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Maternal and Child Health Nursing Pregnancy

MATERNAL and CHILD HEALTH NURSING PREGNANCY Lecturer: Mark Fredderick R. Abejo RN, MAN

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Fertilization to Conception  Fertilization: the union of the ovum & sperm. The start of Mitotic cell division &fetal sex determination. > Primary oocyte (immature ovum) contains Diploid number of chromosomes (46). > One oocyte contains a haploid (23) number of chromosomes after division. > Gamete (mature ovum): is a cell or ovum that has undergone Maturation & will be ready for fertilization. > One gamete carries 23 chromosomes. > A sperm carries 2 types of sex chromosomes. X & Y. > 400 million sperm cells in one ejaculation. > Functional Life of spermatozoa is 48 hours > XX= female, XY= male.

Morula

Process of Fertilization: After ovulation ovum will be expelled from the Graafian follicles ovum will be surrounded byZona Pellucida(mucopolysaccharide fluid) & a circle of cells (Corona Radiata) which increases the bulk of the Ovum expelled from the Fallopian Tube by the Fimbriae (infundibulum). Sperms move by flagella & Penetrate the & dissolve the cell wall of the ovum by releasing a proteolytic enzyme ( Hyaluronidase) After penetration Fusion will result to Zygote. Zygote migrate for 4 days in the body of the uterus (Mitosis will take place-Cleavage formation will begin) After 16-50 cell formation from mitosis, a mulberry & Bumpy appearance will follow morula after 3-4 days, the structure will be ball like in appearance which will be called Blastocyst. Cells in the outer ring are called Trophoblast (later it forms the placenta, responsible for the dev’t of placenta & fetal membrane; Cells in the inner ring are called Erythroblast cells (which will be the embryo).

Terms to remember: Ovum: From ovulation to fertilization Zygote: From fertilization to implantation Embryo: From implantation to 5-8 weeks. Fetus:From 5-8 weeks until term The ovum is said to be viable for 24-36 hours. Sodium Bicarbonate- the frequent medication to alter the vaginal ph, decrease the acidity of the vagina so as to INCREASE THE MOTILITY OF THE SPERM.

Pregnancy

Abejo

and cell layers develop. cavities. Implantation occurs at the end of the 1st week after fertilization. 2. During the 2nd week (14 days after implantation). CONTAINS 2 ARTERIES & 1 VEIN. Chorionic Villi: finger like projections from the chorion. lanugo from fetal skin & epithelial cells. Amniotic Fluid: surrounds the embryo. Amnion: shiny membrane on the 2nd week of Embryonic Development & encloses the Amniotic Cavity 2. may indicate infection. notochord. Chorion: Outer membrane that supports the sac of the amniotic fluid. clear. Protects the umbilical cord from pressure. Umbilical Cord: 21 inches in length & 2 cm in thickness. & give the placenta the shiny appearance. Polyhydramniosmore than 2000 ml. circulatory communication of the fetus to the mother. Oligohydramniosless than 300 ml. with white tiny specks Dark amber or yellow: Ominous sign of presence of Bilirubin. Early during the 4th week (28 days after implantation).025 Normal Amount: 500 – 1000 ml. hemolytic disease Port Wine Colored: Abruptio Placenta Greenish: Meconium Stained / FETAL DISTRESS: always go for Cesarian Section! Also if ph is less than 7. the embryonic disk evolves into three layers. implantation progresses and two germ layers.005 – 1. This is the place where gases. cellular differentiation and organization occur. b. observe for Down syndrome & congenital defects Functions of Amniotic Fluid: a. when the blastocyst attaches to the endometrium.Maternal and Child Health Nursing Pregnancy Fetal Membranes Fetal Membranes: membranes that surround the fetus. Amniotic Fluid Colors: Normal color: transparent. Protects the fetus from changes in the temperature & cushion against injury. During the 3rd week of development (21 days after implantation). Fertilization Cycle Pregnancy Abejo . Covered by a gelatinous mucopolysaccharide called Whartons jelly. contains fetal urine. Ph is 7. and allantois — form. and three new structures — the primitive streak.2 If with odor: deliver within 24 hours. the fetus drinks & breaths the fluid into the lungs. Specific Gravity: 1. 2 Layers: 1. nutrients and waste products between the maternal & fetal blood takes place.

