HNM109 Exam Revision

Complete miscarriage

body has passed all of the pregnancy tissue

Ectopic pregnancy

embryo implants outside of the uterus

Fetal Alcohol Spectrum Disorder (FASD)

diagnostic term for severe neurodevelopmental impairments that result from brain damage caused by alcohol exposure before birth

Glycosuria

presence of excessive amounts of glucose in the urine, which normally contains little to no glucose

Incomplete miscarriage

some but not all of the pregnancy tissue has passed.

Inevitable miscarriage

miscarriage that has started, pregnancy tissue is still in the uterus

Missed/silent miscarriage

embryo/ fetus has died but remains in the uterus

Placenta previa / abruption

previa: placenta covering the cervix

abruption: placenta (abruptly) separating too early from the uterus

Pre-eclampsia

serious pregnancy disorder that causes high blood pressure and organ damage, particularly to the kidneys, typically after 20 weeks of pregnancy or in the postpartum period

Proteinuria

too much protein in the urine

Stillbirth

death of a baby during pregnancy after 20 weeks of gestation or at a weight of 400 grams or more

Sudden Infant Death Syndrome (SIDS)

unexpected and unexplained death of an infant under one year of age, typically during sleep, after a thorough investigation has found no specific cause

Teratogens

an agent that increases the incidence of congenital malformation

Threatened miscarriage

body shows signs that you may miscarry.

Internal os

constriction at the upper end of the isthmus (lower part of uterus that connects to cervix)

Cornu

junction between each fallopian tube + uterus

Fallopian tubes

functions

• capture the egg

• facilitate fertilization by transporting sperm to the egg and providing a suitable environment for fertilization

  • transport the fertilized egg (embryo) from the ovary to the uterus for implantation

Fundus

area above + between uterine tubes (fallopian)

Histological internal os

transition point between the endocervical canal and the uterine body

Oocytes

eggs

Supravaginal cervix

upper larger potion of cervix that extends from the internal os to the external os

Aneuploidy

genetic condition where a cell has an abnormal number of chromosomes, either an extra or a missing copy, rather than the typical 46 in humans

Atresia (of oocytes)

physiological process of degeneration and death of oocytes (immature eggs) and their surrounding follicular cells within the ovary

FSH (follicle-stimulating Hormone)

produced by the pituitary gland that regulates the reproductive system. - stimulates egg development in the ovaries and helps maintain the menstrual cycle and ovulation

Gonadotrophin

set of hormones that stimulates the gonads (ovaries and testes) to produce other hormones and gametes

HPO (hypothalamic-Pituitary-Ovarian) axis

key endocrine system that regulates female reproduction by controlling the menstrual cycle and ovulation

hCg - human chorionic gonadotropin

hormone produced during pregnancy, detected by all pregnancy tests and used to monitor pregnancy progression

Menopause

natural end of your reproductive life, marked by 12 consecutive months without a period and a decline in hormone (estrogen) levels

Primary ovarian insufficiency (POI)

loss of ovarian function before age 40, leading to irregular or absent periods and infertility.

Monotrophic rise

refers specifically to the pattern where only one hormone (e.g. follicle-stimulating hormone or FSH) rises while others like estradiol remain relatively unchanged

Oestrogen

female sex hormone produced mainly by the ovaries, responsible for sexual and reproductive development, bone health, and other bodily functions - promotes growth of muscle fibres

Oogenesis

Process of female gamete (egg cell) formation in ovaries - First meiotic division begins before birth but is arrested until post-puberty

Ovulation

Oestrogen increase → LH surge → stimulates prostaglandin release → oestrogen drops → rupture of vesicular follicle (aka egg release)

Progesterone

endogenous steroid hormone, a type of progestogen, crucial for the female menstrual cycle, pregnancy, and embryogenesis

4Ds

When feeling an urge to smoke:

• Delay

• Deep breathe

• Do something else

• Drink water

5 A’s

Steps to intervention:

Ask, Advise, Assess, Assist, Arrange

motivational R’s

Relevance, Risk, Reward, Roadblocks, Repetition

BMI formula

weight/ height^2

Naegele's Rule

add 7 days to the first day of the LMP and subtract 3 months, or add 9 months.

