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  1. Maternal mortality rate?
    • 8 women deaths out of 100,000 live births due to hypertension (eclampsia)
    • causes: hemorrhage, gestational hypertension, embolism
  2. Infant mortality rate?
    • 7 out of 1000 live births
    • US is 29th in the world
    • 6/1000 white infants, 14/1000 black infants
  3. Adolescent pregnancy
    • 54/1000 between 15-19 yrs old
    • 3 out of 10 teens will be pregnant before age 19
  4. infertility issues
    • 20% of all women have infertility issues
    • decreased fertility due to STIs and scarring
  5. Access to care
    Only 60% of women get prenatal care
  6. Conception and fetal development
    • Union of mature ovum and sperm equal human life
    • Ovum=22 autosomes+XX(sex)=23
    • Sperm=22 autosomes+XY(sex)=23
    • Ova are viable for 24 hours after ovulation
    • Sperm are viable for 72 hours after ejaculation
    • Fertilization takes place in ampulla's of fallopian tube
    • Scarring in the tube prevents the sperm form getting to the egg
  7. Zygote
    new cell formed when egg is fertilized
  8. Intrauterine development
    • Union of ovum and sperm-zygote (1st week)
    • 16 cells-morula (60 hours later)
    • morula attaches to uterine wal (4 days later)
    • best place for the morula to attach is the fundal area on top of the uterus because we want the baby to come out first then the life line second.
    • need uterine muscle at the top to contract to keep from bleeding to death
    • Placenta previa-zygote settling at the bottom of the uterus
  9. tropoblasts and embroblasts
    • 99 tropoblasts forms all supportive structures
    • 8 embroblasts froms embryo and eventually the fetus
  10. human chorionic gonadotropin (hCG)
    • zygote secretes hCG which stimulates the corpus luteum of the ovary to remain viable and continue to secrete progesterone for 4 to 12 weeks to secure the pregnancy.
    • prevents normal involution of the corpus luteum at the end of menses
    • if corpus luteum ceases functioning before 11th week of pregnancy-spontaneous abotion occurs
    • in male fetus, it stimulates testes to produce testosterone which causes male sex organs to grow.
    • Bases for all pregnancy tests
    • Cause of morning sickness (6-12 weeks) 50% of women experience morning sickness
  11. Progesterone
    • valium of pregnancy causes profuse vasodilation to calm down contractions
    • causes edometrium to change into the decidua which provides nourishment for the embryo
    • reduces uterine contraction, thus preventing spontaneous abortions
    • drop in progesterone causes early miscarriages
    • BP is lowered because vessels are dilated, if BP goes up it is abnormal
  12. Placenta
    • Formed by the end of the 12th week and takes over the responsibility of producing progesterone and other needed hormones
    • Thick, disk-shaped organ whose major function are 1. metabolic, 2. transfer of substances between mother and fetus and, 3. endocrine
    • 1/6th of weight and the end of a term pregnancy
    • total surface area of a full term placenta is 15 square yards
    • Maternal side is red, flesh like
    • Fetal side is shiny gray-white with vessels visible
  13. Human Placental Lactogen (hPL)
    • promotes normal nutrition and growth of fetus
    • prepares maternal breast development for lactation
    • facilitates transport of glucose across the placenta by diffusion, active transport, and pinocytosis
    • production increases progressively during 2nd half of pregnancy
    • decreases maternal insulin sensitivity and utilization of insulin (an insulin antagonist)
  14. estrogen (estriol)
    • causes enlargement of the women's uterus, breast and external genitalia
    • increases vascularity to reproductive organs
  15. Amniotic fluid
    • provides a protective environment for fetus
    • clear fluid surrounds baby in utero
    • provides stable temperature surrounding fetus (98.6)
    • allows rooom and buoyancy for fetal movement
    • derives from fetal urine and fluid transported from maternal blood across the amnion.
