OB Midterm

*Healthy People 2030*

58% of all citizens as of 2020 belong to a minority group

Calgary Family Assessment Model (CFAM)

Life cycle

Behaviors and interactions (ADLs)

Genogram

3 generations and sees health care issues

Ecomap

Social relationships of the client and family such as support systems and interactions

Culture

Shared beliefs and values

Cultural Knowlege

What healthcare workers need to have to be culturally competent

Subculture

Ethnicity

Acculuration

The change from one culture to another but you do not lose your customs and traditions from your primary culture

Assimilation

When you lose your primary cultural identity

Ethnocenterism

Having the belief that you’re the dominant culture and your way is best (negative)

Cultural Relativism

You’re trying to learn and relate to other people’s cultures (positive)

Hmong/Vietnamese/Thai Womens Births

Families take an active role/women labor and give birth in silence preferably in-home

Chinese Womens Births

3 customary rituals (1) confinement of mother for 30 days (2) mother is fed with confinement diet which usually involves placenta (3) making offerings to ancestors

Hispanic Women Births

Birth partner is mother-in-law or mother/stoic

Native American Womens Births

Only women in attendance/give birth without much assistance

African American womens births

Females (sisters) and mother in the squatting position

Cultural Competence

Recognizing disparities between one’s own culture and those of the client

Vulnerable Populations

Women

Racial and ethnic minorities

Adolescent girls

Older women with chronic illnesses

Incarcerated women

Immigrant/refugee

Rural vs. urban (transportation)

Homeless women/families

Perinatal Continuum of Care

Continuous care across life stages and from home to hospital is crucial for health

Guidelines for Nursing Practice

AWHONN

NANN

ACNM

Genomics

Study of all genes in the genome

Genes

Basic unit of inheritance

Genome

Entire genetic instruction of a cell

Genetics

Study of a particular gene

Epigenetics

Activation and reactivation of genes

Genomic Medicine

Use of genome mixes in our healthcare system

Precision Medicine

Preventing and treating illness related to genes

ENCODE project

* Organized to identify the genome’s functional elements


* Function elements are proteins which interact with DNA to impact our genes

Presymptomatic testing

A gene mutation -> 100% chance of getting illness/disease with no symptoms yet

Predispositional Testing

A genetic mutation -> only predisposed to the illness/disease -> MAY OR MAY NOT get it (BRCA gene)

Gene therapy

An experimental technique that uses genes to treat or prevent disease

Cancer Genomics

* Environmental factors, acquired by change, inherited
* When cells reproduce more quickly your chance of cancer rises
* Oncogenes -> mutation in the gene
* Tumor suppressor genes -> genes are functioning
* Hereditary breast and ovarian cancer -> BRCA 1 or 2
* Colorectal cancer -> APC tumor suppressor gene or mutations in two MMR genes

Amenorrhea

* Absence of menstrual flow (not a disease but a sign of one)
* Absence of menstruation after breast development
* One of the most common gynecologic problems in women

Primary Amenorrhea

Absence of menses by age 15, regardless of presence of normal growth and development

Secondary Amenorrhea

A 6-month or more absence of menses after a period of menstruation

Hypogonadotropic Amenorrhea

* Dysfunction of the central hypothalamic – pituitary axis
* Due to stress, weight loss, strenuous exercise, eating disorder, mental illness
* Assessment: TSH and estrogen

Cyclic Perimenstrual Pain and Discomfort (CPPD) Primary

* (

Cyclic Perimenstrual Pain and Discomfort (CPPD) Secondary

* >25 years
* Acquired menstrual pain that develops later in life
* Pelvic pathology – bloating and pelvic fullness

A lot of pain but also heavy bleeding

PMS Management

* Diet, exercise, herbal (fennel, ginger, chamomile)
* PMS is a disorder with symptoms that begin in the luteal phase and end with the onset of menses

Endometriosis

* Presence and growth of endometrial tissue outside of the uterus
* Dysmenorrhea, deep pelvic dyspareunia (painful intercourse)
* Characterized by secondary amenorrhea, dyspareunia, AUB, and infertility

Oligomenorrhea

40-45 days without period (infrequent bleeding)

Hypomenorrhea

Decreased bleeding

Metrorrhagia

Between period bleedings (ovarian cysts, trauma, cyst, malignancy, polyps)

Hypermenorrhea

Excessive bleeding (neoplasm, infection, IUD)

Abnormal Uterine Bleeding (AUB)

Bleeding irregular in amount, timing, etc. (stops within 12-24 hours and is treated with estrogen)

Menopause

* Complete cessation of menses for >1 year
* Approx. 51.4 years old
* Premenopausal transition = 46 years
* 95% onset: 42-58 years
* Physiologic characteristics: frequent anovulation, cycles increase in length, ovarian follicles less sensitive to hormonal stimulation, progesterone is not produced by the corpus luteum, FSH values rise
* Physical: bleeding, vasomotor instability (hot flashes), mood and behavioral responses, insomnia,
* Estrogen stimulates egg release, maintains vaginal wall and lubrication, helps with lipid metabolism, and converts vitamin D to calcitonin for bone density
* Progesterone helps with the lining of the endometrium

