Maternity Week 1 The Menstrual Cycle, Family Planning, Fertility, and Conception Objectives:  1. Compare the menstrual cycle in relation to hormonal, ovarian, and endometrial response. 2. Discuss Fertility Awareness Methods and how they can be utilized to assist with family planning. 3. Compare the hormonal methods of contraception and their advantages and disadvantages. 4. List common causes of infertility. 5. Describe common diagnosis and treatments for infertility. 6. Summarize the process of fertilization. Detailed Course Outline  I. Introduction to Maternity and Women’s Health Care  II. Reproductive Issues in Nursing Practice A. The Menstrual Cycle B. Fertility Awareness  1. Natural Family Planning  2. Hormonal Methods of Contraception C. Infertility (Primary and Secondary)  1. Issues Related to Infertility Treatment  2. Fertility Awareness  3. Diagnostic Tests Menerche & Puberty  -Young girls release small rather constant amounts of estrogen, a marked increase occurs between ages 8- 11 years of age.  -Menarche: denoses the 1st menstruation  -Puberty: broader term that denotes the entire transition between childhood & sexual maturity.  -Increasing amounts of GnRH and estrogen secretion develop into a cycle pattern at least a year before  menarche.  -Initially menstrual periods are irregular, unpredictable, painless and anovulatory (no ovum is released  from the ovary). After 1+ years, a hypothalamic pituitary rhythm is developed and ovary produces  adequate cyclic estrogen to make mature ovum.  -Ovulatory (ovum released from the ovary) periods tend to be regular with estrogen dominating the first  half of the cycle and progesterone dominating the second half.  The Menstrual Cycle: Menstruation = periodic uterine bleeding that begins approx. 14 days after ovulation, controlled bya  feedback system of 3 cycles: endometrial, hypothalmoc-pituitary, and ovarian. The average length of  menstrual cycle = 28 days.  -First day of bleeding aka day 1 of menstrual cycle = menses.  -Avg duration of flow is 5 days, avg. blood loss is 50 mL.  -Menstrual cycle prepares uterus for pregnancy, when pregnancy does not occur, menstruation follows.  -A woman’s age, physical and emotional status, and environment influence the regularity of her menstrual  cycle. http://www.youtube.com/watch?v=8_rfZ_qj1z4 Hypothalamic-Pituitary Cycle: At the end of the menstrual cycle, falling levels of estrogen and  progesterone stimulate the hypothalamus to secrete gonadotropin releasing hormone (GnRH) which  stimulates the anterior pituitary to secrete FSH.  -FSH stimulates development of ovarian graafian follicles and their production of estrogen. -As estrogen levels further decrease, the hypothalamic GnRH triggers the Anterior Pit to then release  lutenizing hormone (LH).  -A marked surge of LH and a smaller peak of estrogen (which occurs around day 12) precede the expulsion  of the ovum from the ovary by about 24-36 hours.  - LH peaks at about day 13 or 14 of the 28 day cycle.  -If fertilization & implantation of the ovum does not occur by this time, regression of the corpus luteum  follows. Progesterone and estrogen decline, menstruation occurs and the hypothalamus is once gain  stimulated to secrete GnRH. This process = hypothalamic-pituitary cycle.  Ovarian Cycle:  -FSH causes a graafian follicle to mature, and LH causes the release of the egg.  -The preovulatory surge of LH affects a selected follicle.  -The egg matures, ovulation occurs, and the empty follicle transforms into corpus luteum.  -This follicular phase of the ovarian cycle varies in length woman to woman.  -After ovulation, estrogen levels drops.  -The luteal phase begins right away after ovulation and ends with the start of menstruation. This post  ovulatory phase of the ovarian cycle usually requires 14 days (days 13-15). The corpus luteum reaches its  peak of functional activity 8 days after ovulation, secreting the steroids estrogen & progesterone.  -The fertilized ovum is implanted in the endometrium. If no implantation does not occur, the corpus luteum levels regress and steroid levels drop. -2 weeks after ovulation, if fertilization and implantation do not occur, the functional later of the uterine  endometrium sheds blood via menstruation.  *If fertilization and implantation does occur, the corpus luteum release progesterone, an important  hormone needed for maintaining a pregnancy. The corpus luteum releases progesterone until the placenta forms and takes over the job for it. The follicular phase is the preovulatory phase and the luteal phase (postovulatory) begins immediately  after ovulation and lasts until menses begins. 4 phases of Endometrial cycle:  1.Menstrual phase: bleeding (first day of bleeding marks the first day of the cycle) Sheds the functional  2/3s of the endometrium (spongy and compact layers) is initiated by vasoconstriction in the upper layers  of the endometrium.  