darker areola.a brown line running from the umbilicus to the symphysis pubis Stretch marks will eventually fade to a silvery white color. bones. movement felt by the Detectable 10 days after the missed period examiner. Increase size of the uterus The most objective sign of + Pregnancy Test pregnancy is fetal > Secretion of HCG in the urine (Frog Test). bladder & urethra Pregnancy Abejo . embryolast) Implants complete w/n 7-10 days THREE PREGNANCY SIGNS & SYMPTOMS PRESUMPTIVE Amenorrhea Nausea/Vomiting Breast sensitivity and increased size Fatigue Abdominal enlargement Skin pigmentation changes (Melasma chloasma. The fetal outline becomes palpable and the fetus is highly mobile between 28 and 31 weeks. Braxton Hicks contractions increase in frequency and intensity between 32 and 35 weeks. Urinary Frequency Melasma . Fetal movements palpated Rationale: due to increase vascularity & blood by the provider by week vessel engorgement. cartillage Lining of the GI tract. Ultrasound: 6 weeks can auscultate the fetal heart. Respiratory Tract. Breast changes. Reproductive. circulatory & upper Urinary system. PROBABLE Pregnancy test (presence of HCG) Softening of the uterine isthmus (Hegar’s sign) Cervical softening (Goodell’s sign) POSITIVE Auscultation of fetal heart by week 8 Ultrasound imaging of fetal heart motion Braxton-Hicks contractions by week 7 Ballotment: bouncing of the fetus in the amniotic fluid against the Ultrasound examiners hand. travels to the uterus    IMPLANTATION Morula (after 3-4 days implantation) Blastocyst (trophoblast. about 24-48 hrs. divides. . but it is highly unlikely that they will completely disappear. During the 16th-20th week.increase in fullness. 20. Chadwick’s sign is a bluish coloring of the vaginal mucosal that occurs as early as 6 weeks gestation.Maternal and Child Health Nursing Pregnancy PRE-FERTILIZATION ACTIVITIES    Ovum moves to amulla of fallopian tubes Capacitation Acrosome reaction CONCEPTION   Zona reaction Zygote (fertilized ovum. The fetal heartbeat typically can be heard and fetal rebound is possible between 18 and 22 weeks. Quickening: first fetal mov’t. linea nigra. mucus membranes. anus & mouth Connective Tissue. cleavage divides. FETAL DEVELOPMENT ORIGIN OF BODY TISSUE Tissue Layer Ectoderm Mesoderm Endoderm Body Portion Formed Nervous system. confirmation of gestational sac by Braxton Hicks Contractions: painless week 6 contractions felt for 20-30 minutes occurs on the 16th week.

Length 280-320 mm. Eyebrows and scalp hair is present. 21-25 WEEKS… OLD MAN’s FACE Length 200-240 mm. Liver is already pancreas functioning. skin. In length and weighs approximately 260-460 gms. Head is erected. REM begins Eyebrows and fingernails develop. genitourinary system. Placenta dev’t. /30-34 weeks 9 mos. If the mother is treated before 18th week. ears. nose appear Cardiovascular system functioning. Lecithin. Heartbeat is present Nasal septum and palate close Fingerprints are set  LANUGO APPEARS IN THE BODY Fetus is 150-190 mm. Heart is audible in a Doppler ( 11th week) Fetus swallows. Lanugo covers entire body. the baby will most likely not be affected. Production of lung surfactants. Length 250-275. lower limbs are well developed. Heart sounds in the stethoscope Can be heard ( 17. Kidneys able to secrete. Fetal circulation is complete. and lungs are formed Rudiments of eyes. Assumes the delivery position. neonate may survive. /26-29 weeks 8 mos. beginning of heart circulation. /17-20 weeks 6 mos. Wt. Increased chance of survival. /13-16 weeks CVS done (8 12 weeks) every organ present. Skin appears wrinkled and pink to red.  LANUGO DISAPPEARS. If born. Bones are fully developed.  Aware of sounds outside the body. Heart sounds are perceptible by auscultation. Length 330-360 mm. /35-37 weeks Pregnancy . Face and body has a loose wrinkled appearance because of subcutaneous fat deposit. Placental transport of substances ( 5 weeks) The fetus is 27-31 mm and weighs 2-4 grams Fetus s markedly bent Head is disproportionately large due to brain development Centers of bone begin to ossify Ganglionic cells (5th to 12th weeks) Placenta and meconium are present. Has the ability to hear. /21-25 weeks 7 mos.  Quickening felt by a mother. Head greatly enlarged Average length is 50-55 mm and weighs 45 gms.  Increase Development.Maternal and Child Health Nursing Pregnancy 1 mo/ 4 weeks  2 mo/ 5-8 weeks Embryo is 4-5 mm length Trophoblasts embedded in deciduas Foundations for nervous system. External genitalia show definite characteristics. Skeleton begins to develop. Brown Fats begin to form. 94-140 mm length and weighs 97-200 gms.Sphingomyelin (L/S ratio is already 2:1)  Brains fully developed. Ganglionic cells  SEX IS VISUALLY RECOGNIZABLE. With nails. Body is usually lump and lanugo disappears Nails reach fingertip edge Amniotic fluid decreases.  VERNIX COVERS THE ENTIRE BODY. weight 2700-3400 gms./9-12 wks 4 mos. weight 910-1500 gms.20 weeks) NOTE: There is a placental barrier to syphilis until the 18th week of pregnancy. Vernix caseosa covers skin. Skin red Rhythmic breathing occurs Pupillary membrane disappears from eyes. with facial features 3 mos. Toenails become visible Steady weight gain occurs Vigorous fetal movement occurs. Rudimentary kidneys secrete urine. 495-910 gms. Abejo  5 mos. Fetus often survives if born prematurely Brain develops rapidly. weight 1700-2500 gms.  Heartbeat can be heard in the fetoscope ( 18 weeks—20 weeks). Good chance of survival. heart beginning to beat. bones. Passive Antibody transfer ( placental immunoglobulin G) Sustained weight gain occurs. Fingers and toes are distinct. Sole of the foot have already  creases.

