Maternity Exam Notes 2 - PDF

BEGINNING MATERNITY UNIT LECTURE 01/11/2022 WEDNESDAY SEXUALITY & REPRODUCTIVE CONCEPTS , Sexuality Sexuality includes the thoughts, feelings, and behaviors related to the adolescent’s sexual identity. Refers t...

BEGINNING MATERNITY UNIT LECTURE 01/11/2022 WEDNESDAY SEXUALITY & REPRODUCTIVE CONCEPTS , Sexuality Sexuality includes the thoughts, feelings, and behaviors related to the adolescent’s sexual identity. Refers to a “persons characteristics and perceptions concerning sexual expression but also includes function of the sexual organs. In fertility issues, it is cheaper to treat males versus females. Reproduction Refers to the fusion of females and males to create human offspring. Within reproduction are the process of conception, gestation, and childbirth. Nurses play a key role in maternal and pediatric settings. “Preconception, Pregnancy, Birthing, and lactation needs of Transgender Men” article. ○ There’s a lot of barriers that are permitting transgender from seeking medical health. ○ Transgender men have a higher chance of getting cervical cancer vs women because of the lack of Pap smears. ○ Transgender men are using more midwives versus women. - Probably because of the way that providers treat them versus midwives. ○ Providers seem to refuse care for transgender men. - Could it be because of a lack of knowledge with this population? ○ Gender transitioning surgeries can lead to a lack of fertility. ○ Providers needed to be educated more with transgender men. ○ Testosterone use during pregnancy can lead to a teratogenic pregnancy. ○ Transgender men are afraid to use birth control because they are afraid to add more estrogen into their bodies. ○ There is limited research on transgender men and pregnancies. ○ There is limited research on postpartum depression in trans men.  ○ In chest masculinity, where they reduced their chest tissue, transmen are still able to lactate. ○ More research is needed to develop more evidence-based practice for gender men. ○ Providers and medical staff need to learn how to use the proper language when addressing transgender men. They are so used to assuming pregnancy and women. ○ Transgender men may have a bad medical experience will struggle to come back in the future. As well as providers, transgender men need to have proper education too. How did the lecture and article today affect the way you will address the LGBQT community, as well as transgender people? ○ Have an open mind. ○ Listen. ○ Advocate. ○ Patient first :) ○ Don’t be simple minded. ○ Watch your tone, mannerism, and nonverbal body language. A patient can tell if you are genuine, or you just hate being there. ○ Regardless of your beliefs and theirs, treat everyone equally like humans. ○ Look at the patient's chart to familiarize yourself with the patient prior. ○ Establish a rapport with your patient. First impressions count! What did you learn? ○ People identify as different pronouns. ○ There are such high numbers of suicide and being turn down for health care for transgender men. ○ Just because you have an assigned gender at birth, does not mean you have to stick to that gender forever. ○ Nursing is an art and a science. Human interaction does not always come easy. ○ Providers rely on nurses a lot- there is a huge dependence. —————————————————————————————————————————— ————————————————————————------------------------------------------------------  Lecture 01/13/2023 Unit 1 Reproduction and Sexuality Reproduction · Refers to the fusion of female and male gametes to create human offspring. Within reproduction are the processes of conception, gestation, and childbirth. Nurses play a key role in the multiple aspects of reproduction in maternal and pediatric settings. Sexuality · Refers to a person’s characteristics and perceptions concerning sexual expression but also included function of the sexual organs. ******TO DO LIST********************************* *Read before class starts, be prepared. Not much lecture notes, more hands-on activities to learn. ********* *EXAM 1 : MONDAY FEB 6TH, 2023 *Level 3 practice A 3/27 tile 3/31- critical points are due 4/3 0800 *Level 3 practice B 4/3 till 4/7-critical points are due 4/10 0800 *Level 3 proctored assessment 4/24 @ 0800- critical points due 4/26 @ 0800 *Level 3 retake if scored under a level 2 on proctored exam 4/26 @ 0800 ** If you final the proctored---- Templates 4/28 **************************************************** Concepts: Individual Safety Metabolism Nutrition Oxygenation Cognition Mobility Infection ————————————————————————— Men - erectile dysfunction Sildenafil (viagra) to medicate ○ Vasodilator ○ Causes: Lowers BP Produces an antidepressant effect Can contribute to higher blood sugar ○ Should consults HCP if the effects lasts longer than 4 hours. ○ Contraindications Heart issues Low blood pressure Chest pain ————————————————————————- (Know hormones, what they are, and how they are during pregnancy and not pregnant) Women’s Bodies Goal is to achieve or void a pregnancy ○ Need a brain (hormones), ovaries (ova), and uterus (supports pregnancy) BRAIN: Three important hormones ○ Estrogen (follicle phase) 1st Gives us secondary sex characteristic Increases libido Increases size and weight of uterus and breast to grow during pregnancy Helps women start a pregnancy Hypertrophy- increase in muscle hyperplasia - increase in vessels ○ Progesterone (corpus luteum phase) 2nd “Pro gestation “  Secreted by ovaries (corpus luteum) Needs to maintain pregnancy Hormone of pregnancy Relaxes the muscles to prevent preterm labor ○ Prostaglandins Fatty acids that are released from the lining of the endometrium (innermost lining of the uterus) Purpose: cause vasoconstriction and vasodilation——- (CRAMPING, contractions) Prostaglandins is what triggers cramps Take anti-prostaglandin like ibuprofen to help with the cramps ○ Aspirin will not help with cramps ○ Prolactin Prolactin is a hormone made by the pituitary gland, a small gland at the base of the brain. Prolactin causes the breasts to grow and make milk during pregnancy and after birth. Prolactin levels are normally high for pregnant women and new mothers. ○ Indigenous hormones are natural ○ Exogenous hormones are not natural Cause women to have cardiac events Brain (hypothalamus) releases these hormones (FSH & LDH) on a typical day, one of the menstrual cycles. Ova ( more then one egg) lives 24 hours Ovum (one egg) Sperm lives up to 5 days Ampulla is where fertilization takes place inside the fallopian tubes. Ovulation happens normally in day 14 / 15 ○ Sex drives increase during ovulation ○ Thick endometrium Ovulation happens and no fertilization happens, then the ovarian cycle then degenerates. ○ Ova becomes a corpus ludum and it goes away (menstrual period) Thick lining is needed to achieve implantation Thin lining at the end of menstruation Menstrual Cycle based on a 28 day cycle Two Phases  ○ Follicular until ovulation then luteal ovarian phase Follicular Ovarian phase ○ Menstrual phase: The menstrual cycle is occurring. Hormone levels are dropping. Endometrium is getting very thin. (Spiral arteries are in the endometrium. Causes the endometrium to grow) A lush endometrium is when it has a thick lining. This is preferable when you are trying to get pregnant. Estrogen here and no progesterone ○ Proliferation Phase: Day 5 of menstrual cycle Lasts till the time of ovulation Cervical mucus becomes thin, as it waits for sperm to fertilize Estrogen is high here No progesterone Luteal ovarian phase ○ Secretory Phase: MOST FERTILE time Begins at ovulation to about 3 days before the next menstrual period. This phase lasts from day 15 to day 28 In the absence of fertilization by day 23 of the menstrual cycle, the corpus luteum begins to degenerate and hormone levels decrease. The endometrium undergoes involution. Progesterone high here And high estrogen ○ Ischemic phase If fertilization does not occur, the ischemic phase begins. Estrogen and progesterone levels drop Corpus luteum start to degenerate Spasm of the arterioles occur which results in the ischemia of the basal layer Leads to shedding of the endometrium down to the basal layer Menstrual cycle begins ○ Menstrual phase Begins as the spiral arteries rupture secondary to ischemia, releasing blood into the uterus and the sloughing of the endometrium lining begins. If fertilization does not take place, the corpus luteum degenerates. Hormone levels decrease. Most menstrual cycles last 3-7 days. Infertility ○ Defined: as the inability to conceive a child after 1 year of regular sexual intercourse unprotected by contraception. ○ How do we get her pregnant? Fertility drugs: Clomiphene citrate, human menopausal gonadotropin, artificial insemination ○ Serious symptoms include: ascites, ovarian rupture, SOB, vomiting, distension In vitro fertilization (IVF) Avoid Fallopian tubes. Cause more follicles to be mature and implant them in the uterus. Oocytes are fertilized in the lab and transferred to the uterus. Usually indicated for tubal obstruction, endometriosis (number 2 cause of infertility)., pelvic adhesions, and low sperm counts Number 1 cause of infertility: STIs cause inflammation and tubal scarring and obstruction Gamete intrafallopian transfer (GIFT) Oocytes and sperm are combined and immediately placed