Normal OB Nursing: Male & Female Reproductive Systems PDF

NORMAL OB NURSING PART 1 MALE REPRODUCTIVE SYSTEM SCROTUM - is a rugated, skin-covered, muscular pouch suspended from the perineum. - FUNCTIONS: Its functions are to support the testes and to help regulate the temperature of sper...

NORMAL OB NURSING PART 1 MALE REPRODUCTIVE SYSTEM SCROTUM - is a rugated, skin-covered, muscular pouch suspended from the perineum. - FUNCTIONS: Its functions are to support the testes and to help regulate the temperature of sperm. - Testes in a fetus first form in the pelvic cavity. - Cold: directs testes closer to the body They descend, late in intrauterine life (about the - Hot: directs testes away from the body 34 to 38 week), into the scrotal sac. - 1 testes is lower than the other - Because this descent occurs so late in pregnancy, many male preterm infants are born with undescended testes, termed medically as cryptorchidism. - Orchidopexy: surgical repair of undescended testes TESTES / TESTIS - are two ovoid glands, 2 to 3 cm wide, that lie in the scrotum. - encased by a protective white fibrous capsule and is composed of several lobules: PENIS 1. Seminiferous tubules produce spermatozoa. - composed of three cylindrical masses of erectile 2. Leydig cells / Interstitial cells are responsible tissue in the penis shaft. for the production of testosterone - The urethra passes through these layers of Hypothalamus erectile tissue, making this organ serve as the ↓ outlet for both the urinary and the GNRH (Gonadotropin-Releasing Hormone) reproductive tracts in men. ↓ Nitric Oxide - a substance released from Stimulate Anterior Pituitary Gland the endothelium of blood vessels during ↓ sexual excitement Penile Artery - a branch of the pudendal artery that provides the blood supply FSH (Follicle LH for the penis. Stimulating (Luteinizing Hormone) Hormone) EPIDIDYMIS ↓ ↓ - About 20 ft long Stimulates Testosterone - Responsible for conducting sperm from the Seminiferous testis to the vas deferens Tubules - Some sperm are stored here (androgen - Its cells partly produce an alkaline fluid that binding surrounds sperm (seminal fluid containing basic proteins) sugar and mucin, a form of protein) ↓ Spermatozoa (Sperm Jam production)  BULBOURETHRAL GLAND (COWPER’S GLAND) - Lie beside the prostate gland and empty via short ducts into the urethra. - Like the prostate gland and seminal vesicles, they secrete an alkaline that helps counteract – Sperms are immobile as they pass or are stored the acid secretion of the urethra and ensure the at this level safe passage of spermatozoa. – It takes at least 12 to 20 days for them to travel the length of the epididymis and a total of 60 days for them to reach maturity. VAS DEFERENS / DUCTUS DEFERENS - It carries sperm from the epididymis through the inguinal canal into the abdominal cavity, where it ends at the seminal vesicles and the ejaculatory ducts. Semen: - Sperm mature as they pass through here – Derived from: - Male vasectomy → sterilization The prostate gland The seminal vesicles SEMINAL VESICLES The epididymis - are two convoluted pouches that lie along the The bulbourethral glands lower portion of the posterior surface of the bladder and empty into the urethra by way of the URETHRA ejaculatory ducts. - is a hollow tube leading from the base of the - These glands secrete a viscous alkaline liquid bladder, which, after passing through the that has a high sugar, protein, and prostaglandin prostate gland, continues to the outside through content. the shaft and glans of the penis. - It is approximately 8 inches (18 to 20 cm) long. PRSOTATE GLAND [6-8 inches] - chestnut-sized gland that lies just below the - Passageway of urine and semen bladder. - 0.5 – 2 inches = UTI (female) - The urethra passes through the center of it, like the hole in a doughnut. - Secretes a thin, alkaline fluid. - Enlarges / inflamed, Benign Prostatic Hypertrophy → dribbling of urine FEMALE REPRODUCTIVE SYSTEM MONS PUBIS / MONS VENERIS - a pad of adipose tissue located over the symphysis pubis, the pubic bone joint. - It is covered by a triangle of coarse, curly hairs. Jam - The purpose of the mons veneris is to protect SKENE’S GLAND / PARAURETHRAL GLAND the junction of the pubic bone from trauma. - are located just lateral to the urinary meatus, one on each side. - Their ducts open into the urethra. BARTHOLIN’S GLAND / VULVOVAGINAL GLAND - are located just lateral to the vaginal opening on both sides. - Their ducts open into the distal vagina. + Secretions from both of these glands help to LABIA MINORA lubricate the external genitalia during coitus. - Just posterior to the mons veneris spread two + The Alkaline pH of their secretions helps to hairless folds of connective tissue improve sperm survival in the vagina. Slightly acidic pH: 7.2 LABIA MAJORA - are two folds of adipose tissue covered by loose connective tissue and epithelium that are positioned lateral to the labia minora. - Covered by pubic hair, the labia majora serve as protection for the external genitalia and the distal urethra and vagina. - These are homologues or counterparts of the FOURCHETTE scrotum. - Is the ridge of tissue formed by the posterior joining of the two labia minora and the labia majora. - This is the structure that is sometimes cut during childbirth to enlarge the vaginal opening. PERINEUM - Posterior to the fourchette - Because this is a muscular area, it is easily stretched during childbirth (bulging of the perineum) to allow for enlargement of the vagina CLITORIS and passage of the fetal head. - Is a small, rounded organ of erectile tissue at the forward junction of the labia minora. LEVATOR ANI - It is covered by a fold of skin, the prepuce. - It is the muscle most frequently torn or - Sensitive to touch and temperature and is the lacerated during childbirth, when during the center of orgasm and sexual arousal in a second stage of labor. woman. - It is situated about 2 to 2.5cm above the external urethral orifice and serves as a useful landmark in locating the urethral opening for catheterization - It is homologous to the penis. Jam  OVARIES - are approximately 4 cm long by 2 cm in diameter and approximately 1.5 cm thick, or the size and shape of almonds. - They are grayish white and appear pitted, or with minute indentations on the surface. - Function: to produce, mature, and discharge ova (the egg cells). - In the process, the ovaries produce estrogen and progesterone and initiate and regulate menstrual PARTS: cycles. INTERSTITIUM - 1 cm - The most proximal division, that part of the tube that lies within the uterine wall. ISTHMUS - 2 cm - the next distal portion. - This is the portion of the tube that is cut or sealed in a tubal ligation, or tubal sterilization Hypothalamus procedure ↓ GNRH (Gonadotropin-Releasing Hormone) AMPULLA ↓ - 5 cm Stimulate Anterior Pituitary Gland - The third and also the longest portion of the ↓ tube. - It is in this portion that fertilization of an ovum usually occurs. FSH (Follicle LH (Luteinizing Stimulating Hormone) INFUNDIBULUM Hormone) ↓ - is the most distal segment of the tube. ↓ Ovulation - The rim of the funnel is covered by fimbria (small Maturation of ↓ hairs) that help to guide the ovum into the ovum Release of fallopian tube. mature ovum UTERUS FALLOPIAN TUBES - a hollow, muscular, pear-shaped organ located - Muscular tubes (oviducts) lying near the ovaries in the lower pelvis, posterior to the bladder and and connected to the uterus anterior to the rectum. - approximately 10 cm long in a mature woman. - In a nonpregnant state, it weighs approximately - Tubes that propel the ova from the ovaries to 60 g. the uterus - FUNCTIONS: to receive the ovum from the - Provide a place for fertilization of the ovum by fallopian tube; provide a place for implantation sperm. and nourishment; furnish protection to a growing - Specific site of fertilization: Ampulla → outer fetus; and, at maturity of the fetus, expel it from third of the fallopian tube a woman’s body. - After a pregnancy, the uterus never returns to its nonpregnant size but remains approximately 9 Jam  cm long, 6 cm wide, 3 cm thick, and 80 g in RETROFLEXION weight. - a condition in which the body is bent sharply - Palpate uterus post op back just above the cervix - non-contracting = bleeding - massage fundus, roll nipples → relieve bladder distention THREE DIVISIONS OF THE UTERUS 1. BODY OF THE UTERUS - the uppermost part and forms the bulk of the organ. - During pregnancy, the body of the uterus is the portion of the structure that expands to contain the growing fetus. - The portion of the uterus between the points of attachment of the fallopian tubes is termed the fundus; the portion that can be palpated abdominally to determine the amount of 3. CERVIX uterine growth occurring during pregnancy. - Is the lowest portion of the uterus. - Approximately half of it lies above the vagina and 2. ISTHMUS half extends into the vagina. - is a short segment between the body and the - The internal cervical os of the cervix opens into cervix. the body of the uterine cavity. - During pregnancy, this portion also enlarges - The external cervical os opens into the vagina. greatly to aid in accommodating the growing - The level of the external os is at the level of the fetus. Ischial spine - an important relationship in - It is the portion of the uterus that is most estimating the level of the fetus in the birth commonly cut when a fetus is born by a canal. cesarean birth. NORMAL POSITION OF UTERUS - body of the uterus is tipped slightly forward. - Slight anteflexion / slightly anteflexed POSITIONAL DEVIATIONS OF THE UTERUS ANTEVERSION - a condition in which the entire uterus is tipped far forward FERNING / ARBORIZATION / FERN TEST RETROVERSION - Due to high levels of estrogen are present in the - a condition in which the entire uterus is tipped body, as they are just before ovulation, the backward cervical mucus forms fernlike patterns - caused by the crystallization of NaCl on mucus ANTEFLEXION fibers when it is placed on a glass slide and - a condition in which the body of the uterus is allowed to dry. bent sharply forward at the junction with the - Cervical mucus can be examined at midcycle. cervix - Done approx. 10 mins - Can be seen at 7-18 days / 14th day (peak) Jam  VAGINA - is a hollow, musculo-membranous canal located posterior to the bladder and anterior to the rectum. - Glycoprotein / Glycogen: The content of the mucus produced by the vaginal lining. Can be broken down by the lactose- fermenting bacteria that frequent the vagina known as Doderlein’s bacilli which leads to lactic acid formation. Instruct women not to use vaginal douches or sprays (alter normal pH) as a daily SPINNBARKEIT hygiene measure because they may clean - Due to high estrogen away this natural acid medium of the vagina, - Cervical mucus becomes thin, watery and can inviting vaginal infections. be stretched into long strands; at the height of estrogen secretion FEMALE PELVIS AND MEASUREMENTS - A woman can do this herself by stretching a A. TRUE PELVIS mucus sample between thumb and finger - Lies below the pelvic brim - 2 – 4 inches (fertile) - The inferior half; that portion of the pelvis below the pelvic brim through which the fetus must pass during childbirth; Is a curved bony canal B. FALSE PELVIS - The shallow portion above the pelvic brim - The superior half; supports the uterus during the late months of pregnancy and aids in directing the fetus onto the true pelvis for birth UTERINE WALL LAYERS 1. Endometrium (Inner Layer) 2. Myometrium (Middle Layer) 3. Perimetrium (Outer Layer) Jam  TYPES OF PELVIS 1. GYNECOID - Normal female pelvis - Transversely rounded or blunt 2. ANTHROPOID - Oval shape - Adequate outlet, with a narrow pubic arch 3. ANDROID - Heart-shaped or angulated - Resembles a male pelvis - Not favorable for labor and vaginal birth - Narrow pelvic planes can cause slow descent and mid-pelvic arrest. 4. Platypelloid - Flat with an oval inlet - Wide transverse diameter, but short antero- posterior diameter, making labor and vaginal birth difficult. Transverse Diameter: The largest of the pelvic inlet PELVIC INLET DIAMETERS diameters; located at right angles to the true 1. ANTEROPOSTERIOR DIAMETERS conjugate a. Diagonal Conjugate: Distance from the lower Anteroposterior Diameter: extends from the tip of margin of the symphysis pubis to the sacral the coccyx to the lower part of the pubic symphysis; promontory; 10.5 CM distance between the pubic symphysis and the b. True Conjugate: Distance from the upper sacral promontory. margin of the symphysis pubis to the sacral promontory; 11.5 CM c. Obstetric Conjugate: Extends from the sacral promontory to the top of the symphysis pubis. It is the smallest front-to-back distance through which the fetal head must pass in moving through the pelvic inlet.; 10.5 CM Jam  OVULATION AND MENSTRUAL CYCLE OVULATION Ovulation Cycle: 6 – 13th day (Follicular / Estrogenic / Proliferative Primordial cells Phase) ↓ ↑FSH / Graafian follicle (prepares endometrium for Grow and mature implantation) ↓ Produce a clear follicular fluid (rich in estrogen / Day 14 (Ovulation), on a 28 day cycle 14-26th day Luteal / Secretory / Progestational estradiol); FSH - ↑LH (release of mature ovum) ↓ - ↑LH / Corpus Luteum → secretes progesterone Diameter: 0.25 – 0.5 inches (mature) - ↑capillary blood vessel → vascular bed (thick, soft, ↓ tortuous, corkscrew → rich spongy velvet) propelled into the surface of the ovary (seen as clear white blister / Graafian Follicle); No Conception / Fertilization: happens 6 – 13 days Corpus luteum (8-10 days) → regress / atrophy (4- 5 days) On the 14th day: ↓ Graafian Follicle ruptures replaced w/ white tissue [corpus albicans: whitish ↓ dull in appearance]) Day 27-28 Ischemia Propelled into Left with empty hollow pit ↓ ↓ the fallopian Slowly filled w/ yellow fluid (lutein: rich ↓ progesterone tube (ampulla) in progesterone); ↑LH (causes ↓ maturation of ovum) Endometrium starts to slough off ↓ Yellow fluid cavity Day 1-5 (Menstrual Phase) ↓ Rupture capillary blood vessels If none, atrophy (regress Corpus luteum ↓ corpus luteum is ↓ Produces menses (30-80 mL) replaced w/ white tissue ← Remain until 6 wks, if there is [corpus albicans: whitish conception dull in appearance]) Jam Jam  PART 2 Hyaluronidase FERTILIZATION AND IMPLANTATION All spermatozoa produce enzyme as it penetrates FERTILIZATION - the fertilized ovum has 46 chromosomes + Spermatozoa / ovum: 23 chromosomes, 22 autosomes, 1 sex chromosome + If spermatozoa carries X chromosome and unite with X = XX Female + If spermatozoa carries X chromosome and unite with Y = XY Male - AKA: Impregnation, Fecundation, Conception IMPLANTATION - is the union of an ovum and a spermatozoon. - Once fertilization is complete, a zygote migrates - This usually occurs in the outer third of a over the next 3-4 days toward the body of the fallopian tube, ampulla uterus, aided by the currents initiated by the - an ovum is capable of fertilization for only 48 muscular contractions of the fallopian tubes. hours Upper portion of uterus, high in the uterus - the functional life of a spermatozoon is about - During this time, mitotic cell division, or 48-72 hours cleavage, begins. - the total critical time span during which sexual - The first cleavage occurs at about 24 hours. relations must occur for fertilization to be - cleavage