Maternal nursing 107.docx

**REPRODUCTIVE DEVELOPMENT** - Reproductive development and change begin at the moment of conception and continue throughout life. - The sex of an individual is determined at the moment of conception by the chromosome from both the father's sperm and the mother's ovum. - Gonad i...

**REPRODUCTIVE DEVELOPMENT** - Reproductive development and change begin at the moment of conception and continue throughout life. - The sex of an individual is determined at the moment of conception by the chromosome from both the father's sperm and the mother's ovum. - Gonad is the term used for the organs which produce cells necessary for reproduction. \+ they are: 1\. **ovum --** females **2.** **testis/testes --** males At approximately 5 weeks intrauterine life, primitive gonadal tissue is already formed **PUBERTAL DEVELOPMENT** - Puberty - Stage of life at which secondary sex characteristics begin to appear - Girls begin developing at about ages 9-12 characterized by menarched (maybe followed anovulatory periods) - Growth of breasts (thelarche) and appearance of fine hair in the pubic area and the axillae (adrenarche) - Enlargement of the labia minora and the clitoris and also the internal reproductive organs - Girls: - Growth spurt - Increase in transverse diameter of the pelvis - Breasts development - Onset of menstruation - Vaginal secretions - Growth of axillary hair - Males develop at about ages 12-14 - Testosterone level rises which influence the development of testes, scrotum, penis, prostate and the seminal vesicles - Appearance of male pubic hair, axillary and facial hair (adrenarche) - Enlargement of the larynx and accompanying voice changing - Maturation of the spermatozoa - Secondary sex characteristics of boys occur in the order of: - Increase in weight - Growth of the testes - Growth of facial, axillary and pubic hair - Voice changes - Penile growth - Increase in height - Spermatogenesis - **MALE REPRODUCTIVE SYSTEM** - External structures - Scrotum - Testes - Penis **REPRODUCTIVE ANATOMY AND PHYSIOLOGY** - Male internal structures - Epididymis - Vas deferens - Seminal vesicles prostate gland - Bulbourethral glands - Urethra **Testes or Testicles** - Egg-shaped organs where sperm is produced - Testes form in the abdominal cavity then move down into the scrotum either before or shortly after birth - Typical male produced million sperm hundred million sperm each day **Epididymis** - After being produced in the seminiferous tubules, sperm travel to the epididymis, where they mature - Site where sperm are stored **Seminiferous Tubules** - 100's of tightly coiled tubules located in the testes where sperm is produced through meiosis - Luteinizing Hormone (LH) released by the pituitary gland, stimulates the secretion of testosterone - Follicle Stimulating Hormones (FSH) and testosterone stimulating sperm production **Scrotum** - External skin sac that regulates temperature for sperm production - 37 degrees Celsius (98-degree Fahrenheit) -- normal body temperature for sperm to complete development - The scrotum is 3 degree Celsius cooler and ideal temperature for sperm development **Vas Deferens** - Long tube that connects the epididymis to the urethra **Urethra** - Sperm leave the body by passing through the urethra - Same duct through which urine exits the body - As sperm pass through the urethra, they mix with fluids secreted by 3 exocrine glands; seminal vesicles, prostate gland, and the bulbourethral gland **Seminal Vesicle** - Located between the bladder and the rectum - Produce a fluid rich in sugars that sperm use for energy **Prostate Gland** - Located below the bladder - Secretes and alkaline (basic) fluid that neutralizes the acids in the female reproductive system **Penis** - Deposits sperm in the female reproductive system during sexual intercourse - Contains spongy tissue. When the spaces in this tissue fill with blood, the penis becomes erect. - Flaccid -- when not stimulated **FEMALE EXTERNAL REPRODUCTIVE ORGANS** - External Genitalia -- "Vulva" collective term for external female reproductive organ 1. **Mons Pubis** -- "Mons Veneris" **=** mound of fatty tissue that lies over the symphysis pubis covered by skin and at puberty, it becomes covered by pubic hair. It serves as cushion or protection of the symphysis pubis 2. **Labia Majora** -- "large lips" =longitudinal fold of pigmentation skin that extend from the symphysis to the perineum. 3. **Vestibule** -- flat smooth surface inside the labia where the urethra (opening to the bladder) and vagina (opening to the uterus) 4. **Skene's Gland** -- paraurethral glands located on each side of the urinary meatus. Secrete small amount of mucus as lubrication during coitus. Common site of external genital infection. 5. **Bartholin's Gland** -- located on each side of the vaginal orifice, also secretes mucus as lubrication during coitus. 6. **Labia Minora** -- soft longitudinal fold located between the labia majora. These folds are pinkish, covered with mucus membranes, and sebaceous glands. Before menarche they are small, but it becomes firm and full during child bearing age and at menopause, they become much smaller. 