PERINATAL HEALTH INDICATORS

• multiparty

• birth weight

• infant mortality

SIGNS OF PREGNANCY

• 3-4wk breast changes

• 4wk, amenorrhea

• 4-14wk nausea, vomiting

• 6-12wk, urinary frequency

• 12wk, fatigue

• 16-20wk, quickening

5-6wk GOODWELL SIGN, pelvic congestion (probable)

6-8wk CHADWICK SIGN, pelvic congestion and softening of cervic (probable)

6-12wk HAGER SIGN, pelvic congestion and softening of lower segment of uterus

16wk, Braxton hicks

16-28 wk, ballottement

POSITIVE SIGNS OF PREGNANCY

• 5-6wk, visualization of fetus by ultrasound

• 6wk, fetal heart tones detected by ultrasound

• 16wk, visualization of fetus by radiographic study

• 8-17wk, fetal heart tones detected by fetal stethescope

• 19-22wk, fetal movememnts palpated

what is goodwill’s sign?

• caused by increased vasculatiry, hypertrophy and hyperplasia. increased friability, there may be slight bleeding after a vaginal exam is performed.

Operculum is the term for a mucus plug, the mucus plug acts as a barrier against a bacterial invasion into the uterus.

Chadwicks sign

• classified as deepened color (violet, bluish color) of the vaginal mucosa and cervix, this is caused by increased vascularity. Usually seen at 6-8wks of pregnancy. The vagina has an acidic ph which makes it protective against bacterial infections but may cause yeast infections.

estrogen-induced changes: hypertrophic tissues are enriched with glycogen, increased secretions (leukorrhea) are thick, white and more acidic

changes in the cardiovascular system during pregnancy:

• uterus pushes diaphragm up and to the left

• plasma volume increases by 40-60%, 1500mls

• heart rate increases 10-15bpm and cardiac output increases by 30-50%

• increased rbc production by 20-30%

• peripheral vasodilation caused by progesterone causes BP to lower

• changes to the cardiovascular system is due to the demand of the enlarged uterus, fetal and maternal tissues and compensate for blood loss during birth and postpartum.

FOLIC ACID SUPPLEMENTATION!!

• very important to prevent anemia in mom and tp defuse the risk of neural tube defects in baby.

what is the recommended amount? 0.4mg/day

changes in the musculoskeletal system:

• lordosis - caused by abd distention and shift to the centre of gravity

• slight desertion of symphysis pubis

• diastases recti: this is the separation of the rectus abdominus which allow for abdominal contents to protrude at midline, and may persist after birth

PREGNANCY HORMONES

• HCG: primary function is to maintain production of estrogen and progesterone until placenta takes over. source is at the ovum and chorionic villi

• progesterone: primary function is to suppress secretion of FHS and LH by the anterior pituitary. it maintains pregnancy by relaxing smooth muscles, decreases uterine contractibility and decreases mothers ability to use insulin. source is at the corpus luteum until 14wk of gestation, the function is taken over by placenta

• Estrogen: suppresses secretion of of FHS and LH, causes fat to deposit in maternal stomach, increases vasculatrity, and promotes retention of sodium and water, source is at corpus leteum until 14 wk gestation until placenta takes over

• Serum prolactin: prepares breasts for lactation, source is at the anterior pituitary

• Oxytocin: stimulates uterine contractions and stimulates milk ejection from breasts. Source is at the anterior pituitary

ANTEPARTUM HEALTH ASSESMENT

• objective assesments

  • nourishments - posture, mood, affect

  • skin - brushing, scars

  • breasts - clinical breast exam, enlarged breasts, Montgomery tubercules can be visible

  • heart and lungs - possible systolic murmur, due to decreased cardiac volume

  • abdomen - palpate and inspect, stria or lines nigra may be present, asses final height

fundal height - done at 20 wks, you measure the distance in cm of the funds ( top of uterus ) from the symphysis pubis, roughly will correspond to gestational week. ex, if woman is 32wks, measurement of fundal height should be around 32cm

leopards maneuver:

1. first maneuver: assess, part of funds by hand placement along uterus

2. second maneuver: assess which parts are on the side of the uterus by placing hands on the side of the uterus

3. third maneuver: bend knees slightly, grasp lower abdomen with finger and thumb, above symphysis pubis to assess which part of fetus is there.

4. fourth maneuver: knees bent, two hands on lower abdomen, and asses engagement, if your fingers meet the presenting part fetus is not engaged.

auscultation of fetal heart rate is best heard over the fetal back. auscultate for a full minute by listening for rate and rhythm.

ROUTINE TESTS IN PREGNANCY

• CBC

• Rubella antibody titre - if woman is non immune (titre less than 10) should be immunized after delivery

• blood type - ABO done to rule out blood incompatalies early and also determine RH factor with antibody screen

• RH negative, additional testing is done at 26-28 wk, if fetus is RH positive the antibodies can cross placenta, attach to fetal RBC’s and begin to hemolyze. This can then lead to fetal anemia called erythroblastosis fettles or hemolytic disease of the newborn.

• if mom is RH negative, she will receive a dose of RH immunoglobulin at 28 wks gestation as prophalixis.