2.Proliferative phase: period of rapid growth that lasts from the 5th day to the time of ovulation 3.Secretory phase: day of ovulation to about 3 days before the next menstrual period. Progesterone is  heavily secreted by the corpus luteum to prepare the uterus for implantation. The corpus luteum also  secretes estrogen. 4.Ischemic phase: Tissue death; the blood supply to the endometrium is blocked and necrosis develops  which results in menstrual bleeding or the start of the menstrual phase Implantation of the fertilized ovum generally occurs about 7-10 days after ovulation. If implantation does  not occur, then the corpus luteum regresses and causes a decrease in estrogen and progesterone, which  stimulates the hypothalamic-pituitary cycle. -Progesterone and estrogen are low making moods low that affects the hypothalamus -Hypothalamus stimulates its girlfriend AKA GnRH (which is a hormone) that picks up the fact the  hormones are low, and then it stimulates pituitary gland tries to raise the estrogen and progesterone levels -Girlfriend GnRH doesn’t do a good job so she recruits over FSH and tells hormones you need to grow up  and mature and takes tiny follicles and mature it into an egg so it can go out into the world before released from ovaries.  -Luteinizing hormone (LH) means let’s hurry, hormone is responsible for releasing that egg, and is  responsible for ovulation. So the egg is ready, good to go.  AKA LH SURGE  -So this follicle went from a follicle to an egg to now what is called a CORPUS LUTEAUM: which is when the  egg gets to a point where it is mature, and ready to be fertilized.  -Corpus luteaum becomes part of the placenta to support the pregnancy.  -Progesterone is your friend, It’s role is to set the whole scenario, to make sure where you’re going is all  prepped and ready such as the lining of the uterus, it promotes the pregnancy, it builds the lining up in the uterus, protects pregnancy from being rejected.  -Now we just wait for the sperm, if sperm gets cold feet, turns around and goes home,progesterone and  estrogen, corpus luteaum all gets mad, so the environment is no longer inducive to support a baby, clamps down and causes blood to shed. If sperm does decide to show up then we see if sperm can get the job  done, if it does, the hormones remain high. KNOW GnRH, hypothalamus and pituitary how they play a role in FSH & LH, role of  progesterone, when progesterone is high and low.  Sperm remains in environment for 72 hours, egg stays lingering around for 24 hours. So remember if you  have intercourse the day before you ovulate, the eggs are still hanging around. SO be CAREFUL!!!  Fertility Awareness 24:00 We want 28 day cycle. • Physiologic cues to predict ovulation  • Can be used to assist with conception or to prevent conception • Uses a combination of the following methods: • Calendar Method -Determine the average cycle length over 6 months.  -(if cycle is 28 days), ovulation occurs approximately 14 days before the onset of menses (day 14). -Most fertile on days 12-16 of menstrual cycle -Decision based on desire to pregnancy (days 12-16) • Standard Days Method: visual cue when they are fertile, more for cookie cutter cycles.  -Uses a string of color coded beads to keep track of the days of each cycle.  -Designed for women with cycles from 26-32 days.  -Days 8-19 are considered fertile days.  • Basal Body Temperature: GOLD STANDARD: How to teach this to a patient…  Chart oral temperature each morning before getting out of bed.  Some women have a slight temperature drop before ovulation followed by a rise of 0.4- 0.8 degrees with ovulation -A special basal body thermometer must be used, keep at bedside, take temperature  before you put anything on your lips, before you remove the bed sheet covers because  that can fluctuate your body temperature.  -Temp must be taken at the same time every morning. -Dip then a spike = when you are fertile 98, then 97.6-98.4, when you dip and  3 days after that including the dip day, that is when you are FERTILE! ON  TEST!!! • -some people don’t have a dip so when that happens you start counting when  they have a spike (LH is responsible for that spike) means egg is released, all  ready to go.  -Progesterone is responsible for maintaining that elevated temperature until  your cycle starts over again. Progesterone has set the ambience, all ready, it  will show up…. finally it drops temperature.  • Cervical Mucous: you want it to be clear, stretchy, and odorless. To avoid pregnancy,  couples must abstain from the time clear stretchy mucus is first present day to 4 days  after the end of slippery mucus, abstain from sex that day after the 4th day to avoid  pregnancy!  • Symptothermal Method: Combines the Calendar, Basal Body Temperature, and  Cervical Mucus methods. Symptoms that occur near ovulation are noted: weight gain,  abdominal bloating, mittelschmerz (pain on ovulation), and increased libido are noted.  