Health risks for perimenopausal women

Osteoporosis and coronary heart disease (because of changes in lipid metabolism)

FSH and LH should be equal levels (1:1)

* Both help growth and maturity
* Egg and sperm production

5 P’s (Primary Prevention)

Partners, protection, prevention, practices, and past history

Secondary Prevention of STI’s

* Prompt diagnosis and treatment and vaccinations
* Nonoxygnol-9: N-0 lubricated condoms and spermicides are NOT recommended for prevention of HIV and STIs

Chlamydia Trachomatis

* Most common and fastest spreading
* Often silent and highly destructive
* 15-24 years old highest rates of infection, with women ages 18-20 having the highest rates
* NAAt test
* Treatment/management: Doxycycline and Azithromycin
* Left untreated = PID

Gonorrhea

* Oldest communicable disease in the US (second to chlamydia)
* Screened first trimester and 36 weeks’ gestation
* Management: antibiotics (ceftriaxone and azithromycin dual therapy) and concomitant treatment for chlamydia

Syphilis

* Caused by *treponema pallidum*
* *Complex disease that can lead to systemic problems and even death*
* *Primary: 5-90 days after exposure*
* *Secondary: 6 weeks-6 months*
* *Tertiary: develops in 1/3 of women infected*
* *Rates highest in 20-24 years and black women*
* *Nontreponemal screening tests (VDRL and RPR) and treponemal diagnostic test (FTA-ABS and TP-PA)*
* *Management: penicillin G, abstinence during treatment, and follow-up*

Pelvic Inflammatory Disease (PID)

* Infectious process that most commonly involves the fallopian tubes, uterus, and occasionally the ovaries and peritoneal surfaces
* Risk factors: young age, nulliparity (never have conceived), multiple partners, high rate of new partners, hx of STI’s and PID
* Increased risk for: ectopic pregnancy, infertility, chronic pelvic pain
* Symptoms: lower abdominal tenderness, cervical motion tenderness, oral temp (>38.3), abnormal cervical/vaginal discharge, elevated C-reactive protein
* Management: prevention, education, broad-spectrum antibiotics
* Women with PID may still use IUDs

HPV

* “Genital warts”
* Most common viral STI seen in an ambulatory setting
* Primary cause of cervical neoplasia
* Pap test and physical inspection
* Management: often resolves by itself (in young women), NO CURE, counseling, HPV vaccine now available, removal if needed to help with symptoms

HSV

* HSV-1 transmitted non-sexually
* HSV-2 transmitted sexually
* Multiple painful lesions, fever, chills, malaise, and severe dysuria
* Chronic and recurring
* Antiviral medications: acyclovir, valacyclovir, famciclovir
* Maternal infection with HSV-2 can have adverse effects on mom and fetus
* Stress can trigger an outbreak
* C-birth is recommended if lesions present

Viral Hepatitis (ABCDE)

D and E are common among users of IV drugs and recipients of multiple blood transfusions

Hep A (HAV)

* Acquired primarily through fecal-oral route
* Vaccination is the most effective means of preventing HAV transmission
* Characterized by flulike symptoms with malaise, fatigue, anorexia, nausea, pruritus, fever, and RUQ pain

Hep B (HBV)

* Most threatening to fetus and neonate
* Disease of the liver and often a silent infection
* Transmitted parenterally, perinatally, and rarely, orally as well as through intimate contact
* Vaccine series available
* No specific treatment: recovery is usually spontaneous within 3-16 weeks
* EDUCATION

BRAIDED Acronym

B: benefits

R: risks

A: alternatives

I: inquiries (chance to ask questions)

D: decisions

E: explanations

D: documentation

Methods of contraception

Coitus interruptus (“pulling out”) and Fertility Awareness Based Methods (FABs - which rely on avoidance)

How to calculate if a woman is fertile

For 6 months, note when period starts and ends

For the shortest period cycle subtract 11 days

For the longest period cycle subtract 18 days

Between those two calculated days

(Two days without secretions = not fertile)

Basal Body Temp

* Varies from 36.2-36.3 at wake during menses and approx. 5-7 days after (category of FABs)
* If you don’t drop after menses, could be pregnant

Barrier Methods

* Condoms: male and female
* Diaphragm: coil spring, flat spring, wide seal rim
* Cervical caps: FemCap 
* Contraceptive sponge
* Toxic shock syndrome risks are present with diaphragms, cervical caps, and sponges

Hormonal Methods

* Combined estrogen-progestin oral contraceptives
* Side effects: decrease FSH and LH
* Advantages/disadvantages: regular periods, decrease PMS, protects against endometrial cancer/stroke, gallbladder disease, blood clots if smoker
* OC 91-day regimen
* Transdermal contraceptive system
* Vaginal ring