7. **Clitoris** -- a rounded organ of erectile tissue at the forward junction of the labia minora. It is covered by a folded skin called the prepuce. It is the center of sexual arousal in a woman 8. **Fourchette** -- a ridge of tissue formed by the posterior joining of the two labia minora and labia majora. This is the structure that is sometimes cut (episiotomy) during childbirth 9. **Perineum** -- posterior to the fourchette is a muscular area which is stretched during childbirth to allow for enlargement of the vagina and passage of the fetal head. 10. **Hymen** -- a tough elastic semicircle of tissue that covers the opening of the vagina in childhood. It is very fragile that it could be damaged even without sexual intercourse. **FEMALE INTERNAL REPRODUCTIVE SYSTEM**  **Ovaries (2)** - Produce egg and sex hormones - Each month, the female reproductive system prepares for a possible pregnancy by producing a mature egg cell. - At birth, female has all the eggs she will ever have, - 2 million - At puberty (sexual maturity) one immature egg matures every 28 days and is released into the oviduct (fallopian tubes) - Mature egg is called ovum - In the lifetime of a female, only 300-400 eggs will mature **Fallopian Tubes (Oviducts)** - Cilia sweep ovum into the fallopian tube - Passageway -- leads ovum from the ovary to the uterus - Smooth muscle contractions move ovum towards the uterus, about 10 cm long - Journey takes 3-4 days - Site of fertilization - If the ovum in not fertilized in 1-2 days, it dies - As long as fallopian tube is healthy, fertilized egg can pass through **Four Parts of the Fallopian Tube** - **Interstitial Portion --** part that lies within the uterine wall. - **Isthmus --** portion of the fallopian tube which is cut or sealed in tubal ligation - Estrogen -- propel by rhythmic movements - Progesterone -- nourishment of the zygote - **Ampulla --** longest portion of the fallopian tube where fertilization (union of egg and sperm) occur - Fertilization -- outer 3^rd^ of the ampulla (distal portion) - **Fimbriated end --** (infundibular portion) with funnel shaped end which is covered by fimbria (small hair) that help guide the ovum into the fallopian tube. **Uterus** - Hollow, muscular organ (size of fist) - If ovum is fertilized, implants in the wall of uterus -- pregnancy - If not fertilized, ovum disintegrates within 24 hours after ovulation **Three Division:** - **Body or corpus --** uppermost portion and forms the bulk of uterus. It is this portion which expands during pregnancy to contain the growing fetus. Fundus -- point of attachment to the fallopian tube, this portion can be palpated during pregnancy. - **Isthmus --** short segment between the body and cervix. This is the portion which is cut in Caesarian birth. - **Cervix --** lowest portion of the uterus which represent 1/3 of the total uterus size. Half of it lies above the vagina and half extends into the vagina. - Its cavity is called the cervical canal - **Internal Os --** opening of the canal at the junction of the isthmus and the cervix - **External Os --** distal opening to the vagina. - Layers of the uterus (uterine coats) - **Endometrium --** for menstrual function. Innermost layer - **Myometrium -** muscle fibers which provides extreme strength to the organ. Myomas arise from the myometrium - **Perimetrium --** outermost layer of the uterus which also provides for strength. **Cervix** - Narrow portion at the bottom of uterus - Provides opening to uterus from vagina **Vagina** - Muscular tube that leads from the outside of the body to the uterus - Birth canal through which infants pass when born **Follicles** - Each primary oocyte is packaged in an epithelial vesicle called FOLLICLE - It is within follicle that second meiotic division takes place to create secondary oocyte - Follicular structure has 4 stages - **Primordial follicle (primary follicle) --** not yet growing - **Vesicular ovarian follicle (graffian follicle) --** about ready to release a secondary oocyte - **Corpus luteum --** what is left of oocyte after it released for ovulation. Corpus luteum secretes ESTROGEN and PROGESTERONE, both of which are important in regulating female menstrual cycle. - **Corpus albicans --** degenerate form. **MENSTRUAL CYCLE** - **Follicle --** small sacs filled with fluid found in the woman's ovaries - **Primordial Follicle Oocyte --** not yet growing follicle - immature egg cell or ovum, they are initiated to grow and mature during menstrual cycle and reach ovulation. - **Vesicular ovarian follicle (Graafian follicle) --** a follicle containing a cavity or mature ovarian follicle. - **Corpus luteum --** develops from the ovarian follicle after the release of the mature ovum during the luteal phase of menstrual cycle - **Corpus albicans --** a scar tissue that forms after the corpus luteum degenerates. (Latin for white body). It persists on the ovary for a few months. - **Ovulation --** refers to the release of a mature/ripe egg or ovum from the Graafian follicle during menstrual cycle in females - **Gonadotropin releasing hormone (GnRH) --** a hormone secreted by the hypothalamus to stimulate the anterior pituitary gland to secrete FSH and LH - **Follicle stimulating hormone (FSH) --** a