in the fallopian tube so fertilization can occur naturally Nurse needs to inform couple of risks and have consent signed Intracytoplasmic sperm injection (ICSI) One sperm is injected into the cytoplasm of the oocyte to fertilize it. Indication for male factor infertility Nurse needs to inform the male that sperm will be aspirated by a needle through the skin into the epididymis Donor of oocytes or sperm Eggs or sperm are retrieved from a donor, and the eggs are inseminated; resulting embryos are transferred via IVF Recommended for women older than 40 years and those with poor- quality eggs Preimplantation Genetic Diagnosis (PGD) Used to identify genetic defects in embryos created through IVF This is done specifically when one or both genetic parents have a known genetic abnormality and testing is performed on an embryo to see if it also carries a genetic abnormality Nurse should inform couple about this option and support them until test results return Gestational carrier (surrogacy) Laboratory fertilization takes place and embryos are transferred to the uterus of another woman, who will carry the pregnancy or intrauterine insemination can be done with the male sperm Medical legal issues have resulted over the “tree ownership” of the resulting infant  Nurse should encourage an open discussion regarding implications of this method with the couple Menopause ○ Irreversible part of the aging process. She will no longer menstruate. ○ This is the occurring phase of every woman's life that marks the end of her childbearing capacity. ○ No more ovaries when menopause starts ○ Hormone levels drop ○ Estrogen has a natural anti-atherosclerosis (cholesterol) effect Interferes with metabolism When estrogen stops, you get atherosclerosis More prone to heart disease ○ Endogenous- inside of body ○ Exogenous - outside of body - synthetic made, it doesn’t work the same as inside ○ Vasomotor symptoms of menopause Heat flashes Mood changes Hormone therapy will help this ○ The average age of menopause is 50 years old. ○ Estrogen direct erostrate effect. Having plague issues because estrogen levels decrease which can cause cardiac issues Lipid metabolism changes Metatrope- will help OOHS ○ Fun Fact: Babies are born with 4 million eggs At puberty it goes down to 400,000 ——————————————————————- Contraception Lecture Defined as birth control when referring to the intentional prevention of pregnancy Different types: ○ Sexual abstinence Not having intercourse One of the least expensive forms of contraception Pregnancy cannot happen if sperm is out of the vagina  Reduces risk of contracting HIV/AIDS and other STIs, unless body fluids are exchanged through oral sex, some infections like herpes and human papilloma virus, can still be passed by skin-to-skin contact Many people choose sexual abstinence because Wait to have sex until they are older ○ Male and female sterilization Vasectomy Bilateral Tubal ligation Non-operative sterilization (spring in the tube) ○ Intrauterine contraception ○ Implant IUD, Mirena, Nexplanon (arm) ○ Injectable contraceptive Progesterone only (DEPO) ○ Contraceptive patch ○ Rings ○ Pills Estrogen and progesterone pills Progesterone only pills ○ Male and female condoms ○ Fertility awareness ○ Diaphragm (condom for vagina) Barrier method ○ Benefits: Good for those who cannot use hormones. Condoms, diaphragms, IUD Least expensive, non-hormonal, readily available, good for a client who cannot use hormones Diaphragms- used in Amish night communities, used with a jelly or spermicide, not felt while having intercourse, bend in half and up through the vagina, bones hold it in place 3 different sizes Put it in the comfort of their home and come back into the office and check to make sure it is in place Dignified Sponges Stays at surface of the vagina Remain in place for 4-6 hours to make sure sperm dies ○ Risks Does not protect against STI, can perforate uterus, infection, can break  Not most effective Allergies Could forget ○ Alternatives Abstinence, vasectomy, tubal ligation, fertility awareness ○ Inquires What is the effectiveness? How long does it stay in place? Number of sexual partners? Does it protect against STI? Comfort levels? OB-GYN and doctor appts ○ Decision Is this the right decision for the client? Most easily accessible Does not need insurance All reversible or removable ○ Explanation Various introductions Abstinence only pertains to vagina sex. Can have oral and anal. Behavioral method Checking cervical mucus to see how much estrogen you have. Ovulation tests Basal thermometer- track over a month Progesterone is thermogenic- meaning temp will go up lactation method- breastfeed for 6 months for a minimum of 6 times a day. Thought that the female will not ovulate. Follow manufacturer's instructions for both short term and long term Benefits ○ Free ○ No hormones required Risks ○ Fully accountable for anything that happens ○ Easily pregnancy ○ No STI protection ○ Low success rate Alternatives ○ Barrier ○ Hormonal ○ Permanent  Inquires ○ Is there any way to prevent STIs? ○ Abstinence, withdrawal, lactation, amenorrhea method, fertility method, what methods are included Decisions ○ Religion consideration ○ Waiting until marriage ○ Are you responsible? ○ Can change your mind at any given time ○ Use other methods ○ Educate on risk Explanation ○ Fertility app ○ Calendar ○ Pull out method before ejaculation ○ Dental Dam prevent STI transmission ○ Use the bodies physiological process to understand when fertility or not Hormonal methods Includes oral contraceptives, injectables, implants, vaginal rings, transdermal patches Benefits ○ Helps with acne ○ Most reliable form of contraceptive if taken as prescribed ○ Regulates menstrual cycle ○ Less painful periods ○ Reduces the risk of uterine cancer ○ Reduces the risk of ovarian cysts Risks ○ Decrease lipid ○ Blood clots ○ Heart attack/ stroke ○ Breast tenderness ○ Breakthrough bleeding ○ No protection against STIs ○ ovarian/endometrial carcinomas Alternatives ○ Condoms ○ IUD ○ Abstinence ○ Cervical caps ○ Sponge ○ Hypothermal method  ○ sterilization Inquires ○ Effectiveness if dose skipped ○ Long term effects ○ Are the effects reversible ○ any changes to mind or physiological characteristics ○ Take at the same time everyday Decisions ○ Age ○ Frequency ○ Smoking ○ Cost ○ Religious belief ○ Hormone deficiency ○ Use of antibiotics Explanation ○ Explain the contraceptives and explain the risks and benefits. ○ Stop body from releasing the egg (ovulation) ○ Change the cervical mucus and thins lining of the uterus Patches and Rings have the most highest amounts of estrogen, which leads to the MOST complications. Emergency Birth Control ○ Benefits Avoidance of pregnancy Stops ovulation ○ Risks Nausea Breast tenderness Abdominal pain Menstrual changes Dizziness Cost Wait time for appointment (Paragard) ○ Alternatives Take Action My choice pills ○ Inquires How quickly after unprotected intercourse do I have to use EC? Does EC affect future fertility? ○ Decisions Is that the right method for this patient?  Condom broke or fell off Miss too many pills ○ Explanation Plan B: take within 72 hours of unprotected sex Ella: take within 5 days of unprotected sex Plan B an Ella- Stop ovulation from happening Paragard (emergency, and barrier): Inserted by OB/GYN into uterus Occasionally check the strings Can’t be used with a patient who has anemia If religion does not belief in abortion because they have a fertilized ova which causes an abortion Sterilization (vasectomy, bilateral tubal ligation, non-operative) ○ Benefits Very effective- more than 99% Doesn’t change hormone Most permanent option Convenient Low to no maintenance Vasectomies can be reversed. ○ Risks Surgery complications Bleeding Infection Reaction to anesthesia Risk of regret Expensive to attempt to reverse and or irreversible Might not always work (rare) People - females can still get pregnant ○ Alternatives: Birth control contraceptives: pills, shot, patch, implant Abstinence Significant other fixed over the other one ○ Inquires Is it reversible? Does it prevent STI? Do you want more kids? Are you okay with surgery? Do you have any known complications with anesthesia? ○ Decisions  After surgery, the procedure usually is permanent. Can be attempted to be reversed but expensive and no guarantee it will work. Long term contraceptives should be used if possibility of wanting children later ○ Explanation Only should be used when patient is done having kids Explain the pro and cons of the methods Surgical and non-surgical option Vasectomy: vas deferens cut or tied Tubal ligation: clipped, burned, bonded Ensure/ non-surgical: coils placed bilaterally in tubes to allow tissue to grow over —————————————————————- Hour 12 of lecture: Sexually transmitted infections (STIs)- Fallopian tubes are inflamed which leads to infertility Systemic (HIV, Hepatitis A, Hepatitis B, Zika, Scabies, Pediculosis Pubis, Ectoparasitic) Systematic can be passed off to the baby ○ HIV Viral load < 1,000 3 antiretrovirals- triple therapy Biktarvy med to treat Patient education Health people 2030: encourage abstinence and promote protection, provide an open and confidential environment so women report symptoms and seek treatment earlier Psychosocial effects Coping with other reactions to stigmatized disease Accepting