Written Report Group 2 Unit 3 Antepartal Care PDF

PAMANTASAN NG LUNGSOD NG MAYNILA (University of the City of Manila) Intramuros, Manila COLLEGE OF NURSING (Dalubhasaan ng Narsing) In Partial Fulfillment of the Requirements in: Maternal and Child Nursing (Lecture)-(NRS-2110-3)...

PAMANTASAN NG LUNGSOD NG MAYNILA (University of the City of Manila) Intramuros, Manila COLLEGE OF NURSING (Dalubhasaan ng Narsing) In Partial Fulfillment of the Requirements in: Maternal and Child Nursing (Lecture)-(NRS-2110-3) Topic: UNIT III- Care for the Mother and Fetus Submitted by: GROUP 2 DAMIAN, Eunelyn B. DE ASIS, Ella Mae M. DELA ROSA, Maria Angelika M. ESTAÑO, Rianne Evonne T. EVANGELISTA, John Irvin B. EVANGELISTA, Rogelio S. III GERVACIO, Divine B. Submitted to: Prof. Maria Lourdes B. Balleza September 2024  TABLE OF CONTENTS ANTEPARTAL CARE: THE GROWING FETUS Stages of fetal Development DAMIAN, Eunelyn B. GERVACIO, Divine B. Embryonic & Fetal Structure DE ASIS, Ella Mae M. EVANGELISTA, John Irvin B. Origin & Development of Organ Systems DAMIAN, Eunelyn B. DELA ROSA, Maria Angelika M. Milestone of Fetal Growth and Development EVANGELISTA, John Irvin B. EVANGELISTA, Rogelio S. III Assessment of Fetal Growth & Development ESTAÑO, Rianne Evonne T. DELA ROSA, Maria Angelika M. Assessment of fetal wellbeing EVANGELISTA, Rogelio S. III GERVACIO, Divine B ANTEPARTAL CARE: NORMAL CHANGES IN PREGNANCY Psychologic ESTAÑO, Rianne Evonne T. DE ASIS, Ella Mae M. DELA ROSA, Maria Angelika M. Physiologic GERVACIO, Divine B. DAMIAN, Eunelyn B. EVANGELISTA, Rogelio S. III Systemic DE ASIS, Ella Mae M. ESTAÑO, Rianne Evonne T. EVANGELISTA, John Irvin B.  ANTEPARTAL CARE: THE GROWING FETUS I. STAGES OF FETAL DEVELOPMENT In just 38 weeks, a fertilized egg grows from a single cell into a fully developed baby. This development is divided into three stages: the pre-embryonic stage (first 2 weeks), the embryonic stage (weeks 3 to 8), and the fetal stage (week 8 until birth). FERTILIZATION (the beginning of pregnancy) - Also known as conception or impregnation, is the process where an egg and a sperm join together. This typically takes place in the outer third of a fallopian tube, called the ampullar section. LOCATION OF FERTILIZATION - outer third of the fallopian tube, specifically in the ampullar portion. OVUM MATURITY - only one ovum reaches maturity each month in a woman. TIMING OF OVULATION - once the egg is released, it can only be fertilized for about one day. SPERM LIFE SPAN - the lifespan of a spermatozoon is approximately 48 hours, but it can last up to 72 hours. CRITICAL FERTILIZATION WINDOW - the total critical time frame for successful fertilization is about 72 hours, which includes 48 hours before ovulation and 24 hours afterward. FERTILIZATION PROCESS Release of the Egg The egg (ovum) is released from the ovary during ovulation. It is surrounded by a protective layer and cells. Travel to Fallopian Tube The egg moves into the fallopian tube with help from tiny hair-like structures and contractions in the tube. During ejaculation, millions of sperm are released. Sperm Transport Sperm travel through the cervix and uterus to the fallopian tube. Sperm reach the fallopian tube within minutes after ejaculation. Sperms cluster around the egg and release an enzyme to break down the egg's protective layer. Only one sperm can enter the egg; Fertilization Process the egg’s membrane then prevents other sperm from entering. The genetic material from the sperm and egg combine to form a zygote with 46 chromosomes. If the sperm carries an X chromosome, the baby will be female Formation of Zygote (XX). If the sperm carries a Y chromosome, the baby will be male (XY). Both the sperm and egg must be mature.  Fertilization Factors The sperm must reach the egg. The sperm must penetrate the egg’s protective layers. Development of the Zygote The zygote develops into a baby and forms structures needed for pregnancy (placenta, amniotic fluid, umbilical cord). IMPLANTATION In the three to four days that follow fertilization, the zygote is cleaved as it moves in the direction of the uterus. When it gets to the uterus, it has grown into a blastocyst, which has an inner cell mass and an outside layer of trophoblast cells. The blastocyst implants itself into the uterine lining during the 8–10 day period that follows fertilization. Pregnancy loss can occur early because up to 50% of zygotes do not implant, making this phase essential (Gardosi, 2012). Placenta previa is one consequence that might arise from implantation taking place low in the uterus. Some women may have bleeding during implantation, which is mistaken for menstruation. Depicted in Figure 9.1, the stages.  II. EMBRYONIC AND FETAL STRUCTURE A. DECIDUA It forms the base of the placental bed, a specialized layer of the endometrium (mucous membrane of the uterus that thickens during menstrual period). After implantation of the fertilized egg cell, the embryo will start excreting hCG. This hormone then activates the corpus luteum in the ovary to start secreting progesterone. With the pregnancy hormone being secreted, it will affect the endometrium by increasing its thickness rather than shedding (decidual reaction), thus now forming the decidua. The term “decidua” is Latin word for “falling off” as it is discarded after birth, and is divided into three parts: ○ Decidua Basalis: The endometrium at the base of pregnancy/site of implantation (blastocyst) ○ Decidua Capsularis: The endometrium that encapsulates the site/blastocyst except the embryonic pole, isolating it from the rest of the uterine cavity. ○ Decidua Parietalis: The normal endometrium; that lines the rest of the uttering cavity. At around 14-16 weeks of pregnancy, the Decidua Capsularis and Decidua Parietalis merge to form the Decidua Vera. In ectopic pregnancies (pregnancies outside the uterus), only the Decidua Parietalis are formed, as the pregnancy is taking place externally. B. CHORIONIC VILLI According to Britannica (n.d.), a sizable portion of the placenta constitutes the chorionic villi as a means of increasing the surface area by which products from the maternal blood are made available to the fetus. The cells from these structures have identical genetic material found in the fetus. It is composed of three layers— an outer multinucleated syncytiotrophoblast layer, a middle cytotrophoblast layer, and an inner mesodermal core (Wapner, 2005). The villus are described to be ‘finger-like’ in structure and acts like it is branching out from a single origin. This makes sense as after implantation, the decidua capsularis surrounds the bastocyst, serving as the origin, will then need to branch out to garner its needed sustenance. It is composed of three major layers: ○ Outer Layer (Syncytiotrophoblast)  It is the most superficial layer and serves as a protective layer. It allows the blastocyst to fully adhere to the uterine wall It produces hCG to keep the corpus luteum in the early stages while the placenta is still taking its time to form ○ Intermediate Layer (Cytotrophoblast) Langhans’ layer It plays a supporting role to the outer layer by providing protection and immune response. It helps it organizing and configuring the formation, distribution and structure of the villi in the uterus ○ Core (Mesoderm) A Mesodermal core implies that the area is highly vascularized (blood vessel rich) thus serving as the main channels of nutrient exchange between the maternal and fetal circulations. This is essential to sustain the fetus as these are the starting points of the main nutrient/gas exchange channels that the baby will need to survive. It also provides the necessary hormones that aid its function and the immune response needs to ensure that the maternal and fetal connections remain intact, physiologically. C. PLACENTA The placenta (Latin for “Pancake” due to its shape) is a temporary organ only formed during pregnancy. Its main function is to deliver nutrients and oxygen to the fetus through the umbilical cord. It manages waste and generates hormones to maintain/ sustain the pregnancy. Also, it acts as a protective layer for the baby from foreign bodies, virues and other microorganisms. Its formation starts with the growth of trophoblastic cells and by the release of progesterone, turns into a full organ, covering over half of the area of the internal uterus. If a problem occurs with the placenta, it could be potentially life-threatening for the mother and the baby. Thus, any abnormalities should be rightfully consulted with one’s healthcare provider/ physician. Circulation through the placenta ○ The blood of the mother pools in the intervillous spaces of the endometrium and surrounding chorionic villi. Different types of nutrients, vitamins, minerals, water  and more go through osmosis and enter the villi capillaries, to the developing embryo. ○ Placental transfer is dynamic, as it is minimally selective with the substances it lets in. This implies that even if the substance is harmful (i.e. drugs, alcohol and nicotine), it will flow through, despite it harming the fetus. ○ Chorionic villi increases as the mother proceeds with the pregnancy, allowing the villi to grow more complex and intertwined with its maternal connection thus, allowing a larger exchange of products between mother and child as time