OB First: Exam 1

Nursing

• Nursing Shortage

• Collaborative Practice

• Standards of Nursing Care

• Respected Profession

Changes in Maternal-Newborn Nursing

• Family Centered Care:

  • Refers to the collaborative partnership among the individual, family, and caregivers to determine goals, share information, offer support, and formulate plans for healthcare.

• Emphasis on Early Prenatal Care:

  • Early, adequate prenatal care has been long associated w/ improved pregnancy outcomes.

  • It is a comprehensive process in which problems associated w/ pregnancy are identified and treated.

• 40 reasons to go 40

• Epidurals

• Increase in C-Section Rates

• Induction:

  • use of pitocin

• Birth Plans

• Newborns’ and Mother’s Health Portection Act of 1996

COVID-19 and Pregnancy & Birth

Maternal Mortality

• Complications during pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries.

Maternal Death is…

the death of a woman while pregant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Types of Families

• Nuclear

• Dual-Career/Dual-Earner

• Childless or Childfree

• Extended

• Single-Parent

• Blended

• Adopted

• Foster

• Binuclear

• Cohabitating

• Gay and Lesbian

Reproductive Assistance

• Infertility: lack of conception despite unprotected intercourse for at least 12 months.

  • If 35 or older, lack of conception despite unprotected intercourse for at least 6 months.

    _________________________________________________________

• IVF

• Fertility Clinic

Culture and Religion Influcences

• Culture: the beliefs, values, attitudes, and practices that are accepted by a population, a community, or an individual.

• Religion: institutionalized system that shares a common set of beliefs and practices.

Ethical Issues

• Rights of Parents

• Rights of Child

• Court Decisions

• Positive Drug Test

• Impact on Families

What is gestation?

• Period of time between conception & birth during which fertilized ovum matures & grows in the female's uterus.

AKA pregnancy

How long does gestation last?

40 weeks (280 days)

Female Reproductive Cycle

• 28 day cycle (typically)

• Day 14 → ovulation (ovum released from ovary so can be fertilized)

• Need to know cycle length to know when woman is ovulating so she can get pregnant.

Spermatogenesis is…

• The production of sperm.

• 200-400 million sperm released during ejaculation, but only 200 make it to uterus.

Where does fertilization usually occur?

Outer third of Fallopian tube (ampulla)

When is Ovum receptive to fertilization after release from Ovary?

24-48 hours

How long is sperm viable after ejaculation?

24-72 hours

What is a Zygote?

Fertilized Ovum will begin cell division

When does the Blastocyst implant to the endometrium & implant on top of Uterus?

6-10 days

What is gestational age?

• Age of pregnancy from last normal menstrual period (LMP); starts on 1st day of last period.

  • Most people reference this for their pregnancy.

What is fetal age?

The actual age of the growing baby from conception.

The pre-embryonic stage is the…

First 14 days

Embryonic Stage

• 15 days to 8 weeks

  • Most critical period b/c all main organ systems are being developed.

  • Most vulnerable to malformation by environmental teratogens.

The fetal stage lasts from __ weeks to __ weeks.

9 weeks to 40 weeks

When is the heart beating in an embryo?

4 weeks

When are the organs fully developed, but not fully functional?

8 weeks

Teratogens are…

Any agent or factor that induces or increase the incidence of abnormal prenatal development.

What are teratogenic agents?

• Alcohol

• Tobacco

• Medications (Prescribed, OTC, illegal)

• Infections

• Herbs

What are other factors that affect development?

• Quality of Sperm and Ovum:

  • older eggs possibly increase rx of down syndrome; older sperm quality diminishes and can cause some abnormal development.

• Genetics

• Maternal Nutrition

• Maternal Hyperthermia:

  • extreme increases in body temperature (avoid hot tubs/saunas, etc. esp early on)

Trimesters

• 1st trimester: from conception to the end of 12th week

• 2nd trimester: from week 13 through 27

• 3rd trimester: from week 28 through 40

When are fetal heart tones heard by Doppler?

8-12 weeks

When can baby's gender be seen?

16 weeks

What occurs when baby is 20 weeks in uteuro?

• Mom can feel movement called quickening—first movement of the baby.

• Baby develops regular schedule of sleeping, sucking, & kicking.

• Hands can grasp.

• Head hair, eyebrows, & eyelashes present.

What happens when a baby is 24 weeks in uteuro?

