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Where does fertilization occur?
distal 3rd of the fallopian tube (near ovary), enters uterus 3 days later
How long do sperm survive?
1-2 days
How long do sperm remain in the female tract?
up to 80 hours
Embryonic Period
Extends from beginning of the third week until the eighth week after conception, by end of 8th week all organ systems in place but developing
What period do teratogens cause major structural and functional damage to developing organs?
Embryonic period
Week that embryo develops heartbeat
4th week of gestation
Fetal Period
Beginning 9 weeks after conception and extending until birth, rapidly dividing cells become fetus, dramatic growth and refinement of established organs
12 Weeks Gestation
Fetus: 8cm long, 45 g
Sucking reflex
Fetal sex determination
Lanugo develops
Fetus excretes urine into amniotic fluid
Baby's heart rate heard with doppler (10-12 weeks)
When can a fetal heart rate be heard with a doppler?
10-12 weeks gestation
16 Weeks Gestation
Fetus: 14 cm, 200 g
Swallowing amniotic fluid
Quickening occurs
Eyes face forward rather than to the side
What is quickening and when does it occur?
Fetal movement, can be felt at 16 weeks (earlier if mom has been pregnant before)
20 Weeks Gestation
Fetus: 19 cm, 450 g
Vernix caseosa/lanugo covers entire body
Fetus reacts to loud noises
Fetal movement felt by all moms
Brain developing rapidly
Vernix
Thick, greasy substance that forms protective coating on baby's skin in utero
Lanugo
Fine, soft, downy hair that covers the baby's skin in utero
When are fetal movements usually felt by all moms?
16-20 weeks gestation
20 Weeks Gestation
Mom definitely should feel fetal movement
Fetal heartbeat can be heard with fetoscope
24 Weeks Gestation
Fetus: 23 cm, 820 g
Eyebrows, eyelashes, fingernails
Able to hiccup
Activity increases
Fingerprints, footprints develop
Surfactant production begins
Surfactant
Slippery, soap-like substance needed for breathing at birth, starts to be produced at 24 weeks; reduces surface tension in alveoli so they don't collapse with each breath
28 Weeks Gestation
Fetus: 27 cm, 1300 g
Eyes open and close (~26 weeks)
Lungs not fully mature
SubQ fat deposition
32 Weeks Gestation
Fetus: 30 cm, 2100 g
Rapid growth
Tremendous brain development
Lanugo begins disappearing
38-40 Weeks Gestation
Fetus: 36 cm, 3400 g
Fills total uterus
Mature lungs
Fully developed, able to survive outside utero
Vernix present in creases/skin folds
Lanugo present on upper shoulders/back
Firm ear cartilage
Fingernails extend past fingertips
Testes palpable in scrotum
Auxiliary Structures of Pregnancy
Placenta, Umbilical Cord, Fetal Membranes
Functions of the placenta
Metabolic and gas exchange, hormone production (progesterone, estrogen, hCG, hPL)
When is the placenta fully functional?
Between 8th and 10th week of pregnancy
Describe vascular characteristics of umbilical cord
1 umbilical vein (carries oxygenated and nutrient rich blood from mom to fetus)
2 umbilical arteries (carries deoxygenated blood/waste products from baby to mom)
Dirty Duncan
Maternal side of placenta, rough where it attaches to uterus
Shiny Schultz
Fetal side of placenta, smooth
Where does exchange of substances between mother/fetus occur?
Within intervillous space of placenta
Why are mother's blood and fetal blood separated?