ACHES Acronym

A: abdominal pain may indicate a problem with the liver or gall

C: chest pain or SOB may indicate clot problem with lungs or heart

H: headaches may be caused by cardiovascular accident or HTN

E: eye problems may indicate vascular accident or HTN

S: severe leg pain may indicate a thromboembolic process

Progestin only contraception

Minipill same time everyday

Implanatable Progestins

Nexplanon is a single rod implant

Emergency Contraception

* Taken by a woman asap with within 5 days of unprotected intercourse, or birth control mishap
* Levonorgestrel tablets (Plan B One-Step, Take Action, Aftera, Next Choice One-Dose, My Way)
* Ulipristal acetate (Ella) by prescription
* IUD (Copper IUD) insertion as an emergency (for women obese or overweight)

Intrauterine Devices (IUD)

* Small T-shaped device inserted into the uterine cavity
* ParaGard (10 years), Mirena (5 years), Liletta (3 years), Skyla (3 years)
* Typical failure in first year = 0.2%
* No protection against STIs or HIV
* Mirena, Liletta, and Skyla release levonorgestrel

PAINS Acronym

P: period late

A: abdominal pain or intercourse

I: infection or abnormal discharge

N: not feeling well

S: string is missing/longer/shorter

Permanent Sterilization

* Surgical procedure intended to render a person infertile
* Female: tubal occlusion, transcervical sterilization, tubal reconstruction
* Male (vasectomy): surgical interruption of a man’s vas deferens

Breastfreeding lactation amenorrhea method (LAM)

* Highly effective; temporary method
* More popular in underdeveloped and traditional societies

Future trends in development

* Vaginal ring for one-year use
* Self-administered injectables
* Pill taken only at the time of intercourse
* Male hormonal methods being investigated

Induced Abortion

* Purposeful interruption of pregnancy before 20 weeks of gestation
* Elective or therapeutic abortion
* __First-trimester__
* Aspiration: most common in first trimester
* Medical abortion: methotrexate/mifepristone and misoprostol
* __Second-trimester__
* Dilation and evacuation: can be performed at any point up to 20 weeks of gestation, although more commonly performed between 13-16 weeks

Infertility Rates

* Affects about 18% of reproductive-aged couples
* Increases with age (35 in women)
* Before 25 = 25-30% chance of conception in each ovulatory cycle
* 80% can conceive in 6 months

Female Infertility Causes

Hormonal and ovulatory factors, tubal and peritoneal factors, uterine factors (developmental anomalies or endometriosis), hypothalamic pituitary axis, and strenuous exercise

Male infertility causes

Undescended testes, hypospadias, varicocele, low testosterone levels, no sperm cells (azoospermia), or few sperm cells (oligospermia)

Management of Infertility

* Detection of ovulation, hormone analysis, imaging (transvaginal ultrasound, MRI, sonohysterography, hysterosalpingography, laparoscopy)
* Male: semen analysis, ultrasonography, tests for hormonal causes, chronic disease causes, environmental hazards

Interventions for Infertility

* Psychosocial (major life stressor?)
* Nonmedical (lifestyle changes)
* Medical therapy (ovarian stimulation)
* Assisted Reproductive Therapy (ART)
* Intrauterine insemination (IUI)
* In Vitro Fertilization-Embryo Transfer (IVF-ET)

Conception

Union of a single egg and single sperm (not an isolated event)

Mitosis

When body cells replace and repair themselves

Meisosis

When cells divide

Gamete

Sex cells (egg/ovum and sperm) not fertilized

Oogenesis

The process of egg formation

Spermatogenesis

Process of sperm formation

Zygote

First cell of the new individual fertilized

Embryo

After fertilization, conception, and implantation into the endometrium from day 15-56 (more critical time for development)

Fetus

9 weeks to birth  

Where fertilization takes place

O*uter third of the fallopian tube*

When implantation takes place

6*-10 days after conception and takes place in the endometrium (lining of the uterus)*

Chorionic Villi

Fingerlike projections of placenta that help move the egg towards implantation

Decidua

Once the egg is implanted this is the new endometrium

How long pregnancy lasts

280 days/9 months/40 weeks calculated from LMP

Tertogens

Substances or exposure that causes abnormal development

Two fetal membranes

Chorion and amnion

Chorion

On the fetal side of the placenta

Amnion and what it does

* Inner cell membrane that forms the fluid filled sac of amniotic fluid (mostly water)
* Normal amount = 700-800 mL
* Oligohydramnios =

Yolk sac

A cavity on the other side of the developing embryonic disk that babies are dependent on

Umbilical cord

Typically located centrally on the placenta with 2 arteries and 1 vein (Wharton’s jelly: surrounds vessels to prevent compression)