2600_Module 3

Module 3: Pregnancy
Readings
 Maternity
o Ch 10 Fetal Development and Genetics
o Ch 11 Maternal Adaptation During Pregnancy
o Ch 12 Nursing Management During Pregnancy
 Caroline’s
o Ch 42 Obstetric Emergencies

Key Terms
Mosaicism
Morial
Organogenesis
Polyploidy
Ballottement
Chadwick’s sign
Goodell’s sign
Hegar’s sign
Linea nigra
Alpha-fetoprotein
Amniocentesis
Teratogen
Learning Objectives Notes
Review the anatomy and physiology
of the female reproductive system
Explain the process of fertilization, Conception and gestation
implantation, and cell Fertilized egg is implanted in the endometrium
differentiation  Major physiological, hormonal, and chemical changes
 Egg begins absorbing uterine fluid
 Blastocyst
 Occasionally the mechanisms of implantation may result in vaginal bleeding that is spotty and painless

Describe the functions of the
placenta, umbilical cord, and
amniotic fluid
Summarize fetal development from
conception through to birth
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Development of placental tissues
 Triggered by implantation
 Stimulates the release of human chorionic gonadotropin hormone
 Corpus luteum produces hormones designed to support the pregnancy
 Embryonic disc
 Lacunae
Placenta
Serves as the interface between the mother and fetus
Makes hormones to control the physiology of the mother
Protects the fetus from immune attack by the mother
Removes waste produces from the fetus
Induces the mother to bring more food to the placenta
Produces hormones that mature fetal organs
Umbilical cord
Formed from the amnion
Lifeline from the mother to the growing embryo
One large vein and two small arteries
Wharton’s jelly surrounds the vein and arteries to prevent compression
Amniotic sac
Membranous bag that encloses the fetus in a watery fluid
Amniotic fluid
 Helps maintain a constant body temperature for the fetus
 Permits symmetric growth and development
 Cushions the fetus from trauma
 Allows the umbilical cord to be relatively free of compression
 Promotes fetal movement to enhance musculoskeletal development
In later stages of pregnancy, the fetus swallows amniotic fluid and passes wastes out into the fluid
Pre-embryonic stage: fertilization through 2nd week
 Fertilization; cleavage; morula
 Blastocyst and trophoblast
 Implantation
Embryonic stage: end of 2nd week through 8th week
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 Embryo: 3rd week after conception

o Ready to begin the process of forming specialized body systems
o S-shaped tubular heart begins to beat
o Blood cells begin to circulate
o Embryonic layers
 Ectoderm: forms the central nervous system, special senses, skin, and glands
 Mesoderm: forms skeletal urinary, circulatory, and reproductive organs
 Endoderm: forms respiratory system, liver, pancreas, and digestive system
Fetal stage: end of the 8th week until birth
Fetal circulation
Blood from the placenta to and through the fetus and then back to the placenta
Three shunts during fetal life:
1. Ductus venosus: connects the umbilical vein to the inferior vena cava
2. Ductus arteriosus: connects the main pulmonary artery to the aorta
3. Foramen ovale: anatomical opening between the right and left atrium
Only a small portion of the blood flows to the non-functioning lungs
Pathway of circulation
Umbilical vein carries oxygenated blood from the placenta to the fetus
Umbilical arteries carry deoxygenated blood to the placenta
Bypasses the lungs until birth

Gestational period
The time that is takes for the infant to develop, normally 40 weeks to reach full-term
Calculated from the first day of the pregnant woman’s last menstrual period
First trimester
Fourth through eighth weeks and critical for normal development. Major organs and other body systems are
forming. Prescription and OTC medications may have harmful side-effects, as well as illicit drugs, tobacco,
alcohol, or toxic materials
 4th week
o Basic structures of major body organs and external features (table 10.1)
 Heart appears as a prominent bulge on anterior surface
o Spinal cord is formed and fused at midline
 8-12 weeks
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o Fetus begins to move, some reflexes are present

o Fetal heart can be heard with Doppler
 12th week
o Urine secretion begins
Second trimester
 16th week
o Looks like a baby
o Lanugo: fine hair; keeps oil on skin
o Baby’s sex can be seen on ultrasound
o Active movement present
o Makes breathing movements
o Swallows amniotic fluid
o Urine is present in amniotic fluid
 20 week
th

o Vernix: protective, cheese-like substance that protects skin

o Sleep and wake cycles present
o Mother feels “quickening”
o Hair begins to form
o Brown fat begins (needed for temperature regulation at birth)
 24 week
th

o Can hear
o Eyes now able to open
o Lung surfactant begins to be produced
o Grasp and startle reflexes reflex
o Fetus is truly viable
Third trimester
 28th week
o Head hair, eyebrows, and eyelashes present
o Lung alveoli begin to mature, surfactant can now be found in the amniotic fluid
o Testes begin to descend into the scrotal sac
o Blood vessels of retina are formed but thin
 32 week
nd

