NURS3500 MIDTERM

2 types of contraception

• permanent (sterilization)

• reversible 

3 types of reversible contraception

1. hormonal - oral, injectable, transdermal, vaginal ring, PlanB

2. barrier methods - condoms

3. behavioural - abstinence, fetility awareness, withdrawal, lactational amenorrhea

fertility awareness

• 6 day fertility window 

  • 3 days before and affter ovulation 

• egg is released ~14days before menstruation begins

  • survives for ~24hrs

self-assessment: cervical mucus monitoring

• dry → non-fertile 

• sticky → possibly fertile 

• creamy → possibly fertile 

• egg white texture → very fertile 

*can be checked via finger, toilet paper, or underwear method

self-assessment: checking cervical positioning

determines when peak successful contraception

• fertile cervix → during ovulation - high, soft, and open

• non-fertile → before or after ovulation - low, hard, and closed 

self-assessment: basal body temp (BBT)

estimates ovulation and fertile window

• must be exact with a BBT thermometer (within 1/100th of a degree) 

• orally, vaginally, or rectally 

• every morning the second you wake up 

3 types of ovulation tests

• self-assessment tests

• at-home ovulation tests 

• medication ovulation tests 

3 types of pregnancy tests

• hCG 

• urine test

• blood (β-hCG) test

  • should double everyday for the first 72hrs

2 types of infertility

1. inability to concieve after 1 year of regular sexual intercourse in absence of contraception (for females <35yrs) 

   1. 6 months of inability to concieve for 35yrs+

2. secondary infertility - inability to concieve after prior pregnancy

4 causes of infertility

1. male-factor 

2. female-factor 

3. combined 

4. unexplained

2 infertility assessments - male evaluation

• semen analysis 

  • measures sperm count, motility, and morphology

  • teaching: abstain from sex for 48hr before 

• bloodwork

  • evaluates hormone levels that affect fertility 

5 infertility assessments - female evaluation

• hormone monitoring

  • track LH levels

• bloodwork

  • measure homrone levels + ovulation issues?

• sonohysterogram

  • monimally invasive US using sterile saline in the uterus

  • analyzes uterine lining, fallopian tube patency, and can detect abnormalities

• hysteroscopy

  • uses think, lighted camera to see inside of uterus

• hysterosalpingogram (HSG) 

  • x-ray with contrast through cervix to ensure fallopian tubes are open

6 infertility treatment options

1. ovulation induction (meds + timed sex) 

2. intrauterine insemination 

3. donor insemination 

4. IVF

5. intracytoplasmic sperm injection 

6. surgical sperm retrieval (prior to ICSI)

2 types of surrogacy in canada

• gestational surrocacy 

  • intended pregnant persons egg and paternal sperm injected via IVF into surrogate

  • neonate is genetically related to both parents and NOT surrogate

• traditional surrogacy

  • insemination of surrogate with paternal sperm

  • neonate is genetically related to father and surrogate

  • only used when mother does not have any viable eggs 

4 types of spontaneous abortions (miscarriages) 

1. early pregnancy bleeding (<20wks) 

2. complete abortion (all bioproducts passed vaginally) 

3. incomplete abortion (some bioproducts passed vaginally)

4. missed abortion (no expulsion of bioproducts)

2 types of induced abortions

• medication abortion (40%)

  • mifepristone and misoprostol 

  • up to 9 wks

• procedural abortions (60%)

  • dilation and curettage

  • vacuum aspiration (12-14wks)

  • dilation and evacuation (12-23wks)

medication abortion steps

• mifepristone

  • first step

  • detaches products of conception from uterus and ends pregnancy

• misoprostol

  • 2nd step 

  • causes uterine contractions → eliminates of uterine contents

procedural abortion - dilation and curettage

• the cervix is dilated

• curette is used to scrape the contents out of the uterus 

procedural abortion - dilation and evacuation

• weeks 14-23+6

• cervix is ripened with medication + local/general anesthetic 

• instruments and suction used to eliminate uterus contents 

• cramping can occur for weeks after 

procedural abortion - vacuum aspiration

• up to 14 wks 

• local or general anesthetic 

• gentle suction is used to empty uterus 

folic acid 

• if pregnant or planning to become pregnant, take multivitamin with 0.4mg of folic acid

• prevents neural tube defects (anencephaly and spina bifida)

anencephaly and spina bifida

• anencephaly

  • failure of closure of the anterior neuropore 

• spina bifida

  • failure of closure of the posterior neuropore 

medications and pregnancy 

*review current medications 

• category A

  • lots of studies on pregnant people, shows no risk to fetus 

• category B

  • studies on pregnant animals show no risk, but not enough research on humans 

• category C

  • studies on animals show risk to fetus, but not enough research on humans to weigh out benefits 

