NEU_Module_4_Care_of_a_Pregnant_Mother_Fetal_Development_2024.pdf

New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm...

New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development Introduction This module examines the key events that take place during conception and fetal development. The birth of the newborn begins with conception (union of single egg and sperm) and continues throughout the period of fetal growth and maturation. During this time, many complex events take place: fertilization, implantation to the hormonally prepared uterus, development of the placenta, umbilical cord, amniotic fluid and amniotic membrane. While the fetus is growing, the mother’s body changes and adapts to the demands of the growing fetus. The role of the nurse is paramount in achieving mother’s optimal functioning to support the needs of the fetus. Learning Outcomes After completing the module, you should be able to: 1. Integrate concepts of growth and development of fetus by gestational age in weeks and application of appropriate nursing care to the mother during childbearing years. 2. Assess fetal growth and development through maternal and pregnancy landmarks. 3. Formulate nursing diagnoses related to the needs of a fetus. 4. Implement nursing care to help ensure a safe fetal environment 5. Provide individual/group health education activities to promote fetal development. 6. Evaluate expected outcomes for the achievement and effectiveness of care. Topic Outline I. The Process of Conception II. Embryonic and Fetal structures III. Fetal development IV. Assessment of fetal growth and development V. Nursing diagnosis: fetal growth and development VI. Nursing outcomes: fetal growth and development VII. Implementing nursing care VIII. Evaluating nursing care I. The Process of Conception A. Fertilization As one egg cell (ovum) is expelled from the graafian follicle of an ovary with ovulation, it is surrounded by a ring of mucopolysaccharide fluid (zone pellucida) and a circle of cells (corona radiata). The ovum is capable of fertilization for only 24-48 hours; afterwards, it atrophies and becomes non-functional. The sperm, cells usually around 400 million per ejaculation or 50 to 200 million per ml, enters the vagina into the cervix of the woman. Sperm transport is so efficient close to ovulation the spermatozoa deposited in the vagina generally reach the cervix within 90 seconds and outer end of the fallopian tube within 5 minutes after deposition. Because the functional life of a spermatozoon is about 48-72 hours, the total critical time span during which sexual relations 1  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development must occur for fertilization to be successful is about 72 hours (48 hours before ovulation plus 24 hours afterward). The zygote is the cell formed by the union of the sperm and the ovum (Figure 1.1), and it is transported through the fallopian tube and into the uterus. Fertilization normally occurs in the outer third of the fallopian tube. The sex of the human being is determined at fertilization. The ovum always contributes an X chromosome, where the sperm can carry an X or Y chromosome. When a sperm carrying the X chromosome fertilizes the X-bearing ovum, a female offspring (XX) result. When a Y-bearing sperm fertilizes the ovum, a male offspring (XY) is produced. The zygote undergoes rapid mitotic division or cleavage during transport through the fallopian tube. The individual cells become smaller as they divide and eventually form a solid ball called morula. The morula enters the uterus on the third day and floats there for another two to four days. The cells now called blastocyst form a cavity, and two distinct layers evolve. An inner layer called embryoblast develops into the embryo and the embryonic membranes and trophoblast which is the outer layer of the cells, develops into an embryonic membrane, the chorion. B. Implantation The zygote usually implants (Figure 1.1) in the upper section of the posterior wall about 8 to 10 days after fertilization. The cells (blastocyst) burrow into the prepared lining of the uterus, called endometrium. The endometrium is now called the decidua (Figure 1.2): the area under the blastocyst is called the decidua basalis, the area which covers the embryo is the decidua capsularis, and the remaining portion is called decidua vera. Occasionally, a small amount of vaginal spotting appears on the day of implantation because capillaries are ruptured by the implanting trophoblast cells. A woman who normally has a particularly scant menstrual flow could mistake implantation bleeding to her menstrual period. If this happens, the predicted date of birth of her baby will be calculated 4 weeks late. This is the importance of asking not only the last menstrual period but also the previous menstrual period and the number of days of bleeding. Figure 1.1 Ovulation, fertilization, and implantation. The blastocyst is differentiated into three germ layers (ectoderm, mesoderm, and endoderm). Cells at the periphery are trophoblast cells that mature into the placenta. 