Cardiotocography (CTG)

medical test to monitor a baby's heart rate and uterine contractions

Pulsality index

non-invasive measurement that quantifies the degree of blood flow pulsatility in an artery

fetal middle cerebral artery pulsality index

assesses blood flow resistance in the fetal brain

Embryogenesis

process of forming a fertilized egg (a zygote) into an embryo

Electronic fetal monitoring

use of electronic fetal HR monitoring for evaluation of fetal wellbeing in labour

• external FHR monitoring: uses a device to listen to or record fetal HR through mother’s abdomen

• internal FHR monitoring: uses an electronic transducer connected directly to fetal scalp

Fertilisation

biological process in sexual reproduction where a male gamete (sperm) and a female gamete (ovum or egg) fuse to form a new single cell called a zygote

Group B Strep

common bacterium that usually causes no problems but can lead to serious infections in newborns.

• GBS can be passed to a baby during birth, leading to potentially life-threatening conditions like sepsis, pneumonia, or meningitis.

• Preventive antibiotics during labor protect the baby, and if a baby develops GBS, it can be treated with antibiotics after birth.

NST (non-stress test)

safe, non-invasive prenatal test that monitors a baby's heart rate and movement during the third trimester to assess fetal health and well-being

Oral glucose tolerance test

medical test that measures how the body responds to sugar; used to diagnose conditions like diabetes, pre-diabetes, and gestational diabetes

Non-invasive prenatal screening/ prenatal testing (NIPS/ NIPT)

examines cell-free DNA from the placenta circulating in the mother's blood.

• It screens for common chromosomal abnormalities, including Trisomy 21 (Down syndrome), Trisomy 18 (Edwards syndrome), Trisomy 13 (Patau syndrome)

Surfactant

increases lung compliance (can be inflated with less effort) - collapse of alveoli is prevented, absorbs lung fluid after birth

Umbilical artery Doppler velocimetry (DV)

used to assess flow velocity waveforms in the fetal umbilical artery

umbilical vein

takes O2 blood to liver then heart (inferior vena cava)

ductus venosus

allows blood to go through umbilical vein to meet up with inferior vena cava

• shortcut through liver

foramen ovale

sends blood from RA → LA

• opening between the heart's left and right atria that is essential for fetal circulation

• allows oxygenated blood from the placenta to bypass the lungs and enter the systemic circulation

ductus arteriosis

vessel b/w pulmonary artery + aorta

umbilical artery

takes blood back to placenta

“FETUS” acronym:

Foetal movement felt by experienced clinician

Electronic device detects foetal heartbeat

The birth of the baby

Ultrasound detects baby

See visible movements (experienced clinician)

“PROBABLE” acronym:

• Positive pregnancy test

• Returning of fetus when uterus is palpated - ‘ballotement’

• ‘Osiander’s sign’ - pelvic congestion - pulsation of fornices

• Braxton-Hicks contractions

• A softening of the cervix (Goodell’s sign)

• Bluish colour of vagina + cervix ‘Chadwick’s sign’

• Lower uterine souffle (whistling noise)

• Enlarged uterus/ abdomen

• Skin changes - pigmentation changes

“PRESUME” acronym

• Period absent

• Really tired

• Enlarged breast

• Sore breast

• Urination increased

• Movements (maybe?)

• Emesis (N+V)

Gravidity

the number of times a woman has been pregnant

Parity

number of times that she has given birth to a fetus with a gestational age of ≥20/40

Sepsis

body’s immune system has an extreme response to an infection

Vaginal functions

• Escape of menstrual blood flow

• Coitus with entry of the male penis

• Birth of the fetus, placenta and membranes

role of the midwife

Midwife = professional who works in partnership with women to give necessary

Woman-centred care

Philosophy - work in partnership with the woman

Continuity of care

• meeting the same health professional for each antenatal visit + ongoing labour, birth and postnatal care

  • Opposite = fragmented care (seeing many different healthcare professionals)

  • Aligned with midwifery primary care

  • Can be provided under private obstetric care

Effect of smoking on the baby

• carbon monoxide replaces some of the oxygen in the blood

• → reducing amount of O2 baby receives via umbilical cord

• affects how placenta forms

• reduces nutrients crossing placenta to the baby

Associated risks of smoking

• increased risk of Sudden Infant Death Syndrome (SIDS)

• miscarriage

• ectopic pregnancy - embryo implants outside of the uterus

• low birthweight

• small gestational age, pre-term birth (less than 37 weeks)

• weaker immune system

• pre-eclampsia

• long term damage to lungs/ brain/ blood e.g. asthma or pneumonia

• placenta issues

  • placenta previa: placenta covering the cervix

  • placental abruption: placenta separating too early from the uterus

What actions should the midwife take thereafter in terms of assessing smoking behaviours?

