because if it didn't, we would have too many chromosomes) -once that fertilization occurs, that organism is called a zygote which has one cell and 46 chromosomes. Zygote: united egg and sperm -Egg (23 chrom) + sperm (23 chrom)= zygote (46 chrom) After fertilization: the zygote begins to travel the length of the fallopian tube to get to the uterus, which can take 3-4 days and then will implant in the uterus.

Uterus

Divided into two parts: corpus and cervix -Corpus: upper triangular portion, upper 2/3 of uterus (body of the uterus) -Rounded top of the uterus- fundus -Cervix: lower 1/3, meets body of uterus at the internal os and connects with the vagina at the external os. (mouth to the uterus)- the external and interna os will open during labor -Very elastic- to accomodate and grow a baby -the cervical canal is what will shorten and go away when patients are in labor -pay attention to the layers of the uterus, especially endothelium when we get to fertilization

Common Genetic Disorders- Down's Syndrome: Trisomy 21

Down's Syndrome: Trisomy 21 Characteristics: (could have some or all of them) -All individuals have some degree of intellectual disability -Upward slant of eyes -Small skin folds in inner corner of eyes (epicanthal folds) -Flat facial profile, depressed nasal bridge and small nose -Small, low-set ears -Enlarged tongue -Small deep crease across center of palms (simian crease) -Hypotonia -Hyperflexibility risk increases with higher aged pregnancy

Papanicolaou test

Educate on importance and frequency of pap smears -First exam should be by 21 years -Ages 21-65: every 3 years -Ages 30-65: every 5 years if PAP testing plus HPV testing done -After age 65 and 3 consecutive negative results: discontinue screening -After total hysterectomy FOR BENIGN REASONS: discontinue screening -if a malignant reason, they will continue getting paps and smear where the cervix once was -More frequent screening needed if history of abnormal pap -no sex or creams or pills vaginally for the last 48 hours before a pap smear because it can throw off results

Fetal development

Fetal circulatory system -very first organ system to start functioning (about 3 weeks after conception does it start beating) -by the end of the embryonic phase, it is fully developed (still has to mature but still does) -Ductus venosus: connects umbilical vein to babies inferior vena cava (travels through the fetal liver) -Foramen ovale: divert blood away from the fetal lungs, opening between right and left atria. blood shunts from right to left then to the rest of the body. -Ductus arteriosus: divert blood away from the fetal lungs. The blood that gets to the right ventricle normally would go to thee pulmonary artery then lungs, but instead it shunts straight across to the left ventricle to then go to aorta and out the rest of the body. -the foramen ovale and ductus arteriosus are both acting as shunts and making the blood move to the lest resistance since there is a lot of pressure. Respiratory system -the last organ system to mature, and not even completely matured when the baby is born -Development begins in embryonic stage and continues through fetal life and childhood -Alveolar formation: this continues all the way up to term in the fetus. -Pulmonary surfactant: this prevents the alveoli from collapsing when the baby exhales. It is released usually around 36 weeks which is why we are concerned about lung development and potential of respiratory distress when baby's are born at or before 36 weeks. -Respiratory movements: "practice breathing" that we see baby's doing on ultrasound and they go through the motions of inhaling and exhaling with fluid to help the lungs mature. Renal system -Fetal urine and amniotic fluid volume -malformation of renal can a be diagnosed in utero and we would be seeing oligohydraminos with that. -kidneys are considered fully developed at birth and baby's should void within 24 hrs of birth- may only pee 1 or 2 times a day but that number tends to increase as the days go on. Neurologic system -Sensory awareness- different senses can occur as the pregnancy progresses -we can see the baby sucking as early as 12 weeks -around 24 weeks the fetus can hear and respond to the moms voice -they can distinguish taste -around 28 weeks, if you sign a bright light on moms belly, the baby can see and respond to that -baby's do perceive pain at the age of viability (around 23 weeks) Reproductive system -Sex differentiation -considered fully complete by the end of first trimester, about 12 weeks so we can determine sex by then Musculoskeletal system -Movements: the baby moves very early on in pregnancy, and in the late of first trimester but mom may not feel it. Mom can usually perceives and feel those movements by about 15 to 20 weeks -Fontanels: fontanels are where more than 2 bones comes together while sutures are where 2 bones come together. At birth, the suture lines can be very prominent and this is what helps the baby come through and mold out the birth canal bc they overlap through the vaginal canal and that is why they have that cone shaped head. The fontanels will close later. Integumentary system -Vernix caseosa: cheesy white substance that protects baby's skin from the effects of siting in water for 40 weeks. -Lanugo: fine hair that the baby is covered in, some babies will still have a little by term but for the most part should have disappeared. -these both appear around 20 weeks of pregnancy and for the most part, have disappeared by term. -the skin itself is very thin, sticky, and transparent- in a 24 week baby you can see the blood vessels straight through and it is not unless the third trimester that they develop adipose and cutaneous tissue. If they are really young, they may have to turn on humidity since the preemie can lose their insensible losses and moisture from their skin very easily.

Nägele's rule

First day of LMP + 7 days - 3 months LMP = October 10, 2019 What would this patient's due date be? July 17, 2020 would be the due date

Care Management (cont.)

