maternity nursing encompasses the care of childbearing women and their families through what stages of life?
all stages of pregnancy and childbirth & then the first 6 weeks after birth
addresses the differences in access, use of health care services, and health outcomes for various factors such as age, race, ethnicity, socioeconomic status, and geographic groups and health status of these populations
health disparities
what are health disparities linked to?
biological factors, environment, socioeconomic factors, and health behaviors
what is the critical component of health disparities on low income women?
they're less likely to seek early & continuous prenatal care which places her & the fetus at higher risk for complications during pregnancy, labor, birth, & postpartum.
Examples of barriers to access include limited finances (inability to pay), lack of tr
true or false: other ethnic groups experience shorter life expectancy, higher infant & maternal mortality rates, more birth defects, & more STIs
true
Health People 2020 has ____ objectives related to maternal, infant, & child health
33
4 over-arching goals
10 year national (US) objectives for improving health of all Americans
The Millennium Developmental Goals were developed by _____ & consist of ____ goals that were to be achieved by 2015 in response to main developmental challenges in the world. Goals _____ are related to women & children
the UN
8
3 through 5
The UN continued the Millennium Developmental Goals with a 2030 agenda for ______. There are 17 sustainable developmental goals, all of which are relevant to ____ & _____
sustainable development
childbearing and childrearing
There are 6 problems with the current US health care system as discussed in lecture/PPT, what are they?
- Structure of the system (fragmented, expensive, & inaccessible to many)
- Reducing medical errors (3rd leading cause of death in the US)
- High cost of healthcare (high costs due to higher prices, readily accessible to tech, greater obesity, increased #
the total # of live births per 1,000 of reproductive age (15 - 44 years)
fertility rate
the # of live births per 1,000 people
birth rate
Across the board there has been a decline in fertility and birth rates in the U.S. with one exception. What is it?
There has been an increase in birth rates fro women in their 30's and early 40's.
(Birth rates have also decreased among teenagers.)
A baby born weighing ____ is considered to have low-birth weight (LBW)
weighing less than 2500g or 5.8lbs
this increases the risk of morbidity and morality
true or false: multiple births contribute to LBW & non-Hispanic black infants are almost 2X likely to be LBW than non-Hispanic white infants
true
what contributes to LBW?
associated with cigarette smoking, prematurity, and intrauterine growth restriction.
true or false: Of concern is the percentage of infants born preterm (before 37 weeks gestation) which is on the rise.
TRUE
Infant mortality in the US in 2010 places us at 26th compared to other industrialized countries (trends do not keep pace w/ rates of other industrialized countries). Rather, the US has a higher rate of ____ infants.
LBW
True or false: maternal mortality in the US is increasing.
TRUE
remains a significant problem because a high proportion of deaths are preventable by improving access to and use of prenatal services
True or false: we also see a significant racial disparity in maternal deaths in the US
true
What are the top causes in the US for increasing maternal death rates?
�cardiovascular disease, non-cardiovascular disease, and infection. Interesting note: top world wide causes of maternal mortality: severe hemorrhage, infections, pre/eclampsia, obstructed labor (ex. shoulder dystocia), complications of abortions, and othe
What are some adverse effects of obesity in regards to maternal nursing?
In the U.S. 35.7% of adults are obese and 16.9% of children are obese. Issues: fetal abnormalities such as spina bifida, heart defects, anorectal atresia, and hypospadias.
evidence-based practice (EBP) is to be the integration of the best ____, ____, & ____ in making decisions about the care for patients.
research evidence, clinical expertise, and patient values
healthcare can fall short on implementing EBP
In regards to legal issues & maternal nursing, we're trying to ______ _____. This is done through TJC's _______ list, sentinel events outlining ____, & failure to rescue which evaluates _____.
prevent errors
TJC's "Do not use" list
sentinel events outlining unexpected outcomes involving death or serious injury
failure to rescue which evaluates the quality indicators of nursing care relative to outcomes
In regards to ethical issues in maternal nursing, what are the ethical principles?
autonomy, respect, beneficence, nonmaleficence, justice, fidelity, and veracity
in regards to ethical issues in maternal nursing, what are the ethical approaches?