divisions continue to occur at a rate of successful is about 72 hours about ONE every 22 hours. - Normally, an ejaculation of semen averages 2.5 - By the time the zygote reaches the body of the mL of fluid containing 50 - 200 million uterus, it consists of 16 to 50 cells. spermatozoa per milliliter, or an average of 400 - 500 million sperm per ejaculation - spermatozoa deposited in the vagina generally reach the cervix within 80 seconds and the outer end of a fallopian tube within 5 minutes after deposition. - Capacitation: final process that sperm must undergo to be ready for fertilization. - At this stage, because of its bumpy outward appearance, it is termed a morula (from the Latin word morus, meaning “mulberry”). - The morula continues to multiply as it floats free Zona Pellucida in the uterine cavity for 3-4 additional days. - Inner layer - Large cells tend to collect at the periphery of the - made up of polysaccharides protein ball, leaving a fluid space surrounding an inner - Ring of mucopolysaccharide proteins cell mass. At this stage, the structure becomes a blastocysts. (Attaches to the endometrium) Corona Radiata - The cells in the outer ring are trophoblast, ---are - outermost layer the part of the structure that will later form the - Protects ovum placenta and membranes. Jam  + Produces HCG as early as 4 wks; EMBRYONIC AND FETAL STRUCTURES + will become placenta and fetal membranes: - After fertilization, the corpus luteum in the ovary o Chorionic membrane: aka chorion, continues to function rather produce sac, house amniotic fluid - than atrophying, because of the influence of o Amniotic membrane: inner layer, aka human chorionic gonadotropin (HCG), a amnion, produces amniotic fluid hormone secreted by the trophoblast cells. + produce proteolytic enzyme to dissolve tissues of endometrium so that blastocyst DECIDUA could burrow itself. - the Latin word for “falling off” - The decidua has three separate areas EMBRYOBLAST 1. Decidua basalis: the part of the The inner cell mass of the blastocyst or the portion endometrium that lies directly under the of the structure that will form the embryo. embryo (or the portion where the trophoblast Implantation, or contact between the growing cells establish communication with maternal structure and the uterine endometrium, occurs blood vessels) approximately 8-10 days after fertilization. 2. Desidua capsularis: the portion of the endometrium that stretches or encapsulates 3 PROCESS the surface of the trophoblast - Apposition: The process when the growing 3. Desidua parietalis / Desidua vera: the structure brushes against the rich uterine remaining portion of the uterine lining endometrium - Adhesion: The process when the growing structure attaches to the surface of the endometrium - Invasion: Process when the growing structure settles down into its soft folds. As invasion continues, the structure establishes an effective communication network with the blood system of the endometrium CHORIONIC VILLI Occasionally, a small amount of vaginal - are microscopic, finger-like projections which spotting appears on the day of implantation resemble probing fingers that contain because capillaries are ruptured by the capillaries that reach out into the uterine implanting trophoblast cells. endometrium to begin formation of the placenta Once implanted, the zygote becomes an as early as the 11th or 12th day, embryo - At term, almost 200-300 such villi will have formed. Core - made up of loose connective tissues that contains fetal capillaries Intervillous space - spaces between chorionic villi 12th day of pregnancy: mature blood starts to collect at the intervillous space so that at 3rd to 4th week, O2, nutrients (amino acids, fatty acids, vitamins, minerals, water, glucose) will diffuse from the maternal blood into the chorionic villi and into embryo by way of the umbilical cord. Jam - Surrounded by a double layer of trophoblast early pregnancy in coordination with embryo cells growth. - Syncytiotrophoblast / Syncytial layer: The - At term, placenta weighs 400-600 g (1 lb), one- outer of the two covering layers. This layer of sixth the weight of the baby cells produces various placental hormones, such as hCG, somatomammotropin (human placental lactogen [hPL]), estrogen, and progesterone. - Cytotrophoblast / Langhan’s layer: The middle layer that is present as early as 16 days’ gestation and appears to function early in pregnancy to protect the growing embryo and fetus from certain infectious organisms. - This layer of cells disappears, however, between the 20th and 24th weeks. Prone to syphilis SCHULTZ PRESENTATION - Appearing shiny and glistening from the fetal membranes– “SHINY” - If the placenta separates first at its center and INTERVILLOUS SPACE lastly at its edges - is the space between chorionic villi, and contains - it tends to fold on itself like an umbrella and maternal blood, where maternal blood enters to presents at the vaginal opening with the fetal provide nutrients and gas exchange surface evident. - In a mature placenta, there are as many as 30 separate segments, or cotyledons. DUNCAN PRESENTATION - About 100 maternal uterine arteries supply the - “DIRTY” mature placenta. - If the placenta separates first at its edges, it - The rate of uteroplacental blood flow in slides along the uterine surface and presents at pregnancy increases from about 30 ml/min at 10 the vagina with the maternal surface evident. weeks to 500-600 ml/min at term. - It looks raw, red, and irregular, with the ridges Recommended position for oxygen supply to enter or cotyledons that separate blood collection umbilical vein: left side lying to prevent uterus spaces evident. compression Right side lying → compress inferior vena cava → HORMONES supine hypotension position / vena cava syndrome HUMAN CHORIONIC GONADOTROPIN (HCG) - The first placental hormone produced, PLACENTA - Can be found in maternal blood and urine as - (Latin for “flat cake”) arises out of the continuing early as the first missed menstrual period (shortly growth of trophoblast tissue. after implantation has occurred) through about - serves as the fetal lungs, kidneys, and the 100th day of pregnancy. digestive tract in utero, begins growth in Jam - The woman’s blood serum will be completely AMNIOTIC MEMBRANES negative within 1 to 2 weeks after birth. CHORIONIC MEMBRANE / CHORION - Present on 4th day - the outermost fetal membrane. - Prevents maternal immunosuppression → the - Its purpose is to form the sac that contains the body will not reject placenta amniotic fluid. - Methotrexate, 1 yr di pwede magbuntis - At birth they can be seen covering the fetal surface of the placenta, giving that surface its ESTROGEN typically shiny appearance. - (primarily estriol) is produced as a second product of the syncytial cells of the placenta. AMNIOTIC MEMBRANE / AMNION - contributes to the woman’s mammary gland - offers support to amniotic fluid and actually development in preparation for lactation and produces the fluid. stimulates uterine growth to accommodate the - it produces a phospholipid that initiates the developing fetus. formation of prostaglandins, which can cause uterine contractions and may be the trigger PROGESTERONE that initiates labor. - the “hormone of mothers” - necessary to maintain the endometrial lining of the uterus during pregnancy. - It is present in serum as early as the 4th week of pregnancy, as a result of the continuation of the corpus luteum. - this hormone also appears to reduce the contractility of the uterus during pregnancy, preventing premature labor. HUMAN PLACENTAL LACTOGEN (HPL) - a hormone with both growth-promoting and lactogenic (milk-producing) properties. AMNIOTIC