hormone secreted by the anterior pituitary gland which stimulates the growth and maturation of an ovarian follicle and the ovum in the female ovaries. FSH levels changes throughout the menstrual cycle. The highest level of which is before the releasing of the egg/ovum by the ovary. - in men, FSH helps control production of sperm - **Luteinizing Hormone (LH) --** Also secreted by the anterior pituitary gland which causes the release of the ovarian follicle (ovulation). It also stimulates the corpus luteum to produce progesterone, required to support the endometrium thickness during early stages of pregnancy if fertilization occur. - In male, LH stimulates the Leydig cells in the testes to produce testosterone. - **Estrogen --** it is a primary female sex hormone secreted by the ovaries. It is responsible for the development and regulations of the female reproductive system and secondary sex characteristics. - **Progesterone --** it is a hormone mainly secreted by the corpus luteum by the ovary. It has 2 main functions: A. It prepares the endometrium in the event that the mature ovum is fertilized during ovulation. B. When fertilization occurs, it maintains thickness of the endometrium and secretes nutrients that nourish the embryo throughout the pregnancy. **PHYSIOLOGY OF MENSTRUATION:** Involves 4 body structures of the Female. Each structure must contribute their roles/functions to complete the menstrual cycle. Inactivity of any part will result to incomplete or ineffective cycle. **The four structures are:** 1\. Hypothalamus 2\. Pituitary Gland 3\. Ovaries 4\. Uterus - **Luteinizing Hormone (LH)** from the pituitary gland increases level by about 14th-day of the cycle, the Graafian follicle ruptures and ovum is released (ovulation). The FSH has done its work and now decreases in amount. The LH continues to rise in amount and directs the ruptured Graafian follicle to produce **Lutein (a bright yellow-fluid which contains progesterone).** This structure is now called the **Corpus Luteum (yellow body).** Progesterone level continues to rise which also causes a rise in body temperature of the woman until day 24 of the cycle. - When feralization of the released ovum occurs in the Fallopian tube, **the corpus luteum continues to produce progesterone until about 16 to 20 weeks of pregnancy** to maintain the thickness and nourishes the endometrial lining. - If fertilization does not take place in 24 hours after ovulation, the corpus luteum is short-lived and regresses in **8-10 days and becomes a white fibrous tissue called the corpus albicans (white body)** which remains a scar tissue in the ovary. Then menstrual bleeding follows. - **UTERUS-** organ of menstruation. - **Uterine changes during the Phases of Menstrual Cycle:** - **First Phase of the Menstrual Cycle (PROLIFERATIVE PHASE)** Immediately after the menstrual flow (which occurs during thefirst 4 to five days of the cycle), the endometrium or uterine lining is very thin. As the ovary begins to produce estrogen (in the developing Graafian follicle under the influence of FSH of the pituitary gland), the endometrium begins to proliferate or thickens from 5th day after menstruation to day 14 of the cycle. This phase is called proliferative, or estrogenic, or follicular phase.  **The second phase of the menstrual cycle (secretory phase)** Approximately 14^th^ day of the cycle, the egg/ovum is released from the ovary ( a process called **ovulation**) , the formation of progesterone (**in the corpus luteum under the influence of the LH by pituitary gland**), causes the uterine endometrium to become **thicker** and filled with blood vessels, dilated with large amounts of **glycogen** and **mucin**, in preparation for possible implantation of the fertilized ovum. This second phase of the menstrual cycle is called **secretory, progestational, luteal phase.** **The Third Phase of the Menstrual Cycle (ISCHEMIC PHASE)** If fertilization does not occur, the corpus luteum in the ovary begins to regress after 8 to 10 days from ovulation which result to decrease production of progesterone. This lowering amount of progesterone causes the endometrium to degenerate on day 24 to day 25 of the cycle after which the capillaries of the endometrium rupture, resulting to minimal bleeding and the endometrium sloughs off or shredding of the endometrial. **The Fourth Phase of the Menstrual Cycle (MENSES)** Menses, or menstrual flow is composed of a mixture of blood from ruptured capillaries, mucin, fragments of endometrial tissue; and microscopic atrophied, and unfertilized ovum. It is also known as the end of the menstrual cycle which is also the only external marker or sign cycle, however, the first day of the menstrual flow is used to mark the beginning of a new menstrual cycle. **Disorders in the Shape of the Uterus** FERTILIZATION: The beginning of Pregnancy FERTILIZATION - Conception; impregnation; - Union of a sperm and mature ovum - Occurs in the outer third portion of the F. tube or - It must occur within 24 hours after release from the - Copulation must take place 72 hours before the ovum is released and 24 hours after.  