Duchenne muscular dystrophy & hemophilia. closes at birth. DNA & biochemical abnormalities. .. specifically there is already exchange of nutrients with the maternal circulation in the chorionic villi.) It CONTAINS a mixture of arterial & venous blood . Premature rupture of the membranes  After an Rh-negative patient undergoes amniocentesis or CVS. Risk of Abortion 2. fetal blood is already is circulating. (16th. Testes are in scrotum.  Chorionic Villi Sampling: removal of a small piece of Chorionic villi sampling to detect the ff: fetal chromosome.Maternal and Child Health Nursing Pregnancy 10 mos.7 days compared to 20-28 days for an amniocentesis. thallasemia. A small amount of spotting is normal for the 1st 24-48 hours. Use of sound and returning echo patterns to identify intrabody structures.Ductus Venosus (by pass the liver. Laboratory results are obtained in 1 . a.Foramen Ovale : between right & left atrium DUE TO NON-FUNCTIONING LIVER: ----. uterine anomalies and adnexal masses. ----. chest is prominent Eyes are uniformly slate colored Bones of skull are ossified and are nearly together at sutures. Disadvantages: 1. safe for fetus (no ionizing radiation) Abejo ULTRASOUND Pregnancy . > Arteries carry UNOXYGENATED BLOOD. to prevent Rh sesnsitization.Ductus arteriousus (between pulmonary artery & Aorta. Use adjunct to amniocentesis. OPENS AT BIRTH & CLOSES 24 –48 hours after delivery. anomalies.  Most common indication: advance maternal age: increases risk of chromosomal damage from aging of oocyte. Can detect the ff. Maternal & Fetal Diagnostic Test CHORIONIC VILLI SAMPLING Earliest test possible on fetal cells. Fetal Circulation As early as 3rd week of intra-uterine life. sample obtained by slender catheter passed through cervix to implantation site. > Fetal Circulation Bypass: Why: DUE TO NON-FUNCTIONING LUNGS: ----. later uses include assessment of fetal viability. enzyme.  The patient does not require complete bed rest after CVS---SHE SHOULD REFRAIN FROM SEXUAL INTERCOURSE AND PHYSICAL ACTIVITY FOR 48 hours. useful early in pregnancy to identify gestational sacs. Embryo-fetal/placental damage 4. trisomy 21. an umbilical vein that carries High oxygen from the placenta. Genetic Defects: Cystic fibrosis. Skin is smooth. Infection 3. VEINS carry OXYGENATED BLOOD. Weight 3400-3600 gms. Tay Sachs. the nurse should administer Rh (D) immune globulin (RhoGAM). growth patterns. / 38-40 weeks  Length 360 mm. Spontaneous abortion 5. fluid volume. an antigen antibody immunologic reaction that sometimes occurs when an Rh negative mother carries an Rh + fetus.20th week of gestation). sickle cell anemia.  Greatest Advantage over Amniocentesis: PERFORMED DURING THE FIRST TRIMESTER. Performed between the 8th – 11th weeks of gestation.