• Activity increases

• Fetal respiratory movements begin (moves fluid in and out to practice for air)

What happens when a baby is 28 weeks in uteuro?

• Eyes begin to open & close (fused before now)

• 2/3 baby's final size

What happens when a baby is 38+ weeks in uteuro?

Baby gets antibodies from mother (decreases risk for sickness)

Amniotic Fluid

• Liquid surrounding the fetus in uterus.

• Absorbs shocks, permits fetal movement, & prevents heat loss (absorbs & protects baby).

• Volume of fluid changes constantly (increases w/ pregnancy) --- baby adds to fluid level b/c baby pees & kidneys start functioning.

• Fetus swallow fluid for lung movement.

• Fluid flows into & out of fetal lungs.

• Fetus urinates

• Oligohydramnios vs. Polyhydramnios

  • O: (too little fluid; cause: kidneys not functioning)

  • P: (too much fluid; cause: high BBG in mother—insulin resistant → mom is thirsty and pees a lot and then baby pees a lot → increased rx of rupturing)

Amniotic Fluid Functions

• Temperature Control

• Protection

• Growth & Development

  • allows room to grow—IUGR

• Prevention

  • makes amnion not attach to baby, which can make something not grow like a hand, foot, fingers, toes, etc.

Dirty Duncan Side of Placenta is who's side?

• Maternal blood supply & nutrients that are attached to mom.

• Attached to uterine lining itself.

Shiny Schultz of Placenta is who's side?

The fetal side.

What does the Placenta provide?

• Fetal Oxygen-Carbon Dioxide exchange

• Essential nutrients

• Excretion of metabolic waste products

• Needed metabolic processes

Placenta Functions

• Metabolism:

  • synthesizes glycogen in early pregnancy.

• Organ of Transfer:

  • responsible for transfer of materials between maternal & fetal circulation.

• Endocrine Synthesis:

  • hCG—human chorionic gonadotropin; picked up on prego tests & causes nausea in women; increases until 10 weeks.

  • hPL—human placental lactogen; insulin antagonist, allows glucose to be free to let baby grow; higher 24-28 weeks.

  • Estrogen & Progesterone—development & more.

Umbilical Cord

• Lifeline between baby & mom

• AVA: 2 arteries & 1 vein

• Wharton's Jelly: connective tissues keeps the cord open so no compression on the arteries or vein.

• Usually around 22 inches long.

• No nerve fibers in cord so won't hurt baby.

Nuchal Cord

It is a cord wrapped around baby (usually around neck).

Fetal Circulation

• The cardiovascular system is the 1st organ system to function in developing human.

• Most of blood supply bypass lungs (since no respiratory gas exchange).

• Placenta assumes the function of the fetal lungs.

Path of Oxygenated blood from Placenta

1. Travel through umbilical vein

2. Ductus Venous (shunt @ liver)

3. Inferior Vena Cava

4. Right Atrium

5. Foramen Ovale (shunt to left atrium - bypasses lungs)

6. Left atrium

7. Left ventricle

8. Aorta

Path of Deoxygenated Blood Route to Placenta

1. Superior Vena Cava

2. Right atrium (through tricuspid valve)

3. Right ventricle

4. Ductus arteriosus (shunts from pulmonary artery from lungs since non-functioning)

5. Aorta

6. Descending Aorta

7. Umbilical arteries

8. Placenta

What are the shunts of Fetal Circulation?

• Ductus Venosus: shunt @ liver

• Foramen Ovale: shunts to the left atrium - bypasses lungs

• Ductus Arteriosus: shunts from pulmonary artery from lungs since non-functioning

How long does the Foramen Ovale stay open?

24 hours after clamping; You can hear a murmur which is normal.

Presumptive Signs of Pregnancy

• Amenorrhea (no menstrual period)

• Nausea/vomiting (“morning sickness” but for some “all-day sickness”)

• Urinary frequency

• Breast changes

• Fatigue

Probable Signs of Pregnancy

• Enlargement of abdomen

• Hegar's Sign: softening of uterus isthmus.

• Goodell's Sign: softening of cervix.

• Chadwick's Sign: blue discoloration of cervix b/c increased blood supply.

• Positive pregnancy test:

  • false negatives can occur.

• Pigmentation of skin:

  • chloasma—pigmentation of the face; butterfly effect.

  • linea nigra—dark line on abdomen.

