Reproductive/Maternity Exam 1

Spermatogenesis process

• First meiotic division – 2 haploid secondary spermatocytes are formed from primary spermatocytes 

• Secondary spermatocytes divide, results in 4 sperm

• Overall: 1 spermatogonium → 4 spermatozoa (sperm)

Oogenesis process

• Before birth: primary oocytes that are arrested in prophase I

• After puberty, meiosis continues, produces secondary oocyte (arrested in metaphase II) and polar body

• Ovulation occurs, sperm entry causes second meiotic division and fertilization resulting in a fertilized egg and polar body

Describe fertilization and the steps to implantation

• Fimbria of uterine tubes pulls ovum into tube

• Corpus luteum on the ovary produces progesterone

• Sperm and ovum meet in ampulla (outer third) of the uterine tube 

• Head of sperm contain enzymes that help get past those protective layers of the ovum (zona pellucida and corona radiate)

• sperm entry causes second meiotic division and fertilization resulting in a fertilized egg and polar body

• Chemical reaction prevents more than one sperm from entering the ovum – called the zona reaction

steps to implantation

• Takes 3-5 days to move through uterine tube

  • Day 3: becomes a morula (undifferentiated cell mass)

  • Day 4: becomes a blastocyst

• Blastocyst imbeds in endometrium, usually in fundus

Explain the hormones of early pregnancy

• Outer layer of blastocyst, the trophoblast (chorion and placenta), produce human chorionic gonadotropin (hCG) on day 4

• corpus luteum secretes progesterone, estrogen, relaxin

categories of genetic mutations (translocation, deletion, inversions)

• Translocation – exchange of chromosomal material from one chromosome to another

• Deletion-segment of chromosome gets erased

• Inversions – reversed order of chromosome

Multifactorial inheritance

• Most common congenital conditions

• result of multiple genes and environmental interactions

Unifactorial inheritance and types

caused by mutations in a single gene

• Autosomal dominant and recessive

• X-linked dominant and recessive

Sex chromosomes abnormalities

Alterations in number of chromosomes:

Aneuploidy (monosomy or trisomy)

euploid=normal

Alpha-Fetoprotein (AFP) genetic test

Maternal serum blood test that looks for elevated levels of AFP (neural tube defects)

Triple & Quad Screening

Maternal serum measure of AFP, estriol, beta-HCG and inhibin A

checks for trisomy conditions

Fetal nuchal translucency (FNT) genetic screen

ultrasound to measure the thickness of the nuchal (neck) fold, measured in mm

checks for genetic disorders, trisomy conditions, and Turner’s syndrome

Cell-free DNA or non-invasive prenatal testing (NIPT)

• Maternal plasma is drawn and fetal cells extracted

• for Fetal sex, genotyping, Trisomy 13, 18, 21

• good test but high cost

risk factors or reasons for genetic testing

• Advanced maternal age (over 35)

• Known or suspected chromosomal rearrangement

• Previous pregnancy with congenital disorder

• History of perinatal loss

• Family history of congenital anomalies, genetic disorders

• Patient request

Discuss aspects of amniotic fluid including source, volume, and functions

• Produced by fetal kidneys & lungs at 10 weeks

• At term, approximately 1000mL

amniotic fluid functions

• Maintains constant temperature in uterus

• Cushions fetus

• Allows movement and development of fetal limbs, without fluid, contractures

• Antibacterial properties

• Critical to fetal lung development, fetal lungs will NOT develop in the absence of amniotic fluid

Describe the structure and function of the placenta

• Supplies oxygen and nutrients from maternal blood supply

• Carries out waste and CO2 from fetus

  • Exchange occurs in intervillous spaces

• Has endocrine and immune functions

• 2 layers: fetal side and maternal side

  • Maternal side: rough, convoluted, dull, attached to uterine wall, has cotyledons (bumps)

  • 2 fetal membranes: Chorion and amnion

Describe the umbilical cord structure and function

• 3 vessels (2 arteries and 1 vein)