Anatomy of the OVUM: Zona Pellucida - mucopolysaccharide fluid which surrounds the ovum. Corona Radiata - circle of cells which serve to protect the mature ovum from injury. Reduction of Viscosity of the cervical mucus makes it possible for the sperm to penetrate the ovum. - Semen - average ejaculation 2.5 ml fluid which contains 50 to 200 million/ml = 400 million sperm per ejaculation. - It reaches the f.tube within 5 minutes after ejaculation. **ZYGOTE:** - Term used for the fertilized ovum which the future child and accessory structures needed during intra uterine life are all formed. - **Accessory Structures** - Placenta - Fetal membrane - Amniotic fluid - Umbilical cord **IMPLANTATION PROCESS** - Zygote travels 3-4 days towards the body of uterus thru contraction of the f.tube - During these days what happens? - Mitotic cell division or cleavage takes place. - By the time the zygote reached the body of uterus it already consists of 16-50 cells. This bumpy structure is now called the morula (Mulberry) - The morula continues to float in the uterine cavity for about 3-4 days more. - Changes that take place with the Morula: - Large cells collect at the periphery of the ball, leaving a fluid space surrounding an inner mass of cells. This structure in now called the **blastocyst.** - **Blastocyst-** this is the structure that attaches to the uterine endometrium. - **Trophoblast cells-** the cells in the outer ring. They are the part of the structure that will later form the **placenta and membranes**. - **Embryoblast cells-** the inner cell mass is the portion of the structure that will form the embryo. - **Implantation-** the contact between the growing structure (blastocyst) and the uterine endometrium. - It occurs about 8-10 days; - **Adhesion --** the blastocyst brushes itself into the rich uterine endometrium (during the secretory phase); and settle down into the soft folds (**invasion)** - **As it burrows deeply into the endometrium,** it now receives nourishment and establish a connection with blood vessels of the endometrium. - Implantation must take place in the high portion of the uterus on the posterious portion - Low implantation may occlude the cervix -- resulting to placenta previa. - Occasionally, a small amount of vaginal spotting appears with implantation of the trophoblast cells. - Once implanted, the zygote now is called the **EMBRYO.** **EMBRYONIC AND FETAL STRUCTURES** **Decidua** - the endometrium continues to grow in thickness and vascularity (influenced by the hCG) secreted by the trophoblast cells. - The endometrium is now called decidua. - Decidua basalis - Decidua capsularis - Decidua vera **Chorionic Villi** - Once implantation is achieved, the trophoblast begins to mature - 11^th^ -12^th^ day -- miniature fingerlike structures (200 of them) develops and reach out to the endometrium called the CHORIONIC VILLI - Coverings: - **Synctiotrophoblast** (synctial layer) produces hormones such as hCG, somatomammotropin (human placental lactogen (hPL) estrogen and progesterone) - **Cytotrophoblast --** (langhan's layer) present as early as 12^th^ day gestation. - It serves to protect the growing embryo from certain infection organisms such as syphilis. - This layer disappears between the 20^th^-24^th^ week which may cause fetal damage due to sexually transmitted disease occur during this gestational week. - There is no protection from viral infection at any time. **Placenta** - Interface between maternal, fetal tissues - Maternal = decidua - Endometrial lining - Falls off at parturition - Supplied by spiral arteries - Fetal cells = trophoblast - Exchange organ **PLACENTAL CIRCULATION** - On the 12^th^ day of pregnancy, maternal blood begins to collect in the spaces of the endometrium surrounding the chorionic villi. - Oxygen and food nutrients diffuse from maternal blood through the cell layers of the chorionic villi to the developing embryo. - **Note:** **There is no direct exchange of blood between embryo and mother during pregnancy. It is carried out only thru selective osmosis.** - Placental Osmosis is so effective that all substances except for a few are able to cross from the mother to the placenta. - All drugs are able to cross into the fetal circulation; therefore, the mother should not take nonessential drugs, alcohol, and nicotine during pregnancy. - A chorionic villi continue to increase in numbers, it forms a complex communication network with maternal blood and as they become larger and larger, they become separated by partitions called **cotyledons** about 30 of them (they make the maternal side of placenta rough and uneven.) - The rate of utero-placental blood flow during pregnancy increases from 50ml/min to 500-600ml/min at term. - This is the reason for the increase supply the placenta. - **Braxton Hick's Contraction-** barely noticeable uterine contraction during/about the 12^th^ week as a result of maintaining pressure and contraction of the uterine veins. - To increase uterine perfusion and placental circulation, it is advised that mother lies on her left side to lift the uterus away from the inferior vena cava, preventing blood from being trapped in the lower extremities. - If the mother lies on her back, (supine position) the uterus compresses the inferior vena