Conception%20and%20Development%20of%20the%20Embryo%20and%20Fetus

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Chapter 7

• Conception and Development of the Embryo and
  Fetus

2
Basic Concepts of Inheritance

• Human Genome Project (1990)
• Chromosomes
• 23 matched pairs
• DNA
• Genes

3
Cellular Division

• Gametes
• Ovafemale gamete
• Spermmale gamete
• Gametogenesis
• Meiosis
• Mitosis

4
Inheritance of Disease

• Multifactorial
• Genetic and environmental factors
• Examples cleft lip, neural tube defects
• Unifactorial
• Single gene inheritance
• Examples autosomal dominant, autosomal
  recessive, X-linked disorders

5
Mendelian Inheritance

• Autosomal Dominant
• Affected person has affected parent
• 50 chance of passing the trait
• Males females equally affected--dad can pass to
  son

• Autosomal Recessive
• Can have clinically normal parents, but both
  parents must be carriers
• 25 chance of affected child
• 50 chance child is carrier
• Males females affected equally

6
X Linked Inheritance

• X-Linked Recessive
• No male to male transmission
• 50 chance carrier mom passes to son who will be
  affected
• 50 chance carrier mom passes to daughters who
  become carriers
• Affected dads cannot pass to sons, but all
  daughters are carriers

• X-Linked Dominant (Extremely rare)
• Fragile X syndrome
• Heterozygous females may be affected
• No male to male transmission
• Affected fathers will have affected daughters,
  but no affected sons

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Nursing Responsibilities

• Assess for signs and symptoms of genetic
  disorders
• Offer support
• Assist in value clarification
• Educate on procedures and tests

8
Assessing for Genetic Disorders

• Chorionic villi sampling (CVS)
• Biopsy chromosomal analysis of chorionic villi
  of placenta (transvaginal or abdominally)
• 8-12 weeks (earlier than amnio)
• Risks
• Limb reduction syndrome
• Excessive bleeding pregnancy loss
• Infection
• Rh-Negative mom needs RhoGAM
• Advantages 1st trimester,highly accurate,
  quicker results than amnio

9
Assessing for Genetic Disorders

• Ultrasound--best between 16-20 weeks
• Detect head and craniospinal defects
  anencephaly, microcephaly, hydrocephalus
• GI malformations omphalocele, gastroschisis
• Renal malformations dysplasia or obstruction
• Skeletal malformations caudal regression,
  conjoined twins
• Fetal nuchal translucency 10-13 weeks

10
Assessing for Genetic Disorders

• Amniocentesis 15 - 20 wks
• Risks miscarriage, bleeding, infection
• Maternal age 35
• Hx of child with chromosomal abnormality
• Parent carrying chromosomal abnormality
• Mother carrying x-linked disease
• Parent with in-born error of metabolism
• Both parents carrying autosomal recessive disease
• Family hx of neural tube defects

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Process of Fertilization

• Oocyte and sperm meet in fallopian tube
• Ovulationcervical mucus changes
• 200 sperm reach fertilization site
• Capacitation
• Penetrates zona pellucidaprevents fertilization
  by other sperm

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Implantation

• Zygote propelled by
• Cilia
• Peristalsis
• Reaches uterine cavity in 3 to 4 days

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Nidation

• Occurs by 10th day after fertilization
• Implantation bleeding
• Blastocyst is buried beneath the endometrial
  surface

15
Placenta

• Develops from trophoblast cells
• Lacunae
• Chorionic villi
• Intervillous spaces
• Provides oxygenation, nutrition, waste
  elimination, and hormones
• Protects fetus

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Placenta
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Embryonic and Fetal Structures

• Placenta
• Serves as the fetal lungs, kidneys and GI tract
  and as a separate endocrine organ throughout the
  pregnancy
• Placental circulation established as early as 3rd
  week of pregnancy
• Grows to 15-20 separate lobes called cotyledons
• By wk 20, covers approx. 1/2 surface of internal
  uterus
• No direct exchange of blood between the embryo
  and the mother during pregnancy--exchange is
  through selective osmosis

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Placental Circulation

• Maternal blood from spiral arteries enters
  intervillous space of endometrium
• Fetal chorionic villi reach into endometrium
• Membrane of chorionic villi is 1 cell thick
• Exchange of nutrients/substances

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Placenta
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Placenta
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Substance Transport Across Placenta

• Diffusion
• Active transport
• Pinocytosis
• Bulk flow and solvent drag
• Accidental capillary breaks
• Independent movement

23
Placental Hormones

• Human chorionic gonadotrophin (hCG)
• Human placental lactogen (hPL)
• Progesterone
• Estrogen

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Development of the Embryo and Fetus
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Yolk Sac

• Develops 8 to 9 days after conception
• Essential for transfer of nutrients during second
  and third weeks of gestation
• Hematopoiesis
• Atrophies and is incorporated into umbilical cord

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Umbilical Cord

• Usual locationcenter of placenta
• 55 cm long (21 in) 1 to 2 cm diameter
• Vessels one vein, two arteries
• Whartons Jelly protects umbilical cord from
  compression

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Fetal Circulation

• Heart begins to beat and circulate blood by end
  of third week
• Umbilical vein blood from placenta to fetus
• Low Po2 important to maintain fetal circulation

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Fetal Circulation

• Fetus derives oxygen and excretes carbon dioxide
  from oxygen exchange in the placenta, NOT lungs
• Specialized structures in fetus shunt blood flow
  away from non-functioning lungs to supply
  important organs of the body, especially the
  brain
• Foramen ovale (right to left atrium)
• Ductus arteriosus (pulmonary artery to aorta)
• Ductus venosus (umbilical vein to inferior vena
  cava, bypassing liver)

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Critical Thinking

• During a prenatal examination, an adolescent
  client asks, "How does my baby get air?" The
  nurse would give correct information by saying
  A) "The fetus is able to obtain sufficient
  oxygen due to the fact that your hemoglobin
  concentration is 50 greater during pregnancy."
• B) "The lungs of the fetus carry out respiratory
  gas exchange in utero similar to what an adult
  experiences."
• C) "The placenta assumes the function of the
  fetal lungs by supplying oxygen and allowing the
  excretion of carbon dioxide into your
  bloodstream."