possibly of shortened lifespan Health insurance (lack thereof)/ cost of meds/treatments Not treatable Symptoms Weight loss Flu-like symptoms Fatigue Fever  Swollen lymph nodes Asymptomatic after acute phase Acute phase- 2-6 weeks after exposure Decreased immune system FDA medications Entriva Epivir Retrovir Transmission Sexual intercourse Needle sharing Mother to child pregnancy/ childbirth Breastfeeding Nursing interventions Promote skin integrity Prevent infections Relieve pain/discomfort Improve nutritional status ○ Hepatitis A (vaccine) ○ Hepatitis B ○ Zika ○ Scabies ○ Pediculosis Pubis ○ Ectoparasitic Infection STIs that affect the Cervix ○ Gonorrhea Affects mucosal surfaces Aerobic gram negative Increase risk for PID Increase risk for infertility Increase risk for ectopic pregnancy Second most reported infection Transmitted to a newborn in the form of an ophthalmia. Often asymptomatic! In pregnancy, it is associated with chorioamnionitis (placental sack is infected, preterm labor, PROM, and postpartum endometritis (inner lining of the uterus is infected Pregnant women should be screened at first prenatal visit and at 36 weeks  If left untreated, it can lead to ophthalmia neonatorum (baby going blind) during birth. If undetected, leads to blindness, joint infection, and life-threatening blood injections to the newborn Treatment (CDC) Dual therapy: azithromycin (PO) and Ceftriaxone (IM) ○ Chlamydia- most common STI in the US Risk for PID Can infect animals Both genders can be asymptomatic Men can develop urethritis Women develop cervicitis Bartholinitis- a fluid filled swelling (cyst) in the Bartholin's glands, which lubricate the vagina Endometritis-inflammation or irritation of the lining of the uterus Salpingitis- inflammation of the fallopian tubes caused by bacteria Dysfunctional uterine bleeding Antibiotics can treat Newborns delivered to infected mothers may develop conjunctivitis Both partners need to be treated Can cause Ophthalmia neonatorum which cause the baby to be blind Must have erythromycin eyes to babies Treatments (CDC) Doxycycline 100mg PO BID or Azithromycin 1g IM ○ Uterus (Pelvic inflammatory disease-PID) Frequently caused by untreated chlamydia or gonorrhea If left untreated may lead to infertility Treatment (CDC) Cephalosporin-single injection Doxycycline 100mg BID for 14 days STIs that affect the Vagina Vaginal (yeast infection) Vaginal discharge- not an STI but places patient at a higher susceptibility for developing an STI) ○ Vulvovaginal Candidiasis Fungal infection Not an STI, because Candida is normal and only becomes a problem when the vaginal environment becomes altered. 75% of women will have one episode. 40-50% will have two or more episodes in their lifetime. Nursing Assessment  Assess the client’s health history for predisposing factors for VC, which include pregnancy, high estrogen birth control pills, diabetes, antibiotics, obesity, HIV infection, tight and restrictive clothing Assess the client for clinical manifestation of VC. Typical symptoms which can worsen just before menses include: Pruritus, vaginal discharge, soreness, burning, dysuria, erythema, and dyspareunia Most common cause of vaginal discharge, NOT AN STI Advise patient to wear 100% cotton underwear Avoid baths Treatment Miconazole cream or suppository Nurse Management Teach preventive measures to women with frequent VC infections including: Reduce sugar intake Wear white cotton underpants Avoid wearing tights Shower rather than taking baths Wash with a milk, unscented soap Good body hygiene Avoid using douche Avoid using super absorbent tampons Wipe from front to back Trichomoniasis ○ Vaginal infection that causes a discharge, but not always sexual transmitted ○ Most prevalent non-viral STI ○ Men are symptomatic or asymptomatic ○ When symptoms are present, women may experience vulvar itching and malodorous greenish gray foamy vaginal discharge ○ Lead to infertility ○ Therapeutic management: · A single dose of 2g oral metronidazole. · Sex partners with infected women should all be treated to avoid recurrence of infection · Avoid alcohol · No intercourse (female condom) ○ Nursing assessment · Assess for clinical manifestation Vagina pruritus Heavy yellow or green or bubbly discharge Dyspareunia Vaginal odor  · Nursing management Avoid sex until all is treated. Avoid consuming alcohol. Educate patient on Trichomoniasis Bacterial Vaginosis ○ Get tested if preterm labor ○ “Yeast infection” ○ Third common infection of the vagina caused by gram negative bacillus G. Vaginalis. ○ 50% to 75% are asymptomatic. ○ Vaginal discharge may be present ○ Stale fishy odor (whiff test) ○ STI that results in the alterations in vaginal flora of anaerobic bacteria in the vagina. · Results from multiple sex partners, douching, lack of vagina flora ○ Can result in preterm labor, premature rupture of membrane, postpartum endometritis. ○ Therapeutic management: · Metronidazole or clindamycin cream · Treatment of male partner has not been beneficial in preventing recurrence ○ Nursing assessment · Assess for clinical manifestation Vaginal pH 4.5 Positive whiff test - very unpleasant odor- fishy test Thin, white homogeneous vagina discharge The presence of clue cells on wet-mount examination STIs that affect Perineum (area between the vulva and anus) Genital herpes simplex I is above the waist ○ Genital Herpes Simplex II- below the waist Can remain latent and reoccur Direct contact with someone with the virus Kissing, sexual contact, vagina birth Recurrent, lifelong viral infection. HSV 2 invades the mucous membranes of the genital tract Very painful and uncomfortable especially first outbreak If no lesions can deliver vaginally Even if the patient is not having a viral outbreak, they can still transmit it Most transmission occurs by individuals unaware that they have the infection  Primary outbreak, then the virus dormant in the nerve cells for life, resulting in periodic recurrent outbreaks Viral shedding takes up to 2 weeks to complete Reoccur by: Stress, intercourse, menses Symptoms Itching, tingling, pain, fever, blisters (in perineal area) Treatment No Cure Acyclovir 400 mg 7-10 weeks when symptomatic Prevention Abstinence Detected by antibody testing and swabbing ○ Syphilis Chronic and curable bacterial infection Primary- painless ulcer (chancre) secondary - flu-like symptoms, maculopapular rash Tertiary- life threatening heart disease and neurologic disease that destroys the heart, eyes, brain, and CNS, Can treat but cannot reverse the damage Strong psychosocial component Treatment Penicillin G, IM or IV Sexual contact with infected person causes the spread and childbirth Can cause infertility in both men and women if untreated. P-LI-SS-IT Model- done when the patient is by themselves ○ P- Permission- gives the woman permission to talk about her experience ○ LI- limited information- information given to the women about STI Information to dispel myths about STIs Specific measures to prevent transmission Ways to reveal information to her partner Physical consequences if the infections are untreated Give information or a pamphlet and then they come back ○ SS- specific suggestions- an attempt to help women change their behavior to prevent recurrence and prevent further transmission of the STI More responsible Health promotion ○ IT- intensive therapy- involves referring the women or couple for appropriate treatment elsewhere based on their life circumstances —————————————————————————————————————————— ————————————————————————------------------------------------------------------ —————————————————————---------------------------- Lecture Friday 01/13/2022 Unit 1 Pregnancy Hour 13 The beginning of Pregnancy Trimesters Pregnancy is 40 weeks. First: 0-13 Second: 14-26 Third: 27-40 Hemoglobin (Hb) for female: 12-16 is normal (12 x 3 = 36 for hematocrit) Pregnant females: 11-13.5 because of physiologic anemia - thins out the volume of plasma Hemoglobin (Hb) for male 14-18 is normal More than females due to more muscle mass ———————————————------------------------------------————————————- Maternal Emotional Responses Ambivalence  The realization of a pregnancy can lead to fluctuating responses, possibly at opposite ends of the spectrum. Considered normal when preparing for this lifestyle change. The woman’s personality, her ability to adapt to changing circumstances, and the reactions of her partner will affect her adjustment to being pregnant and her acceptance of impending motherhood. This is a normal feeling. Validate her feelings. Have to work through these feelings. Teratogen The potential to cause a birth defect Examples: not eating the rights foods, or getting enough nutrients especially during the first trimester Introversion Only want to focus on themselves ( mom and baby) during the pregnancy Socially isolate yourself from family and friends Look up information on the pregnancy Common during early onset of pregnancy (1st and 3rd trimesters) It will heighten in the first and third trimester. Couples need to be aware of this behavior and should be informed about measures to maintain and support the focus on the family. “Nesting period” at the end of pregnancy. Getting ready for baby to come. Acceptance When people start to have physical changes of feeling the baby move and baby bump appears, start