  • Arteries: return blood to the placenta/chorionic villi

  • vein: carries nutrient and oxygen rich blood to the embryo/fetus

newborn assessment: general appearance

• Vital signs (no BP)

• Posture

• Color

• Alertness (usually first 1-2 hours)

newborn assessment: head

• Note shape

• Suture lines

• Fontanels: flat, bulging sunken

• Molding

• Caput succedaneum: edema that DOES cross suture lines, generally a result of birth

• Cephalohematoma: bleeding/edema under the periosteum and does NOT cross suture lines

newborn assessment: face

• Eyes: symmetric, closely or widely spaced

• Ears: top of the pinna should be above an imaginary line from the outer canthus of the eye

• Nose: nares patent? Newborns are nose breathers

• Mouth: intact, cleft lip or palate, teeth, suck reflex

newborn assessment: chest and abdomen

• Heart rate normal?

  • Murmurs common in the first few hours

• Size, shape, symmetry of respirations

• Assess clavicles for crepitus

• Breast development (breast tissue and nipples)

• Shape of abdomen: rounded, not scaphoid or sunken

• Abdomen is soft and nondistended

• + Bowel sounds

• Umbilicus: what does the cord look like (# of vessels, condition, hernia)

newborn assessment: genitalia

• 1st Void within 24 hours of birth

• Hernia (inguinal)

• Undifferentiated genitalia

• Male– foreskin or prepuce completely covers the glans

• Female– spotting can be normal, do not scrub to remove vernix

• Female– labia should cover the vestibule

newborn assessment: skin

• All skin structures are present at birth

• The epidermis and dermis are very thin

• Vernix caseosa is a cheese-like, whitish substance that is bound to the epidermis and serves as a protective covering.

• Skin of term newborn infant is erythematous for a few hours after birth then fades to its normal color

• May see petechiae on presenting part

• Hands and feet appear slightly cyanotic (acrocyanosis)

• Lanugo or fine hair may be present on the face, shoulders, and back

• For a term infant, creases should cover the palms and soles of the feet

• Desquamation (peeling) does not occur for the first few day but can be seen in the post-term newborn

root/suck reflex

• Elicit: Touch the lip, cheek, mouth with nipple or finger

• Response: Turns head toward the stimulus & opens mouth

grasp/palmar reflex

• Elicit: Place finger in the palm of hand

• Response: Infant fingers curl around finger

plantar reflex

• Elicit: place finger at base of toes

• Response: toes curl downward towards finger

swallow reflex

• Elicit: follows sucking, usually at a pause

• Response: may be slow/absent in preterm

Moro reflex

• Elicit: Hold infant semi-sitting allow head and trunk to fall backward

• Response: Symmetric extension and abduction of the limbs, thumb and forefinger can form a ‘C’, simulates an ‘embrace.’

tonic neck reflex

• Elicit: With the infant supine, turn the neck in one direction

• Response: The arm and leg on that side will extend

babinski reflex

• Elicit: backwards 7 on bottom of foot

• Response: big toe bends backwards and other toes spread

trunk incurvation reflex

• Elicit: Place infant prone and run finger down the back lateral to 1 side of the spine

• Response: Trunk is flexed and pelvis is swung toward the stimulated side

step reflex

• Elicit: Hold infant vertically and allow one foot to touch the table surface

• Response: simulate walking

Apgar scoring: respiratory effort

• 0: absent, not breathing

• 1: weak cry, stimulation needed

• 2: vigorous cry without stimulation

Apgar scoring: heart rate

• 0: 60 or below

• 1: 100 or below

• 2: over 100

Apgar scoring: tone

• 0: limp, flaccid

• 1: some flexion

• 2: active movement, limbs tightly flexed into trunk

Apgar scoring: reflex irritability

• 0: no response to drying, movement, or bulb suctioning

• 1: grimace or gag with stimulation

• 2: startle reflex (Moro), gag, sneeze

Apgar scoring: color

• 0: pale all over OR if any blue/gray extends beyond hands/feet

• 1: blue only on hands/feet

• 2: completely pink

Describe immediate care of the newborn infant after birth

• APGAR score

• skin to skin

• newborn medications

Newborn medications

• Vitamin K (phytonadione)