    • exchanged constantly everyday
    • volume increases during pregnancy-should have 1000ml at term
    • characteristics-98% water, alkaline 2% organic solids, clear in color
    • Green-meconium; red-bleeding; cloudy-infection-; amber-bilirubin
  16. embryonic period-conception to 8 weeks gestation
    • differentiation of ceels and rapid growth
    • rudimentary body parts formed
    • heart has four chambers and begins beating
    • beginning of all major body structure
    • external genitalia present-no gender yet
    • some movement by limbs
  17. third month (9-12 weeks)
    • eyelids fused; nail beds formed
    • teeth and bones begin to appear
    • kidneys begin to function-amniotic fluid
    • begins to swallow
    • grasps, sucking and withdrawal reflexes present
    • gender distinguishable
    • downy lanugo begins development
    • normally women do not know they are pregnancy during this time
  18. fourth month (13-16 months)
    • much spontaneous fetal movement
    • moro reflex present
    • rapid skeletal development
    • meconium present in GI tract
    • uterine development in female
    • lanugo (fine hair) appears over body
    • quickening-fetal movement felt by mom
  19. fifth month (17-20 weeks)
    • eyebrown and head hair appears
    • skeleton begins to harden
    • permanent tooth bud appear-tetracyclin discolor infant teeth
    • vernix caseosa appears-surround fetus, thick lotion to preserve skin
  20. six months (21-24 weeks)
    • miniature baby in appearance
    • extra uterine life possible
    • skin has red, wrinkled appearance
    • responds to external sounds
    • fetus is very active
  21. seventh month (25-28 weeks)
    • eyelids are no longer fused
    • testes begin to descend into scrotum for males
    • assumes head-down position in uterus
    • respiratory-like movement detected
    • subcutaneous fat is being deposited under skin
  22. eighth month (29-32 weeks)
    • begins to store fat and minerals
    • lanugo disappears from the face
    • skin loses reddish color
    • exhibits good reflex developent
  23. ninth and tenth month (33-40 weeks)
    • fetal body begins to round out
    • increas of iron storage by liver
    • ear cartilage firm on both ears
    • lanugo and vernix caseosa disappear
    • high absorption of maternal hormones
    • ready for birth
  24. fetal circulation
    • 1 umbilical vein brings in oxygenated blood via the placenta
    • 2 umbilical arteries bring deoxygenated blood back to the placenta
    • SpO2 is 40-45% for fetus
    • fetal lungs and liver functions are from the placenta
  25. three unique fetal structures
    • ductus venosus-bypasses liver to inferior vena cava
    • foramen ovale-shunts blood from R to L heart
    • ductus arteriosis-bypasses lungs-brings blood to the brain the quickest
  26. abortion
    termination of pregnancy prior to 20th week gestation
  27. term
    the normal duration of pregnancy 38-40 weeks
  28. preterm labor
    occurs after 20 weeks, before 30 weeks
  29. post term labor
    after 42 weeks
  30. still birth
    • fetus born dead after 20 week gestation
    • diabetes is a big risk factor
  31. gravida
    any pregnancy regardless of duration, including present one
  32. primigravida
    a woman who is pregnant for the first time
  33. multigravida
    a woman who is in her second or subsequent pregnancy
  34. nulligravida
    a woman who has never been pregnant
  35. parity
    number of pregnancies that have reached viability, regardless of whether the infant was alive or stillborn
  36. primipara
    a woman who has have one birth greater than 20 weeks regardless of whether the infant is born alive or dead
  37. multipara
    2 births greater than 20 weeks
  38. Estimated Date of Birth
    • Nageles rule: 1st day of last normal menstrual period (LNMP) subtract 3 months add 7 days and 1 year
    • 90% of women will deliver +/-2 weeks of estimated date
  39. fundal height
    • top of uterus