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Fetal Membranes and Amniotic Fluid

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Embryonic Membranes

• Early protective structures
• Two separate membranes
• Amnioninner membrane, contains amniotic fluid
• Chorionouter membrane, forms fetal portion of
  placenta
• Slightly adherent, form amniotic sac

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Purposes of Amniotic Fluid

• Protects and cushions fetus
• Maintains normal body temperature
• Symmetrical fetal growth
• Freedom of movement
• Essential for normal fetal lung development

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Amniotic Fluid

• Amount 800 mL at 24 weeks
• Fetal urine and lung secretions primary
  contributors
• Slightly alkaline
• Contains antibacterial, other protective
  substances

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Human Growth and Development
36
Pre-Embryonic Period

• First 2 weeks after conception
• Rapid cellular multiplication and differentiation
• Establishment of embryonic membranes and primary
  germ layers

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Embryonic Period

• Begins third week after fertilization through end
  of eighth week
• Organogenetic period formation, differentiation
  of all organs
• Germ layers ectoderm, endoderm, mesoderm
• Vulnerable to environmental insults

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Fetal Development
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Fetal Period

• Beginning ninth week until birth or termination
  of pregnancy
• Rapid body growth and differentiation of tissues,
  organs, and systems
• Less vulnerable stage

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Weeks 17 to 20

• Growth slows
• Quickening
• Vernix caseosa
• Lanugo
• By 20 weeksfetus 300 g and 19 cm (7.3 in)

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Weeks 21 to 25

• Gains weight
• Skin pink
• Rapid eye movements
• Surfactant by 24 weeks

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Weeks 26 to 29

• If born, fetus may survive
• Weeks 30 to 40
• Strong hand grasp reflex
• Orientation to light
• 38 to 40 weeks 30003800 g and
• 4550 cm (17.319.2
  in)

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Nurses Role in Prenatal Evaluation

• Initial prenatal visit
• Assessment cultural, emotional, physical,
• and physiological factors
• Education
• Genetic disorders
• Prenatal tests

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Nursing Responsibilities

• Assess for signs and symptoms of genetic
  disorders
• Offer support
• Assist in value clarification
• Educate on procedures and tests

45
Maternal Age and Chromosomes

• Age 35 and above
• Increased risk of chromosomal abnormalities
• Down syndrome
• Deletion
• Translocation

46
Multifetal Pregnancy

• Monozygotic
• Develop from one zygote
• Division occurs at end of first week
• Dizygotic
• Develop from two zygotes
• Separate amnions and chorions

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Fraternal Twins 2 Ova
Identical Twins 1 Ovum
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Minimizing Threats to Embryo/Fetus

• Nurses role
• Assessment
• Environmental and lifestyle risks
• Knowledge
• Physical and psychosocial well-being
• Preconception counseling

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Chapter 8

• Physiological and Psychosocial Changes During
  Pregnancy

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Hormonal Influences

• Pituitary hormones
• Influence ovarian follicular development
• Prompt ovulation
• Stimulate uterine lining
• Corpus luteum
• Estrogen growth
• Progesterone maintenance

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Ovarian Hormones

• Maintain endometrium
• Provide nutrition
• Aid in implantation
• Decrease uterine contractility
• Initiate breast ductal system development

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Reproductive System
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Uterus

• Patterns of uterine growth
• Estrogen, progesterone hyperplasia, hypertrophy
  allow uterus to enlarge, stretch
• Weight increases from 70 g to 1100 g at term
• Increased blood flow

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Braxton-Hicks Contractions

• Irregular, painless
• Prepare uterine muscles
• If irregular and last lt60 seconds, reassure woman
• Regular pattern or associated with other
  symptoms, seek medical attention

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Cervix

• Chadwicks sign
• Goodell sign
• Softens
• Forms mucus plug
• Call if discharge bloody or yellow/green, foul
  odor, itching, or pain

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Vagina and Vulva

• Thickening of vaginal mucosa
• Rugae
• Becomes edematous
• More susceptible to yeast infections
• pH decreases from 6.0 to 3.5
• Discuss vulvar hygiene

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Other Reproductive Changes

• Ovaries
• Breasts
• Montgomery tubercles
• Increased pigmentation (areolae)
• Discuss bra size changes, options for infant
  feeding, and strategies for successful
  breastfeeding

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Integumentary System

• Hyperpigmentation
• Chloasma
• Linea nigra
• Cutaneous vascular changes
• Striae gravidarum
• Angiomas
• Palmar erythema

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Neurological System

• Decreased attention span
• Poor concentration
• Memory lapses
• Carpal tunnel syndrome
• Syncope
• Anticipatory guidance regarding changes

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Cardiovascular System

• Heart
• Position pushed upward, laterally to left
• Cardiac hypertrophy due to increased blood
  volume, cardiac output
• Heart sounds exaggerated first and third
  systolic murmurs

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Blood Volume

• Plasma and erythrocyte volume increase
• Increased need for iron
• Physiologic anemia
• Teach regarding adequate hydration and diet high
  in protein, iron
• Increased fibrinogen volume

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Cardiac Output

• Blood pressure
• Stasis of blood in lower extremities risk for
  varicose veins and venous thrombosis
• Encourage daily walks to enhance circulation,
  improve intestinal peristalsis

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Supine Hypotension Syndrome

• Pressure from enlarged uterus decreases venous
  return from lower extremities
• Hypotension, dizziness, diaphoresis, pallor
• Orthostatic hypotension
• Stagnation of blood in lower extremities
• Encourage to rise slowly keep feet moving while
  standing

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MATERNAL POSITION BLOOD FLOW
side lying
supine
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Respiratory System

• Increased tidal volume
• Increased oxygen consumption
• Diaphragm elevates
• Increased chest circumferencedyspnea
• Educate regarding normal changes and symptoms

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Eyes, Ears, Nose, Throat

• Blurred visiondecreased intraocular pressure and
  corneal thickening
• Temporary condition
• Nasal stuffiness, congestionincreased mucus
  production
• Epistaxis
• Encourage increased fluid intake

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Upper GI Tract

• Mouth
• Gingivitis, ptyalism, hypertrophy of gums, epulis
• Esophaguspyrosis, reflux
• Stomach and small intestine
• Morning sickness, absorption of nutrients