passes by. From 50ml/min of blood (10 weeks) to 500-600ml/min at term, arteries increase in size to accommodate. ○ Uterine perfusion and placental circulation are most efficient when the mother lies on her left side, as this position lifts the uterus away from the inferior vena cava, preventing blood from becoming trapped in the woman’s lower extremities. (Pilliteri) Endocrine ○ Human Chorionic Gonadotropin (hCG) Its quantity varies in pregnancy. Ensure that the corpus luteum continues producing progesterone and estrogen to maintain the integrity of the endometrium. It plays a part in ensuring that the uterine wall is not perceived by the body as a threat. During the 8th week of pregnancy, the placenta starts to produce its own progesterone, thus rendering the corpus luteum moot, thus decreasing its quantity. ○ Progesterone Known as the “Pregnancy Hormone” as it is primarily used to maintain the endometrial lining of the uterus. It is initially produced by the corpus luteum and after the 12th week, its quantity increases due to the generation of the placenta. ○ Estrogen Known as the “Woman Hormone”, it is a second product of the placenta’s syncytial cells. It aids in the development of mamary glands for future breastfeeding practices and entices uterine growth. ○ Human Placental Lactogen (Human Chorionic Somatomammotropin) Growth-promoting and milk-producing hormone  Produced by the placenta as early as 6 weeks that increases towards the term It is vital in the regulation of maternal glucos, protein and fat levels in such a way that the fetus obtains a sufficient supply. ○ Placental Proteins Plasma proteins produced by the placenta May contribute to decreasing immunologic impact of placenta and prevents the hypertension of the pregnancy. D. AMNIOTIC MEMBRANE The chorionic villi on the trophoblast's medial surface thin to form the chorionic membrane, the outermost fetal membrane. The amniotic membrane, or amnion, forms beneath the chorion and is a dual-walled sac with the chorion as the outermost part and the amnion as the innermost part. As pregnancy progresses, the two fuse together, appearing as a single sac by term. They have no nerve supply, so when they rupture spontaneously (water breaks) or artificially, neither the pregnant woman nor fetus experience pain (Coad & Dunstall, 2011). The amniotic membrane, in contrast to the chorionic membrane, is the second membrane that both creates and supports amniotic fluid. Furthermore, it creates a phospholipid that begins the creation of prostaglandins, which may be the trigger that causes labor. E. THE AMNIOTIC FLUID The amniotic sac, which is made up of the amnion and the chorion membranes, is where an embryo is located while it is still inside the womb. Amniotic fluid envelops the developing fetus as it grows and develops inside this sac. The liquid is initially made up of the mother's water. But by the time the fetus reaches about week 20, it has completely replaced this with fetal urine, which it consumes and excretes. Vital substances include hormones, minerals, and antibodies that combat infections are also present in amniotic fluid. Some conditions can cause there to be more or less than the normal amounts of amniotic fluid. Too much little amniotic fluid is called Oligohydramnios while Polyhydramnios, also referred to as hydramnios or amniotic fluid disorder, is when there is too much fluid. A green or brown amniotic fluid suggests that the infant has already passed meconium before delivery. The term for the first bowel movement is meconium. Problems may arise from meconium in the fluid. When the meconium reaches the lungs, it might result in meconium aspiration syndrome, a breathing issue. Babies might require medical attention after birth. FUNCTIONS OF AMNIOTIC FLUID Amniotic fluid is responsible for: Protecting the fetus: The fluid functions as a shock absorber, protecting the unborn child from external stresses. Temperature control: The baby is kept warm and at a consistent temperature by the fluid's insulation. Control of infection: Antibodies are present in amniotic fluid. Development of the digestive and respiratory systems: As the infant grows, it gets practice using the muscles in these systems by breathing and ingesting amniotic fluid. Development of muscles and bones: The baby's freedom of movement while floating inside the amniotic sac allows for the healthy growth of its muscles and bones. Lubrication: If amniotic fluid levels are low, webbing may develop because amniotic fluid keeps body parts like fingers and toes from developing together. Support for the umbilical cord: The uterine fluid keeps the cord from compressing. Food and oxygen are transferred from the placenta to the developing fetus via this cord. F. THE UMBILICAL CORD The fetal membranes, the chorion and amnion, combine to produce the umbilical cord, which connects the embryo to the placenta's chorionic villi by means of a circulatory pathway. Its job is to carry waste products from the fetus back to the placenta and deliver oxygen and nutrients to the fetus from the placenta. At term, it is approximately 53 cm (21 in.) in length and 2 cm (0.75 in.) in thickness. Wharton jelly, a gelatinous mucopolysaccharide that gives the cord body and relieves pressure on the vein and arteries that flow through it, makes up most of the chord. Smooth muscle lines the walls of the arteries in the cord. The cord arteries and vein are compressed as these muscles tighten after birth to stop the newborn from bleeding via the cord. The umbilical cord has no nerve supply, therefore neither the mother nor the kid will experience any pain when it is clamped or cut during birth. III. ORIGIN & DEVELOPMENT OF ORGAN SYSTEMS Stem Cells Stem cells are known as specialized cells since those can have 2 functions that other cells don’t possess. 1: they can newly create cells exactly like them that have the same replica; 2: they can replace damaged tissues or have the other cell’s function to do a differentiation that is also called as totipotent stem cell. These are observed in the 4 days of life and are found in embryonic, fetal, and adult tissues. After another 4 days, it then shows differentiation or either loses its ability to change in another body cell. It may become a more specific body cell such as nerve, brain, or skin and called as pluripotent stem cells. As days go by, it becomes multipotent to be a distinct organ (Chen, et al., 2016). Zygote Growth After conception, the growth of zygote will take place. The development starts in a direction that is cephalocaudal which is where the head first forms then the tail. This pattern is also observed after birth when the babies try to lift their heads first before they learn to walk. Primary Germ Layers As the fetus continues to develop, germ layers start to form and this is considered important in  developing the body organ systems. The blastocyst has gone through differentiation by the time of implantation. The ectoderm, mesoderm, and endoderm are called germ layers. These are important for our understanding since most congenital disorders arise from these germ layers. An example would be a newborn with a malformation of heart and understanding this will lead us to knowing which germ layer it was which is the mesoderm and it helps in locating the origin of defect and its importance in diagnosis and treatment. Most organ systems are complete or at least have the basic form at 8 weeks gestation. During Organogenesis, it is vulnerable when invaded by teratogens and may affect the fetus by smoking and alcohol ingestion. Cardiovascular System This system is one of the earliest systems to function in intrauterine of the mother. Blood cells attach to the walls of the yolk sac then become blood vessels and form a single heart tube on the 16th day that beats by the 24th day. The Septum of heart that is known to divide the chambers forms during 6th or 7th week and heart valves at 7th week. A Doppler instrument is used to hear heartbeats as early as 10th to 12th week of pregnancy and electrocardiogram can be used by 11th week. The fetus’ heart rate is affected by level of oxygen, activity, and circulation of blood volume and when the sympathetic nervous system matures after 28th week, the heart stabilizes and has consistent 110-160 bpm.  