    • indicated uterine size by measuring from the top of the symphysis pubis to the top of the fundus
    • correlates with weeks of gestation between 20-30 weeks
    • order ultrasound, if it does not correlate
  40. Alpha-fetoprotein (AFP)
    • predominant protein in fetal plasma
    • can be measured in both maternal serum and in amniotic fluid
    • increased levels-indicate open neural tube defects
    • decreased levels-could indicate down syndrome, molar pregnancy
    • test is done between 15-18 weeks gestation
  41. glycosylated hemoglobin (Ghb A1C)
    • minor hemoglobin with glucose attached
    • previous 90 days of blood sugar and measurement of glycemic control
    • levels of 6 or less: measured from 1-15, 15 i out of control, 6 or less is controlled
    • When baby is exposed to high blood glucose levels in first trimester, baby will most likely have cardiac anomalies
  42. prenatal visits
    • Every 4 weeks until 28 weeks
    • Every 2 weeks up to 36 weeks
    • Every week after 36 weeks
    • More frequent for high risk
  43. uterus
    • goes from 2oz to 2 lbs at term
    • increase in size due to hypertrophy of myometrium cells under estrogen influence
    • 1/6 of total masternal blood volume is contained within the vascular system of the uterus by term
  44. cervix
    • estrogen causes the cervix to become congested with blod, resulting in a bluish color that extends to include the vagina-Chadwick's sign
    • increased vascularity causes the cervix to soften-Goodell's sign
    • Increased mucus forms the mucus plug to seal off the cervix from outside bacteria
  45. ovaries
    • cease ovum production during pregnancy
    • corpus luteum persists til 12 weeks to secrete progesterone til the placenta takes over
  46. vagina
    • increased vasculaity and hyperplasia
    • increased vaginal secretion and decrease in pH to prevent infections
  47. breasts
    • increase in size and nodularity to prepare for lactation
    • nipples increase in size, become more erect and more pigmented
    • colostrum-an antibody rich, yellow fluid can be expressed after the 12th week. it converts to mature milk after delivery
  48. respiratory system
    • oxygen consumption increases by 15-20%
    • tidal volume increases 40%
    • by the third trimester, the diaphragm is lifted 1.5inches which prevents the lungs from expanding fully
    • breath becomes thoracic rather than abdominal in nature
  49. cardiovascular system
    • 45% increase in blood volume which peaks in the 7th month
    • 30% increase in total RBC volume (mostly plasma) which causes the hemodilution of pregnancy in the second trimester
    • decrease in BP due to decreased peripheral vascular resistance
    • WBCs increase throughout gestation
    • 12-15 WBC is normal for pregnant women
  50. GI system
    • reflux of gastric contents common due to relaxation of smooth muscles by progeserone
    • ptyalism (excessive salivation) is a common condition of pregnant women
    • decreased in intestinal motility-constipation
    • nausea and vomiting (morning sickness) is due to high hCG levels from 6-12 weeks
  51. renal system
    • 50% increase in glomerular filtration rate
    • kidneys and ureters dilate due to high progesterone levels
    • glycsuria is common during pregnancy due to kidney's inability to absorb all the glucose filter by the glomeruli. this environment increases the risk of UTIs during pregnancy
    • UTIs can lead to preterm labor
  52. integumentary system
    • increase in activity of sweat and sebaceous glands-perspiration and acne
    • hyperpigmentation-chloasma or mask of pregnancy darkens forehead, cheeks and nose
    • linea nigra-dark line of pigmentation from umbilicus to the symphysis pubis
    • striae (stretch marks) occur on abdomen, breasts, and thighs as pregnancy progresses
  53. metabolism
    • BMR increases to support the additional demands of the growing fetus
    • 25-35 lbs is the average weight gain during a single pregnancy