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Lower GI Tract

• Large Intestineconstipation
• Liver and gallbladder
• Cholestasia, cholecystitis, cholelithiasis

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Urinary System

• Bladder
• Urinary frequency and urgency
• Kidneys and ureters
• Structural changes
• Functional changes
• Glomerular filtration rate increases

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Endocrine Glands

• Thyroid gland
• Increased T4
• Progressive increase in basal metabolic rate
• Pituitary gland
• Prolactin
• Oxytocin
• Vasopressin

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Musculoskeletal System

• Postural changes
• Lumbar lordosis
• Waddle gait
• Calcium storage
• Decreased maternal serum calcium
• Lower extremity cramps

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Psychological Responses of Mother

• Intendedness
• Ambivalence normal response
• Acceptance quickening (20 wks)--baby is real

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Psychosocial Changes

• Decreased ability to deal with stress and cope
  with changes of pregnancy
• Major developmental phasesambivalence and
  conflicting emotions
• Nursing care tailored through each pregnancy
  milestone

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Developmental and Family Changes

• Duvall stages of family development
• Prepare for role as childcare providers
• Reorganize home, family member duties, patterns
  of money management
• Reorient family relationships
• Each pregnancyadjust to transitions in
  relationships with each other, children

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Maternal Role Transition

• Rubintasks of pregnancy
• Incorporate pregnancy into identity
• Acceptance of the child
• Reorder relationships

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Maternal Tasks of Pregnancy

• Seeking safe passage
• Securing acceptance
• Learning to give of self
• Committing self to the unknown child

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Pregnant Adolescent

• Normal adolescent developmental tasks conflict
  with tasks of pregnancy
• May not seek prenatal care
• Not future orientedmay not accept reality of
  unborn child
• Acceptance of pregnancy hindered

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Nursing Assessment of Psychosocial Changes

• Thorough history family background, past
  obstetrical events, status of current pregnancy
• Each visitask about pregnancy experience,
  address concerns, offer anticipatory guidance

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Obstetrical History--G/P

• Gravida any pregnancy, including present
• Nulligravida never been pregnant
• Primigravida in first pregnancy
• Multigravida 2nd or more pregnancy
• Para birth after 20 wks gestation (before 20
  wks spontaneous abortion (SAB)
• Nullipara never given birth at gt 20 wks
• Primipara has had 1 birth gt 20 wks
• Multipara 2 or more births gt 20 wks
• Multiples such as twins are counted as ONE birth

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G/P

• Susie Smart is pregnant.
• She has four sons at home
• twins born in 1996 at 34 weeks,
• then singletons born in 1998, and 2001.
• She had 1 miscarriage in 2000.
• What is her Gravida/Para?

G 5 P 3
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Obstetrical History--G/PP TPAL

• G gravida, of pregnancies
• P is further broken down multiples are counted
• T of term infants born (37 wks)
• P of preterm births (gt 20, lt 37 wks)
• A pregnancies ending in spontaneous or
  therapeutic abortion (SAB/TAB)
• L of currently living children

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G/P vs GTPALSusie Smart is pregnant. She has
four sons at home twins born in 1996 at 34 wks,
then singletons born in 1998, and 2001. She had
1 miscarriage in 2000.
Reflection
Reflection

• What is her G/P?

• What is her GTPAL?

• G 5
• T (term) 2
• P (preterm) 1
• A (abortions) 1
• L (living) 4

G 5 P 3

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Example

• Nancy Tam is seeing the MD for her first PN
  visit. She has 4 kids at home, two of whom are
  twins and were born at 33 wks. She has had 1
  miscarriage and 1 abortion.

• ? What is her gravida/para?
• G6 P3 AB 2 (SAB 1 TAB 1)
• ?

• What is her GTPAL?
• G6 T2 P1 A2 L4 or (G 6 P 2124)

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????

• Tracy H. is pregnant. She has one son at home
  born at 38 wks. Her 2nd pregnancy ended at 10
  wks gestation. She then had twins at 30 wks. One
  twin died soon after birth.
• What is her G/P?
• G 4 P 2 AB 1
• What is her GTPAL?
• G 4 P 1112

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Estimated Birth Date (EDC/EDD/EDB)

• Use LMP (last menstrual period)

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Assessment and Health Education

• Comprehensive history and physical exam
• Ongoing education focusing on current trimester
  and physical changes

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First Prenatal Visit

• Complete Physical Exam
• Pelvic exam external genitals, vagina, cervix
• Signs of pregnancy (Goodells, Hegars, Chadwicks)
• Pelvic measurements diagonal conjugate,
  obstetric conjugate, ischial tuberosity diameter
• Sterile speculum, pap smear
• (infection, discharge, growths?)
• GC, Clamydia cultures

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Laboratory Work

• CBC
• ABO Rh type
• Antibody screen
• Rubella titer
• VDRL or RPR (syphillis)
• Hepatitis B surface antigen
• Gonorrhea culture
• Chlamydia culture
• Alpha-fetoprotein _at_ 14wks

• HIV screen
• Urine glucose, protein ketones by dipstick.
• Urinalysis RBCs, leukocytes, bacteria
• Hereditary disease screening
• Sickle cell
• Tay-sachs
• Cystic fibrosis

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Assessment of Growth Development(Confirm
dating of pregnancy)

• Estimating fetal growth
• Fundal height symphysis to top of fundus
• McDonalds Rule Between wks 22-34 fundal height
  in cms should match no. of weeks gestation ( 2
  cm)
• Milestones
• 12 weeks fundus clears symphysis
• 20 weeks fundus at umbilicus
• 36 weeks, fundus at xyphoid

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Assessing Fetal Development Fetal
Movement/Heartbeat/Ultrasound

• Quickening fetal movement felt by mom between
  18-20 weeks (fetal movement record)
• Fetal heart tones by doppler (intermittent) or
  ultrasound transducer (continuous)
• Can be heard as early as 10th or 11th week of
  pregnancy by Doppler
• Normal 110-160 BPM
• Ultrasound gestational sac by 5-6 wks
• Crown-to-rump, biparietal measurements