Food safety and pregnancy -E. Coli, Salmonella, Listeria (there are bacteria that can reek havoc if the mom intakes this through food bc can cross the placenta and be detrimental to the baby) -no unpasteurized milk or cheeses (brie, feta, soft mexican cheeses) -no raw cookie dough/cake batter -no raw sushi or raw oysters -hot dogs, lunch meats, and deli meats should be eaten only if cooked thoroughly -Cook meat, poultry, fish, eggs to safe internal temperature -Good hand hygiene -Avoid contact with raw meat, fish, poultry -Wash fruits and vegetables -Proper food storage (not keeping things in the fridge too long and then eating it)

Amniotic fluid

Functions of Amniotic fluid: -Maintains constant body temperature for fetus -contributes to healthy Musculoskeletal development (allows baby to move freely in the sac with the water) -Barrier to infection (the actual amniotic sac creates this barrier to keep out unwanted bacteria, etc.) -Allows for fetal lung development (since baby is taking in fluid into the lungs and exhaling it- it gives them practice breathing and the fluid contains things to help develop their lungs) - ex: if a moms sac broke at around 20 weeks, they can try to keep baby in for about 6-8 weeks longer since they may develop an infection without having amniotic fluid and when those babies are born at like 28 weeks, they have very hypoplastic or underdeveloped lungs which proves amniotic fluid helps with lung development

Assessing fundal height

Fundal height: -12 weeks -Just above symphysis pubis -16 weeks-1/2 way between the symphysis pubis and umbilicus -20 weeks fundus is at level of umbilicus -21-36 weeks-fundal height in centimeters correlates with weeks gestation +/- 2 cm (so around 24 weeks, the fundal height should be about 24 cm, give or take 2 cm) -this gives us an indirect measure of the baby's well being. -if a mom is having multiples, it would not be the same as those listed above -this fundal height can either tell us if they are measuring behind that we have a small baby that is not growing well, or we have low amniotic fluid. Or if she is measuring ahead, the baby could be huge or an excessive amount of amniotic fluid.

Sex Chromosome Abnormalities- Turner Syndrome

Turner Syndrome they are missing the 2nd sex chromosome for that last pair (the 23rd pair) -Monosomy X (45 X)- they only have 45 chromosomes instead of 46 -Affects females only -Lack of secondary sex characteristics -Juvenile external genitalia (will never develop pubic hair, etc.) -Underdeveloped ovaries -Short stature -Webbed neck -Low-set ears -Impaired intelligence -most of the time these girls are infertile -sometimes they don't even make it to delivery and they will spontaneously abort

Gravidity and Parity

Gravida: number of times a woman has been pregnant -Regardless of duration or outcome -Includes present pregnancy -any positive pregnancy test -Multigravida: woman who is pregnant for at least the second time -Primigravida: first pregnancy -Nulligravida: Never been pregnant Parity: any birth after 20 weeks -Regardless of whether the baby was born alive or dead, regardless of how many babies it is -Nullipara: woman who has had no births at more than 20 weeks gestation -Primipara: woman who has had 1 birth at more than 20 weeks gestation -Multipara: woman who has given birth two or more times at more than 20 weeks gestation -Grandmultipara: woman who has given birth 5 or more times -Gestational age: the number of weeks pregnant since the first day of the last menstrual period (LMP)- we give them credit for every day so we could say 39 +6 meaning they were 39 weeks and 6 days pregnant -Term: pregnancy from the completion of 37 weeks (and 0 days) to the end of week 42 of gestation -Postdate or postterm: pregnancy that goes beyond 42 weeks of gestation (you will really never see this anymore because the placenta was meant for only caring for the baby for about 40 weeks so most doctors don't want them going much past 40 weeks) -Preterm: pregnancy that has reached 20 weeks of gestation but before completion of 37 weeks of gestation (36 weeks and 6 days is considered preterm) -Viability: capacity to live outside the uterus -Stillbirth: a baby born dead after 20 weeks -Intrauterine Fetal Death (IUFD): a baby that has died in utero after 20 weeks -Abortion: any delivery before 20 weeks (any pregnancy loss meaning a spontaneous abortion, meaning miscarriage, or an elective termination of pregnancy, etc.)

Pregnancy and Birth History G-T-P-A-L

G—the number of pregnancies including current pregnancy or GRAVIDA T—the number of pregnancies that were delivered at term (37 weeks or >) P—the number of pregnancies that were delivered preterm between 20 and 37 weeks A—the number of pregnancies ending in abortion L—the number of children currently living -Example: G T-P-A-L can be written as: G2 P1001 -This patient is currently pregnant -This patient has had 1 term delivery, 0 preterm deliveries, 0 abortions, and has 1 living child Christy Meadows is pregnant for the first time. -What is her obstetrical history using G TPAL? G1 P0000 Jean Sanchez has one child born at 36 weeks gestation and became pregnant a second time. The second pregnancy ended in a spontaneous abortion (Ab) at 15 weeks gestation. -What is her obstetrical history? G2 P0111 Tracy Hopkins is pregnant for the 4th time. At home she has a child who was born at term. Her 2nd pregnancy ended at 10 weeks gestation. She then gave birth to twins at 35 weeks. One of the twins died soon after birth. -What is her obstetrical history? G4 P1112 Ex: not pregnant right now but had a term twin pregnancy: G1 P1002. If she was currently pregnant also, it would be G2 P1002.