When it comes to the gas exchange of oxygen and carbon dioxide from the placenta is where the fetal circulation happens. The rich oxygenated blood will go to the fetus via the umbilical vein that comes from the mother’s placenta. It will then go from one of the most important organs to another such as liver, heart, kidney, and brain. Oxygenated blood flows from the umbilical vein to ductus venosus, which bypasses the fetal liver, then goes to fetal inferior vena cava to the heart. Blood shunts from right atrium to left atrium via atrial septum opening also known as foramen ovale. Then from left atrium to left ventricle, then aorta, and to other parts.of the body. The usual circulation in the heart occurs however it has only a small amount of blood that goes to vena cava, the right atrium passing through the tricuspid valve to the right ventricle to pulmonary artery then to the lungs. But the larger portion of blood is shunted to the ductus arteriosus to the descending aorta. As the descending aorta releases the deoxygenated blood, it passes through the umbilical arteries on to placenta villi by mother’s umbilical cord. The oxygen saturation of the fetus only reaches 80% since there is a mixture of blood in the fetus and a normal heart rate is 110-160 bpm to accommodate cells that need oxygen. Fetal hemoglobin has two alpha and two gamma chains with increased concentration and has plenty of hemoglobin that binds to oxygen. The newborn’s hemoglobin level is around 17.1 g/100  ml, while adults have 11 g/100 ml; a baby's hematocrit is about 53%, while adults have 45%. Usually, gamma cells of a fetus are exchanged for beta cells before birth and still in process after birth. However, there are some defects that are only observed after 6 months. Respiratory System During the 3rd week of intrauterine life, the respiratory and digestive tract are in one single tube and only by the end of 4th week septum divides the esophagus from the trachea and will later on form the lung buds at the end of it. The thoracic cavity and abdomen are still not completely divided by diaphragm until the 7th week of life. If it does not close, there might be some complications such as stomach, spleen, liver, and intestines pulled up at the thoracic cavity and heart displacement. Respiratory developmental milestone include: ○ There is a respiratory practice movement that starts at 3 months gestation and continually becomes spontaneous. ○ For the expansion of alveoli, the low surface tension and viscosity of lung fluid forms and is absorbed rapidly after birth. ○ To decrease the surface tension of alveolar during expiration and prevent collapse, a phospholipid substance called surfactant is formed by the 24th week (Rojas-Reyes, et al, 2012). The surfactant components are lecithin (L) and sphingomyelin (S). As surfactant forms, it mixes  with amniotic fluid while the fetus practices to breathe. The amniocentesis technique is used to analyze the ratio that should be 2:1 and see the fetal maturity. If there is a breathing disorder then it can be because of lack of surfactant. If there are any interference in the blood supply for the fetus, such as insufficient nutrients from placenta or hypertension of the mother, it may raise the level of steroids in the fetus that may speed up the maturation of alveolar. Nervous System A neural plate is formed by the 3rd week of gestation. It has the neural tube for the central nervous system and the neural crest for the peripheral nervous system. The cerebrum, cerebellum, pons, and medulla oblongata in the brain from inside the womb and will continue to mature until 5 to 6 years old. An electroencephalogram can detect brain waves by the 8th week. As the eye and inner ear forms from the neural tube, by 24 weeks the ear can hear sound and eyes can have pupillary reaction. The neurologic system is sensitive and prone to having tube disorders and damage Endocrine System Endocrine organ function begins alongside the development of the nervous system. The fetal pancreas produces its own insulin, as insulin does not pass through the placenta from the mother. The thyroid and parathyroid glands are key for the fetal metabolic process and calcium balance. The fetal adrenal glands provide a precursor needed for estrogen production by the placenta. Digestive System Digestive Tract Separation occurs around the fourth week; rapid growth follows. Canalization: The tract forms as a solid tube, hollows out, and must recanalize later. Common Anomalies: Atresia (blockage) and stenosis (narrowing) can occur if canalization fails. Intestines push into the umbilical cord by the sixth week, return to the abdomen by the 10th week, and must rotate 180 degrees. Omphalocele and gastroschisis result from incomplete abdominal closure. Meconium Formation: Begins by the 16th week, helps assess newborn health. Newborns have low vitamin K, immature enzymes, and need monitoring for hypoglycemia and hyperbilirubinemia. Musculoskeletal System Cartilage supports the fetus in the first 2 weeks. Cartilage turns to bone starting at the 12th week; some bones complete this process just before birth. The fetus moves by the 11th week, but the mother typically feels it around 20 weeks. Reproductive System Sex is set at conception by the X or Y chromosome and can be identified by 8 weeks. Gonads form around 6 weeks; testosterone causes male organ development, while its absence leads to female organs. Unintentional androgen use by a pregnant woman can cause a genetically female baby to develop male traits. Testes descend into the scrotum between the  34th and 38th weeks; preterm boys may need follow-up for undescended testes, which may require surgery if they don’t descend naturally. Urinary System Rudimentary kidneys appear by the end of the fourth week, but the placenta handles waste removal before birth. Urine is produced by the 12th week and enters the amniotic fluid by the 16th week. By birth, the fetus may produce up to 500 ml of urine daily. Low amniotic fluid (oligohydramnios) may indicate kidney issues. Kidneys mature over months; newborns have immature kidney function and cannot concentrate urine well. The bladder connects to the umbilicus early on. If this connection doesn’t close, it can cause urine to drain from the umbilicus, known as a patent urachus. Integumentary System Fetal skin is thin and translucent until about 36 weeks, when fat deposits underneath. Soft, downy hair called lanugo covers the skin, providing insulation to keep the fetus warm. A cream-like substance called vernix caseosa covers the skin, protecting it from amniotic fluid and aiding lubrication. Both lanugo and vernix are still present at birth. Immune System Immunoglobulin (Ig) G antibodies from the mother cross the placenta starting around the 20th week, providing temporary protection against various diseases. Infants born before the 20th week may lack these  antibodies and need extra protection from infections. The fetus begins producing its own antibodies late in pregnancy but doesn’t need them until after birth. Presence of IgA and IgM antibodies in a newborn indicates exposure to infection, as these do not cross the placenta. IV. MILESTONE OF FETAL GROWTH AND DEVELOPMENT Fetal milestones can be confusing because the length of a pregnancy is often counted from the first day of the last menstrual cycle, but the life of the fetus is typically measured from the time of ovulation or fertilization (ovulation age). The following explanation of fetal developmental milestones is based on gestational weeks since it is useful for expectant parents to correlate fetal development with how they measure pregnancy. Figure: Human embryos at different stages of life. (A) Implantation in the uterus 7 to 8 days after conception. (B) The embryo at 32 days. (C) At 37 days. (D) At 41 days. (E) Between 12 and 15 weeks. FETAL GROWTH AND DEVELOPMENT GESTATIONAL WEEK FETAL DEVELOPMENT The embryo weighs about 400 mg and is about 0.75 cm long.  The spinal cord is formed and fused at the End of Fourth Gestational Week midpoint. The head is large in proportion and represents about one third of the entire structure. The rudimentary heart appears as a prominent bulge on the anterior surface. Arms and legs are bud-like structures; rudimentary eyes, ears, and nose are discernible. The fetus weighs roughly 20 g and is about 2.5 cm (1 in) long Organogenesis is completed. The heart beats rhythmically due to its septum and valves. Arms and legs have developed; facial features are End of Eighth Gestational Week clearly visible. Although external genitalia are developing, sex cannot yet be identified by simple observation. The fetal intestine grows so quickly that the abdomen bulges forward. A sonogram shows a gestational sac, which is diagnostic of pregnancy The fetus weighs about 45 g and is 7 to 8 cm long. On the fingers and toes, nail beds are growing. While spontaneous movements are possible, they are typically too tiny for the mother to notice. There are certain reflexes, such as the Babinski End of 12th Gestational Week reflex. (First Trimester) Centers for bone ossification start to develop. There are tooth buds. Sex can be identified based on appearance. Urine secretion begins, however it may not yet be seen in amniotic fluid.  Using Doppler technology, the heartbeat may be heard. The fetus weighs between 55 and 120 g and is 10 to 17 cm in length. A regular stethoscope can detect fetal heart sounds. End of 16th Gestational Week Lanugo has a good shape. The pancreas and liver are both working. The fetus actively swallows amniotic fluid, demonstrating an intact but uncoordinated swallowing reflex; urine is present in amniotic fluid. Sex can be determined by ultrasonography. The fetus weighs 223 g and measures 25 cm in length. The mother is able to detect spontaneous movements in the fetus. Antibody production is possible. On the head, vernix caseosa starts to cover the skin, and hair, including eyebrows, begins to form. End of 20th Gestational Week Meconium is present in the upper intestine. Brown fat, a special fat that aids in temperature regulation, begins to form behind the kidneys, sternum, and posterior neck. The mother starts to transfer passive antibodies to the fetus. Definite sleeping and activity patterns are distinguishable as the fetus develops biorhythms that will guide sleep/wake patterns throughout life. End of 24th Gestational Week The fetus weighs 550 g and measures 28 to 36 cm (Second Trimester) in length. Meconium is found all the way up to the rectum.  