• Striae:

  • stretch marks.

Positive Signs of Pregnancy

• Fetal heartbeat (using doppler)

• Fetal movement on palpation

• Ultrasound

Assessment Health History

• Menstrual Cycles/Gynecological History

• Obstetric:

  • prior pregnancies

• Medical:

  • diabetes, HTN, mental health, meds, etc.

• Health Care Activities:

  • exercise, jog, etc.

• Nutrition:

  • Need Ca & Fe, limited folic acid

• Exercise

• Roles & Relationships:

  • support system for stress

Physiologic Changes During Pregnancy

• Uterus: gets larger and pushes everything away as it's growing.

• Cervix: softens & changes to have the baby; develops mucus plug to protect baby against infection.

• Vagina: more muscular; vaginal secretions become more acidic for protection of baby, but increased rx for infection.

• Breasts: enlarged for lactation, areola darken & leak colostrum (1st milk).

• Thyroid Gland: release of T4 is increased so she stays warmer.

• Respiratory: can't get good deep breaths b/c baby is pressing up on diaphragm and lungs.

• Cardiovascular: produce 40% more blood volume, more hemoglobin; H&H decreased b/c diluted w/ blood volume.

• Urinary: urgency & go a lot more.

• Gastrointestinal: slowing of peristalsis b/c everything moved around; constipation which can lead to hemorrhoids.

• Musculoskeletal: may waddle b/c things are relaxed in joints and lordosis.

• Integumentary: darkening of areola, linea nigra, chloasma, acne, & patches of hair they didn't have before.

• Neurological: baby may be pushing on certain nerves (sciatic).

Hormones for Pregnancy

• Estrogen: helps prepare for lactation; will have lower level than progesterone during pregnancy b/c it will make uterus irritable, but after baby is delivered, estrogen levels will rise to allow uterus to contract.

• Progesterone: level has to stay high to keep the uterine lining thick or else mom will lose the pregnancy; relaxes the uterus; prepares breast for lactation.

• Relaxin: causes uterus not to contract; softens the cervix and relaxes joints in preperation for L&D.

• Human Chorionic Gonadotropin (hCG): hormone that is tested for in pregnancy tests; produced in the first several weeks; labwork to see if mom is losing the pregnancy)

Beta-Human Chorionic Gonadotropin (hCG)

• Released from the placenta in increasing amounts.

• Levels should double every 48 hours in a normally developing pregnancy.

• Peaks at week 10 and then declines.

• Almost undetectable at term.

• Used for urine pregnancy test (positive 10 days after conception).

Nagele's Rule

• Based on 28 day cycle.

• 1st day of last menstrual period (LMP) Subtract 3 months & add 7 days.

Ex: LMP - Aug 10, 2024 & EDD - May 17, 2025

Full term

Delivery is any birth 38+ weeks.

Pre term

Delivery is birth between 20-37 weeks.

Postdate

Delivery is any delivery after the completion of the 40th week.

Abortion

Delivery before the age of viability (before 20 weeks).

Gravida

• Refers to the # of times that a woman has been pregnant.

  • nullgravida, primigravida, multigravida

Parity (Para-)

Refers to # of births

Gravida/Para Counting Systems: 5 Digit

G - # of pregnancies

T - # of term deliveries

P - # Preterm

A - # of abortions

L - # of living children

Gravida/Para Counting Systems: 2 Digit

• Gravida (# of pregnancies)

• Para (# of births 20 weeks +)

  • The quickie way used in the hospital setting.

Fundal Height

• Is used to determine if baby is growing how it should.

• The fundus measures the very top of the uterus.

• Just a quick and easy tool; measured in cm.

• Not as accurate towards the end of pregnancy as the baby drops.

  (seen in second pic below)

Prenatal Lab Tests

• CBC

• Blood Type & Rh factor:

  • + or -; will have issues w/ future pregnancies.

• Rubella titer:

  • If mom is not immune, we cannot give her the vaccine while she is pregnant b/c the vaccine is a live virus.

• Urinalysis

• STD's

• Hepatitis B

• HIV

• Group B Strep:

  • inactive in the vaginal/rectal area and may become activated and make baby sick.

• Quad Screen:

  • determines things like down syndrome - not 100%

• Oral Glucose Tolerance Test

Fetal Heart Rate

• Normal Range: 110-160

• Doppler (easiest)

• Fetal monitor

What is an ultrasound?