Hormonal Methods of Contraception • Using different combinations of hormones (estrogen, progestin, and progestational agents) to  prevent ovulation and create an inhospitable uterine environment (prevents implantation) -Combination pills is the most common: low levels, titrated up eventually =, preventing envt from being  inducive for pregnancy, prevents environment from being comfortable for the egg, last pill is placebo just  to have that routine.  -Injectable: ex. Depo-Provera  -Patches are also combination as well.  -Vaginal rings are inserted; don’t give these to people who are squeamish of touching themselves.  -IUD aka Mirena: insertive device that is no effort, major consequences.  -Emergency contraceptives doesn’t have to be prescription anymore. Oral contraceptives: If you forget during active weeks (1-3), take it right away as soon as you realize. Take  next dose as soon as it is due. The catch is if more than 12 hours you need a back up birth control until the start of the next cycle.  -How to take properly:  -Side effects vs. complications: Complications: calf tenderness and redness = DVT, any signs of clot formation  When are Hormonal contraceptives contraindicated? • History of thrombophlebitis • CVA or CV disease: high BP, overweight, smoker, you need alternative.  • Estrogen dependent cancer or breast cancer: speeds up cancer so no combination drugs (no  estrogen and progesterone together) are given.  • Benign or malignant liver tumors: • Hypertension • Migraines with focal aura • Diabetes with vascular involvement: anything to do with circulation, contraceptives are a NO NO.  • Impaired liver function • Suspected or known pregnancy• Undiagnosed vaginal bleeding: YOU STOP THE PILL until you figure out what is causing the  bleeding. You cannot know if she has uterine cancer that causes bleeding so it’s a no until its  diagnosed, onve you find out its not cancer you can adjust the dose.. • Heavy cigarette smoking in women over 35 years of age. • Major surgery requiring prolonged immobilization do to clot risk.  Most Important Potential Complication of Hormonal Contraceptives • Strokes, DVT, Blood Clots • Risk increased if over 35 and smoke, or have a history of DVT Depo-Provera • An IM injection of progesterone only, progesterone does not feed cancer, but estrogen does.  • So this is good for people who have history of clots, history of cancer, they want to breast feed.  • Come in every 11-13 weeks get a shot, no problem… • Prevents ovulation for 12 weeks  • Failure rate of 3% • SE: irregular menstrual bleeding (never ending periods sometimes do to irregularity), significant  weight gain (4lbs per year), depression, headaches, nervousness, decreased libido, and breast  discomfort.  • In prolonged use, extensive years, decreased bone density in adolescents may occur, therefore  adequate calcium and vitamin D must be stressed, DEXA scans! • DOESN’T PROTECT FROM STDs, HIV!!  • Could take up to a year- year and a half for cycle to return back if you do want to get pregnant.  • There are no effects on breast milk and fertility returns in approximately 10-18 months Ortho Evra: transdermal patch, same rules apply, clean, intact no rash on that area of skin. Combination  of estrogen and progesterone.  Smokers, over 35, obese, history of clots, history of HTN NOT a good idea to take. Patch on for 3 weeks,  take it off for 1 week. Don’t handle with bare hands.  Nuvaring: Ring is similar to patch, except it is inserted up there…. Combination of time released  hormones: estrogen and progesterone. Can’t have a squeamish person to get this. If you gain or lose 20%  of your weight or you just had a baby, you might need a fitting.  Does not need to be fitted, one size fits all, place for 3 weeks, remove it the last week.  Smokers, over 35, obese, history of clots, history of HTN not a good idea to take, stroke pts.  IUD: Mirena: Can have progesterone that is time released or copper IUDs that can last 10 years, makes  environment hostile so it won’t be able to support a pregnancy. Mirena has progesterone that is time  released, shorted lifespan, 5 years span, pull it out and put it right back in.  People who had history of stroke, clots, women who want to breastfeed, cancer pts, this is the better route  because it only has progesterone no estrogen!  Not as systemic absorbed, even-tempered release, more localized. You can have irregular bleeding, less of  a weight gain compared to Depo-Vera.  The rule of thumb is you have to have a baby before, monogamous relationship, no gonorrhea or  chlamydia (you get screenings, make them wait).  Mirena Side Effects & Complications:   Irregular periods with light bleeding followed by amenorrhea  Perforation of the uterus at time of insertion  Expulsion of the device by 2-10% of users  Ectopic pregnancy (rare): pregnancy takes place outside the womb  If pregnancy does occur: spontaneous abortion or preterm birth  Risk for infection at time of insertion, cultures done prior to insertion • Mirena Teaching: Presence of “Tail” extending into vagina, check for strings once a week for 1st four weeks, then monthly after her period, or if signs of expulsion are present (cramping,  bleeding). Check for length of strings, if longer or shorter, may not be in proper place – If missing, expulsion may have occurred • S/S infection: vaginal pain, discharge, itching, low pelvic pain, and fever 1-sided pain, and you are pregnant, = ectopic pregnancy • Emergency Contraception aka Plan B • The sooner you take it, the quicker it will work. Effective 96 hrs after the fact.. but you shouldn’t  wait that long.  • It will not interrupt an already made pregnancy…  Plan B is just extreme doses of hormones. This is no joke… violently ill, makes uterus contracts, looks like they’re in labor.  Ovulation must occur, you need informed consent when you give this to a person.  • Sexual abuse pt? does she have control in this situation? If this is countless administration.  • You must have Fallopian tubes must be patent • You must have Healthy sperm, in adequate numbers, must be ejaculated near the cervix • You must have Cervical mucus must be hospitable to sperm to allow passage into the uterus • You must have the endometrium hormonally prepared to receive the conceptus • Adequate hormones must be produced to maintain the pregnancy • Obese people require an IUD more than plan B because it’s more effective than a pill.  Infertility:  • Not an absolute condition, but is a reduced ability to conceive • A lack of conception after 12 months of unprotected intercourse (rule varies with age), always  looks at the men first! – Primary: in woman who never conceived -Depends on her age, under 35 and has been trying to conceive for 1 solid year -Over 35, try in 6 mos because we have less time on our hands – Secondary: conceived in the past, but unable to do so again We ask commonly do you have the same partner? *  -The younger they are the better they can bounce back, just how it works.  Factors Contributing to Infertility:  • Age at which the woman attempts to conceive has risen • Male fertility has declined, reducing the chance that the man will father children without therapy • Expectations of successful results of infertility therapy have risen Factors in Men • Abnormalities of the Sperm – Azoospermia: no sperm comes out – Oligospermia: lower quantities of sperm – Motility: how well does it move?  – Inability to penetrate ovum: can’t penetrate ovum?  • Abnormal Erections • Abnormal Ejaculations: Can they ejaculate?  • Retrograde ejaculation (sperm deposited into bladder)- tubing is kinked and the sperm backflows  to bladder.  • Abnormal Seminal Fluid • Smoking, caffeine, stress, obesity, tidy widys  higher temperature not good for sperm.  • High blood pressure makes men more impotent due to vasodilation.. lowering the pressure you  can’t get erection.  • psychiatric and street drugs also can cause impotency.  Factors in Women  • Abnormalities of Fallopian Tube • Abnormalities of the Cervix  • Disorders of Ovulation • What does her uterus look like?  • Repeated Pregnancy Loss:  -Abnormalities of fetal chromosomes: 99% of the time, body knew the child won’t make it.. too  many defects.  -Abnormalities of cervix or uterus -Endocrine abnormalities: sugars are off, type 1 diabetics, and A1C is off the charts = babies with  defects..  -Immunologic factors: Rogan used for blood …. -Environmental agents -Infections such as Rubella: can cause defects of the baby Evaluation of Infertility • Preconception Counseling • History and Physical Examination • Diagnostic tests • Basal Body Temp and Standard calendar: see if they are ovulating, otherwise give  Clomin to release that egg. 2 major downfalls could be too many eggs, could make ovary burst and hemorrhage internally and lose that egg.  • Ovulation Predictor Kits: tells if you have that LSH surge • Hormone Evals: draw blood, test fluids, come in an hour after 1 intercourse • Ultrasound: structural tool  • Hysterosalpingogram: radiology test injecting dye in uterus, what lights up in pathways,  are tubes patent and sometimes they push tubes open.  • Endometrial Biopsy: straw like catheter, suck out the cells in the linings of the uterus to  take samples to check abnormal cell growth.  • Semen analysis (easiest and most cost effective, usually done first!) • Male Diagnostic Tests: Semen Analysis – Structure and function – Composition of seminal fluid – Sperm concentration, motility, morphology, viability, liquefaction • Endocrine tests • Ultrasonography • Testicular Biopsy • Sperm Penetration Assay (evaluates fertilizing ability of sperm) Female Diagnostic Tests • Ovulation Prediction • Ultrasonography • Postcoital Test (cervical mucus and sperm function) Infertility Therapy • Timing of Intercourse • Medications: Clomid • Ovulation Induction • Surgical Procedures • Therapeutic Insemination: IUIs, make environment as best as possible • Egg donation:  • Surrogate Parenting:  • Assisted Reproductive Technology Surgical Procedures • Endoscopic procedures to remove blockages in male or female • Laparotomy to relieve pelvic adhesions and obstructions • Transcervical Balloon Tuboplasty: minimally invasive, unblocks fallopian tubes Medications:  • Clomid • Progesterone: keeps pregnancy supportive  • Erectile agents • Therapuetic Insemination  Partner or donor semen • IUI (intrauterine insemination): sperm placed directly into the uterus Egg Donation:  -More complicated procedure -There are less egg donors than sperm donors. Surrogate Parenting:  May supply uterus and egg and sperm from couple are usedMay supply reproductive system and male sperm is used Many ethical issues arise Assisted Reproductive Technology (ART) • In Vitro Fertilization (IVF): fertilization occurs outside the body and embryos transferred to the  uterus for implantation • Gamete Intrafallopian Transfer (GIFT): fertilization occurs inside the body, sperm and eggs  injected into fallopian tubes for fertilization • Zygote Intrafallopian Transfer (ZIFT) or tubal embryo transfer (TET): fertilization occurs outside  the body and embryo placed in fallopian tube Risks:  IVF used most of the time  Risk for fallopian tube implantation with GIFT and ZIFT Issues Related to Infertility Treatment • Influences on decision making – Social, cultural, and religious values – Difficulty of treatment – Probability of success – Financial concerns • Psychological Reactions: I am SORRY FOR YOUR LOSS!!!  • Guilt • Isolation • Depression • Stress on the relationship Cell Division • Mitosis: body cells replicate to yield two cells with the same genetic makeup as the parent cell • Meiosis: process by which germ cells divide and decrease their chromosomal number by half  (produces gametes)  – Each gamete contains 23 single chromosomes Conception -Preparation of the Female -Preparation of the Male -Fertilization Implantation: • Occurs 6-10 days after conception • Usually in the posterior fundal region Fetal Development & Nutrition during Pregnancy -You’re really pregnant for 40 weeks (10 months), 280 days.  -Length of pregnancy computed from the first day of the last menstrual period.  -Due date:  -Intrauterine Development:  >Ovum/preembryonic (days 1-14) > Embryo (2-8 weeks) (most critical)  >Fetus (9 weeks to delivery)   Estimating Date of Birth: all these mean the same thing, estimated due to last menstrual  period…   EDB (Estimated Date of Birth)   EDC (Estimated Date of Confinement)  EDD (Estimated Date of Delivery)  How do we calculate the due date?  Naegele’s Rule: Determine the first day of the last menstrual period, subtract 3 months, add 7 days and adjust year First day of the last menstrual period: June 1 then the due date would  be March 8th (adjust for the year) ex. July 1 (subtract 3 months) go back to April, add 7 days and that  will give you the estimated due date, adjust the year accordingly.  Amniotic Fluid: surrounds the baby in the bubble aka force field  -Cushions the embryo and fetus (gives the baby room for blows, more fluid, baby is protected)  -Controls Temperature -Promotes symmetrical growth: (little amniotic fluid causes less morph growth, otherwise  anomalies might develop)  -Prevents fetal adherence to the amnion (slippery so it won’t stick to the lining)  -Allows freedom of movement -Circulating volume at 10 weeks 30ml=1oz (don’t need to memorize)  -Circulating volume at 20 weeks 350 ml -Circulating volume at term 800-1000 ml= 1 L fluid  Umbilical Cord: there’s 3 vessels in the cord, AVA (2 arteries, 1 vein), the longer the cord, the  more the child would wrap around. Cord has Warton’s jelly and if it is compressed then you’re  cutting off it’s oxygen. If short cord, the baby can compress the cord themselves -Formed about the 5th week -Two Arteries carry deoxygenated blood from the embryo to be oxygenated by the placenta -One Vein returns oxygenated blood from the placenta to the embryo -At term ranges from 30-90cm long and 2cm wide -Shiny Shultz: smooth side, fetal side.  -The Maternal side is more wrinkly.  -Inspect to see if there’s no pieces missing, if there is there could be infection or hemorrhage.  All Major systems present in their basic form Dramatic growth and refinement of structures occurs Teratogens (any harmful substance for baby) less likely to damage already formed structures  by 8 weeks.  CNS vulnerable throughout entire pregnancy  Viability: Can this child survive outside the womb.   The answer is Viability possible at 20 weeks although survival more likely after 24  weeks  A 24 week gestation baby is about the size of a beanie baby and weighs in at about 1.5 lbs  between 20-24 weeks depends of doctor if baby is viable or not. KNOW Foramen Ovale, Ductus venosus, Ductus arteriosus, You will hear murmurs normally for the first 24 hours and if structures are not closed. In mean  time they may have bluish color, around lips trunks NEVER NORMAL.  