Contemporary Issues and Trends: Healthy People 2030

Healthy People 2030 goals related to maternal health (morbidity and mortality): -Reduce the rate of fetal and infant deaths -Reduce the rate of fetal deaths at 20 or more weeks of gestation -Reduce the rate of all infant deaths (within 1 year) -Reduce the rate of maternal mortality -Reduce maternal illness and complications due to pregnancy (complications during hospitalized labor and delivery) -Reduce cesarean births among low-risk (full-term, singleton, and vertex presentation) women -Reduce low birth weight (LBW) and very low birth weight (VLBW) -Reduce preterm births Healthy People 2030 goals related to maternal health (pregnancy and health behaviors): -Increase the proportion of pregnant women who receive early and adequate prenatal care -Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women -Increase the proportion of pregnant women who attend a series of prepared childbirth classes -Increase the proportion of mothers who achieve a recommended weight Healthy People 2030 goals related to maternal health (postpartum health and behavior): -Reduce postpartum relapse of smoking among women who quit smoking during pregnancy -Increase the proportion of women giving birth who attend a postpartum care visit with a health care worker -Decrease the proportion of women delivering a live birth who experience postpartum depressive symptoms

Changes in the cardiovascular system

Heart -HR increases by about 10-15 beats per min by the 3rd trimester -Slight hypertrophy: sense the CO is more and it is having to work a little harder, but should go back to normal after delivery. Cardiac output: -Increases to 50% over the non-pregnant rate by 32 weeks (listen to recording?) -Dependent edema: the really heavy uterus sits on the femoral and pelvic veins so it interferes with venous return back to the heart and bc of that you will see dependent edema (legs)- general edema is not normal though -Varicosity of veins in legs, vulva and anus (like hemorrhoids) due to the same issue with why we have dependent edema -in general the moms heart has to work a lot harder (and we know moms are getting pregnant when they are not very healthy such as being obese Blood pressure: -Maternal position -Supine hypotension -Change throughout pregnancy: BP generally stays about the same or slightly decreases - bc the progesterone in our body causes us to relax so the vasodilatory effects of progesterone causes the BP to slightly drop. Also, the presence of the utero-placental vascular bed (moms blood volume is circulating all over her body and she also has this new circulation that is perfusing her and the baby- think of lanes on a road and then you get to Atlanta and there are now 5 lanes so the pressure decreases just like in mom, the blood has spread out a little more and that also helps decrease the BP) -Heart rate: the rate has to speed up and usually by the 3rd trimester, HR is up 10-15 beats above the mom's baseline Respiratory system -Increase in O2 requirements (as moms body is trying to support the pregnancy, her metabolic rate is going to increase which will then increase the oxygen requirements to support herself and the baby- she is also getting rid of more CO2 as well as intaking more oxygen) So how it does this is the mom has a slight increase in respiratory rate (may not be even that noticeable) -Increased vascularity to respiratory tract -Nasal stuffiness and epistaxis are common (related to estrogen causing an increase in blood flow) -Structural changes: all of the ligaments around the rib cage relax under the influence of progesterone (since progesterone causes an overall vasodilatory effect all over the body and relaxing everything), making the rib cage a little bit bigger to accomodate more air and facilitate taking in more oxygen bc allows bigger expansion). Also the uterus pushes on the diaphragm and so especially towards the end of the pregnancy, the women complains of not getting a good deep breath. Renal system Anatomical changes: -Nocturia, urinary frequency/ urgency are common early pregnancy symptoms (esp in first rimester bc the growing uterus is sitting right on top of the bladder) -May return closer to term related to uterine pressure on the bladder (so gets better in 2nd trimester but returns in the third as the baby is dropping and the baby's head is right on the bladder) -we also see a dilation in the ureters and the renal pelvis which is basically where urine comes from kidneys into the ureters and some of that is caused by he relaxation of hormones but also some is from the increasing uterus hat blocks the urine, it can back up the urine and cause urine to not be able to flow and that is also why women are at increased risk for UTI's because of that. Functional changes: -Kidneys must manage increased metabolic and circulatory demands of maternal body and fetal waste products (mom's GFR increases by about 50% to meet these increased demands so they also have increase blood flow) so if the mom's kidneys are filtering very efficiently and fast, you will actually see a decrease in BUN and creatinine (so since the high point is 1.2 in creatinine, in a pregnant patient, you would probably get a little bit concerned in the creatinine was above 1 since you except that it should go down during pregnancy) Fluid an electrolyte balance -Physiologic edema (generalized edema would never be normal in a pregnant women, but the dependent edema (lower extremity) swelling ha normally occurs at the end of the day after mom has been standing, that is normal. The ideal position to relieve edema in a pregnant patient is lying her on her side to get rid of the lower extremity edema to get back to her heart, then kidneys, and excreted. -Proteinuria: bc of some of the renal changes, we do see some of this spilled into the urine due to the increased blood flow to kidneys and increased GFR and some