cava, placental circulation is sharply reduced, **causing supine hypotension, (very low maternal BP)** - At term -- placenta weighs 400-600g (1lbs). if the placenta weighs less than this (smaller) may suggest that circulation to the fetus may have been inadequate. **ENDOCRINE FUNCTION OF PLACENTA** **From the Synctial Cells** **(Human Chorionic Gonadotropin)** - Found in maternal blood and urine; hormone analyzed by Pregnancy Test - Mother's serum will completely be negative to hCG within 1-2 weeks after birth. - Acts to maintain production of progesterone by the CI - It also stimulates testosterone production which causes maturation of the male reproductive system - Production of progesterone by the placenta on the 8^th^ week/diminishes production of HCG **ESTROGEN ("hormone of women")** - Contributes to the development of mammary glands in preparation for lactation - Stimulates Uterine growth to accommodate developing fetus **PROGESTERONE ("Mother's Hormone")** - Maintain endometrial lining; - Reduces contractility of the uterine muscle during pregnancy which prevents premature labor. **HUMAN PLACENTAL LACTOGEN (hPL)** - Both lactogenic (milk Producing) and growth promoting hormone as early as 6^th^ week of pregnancy. **UMBILICAL CORD** - Formed from fetal membranes (amnion & chorion) - About 21 inches length at term - Provides circulation pathways that connect the embryo to the chorionic villi. - Transport of Oxygen and nutrients to the uterus from placenta and return waste products of the fetus to the placenta. - Gelatinous mucopolysaccharides- **wharton's Jelly,** serves to give the cord and prevents pressure on the veins and arteries. - Contains 1 veins and 2 arteries (AVA) - The number of arteries must always be assessed and recorded after birth. **Why?** - Infants with only 1 veins and 1 artery indicates that 15% of these infants have accompanying congenital anomalies of the heart and the kidneys **AMNIOTIC MEMBRANES** 1. **Chorionic membrane** come from the middle surface of the trophoblast - This membrane is the outer most fetal membrane. As it becomes smooth, it serves to protect the sac that contains the amniotic fluid. 2. **Amniotic membrane (amnion)** forms beneath the chorion - It also serves as protection and production of the amniotic fluid - It also produces the **prostaglandins,** which cause uterine contraction and triggers labor. **AMNIOTIC FLUID** Characteristics: - It is constantly being newly formed by the amniotic membrane. - Some of it is absorbed by the placenta. - It is continually swallowed by the developing fetus, then absorbed into the fetal bloodstream and goes back to the umbilical arteries to the placenta. - At term, amount of amniotic fluid is 800-1,200ml. **AMNIOTIC FLUID (Functions)** - AMNIOTIC FLUID -- serves as protective mechanism for the fetus from blows or pressure to the mother's abdomen. - It protects the fetus from changes in temperature. - It also promotes muscular development for the fetus, since it allows the fetus freedom to move. - It protects the umbilical cord from pressure thus protecting the fetal O~2~ supply - POLYHYDRAMNIOS- excessive amniotic fluid (more than 2000 ml) which happens due to congenital anomalies like **esophageal atresia or anencephaly or when mother has diabetes.** - Fetal urine also adds to the amount of Amniotic Fluid. A reduction of fetal kidney function may also result in the reduction of the amniotic fluid called **oligohydramnios** (less than 300 ml) **ORIGIN AND DEV'T OF THE ORGAN SYSTEM OF THE FETUS** **Stem Cells** - On the 4^th^ day of life, the zygote cell are called **totipotent** (undifferentiated cells) capable of becoming any kind of bodily cells. - Another 4 days, as it implants and becomes an embryo, the cells begin to show differentiation to become specific body part (e.g. heart, brain, lungs, etc.) - **Multipotent** -- in the succeeding days, cells grow so specific that they already have a course toward what body organ they will become. **GROWTH OF THE ZYGOTE** - Growth of the zygote is **cephalocaudal --** from head to tail direction. - PRIMARY GERM LAYER -- origins of the development of the body systems. - Ectoderm - Endoderm - Mesoderm **NOTE:** Knowing which structures arise from each germ layer is important. Coexisting congenital defects arise from the same germ layer. EX. = esophageal atresia and tracheal atresia arise from the endoderm =heart and kidney malformation arise from the mesoderm However: **Rubella Infection (German measles) a serious infection during pregnancy affects all three germ layers causing many congenital anomalies.** - At 8^th^ week, all organs system is formed in a rudimentary form. During this period, the structures are most vulnerable to **teratogenic.