to have more positive feelings towards being pregnant This usually happens during the second and third trimester Pregnancy is becoming real Women are much happier Moms are moving on to feel better, no more morning sickness Include the dad more often to help dad feel the same way as mom does 2nd trimester Mood Swing Ongoing roller coaster of emotions. One moment a woman may feel great joy and within a short time, she can feel shocked and disbelief. These emotional extremes can make it difficult for partners and family members to communicate with pregnant women. This is normal Can be throughout the whole pregnancy Change in Body Image  Different from person to person Some people feel as though they are beautiful others may feel as though they are overweight and uncomfortable with the body changes that are going on. Offering an explanation and initiating discussion of the expected bodily changes may help the family cope with them. Remind them that it is a baby that is in there and is growing. The weight can come off after having the baby. Remind them to focus on the baby Becoming a mother First trimester- associated with self Second trimester- when seeing the changes to the body, becoming a mother sets in. Start to become more accepting to becoming a mother Third trimester- accepts the pregnancy Reba Rubin (nursing theorist) ○ Postpartum: we want bonding with mom and baby. Have mom take care of the baby towards the end of stay in the hospital ○ Make sure to have family members involved as well. Psychosocial ○ Sometimes you may see emotions from mom that are normally not how they would act. ○ Can say it is the hormones talking ○ Trying to create that bond ------------------------------------------------------------------ Physiological Changes of Pregnancy Hour 14 Respiratory Increased amount of air breathed in and out. Body oxygenation needs increase by 20%. Decreased amount of air in lungs Increase oxygen use Chest increases in size Often feel shortness of breath Stuffy nose and nosebleeds are common Diaphragm moves upward towards chest Lungs cannot expand as much at the end of the pregnancy ○ Almost hyperventilating (respiratory alkalosis) Pregnancy is a state of respiratory alkalosis (hyperventilating) compensated by mild metabolic acidosis  ○ Taking more oxygen in (respiratory alkalosis), and not letting out enough carbon dioxide. Body is compensating with metabolic acidosis (homeostasis) ○ Metabolic acidosis- due to holding urine, more issues with kidneys Having twins, triplets, quads increase risk for pulmonary edema ○ Storing fluid in body going right up to the lungs ○ 500ml of water will filter to the baby and increase the babies heart rate Babies blood can mix ….. BUT SHOULDN’T BE MIXING! ○ During birth ○ Placenta abruption ○ Trauma ○ Uterine rupture Breast Sensitive nipples Can leak towards the end of the pregnancy Breast tenderness Sore heavy or tingly as early as 1-2 weeks after contraception Increase in size and areolar pigmentation Colostrum that comes out of the breast which has a lot of antibodies for the baby ○ Comes in pre-milk. Milk normally takes 4-5 days to come in. Gastrointestinal ○ Acid Reflex ○ Motility goes down Leads to more constipation Can lead to hemorrhoids Can lead to diarrhea Drink lots of water Progesterone cause motility to go down ○ Gallbladder delayed with emptying ○ Slowing of digestion ○ More water gets absorbed, so there is more constipation, more hemorrhoids ○ Hungrier than usual ○ 2nd trimester pregnancy is in the abdomen, not pushing on the organs Vagina Increase vascularity due to estrogen Swollen and feel fuller Increase blood May increase libido Easily aroused Rugae- skin folds to hold the semen in their to get you pregnant ○ Once pregnant the vagina walls becomes smooth walls and rugae goes away ○ Progesterone causes rugae to go away Cervix is cyanotic looking -Chadwick’s sign ○ Due to estrogen and the congestion of blood in the area. ○ 60% of blood is in the pelvic area Vaginal valvar tends to lengthen. ○ Has Regi that helps get you pregnant. ○ Ejaculation occurs during sexual intercourse the Regi tries to hold the sperm to send it up the vagina to get you pregnant ○ Progesterone causes the urge to go away which cause the vagina to lengthen Hegar’s signs- vaginal exam- touch the tip of the cervix will feel soft. ○ Softening of cervix at 6 to 8 weeks McDonald’s sign- tip of cervix feels soft ○ an ease in flexing the body of the uterus against the cervix - felt 8-12 weeks No pregnant female, cervix will feel hard. Integumentary chloasma and Melasma- Mask of the pregnancy possible pigmentation in the face. Butterfly rash on the face Stretch marks (striae) and varicose veins (spider veins) Lighter skin gets lighter Darker skin gets darker Dark Line during pregnancy ○ “Linea nigra” is a dark, vertical line on your belly that appears during pregnancy. Latin for "black line," the Linea nigra usually extends from your belly button down to your pubic area. In some women it also extends upwards from the belly button. ○ Estrogen causes this Skin tone changes on the feet with calluses Skin can become oily Feet tend to grow or swell while pregnant Acne during pregnancy Hair gets thicker, nails grow and get thinner Hyperpigmentation- genital area, areolas, nipples due to estrogen..  **** It is normal for legs and feet to swell. HOWEVER, swelling in face and hands will indicate preeclampsia.****** Endocrine Placenta ○ Increase to support the pregnancy. ○ Houses the baby ○ Nourishes the baby ○ Thyroid ○ Enlarges ○ More activity ○ Metabolism increase - HPL hormone response Parathyroid ○ Increases in calcium production ○ Prolactin influences on breast increases Pituitary ○ Enlarges Uterus ○ Response to the baby and hormones ○ Estrogen is responsible for the increase in size and weight ○ Increase in size and weight. ○ Hypertrophy and hyperplasia ○ Fundus top of uterus Contractions start at the fundus and it is 1 or more of muscle Involution - shrinking of the fundus Urinary-renal ○ More need to pee frequently ○ Increase in GFR ○ Progesterone is a relaxing hormone Dilates vessels Holds more urine  Prone to UTI (in first trimester can cause an abortion) and kidney stones ○ Kidneys must adapt to more blood volume. ○ Kidney becomes larger in size. ○ Ureters get wider in response to progesterone equals a high chance of developing UTI Cardiovascular Elevated heart rate Elevated blood volume Elevated plasma volume Elevated Blood Volume, elevated HR, elevated CO to get more blood flow to the baby 40-50% blood increase at term, most is plasma. Increased cardiac output. Angiogenesis- beginning of new vessels blood pressure could drop due to a lot of activity and blood volume did not increase yet, not until term Pregnancy is the state of hyper coagulation ○ Which makes moms more susceptible to abnormal clotting because the body is spending its effort abnormally clotting, that when it needs to work and clot, it doesn’t Blood pressures do not drastically change Hypertrophy of the heart Heart arrhythmias- Afib Increase in vascularity in response to estrogen and progesterone ○ Chadwick sign bluish color of cervix meaning an increase in blood flow by 50% ○ High chance to form clots in the pelvic area due to increase blood flow to that area ○ Hypercoagulability- thicker blood and prone to blood clots Can be put on lovenox, comudin is teragenic for baby Example, if pregnant lady has heart block, with pregnancy, it will get worse and damage the hardware of the heart. It can get better, but not always. The components of the heart will be damage. Musculoskeletal Waddle and gait changes What happens when you walk up a hill at 40 weeks? ○ Has mild respiratory alkalosis (hyper venting, blow off oxygen and bringing in CO2) by compensating mild metabolic acidosis (opposite of Respiratory alkalosis)  Ligaments that hold the sacroiliac joints and pubis symphysis begin to soften and stretch due to progesterone Increase sway back, trying to compensate for the big belly Has lordosis- loses curve Knees, ankles, joints, Relaxin- causes knees, ankles, joints to relax leads to a higher chance of them to fall ○ Causes ligaments and joints to become looser ○ Hips are getting ready to expand to have the baby ○ Helps with breastfeeding, letdown Feet get wider due to relaxin, shoes size wont go back to pre pregnancy shoe size Higher chance for falls due to relaxin Edema increase Relaxin helps you get ready for delivery, causing bone separation Progesterone helps release relaxin Metabolism ○ Increases- accelerates enhance production of increased estrogen and progesterone ○ Hormone increases maternal metabolism: human placental lactogen (HPL). produced by placenta ○ Increased to support growing a baby ○ Glucose vacuolates according to trimesters and growth goes on. —————————————————————- Hour 15-20 Reproduction Fetal Development and Genetics Fertilization (very rapid cell division) ○ Ovum + sperm = zygote (fertilized) ○ Maturity of zygote becomes a Morula ○ Blastocyst (outer layer called trophoblast) Does not contain fetal tissue ○ Embryo + amnion—-------chorion (amniotic membrane) ○ Amnion- closest to the baby ○ Trophoblast becomes Chorion- away from the baby These two membranes hold the sac together to form the uterus ○ Yok sac helps until placenta is formed  Takes the place of the placenta