FLUID - It is produced by the placenta beginning as early - At term, the amount of amniotic fluid is 800 mL as the 6th week of pregnancy, increasing to a to 1200 mL. peak level at term. - Amniotic fluid is slightly alkaline, with a pH of - It promotes mammary gland (breast) growth in about 7.2 preparation for lactation in the mother. - Checking the pH of the fluid at the time of rupture - It also serves the important role of regulating helps to differentiate it from urine, which is maternal glucose, protein, and fat levels so nitrazine paper test (pH 4.5 to 5.5). that adequate amounts of these nutrients are - Blue: alkaline; Yellow/Pink: acidic always available to the fetus HYDRAMNIOS / POLYHYDRAMNIOS AFTER CHILDBIRTH - excessive amniotic fluid - Prolactin: hormone released from the anterior - CAUSES: pituitary gland that stimulates milk production o Esophageal atresia: A condition when the - Oxytocin: hormone which stimulates milk esophagus ends in a blind-ended pouch ejection or “let down “reflex rather than connecting normally to the - Abortion: Rhogam stomach o Anencephaly: A serious birth defect in which a baby is born without parts of the brain and skull. Jam  o Diabetes / Gestational Diabetes: - Nursing intervention: none, normal hyperglycemia causes excessive fluid shifts occurrence into the amniotic space 3. Late deceleration EFFECTS OF HYDRAMNIOS - ↓ FHR after uterine contraction → - Malpresentation: float fetus, breech uteroplacental insufficiency presentation 1. Stop oxytocin if present - Cord prolapse: umbilical cords slips down and 2. Position the mother to the left side out of the vagina before fetal presentation part 3. Oxygenate mother 1. Do not attempt to reinsert it, cover with 4. Notify physician sterile gauze with NSS, do not let it dry, can lead to cord compression; AMNIOTIC FLUID - 5-10 mins to cord compression - NORMAL COLOR: clear colorless leads to irreversible brain damage - ODOR: musky odor - Exposure to cold temperature → - YELLOWISH: blood incompatibility arterial vasospasm → decreased - GREENISH: meconium staining, ARDS, uteroplacental blood flow of baby meconium aspiration fetal distress → fetal hypoxia - BROWNSH: fetal death - Avoid handling of the cord can lead - REDDISH: hemorrhage to vagal nerve stimulation → - GRAYISH: infection decreased fetal HR (Normal HR: 120-160 bpm) 2. Administer oxygen to the mother 3. Positioning: slight Trendelenburg / knee chest prevent cord compression 4. Manually elevate the fetal head away from the umbilical cord to prevent cord loop / nuchal cord - Precipitate delivery - Lacerations/postpartal hemorrhages OLIGOHYDRAMNIOS - a reduction in the amount of amniotic fluid - CAUSE: o Kidney agenesis: absence of kidney in a fetus may also affect urine production. - EFFECTS: o Cord compression o Lack of fetal descent 1. Variable Deceleration - several decrease of FHR prior - Cord compression - Reposition: Left sided 2. Early deceleration - ↓ FHR before uterine contraction - Head compression Jam  PART 3 Origin and Development of Organ Systems MILESTONES OF FETAL GROWTH AND DEVELOPMENT ASSESSMENT OF FETAL WELL- BEING Terms Used to Denote Fetal Growth - Ovum: From ovulation to fertilization - Zygote: From fertilization to implantation - Embryo: From implantation to 5–8 weeks - Fetus: From 5–8 weeks until term - Conceptus: Developing embryo or fetus and PRIMARY GERM LAYERS placental structures throughout pregnancy ECTODERM - Age of variability: The earliest age at which - Central nervous system (brain and spinal cord) fetuses could survive if they were born at that - Peripheral nervous system time, generally accepted as 20-22 weeks, or - Skin, hair, nails, and tooth enamel fetuses weighing more than 400g - Sense organs - Mucous membranes of the anus, mouth, and ORIGIN AND DEVELOPMENT OF ORGAN nose SYSTEMS - Mammary glands MESODERM - Supporting structures of the body (connective tissue, bones, cartilage, muscle, ligaments, and tendons) - Upper portion of the urinary system (kidneys and ureters) - Reproductive system Heart, lymph, and circulatory systems and blood cells ENDODERM / ENTODERM - Lining of pericardial, pleura, and peritoneal cavities - During the first 4 days of life, zygote cells are - Lining of the gastrointestinal tract, respiratory termed totipotent cells or cells that are so tract, tonsils, parathyroid, thyroid, and thymus undifferentiated that they have the potential to glands form a complete human being. - Lower urinary system (bladder and urethra) - In another 4 days, as the structure implants and becomes an embryo, cells begin to show CARDIOVASCULAR SYSTEM differentiation and are now slated to become - a single heart tube, which forms as early as the specific body cells such as nerve, brain, or skin 16th day of life and beats as early as the 24th cells and are termed as pluripotent cells day. - The septum that divides the heart into chambers develops during the sixth or seventh week; - Heart valves develop in the seventh week. - The heartbeat may be heard with a Doppler instrument as early as the 10-12th week of pregnancy. - An electrocardiogram (ECG) may be recorded on a fetus as early as the 11th week Jam  FETAL CIRCULATION - Bulk of fetal hemoglobin has matured to adult hemoglobin, at about 6 months of age RESPIRATORY SYSTEM - At the third week of intrauterine life, the respiratory and digestive tracts exist as a single tube. - By the end of the 4th week, a septum begins to divide the esophagus from the trachea. SURFACTANT - a phospholipid substance, is formed and excreted by the alveolar cells of the lungs - beginning at approximately the 24th week of pregnancy. Very important in lung maturity O2 rich blood from placenta - Surfactant has two components: Lecithin and ↓ Sphingomyelin Umbilical vein - Early in the formation of surfactant, ↓ sphingomyelin is the chief component. Ductus Venosus (bypassing the liver) ↓ - At approximately 35 weeks, there is a surge in the production of Lecithin, which then becomes Inferior Vena Cava ↓ the chief component by a ratio of 2:1 (2 Lecithin Right Atrium : 1 Sphingomyelin) ↓ NERVOUS SYSTEM ↓ ↓ - The nervous system and sense organs form Left Atrium Small amount of blood during the 3rd and 4th week of pregnancy. thru foramen would leave RA - A neural plate (a thickened portion of the ovale ↓ ectoderm) is apparent by the third week of Right Ventricle through ↓Mitral Valve Tricuspid Valve gestation. Left Ventricle ↓ - The top portion of the neural plate differentiates ↓ Pulmonary Artery into the neural tube, which will form the central Ascending ↓ nervous system (brain and spinal cord), and the Aorta Strong resistance of blood neural crest, which will develop into the ↓ flow into the lungs, shunted peripheral nervous system. Brain away from the lungs ↓ - Brain waves have been detected on an Ductus Arteriosus electroencephalogram (EEG) by the 8th week. ↓ - By 24 weeks, the ear is capable of responding Descending Aorta to sound, and the eyes exhibit a pupillary ↓ reaction, indicating sight is present. Umbilical Arteries ↓ ENDOCRINE SYSTEM Placenta - The fetal pancreas produces insulin needed by - a newborn’s hemoglobin level is about 17.1 g per the fetus (one of the few substances that does 100 ml not cross the placenta from the pregnant person - Normal adult level of 11 g per 100 mL to the fetus). - Newborn’s hematocrit is about 53% - Normal adult level of 45%. Jam - The thyroid and parathyroid glands play vital - Ossification of this cartilage into bone begins at roles in fetal metabolic function and calcium about the 12th week and continues all through balance. fetal life and into adulthood. o T3 (Triiodothyronine): basal metabolism - A fetus can be seen to move