WEEK 1-2 FRAMEWORK OF MCN - REPRODUCTIVE SYTEM – HUMAN SEXUALITY
Mercer’s Theory of Maternal Role Attainment
FRAMEWORK FOR MATERNAL & CHILD
HEALTH NURSING
Primary goal: “the promotion and maintenance of optimal
family health”
 rooted in the nursing primary goal which is health
promotion and disease prevention
 focus on the family & client/ needs of the family
 all members of the family extending from pre-conception
to menopause = ‘womb to womb’
PHILOSOPHY OF MCHN
 Family Centered – consider the needs of each member of
the family (husband and siblings)
 Community Centered - care not only in the hospital but
also in the community setting
 Evidence Based Practice – the conscientious, explicit,
and judicious use of current best evidence in making
decisions about the care of the individual patient
 Critical knowledge emerges; all actions are justified
by studies and researches which provides confidence
when giving care to clients
 Advocate to protect the rights of all family members
- Ensure safety in the setting
- Giving patients especially those vulnerable a
voice (communicating and understanding their
health)
- Educate (promoting independence)
- Protect patient’s rights (acknowledge px
decisions)
- Double check for errors
- Connect px to resources inside or outside the
hospital (e.g. PhilHealth, transportation services
& financial assistance) to support well-being
MCHN GOALS AND STANDARDS
 2020 National Health Goals (reviewed every 10 yrs)
 To increase quality and years of healthy life
 To eliminate health disparities
 Millennium Health Goals (by UN and WHO)
 To reduce child mortality
 Reduced 2/3 between 1990-2015 under-
five mortality rate
 To improve maternal health
 Reduced 3 quarters between 1990-2015
maternal mortality ratio
In WHO’s 17 Sustainable Developmental Goals
Goal # 3 Good health and well-being for all at all
ages
“Ensure healthy lives and promote well-being for
all at all ages.”
- Increased life expectancy
- Reducing the common killers in child and
maternal mortality
- Goal is to achieve universal health coverage
including access to medicines and vaccines, end
preventable child deaths, end epidemics
like AIDS, TB, Malaria, and water-borne
diseases.
THEORY APPLICATION ON MCHN
- Motherhood is a developmental and interactional
process through which the mother and child
bond over time.
1. Commitment, Attachment, and Preparation
(Anticipatory Stage) - initial stage; new mother
begins to adjust to the realities of her new role;
learning social expectations of motherhood; adapting
to the physical and physiological changes of
pregnancy; fantasizing about motherhood; dealing
with health concerns (pre- natal care, preparation for
childbirth)
2. Acquaintance, Learning, and Physical Restoration
Stage (Formal Stage) – immediately after
childbirth/adoption/bringing a new child into the
home; stage the new mother adapts to the role by
modeling learned behaviors, conforming closely to
family and social norms.
3. Moving towards the new normal (Informal Stage) –
the period in which the mother develops own
maternal identity and becomes comfortable with her
decision making and mothering skills.
4. Achievement of Maternal Identity (Personal Stage)
– final stage (occurs at 4 months after birth); mother
has successfully integrated learning with prior
knowledge and personal experience; feels confident,
competent; and accomplished in her role; joy of
motherhood and secure attachment to the child.
SCOPE OF MCHN
 Preconception Healthcare – ideal for a couple to submit
themselves for screening if they would like to have
children
 nurses should educate and be advocates for the
couple
 Taking Care of the Pregnant Woman in Gestation – we
take care of the px throughout the trimesters of pregnancy
and even immediately after delivery.
 New Client – the Newborn; we should attend to the needs
of our vulnerable client while the mother is recovering;
assits the family in welcoming
 Growth and Dev’t of the Child – from infancy up to
adolescence.
 Ensure the Continuity of Care from the Hospitals up to
Homes – community health nurses look into the health of
the mother and child at home especially to the adaptation
of the mother to her new role.
WHAT DOES A MATERNAL AND CHILD NURSE DO THEN?
Roles and Responsibilities of an MCN
 Considers the family as a whole
 Advocate for the family including the growing fetus
 Teaches and counsels as an independent nursing function
 Promotes health and prevent disease (main goal)
 Resource managers for the families esp. during
childbearing and childrearing periods (esp. basic needs of
the growing child); well provided by the community
 Encourage developmental stimulation: we follow according
 to child age
 Assess the needs of the families
 Encourage family bonding, early hospital discharge, and
reaching out to the community.

MCHN AS A CHANGING DISCIPLINE

 Evolved in so many aspects
1. Trends in the MCHN population, changes in lifestyle, and
social structure. (Family structure evolved as well)
2. Changes in the settings of maternity and childcare. (From
home birth to opting for hospitals)
3. More involvement of technology (portable dopplers,
ultrasound machines that capture realistic pictures of
newborns)
4. Government Policies
Example:
A. Expanded Maternity Leave Act
- 105 days maternity leave
- 14 days paternity leave

Ethical Considerations
 Documentation – ensure accurate documentation; what is
not on the chart is good as not done
 Informed Consent - ensure that the client understands all
the undertakings with their consent as is signed by the
client or a responsible part if he client is a minor.
1. Conception
2. Pregnancy Termination/ Abortion
3. Stem cell research
4. Invasive procedure on children
*May include religious and moral affiliations
MALE REPRODUCTIVE SYSTEM semen travels through to exit the penis
5) Corpus cavernosa – outer erectile tissue
6) Corpus spongiosum – inner erectile tissue
7) Root – accumulation/ bundle of the nerves and blood
vessels

External
1) Glans – foreskin
2) Prepuce – excised during circumcision
3) External Urethral Meatus – opening from the urethra
4) Urethra – innermost of the body or shaft, urine and
 1. Mons Pubis – pubic hair initially appears here
Internal 2. Labia Majora – on the sides
1. Scrotum – houses the testis 3. Labia Minora – going inside
2. Testis – housed by the scrotum; production of 4. Clitoris – where the labia minora meet
testosterone and sperm; primary male sex hormones superiorly
3. Epididymis – matures sperm 5. Urethral orifice – opening from the urethra; landmark for
4. Vas deferens – transports sperm from the epididymis catheterization; urine comes out
5. Seminal Vesicle (65% of semen) – produces sugar-rich 6. Vaginal orifice - head of the baby comes out first and the
fluid with fructose for sperm motility and energy opening from the vaginal canal
6. Ejaculatory duct – where the fluids combine 7. Perineal Body
7. Prostate gland 8. Anus
8. Cowper’s gland/ bulbourethral gland – reduces the
acidity of the urethra Perineum
 Knowing the parts of the perineum will help you get
Physiology acquainted of the parts affecting labor and delivery
Spermatogenesis – production of sperm in the testes  It plays an important role in functions such as defecation,
 Sperm travels from the testis to the epididymis sexual intercourse and child birth.
from 12-20 days; matures 65-75 days; 20million
per mL/ ejaculation PHYSIOLOGY:
Endocrine Gland – hormonal influence
 Pubertal development:
 Increase in height and weight
 Enlargement of testes and scrotum
 Appearance of body hair
 Penile growth and enlargement
 Nocturnal emissions (sign of
spermatogenesis)
The Ejaculate of the Semen - 2.5-5ml (sticky)
- Testicle (10%)
- Seminal vesicle (65%)
- Prostate Gland (25%)
- Bulbourethral glands (minimal)

 Fourchette – posterior meeting of the labia minora;

surgically incised to increase passageway for fetus
(episiotomy): important landmark; may extend down
depending on the size of the baby if the baby’s head
is too large
 Perineal body
 Hymen – thin piece of mucosal tissue that partially
covers the vaginal opening; perforated by mechanical
means; hematocolpometra - may occur if the hymen
can’t be perforated, accumulation of blood in the
vagina and the uterus, hymenectomy (incision of
hymen) may be done.

FLOW:

SPERMATOGENESIS occurs in the testis. It

goes up to epididymis and travel to vas
deferens. It means with the fluid from seminal
vesicle, fluid from the prostate then to the fluid
of Bulbourethral Glands. This is the
ejaculatory duct. It empties towards the
urethra out of urethral meatus.