    • increase in water retention of 7 liters of water by term
  54. subjective changes
    • amenorrhea-earliest symptom of pregnancy
    • nausea and vomiting-50% of women experience this
    • excessive fatigue-presents in 1st trimester
    • urinary frequency-common during 1st and 3rd trimester due to uterine pressure
    • breast tenderness-due to growth
    • quickening-fetal movement felt by mother
  55. objective changes
    • Goodell's sign-softening of the cervix
    • Chadwick's sign-bluish coloration or cervix
    • Hegar's sign-softening of isthmus
    • Abdominal enlargement-uterine growth
    • Pigmentation of skin-occurs in 50%
    • palpation of fetal outline-greater than 24 weeks
    • Ballottement-passive fetal movement
    • Positive pregnancy test-hCG present
  56. Diagnostic changes of pregnancy
    • fetal heart beat-110 to 160 bpm
    • fetal movement-palpated by trained examiner greater than 20th week gestation
    • ultrasound-fetal outline detected
  57. physiological response to pregnancy
    • ambivalence-initial response, no visible body change yet
    • acceptance-triggered by quickening in 2nd trimester
    • introversion-turning in on one's self
    • mood swings-from great joy to despair
    • body image change-the picture of your body you have of yourself
  58. common discomforts of pregnancy
    • morning sickness-eat 4-5 crackers at the bedside, eat protein meal at the end of night
    • urinary frequency-stop caffeine, no sugar
    • vaginal discharge-shower twice a day
    • heartburn-smaller more frequent meals, tums, no lying down 2 hours after you eat
    • hemorrhoids-fiber, witch hazel tucks
    • leg cramps-dorsiflex, bananas, calcium
    • backache-flat shoes, posture
  59. ultrasound
    • sound waves bounce off densities to form picture
    • measures bi-parietal diameter, femur length, and crown to rumb length to determine gestational age
    • localize placenta
    • identifies fetal anomalies
    • validates suspected multiple pregnancies
    • evaluates amniotic fluid
  60. alpha-fetoprotein screening
    • predominate protein in fetal plasma; excreted in fetal urine into amniotic fluid
    • test is run between 15-18 weeks gestation
    • if abnormal results return-amniocentesis is done
  61. amniocentesis
    • aspiration of amniotic fluid for analysis of chromosomal abnormalities, blood incompatibility and determin fetal maturity
    • to determine fetal lung maturity: detects lecithin/sphinogomyelin ratio that make up surfactant; a ratio of 2:1 indicates surfactant is adequate at 35 weeks
    • to determine fetal hemolytic disease-bilirubin concentration: levels of bilirubin in amniotic fluid reflects the amount of fetal RBC destruction that had taken place
  62. indications for amniocentesis
    • maternal age of 35 or above
    • previous genetic disorder
    • altered chromosomal pattern (trisomy 21)
    • history of 3+ spontaneous abortions
    • elevates MS-AFP level
    • history of neural tube defects
    • usually performed between 15-17 weeks
    • tissue cultures must be grown for several weeks, thus results aren't available immediately
  63. complications of amniocentesis
    • uterine infection
    • spontaneous abortion
    • PROM-premature rupture of membranes
    • fetal injury
    • placental abruption
  64. Chorionic villus sampling (CVS)
    • alternative to amniocentesis which can be done earlier
    • usually performed between 10-12 weeks
    • developing placenta is biopsied via transvaginally or abdominally under ultrasound guidance
    • complications-spontaneous loss
    • greatest benefit is the option to terminate
  65. conditions that accelerate or increase l/s ratio sooner
    • premature rupture of membranes
    • hypertension disease
    • prolonged rupture of membranes
    • placental insufficiency
    • all these things causes stress to the baby which secretes cortisol and cortisol increases surfactant production.