on ultrasonography o T4 (Thyroxine): body heat production as early as the 11th week o Thyrocalcitonin: inhibits calcium - *Quickening is felt during pregnancy at 16 to 20 absorption weeks gestation or earlier - The fetal adrenal glands supply a precursor necessary for estrogen synthesis by the REPRODUCTIVE SYSTEM placenta. - A child’s sex is determined at the moment of conception by a spermatozoon carrying an X or DIGESTIVE SYSTEM a Y chromosome and can be ascertained as - The digestive tract separates from the early as 8 weeks by chromosomal analysis or at respiratory tract at about the 4th week of 8 weeks intrauterine life and, after that, begins to grow - At about the sixth week after implantation, the rapidly. gonads (i.e., ovaries or testes) form. - Meconium, a collection of cellular wastes, bile, - The testes first form in the abdominal cavity and fats, mucoproteins, mucopolysaccharides, and do not descend into the scrotal sac until the 34- portions of the vernix caseosa (i.e., the 38th week of intrauterine life. lubricating substance that forms on the fetal - descended testes = cryptorchidism skin), accumulates in the intestines as early as the 16th week. It is sticky in consistency and URINARY SYSTEM appears black or dark green (obtaining its color - Rudimentary kidneys are present as early as the from bile pigment). end of the fourth week of intrauterine life - The gastrointestinal tract is sterile before birth. - Urine is formed by the 12th week and is excreted o Escherichea coli → synthesizes into the amniotic fluid by the 16th week of menaquinones (source of Vit. K) gestation. - Since the GI tract is sterile, Vit K, necessary for - At term, fetal urine is being excreted at a rate of blood clotting, is synthesized by the action of up to 500mL per day. bacteria in the intestines, are almost nonexistent in a fetus and are still low in a newborn INTEGUMENTARY SYSTEM - Sucking and swallowing reflexes are not mature - The skin of a fetus appears thin and almost until the fetus is approximately 32 weeks translucent until subcutaneous fat begins to be gestation, or weighs 1,500 g. deposited underneath it at about 36 weeks. - The gastrointestinal tract used to secrete - Skin is covered by Lanugo which are soft enzymes essential for carbohydrate and protein downy hairs that serve as insulation to preserve digestion is mature at 36 weeks. warmth in utero as well as vernix caseosa, a - Amylase an enzyme found in saliva and cream cheese–like substance, which is necessary for digestion of complex starches, important for lubrication and for keeping the skin does not mature until 3 months after birth. from macerating in utero. Protein: protease IMMUNE SYSTEM MUSCULOSKELETAL SYSTEM - IgG - maternal antibodies cross the placenta into - During the first 2 weeks of fetal life, cartilage the fetus as early as the 20th week and certainly prototypes provide position and support to the by the 24th week of intrauterine life to give a fetus. fetus temporary passive immunity against diseases for which the mother has antibodies. Jam - RH incompatibility → maternal sensitization → - Brown fat,a special fat that aids in temperature immune system of mother will consider the fetus regulation, as a foreign object resulting to abortion → Within - Passive antibody transfer from the pregnant 72 hrs. administer Rhogam person to fetus begins. MILESTONES OF FETAL GROWTH AND END OF 24TH GESTATIONAL WEEK DEVELOPMENT (SECOND TRIMESTER) END OF FOURTH GESTATIONAL WEEK - The length of the fetus is 28 to 36 cm; weight is - The length of the embryo is about 0.75 cm; 550 g. weight is about 400mg. - Meconium is present as far as the rectum - *Active production of lung surfactant begins. END OF EIGHTH GESTATIONAL WEEK - *Eyelids, previously fused since the 12th week, - The length of the fetus is about 2.5 cm (1 in.); now open; pupils react to light. weight is about 20g. - *Hearing can be demonstrated by response to - *Organogenesis is complete. Process of sudden sound. embryonic differentiation END OF 28TH GESTATIONAL WEEK END OF 12TH GESTATIONAL WEEK - The length of the fetus is 35 to 38 cm; weight is (FIRST TRIMESTER) 1,200 g. - The length of the fetus is 7 to 8 cm; weight is - Lung alveoli are almost mature; surfactant can about 45 g. be demonstrated in amniotic fluid. - *Some reflexes, such as the Babinski reflex, - Testes begin to descend into the scrotal sac from are present. Babinski reflex - tap the sole of the the lower abdominal cavity. feet, the toes will move upward - *Bone ossification centers begin to form. END OF 32ND GESTATIONAL WEEK - *The heartbeat is audible through Doppler - The length of the fetus is 38 to 43 cm; weight is 1,600 g. END OF 16TH GESTATIONAL WEEK - *Subcutaneous fat begins to be deposited. - The length of the fetus is 10 to 17 cm; weight is - Fetus responds by movement to sounds 55 to 120 g. outside the pregnant person’s body. - Fetal heart sounds are audible by an ordinary - *An active Moro reflex is present. Startle reflex stethoscope. - Iron stores are beginning to be built. - Lanugo is well formed. - Both the liver and pancreas are functioning. END OF 36TH GESTATIONAL WEEK - The fetus actively swallows amniotic fluid, - The length of the fetus is 42 to 48 cm; weight is demonstrating an intact but uncoordinated 1,800 to 2,700 g (5 to 6 lb). swallowing reflex. Normal amniotic fluid: 800- - Body stores of glycogen (source of energy), iron, 1200 carbohydrate, and calcium are deposited. - Urine is present in amniotic fluid. - Additional amounts of subcutaneous fat are - *Sex can be determined by ultrasonography. deposited. - *Amount of Lanugo begins to diminish. END OF 20TH GESTATIONAL WEEK - Most fetuses turn into a vertex (head down) - The length of the fetus is 25 cm; weight is 223 g. presentation during this month - Spontaneous fetal movements can be sensed by the mother. Quickening - Antibody production is possible. - Vernix caseosa begins to cover the skin. - Meconium is present in the upper intestine. Jam  END OF 40TH GESTATIONAL WEEK *Over the symphysis pubis: 12 weeks (THIRD TRIMESTER) *Over the umbilicus: 20 weeks - The length of the fetus is 48 to 52 cm (crown to *Over the xiphoid process: 36 weeks rump, 35 to 37 cm); weight is 3,000 g (7 to 7.5 lb). ASSESSMENT OF FETAL WELL-BEING - Fetal hemoglobin begins its conversion to adult DAILY FETAL MOVEMENT COUNT hemoglobin. (KICK COUNTS) - Creases on the soles of the feet cover at least - Quickening: Fetal movement that can be felt by two-thirds of the surface. the pregnant person occurs at approximately 18 - *Lightening --the fetus often sinks into the birth to 20 weeks of pregnancy and peaks in intensity canal during the last 2 weeks of pregnancy, a at 28 to 38 weeks. fetal announcement that the fetus is in a ready - A healthy fetus moves with a degree of position and birth is nearing. consistency at about 10-20 times per hour. (10- 20 fetal movement per hour) NAEGELE’S RULE - standard method used to predict the length of CARDIFF METHOD/COUNT TO TEN pregnancy - interval it takes for her to feel 10-20 fetal ESTIMATION OF BIRTH DATE movements FROM JANUARY TO MARCH - usually occurs within 60 mins (+ 9 MONTHS + 7 DAYS) 1. JANUARY 15, 2024 - Oct 22, 2024 DOPPLER TECHNIQUE 2. JANUARY 25, 2024 - Nov 1, 2024 - fetal heart sounds heard and counted as early as 3. FEBRUARY 10. 2024 - Nov 17, 2024 the 12th week 4. FEBRUARY 15, 2024 - Nov 22, 2024 5. FEBRUARY 27, 2024 - Dec 4, 2024 SANDOVSKI METHOD 6. MARCH 4, 2024 - Dec 11, 2024 1. Turn left recumbent position after a meal 7. MARCH 14, 2024 - Dec 21, 2024 2. Record fetal movements for 1 hour 8. March 20, 2024 - Dec 27, 2024 3. Expect twice fetal movements for every 10 9. March 25, 2024 - Jan 1, 2025 minutes 10. March 29, 2024 - Jan 5, 2025 FETAL HEART RATE ESTIMATION OF BIRTH DATE normal: 120-160 beats/min FROM APRIL TO DECEMBER (- 3 MONTHS + 7 DAYS + YEAR) TYPES OF DECELERATIONS 1. APRIL 15, 2024 - January 22, 2025 EARLY DECELERATION 2. MAY 19, 2024 - February 26, 2025 INDICATION: head compression; head passes 3. JUNE 10. 