FEMALE REPRODUCTIVE SYSTEM

External

Internal
1. Vaginal Canal – port of entry from the external to internal
structures; passes through the cervix
2. Cervix – internal OS; external OS; keeps the pregnancy
intact all throughout the 9 months of gestation
3. Uterus – most part of the female reproductive system
 Divided in three walls:
1. Endometrium – inner portion/lining; this wall
sheds off down to the cervical canal and out of
the vagina during menstruation
2. Myometrium – underneath; contractions of
uterus during labor and delivery
3. Perimetrium – outer layer/lining
4. Fundus – important landmark of pregnancy for it gives
us information for fetal growth; firm upon touch if
palpated
5. Fallopian Tube
 Isthmus – narrowest part
 Ampulla - where fertilization occurs; where sperm
and mature egg meets for fertilization
 Infundibulum – holds the finger-like projections which
captures the ovum from the ovary
6. Fimbriae- captures the ovum
7. Ovary – where oogenesis occurs; production of egg cell
occur
8. Ligaments
 Round Ligament – extends from the uterine
horns to the labia majora via inguinal canal
 Broad Ligament – double layer of peritoneum
attaching the sides of the uterus to the pelvis;
acts as a mesentery of the uterus and contributes
to maintaining the position of it
 Ovarian Ligament – holds the ovary
 Cardinal Ligament – base of the broad ligament;
extends from the cervix to the lateral pelvic walls and
contains uterine artery and vein.
 Utero-sacral Ligament – extend from the cervix to
the sacrum.
OVARIAN CYCLE
I. Day 0 - beginning of the ovarian cycle
 15-20 primordial follicles begin maturation
(GnRH - FHS)
 Atresia – degeneration of follicle turning them to
atretic follicle
II. Early Primary Follicles (squamous to cuboidal)
III. Late Primary Follicles
 Granulosum Cells (stratum granulosum) – feeds the
oocyte
 Zona Pellucida - transparent zone
 Stromal Cells (Theca Folliculi) – covers the outer
cell
IV. Secondary Follicles
- Granulosa cells forms Antrum
- Cumulus oophorus – within the antrum
V. Differentiation of the theca folliculi; theca
interna (vascularized and releases hormones)
and theca externa (contracts)
- Oocyte: completes Meiosis 1, enters
meiosis 2, arrests at metaphase 2 =
Secondary oocyte & polar body (no
function)
VI. Graafian Follicle (Dominant Follicle)
- Enlarged antrum
Day 14: the oocyte and the cumulus oophorus detatches and
floats inside the cell creates the corona radiata
Ovulation: oocyte ejection through the contraction of theca
externa
After Day 14:
Corpus Luteum/yellow body (LH)
 Essential for the maintenance of the uterus and
growing embryo; secretes progesterone
 Fertilized oocyte = Corpus Luteum Grows
 Unfertilized oocyte = degenerates and turns into
Corpus Albicans/white body (no purpose)
Day 28: Cycle Done!

Physiology:
- Frequent urination and constipation because
the growing fetus compresses the bladder and
compresses the rectum backward.
- Ensure strong pelvic muscles to avoid
BLOOD SUPPLY OF THE UTERUS pulling down of the muscle.
Cystocele – protrusion of the bladder out of the vagina
Rectocele – protrusion of the rectum out of the vagina

Oogenesis
– the formation of female gametes
 Endocrine Glands - GnRH from the Hypothalamus
signals the anterior pituitary gland to produce LH an FHS
during oogenesis. LH encourages the production of
progesterone; FSH encourages the production of Estrogen:
Hormonal Control
 Estrogen – reproductive hormone in F that assist in
endometrial growth, ovulation, and calcium absorption, and
the development of secondary sexual characteristics
PUBERTAL DEVELOPMENT:
 Growth spurt
 Breast budding
 Increase in size of pelvis
 Appearance of body hair
 Menstruation then ovulation

VARIATIONS OF THE UTERUS

BLOOD SUPPLY: - Congenital uterine malformations
 Hypogastric Artery
 Uterine Artey – minute blood vessel surrounding the
uterus
 Ovarian Artery – supplies blood direct to the ovaries

A. Normal – ample space for embryo to grow inside it

B. Bicornuate Uterus – may appear normal however there
will be a part of septum that may disrupt the growth of
the fetus
C. Septum-dividing Uterus – most complicated; disrupts or
halts the growth of the fetus (termination of pregnancy);
very hard of fetus to grow
D. Double Uterus – 2 uterus; 2 cervices, 2 vaginal canals; very
rare congenital of uterus
Based on Positioning in the Pelvic Cavity: Within each lobes, there are small structures called lobules. In
each lobes, there are minute lobules where nilk is
produced. The milk travels through a network of tiny tubes
called ducts. Ducts connect and come together into large
ducts which eventually exits the skin through the nipple.
The dark area of the skin surrounding the nipple is called
areola.

THE MENSTRUAL CYCLE

 Ovarian Cylce + Uterine Cycle = Menstrual cycle (more
or less 28 days)

 Version – where the uterus leans towards

(towards the front/sacrum/mons pubis)
 Flexion - bending of the uterus on itself
 Retroverted and Retroflex (RV) – leans to the
sacrum and flexed backwards; could compress
the back/sacral nerves during pregnancy
 Anteverted and Anteflex (AV) – leans forward and flex
on its own; aggravately compress the bladder

BREASTS THE MENSTRUAL CYCLE: HORMONAL REGULATION

 Important part of the reproductive system for lactation
and breastfeeding of the infant. PART 1 OVERVIEW:
 Similar hormones
 Tissue overlying the chest or pectoral muscles
- Made of specialized tissue that produces
milk and fatty tissue (amount of fat = size of
breasts)
 Lobes (15-20 sections) or Lobules – produces milk /
fatty tissue
 SUMMARY:

SUMMARY OF MENSTRUAL CYCLE:

MENSTRUATION:

 Menarche – 9-17 yrs old, ave. 28 days (cycle)

 Bleeding Days: 4-6 days duration
 30-80ml/period
 Vaginal Discharge: Dark red color, endometrial
cells, vaginal secretions
 Odor: marigold

I. Menstrual Phase/ Bleeding Phase

 1-4 days, terminal phase of menstruation
 sloughing off (inner glandular layer)
 First bleeding day is considered Day 1
II. Follicular Phase/Proliferative Phase
 reformation of endometrium
 High estrogen, low progesterone
 High Estrogen: responsible for thickening or growth of
uterus
III. Luteal Phase/Secretory Phase
 Increased in LH produced by the corpus
luteum/yellow body w/c lives for 10-14 days
IV. Ischemic Phase
 Corpus albicans for 10-14 days
 Low estrogen and progesterone

ESTROGEN V.S. PROGESTERONE

OVULATION
 pain)
- + Ferning test (NaCl): crystallization

- Middle of the cycle

- 14 days prior the next cycle
Signs of ovulation:
- Breast tenderness
- Increased basal body temp (BBT) due to
high levels of progesterone
- + Spinnbarkeit test (cervical mucus is
abundant and can be comparable to egg
white)
- Mittelschmerz (one sided lower abdominal

TERMS:
1. Dysmenorrhea – painful menstruation
 Primary dysmenorrhea
 absence of anatomic abnormality, high
prostaglandin levels produced by
endometrium, psychological factors
 Nursing responsibilities: rest, heat, analgesics;
 Secondary dysmenorrhea – underlying anatomical
abnormality/pelvic inflammatory diseases/uterus
2. Amenorrhea – absence of menstruation
 Primary amenorrhea – menarche has never
occured, hormonal alteration
 Secondary amenorrhea - cessation of menstrual
cycle for more than 3 months after regular
cycles have been established, may be caused by
pregnancy/other medical conditions
3. Oligomenorrhea – infrequent menstruation
4. Polymenorrhagia – frequent menstruation
5. Hypomenorrhea – abnormally short menstrual cycle
(less than 28 days)
6. Hypermenorrhea – abnormally long menstrual cycle
(more than 28 days/ more than 31 days)
7. Metrorrahgia – the abnormal bleeding between
menstrual cycles or the inter-cyclic bleeding related to
cancers and other gynecologic problems.
8. Meorrhagia – excessive/perfuse menstrual flow
caused by infections/uterine tumors/hormonal
imbalance
9. Menopause – end of a woman’s reproductive abilities

NURSING RESPONSIBILITIES
 Exercise (yoga/aerobics prior to menses)
 Diet (restrict sugar, salt, or stimulants; encourage
complex cars and protein)
 Activities of Daily living (rest and
verbalization of any concerns)
 Nutrition
 Pain Relief
 Rest & Psychological Support

HUMAN SEXUALITY  Sexuality – feelings, attitude & actions

 Who we are than what we do  Biologic Gender – chromosomal sex (F: XX, M:
Terms: XY), reproductive sex/ innate sex determination
 Gender Identity – inner sense of being, one’s inner
 concept of self, how individuals identify themselves
Transgender – an umbrella term for people whose gender
identity and expression is different from cultural
expectations based on the sex they were assigned at birth.
Being trans does not imply any specific sexual orientation.
 Transgender: gay, lesbian, straight or bisexual etc.
 Cisgender – opposite of trans. term for people whose
gender identity matches the sex they were assigned at
birth.
 Gender Dysphoria – a clinically significant distress
caused when a person’s assigned birth gender is not the
same as the one with which they identify. (Replaces
Gender Identity Disorder)
 Gender Role – behavioral expression of expectation
based upon our assigned; sex, act, dress, groom
SEXUAL ORIENTATION
 Heterorsexuality – romantic/sexual attraction to the
opposite sex/gender
 Homosexuality – MSM, WSW
 Romantic/sexual attraction/ sexual behaviors
between people of the same sex/gender
 Bisexuality – romantic/ sexual attraction/sexual behaviors
with the same or with the opposite sex/gender
 Asexual – lack of sexual attraction to others; no or low
interest in sexual activity
 shortest of the phases
 involuntary muscle contraction
 blood pressure and HR are at highest rates
(rapid intake of oxygen)
 feet muscles spasm
 sudden forceful release of sexual tension: women:
the muscle of the vagina contracts, rhythmic
contractions of the uterus, men: contraction of the
muscle at the base of the penis resulting in
ejaculation.
 rash or sex flush may appear over the entire body
4. Resolution (Resolution Phase)
 body returns to normal functioning
 swelled and erect body parts return to prev size and
color
 marked by sense of well-being and fatigue
 women are capable of rapid return to orgasm
phase, men need recovery time (refractory period)