• High-frequency sound waves that may be directed, through the use of a transducer, into the maternal abdomen.

• The ultrasonic sound waves reflected by the underlying structures of varying densities allow identification of various maternal and fetal tissues, bones, and fluids.

Uses of Ultrasound

• Location & presence of early pregnancy

• Gestational age & maturity

• Fetal weight

• IUGUR (intra uterine growth restriction)

• Polyhydramnios or Oligohydramnios

• Fetal death

• Placenta location:

  • should be in the upper part of the uterus; if low → placenta previa → c-section)

• Biophysical profile:

  • anything below 8 then baby is compromised.

• Fetal lie & presentation:

  • able to see if baby is in postion w/ head down ready for delivery.

Biophysical Profile

1. Fetal heart rate acceleration

2. Fetal breathing

3. Fetal movements

4. Fetal tone

5. Amniotic fluid volume

** Looking for fetal well-being when doing this.

** Monitor is placed to monitor fetal HR and the ultrasound is used to see other areas of the baby.

** Each category can get a score of a 2; there are 5 categories; a perfect score is a 10; a score below an 8 will make the provider think of negative outcomes.

Amniocentesis

• Procedure that is done to obtain amniotic fluid for testing.

• Indications:

  • Diagnosis of genetic disorders or congenital anomalies

  • Assessment of pulmonary maturity

  • Diagnosis of hemolytic disease

Daily Fetal Movement Recording is a…

Maternal assessment of fetal activity; # of fetal movements within a specified time are counted.

AKA kick count

NonStress Test (NST)

• Evaluation of fetal response (Fetal heart rate) to natural contractile uterine activity or to an increase in fetal activity.

• Reactive:

  • at least 2 accelerations that occur w/ movement lasting 15 seconds with increase of 15 beats in 20 minutes.

• Non-reactive:

  • above criteria not met.

Reactive NST

Nonreactive NST

Contraction Stress Test

• Test to stimulate uterine contractions for the purpose of assessing fetal response.

• A healthy fetus doesn't react to contractions (a negative stress test).

  • The baby can handle the contractions so the baby HR increase.

• A compromised fetus demonstrates late decelerations in fetal HR (a positive stess test; as shown in picture).

  • This means that the baby is not tolerating the contractions and they are not being well-oxygenated.

1st Trimester Discomforts

• Nausea/Vomiting

• Urinary Frequency/Urgency

• Fatigue

• Breast tenderness

• Nasal stuffiness & epistaxis

2nd & 3rd Trimester Discomforts

• Heartburn (pyrosis)

• Hemorrhoids (no straining)

• Ankle Edema

• Varicosities

• Leg cramps

• Round Ligament Pain

Danger Signs of Pregnancy

• Vaginal Bleeding

• Edema face & fingers

• Severe, continuous HA

• Blurred vision, dizziness

• Abdominal pain

• Persistent vomiting

• Fever & chills

• Sudden or constant leakage of fluid from vagina

• Scant amount of urine

• Absence or decrease in fetal movement

Prenatal Visits

• Every 4 weeks until 28 weeks.

• Every 2 weeks until 36 weeks.

• Every week until delivery after 36 weeks.

Weight Gain

• Total weight gain: 25-35 lbs

• 1st trimester: 3-5 lbs

• 2nd & 3rd trimester: 1 lb/wk

_____________________________________

11 lbs - baby & amniotic fluid

2 lbs - uterus

4 lbs - increased blood volume

3 lbs - breast tissue

5-10 lbs - fat (maternal stores)

Antepartum: Keys to Nutrition

• Calories

• Folic Acid—leafy greens (spinach, asparagus), citrus friuits (oranges, grapefruits, lemons), fortified foods (cereals, bread, pasta), legumes (black beans, lentils, chickpeas)

• Iron—red meat, poultry, fish, liver, spinach, tofu, etc.

• Calcium—dairy products, kale, collard greens, orange juice, tofu, almonds.

Additional Care for Pregnant Women

• Rest

• Exercise

• Sexual Activity (unless dr says no)

• Travel (make sure you walk so no blood clots)

Preparation for Childbirth

• Early pregnancy classes

• Infant care classes

• Breastfeeding classes

• Sibling classes

• Childbirth classes

Theories of Labor

• Uterine distention, increasing uterine pressure

• Aging of placenta

• Increased sensitivity to Oxytocin (normal hormone that produces breast milk & induces labor)

• Changes in barometric pressure --> more L&D's

• Changes in hormonal concentration:

  • Estrogen increase

  • Progesterone decreases

What are early signs and symptoms of impending labor?

