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OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
Topics covered include: Changes during pregnancy, nutrition/weight gain, antenatal testing, prenatal
care, bleeding during pregnancy
Maternal Morbidity and Mortality:
o US ranks 49th in list of rates of industrialized nations
o US ranks 30/31 for infant mortality
o Causes of maternal morbidity and mortality:
HTN
Emboli
Infx
Hemorrage
o Neonatal/fetal morbidity and mortality:
Low birth weight
Congenital anomalies
Consequences of maternal disease
Prematurity
Selected Anatomy and Physiology Review:
o Caldwell-Molloy pelvic types:
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
Gynecoid is ideal, others may present difficulties
o Android: narrower midpelvis complicates travel
o Antrhopoid: narrower inlet
o Platypelloid: wider outlet
Ischial spines: toughest part of birth passage
Pubic crest can (and does) break
Hormones:
o Estrogens:
Estradiol: available only during reproductive years
Estriol: available only during pregnancy
Estrone: Estrogen of menopause
o Progesterone: THE PREGNANCY HORMONE
o Prostaglandins
PGe: vasodilation, smooth muscle relaxant
PGf: vasoconstriction, smooth muscle contraction
The Female Reproductive Cycle
o Highlights:
Cycle is comprised of (3) Main Phases: Follicular phase, Ovulation, and
Luteal Phase
Because luteal phase is more regular (approx. 14 days), if we know length of
cycle and it’s regularity we can predict ovulation.
By default this makes the follicular phase the more variable part of
the cycle
During the follicular phase, estrogen is the predominant hormone and a
surge of Luteinizing Hormone (LH) causes release of the ovum (egg) from
the follicle. Following this, the follicle forms into the Corpus Luteum (CL) to
support pregnancy. Progesterone becomes dominant hormone.
During this time, the uterine tissue is building up and preparing for
implantation of the fertilized embryo (known as the secretory phase).
If there is no sustained pregnancy, the lining is shed through the
menstrual phase, occurring at the end of the cycle (Important to
know LAST KNOWN MENSTURAL PERIOD (the first day of bleeding)
Can be used in determining cycle length, potential pregnancy)
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
Development of Pregnancy
o Terminology:
Gestational age: Includes length of pregnancy + 2 Additional Weeks (1 Week
for LMP, and preceding week)*ASSUMES A REGULAR 28 DAY CYCLE*
Pregnancy typically lasts 280 gestational days:
o 40 weeks
o 10 lunar months
o 9ish calendar months
Fertilization: union of ovum and sperm in the ampulla of the fallopian tube
Cellular Multiplication:
Zygote (4 cell mass) differentiates into Morula (Day 3)
Morula further differentiates into Blastocyst and Trophoblast (by
Day 5)
o Blastocyst: inner cell mass which will become embryo,
amnion, & yolk sac
o Trophoblast: outer layer which becomes chorion and
placenta
Trophoblast IMPLANTS into endometrium between days 6-10
o Formation of Chorionic villi serves 2 functions:
Maintains estrogen/progesterone
Inhibits ovarian and menstrual cycles
Cellular Differentiation:
Differentiation of germ layers: ectoderm, endoderm, mesoderm
o Ectoderm: Epidermis, hair, teeth, facial features, CNS
o Endoderm: Dermis, muscles, bones, kidneys, ears, lymph,
CV, spleen
o Mesoderm: organs
Embryonic membranes: chorion, amnion
Amniotic fluid
Yolk sacprimitive RBCs
Umbilical cord
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
First two weeks following conception= embryo is most likely to be damaged, most succepitble to
teratogens
Fetal developmental milestones:
o 28 Days p conception: Heart beat
o 4-6 weeks: Male differentiation BEGINS (not necessarily determinable)
o 8-10 wks: all organs formed
o 16 wks: Fetal respiration
o 23 wks: Youngest preterm survivor