in the beginning. Yok sac forms and goes away later. As the food gets used it gets smaller and smaller until it disappears. If it doesn’t happen, then it becomes an issue later in life. Stages of fetal development Pre-embryonic ○ Fertilization to 14 days Rapid cell division Blastocyst formation Implantation Embryonic ○ Day 15 to 8 weeks If you do drugs or alcohol, this is a crucial time to stop. There are teratogenic effects. Potential to develop birth defects Organs and external features develop Most vulnerable to teratogens during this period Starts after implantation Development of germ layers Ectoderm: forms exosketeon Mesoderm: forms into organs Endoderm: forms into lining of organs Development of embryonic layers Amnion ---> amniotic fluid begin to form at the time of implantation Umbilical cord ; AVA ○ Two arteries carries deoxygenated blood from fetus to placenta. ○ One vein carries oxygenated blood nutrients to fetus. Placenta develops Fetal ○ 8 weeks till birth Refining structures and perfecting function A woman might not know that she is pregnant until she is further along. For some, they do not stop their extracurricular activities until later. Embryonic Membranes: Chorion and Amnion ○ Begin to form @ time of implantation ○ Protect and support embryo ○ Together and form the sac then becomes the decidua Chorion ○ Outermost  ○ Finger like projections, chorionic villi Amnion ○ Amniotic cavity Inner layer of endometrium becomes Decidua means pregnant Amniotic fluid Initially derives its fluid by diffusion from maternal blood Amount increases weekly At term = 800-1200ml Baby has to move in order to grow and develop Volume constantly changes ○ “Hydramnios”: amniotic fluid ○ Polyhydramnios - too much fluid ○ Too little fluid is Oligohydramnios ○ Too little urine- oliguria Functions of amniotic fluid ○ Begin to form @ the time of implantation ○ Helps maintain constant body temperature ○ Serves as source of oral fluid, repository for waste ○ Cushions fetus from trauma (protects and supports) ○ Allows freedom of movement ○ Lungs are the last system to develop ○ LS - Lecithin Syncmyocin: there is a 2:1 ratio These lungs should be ready to receive air If not, baby will have to go to nicu. (32 week old baby VS a 40 week old baby) ○ Amniotic fluid is needed for babies to learn how to breathe and to swallow. Fetal Stage The time from the end of the 8th week until birth ○ Longest period of fetal development Genetics (Punnett squares) Autosomal Dominant inheritance ○ Chromosome that is not a sex chromosome ○ Normal mother and affected father 50% becoming affected and 50% becoming normal Autosomal Recessive inheritance  ○ Carriers - means they carry the gene for the disease ○ Carrier mother and carrier dad 25% in recessive offspring X-linked recessive inheritance ○ Genes located on the X chromosome ○ 25% affected X-linked Dominant inheritance ○ Genes located on X chromosome ○ Affected mother and normal father ○ 50% affected We can do genograms (family medical history) ○ Map of Genetics ○ Tell about parents ○ Grandparents ○ Children ○ Aunts ○ Uncles Genetic evaluation and counseling Genetic counseling is a communication and educational process where the genetic influence of health is explained along with information regarding a specific genetic disorder, its transmission, inheritance, and options available in management and family planning. It helps people understand and adapt to the medical, physiological, and familial implications of genetic contributions to disease. Amniotic fluid CONTAINS: Albumin (indicate nutrition/protein) ******** Urea (urine) Uric acid (urine) Creatinine (kidneys) Bilirubin (liver, growth, and development) Fructose (carbohydrate) Fat (lipid) Lanugo (thin, fine hair on babies, protective) Sphingomyelin & Lecithin********* ○ (Lung surfactant- keeps lungs apart, inner lining of lung to repel and keep lungs expanded) ○ LS ratio 2/1 ready to receive air at birth. Less than that, not ready to receive air.  Doctors will test amniotic fluid for LS ratio, which will determine lung maturity level Umbilical cord AVA: Two arteries and one Vein Deoxygenated fetal blood flow through the 2 umbilical arteries > to chorionic villi of placenta ○ Pulmonary arteries oxygen- enriched oxygenated blood flows back through the 1 umbilical vein to fetus ○ Pulmonary vein Cord is located centrally in the placenta ○ More surface area more perfusion and growth Placenta Serving as the interface between the mother and the fetus Makes hormones to support pregnancy ○ HCG (human chorionic gonadotropin) biomarker for pregnancy Excreted from the endocrine system and can be an indicator for cancer ○ HPL (human placental lactogen) increase mom’s metabolism ○ Progesterone- vasodilates, relaxes the uterus, ligaments, joints, feet widen, breast feeding Give shots to help maintain pregnancy ○ Estrogen - causes uterus to increase, bigger boobs, (literally all the pregnancy symptoms) ○ Relaxin- relaxes joints Placental development Baby and momma are two separate systems. They do not mix unless it is trauma or delivery- not planned, not suppose to be. ○ Know as syncytium Cotyledons-subdivisions of the placenta (anchoring vill) ○ ATTACHES to endometrium that becomes the DECIDUA Allows for uteroplacental circulation Allows for the exchange of gasses and nutrients Simple diffusion takes place Each cotyledon is a functional unit must all work together Each placenta has 15-20 cotyledons Placental functions (Placenta does everything. It is the lifeline. If it isn’t intact then pregnancy has an issue. Also placenta is not an effective filter.) Metabolic activities ○ Produces glycogen, cholesterol, fatty acids-hormone production acid-base, nutrition excretion Transport function ○ Simple diffusion, facilitated transport, active transport Endocrine function ○ Produces hormones which are vital for survival of the fetus Immunologic properties ○ Embryo and placenta are transplants of living tissue ○ Suppression of cellular immunity by progesterone Virus is small- will pass Bacteria are bigger and will not pass as easily than virus ○ This is why Group B strep can pass off to babies from birth canals. ○ Placenta is not an effective filter Placental / Fetal Circulation AVA: Two arteries and one Vein Deoxygenated fetal blood flow through the 2 umbilical arteries > to chorionic villi of placenta ○ Pulmonary arteries oxygen- enriched oxygenated blood flows back through the 1 umbilical vein to fetus ○ Pulmonary vein Placental and cord Abnormalities (when placenta attaches itself abornmally) Accrete ○ Serious pregnancy condition ○ Grows too deep into the outer layer, it is not going to be okay because the placenta is not going to come out and may hemorrhage  ○ Hemorrhage Leads to Death Septic shock Percreta ○ The MOST SEVERE of all times ○ When the placenta passes through the wall of the uterus. ○ The placenta might grow through the uterus and impact other organs such as bladder or intestine increta ○ Placenta attaches more firmly to the uterus and becomes embedded in the organ’s muscle wall Knot in the umbilical cord ○ Baby not getting the right amount of nutrients, oxygenation, circulation ○ Stillbirth baby Fetal circulation Blood: ○ From the placenta to the fetus (DEOXYGENATED) ○ Then fetus to placenta (OXYGENATED) Three shunts during fetal ○ Ductus venosus: connects the umbilical vein to the inferior right vena cava ○ Ductus arteriosus: connects the main pulmonary artery to the aorta ○ Foramen ovule: anatomical opening between the right and left atrium (blood can go back and forth) ○ Ibuprofen can cause these issues. Do not take ibuprofen unless otherwise prescribed. ○ Going to hear murmurs because shunts are not closed yet. ○ If do not close can get valve replacements if not taken care off ○ Close after birth ————————————————————————————- Hour 16 Reproduction Lecture Textbook page: 390, 405, 469 Signs of Pregnancy Presumptive signs (SUBJECTIVE) “I think I am pregnant; however, these signs can also indicate something else.” Subjective changes of pregnancy o Amenorrhea- breast feeding, pituitary tumors, stress, athlete, menopause, birth control, anemic (4 weeks) o Urinary frequency- UTI, pelvic tumor, diabetes, furosemide (6-12 weeks) o Hyperpigmentation of skin-exposure to sun, skin cancer, hormonal changes, birth control (16 weeks) o Uterine enlargement- tumors, menstrual cycle, constipation (7-12 weeks) o Nausea and vomiting- norovirus, food poisoning, flu (4-14 weeks) o Fatigue- depression, stress, hypothyroidism (week 12) o Breast changes- menstrual cycle, birth control, brain tumors, medication o Quickening (16-20)- gas, Probable signs (OBJECTIVE) - think signs for a doctor “I am pretty sure I am pregnant, I have some good reasons to think so.” Physical signs of pregnancy are those that can be detected on physical examination by a healthcare provider. Objective changes Signs Chadwick’s sign ○ blue/purple hue of cervix, vagina, vulva-estrogen increase Goodell sign ○ Softening of cervix Hager sign ○ Softening of the lower uterine segment Enlargement of the abdomen- ○ Subserous uterine myoma Braxton hicks’ contractions (16-28)- ○ tumor or hematometra, gastrointestinal distress Ballottement- Positive pregnancy test- ○ Ascites, uterine tumor, or polyps ○ Cross reaction of luteinizing hormone  ○ Pregnancy test