1. Lightening: (baby dropping) fetus descends into the pelvic inlet (engagement).

Pressure is then moved from the pressing up against the diaphragm to the lower abdominal area causing:

• leg cramps, increased pelvic pressure, venous stasis, urinary frequency, increased vaginal secretions.

2. Braxton-Hicks Contractions: irregular intermittent contractions; may become uncomfortable ((False contractions/labor)).

3. Cervical changes: softening (ripening)

4. Bloody show: cervical secretions mixed with some blood from ruptured capillaries; mucus plug is expelled.

5. Ruptured Membranes: occurs in 8-10% of women prior to labor; 80% will go into labor within 24-48 hours.

6. Sudden burst of energy

7. Others: weight loss, back ache, indigestion, diarrhea.

What are the components of true labor?

• Presence of Bloody Show:

  • pink mucus

• Contractions:

  • regular pattern

  • interval shortens

  • intensity increases

  • duration increases

  • starts from back to front

  • intensified by walking

• Cervix:

  • change in dilation and effacement

***WHAT DETERMINES TRUE LABOR IS DILATION OF THE CERVIX AND REGULAR CONTRACTIONS!!!

What are the components of false labor?

• No Bloody Show:

  • brown mucus (old blood)

• Contractions:

  • irregular pattern

  • no change in intervals

  • no change in intensity

  • stays in the front

  • not changed by walking

• Cervix:

  • no change

Electrical Fetal Heart Monitoring is…

Commonly used for tracking how well the baby is doing within the contracting uterus and for detecting signs of fetal distress.

Leopold's Maneuver

What does the external fetal monitoring strip tell us?

• Identifies baseline of fetal HR.

• Determines whether there are accelerations or decelerations from the baseline.

• Identifies patterns of uterine contractions.

• Correlate accelerations & decelerations with uterine contractions.

With this, we can determine if the recording is reassuring/reactive, non reassuring/nonreactive, or ominous!

Segments of Contractions

• Frequency: how often contractions come in minutes (from start of contraction to start of another); a range; increases if progressing.

• Duration: length of contraction; a range (from the start of the contraction to the end of that contraction)

• Intensity: how hard/strong contraction is (not accurate on external monitor--usually just ask momma—pain scale; feeling the fundus)

If there is minimal/absent variability on the strip, the baby could be sleeping, so you will give momma some…

SUGAR

Normal Fetal HR Range

110-160 bpm

Determine Baseline of Baby's HR

1. Average Fetal HR that occurs during a 10 min segment.

2. Excluding periodic rate changes.

3. Excluding time during a contraction.

What is variability?

• Small up & down fluctuations.

• Want in a healthy baby.

Moderate Variability means a…

Well developed, well oxygenated fetus, and a good sign for fetal well being.

Absent or Minimal Variability is caused by…

• Fetal Academia Secondary to Placental Insufficiency

• Cord Compression

• Preterm Fetus

• Maternal Hypotension

  • mom is not well hydrated (Ex: bottoming out after an epidural)

• Uterine Hyperstimulation

  • uterus is contracting too often → not enough oxygen going to baby.

• Placental Abruption

  • placenta is pulling off the uterus.

• Fetal Dysrhythmia

Marked Variability

• More than 25 beats of fluctuation in the FHR baseline.

• Usually caused by:

  • Cord Prolapse or Compression

  • Maternal Hypotension (mom is not well hydrated.)

  • Uterine Hyperstimulation/Tetonic—hard & stays hard (too many contractions, too close & uterus needs a break)

  • Placental Abruption—(placenta pulls away from uterus - no blood or O2)

Interventions for Absent, Minimal, and Marked Variability

These are standing orders!

• Lateral positioning of mother (left side is optimal; NO back)

  • Baby is laying on the cord!

• Stop the Pitocin (oxcytocin) if infusion running

• Increase IV fluid rate

  • decreased amniotic fluid, etc.

• Administer Oxygen 8-10 mL/min by mask

  • mom needs oxygen

• Consider internal fetal monitoring

• Notify MD

  • One of the last things to do.

  ***If no change after these interventions, may need to prepare for C-section!***