Review of fetal circulation:
o Teratogens:
ETOH: no safe allowable level established
Caffeine: hard to determine effects, restrict until 2nd/3rd trimester and then limit
intake
Drug classifications:
Category A: OK
B: No risk in anaimals
C: questionable risk
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
D: Evidence of risk
X: definite risk (i.e. ASPIRIN! BECAUSE IT CLOSES FETAL CIRCULATORY
DUCTS)
Maternal changes during pregnancy
o Familial changes:
Role crisis, perceived body image, financial concerns
Hensley’s rule: 1) Include the partner 2) Don’t assume gender of partner
o Psychosocial adaptations:
1st Trimester: Surprise, ambivalence, focus on discomforts
2nd: Accept growing fetus, introversion
3rd: Preparation for birth, focus on physical discomforts, preparation of maternal role
o Partner couvade: Unintentional taking on of symptoms by partner
o Physical changes:
Signs of pregnancy (with differentials):
Presumptive:
o Nausea (upset stomach, flu, food poisoning)
o Fatigue (sleep deprivation)
o Breast tenderness (fluctuates with cycle)
o Vomiting (food poisoning, migraines)
o Weight gain (sedentary lifestyle, diet)
o Urinary frequency (UTI, cystitis)
o Quickening (fluttering sensation: gas, ovulation)
Can be expected at 18-20
weeks
o Ammenorrhea (low body weight, irregular cycle, contraceptive
use)
o Abdominal striae (weight/muscle gain)
Skin alterations attributed
to estrogen
Probable:
o Uterine souffle (uterine myomas)
soft bowing sound in sound
with maternal pulse due to
increased vascularization
o Chadwick’s sign (intense intercourse)
“blue” vagina d/t incr
vascularization
o Ballotment (ghost pregnancy, ascities, polyps/fibroids)
Passive fetal movements
elicited by palpating cervix
o Goodell’s sign (hormonal contraception, intense intercourse)
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
Softening of cervix
o Progressive enlargement of abdomen (obesity, ascities, pelvic
tumors)
o Palpation of fetal outline (uterine myoma)
o Braxton-Hick’s contractions (soft myomas)
o Darkened areola (sun, hormonal contraception)
o Positive pregnancy test (false positive, inpropper
use/interpretation, proteinuria)
o Linea negra (hormonal stimulation)
Positive
o Fetal heartbeat per Doppler
o Fetal heartbeat per fetoscope
o Fetal movement per trained provider
o Visualization of fetus on US
Enlarging uterus has effects on:
Lungs, diaphragm: displacementdecr tidal volumeshortness of breath
Intestines: again displacement alters function
Bladder
Spine curvature
o By 20 weeks, women experience an exaggerated lordosis, can
be corrected by alternating legs on a stool
o Altered center of gravity: PROBLEMATIC b/c more prone to falls
Round uterine ligaments
o Late into pregnancy, sudden movement can pull on ligmanets
causing “stabbing pain” Need to warn and teach to splint to
decr pain
HEENT
Bleeding gums, nose bleeds, sensitivity to tastes/smells
Skin/Hair
Linea nigra, striae , acne vulagris, darkening areola, increased hair, palmar
erythema
Melasma (Cholasma): appearance of gray/brown patches on face
Spider angiomas
Warn patients about cocoa butter and caffeine
Breasts
Glandular hypertrophy, tenderness, nipple sensitivity, vein prominence,
colostrum
Resp
Respiratory alkalosis (breathing off CO2 through rapid exhalation)
Incr respiratory rate
20% increased oxygen consumption
GI:
Decr GI motility and emptying
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
N/V
Incr risk for gallstones
Heartburn: progesterone “softens” cardiac sphincter
Hemmoroids
Elevated, benign alkaline phosphate
Renal:
Incr renal blood flow
Renal stasis in pelvicies (risk for UTI)
Incr GFR: So increased, it may cause filtrate to slip through showing benign
proteinuria or glycosuria
CV
Increase in stroke volume, heart rate, cardiac output, and blood volume
(HUGE)
o Incr in HR by 10-15 beats
