NCM 107 Care of Mother, Child and Adolescent (Well-Clients) PDF

2023 updated by: Jeanette F. Kwok,RN,MAN AY - 2023-24  NURSING PROGRAM NCM 107: CARE OF MOTHER, CHILD AND ADOLESCENT (WELL-CLIENTS) Module 2: Care of the Mother and Fetus dur...

2023 updated by: Jeanette F. Kwok,RN,MAN AY - 2023-24  NURSING PROGRAM NCM 107: CARE OF MOTHER, CHILD AND ADOLESCENT (WELL-CLIENTS) Module 2: Care of the Mother and Fetus during the Perinatal Period Module Overview: Welcome to NCM 107: CARE OF MOTHER, CHILD AND ADOLESCENT (WELL-CLIENTS) Module 2! This module will provide you with the basic knowledge, attitudes and skill regarding the antepartum stage of pregnancy. Together we will be discovering the beginning of life until the preparation for labor and delivery. You will also utilize the nursing process to provide antepartal care for both the mother and child. I hope that we will work together with enthusiasm in the pursuit of your goals to become future nurses. So, lets get started! Module Outcomes: At the end of the discussion the learner should be able to: 1. Assess mother and child’s health status with the use of specific methods and tools to address existing health needs. 2. Formulate nursing diagnosis/es focusing on health promotion and disease prevention related to mother and child health. 3. Implement safe and quality nursing interventions addressing health needs affecting women from pregnancy to postpartum and children from perinatal to adolescent stage. 4. Conduct individual/ group health education activities based on the priority learning needs of mother and child. 5. Evaluate with the client the health outcomes of nurse-client working relationship. 6. Institute appropriate corrective actions to prevent or minimize harm arising from adverse effects. 1|Page Module Content: A. Care of the Fetus  Stages of Fetal Development - Fertilization - Implantation, - Embryonic & Fetal Structures (Decidua, chorionic villi, placenta, Amniotic Membranes, Amniotic Fluid, Umbilical Cord) - Origin & Development of Organ Systems - Estimating Fetal Health (Fetal Growth, Fetal Heart Rate, Ultrasonography B. Care of the Mother  Physiology of Menstrual Cycle  Confirmation of Pregnancy  Local and systematic physical changes including vital signs, review of systems  Psychological Changes of Pregnancy  Psychological Tasks of Pregnancy  Danger signs of pregnancy  Discomforts of pregnancy and nursing interventions  Health history: past, present, potential, biographical data, menstrual history, current pregnancy (EDD, AOG, gravid, para) previous pregnancies & outcomes (TPAL) score, gynecologic history, medical history and nutritional status.  Assessment of body systems  Normal diagnostic/laboratory findings & deviation Pregnancy test, Urine test, Blood test (CBC), ultrasound  Prenatal exercises  Common teratogens and their effects  Preparation for labor and delivery 2|Page Course Content: CARE OF THE FETUS: Process of Conception and Stage of Fetal Development Gamete – is the male or female reproductive cell that contains half the genetic material of the organism. https://ib.bioninja.com.au/higher-level/topic-11-animal-physiology/114-sexual- reproduction/egg-and-sperm.html Female Gamete: Human Egg (Ovum) - reproductive cells that is produced in the ovary. - Largest cell in the female body - Contains 23 chromosomes Haploid Nucleus Contains one copy of each chromosome Cortical granule releases enzymes during fertilization that harden the zona pellucida and digest binding proteins on sperm to prevent POLYSPERMY** after a sperm cell has entered the ovum. Corona radiata External layer of follicular cells which provide SUPPORT and NOURISHMENT to the egg cell. Zona pellucida/ jelly coat Contains glycoprotein matrix which acts as a BARRIER to sperm entry. 3|Page  Male Gamete: Human Sperm (Spermatozoa) - reproductive cells that originates in the testicles - contains 23 chromosomes - smallest cell in the male body - ejaculation of semen averages 2.5 ml of fluid containing 50 to 200 million spermatozoa per milliliter or an average of 400 million sperm per ejaculation Head Acrosome Contains HYDROLYTIC EZYMES which help PENETRATE the jelly coat. Nucleus Contains the PATERNAL DNA (this will combine with maternal DNA if fertilization is successful). Centriole Needed by a zygote in order to divide Midpiece Mitochondria Provide the ENERGY (ATP) needed FOR THE TAIL TO MOVE. Tail/Flagellum Axoneme A (microtubule structure) which BENDS TO FACILITATE MOVEMENT. Conception is also referred as fertilization or impregnation. It is the union of the sperm and the ovum. This usually occurs in the outer third of a fallopian tube, termed the ampullar portion. The period of gestation of the human infant is 38 weeks (about 265 days). These 38 weeks are divided into three stages of unequal length, identified by specific changes within the developing organism. Stages of Fetal Development Sperm and ovum unite, forming a zygote. First 2 weeks, Pre embryonic beginning with The zygote burrows into the Stage fertilization lining of the uterus. Embryonic Week 3 through 8 All the embryo’s organ systems form during the 6- week period following implantation. Fetal From week 8 Growth and Organ through birth refinement. 4|Page THE PROCESS OF CONCEPTION 1. Ovulation Each month inside your ovaries, a group of eggs starts to grow in small, fluid-filled sacs called follicles. Eventually, one mature egg is release from one of the ovaries, which happens every month. A woman is most fertile around the time of ovulation. An ovum is capable of fertilization for only about 24 hours (48 hours at the most). After that time, it atrophies and becomes nonfunctional. Because the functional life of a spermatozoon is also about 48 hours, possibly as long as 72 hours, the total critical time span during which sexual relations must occur for fertilization to be successful is about 72 hours (48 hours before ovulation plus 24hours afterward). 