2  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development Figure 1.2 three areas of the Decidua II. Embryonic and Fetal structures 1. Primary germ layers Each germ layer develops into different tissues and organs of the embryo (Figure 1.1) Germ layer Body portions formed Ectoderm (outer layer) Central nervous system (brain and spinal cord); Epidermis (outermost layer of the skin); Sense organs. Mammary glands. Mucous membranes of the anus, mouth, nose. Mesoderm (middle layer) Supporting structures of the body (connective tissue, bones, cartilage, ligaments, and tendons); Kidneys and ureters. Reproductive system. Circulatory system and blood cells. Endoderm (inner layer) Lining of the pericardial, pleura and peritoneal cavities Lining of the gastrointestinal tract, respiratory tract, tonsil, thyroid, parathyroid, and thymus glands Lower urinary system (bladder and urethra) 2. Amniotic Membranes The amniotic membrane is a dual-walled sac: amnion and chorion (Figure 1.3). Membrane Characteristic CHORION Develops from trophoblast Envelops amnion, embryo, and yolk sac Thick membrane has projections called villi Villi extend into the deciduas basalis on uterine wall 3  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development AMNION Develops form interior of blastocyst Thin structure that envelops and protects the embryo Together with chorion form the amniotic sac filled with fluid The two fuses together as the pregnancy progresses, and by term they appear as single sac. They have no nerve supply, so when they spontaneously rupture at term, neither the pregnant woman nor the fetus experiences any pain. 3. Amniotic Fluid Amniotic fluid is clear, has a mild odor, and may contain bits of vernix or lanugo. Amniotic fluid never becomes stagnant because it is constantly being newly formed and absorbed by direct contact with the fetus. Because the fetus continually swallows the fluid, it is absorbed from the fetal intestines into the fetal bloodstream. From there, it goes to the umbilical arteries and to the placenta and is exchanged across the placenta to the mother’s blood stream. At term, the amount of amniotic fluid ranges from 800 to 1,200 ml; with a pH of about 7.2. Abnormal amount of amniotic fluid occurs oligohydramnios and hydramnios: Oligohydramnios Reduction in the amount of amniotic fluid (less than 300 ml) Disturbance of fetal kidney function Polyhydramnios or Excessive amniotic fluid (more than 2,000 ml) Hydramnios Fetus unable to swallow (esophageal atresia/anencephaly) Woman in diabetes Functions of amniotic fluid Maintains constant body temperature Source of oral fluid Assist in fluid and electrolyte homeostasis Permits buoyancy and movement for musculoskeletal development Barrier to infection Acts as a cushion to protect the fetus and umbilical cord from injury 4  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development Figure 1.3 Membranes with embryo lying within amniotic sac 4. Umbilical cord The umbilical cord is formed from the fetal membranes, the amnion and chorion, and provides a circulatory pathway that connects the embryo to the chorionic villi of the placenta. Its function is to transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta. It is about 53 cm (21 in.) in length at term and about 2 cm (0.75 in) thick. The bulk of the cord is a gelatinous mucopolysaccharide called Wharton jelly, which gives the cord body and prevents pressure on the vein and arteries that pass through it. The umbilical cord contains only one vein (carrying blood from the placental villi to the fetus) and two arteries (carrying blood from the fetus back to the placental villi). The umbilical cord contains no nerve supply, it can be clamped and cut at birth without discomfort to either the child or mother. 5. Placenta The placenta, originates from the chorionic villi (fingerlike projections growing into uterine endometrium), is complete at 12 weeks of gestation and grows diameter until 20 weeks, covering about half the upper uterine surface. It is divided into 15 to 20 cotyledons which are the functional unit of the placenta. Functions Provides circulation between mother and fetus Serves as site for interchange of food, gases, and wastes between mother and embryo/fetus. Protective barrier against some harmful effects of some drugs and microorganisms but nutrients, some drugs, alcohol, antibodies, and viruses can pass through the placenta. Produces hormones Hormones Functions Progesterone “Hormone that maintains pregnancy” Maintains uterine lining for implantation Reduces uterine contraction to prevent spontaneous abortion Prepares glands of the breasts for lactation 5  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development Stimulates testes to produce testosterone which aids the male fetus in developing the reproductive tract Estrogen “Hormone of women” Stimulates uterine growth and development of the breast ducts to prepare for lactation Human chorionic Makes pregnancy tests positive gonadotropin (hCG) Maintains corpus luteum function Human chorionc Prepares breasts for lactation (lactogenic hormone) somatomammotropin Regulates glucose metabolism (hCS) (formerly known Helps make more glucose available to fetus to meet growth needs as human placental lactogen (hPL) III. Fetal Development Fetal development milestones based on gestation weeks: Age of gestation Fetal development 4weeks Spinal