Maternal and Child Health Nursing Pregnancy

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 devt 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. Oligohydramniosless than 300 ml. Polyhydramniosmore 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
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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

THREE PREGNANCY SIGNS & SYMPTOMS

PRESUMPTIVE 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 movt. Urinary Frequency Melasma . PROBABLE Pregnancy test (presence of HCG) Softening of the uterine isthmus (Hegars sign) Cervical softening (Goodells sign) POSITIVE

Auscultation of fetal heart by week 8 Ultrasound imaging of fetal heart motion Braxton-Hicks contractions by week 7 Ballotment: bouncing of the fetus in the amniotic fluid against the Ultrasound examiners hand. During the 16th-20th week. confirmation of gestational sac by Braxton Hicks Contractions: painless week 6 contractions felt for 20-30 minutes occurs on the 16th week. Ultrasound: 6 weeks can auscultate the fetal heart. Chadwicks sign is a bluish coloring of the vaginal mucosal that occurs as early as 6 weeks gestation. Fetal movements palpated Rationale: due to increase vascularity & blood by the provider by week vessel engorgement. 20. Increase size of the uterus The most objective sign of + Pregnancy Test pregnancy is fetal > Secretion of HCG in the urine (Frog Test). movement felt by the Detectable 10 days after the missed period examiner. . 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.

FETAL DEVELOPMENT

ORIGIN OF BODY TISSUE Tissue Layer Ectoderm Mesoderm Endoderm Body Portion Formed Nervous system, mucus membranes, anus & mouth Connective Tissue, Reproductive, circulatory & upper Urinary system, bones, cartillage Lining of the GI tract, Respiratory Tract, bladder & urethra

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1 mo/ 4 weeks

2 mo/ 5-8 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 devt. 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

4 mos. /13-16 weeks

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. 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 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 weeks20 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. 21-25 WEEKS OLD MANs 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. 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. 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. 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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5 mos. /17-20 weeks

6 mos. /21-25 weeks

7 mos. /26-29 weeks

8 mos. /30-34 weeks

9 mos. /35-37 weeks

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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. 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)
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ULTRASOUND

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Ultrasound: abnormalities, THE BEST PREGNANCIES

done 18-40 weeks for fetal

TEST

FOR

ECTOPIC

- 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.

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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 isnt 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. 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, hydrocephaluscan be reduced through increase folic acid0.4 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. Uses amniotic fluid to ascertain fetal lung maturity through measurement of presence and amounts of the lung surfactants lecithin and sphingomyelin. At 3536 weeks; ratio is 2:1 indicative of mature levels. 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. Estimates fetal renal maturity and function, uses amniotic fluid. Level-high early in pregnancy; drops after 36 weeks gestation; uses amniotic fluid. The yellow color is the result of fetal anemia and bilirubin. 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. Uses ultrasound to locate umbilical cord. Cord blood aspirated and tested. Used in second and third trimesters. A collection of data on fetal breathing movements, body movements, muscle tone, reactive heart rate and amniotic fluid volume.

ALPHA-FETOPROTEIN SCREENING

L/S RATIO

PHOSPHATIDYL GLCEROL

CREATININE LEVEL BILIRUBIN

FETAL MOVEMENT COUNT

PERCUTANEOUS UMBILICAL BLOOD SAMPLING BIOPHYSICAL PROFILE

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-Fowlers 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 mothers blood > Test will confirm the diagnosis for Hemolytic Disease in the Newborn. Types: 1. Indirect Coombs 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 Coombs test: tests for newborns cord blood- determines presence of maternal antibodies attached to the babys cell. Rh (D) & D negative who hasnt 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 movt 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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