2. Hormones Rise The follicle develops into something called the corpus luteum. The corpus luteum releases a hormone that helps thicken the lining of your uterus, getting it ready for the egg. 3. The Egg Travels to the Fallopian Tube The released egg (ovum) is propelled into a nearby fallopian tube by currents initiated by the fimbriae—the fine, hair-like structures that line the openings of the tubes. A combination of peristaltic action of the tube and movements of the tube cilia help propel the ovum along the length of the tube. It is fertilized in the fallopian by a single sperm. If no sperm is around to fertilize the egg, it moves through the uterus and disintegrates. Your hormone levels go back to normal. Your body sheds the thick lining of the uterus, and your period starts. During the journey, fluids in the female reproductive tract prepare the sperm for fertilization through a process called capacitation or priming. The fluids improve the motility of the spermatozoa. Thinning the membrane in such a way that will help facilitate the release of the lysosomal (digestive) enzymes needed for the sperm to penetrate the oocyte’s exterior once contact is made. Sperm must undergo the process of capacitation in order to have the “capacity” to fertilize an oocyte. If they reach the oocyte before capacitation is complete, they will be unable to penetrate the oocyte’s thick outer layer of cells. ACROSOME REACTION It is the final step undergone by the sperm to penetrate the protective layers of the ovum before fertilization by releasing enzymes to dissolve the ovum’s membrane (HYALURODINASE – proteolytic enzyme) 5|Page 4. ​ Fertilization The process of fertilization takes about 24 hours. Once a sperm has penetrated the egg, the egg surface changes, preventing entry of other sperm. Fertilization completes the genetic makeup of the baby, including whether it will be a girl or boy. For fertilization to take place, three events must occur during the encounter of the spermatozoa and the oocyte. - The sperm cells must migrate between any present cumulus cells and corona radiate cells. - The sperm cell must attach to and penetrate the zona pellucida (ZONA REACTION membrane enclosing the ovum & sperm becomes impenetrable to other sperm) - Finally, the plasma membranes of the ovum and the sperm must fuse. Only one spermatozoon can penetrate the cell membrane of the ovum. Once it penetrates the cell, the cell membrane changes composition to become impervious to other spermatozoa. An exception to this is the formation of gestational trophoblastic disease in which multiple sperm enter an ovum; this leads to abnormal zygote formation. https://opentextbc.ca/anatomyandphysiology/chapter/28-1-fertilization/ FACTORS IMPORTANT TO FERTILIZATION I. Maturation of the ovum & sperm II. Motility of the sperm to reach the ovum III. Ability of the sperm to penetrate the zona pellucida & cell membrane of the ovum to achieve active fertilization 6|Page  5. Cell Starts to Divide Once the egg is fertilized, a rapid process of division begins. The chromosomal material of the ovum and spermatozoon fuse to form a zygote. Because the spermatozoon and ovum each carried 23 chromosomes (22 autosomes and 1 sex chromosome), the fertilized ovum has 46 chromosomes. If an X-carrying spermatozoon entered the ovum, the resulting child will have two X chromosomes and will be assigned female at birth (XX). If a Y-carrying spermatozoon fertilized the ovum, the resulting child will have an X and a Y chromosome and will be assigned male at birth (XY). During this time, mitotic cell division, or cleavage, begins. The first cleavage occurs at about 24 hours; cleavage divisions continue to occur at a rate of about one every 22 hours so by the time the zygote reaches the body of the uterus; it consists of 16 to 50 cells. Over the next 3 or 4 days, large cells tend to collect at the periphery of the ball, leaving a fluid space surrounding an inner cell mass. At this stage, the structure is termed a blastocyst. The cells in the outer ring are trophoblast cells. They are the part of the structure that will later form the placenta and membranes. The inner cell mass (embryoblast cells) is the portion of the structure that will form the embryo. The fertilized egg leaves the Fallopian tube and enters the uterus 3 to 4 days after fertilization. A tubal or ectopic pregnancy results in the rare cases in which the fertilized egg does not properly enter the uterus. An ectopic pregnancy poses serious health risks to the mother. https://opentextbc.ca/anatomyandphysiology/chapter/28-2-embryonic-development/ 6. Implantation: Moving to the Uterus It signals the end of the pre-embryonic stage of development. It is the process by which the fertilized egg attaches to the endometrium (lining tissues of the uterus) approximately 8 to 10 days after fertilization. The cells in the fertilized egg continue to divide. 7|Page  Some women notice spotting (or slight bleeding) for 1 or 2 days around the time of implantation. The lining of the uterus gets thicker and the cervix is sealed by a plug of mucus. It will stay in place until the baby is ready to be born. Implantation usually occurs high in the uterus on the posterior surface. Almost immediately, the blastocyst burrows deeply into the endometrium and establishes an effective communication network with the blood system of the endometrium. Once implanted, the zygote is called an embryo. https://opentextbc.ca/anatomyandphysiology/chapter/28-2-embryonic-development/ TROPHOBLASTIC LAYER OF CELLS: CONTACTS THE ENDOMETRIUM (CHORIONIC VILLI) & DIFFERENTIATES INTO: CYTOTROPHOBLAST SYNCYTIOTROPHOBLAST, ( LANGHAN’S LAYER): OR THE SYNCYTIAL LAYER protects the growing embryo and fetus from production of various placental hormones, certain infectious organisms disappears such as hCG, somatomammotropin between the 20th and 24th week. (human placental lactogen [hPL]), estrogen, and progesterone. 7. Pregnancy Hormones A hormone called human chorionic gonadotrophin (HCG) is produced by the cells that will eventually form the placenta. It can be found in the mother's blood within about a week of conception and is detected in pregnancy tests done on blood or urine. 