Respiratory System: surfactant (no surfactant = makes stiff, babies younger than 24 mos have 0 surfactant)  White males are the most premature (cannot reach surfactant much)   4th-17th week larynx, trachea, bronchi, and lung buds form (Don’t worry about this)   16th-24th week bronchi and terminal bronchioles enlarge, vascular structures and  primitive alveoli are formed  24th-birth more alveoli form  Type I and II alveolar cells produce surfactant which is present in adequate  amounts for survival by 32 weeks  Survanta is a manmade chemical that mimics surfactant that is poured down  to lungs (done in NICU)  Determining Fetal Lung Maturity  Lecithin/Sphingomyelin (L/S) present in surfactant: how much surfactant was floating in amniotic fluid.   Surfactant is detectable at approx. 21 weeks  L/S present in a ratio of 2:1 in mature fetal lungs, if less than 1:1 they will send you  home because they know the baby’s lungs are not developed. They increase the stakes if pt is diabetic (3:1) because babies that have diabetic moms produce surfactant a  little slower.   Specimen obtained from amniotic fluid via amniocentesis  In conditions that slow down fetal lung maturity a ratio of 3:1 is necessary. PG  (phosphatidylglycerol) test may also be done.  Acceleration of fetal lung maturity (due to stress in the womb)   Decreased maternal blood flow (HTN, placental dysfunction, infection, stress,  drug use, corticosteroid use, (betamethasone (corticosteroid) IM injections  given to women in PTL to accelerate fetal lung maturation) these babies come  out better statistically when exposed to stressors. Betamethasone makes  babies produce surfactant quicker.   The longer I can give it to them, the better the baby will turn out.  Betamethasone cannot be given to someone who has active infection,  cautiously use with DM pt.   Deceleration of fetal lung maturity  Preexisting DM or Gestational DM  Chronic glomerulonephritis (kidney disease)  Renal System:   5th week kidneys form  9th week begin to function  Excretes urine to form majority of amniotic fluid   Not an organ of excretion until after birth  Oligohydramnios (too little amniotic fluid) indicative of renal dysfunction  polyhydramnios (too much amniotic fluid) indicative mom is probably a diabetic, uterus probably can’t hold all that fluid because she probably could go into premature labor or cause infection..   Sensory Awareness: (don’t need to know the numbers)  20 weeks: distinguishes taste  24 weeks: responds to sound  Fetus reacts to temperature changes  Fetus can see  Eyelids open in the third trimester.(28-30 weeks)  Reproductive and Musculoskeletal Systems  7th week sex differentiation occurs  9th week distinguishing characteristics appear and are fully differentiated by the 12th week, although difficult to see by ultrasound until after 20th week gestation.  Bones and muscles form during embryonic development  Generally 18-20 weeks, you can check ultra sound to see gender.  Integumentary and Immunologic Systems  4th week skin development begins  Vernix Caseosa (thick, white, cheesy substance) also tells if full term or pre term  baby: covers and protects skin and is thickest at 24 weeks and thinnest at term.   Lanugo appears at 12 weeks (fine downy hair) and thins and disappears by term  gestation  IgG crosses placenta to provide passive immunity  Fetus produces IgM by the end of the first trimester  IgA not produced by fetus but is present in colostrum-beginning breast milk loaded  with antibodies.  Quickening  16-20th week “Quickening” occurs (mother can feel baby moving or fluttering)  Sometimes occurs earlier in multipara (had been pregnant more than 1x, feel  at 16 weeks) or later in primipara (first time pregnant in her life, feel usually  20th week.   movement the mother feels, earliest at the 4th month.   steady movement: 32 weeks, if no steady movement = go to ER ASAP!  Nongenetic Factors Influencing Development  Congenital: condition present at birth  Congenital disorders are multi-factoral defects, may be inherited, may be caused by  environmental factors, or by inadequate maternal nutrition.  Daily Energy Intake: check ppt table Nutrition for Childbearing: Weight Gain  An important determinant of fetal growth  Poor maternal weight gain associated with preterm labor and increased risk of  newborn mortality and morbidity, Small for Gestational Age (SGA)  Excessive weight gain associated with macrosomia, prolonged labor, birth trauma, and Cesarean birth  Obesity during pregnancy associated with: gestational diabetes, preeclampsia,  cesarean birth, and Large for Gestational Age (LGA) infants  IUGR: smokers  Any kid over 9 lb is LGA.. the bigger the kid, the harder it is to get the kid out. Risk of  hemorrhage, higher BP for mom..  Recommendations for Total Weight Gain: MEMORIZE   25-35 lbs. for those with normal BMI, or normal weight for height  Less for obese  More for underweight  Pattern: 2-4 lbs. during first trimester, second and third 0.5-1 lb. per week BMI Low BMI <18.5 Rec: weight gain 28-40 lbs. Normal BMI 18.5-24.9 25-35 lbs. High BMI 25-29.9 15-25 lbs. Obese BMI > 30 11-20 lbs.

 How do we calculate the due date?

• What does her uterus look like?

– Motility: how well does it move?