just slips through. We would get concerned about proteinuria if we also know the patient has hypertension or if we find out the patient has hypertension. -Glycosuria: bc of some of the renal changes, we do see some of this spilled into the urine due to the increased blood flow to kidneys and increased GFR and some just slips through and the kidneys are not able to reabsorb glucose fast enough (normally, glucose is normally all reabsorbed). But, it could be a problem and could show the mom may have gestational diabetes if the glucose was found in excess. -to recap, a little bit of protein and glucose in urine are normal for pregnant women, but if it is found in excess, then it could be a problem Integumentary system -mostly due to stretching and an increase in pigmentation. We already. says the nipples of the breast and the vulva are darker pigmented -Chloasma (or molasma): an area of hyperpigmentation that occurs on the face and usually affects the forehead, nose, and cheeks. Typically you will see it in more medium to darker skin tones, and typically it is more aggravated from the sun when people are more in the sun, and it usually goes away after the pregnancy. Linea nigra: -Pigmented line extending from the symphysis pubis to the top of fundus midline (down center of abdomen) -Striae gravidarum: stretch marks that are associated with pregnancy. They represent where the collagen fibers separate where the stretching occurs. The abdomen, breasts, and maybe thighs are the main places. The color of the stretch marks depend on the patients skin color, and unfortunately, they will not go away, although they can fade a little in color. Palmar erythema: -Pinkish red blotches over palmar surfaces -Spider nevi: blueish red elevations as a result of increased blood flow to the subcutaneous tissue (mainly on face, neck, and chest) -common to have increased hair and nail growth during pregnancy (they have this beautiful hair and fast growing nails) -variable effects on acne, for some it gets better, and for others their acne gets worse during pregnancy -pregnant women have the tendency to sweat and perspire a lot and they stay hot. -remember, all of this increased blood flow on the skin is all due to the estrogen Musculoskeletal system -Posture changes: -Lordosis (so the mom does not fall, she has to compensate and exaggerate the lumbosacral curve, but it leads to low back pain, esp getting into the 3rd trimester) -Relaxation of the pelvic joint (under influence of hormones- progesterone): preparing woman to get ready for birth, this relaxation causes that waddling walk pregnant women do. There is also hip pain that occurs due to that. -Diastisis recti abdominis: separation of the ab muscles and pregnancy causes this to occur and the ab muscles to lose tone and the tone doesn't usually ever go back to what there was pre-pregnancy and each baby mom has, the ab muscles lose more and more of the tone. (this is also kind of why first time moms don't show they are pregnant as fast bc they still have the ab tone and after they continue having kids, they show faster bc they don't have as much ab tone anymore) Neurologic system -Lordosis may cause pain, compressing nerves -Carpal tunnel (caused by compression of median nerve of the wrist and they will have the paresthesia in their hands and this too typically goes away after pregnancy) -can have paresthesia (numbness, tingling, shooting pain) of the legs Gastrointestinal system Appetite: -Morning sickness (due to the increase of hCG in the firstt trimester, that levels off after the end of first trimester and as thee hCG decreases- this morning sickness is very variable to each pregnant women) -Changes in taste (women normally crave weird things with food that don't really go together like pickles and ice cream. They also have aversions to food they used to like- things they once liked, they can't stand anymore) -Pica: when people crave non-food sources such as eating ice, dirt, or starch and things with no nutrients. A little bit of pica is not harmful, like eating a little of ice and dirt but it can turn harmful when they are doing it too much where they are not getting the nutrients they need for them or baby (and so if a mom is not gaining weight like she should, you may want to investigate if she has pica. Mouth: -Gums (they get really red, swollen, and spongy from increased blood flow and will bleed easily) -Ptyalism (excessive salivation)- this is hormonal and only affects some women, and when this does affect someone, it can get bad to the point where the women has to carry around with a spit cup. Esophagus, stomach, and intestines: -under influence of progesterone and the relaxation, we have a slowing of GI motility during pregnancy and an increase in gastric emptying time (so takes the stomach longer to empty) -relaxation of the gastro-esophageal sphincter -Pyrosis: heartburn (bc a stomach that does not want to empty as quickly, a relaxed sphincter, and a baby pushing up, there can be a lot of reflux) -Constipation (since everything is relaxed and decreased peristalsis)- also some women have to take iron and that further makes it worse. Endocrine system -in order to support mom and growing baby, the metabolism has to increase so mom will have increase in the thyroid levels and parathyroid Thyroid gland: -Increase in thyroid hormone production -Most metabolic functions increase in pregnancy because mother must meet own needs and needs of growing fetus Parathyroid gland: -Increase levels of parathyroid hormone to take over for the demands of the fetus for calcium for fetal skeleton growth (so we need more calcium availability for a baby to grow teeth and bones, etc.) Parathyroid binds to intestine, kidneys, and the bone and cause release of of calcium from the bone, reabsorption in the kidneys, and absorption in the intestines, all allowing body to make more calcium for the fetus.