8|Page 8. Fetal Development After implantation in the uterus, some of the cells form the placenta while others form the embryo. The heartbeat begins during the fifth week of gestation. At the eighth week the developing embryo is now called a fetus. The fetus at eight weeks is about ½ inch long and constantly growing. Milestones in the Process of Fertilization A. PRE FERTILIZATION (Transit of Sperm) i. Release of the egg during ovulation ii. Capacitation iii. Acrosome reaction B. FERTILIZATION (Contact between Sperm & Oocyte) 3 ways of the egg’s response upon sperm’s penetration I. Cortical & zona reactions – impenetrability of other sperms II. Resumption of 2nd meiotic division – occurs immediately after entry of 1 sperm III. Metabolic activation of the egg –post fusion activation; initial cellular & molecular changes for growth & development associated with embryogenesis C. POST FERTILIZATION i. Sperm’s tail detaches from head & degenerates ii. Male & female nuclei lose their nuclear membranes fuse and intermingle with their chromosomes forming a zygote. D. PRE-EMBRYONIC PERIOD – 1ST 14 days after conception CHARACTERISTICS: i. Rapid cellular multiplication & differentiation ii. Establishment of embryonic membranes iii. Development of primary germ cell layers To have a better understanding about our lesson, please click the attached links below. 1. https://www.youtube.com/watch?v=7ww5T7hCdn4 2. https://www.youtube.com/watch?v=1KL8HAm3uSY 3. https://www.youtube.com/watch?v=dAOWQC-OBv0 4. https://opentextbc.ca/anatomyandphysiology/chapter/28-1-fertilization/ 9|Page  NURSING PROGRAM CARE OF THE FETUS: Embryonic & Fetal Structures (Decidua, chorionic villi, placenta, Amniotic Membranes, Amniotic Fluid, Umbilical Cord) The placenta and membranes, which will serve as the fetal lungs, kidneys, and digestive tract in utero as well as help provide protection for the fetus, begin growth in early pregnancy in coordination with embryo growth. PREPLACENTAL PHASE The endometrium is now typically termed the decidua (the Latin word for “falling off”) because it will be discarded after birth of the child. DECIDUA BASALIS part of the endometrium that lies directly under the embryo (or the portion where the trophoblast cells are establishing communication with maternal blood vessels). DECIDUA CAPSULARIS the portion of the endometrium that stretches or encapsulates the surface of the trophoblast DECIDUA VERA remaining portion of the uterine lining CHORIONIC VILLI As early as the 11th or 12th day after fertilization, miniature villi, resembling probing fingers and termed chorionic villi, reach out from the trophoblast cells into the uterine endometrium to begin formation of the placenta. Chorionic villi have a central core consisting of connective tissue and fetal capillaries surrounded by a double layer of cells, which produce various placental hormones, such as hCG, somatomammotropin (human placental lactogen [hPL]), estrogen, and progesterone. PLACENTA a Fleshy, disk-like organ, 15- 20cm in diameter, 2-3 cm in thickness, weighs 400 -600 grams @ term. It formed through the union of the chorionic villi (fetal) and decidua basalis (maternal) on the 12th day. 10 | P a g e PLACENTAL PRESENTATIONS: SCHULTZE DUNCAN https://embryology.med.unsw.edu.au/embryology/index.php/BGDA_Practical_Placenta_- _Placental_Functions Functions of Placenta I. METABOLIC FUNCTIONS: Respiratory Renal Gastrointestinal Skin Liver System System System Transfer of Excretion Nutrition & storage Transfer Detoxification Transmission gases – of wastes; – active transport of heat of some of maternal diffusion drugs & antibodies Detoxified Transport of chemicals in the nutrients mother’s liver II. ENDOCRINE GLAND – Hormone production: HcG, hPL, progesterone, estrogens HcG - first placental hormone - suppress maternal immunologic response so placental tissue is not detected and rejected as foreign substance - in male fetus, exerts an effect on the fetal testes to begin production and maturation of Testosterone 11 | P a g e  Progesterone - hormone that maintains pregnancy - maintains the endometrial lining of the uterus during pregnancy - reduces the contractility of the uterus during pregnancy, thus preventing premature Labor Estrogen - contributes to woman’s mammary gland development - stimulates uterine growth PLACENTAL DEVELOPMENT At time of implantation two (2) fetal membranes surround the developing fetus I. CHORION II. AMNION PURPOSES: - Encloses the fetus and the amniotic fluid - Protects the fetus against ascending bacterial infection. - Woman is prone to develop infection if integrity of the membranes are destroyed. CHORION / CHORIONIC MEMBRANE - Develops from the trophoblast - Originates from the portion of the chorionic villi (Contains the chorionic villi → Burrows into decidua basalis; Fetal side of the placenta (CHORION FRONDOSUM – LEAFY CHORION) Contains the major umbilical blood vessels CHORION LAEVE (BALD CHORION)- Smooth membrane which degenerates as embryo grows, chorionic villi atrophies & decidua capsularis stretches - Supports the amniotic membrane AMNION / AMNIOTIC MEMBRANE - Inner cell membrane develops from the interior cells of the blastocyst; smooth glistening thin, tough, and translucent membrane directly enclosing the fetus and the amniotic fluid. - Covering of the umbilical cord and the chorion on the fetal surface of the placenta and umbilical cord - Eventually comes in contact with the chorion surrounding the fetus ** The amniotic membrane not only offers support to amniotic fluid but also actually produces the fluid. In addition, it produces a phospholipid that initiates the formation of prostaglandins, which can cause uterine contractions and may be the trigger that initiates labor AMNIOTIC CAVITY - Develops between the inner cell mass & outer layer of cells (trophoblast). - Fetus floats & moves - At full term, normally contains from 500ml to 1200ml of liquor amnii or “the waters”. - Derives its fluid by diffusion from maternal blood 12 | P a g e AMNIOTIC FLUID Clear and colorless to straw, slightly yellowish color; non-foul odor.  1st half of pregnancy – similar in composition to maternal plasma with a lower protein concentration - Fetus begins to urinate after the 10th week of pregnancy, fetal urine contributes to the volume of amniotic fluid  Late in pregnancy – fetal urine excretion, absorbs amniotic fluid thru GIT by swallowing fluid – Responsible for absorbing nutrients & O2 from maternal blood stream & disposing of fetal waste products (CO2) – weekly – 500 -1200 ml from first trimester – 38th week until term AMNIOTIC FLUID’S Composition: - 98% water and 1-2 % organic & inorganic - solid particles - albumin, urea, uric acid, leukocytes, enzymes, - creatinine, lecithin, sphingomyelin, CHON, - lanugo, bilirubin, fructose, fat, epithelial cells, - phospolipids and vernix caseosa. Oligohydramnios Hydramnios 300 ml (fetal renal abnormalities) 2L (GIT & other malformations) Associated with poor fetal lung development Fetus has a severe malformation of the CNS malformations that results from compression or GIT that prevents normal ingestion of of fetal parts. amniotic fluid May occur because the kidneys fail to develop, urine excretion is blocked, or placental blood flow is inadequate AMNIOTIC FLUID’s Functions: 1. Protects the fetus from trauma, blows and pressure by blunting & dispersing the forces. 