  66. conditions that delay l/s ratio
    • diabetes
    • nonhypertensive glomerulonephritis
    • blood incompatibilities
  67. fetal movement count (FMC)
    • daily maternal assessment of fetal activity by counting the number of fetal movement within a specified time period
    • usually starts at 28 weeks for high risk
    • side lying position utilized after eating a meal
    • a count of 3+ movement/hour needs further evaluation
    • is a non-invasive no cost method to evaluate fetal well being in last trimester of pregnancy
  68. nonstress test
    • assesses fetal well being by evaluating FHR acceleration in association with fetal movement
    • FHR accelerations indicate adequate oxygenations, a healthy CNS, and the ability of the fetal heart to respond to stimuli
    • procedure: client is placed in semi-fowlers position, an external fetal monitor is applied, a baseline strip is obtained, fetal movement indicated by the mother, interpretation reactive 2 accelerations/10 minutes 15bpm lasting 15 seconds
  69. contraction stress test (CST)
    • is used to identifty the fetus at risk for intrauterine hypoxia by observing the response o the FHR to contraction
    • if fetal hypoxia is demonstrated-late decelerations
    • FHR and patterns are evaluate in response to contractions (stress)
    • Methods: nipple stimulation to produce 3 contractions within a 10 minute period
    • interpretation: 50% late decelerations with contractions in 10 minute is a problem
  70. Biophyisical profile assess 5 parameters+NST
    • FHR
    • fetal breathing
    • gross fetal movement
    • fetal tone
    • amniotic fluid volume
    • criterion: up to 10 points are assigned
    • each parameter is either present=2 or absent=0
    • 8-10 points is normla
  71. Fetal heart rate
    • use leopold maneuvers to identify the best postion to locate the transducer to hear the loudest FHR
    • usually heard the loudest through the fetal back
    • typically found in the mother's lower quadrant on left side if fetus is in a LOA position
  72. Baseline changes
    • tachycardia 160bpm+for 10 minutes
    • in prematurity, chronic fetal hypoxia, maternal fever (#1 reason), fetal anemia

    • bradycardia 110 or below bpm for 10 minutes
    • in fetal hypoxia, maternal drugs, compressed cord, maternal supine position (convenient for HCP)
  73. early decelerations
    • fetal head compression
    • mirrors the contraction below
    • begins and ends with the contraction below
    • FHR usually stays within normal range
    • generally benign and seen in late labor
    • head compression stimulates vagus nerve to slow HR
    • no interventation considered category 1, benign
  74. late decelerations
    • due to uteroplacental insufficiency (UPI) causes by being on back, baby isnt getting oxygen
    • onset is late-after peak of contraction
    • tend to occur with every contraction
    • degree of fall doesnt reflect insufficiency
    • usually goes below normal range
    • Interventions: turn client to left side, give oxygen, increase IV
    • turn pitocin off if infusing
    • document and report observations
  75. variable deceleration
    • due to cord compression
    • FHR goes below normal range
    • deceleration dont have a uniform shape
    • they fall and rise abruptly
    • occurs at times unrelated to contractions
    • interventions: change maternal position, C-section if can't change pattern within 30 minutes
  76. interpretation of fetal HR patterns: Category 1
    • predictive of normal acid base balance
    • accelerations with fetal movements
    • no periodic changes to baseline
  77. Category 2
    • tracings are indeterminate and not predictive
    • tachycardia or bradycardia
    • minimal or absent variability
    • late or variable decelerations
  78. category 3
    • tracings are abnormal
    • predictive of abnormal acid base status
    • absent baseline variability
    • recurrent late and/or variable decelerations
    • requires prompt evaluation and interventions:
    • maternal oxygen
    • changes in maternal position
    • discontinue pitocin
    • treatment of maternal hypotension
  79. nursing care of category 3
    • identify the cause of the specific pattern
    • stop pitocin infusion if being administered
    • reposition the client several times
    • administer oxygen via face mask at 8-10liters/minute
    • call to have HCP put in internal monitor
    • notify HCP of category assessed
    • notify other staff to prepare for c-section
  80. Fetal position
    • relationship of presenting part to maternal pelvis
    • LOP-left, occipital, posterior
  81. fetal attitude
    degree of flexion of body parts
  82. engagement
    occurs when the largest diameter of the presenting part (BPD) reaches or passes through the pelvic inlet