  • Single IM injection in thigh 

  • For blood clotting

• Erythromycin ophthalmic ointment

  • Applied across eye to prevent bacterial infection

anatomic and physiologic changes that occur in the postpartum period: cardiovascular

• Blood volume decreases

  • Diuresis (ECF)

• Cardiac output increases by 60-80% immediately post delivery

  • Returns to pre-labor values within 1 hour of birth

  • Returns to pre-pregnancy levels by 6-8 weeks postpartum 

• Shivering (SNS)

anatomic and physiologic changes that occur in the postpartum period: endocrine

• Estrogen & progesterone drop dramatically 

• Increased prolactin supports production of milk

• Oxytocin produced in response to nipple stimulation– triggers let-down reflex 

• Return of ovulation– 6-9 weeks postpartum if non-lactating

Describe components of a postpartum assessment (BUBBLE-HEAD)

• B-breasts

  • Engorgement, nipples

• U-uterus

  • Involution: shrinking by 1cm per day; fundal massage

  • Cesarean Incision: REEDA scale

  • Diastasis Recti

• B-bladder

  • Might displace fundus if distended, measure voids, frequent peri care

• B-bowel

  • Especially important post-cesarean delivery: passing flatus + bowel sounds in all 4 quadrants?

  • Soft abdomen is normal

  • Eat when hungry, prevent constipation, NPO if N/V

• L-lochia

  • 3 stages: Rubra, serosa, alba

  • Estimated blood loss should be less than 1000 mL

• E-episiotomy/lacerations/perineum

  • REEDA (redness, edema, ecchymosis, drainage, approximation)

  • Hemorrhoids and hematomas 

  • Can treat with ice packs and ibuprofen, topical applications

• H-hematocrit & hemoglobin

  • Leukocytosis, Hgb drops, Hct drops, clotting factors stay elevated

• E-extremities 

  • Increased soreness and edema, varicosities

  • Check for abnormal signs of thromboembolism 

• A-affect

  • PP blues Day 3 – Day 10, should not persist

  • Postpartum Depression: Lasts beyond the first 2 weeks and/or interferes with functioning

  • Psychosis: Can begin suddenly within 2 weeks after birth

• D-discomfort

vital signs unique to the postpartum period: temp

• Might be slightly elevated for 24 hours

• Chills and diaphoresis normal 

• Abnormal: over 101°F

vital signs unique to the postpartum period: heart rate

• 50-90 is normal, elevated for 1 hour after birth

• Gradually decreases over 48h, may be bradycardiac

• Tachycardia is abnormal, increases always an issue (sepsis)

vital signs unique to the postpartum period: respirations

16-24 is normal, shouldn’t be depressed

vital signs unique to the postpartum period: blood pressure

• Slightly increased, returns to normal in a few weeks

• Orthostatic hypotension risk for 48h

• Severe hypotension abnormal (hemorrhage)

Oxytocin medication

• Used to induce labor or strengthen contractions

• Given after birth to prevent hemorrhaging 

• Usually given IV

Fentanyl/morphine

• MSIR: morphine sulfate immediate release, 

  • oral analgesic, 15mg-30mg every 4-6 hours. 

  • Used for severe/breakthrough pain

• Ibuprofen and acetaminophen are gold standards for pain, rotate between the two

Erythromycin eye ointment

• Prevents chlamydia and gonorrhea (and E. coli, group B strep)

• Given within the first 1-2 hours

Rhogam

• Administered to mother within 72-hours of delivery if newborn is Rh positive and mom is Rh negative

  • Check blood type using cord blood sample

• Suppresses immune response in Rh-negative blood when exposed to Rh-positive blood (for mom in the future)