Conception and Pregnancy

• Fertility problems arise from male or female factors
• Pregnancy averages 40 weeks or 280 days; viability depends on hospital standards, typically aiming for longer than 24 weeks to aid fetal lung development

Calculating Estimated Delivery Date (EDD)

• Nagel's Rule: Determine first day of LMP, subtract 3 months, and add 7 days
  • Example: If LMP is July 20, subtract 3 months to April, then add 7 days, making the due date April 27

Conception and Pregnancy Initiation

• Egg travels from the ovary to the fallopian tube
• Sperm meets the ovum, combining 23 chromosomes from each
• Fertilization prompts movement to the uterus
• Sperm determines the gender: X for female, Y for male
• The fertilized egg floats in the uterus for 7-10 days then implants
• The first 14 days post-conception is the pre-embryonic phase
• Rapid cell division and differentiation occur
• The endometrium and embryo develop simultaneously

Cell Differentiation

• Some cells form the embryonic membrane filled with amniotic fluid, which cushions, protects, and regulates the embryo's temperature
• Yolk sac, later becomes part of the umbilical cord facilitates early RBC formation and connects the embryo to the placenta via 2 arteries and 1 vein(AVA)
• Placenta develops performing metabolic and nutrient exchange between mother and fetus, with fetal side picking up oxygen/nutrients and the maternal side removing waste

Placenta

• Temporary, lasting about 40 weeks, becomes less effective afterward
• Consists of 2 arteries and 1 vein (AVA)
• Fetal blood circulates to the placenta through arteries
• Oxygen-rich blood returns to the fetus through the vein
• Metabolic tasks include producing glycogen, cholesterol, and fatty acids for the fetus
• Transports O2, CO2, electrolytes, etc
• Vital hormone provider for survival: HCG, estrogen, progesterone, relaxin, etc
• Progesterone & HCG prevent antibodies against the embryo & placenta by preventing recognition as a foreign body

Fetal Circulation

• A well-perfused placenta ensures adequate blood, nutrients, and oxygen, while removing CO2 and waste
• The fetus has unique blood flow
• Ductus venosus bypasses the liver
• Foramen ovale bypasses the atria
• Ductus arteriosus bypasses the lungs

Fetal Development Stages

• Embryo Stage: From 3 to 8 weeks of gestation

  • Highly susceptible to teratogenesis causing congenital malformations
  • 4 weeks: Fetal heart begins to beat
  • 6 weeks: Fetal circulation is established

• Fetus Stage: 8+ weeks

• 8-12 weeks: FHR detectable via Doppler

• By 12 weeks, gender can be determined, all organs are formed but require maturation

• 20 weeks: Quickening, lanugo, and vernix appear, plus brown fat

• 24 weeks: Lungs begin surfactant production to aid development of alveoli

• 28 weeks: Nervous system begins the regulatory process

• 35-36 weeks: Subcutaneous fat accumulates for plumping effect

• 38-40 weeks: Minimal vernix and lanugo remain

Effects of Substance Abuse on Pregnancy

• Teratogenic medications can cause harm
• Tobacco – causes poor growth, vasoconstriction of blood vessels
• Cocaine - causes vasoconstriction, may cause abruption
• Opiates – lead to miscarriage, premature rupture of membranes, preterm labor/birth, fetal death, neonatal abstinence syndrome(NAS)
• Sedatives – withdrawal syndrome, seizures, delayed lung maturity
• Amphetamines – lead to fetal growth restriction, cardiac anomalies, prematurity, & abruption
• Marijuana - causes preterm birth, delayed cognitive/language development & growth restriction

Cultural Competence

• Awareness of culture, avoid stereotyping, assess own biases, ask questions, and show respect
• Be aware of home remedies, PICA, chiropractic care, old wives’ tales, traditional healers, birth rituals, and multigenerational practices

Signs and Symptoms of Pregnancy

• Presumptive S&S: Amenorrhea (absence of menses), N/V, breast changes, excessive fatigue, quickening, urinary frequency, and skin changes
• Objective (Probable) S&S: Abdominal enlargement, Goodell's, Hegar's, Piskacek's, and Chadwick's signs, Braxton Hicks contractions, + pregnancy test & ballottement

Confirming Pregnancy

• Detecting the fetal heartbeat
• Palpating fetal movement
• Visualization of the fetus via ultrasound

Physical Changes due to Pregnancy

• Vaginal discharge changes, breast enlargement, and vasodilation of breasts and labia
• Breathing difficulties, increased rate, increased demand, and nasal mucus congestion
• Blood volume increases, temporary murmur, reduced activity and edema
• Reflux, constipation, N/V, gallstones or excessive saliva
• Rashes, hair changes, linea nigra/stretch marks and chloasma/melasma
• Diastasis recti, lordosis, and round ligament pain
• Syncope, attention span decreases, memory lapses, causes "pregnancy brain" and temporary carpal tunnel symptoms
• Endocrine effects of enlarged parathyroid/thyroid glands and increased prolactin

Antepartum Care:

• Gravida: Total number of pregnancies, including current one, even if short-lived
• Para: Number of births after 20 weeks, regardless of outcome

TPAL Acronym

• T: Number of term births (37+ weeks)

• P: Number of preterm births (20 to 36+6 weeks)

• A: Number of abortions/miscarriages (ended before 20 weeks)