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Chapter 10

• Promoting a Healthy Pregnancy

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Planning for Pregnancy

• Preconception
• Periconception
• Interconception
• Preconception counseling
• Identify conditions that could adversely affect
  pregnancy

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The Healthy Body

• Menstrual and medical history
• Exposure to childhood illnesses
• Exposure to STIs
• Exposures related to lifestyle choices
• Physical examination
• Laboratory evaluation
• Genetic testing
• Dental Care

97
The Healthy Mind

• Readiness for motherhood
• Psychological changes during pregnancy
• The healthy relationship
• Readiness for fatherhood
• Support for life changes

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Recommended Weight Gain

• 1st Trimester 1 lb/month (3 lbs)
• 2nd Trimester ½ - 1 lb/ wk
• 3rd trimester 1 lb/week , esp last month ?
  fetal wt gain
• Total
• 25-35 lbs--normal wt.
• 30-40 lbs--underweight
• 15-20 lbs--overweight
• Multiple gestation 1 lb per week throughout
  pregnancy (40-45 lbs total)

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Where does weight come from?
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Maternal Nutrition

• Caloric Intake 300 calories/day additional
• 2000-2500/daily
• Protein increases to 60 g/day
• Fat need linoleic acid (not manufactured in
  body)
• - need more vegetable oils
• Prenatal vitamins (contain folic acid)
• Folic Acid prevents neural tube defects
• Minerals calcium, phosphorus, iodine, iron,
  fluoride, sodium, zinc

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Maternal Nutrition (Continued)

• Fluid Needs
• Two glasses of fluid daily over and above a daily
  quart
• (a total of 6-8 glasses)

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Promoting Nutritional Health

• Nutritional Outcomes Planning
• Nursing diagnosis
• Outcome identification and planning
• Outcome evaluation
• Family considerations
• Financial considerations
• Cultural considerations

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Assessment Nutritional HealthRisk Factors
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Assessing Nutritional Health

• Typical day, 24-hour recall
• Nausea/vomiting?, cravings?, pica?
• Lab results HH for anemia, urinalysis for
  specific gravity
• Physical findings
• Hair, mouth, eyes, neck, extremities, finger/toe
  nails, over/under weight (BMI), poor weight gain

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Factors That Affect Nutrition

• Eating disorders
• PICAabnormal craving for nonfood substances
• Includes cravings for clay, ice cubes, dirt,
  cornstarch
• Iron deficiency anemia can result
• Anorexia nervosa, bulimia nervosa
• Cultural factors
• Vegetarian diets
• Food cravings and food aversions

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Common Nutritional Problems

• Nausea and Vomiting (Morning Sickness)
• Associated with a high level of chorionic
  gonadotropin, estrogen and/or progesterone levels
• Lowered maternal blood sugar levels
• Lack of vitamin B6
• Diminished gastric motility
• Affects 50 of pregnant women

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Common Nutritional Problems

• Nausea and Vomiting Teaching
• Crackers, pretzels, sourballs, delay breakfast
• Frozen yogurt, fruit popsicles
• Make up missed meals later in day
• Do not go gt 6 hours without food
• small, frequent meals keep Blood Sugar levels
  up
• Snack at bedtime delay eating in AM if nauseous
• Call MD if cant keep anything down 24 hours
  (hyperemesis gravidarium?)

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Nutritional Health-Special Needs

• Pregnant adolescents need at least 2500
  calories/day
• Good nutrition a problem
• More apt to eat junk food
• Help them ID nutritious food within their food
  preferences
• Inadequate iron calcium intake common

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Critical Thinking

• A pregnant client who is a lacto-vegetarian asks
  the nurse for assistance with her diet. What
  instruction should the nurse give the client
  about protein intake?
• A) "Protein is important therefore, the
  addition of one serving of meat a day is
  necessary."
• B) "Eggs are important to add to your diet.
  Eat six eggs per week."
• C) "A daily supplement of 4 mg vitamin B12 is
  important."
• D) "Milk products contain protein, but they
  are very low in iron."

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Exercise, Work, and Rest

• Exercise
• Muscle strengthening
• No rigorous aerobic activity
• Work
• Impact on pregnancy
• Maternity leave
• Rest

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Medications

• Safe versus teratogenic
• Over-the-counter
• Herbal and homeopathic preparations
• Prescription
• FDA pregnancy categories

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Teratogens

• Medications FDA Classification/Category A-D, X
• Cigarettes Low birth weight, IUGR, SAB, SIDS
• Alcohol Fetal alcohol syndrome SGA, cognitive
  deficits, characteristic craniofacial deformity
• Caffeine hi doses SAB, IUGR. Limit to 300
  mg/day
• Cocaine abruption, PT birth, IUGR, cognitive
  deficits
• Environmental chemicals, metals, radiation,
  etc.

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Fetal alcohol syndrome
114
Advanced Maternal Age

• Increased risk if mom gt 35
• maternal death (chronic medical conditions)
• SAB, low birth wt preterm birth
• cesarean section
• gestational DM, PIH, HTN, placenta previa,
  difficult labor, newborn complications
• Down syndrome
• Advanced paternal age ?genetic problems and
  late fetal death

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Adolescent Pregnancy Developmental Tasks

• Early ( 14 ) impulsive, self-centered, concrete
  thinker
• Middle (15-17) rebellious, peer group, moving to
  formal operational thought, does not see
  long-term consequences
• Late (18-19) better decision-making ability,
  concrete operation thought, abstract thought,
  understands consequences 0f behavior

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Adolescent Pregnancy

• Increased risks
• Late prenatal care often do not follow
  recommendations (smoking, wt. gain)
• Preterm birth, low birth wt, preeclampsia,
  iron-deficiency anemia, Alcohol, drug, tobacco
  use, STI
• ? cephalopelvic disproportion (CPD
• Undeveloped pelvis

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Common Discomforts

• Nausea and vomiting Fatigue
• Nasal congestion Backache
• Dental problems Leukorrhea
• Constipation/hemorrhoids Dyspepsia
• Leg cramps Flatulence
• Dependent edema Insomnia
• Varicosities Dyspareunia
• Round ligament pain Nocturia
• Hyperventilation, shortness of breath
• Numbness/tingling in fingers
• Supine Hypotensive Syndrome