2024 - March 17, 2025 thru birth canal 4. JULY 25, 2024 - May 1, 2025 5. AUGUST 27, 2024 - June 3, 2025 VARIABLE DECELERATION 6. SEPTEMBER 4, 2024 - June 11, 2025 - Severe decrease in FHR over 10- minute period 7. OCTOBER 14, 2024 - July 21, 2025 - INDICATION: cord compression 8. NOVEMBER 22, 2024 - August 29, 2025 - NURSING INTERVENTIONS: 9. DECEMBER 3, 2024 - September 10, 2025 1. Position towards left side to prevent vena 10. DECEMBER 15, 2024 - September 22, 2025 cava syndrome 2. If positioned right side, place folded pillow to MC DONALD’S RULE keep vena cava compressed upon - symphysis- fundal height measurement - distance from uterine fundus to the symphysis Jam  LATE DECELERATION 2. If no fetal movement occurs or if there is low - INDICATION: uteroplacental insufficiency; short-term fetal heart rate variability (less than 6 fetus is in distress; cant tolerate contractions beats per minute) throughout the testing period - NURSING INTERVENTIONS: Fetal heart variability 1. Stop oxytocin, if present FHR fluctuations 2. Position towards left side Normal: 6-20 bpm / 6-25 bpm 3. Administer oxygen Less than 6: absent / minimal FHR variability 4. Notify physician - If a 20 period passes without any fetal NON STRESS TEST movement, it may only mean that the fetus is - measures the response of the fetal heart rate to sleeping, maternal smoking, maternal drug fetal movement. use, or hypoglycemia. - Position the patient and attach both a fetal heart - How to increase enough to cause fetal rate and a uterine contraction monitor. movement? - Instruct the patient to push the button attached 1. Give the patient an oral carbohydrate to the monitor (similar to a call bell) whenever snack, such as orange juice, it can cause they feel the fetus move. This will create a dark the blood glucose level to increase mark on the paper tracing at these times. 2. The fetus also may be stimulated by a loud - When the fetus moves, the fetal heart rate should sound to cause movement increase approximately 15 beats per minute and remain elevated for 15 seconds. UTRASOUND - It should decrease to its average rate again as - measures the response of sound waves against the fetus quiets. solid objects, is a much used tool for fetal health assessments. - It can be used to: 1. Diagnose pregnancy as early as 6 weeks gestation. 2. Confirm the presence, size, and location of the placenta and amniotic fluid. 3. Establish a fetus is growing and has no gross anomalies such as hydrocephalus; anencephaly; or spinal cord, heart, kidney, and bladder concerns. 4. Establish the sex if a penis is revealed. 5. Establish the presentation and position of the fetus. - A nonstress test usually is done for 10-20 6. Predict gestational age by measurement minutes. of the biparietal diameter of the head or crown-to-rump measurement. REACTIVE 7. Discover complications of pregnancy, - (healthy) if 2 accelerations of fetal heart rate (by such as the presence of an intrauterine 15 beats or more) lasting for 15 seconds occur device, hydramnios (excessive amniotic after movement within the time period. fluid) or oligohydramnios (lessened amniotic fluid), ectopic pregnancy, missed NONREACTIVE: miscarriage, abdominal pregnancy, 1. (Fetal health may be affected) If no placenta previa (a low implanted placenta), accelerations occur with the fetal movements. premature separation of the placenta, Jam  coexisting uterine tumors, or multiple MATERNAL SERUM: pregnancy. ALPHA-FETOPROTEIN 8. Genetic disorders such as Down - Substance produced by the fetal liver that is syndrome and fetal anomalies such as present in amniotic fluid and maternal serum neural tube disorders, diaphragmatic - Should be done 15-16th week of pregnancy hernia, or urethral stenosis also can be ↑ AFP: neural tube defects, spina bifida diagnosed. Normal: 10-150 ng/dL 9. Fetal death can be revealed by a lack of ↓ AFP: Down syndrome heartbeat and respiratory movement. 10. After birth, a sonogram may be used to CHORIONIC VILLI SAMPLING detect a retained placenta or poor uterine - Analyses chromosomes of chorionic villi that is involution in the birthing parent. done at 10-12 weeks of pregnancy. - Genetic screening test for genetic anomaly PREPARATION: particularly Down syndrome - The patient has a full bladder at the time of the procedure. - To ensure this, ask them to drink a full glass of water every 15 minutes beginning 90 - minutes before the procedure and to not void until after the procedure - To prevent vena cava syndrome / supine hypotensive syndrome, place a towel under her right buttock so that the uterus rolls away from the inferior vena cava. - A gel at room temperature/ slightly warmer AMNIOCENTESIS applied to her abdomen - aspiration of amniotic fluid from the pregnant uterus CONTRACTION STRESS TESTING - scheduled between 14-16th weeks of - FHR is analyzed in conjunction with pregnancy contractions - PREPARATION: asking woman to void, placed - Currently achieved by nipple stimulation; Gentle in supine, placing folded towel under right stimulation of the nipples releases oxytocin buttock, taking FHT and maternal BP, to prevent (PPG: oxytocin and vasopressin) accidental puncture to the bladder - With external uterine contraction monitors - *A local anesthetic will be given and FHR monitors in place - Needle used for aspiration: 3- or 4- inch, 20- 22 - The mother rolls a nipple between her finger and gauge, spinal needle is introduced thumb until uterine contractions begin which - 15 ml of amniotic fluid is withdrawn and after which the woman rests quietly for about 30 are recorded by a uterine monitor - 3 contractions with a duration of 40 seconds or minutes longer must be present in a 10-minute window before test is interpreted - NEGATIVE/NORMAL: If no FHR decelerations are present with contractions - POSITIVE/ABNORMAL: 50% or more contractions cause a late deceleration Jam  PART 4 - Striae Gravidarum: red streaks on abdomen. Physiologic Changes of Pregnancy Week 24; after birth → striae albicans / SYSTEMIC CHANGES IN PREGNANCY atrophicae PRESUMPTIVE SIGNS OF PREGNANCY - Breast Tenderness: Feelings of tenderness, PROBABLE SIGNS OF PREGNANCY fullness, tingling; enlargement and darkening of - (+) HCG Serum Test: A venipuncture of blood areola. Week 2 serum reveals the presence of this hormone. - Nausea and Vomiting. Week 2 Week 1 Due to ↑ HCG - Chadwick’s sign: change of vaginal color from Only for the first 3 months, if more = complication pink to violet. Week 6 Management: - Hegar’s sign: softening of the cervix. Week 6 o eat dry crackers in the morning / upon - Goodell’s sign: softening of the lower uterine arising segment. Week 6 o eat sour candy (from out) (alphabetical) - Amenorrhea: Absence of menstruation. Week 2 Vagina → Chadwick’s - Frequent urination: Sense of having to void Cervix → Goodell’s more often than usual. Week 3 Uterus → Hegar’s Due to compression of bladder Compensatory of kidneys since ↓ PCO2 so fetus - Sonographic evidence of Gestational sac by can have ↑PCO2 (Normal: 35-45) ultrasound: Characteristic ring is evident. ↓ PCO2 – pregnant – 32 only Week 8 ↑PCO2 – fetus - to prevent acidosis - Ballottement: when lower uterine is tapped, the Shifting of PCO2 from fetus to the mother fetus can be felt to rise against abdominal wall. ↓ Week 16 ↓pH, ↑PCO2 – acidotic - Braxton Hicks Contraction: periodic uterine ↓ tightening