HUMAN SEXUAL RESPONSE

 Sequence of physical and emotional changes as a person
is slowly aroused and participates in sexually stimulating
activities (e.g. intercourse and masturbation)
1. Desire (Excitement Phase)
 muscle tension increases
 heart rate quickens
 breathing accelerated
 nipples hardened
 skin flushed
 bloodflow to the genitals increases resulting in
swelling of clitoris and labia minora, erection of
man’s penis, vaginal lubrication begins.
 women’s breast become fuller
 vaginal walls will swell
 man’s testicles swell
 scrotum tightens
 begins secreting lubricating liquid
CARE OF THE MOTHER & THE FETUS DURING
PERINATAL PERIOD
 Perinatal period: commences at 22 completed weeks or 154
2. Arousal (Plateau Phase) days of gestation and ends 7 completed days after birth
 changes during the first phase are intensified  Prenatal- during pregnancy/ before birth
 vagina continues to swell from increased bloodflow  Intrapartal- labor/delivery
 vaginal walls turn dark purple  Postpartum- period after delivery
 clitoris becomes highly sensitive and retracts  Natal- birth of the newborn
under clitoral hood.  Peri- period surrounding the birth of the newborn
 man’s testicles withdraw up the scrotum  From the time the egg has been fertilized, implanted
 breathing and heart rate continue to rise into uterus, until post partum
 muscle spasms may begin in the ,feet ,face ,and  Post partum- mother recovering from the delivery
hands  Prenatal care
 muscle tension increases  Care of the fetus
 Care of the mother
 Age of Gestation (AOG)- age of pregnancy
3. Orgasm
 Counted by weeks and days
 climax of the cycle
  Ex. 4 3/7- 4 weeks 3 days out of 7 days
 Ex. 32 6/7- 32wks 6 days out of 7 days
PRENATAL PERIOD: CARE OF THE FETUS
FETAL FORMATION
FERTILIZATION
 Occurs once a mature egg cell unites with a sperm cell at
the ampulla.
 Can also be called conception, fecundation, or
impregnation.
 Each sperm reaches the site of fertilization at the ampulla
of the fallopian tube shortly after ejaculation often only
within five minutes but an average of 46 hours seems
more reasonable.
 Sperm must be in the genital tract 4- 6 hours before they
are able to fertilize an egg. It is at this time when the
enzyme needed to dissolve the semen substance
hyaluronic acid that holds together the cells covering the
ovum is activated.
 Hyaluronidase - enzyme that dissolves hyaluronic acid
covering the ovum.
 Factors affecting fertilization:
1. Equal maturation of sperm and ovum.
 Both the sperm and the ova should be
mature.
2. These cells should undergo 2 processes:
a) Sperm Capacitation - ability or capacity
of sperm to reach the ovum.
 Process by which the sperm becomes
hypermobile, breaking down the plasma
membrane exposing the acrosomal
membrane or covering of the sperm head,
allowing the sperm to bind with the zona
pellucida of the ovum.
b) Acrosomal Reaction - ability of the
sperm to penetrate the zona pellucida and
cell membrane.
 Follows capacitation
 The acrosomal covering of the head of the
sperm contains hyaluronidase.
 As millions of sperm surround the ovum,
they deposit minute amounts of
hyaluronidase in the corona radiata, the
outer layer of the ovum.
 This allows the sperm head to penetrate
the ovum.
 As soon as the sperm penetrates the zona pellucida, it
makes contact with the vitelline membrane of ovum.
 A cellular change then occurs in the ovum that inhibits
other sperms to penetrate. The cellular change is mediated
by the release of material from the cortical granules,
organelles found just below the egg surface.
 When fertilization occurs, the male pro nucleus unites with
the female pro nucleus. Thus, the chromosome, diploid 46
is restored, on a new cell. The zygote is created with new
combination of genetic material which creates a unique
individual from the parents and anyone else.
SEX IDENTIFICATION: CHROMOSOME PAIRS
 The ovum releases 23 chromosomes while the sperm
releases 23 chromosomes as well. It then unites forming 23
pairs of chromosomes, total 46.
 Autosomes - 22 pairs
 Sex chromosome - last pair of chromosome
 Determines the sex/gender of the fetus.
 If the female gives off an X and the male gives of an
X, the fetus is a female (XX).
 If the female(ovum) gives off an X and male(sperm)
gives off a Y chromosome, the fetus will be male
(XY).
EMBRYO DEVELOPMENT: EMBRYOGENESIS
 Process that follows fertilization.
 The fertilized egg, travelling in the fallopian tube, will
divide into 2, 4, 8 , 16 cells, etc.
 This will result in a ball-like structure
 Contains many cells inside it
 Morula - ball structure with 16 cells
 Blastula
 Morula further divides to form this
 Stage wherein the cells arrange themselves into a
hollow mass structure.
 They align on the edges leaving a cavity that will soon
be filled with fluid.
 Blastocyst - the stage where the embryo will have cells that
have got differentiated and will differentiate further.
 Differentiation - one cell gets differentiated from the other
cells in its vicinity.
 The blastocyst is now a mass containing differentiated
cells.
 As it grows further, the body of the embryo begins to
develop. For its proper growth and development, embryo
needs nutrition.
 Implantation- blastocyst will have to attach or implant itself
on the mother’s body at one fixed position ---uterus
 Reasons for implantation:
1. Deriving nutrition
2. Give away wastes
3. Exchange gases
 All these are served through the barrier, an organ, called the
placenta.
  The placenta connects baby to the mother.
 Fetal stage - stage where the organs of the baby start to
develop such that they can be identified
 The embryo can now be called a fetus.
 Fetus grows in the uterus after taking the required
amount of time and when the growth is completed,
the child can now enter the world
TYPES OF EMBRYOGENESIS BASED ON LOCATION:
1. Viviparity - the fetus grows inside the mother’s body.
a) Viviparous organisms (humans)
2. Oviparity - the fetus grows outside of the mother’s body.
a) Oviparous organisms (ex. Hens)
 External Fertilization- fertilization process that occurs
outside the female body.
 Ex. Fertilization in frogs
FETAL FORMATION
 Blastocyst- fluid filled cavity that reaches the uterine
cavity
 Important part of embryonic development
 Over the next three to four days of development, a
differentiation of cells as to their specific potencies occurs.
The reorganization of the morula follows forming a
blastocyst.
 Morula- jam-packed cell of divided differentiated cells.
 Once the cells accumulate in one area forming a
cavity, it becomes a blastocyst.
 This is the stage when there is a cavity in the morula
called the blastocele
 When it enters the uterine cavity, the cavity enlarges and
pushes the morula cells into an outer layer of cells called
the trophoblast.
 Trophoblast- portion that attaches itself to the
endometrium of the uterus.
 Along with this is an inner cell mass attached to one
side of the blastocyst. The division and
reorganization has consumed all the energy of the
zygote that it becomes necessary for the blastocyst to
embed or implant itself in the uterine wall for
nourishment, for its further development
IMPLANTATION
 Implantation/Nidation - happens in the fundal portion or
the upper one third of the uterus; can be anterior (to the
mother’s front) or posterior (to the mother’s back).
 Abnormal implantation sites are fallopian tubes leading to
ectopic pregnancies or the lower uterine segment which
causes placenta previa.
 During implantation, the blastocyst completely buries itself
in the endometrium.
 Trophoblast- responsible for attaching itself to
maternal side
 After this, the embryo encloses itself in an amniotic sac
filled with amniotic fluid.
 Amniotic Sac- thin but tough transparent pair of membranes
that hold a developing embryo
 Amnion- inner portion of these fetal membranes
 Encloses the amniotic cavity, amniotic fluid, and the
fetus.
 Chorion- outer membrane
 Contains the amnion and is part of the placenta.
 The Langerhans layer- part of the placenta, prevents
penetration of viruses in the early stage of pregnancy.
ABNORMAL IMPLANTATIONS
 Ectopic Pregnancy
 Implantation of the embryo, other than the uterus.
 It can be fatal if detected late because the fallopian
tube may burst due to the growing embryo.
 Low Implantation /Placenta Previa
 Possible cervix obstruction or the passageway for fetal
delivery.
 Ideal delivery: head first → fetus → placenta follows
 Usually complications occur late in the pregnancy or
once mother goes into labor
 Usually detected late
PLACENTA