• See if they need written resources or a Quitline referral

• Quitline - refer woman if they are smoking during the pregnancy

• monitor the baby closely

• continue encouraging mother/partner to stop smoking

Effect of alcohol on the baby

• No safe level of alcohol consumption during pregnancy/ breastfeeding has been identified

• Risk of harm to the fetus increases the higher the amount + frequency the mother drinks

Associated risks of alcohol on baby

• lower birth weights

• miscarriage

• stillbirth

• premature birth

• birth defects

• a range of conditions known as Fetal Alcohol Spectrum Disorder (FASD)

Effect of alcohol on breastfeeding

• alcohol crosses into the breastmilk and can:

  • stay there for several hours

  • reduce the flow of your milk (this can unsettle your baby and cause them to eat and sleep less)

  • affect how the baby’s brain and spinal cord develops

What sort of support will help women to reduce or cease alcohol use in pregnancy?

• Pregnant Pause

• support network - e.g. family, partner, friends

What actions should the midwife take thereafter in terms of assessing smoking behaviours?

• See if they need written resources or a Quitline referral

  • Quitline - refer woman if they are smoking during the pregnancy

• monitor the baby closely

• continue encouraging mother/partner to stop smoking

• urge to smoke, 4Ds

Diet changes for nausea/ morning sickness

• can be made worse by sugary foods (e.g. ginger stuff)

• made better with carbs + proteins (meals + small snacks throughout the day

• avoiding refined, fried and spicy foods

• eat foods rich in B group vitamins

• reduce coffee + tea

Diet changes for constipation

• can be helped with increased fibre intake (fruit + veggies, grains, beans + lentils, brown rice, nuts, seeds, dried fruits)

Diet changes for heartburn

• avoid fried, fatty, spiced foods

• avoid coffee, tea, alcohol, cigarettes (worsen heartburn)

• chew food thoroughly + eat slow

• eat apple, pineapple, papaya, kiwifruit (have enzymes which speed digestion of food)

• eat raw almonds / cashew nuts

How BMI affects where woman gives birth:

• low pre-pregnancy BMI: increased risk of

  • preterm birth, small for gestational age, low birthweight

• high pre-pregnancy BMI: increased risk of

  • large for gestational age, macrosomia, childhood obesity/ overweight

What foods should pregnant women avoid in pregnancy and why?

• undercooked or raw meats, fish, and eggs

• pate - avoid

• very high in vit A, too much may not be good for bebe

• blue cheese - avoid

Important micronutrients

folic acid, iron, calcium, iodine, and vitamin D

Role of motivational interviewing

The suggested structure (5Rs) below may assist with discussion on smoking behaviours + other behaviours

Physiological factors affecting fertility

Age + menopause

• as a woman grows older, ongoing atresia (death) of oocytes

• decrease in quality of oocytes with advancing maternal age

  • shown by higher incidence of chromosomal anomalies e.g. aneuploidies —> reduce chances of successful fertilisation, implantation and early embryo development

Menopause timing

• estimated that natural fertility ceases ~10 years before menopause

• primary ovarian insufficiency (POI): menopause before the age of 40 years

  • aka premature ovarian failure or hypergonadotrophic amenorrhoea

  • once this condition is established, fertility is usually lost, although spontaneous pregnancies may occur

Epigenetics

• changes in gene expression caused by the environment

• environmental factors can cause epigenetic changes assoc w DNA methylation + histone proteins

• can shorten functional life span of a woman’s ovaries

Pelvic diseases

• e.g. endometriosis, neoplasms, infection

• may involve surgery

  • which can lead to early menopause

Body-fat connection

• excessive exercise/undernutrition can postpone puberty, reduce fertility, prevent menstruation

Older women and childbirth

• women over 35 may have more difficulty conceiving, are more likely to bear twins

• declining fertility (may be due to less-frequent ovulation or problems e.g. endometriosis)

• risks that increase with age

  • Miscarriage

  • chromosomal abnormalities (#1 cause of miscarriage)

  • hypertensive complications (increase w/ age)

Teenage pregnancy

• tend to be poor + relatively socially and economically disadvantaged espec. compared to older mothers

Conception factors + lifetime health

Vaccinations

• German measles (Rubella): normally a mild viral disease; however, infection during the first 20 weeks of pregnancy can result in severe abnormalities in an unborn baby.

• Chicken pox: in very early pregnancy/ close to the baby’s due date can cause infection in the baby, miscarriage or possible abnormalities. COVID-19 vaccination: The Pfizer vaccine (Cominarty) and Moderna vaccine (Spikevax) are safe and effective at any stage of pregnancy, or if breastfeeding or if planning to get pregnant.

• Flu vaccination: Pregnant women can become quite sick with flu and are also at risk of complications. 