occurs. Week 20 Compensatory mechanism - Fetal line: felt by examiner. Week 20 ↓ - In the pregnant person, trace amounts of hCG Pregnant: blow off excess PCO2 appear in serum as early as 24 to 48 hours after ↓ implantation and reach a measurable level ↓pH, ↑PCO2, ↑HCO3 (about 50 mIU per mL) 7-9 days after Mild hyperventilation conception. ↓ - Levels peak at about 100 mIU per mL between ↑bicarbonate the 60th and 80th day of gestation. ↑urination - After that point, the concentration of HCG declines and stabilizes between 2,000 and - Fatigue: General feeling of tiredness. Week 12 50,000 mIU per mL until delivery. - Uterine Enlargement: Uterus can be palpated over symphysis pubis. Week 12 POSITIVE SIGNS OF PREGNANCY - Quickening: fetal movement felt by the woman. - Sonographic evidence of Fetal outline can be Week 16-20 seen and measured by sonogram. By UTZ; - Linea Nigra: line of dark pigment on the Week 8 abdomen. Week 24 - Fetal Heart Rate: audible; Doppler ultrasound - Melasma: dark pigment on face / mask of reveals heartbeat. Week 10-12 pregnancy. ↑ MSH (Melanocyte-stimulating - Fetal Movement: felt by examiner and can be hormone); Week 24 palpated through abdomen. week 20 - Fetal heartbeat can be heard through an ordinary stethoscope at 18-20th weeks of pregnancy. Jam - Echocardiography can demonstrate a heartbeat - Doppler ultrasonography has shown that, before as early as 5 weeks. Stronger at 10-12th week pregnancy, uterine blood flow is 15-20mL per - An ultrasound can reveal a beating fetal heart as minute. early as the 6-7th week of pregnancy. - By the end of pregnancy, it expands to as much - Doppler instrumentation that converts ultrasonic as 500-750 mL per minute, with 75% of that frequencies to audible frequencies is able to volume going to the placenta detect fetal heart sounds as early 10-12th week - During the 16-20th week of pregnancy, when the of gestation. fetus is still small in relation to the amount of - The fetal heart rate ranges between beats 120- amniotic fluid present, if the lower uterine 160 per minute. They are heard best when the segment is tapped sharply during a pelvic position of the fetus is determined by palpation exam, the fetus can be felt to bounce or rise and the stethoscope is placed over the area of in the amniotic fluid up against a hand placed the fetal back. (Leopold’s Maneuver) on the abdomen. This phenomenon, termed - Fetal movements may be felt by a pregnant Ballottement (from the French word ballotter, person as early as 16-20th weeks of pregnancy. meaning “to quake”) - An objective examiner can discern fetal - Uterine contractions begin early in pregnancy, at movements at about the 20th to 24th week of least by the 12th week, and are present pregnancy. throughout the rest of pregnancy. These - Visualization of the Fetus by ultrasound is the “practice” contractions, termed Braxton most common method for confirmation of Hicks Contraction, serve as warm-up pregnancy today. exercises for labor and also play a role in - If a person is pregnant, a characteristic ring, ensuring the placenta receives adequate blood indicating the gestational sac, will be revealed - Amenorrhea (i.e., an absence of a menstrual on an oscilloscope screen as early as the 4-6th flow) occurs with pregnancy because of the week of pregnancy. This method also gives suppression of Follicle Stimulating Hormone information about the site of implantation and whether a multiple pregnancy exists. CERVICAL CHANGES - By the 8th week, a fetal outline can be seen so - A mucus plug, called the operculum, forms to clearly that the crown-to-rump length can be seal out bacteria and help prevent infection in the measured to establish the gestational age of the fetus and membranes. pregnancy. - Increased fluid between cells causes it to soften in consistency, and increased vascularity causes PHYSIOLOGIC CHANGES OF PREGNANCY it to darken from a pale pink to a violet hue called A. UTERINE CHANGES Goodell’s sign - By the end of the 12th week of pregnancy, the - The consistency of a nonpregnant cervix can uterus is large enough that it can be palpated as be compared with that of the nose a firm globe under the abdominal wall, just - The consistency of a pregnant cervix more above the symphysis pubis. closely resembles an earlobe - By the 20th or 22nd week of pregnancy, it - Just before labor, the cervix becomes so soft typically reaches the level of the umbilicus. that it takes on the consistency of butter or is - By the 36th week, it usually touches the said to be “ripe” for birth xyphoid process and can make breathing difficult. VAGINAL CHANGES - About 2 weeks before term (the 38th week) for - Under the influence of estrogen, the vaginal a primigravida, a person in their first pregnancy, epithelium and underlying tissues increase in the fetal head settles into the pelvis and the size as they become enriched with glycogen. uterus returns to the height it was at 36th weeks. Glycogen This is termed as lightening. ↓ Jam  Promotes growth of lactobacillus acidophilus = - The areola of the nipple darkens, and its creates vaginal microbiome diameter increases from about 3.5 cm (1.5 in.) ↓ to 5 or 7.5 cm (2 or 3 in.). Lactic acid production ↓ SYSTEMIC CHANGES IN PREGNANCY Acidic vaginal environment IMMUNE SYSTEM ↓ - IgG production is particularly decreased, which Prevents infection can make a pregnant person more prone to infection during pregnancy. - An increase in the vascularity of the vagina - A simultaneous increase in the WBC count may parallels the vascular changes in the uterus. The help to counteract this decrease in the IgG resulting increase in circulation changes the response color of the vaginal walls from their normal light pink to a deep violet called Chadwick’s sign INTEGUMENTARY SYSTEM - Vaginal secretions before pregnancy have a pH - As the uterus increases in size, the abdominal value greater than 7 (an alkaline pH). wall must stretch to accommodate it. - During pregnancy, the pH level falls to 4-5 (an - This stretching (plus possibly increased adrenal acid pH), which helps make the vagina resistant cortex activity) can cause rupture and atrophy of to bacterial invasion for the length of the small segments of the connective layer of the pregnancy. skin, leading to streaks CALLED striae - This occurs because of the action of gravidarum on the sides of the abdominal wall Lactobacillus acidophilus / Doderlein’s and sometimes on the thighs bacillus, a bacteria that grows freely in the - During the months after birth, striae gravidarum increased glycogen environment, which lighten to a silvery color CALLED striae increases the lactic acid content of secretions. albicans / atrophicae - Often, the abdominal wall has difficulty stretching OVARIAN CHANGES enough to accommodate the growing fetus, - The corpus luteum that was created after causing the rectus muscles underneath the skin ovulation continues to increase in size on the to painlessly separate, a condition known as surface of the ovary until about the 16th week of diastasis recti. pregnancy, by which time the placenta takes - The umbilicus is stretched by pregnancy to such over as the chief provider of progesterone and an extent that by the 28th week, its depression estrogen. becomes obliterated, and it is pushed so far - The corpus luteum, no longer essential for the outward in some patients that it appears as if it continuation of the pregnancy, regresses in size has turned inside out, protruding as a round and appears white and fibrous on the surface bump at the center of the abdominal wall. of the ovary called corpus albicans. - Extra pigmentation generally appears on the abdominal wall because of ↑melanocyte CHANGES