2. Allows freedom of movement for symmetrical musculoskeletal system growth and development; prevents from tangling with the membrane. 3. Acts as an excretion and secretion system; source of oral fluid & repository for waste. 13 | P a g e  4. Maintain a constant, even temperature. 5. Protects from infection. 6. Aids in diagnosis of maternal and fetal complications. 7. Aids fetal descent during labor by providing lubrication in the birth canal. 8. During labor, if the membranes are intact, the amniotic fluid protects the fetus from uterine contractions. 9. It also aids in effacement and dilatation of the cervix 10. Prevents pressure on the cord. AMNIOTIC FLUID Color’s indications: Green tinged or meconium stained amniotic fluid in non-breech presentation = fetal distress. Golden = hemolytic disease such as Rh or ABO incompatibility Gray = infection. YOLK SAC – 8-9 days after implantation Membrane surrounding the blastocyst cavity formed on either side of the developing embryonic disk. Functions: 1. Helps transfer maternal nutrients & O2 by diffusion through the chorion (embryo while uteroplacental circulation is being established. 2. Forms early blood cells until hemopoeitic activity begins in the liver UMBILICAL CORD Lifeline (circulatory pathway) linking the embryo & the chorionic villi of the placenta which extends from the umbilicus to the fetal portion of the placenta Function 1. Transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta - length at term – 50 - 55 cm , diameter – 2 cm (¾ in), ocation – centrally Contains: *One vein  carries blood, nourishment & oxygenated blood from the placental villi to the fetus *Two arteries  The amino and the chorion does not have nerve supply and blood vessels so the mother neither the fetus experience pain when they rupture.  Take waste products from fetus to placenta to be excreted by the mother  Return deoxygenated blood to placenta * Wharton's jelly  Transparent, bluish white gelatinous substance (mucopolysaccharide) – gives the cord body and prevents compression of the blood vessels to ensure continued nourishment of the embryo-fetus. 14 | P a g e   A loose connective tissue containing a cushioning material & prostaglandin vasoconstrictive effect – carries blood, nourishment & oxygenated blood from the placental villi to the fetus To have a better understanding about our lesson, please click the attached links below. 1. https://www.youtube.com/watch?v=bped-RVWsLk 2. https://www.youtube.com/watch?v=bQioHx12JuY&t=107s 3. https://www.youtube.com/watch?v=bQioHx12JuY&t=135s 4. https://opentextbc.ca/anatomyandphysiology/chapter/28-2-embryonic- development/ CARE OF THE FETUS: Origin & Development of Organ Systems Following the moment of fertilization, the zygote, which later becomes an embryo and then a fetus, begins to grow at an active pace. STEM CELLS PRIMARY GERM LAYERS As a fetus grows, body organ systems develop from specific tissue layers called germ layers. Ectoderm = Outer layer Mesoderm = Middle Layer Endoderm = Inner Layer Nervous system including Bones and muscle tissue, Lining of digestive tract brain, spinal cord and cartilage Lining of trachea, bronchi, peripheral nervous system, Heart, blood and blood and lungs pituitary gland, nerves, vessels Liver, pancreas Lining of the mouth, nostrils, Reproductive and excretory Thyroid, parathyroid, and anus, sensory epithelium systems thymus, urinary bladder, of the eye, ear, and nose Inner layer (connective tissue urethra, ear canal, and tonsils Epidermis of skin, sweat dermis) of skin glands, hair, nails Lymphatic system, spleen, Subcutaneous glands, kidneys, adrenal cortex, and mammary glands and tooth lining membranes enamel. (pericardial, pleural, peritoneal). All organ systems are complete, at least in a rudimentary form, at 8 weeks gestation (the end of the embryonic period). During this early time of organogenesis (organ formation), the growing structure is most vulnerable to invasion by teratogens (i.e., any factor that affects the fertilized ovum, embryo, or fetus adversely, such as a teratogenic medicine; an infection such as toxoplasmosis; cigarette smoking; or alcohol ingestion). To have a better understanding about our lesson on germ layesr, please click the attached link below. 1. https://www.youtube.com/watch?v=QPvhl66QCqo 2. https://opentextbc.ca/biology/chapter/13-2-development-and-organogenesis/ 15 | P a g e CARDIOVASCULAR SYSTEM The cardiovascular system is one of the first systems to become functional in intrauterine life. Fetal circulation differs from extrauterine circulation because the fetus derives oxygen and excretes carbon dioxide not from gas exchange in the lungs but from exchange in the placenta. https://www.stanfordchildrens.org/en/topic/default?id=fetal-circulation-90- P01790#:~:text=The%20shunt%20that%20bypasses%20the,the%20placenta%20to%20the%20fe tus. To have a better understanding about our lesson, please click the attached link below. 1. https://www.youtube.com/watch?v=8WX0POOZhvE 2. https://www.stanfordchildrens.org/en/topic/default?id=fetal-circulation-90- P01790#:~:text=The%20shunt%20that%20bypasses%20the,the%20placenta%20to% 20the%20fetus. 