Amniotic fluid embolism  CALL THE PHYSICIAN FOR THE FF: Chills.Non-invasive procedure with high frequency sound waves to obtain outline of the fetus. gestational age. Amniocentesis: invasive procedure for amniotic fluid analysis. fever. placenta & uterine cavities and to confirm gestational age & EDD. leakage of fluid. The client should be supine during the procedure. then. used to identify chromosomal aberration. sex of fetus. needle insertion in a 20-22 gauge spinal needle. COMMON METHOD IN LOCATING THE PRECISE POSITION OF THE FETUS & PLACENTA BEFORE AMNIOCENTESIS. AMNIOCENTESIS Location and aspiration of amniotic fluid for examination. & fetal lung maturity.  NORMAL L/S RATIO (lecithin/sphingomyelin): 2:1 = normal fetal lung maturity ratio  Most important factor affecting Amniocentesis: NEEDLE INSERTION-because of the risk of puncture or damage to the placenta.  Typically performed on the 3rd trimester to assess LECITHIN-SPHINGOMYELIN RATIO IN THE AMNIOTIC FLUID (this ratio indicates fetal lung maturity). withdrawing amniotic fluid. Procedure: Ultrasound 1st: the rationale: to locate the Placenta. THE BEST PREGNANCIES done 18-40 weeks for fetal TEST FOR ECTOPIC . NEEDS A FULL BLADDER TO OBTAIN A BETTER IMAGE (drink a full glass every 15 minutes beginning an hour & half the procedure) . promote venous return. levels of alpha-fetoprotein and other chemicals indicative of neural tube defects and inborn error of metabolism. Infection 3.  PLACE A FOLDED TOWEL ON HER RIGHT BUTTOCKS TO TIP HER SLIGHTLY TO THE LEFT & MOVE THE UTERUS OFF THE VENA CAVA TO PREVENT SUPINE HYPOTENSION SYNDROME. decrease fetal movement or uterine contractions. abruptio placenta 5. possible after the 14th week when sufficient amounts are present. bladder & uterine arteries. The patient MUST EMPTY THE BLADDER TO REDUCE THE SIZE OF THE BLADDER. . Vital signs are assessed every 15 minutes. fetus.V.Maternal and Child Health Nursing Pregnancy Ultrasound: abnormalities. Rh immunization 4. I. umbilical cord.  Disadvantages: Risk for: 1.  ABDOMINAL PREP IS DONE. Position: Supine. Pregnancy Abejo . RH factor. she should be placed on her left side to avoid supine hypotension. which is commonly delayed in a  diabetic client. anesthesia isn't given for amniocentesis. Cesarean Delivery  should not be done. Maternal hemorrhage 2. afterward. unless the fetal lungs are matured. and ensure adequate cardiac output.

mother should notify care giver immediately of abrupt change or no movement. A collection of data on fetal breathing movements. drops after 36 weeks gestation. the monitor records a mark at each point of fetal movement.Observation of fetal heart rate related to fetal movement. PREPARATION: Patient should eat snacks. reactive heart rate and amniotic fluid volume. Level-high early in pregnancy. body movements. anencephaly & the absence of ventral abdominal wall. uses amniotic fluid. ratio is 2:1 indicative of mature levels. In conjunction with the L/S ratio. diabetes and Pre-eclampsia. hydrocephaluscan be reduced through increase folic acid0. 30-60 minutes each time. Maternal serum screens for open neural tube defects.4 mg/day in the 1st trimester) > Maternal blood sampling between 16-20 weeks. Cord blood aspirated and tested. Used in second and third trimesters. Maybe done in laboratory. premature delivery. fetal well being. the patient is monitored for uterine contractions. During this period. toxemia & fetal distress & Rh immunization. should feel 5-6 movements per counting time. Non-Stress Test – accelerations in heart rate accompany normal fetal movement. non-invasive Tocodynamometer records fetal movements and Doppler ultrasound measures . Found in amniotic fluid after 35 weeks. not used in early pregnancy to avoid possibility of causing damage to fetus and mother. fetal heart rate changes and leakage of amniotic fluid from the puncture site. given after the 32nd week. it contributes to increased reliability of fetal lung maturity testing. LOW: chromosomal defects (Downs syndrome) HIGH: (greater than 10 mg/dl) Neural tube defects. At 3536 weeks. The yellow color is the result of fetal anemia and bilirubin. the patient isn’t ambulated. GI tract and liver. it can be predicted that respiratory distresss will not occur. X-RAY Can be used late in pregnancy (after ossification of fetal bones) to confirm position and presentation. evaluates fetal heart rate in response to fetal movement especially for: Maternal Problems such as chronic hypertension. Indicated for: assess placental function & oxygenation. uses amniotic fluid. ALPHA-FETOPROTEIN SCREENING L/S RATIO PHOSPHATIDYL GLCEROL CREATININE LEVEL BILIRUBIN FETAL MOVEMENT COUNT PERCUTANEOUS UMBILICAL BLOOD SAMPLING BIOPHYSICAL PROFILE ELECTRONIC MONITORING A.Maternal and Child Health Nursing Pregnancy After amniocentesis. Phosphatidyl Glycerol (PG): when present in the amniotic fluid. Pregnancy Abejo . muscle tone. or RDS will not occur. It is a glucoprote in produced by fetal yolk sac. Alpha Fetoprotein:  PRINCIPAL SCREENING TEST DOR THE DETECTION OF NEURAL TUBE DEFECTS (spina bifida. Uses ultrasound to locate umbilical cord. Uses amniotic fluid to ascertain fetal lung maturity through measurement of presence and amounts of the lung surfactants lecithin and sphingomyelin. Teach mother to count 2-3 times daily. Position: Semi-Fowlers or left lateral positions the mother may ask tom press the button every time she feels fetal movements. Estimates fetal renal maturity and function. Fetal well-being. Test done between 16 and 18 weeks gestation.