• Whooping cough: Whooping cough (pertussis) vaccination does not last a lifetime.

Fetal alcohol spectrum disorder (FASD)

• important that women don’t drink alcohol until they know whether they’re pregnant

• Sperm - not sure how it’s affected by alcohol so it is best for both parents to avoid when trying

• alcohol decreases/ inhibits milk production

  • enters breast milk approx. 30-60 mins after you start drinking

  • for every standard drink, need to wait at least 2 hours before you can breast feed

• avoid drinking for first month post birth

  • always breastfeed baby before you drink

• If there is alcohol in ur system, no amount of pumping and dumping will clear the alcohol

  • only once bloodstream has cleared of alcohol that breastmilk will clear

Vaping + smoking

• Smoking = most common + impo factors affecting follicle maturation due to compounds in tobacco

• nicotine from e-cigarettes passes through placenta - same as tobacco

• nicotine + other chemicals can interfere with milk supply and pass into breast milk

Pre-conception health

• underweight + overweight obesity can impact chance of conception + healthy pregnancy

  • high BP, diabetes, blood complications

  • underweight during pregnancy is assoc w/ pre-term birth

Oogenesis process

• First meiotic division begins before birth but is arrested until post-puberty

Ovulation process

• Begins when oestrogen levels peak; ends when vesicular follicle ruptures

  • Triggers release of 2ndary oocyte (surrounded by zona pellucida and corona radiata)

1. Rise in oestrogen levels (~48h before ovulation) triggers LH surge

2. luteinizing hormone (LH) interacts with LH receptors on granulosa cells (increasing production of oestrogen by dominant follicles)

3. High level of LH stimulates production of prostaglandins (PGF2a and PGE2)

• Allows primary oocyte to complete 1st meiotic division + become secondary oocyte

4. Simultaneously, oestrogen lvls drop + proteolytic enzymes are synthesis

• Breaks down thecal cells + assist rupture of vesicular follicle = egg release

Fertilisation

1.  Capacitation 

• process of maturation enabling a freshly ejaculated sperm to fertilize an ovum

• Glycoproteins + seminal plasma proteins removed from acrosome (head of sperm cell)

2. Acrosome reaction= acrosome cap perforates - contents in acrosomal vesicle are released

• Lytic enzymes released around oocyte

  • Digests first physical barrier and corona radiata follicular cells disperse

• Sperm makes contact with zona pellucida + binds with glycoproteins on its surface

• Enters cytoplasm of the ovum

• Cell membranes of oocyte + sperm fuse

  • Head + tail of sperm enter the oocyte (leaving the sperm’s plasma membrane behind)

• ***oocyte completes 2nd meiotic division

Describe the changes to the uterus that facilitate growth of the embryo

• pear-shaped —> globular (until 20w)

  • upper part enlarges due to estrogen

• pelvic is anteverted —> upright + inclines/ rotates to the right

  • due to colon in left side of pelvic cavity

• uterine wall 10mm —> 25mm

• lower uterus 7mm —> softens + elongates to 25mm

  • differentiation of lower uterine segment

• size 7.5cm length 2.5cm wide/deep —> 20cm long, 25cm wide, 22.5 deep

• 50g weight —> 80 + 1200g

  • x20 increase

• muscle fibres —> early pregnancy: more fibres + more compliant —> term: muscle fibres increase three-fold

  • due to hyperplasia; due to estrogen

Uterine muscle during pregnancy

• (like other smooth muscles) - uterus is spontaneously contractile

• Can perform considerable muscular feats to expel its contents (e.g. during menstruation + childbirth)

  • At other times, it's prevented from contracting

  • Must remain inactive to allow development + growth of fetus + placenta during pregnancy

• Uterus usually follows predicted rate of growth (only a reliable indicator of gestational age in 20/40)

• Main part of uterine growth during second half of pregnancy is almost entirely due to hypertrophy (size increase)

  • Growth of the fetus acts as powerful stimulator for growth of contractile proteins of the myometrium

Hormonal influences on uterus in pregnancy

• Oestrogen + progesterone (initially from corpus luteum + placenta) are mainly responsible for influencing uterus

  • Oestrogen promotes growth of muscle fibres

  • Progesterone maintains inactiveness of myometrium

• Interaction has growth-promoting effect ⇒ increases uterine muscle compliance

Actions of oestrogen + progesterone on target cells

• estrogen stimulates RNA synthesis

• Progesterone's role is less understood

  • May be responsible for increasing membrane resting potential in pregnancy (so muscle fibre contractions are less likely to occur)