 Decidua- as the embryo implants itself in the endometrium
of the uterus, the endometrial lining thickens
 The decidua is supported by HCG or the Human
Chorionic Gonadotropin Hormone, an essential
hormone that helps maintain pregnancy.
 Approximately 5- 10mm thick.
 Decidua basalis- portion beneath the site of the
implantation.
 Decidua capsularis- portion overlying the developing
fetus.
 Decidua parietalis or decidua vera- lines the remainder of
the uterus
 Trophoblast- forms a hair-like structure called the
chorionic villi.
 Chorionic villi and the decidua basalis forms the placenta
 Placenta- organ that develops in the uterus during
pregnancy
 Provides oxygen and nutrients for the growing baby
 Removes waste products from the baby’s blood.
 The placenta attaches to the wall of the uterus and the fetal
umbilical cord arises from it and has a discoid shape.
 The placenta matures when it reaches 12 weeks and it is in
its utmost effectiveness when it reaches 40-42 weeks age
of gestation.
 AOG or age of gestation - refers to the age of pregnancy.
 Beyond 42 weeks of pregnancy, the placenta will lose its
function.
FUNCTIONS OF THE PLACENTA
1. Transport of nutrients and fluid.
a) Alpha-fetoprotein (AFP)- synthesized by fetus; fetus
brings back to the mother
2. Excretion of amniotic fluid.
 Clear straw fluid produced by the fetus and mother which
helps nourish the fetus
3. Respiratory organ of the fetus.
 Size of placenta affects amount of blood exchanged
4. Protective Barrier
 Placental barrier to some substances and organisms like
heparin, bacteria
 Ineffective for virus, alcohol, nicotine, antibiotics,
depressants stimulants
5. Secretes Hormones.
 Estrogen, progesterone, HCG, HPL/HCS
 Duncan- maternal side
 Dirtier side due to the rugated part, a beefy-like
structure of the placenta called the cotyledons.
 Schultz- fetal side
 Portion where the fetus lies.
 Shiny and clean
 Upon placental delivery, it is the nurse’s responsibility to
take note of the cotyledons. If there are missing cotyledons,
inform the doctor immediately. This implies retained
placental fragments which can cause bleeding to the mother
postpartum.
 If it’s D for dirty, it is the Duncan. If it’s S for shiny, it’s
the Schultz.
PLACENTAL HORMONES
1. Human Chorionic Gonadotropin Hormone (HCG)
 Secreted as early as 8-10 days after fertilization.
 Detected in the serum as early as the time of implantation
by the most sensitive pregnancy tests
 Present in urine and blood until 1-2 weeks postpartum.
 When women miss their menstruation, they immediately
buy test kits which detect the presence of HCG.
 HCG suppresses the rejection of placenta
 Prolongs the life of the corpus luteum which produces
progesterone in the first few weeks
 Responsible for the nausea and vomiting experienced by
pregnant women.
 Not all women that have high HCG are pregnant.
 HCG is also produced in other conditions such as H Mole
or Hydatidiform Mole which follows the symptoms of
pregnancy.
 Hydatidiform Mole- rare complication of pregnancy
characterized by the abnormal growth of trophoblasts.
 Make women think they are pregnant because the
womb will grow large
 Treated similarly to cancer
 N= 400,000 IU/24 hours.
After the first 2mos of gestation, estrogen and progesterone is
produced by the placenta
1. Progesterone- maintain pregnancy and prevent uterine
contraction
2. Estrogen- mammary gland and uterine development.
3. Human Chorionic Somatomamotropin or Human Placenta
Lactogen
 Secreted by the third week after ovulation
 It influences somatic cellular growth of the fetus.
 Also resembles the growth hormone.
 Principal diabetic or diabetogenic factor as it is a
major insulin antagonist or glucose staring hormone.
 Prepares the breast of the mother for lactation.
 AMNIOTIC FLUID
 Clear, straw-colored fluid in which the fetus floats
 Slightly alkaline at pH 7.2
 Originates from both the fetus and mother
 Produced by:
 Amniotic membrane
 Fetal urine contributes to the fluid by the 10th week
of fetal life
 800 - 1,200 mL
 Oligohydramnios- if the amniotic fluid index drops below
500 mL
 May imply a kidney problem of the fetus
 Polyhydramnios- excessively large amount of amniotic
fluid
 May imply esophageal atresia.
 Atresia- blocked esophagus
 In this case the fetus is unable to ingest
amniotic fluid causing excessively high
amounts
 Meconium-stained- amniotic fluid is green in color
 Meconium is fetal stool expelled intra-uteri
especially if the gestational age goes beyond the
normal span.
 Gold colored amniotic fluid- may signify a hemolytic
disease or the breakdown of red blood cells at a faster rate.
 It causes the release of high bilirubin causing yellow
discoloration.
 Nurses should take note of the color and report it to the
doctor immediately
Purposes:
1. Protective cushion or shock absorber- it separates the fetus
from the membrane allowing symmetrical growth and free
movement of the fetus.
2. Medium of excretion.
3. Specimen- it serves as a fetal drink and a specimen for
diagnostic exams to determine fetal well-being or its absence
4. Fetal temperature- maintenance of fetal temperature and
equalizes uterine pressure and prevents marked interference
with placental circulation during labor.
UMBILICAL CORD
 Conduit between the developing embryo/fetus and the
placenta.
 Approximately 55 cm in length and an inch thick
 A bundle of one umbilical vein that carries oxygenated
blood to the fetus and two umbilical arteries that carry
deoxygenated blood from the fetus to the placenta.
 AVA ( artery vein artery) - two arteries & one vein
 Determinant for heart and kidney diseases
 Covered by Wharton’s Jelly - gelatinous
mucopolysaccharide, which prevents the cord from
compression.
 Blood volume in the cord prevents cord compression.
 Cord extends from the fetal surface of the placenta to the
umbilicus of the fetus.
 Umbilical cord transports oxygen and nutrients to the fetus
and returns metabolic wastes, including carbon dioxide,
from the fetus to the placenta
 Nuchal Cord - cases wherein the umbilical cord wraps
around neck of the fetus; it is very common and may occur
during pregnancy, labor, and delivery.
STAGES OF INTRAUTERINE DEVELOPMENT
1. Pre-embryonic stage
 1 st 2 weeks after fertilization wherein the fertilized ovum
implants itself on the uterus and becomes a zygote.
 Predifferentiation of organs occur.
 All or none law- when the ovum is exposed to a teratogen
or any harmful substance to the fetus. This implies the
ovum is damaged and is out in spontaneous abortion or it is
not affected at all and may continue to grow normally.
2. Embryonic Stage
 3-8 weeks of gestation/ after fertilization
 Period of organ differentiation or organogenesis.
 Most dangerous period of the development--a teratogen or
any harmful agent that is introduced in this stage may result
in severe organ malformation and dysfunction resulting to
congenital defects of the newborn.
3. Fetal Stage
 8 weeks up to birth
 Period of post-differentiation
 If the fetus is exposed to a teratogen at this time,
malformation is least likely to occur.
 If ever the fetus is affected, the effects will most likely be
an alteration in size or function.
 We can see a fetus being viable or being able to survive
outside of the uterus after birth, natural or induced when
supported by up to date medicine
 Age of Viability- at least 20-24 weeks age of gestation and
should be greater than 500 grams.
 Abortus/ product of abortion- any fetus born less than
these values are
EMBRYONIC GERM LAYERS
  Ductus Venosus- most of the blood is sent through this
 Germ layer- group of cells in an embryo that interact with shunt .
each other as the embryo develops and contribute to the  Coming from placenta direct to inferior vena cava
formation of all organs and tissues  This shunt lets highly oxygenated blood bypass the
 Development of organs happens in a cephalocaudal liver to the inferior vena cava and to the right atrium of
fashion. the heart for pumping.
 Ectoderm- responsible for the formation of the nervous  A small amount of blood goes to the liver to give it the
system, hair, nails, skin, epidermis, sebaceous and sweat oxygen and nutrients it needs.
glands, salivary glands, mucous membrane of the mouth,  Waste products from the fetal blood are transferred back
epithelium of nasal oral passages across the placenta to the mother’s blood.
 Mesoderm- middle layer and develop into dermis,
cardiovascular system, reproductive system,
musculoskeletal system, and urogenital system except for
the bladder
 Endoderm or entoderm- the inner layer that develops into
the linings of the GI tract, from pharynx to rectum, liver,
pancreas, thyroid, parathyroid, respiratory tract, bladder,
and the thymus.