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Signs and Symptoms of Danger
119
First Trimester

• Severe, persistent vomiting
• Abdominal pain and vaginal bleeding
• Indicators of infection

120
Second Trimester

• Maternal complications
• Preeclampsia
• Premature rupture of the membranes
• Preterm labor
• Fetal complications
• Decreased fundal height
• Absence of fetal movement after quickening

121
Third Trimester

• Maternal complications
• Gestational diabetes
• Placenta previa
• Abruptio placentae
• Fetal complications
• Hypoxia

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Pregnancy Map

• Prenatal care map
• Timetable

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Childbirth Education

• Primary goal
• To promote a positive childbearing experience
• Empowerment
• Dispelling myths
• Alleviate fear
• Topics
• Anatomy and physiology
• Comfort measures
• Labor and birth process
• Relaxation and pain management

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Childbirth EducationMethods

• Lamaze
• Empowerment
• Dispelling myths
• Controlled breathing, position, massage,
  relaxation
• Bradley
• Inward relaxation
• Normal breathing

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Other Methods

• Dick-Read
• HypnoBirthing
• LeBoyer method
• Odent method
• Birthing from within

126
Finding Information on Childbirth Education

• Primary sourcehealth care provider
• Online and at-home programs
• Parents need to ask questions about the class to
  determine if it fits their needs
• Factors related to personal values and beliefs
• Decrease fear through knowledge

127
The Birth Plan

• Written information that identifies labor and
  birth preferences
• The choices
• Choosing a provider
• Choosing a location
• Discussion with healthcare provider

128
Chapter 11

• Caring for the Woman Experiencing Complications
  During Pregnancy

129
Early Pregnancy Complications

• Perinatal loss
• Ectopic pregnancy
• Gestational trophoblastic disease
• Signs/symptoms vaginal bleeding, excessive
  nausea/vomiting, abdominal pain, size/date
  discrepancy
• Management remove uterine contents

130
Gestational Trophoblastic DiseaseHydatiform Mole

• Abnormal proliferation degeneration of
  throphoblastic cells (which give rise to the
  chorion)
• Molar pregnancy Embryo fails to develop, cells
  proliferate, then become clear, fluid-filled
  vesicles (grape-size)
• S/S ?fundal height for dates, ?hCG levels,
  brownish vaginal bleeding discharge of vesicles
• TX suction evacuation f/u for possible
  choriocarcinoma, hCG testing, delay new pregnancy
  for 12 months

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Spontaneous Abortion

• Before 20 weeks of gestation
• Signs/symptoms bleeding, cramping, abdominal
  pain, decreased symptoms of pregnancy
• Management D C

133
Premature Cervical Dilatation (incompetent cervix)

• Painless dilation of cervix without contractions
  due to structural or functional defect of cervix
• S/S pinkish show, ?pelvic pressure, followed by
  ROM, UCs birth.
• Associated with adv maternal age, congenital
  structural defects, trauma to cervix
• Treatment
• Cerclage -with next pregnancy

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Hyperemesis Gravidarum

• 0.5-2 of pregnancies
• Severe nausea and vomiting
• Dehydration, ketonuria, significant weight loss
  in first trimester, or
• Continues after 12 weeks
• Carbohydrate depletion/ketonuria
• Unable to maintain usual nutrition
• Dehydration/electrolyte imbalances
• Low sodium, potassium, chloride

136
Hyperemesis Gravidarum

• Therapeutic management
• Hospitalization
• NPO
• IV hydration (KCl if hypokalemic)
• Vitamin replacement
• Parental nutrition
• Medication (Reglan, Zofran)
• Gradual reintroduction of food

137
Chapter 19 Pregestational Problems Diabetes

• PATHOPHYSIOLOGY
• In 2nd half of pregnancy, hPL other hormones
  cause ? maternal peripheral resistance to insulin
  to ensure sufficient circulating glucose for
  fetus. Due to this, existing diabetes is
  augmented and diabetic potential may result in
  gestational DM.

138
Diabetes Mellitus

• Preexisting DM during pregnancy
• Regulation of glucose insulin more difficult
• Insulin needs ? in 1st trimester BUT ? in 2nd
  3rd trimester--may be 2 to 4 x greater by end
• Glucose levels can become out of control-balance
  is upset
• GOAL close control of glucose levels (fasting
  glucose lt 95 mg/dL 2 hour postprandial lt 120
  mg/dL)
• Glycosylated hemoglobin (HbA1c) measures control
  normal 4.8-7.8. gt 10 associated with 20-25
  rate of fetal anomaly

139
Gestational DM

• 1-14 of pregnancies
• Manifests at midpoint of pregnancy, when insulin
  resistance increases
• Risk of type 2 later as high as 50
• Risk factors
• Obesity, age, hx of large babies, unexplained
  fetal loss, congenital anomalies, family hx,
  Native Americans, Hispanics, Asians
• May or may not need insulin

140
Effects of DM

• MOTHER
• Hydramnios
• Preeclampsia
• Ketoacidosis
• Difficult labor (dystocia)
• Retinopathy

• BABY
• Congenital anomalies
• Heart, CNS, skeletal
• Stillbirth
• Macrosomia
• Hypoglycemia
• Respiratory distress syndrome (RDS)
• Polycythemia/hyper-bilirubinemia

141
Diabetes Mellitus Screening in pregnancy

• 1 hour, 50 g oral glucose challenge at 24-28 wks
  (at 1st PN visit if hi-risk)
• If 1 hour value 130 - 140, do 3 hour test.
• 3 hour, 100 g oral glucose tolerance test
• Diagnosis of gestational DM if 2 or more of the
  following values
• are met or exceeded
• Fasting 95 mg/dL
• 1 hour 180 mg/dL
• 2 hours 155 mg/dL
• 3 hours 140 mg/dL

142
Management

• Patient Teaching
• Diet Exercise
• Glucose monitoring Insulin pump therapy
• Insulin administration Signs of
  hypo/hyper-glycemia
• Placental functioning fetal well-being testing
• NST, AFI Assessment of fetal size and
• Fetal kick counts maturation
• Delivery at term or possibly 38 weeks,
• c-section if macrosomia/ CPD suspected

143
Abruptio Placentae

• Premature separation of placenta from uterine
  wall
• S/S sharp, stabbing pain high in fundus, heavy
  bleeding (may be occult), hard, board-like
  uterus, tense, painful uterus, signs of shock due
  to blood loss, Port-Wine aminotic fluid if ROM.
• Predisposing fx ?parity, adv. maternal age,
  short umbilical cord, chronic HTN, PIH, direct
  trauma, vasoconstriction from cocaine or
  cigarette use
• Fetal distress on monitor. Can progress to DIC.