cord is formed Arms and legs are bud-like structures; rudimentary eyes, ears, and nose are discernible Wt: 400 mg; length 0.75 cm 8 weeks Organogenesis complete Every organ system is present Heart beats rhythmically A sonogram shows gestational sac Wt: 20 g; legth 2.5 cm 12 weeks Bone ossification centers begin to form Tooth buds are present Kidneys begin to form urine Fetal heart rate is audible by Doppler (FHR 110-160 beats/min) Wt:45 g; length 7 to 8 cm 16 weeks Sex can be determined by ultrasonography Amniotic fluid is 200 ml (amniocentesis is 14-16 weeks) 6  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development Lanugo is well-formed Liver and pancreas functioning Sex determined by ultrasonography FHR is audible by an ordinary stethoscope Wt: 55 to 120 g; length 10-17 cm 20 weeks Spontaneous movement felt by the mother (quickening) Hair growth on eyelashes, and brow Passive antibody transfer from the mother Definite sleeping and activity patterns are distinguishable Wt: 223 g; length 25 cm 24weeks Meconium is present Lung surfactant present Hearing present Age of viability Wt: 550 g; length: 28 to 36 cm 28weeks Lung alveoli are almost mature If born, newborn can breathe at this time Wt: 1,200 g; length 35 to 38 cm 32 weeks Subcutaneous fat begins to be deposited Iron stores beginning to be built Wt: 1,600 g; 38 to 43 cm 36 weeks Additional amounts of subcutaneous fat are deposited Lanugo disappears Vernix increases Testes palpable in scrotum Wt: 1,800 to 2,700 g; length 42 to 48 cm 40 weeks Fetus kicks actively Fetal hemoglobin to adult hemoglobin Sole creases cover the feet at least 2/3 Lightening occurs Wt: 3,000 g; length 48 to 52 cm 7  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development Fetal circulation After the fourth week of gestation, circulation of blood through the placenta to the fetus is well established. Because the fetus does not breathe and the liver does not have to process most waste products, several physiologic diversions in the prebirth circulatory route are needed. There are three fetal circulatory shunts (Figure 1.4): 1. Ductus Venosus: connects the umbilical vein and the inferior vena cava, by passing the liver 2. Foramen Ovale: is the opening between the right and left atria of the heart, by passing the lungs 3. Ductus arteriosus: connects the pulmonary artery into the aorta, by passing the lungs Oxygenated blood enters the fetal body through the umbilical vein. About half of the blood goes to the liver through the portal sinus, with the remainder entering the inferior vena cava through the ductus venosus. Blood in the inferior vena cava enters the right atrium, where most passes directly into the left atrium through the foramen ovale. A small amount of blood is pumped to the lungs by the right ventricle. The rest of the blood from the right ventricle joins the blood from the left ventricle through the ductus arteriosus. After circulating through the fetal body, blood containing waste products is returned to the placenta through umbilical arteries. Figure 1.4 Fetal Circulation IV. Assessment of Fetal Growth and Development Reasons for testing Predict outcome of pregnancy Manage remaining weeks of pregnancy Plan for possible complications at birth Plan for problems that may occur in newborn Decide whether to continue pregnancy Find conditions that may affect future pregnancies 1. Fetal Growth a. As the fetus grows, the uterus expands to accommodate its size. Typical fundal measure: Over symphysis pubis at 12 weeks 8  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development At umbilicus at 20 weeks At the xiphoid process at 36 weeks b. McDonald’s Rule is a tape measurement from the notch of the symphysis pubis to over the top of the uterine fundus (Figure 1.5) as a woman lies supine is equal to the week of gestation in centimeters between 20th to 31st weeks of pregnancy. 20 weeks = 20 cm 24 weeks = 24 cm 30 weeks = 30 cm A fundal height much greater than this standard suggest: a. Multiple pregnancy b. Miscalculated due date c. Large for gestational age infant d. Hydramnios e. Gestational trophoblastic disease A fundal height much less than this suggest: a. Intrauterine growth restriction b. Miscalculated due date c. Anomaly interfering with fetal growth Fundal measurement becomes inaccurate during third trimester of pregnancy because the fetus is growing more in weight than in height during this time. Figure 1. 5 Measuring fundal height form the superior aspect of the pubis to the fundal crest. The tape is pressed flat against the abdomen for the measurement. 2. Fetal well being a. Fetal heart rate This is done as early as the 10th to 11th week of pregnancy at every prenatal visit (Figure 1.6). The normal FHR is 110-160. Fetal bradycardia and tachycardia indicate further investigation. 