Ethics and Genetic Testing

Imperfect tests -Few tests have a 100% detection rate False-positive results -Client may terminate an unaffected pregnancy -May undergo unnecessary prophylactic bilateral mastectomy (like with BRCA testing) False-negative results -May fail to follow surveillance strategies due to false reassurance that they are not at risk ex: the quad screen is about 85% sensitive so will pick up the majority of cases but can still miss some

Infant mortality

Infant mortality rate -# infant deaths following live birth divided by total number live births (looks art babies dying after live births in the first year) -Reflects pre- and postnatal care in a given population -Leading causes of infant deaths in US -Congenital malformations, preterm birth and LBW, SIDS -higher infant mortality rates shows a more unhealthy population and vice versa Differences among ethnic groups -Non-Hispanic black babies-11.46 per 1000 -Non-Hispanic white babies-5.18 per 1000 -Hispanic babies-5.25 per 1000

Health Assessment Box 4.8 p.69

Interview: Women with special needs -Women with disabilities -Abused women: be very careful with them bc it could recreate a trauma for them. Try asking the male partner to step out for the questions regarding being hurt, etc. -Adolescents: try to ask parents to step out of the room and partner -Midlife and older women: make sure you are asking questions about the vaginal dryness and pain with sex, etc. History -Menstrual history: asking when first period was, what is the frequency and duration of the cycles, when was last period -Obstetric history: how many pregnancies have you had, and ask about outcome for each pregnancies whether miscarriage, abortions, pregnancy complications, what was the gestational age of the newborn -Gravida and Parity: hoe many babies she has carried and delivered -Menopause: after about age 45 and if having symptoms -Preventative care: when was last mammogram and pap smear or colonoscopy -Urinary symptoms: any frequency, urgency, incontinence, etc. -Vaginal problems or discharge: pain with intercourse, discharge that is bothersome, unusual foul smell, itching -Sexual activity: if so, how many partners do you currently have, sexual orientation -Contraception: are you satisfied with the method if on one -STIs: any history of these, especially if multiple partners Physical examination -External inspection and palpation Internal exam ("Pelvic") -Speculum -Collection of specimens, including PAP -Vaginal Exam -Bimanual palpation (palpating internally)

Initial Prenatal visit and Physical Assessment

Laboratory Tests -Blood type and screen (especially want to know if she is Rh + or -) -CBC (H&H, platelet, etc.) -Rubella titer -HIV, RPR (syphilis), and Hepatitis B -Urinalysis/ urine culture (to look for protein, glucose, signs of UTI) -Gonorrhea/Chlamydia cervical swabs -PAP test -Physical Exam including height and baseline weight (to make sure she is gaining weight appropriately), getting a baseline of vital signs, thorough head to toe assessment -Pelvic Exam pap smear, inspect and palpate internal and external genitalia, assess the uterine size via pelvic exam and the provider can determine if the uterine size matches the dates. -Assess fetal heart tones (FHTs) confirm pregnancy and make mom come back if they do not do this on the first visit to make sure it is a viable pregnancy.

Adaptation to Pregnancy

Maternal adaptation -Accepting the pregnancy -Emotional responses may vary by trimester -different responses based on how the pregnancy came about, if the partner is involved, family circumstances, ambivalence (meaning not sure) for people who even wanted the pregnancy, etc. -normally by 2nd semester, people tend to accept the pregnancy a little more

Genetic counseling

Multiple roles for nurses in genetic counseling -Identify families in need of genetic counseling -Make referrals to specialists -Provide information about genetics -Clarify genetics information received during counseling session or from other sources -Provide emotional support -Wide range of responses

Perinatal Care Choices

Physicians -see low and high risk patients -also have specialty doctors who did fellowship in mother and baby that specialized in high risk pregnancies) Nurse-midwives (CNM) -Low risk OB patients (with collaboration with physician) Doulas -Professionally trained to give support during labor -they are support people, not for anything clinical Birth plans -it is only a plan and we try to honor as much as the mom wants that is also safe for mom and baby. -with both the midwives and doulas, there is high satisfaction with birth, more vaginal delivery, less pharmacologic measures, less epidurals and higher successful natural births, etc.

Maternal Morbidity or complications

Pregnancy complications: -Acute renal failure -Cardiomyopathy -Amniotic fluid embolism -Cerebrovascular accident -Eclampsia -Pulmonary embolism -Liver failure -Shock -Septicemia -Complications of anesthesia *Obesity- Greatly increases risk for complications of pregnancy (it is more associated with miscarriages, still births and especially bc they have more adipose tissue and can't feel their baby moving as much and so they can't tell when the baby is moving less and less.

Stages of development

Pregnancy: -Lasts ~ 40 weeks (9 calendar months)- the 40 weeks starts on the 1st day of the last menstruel period -Post-conceptual age vs. LMP dates -there is about a 2 week difference between them. So a post-conceptual age would be 38 weeks while the LMP is 40 weeks since fertilization occurs 14 days after period 3 stages intrauterine development: -Ovum (preembryonic): conception until day 14 -Embryo: Day 15 until 8 weeks after conception (for LMP dates, it would be until 10 weeks)- this is the phase of greatest vulnerability to teratogens such as drugs, medications, viruses, etc. - By the end of this phase, all the major organs have formed which is why that is important, and the embryo has a very human like form now. -Fetus: 9 weeks until the pregnancy ends (or 11 weeks after LMP)

Types of genetic testing used in Maternity nursing

Prenatal genetic testing options -Maternal serum screening (offered to all pregnant women (most common if the quad screen commonly offered between 15 and 20 weeks- which it is not 100% since it is a screening test and not a diagnostic test- but it to looks at neural tube defects, trisomy 13, 18, and 21) -Fetal ultrasound: can also help diagnose genetic problems -Invasive procedures -Amniocentesis and Chorionic Villus Sampling: these are both invasive and diagnostic and confirmatory tests for anything that might have been positive on a screening. -NIPT (Non-invasive prenatal testing): can be given as early as 10 weeks and can also give the gender as well) Carrier testing -Identifies individuals who have a gene mutation for an autosomal recessive condition (for those and for the baby to be affected, it would need 2 mutated copies so both parents would have to be carriers for the baby to have it) -Sickle cell anemia, Cystic fibrosis, Tay-Sachs disease Predictive testing- used to clarify genetic status of asymptomatic family members -predicts the future risk for disease in someone that is asymptomatic, but clarifies in case of a family member that has something. Presymptomatic testing (determines if a person have the genetic mutation for something that condition will certainly appear if they have that mutation) -ex: Huntington's Disease Predispositional testing -ex: BRCA 1 -+ results do not mean there is a 100% risk of developing the condition (breast cancer); it increases the risk of developing the disease but is not certain they will have it. Newborn Screening: mandatory state-supported public health program to look at a bunch of metabolic disorders -Screens for over 50 disorders -such as Cystic fibrosis, Tay-Sachs, PKU, Galactosemia, Congenital hypothyroidism, Sickle cell anemia