144
Abruptio Placentae
145
Abruptio Placentae

• Management
• Emergency. Immediate c-section if birth not
  imminent.
• Lg. gauge IV
• O2 via mask, fetal monitoring, maternal VS,
  lateral positioning, labs, blood transfusion
  (have 2 units avail)
• CBC (HH), Fibrinogen levels, platelet count,
  PT/PTT, fibrin degradation products ( sx of DIC)

146
Placenta Previa

• Low implantation of placenta (1 in 200)
• abrupt, painless, bright red bleeding
• Associated with ?parity, adv. maternal age,
  previous c-section or uterine curettage, multiple
  gestation
• Dx ultrasound. May resolve as pregnancy
  progresses.
• Bleeding common around 30 wks Bedrest, VS, IV
  fluids, type cross-match, observe for bleeding
• Emergency assess bleeding, hx, ucs/labor
• NEVER do vaginal exam !!!

147
Placenta Previas
Low-lying
Marginal
Complete
Partial
148
Prolapsed Cord

• Loop of umbilical cord slips down in front of the
  presenting part
• S/S deceleration of FHT bradycardia, persistent
  variable decels, cord palpatedor seen in vagina
• Associated with
• Premature rupture of membranes
• Transverse or breech presentation
• Multiple gestation
• Placenta previa
• Hydramnios
• CPD (non-engagement of fetal head)

149
Prolapsed Cord

• Management Hold fetal head off cord,
  Trendelenburg or knee/chest position, immediate
  emergency c-section
• Prevention
• Watch fetal heart tones after rupture of
  membranes (SROM or AROM). Do VE if any sign of
  fetal distress.
• If head not engaged, women with ruptured
  membranes should not ambulate.

150
Preterm Labor (PTL)

• Occurs before 37 weeks gestation
• 11-12 of pregnancies
• 75 of neonatal morbidity mortality where
  congenital anomalies do not exist

151
Preterm Labor

• S/S low backache, vaginal spotting, pelvic
  pressure, abdominal tightening, cramping
• Associated with dehydration, UTI,
  chorioamnionitis
• UC gt every 10 minutes
• Can attempt to stop if effacement lt 50 and
  dilatation lt 4-5 cm
• DX clinical presentation, vaginal exam, UA,
  CBC, vaginal culture, test for ROM
• Fetal Fibronection screen

152
Drugs Used in Treating Preterm Labor

• Antibiotics (ampicillin, erythromycin)
• Group B streptococcus prophylaxis,
  chorioamnionitis
• Corticosteroids (Betamethasone or Dexamethasone)
• 24 to 34 weeks gestation
• Accelerate the formation of lung surfactant
  (Betamethasone)
• TOCOLYTICS ( stop contractions)
• Terbutaline 1st line agent (subcutaneous
  injection or PO)
• Works on Beta-2 receptor sites in uterus
• Side effects tachycardia, arrhythmia,
  palpitations, hyperglycemia
• FDA now disallows use for PTL

153
Drugs Used in Treating Preterm Labor

• TOCOLYTICS, cont.
• Magnesium Sulfate (IV) (pg 500)
• Central nervous system depressant
• 4-6 g loading dose, 2 g maintenance
• Procardia (nifedipine) (PO)
• Calcium channel blocker, relaxes smooth muscle
• Side effects hypotension, tachycardia, facial
  flushing, headache
• Becoming drug of choice ---evidence based
  practice

154
PTL Self Care Teaching

• Signs of PTL May be subtle
• UCs q 10 mins or closer, cramping, pelvic
  pressure, ROM, low dull backache, change in
  vaginal discharge
• Evaluation of UCs (uterine contractions)
• Pelvic rest/activity level
• What to do if experiencing symptoms
• Empty bladder, lie on side, drink H20, palpate
  for UCs time, rest, call MD if symptoms persist

155
Preterm Premature Rupture of Membranes

• Loss of amniotic fluid before 37 weeks of
  pregnancy (5-10 of pregnancies)
• Usually associated with chorioamnionitis, vaginal
  infection (chlamydia, gonorrhea) or UTI
• Increased risk of cord prolapse
• DX Observe for vaginal leaking (sterile
  speculum exam for pooling), nitrizine paper,
  ferning test, fetal distress, sx infection

156
Ferning pattern seen on slide with amniotic fluid
157
Premature Rupture of Membranes

• Management
• If less than 37 wks hospitalization,
• Bedrest ? fetal
  monitoring/NST
• steroids (24-34 wks) ? CBC
• broad-spectrum antibiotics
• VS monitoring (temp q 4 hours)
• Betamethasone
• Accelerate lung maturity by ?surfactant
  production
• Usual course 12 mg, IM, q 24 hours for 2 doses
  Side effects maternal hyperglycemia--DM may
  require more insulin

158
Hyperemesis Gravidarum

• Criteria persistent vomiting, measure of acute
  starvation, and weight loss
• Management
• Rest
• Small frequent meals (dry, bland foods)
• High-protein snacks

159
Critical Thinking

• A woman is experiencing preterm labor. The client
  asks why she is on betamethasone (Celestone). The
  best response by the nurse would be, "This
  medication
• A) Will halt the labor process, until the baby is
  more mature.
• B) Will relax the smooth muscles in the infant's
  lungs so the baby can breathe."
• C) Is effective in stimulating lung development
  in the preterm infant."
• D) Is an antibiotic that will treat your urinary
  tract infection, which caused preterm labor."