  83. Contractions
    • frequency: refers to the time between the beginning of one contraction and the beginning of the next one
    • duration: measured from the beginning of the increment to the end of the dcrement (45-90 seconds)
    • intensity: refers to the strength of the contractions during the acneme or peak
  84. stages or labor-1st stage
    • begins when true labor start through complete cervical dilations
    • latent stage-mild contractions 0-3 cm
    • active phase-progressive fetal descent 4-7cm
    • transition-increase fetal descent 8-10 cm significant anxiety, restless, irritabl, contractons are 1 to 2 minutes apart, strong intensity and lasting 60-90 seconds
  85. 2nd stage
    • begins when cervix is 10 cm and ends with birth of infant, pushing stage
    • crowning occurs
    • usually 1 hour long or less
    • laboring down-10cm let the woman's body do the work before we tell them to push. pushing time is decreased and maternal exhaustion are less likely
  86. 3rd stage
    • begins from birth of infant to placental separation, about 5 mins
    • signs of placental separation are globular shaped uterus, rise of fundus in abdomen, sudden gush of blood, further lengthening of cord form vagina fetal side of placenta delivers first
  87. 4th stage
    • 1-4 hours after delivery when physiological adjustment of the mother's body takes place
    • uterus remains contracted and in the midline
    • bladder may be hypotonic
    • vitals taken q15 minute-bradycardic pulse
    • lochia rubra-moderate amount
    • emotional state-excited, fatigued, or quiet
  88. lochia
    • lochia rubra-reddish color with a few small clots occur for up to three days
    • lochia serosa-thinner, brownish pink for 4-10 days
    • lochia alba-yellowish which discharge for 10 to 21 days
    • lochia should be gone by 6 week check up
    • lochia usually has a fleshy smell
  89. Episiotomy
    • turn client to either side to examine area with adequate lighting, separate buttocks
    • inspect REEDA-redness, edema, ecchymosis, discharge, and approx of skin edges
    • severe intractable episiotomy pain-hematoma
    • check status of hemorrhoids
  90. cardiovascular adaptations of newborn
    • at birth fetal circulation must switch to newborn circulation with elimination of 3 fetal structures
    • foramen ovale: closes with clamping of cord which increase pressures in left side of heart
    • ductus arteriosis (shunting blood from the lungs): closes with an increase in oxygen levels
    • duvtus venosus (shunted blood away from liver) cloes within days after placenta is absent
  91. respiratory adaptations
    • hypercapnia, hypoxia and acidosis stimulated the newborns first breath
    • adequate surfacant levels prevent alveolar collapse at the end of expiration and promotes gas exchange
    • fluid fills lungs now and become air filled and pressure in the left side of the lungs become greater than the right side
    • thoracic sqeeze gets rid of lungs fluids
  92. hepatic system
    • stores iron for about 4-6 months
    • bilirubin conjugation to prevent overload
    • RBC breakdown occurs every 80 days
    • enters the GI tract and kidneys to be excreted
    • bilirubin overload-jaundice in newborn
    • bilirubin is toxic to brain and must be removed or bilirubin encephalopathy develops
  93. GI
    • vitamin K production is dependent on bacterial colonization via milk intake
    • stomach capacity is small and CNS control is immature, so regurgitation is frequent
    • 5-10% loss of their birth weight within the 1st week due to inadequate digestion and absorption of nutrients
    • meconium passed within the 1st 24 hours
  94. renal system
    • inability to concentrate urine until 3 months
    • urine has a low specific gravity
    • voids frequently 6-12 times daily
    • limited ability to excrete salt, water loads, and drugs
  95. general newborn appearance
    • head is disproportional large for body
    • head constitutes 1/4 of body size
    • body appears long and exremities short
    • flexed extremities that resist extension
    • hands are tightly clenched
    • no neck appearance
  96. weight and measurements
    • average weight is 7.5lbs
    • 75% of body weight is water
    • 5-10% weight loss in first 3 days of life

    average length is 20 inches-will grow 1 inch/month for next 6 months

    • head circumference is 13-14 inches
    • head is 2cm<chest circumference
    • chest circumference is 12-13cm
  97. vital signs
    • temp is 97.5-98.6 axillary
    • heart rate is 110-160bpm; regular rhythm
    • respirations 30-60bpm: irregular, shallow, unlabored
    • symmetrical chest movements
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