3. http://www.embryology.ch/anglais/pcardio/umstellung02.html 4. https://www.youtube.com/watch?v=-IRkisEtzsk 16 | P a g e  RESPIRATORY SYSTEM At the third week of intrauterine life, the respiratory and digestive tracts exist as a single tube. By the end of the fourth week, a septum begins to divide the esophagus from the trachea. At the same time, lung buds appear on the trachea. https://opentextbc.ca/anatomyandphysiology/chapter/22-7-embryonic-development-of-the- respiratory-system/ Other important respiratory developmental milestones include: Spontaneous respiratory practice movements begin as early as 3 months gestation and continue throughout pregnancy. Specific lung fluid with a low surface tension and low viscosity forms in alveoli to aid in expansion of the alveoli at birth; it is rapidly absorbed shortly after birth. The alveolar cells of the lungs forms and excretes a phospholipid substance called surfactant approximately at the 24th week of pregnancy. This decreases alveolar surface tension on expiration, preventing alveolar collapse and improving the infant’s ability to maintain respirations in the outside environment at birth. NERVOUS SYSTEM The nervous system begins to develop extremely early in pregnancy. All parts of the brain (cerebrum, cerebellum, pons, and medulla oblongata) form in utero, although none are completely mature at birth. Brain growth continues at high levels until 5 or 6 years of age. Brain waves can be detected on an electroencephalogram (EEG) by the eighth week. The eye and inner ear develop as projections of the original neural tube. 17 | P a g e  By 24 weeks, the ear can respond to sound, and the eyes exhibit a pupillary reaction, indicating sight is present. ENDOCRINE SYSTEM The function of endocrine organs begins along with neurosystem development. The fetal pancreas produces insulin needed by the fetus (insulin is one of the few substances that does not cross the placenta from the mother to the fetus). The thyroid and parathyroid glands play vital roles in fetal metabolic function and calcium balance. The fetal adrenal glands supply a precursor necessary for estrogen synthesis by the placenta. DIGESTIVE SYSTEM The digestive tract separates from the respiratory tract at about the fourth week of intrauterine life and, after that, begins to grow extremely rapidly. Initially solid, the tract canalizes (hollows out) to become patent. Later in the pregnancy, the endothelial cells of the gastrointestinal tract proliferate extensively, occluding the lumen once more, and the tract must canalize again. The proliferation of cells shed in the second recanalization forms the basis for meconium (a collection of cellular wastes, bile, fats, mucoproteins, mucopolysaccharides, and portions of the vernix caseosa - accumulates in the intestines as early as the 16th week. Meconium is sticky in consistency and appears black or dark green (obtaining its color from bile pigment). An important neonatal nursing responsibility is recording that a newborn has passed meconium as this rules out a stricture (noncanalization) of the anus. 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 through fetal life and into adulthood. REPRODUCTIVE SYSTEM A child’s sex is determined on conception by a spermatozoon carrying an X or a Y chromosome and can be ascertained as early as 8 weeks by chromosomal analysis or analysis of fetal cells in the mother’s bloodstream. At about the sixth week after implantation, the gonads (i.e., ovaries or testes) form. URINARY SYSTEM Rudimentary kidneys are present as early as the end of the fourth week of intrauterine life, the presence of kidneys does not appear to be essential for life before birth because the placenta clears the fetus of waste products. Urine, however, is formed by the 12th week and is excreted into the amniotic fluid by the 16th week of gestation. 18 | P a g e  INTEGUMENTARY SYSTEM In the earlier weeks of pregnancy, the skin of fetus appears thin and almost translucent. Approximately at the 36th week of pregnancy, subcutaneous fat begins to be deposited underneath. Soft lanugo and vernix caseosa cover the skin, both are still present at birth. To have a better understanding about our lesson, please click the attached link below. 1. https://opentextbc.ca/anatomyandphysiology/chapter/28-3-fetal-development/ CARE OF THE FETUS: Estimating Fetal Health (Fetal Growth, Fetal Heart Rate, Ultrasonography) DETERMINATION OF ESTIMATED BIRTH DATE The acronym EDB (estimated date of birth) is the most common term used to determine the expected date of delivery. (Silbert-Flagg and Pillitteri, 2018) NAEGELE’S RULE Formula: 1. EDB = (1st day of Last Menstrual Period -LMP) - 3 months + 7 days + 1yr. (For April – December) 2. EDB = (1st day of Last Menstrual Period -LMP) + 9 months + 7 days (For January – March) Example: LMP= July 10, 2023 7 10 2022 -3 +7 +1 4 17 2023 (EDB = 17 April 2023) To have a better understanding about our lesson, please click the attached link below. 1. https://www.registerednursern.com/naegeles-rule-nclex-review/ 2. https://www.registerednursern.com/naegeles-rule-nclex-practice-questions/ ESTIMATING GESTATIONAL AGE MCDONALD’S RULE Is a measure of the size of the uterus used to assess fetal growth and development during pregnancy. It is measured from the top of the mother's uterus to the top of the mother's pubic symphysis. cm of fundal height = weeks gestation 19 | P a g e  BARTHOLOMEW’S RULE OF FOURTHS This method estimates the age of gestation relative to the height of the fundus of the uterus above the symphysis pubis. 12 weeks – the uterus is just barely palpable above the pubic bone. 16 weeks – the top of the uterus is half-way between the pubic bone and umbilicus. 20-22 weeks – the top of the uterus is right at the umbilicus. At full term, the top of the uterus is at the level of the xiphoid process. AGE OF GESTATION BASED ON QUICKENING Fetal movement felt by woman = 18 weeks AGE OF GESTATION BASED ON LAST MENSTRUAL PERIOD (LMP) Determine number of days from LMP to the day of consultation and divide it by 7. Exercise : Determine the AOG of the following based on the LMP. Show your computation. Example: You were assigned in a lying-in clinic for your RLE on NCM 107. You are in duty (July 22, 2020) when Mrs. No Name visited the clinic for her prenatal. Written on her record as her LMP was March 15, 2020. Your Clinical Instructor asked you to solved for the AOG based on her LMP. How will you do it? March = 16 days (remaining days in March from her LMP ) April = 30 days June = 30 days July = 22 days (date of visit) 98 days divided by 7days = 14 weeks (on the day on consultation) Assessment of Fetal Growth and Development Tests for fetal growth and development are commonly done for a variety of reasons, including to: Predict the outcome of the pregnancy Manage the remaining weeks of the pregnancy Plan for possible complications at birth Plan for problems that may occur in the newborn infant Decide whether to continue the pregnancy Find conditions that may affect future pregnancies 20 | P a g e  1. HEALTH HISTORY 2. PHYSICAL EXAMINATION 3. ESTIMATING FETAL HEALTH LEOPOLDS MANEUVER Are a common and systematic way to determine the position of a fetus inside the woman’s uterus. Are important because they help determine the position and presentation of the fetus. Named after the gynecologist Christian Gerhard Leopold Maneuver is preferably performed after 24 weeks gestation when fetal outline can be already palpated. The maneuvers are not truly diagnostic Actual position can only be determined by ultrasound performed by a competent technician or professional. 