9  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development Figure 1.6 Measuring fetal hear rate with a Doppler transducer, which detects and broadcasts the fetal heart. b. Kick counts Fetal movement that can be felt by the mother (quickening) is usually 10 times per hour at 28-38 weeks gestation. The typical method used is to ask women with high-risk pregnancies to: Lie in a left recumbent position after meals Observe and record the number of movements (kicks) until they have counted 10 Record the time If an hour passes without 10 kicks, walk around a little and try to count again If 10 kicks cannot be felt, they should telephone the health care provider for further assessment. c. Rhythm Strip Testing Rhythm strip testing refers to an assessment of fetal well-being and assesses the fetal heart rate for a normal baseline rate. The baseline reading refers to the average rate of the fetal heartbeat. Variability denotes the small changes in rate that occur from second to second if the fetal parasympathetic nervous system is receiving adequate oxygen. The steps are: Help woman into a semi-Fowler’s position Attach an external fetal monitor Record fetal heart rate for 20 minutes Variability is rated as: Absent: No peak-to-through range is detectable Minimal: An amplitude range is detectable, but rate is 5 beats/minute or fewer Moderate or normal: an amplitude range is detectable; rate is 6 to 25 beats/min Marked: an amplitude range is detectable; rate greater than 25 beats/min d. Nonstress testing A nonstress test measures the response of the fetal heart rate to fetal movement. During fetal movement, the fetal heart rate normally accelerates (increases from base line). This test is usually performed at 30 weeks gestation. The steps are: Position the woman and attach both a fetal heart rate and a uterine contraction monitor. Instruct the woman to push the button attached to the monitor whenever she feels the fetus moves Usually is done for 20 minutes 10  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development Findings: Results Description Interpretation Reactive If two accelerations of fetal heart rate (by Fetus is healthy 15 beats or more) lasting for 15 seconds Nonreactive If no accelerations occur with the fetal Fetal health may be affected. movements. If no fetal movement occurs or If there is low short-term fetal heart rate variability e. Biophysical Profile A biophysical profile combines five parameters into one assessment. It is more accurate in predicting fetal well-being than any single assessment. Because the scoring system is similar to an Apgar score determined at birth on infants, it is often referred to as fetal Apgar score. Biophysical profile is a combination of sonogram and nonstress testing and includes the following: Fetal breathing Fetal movement Fetal tone Amniotic fluid volume Fetal heart reactivity Biophysical profiles may be done as often as daily during a high-risk pregnancy. Each parameter is given a highest score of 10. The fetal scores are as follows: 8-10 means fetus is doing well 6 is considered suspicious 4 and below denotes a fetus is potentially in jeopardy V. Nursing Diagnoses: Fetal Growth and Development Common nursing diagnoses related to growth and development of the fetus focus on the mother and family as well as on the fetus. Examples might include: Health-seeking behaviors related to knowledge of normal fetal development Anxiety related to lack of fetal movement Deficient knowledge related to need for good prenatal care for healthy fetal well-being VI. Nursing Outcomes: Fetal Growth and Development Be certain that plans for care include ways to educate potential parents about teratogens (any substance that could be harmful to a fetus) that might interfere with fetal health. Be certain that outcome criteria established for teaching about fetal growth are realistic and based on the parents’ previous knowledge and desire for information. When additional assessment measures are necessary, such as an amniocentesis or 11  New Era University College of Nursing NCM 107-18 Care of Mother, Child and Adolescent (Well) S.Y. 2024-2025 | 1st Semester | Midterm Module 4: Care of a Pregnant Mother – Fetal Development an ultrasound examination, add this information to the teaching plan, explaining why further assessment is necessary and what the parents can expect from the procedure VII. Implementing Nursing Care Teaching about fetus at various points in pregnancy to help parents visual coming newborn Teaching about healthy behaviors Showing sonogram to help initiate bonding Individualize care VIII. Evaluating Nursing Care Outcome evaluation related to fetal growth and development usually focuses on determining whether a woman or family has made any necessary changes in lifestyle to ensure fetal growth and whether a woman voices confidence that her baby is healthy and growing. Examples of expected outcomes include: Parents describe smoke-free living at their next prenatal visit. Clients record the number of movements of fetus for 1 hour daily. Couple attends all scheduled prenatal visits. Client states she is looking forward to the birth of her baby. Watch the following videos: 1. Fertilizationhttps://www.youtube.com/watch?v=_5OvgQW6FG4 2. Fetal development https://www.youtube.com/watch?v=-TXkZ_sjyUk 3. Fetal circulation https://www.youtube.com/watch?v=wYNY7VpZIPY References: Silbert-Flagg, J. (2022). Maternal and child health nursing: Care of the childbearing and childbearing family (9thed.). Philadelphia, PA: WoltersKluwer. Murray, S.S., & McKinney, E.S. (2019). Foundations of maternal-newborn and women’s health nursing (7thed.). St. Louis, MO: Elsevier. 12