synthesized by the placenta & adrenal gland of the fetus which secreted by the ovaries Rh Incompatibility Test: Purpose: to discover presence of antibodies present in Rh-negative mother’s blood > Test will confirm the diagnosis for Hemolytic Disease in the Newborn.  Collect a 24-hour urine specimen or serum blood levels. Contraction Stress Test (CST) – based on the principle that healthy fetus can withstand decreased oxygen during contraction but compromised fetus cannot.5 Amniotic fluid: PH: 7. PREPARATION: Woman in semi-Fowler’s or side-lying position. Abnormal: ―Positive Window‖: (+) LATE DECELERATIONS OF FHR with three contractions a 10 minute interval. Interpretations: POSITIVE RESULT: Late decelerations with at least 50% of contractions. NEGATIVE RESULTS: No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in 10 minutes period. Monitor for post-test labor onset. Indicates Uteroplacental Insufficiency.  High Estriol: Good placental function  Low Estriol: Fetal hypoxia Estriol: estrogenic hormone. Normal: ―Negative Window‖: (-) LATE DECELERATIONS OF FHR with three contractions a 10m minute interval Normal and known as “Negative window Laboratory Studies 1. Mothers reveal antibodies as a result of previous transfusion or pregnancy.  Rh (D) & D negative who hasn’t formed antibodies should receive Rhogam at 28 weeks gestation or after 72 hours after delivery.  Nitrazine Test: use of nitrazin strip to detect the presence of amniotic fluid. Indirect Coomb’s Test: women who have Rh negative have this test done to determine if they have antibodies to the factor present. The doctor will order an Oxytocin Test AFTER the patient has non-reactive test. Estriol excretion: measures placental functioning through urine test.2 or more FHR accelerations of 15 seconds over a 20 minutes interval and return of FHR to normal baseline. Placental Grade Interpretation: Fetal score of 8 – 10: normal fetal well-being Fetal score of 4 – 6: fetal distress Pregnancy Abejo .5. Contraindicated for history of PRE-TERM LABOR. Mammary stimulation Test or Breast Stimulation Exam or Nipple Stimulated CST – non-invasive b.  Biophysical Profile : surveillance of fetal well being base on 5 categories: 1. Response of the fetus to induced uterine contractions as an INDICATOR OF UTEROPLACENTAL & FETAL PHYSIOLOGICAL INTEGRITY.2 – 7. Reactive (normal): indicates a fetal fetus  Greater than 15 beats per minute. B.5. Vaginal Secretions: PH: 4. TYPES: a.5 (turns the yellow Nitrazine blue gray. Non-Reactive (Abnormal): No fetal movement occurs or there is short-term fetal heart rate variability (less than 6 beats per minute). NOTE: COMMONLY PERFORMED ON DIABETIC PATIENTS BECAUSE OF THE INCREASE RISK FOR STILL BIRTH. Fetal tone 3. Fetal heart reactivity 5. Oxytocin Challenge test Indications: ALL PREGNANCIES AFTER 28 WEEKS WITH HIGH RISK CLIENTS. 2. Potential risks to the fetus. FAVORABLE RESULTS: . Notify the physician or health care provider if FEWER THAN 3 KICKS.determines presence of maternal antibodies attached to the baby’s cell. 2. Types: 1. blue green – Ruptured Membranes)  Kicks count: fetal movement counting mother sits quietly on the LEFT SIDE for 1 hour after meals & count fetal kicks for 30 minutes. Repeated 28 weeks pregnancy. Abnormal and known as “Positive window”.Maternal and Child Health Nursing Pregnancy RESULTS: 1. Direct Coomb’s test: tests for newborns cord blood. Amniotic fluid 4. Fetal breath mov’t 2. which may necessitate to C-section.occur with fetal movement in a 10 or 20 minute period.