Decrease in blood pressure (systemic vasodilation)
Systolic murmur d/t fluid overload
Incr in clotting factors
Hematologic
Physiologic anemia of pregnancy: dilutional anemia due to incr blood
volume
o Monitor, treat at 11
Vena Cava Syndrome
Implications for prenatal/labor
Decr venous return when laying supine
Complaints of discomforts in pregnancy are ALWAYS treated as serious until proven benign
o ALWAYS serious until proven benign
o Infections:
S/sx: itching, increase in purulent (white) d/c, smell or not, dysuria
Problematic: Incr risk for preterm labor
o PROM (Premature Rupture of membranes)
Miconium (greenish tinged fluid): aspiration risk for fetus, potential sign of fetal stress
Mucus plug (clear, snot-like)
o Pre-eclampsia (Wil be discussed later)
S/sx: sudden onset of swelling, HA, “floaters”
o Hyper-emesis gravidum
Unknown cause (potentially hCG)
Concern if last PO was over 12 hours
o Pre-term labor
Sometimes sneaky “back labor”
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
At-risk pregnancies
o Hypertensive disorders of pregnancy
Chronic Hypertension
Pre-pregnancy BP > 140/90
OR
BP is > 140/90 before 20 weeks gestation without proteinuria
TX: >160/105 with labetalol, nifedipine, methyldopa
o Goal is 120-160/80-105
o More frequent Prenatal visits
o IOL recommended at 38 weeks
Need to be concerned with aggressive treatment, if decrease supply to
placenta can late decelerations
Preeclampsia
HTN that occurs AFTER 20 WEEKS accompanied by:
o Proteinuria OR
>300 mg/dL on 24 hr urine,
urine dipstick of at least 1+
o New onset of 1 severe feature
Severe HTN (SBP >190, DBP
>110)
Thrombocytopenia (plt cnt
<100,000)
Renal insufficiency
Impaired liver function
(doubled LFTs/ persistent
RUQ/epigastric pain)
Pulmonary edema
Cerebral/visual symptoms
Preeclampsia without severe features
Preeclampsia with severe features
Patho: unknown attributed to placental blood supply leading to maternal
vasospam and decreased organ perfusion
Tx: Delivery of fetus and removal of placenta
o If <37 wks WITHOUT severe features: Expectant mgmt. until
planned delivery at 37 weeks
o If >37 weeks WITHOUT severe features: Delivery
o If <34 weeks WITH severe features: Corticosteroids and Mag
sulfate-48 hrs later delivery
o If suspected abruption, eclamptic seizure, or severe IUGR:
DELVERY
Goals:
o Prevention of sz, stroke, hematologic/renal/heaptic disease
o Birth of neonate as close to term as possible
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
Assessment:
o During labor: BPs q 15 min x4, lung sounds, lab tests q6 to catch
HELLP [hemolysis, elevated liver enzymes, low platelet count],
DTR/clonus (pre-eclampsia or MAG toxicity), fundal checks, UCs
o HA, visual disturbances, epigastric pain
o Safety checks, room checks, continuous EFM
o Hourly assessment with Mag:
Make sure Dtr still present
(even if decreased)
RESP: >12/min
UO: >30 mL/hr
Serum level: 4-7 mEq/mL
Effects on contraction,
immediate postpartum, CLE
administration
Complications:
o Eclampsia: seizure in woman with preeclampsia which can’t be
attributed to another cause
Superimposed preeclampsia
Onset of severe feature or proteinuria in pt with chronic htn
Gestational Hypertension
o TORCH Viral Infections:
Toxoplasmosis
Blindness, deafeness, retardation in fetus
Other: varicella, parovirus (“fifth’s disease), syphilis, listeria, coxsackie
Varicella: maternal death d/t pneumonia, limb hypoplasia, contractures,
CNS involvement
Fifth’s: fetal death, fetal hydrops
L&C: miscarriage, fetal death, encephalitis
Rubella
Cataracts, sensorineural deafness, congenital heart defects, mental
retardation, cerebral palsy
CMV
Fetal death, SGA, micro/hydrocephaly, cerebral palsy, mental retardation
HSV
o Other infections:
STI’s
Chlamydia: ophthalmic neonatorum, PNA
Tuberculosis:
Active TB: no direct contact with newborn until non-nfectious