There accuracy in diagnosing pregnancy is 95-99% therefore considered probable rather than positive Based on the analysis of maternal blood or urine from detection of hcG hCG is the earliest biochemical marker for pregnancy, but it can sometimes indicate something else or there can be a positive, but no baby. Non pregnant causes of probable signs o Tumor in pelvis o Tumor on the abdominal organ o Abnormality of endocrine system o Remember tumors secrete hormones - so it is not always pregnancy. Positive signs (Diagnostic) “ I am DEFINITELY pregnant for sure.” Completely objective Cannot be confused with pathologic states Offer conclusive proof of a baby Must be a baby Signs ○ Fetal heartbeat via Doppler 10-12 weeks Rate 110-160 Must be counted and compared with maternal pulse ○ Fetal movement felt by experienced clinician 16-20 weeks Actively palpable by examiner ○ Visualization of the embryo or fetus with ultrasound 4-6 weeks Ultrasound Tanners’ models Noticing, interrupting, responding, and reflecting Common OB terminology Gestation- number of weeks since 1st day of last menstrual period  Abortion-occurs prior to the completion of 20 weeks Post term- after 42 weeks Term: 38-42 weeks Preterm - after 20 weeks but before the completion of the 37th week Gravida - (# of Pregnancies, seen as G), total number of times a woman has been pregnant regardless of if the pregnancy was a termination or multiple babies. ○ Twins still counts as 1 pregnancy ○ nulligravid - women who has never been pregnant ○ Primigravida-women who is pregnant for the 1st time ○ Multigravida-women who is in her 2nd or subsequent pregnancy **Para** (parenting) P with # behind it)- (# of births) ○ The number of births > 20 weeks (including viable and non-viable Nullipara: woman who has not carried a fetus to viability Primipara- woman who has delivered one fetus >20 weeks Multipara: woman who has delivered more than one fetus > 20 weeks Antepartum time between conception and onset of labor - before labor Intrapartum: time between onset of labor until birth of infant / placenta - labor to birth Postpartum- time from birth until woman's body returns to prepregnant state - after birth LMP: last menstrual period EDD: estimated due date EDC: estimate date of confinement EDB: estimated date of birth GA: gestational age GTPAL & TPAL terminology G: (Gravida): number of pregnancies including the current pregnancy T: (Term births): The number of pregnancies ending >37 weeks gestation at term P: (preterm births): the number of preterm pregnancies ending > 20 weeks or viability but before completion of 37 weeks A: (abortion): the number of pregnancies ending before 20 weeks or viability ○ Spontaneous abortions ○ Elective abortions L: Living (living children): # of currently living children ○ Example: GTPAL P (Para), 1 (number of term babies), 0 (number of preterm babies), 1 (number of SABortions or induced ABortions), 2 (number of living children) G(pregnancies), P(term, preterm, abortions, living) G(pregnancies), P(living) P1,0,1,2 Determination of Due Date  ○ Helpful to know the 1st day of the women's LMP ○ Evaluating uterine size ○ Determining when quickening starts ○ Auscultation good FHR ○ Ultrasound Negele’s rule ○ Most common method of determine the EDB ○ Being with 1st day of LMP ○ Subtract 3 months ○ Add 7 days Leopold maneuvers ○ The Leopold maneuvers are used to palpate the gravid uterus systematically. This method of abdominal palpation is of low cost, easy to perform, and non-invasive. It is used to determine the position, presentation, and engagement of the fetus in utero. ○ The four maneuvers are: Identifying the fetal part in the uterine fundus to determine fetal lie and the presenting part (shape, consistency, and mobility) Palpating the fetal back to identify fetal presentation Determining the fetal hand lies over the pelvic inlet to identify fetal attitude (flexed or extended) Locating the fetal cephalic prominence to identify the attitude of the head Cephalic prominence on the same side as feet, hands, and elbows (head is flexed vertex presentation) Cephalic prominence on the same side as back Expected location of the point of maximal impulse Number of fetuses Fetal position, presentation Presenting part (cephalon or breech) Attitude Degree of descent of the presenting part into pelvis Expected location of the point of maximum impulse ○ Interventions Auscultate HR document  Nursing intervention ○ Have client empty bladder - this can interfere with an accurate reading ○ Assist to supine position with pillow under head, knees flexed ○ Place a wedge under right hip to prevent supine hypotension (supine hypotension syndrome) During pregnancy, especially at the end, there is a very high chance at hypotension, so never lie on the back. Measurements Measuring fundal height ○ Symphysis pubis to the top of the fundus ○ During the second trimester ○ The duration of pregnancy at this time generally correlated with the height of the fundus above the symphysis pubis ○ From weeks 20 to 32, the number of centimeters of fundal height is just about equivalent to the weeks of gestation ○ The result in centimeters is a rough estimate of gestational age ○ 32 weeks baby is dissenting to pelvic system Measurements below ○ Fundal height measurements below the estimated gestational age might suggest ○ Miscalculation in due dates ○ Intrauterine growth restriction ○ Fetal anomaly Measurements above the patients gestational age might indicate ○ Hydramnios ○ Large for gestational age fetus ○ Miscalculation in due dates ○ Multiple pregnancy ----------------------------------------------------------------------------------------------------------- ———————————————————————————————- LECTURE 1/20/2023 Changing Nutritional Needs of pregnancy Unit 1 Hour 19 KNOW HORMONES: Human chorionic gonadotropin (hCG) ○ An elevated level might indicate pregnancy or cancer. ○ A hormone that ensures that the endometrium will be receptive to the implanting embryo. ○ Preserves the corpus luteum and its progesterone production so that the endometrial lining of the uterus is maintained. ○ Pregnancy tests tests hCG levels Follicle-stimulating hormone (FSH) ○ An elevated level might indicate ovarian failure ○ Stimulates the ovary to produce five to 20 immature follicles Each follicle houses an immature oocyte or the egg. ○ The fully mature follicle will soon rupture and expel a mature oocyte in the process of ovulation ○ Prompt by hypothalamus ○ Helps control the menstrual cycle and the production of eggs by the ovaries ○ Values throughout a woman’s menstrual cycle and is the highest just before she releases an egg (ovulates). Luteinizing hormone (LH) ○ An elevated level may indicate gonadal dysfunction ○ From anterior pituitary gland ○ Response fo affecting the final development and subsequent rupture of the mature follicle ○ Spurs ovulation and helps with the hormone production needed to support pregnancy ○ Plays an important role in sexual development and functioning ○ LH controls the menstrual cycle ○ Triggers the release of an egg from the ovary Human placental lactogen (hPL) ○ An elevated level might indicate a pituitary tumor ○ Modulates fetal and maternal metabolism ○ Participates in the development of maternal breasts for lactation ○ Decreases maternal insulin sensitivity to increase its availability for fetal nutrition Prolactin ○ Mediates maternal metabolic adaptations to pregnancy by regulating insulin production and sensitivity.  ○ Play a key role in lactation Estrogen (estriol) ○ Causes the enlargement of a woman’s breasts, uterus, and external genitalia ○ Stimulates myometrial contractility Progesterone (progestin) ○ PRO-GESTATION ○ Maintains the endometrium ○ Decrease the contractility of the uterus ○ Stimulates maternal metabolism and breast development ○ Provides nourishment for early conception Relaxin ○ Is a potent vasodilator ○ Regulates maternal hemodynamics ○ Acts synergistically with progesterone to maintain pregnancy ○ Causes relaxation of the pelvic ligaments ○ Softens the cervix in preparation for birth Textbook page 671 Nutrition in Pregnancy: Why is it so important? Nutritional intake during pregnancy has a direct effect on fetal well-being and outcome Childhood obesity Neonatal hypoglycemia- not getting sugar from mother anymore Macrosomia - bigger baby >4000grams while mom is still pregnant - large gestational age ○ Bigger babies have trouble regulating their sugars and temperatures Congenital abnormalities Low birth weight Preterm weight Maternal weight gain: Underweight: BMI: 28-40 pounds Normal BMI: 25-35 pounds Obese: 11-20 lbs. ○ The bigger you are, the less weight they want you gain for your overall weight. Do not want anyone to lose weight Pregnancy Weight and Diet Weight of organs within a pregnant person Infant birth weight- 7.5 Blood volume increase- 4 pounds uterus - 2 pounds Increase in breast tissue- 2 pounds Placenta -1.5 pounds Maternal fluid volume-4 pounds Maternal fat tissue-7 pounds Amniotic fluid- 2 pounds Approximate weight gain- 30 pounds How do we guide pregnant people on what to eat? Variety of foods Increase intake of vitamins, minerals, fiber Lower intake of saturated, trans, and cholesterol Balance calories intake with exercise to maintain ideal healthy weight. Consume adequate synthetic folic acid