• L: Number of living children

• Example documentation: G3 P2, 1102

Prenatal Care and Assessment

• Collect data about LMP, past pregnancies, & medical/family/genetic history and psychosocial/occupational factors
• Assess for high-risk factors; maternal age, substance use, nutrition status, preexisting medical conditions, STI's
• Complete a physical assessment
• Conduct lab tests

Prenatal Visit Schedule

• Until 28 weeks, monthly prenatal visits are needed
• Then bi-weekly until 36 weeks, and then weekly until delivery with monitoring of weight, VS, urinalysis, FHR, and fundal height
• Address concerns, discuss prenatal education, and common symptoms

Maternal Nutrition

• Should consist of adequate fluids, does not require "eating for two"
• The mother should consume 300kcal more per day in the 2nd trimester
• Requires adequate carbohydrates, fats, protein, folic acid, iron and calcium,
• Teaching should include MyPlate recommendations, postpartum considerations, history of disordered eating, adolescent concerns, PICA

Fetal Well-Being

• Kick counts - at least 10 movements in 2 hours
• Ultrasounds - transabdominal and transvaginal
• Umbilical doppler studies, testing for birth defects and chorionic villus sampling

Fetal Surveillance

• Normal fetal HR ranges from 110-160 bpm
• Non-Stress Test (NST) measures heartbeat accelerations
• Reactive: >/= 2 accelerations, 15+ beats, lasting 15 seconds over 20 minutes. reactivity is achieved when fetus is 32 weeks; 28 weeks signifies reactivity at 10 beats for 10 seconds
• Nonreactive: The requirements are unmet
• Biophysical Profile (BPP): Ultrasound assessment to check fetal breathing, movement, tone, and amniotic fluid
• Assesses scores of 2 on 4 portions of ultrasound; given 2 points for reactive NST and a zero for nonreactive
• Scores of 8 or under require immediate action

Contraction Stress Test (CST)

Evaluates ability to oxygenate fetus when exposed to contraction stresses - healthy baby will maintain HR

• Negative results mean no deceleration after at least 3 contractions (in 10 minutes)
• Positive Results mean repetitive late decelerations and contractions

Amniocentesis

• Amniocentesis gathers amniotic fluid for genetic or lung maturity testing around 16-39 weeks but do not require patients to fast
• Fluid pockets are located using an US
• Local anesthetic and cleaning occur during procedure
• Monitor post-procedure for labor S&S, ROM, and infection

Fetal Lung Maturity

• Lung’s surfactant allows elasticity in lungs; develops quickly by the pregnancy’s end
• Components for evaluation involve testing lecithin and sphingomyelin, then calculating the ratio amount
• A 2:1 L/S indicates readiness

Chorionic Villus Testing (CVT)

• Used only when the fetus’s life is endangered
• Sampling chorionic villi from the placenta development to perform genetic testing; performed at 10–12 weeks
• Tests and risks equal amniocentesis

Diabetes Mellitus & Pregnancy

• Macrosomia can result from increased insulin resistance in pregnancy’s second half
• S&S involve shakiness, lethargy or hypoglycemia, irritability, shakiness; baby may need oxygen post birth

Anemia

• Requires prompt fetus’s oxygenation treatment

HIV

Requires treatment to prevent risk transfer when breast feeding; invasive work is discouraged

Diseases

• Heart Disease - Patients with heart disease could feel effects of high blood and cardiac production
• Psychiatric Conditions – Illnesses require monitoring since treatments might be unsuitable for pregnancy

Bleeding

• Report immediately and evaluate
• Monitor for shock, heart and weight during administration

Pregnancy Endings

• Abortion and Miscarriage cause pregnancy ending prior to 20 weeks
• Performed intentionally OR through medical request
• Spontaneous Abortion (AKA Miscarriage) requires threatened, imminent, incomplete, missed, recurrent, and septic measures.
• It could be threatened and resolved, imminent in the time of the abortion, complete
• OR it could be missed following fetal demise and be completely dangerous unless risks are reported with alloimmunization awareness

Ectopic Pregnancy

• Fertilized ovum requires lining or tube removal
• Sharp, one-sided, syncope indicates condition between 6-8 and 12-16 weeks
• Causes include damage (PID), surgery/IUD, anomalies, DES exposure
• Death is risked in 9% of maternal occurrences
• If identified quickly, methotrexate is viable

GTD

• trophoblastic cells proliferate due to genetic trophoblastic disease
• placental cells overgrow and cause Hydatidiform Mole formation: requires monitoring, assessment, evacuation of clusters and uterus, as well as cancer prevention for 1+ year

Severe Vomiting

Hyperemesis Gravidarum involves treating increased HCG count and excessive vomiting

• Causes include dehydration, imbalanced fluids & low protein
• --Offer small meals to minimize odor
• --Replacing electrolytes & utilizing medications

Infection

Infections are tested through TORCHS

• Feces and cat transmissions cause toxoplasmosis, while rubella and herpes are caused through syphilis

Surgeries

Require shielding, post-op devices, fetal monitoring, and spinal (anesthesia) - avoid general if possible.

Trauma

Requires uterine displacement and delivering during emergencies, or after close monitoring if not - avoid general if possible.

Violence

Requires intervention, with proper questions

• 4-30% occur during risk
• Increase pregnancy and infection risk

Lecture 4

Premature break requires membrane stabilization to avoid early labor S&S, deliver or move to a hospital

• PROM(rupture): check for fluid pooling, looking for paper results
• PROM may avoid vaginal tests to maintain fetal state
• S&S-infection, color and odor
• deliver during delivery/rupture
• IV treatment in term periods