o Subcutaneous fat is being laid down


Outline the various inheritance
patterns, including non-traditional
patterns of inheritance
Discuss ethical and legal issues
related to genetic testing
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o Responds to sound outside of mother’s body by moving
o Active Moro reflex
 36th week
o Additional subcutaneous fat deposited
o Lanugo begins to decrease
o Moves to a vertex presentation
o One or two crisscross creases on the sole of the feet
 th
40 week
o Fetal hemoglobin begins to convert to adult hemoglobin
o Creases on the soles of feet cover at least two thirds
Inheritance
Genes: individual units of heredity of all traits
 Organized into long segments of deoxyribonucleic acid (DNA) that occupy a specific location on a
chromosome
 Determine a characteristic in an organism; physical and mental characteristics of humans
Chromosome: long, continuous strand of DNA carrying genetic information
Karyotype: pictorial analysis of number, form, and size of chromosomes
Patterns of inheritance
Mendelian or monogenic disorders
 Autosomal dominant inheritance
 Autosomal recessive inheritance
 X-linked inheritance
o X-linked recessive inheritance
o X-linked dominant inheritance
Multifactorial disorders
Non-traditional inheritance
Genetics
Study of heredity and its variation
Genome: genetic blueprint determines genotype (genetic makeup) and phenotype (observable outward
characteristics)
Human genome project
The international collaborative research program whose goal was the complete mapping and understanding of
all the genes of human beings

Discuss advances in the science of
human genetics and multifactorial
influences on genetics and fetal
development
Define epigenetics
Distinguish between subjective,
objective, and diagnostic signs of
pregnancy
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 Primary goal: translate the findings into new strategies for prevention, diagnosis, and treatment of
diseases and disorders
 Application to heatlh care: rapid and more specific diagnosis
o Ethical, legal, and social considerations: how information would be interpreted and used, who
would have access to it, and how could society prevent harm form improper use of genetic
information
Examines factors other than the DNA sequence in organism development:
 Environment
 Nutrition
 Inheritance
 Behaviour
 Stress
Will have significant impact on public health
Presumptive signs (subjective)
 Fatigue (12 weeks)
 Breast tenderness (3-4 weeks)
 Nausea and vomiting (4-14 weeks)
 Amenorrhea (4 weeks)
 Urinary frequency (6-12 weeks)
 Hyperpigmentation of skin (16 weeks)
 Fetal movements, “quickening” (16-20 weeks)
 Uterine enlargement (7-12 weeks)
 Breast enlargement (6 weeks)
Probable signs (objective)
 Braxton Hicks contractions (16-28 weeks)
 Positive pregnancy test (4-12 weeks)
 Abdominal enlargement (14 weeks)
 Ballottement (16-28 weeks): a sharp upward pushing against the uterine wall with a finger inserted

Describe the physiological changes
that occur in the pregnant patient
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into the vagina for diagnosing pregnancy by feeling the return impact of the displaced
 Goodell’s sign (5 weeks): softening of the cervix
 Chadwick’s sign (6-8 weeks): bluish-purple colour of the vaginal mucosa and cervix
 Hegar's sign (6-12 weeks): softening of the lower uterine segment
Positive signs
 Ultrasound verification of embryo or fetus (4-6 weeks)
 Fetal movement felt by experienced clinician (20 weeks)
 Auscultation of fetal heart tones via Doppler (10-12 weeks)
Uterus
Increases in size, weight, length, width, depth, volume, and overall capacity
Pear shape to ovoid shape; positive Hegar’s sign
Enhanced uterine contractility; Braxton Hicks contractions
Ascent into abdomen after first 3 months
Measurement of fundus:
 Can indicate several developmental problems
 Top of the pubic bone to the top of the fundus
 Length in cm roughly corresponds to length of gestation – until 36 weeks’ gestation
o 20 weeks: level of umbilicus, 20 cm
Cervix
Softening, Goodell’s sign
Mucous plug formation
Increased vascularization, Chadwick’s sign
Ripening about 4 weeks before birth
Vagina
Increased vascularity with thickening
Lengthening of vaginal vault
Secretions more acidic, white, and thick; leukorrhea
Ovaries
Enlargement until 12-14th week gestation
Cessation of ovulation
Breasts
Increase in size and nodularity to prepare for lactation; increase in nipple size, becoming more erect and
pigmented
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Production of colostrum; antibody-rich, yellow fluid that can be expressed after the 12 th week; conversion to
mature milk after delivery
GI system
Gums: hyperemic, swollen, and friable; dental problems: gingivitis
Ptyalism
Decreased peristalsis and smooth muscle relaxation; constipation
Constipation with increased venous pressure and pressure from uterus causes hemorrhoids
Slowed gastric emptying; heartburn
Prolonged gallbladder emptying
Nausea and vomiting
Cardiovascular system
Increase in blood volume (50% above pre-pregnant levels)
 The average woman has about 4-5 L of blood available
 Blood volume increases gradually throughout gestation
o Meets the metabolic needs of the fetus
o Adequately perfuse maternal organs
o Helps to compensate for blood loss
Increase in cardiac output; increased venous return; increased heart rate
 Size of heart increases
 Supine position can impinge the inferior vena cava. If the pressure is not released: cardiac output is
decreases, blood pressure drops, and lower extremity edema will result
Slight decline in blood pressure until mid-pregnancy, then returning to pre-pregnancy levels
Increase in number of RBCs; plasma volume > RBC leading to hemodilution (physiologic anemia)
 Increases the need for iron: prenatal vitamins
 WBC count also increases
Increase in iron demands, fibrin and plasma fibrinogen levels, and some clotting factors, leading to
hypercoagulable state
 Bedridden are at risk of experiencing deep venous thrombus
Respiratory system
Breathing more diaphragmatic than abdominal due to increase in diaphragmatic excursion, chest
circumference, and tidal volume
 Uterus pushes the diaphragm up toward the abdominal cavity
 Rib margins flare outward to compensate
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 Abdominal muscles tend to lose their tone during pregnancy