Signs of pregnancy

Presumptive: changes noticed by the woman but DO NOT confirm pregnancy (symptoms patient is experiencing so it points to pregnancy but could also be caused by other things too so they are subjective symptoms) Symptoms -Amenorrhea -Morning sickness -Fatigue -Breast changes (being more full an tender, sensitive) -Urinary frequency -Quickening (moms perception of first fetal movements- it is subjective because it could just be peristalsis and your GI system moving) Probable: changes observed by the examiner but don't 100% confirm the pregnancy (still does not confirm a pregnancy, but it does lightly point to it) Signs and symptoms: -Goodell's sign: softening of the cervix -Hegar's sign: softening of the lower part of the uterus -Chadwick's sign: blueish discoloration that is evident on the cervix, in the vagina, and even the external genitalia (it is caused by increased vascularity and blood flow) -Uterine Enlargement -Braxton Hicks contractions -+ Pregnancy test: there are things that can cause a false pregnancy test Positive: changes only attributable to the presence of a fetus (only 3 things that 100% confirm) -Auscultate fetal heart tones using a doppler -Visualization of fetus on ultrasound -Fetal movements present by the provider (not moms perception)

Nursing and women's health

Problems related to health and health care of mothers and infants -Lack of access to pre-pregnancy and pregnancy care: when women get pregnant, they can apply for pregnancy medicaid but any other time, they can't get any doctor visits and not being able to do that can make the mom very unhealthy by the time she is pregnant and actually applies for care. -Lack of reproductive care for adolescents: such as contraception and birth control and as a result, there is lots of teen pregnancy -Prevalence of STIs: especially in teens and younger women -Significant disparities in health outcomes among various racial/ethnic groups

Common Discomforts of 2nd and 3rd trimesters

Pyrosis -Caused by the displacement of stomach by enlarging uterus -Also from progesterone decreases GI motility Ankle edema and Varicose Veins -Pressure of the enlarged uterus that decreases venous return Flatulence -increased progesterone decreases GI motility -pressure of uterus on the large intestine Hemorrhoids -Occur from underlying constipation and increased blood volume -Caused by decrease venous return and uterine pressure on veins Constipation -Caused by increased progesterone that decreases GI motility -Displaced intestines from enlarging uterus -Possibly from iron intake Backache -Caused by increased lumbosacral curve from the enlarging uterus Leg cramps -Caused by pressure of the enlarged uterus on the pelvic nerves and blood vessels leading to legs Faintness -Postural hypotension -Supine hypotension Shortness of breath -Caused by the enlarging uterus pressing on the diaphragm Difficulty sleeping -Enlarging uterus makes finding a comfortable position difficult Round ligament pain -Stretching of the round ligaments from the enlarging uterus and preparing for childbirth (usually groin pain) Carpal tunnel syndrome -Edema causing compression on median nerve of the wrist

Reasons for Entering the Health Care System

Reasons for visiting the women's health provider: -Preconception counseling and care: great time to get chronic disease under control, make sure they are taking safe meds for pregnancy, no more alcohol and drugs, smoking, etc. to ensure the women is as healthy as possible before they get pregnant -Pregnancy-> Prenatal care: early and consistent prenatal care is the key for good outcomes -Well-woman care: pap smears, screenings, etc. -Fertility control and infertility -Menstrual problems such as pain, really bad cramps, heavy periods -Perimenopause: care for the wonky symptoms that come along with menopause such as hot flashes, bleeding irregularities, vaginal dryness, etc.

Growth of the fetus

Teratogens -Substances or exposure that causes abnormal development (embryonic phases is most susceptible o these- up to 8 weeks after conception or 10 weeks after LMP) Fetal maturation -Viability: the capability of the fetus to survive outside of the uterus (about 23-24 weeks of pregnancy is where they can still save them) -as a fetus not as vulnerable but can still be some adverse effects such as fetal alcohol syndrome -the pic is showing post conceptual age.

Nursing interventions: education

Travel -Seatbelts (make sure the lap band is across the patients thighs and not across the abdomen) -Airlines (usually domestic flights will let pregnant women to fly up to 36 weeks. International flights usually stop them from flying a little bit earlier) -we need to teach patients to get up and walk around every hour or so on trips to prevent venous stasis and decrease blood clots from occurring. -Medication/herbal preparations anything mom takes in has the potential to cross and get to the baby, so make sure they are taking all safe medications. Most pregnant women get a sheet that tells them what they can take when they have when having heart burn, headache, etc. -Immunizations When pregnant, we want to make sure they are up to date on vaccines. They can not get live vaccines which are MMR and varicella (chicken pox) bc they would have teratogenic effect on the baby. -Hep B, tdap, flu vaccines are all good and we want women to get these. they can even get the covid vaccine. -Normal discomforts- see Table 14.2 p. 285-287 -Recognizing potential complications -Recognizing preterm labor (educating how to know where going into preterm labor and Braxton hicks) -Sexual counseling it is safe during pregnancy- it does differ bc in the 1st trimester, they are fatigued so much that they don't want to, in 2nd trimester it gets better, and in the 3rd trimester, they can develop body image issues and also there is awkward issues with the size. It is actually recommended towards the end or pregnancy bc it can actually help with the labor bc it stimulates contractions. There are some times where sex is not good such as a women continually going into preterm labor, or those who have had miscarriages

