pregnancy handouts

Maternal and Child Health Nursing

Pregnancy

Pregnancy Abejo

MATERNAL and CHILD HEALTH NURSING

PREGNANCY

Lecturer: Mark Fredderick R. Abejo RN, MAN

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Fertilization to Conception

Fertilization: the union of the ovum & sperm. The start of Mitotic cell division &fetal sex determination.

> Primary oocyte (immature ovum) contains Diploid number of chromosomes (46).

> One oocyte contains a haploid (23) number of chromosomes after division.

> Gamete (mature ovum): is a cell or ovum that has undergone Maturation & will be ready for

fertilization.

> One gamete carries 23 chromosomes.

> A sperm carries 2 types of sex chromosomes. X & Y.

> 400 million sperm cells in one ejaculation.

> Functional Life of spermatozoa is 48 hours

> XX= female, XY= male.

Morula

Process of Fertilization:

After ovulation ovum will be expelled from the Graafian follicles ovum will be surrounded byZona

Pellucida(mucopolysaccharide fluid) & a circle of cells (Corona Radiata) which increases the bulk of the Ovum

expelled from the Fallopian Tube by the Fimbriae (infundibulum). Sperms move by flagella & Penetrate the &

dissolve the cell wall of the ovum by releasing a proteolytic enzyme (Hyaluronidase) After

penetration Fusion will result to Zygote. Zygote migrate for 4 days in the body of the uterus (Mitosis will

take place-Cleavage formation will begin) After 16-50 cell formation from mitosis, a mulberry & Bumpy

appearance will follow morula after 3-4 days, the structure will be ball like in appearance which will be called

Blastocyst. Cells in the outer ring are called Trophoblast (later it forms the placenta, responsible for the dev’t of

placenta & fetal membrane; Cells in the inner ring are called Erythroblast cells (which will be the embryo).

Terms to remember:

Ovum: From ovulation to fertilization

Zygote: From fertilization to implantation

Embryo: From implantation to 5-8 weeks.

Fetus:From 5-8 weeks until term

The ovum is said to be viable for 24-36 hours.

Sodium Bicarbonate- the frequent medication to alter the vaginal ph, decrease the acidity of the vagina

so as to INCREASE THE MOTILITY OF THE SPERM.


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Fetal Membranes

Fetal Membranes: membranes that surround the fetus, & give the placenta the shiny appearance.

2 Layers:

1. Amnion: shiny membrane on the 2nd

week of Embryonic Development & encloses the Amniotic Cavity

2. Chorion: Outer membrane that supports the sac of the amniotic fluid.

Chorionic Villi: finger like projections from the chorion. This is the place where gases, nutrients and

waste products between the maternal & fetal blood takes place.

Amniotic Fluid: surrounds the embryo, contains fetal urine, lanugo from fetal skin & epithelial cells.

Ph is 7. 2. Specific Gravity: 1.005 – 1.025

Normal Amount: 500 – 1000 ml.

Oligohydramnios- less than 300 ml.

Polyhydramnios- more than 2000 ml. observe for Down syndrome & congenital defects

Functions of Amniotic Fluid:

a. Protects the fetus from changes in the temperature & cushion against injury.

b. Protects the umbilical cord from pressure, the fetus drinks & breaths the fluid into the lungs.

Amniotic Fluid Colors: Normal color: transparent, clear, with white tiny specks

Dark amber or yellow: Ominous sign of presence of Bilirubin, hemolytic disease

Port Wine Colored: Abruptio Placenta

Greenish: Meconium Stained / FETAL DISTRESS: always go for Cesarian Section! Also if ph is less

than 7.2

If with odor: deliver within 24 hours, may indicate infection.

Umbilical Cord: 21 inches in length & 2 cm in thickness, circulatory communication of the fetus to the

mother. CONTAINS 2 ARTERIES & 1 VEIN. Covered by a gelatinous mucopolysaccharide called

Whartons jelly.