The start of lung surfactant's active synthesis. After being fused since the 12th week, the eyelids are now open, and the pupils respond to light. The ability to respond to abrupt sounds is a sign of hearing. If a fetus is kept in a contemporary intensive care unit after birth, they have reached a feasible low-end age of viability when they weigh 500–600 grams, or 24 weeks. End of 28th Gestational Week The fetus weighs 1,200 g and measures 35 to 38 cm in length. Amniotic fluid shows surfactant; lung alveoli are nearly fully developed. The testes start to move from the lower part of the abdomen into the scrotal sac. Although the retina's blood vessels are developed, they are small and extremely vulnerable to injury from increased levels of oxygen (an important problem when caring for oxygen-dependent preterm infants). End of 32nd Gestational Week The fetus weighs 1,600 g and measures 38 to 43 cm in length. The appearance of the formerly stringy, "little old man" is lost as subcutaneous fat starts to accumulate. The fetus moves in response to noises outside of the mother's body. The Moro reflex is in action. Newborns are beginning to build up iron reserves, which will provide them with iron throughout the time after delivery that they will only be able to eat breast milk.  Nails cover the tips of the fingers. End of 36th Gestational Week The unborn child is 42 to 48 centimeters long and weighs between 1,800 and 2,700 g (5 to 6 kg). The body saves more calcium, iron, glucose, and glycogen. The reserves of fat under the skin are rising. Of the whole pattern shown at term, the sole of the foot has only one or two crisscross wrinkles. The amount of lanugo starts to drop. Almost all newborns appear as heads down, or vertex, during this month. End of 40th Gestational Week The fetus measures 48 to 52 cm in length (from (Third Trimester) crown to rump, 35 to 37 cm) and weighs 3,000 g (7 to 7.5 lb). The fetus kicks a lot, often hard enough to cause the mother a lot of discomfort. Fetal hemoglobin begins to change into adult hemoglobin. As the baby gets closer to 40 weeks or more gestational age, vernix caseosa may become more noticeable in the creases than on the body covering. Vernix caseosa begins to diminish after the baby reaches 37 weeks gestation. The fingertips are covered in fingernails. At least two thirds of the soles of the feet are covered in crevices. DETERMINATION OF ESTIMATED BIRTH DATE To calculate the date of birth using Naegel’s rule, count backward 3 calendar months from the first day of a woman’s last menstrual period and add 7 days.  V. ASSESSMENT OF FETAL GROWTH & DEVELOPMENT The Assessment of fetal growth and development plays a pivotal role in the aspect of prenatal care by providing valuable insights on how the fetus develops in terms of its health and well-being. This involves a series of tests that evaluates and provides measurements to help monitor the fetus throughout the whole pregnancy. These tests are done due to variety of reasons that includes: Predict the outcome of the pregnancy Manage the remaining weeks of the pregnancy Plan for possible complications at birth Plan for problems that may occur in the newborn infant Decide whether to continue the pregnancy Find conditions that may affect future pregnancies In cases where the fetus has a metabolic or chromosomal disorder, both the fetal growth and development can be compromised as these interfere with the fetus normal growth. On a condition that the structures that support the fetus like the placenta or the cord do not form naturally, or if there are presence of environmental influences that are not good for the fetus like air pollution and nicotine in cigarettes causes fetal growth restriction. Nursing responsibilities in these assessment include confirming signed consent for procedures that may induce any form of risk to the mother or fetus, ensuring that the mother and her support system are aware of will happen in the procedure and what are the possible risks they might encounter, prepare the woman physically and psychologically, supporting them throughout the procedure, educating them about self-care and providing necessary care post-procedure. AN INTERPROFESSIONAL CARE MAP FOR A WOMAN UNDERGOING FETAL STUDIES Louise Swan, an 18-year-old, this is her first pregnancy and she is about 20 weeks pregnant (cannot remember date of her last menstrual period). She claims that she is aware that she should have stopped smoking since the beginning of her pregnancy but she was not yet able to do so. During the pregnancy about fourth and tenth week, she attended picnics and she drank beer. In her clinic visit today, she said she felt her fetus move. She said that “Feeling my baby move made me want to be careful in what I do now since I have a human growing inside me.” Louise works in a fast food chain. The boyfriend (father of the fetus) is supportive but does not have enough money to give her financial support. She states, “ I am not getting married. I’m just not ready for that.” Family Assessment: Patient lives in a single-bedroom apartment; supports self by working at the restaurant. She States, “My parents would help out if I begged them, but I’m not going to do that.” Patient Assessment: Patient takes aspirin, 10 g, for almost daily sinus headaches. She smokes a pack of cigarettes a day.No recreational drug use. Nutrition: Takes no breakfast, to help control her weight. Lunch: A burger and salad. One diet coke. Dinner: Baked mac and cheese; applesauce. One cup coffee. Snack: Half bag of potato chips and cream-cheese dip. Physical examination: Fundal height is 16 cm. Fetal heart tones by Doppler at 160 beats/min. Has been advised to have an ultrasound done to assess for fetal growth and to date pregnancy. Nursing Diagnosis: Risk for altered fetal growth related to inadequate nutrition and alcohol and nicotine consumption. Outcome Criteria: Patient consents to sonogram for fetal growth assessment; reports lessened alcohol and cigarette use at the next visit. Team Member Assessment Intervention Rationale Expected Responsible outcome Activities of Daily Living, Including Safety Nurse Ask the patient Talk through the Understanding Patient states about what they common actions what constitutes she will stop normally do that are unsafe practices drinking everyday to dangerous during Alcohol; she is unfold any during pregnancy is the using an online action that might pregnancy, such woman’s best quitline be unsafe for as smoking and protection to help reduce fetal growth. drinking against fetal smoking. alcohol. harm. Teamwork and Collaboration Primary Identify if the Schedule Patient believes Patient reports healthcare sonogram sonogram 1 she might be 20 for scheduled provider/nurse department has week in weeks pregnant. ultrasound in 1 an appointment advance with Fundal height, week. in the coming sonogram recent fetal week. department. movements correspond more closely to 16 weeks. Procedures/Medications for Quality Improvement Nurse Evaluate the Explain to Acetylsalicylic Patient reports patient’s patient the acid (aspirin) at next prenatal prescription or inadvisability of might lead to visit she takes over-the-counter taking aspirin bleeding or acetaminophen or alternative during longer for any pain she therapies. pregnancy; pregnancy. is feeling. suggest she take acetaminophen (Tylenol) as a replacement. Nutrition Nurse/nutritionist Ask patient for Explain the Understanding Patient reports a 24-hour recall advisability of the benefits of at prenatal visits nutrition history. eating breakfast healthy diet she eats her while pregnant helps guarantee breakfast before to help avoid that the fetus will leaving for work; Hypoglycemia receive includes more (low sugar) in adequate protein in fetus. nutrients. intake. Patient-Centered Care Nurse Analyze whether Inform patient A well-prepared Patient will patient about patient is more describe understands preparation for apt to result in accurate ultrasound is not sonogram (drink an effective preparations for an X-ray, so it is fluid; avoid procedure and a procedure; not harmful to emptying satisfied patient. receives printed the fetus. bladder). instructions for ambulatory ultrasound. Spiritual/Psychosocial/Emotional Needs Primary Evaluate the Analyze the Knowing the Patient states healthcare extent of possibility with contributors to she understands provider/nurse factors, such as patient that her fetal health is the discrepancy alcohol and pregnancy necessary for in fundal height cigarette use, dating may be women to make and weeks that could have wrong because informed gestation led to fundal height is choices during following intrauterine below usual. pregnancy. explanation. growth Alternate cause restriction. could be fetal growth restriction. Informatics for Seamless Healthcare Planning Nurse/primary Execute a Mark chart as Document the The patient healthcare complete high-risk patient risk factors chart documents provider assessment to for intrauterine helps to high-risk status. help ensure growth Protect the  continuity of restriction fetus. care with other (fundal height services. below average for weeks gestation). HEALTH HISTORY A fetal assessment, like any other, also begins with a detailed health history. It's important to ask the mother about any pre-pregnancy illnesses, such as gestational diabetes or heart disease, as these can impact prenatal development. Additionally, inquire about any medications she is taking, as some commonly used drugs, like those for treating recurrent seizures, can be teratogenic which poses risks during the pregnancy. Inquiring the nutritional intake of the mother is important to know if she is eating a well-balanced diet because she may not take- in enough nutrients that would supply nutrients that enhance fetal growth. Ensure to ask about personal habits such as smoking, use of prescription or recreational drugs, alcohol consumption, and exercise, as these can all impact glucose/insulin balance and fetal growth. While many women know that alcohol can harm a fetus and lead to fetal alcohol spectrum disorder, fewer may be aware of the dangers associated with fetal tobacco syndrome. This syndrome affects the fetus of the woman who smokes more than five cigarettes a day, leading to growth restriction, with a birth weight of less than 2,500 grams at term. Smoking may also contribute to ectopic (tubal) pregnancies, as it can cause irritation in the fallopian tubes. Ectopic (tubal) pregnancy is a pregnancy that occurs outside the uterus. Fertilized egg in an ectopic pregnancy is not “viable” therefore this type of pregnancy will result miscarriage. Most women naturally protect their growing fetus, so pregnancy often motivates them to opt for healthier lifestyles. Asking the mother about exposure to teratogens can uncover potential risks from substances like chemicals, paint fumes, cleaning products, poor air quality, or excessive noise. Additionally, checking for unintentional injuries or intimate partner violence can help identify any trauma the pregnant woman or fetus may have experienced, as intimate partner violence often increases during pregnancy due to the added stress it can bring. Conducting an in-depth health history taking helps healthcare providers identify and manage potential risk, plan the appropriate prenatal care, and establish better outcomes for the mother and her baby. Understanding the lifestyle of the mother can help address several factors that may endanger the baby. Having a positive environment throughout the pregnancy provides peace for the mother that her child is safe and well, free from any distress and trauma. Nursing Care Planning to Respect Cultural Diversity As a member of this multicultural society and as nurses it is essential that we are able to respect the cultural diversity and recognize the values of the differences in cultural backgrounds, practices, and beliefs of each and every client, which influences their health beliefs, preferences and responses to treatment. Different cultures have different ideas as to what foods to eat, how much exercise is good during pregnancy Whether fetal tests for well-being are ethical. Believing it is wrong to have a photograph taken during pregnancy because that will alert unknown spirits that the woman is pregnant (the origin of lullabies were songs to keep away Lilith, an avenging creature in Jewish folklore who was thought to bring harm to babies). Believing photographs are harmful may make a woman reluctant to have a sonogram taken during pregnancy; unlike most women, she may not like a photograph of the ultrasound for a baby keepsake. Some religions also do not support a full range of contraception options; the nurse can suggest other family planning methods align with the woman’s beliefs Physical Examination After taking the health history of the mother, a physical examination will be carried out. Nurses will assess the mother’s overall general appearance, weight and nutrition, monitor the blood pressure, check for bruises, and so on that may affect the fetal growth. Estimating Fetal Health Both invasive and non-invasive procedures are used to evaluate the health of the fetus. These procedures help pregnant women especially those who are at high risk to maintain a sense of control. Fetal growth The uterus of the mother expands as the fetus grows. Typical fundal measurements are:  i. Over or on top of the pubic symphysis at 12 weeks ii. Right at the umbilicus at 20 weeks iii. At the sternum’s xiphoid process at 36 weeks Mcdonald’s rule has been used as a method for measuring fetal growth and gestational age. It is called symphysis-fundal height measurement since the measurement will start from the notch of symphysis pubis to over the top of the uterine fundus. Usually the weeks of gestation are equal to the measurement in centimeters. For example if the pregnant woman is at 24 weeks then measurement should be 24 cm. If the fundal height does not match to the age of gestation, then it may suggest a multiple pregnancy or the fetus is failing to grow. However it becomes unreliable during the 3rd trimester since the fetus increases more in weight than in height. VI. ASSESSMENT OF FETAL WELLBEING To ensure health, growth, and development of the fetal, routine prenatal care—including assessments of the fetal well-being—is essential as it provides guidelines of how well the fetus is inside the woman’s womb. Frequent evaluations increase the chances of a safe pregnancy and delivery by detecting potential issues early on and enabling prompt interventions. Knowledge about it would help the expectant family to begin thinking of how they’re going to welcome a new member of the family and to understand the woman herself of some changes in her body during her pregnancy. Fetal well-being is commonly evaluated using ultrasonography, biophysical profile, non-stress test, fetal heart rate and movement counts, and other procedures. 1. Fetal Heart Rate Fetal heart rate (FHR) is a crucial indicator of a baby's well-being. It can be heard and counted using a doppler ultrasound or a fetoscope by early 10th or 11th week. Regular monitoring of the FHR helps healthcare providers identify potential issues early on and take appropriate measures. 2. Daily Fetal Movement Count (Kick Counts) Quickening, or fetal movement, starts between weeks 18 and 20 of pregnancy and peaks between weeks 28 and 38. About ten times an hour, a healthy fetus moves; a fetus with inadequate placental nutrients moves less frequently. One way to evaluate fetal movements in high-risk pregnancies is by kick counts.  After a meal, women should lie in a left recumbent position and count the number of movements of the fetus until they reach ten. The woman should move around and try again if an hour goes by without her making ten motions. The woman should get in touch with their primary healthcare practitioner if she does not feel 10 movements within a one-hour period. If a fetus is not getting enough nutrients, kick counts can be especially helpful in growth-restricted or postterm pregnancies. Understanding fetal movements is crucial for the mother in order to prevent her from worrying excessively about the health of the fetus, especially when it comes to activity, sleep cycles, and the amount of time since her last meal. A. Rhythm Strip Testing Fetal heart rate can be measured using a technique called "rhythm strip testing" to determine both long and short-term variability as well as a solid baseline. It entails putting the woman in a posture that is somewhat similar to Fowler's, connecting an external fetal heart rate monitor, and measuring the fetal heart rate for a duration of twenty minutes. The average fetal heartbeat serves as the baseline reading, and any short-term variability indicates slight variations in the rhythm. The condition of the fetal sympathetic nervous system is reflected in long-term variability. Because an average fetus moves twice every ten minutes, the test usually detects two or more episodes of fetal heart rate acceleration in a 20-minute rhythm strip. The rating for variability is: Absent: No discernible peak-to-trough range. Minimal: There is a measurable amplitude range, but the pace is 5 beats per minute or less. Normal or moderate: There is a discernible amplitude range, and the rate ranges from 6 to 25 beats per minute. Marked: The rate is higher than 25 beats per minute and there is a noticeable amplitude range (American Congress of Obstetricians and Gynaecologists [ACOG], 2009) A woman must spend 20 minutes in a somewhat stationary position in order to undergo a rhythm strip test. Make sure she knows the significance of the exam's objectives and importance, and that she is aware of how the test will determine her results. B. Nonstress Testing A nonstress test gauges how the fetal heart rate reacts to movement. A fetal heart rate monitor and a uterine contraction monitor should be attached once the mother is positioned. Tell the woman that every time she feels the fetus move, she should press the button on the monitor, which resembles a call bell. At certain occasions, this will leave a dark stain on the paper trace. When the fetus moves, its heart rate should rise by roughly 15 beats per minute and stay raised for 15 seconds. As the fetus quiets, it ought to return to its typical rate. It is recommended