CVS - physiological changes

- Plasma volume increases by 30%-40% (approx 1,500mL) between weeks 7–34

- Cardiac output increases by 30%-50% (from 5L/min at 10 weeks to 6.5L/min at 25 weeks)

- Stroke volume increases by 30%, heart rate by 15%

- Blood pressure remains same or drops slightly due to decreased total peripheral resistance (via progesterone)

- Vasodilation due to progesterone-induced arterial smooth muscle relaxation

- Relaxation of venous smooth muscle increases venous capacity

- Uterine blood flow rises from 50mL/min (10 weeks) to 500mL/min (term)

- Decreased resistance in renal blood vessels early in pregnancy

- Skin and mucous membrane blood flow increases up to 70% by week 36, causing heat intolerance, sweating, nasal congestion

- Supine position can compress vena cava in late pregnancy, decreasing venous return and cardiac output (left side to supine can decrease cardiac output by 25%-30%)

- Additional blood volume accommodated in uterus, breasts, muscles, kidneys, and skin

Respiratory - physiological changes

- Increased basal metabolic rate leads to 20% rise in O₂ consumption and CO₂ production

- Progesterone increases chemoreceptor sensitivity to CO₂

- Ventilation increases by 40%, mainly via 25%-40% increase in tidal volume

- Hyperventilation from increased ventilatory drive can cause dyspnoea

Genitourinary/ Renal - physiological changes

- Glomerular filtration rate (GFR) increases by 40%-50% in 1st trimester and falls in last few weeks

- Increased renal blood flow caused by reduced vascular resistance

- Reabsorption of electrolytes increases due to RAAS activity (stimulated by estrogen & progesterone)

- Progesterone dilates and may kink ureters from 10 weeks, raising risk of urinary stasis and infection

- Increased urinary frequency in early pregnancy from increased renal plasma flow; later, from fetal/uterine pressure

Endocrine/metabolic - physiological changes

- Human chorionic gonadotrophin (hCG) prevents corpus luteum degeneration and stimulates estrogen & progesterone

- Human placental lactogen reduces maternal glucose, mobilizes lipid stores, accelerates fetal amino acid transfer

- Estrogens induce uterine hyperplasia, hypertrophy, vascularization, swelling of tissues®

- Progesterone increases decidual secretions, suppresses maternal immunity, lowers smooth muscle excitability

- Anterior pituitary enlarges and increases ACTH secretion

- Placental CRH increases throughout pregnancy, playing a role in initiating labor

- Corticosteroid production (glucocorticoid & aldosterone) rises, cortisol up to 2-3x by term

- Thyroid gland enlarges, T3/T4 increases due to higher iodine clearance

- Parathyroid hormone increases, boosting calcium absorption

GIT - physiological changes

- Progesterone relaxes oesophageal sphincter causing reflux/heartburn

- Decreased stomach tone, motility, and reduced secretion delay gastric emptying

- Nausea/vomiting from decreased peristalsis, increased abdominal pressure, high hCG & sex steroids

- Slower peristalsis improves absorption but causes constipation

- Water reabsorption in colon and uterine compression further aggravates constipation

- Fluid retention in gums, leading to sponginess & bleeding

- Hormonal changes increase vulnerability to dental issues

Integument - physiological changes

- Melanocyte-stimulating hormone increases pigmentation, leading to chloasma and linea nigra

- Areola and perineum darken/toughen

- Collagen stretching causes stretch marks (striae gravidarum), linked to corticosteroids

- Perineum stretches during pregnancy

Musculoskeletal - physiological changes

- Increased laxity of joints (symphysis pubis, sacroiliac, sacrococcygeal) to increase pelvic capacity

- Ligament relaxation due to relaxin & estrogen

- Relaxin-induced symphysis widening begins at 10–12 weeks

- Greater joint mobility allows coccyx movement during labor

- Weight gain, cardiovascular/respiratory changes, and edema contribute to discomfort

Signs of miscarriages (cervix, bleeding, pain)

	Cervix	Bleeding	Pain
Threatened	Closed	Yes	Some
Inevitable	Open	Yes	Yes
Incomplete	Open	Yes - may be heavy	Yes- may be intense
Complete	Closed	Minimal, decreasing	Yes, ~decreasing
Missed	Closed	No	No

What signs would indicate that a pregnancy loss may be occurring or is inevitable?

• Miscarriage happens when pregnancy stops growing

• Lots of bleeding - enough to fill 2 pads in an hour

• Large blood clots - golf ball size

• Very bad cramps + stomach pain

• Fever/ chills

• Dizzy like you'll faint

• Unusual smelling vaginal discharge

• Ectopic pregnancies cause bleeding