Implantation occurs at the end of the 1st week after fertilization, when the blastocyst attaches to the endometrium.

During the 2nd week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell

layers develop. During the 3rd week of development (21 days after implantation), the embryonic disk evolves into

three layers, and three new structures — the primitive streak, notochord, and allantois — form. Early during the

4th week (28 days after implantation), cellular differentiation and organization occur.

Fertilization Cycle


Pregnancy

Pregnancy Abejo

THREE PREGNANCY SIGNS & SYMPTOMS

PRESUMPTIVE PROBABLE POSITIVE

Amenorrhea

Nausea/Vomiting

Breast sensitivity and

increased size

Fatigue Abdominal

enlargement

Skin pigmentation

changes

(Melasma chloasma,

linea nigra- a brown line

running from the

umbilicus to the

symphysis pubis

Stretch marks will

eventually fade to a silvery

white color, but it is highly

unlikely that they will

completely disappear.

Breast changes- increase in

fullness, darker areola.

Quickening: first fetal

mov’t.

Urinary Frequency

Melasma .

Pregnancy test (presence of HCG)

Softening of the uterine isthmus (Hegar’s sign)

Cervical softening (Goodell’s sign)

Braxton-Hicks contractions

Ballotment: bouncing of the fetus in the amniotic fluid against the

examiners hand. During the 16th

-20th

week.

Braxton Hicks Contractions: painless

contractions felt for 20-30 minutes occurs on

the 16th

week.

Chadwick’s sign is a bluish coloring of the vaginal

mucosal that occurs as early as 6 weeks gestation.

Rationale: due to increase vascularity & blood

vessel engorgement.

Increase size of the uterus

+ Pregnancy Test

> Secretion of HCG in the urine (Frog Test).

Detectable 10 days after the missed period

. The fetal heartbeat typically can be heard and fetal

rebound is possible between 18 and 22 weeks. The

fetal outline becomes palpable and the fetus is highly

mobile between 28 and 31 weeks. Braxton Hicks

contractions increase in frequency and intensity

between 32 and 35 weeks.

Auscultation of fetal

heart by week 8

Ultrasound imaging

of fetal heart motion

by week 7

Ultrasound

confirmation of

gestational sac by

week 6

Ultrasound: 6 weeks can

auscultate the fetal heart.

Fetal movements palpated

by the provider by week

20.

The most objective sign of

pregnancy is fetal

movement felt by the

examiner.

FETAL DEVELOPMENT

ORIGIN OF BODY TISSUE

Tissue Layer Body Portion Formed

Ectoderm Nervous system, mucus membranes, anus & mouth

Mesoderm Connective Tissue, Reproductive, circulatory & upper Urinary

system, bones, cartillage

Endoderm Lining of the GI tract, Respiratory Tract, bladder & urethra

PRE-FERTILIZATION

ACTIVITIES

Ovum moves to amulla of

fallopian tubes

Capacitation

Acrosome reaction

CONCEPTION

Zona reaction

Zygote (fertilized ovum;

about 24-48 hrs, divides;

cleavage divides, travels to

the uterus

IMPLANTATION

Morula (after 3-4

days implantation)

Blastocyst

(trophoblast;

embryolast)

Implants complete

w/n 7-10 days


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1 mo/ 4 weeks

Embryo is 4-5 mm length

Trophoblasts embedded in deciduas

Foundations for nervous system, genitourinary system, skin, bones, and

lungs are formed

Rudiments of eyes, ears, nose appear

Cardiovascular system functioning, heart beginning to beat, beginning of heart circulation.

Placenta dev’t.

2 mo/ 5-8 weeks

Placental transport of substances ( 5 weeks)

The fetus is 27-31 mm and weighs 2-4 grams

Fetus s markedly bent

Head is disproportionately large due to brain development

Centers of bone begin to ossify

Ganglionic cells (5th

to 12th

weeks)

Placenta and meconium are present, with facial features

3 mos./9-12 wks CVS done (8 12 weeks) every organ present, Head greatly enlarged

Average length is 50-55 mm and weighs 45 gms.