Increase in oxygen consumption
 Progesterone decreases the threshold of the medullary respiratory center to carbon dioxide
 Oxygen consumption increases by about 20%
 Tidal volume increases gradually to about 40%
 Slight increase in plasma pH levels
 Respiratory alkalosis is balanced by metabolic acidosis
Congestion secondary to increased vasculature
Renal system
Dilation of renal pelvis; elongation, widening, and increase in curve of ureters
Increase in length and weight of kidneys
Increase in GFR; increased urine flow and volume
Increase in kidney activity with woman lying down; greater increase in later pregnancy with woman lying on
side
Musculoskeletal system
Softening and stretching of ligaments holding sacroiliac joints and pubic symphysis
Postural changes: increased swayback and upper spine extension
Forward shifting of center of gravity
Increase in lumbosacral curve (lordosis): compensatory curve in cervicodorsal area
Waddle gait
Integumentary system
Hyperpigmentation; mask of pregnancy (facial melasma)
Linea nigra
Striae gravidarum
Varicosities
Vascular spiders
Palmar erythema
Decline in hair growth; increase in nail growth
Endocrine system
Thyroid gland: slight enlargement; increase activity; increase in BMR
Pituitary gland: enlargement; decrease in TSH and GH; inhibition of FSH and LH; increase in prolactin and MSH;
gradual increase in oxytocin with fetal maturation
Pancreas: insulin resistance due to hPL and other hormones in 2nd half of pregnancy

Discuss various pre-existing medical
conditions that can compromise the
woman and the developing fetus
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Adrenal glands: increase in cortisol and aldosterone secretion
Prostaglandin secretion
Placental secretion: hCG, hPL, relaxin, progesterone, estrogen
Metabolic changes
Weight gain
 Intracellular and extracellular fluid
 Uterine growth
 Placental growth
 Fetal growth
 Breast tissue
 Increase protein and fat deposits
 Average weight gain is 12.3 kg
Relaxin
 Hormone released during pregnancy that causes collagenous tissues to soften
 Generalized relaxation of the ligamentous system
 Contributes to lordosis of later pregnancy and increased flexion of the neck
Demand for carbohydrates
 Fetal demand for glucose
 Insulin is unable to pass through the placental barrier
 May become diabetic (gestational diabetes)
 Homan chorionic somatomammotropin
Heart disease
Hypertension
Diabetes
Respiratory disorders
Renal disorders
Hemoglobinopathies
Viruses and parasites
 Group B streptococcus
o Leading cause of life-threatening infections in newborns
o Women are not routinely screened for it as it is controversial
o Caused by Streptococcus agalactiae
o Can cause respiratory problems, pneumonia, septic shock, and meningitis