that the fetus have inadequate oxygen perfusion if there is no discernible rise in heart rate during fetal movement. Typically, a nonstress test lasts 20 minutes. If there are two accelerations of the fetal heart rate (by 15 beats or more) that remain for 15 seconds after movement within the allotted time, the test is considered reactive (healthy). If there are no accelerations in the fetal movements, the test is nonreactive (fetal health may be compromised). If there is no fetal movement or minimal short-term fetal heart rate variability (less than 6 beats/min) during the testing time, the data can also be interpreted as nonreactive. The fetus may simply be asleep if a 20-minute period goes by without any movement; however, additional factors that may contribute to decreased variability include maternal smoking, drug use, or hypoglycemia. Giving the woman an oral carbohydrate snack, like orange juice, may raise her blood glucose levels to the point when fetal movement occurs, despite the fact this is not supported by any data. Another way to get the fetus to move is to excite it with a loud sound. Both nonstress testing and rhythm strip testing are safe, noninvasive methods that can be used as screening tests in any pregnancy because they pose no risks to the mother or fetus. As part of a home monitoring regimen for a pregnant woman experiencing a problem, these can be completed every day at home. An extra fetal evaluation, like a biophysical profile test, will be scheduled if a nonstress test yields no results. C. Vibroacoustic Stimulation An acoustic stimulator, specially designed to stimulate sound and wake the fetus, is affixed to the mother's abdomen. The sound produced by this gadget has a frequency of 80 Hz, or about 80 dB. It is sharp. (2011) Russo et al. If a spontaneous acceleration has not occurred after five minutes of a standard nonstress test, apply one or two seconds of sound stimulation to the lower abdomen. This can be repeated if after 10 minutes there is still no spontaneous movement, enabling the assessment of two moves within the twenty minutes allocated. 3. Ultrasonography The use of ultrasound in fetal health assessments is essential as it helps detect pregnancy complications, genetic disorders, and fetal anomalies. It also confirms the presence of the placenta and amniotic fluid, establishes fetal growth, determines fetal presentation, predicts maturity, and establishes fetal growth. Through the absence of a heartbeat and respiration, it can also identify fetal death. Ultrasonography can identify inadequate uterine involution in the postpartum mother or retained placenta after delivery. During an ultrasound, a transducer that is applied to the belly or vagina transmits high-frequency sound waves towards the uterus. An oscilloscope screen shows the images, which give a visual depiction of the fetal heart and extremity movement. A fetus's wellbeing might be reassured to parents by an ultrasound image. It is crucial to provide the father and the fetus a thorough explanation and assurances that the operation is safe before beginning. The woman must drink water every 15 minutes prior to the treatment because this is when the sound waves reflect the best. The transducer is adjusted until the uterus and its contents are completely scanned after a gel is administered to the abdomen to improve contact with it. An intravaginal approach can be used for ultrasonography, however it is not recommended to preserve ultrasound images for sentimental or souvenir purposes. A. Biparietal Diameter By measuring the fetal head's biparietal diameter, or side-to-side measurement, ultrasound can be used to estimate fetal maturity. It is estimated that the baby will weigh more than 2,500 g (5.5 lb) at delivery or be 40 weeks along in 80% of pregnancies in which the biparietal diameter of the fetal head is 8.5 cm or more. B. Doppler ultrasonography Determines the speed at which erythrocytes move through the uterine and fetal vessels. Evaluating the blood flow via uterine blood arteries can assist identify vascular resistance in women with hypertension or gestational diabetes, as well as whether placental insufficiency is happening as a result. Since it indicates that the fetus is only receiving a restricted amount of nutrients, decreased velocity is a significant predictor of the occurrence of uterine growth restriction. C. Amniotic Fluid Volume When a fetus is under stress in the mother's uterus, its circulatory and kidney function declines, leading to decreased urine output or amniotic fluid volume. The fetus is at risk of umbilical cord compression due to amniotic fluid volume reduction, lack of exercise and muscle tone, and interference with nutrition. During the timeframe of 28 to 40 weeks, the average length of amniotic fluid pockets detected by sonograms is 12 to 15 cm. Hydroniosis, which is caused by an inability to swallow the fluid and falls within the 20 to 24 cm range, is a sign of this condition. A low volume of fluid under 5 to 6 cm indicates oligohydramnios, which may be due in part to poor perfusion and kidney failure. D. Nuchal Translucency Are abnormal pockets of fat or fluid in the posterior neck, is visible on sonograms in children with several chromosomal abnormalities. E. Placental Grading for Maturity Placentas can be graded by ultrasound predicated on the particular amount of calcium deposits present in the base. Placentas are graded as: 0: Between 12 and 24 weeks 1: 30 to 32 weeks 2: 36 weeks 3: 38 weeks (because fetal lungs are apt to be mature by 38 weeks, a grade 3 placenta suggests the fetus is mature). 4. Biophysical Profile A biophysical profile assesses overall fetal health. It is composed of two painless and non-invasive tests:  Nonstress Test - To check the baby's heart rate, the patient will be laying on her left side. The nurse or practitioner will place two monitor components on the abdomen, fastened in place with elastic straps. The baby's heartbeat is recorded by one component, while any uterine contractions are recorded by the other. The fetus's movement and heart rate will be monitored by the test's administrator. Like the patient, the fetus should have a faster heartbeat when it kicks and moves. Ultrasound - The baby will be spotted and any movements are monitored by a doctor using ultrasonography devices. The doctor puts the patient on a table and uses a transducer device on their stomach. Images of the uterus and fetus are carried onto the body by the transducer using safe sound waves that echo against the inside organs. Furthermore, the ultrasound will establish that the amount of amniotic fluid is appropriate for the stage of pregnancy and help visualize the pocket of fluid inside the uterus. Visualizing a fetus's respiration patterns, bodily motions, and muscular tone is also beneficial. Typically, it takes 30 to 70 minutes to get it done. A BPP can be scheduled once or twice a week alongside your obstetrician visits if possible. There is no need for prior preparation for a simple test. Nonetheless, the healthcare provider might advise the patient to eat before the test, since some babies are more active after their mothers eat. Before the procedures start, make sure to empty the bladder because it will make the patient more comfortable while doing the procedures. It may be performed when other test results are nonreassuring. The practitioner assesses fetal well-being in these five areas using a scoring system: Fetal heart rate Fetal breathing movements Fetal body movements Fetal muscle tone Amount of amniotic fluid Each of the areas that are given has a score of 0 or 2 points, for a possible total of 10 points. 8 out of 10 is a comforting score. 6 is a confusing score, meaning it is neither reassuring nor unreassuring. Depending on how far along the pregnancy, it needs another BPP within the next 12 to 24 hours if the score is unclear, or it might be chosen to give birth. More testing is required if the score is 4 or lower. It can sometimes indicate that the baby needs to be delivered immediately or early. Whatever the result, insufficient amniotic fluid indicates that more frequent testing is necessary or that delivery may need to be taken into consideration. 5. Magnetic Resonance Imaging Fetal magnetic resonance imaging (MRI) is a simple testing method that gives exact structural details about a growing baby as well as clear, high-quality images. In the second or third trimester of pregnancy, it is completed. This kind of test examines any physical, mental, or spinal abnormalities in your child. During tough circumstances, an MRI may offer relevant other diagnostic information or support an ultrasound diagnosis. Magnetic resonance imaging, or MRI for short, takes images for analysis using a magnetic field as opposed to radiation. In order to provide precise inside images, magnetic forces produced by MRI machines are measured in Teslas (T), a unit of change in a magnetic field (flux). Most MRI machines have magnetic field strengths between 1.5T and 3.0T. An MRI examination typically takes between thirty and forty-five minutes. You'll be required to complete a metal screening form prior to entering the MRI room in order to make sure you don't wear any jewelry or metal objects on the day of your scan since it might cause harm to the patients. Caffeine and sugary foods should be avoided four hours before your MRI treatment since they stimulate the fetus and make it more challenging to obtain still images. For your comfort, we will ask you to have your bladder empty before the MRI. The technologist will give you headphones so you can talk to them while you have your scan if you would like to listen to music. Earplugs are offered if you prefer silence over music to avoid the “thumping” sound. We make every effort to place your feet first in the MRI system. It is preferred that you lie on your back for the MRI process. If you are unable to do so, we will attempt to relieve some of the pressure on your lower back by putting a bolster beneath your knees. Partially lying on your side is another position.  