Fingers and toes are distinct.

Rudimentary kidneys secrete urine.

Fetal circulation is complete.

External genitalia show definite characteristics.

Ganglionic cells

SEX IS VISUALLY RECOGNIZABLE. Heart is audible in a Doppler ( 11th

week)

Fetus swallows. With nails. Kidneys able to secrete.

4 mos. /13-16 weeks 94-140 mm length and weighs 97-200 gms.

Head is erected, lower limbs are well developed.

Heartbeat is present

Nasal septum and palate close

Fingerprints are set

LANUGO APPEARS IN THE BODY

5 mos. /17-20 weeks Fetus is 150-190 mm. In length and weighs approximately 260-460 gms.

Lanugo covers entire body.

Eyebrows and scalp hair is present.

Heart sounds are perceptible by auscultation.

Vernix caseosa covers skin.

Heartbeat can be heard in the fetoscope ( 18 weeks—20 weeks). Liver is already pancreas

functioning.

Quickening felt by a mother. Skeleton begins to develop.

Brown Fats begin to form. Heart sounds in the stethoscope

Can be heard ( 17- 20 weeks)

NOTE: There is a placental barrier to syphilis until the 18th

week of pregnancy. If

the mother is treated before 18th

week, the baby will most likely not be affected.

6 mos. /21-25 weeks 21-25 WEEKS… OLD MAN’s FACE

Length 200-240 mm. Wt. 495-910 gms.

Skin appears wrinkled and pink to red.

REM begins

Eyebrows and fingernails develop.

VERNIX COVERS THE ENTIRE BODY. Has the ability to hear. Production of lung surfactants.

Passive Antibody transfer ( placental immunoglobulin G)

Sustained weight gain occurs.

7 mos. /26-29 weeks Length 250-275; weight 910-1500 gms.

Skin red

Rhythmic breathing occurs

Pupillary membrane disappears from eyes.

Fetus often survives if born prematurely

Brain develops rapidly. Lecithin- Sphingomyelin (L/S ratio is already 2:1)

Brains fully developed. If born, neonate may survive.

8 mos. /30-34 weeks Length 280-320 mm. weight 1700-2500 gms.

Toenails become visible

Steady weight gain occurs

Vigorous fetal movement occurs.

LANUGO DISAPPEARS. Bones are fully developed.

Aware of sounds outside the body. Assumes the delivery position. Increased

chance of survival.

9 mos. /35-37 weeks Length 330-360 mm. weight 2700-3400 gms.

Face and body has a loose wrinkled appearance because of subcutaneous fat

deposit.

Body is usually lump and lanugo disappears

Nails reach fingertip edge

Amniotic fluid decreases.

Increase Development. Sole of the foot have already

creases. Good chance of survival.


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10 mos. / 38-40 weeks Length 360 mm.; Weight 3400-3600 gms.

Skin is smooth, chest is prominent

Eyes are uniformly slate colored

Bones of skull are ossified and are nearly together at sutures.

Testes are in scrotum.

Fetal Circulation

As early as 3rd

week of intra-uterine life, fetal blood is already is circulating, specifically there is already exchange of

nutrients with the maternal circulation in the chorionic villi.

> Arteries carry UNOXYGENATED BLOOD. VEINS carry OXYGENATED BLOOD.

> Fetal Circulation Bypass: Why:

DUE TO NON-FUNCTIONING LUNGS:

----- Ductus arteriousus (between pulmonary artery & Aorta, OPENS AT BIRTH & CLOSES 24 –48 hours after

delivery.) It CONTAINS a mixture of arterial & venous blood.

----- Foramen Ovale : between right & left atrium

DUE TO NON-FUNCTIONING LIVER:

----- Ductus Venosus (by pass the liver, closes at birth; an umbilical vein that carries High oxygen from the placenta.