21 | P a g e FUNDIC HEIGHT MEASUREMENT Symphysis-fundal height (SFH) measurement refers to the distance measured in centimeters on the longitudinal axis of the abdomen from the top of the fundus to the upper border of the symphysis pubis. Symphyseal fundal height is to be performed at every scheduled antenatal visit after 20 weeks gestation. Symphyseal fundal height must always be documented in centimeters. In normal singleton pregnancies the measurement in centimeters approximates the gestational age after 24 weeks of pregnancy. Purpose: - To determine the gestation and growth of the fetus. - To identify multiple pregnancies and complications of pregnancy e.g. amniotic fluid disorders, hydatidiform mole, and fetal growth disturbances. To have a better understanding about our lesson, please click the attached link below. 1. https://www.registerednursern.com/leopold-maneuvers-how-to-correctly-perform- leopold-maneuvers-clinical-nursing-skills/ 2. https://www.youtube.com/watch?v=skiywJHCp-g 4. ASSESSING FETAL WELL-BEING - Fetal Heart Rate - Daily Fetal Movement Count (Kick Counts) - Nonstress Testing - Ultrasongraphy - Amniotic Fluid Volume - Amniocentesis 22 | P a g e CARE OF THE MOTHER: Physiology of Menstruation A menstrual cycle (the female reproductive cycle) is episodic uterine bleeding in response to cyclic hormonal changes. During the menstrual cycle, the ovum reaches its maturity, and a new uterine bed is made ready for the implantation of the fertilized ova. CHARACTERISTICS (Silbert-Flagg and Pillitteri, 2018) Menarche Average age of onset 12.4 years old; average range of age onset is 9 – 17 years old. Interval cycles Average interval between cycles is 28 days; 23-35 days is also normal Duration of Average is 4 – 6 days; 2 – 9 days is also normal Menstrual Flow Amount of menstrual average amount of menstrual flow is 30-80 mL flow Color or menstrual Dark red; a combination of blood, mucus and endometrial cells cycle Four body structures are involved in the physiology of the menstrual cycle: the hypothalamus, the pituitary gland, the ovaries, and the uterus. (Silbert-Flagg and Pillitteri, 2018) 23 | P a g e The First Phase of the Menstrual Cycle (Proliferative) The Second Phase of the Menstrual Cycle (Secretory) The Third Phase of the Menstrual Cycle (Ischemic) The Fourth Phase of the Menstrual Cycle (Menses) To have a better understanding about our lesson, please click the attached link below. 1. https://www.youtube.com/watch?v=tOluxtc3Cpw&vl=en 2. https://www.youtube.com/watch?v=lVPQ_w7ZUTA 3. https://www.youtube.com/watch?v=2_owp8kNMus Confirmation of pregnancy is most important for both the mother and the fetus. It is then when the woman can begin receiving medical care for the health and welfare of herself and the baby. There are three different categories for the signs of pregnancy. The categories are Presumptive, Probable and Positive. Presumptive (SUBJECTIVE) Symptoms – These are signs of pregnancy the woman is experiencing that makes her suspicious that she may be pregnant. They are subjective signs reported by the woman and are not definite that a baby is growing in the uterus. When symptoms are taken as single entities, it could easily indicate other conditions. Week Finding Description 1 Breast changes Tenderness, fullness, tingling; enlargement & darkening of areola 2 Nausea & Vomiting Arising when fatigues 2 Amenorrhea Absence of menstruation 3 Frequent Urination Sense of having to void more often than usual 12 Fatigue Generally feeling of tiredness 12 Uterine Enlargement Can be palpated at the symphysis pubis 18 Quickening Fetal movement felt by woman 24 Linea Nigra Line of dark pigment forms on the abdomen 24 Melasma Dark pigment forms on face 24 Striae Gravidarum Red streaks form on abdomen Probable (OBJECTIVE) Findings – It is objective and so can be verified by an examiner. Although they are more reliable than presumptive symptoms, they still do not positively diagnose a pregnancy. Week Finding Description 1 Maternal serum test Presence of HCG hormone 24 | P a g e  6 Chadwick’s sign Color change of vagina (pink-violet) 6 Goodell’s sign Softening of cervix 6 Hegar’s sign Softening of the lower uterine segment 6 Sonographic Characteristic wing is evident evidence of gestational sac 16 Ballottement Fetus can be felt to rise against the abdominal wall 20 Braxton Hicks Periodic uterine tightening Contractions 20 Fetal outline felt by Fetal can be palpated through abdomen examiner Positive Findings – Positive signs of pregnancy are those signs that are definitely confirmed as a pregnancy. Week Finding Description 8 Sonographic Fetus can be felt to rise against the abdominal wall Evidence of fetal outline 10 -12 Fetal Heart Audible Periodic uterine tightening 20 Fetal movement felt Fetal can be palpated through abdomen by examiner To have a better understanding about our lesson, please click the attached link below. 1. https://www.youtube.com/watch?v=SUc2RN_qH8Q CARE OF THE MOTHER: Local and Systematic Physical Changes Including Vital Signs, Review of Systems Physiologic changes of pregnancy occur gradually but eventually affect all of a woman’s organ systems. They are necessary changes because they allow a woman’s body to be able to provide oxygen and nutrients for her growing fetus as well as extra nutrients for her own increased metabolism. They also ready her body for labor and birth and for lactation (breastfeeding) once her baby is born. They can be categorized as local (i.e.,confined to the reproductive organs) or systemic (i.e., affecting the entire body). Despite the magnitude of these changes, such as a woman’s blood volume doubling in amount, they are all extensions of normal physiology. At the end of pregnancy, her body will virtually return to its prepregnant state. 