• category D

  • humans studies show risk to fetus, but benefits outweigh

• category X

  • human and animal studies show adverse fetal outcomes

vaccinations and pregnancy

• safe 

  • influenze, TDAP, HepB, COVID

• contraindicated 

  • live vaccines - MMR ot varicella

• preconception

  • check immunity, vaccinate >1 month before pregnancy

infections and pregnancy (TORCH)

• tocoplasmosis

• other (syphilis, varicella, parvovirus B19) 

• rubella 

• CMV

• herpes

what is toxoplasmosis

• parasitic infection 

• transplacental 

• transferred through animal feces, uncooked meats, contaminated produce

• LBW, IUGR, jaundice, neuro complications

syphilis

• bacterial STI that crosses the placenta

• fetal outcomes: congenital syphilis, stillbirth, neuro complications 

• treat with penicillin

• screen at first prenatal appt

varicella (chickenpox)

• at risk: migrant women from tropical climates

• congenital varicella syndrome

  • skin lesions, cataracts, neurological defects 

• treat with VZIG antibodies and antivirals 

parvovirus B19 (aka 5th disease)

• common childhood illness

• transferred via resp droplets

• fetal concerns: anemia, hydros fetalis, miscarriage risk 

rubella

• viral infection that crosses the placenta 

• congenital rubella syndrome: deafness, cardiac defects, cataracts, microencephaly 

• **1st trimester transmission 

• check immunity at 1st prental appt

cytomegalovirus

• most comon transplacental viral infection 

• transferred via contact 

• causes hearing loss and neurodevelopmental delays

• treat with antivirals

• **do not put child’s pacifier in your mouth

HSV (herpes)

• viral infection via STI

• increase neonatal mortality rate w/ primary exposure

• treat with antivirals 

group B streptococcus (GBS)

• a bacteria present in the lower genital tract or rectum

• colonizes 15-30% of women

• causes neonatal sepsis and meningitis

• screen at 35-37wks 

• treat with antibiotics 

3 nursing roles in infection prevention

1. screen 

2. teach 

3. support 

S&S of pregnancy (1st trimester)

• amenorrhea

  • wk 4

• breast tenderness and enlargement

  • wk 3+

• N&V

  • wk 4/6-18

• increased UO

  • wk 6+

• uterine enlargement

  • wk 7+ 

• fatigue 

“signs” of pregnancy

• Hegar’s Sign

  • 4-6 wks

  • uterine segment has softened 

• Goodell’s Sign 

  • 4 wks 

  • softening of the cervix

• Chadwick’s Sign

  • 6 wks 

  • discolouration of cervical mucosa 

• ballottement 

  • end of pregnancy 

  • rebound of fetus against examiner’s fingers 

uterus changes in pregnancy

• substantial increase in size, weight, and shape (estrogen) 

• Hegar’s 

• increase vascularization and fundal height

• contactility → thin cervix (effacement)

cervix changes in pregnancy

• increase in size, and vascularization, ridged → cervical ripening in 3rd trimester

  • soft (Goodwell’s) and discoloured (Chadwick’s)

• PG creates thick mucus plug for infection prevention

vagina changes in pregnancy

• increased vascularization (estrogen)

• secretion are white, thick, milky, and acidic

• vaginal hypertrophy and lengthening

ovary changes in pregnancy

• increased vascularization → enlargement 

• actively support pregnancy via hormone production (wks 6-7)

breast changes in pregnancy

• tenderness and fullness

  • hyperpigmentation and striae

• vascularization 

• leak fluid (colostrum)

GI changes in pregnancy

• bleeding gums, dental health, excessive saliva secretion 

  • due to increase estrogen and vascularization

• N&V

• heartburn, bloating, constipation

• hemorrhoids

CV changes in pregnancy

• blood volume increases

  • supplies uterus and reserves for birth 

• increase in plasma, WBC and RBCs → physiological anemia (Hb/Hct thresholds lower)

• clotting factors increase → hypercoagulability 

• cardiac output increases

• BP decreases in 2nd tri 

  • progesterone → vasodilation

resp changes in pregnancy

• increased O2 consumption, RR, and tidal volume 

• change in anatomical shape of thoracic cavity

• increased risk of pneumonia and asthma

renal/GU changes in pregnancy

• kidneys enlarge

• increased blood volume and increased waste (from mother and baby)