Common genetic disorders- Trisomy 13

Trisomy 13 -"Patau syndrome" -1 in every 10,000 live births (now 16,000) -Numerous abnormalities -Holoproscencephaly (fusion of the developing eyes that create a cyclops appearance) -small head -cardiac defects -cleft lip and palate -Very poor prognosis -most lethal but least common -many of the babies are stillborn

Common genetic disorders- Trisomy 18

Trisomy 18 -"Edward syndrome" -1 in every 3,000 live births (now 6,000) -Variety of anomalies, a lot of them seen on ultrasound -Severe mental retardation -Poor prognosis -will definitely see cardiac defects, craniofacial abnormalities, a really small mouth and jaw, clenched fists (commonly seen on ultrasound), and rocker bottom feet (feet look like the bottom of a rocker) -some of these babies will be stillborn and some survive around a year and some up to around 20.

Human Genome Project: Implications for Clinical Practice

Two key findings: -All human beings are 99.9% identical at the DNA level. -There are probably about 20,500 genes in the human genome. Importance of family history: -Completion of the Human Genome Project has resulted in renewed interest in family history -Single most cost-effective piece of genetic information (best tool to identify your risks for pregnancy, etc.) -A number of family history tools are available online. Pharmacogenomics -Using genetic information to guide a client's drug therapy - ex: Genotype-guided warfarin dosing (a genetic test can influence their dosing of Warfarin bc it looks at how a person metabolizes meds, etc.) Gene therapy -Inserting a healthy copy of the defective gene into somatic cells of affected individuals and therefore prevent future disease

Umbilical cord

Umbilical cord: connects the placenta to the fetus -2 arteries and 1 vein (AVA) -Arteries: deoxygenated -Vein: oxygenated Wharton's jelly -Connective tissue that prevents compression of the umbilical cord in utero -Ensures continued nourishment to the fetus -protective mechanism to ensure continuous perfusion to this baby and prevents cord from getting kinked or compressed. - if there was a kink or no blood flow to the baby for a period of time, it could die -Nuchal cord: cord wrapped around the baby's neck -this is one of the most common problems with the umbilical cord (it will be documented nuchal x1 or x3 - however many times it is wrapped around). Normally does not cause any problems until very end of labor when they are being delivered. The effect on the baby depends on how tight the cord is around the neck. -we can also get knots in the cord- consequences depend on how tight the knot is and if it is tight enough to cut off perfusion -2 arteries are a little smaller and the vein is bigger. Arteries go away from the baby and carrying deoxygenated blood and waste products back to mom. The pulse you hear at the base of the umbilical cord is the 2 arteries we are palpating. -The vein is carrying all the nutrition and oxygenated blood from mom and the placenta to the baby. The vein should insert centrally on the umbilical cord- right in the middle -sometimes there can be a 2 vessel cord with one artery and one vein- this may prompt us to do extra chromosome testing, and we would also watch baby's growth more carefully. There is also an association with renal problems with a 2 vessel cord

Changes in the reproductive system and breasts

Uterus: -Size: there is an increase in uterine size normally due to the influence of estrogen, increase in vascularity, and the baby growing -Position: -you can palpate the fundus just above the symphysis pubis right around 12 weeks -around 20 weeks of pregnancy, you can palpate the fundus right at the sight of the umbilicus -Lightening: when the baby drops toward the end of pregnancy getting ready for birth and that will cause the fundal height to drop which is normal (shown in pic that the 40 week height of fundus is lower than opposed to the 36 week mark) -Pregnancy may "show" after the 14th week: it is obvious to other people that you are pregnant. If the patient is more obese, they may not even show at all. If it is a really skinny patient, she may show more and also the more babies you have, the more you show. -Displacement of abdominal organs -Hegar's sign: softening of lower uterine segment- causes the fundus to call on the bladder and that causes a lot of urgency early in pregnancy. Contractility: -Braxton Hicks contractions (this will occur in about the 2nd trimester and beginning by the 3rd, the mom will start to perceive and feel them). It does not hurt but you can feel the uterus tightening and they do not cause any cervical change so are not true labor contractions. Uterus: Uteroplacental blood flow: -Increases rapidly as the uterus increases in size -Factors that decrease uterine blood flow (nicotine, drugs, hypertension, vena cava syndrome or any hypotension) Cervical changes -Tissue changes from increased estrogen (very vascular and can bleed very easily so can have spotting after sex or an exam which is normal) -Mucous plug: develops inside the endo-cervical canal. It is a protective mechanism from outside microorganisms from getting in to where the fetus is. -Goodell's sign -Chadwick's sign Uterus -Quickening: fetal movement or "flutter", like butterflies (around 15-20 weeks it occurs). Someone who is obese may not feel this. -Ballottement: passive movement of the unengaged fetus (meaning baby is not in pelvis, not ready for delivery and labor). the examiner, with their fingers can press the cervix and push the baby up and it will come back down and hit the examiners finger. You want the baby to not be ballotable at the end of pregnancy, meaning they are ready to start giving birth bc the baby's head is engaged. Vagina and vulva -the vaginal canal will lengthen and the mucosa and lining of it will thicken to prepare and get it ready for stretching and birth. -Vaginal epithelium -Chadwick's sign -Leukorrhea: thin, white or slightly gray mucous discharge with a faint odor (normal and due to the increases of estrogen and hormone). They are also more acidic to help with bacteria and fighting off infection. z -increases of viscosity increases sexual arousal and sensitivity. Also, it increases the risk of fibroids an hemorrhoids. -pregnant are more prone to yeast infections though. Breasts -Feeling of fullness, heightened sensitivity, tingling -venous patterning occurs due to increased blood flow as the breast prepare for lactation -Heaviness is normal -Nipples and areola: they get darker -can also have stretch marks Montgomery tubercles: -Hypertrophy of the oil glands embedded in the areola -May be seen around the nipples -they will become even more prominent- secretes a substance to help lubricate during lactation to protect the breasts Colostrum: -Creamy white to yellowish pre-milk fluid -Can be expressed from the nipples as early as 16 weeks -present in very small amounts (it is what the baby gets in the first 3-5 days after the baby is born)