25 | P a g e Areas of the body Physiological changes Women’s experience Endocrine system. Human chorionic gonadotrophin The early rise in this hormone is the Important because basis for many pregnancy tests, hormonal control and it is thought to be the cause of affects the woman early pregnancy nausea throughout pregnancy; the Estrogen: produced by the Tender breasts most placenta after 12 weeks of Amenorrhoea (no menstrual active hormones gestation; suppresses ovulation, period) include: inhibits lactation, encourages Uterus grows growth of the breasts, uterus and vagina Progesterone: produced by the Tender breasts placenta after 12 weeks of Prevents uterine contractions gestation; responsible for May lead to varicose veins, development of breast tissue, constipation or relaxes smooth muscle all over the urinary tract infections body Thyroid-stimulating hormone: Feeling of warmth stimulates the metabolism through the action of thyroxin Melanocyte-stimulating hormone: Darkening of skin pigment as pregnancy progresses and the Linea nigra, chloasma and pituitary gland enlarges more is secondary areola of nipples produced develops Metabolism Increases to meet demands of Weight gain of about 10–12 kg mother and fetus Respiratory system 15–20% increase in demand for Dyspnoea (awareness of oxygen; easier gas exchange; lower breathing) in later pregnancy ribs flare Gastrointestinal Whole system relaxes, mainly due Heartburn system to progesterone, although internal Constipation organs are squashed by growing May need smaller meals uterus 26 | P a g e Renal system Increased blood flow to kidneys Glycosuria (sugar in the urine) can causes 50% increase in glomerular occur filtration Action of progesterone causes Urinary tract infection can occur, kinking of the ureters frequency of micturation due to pressure on the bladder from the growing uterus and fetal head Reproductive Uterus: thickens and grows from a Changing body image: system pelvic organ weighing 70 g to an at 12 weeks, uterine fundus is felt abdominal organ weighing 1 kg above the pubic bone at 24 weeks, uterine fundus is Much greater blood supply palpated above the umbilicus Cervical canal is filled by at 38 weeks, uterus presses on operculum, mucous plug or show xiphisternum (lower edge of Vagina: has increased blood supply sternum, in the centre of rib cage) and estrogen acts on mucous- Increase in vaginal discharge producing cells Breasts Both estrogen and progesterone Vascular changes visible, encourage growth and blood colostrum may be secreted from supply increases 16 weeks Montgomery’s tubercules become more active and prominent Skeletal system Progesterone softens the Can cause back pain, or lordosis ligaments, which assists in the (curved spine) delivery Exercise : I. Each of the following phrases is closely related to a body part and is one of the signs or symptoms of pregnancy. Fill in the blanks opposite each phrase by writing the body part or action and the correct sign or symptom category. Example: fetal movement in the uterus = quickening/presumptive Softening of the lower uterine = uterine probable 1. Marks on the abdomen and or buttocks = 2. Ballottement = 3. Enlargement of the Montgomery glands = 4. Marked softening of the cervix = 5. Gestation sac can be seen and photographed = 6. Presence of colostrum = 7. Can be heard with a doppler = 27 | P a g e  II. Identify the following images. To have a better understanding about our lesson, please click the attached link below. 1. https://www.youtube.com/watch?v=A0sp7I9rlz8 2. https://www.youtube.com/watch?v=yczO0231BnE 3. https://www.youtube.com/watch?v=Y8WMYV3md4Y CARE OF THE MOTHER: Psychological Changes of Pregnancy FIRST Uncertainty TRIMESTER  Early weeks - unsure - pregnant and tries to confirm it.  Observes her body for changes  Reaction uncertainty of pregnancy o Eagerness : pregnant or not Ambivalence  Conflicting feelings, or ambivalence, about being pregnant.  Examine the meaning of the pregnancy in terms of changes that must be made in their lives and what they must give up as a result of the pregnancy. The Self as Primary Focus  Because she has not gained weight to confirm a growing, developing fetus, she probably says “I am pregnant” rather than “I am going to have a baby”  Physical changes and increase hormone levels may cause emotional lability (unstable moods). 28 | P a g e  SECOND Physical Evidence of Pregnancy TRIMESTER  Physical changes occur in expectant mother that make the fetus “real”. o Uterus grows rapidly and can be palpated in the abdomen, weight increases, and breast changes are obvious. o (Quickening), which confirms that a life is developing within the uterus. Now she might say “I am going to have a baby”. The Fetus as Primary Focus  The discomfort of the first trimester has usually abated and her size does not alter her activity.  Now concern about producing healthy infant. Narcissism’s and Introversion  Increasingly concern about their ability to protect and provide for the fetus.  The primigravida wonders about the infant. o Looks at baby pictures of herself and her partner and wants to hear stories about themselves as infants. o Multiparas interested in infant and concerned with child’s acceptance by sibling and grandparents. Body Image Rapid and profound changes take place in the body during second trimester. Changes in Sexuality THIRD Vulnerability TRIMESTER  The sense of well-being and contentment that dominates the second trimester gives way to increasing feelings or vulnerability, particularly during the seventh month of pregnancy.  Many mothers have fantasies or nightmares about harm coming to the infant and become very cautious as a result. Increasing Dependence  Dependent on partner in the last weeks of pregnancy. o Need for love and attention from her partner - more pronounced in late Preparation for Birth  Feelings of vulnerability decreased as the woman comes to terms with her situation.  Are concerned - ability to determine when they are in labor.  