• hepatitis b surface antigen to indicate if mom has hepatitis b

• HIV screen, requires treatment with a antiretroviral meds to prevent transmission to fetus

• midstream urine for culture at 12-18wks for bacteriuria

urinalysis for protein and glucose

ROUTINE TESTING

• pelvic exams and cervical smear to screen for cancer and STI

• vaginal screen for C and S ( bacterial vaginosis )

• vaginal/anal swab for GBS at 35-37wks

• anatomical ultrasound at 18-20wks to detect an fetal defects

• screening offered for Down syndrome and trisomy 18 and neural tube defects

  • nuchal translucency at end of 1st trimester

  • maternal quad screening done in the early second trimester

• chronic virus sampling (CVS)

  • done with concurrent ultrasound

  • performed at 10-13wks

  • sampling of the chorionic villi tissue is obtained through needle (trans abdominal or transvaginal with catheter)

  • dna is obtained from tissue, and cells and analysis of the chromosomes are done

  • risk of miscarriage is higher with CVS than an amnio

amniocentesis done in the 2nd trimester

Gestational diabetes testing done at 24-28wks, done with 50g of the glucose tolerance test. If 75g is failed pt is generally classified as a gestational diabetic.

** some additional testing will be done in special populations for hep c, thyroid hormone levels, ferritin, v b12, sickle cell anemia, tay-sachs disease and cystic fibrosis

FETAL DEVELOPMENT

• stages of prenatal development

  • conception - union of egg and sperm. sperm remain viable for 2-3 days.

  • fertilization - takes place in ampulla, outer third of uterine tube. Once sperm penetrates membrane around egg, new membrane forms around both and begin to form chromosomes, which results in formation of zygote. zygote will then travel the uterine tube while dividing into blastocyste (structure that will become embryo) and trophoblast (placenta). process is 3-4 days.

  • implantation - happens 6-10 post fertilization. Blastocyte embeds in the endometrium.

Germinal stage which is also referred to ovum or pre embryonic. Stage lasts until 14 days, and includes cellular replication, blastocyst formation and primary germ layers.

embryonic stage - 15 to 8 weeks after conception, embryo will measure 3cm from crown to rump. The MOST critical time in development of organs and external features.

Multi-fetal pregnancy

• dizygotic: occur most often in families with history of twins. Increased maternal age, with increasing parity and use of fertility drugs

• monozygotic twins: division occur between 4 and 8 days after fertilization, complications increase with late division. No association between race, heredity, maternal race or parity. Fertility drugs increase incidence of monozygotic twinning.

  • formation of monozygotic twins:

    • A) one fertilization: blastomeres separate, resulting in two implantations, two placentas, and two sets of membranes

    • B) one blastomere with two inner cell masses, one fused placenta, one chorion and separate amnionic sacs

    • C) one blastomere with incomplete separation of cell mass, resulting in conjoined twins

Primary Germ Layers

• Ectoderm - upper layer* becomes epidermis, glands, nails and hair, tooth enamel

• Mesoderm - middle layer* becomes bones, teeth, muscles, connective tissue

• Endoderm - lower layer, becomes epithelial lining of rest and digestive tract.

  • ***all tissues and organs of the embryo develop from these layers

Membranes*

• amnion: develops from interior cells of blastocyst, forms a fluid filled sac. Becomes the covering of the umbilical cord, will enlarge to fit embryo and surrounding amnionic fluid.

• Chorion: develops from the trophoblast. Contains chorionic villi on surface. The villi will develop into vascular system of placental and chorion will cover the fetal side of placenta.

Organogenesis

• All of embryos organ systems form during 6 week period following implantation.

• 4 wks - heart beat is detected, beginning of lungs, limbs, rudimentary fingers, toes, eyes, eyelids, nose, mouth, external ears, parts of nervous system present

Amnionic fluid

• surrounds the embryo to:

  • fetal movement to enhance muscle development

  • cushion fetus from trauma

  • allow umbilical cord to be free from compression

  • permit growth and development

  • maintain constant body temp for fetus

  • during labour protects placenta and umbilical cord from pressure from uterine contraction and aids effacement and dilation of cervix

Placenta

• functioning by end of the 3rd week

• protects fetus from immune attack from mom

• removes waste produced by fetus

• placental barrier prevents the mix of maternal with fetal blood

  • hCG - can be detected in maternal blood by 8-10 days after conception. This is hormone that gives positive test. Ensures the supply of estrogen and progesterone needed to maintain pregnancy. If the corpus lute stops functioning before placenta produces enough estrogen and progesterone, it will result in miscarriage.

  • hPL - similar to a growth hormone, stimulates maternal metabolism to supply nutrients needed for fetal growth. Results in increases resistance to insulin and stimulates breast development to prepare for lactation.

  • Placenta will produce more maternal estrogen to stimulate uterine growth and uteroplacental blood flow

    • progesterone maintains endometrium, decrease contractility of uterus

    • placental function depends on maternal blood pressure supplying circulation

    • ** some drugs can cross placental membrane and harm fetus (caffeine, nicotine, alcohol)

Fetal Stage: from the 9th week until end of pregnancy

• two process:

  • rapid growth

  • continued tissue and organ refinement

STAGES OF PREGNANCY

1st trimester Weeks 3-12

• organs, muscles, nervous system continue to develop

• fetus kicks, curls toes, suck thumb

2nd trimester Weeks 13-27

• by end of trimester most of brains billions of neuron’s are in place

• stimulated by sounds

• sense of sight is developing

• still cannot survive on its own outside of womb

3rd trimester Weeks 27-40

• first chance of survival outside of womb

• lungs are not yet finished until end of trimester

• brain continues with development

  • fetus can survive outside uterus between 22 and 25wks