MRI procedures might cause claustrophobia in certain patients. We can administer oxygen or let a companion stay in the room while the treatment is being done to help with this feeling. You have access to additional techniques for relaxation, such as music listening and lavender aromatherapy. After the MRI, every picture is carefully reviewed by a radiologist who is there. Later that, you and your family will go over this material with the maternal-fetal medicine specialist, and they will discuss it at the end of the day. 6. Maternal Serum Prenatal exams search for health issues before the birth of your child. Maternal serum screening, also known as AFP (alpha fetoprotein) Maternal or Maternal Serum AFP, is a blood test that helps your doctor determine your baby's risk of chromosomal problems and screen for neural tube disorders that includes: Down’s syndrome (Trisomy 21) Edward’s syndrome (Trisomy 18) Patau’s syndrome (Trisomy 13) Spina bifida Anencephaly This test is recommended for women who: Have a family history of birth defects Are 35 years or older Have diabetes Have used certain medicines or drugs during pregnancy A blood test known as the maternal serum screening is performed in the second trimester of pregnancy. Your arm will be punctured with a needle to remove blood, which will then be sent to a lab for examination. Your doctor may also recommend additional tests. These test results can be combined with other health indicators and the results of your maternal serum screening to give a comprehensive picture of your baby's risk. This is referred to as a triple or quad screening when combined. A greater chance of chromosomal or neural tube disorders in your unborn child can be detected by a positive screening result. Just that this is a screening and will only inform you if your child is at risk, that should always be kept in mind. It cannot determine with certainty whether your child has a health issue. It can be difficult to interpret your test results, as it is with many exams. A genetic counselor or your physician should be consulted on the screening results. 7. Invasive Fetal Testing It is possible to directly analyze fetal genetic material for chromosomal and genetic disorders using a number of methods. There is a tiny chance of miscarriage or injury to the fetus with these invasive tests, which involve the insertion of an instrument into the body and these are: A. Amniocentesis Amniocentesis is a test performed to find any abnormalities in a fetus. It is available to all pregnant women, however it is frequently advised for women who's over 35 because of the increased chance of chromosomal abnormalities. Usually it is conducted after 15 weeks of pregnancy, amniotic fluid containing fetal cells is extracted and examined. In comparison to blood testing, the fluid is utilized to analyze alpha-fetoprotein levels and study chromosomes, which can help reveal brain or spinal cord problems. Amniotic fluid can be analyzed for: acetylcholinesterase, bilirubin determination, chromosome analysis, color, fibronectin, inborn errors of metabolism, l/s ratio, phosphatidylglycerol and desaturated phosphatidylcholine. Before amniocentesis, ultrasonography is performed to assess the fetus's heart, confirm the duration of the pregnancy, locate the placenta and amniotic fluid, and determine the number of babies. The procedure is passing a needle into the abdomen and into the amniotic fluid, usually with ultrasound guidance. Results can become complicated when fluid is removed and, on rare occasions, fetal blood gets mixed in with the sample. Antibody formation against Rh-positive fetal blood is inhibited by administering Rho(D) immune globulin if the mother has Rh-negative blood. Although 1-2% of instances may result in transient pain, spotting, or leakage, the operation is generally safe. Fetal harm is extremely uncommon, and the chance of miscarriage is small (1 in 500–1,000). Multiple fetuses may also be amniocentesiscally operated on. B. Chorionic Villus Sampling Between weeks 10 and 12, a procedure called chorionic villus sampling, or CVS, appears to detect problems in the fetus. Under the guidance of ultrasonography, just a small amount of chorionic villi from the placenta is taken out from the cervix or the abdominal wall.It is not feasible to assess alpha-fetoprotein levels in order to look for neural tube abnormalities since, unlike amniocentesis, amniotic fluid is not supplied via CVS. Future testing might be necessary as a result of this. The main advantage of CVS is early diagnosis, allowing earlier relief of anxiety or decisions regarding pregnancy termination. Women with Rh-negative blood receive Rho(D) immune globulin after the procedure to prevent Rh incompatibility. Risks, including miscarriage (about 1 in 500), are similar to amniocentesis, and in rare cases, further testing with amniocentesis may be needed for unclear results. C. Percutaneous Umbilical Blood Sampling Percutaneous umbilical blood sample is the process of taking fetal blood for analysis from the umbilical cord using a needle under ultrasonography guidance. With a 1 in 100 chance of miscarriage, this invasive treatment was originally often employed for quick chromosome analysis. However, because safer options such as amniocentesis and chorionic villus samples are available, it is now rarely utilized. Nowadays, it is typically carried out when fetal anemia is suspected, and in extreme circumstances, the fetus may receive a blood transfusion via the same needle. D. Genetic Testing Doctors can occasionally identify genetic abnormalities in the embryo before it is transferred to the woman's uterus if pregnancy is to be obtained by in vitro (test tube) fertilization. Preimplantation genetic testing is costly and demands a high level of technical proficiency. These tests are mostly used by prospective parents who are highly likely to carry a child with chromosomal abnormalities or certain genetic disorders, including cystic fibrosis. Conversely, newer techniques may result in reduced costs and improved test accessibility.  NORMAL CHANGES IN PREGNANCY I - PSYCHOLOGICAL CHANGES OF PREGNANCY Pregnancy triggers profound psychological changes, comparable only to those experienced during puberty. A woman's ability to adjust to pregnancy is shaped by her upbringing, family attitudes towards pregnancy, cultural context, and whether the timing of the pregnancy in her life. For many women, a prenatal visit may be their first interaction with a healthcare provider since childhood. The support and advice offered during this time are crucial, not only for ensuring a safe pregnancy but also for reconnecting women with ongoing healthcare. Social influences During the 20th century, pregnancy was often treated like a nine-month illness, that heavily focused on medical management. Women commonly attended prenatal appointments alone and were isolated from their families during childbirth. After delivery, they were kept apart from their newborns for a week, with nurses handling feedings. In our time, pregnancy is considered a healthy and natural phase, ideally shared with a supportive partner or family. Women now often involve their families in prenatal care and childbirth, choose their preferred pain management methods, and many opt to breastfeed. How a pregnant woman and her partner navigate pregnancy and prepare for parenthood is influenced by their cultural background, personal beliefs, input from friends and relatives, and the vast information online. Nurses play a crucial role in educating women about their healthcare choices and collaborating with other providers to "demedicalize" or humanize childbirth. Cultural influences A woman's cultural background can significantly impact the level of involvement she desires in her pregnancy, as specific beliefs and taboos may impose limitations on her behavior and activities. To understand the beliefs of a woman and her partner, it's important to ask during prenatal visits if there are any practices they believe should be followed or avoided to ensure a healthy pregnancy and fetus. Respecting and supporting these beliefs acknowledges the woman's individuality and understanding of maintaining good health.  