During this trimester an expectant mother may say “I am going to be a mother” as she prepares for the infant. CARE OF THE MOTHER: Psychological Tasks of Pregnancy 3 Developmental Tasks: by Rubin FIRST TRIMESTER: ACCEPTANCE OF PREGNANCY Phase I= woman accepts the biological fact of pregnancy; able to state “ I am pregnant” and incorporate the idea of a child into her body and self image ( fetus as an real ). SECOND TRIMESTER: ACCEPTANCE OF THE FETUS AS A SEPARATE INDIVIDUAL Phase II= 29 | P a g e Accept the growing fetus ask distinct from the self as a person to nurture; can say” I am going to have a baby” at second trimester beginning of mother- child relationship; becomes more introspective and enters a quiet period. THIRD TRIMESTER: ACCEPTANCE OF MOTHERHOOD Phase III= Prepare realistically for birth and parenting of the child; expresses “ I am going to be a mother “, defines the nature and characteristics of the child. CARE OF THE MOTHER: Discomforts of pregnancy and nursing interventions  Nausea & Vomiting  Syncope  Urinary urgency & frequency  Breast tenderness  Nasal Congestion  Fatigue  Heartburn  Ankle Edema  Varicose vein  Headaches  Hemorrhoids  Constipation  Flatulence  Leg Cramps  Shortness of Breath  Insomnia  Leukorrhea  Numbness/tingling of the fingers and/or toes  Palpitations  Nosebleeds (epistaxis)  Pelvic Pressure  Skin changes CARE OF THE MOTHER: Health history: past, present, potential, biographical data, menstrual history, current pregnancy (EDD, AOG, gravid, para) previous pregnancies & outcomes (TPAL) score, gynecologic history, medical history and nutritional status. Determining Gravidity & Parity Gravidity- number of pregnancies regardless of outcome Parity- defined as the number of times that she has given birth to a fetus with a gestational age of 20 weeks or more, regardless of whether the child was born or was stillborn. Gravida – is the no. of pregnancies regardless of duration or outcomes. 30 | P a g e A gravida (G) woman is a woman who is pregnant (present) now has been pregnant(past) , irrespective of the outcome of pregnancy. A nulligravida (Go) is a woman who: Is not pregnant now, has never been pregnant Principles in Identifying Parity 1. The no. of pregnancies is counted and not the no. of fetuses Ex. Cynthia is pregnant for the first time and is carrying twins. She is presently G1P0. At 37-38 weeks, Cynthia delivered to monozygotic twins making her G1P1. 2. Abortion is not included in parity count because the fetus is delivered before the age of viability (before 20 weeks). Parity will include all pregnancies beyond the age of viability Ex. Sussie is pregnant for the second time. Her first pregnancy 3 years ago ended in an abortion. Sussie is presently G2P0. After delivery of a preterm or a full term baby, Sussie will be designated G2P1. 3. Live birth or still birth is counted in parity count whether the fetus is born alive or still, for as long as it has reached 20 weeks, it is counted as one parity. Ex. Josette is pregnant for the first time (G1P0). After 34 weeks, she delivered a 4-lb baby boy with no signs of life (stillbirth). This makes Josette a primipara (G1P1) A nullipara is a woman who had not carried a pregnancy beyond 20 weeks or beyond the period of abortion. A primipara is a woman who has completed one pregnancy to age of viability and subsequently delivered the fetus, whether alive or dead at birth. A multipara is a woman who has carried 2 or more pregnancies to stage of viability and subsequently born alive or dead. A grandmultipara is a woman who has had 6 or more viable deliveries, whether, the fetuses were alive or dead. A woman who is described as “gravida 2, para 2”or G2P2 has had two pregnancies and 2 deliveries after 24 weeks A woman who is described as “gravida 2, para 0”or G2P0 has had two pregnancies, neither of which survived to a gestational age of 24 weeks If they are both currently pregnant again, these women would have the obstetric resume of G3P2 and G3P0 OBSTETRICAL SCORING TPAL – is one of the methods to provide quick overview of a female’s obstetric history. Two other methods often used are gravida/para and GPA. 31 | P a g e  T : number of full term infants born ( infants born at 37 weeks or after) P: number of preterm infants born ( infants born before 37 weeks) A: number of spontaneous miscarriage or therapeutic abortions L: number of living children M: multiple pregnancies CARE OF THE MOTHER: Management of pregnancy (Examinations) The traditional regime is monthly from the booking visit to 28 weeks’ gestation, fortnightly to 36 weeks’ gestation and then weekly until delivery. A systematic approach is applied in each visit of the woman. Good communication is essential; the woman should be able to communicate how she is feeling and if she has any problems. Her general appearance and demeanour will notify the recognition of several complaints such as stress, anxiety, concern, illness, disability or lack of sleep. Careful observation of the woman’s general appearance, her demeanour and the way she communicates can provide vital information and should not be overlooked. Blood pressure Most antenatal regimes require the woman’s blood pressure to be taken at each visit to identify signs of hypertension. Urinalysis This should be tested at booking for the presence of bacteria to screen for asymptotic bacteriuria. And at subsequent visits the urine should be tested for the presence of protein. Weight Fundal height Abdominal palpation Fetal heart/fetal movements Blood tests Rhesus Ultrasound scans Visualization of the fetus to assess fetal wellbeing using an ultrasound scan Non-stress cardiotocography CARE OF THE MOTHER: Prenatal exercises Common teratogens and their effects : Complete the following table on the common teratogens and their effects. Example: Description Effects on Fetus Management 1. Malaria 2. Toxoplasmosis 3. Rubella 32 | P a g e  5. Syphillis 6. Alcohol 7. Tobacco 8. Radiation 9. Environmental Teratogens CARE OF THE MOTHER: Preparation for labor and delivery References: Hill, M.A. (2015) Embryology Lecture - Fertilization. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Lecture_-_Fertilization Lowdermilk, DL. et al., (2016). Maternity & Women’s Health Care. 11th edition. Elsevier McKinney, E.S. (2015). Introduction to Maternity and Pediatric Nursing. 7th edition. Elsevier Saunders Silbert-Flagg, J. and Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family 8th edition. Wolters Kluwer Swearingen, P.L. (2016). All-in-one Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity and Psychiatric-Mental Health. 4th edition. Elsevier World Health Organization (2016). Guideline on Antenatal Care: Overview. Retrieved from https://who.org Zerwekh, J. (2016). Illustrated Study Guide for the NCLEX-RN Exam. 9th edition. Elsevier 33 | P a g e https://ib.bioninja.com.au/higher-level/topic-11-animal-physiology/114-sexual- reproduction/egg-and-sperm.html https://opentextbc.ca/anatomyandphysiology/chapter/28-1-fertilization/ 34 | P a g e