from supplements or fortified foods (prenatal vitamins with folic acid) ○ Folic acid helps with neural tube development. - prevent neural tube defects. Foods to avoid: Artificial sweeteners ○ Diet sodas Fish with high levels of Mercury like swordfish Listeriosis: Type of bacteria found in soil, groundwater, animals, and some plants Listeriosis in pregnancy: unremarkable febrile illness in mother, but fatal for fetus, passed through the placenta. Avoid soft cheeses, lunch meats Cleaning out cat litter box- should be wearing gloves PICA: Soil: replaces nutritive sources and causes iron deficiency anemia Clay: produces constipation, parasitic infections Laundry starch: iron deficiencies, replaces protein metabolism thus depriving the fetus of amino acids needed for development. Ice: iron deficiency anemia, tooth fracture, freezer burn. Hyper-nemesis Severe nausea during pregnancy 10% weight loss is acceptable. More is the issue Does not get better after 1st trimester - an actual issue Normal morning sickness should resolve by 2nd trimester. Not keeping any fluid or food down. Sometimes needs TPN because needs nutrition to house baby, If you have this baby 1, you might have this during next pregnancies Characterized by: ○ Persistent vomiting ○ Dehydration ○ Ketonuria ○ Electrolyte disturbance ○ Weight loss greater than 5% of prepregnant weight ○ Seen more with twins, triplets, etc. and gestational trophoblastic disease Medications ○ Promethazine ○ Prochlorperazine ○ Ondansetron Teaching ○ Eat small, frequent meals through the day ○ Separate fluids from solids by consuming fluids in between meals ○ Avoid laying down or reclining after meals If a mother has Olihydromios, you are going to see variable deceleration Oligohydramnios : less than normal value of amniotic fluid ○ Causes miscarriage or stillbirth ○ Amniotic fluid plays a vital role in lung maturity and without fluid, baby will not have much breathing capacity. ○ Who's at risk? Water breaking too early or staying past due date. ——————————————————————————- Childbirth Education Unit 1 Hour 20 Pg. 487 Early Pregnancy Classes: - first trimester (conception - 13 weeks) Content includes self-care during pregnancy ○ Nutrition teaching ○ Avoidance of smoking and alcohol ○ Common discomforts of pregnancy (by trimester symptoms of pregnancy) ○ Fetal development ○ Exercise and work during pregnancy Couple meets other couples in early pregnancy support system develops ( FUN FACT: Years ago, there was nitrous oxide in the room and when women needed help breathing, they would give them the nitrous oxide mask. Nowadays, they are limiting that use in America.) Second Trimester Classes: (14 weeks - 27 weeks) Begins to focus on the birth Birth plan develops-will eventually include: ○ Choice of provider ○ Birth location ○ Who will be present during the labor and birth? ○ Labor interventions that are desired ○ Labor interventions not desired ○ Newborn care choices Third Trimester Classes: (28 weeks-40 weeks) Focus on the process of labor Early postpartum period Newborn characteristics and care Pediatrician should be picked out Key concept: Relaxation In all childbirth preparation methods: Accomplished through:  ○ Cutaneous stimulation Touching, holding hand, message ○ Progressive relaxation “Try to relax your hand, now try to relax your arm” it progressively improves ○ Disassociation Let’s forget about what is going on at this current time. Not focus on the pain Ex) tell me more about your dog. Hobbies that they do ○ Effleurage Light abdominal massage- abdominal relaxation Rubbing tummy. Rubbing back. ○ Deep pressure Back ache due to the way baby is laying in the uterus Make dad make a fist and push the lower back by tailbone. it will push the baby off the tail bone. Slow deep breathing, paced breathing, patterned breathing: alternate form of pain relief Teaches woman: cleansing breaths to signal relaxation (deep breath then sigh) Start with cleansing and end with a cleansing breath. Slow deep breathing to promote relaxation in latent labor (0-3cm) ○ 4 seconds in and out Paced breathing: for active labor (4-7 cm) (hee) ○ PAC- comes before PAT Patterned breathing: for transition phase (8-10cm) (hee-hee-who) Opening glottis breathing for pushing (Know the breathing patterns and order of breathing). Nursing implications for Labor: Review the chart and talk to couple early in labor to identify their philosophy regarding birth Advocate for the couple when needed Be open to new ideas different than own Review birth plan Cultural competence Provide an environment that supports their birth choices. ————————————————————————————————— ———————————————————————————————— Nursing Management for Labor and Birth Unit 1 Hour 21 Fun Facts: Normal heart rate fetal ○ 110-160 How to read baby graphs (FHR Tracing) ○ Each block is 10 seconds on graph ○ Internal and external equipment to measure it. ○ Top is fetal heart rate ○ Bottom is contraction ○ Also monitors mom’s heart rate and baby’s movements. Need about a 10-minute strip to establish a baseline Contractions For term women, the uterus gets to 1 - 1.5 in thick. Cervix will thin out and “efface” so it can get ready for delivery Think of upside-down pear, top part of pear is fundus. Stem area is the cervix. Why do we need to know how strong contractions are? ○ Want a contraction between 40-60 or 50-70 meters per mercury How long does a contraction last? ○ From when it starts to when it ends within one contraction. (duration) ○ How far apart are your contractions? (Frequency) Time your contractions from the time one starts to the next one starts. ○ Resting time occurs at the end of one contraction to the beginning of the next  ○ Heart rate can fluctuate because of parasympathetic and sympathetic (fight or flight) bouncing off each other. Normal. Means that everything is communicating with each other. ○ One pulse that is the same across the monitor: heart block ○ Want a contraction between 40-60 or 50-70 meters per mercury To progress labor ○ Resting tone between contractions Want 20 meters per mercury Perfusion is cut off when having an contraction We also know intensity of contractions ○ Balance interplay between the sympathetic and parasympathetic branches of the autonomic nervous system (why we have wiggling heart rate on monitor)- means everything is intact. ○ Accelerations means that the baby moved Assessing uterine contractions Increment (building up) Acme (peak) Decrement (let down) Rest period (resting tone) 20mm of mercury or less (Greatest area is in the uterine fundal area.) ○ For term women, uterus gets to 1 - 1.5 in thick ○ Contractions start in the back and comes around to the front ○ True labor is dilation of the cervix Analysis of FHR and uterine contractions Primary evaluation tools used to determine fetal oxygen status and uterine activity. Look between contractions to find FHR Fetal heart rate ○ Continuous or intermittent Uterine contractions Continuous - intermittent External: doppler ultrasound and gel ○ External (Toc transducer) Internal: spiral electrode ○ internal (IUPC)- Telling us pressure of the contractions (intensity) ○ Go through the cervix and attach to the baby's head. Catches the ECG Common for use when the doctors cannot pick up the movements of the baby Baby wiggles a lot  Mom might be too big. ○ How strong are contractions? ○ Risk for internal infection *******Interpretation of FHR Tracings****** KNOW THIS (The steps that the nurse must follow are in this order) #1. Determine Baseline fetal heart rate #2. Assess Baseline variability #3. Look at periodic baseline changes ○ Accelerations ○ Decelerations Pg.: Starts on 487 through chapter FHR Baseline The mean FHR rounded to increments of 5 bpm during a 10-minute segment, excluding: ○ Accelerations/decelerations ○ Periods of marked FHR variability ○ The baseline must be for a minimum of 2 minutes in any 10-minute segment EX. 120bpm, 125bpm, 130bpm, 135bpm ○ Fetal heart rate that occurs when there is no stress / stimulation to the fetus ○ Balanced interplay between sympathetic and parasympathetic branches of Autonomic nervous system ○ Average is 110-160 bpm ○ (Measure baseline when the FHR is at rest not elevated or dipping in value- also report it in a 10-bpm difference. Ex) 125 - 135 bpm) ○ How to determine FHR baseline. Look between contractions. Look between 2 minutes within a 10 min window. Ignore the ones with accel or decels. - determine FHR baseline. You need to know this for the variability for comparison Resting tone: 20 mmHG or below - this is what they want Variability  Normal irregularity of cardiac rhythm resulting from a continuous balancing interaction of sympathetic and parasympathetic branches of ANS (fluctuations in the FHR) Reflects an intact neurological pathway ○ Absent: amplitude range is undetectable - straight line on FHR tracing We DO NOT WANT THIS! ○ Minimal: amplitude range detectable, but 5 beats per minute or less ○ Moderate- amplitude range is detectable: normal- 6-25 bpm ○ Marked - amplitude range is detectable: greater than 25 bpm ○ How to measure variability? You must compare the range to the 10bpm baseline. (Professors do not like to chart absent) Accelerations A visually apparent increase in the FHR from the most recently calculated baseline Indicates intact CNS Associated with fetal movement and