Avoids mixing of fetal and maternal blood which may not be compatible (ABO types, Rh factor)
Amnion
Inner membrane of amniotic sac, develops from embryoblast
Chorion
Outer membrane of amniotic sac, develops from trophoblast
Amniotic Sac / Bag of Waters
Membranes containing fetus and amniotic fluid, helps maintain sterile environment and prevent bacterial infiltration
Amniotic Fluid Characteristics
Usually clear
Composed of water, proteins, carbohydrates, lipids, electrolytes, fetal cells, lanugo, vernix
Peaks at 500-1000 mL of fluid at term
1st trimester amniotic fluid production
Amniotic membrane
2nd/3rd trimester amniotic fluid production
Fetal kidneys
Polyhydramnios
Excess amniotic fluid greater than 2000 mL
Increased incidence of chromosomal disorders, CNS or GI defects
Oligohydramnios
Decreased amount of amniotic fluid less than 500 mL at term, or 50% reduction in nL amount
Increased incidence of congenital renal problems
Functions of amniotic fluid
Cushions fetus
Prevents adherence of embryo to membranes
Allows fetal movement and musculoskeletal development
Consistent thermal environment
Duration of Pregnancy
280 days
40 weeks
9 months
3 trimesters
First trimester
Weeks 1-13
Second trimester
Weeks 14-26
Third trimester
Weeks 27-40
Antepartum
1st day of last menstrual period (LMP) to onset of labor
Intrapartum
Begins with the onset of labor, ends with expulsion of placenta
Postpartum
Begins with expulsion of placenta, lasts 6 weeks
Naegele's Rule
Most common method of determining due date; begin with 1st day of LMP, subtract 3 months, add 7 days
Antepartal physiological changes: vagina/vulva
Increased vascularity
Bluish-purple appearance
Loose connective tissue
pH becomes more acidic
Increased chance of yeast infection
Antepartal physiological changes: Cervix
Increased vascularity
Chadwick's sign
Goodell's sign
Secretion of mucous to form mucous plug
Chadwick's Sign
Blue-purple coloration of cervix due to increased vascularity
Goodell's Sign
Cervical softening
Antepartal physiological changes: Uterus
Amenorrhea
Braxton-Hicks cx's (aid placental perfusion)
Hegar's sign
Growth increases
Hegar's Sign
Compressibility and softening of cervical isthmus
Antepartal physiological changes: ovaries
Secrete progesterone from corpus luteum until placenta takes over
Ovulation stops
What is the hormone of pregnancy, and what other hormones does it inhibit?
Progesterone: inhibits FSH and LH, stopping ovulation
Antepartal physiological changes: breasts
Increased size
Tenderness
Visible veins
Colostrum (12 weeks)
Larger nipples w/ increased pigmentation
Antepartal physiological changes: cardiovascular system
CO increase by up to 50%
Slightly elevated pulse (15-20 bpm)
Systolic murmurs possible
Increased blood volume (40-45%)
Decreased BP through 2nd TM
Supine hypotension
When does mom's BP return to pre-pregnancy levels?
By term r/t decrease in peripheral vascular resistance
Antepartal physiological changes: blood
Anemia of pregnancy
RBC increase (20-30%)
Plasma volume increase (40-60%
Leukocyte increase (5,000-15,000 up to 25-30,000 during labor)
Platelets slightly decrease
Increased coagulation factors
Increased demand for iron
Why do we teach moms to take Ferrous Sulfate with vitamin C?
Enhanced absorption
Antepartal physiological changes: Respiratory
Elevated diaphragm, flared rib cage
Increased TV (30-40%)
Increased O2 consumption (15-20%)
Rhinitis, congestion
SOB when reclining (3rd TM)
Epistaxis (nosebleeds)
Antepartal physiological changes: GI
N/V (morning sickness)
Gum bleeding
Displaced stomach, intestines
Heartburn
Excessive saliva
Slowed motility, delayed gastric emptying
Bloating, constipation, hemorrhoids
Pica
Gallbladder/gallstones
Antepartal physiological changes: metabolic changes
Potential increase of blood glucose from insulin resistance in last half of pregnancy (gestational diabetes)
Guidelines for total weight gain during pregnancy
Underweight: 28-40 lbs
Normal: 25-35 lbs
Overweight: 15-25 lbs
Obese: 11-20 lbs
Antepartal physiological changes: urinary system
Urinary frequency (1st, 3rd TM)
Increased GFR
Glycosuria
Antepartal physiological changes: vascular
Hemorrhoids
Varicosities in legs/labia
Antepartal physiological changes: integumentary
Skin pigmentation (hyperpigmentation, linea nigra, melasma)
Striae Gravidarum (stretch marks)
Spider nevi
Hyperactive sweat/sebaceous glands
Hair growth
Edema
Antepartal physiological changes: musculoskeletal
Pelvic joint/ligaments relax
Center of gravity changes
Increased lumbosacral curve
Waddling
Diastasis recti
Lordosis
Antepartal physiological changes: Endocrine
Pituitary: increases prolactin
Thyroid: enlarges, crucial for fetal brain
BMR: increases up to 25%
Presumptive (Subjective) Indications of Pregnancy
Amenorrhea, morning sickness, fatigue, urinary frequency, breast tenderness, Chadwick's sign, fetal movement
PRESUME acronym
Period absent
Really tired
Enlarged breasts
Signs (Chadwicks)
Urinary frequency
Movement perceived
Emesis
PROBABLE acronym
Positive test
Rebound (ballottement)
Outline of fetus
Braxton Hicks cx
A soft cervix
Belly
Lower uterine segment soft
Enlargement of abdomen
Are pregnancy tests probable or positive signs of pregnancy?