Maternal & Fetal Diagnostic Test

CHORIONIC VILLI SAMPLING

Earliest test possible on fetal cells; sample obtained

by slender catheter passed through cervix to

implantation site.

a. Chorionic Villi Sampling: removal of a

small piece of Chorionic villi sampling to

detect the ff: fetal chromosome, enzyme, DNA

& biochemical abnormalities. Performed

between the 8th

– 11th

weeks of gestation. Can

detect the ff; Genetic Defects:

Cystic fibrosis, trisomy 21, Tay Sachs, sickle

cell anemia, thallasemia, Duchenne

muscular dystrophy & hemophilia.

Most common indication: advance maternal

age: increases risk of chromosomal damage

from aging of oocyte.

Greatest Advantage over Amniocentesis:

PERFORMED DURING THE FIRST

TRIMESTER. (16th

- 20th week of gestation). .

Laboratory results are obtained in 1 - 7 days

compared to 20-28 days for an amniocentesis.

Disadvantages:

1. Risk of Abortion

2. Infection

3. Embryo-fetal/placental damage

4. Spontaneous abortion

5. Premature rupture of the membranes

After an Rh-negative patient undergoes

amniocentesis or CVS, the nurse should

administer Rh (D) immune globulin

(RhoGAM), to prevent Rh sesnsitization, an

antigen antibody immunologic reaction that

sometimes occurs when an Rh negative mother

carries an Rh + fetus.

The patient does not require complete bed

rest after CVS---SHE SHOULD REFRAIN

FROM SEXUAL INTERCOURSE AND

PHYSICAL ACTIVITY FOR 48 hours. A

small amount of spotting is normal for the 1st

24-48 hours.

ULTRASOUND

Use of sound and returning echo patterns to identify

intrabody structures; useful early in pregnancy to

identify gestational sacs; later uses include

assessment of fetal viability, growth patterns,

anomalies, fluid volume, uterine anomalies and

adnexal masses. Use adjunct to amniocentesis; safe

for fetus (no ionizing radiation)


Pregnancy

Pregnancy Abejo

Ultrasound: done 18-40 weeks for fetal

abnormalities,

THE BEST TEST FOR ECTOPIC

PREGNANCIES

- Non-invasive procedure with high frequency sound

waves to obtain outline of the fetus, placenta &

uterine cavities and to confirm gestational age &

EDD.

- NEEDS A FULL BLADDER TO OBTAIN A

BETTER IMAGE (drink a full glass every 15

minutes beginning an hour & half the procedure)

- COMMON METHOD IN LOCATING THE

PRECISE POSITION OF THE FETUS &

PLACENTA BEFORE AMNIOCENTESIS.

AMNIOCENTESIS

Location and aspiration of amniotic fluid for

examination; possible after the 14th

week when

sufficient amounts are present; used to identify

chromosomal aberration, sex of fetus, levels of

alpha-fetoprotein and other chemicals indicative of

neural tube defects and inborn error of metabolism,

gestational age, RH factor.

I.V. anesthesia isn't given for amniocentesis. The

client should be supine during the procedure;

afterward, she should be placed on her left side

to avoid supine hypotension, promote venous

return, and ensure adequate cardiac output.

Amniocentesis: invasive procedure for amniotic

fluid analysis, & fetal lung maturity.

Procedure: Ultrasound 1st: the rationale: to locate

the Placenta. The patient MUST EMPTY THE

BLADDER TO REDUCE THE SIZE OF THE

BLADDER. Vital signs are assessed every 15

minutes.

Typically performed on the 3rd

trimester to assess

LECITHIN-SPHINGOMYELIN RATIO IN THE

AMNIOTIC FLUID (this ratio indicates fetal

lung maturity), which is commonly delayed in a

diabetic client, Cesarean Delivery should

not be done, unless the fetal lungs are matured.

Position: Supine.

PLACE A FOLDED TOWEL ON HER RIGHT

BUTTOCKS TO TIP HER SLIGHTLY TO THE

LEFT & MOVE THE UTERUS OFF THE VENA

CAVA TO PREVENT SUPINE HYPOTENSION

SYNDROME.