IN THE BREASTS stimulating hormone from the pituitary. - Subtle changes in the breasts may be one of the - A narrow, brown line CALLED Linea nigra may first physiologic changes of pregnancy a person form, running from the umbilicus to the notices (at about 6th weeks) symphysis pubis and separating the abdomen - Typical changes are a feeling of fullness, tingling, into right and left halves or tenderness that occurs because of the - Darkened or reddened areas may appear on the increased stimulation of breast tissue by the high face as well, particularly on the cheeks and estrogen level in the body. across the nose. This is known as melasma / chloasma or the “mask of pregnancy.” Jam - Vascular spiders / telangiectasis (small, fiery- toward the end of pregnancy that a person red branching spots) sometimes develop on the develops a respiratory alkalosis or exhales skin, particularly on the thighs. more than the usual amount of CO2. - Palmar erythema may occur on the hands. - To compensate, kidneys excrete plasma - Both of these symptoms result from the bicarbonate in urine to lower this pH. This increased level of estrogen in the body. results in ↑urination, a sign of pregnancy. - The activity of sweat glands increases - The oxygen content of pregnant patient’s blood throughout the body beginning early in (PO2), IS RAISED from a usual level of about 92 pregnancy, leading to increased perspiration. to about 106 mmHg. Leukorrhea; **bath daily TEMPERATURE RESPIRATORY SYSTEM - Early in pregnancy, body temperature increases - A local change that often occurs in the slightly because of the secretion of respiratory system is marked congestion, or progesterone from the corpus luteum (the “stuffiness,” of the nasopharynx, a response, temperature, which increased at ovulation, again, to increased estrogen levels. remains elevated). - Because the uterus enlarges so much during - As the placenta takes over the function of the pregnancy, the diaphragm, and ultimately, the corpus luteum at about 16 weeks, the lungs, receive an increasing amount of pressure. temperature usually decreases to normal. - Toward the end of pregnancy, this can actually displace the diaphragm by as much as 4 cm CARDIOVASCULAR CHANGES upward. Plasma Volume ↑ 2600 – 3600 - Two major changes do occur with Cardiac output ↑ 25%–50% pregnancy: a tachypnea / ↑RR, more rapid increase than usual breathing and a chronic feeling of blood volume Heart rate from 80–90 shortness of breath (beats/min) 70-80 - The physiologic reasons for those changes Blood volume (mL) 4,000 5,250 include: RBC mass (mm3) 4.2 M 4.65 million o Residual Volume (the amount of air Leukocytes (mm3) 20, 000 25,000– remaining in the lungs after expiration) is 300,000 decreased up to 20% Fibrinogen (mg/dL) 300 450 o Tidal volume (the volume of air inspired) is increased up to 40%. - Blood pressure (BP) decreases in second o Total oxygen consumption increases by as trimester, rises to prepregnancy level in third much as 20%. trimester o During pregnancy, a person’s body tends - Blood pressure determination is an important to maintain a PCO2 at closer to 32 mmHg assessment during pregnancy. than the usual 40 mm Hg. d/t - Increased heart rate and cardiac output ↓progesterone usually cause no change in BP. - Iron Need --- 800 μg more daily. Fetal growth - To keep the pregnant patient’s pH level from increase in maternal RBC, prevent hypoxia becoming acidic because of the load of CO2 - Folic acid Need--- 400 μg daily. ↓ folic acid being shifted from the fetus, increased leads to large nonfunctioning RBC and ↑ risk for expiration (mild hyperventilation) to blow off fetal neural tube and abdominal wall defects excess CO2 begins early in pregnancy. - Peripheral blood flow ---- Impaired blood return - At full term, a person’s total ventilation capacity from lower extremities through the pelvis (due to may have risen by as much as 40%. This weight of the baby) leads to edema & varicosities increased ventilation may become so extreme in vulva, rectum, and legs Jam - Supine hypotension syndrome: Lying supine - Fluid Retention: Increased aldosterone compresses the vena cava, blood return to the production. ↑sodium reabsorption heart decreases. Decreased cardiac output and - Compression of the bladder and ureters by the hypotension leading to faintness and growing uterus hypotension and possibly fetal hypoxia - Increased blood volume increases kidney production of more urine GASTROINTESTINAL SYSTEM - At least 50% of pregnant people experience MUSCULOSKELETAL SYSTEM some nausea and vomiting early on in - Calcium and phosphorus needs are increased pregnancy. It is most apparent nausea and during pregnancy because an entire fetal vomiting early in the morning, on rising, or if a skeleton must be built. person becomes fatigued during the day. - As pregnancy advances, a gradual softening of - Known as morning sickness, nausea and a pregnant person’s pelvic ligaments and joints vomiting begins to be noticed at the same time - To change the center of gravity and make levels of hCG and progesterone begin to rise, ambulation easier, a pregnant person tends to so these may contribute to its cause. stand straighter and taller than usual. This - Nausea usually subsides after the first 3 stance is sometimes referred to as the pride of months, after which time a pregnant person may pregnancy. have a voracious appetite - Standing this way, with the shoulders back and - Although the acidity of stomach secretions the abdomen forward, creates a lordosis decreases during pregnancy, heartburn / (forward curve of the lumbar spine), which may pyrosis can readily result from reflux of stomach lead to chronic backache. contents into the esophagus, caused by both the upward displacement of the stomach by the LABORATORY ASSESSMENT uterus and a relaxed cardio esophageal URINALYSIS sphincter, caused by the action of relaxin - Urine is tested for proteinuria (protein in urine), produced by the ovary. glycosuria (glucose in urine), nitrites - As the uterus increases in size, it pushes the (byproducts of Gram-negative bacteria in urine), stomach and intestines toward the back and pyuria (white blood cells in urine suggesting an sides of the abdomen. At about the midpoint of infection). pregnancy, this pressure may be sufficient to slow intestinal peristalsis and the emptying time BLOOD SERUM STUDIES of the stomach, leading to constipation AND 1. A complete blood count, including hemoglobin or flatulence. hematocrit and red cell index to determine the - Pressure from the uterus on veins returning from presence of anemia, a white blood cell count to the lower extremities can lead to varicosities. determine infection, and a platelet count to - Some pregnant people notice hypertrophy at estimate clotting ability. their gum lines and bleeding of gingival tissue 2. A genetic screen for inherited disease common when they brush their teeth. This is termed as in people with certain ethnic backgrounds. Gingivitis / Gingival Hyperplasia - African American patients, for example, - There also may be increased saliva formation may have a blood sample taken to screen known as hypertyalism, probably as a local for sickle cell anemia and G6PD response to increased levels of estrogen. - Asian and Mediterranean patients may have this done for B-thalassemia URINARY SYSTEM - Those with Jewish ancestry may have - Urinary Frequency: Increased slightly in first this done for Tay-Sachs disease trimester, last 2 weeks of pregnancy - White patients may be tested to see if increases to 10–12 times per day they are carriers for cystic fibrosis Jam  INDIRECT COOMBS TEST 4. SUDDEN ESCAPE OF CLEAR VAGINAL - or indirect antiglobulin test