pic of skin changes in pregnancy

pic on left is of the cholasma and the pic on right is of linea nigra.

Female breast

there are epithelial cells surrounding each alveoli and that is what is responsible for secreting breast milk -the breast is rich with blood flow and so that can cause metastasis more common

Assessing fetal heart tones

•Assessment of fetal heart tones (FHT) or the fetal heart rate (FHR) using a handheld doppler •Normal FHR ranges from 110-160 bpm -dopplers can be used at around 10-12 weeks. -if we are not able to hear any heart ones, esp. on someone we previously heard heart tones, this could be a problem and would prompt us to use an ultrasound to see what is going on. -also on a more obese mom, it may be after 12 weeks that we can finally hear the heart tones.

Signs Preceding Labor

•Lightening: when the baby is coming down and the mom can then breathe a little easier, but the mom might get more frequency and urgency because the baby is now sitting low on her bladder. •Low back ache & sacroiliac distress: this is also bc the baby is dropping- as mom is getting closer to delivery, the pelvis widens and relaxes and causes this lower back ache and SI pain •Braxton hicks contractions: they are not actually doing anything that is putting you into labor (they feel it in the belly button, abdomen area and they are not really true) •Loss of mucous plug/ bloody show (if it comes out, it does not mean that you are going into labor but can) •Rupture of membranes (your water can break And you not be in labor, but if i does break, you have to go to the hospital bc this bag of water is protecting the fetus from infection so you want to speed things along if your body does not put itself into labor) •Surge of energy (mom is ready to go and getting stuff together for birth) •Weight loss of 0.5-1.5 kg (1-3.5lbs)- this can be confusing for moms bc they think they need to be gaining, but it is okay because our hormones are just preparing our body to have a baby •GI disturbances (may experience more nausea, diarrhea) -these can come anywhere up to 2 weeks before labor happens -these may or may not occur before labor begins

Passenger

•Passenger: Fetus and Placenta -You have these 2 passengers. They both have to come through the birth canal and the fetus is bigger and the biggest portion of the fetus is the head (you have 4 sutures and 2 fontanels on the head) and bc the sutures are not completely fused together, those bones can overlap eachother in order for the head to fit through the birth canal and we call that molding- the head molds to fit through and wee want that to happen. That can sometimes lead to a cone head and if will go away after about 3 days. Size of fetal head: Size of fetal shoulders: It is all about the baby's movement to get the shoulders through. After the baby's head is out, the baby shifts their body and one shoulder comes down further than thee other so that one comes out before the other. bc they can't come out at the same time. •Fetal presentation: part of the fetus that enters the pelvis first and leads through the birth canal during labor -meaning head down, feet first -if the head is coming first, we call it the vertex presentation. The part of the head that we want to. present itself first is actually the occiput so in order for that o happen, the chin of thee baby needs to. be really tight against their chest •Presenting part: part of the fetus that lies closest to the cervix -this could be thee mentum or the chin, meaning it is coming down first •Fetal lie: relation of the spine of the fetus to the spine of the mother ( if the baby's spine is lying the same direction as moms, then that is called longitudinal lie and that is what we want (no matter if the baby is head or butt down, but it would be called the same thing). Or if the baby is sideways, it is called transverse or horizontal lie and you can not have baby come out that way vaginally so if that is the case, the the mom would have to have a C section. -we want the baby to be in general flexion, meaning the chin is right on top of the chest, the hips and knees are bent up and the arms are flexed in as well, and the cord is lying somewhere in between all of that. •Fetal attitude: relation of the fetal body parts to each other •Fetal position -Relationship of the presenting part to mother's pelvis 3 part abbreviation: -1st letter: location of the presenting part (R) or (L) -if we said the occiput is the presenting part, you say which side the presenting part is facing -2nd letter: presenting part (O:occiput, S:sacrum) -3rd letter: location of the presenting part in relation to the anterior (A), posterior (P) or transverse (T) (meaning on the side of the pelvis) portion of the maternal pelvis -this is important bc the manner of the baby is coming through, it tells us how hard the labor will be (if in ROA or LOA, it is much easier for the mom to push baby out) -ex: so you would put ROA -transverse is when the head is sideways that can be pretty easy for the doctor to come and turn it a little bit to put in an anterior position -head presentation or chin presentation and the OP positions (meaning the baby is sunny side up, in an OP position bc if the occiput is posterior, the baby's face is looking up to the "sun")