ABDOMINAL PREP IS DONE, then, needle

insertion in a 20-22 gauge spinal needle,

withdrawing amniotic fluid.

NORMAL L/S RATIO (lecithin/sphingomyelin):

2:1 = normal fetal lung maturity ratio

Most important factor affecting Amniocentesis:

NEEDLE INSERTION-because of the risk of

puncture or damage to the placenta, fetus,

umbilical cord, bladder & uterine arteries.

Disadvantages:

Risk for:

1. Maternal hemorrhage

2. Infection

3. Rh immunization

4. abruptio placenta

5. Amniotic fluid embolism

CALL THE PHYSICIAN FOR THE FF: Chills,

fever, leakage of fluid, decrease fetal movement

or uterine contractions.


Pregnancy

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After amniocentesis, the patient is

monitored for uterine contractions, fetal heart

rate changes and leakage of amniotic fluid

from the puncture site. During this period, the

patient isn’t ambulated.

X-RAY Can be used late in pregnancy (after ossification of

fetal bones) to confirm position and presentation; not

used in early pregnancy to avoid possibility of

causing damage to fetus and mother.

ALPHA-FETOPROTEIN

SCREENING

Maternal serum screens for open neural tube defects.

It is a glucoprote in produced by fetal yolk sac, GI

tract and liver. Test done between 16 and 18 weeks

gestation.

Alpha Fetoprotein:

PRINCIPAL SCREENING TEST DOR

THE DETECTION OF NEURAL TUBE

DEFECTS (spina bifida, hydrocephalus-

can be reduced through increase folic acid-

0.4 mg/day in the 1st trimester)

> Maternal blood sampling between 16-20

weeks.

LOW: chromosomal defects (Downs

syndrome)

HIGH: (greater than 10 mg/dl) Neural tube defects,

anencephaly & the absence of ventral abdominal

wall, premature delivery, toxemia & fetal distress &

Rh immunization.

L/S RATIO Uses amniotic fluid to ascertain fetal lung maturity

through measurement of presence and amounts of the

lung surfactants lecithin and sphingomyelin. At 35-

36 weeks; ratio is 2:1 indicative of mature levels.

PHOSPHATIDYL GLCEROL Found in amniotic fluid after 35 weeks. In

conjunction with the L/S ratio; it contributes to

increased reliability of fetal lung maturity testing.

Maybe done in laboratory.

Phosphatidyl Glycerol (PG): when present in the

amniotic fluid, it can be predicted that respiratory

distresss will not occur, or RDS will not occur.

CREATININE LEVEL Estimates fetal renal maturity and function, uses

amniotic fluid.

BILIRUBIN Level-high early in pregnancy; drops after 36 weeks

gestation; uses amniotic fluid.

The yellow color is the result of fetal anemia and

bilirubin.

FETAL MOVEMENT COUNT Teach mother to count 2-3 times daily, 30-60

minutes each time, should feel 5-6 movements per

counting time; mother should notify care giver

immediately of abrupt change or no movement.

PERCUTANEOUS UMBILICAL

BLOOD SAMPLING

Uses ultrasound to locate umbilical cord. Cord blood

aspirated and tested. Used in second and third

trimesters.

BIOPHYSICAL PROFILE A collection of data on fetal breathing movements,

body movements, muscle tone, reactive heart rate

and amniotic fluid volume.

ELECTRONIC MONITORING

A. Non-Stress Test – accelerations in heart rate accompany normal fetal movement; non-invasive

Tocodynamometer records fetal movements and Doppler ultrasound measures

- Observation of fetal heart rate related to fetal movement. Fetal well-being.

Indicated for: assess placental function & oxygenation, fetal well being, evaluates fetal heart rate in response to

fetal movement especially for: Maternal Problems such as chronic hypertension, diabetes and Pre-eclampsia, given

after the 32nd

week.

PREPARATION:

Patient should eat snacks.