• increased eGFR, protein, and glucose in urine

• decreased BP - more renal blood flow 

• decreased Cr, BUN, and serum Na

skin changes in pregnancy

• hyperpigmentation

  • on breasts, abdomen, and face

• stretch marks

MSK changes in pregnancy

• increased lordosis

• gait changes 

• relaxation of pelvic ligaments 

2 ways of calculating due date

• EDM by LMP

  • uses last menstrual period date

  • not completely accurate (some assume 28 day cycle)

• final EDB 

  • confirmed by US

Nagele’s Rule

• measures expected date of birth 

• first day of LMP, subtract 3 months, add 7 days, add 1 year

what is GTPAL

G - gravida 

• # of pregnancies including current 

T - term births 

• >37 wks 

P - preterm births 

• <37 wks

A - abortus 

• abortions/miscarriages (<20wks)

L - living children

• living children 

management of N&V in pregnancy

• first line 

  • vit. B6/pyridoxine monotherapy

  • or adding doxylamine

• adjuncts

  • metoclopramide or antihistamines 

• ondansetron/Zofran

  • if all else fails - must use under MD or RN direction

• avoid corticosteroids in 1st trimester 

• sub prenatal for one with high folate and low iron

health hx components

• nutrition 

  • folic acid, prental vitamin, calcium, vitamin. D, food access, dietary restrictions

• surgical hx

• medical hx 

• family hx 

• genetic hx of gametes 

  • maternal age, ethnicity, known genetic conditions, other inherritance patterns 

• infectious diseases + vaccination hx

• mental health hx 

• substance use

• lifestyle/social (SDoH)

physical exam in pregnancy

• height 

• pre-pregnancy and BMI

• BP 

• HTT (head + neck, breasts/nipples, heart + lungs, abdomen, MSK, pelvic)

• last pap smear 

complications of obesity throughout pregnancy

• antepartum

  • HTN, preeclampsia, GDM, sleep apnea

• intrapartum 

  • induction failures, prolonged labout, increased risk of c-sections, anesthesia challenges

• postpartum

  • hemorrhage, wound/urinary infections, thromboembolism

• fetal 

  • congenital anomalies, growth restriction/macrosomnia, increased risk of stillbirth

initial labs - bloodwork

• rubella immunity

• HepB surface antigen pressence

• syphillis 

• HIV

initial labs - urine

• gonorrhoea

• chlamydia 

• urinalysis and cultures 

• group B strep (GBS) bacteriuria

preeclampsia urine results

• high protein 

• everything else normal

asymptomatic bacteriuria urine results

• cloudy, increased pH and protein, erythrocytes <0.5, positive nitrates, and high WBC

2 prenatal genetic screening tools (not diagnostic)

• eFTS

  • done via US, blood test, and age at 11-13 wks 

  • looks for down syndrome and edwards syndrome (higher or lower chance)

• non-invasive prenatal testing (NIPT)

  • blood test that looks at placental DNA at 9-10 wks 

  • cna also test sex of fetus, sex chromosome differences, and micro-deletion syndromes 

  • only covered if high risk 

CVS vs. aminocentesis

• CVS

  • dianostic test using placental tissue at 11-13 wks 

  • detects chomosomal conditions

• aminocentesis 

  • diagnostic test using amniotic fluid at 15wks +

  • detects chromosomal conditions and neural tube defects 

glucose screening

• non-fasting glucose challenge test 

  • drink sugar drink and then blood glucose serum test 1hr later 

  • 7.8-11mmol = 75g glucose test 

  • 11mmol+ = GDM

US documentation

• dating U/S

• nuchal translucency (NT) scan → 11-13+6 weeks

• anatomy scan → 18-22 wks (incl. placenta, cervix, fetal anatomy)

• other ultrasounds → amniotic fluid, follow-ups, growth

• placental location → note if low-lying/previa

• soft markers & EFW → document if reported

2 main US’s in pregnancy

• dating (1st tri)

  • 7-12/14 wks 

  • most accurate way to date EDB

  • measures fetal CRL → predicts DOB within 5 days 

• anatomy (2nd tri)

  • 18-22 wks 

  • examines fetal anatomy, placenta location, umbilial cord, amount of amniotic fluid, cervix, bladder, ovaries 

GBS screening

• all pregnant people must be screened at 35-37 wks

  • one swab in the vagina and one at the anal sphincter

• treatment (if positive): IV antibiotic at onset of labour or rupture of membranes

  • if <37wks, give antibiotics for 48hrs and wait for labour ir IOL

  • if >37wks give antibiotics

immunoprophylaxis

mom needs

• RhG at 28-29 wks if Rh negative

• influenza vaccine

• Tdap at 21-32 wks ideally (every pregnancy)