** **PLACENTAL CIRCULATION** - On the 12^th^ day of pregnancy, maternal blood begins to collect in the spaces of the endometrium surrounding the chorionic villi. - Oxygen and food nutrients diffuse from maternal blood through the cell layers of the chorionic villi to the developing embryo. **Note:** - There are no direct exchanges of blood between embryo and mother during pregnancy. it is carried out only thru selective osmosis. **FETAL PARTS/SYSTEM** **Cardiovascular System** - One of the first system to be functional intra-uterine life. - It forms on the 16^th^ day of embryonic life and beats as early as the 24^th^ day of life. - The septum that divides the heart develops on the 6^th^ -7^th^ week - Heart beat maybe heard on the 12^th^ week/ECG on 20^th^ week pregnancy. **Fetal Circulation** - Exchange of nutrients with maternal circulation across the chorionic villi to the placenta. - Fetus derive oxygen and excretes CO~2~ thru the placenta. - Blood enters the fetus thru the umbilical vein towards the fetal heart blood flows to the inferior vena cava via the **ductus venosus** which allow oxygenated blood directly to the fetal liver. - Blood from inferior vena cava enters the **right side of the heart** and flows to the **left side thru an opening between the atrial septum called FORAMEN OVALE.** - From the foramen ovale blood in the left atrium. It follows the normal flow of blood into the left ventricle and then to the aorta. - **Ductus arteriosus** another fetal structure which is shunts blood to lungs and allow blood flow directly to the descending aorta. **FETAL RESPIRATORY SYSTEM** **Developmental milestone:** - Alveoli and capillaries begin to form between the 24^th^ and 28^th^ weeks. Both alveoli and capillary must be complete before gas exchanges can occur in fetal lungs. - Specific lung fluid with low surface tension of the alveoli at birth. (rapidly absorbed after birth) - **Surfactant** a phospholipid substance, formed and excreted by the alveolar cell during the 24^th^ week which prevents alveolar collapse by decreasing alveolar surface tension. **Surfactant has 2 components:** - Lecithin - Sphingomyelin - These 2 substance mixes with amniotic fluid which serves as one of the primary test maturity - Ratio 1:2 **FETAL NERVOUS SYSTEM** **Develop in the 3^rd^ -4^th^ week of life** - **Neutral Tube (ectoderm)** forms the CNS (brain and spinal cord) - **Neutral Crest** develop into the peripheral nervous system - 8^th^ week- brain waves can be detected by EEG - All parts of the brain that form in utero are not completely mature. They mature on the first year of life and continues at high level until 5-6 years of age. - 24^th^ week, the ear is capable of responding to sound **FETAL DIGESTIVE SYSTEM** - 4^TH^ week, the digestive tract and respiratory tract separates. - **MECONIUM** a collection of cellular waste, bile, fats some vernix caseosa and other fetal secretions are absorbed in the intestinal tract. - GIT is sterile, that is why vit. K are at low levels. Vit. K is synthesized by bacterial action. - Sucking and swallowing reflex are immature until the 32th week gestation or 1,500g weight of the fetus. - Liver is active but still immature at birth. **URINARY** - Urinary system begins to develop at the end of 4^th^ week, they are not functional until birth because the placenta serves as excretory organ for the fetus. - **12^th^ week** urine is formed and is excreted to the amniotic fluid by 16^th^ week - at term fetal urine is secreted at 500ml per day. **IMMUNE SYSTEM** **IMMUNOGLOBULIN G (IgG)** maternal antibodies cross the placenta during the 3^rd^ trimester. This gives the fetus temporary passive immunity against diseases. **(EDB) ESTIMATION OF DATE OF BIRTH** - 280 days is the approximate number of days of pregnancy from last menstrual period - Some end within 1 week of the 280^th^ day - Pregnancy ending 2 weeks before and 2 weeks after the calculated EDB is considered well within the normal limit which is 38-42 weeks. **How to complete:** **NAGELE'S RULE** - Count 3 months from the 1^st^ day of the last menstrual period. - Add 7 days to arrive at the EDB **Example:** - May 15, 2022 -- 1^st^ day of menstruation - Count back: April, March, February - February 15 plus 7 days - February 22, 2023 -- EDB **ASSESSMENT OF FETAL G&D** **Some factors affecting fetal development** - Chromosome disorder - Metabolic disorder - Undeveloped supporting structures like placenta or umbilical cord - Smoking, alcohol **ESTIMATING FETAL GROWTH** **McDonald's Rule** - Measuring the distance from the fundus to the symphysis pubis in cm. equal to the gestational week between 20^th^ and 31^st^ week - It is common method of determining during mid pregnancy because the fetus is now growing move in weight than in height - 12^th^ week- over the symphysis - 20^th^ week -- at the umbilicus - 36^th^ week -- xyphoid process **FETAL MOVEMENT** - Can be felt approx 18 to 20 weeks - Peak at 28^th^ to 38^th^ weeks - Quickening - Healthy fetus moves with degree and consistency at least 10 times a day - A fetus not receiving enough nutrients due to placental insufficiency has decrease movements. - Ask mother to observe and record the number of movements daily for gross assessment of fetal well-being. **METHODS OF ASSESSING FETAL MOVEMENTS:** **Sandovsky Method** lie on the left recumbent position after a meal and record how many fetal movements for the next hours. In this position, the fetus normally moves 2x every 10 minutes or an average of 10-12 times an hour. **Cardiff Method "count-to-ten"** - Count the interval it takes for her to feel 10 fetal movements **HEALTH ASSESSMENT DURING THE FIRST PRENATAL