Inactive: May breastfeed, treatment delayed until post-partum
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
GBS discussed in L&D
o Diabetes:
In early pregnancy, placenta stimulates insulin production
In later pregnancy, pregnancy hormones lead to insulin resistance allowing for greater
access to fetus
Different diagnoses:
TIDM
TIIDM
A1GDM (Diet controlled gestational diabetes)
A2GDM (Medication required gestational diabetes)
Screening:
Pre-exisiting are not screened
Low risk: screened with 1 hr gtt
High risk: early 1 hr gtt before universal screen at 24-28 weeks
Normal value is <135 mg/dL
o If 135-180 proceed to 3hr gtt
Antental/Prenatal Care
o Pre-conception health goals:
Normal BMI, reg daily exercise, dental work up, varicella/MMR vaccines (live
vaccines), GYN care up to date, tracking of menses, prenatal vitamins (Folic acid 6 wks
prior to pregnancy, absorption finished at 10 wks)
o At first prenatal visit:
Establish/accurately date pregnancy
Evaluate risk factors
Support for discomforts and anticipatory guidance
o Establishing due date:
40 weeks from LMP
Neagle’s Rule: LMP + 1 yr – 3 months + 7 days
Ultrasound: accuracy in first trimester is within 5-7 days (keep EDD and suspect
developmental delays)
o Rh Status:
Rhogam: give 28 weeks, within 72 hrs of delivery
o Gs and Ps GxPxTPAL
G= Gravidity: ALL PREGNANCIES, regardless of outcome
P=Parity: Number of births after 20 weeks born dead or alive
o Uterine emptying: only emptied once with twins/triplets/etc
T: Term (how many babies delivered at later than 37 wks)
P: Pre-term: babies from 20 to 37-38 weeks
A: Abortions: spontaneous or therapeutic; LESS THAN 20 WEEKS
L: Living children
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
o Anticipatory Guidance: Weight Gain
IOM Guidelines based on Pre-pregnancy BMI
Underweight (<18.5): Gain 28-40 lbs
Normal (18.5-24.9): Gain 25-35 lbs
Overweight (25-29.9): Gain 15-25 lbs
Obese: Gain 11-20 lbs
Inadequate weight gain increases likelihood of low birth weight baby
Obesity during pregnancy increases risk of:
NTDs, HTN, pre-gestational diabetes, gestational diabetes, sleep apnea
Primary/repeat c/s, medical inducation/augmentation, prolonged first
stage, excessive blood loss, macrosomia
Wound infection, urinary incontinence, postpartum hemorrhage, retained
weight, failure to initiate breastfeeding
For a woman with a normal BMI:
0.5-3 lbs gain during total first trimester followed by 1 pound/wk
o Anticipatory Guidance: Antenatal Testing
Screening: Determines RISK
Quad Screen
o Screens for Trisomy 18 and 21
o 15-25 weeks
Sequential Screen
o Screens for Trisomy 13, 18, 21; cardiac/neural tube defects
o New standard screen
o 1st draw at 10-13 weeks; 2nd draw at 15-21 weeks
Cell-Free DNA
o Screens Trisomy 13, 18, 21
o After 10 wks measures fetal DNA in maternal blood
MaterniT21
o Screens for Trisomy 13,16,18,20,21; chromosome aneuploidies
and microdeletions
Carrier Screening
ROS Sonogram
o 2nd/3rd trimester
o Identifies:
Fetal presentation/number
Amniotic fluid index
Placental location
Presence of cardiac activity
Fetal biometry
Anatomy
Diagnostic
Chorionic villus sampling
o 10-12 weeks used for genetic, metabolic, DNA abnormalities
OB Nursing: Fetal conception/development; Pregnancy
Review Questions: Conception Case Study (word doc and end of ppt), Saunders: p. 303 242-251; 322 262-276, 340 277-290; Lippincott: p. 36 1-115, p. 67 1-97
o Transabdominal/transcervical
o Does not detect neural tube defects
o Risks: SAB, fetal loss, fetal limb defects, bleeding, infx, leaking
amniotic fluid
Amniocentesis
o 15-18 wks
o Needle guided aspiration of amniotic fluid
o Less risk than CVS
Percutaneous umbilical cord blood sampling
o Obtain fetal blood from base of umbilical cord
o Dx: Hemophilia, hemolytic disorders, fetal infections,
chromosomal abnormalities, fetal hydrops, fetal H&H
Recommended