Discuss maternal and fetal
nutritional needs
List the emotional and psychological
changes that occur during
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Epilepsy
Isoimmunization (Rh disease)
 Rh factor is a protein found on the RBC of most people
 Maternal antibodies to the factor
 Not normally a problem in first pregnancies
 Can result in death for the fetus or hemolytic disease in a newborn
Cholestasis, disease of the liver
 Occurs during pregnancy
 Slows down or blocks the normal bile flow, causing it to spill into the bloodstream
 Profuse, painful itching
 Colour changes in waste elimination
 Relatively benign for the pregnant woman
 Can have serious effects on the fetus
Gestational diabetes mellitus
Inability to process carbohydrates
 Increased maternal insulin production
o Increased placental production of lactogen
o Imbalance between the mother’s insulin and glucose production
 Patient may be asymptomatic
 Diet control and insulin therapy if required
Nutritional needs
Direct effect of nutritional intake on fetal well-being and birth outcome
Need for vitamin and mineral supplement daily
Dietary recommendations:
 Increase in protein, iron, folate, and calories
 Use of Canada’s Food Guide
 Avoidance of some fish due to mercury content
All women should aim for a steady rate of weight gain throughout pregnancy
 1st trimester: pre-pregnant weight is in the normal range, the overall weight gain should be about 2 kg
 2-3rd trimester: weight gain of about 0.5 kg per week
 Weight gain expectations should be based on the woman’s BMI
Maternal emotional responses: ambivalence, introversion, acceptance, mood swings, changes in body image

pregnancy
Identify substances that may have
teratogenic effects on the fetus
Explain the components of health
assessment for a woman before and
during pregnancy
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Teratogen: anything detrimental to fetal health
 Medications: prescription or OTC, herbs, recreational drugs
 Infections: TORCH, viral diseases, live virus vaccinations
 Others: alcohol, caffeine, tobacco, environmental, metal and chemical, radiation, hyper- or
hypothermia, and maternal stress
TORCH: toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus
Tobacco: infertility, low birth rate (vasoconstriction of uterine vessels limits blood supply to fetus), stillbirths,
growth restriction, SIDS
Alcohol: no safe level identified, risk of FAS
Caffeine: high intake (>3 cups a day) increases risk of low birth weight and increased risk of miscarriage
Preconception care
Immunization status
Underlying medical conditions
Reproductive health care practices
Sexuality and sexual practices
Nutrition
Lifestyle practices
Psychosocial issues
Medication and drug use
Support system
Comprehensive health history
Reason for seeking care
 Suspicion of pregnancy
 Date of last menstrual period
o Age at menarche, days in cycle, flow characteristics, discomforts, use of contraception
 Signs and symptoms of pregnancy
 Urine or blood test for hCG
Past medical, surgical, and personal history
Woman’s reproductive history: menstrual, obstetric, and gynecologic history
Obstetric history
Gravida: a pregnant woman
 Gravida I (primigravida): first pregnancy

Discuss the components of fetal
health assessment
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 Gravida II (secundigravida): second pregnancy
Para: a woman who has produced one or more viable offspring carrying a pregnancy 20 weeks or more
 Primipara: one birth after a pregnancy of at least 20 weeks
 Multipara: two or more pregnancies resulting in viable offspring
 Nullipara: no viable offspring, para 0
Terminology
 G (gravida): the current pregnancy
 T (term births): the number of pregnancies ending >37 weeks’ gestation, at term
 P (preterm births): the number of preterm pregnancies ending >20 weeks or viability but before
completion of 37 weeks
 A (abortions): the number of pregnancies ending before 20 weeks or viability
 L (living children): number of children currently living
Physical examination
Vital signs
Head-to-toe assessment
 Head and neck, chest, abdomen including fundal height if appropriate, extremities
Pelvic examination
 Examination of external and internal genitalia
 Bimanual examination
 Pelvic shape: gynecoid, android, anthropoid, platypelloid
 Pelvic measurements: diagonal conjugate, true (obstetric conjugate), and ischial tuberosity
Laboratory tests
Urinalysis, complete blood count, blood typing, Rh factor, rubella titer, hepatitis B surface antigen, HIV, VDRL,
and RPR testing, cervical smears, and ultrasound
Ultrasonography
Alpha-fetoprotein analysis
Marker screening tests
Amniocentesis
Chorionic villus sampling (CVS)
Percutaneous umbilical blood sampling (PUBS)
Nonstress test; contraction stress test
Biophysical profile
Doppler flow studies

Discuss approaches used in health
promotion and comfort during
pregnancy
Describe the various approaches to
perinatal care in Canada
Demonstrate appropriate patient
assessment and management of a
patient in active labour and/or
imminent delivery
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Preparation for labour, birth, and parenthood – perinatal education
Lamaze (psychoprophylactic) method: focus on breathing and relaxation techniques
Bradley (partner-coached childbirth) method: focus on exercises and slow, controlled abdominal breathing
HypnoBirthing: aims for a trance-like state in the woman, decreasing need for medications and minimizing her
stress during childbirth
Birthing from within: stresses self-discovery as the essence of childbirth preparation
Options for birth setting:
 Hospitals: delivery room, birthing suites
 Birth centers
 Home birth
Options for care providers:
 Obstetrician
 Midwife
 Doula