160
Hypertensive Disorders

• Classifications
• Chronic
• Preeclampsia-eclampsia
• Chronic hypertension with superimposed
  preeclampsia
• Gestational/transient

161
Preeclampsia

• Multisystem, vasopressive
• Disease of placenta
• SPASMS
• Morbidity and mortality
• Management
• Delivery of fetus only cure

162
Nursing AssessmentsPreeclampsia

• Identify hypertension
• Proteinuria
• Edema
• CNS alterations
• Eclampsia seizures

163
Pregnancy Induced Hypertension

• Cause unknown. 5-7 of pregnancies in US.
  Manifests in 2nd half of pregnancy
• Vasospasm of small large arteries
• Dx ?BPs (140/90), proteinuria (gt1)
• Non-diagnostic findings edema (truncal/facial),
  headache, visual disturbance, epigastric pain,
  hyperreflexia
• ?Risk ethnicity, multiple gestation, primigravid
  lt 20 or gt 40 y.o., ?socio-economic, grand
  multiparity, underlying disease (heart, HNT, DM,
  kidney), previous history

164
Pathology of Pregnancy Induced Hypertension

• As a result of increased vasoconstriction, GFR is
  greatly compromised
• Organ perfusion is poor and fluid diffuses from
  blood stream into interstitial tissue ? edema
• Decreased urine output and proteinuria.
• Edema occurs as result of protein loss, and
  lowered GFR.

165
Concept Map of PIH Symptoms
Anti-angiosin from placenta ? Fibrin
Deposits Vasospasm Renal damage ?
Liver Damage ? Renin-Angiotensin System
?Liver Panel
?Platelets
DIC
Monitor sx Bleeding
Strict IO
Oligouria
? Hct
HYPERTENSION
?osmotic pressure ? Intravascular Volume
EDEMA
PROTEINURIA
Glomerular Damage
Headache
Antihypertensives
Mannitol Decadron
Cerebral Edema
24 hr Urine Renal labs
Blurred Vision
MgSo4
Hyperreflexia
166
Diagnosis of pregnancy induced hypertension

• 24 hour urine is the most definite diagnosis
• Protein 2 or higher
• Metabolic Panel (Comprehensive or Basic)
• Elevated BUN, uric acid and creatinine
• Elevated liver function tests (AST, ALT)
• Low Albumin
• Complete Blood Count
• Low Platelet Count--level determines the
  severity of hypertension
• Hemoconcentration increased (? Hct/Hgb)

167
Pregnancy Induced Hypertension

• S/S edema, visual changes, epigastric pain,
  severe headache, hyperreflexia, clonus, oliguria
• Management bedrest, maternal/fetal monitoring,
  quiet, darkened room, seizure precautions,
  delivery
• Medications
• IV magnesium sulfate to prevent seizure
• IV hydralazine or labetalol to ?BP

168
Magnesium Sulfate

• Purpose Prevents seizure (eclampsia)
• Dosage 4 gram loading dose over 20-30 mins,
  then 2 gram/hr maintenance dose
• Nursing considerations
• Limit total IV intake to 125 cc/hr
• Foley catheter strict IO
• Serum magnesium levels q 6 hrs
• Normal 1.8-2.5
• Therapeutic 5-7
• Hyporeflexia, slurred speech, N, somnolence 9-12
• Respiratory distress gt12
• Cardiac arrest gt15

169
MgSO4 Nsg Considerations, cont.

• Assess deep tendon reflexes, BP, RR, lung sounds,
  urine output, level of consciousness. Stop
  infusion if s/s of toxicity occur.
• Pt. Teaching
• Normal side effects with MgSO4
• Warmth over body/flushing
• Burning at IV site
• Mild SOB, mild chest pain
• Congestion, headache, dizziness
• Antidote 10 Calcium Gluconate, 10 ml, IVP over
  2-3 mins.

170
Pregnancy Induced Hypertension

• Eclampsia seizure - tonic-clonic type
• Maintain airway, position to side, O2, pulse ox,
  suction as needed
• Continuous fetal monitoring, monitor for possible
  abruption (vaginal bleeding, non-reassuring FHT)
• Delivery after stabilization
• Seizure may cause precipitous birth

171
Pregnancy Induced Hypertension

• HELLP Syndrome (Hemolysis, Elevated Liver
  enzymes, Low Platelets)
• Complication of preeclampsia (4-12 of women with
  preeclampsia)
• S/S nausea, epigastric pain, general malaise,
  RUQ tenderness, visual changes
• Lab hemolysis of RBCs, platelets lt 100,000,
  elevated liver enzymes (ALT/AST)
• TX platelet transfusion, delivery of baby,
  monitor for hemorrhage DIC, steroids to ? renal
  function

172
Disseminated Intravascular Coagulopathy (DIC)

• External or internal bleeding
• Nursing care
• Meticulous maternal and fetal assessment
• Place indwelling catheter with strict IO
• Oxygenrebreathing mask
• Blood and blood products
• Emotional support

173

• DIC Is A Disorder Of The "Clotting Cascade."
• It Results In Depletion Of Clotting Factors In
  The Blood.

174
Causes of DIC

• DIC is when your body's blood clotting mechanisms
  are activated throughout the body.
• Micro Blood clots form throughout the body, and
  eventually using up the blood clotting factors.
  These are then not available to form clots at the
  local sites of real tissue injury. (microthrombi)
• Clot dissolving mechanisms are also
  increased-fibrinolysis

175
Possible Precursors To DIC

• Hemorrhagic shock
• Transfusion reaction
• Sepsis
• Severe pre-eclampsia or HELLP syndrome
• Retained fetal demise
• Premature separation of the placenta
• Retained placenta
• Amniotic fluid embolism (usually not able to be
  determined until autopsy)

(Human Labor and Birth, Oxorn and Foote)
176
Critical Thinking

• The nurse identifies the following assessment
  findings on a client with preeclampsia blood
  pressure 158/100 urinary output 50 mL/hour
  lungs clear to auscultation urine protein 1 on
  dipstick and edema of the hands, ankles, and
  feet. On the next hourly assessment, which of the
  following new assessment findings would be an
  indication of worsening of the preeclampsia?
• A) Blood pressure 158/104
• B) Reflexes 2
• C) Platelet count 150,000
• D) Urinary output 20 mL/hour

177
Special Conditions and Circumstances that may
Complicate Pregnancy
178
Multiple Gestation

• High-risk pregnancy
• Morbidity and mortality
• Management
• Delivery at Level III facility

179
Hemoglobinopathies

• Sickle cell disease
• Thalassemia
• Close maternal and fetal surveillance
• Rh0(D) isoimmunization
• Admininster RhoGAM to prevent
• ABO
• Coombs test

180
Isoimmunization-Rh Incompatibility

• Rh Negative mom
• If fetus is Rh positive,
• --MOM may make antibodies against fetal blood
• Causes hemolysis of fetal RBC--extreme anemia
  (erythroblastosis fetalis)
• Indirect Coombs tests whether MOM has been
  sensitized. If negative (no sensitization has
  occurred), Rhogam will be given to prevent
  sensitization.

