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OBSTETRIC NURSING Lecture / First Semester Maternal and Child Nursing Encourages families to reach out their Family centered: assessment should community so the family can develop a always include the family as well as an we...

OBSTETRIC NURSING Lecture / First Semester Maternal and Child Nursing Encourages families to reach out their Family centered: assessment should community so the family can develop a always include the family as well as an wealth of support people they can call on individual in a time of family crisis Community centered: the health families is both affected by and influences the health B. Goal and Philosophy of communities The primary goal of maternal and child Evidence based: this is the means health nursing care can be stated simply whereby critical knowledge increases as the promotion and maintenance of A challenging role for nurses and a major optimal family health to ensure cycles of factor in keeping families well and optimal childbearing and childrearing. optimally functioning C. The Range of Practice A. Maternal and Child Health Nurse Preconceptual health care​ Considers the family as a whole and as a Care of women during three trimesters of partner in care when planning or pregnancy and the puerperium (the 6 implementing or evaluating the weeks after childbirth, sometimes termed effectiveness of care the fourth trimester of pregnancy)​ Serves as an advocate to protect the Care of children during the perinatal rights of all family members, including the period (6 weeks before conception to 6 fetus. weeks after birth)​ Demonstrates a high degree of Care of children from birth through independent nursing functions because adolescence​ teaching and counseling are major Care in settings as varied as the birthing interventions room, the pediatric intensive care unit, and Promotes health and disease prevention the home because these protect the health of the next generation D. 2030 National Health Goals Serves as an important resource for Overarching Goals​ families during childbearing and Attain healthy, thriving lives and well-being childrearing as these can be extremely free of preventable disease, disability, stressful times in a life cycle injury, and premature death​ Respects personal, cultural, and spiritual Eliminate health disparities, achieve attitudes and beliefs as these so strongly health equity, and attain health literacy to influence the meaning and impact of improve the health and well-being of all childbearing and childrearing Create social, physical, and economic Encourages developmental stimulation environments that promote attaining the during both health and illness so children full potential for health and well-being for can reach their ultimate capacity in adult all.​ life Promote healthy development, healthy Assesses families for strengths as well as behaviors, and well-being across all life specific needs or challenges stages. Encourages family bonding through Engage leadership, key constituents, and rooming in and family visiting in maternal the public across multiple sectors to take and child healthcare settings action and design policies that improve Encourages early hospital discharge the health and well-being of options to reunite families as soon as possible in order to create a seamless, helpful transition process OBSTETRIC NURSING Lecture / First Semester example, children in war-torn areas of the world are 20 times more likely to die from unsafe drinking water and diarrheal disease than from the conflict itself. Goal 10: Reduced Inequality​ When health services are not distributed equally, marginalized populations and those with higher poverty rates are more likely to not receive sufficient medical care.​ Goal 14: Life Below Water​ The World Wildlife Organization reports E. Goal 3: Good Health and Well-Being that contaminated and overfished water Improving global reproductive health and and polluted fisheries contribute to the reducing mother and child mortality rates​ decline in available seafood, a significant Ending pandemic and communicable animal protein food source for at least 3 diseases and reducing mortalities from billion people. noncommunicable diseases​ Bolstering efforts to prevent and treat F. 4 Phases of Health Care substance abuse Health promotion Providing universal health coverage and Health maintenance​ access to sexual and reproductive Health restoration​ services​ Health rehabilitation Reducing death and illness caused by chemicals and pollution​ G. A Framework for Maternal and Child Supporting medical research and Health Nursing Care development The Nursing Process is designed and implemented in a thorough manner, using F. 5 Adjacent Global Health Goals an organized series of steps, to ensure Goal 1: No Poverty​ quality and consistency of care (Carpenito, In a recent position paper, the American 2004)​ Association of Family Physicians drew a Evidence-Based Practice involves the use direct line from poverty to poor health. The of research or controlled investigation of a impact of poverty on life, beginning even problem in conjunction with clinical before birth, can be felt for generation expertise as a foundation for action​ Nursing Theory One of the requirements Goal 2: Zero Hunger​ of a profession (together with other critical The American Psychological Association determinants, such as member-set says that children who experience food standards,monitoring of practice quality, deficiencies and extreme hunger are much and participation in research) is that the more likely to suffer from chronic health concentration of a discipline’s knowledge issues.​ flows from a base of established theory Goal 6: Clean Water and Sanitation​ H. Association of Women’s Health, The Water, Sanitation and Hygiene Obstetric, and Neonatal Nurses Program (WASH) developed by UNICEF Standards and Guidelines highlights the importance of clean water Standard I: Quality of Care ​ and sanitation, especially for children. For OBSTETRIC NURSING Lecture / First Semester The nurse systematically evaluates the quality Fetal death rate: The number of fetal and​effectiveness of nursing practice.​ deaths (over 500 g) per 1,000 live births or in the first 28 days of life Standard II: Performance Appraisal​ Perinatal death rate: The number of The nurse evaluates his/her own nursing practice deaths during the perinatal time period​ in​ relation to professional practice standards and (beginning when a fetus reaches 500 g, relevant statutes and regulations. about week 20 of pregnancy, and ending​ about 4 to 6 weeks after birth); it is the Standard III: Education​ sum of the fetal and neonatal rates.​ The nurse acquires and maintains current Maternal mortality rate: The number of knowledge in nursing practice.​ maternal deaths per 100,000 live births that occur as a direct result of the Standard IV: Collegiality​ reproductive process. The nurse contributes to the professional Infant mortality rate: The number of deaths development of peers, colleagues, and others.​ per 1,000 live births occurring at birth or in the first 12 months of life.​ Standard V: Ethics​ Childhood mortality rate: The number of The nurse’s decisions and actions on behalf of deaths per 1,000 population in children patients are determined in an ethical manner aged 1 to 14 years. Standard VI: Collaboration​ J. Legal Considerations in Maternal and The nurse collaborates with the patient, Child Practice significant others, and health care providers in Nurses are legally responsible for providing patient care.​ protecting the rights of their patients, including confidentiality, and are Standard VII: Research​ accountable for the quality of their The nurse uses research findings in practice.​ individual nursing care and that of other healthcare team members.​ Standard VIII: Resource Utilization​ Understanding the scope of practice (the The nurse considers factors related to safety, range of services and care that may be effectiveness, and cost in planning and delivering provided by a nurse based on state patient care requirements) and standards of care can help nurses practice within appropriate Standard IX: Practice Environment​ legal parameters. The nurse contributes to the environment of care delivery within the practice settings.​ K. Emancipation Emancipation in the Philippines can take Standard X: Accountability​ place in the following ways​ The nurse is professionally and legally - By the attainment of majority.​ accountable for his/her practice. The professional - By the marriage of the minor.​ registered nurse may delegate to and supervise - By the concession of the father or of the qualified personnel who provide patient care. mother who exercise parental authority. I. Measuring Maternal and Child Health L. Ethical Considerations Birth rate: The number of births per 1,000 Conception issues​ population.​ Pregnancy termination​ Fertility rate: The number of pregnancies Fetal rights versus rights of the mother​ per 1,000 women of childbearing age.​ Stem cell research​ Resuscitation (and length of its continuation)​ OBSTETRIC NURSING Lecture / First Semester Number of procedures or degree of pain a Allows vaginal canal to stretch and child should be asked to endure enlarge during delivery Balance between modern technology and quality of life​ E. Vaginal Column Difficulty maintaining confidentiality of Longitudinal folds of skin in the vaginal records when there are multiple caregiver canal Vaginal vault-upper end of the vagina Anatomy and Physiology I. Female Reproductive System F. Fornix/Fornices A. External Genitalia Anterior fornix Posterior fornix Lateral fornices G. Vaginal pH Before puberty 6.8-7.2 (Alkaline) After puberty 4-5 (Acidic) H. Blood supply Derived from vaginal artery (branch of uterine arteries) Upper portion - cervicovaginal branch of uterine artery Middle portion - inferior vesical arteries B. Internal Genitalia Lower portion - rectal and pudendal 1. Vagina arteries Hollow, membranous and muscularcanal about 8-12 cm infront of the rectum and I. Nerve Supply behind the bladder. Utero vaginal plexus or Lee Franken Its upper portion is separated from the hauser plexus rectum by the cul de sac of Douglas Functions: Organ of copulation Discharges menstrual flow Birth canal C. Cul De Sac J. Uterus hollow , muscular canal resembling an inverted pear Situated in the true pelvis About 2.5-3 inches ;ong, an inch thick, 2 inches wide and has a weight between D. Rugae 50-70 grams Transverse fold skin in the vaginal wall Reaches maximum size at 17 years old Absent in childhood, appear after puberty and disappears after menopause Functions: OBSTETRIC NURSING Lecture / First Semester Organ of reproduction K. Fallopian Tubes (Oviducts) Organ of menstruation Pair of tube-like structures originating fro Uterine contraction the cornua of the uterus with the distal ends located near the ovaries. Parts of the Uterus Each tube is about 4 inches long and 1/4 Fundus inch in diameter. Cornua Its surface is lined by ciliated columnar Isthmus epithelium. Corpus Rhythmic contractions of the fallopian Cervix (internal os, cervical canal, external tubes are strongest at the time of os) ovulation and weakest during pregnancy. Layers of Uterus Functions: Perimetrium Transport ovum from ovary to the uterus Myometrium Site of fertilization Endometrium Provides nourishment to the ovum during - Glandular layer its journey - Basal layer Parts of the Oviducts: Interstitial/intramural Isthmus Ampulla Infundibulum Blood Supply Derived from the ovarian artery and drainage is via the ovarian and uterine arteries Uterine Ligaments Cardinal/transverse-cervical/mackenrodt L. Ovaries ligaments Almond-shape glandular organs located Broad ligaments/peritoneal ligaments on both sides of the uterus Round ligament Before puberty, the ovaries are smooth, Uterosacral ligament flat, and ovoid organs Anterior ligament After several ovulations, they assume a Posterior ligament nodular and pitted appearance Each ovary weighs between 6 to 19 Different Position of the Uterus grams, 1.5 cm to 3 cm wide and 2-5 cm Normal long Anteverted Anteflexed Functions: Retroverted Oogenesis Retroflexed Ovulation Hormone production Layers of Ovary Tunica albuginea Cortex Primordial follicles Graafian follicles OBSTETRIC NURSING Lecture / First Semester Corpus luteum that will be necessary for the ova’s growth Corpus albicans should it be fertilized.​ Medulla The length of menstrual cycles differs from woman to woman, but the average length is 28 days (from the beginning of one menstrual flow to the beginning of the next). ​ It is not unusual for cycles to be as short as 23 days or as long as 35 days. The length of the average menstrual flow (termed menses) is 4 to 6 days, although women may have flows as short as 2 days or as long as 9 days (Ledger, 2012). Menstrual Cycle Terminology Menarche: 1st menstrual period ​ Menses: the time of menstruation​ Perimenopause: interval (months to years) of menstrual irregularities leading up to the total cessation of cycles​ Menopause: cessation of menses for 12 months or more Phases​ The menstrual cycle is the cyclic pattern of The menstrual cycle is divided into 2 components: hormonal and tissular activity that ovarian cycle and endometrial cycle:​ prepares a suitable uterine environment for the fertilization of an ovum and Average adult menstrual cycle is 28–35 days.​ implantation of an embryo. ​ The menstrual cycle involves both an “Normal” cycle length is defined as 24–38 days.​ endometrial and ovarian cycle that are dependent on one another for proper “Regular” cycles are when variation in cycle functioning. ​ length is ≤ 7‒9 days.​ There are 2 phases of the ovarian cycle (follicular and luteal) and 3 phases of the Intervals in cycles usually remain consistent until endometrial cycle (desquamation or perimenopause, when follicular phases become menses, proliferative, and secretory). ​ shorter and more frequent. The menstrual cycle is regulated by the hypothalamic-pituitary-ovarian axis via Ovarian cycle phases follicle-stimulating hormone (FSH) and Follicular phase:​ luteinizing hormone (LH). Represents the time during which the follicle and is episodic uterine bleeding in response to its oocyte develop, leading up to ovulation​ cyclic hormonal changes. The purpose of Spans from menses onset (day 1) to the day a menstrual cycle is to bring an ovum to before the surge of luteinizing hormone (LH), maturity and renew a uterine tissue bed leading to ovulation​ OBSTETRIC NURSING Lecture / First Semester Length: 14 to 21 days (may be shorter, especially in perimenopause)​ Luteal phase:​ The time after ovulation when the ovary produces hormones to support a potential pregnancy and maintain a healthy endometrium.​ Spans from the day of LH surge until the onset of the next menses​ Length: 14 days​ Endometrial cycle phases:​ Desquamation: shedding of the endometrial lining (menses) ​ A. Regulation of the Menstruation The menstrual cycle is regulated by the Proliferative phase: endometrial proliferation with hypothalamic-pituitary-ovarian axis.​ straight, tubular glands​ Hypothalamus:​ Secretory phase: maturation of the spiral arteries ​Releases gonadotropin-releasing and endometrial glands, preparing the hormone (GnRH) → stimulates endometrium for potential pregnancy gonadotropes of the anterior pituitary​ Secreted from the preoptic neurons of the hypothalamus in a pulsatile fashion​ Regulated by biologic rhythms (and to a lesser extent by other physiologic factors, such as stress) Anterior Pituitary Stimulated by GnRH → releases follicle-stimulating hormone (FSH) and luteinizing hormone (LH)​ FSH and LH → stimulate the ovaries​ FSH:​ Stimulates follicular development and egg maturation​ Stimulates the granulosa cells within the ovary to produce estradiol​ LH:​ Stimulates theca cells within the ovary to produce testosterone (most of which is converted to estradiol in the granulosa cells)​ A surge of LH mid cycle triggers ovulation. Ovaries:​ Estrogens Estradiol is the most notable.​ OBSTETRIC NURSING Lecture / First Semester Secreted by the granulosa cells of ovarian Secreted by the granulosa cells of ovarian follicles → stimulated by FSH​ follicles (stimulated by FSH)​ Stimulates the endometrium to Provides negative feedback to grow/develop​ gonadotropes → selectively inhibits further Makes the developing follicles more FSH secretion sensitive to FSH​ Feedback/regulation:​ Negative feedback inhibition: During most of the menstrual cycle, estrogens inhibit further secretions of FSH, LH, and GnRH.​ Positive feedback: For a short time mid cycle, estradiol stimulates FSH and LH secretion from the pituitary → results in ↑ estrogen production in the ovaries and causes the surge of LH, which triggers ovulation Progestins:​ Progesterone is the most notable.​ Secreted by the theca-lutein and granulosa lutein cells in the corpus luteum (stimulated by LH) after ovulation​ B. Ovarian Cycle Uterine effects:​ Follicular phase​ ↓ Endometrial growth​ The phase representing the time during Stabilizes and causes maturation of the which the follicle (and the oocyte it endometrium → prepares the contains) develop, leading up to ovulation. endometrium for implantation​ The follicular phase of the ovaries ↑ Endometrial secretions (↑ secretion thickness)​ coincides with menses and the Progestin withdrawal at the end of the proliferative phase of the endometrium.​ luteal/secretory phases triggers menstrual bleeding.​ Takes place during days 1–14 (up to day 21) of the menstrual cycle​ Breast effects:​ Primarily under the control of FSH​ ↑ Lobular development​ GnRH is released from the hypothalamus Inhibition of milk production​ → stimulates the release of FSH from the ↑ Body temperature → can be used to track anterior pituitary → stimulates the primary ovulation​ follicles of the ovary to begin Required for the development of the developing/maturing placenta during pregnancy Maturing primary follicles produce (via granulosa and theca cells):​ Activins:​ Secreted by the granulosa cells of ovarian Estradiol:​ follicles (stimulated by FSH)​ Stimulates development of the Provides positive feedback to endometrium​ gonadotropes → stimulates secretion of Helps select a dominant follicle by LH, especially mid cycle​ inhibiting further release of FSH (“starving” other follicles) while simultaneously Inhibins:​ OBSTETRIC NURSING Lecture / First Semester making the remaining follicles more The oocyte migrates to the fimbria of the sensitive to the dwindling FSH ​ fallopian tube (can take 3 days).​ Potential for fertilization by sperm at this Inhibin A → inhibits the release of FSH from the phase​ anterior pituitary (negative feedback)​ The corpus luteum of the mature oocyte produces progesterone:​ The anterior pituitary releases a luteinizing - Causes maturation of the endometrium burst or “surge” → triggers ovulation (proliferative → secretory endometrium)​ approximately 12 hours later​ - Progesterone feedback inhibits LH During ovulation, a mature oocyte is secretion from the anterior pituitary. released from the dominant follicle.​ The LH surge ends the follicular phase. If conception does not occur:​ LH levels continue to ↓ and the corpus luteum recedes into a corpus albicans.​ As the corpus luteum recedes:​ Progesterone ↓ → triggers menstruation (end of the luteal phase)​ Estradiol ↓ → releases negative feedback on hypothalamus and pituitary → GnRH pulse begins again to start the next cycle ​ If pregnancy occurs, the secretion of human chorionic gonadotropin (hCG) saves the corpus luteum and allows it to continue its secretory function. Endometrial Cycle There are 3 phases of the endometrial cycle:​ Desquamation or menses ​ Proliferative phase​ Secretory phase​ Menses​ Day 1 of menstrual bleeding marks the beginning of the next cycle.​ Coincides with day 1 of the follicular phase​ If conception does not occur, the corpus luteum degenerates and progesterone levels decrease ​ Progesterone withdrawal triggers desquamation of the functional layer of the endometrium (menses)​ Luteal Phase​ - Spiral arteries constrict.​ The luteal phase of the ovaries coincides with the - Endometrium dies secondary to apoptosis.​ secretory phase of the endometrium.​ - Uterine contractions shed and expel the upper endometrial layer (stratum Takes place typically during days 15–28 of functionalis).​ the menstrual cycle, after the oocyte is released. ​ Normal menstruation:​ OBSTETRIC NURSING Lecture / First Semester Lasts 3‒8 days​ minute hemorrhages, and the Loss of < 80 ml of blood/tissue​ endometrium sloughs off. The oocyte is lost in menstrual bleeding. C. Ovulation Proliferative phase​ Primordial follicles​ Proliferative phase (days 4–14) → new endometrium develops (stratum Immature follicles inside the ovary that functionalis grows from the remaining contain immature ova.​ deeper layer of endometrium (the stratum basalis) that does not shed during Graafian follicles​ menses)​ Described by Regner de Graaf​ Stimulated by estrogen produced by the Developing primordial follicles​ growing follicles:​ From numerous follicles that show signs of development, only one will be chosen to - Theca cells in the developing follicles reach full maturity and release the ovum make androgens.​ - Granulosa cells release aromatase → Very high estrogen and low progesterone converts androgens into estrogens, which triggers the release of luteinizing hormone act as a growth factor in endometrial (LH)​ tissue​ Part of menstrual cycle, when an egg is - Endometrial proliferation with straight, released from the ovary​ tubular glands Ovulation occurs 14 days before menstruation (+/- 2days)​ Secretory phase​ Starts between days 13 and 15 of the Signs of ovulation​: menstrual cycle (later in some individuals) ​ Mittelschmerz​ Preparation of the spiral arteries and Spinnbarkeit​ endometrial glands for potential Increased basal temperature​ implantation of an embryo:​ Peek blood level of LH - Triggered by progesterone release ​ - Increased endometrial gland tortuosity​ - Glycogen-rich secretions - Edematous stromal cells​ - Uterine spiral arteries extend the full length of the endometrium.​ If no pregnancy progesterone levels decrease → inducing apoptosis of the functional layer of the endometrium, leading to menses Ischemic phase D. Clinical relevance If fertilization does not occur, the corpus Pregnancy: the period of time in which a luteum in the ovary begins to regress after fetus develops inside a uterus. When the 8 to 10 days, and therefore, the production oocyte is fertilized by a sperm cell and the of progesterone decreases. ​ developing embryo is implanted into the With the withdrawal of progesterone, the endometrium, the menstrual cycle is endometrium of the uterus begins to suppressed to prevent the evacuation of degenerate (at about day 24 or day 25 of the uterine lining and embryo via uterine the cycle). The capillaries rupture, with contractions. Pregnancy lasts approximately 40 gestational weeks and OBSTETRIC NURSING Lecture / First Semester creates a physiological state in the body to support a fetal gestation.​ Management​ Dysmenorrhea: recurrent abdominal pain Estrogen replacement therapy​ associated with menstruation; may be primary or secondary in nature​ Provide info regarding possibility of Endometrial hyperplasia: occurs when pregnancy exists up to 12 mos after the the endometrium receives prolonged last menses​ stimulation by estrogens to proliferate. Calcium and vitamin d supplementation​ Presents as abnormal uterine bleeding. Increased fluid intake of 3oooml Women who suffer from endometrial hyperplasia are at increased risk of Management of Hot Flushes​ developing dysplasia and endometrial Dress in layered look, remove outer during cancer. attacks​ Avoid hot environment​ E. Menstrual Problems Avoid getting excited and emotional stress​ Dysmenorrhea (primary and secondary) Avoid spicy foods, coffee, tea and alcohol​ Amenorrhea Use cooling techniques​ Oligomenorrhea Keep a diary to monitor hot flushes​ Menorrhagia Supplements of vit B and E​ Metrorrhagia Polymenorrhea Role of nurse/midwife​ Regular exercise​ F. Menopause Adequate intake of calcium and vit D​ Climacterium ​ Use of water soluble vaginal lubricant​ “change of life”​ Provide emotional support and Transition from reproductive age to parasympathetic non-reproductive age​ understanding​ Generally occurs between the ages 45 to 55 or at Refer of counseling​ earlier times in some women​ Avoid smoking and alcohol​ Regular physical examination Menopause ​ “rung of the ladder “​ Fertilization Culmination of climacterium​ Ovum​ No follicles left in the ovary, can no longer Female sex cell or gamete​ ovulate, reproductive capacity has ended​ Regularly released by the ovary through Early menopause caused by:​ the process of ovulation​ - Oophorectomy - Hysterectomy​ Two layers of protective covering​: - Over exposure to radiation​ - Corona radiata – outer​ - Hard physical work​ - Zona pellucida – inner - Strenuous exercise Has lifespan of 24 hours, thus it can only be fertilized within this period, ​ Signs and Symptoms hot flushes​ Sperm cell​parts:​ Loss of breast mass and firmness, and - Head​ atrophy of reproductive organs​ - Neck/mid-piece​ Dyspareunia​ - tail​ Musculoskeletal symptoms​ Lifespan of48 to 72 hours after ejaculation​ Mood instability, loss of sexual desire, The sperm must be in genital tract 4-6 depression and anxiety​ hours before they are able to fertilize an OBSTETRIC NURSING Lecture / First Semester ovum to give time for the enzyme Step 1: 1st contact​ hyaluronidase to be activated​ Sperm burrow through the external matrix to touch the oocyte.​ 2 kinds​ Facilitated by protein PH-20 Gymnosperm​ Androsperm Step 2: Binding of Sperm and Oocyte​ Penetration of the zona pellucida by Insemination​ sperm​ Deposition of sperm cell in the female Sperm receptor binds ZP3 glycoprotein of internal organs which occur during sexual zona pellucida → digestive enzymes intercourse​ (acrosin) release from the acrosome → Only few sperm cells reach the uterus sperm moves closer → sperm binds ZP2 because many of them are immobilized by glycoprotein → the head moves inside the the acidic vaginal environment​ zona pellucida The spermatozoa swims so fast that within 90 seconds it is in the uterus and reach Step 3: Release of Sperm Contents​ the fallopian tube within 5 minutes after Sperm fuses with the egg membrane by deposition​ an interaction between integrins (oocytes) and disintegrins (sperm) → DNA released Fertilization​ into the ovum​ When the sperm cell reach the uterus, its Phospholipase C:​ head undergoes structural changes called Released by sperm into the ovum​ capacitation​ Breaks down PIP2 into IP3 and DAG → When it meets the ovum in the fallopian calcium signalling cascade → cortical tube, it secrets the enzymes reaction​ hyaluronidase to dissolve the corona Cortical reaction makes the egg radiata​ impenetrable to further insemination.​ Another enzyme will be secreted by sperm called acrosin which dissolve the portion of zona pellucida.​ After the sperm has entered the ovum, plasma membrane will undergo structural changes to prevent polyspermy​ The second meiotic cell division of the ovum is completed after fertilization and it is the secondary oocyte that is fertilized​ Hereditary traits and characteristics are found inside the cell’s nucleus in the form of chromosomes​ Body cells or somatic cells contain 46 chromosomes, 23 pairs Fertilization Sperm enter the uterus with sexual intercourse, subsequently entering the fallopian tubes and traveling upstream to the ampulla of the fallopian tube. The ampulla is the location of fertilization, which is a multistep process.​ ​ OBSTETRIC NURSING Lecture / First Semester Bleeding experienced by some women is called implantation bleeding​ Ideal site of implantation is fundal portion Zygote​ First cell formed from the fertilization of sperm and ovum​ Trophoblasts​ 46 chromosomes: 44 autosomes 2 sex Two distinct layers​ chromosomes​ Cytotrophoblast​ Zygote journeys from fallopian tube to the Langhan’s layer​ uterus for a period of 3-4 days​ Protects the fetus against treponema 24 hours after fertilization, it undergoes pallidum​ first cell division​ WhEn there is 16 or more blastomeres the Syncytiotrophoblast​ zygote is termed morula​ Outer layer that originated from the Upon reaching the uterine cavity, the cytotrophoblast​ remaining zona pellucida disintegrates It produces hormones​ and the morula is transformed into Also known as syncytium​ blastocyst Chorionic villi​ Blastocyst​ Tiny projections around the zygote​ A ball like structure composed of an inner On the 17th day, fetal-maternal circulation cell mass called embryonic disc or is already established​ blastocoele​ Chorion frondosum​ Outer layer called trophoblast or Chorion laeve trophoderm​ The trophoderm layer gives rise to tha placenta, fetal membranes, umbilical cord and amniotic fluid​ The blastocoele or embryonic disc give rise to the 3 primary germ layers​ - Ectoderm​ - Mesoderm​ - entoderm ​ Implantation​ Blastocyst remain floating in the uterine cavity for 3-4 days​ Decidua​ Blastocyst implants in the endometrium After implantation, the endometrium is 6-7 days after fertilization​ referred to as decidua​ OBSTETRIC NURSING Lecture / First Semester 3 layers Wharton’s jelly​ Decidua parietalis​ Gelatinous substance found inside the Decidua basalis​ cord - Zona compacta​ - Zona spongiosa​ Placenta​ - Zona basalis​ Decidua capsularis​ Origin​ Formed from the chorionic villi and Membranes​ decidua basalis​ Chorionic membrane​ Maturity at 12 weeks and degenerates Amniotic membrane​ after 42nd week​ Amniotic fluid​ Weight​ Volume: 500 to 1000ml​ 500 grams at term​ Composition: 99%water and 1% particles​ 15 to 20 cm in diameter and 3 cm thick​ Appearance: clear and colorless to straw colored​ Maternal and fetal sides​ pH: 7.0 to 7.25, neutral to alkaline​ Duncan​ Specific gravity: 1.005 – 1.025​ Schultze Functions​ Protects fetus​ Allows freedom of movement​ Acts as secretion and excretion system​ Maintain constant temperature​ Source of oral fluid​ Aids in diagnosis of maternal and fetal complications​ Aids in fetal descent​ Aids in effacement and dilatation​ Prevents pressure on the cord Umbilical cord​ Function​ Carry oxygen and nutrients​ Blood vessels​ 2 arteries-carry the most un oxygenated Birth Control blood​ Non Hormonal Contraception 1 vein-carries oxygenated blood to the A. Definition fetus​ Non Hormonal contraception refers to mechanisms that prevent pregnancy Length​ without affecting the reproductive 50-55 cm and 2cm in diameter​ hormones in the user. Non Hormonal contraception includes physiologic Origin​ methods, barrier methods, surgical Originated from the yolk sac and umbilical methods, or the use of a copper vesicles​ intrauterine device (IUD). Efficacy levels Meckel diverticulum​ vary significantly between methods. Most physiologic methods are associated with OBSTETRIC NURSING Lecture / First Semester high failure rates, while, on the other 2. Fertility awareness methods hand, surgical methods are permanent Methods involving determination of a and highly effective. The copper IUD is the woman’s “fertile window” during the most effective reversible method. Some menstrual cycle barrier methods can prevent sexually Penis-in-vagina (PIV) intercourse is transmitted infections (STIs) and, in avoided (or other contraceptives are used) addition, provide contraceptive coverage. during the time. Since sperm can live for up to 5 days and B. Classification the egg is viable for approximately 24 Non Hormonal contraception can be classified hours, the fertile window is approximately into: 6 days each cycle. Physiologic methods: The timing of ovulation can vary widely - Withdrawal/coitus interruptus from cycle to cycle → predicting the fertile Fertility awareness method (FAM): window in real time can be challenging - Rhythm method and is highly prone to error - Basal body temperature method The methods are frequently used to - Cervical mucus method intentionally achieve pregnancy by Lactational amenorrhea engaging in intercourse during the fertile Abstinence from all sexual activity window. Barrier methods: - Condom (male or female) 3. Rhythm method (calendar method) - Spermicide The fertile window is determined by - Contraceptive sponge - Diaphragm looking at the woman’s recent menstrual - Vaginal pH history: - Regulator gel Calculated by an equation using the Copper woman’s longest and shortest cycles over Intrauterine device Surgical methods: the last 6 or more months - Tubal occlusion or salpingectomy Use the “standard days”: If a woman’s - Vasectomy cycle is reliably between 26 and 32 days, the standard fertile window is between cycle days 8 and 19 (inclusive). The cycle has to be regular. Associated with a high failure rate due to variation in the timing of ovulation 4. Basal body temperature method The woman tracks her basal body temperature (BBT) each morning. Approximately 1‒2 days following ovulation, the increase in progesterone C. Physiologic Methods will cause an increase in BBT by about 1. Withdrawal/coitus interruptus 0.5° F. A traditional method that has been in use The egg is no longer viable by the time the for centuries sustained increase in temperature is The penis is completely withdrawn from noted. the vagina prior to ejaculation. The fertile window is over until the Prevents fertilization by preventing the temperature drops again with menses. sperm from reaching the egg Associated with a high failure rate (since Very high failure rate because many other factors can cause subtle pre-ejaculate fluid contains viable sperm increases in BBT) OBSTETRIC NURSING Lecture / First Semester 5. Cervical mucus method Based on cervical mucus changes Does not affect fertility observed before, during, and after Protection from STIs ovulation due to hormonal changes Easily accessible (condoms for men) throughout the cycle Inexpensive Leading up to ovulation, the mucus Minimal side effects becomes progressively thinner, clearer, Does not require medical evaluation or and stretchier. special fitting The increase in progesterone that occurs Condoms for women offer protection if the following ovulation causes the mucus to partner refuses to use a condom “dry up” → indicates ovulation has already occurred and the egg is no longer viable Disadvantages: High failure rate due to misinterpretation of Potential allergies to the materials of the mucus consistency condom Potential ↓ in sensitivity D. Barrier Methods Some individuals may have difficulty 1. Condoms finding a proper fit. Mechanism: Slippage or breakage can occur. Creates a physical barrier between the Condoms for women may be difficult to male and female genitalia and secretions find and/or insert/remove properly. Effects: Protects against pregnancy by preventing 4. Spermicides semen from entering the cervix Mechanism: ↓ STI risk, including HIV Most spermicides contain nonoxynol-9 (a Some protection against HPV infections → surfactant) ↓ risk of cervical neoplasia Provide a chemical barrier by killing or immobilizing sperm cells 2. Male condom: Only reversible male contraceptive Use: method (except for withdrawal) Can be in the form of foams, creams, and A thin (usually latex) tube with a reservoir suppositories at the tip and a base ring Suppositories should be placed in the Applied to an erect penis before vagina at least 10‒30 minutes (no more penetration than 1 hour) before sexual intercourse Pregnancy rate at 1 year: Typically used in combination with 2% with perfect use condoms 18% with typical use (inconsistent use) Decreases the chance of pregnancy if used immediately following a condom 3. Female condom break/slip/spill A pouch with an inner and an outer ring The inner ring is inserted into the vagina. Advantages: The outer ring remains outside and covers Does not require a prescription the perineum. Easy to use Should be used no more than 8 hours Does not affect fertility before intercourse Pregnancy rate at 1 year: Disadvantages: - 5% with perfect use Should be used with other barrier methods - 21% with typical use due to limited efficacy alone Does not protect against STIs Advantages OBSTETRIC NURSING Lecture / First Semester May cause vaginal irritation → ↑ risk for 12% with typical use HIV infection Pregnancy rate: 6. Contraceptive sponge 18% with perfect use Mechanism: 20% with typical use Foam disk impregnated with nonoxynol-9 Acts as both a barrier device and 5. Diaphragm spermicidal agent Mechanism: A reusable, dome-shaped rubber cup with Use: a flexible rim that fits over the: Moisten with water before insertion into - Cervix the vagina - Upper and lateral wall of the vagina → activates spermicide Provides a physical barrier to sperm Should cover the cervix Can be inserted up to 24 hours before Types: intercourse Conventional latex diaphragm: Should be left in place for ≥ 6 hours after Available in various sizes intercourse Requires a medical visit and special fitting Should be refitted after childbirth or weight Advantages: changes Available without a prescription or special New single-size diaphragm: fitting Made of silicone Does not affect fertility 1 size fits most. Does not require a fitting Disadvantages: More durable Less effective than other barrier methods Can cause vaginal irritation or dryness → Advantages: ↑ risk of HIV Does not affect fertility transmission Can be placed at a convenient time before May be difficult to remove (can break intercourse apart during removal) Durable and reusable (can last up to 2 Associated with ↑ risk of toxic shock years) syndrome More effective than the sponge (rare) Disadvantages: Pregnancy rate: Individuals need instruction on proper use 12% for nulliparous women (may be difficult for some) 24% for multiparous women Requires a prescription Does not prevent STIs 7. Vaginal pH regulator gel Should be avoided during menses Mechanism: Can cause discomfort and vaginal irritation Lowers the vaginal pH to 3.5‒4.5 (even in May become dislodged the presence of alkaline semen) → Associated with: immobilizes sperm - Urinary tract - Infections Use: - ↑ Risk of toxic shock syndrome Used as an alternative to spermicide - (rare) Comes in single-dose, pre filled vaginal applicators Pregnancy rate: Should be applied within one hour of 6% with perfect use intercourse OBSTETRIC NURSING Lecture / First Semester Primary advantage: Provides long-term efficacy Has a lower risk of vulvovaginal and penile Convenient irritation compared to spermicide Does not affect fertility Minimal systemic effects Disadvantages: Can be used as emergency contraception Requires a prescription May be removed at any time (by a Typically used in conjunction with other clinician) products (e.g., condoms, diaphragms) FDA approved, but newer product Disadvantages: with less data regarding efficacy Requires a medical visit for placement and removal E. Copper Intrauterine Device Does not protect against STIs The copper IUD is the only nonhormonal Side effects: long-acting, reversible contraceptive - Heavier menstrual bleeding (primarily available. In the United States, the copper during the 1st year) IUD is sold under the brand name - Severe cramping Paragard®. Contraindications: Mechanism: Current STIs or pelvic inflammatory A T-shaped polyethylene device with a disease (PID) fine copper wire wound around the stem Anatomic abnormalities that distort the (and often the horizontal arms) is inserted uterine cavity into the endometrial cavity. Unexplained vaginal bleeding The copper causes local, sterile Known cervical cancer or endometrial inflammation and releases small amounts cancer of copper → affects sperm mobility and Pregnancy implantation Wilson disease or copper allergy Complications: Expulsion (rates are < 5% within the 1st year after insertion) Uterine perforation Ectopic pregnancy (lower overall risk; however, risk of ectopic pregnancy is high if pregnancy occurs) Pregnancy rate: 0.5%-0.8% Higher failure rate in younger women Use: Inserted by a clinician in the office F. Surgical Method Can remain in place for 10 years Female sterilization (evidence suggests the device is safe and Mechanism: effective for at least 12 years) Removes the ability of the egg and sperm Can be used for emergency contraception to come into contact with one another in if placed within 5 days of unprotected the fallopian tubes intercourse Accomplished surgically Advantages: Highly effective Methods: Salpingectomy: OBSTETRIC NURSING Lecture / First Semester - Complete removal of the fallopian tubes Approximately 30% of pregnancies that - Reduces the risk of ovarian, fallopian tube occur after tubal occlusion are ectopic. and primary peritoneal cancer → reason why salpingectomy is becoming standard Partial salpingectomy: cutting and excising a segment of the fallopian tubes Tubal ligation or occlusion: - Ligation - Fulguration - Various mechanical devices (plastic bands or rings, spring-loaded clips) Indications and Contraindications G. Vasectomy Indicated for women with a desire for Mechanism: permanent contraception (requires Disrupts the patency of the vas deferens extensive counseling) Can be accomplished surgically by: No absolute medical contraindications - Transection of the vas deferens In the United States, legal restrictions - Ligation or fulguration prevent federal funding for permanent contraception in women under 21 years of Indications and contraindications: age (18 years in some states) Indicated for men with a desire for Risk for complications should be assessed permanent contraception (should be given and weighed against the risk of pregnancy extensive counseling) and risks associated with alternative contraceptive methods. Contraindications: Risk factors for complications include: Scrotal hematoma - Severe obesity Infections - Prior abdominal surgery Statistically safer (and easier to perform) - Previous PID or abdominal infections than female-sterilization procedures - Comorbidities Complications: Complications: Hematoma Risk of regret: (≤ 5%) Biggest risk with female sterilization Sperm granulomas Highest in young women (up to 20%) (inflammatory response to sperm Parity leakage) (including nulliparity) is not a significant Epididymitis risk factor for regret. Post-vasectomy pain syndrome Death: 1–2 per 100,000 women Spontaneous reanastomosis: Hemorrhage or intestinal injuries: - Usually occurs shortly after the procedure approximately 0.5% of women - A follow-up semen analysis is usually 10-year failure rates (depends on surgical required approximately 3 months following technique): the procedure to ensure efficacy - Partial salpingectomy: 2% - Tubal occlusion with clips or bands: 2%‒3.5% - Complete salpingectomy: thought to be significantly lower (less data) Ectopic pregnancy OBSTETRIC NURSING Lecture / First Semester