• RSV at 32-36 wks

• postpartum vaccines (MMR, RSV, etc)

newborn needs

• HepB and HIV prophylaxis

RhIG Indications

• Rh is given routine at 28wks, but some cases call for it earlier 

  • vaginal bleeding, extopic pregnancy, molar pregnancy, CVS

  • abdominal trauma, invasive procedures, fetal demise in 2nd and 3rd tri, suspected or confirmed antepartum hemorrhage

  • postpartum if infant is Rh+

5 compoents of an antenatal assessment

1. physical assessment

2. fetal movement monitoring

3. fundal height 

4. Leopold’s and fetal presentation 

5. FHR/NST

antenatal assessment - physical assessments

• gestational age

  • in weeks + days based on EDB

• weight (kg)

  • assess trend in weight gain during pregnancy 

• BP 

antenatal assessment - fetal movement monitoring

• begin monitoring at 26-32 wks in pregnancies with risk factors 

• teach about importance of movement in 3rd trimester 

• 6 movements in 2 hrs

  • anything less may signal placental insufficiency or hypoxia

antenatal assessment - symphysis-fundal height

• 20 wks 

• measured in cm (same as GA - + or - 2cm/wk)

• from symphysis pubis to top of fundus

what is fetal presentation

• fetal part closest to pelvic inlet

  • record as cephallic or breech (or lie)

steps of a Leopold’s Maneuver

• fundal grip 

  • place hands on fundus and find baby head and butt 

• umbilical grip 

  • move hands down and feel baby back and limbs

• Pawlick’s grip 

  • move hands down by symphysis pubis and find head or butt

• pelvic grip 

  • face clients feet but keep hands there and place pressure (resistance?)

fetal heart rate normal and abnormal rhythms

• normal range = 110-160 bpm

  • 14wks: 150bpm

  • 20wks: 140bpm

  • term: 130bpm

• fetal bradycardia: <110 bpm

• fetal tachycardia: >160-180bpm

4 high risk fetal health surveilance

• continuous electronic fetal monitoring

• non-stress test 

• biophysical profile (US + non stress test) 

• umbilical artery dopplers 

FHS - electronic fetal monitoring 

• non-invasive assessment of FHR pattern and contraction monitoring for mom

• 23wks - delivery

• usually used with high risk labours

what is variability in FHR monitoring

• moderate variability - 6-25bpm variation 

• minimal variability - 1-5 bpm variation 

• absent variability - no line variation 

• marked variability - 25+bpm variation

FHS - non stress test

• check VS befors starting 

• use Leopold’s to find fetus’ back (FHR)

• 2 abdominal monitors for FHR and contractions + button for mom to document fetal movements

• normal, atypical, or abnormal 

FHS - biophysical profile (BPP)

• usually done at 32wks and only on high risk pts 

• US based test to assess key fetal behaviours and amniotic fluid levels 

  • 2 points for abnormal, 0 for normal 

• lets us know how the baby is adapting to the uterine environment + if baby is oxygenated 

fetal oxygenation + AFV

• S&S of poor oxygenation: move less, have poor tone, not practice breathing, show changes in FHR

• amniotic fluid volume is a reflection of how well the placenta is function + if sufficient oxygen is getting to the baby 

FHS - umbillical artery dopplers

• used for high risk pregnancies to assess placental oxygenation + perfusion

• US based test used to assess direction and speen of blood flow in the umbillical cord as well 

screening questions for substance use in pregnancy

• substance

• route, frequency, and quantity

• time of last use 

• is quitting or reducing use being considered

  • attempted in the past? 

fetal effects from alcohol use

• growth deficiency

• characteristic pattern of dysmorphological facial features 

• CNS dysfunction 

  • poor suck, decreased attention, poor memory, high impulsivity 

fetal effects from cannabis use

• detectable in urine/stool for weeks

• linked with lower birth weight 

• neuro complications 

• suppresses prolactin for mom

• lethargy and decreased intake (short, more frequent feeds)

5 nursing roles to reduce substance use

1. screening and assessment 

2. education and counselling 

3. advocacy and support 

4. clinical care 

5. professional responsibilities 

health teaching: pain meds in pregnancy

• safe

  • acetomenophen 

  • topical comfort measures 

• caution/avoid 

  • NSAIDs (miscarriage, babys kidneys + amniotic fluid, labour complications 

health teaching: when to go in for labour

• S&S of early labour

  • mucus from your cervix

  • contractions or tightenings lengthening

• labour 5-1-1

• reduced fetal movement 

• PROM + water breaks 

LECTURE 4 HERE

3 factors influencing the onset of labour 

• maternal 

  • hormonal changes (increased prostaglandins and oxytocin), and uterine readiness

• fetal 

  • cortisol release triggers placental estrogen production 

• placental

  • estrogen increase causes