fetal well-being Reassuring sign Require no intervention At 28 weeks of gestation, an acceleration has an acumen of 15 bpm or more above baseline with a duration of 15 seconds or more but less than 2 minutes How to measure acceleration? ○ Compare it to the baseline. Accelerations are increase Decelerations A visually apparent decrease in the FHR from the most recently calculated baseline Different types of decelerations: ○ Nursing interventions depend on type of deceleration Different types of decelerations (3 types): ○ Early deceleration Also known as head compression (HC) Baby is coming out of the cervix. Put pressure on the head vaguely response happens - HR drops- Early deceleration occurs when the baby gets pressure on head. Alter cerebral blood flow Mirrors the contraction Usually occurs with advance dilation Physiology: Pressure on fetal skull Alters cerebral blood flow Stimulates vagus nerve Lowers FHR No interventions required Benign (good sign)- closer to delivery From textbook excerpts:  Early decelerations are visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They rarely decrease more than 30 to 40 bpm below the baseline. Typically, the onset, nadir, and recovery of the deceleration occur at the same time as the onset, peak, and recovery of the contraction. They are most often seen during the active stage of any normal labor, during pushing, crowning, or vacuum extraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Early decelerations are not indicative of fetal distress and do not require intervention. Nursing intervention Monitor until delivery ○ Variable deceleration Also known as “umbilical cord compression” Do not need contraction to have variability Can occur anytime (V,U,W) Usually happen from cord compression Have mother reposition to fix this Don't need a contraction to have this kind of decal, but can happen with a contraction An abrupt visually apparent decrease in the FHR below the baseline Those that occur with any interruption in umbilical blood flow during CTX phase Physiology: Cord compression Hemodynamics changes Stimulates vagus nerve Lower FHR Do not need a contraction to have this Nursing Interventions Change maternal position ○ Flip them around Oxygen and IV fluids to increase perfusion to mom and baby. Amnioinfusion might be ordered From textbook: Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be of a U, V, or W, or they may not resemble other patterns (Noritz et al., 2019).  Variable decelerations usually occur abruptly with quick deceleration. They are the most common deceleration pattern found in the laboring woman and are usually transient and correctable (Cunningham et al., 2018). Variable decelerations are associated with cord compression. However, they are classified either as category II or III depending on the accompanying change in baseline variability (Murray et al., 2019). The pattern of variable deceleration consistently related to the contractions with a slow return to FHR baseline warrants further monitoring and evaluation. ○ Late Deceleration Also known as: Uteroplacental insufficiency (UPI) Begins late in the contraction phase Deceleration AFTER the contraction The baby is holding its breath during acme Problem with surface of the placenta so there is a delay between perfusion starting now. So, the baby starts to hold it breath because there is bad perfusion, so heart rate drops. This is bad deceleration, and the fetus is in distress Need a contraction to know that it is LATE Onset, and recovery of the deceleration occur after the bringing, peak, and end of the contraction Smooth and shifted to the right of the contraction Physiology Uterine hyperactivity / maternal hypotension Lower intervillous flow Low oxygen transfer Fetal hypoxia Activate vagal response Lower FHR slows down after the contraction Non-reassuring sign No perfusion with the placenta and uterus Nursing interventions DO EVERYTHING POSSIBLE TO HELP MOM AND BABY Stop oxytocin Switch maternal position Give oxygen via face mask at 10-12 L/min***** Increase perfusion. Contact OB’ Provide family reassurance IV fluid LR Think about doing a C-section From textbook: Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the  contraction. They have a gradual waveform and can be recurrent, occurring with each contraction over a period. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists (Blackburn, 2018). Conditions that may decrease uteroplacental perfusion with resultant decelerations include maternal hypotension, gestational hypertension, placental aging secondary to diabetes and post maturity, hyperstimulation via oxytocin infusion, maternal smoking, anemia, and cardiac disease. They imply some degree of fetal hypoxia. Recurrent or intermittent late decelerations are always category II (indeterminate) or category III (abnormal) regardless of depth of deceleration. Acute episodes with moderate variability are more likely to be correctable, while chronic episodes with loss of variability are less likely to be correctable ○ Prolonged Deceleration Is a visually apparent decrease in FHR below the baseline The decrease is 15 bpm or more and lasting 2 min or longer but less than 10 minutes If the deceleration lasts more than 10 min, it is considered a baseline change From Textbook: Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes (Carvalho, 2019). The rate usually drops to less than 90 bpm. Many factors are associated with this pattern, including prolonged cord compression, abruption placenta, cord prolapse, supine maternal position, vaginal examination, fetal blood sampling, maternal seizures, regional anesthesia, or uterine rupture (AWHONN, 2018). Prolonged decelerations can be remedied by identifying the underlying cause and correcting it. ○ Sinusoidal Pattern From textbook: A sinusoidal pattern is described as having a visually apparent smooth, sinewave-like undulating pattern in the FHR baseline with a cycle frequency of 3 to 5 bpm that persists for more than 20 minutes. A true sinusoidal FHR pattern is rare. It is attributed to a  derangement of CNS control of FHR and occurs when a severe degree of hypoxia secondary to fetal anemia and hypovolemia is present. It is always considered a category III pattern, and to correct it, a fetal intrauterine transfusion would be needed. It indicates the fetus is in marked jeopardy (Blackburn, 2018). How to measure deceleration? ○ Compare it to the baseline. Deceleration are decrease ○ Example, “At 3 mins in, there is a deceleration, same with 5 minutes in” Amnioinfusion Infusion of sterile fluid to put fluid back into the sac Why would we do this? ○ Meconium in lungs ○ Do it with lactated ringers KNOW VEAL CHOP! Variable Cord Compression Early deceleration Head Compression Accelerations Ok Late deceleration Placental Insufficiency Fetal Heart Monitoring Changes ---- VEAL CHOP to a STOP Fetal Heart Rate Observation → Related to → Intervention V Variable decelerations C Cord compression T Turn patient on left side to relieve pressure on cord E Early decelerations H Head compression O Ok, this is okay. No intervention is needed. A Accelerations O Okay, this is okay! A Acceptable- no intervention is needed L Late decelerations P Placental insufficiency S Stop pitocin. T Turn patient on left side. O O2 via facemask- 10-12 L P Increase Plain IV fluid Textbook 477 FHR Evaluation* Category I (good) ○ Normal Acid base ○ FHR- 110-160bpm ○ Moderate variability ○ No variable or late deceleration ○ Early deceleration: present or absent ○ Acceleration: present and absent Category 2: ○ Indeterminate of acid-base status Category 3: ○ Predictive of abnormal acid-base status ————————————————————————————————— Fetal Monitoring: Clinical Judgment Unit 1 Hour 22 Let’s do a case study! Introduction 28 y.o. G 4 P3 40 weeks & in active labor Getting oxytocin 5cm dilated and 100% efface Intact amniotic membrane  Heart rate 88 BP 115/78 RR: 15 Temperature 38 C - 100.4 F Getting lactated ringers at 125ml/hr. via IV Assessment finding Look at the FHR strips Contractions are 1 minute apart Contractions last for 1 minute long Too many contractions Baseline: FHR: around 115-125 or 120-130 DEEP Variable deceleration: umbilical cord compression ○ Sudden drop and sudden up ○ Too much variable ○ Cord compression ○ Not early deceleration Moderate variability - Category 1 NO acceleration Question 2 Moderate fetal HR variability- category 1 Variable FHR deceleration - category 1 FHR acceleration - n/a Question 3: Left lateral position - correct- get pressure off cord so she can breathe better, more room on the left side, less stress on your heart on the left side, vena cava and aorta are on the right side- there’s more return when laying on your left side- you lay on your right side you can pinch those areas. Increase infusion of titrated intravenous oxytocin Administer 101/m of oxygen via nonrebreather mask. - PERFUSION Request that the OB artificially rupture the client’s membranes Check the client’s cervix Increase the maintenance of the IV ○ If mom has more fluid and more perfusion and then baby will have better perfusion too. ------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- -END OF WEEK 2!---------------------------------------------------- ------------------------ Starting Week 3 Monday 1/23/2023 Pharmacological Intervention: