Week One

What/when is the pre-embryonic stage?

known as the germinal phase, is the first and shortest phase of embryonic development. It lasts from fertilization to the second week of the embryo's life. In this phase of embryo development, the zygote repeatedly self-replicates.

what causes the endometrial lining of the uterus to be more vascular

a surge of progesterone

Which very important system is the first one created in the embryo?

cardiovascular system

What is a teratogen?

Any substance that causes fetal abnormality if exposure occurs after day 14 ● Certain medications, tobacco, alcohol, street drugs (e.g. cocaine), infectious agents (e.g. varicella, rubella), certain chemicals (e.g. herbicides, solvents), others

when does fetal stage begin

Begins at week 9 after fertilization or 11 weeks gestation and ends at birth During this stage, we are officially a fetus!

preterm

 before 37 weeks of pregnancy have been completed

term

The number of pregnancies that have ended at term (37+ wks)

Naegele’s Rule:

adding 7 days to the first day of the last normal menstrual period (LMP), going back 3 months from that date, then going forward one year

when does Placental development start?

the first contact of the outer shell of a developing blastocyst with the uterine mucosa.

Function: it truly does “all the things” - Circulation - Protection - Hormone production

How many chords in the placenta

Umbilical Arteries 2

umbilical vein 1

what is a patent foramen ovale

The hole between the top two heart chambers (right and left atrium)

This hole allows the oxygen rich blood to go from the right atrium to left atrium and then to the left ventricle and out the aorta. (Shunting)

What does The ductus arteriosus do

sends the oxygen poor blood to the organs in the lower half of the fetal body. This also allows for the oxygen poor blood to leave the fetus through the umbilical arteries and get back to the placenta to pick up oxygen.

Prenatal Care Visits 1st trimester

1-2 visits, initial bloodwork, initial physical assessment, initial dating ultrasound, nuchal translucency ultrasound

Prenatal Care visits Second Trimester

3-4 visits, ongoing maternal physical assessment, fetal assessment, anatomy ultrasound 18-20 weeks, GTT

Prenatal Care Visits third tri

3-5 visits, ongoing maternal and fetal assessment, GBS swab at 35 weeks

Leopold’s Manuevers

Fetal lie -

Fetal presentation -

Fetal attitude -

Fetal position

\*important to empty bladder prior to this palpation

\*supine with slight side tilt

what is healthy weight gain for a patient with a healthy BMI

11\.5-16kg (25-35lbs)

how many baby movements should you feel

6 movements in 2 hours

Variability

Determinant of normal pH

moderate 5-25 bpm

Decelerations:

a marker of ongoing O2 deprivation

\- No late/variable/prolonged

Accelerations:

\: A marker of normal pH

\-present or absent

early decelerations

occurs before the onset of uterine contraction and usually benign not requiring intervention - drop in FHR is gradual

* head compression

Late Decelerations

occurs after the onset of uterine contraction and is a uniform shape that tends to reflect the associated contraction – drop in FHR is gradual

* placental insufficiency

Variable decelerations

\: onset varies in timing with the onset of the contraction and are variable in shape – drop in FHR is abrupt

\*Umbilical cord compression

APGAR

Appearance

Pulse

Grimace

Activity

Respiratory

radiation heat loss

Heat transfer without direct contact through absorption and emission of infrared rays, e.g. single wall incubators placed in direct sunlight or a cold nursery

convection

Heat transfers via air currents, e.g. cold draughts

conduction

Heat transfer via direct contact, e.g. cold scales, hands and clothing

Evaporation

Heat loss by conversion of liquid into vapour, e.g. wet and dry skin under radiant warmer

trimester one

conception to beginning of 13 weeks

second trimester

Week 13-26

third trimester

Week 27-40

presumptive signs of pregnancy

symptoms that indicate one may be pregnant

* urinary frequency
* breast changes
* quickening
* nausea/vomiting
* amenorrhea

probable signs of pregnancy

signs that can be tested (objective)

* chadwick sign
* positive HCG urine/ serum test
* goodell sign
* hegar sign
* fatigue

positive signs of pregnancy

ultrasound shows fetus

fetal movement

fetal heart tones

\

bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. 

bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. 

goodell sign

significant softening of the vaginal portion of the cervix from increased vascularization. (6 weeks gestation)

hegar sign

It is demonstrated as a softening in the consistency of the uterus, and the uterus and cervix seem to be two separate regions. The sign is usually present from 4–6 weeks until the 12th week of pregnancy. 

Linea nigra

dark line may appear between the umbilicus (belly-button) and the symphysis pubis (pubic bone); in some pregnant women it may extend as high as the sternum (the bone between the breasts). It is a hormone-induced excess production of brown material (pigment) in the skin cells in this area

Mask of pregnancy (chloasma)

Some women produce a brownish pigmentation of the skin over the face and forehead, known as the ‘mask of pregnancy’ (or chloasma). It gives a bronze look. It begins about the 16th week of pregnancy and gradually increases, but it usually fades after delivery. The pregnancy GLOW!

how much extra blood does a women roughly gain when pregnant

about 50%

HCG

• 1. STIMULATES THE CORPUS LUTEUM TO SECRETE ESTROGEN AND PROGESTERONE FOR UP TO APPROXIMATELY 14 WEEKS UNTIL THE PLACENTA TAKES OVER •

2\. INDICATOR FOR BEING PREGNANT – I.E. SERUM AND URINE PREGNANCY TESTS IN THE FIRST TRIMESTER

PROLACTIN

PREPARES BREASTS FOR LACTATION - secreted by anterior pituitary

Insulin

PRODUCTION OF INSULIN IS INCREASED IN RESPONSE TO ANTAGONISTIC EFFECTS OF ESTROGEN AND PROGESTERONE

Oxytocin

STIMULATES UTERINE CONTRACTIONS; MILK EJECTION FROM BREASTS - secreted by posterior pituitary

Estrogen

An increase in estrogen enables the uterus and placenta to further vascularize, transfer nutrients, and support the growth of the fetus

what is the most important hormone during pregnancy

Progestogen

Helps the uterus grow, keeps the mom from having contractions and helps prepare breasts for milk production. If a mom has had premature labor in the past sometimes they are prescribed

progesterone in pregnancy to inhibit early contractions of the uterus.

Primary prevention

Nutrition

Comfort

Sexual

Health

Knowledge

Coping

Secondary prevention

Screening for maternal and fetal well being

Maternal: weight, physical, urine, blood,

US Fetal: heart rate, growth, movement

Tertiary

Management of pregnancy related concerns Gestational HTN GDM Antenatal bleeding

First Trimester Lab Testing and Imaging

Initial lab work CBC, platelets, ABO/Rh, Rubella, Varicella, Syphilis and STI screening.

A1C if high risk for diabetes. Genetic screening offered.

Early dating ultrasound available if LMP unknown or unreliable. Urine for protein

Second Trimester Lab Testing and Imaging

Anatomy US 18-20 weeks, Quad screen, Glucose screening followed by GTT (if required) 24-28 weeks, Hg, Urine for protein

Third Trimester Lab Testing and Imaging

Rh immunoglobulin if needed (28 weeks)\*, rescreen for syphilis if at risk, GBS culture (35-36 weeks)

When do you get tested for GBS

35-36 weeks

When is Winrho given

Given intramuscularly

At any point if bleeding

At 28 weeks routinely if no bleeding Another at delivery

MUST be an RN or LPN with special competency to administer

when does Nuchal Translucency Screening occur

11 w 4 days until 13 weeks 6 days pregnant

Looking for:

Thickness of the neckfolds (less than 3.5 mm is normal) - extra fluid can be indicative of trisomy 13 or trisomy 18.

AND ensuring there is a nasal bone in baby Maternal bloodwork: hCG, PAPP-A and AFP - these may be elevated or decreased. Results - INDICATE A RISK for Down’s Syndrome of a trisomy 13 or 18 condition - NOT a diagnosis

Hyperemesis Gravidarum

severe nausea, vomiting and weight loss

how much bleeding is okay in a vaginal delivery

500ml

how much bleeding is okay in a C section

1000ml

Four causes of PPH

1. Tone (uterine atony)

2. Tissue

3. Thrombin (clotting factors)

4. trauma

Hypertension in Pregnancy

140/90 - without protein in the urine or signs of end organ dysfunction diagnosed at 20 weeks gestation or later.

Preeclampsia

High Blood pressure AND signs of signs of damage to another organ system, often liver or kidneys

check if there is protein in urine

signs of preeclampsia other then htn

severe headaches, changes in vision, upper abdominal pain, nausea/vomiting, decreased urine output, shortness of breath

when does preeclampsia begin

usually after 20 weeks of pregnancy in women whose blood pressure had been normal. Usually develops subsequent to hypertension in pregnancy. So what is the difference between gestational hypertension and preeclampsia? Protein in the urine

what medication is often prescribed during the first tri with a mom who has preeclampsia

aspirin

Women with severe preeclampsia who do not deliver imminently are treated with?

magnesium sulfate

Management of Preeclampsia

• Antihypertensive medications for BP ≥ 160/110mmHg (severe preeclampsia)

• May use MgSO4 to prevent eclampsia in women with severe preeclampsia

• Along with continued laboratory tests and urine analysis, lots of education about signs and symptoms for women to be aware of - huge role of the nurse

• Ongoing assessments of fetal well-being: BPP, ultrasound, NST

• May need to induce labour for women with severe preeclampsia for early delivery

HELLP syndrome acronym

H- hemolysis (Destruction of red blood cells - great now your body has less ability to carry oxygen to the rest of your body)

EL- Elevated Liver enzymes (indicating liver damage)

LP-Low platelet count (Platelets help your blood clot, now you are at risk for serious bleeding)

HELLP syndrome

complication of preeclampsia and is like severe preeclampsia. The only true cure for HELLP is delivery. If this syndrome occurs after 34 weeks, the baby is delivered immediately.

What to do for hellp syndrome before 34 weeks

delivery is still imminent but we often wait 48 hours to deliver and give mom beta - which is a corticosteriod 2 doses, given 24 hours apart - to help with fetal lung development

Gestational diabetes

A form of diabetes mellitus with onset during pregnancy

body's cells use insulin less effectively, a condition called insulin resistance. Insulin resistance increases your body's need for insulin.

Pathophysiology of GDM

• Insulin resistance is a necessary change in the pregnant woman for purposes of securing glucose for fetal growth and development

• Women with GDM cannot compensate for this normal insulin resistance because of ß cell dysfunction (pancreas fails to produce insulin or does not produce enough insulin to allow necessary carbohydrate metabolism)

• This leads to hyperglycemic state and leads to fat metabolism (causing ketosis)

GDM diagnoses

Test should be performed between 24-28 weeks gestation and should not be performed at or after 35 weeks of gestation. Fasting blood glucose and/or Hemoglobin A1C (HbA1c) are the recommended tests at or after 35 weeks gestation

Polyhydramnios

Excess amniotic fluid

Can lead to pre-term birth, postpartum hemorrhage due to distension of uterus and placental abruption

Tx: amnio-reduction

Oligohydramnious

Lower than expected volume of amniotic fluid

Common etiological factors for oligohydramnios include: PROM and fetal anomalies

In some cases maternal dehydration could be a factor – drinking 2 liters of water within 2 hours may help some cases…

Fundal height measuring smaller than expected is often a first sign

Tx: amnioinfusion

Passageway

Includes the pelvis and the soft tissues (uterus, cervix, pelvic floor)

Cervix: ● Cervix changes from a long thick structure to one that is tissue-paper thin

● Moves from posterior to anterior

● Dilates from closed to 10 cm/fully

Pelvis: ● Includes inlet, mid-pelvis, and outlet

● Variety of shapes and sizes (gynecoid is optimal)

● Can potentially not accommodate size of fetus (feto-pelvic disproportion) ● Joints of pelvis become stretchy late in pregnancy and during labour

Power Primary

involuntary uterine contractions

Power secondary

voluntary action of pushing

Second stage considerations

Risk for tearing Episiotomy- Incision made to enlarge vaginal opening

No longer routine and is decided at time of delivery May be needed to make room for baby Local anaesthetic used if needed

what is the fastest stage of labor

transition stage

Pharmacologic Management overview

• INHALATION ANAESTHESIA

•SYSTEMIC OPIOIDS

•REGIONAL ANAESTHESIA

•GENERAL ANAESTHESIA

General Anaesthesia

BASICALLY MEANT TO INDUCE UNCONSCIOUSNESS

•UTILIZED FOR EMERGENCY C/S: SEVERE PREECLAMPSIA AND HELLP; ABRUPTIO PLACENTAE, ABNORMAL FHR REQUIRING IMMEDIATE INTERVENTION; HEMORRHAGIC CONDITIONS

•COMBINATION OF IV AND INHALATION

•WOMAN MUST BE INTUBATED – THIS IS WHEN ISSUES WITH ORAL INTAKE BECOME MORE PREVALENT

calculate the gestational age

October 12, 2017 was lmp

July 19, 2018

add 7 days to lmp and subtract 3 months add 1 year

presumptive signs of labor

Breast tenderness, missing period, nausea, fatigue

Objective probabilities of labor

urine peeing on stick, HCG levels, chadwick sign (blue tinge to cervix)

Positive signs of labor

fetal heart rate, saw fetus, rising hcg with fetal mvt

what is the biggest prenatal question

medication questions

most important hormone in pregnancy

progesterone

why is constipation not a horrible thing for pregnancy

able to absorb more

tests in first tri

Baseline and blood type

tests in second tri

anatomy screening (18-20wks)

glucose testing

tests in third trimester

Rh immunoglobin (28wks). GBS culture (35-36wks)

why are we concerned with a Rh neg women

they will prob have a positive baby, and if that blood mixes it can create antibodies that will affect the second and so on pregnancies. The body will attack the baby causing still born or severe anemia. So we give WinRho 28 WEEkS.

when is babies first immunization

2 months

Hyperemesis gravidarum.

Vommiting to the point of electrolyte imbalance.

Potassium is always the first to fall

at what point do you need an ultrasound if youre bleeding during pregnancy

anymore then 2 tablespoons of blood

Hypertension in pregnancy

>=140/90 W/O protein in urine

two main signs of preeclampsia

hypertension and protein in urine

only cure for HELLP syndrome

deliver baby, will kill both mom and baby if not

4 causes of pph

tone

attony

tissue

trauma