CARDIOVASCULAR SYSTEM
 Develops from the mesoderm
 Starts at the 16th day of life
 Fetal Heart Tone / FHT- is audible through the fetal
doppler at 10-12 weeks AOG
 via Fetoscope at 16 weeks AOG
 via Stethoscope at 20 weeks AOG
 Fetal Heart Rate or FHR is irregular in the first few weeks
FLOW:
but regulates into 110-160bpm starting 28 weeks.
 Structures involved in fetal circulation: placenta, umbilical
 Fetal blood is hemoconcentrated--they normally have high
vein, ductus venosus, ductus arteriosus, foramen ovale,
concentration of red blood cells compared to adults
umbilical arteries
 Blood rich in nutrients and oxygen supplied via the placenta
FETAL CIRCULATION
flows to the umbilical vein to the ductus venosus.
 From here, blood flows from ductus venosus to the inferior
vena cava up to the right atrium. This blood mixes with
blood returning to the heart from the upper body via the
superior vena cava, from the lower body via inferior vena
cava
 In the right atrium, some of the blood flows to the right
ventricle and some flows to the foramen ovale to the left
atrium and into the left ventricle where it is pumped to the
aorta to the body
 Blood that flows into the right ventricle is then pumped into
the pulmonary artery
 The lungs have tighter/narrow vessels because it is fluid-
filled rather than air-filled. The vessels in the lungs are
narrow creating higher resistance to blood flow into the
 Three shunts- these are small passages that direct blood
lungs. Due to the high resistance to blood flow in the
that need to be oxygenated
pulmonary circulation and the low resistance to blood flow
 Purpose of these shunts is to bypass the lungs and the
in the systemic circulation, blood pumped into the
liver. These organs will not work fully until after
pulmonary artery by the right ventricle is more likely to
birth.
flow into the ductus arteriosus and into the aorta
 Foramen Ovale- shunt that bypasses the lungs
 Due to the high blood flow from the superior and inferior
 moves blood from the right atrium of the heart to the
vena cava up to the right atrium, pressure in the right atrium
left atrium which abnormally happens in adults.
are higher. This promotes blood flow through the foramen
 Ductus Arteriosus- moves blood from the pulmonary
ovale at the atrial level
artery to the aorta.
 Only 8% of right ventricular output flows into the lungs
 Oxygen and nutrients from the mother’s blood are sent
providing nutrients for the developing lung tissue.
across the placenta to the fetus. The enriched blood flows
 Most of the blood passes through the ductus arteriosus into
through the umbilical cord to the liver and splits into three
the aorta and out to the rest of the body. The umbilical
branches; the blood that reaches the inferior vena cava.
arteries allows blood to flow from the body back to the
This is a major vein connected to the heart.
placenta to be enriched with oxygen and nutrients.

AFTER BIRTH
 When born and the baby takes the first breath, the
umbilical cord is clamped and the placenta is removed
from the systemic circulation
 Immediately, there is a transition from fetal to post-natal
circulation begins
 With the elimination of the placenta from the circulation,
systemic vascular resistance now rises. With each breath,
more alveoli in the lungs expand and the surrounding
vessels dilate in response to the presence of oxygen
 Pulmonary pressure will start to decrease, although
pulmonary pressures are lower than systemic pressures
within minutes after breath , but it is not until the 6th to
8th week that pulmonary vascular resistance decreases to
normal
 In the postnatal circulation, blood will no longer flow
through the foramen ovale or the ductus arteriosus
 The increase in left atrial pressure after birth forces the
septum primum against the septum secundum,
functionally closing the foramen ovale. Within three
months, the foramen ovale permanently closes as fibrin
deposits fuse the layers of septal wall together.
 While PFO (propatent foramen ovale) may close by
this time, it also may not close in some adults, the
shunt via PFO via birth is usually small
 The ductus arteriosus closes soon after birth as the infant
begins to breathe. Normally, the ductus closes completely
in 4-10 days.
 The ductus venosus is open at the time of birth, making
central venous access possible through the umbilical vein.
As fibrin infiltrates the ductus venosus, it usually closes
within three to seven days. After it closes, the remnant is
called ligamentum venosum.
 Within a week after birth the umbilical vein and the
umbilical arteries are infiltrated with fibrin
RESPIRATORY SYSTEM
 Emerges from the endoderm
 Not functional as a whole, until after birth of the newborn.
 It develops from a hollow tube of esophagus and trachea
until 4th week AOG.
 Respiratory movement is noted at 3rd month of gestation.
 At 24 weeks AOG, the newborn starts to produce
surfactant. This is a phospholipid substance that is formed
and excreted at 24th weeks of pregnancy. It decreases
alveolar surface tension on expiration preventing alveolar
collapse and improving infant’s ability to maintain
respirations in the outside environment. This is one basis of
the determining viability of the fetus. Without the
surfactant, the newborn is not able to breathe on its own in
the extrauterine life having no placenta for gas exchange.
 In cases wherein the mother goes into labor or is about to
deliver the fetus, they are given intramuscular doses of
steroid or betamethasone. Some doctors would prescribe
dexamethasone. This steroid is believed to stimulate the
synthesis and release of the surfactant.
 In cases wherein the newborn is still pre-term they are given
through endotracheal tube or a tube is inserted into the
lungs, giving the baby artificial surfactant (betamethasone).
Common brand is Survanta.
NERVOUS SYSTEM
 Develops from intrauterine from ectoderm
 Neural plate- a thickened portion of the ectoderm, is
apparent by 3rd week AOG
 Top portion- differentiates into the neural tube which
will form the CNS, brain, and the spinal cord.
 Neural crest- will develop the PNS.
 All parts of the brain (cerebrum, cerebellum, pons, medulla
oblongata) form in the uterus, although none are completely
mature at birth.
 Growth proceeds rapidly during the first year and continues
at high level until 5 or 6 years of age.
 Spinal cord disorder such as meningocele or herniation of
meninges may occur because of lack of folic acid which is
present in green leafy vegetable and pregnancy vitamins.
That is why pregnant women may be taking folic acid as
prenatal vitamins.
DIGESTIVE SYSTEM

Develops from the endoderm
 The GI tract of the fetus is sterile, meaning there is no
bacteria or normal flora present in the system
 Because vitamin K is synthesized by the action of bacteria
in the intestine, vitamin K level are low in a newborn
 Common congenital defects in the GI system of the fetus is
atresia and stenosis
 Atresia is a condition wherein an orifice or passage in the
body is abnormally closed or absent
 Stenosis is the narrowing of the GI tract
 Esophagus and trachea forms one hollow tube initially,
failure to separate or develop distinctly may result in atresia
or stenosis which may pose problems of feeding in the
extrauterine life.
 In cases wherein the abdomen fails to close anteriorly, this
may result into omphalocele or a birth defect in which an
 infant’s intestine or other abdominal organs are outside the
body because of a hole in the naval area
 The intestines are covered only by a thin layer of tissue
and can be easily seen.
 Meconium- first stool of the fetus
 Composed of materials ingested during fetal
development, which includes intestinal epithelial
cells, lanugo, mucus, amniotic fluid, bile, and water.
 Viscous and sticky like tar
 Color is a very dark olive green
 Almost odorless.
 An important neonatal nursing responsibility is recording
that a newborn has passed meconium, as this rules out a
stricture or non-canalization of the anus.
 The liver is active throughout gestation. Functioning as a
filter between the incoming blood and the fetal circulation
and as deposit site for fetal spores such as iron and
glycogen. It is still immature at birth. This can possibly
lead to hypoglycemia--low glucose/sugar and
hyperbilirubinemia---high bilirubin levels. These are
problems that may arise during the first 24 hours after
birth.
 The liver does not prevent recreational drugs or alcohol
ingested by the mother from entering the fetal circulation.
REPRODUCTIVE SYSTEM
 Develops from the mesoderm.
 A child’s sex is determined at the moment of conception
via spermatozoon carrying an x or y chromosome and can
be ascertained as early as 8 weeks of chromosomal
analysis.
 At 6 weeks AOG, the gonads (ovaries or testes) form.
 If testes is formed, testosterone is secreted. Apparently
influencing the sexual neutral genital duct to form other
male organs.
 In the absence of testosterone secretion, female organs
will form. The testes first forms in the abdominal cavity
and do not descend into the scrotal sac until the 34th to
38th week AOG. Because of this many male pre-term
infants are born with undescended testes. These children
need follow-up care to be certain that their testes descend
when they reach what would have been the 34th to 38th
week AOG. Testicular descent does not occur as readily in
extrauterine life as it would in utero.
URINARY SYSTEM
 The presence of kidneys does not appear to be essential
for life before birth
 The placenta clears the fetus of waste products. Urine is
formed by the 12th week AOG and is excreted into the
amniotic fluid by the 16th week AOG
 At term, fetal urine is excreted at a rate of 500mL/ day
 Oligohydramnios- amount of amniotic fluid below normal
 can suggest fetal kidneys are not secreting adequate
urine.
INTEGUMENTARY SYSTEM
 The skin of the fetus appears thin and almost translucent
until subcutaneous fat begins to be deposited at about 36
weeks AOG
 Lanugo- soft downy hairs that cover the skin, that serves
as insulation to preserve warmth in utero.
 Develops at 16 weeks AOG and diminishes at end of
36 weeks AOG
 Vernix Caseosa- cream cheese like substance is important
for lubrication and prevention of the skin from macerating
in utero.
 Forms by the end of 20 weeks AOG.
IMMUNE SYSTEM
 IgG maternal antibodies cross the placenta into the fetus as
early as 20 weeks AOG and certainly by the 24th week of
intrauterine life to give fetus temporary passive immunity
against diseases for which the mother has antibodies.
 The level of acquired passive IgG peaks at birth and
decreases over the next 8 months as infant builds up his/her
own stores of IgG as well as IgA and IgM
 IgA and IgM are produced after infection
 Because the passive immunity received by the newborn has
already declined substantially by about 2 months, basic
immunization starts
 A fetus is capable of active antibody production late in
pregnancy because IgA and IgM antibodies cannot cross the
placenta, their presence in a newborn is proof that the fetus
has been exposed to a disease.
ENDOCRINE SYSTEM
 Function of endocrine organs begins along with the
neurosystem development
 Fetal pancreas produces insulin needed by the fetus
 Insulin- one of the few substances that does not cross
the placenta from the mother to the fetus
 Thyroid and parathyroid glands- play vital roles in fetal
metabolic function and calcium balance
 Fetal adrenal glands supply a precursor necessary for
estrogen synthesis by the placenta
MUSCULOSKELETAL SYSTEM
 During the first 2 weeks of fetal life, cartilage prototypes
provide position and support to the fetus
 Ossification of this cartilage into bone begins at about the
12th week and continues all throughout fetal life and into
adulthood
 Carpals, tarsals, and sternal bones- generally do not ossify
until birth is imminent
 Fetal movement at 11th week seen via ultrasonography
 Mother does not feel this movement or Quickening until 16-
20weeks of gestation
 Usually felt earlier in multigravida women
FETAL MILESTONE
 The fetus develops approx for:
 267-280 days
 9 calendar mos
 40 weeks
 3 trimesters
 10 lunar mos