Probable: detection of hCG in blood/urine, not 100% accurate
Positive (Diagnostic) Indications of Pregnancy
Fetal movement (provider confirmed), FHR, delivery of baby, ultrasound, visible movement
FETUS acronym
Fetal movement
Electronic detection FHR
The delivery
Ultrasound
See visible movement
Normal psychological maternal responses to pregnancy
Uncertainty, ambivalence, self as primary focus, introversion, body image changes, sexuality changes, vulnerability, increasing dependence, preparation for birth
Rubin's 4 major tasks of pregnancy
Ensuring safe passage for mom/baby
Ensuring social acceptance of child by SOs
Attaching to child
Giving self to demands of motherhood
Normal psychological responses of father to pregnancy
Sense of pride, feeling left out, confused by partner response, resentment over relationship changes, increased sense of responsibility
Couvade syndrome
AKA sympathetic pregnancy, father experiences similar physical/behavioral changes to pregnant mother (hormone alteration, weight gain, morning sickness, disturbed sleep)
How do both parents prepare for their new roles?
Enhanced communication, clarifying partner expectations, solving unresolved conflicts
Cultural assessment of pregnancy
Mom's concerns, where does mom obtain healthcare info, encouraged or discouraged foods, mom's preparation for baby
Three phases of the ovarian cycle
Follicular, Ovulatory, Luteal
Follicular Phase
Day 1-14
First day of menstrual bleed
LH and FSH rise
Graafian follicles grow
Estrogen levels rise
Endometrium grows
Ends with ovulation
Ovulatory Phase
Day 13-14
Lasts 16-36 hours
Surge of LH and FSH
Ova released from follicle for fertilization
Ovum fertile for 6-24 hours
Estrogen levels peak
Progesterone levels rise
Luteal Phase
Day 15-28
Endometrium thickens if fertilization occurs
hCG produced by fertilized egg
Ruptured follicle becomes corpus luteum (provides progesterone in pregnancy)
No fertilization -> corpus luteum degenerates, progesterone drops
Menses begins 14 days post ovulation
4 phases of endometrial cycle
Menstrual, Proliferative, Secretory, Ischemic
Menstrual Phase
Days 1-6
Low estrogen levels
Resting endometrium
Endometrial tissue sloughing if no pregnancy
Proliferative phase
Days 7-14
Starts after menses
Ends with ovulation
Endometrium thickens, becomes vascular
Secretory Phase
Days 15-26
Starts after ovulation
Endometrium continues thickening
Onset of menses if no pregnancy
Ischemic Phase
Days 27-28
Estrogen and progesterone drop
Menses begins
Fertilization
Occurs in fallopian tube when sperm nucleus enters nucleus of egg
Zygote
Fertilized egg
Implantation
Blastocyst into uterine lining 5-6 days after fertilization, normally in upper, posterior uterine wall
Blastocyst
Cell mass after about 5 days
Oocyte
Sperm nucleus that has entered nucleus of egg
Embryo
Time of implantation through 8 weeks gestation
ACOG goals of prenatal care
Ensure healthy baby
Minimize maternal risk
Early/accurate estimate of gestational age
Identify at risk patients
Anticipate/prevent complications
Patient education
Prenatal Visit Frequency
Initial visit (at 6-10 weeks)
Every 4 weeks (up to 28 weeks)
Every 2 weeks (28-36 weeks)
Every week (36-40 weeks)
More frequently w/ risk factors
1-4-2-1 rule
Define early and adequate prenatal care
Begins in first trimester with 80-100% of appointments attended by expecting mother
Define late prenatal care
Begins in the 3rd TM
Late preterm
34-36 6/7 weeks