Position: Semi-Fowlers or left lateral positions the mother may ask tom press the button every time she feels fetal

movements; the monitor records a mark at each point of fetal movement.


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RESULTS:

1. Reactive (normal): indicates a fetal fetus

Greater than 15 beats per minute- occur with fetal movement in a 10 or 20 minute period.

FAVORABLE RESULTS:

- 2 or more FHR accelerations of 15 seconds over a 20 minutes interval and return of FHR to normal baseline.

2. Non-Reactive (Abnormal): No fetal movement occurs or there is short-term fetal heart rate variability (less

than 6 beats per minute). The doctor will order an Oxytocin Test AFTER the patient has non-reactive test.

NOTE: COMMONLY PERFORMED ON DIABETIC PATIENTS BECAUSE OF THE INCREASE RISK FOR STILL

BIRTH.

B. Contraction Stress Test (CST) – based on the principle that healthy fetus can withstand decreased oxygen during

contraction but compromised fetus cannot. Response of the fetus to induced uterine contractions as an INDICATOR

OF UTEROPLACENTAL & FETAL PHYSIOLOGICAL INTEGRITY.

PREPARATION:

Woman in semi-Fowler’s or side-lying position.

Monitor for post-test labor onset.

TYPES:

a. Mammary stimulation Test or Breast Stimulation Exam or

Nipple Stimulated CST – non-invasive

b. Oxytocin Challenge test

Indications: ALL PREGNANCIES AFTER 28 WEEKS WITH HIGH RISK CLIENTS.

Contraindicated for history of PRE-TERM LABOR.

Interpretations:

POSITIVE RESULT: Late decelerations with at least 50% of contractions. Potential risks to the fetus, which may

necessitate to C-section.

Abnormal and known as “Positive window”. Abnormal: ―Positive Window‖: (+) LATE DECELERATIONS OF

FHR with three contractions a 10 minute interval. Indicates Uteroplacental Insufficiency.

NEGATIVE RESULTS: No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in 10 minutes

period. Normal: ―Negative Window‖: (-) LATE DECELERATIONS OF FHR with three contractions a 10m minute

interval

Normal and known as “Negative window

Laboratory Studies

1. Estriol excretion: measures placental functioning through urine test.

Collect a 24-hour urine specimen or serum blood levels.

High Estriol: Good placental function

Low Estriol: Fetal hypoxia

Estriol: estrogenic hormone, synthesized by the placenta & adrenal gland of the fetus which secreted by the

ovaries

Rh Incompatibility Test:

Purpose: to discover presence of antibodies present in Rh-negative mother’s blood

> Test will confirm the diagnosis for Hemolytic Disease in the Newborn.

Types:

1. Indirect Coomb’s Test: women who have Rh negative have this test done to determine if they have

antibodies to the factor present. Repeated 28 weeks pregnancy. Mothers reveal antibodies as

a result of previous transfusion or pregnancy.

2. Direct Coomb’s test: tests for newborns cord blood- determines presence of maternal antibodies

attached to the baby’s cell.

Rh (D) & D negative who hasn’t formed antibodies should receive Rhogam at 28

weeks gestation or after 72 hours after delivery.

Nitrazine Test: use of nitrazin strip to detect the presence of amniotic fluid.

Vaginal Secretions: PH: 4.5- 5.5

Amniotic fluid: PH: 7.2 – 7.5 (turns the yellow Nitrazine blue gray, blue green – Ruptured Membranes)

Kicks count: fetal movement counting mother sits quietly on the LEFT SIDE for 1 hour after meals & count fetal kicks for

30 minutes. Notify the physician or health care provider if FEWER THAN 3 KICKS.

Biophysical Profile : surveillance of fetal well being base on 5 categories:

1. Fetal breath mov’t

2. Fetal tone

3. Amniotic fluid

4. Fetal heart reactivity

5. Placental Grade

Interpretation:

Fetal score of 8 – 10: normal fetal well-being

Fetal score of 4 – 6: fetal distress

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