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Iron  Iron needed for RBC production in mom and baby  Physiologic anemia of pregnancy: increase in plasma dilutes RBC’s which results in a  decreased concentration of Hgb and Hct (false anemia)   Iron Deficiency Anemia common in 10% of American women  Iron supplements recommended starting at 12 weeks gestation  Iron should be taken on an empty stomach with a beverage high in ascorbic acid such  as orange juice to enhance absorption (more bang for the buck!)   Iron supplementation not for everyone (high levels of iron assoc w/ GDM Preconception: Folic Acid   Folic Acid or Folate is important in adequate amounts prior to conception (400 mcg)  Prevents Neural Tube Defects (cleft lip, palate, spinal bifida   Found in green leafy veggies, broccoli, legumes, etc. (pg. 354) the earlier you take it, the better. Make sure folic acid levels are up to par if you’re  trying to get pregnant before.  Food Safety:  Video: Food Safety for Moms-to-Be  Methyl Mercury Poisoning: if you cook fish, mercury content is still there.  Common foods are: swordfish, tuna. Once or twice tops/week. Sushi is never  allowed during pregnancy  Listeriosis: soft or undercooked meats/lunch, hot dogs meats esp first  trimester. Toxoplasmosis: kitty litter cannot be changed by pregnant women.  Substance Abuse: Smoking, Caffeine, Alcohol, Drugs WIC (Women, Infants & Children)  The WIC target population are low-income, nutritionally at risk:   Pregnant and Lactating women  Infants and children   Benefits  Supplemental nutritious foods  Nutrition education and counseling at WIC clinics  Screening and referrals to other health, welfare and social services   Encourages breastfeeding Nutrition Related Discomforts of Pregnancy  Nausea and Vomiting  Eat dry starchy foods on awakening (crackers)  Separate fluids from solids (don’t eat and drink at the same time)   Eat protein rich food before bed (keeps more even blood sugar, easier to digest and metabolize)   Avoid spicy and high fat foods  Constipation  Eat high fiber foods  Drink plenty of fluids  Physical Activity  Pyrosis (heart burn)  Eat small frequent meals  Don’t lie down right after eating Cultural Influences: IMPORTANT!!! ~   When providing nutrition education be sure to address cultural needs  Fit recommendations to cultural preferences  See pg. 363  Nursing Care During Pregnancy:   Objectives  Explain the expected maternal anatomic and physiologic adaptations to pregnancy for  each body system  Differentiate between presumptive, probable, and positive signs of pregnancy.  Identify the maternal hormones produced during pregnancy, their target organs, and  their major effects on pregnancy. Pregnancy Tests:  -Human Chorionic Gonadotropin (hCG) is the earliest biochemical marker of pregnancy -Produced by the embryo soon after conception and later by the placenta -Can be found in maternal blood and urine -hCG level increases until it peaks at about 60-70 days of gestationSigns of Pregnancy: Presumptive and Probable Uterus:  Slides:  -Braxton Hicks: (4th month) : uncomfortable, they do nothing to open cervix, not preparing your body to get rid of baby.  - Increased blood flow as pregnancy advances.  -Hegar’s Sign: softening of lower uterine segment  -Uterine Souffle: blowing sound of maternal blood (mom’s HR is what you hear)  -Funic Souffle: sound of fetal blood flow  - Ballottment: palpate a floating structure  -Quickening: fetal movement, primaparia: feels 20 weeks, multi: feel around 16 weeks.  Cervix:  -Chadwick’s Sign: Becomes congested with blood. (PROBABLE SIGN) -Friable: fragile, easy to rip.  -Goodell’s signs (softening of the cervix) (PROBABLE SIGN) -Mucous plug: protects from germs getting in.  Vagina & Vulva:  -Increased vaginal vascularity causes bluish color (Chadwicks)  -Leukorrhea present: normal increase in vaginal discharge, odorless, due to hormonal changes, you worry if odor, blood stained or irritating.  -Vaginal mucosa thickens and rugae prominent  -Increased amounts of glycogen cause acidic environment that protects from bacteria but a  good medium for yeast. -Vulva and perineum most pliable due to increased vascularity.  Ovaries:  -Corpus luteum secretes progesterone for first 14 weeks, placenta secretes it thereafter  -Progesterone must be present in adequate amounts from the earliest stages of pregnancy to  maintain the pregnancy  -Helps to suppress uterine cx  -Helps to prevent tissue rejection of the fetus  Breast   Estrogen stimulates growth of mammary ductal tissue  Progesterone promotes growth of lobules, lobes, and alveoli  Become highly vascular  Nipples increase in size  Increased alveolar pigmentation  Montgomery Tubercles  Montgomery tubercles- hypertrophy of the sebaceous glands in the areolae; secrete  antiinfective substances to help protect nipples during breastfeeding  Changes in Reproductive Systems: Cardiovascular ∙ Heart size: slightly increases ∙ BP: remains stable or slight decrease ∙ Blood volume: 40-50% increase ∙ Cardiac output: 30-50% increase  ∙ Plasma volume increase: pseudoanemia of pregnancy false anemia  ∙ Clotting factors increase (protectant mechanism), which can risk for DVT, PE, MI  ∙ Supine Hypotension: never ever put pregnant women flat on the back!  ∙ Varicose Veins: when weight compresses blood flow, you see it in perineum and labia.  ∙ Maternal body adapts to protect woman normal functioning, meet the metabolic  demands in pregnancy and provide fetal development ∙ Splitting in S1, S2, and S3 easily heard after 20wks.  *LEFT SIDE IS BEST TO PROMOTE CIRCULATION  Respiratory:  ∙ O2 consumption increases by 20-40% ∙ RR remains unchanged (slight increase- 3rd trimester) ∙ Tidal volume and minute volume increase by 33% ∙ Progesterone-increasing ventilation by 40% in first trimester; carbon dioxide  sensitivity; increased risk of resp. infection to become more serious  ∙ Estrogen- elevated levels relax the ligaments of the rib cage, permitting chest  expansion; Upper resp Tract more vascular, capillaries become engorged creating  congestion in nose GI  -Nausea common -Estrogen causes hyperemia of gums and mouth -Ptyalism: increased salivation -Reduced lower esophageal sphincter tone: heartburn -Constipation -Hemorrhoids -Occasionally cholestasis (accumulation of bile; can result in severe itching with or without  jaundice) -Gallbladder (stores bile)-progesterone causes tissue to relax, release of bile slows leading to  gallstones Urinary: Bladder  Frequency and urgency of urination (without dysuria): Hormonal influences: 1st trimester   Increase in uterine size: 1st and 3rd trimester  Bladder capacity doubles by term as the bladder relaxes  Bladder more susceptible to trauma and infection   Glycosuria and mild spilling of protein normal  Pay close attention to s/s bladder infection b/c could lead to preterm labor!: Flow of  urine through ureters partially obstructed by uterus  Dilation helps flow  Stasis can lead to bacterial growth Integumentary  >Increased metabolic rate causes sweating and the feeling of warmth >Hyperpigmentation: estrogen, progesterone, and melanocyte-stimulating hormone  (melasma, chloasma, mask of pregnancy, linea alba >Increased vascularity may cause angiomas on face >Striae gravidarum: STRETCH MARKS >Hair and nail growth increases >Linea alba-pigmented line on abdomen, running midline top of fundus to symphysis pubis  (around 3rd month) >Mask of pregnancy-brown and blotchy; found on face..nose/cheeks/forehead >Striae gravidarum=50-80% of woman 2nd half of pregnancy; stretch marks Musculoskeletal System: Increased risk of falling   Postural changes  Due to change in center of gravity  Lordosis- backache  Widening of symphysis pubis  Allows more room for head to deliver  Relaxin and progesterone  Abdominal Wall weaken and may separate Neurological System:  -Sensory changes in legs caused by compression of pelvic nerves -Dorsolumbar lordosis may cause pain related to nerve traction or compression -Edema may cause carpal tunnel syndrome -Numb hands caused by stooped shoulder stance -Light-headedness or faintness usually caused by CV changes -Muscle cramps may be caused by hypocalcemia or hypomagnesemia Endocrine  Pituritary  FSH and LH supressed  Prolactin released  Thyroid gland  Enlarges due to increased vascularity  Hormones increase, but level off at end of first trimester  Parathyroid Calcitonin decreased to allow for calcium needs during pregnancy  Pancreas Hypoglycemia common Tissue sensitivity to insulin decreases r/t hPL  Adrenals Aldosterone and cortisol levels elevate Prenatal Care:   Financial: No medical insurance, Medicaid process lengthy and confusing  Systemic: health care institution (timing of appointments, child care issues, travel)  Attitudinal: “I am not sick, so why see a doctor,” “women have been doing this for  centuries”Preconception Visit  Complete history and examination  Screening for rubella, varicella, and hepatitis B  Folic acid needs before and during pregnancy  STIs: G/C, syphyllis, HIV Initial Prenatal Visit:  ∙ Verify pregnancy ∙ Evaluate physical health ∙ Assess growth of fetus ∙ Establish baseline data ∙ Establish trust ∙ Evaluate psychosocial needs ∙ Negotiate plan of care Histories  Obstetric: GTPAL  Gravida, para  Menstrual History  EDD: Nagele’s Rule, gestational wheel  Contraceptive History  Medical and Surgical History  Family History  Partner’s Health History  Psychosocial History GTPAL:   Gravida: number of pregnancies  Term: number of pregnancies carried to 37 weeks, 0 days gestation (“early” vs “full  term”)  Preterm: number of pregnancies carried to at least 20 weeks gestation, but delivered  before 37 weeks (“preterm” vs “late preterm”) 20 weeks and 0 days, 36 weeks and 6 days = PRETERM  Abortion: number of pregnancies that ended before 20 weeks gestation, either  spontaneously or electively -elective and therapeutic: she made decision to abort baby for whatever reason.  -spontaneous: SAB = miscarriage   Living: number of living children (how many came out alive?)  Initial Physical Exam  Vital Signs  Cardiovascular  Venous congestion  Edema  Musculoskeletal  Posture and gait  Height and weight Pelvic Measurements  Abdomen  Skin  Neurologic: DTR  Endocrine: Thyroid  GI: mouth, intestine  Urinary: protein, glucose, ketones, bacteria  Reproductive: breasts, internal and external reproductive  Labs: see pg. 312, normal ranges- p. 292 Subsequent Assessments o Vital Signs o Weight o Urinalysis o Fundal Height- Fundal Height-start after week 16 o Leopold’s maneuvers o FHR: about 10 weeks +  o Fetal Activity- 16 weeks multi, 2o weeks – 1st pregnancy  o Signs of Labor o Ultrasound screen at 12-20 weeks, closer to 20.  o Glucose screen at 24-28 weeks, because this is when someone typically becomes  diabetic.  o Isoimmunization- what her Rh factor is.  o Pelvic exam during last 4 weeks of pregnancy: 1st visit, then 35 weeks on.

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