FETAL DEVELOPMENT MONTH BY MONTH
MONTH 1
 As the fertilized egg grows, a water-tight sac form around
it, gradually filling with fluid. This is called the amniotic
sac, and it helps cushion the growing embryo
 The placenta also develops. The placena is a round, flat
organ that transfers nutrients from the mother to the baby,
and transfers wastes from the baby
 A primitive face will take form with large dark circles for
eyes. The mouth, lower jaw, and throat are developing.
Blood cells are taking shape and circulation will begin
 The tiny “heart” tube will beat 65x a minute by the end of
the 4th week. By the end of the first month, baby is about
1/4 inch long-- smaller than a grain of rice.
MONTH 2
 Baby’s facial features continue to develop. Each ear
begins as a little fold of skin at the side of the head.
Tiny buds that eventually grow into arms and legs
are forming. Fingers, toes, and eyes are also forming.
 The neural tube (brain, spinal cord, and other neural
tissue of the CNS) is well formed. The digestive tract
and sensory organs begin to develop. Bone starts to
replace cartilage.
 The head is large in proportion to the rest of the
baby’s body. By the end of the 2 nd month, baby is
about 1inch long and weighs about 1/30 of an ounce
 At about 6weeks, baby’s heart beat can usually be
detected. After the 8th week, your baby is called a
fetus instead of an embryo
MONTH 3
 Baby’s arms, hands, fingers, feet and toes are fully
formed. Baby can open and close its fists and mouth.
Fingernails and toenails are beginning to develop and
the external ears are formed
 The beginnings of teeth are forming. Baby’s
reproductive organs also develop, but the baby’s
gender is difficult to distinguish on ultrasound
 By the end of the 3rd month, baby is fully formed. All
the organs and extremities are present and will
continue to mature in order to become functional
 The circulatory and urinary systems are working and
the liver produces bile. At the end of the 3 rd month,
baby is about 4 inches long and weighs about 1 ounce
 Since your baby’s most critical development has taken
place, your chance of miscarriage drops considerably
after 3 months
MONTH 4
 Baby’s heartbeat may now be audible through an
instrument called a doppler. The fingers and toes are
well-defined. Eyelids, eyebrows, eyelashes, nails, and
hair are formed
 Teeth and bones become denser. Baby can even suck
his or her thumb, yawn, stretch, and make faces.
 The nervous system is starting to function
 The reproductive organs and genitalia are now fully
developed, and your doctor can see on ultrasound if
you are having a boy or a girl
 By the end of the 4th month, baby is about 6 inches
long and weighs about 4 ounces
MONTH 5
 You may begin to feel your baby move, since he or
she is developing muscles and exercising them. The
first movement is called quickening
 Hair begins to grow on baby’s head. Baby’s
shoulders, back and temples are covered by a soft
fine hair called lanugo. This hair protects your baby
and is usually shed at the end of the baby’s first week
of life
 Baby’s skin is covered with a whitish coating called
vernix caseosa. This “cheesy” substance is thought
to protect baby’s skin from the long exposure to the
amniotic fluid. This coating is shed just before birth
 By the end of the 5th month, baby is about 10 inches
long and weighs from 1/2 to 1 pound
MONTH 6
 Baby’s skin is reddish in color, wrinkled and veins
are visible through the baby’s translucent skin
 Baby’s finger and toe prints are visible
 Eyelids begin to part and the eyes open
 Baby responds to sounds by moving or increasing the
pulse.
 You may notice jerking motions if baby hiccups
 If born prematurely, baby may survive after the 23 rd
week with intensive care
 By the end of the 6th month, your baby is about 12
inches long and weighs about 2 pounds
MONTH 7
 Baby will continue to mature and develop reserves of
body fat
 Baby’s hearing is fully developed
 He or she changes position frequently and responds
to stimuli, including sound, pain, and light
 The amniotic fluid begins to diminish
 At the end of the 7th month, baby is about 14 inches
long and weighs from 2-4 pounds
 If born prematurely, baby would be likely to survive
after the 7th month
MONTH 8
 Baby will continue to mature and develop reserves of
body fat
 You may notice that your baby is kicking more
 Baby’s brain is developing rapidly at this time and
your baby can see and hear
 Most internal systems are well-developed, but the
lungs may still be immature.
 Baby is about 18 inches long and weighs as much as 5
pounds
MONTH 9
 Baby continues to grow and mature: the lungs are
nearly fully developed
 Baby’s reflexes are coordinated so he or she can blink,
close the eyes, turn the head, grasp firmly, and
respond to sounds, light, and touch
 Baby is definitely ready to enter the world!
 You may notice that baby moves less due to tight
space
 Baby’s position changes to prepare itself for labor and
delivery
 The baby drops down in your pelvis. Usually the
baby’s head is down toward the birth canal
 Baby is about 18-20 inches long and weighs about 7
pounds
FETAL MILESTONE SUMMARY
 1st trimester- period of rapid organogenesis
 Susceptible to teratogens (alcohol, drugs, virus,
radiation)
 2nd trimester- most comfortable period since the initial
signs of pregnancy s tabilizes during this time and
fetus continues to grow
 3rd trimester- rapid fetal growth; rapid deposition of
fats, iron and calcium
ESTIMATED DATE OF BIRTH (EDB)
 Expected due date
 38-42 weeks
 Naegele’s Rule
LMP → 3 months + 7 days= EDB
 LMP → first day of last menstruation
 ex. LMP July 4, 2020, so EDB= April 11, 2021