VISIT** - Importance of Prenatal care in order to avoid premature delivery and screen for danger signs and complication for the woman. - **Major causes of death during pregnancy:** - Ectopic pregnancy - HPN - Hemorrhage - Embolism - Infection **FACTORS THAT MAY CONTRIBUTE TO DIFFICLUTY ACCEPTING PREGNANCY** - Multiple pregnancy - Developmental Abnormality - Pregnancy less than 1 year previous one - Relocation during pregnancy - Moving away from family or back to the family - Role reversal - Job loss - Marital infidelity - Illness - Complications of pregnancy - Hx of previous miscarriages, fertility problems - Previous fetal of neonatal loss **PREGNANCY TASK OF PREGNANCY** - First trimester - Accepting the pregnancy - The woman and partner both spend time recovering from shock of learning they are pregnant and concentrate on what it feels to become pregnant. - Feeling of ambivalence, fear, anxiety. - Second trimester: - Accepting the baby - Woman and partner move through emotions such as narcissism and introversion as they concentrate on what it will feel like to be a parent. Dreaming is common. - This change usually happens when the first fetal movement is felt "quickening" - Third trimester task: - Preparing for the baby and end of pregnancy - Woman and partner grow impatient with pregnancy as they ready themselves for birth. - **IRON, FOLIC ACID AND VITAMIN NEEDS** - Iron supplement is needed in pregnancy due to the following: - Fetus iron requirement -- 350-400mg of iron - Increase demand for RBC cell mass- additional of 400mg iron - Total need of 800 mg while average woman's iron store is only 500mg - Iron absorption of the mother may also be impaired due to decrease acidity of the stomach. - Iron supplements is highly recommended of adequate dosage. - Advise woman to lie on her left side to increase blood flow to the vena cava. - **Clotting factors** - Increase by 50% during pregnancy as a result of increase level of estrogen; increase in VII-VIII-IX-X clotting factors and increase platelet count - These increases protect form major bleeding if placenta is dislodged or uterine arteries open - Increase WBC - Decrease - **Blood Pressure** - Slightly increase or not all, despite hypervolemia - Peripheral blood flow -- 3^rd^ trimester- blood flow towards the lower extremities is impaired by the enlarged fetus which may also cause edema and varicosities of the legs, vulva and rectum - **Supine Hypotension Syndrome** - Lying in supine position, cause pressure on the vena cava against the vertebra, obstructing blood flow from the lower extremities. This cause decrease in blood returning to the heart causing hypotension. S/S dizziness, lightheadedness, faintness because it may result to fetal hypoxia. - **Heart** - To complete for the increase blood volume, the woman's heart increases it cardiac output 25 to 50% causing additional to heart beats/min - This has an implication to a woman who has heart disease. - Heart is also shifted to a more transverse position in the chest cavity, which make it appear enlarged in Chest x-ray. This may also because innocent hear murmurs and also due to pressure of the growing fetus of effects of sympathetic nervous system stimulation. - **Folic Acid Requirement** - Increases during pregnancy and when not supplied by the body, it could result to: - Megahemoglobinenimea (large non-functioning RBC) - Neutral tube disorder (spina bifida) Folic Acid Supplements are given and advise pregnant mothers to eat foods rich in green vegetables. - **Cardiovascular System** - Changes in circulatory system is significant to the health of the fetus for adequate placental and fetal circulation - BLOOD VOLUME -- increase by 30-50% during pregnancy at the end of the trimester and peaks at 28^th^ to 32^nd^ week; - Blood loss in vaginal birth is about 300-400; while caesarian section would be 800-1000ml. - Because of faster increase plasma volume, the concentration of HGB and RBC declines which results to **pseudoanemia** in early pregnancy. **OTHER PHYSIOLOGICAL CHANGES** - **Uterine Changes** - Increase in length, width, depth and weight are evident; also, thickening of the myometrium and stretching of muscle fibers about 7 times the original size. - Growth of the fetus can be measured thru the fundal height using MacDonald's Rule. - Sweat glands increase activity throughout pregnancy manifested by increase perspiration - Palmar erythema (redness and itching) also occur on the palm of the hands resulting from increase estrogen levels. - **Integumentary Changes** - **Striae Gravidarum --** pink or reddish streaks on the sides of the abdominal wall and the sides of the thigh as a result of stretching of the muscles and enlargement of the uterus. - **Linea Negra-** a narrow brown line from the umbilicus to the symphysis pubis separating the abdomen into right and left hemisphere. - **Melasma (chloasma) --** mask of pregnancy resulting from increase pigmentation caused by melanocytes stimulation hormone secreted by the pituitary. **POSITIVE SIGNS** - Sonographic evidence of fetal outline - Fetal heart is audible - Fetal movement felt by the examiner **Breast Changes** - Fullness, tingling, tenderness and enlargement of the breast