Women react uniquely to their pregnancy based on their sole experiences and cultural beliefs and expectations.Eating different foods during the pregnancy which the mother believes will either be “good” or “bad” for the baby. Assess the mother’s intake carefully to ensure she is not eating nonfood substances like ice cubes or raw flour. This is called pica that happens during the pregnancy. These will result for the mother to continue pregnancy with low iron stores, therefore, iron-deficient anemia results. Asking about this can divulge the mother eating substances such as paint chips, or sniffling gasoline that can affect the fetal growth. Before the changes in the woman’s body during pregnancy was scientifically explained, multiple societies had their own explanations on why these changes occurs. For example, it is believed that when you lift your arms over you head when you are pregnant this will cause the umbilical cord of your fetus to twist or when you watch the lunar eclipse this will cause a birth deformity. Family influences The environment where the woman was raised can individually shape her own beliefs about her pregnancy, as it is the foundation of her cultural background. If she experienced a motherly love and was cherished like a blessing in the family, she is more likely to have a positive reaction to her own pregnancy. On the other hand, if she was blamed for unfortunate events like the break up of marriage, her attitude toward her pregnancy would be less positive. A woman who sees mothering as a rewarding role is more likely to be happy about becoming pregnant than one who does not place high value on motherhood. Individual differences A woman's ability to cope with stress greatly influences how she handles her transition to motherhood. Her capacity to adapt depends on her temperament, how she approaches new situations, and her experience with stress and change. Feeling secure in her relationships, especially with the father of the baby or main support person, also affects her acceptance of pregnancy. Concerns about being left to raise a child alone can make her question whether pregnancy is the right choice. Past experiences further shape a woman's view of pregnancy. For instance, if she associates motherhood with losing her youth, fears about changes to her appearance, financial stability, or career prospects might cause anxiety. These concerns are genuine and should be taken seriously during assessments or counseling. Women without a supportive partner may rely on healthcare providers to offer emotional support during pregnancy. Partner’s Adaptation The stronger a partner’s emotional connection to a pregnant woman, the more likely they are to bond closely with the child. A partner’s ability to form a close relationship with the mother and embrace the pregnancy is influenced by the same factors as the woman’s cultural background, past experiences, and family relationships. Although partners may not always express their emotions verbally, they often communicate their feelings through touch or affection, making their presence valuable at prenatal visits and especially in the birthing room. The Psychological Tasks of Pregnancy The pregnancy experience can be considered to be an emotional rollercoaster as one progresses through it. Its experience is extremely varied across a wide spectrum, when mothers are asked “how is your pregnancy?” all answers will be distinct. It encapsulates all the variables and factors within and outside of the mother’s life. Whether good or bad, this significantly impacts the comfort, security and health of the mother and baby, which is why healthcare providers must ensure a holistic and effective approach in recognizing concerns, emotions and providing proper interventions. THE PREGNANT MOTHER 1st Trimester 2nd Trimester 3rd Timester Goal Acceptance of Acceptance of Baby Acceptance of parenthood Pregnancy Associated Ambivalence Amazement Eagerness and Interest Emotions (dread + delight) Problems to Denial of pregnancy Weak attachment to Accepting the reality of the overcome Fears and Anxiety their child ; Unable to situation in terms of: find the desire to have a - Time child - Finances - Physiological, Difficulties in accepting mental and the baby as an addition emotional stress to the family - Overall care plan/setup As well as the responsibilities and  adjustments along with it. Establishing a sense of identity and working relationship with parents Coping/Steps Confirmatory Feeling Fetal Nest-building Taken to reach Diagnosing movement activities. Involves goal Routine (quickening) determining the sonograms Imagining and baby’s Dating the anticipatory ○ Name pregnancy role-playing ○ Room Safeguard Fetal Announcing to ○ Arrangement Health relatives and Attending friends educational classes Shopping and about childbirth Setting up for the Interprofessional baby approaches (family coaching, social services, etc.) Emotional support from families and relatives Assessment of mother and child attachment during checkups Signs of “Oo, Buntis ako.” “Grabe, may taong Interest in attending progress namumuo sa katawan prenatal/ childbirth-related “Feeling more pregnant” ko.” classes after first prenatal visit Realizing that the fetus Socializing and sharing Practicing abstinence is a separate entity, a thoughts with other parents from prohibited drugs, separate human being alcohol and smoking. inside her. Locating good role models May start to call the Reestablishing relationships baby as “she or he” than with family “it” Healthy role-playing and Follows prenatal fantasizing instructions well. PARTNER The role of the partner is often overlooked or least prioritized in the topic of pregnancy. However, it must not be failed to recognize that the partner’s role is crucial in supporting and securing both the mother and the baby, outside of physiological means. They have their own set of goals and responsibilities that cater to ensuring a healthy pregnancy. Healthcare providers must ensure proper handling and involvement of the partner throughout the entire process. 1st Trimester 2nd Trimester 3rd Timester Goal Acceptance of Acceptance of Baby Acceptance of parenthood Pregnancy, reality of child and the woman in changed state Associated Ambivalence Anticipation/Longing for Eagerness and Interest Emotions (Happiness + involvement Overwhelmed) Presence of jealousy Problems to Jealousy of the baby Too absorbed in working Accepting the reality of the overcome (taking up the woman’s (showcasing provider situation in terms of: time) mindsets) thus creating - Time limited time for the - Finances Lack of support woman and their baby - Physiological, systems due to people mental and not being aware on their Misinformation about emotional stress involvement in the pregnancy and sexuality - Overall care pregnancy (i.e. breastfeeding and plan/setup sex) As well as the responsibilities and adjustments along with it. Establishing a sense of identity and working relationship with parents Coping/Steps Assure that both Provide correct Nest-building Taken to reach parties feel and meaningful activities. Involves goal welcome on clinical determining the every prenatal information baby’s visit Debunk false ○ Name Provide an outlet beliefs and ○ Room to discuss stereotypes ○ Arrangement concerns Provide Attending Offer parenting informational educational classes information materials if about childbirth needed Interprofessional approaches (family coaching, social services, etc.) Emotional support  from families and relatives Assessment of mother and child attachment during checkups Additional preparation work to complete in pregnancy: Reworking developmental task This is about working through the previous life experiences before pregnancy or the Erikson's Developmental tasks of autonomy, industry, and identity. Needs and wishes that have been held back for years and will resurface again. Fear of being separated from family and death and will be in pain and distress. To gain a sense of identity, a working relationship with parents needs to be established. She begins to empathize with the way her mother used to worry and she worries that her baby does not move for a few hours. Same thing to do with the partner, a man needs to rethink his relationship with his father. Some men are more emotionally distant and wish to be more available to their children Roleplaying and fantasizing This is about thinking or fantasizing on what it will be like to be a parent. Women may spend time with other pregnant women or mother of young children to learn how to be a mother So if the young girl’s role models are girls who are not interested in commitment to mothering or if her mother showed poor coping , then the girl will assume the same role. Same as with the partner, he or she needs to imagine themselves on becoming a parent especially for the first time and change a view of being a carefree person to being a significant part of a family unit. Other support persons such as grandparents, close friends,ex spouse, also have to work out their roles Emotional responses that can cause concern in pregnancy: Grief Especially to first time mothers, they will think and feel that they need to give up their lifestyle before and will never be as irresponsible and carefree again. This takes mental preparation as she has a new role of being a mother. Narcissism This self-centeredness is when she begins to concentrate on aspects of life. She may start to dress up whether to show or not show her pregnancy, try fixing her own meals, or lose interest in the usual things she has done before sin