ASSESSMENT OF FETAL GROWTH
 Fetal growth and development can be compromised
if:
 A fetus has a metabolic or chromosomal
disorder that interferes with normal growth
 If supporting structures such as placenta or cord
do not form normally
 If environmental influences such as cigarette
smoking, alcohol consumption interfere with
fetal growth
1. History taking
 Health history of mother
 Ask about nutritional intake (bc if woman is not
eating well balance diet, she may not be taking
sufficient nutrients for fetal growth
 Ask about personal habits--cigarette smoking,
recreational drug use, and exercise (because all
of these influence glucose or insulin balance and
fetal growth)
 Ask if woman has had any accidents/
experienced intimate partner abuse helps reveal
whether the fetus could have suffered any
trauma
2. Fundus
 To determine fetal growth objectively
 Determine location of fundus: gently palpate from
the lower end of the sternum/ xiphoid process down
until you can feel firm muscle area beneath xiphoid
process and above fetus
 For laboring women, fundus is the best location to
feel the contraction
ASSESSMENT OF FETAL GROWTH (empty bladder)
 Utilizing 2 methods, we will be able to estimate the
fetal size following the AOG
 This method estimates the AOG relative to the height
of the fundus of the uterus above the symphysis
pubis
(a) Bartholomew’s Rule of Fours
 Follows the 4 landmarks
 12 weeks- fundus is slightly palpated above
symphysis pubis
 16 weeks- between symphysis pubis and
umbilicus
 20 weeks- fundus is palpable at the level of the
umbilicus
 Full term/ 9th lunar month- fundus at the level of
xiphoid process
(b) McDonald’s Rule
 F o l l o
determining during midpregnancy that a fetus is
growing in utero
 Typically the distance from the uterine fundus to the
symphysis pubis in cm= week of gestation between
the 20th and 31st weeks of pregnancy
 Make measurement from notch of symphysis pubis to
over the top of the uterine fundus as a woman lie
supine. Use a tape measure in cm
 Rule becomes inaccurate during the 3 rd trimester of
pregnancy because fetus is growing more in weight
than in height
 Fundal height much greater than this standard suggest
multiple pregnancy
 A miscalculated due date/ too big fundal measurement
could happen if the baby is too large based on standard
size, hydramnios or polyhydramnios, or H mole
 A fundal measurement much less than this suggest
that the fetus is failing to thrive, intrauterine growth
restriction, the pregnancy length was miscalculated or
an anomaly like anencephaly (no brain) fetus has
developed
(c) Johnson’s rule (Empty Bladder)
FH (cm) - n x 155= FW (grams)
n= 11 if unengaged (head of fetus is still above the ischial
spine)
12 if engaged (fetus is already down the ischial spine of
pelvis; happens during the late days of pregnancy)
12 if engaged: constant value
 Enables you to have an approximate data of how the
baby weighs
 Before assessment of pregnant client- always have
empty bladder to avoid disturbance during
assessment and for comfort of the mother; make sure
to warm hands when touching abdomen of mother
(cold hand will cause abdomen to contract)
 Applicable for vertex/ head towards the pelvis of the
mother only. Not applicable for other positions of the
fetus
ASSESSMENT OF FETAL WELL-BEING
 Several actions or procedures are helpful in detecting
and documenting that the fetus is not only growing
but apparently healthy. Most basic assessment is
determining the following:
1. Fetal Heart Rate (110-160 bpm at 28 weeks)
 Used fetal doppler, fetoscope or stethoscope
2. Fetal Movement “quickening” (10 kicks/hr) (2 in 10
minutes)
 Taught on how to do this at home to give them
an idea or the sense of urgency to when to see
their doctor
 Quickening (movement in pregnancy when the
pregnant woman starts to feel or perceive fetal
movement in the uterus; occur at 18 to 20 weeks
and peaks at 28 to 38 weeks)
 Moves at least 10 times per day
 A fetus not receiving enough nutrients because
of placental insufficiency has greatly decreased
movements; asking a woman to observe and
refer the number of movements the fetus is
making offers a gross assessment of fetal well-
being
 “Sadovsky Method”
 ask the woman to lie in a left recumbent
position p̄ a meal and record how many
fetal movements she feels over the next
hour; every after meal the fetus is active
that is why it is the best time to check fetal
movement p̄ meal
 10-12 kicks per hour (2 in 10 minutes); if
less than 10 movements occur in an hour.
The woman repeats the test for the next
hour.
 Duration of test: 2 hours
She should call healthcare provider if feels
fewer than 10 movements half the normal
number during the chosen 2 hours
3. Rhythm Strip Testing – assessment of the fetal heart
rate for whether a good baseline rate in a degree of
variability is present
 Baseline – average rate of the fetal heartbeat per
minute (within fetal heart rate or normal value of
heart rate)
 Variability – small changes in rate that occur if
the fetal parasympathetic and sympathetic
nervous systems are receiving adequate oxygen
and nutrients
when the fetus is stressed or if they have diffusion
in oxygen, they tend to be “fuzzy” inside the
uterus causing an acceleration of the heart rate
 if they are too weak to compensate, the heart rate
could decrease
Categories:
A. Absence or Non-apparent – no changes from the
baseline
B. Minimal – small fluctuations from the baseline (either
increase or decrease of heart rate)
C. Moderate – the amplitude range is 6-25 beats per
minute; if greater than 25, this is called marked
variability
 Example: Basic or basal fetal heart rate is 110,
having an increase of 116-120 would mean a
moderate variability
D. Acceleration – increase of FHR related to the uterine
contraction or intrauterine stress
E. Deceleration – drop of FHR also caused by uterine
contraction or intrauterine stress
Fetal Formation:
 When assisting pregnant client in rhythm strip testing,
procedures, or tests, we assist them in left side lying
position or semi-fowler (have them in semi-fowler
position before doing the left-side lying position)
 Have this in a lounge chair, examination table or bed
with elevated backrest to prevent uterus from
compressing the vena cava and causing supine
hypotension syndrome or vena cava syndrome
 If you let the woman lie towards the left, this will
release the pressure occluding the inferior vena cava;
if the mother maintains complete bed rest flat on her
back, it can cause hypotension or poor circulation due
 to the compression of the inferior vena cava  measures the response of the fetal heart rate to
Rhythm Strip Testing: requires woman to remain in a the fetal movement
fairly fixed position for 20 minutes. As a nurse, you
should:
1. Keep her well-informed of the purpose of
the test
2. How it is interpreted
3. The meaning of the results after the test

 The more she understands the process, the better she

can cooperate for it to be successful.
 Position a woman and attach both fetal heart
rate and uterine contraction monitor. Instruct
Cardiff Count to Ten Movement Method
to push a button attached to the monitor (like a
 A woman records the time interval for her to feel call bell) when she feels the fetal moves and
10 fetal movements creates a dark mark on the paper tracing at this
 Similar to Sadovsky method however, in this time.
method, we use this chart
 Occurs within 60 minutes
 When the fetus moves, the fetal heart rate
 Assure the woman that fetal movements do vary
should increase about 15 beats per minute and
especially in relation to sleep cycle of the fetus,
remain elevated for 15 seconds. It should
her activity, and the last time since the last time
decrease to its average rate again as the fetus
she ate.
quiets.
Otherwise, she can be anxiously worried that her
fetus may be in jeopardy when the fetus is just  If no increase in beats per minute is noticeable
having an inactive time. on fetal movement, poor oxygen perfusion of
 One thing that could be done if mother notes a the fetus is suggested.
decrease in fetal movement is to let the mother
eat, jar the abdomen of the mother as if we are  Duration: 10-20 minutes
awakening the fetus, ring a bell of play a sound so
that the fetus is awake in monitoring the fetal
movement Results:

Reactive - if two acceleration of fetal heart

rate by 15 beats or more lasting for 15 seconds
occur after movement within chosen time
period

Non-reactive – if no acceleration occur in the

fetal movements; if no fetal movement occur
if there is low short term fetal heart rate
variability (less than 6 beats per minute
throughout testing period)

 If a 20-minute period passes without any fetal

movement, it may mean the fetus is sleeping.
Other reasons for lessen variability are:
- maternal smoking
- drug use
4. Nonstress Testing (CardioTocogram) – -hypoglycemia