as a result of high estrogen level in the body, - Hyperplasia of the mammary glands and fat deposits - Darkening of the arcola and nipple and increase in size of diameter. - **Montgomery Tubercles --** enlargement of the sebaceous glands of the arcola. - 16^th^ week -- colostrum can be expelled from the nipples. - Fungal infections have to be treated to prevent transmission of infection to the newborn as it passes to the birth canal **"thrush" -- or oral Monilia** **Vaginal Changes:** - **Chadwick's sign --** Changes in the color of the vaginal walls from normal light pink to dark violet - Vaginal secretions fall from alkaline become acidic which make vagina resistant to bacterial invasion for the length of pregnancy. - However, it favors the growth of candida albicans (fungi) infection. - S/S = itching, burning sensation, cheeselike discharge **Cervical Changes** - Goodell's Sign -- cervical changes marked by softening of the cervix. It maybe compared to the softness of the earlobe. Before labor, cervix becomes so soft and said to be "ripe" for birth. - Operculum- a sticky mucus coating that fills the cervical canal which serves to seal out bacteria during pregnancy which in turn prevents infection of the fetus and membranes. - **Braxton Hick's Contraction --** uterine contraction at about 12^th^ week and hardness and tightening across the abdomen - It serves as a warm-up exercise for labor and increase placental perfusion - It becomes strong and noticeable at term and maybe mistaken for labor contraction (false labor) - It does not accompany cervical dilation - It may also be present in any growing uterine mass that is why is a probable sign. **Terminologies** **UTERINE CHANGES** - **Ballotment --** to "toss about" - By tapping the lower uterine segment, the fetus bounces or rise in the amniotic fluid up against the examining hand. - **Hegar's Sign --** at 6^th^ week there is softening of the lower uterine segment just above the cervix when compressed by the examining fingers **PROBABLE SIGNS** - Serum laboratory tests - Chadwick's sign - Goodell's sign - Hegar's sign - Sonographic evidence of gestational sac - Ballotment - Braxton hick's contraction - Fetal outline felt by the examiner **PRESUMPTIVE SIGNS** - Least indicative of pregnancy - They could easily indicate other condition - Breast changes - N & V - Amenorrhea - Frequency in urination - Fatigue - Uterine enlargement - Quickening - Linea negra - Melasma/striae gravidarum **DIAGNOSIS OF PREGNANCY** - Pregnancy is officially diagnosed on the basis of symptoms reported by the woman and the signs seen by the OB - Three classifications of the signs of pregnancy: - **Presumptive (subjective symptoms)** - **Probable signs (objective signs)** - **Positive signs (documented signs)** - Most women come to a healthcare facility for a diagnosis of pregnancy have already guessed they are pregnant based on many subjective symptoms and they have already performed a home pregnancy test, so the visit to the health care facility is just a confirmation rather than a diagnosis. - Amniocentesis gives information on the following: - Color - Lecithin/sphingomyelin Ratio (2:10) normal lung maturity - Bilirubin Determination -- presence may indicate blood incompatibility between fetus and mother - Chromosome analysis - AFP - Inborn errors of metabolism - Fetal fibronectin- fibronectin helps in the placental attachment to the uterine decidua. When fetal membranes are damage, elevated fibronectin level is present and may indicate preterm labor. **Other Diagnostic Procedures** 1. Maternal Serum Alpha FetoProtein (MSAFP) - AFP -- Present in amniotic fluid and maternal serum - AFP is high in maternal serum if the fetus has an open spinal or abdominal defect - AFP is low if the fetus has chromosomal defect. - MSAFP begins to elevate a 11 weeks gestation and steadily increase until term 2. Chorionic Villi Sampling Biopsy and chromosomal analysis of the chorionic villi done at 10-12^th^ week, also to determine genetic disorders. 3. Amniocentesis - Aspiration of amniotic fluid from the pregnant uterus which may done on the 14^th^ and 16^th^ weeks and also at term to test for fetal maturity. Possible disadvantages: - Hemorrhage, infection, and puncture of the fetus. Polyhydramnios Information \| Mount Sinai - New York **ULTRASOUND/ULTRASONOGRAPHY** **Purposes:** - To diagnose pregnancy as early 6 weeks - To confirm presence, size, and location of the placenta and amniotic fluid - To know if fetus is growing and has gross anomalies. (hydroc/anencephaly, spinal cord, heart, kidney, bladder defects) - To determine sex - To know position of the fetus - To predict maturity of the fetus thru parietal diameter of the head - Complications of pregnancy that can be diagnose in Ultrasound: - Intra uterine device (IUD) - Hydramnios/oligohydramnios - Ectopic pregnancy - Missed miscarriage - Abdominal pregnancy - Placenta previa - Uterine tumors - Multiple pregnancies - Genetic disorders (down's syndrome) - Fetal death **GTPAL** - Mother comes for prenatal visit. She is 18 weeks pregnant now. Previous history: first pregnancy is 38 weeks, followed by37 weeks, 20weeks; 36 weeks. She has 3 boys alive. What is her GTPAL?