181
Isoimmunization-Rh Incompatibility
182
Isoimmunization, cont.

• To prevent maternal antibody formation
• Rh immune globulin (RhIG or Rhogam) is given
• At 28 wks
• After any incident that might cause mixing of
  maternal/fetal blood like abortion, miscarriage,
  ectopic pgncy, amniocentesis, CVS sampling,
  evacuation of mole, external version
• Babys cord blood tested--if Rh or DIRECT
  Coombs positive, Rhogam given to MOM in 1st 72
  hours.
• Treatment for BABY
• Positive DIRECT coombs indicates hemolytic
  disease of newborn. Babys RBC have been
  sensitized which causes lysis of RBCs (will cause
  hyperbillirubenemia).

183
Cardiovascular Disorders

• Most common problems
• Valvular damage---prophylactic antibiotics
• Congenital heart defects
• ? Maternal age--more chronic disease
• Coronary artery disease, varicosities
• Pregnancy taxes circulatory system
• ? volume and cardiac output--danger of CHF
• Class I II, no problem
• Class III IV have risk of severe
  complications--pregestational counseling advised.

184
Heart DiseaseInterventions during labor birth

• Epidural for pain control
• Limit/eliminate pushing--forceps/ vacuum delivery
• Sidelying positions to ? perfusion to baby

• Class III IV may need invasive cardiac
  monitoring
• Danger (S/S CHF)
• ? HR or RR in mom
• Crackles or SOB
• Edema
• Cough

185
Other Cardiovascular Disorders

• Peripartum cardiomyopathy
• No history of cardiac disease
• Signs/symptoms dyspnea, fatigue,
  peripheral/pulmonary edema

186
Trauma

• Preventing accidents
• 6-7 of pregnancies
• Most commonly in 3rd trimester
• Physiologic changes affecting trauma care
• Psychosocial considerations
• Fear for fetus, anxiety, guilt
• Assessment
• Pregnancy history Bleeding? Cramping?
• Fetal movement? Physical exam
• Carefully document accident
• Consider abuse or self-inflicted injury

187
Trauma

• Open wounds
• Lacerations
• Puncture wounds
• Animal or snake bites
• Blunt abdominal trauma/MVA
• Placental abruption
• Kleihauer-Betke test
• Rh Neg Need Rhogam
• Choking chest thrusts

188
Venous Thrombosis and Pulmonary Embolism

• Symptoms
• Diagnosis
• Doppler ultrasound
• Ventilation-perfusion (VQ) scan

189
Respiratory Complications

• Pneumonia
• Aggressive management
• Asthma
• Cystic Fibrosis

190
Inflammatory Disease Pregnancy

• Systemic lupus erythematosus (SLE)
• Increased risk of pregnancy complications
• Management
• Immunosuppression of SLE flare
• Careful fetal surveillance
• If flare-up during pregnancy, rapid
  implementation of treatment

191
Psychiatric Complications

• Depression
• Schizophrenia
• Bipolar disorder
• Anxiety disorders
• Eating disorders
• Substance addiction

192
Antepartum Fetal Assessment

• Chorionic villus sampling
• PUBS
• Amniocentesis
• Amnioscopy or fetoscopy
• Ultrasonography
• Fetal kick counts

193
Assessment of Fetal Well-Being (cont.)

• Doppler ultrasound
• Fetal biophysical profile
• Non-stress test
• Vibroacoustic stimulation
• Contraction stress test
• Electronic fetal heart rate monitoring

194
Antenatal Bedrest

• Regular community health nurse home visits
• Involve various community resources
• Support groups
• Provide emotional support

195
Ultrasonography

• 2 Types transabdominal and transvaginal
• Purposes- ?
• Transvaginal helpful for imaging cervix to look
  for shortening and funneling, signs of
  incompetent cervix

196
(No Transcript)
197
Common Uses of Ultrasound in Pregnancy (pg 545
for AGOC indications)

• Diagnose pregnancy multiple gestation
• Confirm EDC, predict maturity by measurement
• Estimate fetal weight/estimated gestational age
  (EDC)
• 1st trimester crown-rump length (6-10 wks) (
  3-5 days)
• After 1st trimester femur length, abdominal
  circumference biparietal diameter ( 7-21 days)
• Confirm presence, size location of placenta
  amniotic fluid (AFI)
• Determine growth, sex presentation of fetus
• Diagnose fetal death

198
Measuring femur length
Measuring the head
199
Assessing Fetal Well-Being Fetal Movement

• Fetal Movement felt between 18-20 weeks
  (quickening)
• Fetal Kick Count should feel 10 movements in 1
  hour (assess at same time of day)
• Associated with accelerations on non-stress test
  (NST)
• Decreased fetal movement is a DANGER sign

200
Biophysical Profile

• Measures 5 parameters (score max. of 2 for ea.)
• Fetal breathing
• Fetal movement
• Fetal tone
• AFI
• NST
• Score 8-10, baby is well 6, suspect problems
  4, fetus in jeopardy
• Modified Biophysical Profile
• NST AFI Normal if NST is reactive AFI gt 5
  cm

201
Amniotic fluid index (AFI)

• Assessment of amniotic fluid.
• Rationale ?uteroplacental perfusion may lead to
  ?fetal renal blood flow, ?urination
  oligohydramnios (fetal swallowing urine output
  determine amniotic fluid volume)
• Pockets of fluid visualized by US are measured
• From 28-40 wks
• AFI should be 12-15 cm.
• Above 20-24 cm polyhydramnios
• Below 6 cm oligohydramnios

Sli