 If woman is given an oral carbohydrate snack

such as orang juice, it increases blood glucose
level enough to cause fetal movement
 Can also be stimulated by a loud sound to
cause fetal movement
  Both rhythm strip and nonstress testing are
non-invasive procedures and cause no risk to
mother and fetus. It can be used as screening
procedures to all pregnancies and can be
done home daily as a home monitoring
program for the woman who is having a
complication of pregnancy
5. Contraction Stress Testing – fetal heart rate is
analyzed similar to nonstress testing but in this, it
is used in conjunction to contractions.
Contraction is induced by administering oxytocin.
 Oxytocin Challenge Test – medication or
artificial hormone which induces contraction
to the uterus
 Nipple Stimulation test – rolling nipple
between the fingers induces the release of
natural oxytocin which causes the uterus to
contract or induce stress to the fetus.
Monitor the relation of fetal heart rate with the
contraction of uterus.
Results:
 “NEGATIVE” (normal) – shows no
deceleration on 3 contractions.
 “POSITIVE” (abnormal) – on CTG with
3 contractions and with deceleration
CardioTocogram (CTG)
 Used in rhythm strip testing, nonstress testing,
contraction stress testing
 Purpose: effect of contraction to the fetal well-
being. Contraction will serve as the stressor
Cardio – heart
Toco – contraction
 CTG paper – shows the relation between FHR
(upper graph) and uterine contraction (lower
graph)
 Contraction – can see the intensity, how strong it
is, how frequent, and how close is one contraction
to the other
 Small boxes – point in time during the testing
when the fetus moves; can see how baby reacted to
every movement and contraction
 Baseline rate – average heart rate of the fetus
within a 10-minute window; one box is one minute
 Blue shaded part – normal rate of the fetus; goes
beyond means there is a variability
Stimulated or acceleration (heart rate increases) – fetus
is reactive; good well-being
Increase in intensity (heart rate drops) – fetus cannot
compensate with the stress; fetal distress
 Visually attach the mother to a CTG q4h until she
is in the labor room until she delivers the newborn
and take it for 10 minutes at least.
6. Vibroacoustic Stimulation – applied to mother’s
abdomen. This produces a sharp sound of approximately
80 decibels at a frequency of 80 hertz, startling and waking
the fetus.
 Used in conjunction with stress testing or nonstress
testing. Sound is induced to awaken the baby and
monitor accurately the fetus movements.
7. Ultrasonography (Ultrasound) – used tool in modern
obstetrics.
 Can diagnose pregnancy as early as 6 weeks
gestation, confirm the presence, size, and location
of placenta and amniotic fluid
 Establish if fetus is growing and has no gross
anomalies such as hydrocephalus, anencephaly, or
spinal cord, heart, kidney and blood defects
 Establish sex if penis is revealed, presentation and
position of fetus, predict maturity by measurement
of biparietal diameter of the head
 Before ultrasound examination, make sure woman
has received a good explanation of what will
happen and reassurance that the process does not
involve x-rays
 It is safe for father to remain in the room for the
test
 For the sound waves to reflect best in the uterus to
be held stable, it is helpful if the woman has a full
bladder at the time of the procedure. To ensure
this, have her drink a full glass of water every 15
 minutes begin 90 minutes before the procedure  Placentas can be graded by ultrasound as:
and not void until after the procedure 0 – within 10 to 24 weeks
 Have the woman up to the examination table and 1 – within 30 to 32 weeks
drape for modesty but with abdomen exposed. 2 – 36 weeks
 To prevent supine hypotension syndrome or vena 3 – 38 weeks (fetus is mature)
cava syndrome, place towel under the right
buttock to tip her body slightly so that the uterus 11. Maternal Serum
will roll away from the vena cava
 Gel is applied to her abdomen to improve the
contact of the transducer. Be certain gel is room
temperature or warmer because it can cause
uncomfortable uterine cramping
 Alpha-feto protein (AFP) – if fetus has an open body
Doppler ultrasound velocimetry – uses ultrasound but defect, there will be an increase level of AFP produced
focuses on the velocity at which red blood cells in the by the fetal liver and will be present in the amniotic
uterine and fetal vessels travel. fluid because of leakage of the AFP into the fluid
which can be detected in the serum.
8. Biophysical Profile – prenatal test used to check on the
baby’s well-being than any single assessment. May be Level will be decreased in case the fetus has
done as often as daily during high-risk pregnancy. chromosomal defects such as down syndrome.

a. Fetal Breathing  Increase – congenital defect

b. Fetal movement Decrease – down syndrome or chromosomal defect
c. Fetal tone – muscle tone
d. Amniotic Fluid Volume – 12 to 15cm  Best taken after 11 weeks AOG (Age of Gestation)
 Oligohydramnios – low amniotic
index 12. Amniocentesis – involves entering the amniotic sac
 Polyhydramnios – excessively guided with ultrasound imaging to aspirate amniotic fluid
high amniotic index for a variety of diagnostic exams to detect fetal well-being
* all 4 are via Sonogram and uses fetal ultrasound* or lack thereof.
e. FHR – NST

 AFP
 Acetylcholinesterase
 Bilirubin
 Genetic Analysis
 Color
Score:  Fibronectin
8- 10 (fetus is doing well)  Inborn Errors of Metabolism
6 (suspicious)  Lecithin/ Sphyngomyelin Ratio (2:1)
Less than 4 (fetus is Endo carding)
Major risks include:
9. Modified Biophysical Profile - Trauma
a. Amniotic Fluid Index (AFI) - Infection
b. Nonstress testing (NST) - Abortion
- Pre-time labor
If the MBPP shows abnormal finding, then a full
biophysical profile is done.  Since this is an invasive procedure, informed consent
is a MUST. It is done starting at 18 weeks AOG up to
10. Placental grading 30ml of amniotic fluid is obtained.
 Preparation: We ask the woman to void to reduce the
size of the bladder and prevent an in advert puncture.
 If the bladder is full or large, the needle might hit the
bladder instead of puncturing the amniotic sac.
 Position: Supine, Have the woman up to the
examination table and drape for modesty but with
abdomen exposed.
 To prevent supine hypotension syndrome or vena
cava syndrome, place towel under the right buttock
to tip her body slightly so that the uterus will roll
away from the vena cava
13. Percutaneous Umbilical Blood Sampling – done
during the 2nd to 3rd trimester and uses ultrasound to
locate the umbilical cord. Cord blood is aspirated and
tested.
 Cordocentesis
 Via UTZ
14. Fetoscopy (at 16 to 17 weeks) – fetus is visualized by
inspection through a fetoscope.
Fetoscope – an extremely narrow hallow tube inserted by
amniocentesis technique; Helpful in assessing fetal well-
being
MATERNAL LIFESTYLE AND ENVIRONMENTAL
HAZARDS TO THE FETUS
Teratogen – any factor, chemical, or physical that
adversely affects the fertilized ovum, embryo, or fetus.
The typical manifestations of teratogenesis:
 Restricted growth or death of fetus
 Carcinogenesis or malformation – defects in
organ structure or function
This is not only risky for the mother but there is a
possibility of paternal exposure that happens when
substances alter the quality, size, shape, performance, and
production of sperm and may put the fetal at risk.
Teratogens include:
 Smoking
 Recreational drugs
 Medically prescribed drugs
 Alcohol
 Caffeine
 Radiation – not all radiation is harmful; danger
refers to large amounts of exposure
 Environmental chemicals
 Occupational hazards
 Infectious agents/viruses e.g. T-O-R-C-H
 Toxoplasmosis
 Other diseases like syphilis
 Rubella or German measle
 Cytomegalovirus
 Herpes Simplex type 1 & 2)
People infected with these diseases should be kept
away from pregnant women since they are highly
teratogenic.
FDA Pregnancy Categories
 Always look for drug category before administering to
pregnant women
 When giving medications, even if prescribed, it should
be checked
 Do not take over the counter drugs especially if
pregnant
 Most medication belong to category “A”
 The rest has risks that outweighs the benefits
Notes to Remember:
 Ovulation usually happens in the middle of the cycle.
It is not always at the middle. Regardless if irregular
or regular period, you need to subtract 14 days from
the day she had her first day of menstruation (LMP).
This is how you count the days of ovulation.
 Life span: sperm (5 days) and ovum (1 day)
 Most fertile days especially when we do family
planning:
 Fertile window – counted 5 days before ovulation
(considered as life span of sperm) and 1 day after the
ovulation, having a leeway for the ovum to survive 24
hours
 Thelarche – development of the breasts of females;
part of secondary characteristics of development of the
breast
 In doing prenatal assessment, promote comfort and
safety (in all assessment). Since it involves abdominal
palpation, check the fundal height, locate the fundus
and ensure you have warm hands. Ask permission and
properly drape the client.
 In listening to fetal heart sounds, make sure the
stethoscope is also warm because this can cause
contractions to the abdominal muscles of the mother
 Before putting mother onto bed, have her void first
because once you measure the fundal height, it can
alter the measurements and upon palpation, it can
increase the urge to void. Urine sample is an example
of laboratory test used.
 The best source of contraction for us to assess is in
the fundus then palpate the area
 Langerhans layer – protective element of the
chorionic villi that protects fetus from virus and is
effective within the first 20 weeks only and
diminishes its function with the rest of gestation (if
mother is infected with syphilis, it would prevent
fetus to have it because it serves as a protective
barrier)
 If the baby is born <20 weeks, <500 grams =
ABORTUS (less chance of survival
 During fetal circulation, lungs has no function at all.
It only function when the fetus is expelled out of the
mother (if baby cry, lungs has expanded, it is already
functioning)
 During embryonic stage, fetus undergoes
organogenesis (most critical time in fetal
development especially if exposed to teratogens)
 Start from the ovary (fertilized)
 Then it is implanted (implantation to 8 weeks =
zygote)
 first 8 weeks = embryo (undergoes
organogenesis)
 If any kind of teratogen is exposed, it can alter
formation of organs “congenital defects”
 Exposure of teratogen in 2nd and 3rd trimester has
less likely effects of teratogens compared to the 1st
trimester. During 2nd and 3rd trimester by size,
height and weight
 Kick count pregnancy – activity done by mother at
home for monitoring. Nurse should also encourage
and teach mother to find ways for the baby to move
because if it does not move, it is a danger sign and
could warrant mother to seek medical treatment
(distress, not well, or dead)
Ways to stimulate the fetus:
1. Instruct mother to take a high carbohydrate meal
2. Jar her abdomen (no need to be scared because
abdomen is a good shock absorber and it has large
amounts of amniotic fluid)
3. Vibroacoustic stimulation (playing music to
heightened the sensation of the fetus)

*If all methods fail, immediately go to hospital (usually

CTG that monitors heart rate of fetus)*

Estimated date of delivery (EDD)

Estimated date of confinement (EDC)
Estimated date of birth (EDB)
*all three are the same*