�Rights approach: focus on right to choose, to privacy, to know truth and free from injury
�Utilitarian approach: action that provide the greatest good for the greatest number of people
in regards to ethical issues in maternal nursing, who sets forth the standards of practice?
�Ethical standards are set by ANA - ANA Code of Ethics
�The Association of Women's Health, Obstetrics, and Neonatal Nurses (AWHONN) believes standards of practice are the nursing profession's best judgment and optimal practice based on current research an
what are some ethical issues in perinatal nursing as we discussed in class?
-
Ethical dilemma
- a choice that has the potential to violate ethical principles (often advocacy) - often our responsibility is to the mother but indirectly the fetus. This is a unique aspect of maternity nursing because the nurse is an advocate for two
Maternity nursing is the most litigious of all the areas of nursing. What factors contribute to the high rates of litigation in obstetrics?
�Complexity of caring for two patients, the mother and the fetus
�Expectations for the "perfect" baby
�Delayed childbearing
Five clinical situations that account for a majority of fetal and neonatal injuries and litigation:
�Inability to recognize and respond to fetal compromise
�Inability to effect a timely C-section
�Inability to initiate resuscitation on depressed baby
�Inappropriate use of oxytocin or Misoprostol
�Inappropriate use of forceps/vacuum/preventable shoulder
a group existing within a larger cultural system that retains its own characteristics. Avoid generalization that every person practices a cultural belief within a group because this can lead to stereotyping and misunderstanding of the nuances of various c
subculture
refers to changes that occur within one group or among several groups when people from different cultures come into contact with one another. People retain some of their own cultural practices while adopting some cultural practices of the dominant society
Acculturation
occurs when a cultural group losses its cultural identity and become part of the dominant culture. The groups "melts" into mainstream.
Assimilation
Our society is becoming more culturally diverse; therefore, it become essential that nurses become ___ ____
culturally competent
ANA added a new standard of practice that directs nurses to practice "in a manner that is congruent with cultural diversity and inclusion principles.
is the opposite of ethnocentrism. It refers to learning about and applying the standards of another's culture to activities within that culture. It enables nurses to recognize that the behavior of others can be based on a system of logic different from th
Cultural relativism
_____ is one of the most challenging obstacles for nurses working with patients from diverse cultural groups.
Communication
Health care agencies often seek the services of interpreters and translators to bridge the gaps and fulfill obligations for culturally and linguistically appropriate care. Use caution when using a relative, neighbor, or children as interpret
cultural competency in regards to maternal nursing comprises of what 6 things?
1.Recognize disparity exists
2.Educate and promote healthy behaviors
3.Apply abstract knowledge in practical way
4.Communicate respect
5.Recognize importance of different styles
6.Anticipate addressing varied degrees of understanding
�Form of slavery in which people are forced to become pat of the labor force - sweatshops, domestic work, or serve as sex slaves
�Majority are women and children
�Women often have interaction with healthcare providers
�Imperative that nurses recognize the
human trafficking
�Physical, emotional, sexual abuse
�Victim is often isolated
�Controlling all aspects of the woman's life - money, shelter, time, food
�Battering occurs in a repeated cycle
�Crosses all ethnic, educational, religious, and socioeconomic backgrounds
�In pre
Intimate Partner Violence
�Intimate partner violence is the most common form of violence experienced by women worldwide - 1 in 6 women have been a victim of domestic violence.
�In the U.S. 1 in 4 women have experienced severe physical violence by a curren
Signs of Intimate Partner Violence
-Overuse of health services
-Vague, nonspecific complaints
-Chronic pain
-Depression, anxiety
-Missed appointments
-Unexplainable injuries or bruising
-Nonadherence to treatment
-Untreated serious injuries
-Injuries not matching the description
-Intimate
what is the cycle of violence?
Phase 1: Tension building ?That her experiences increased tension, victim minimizes problems ?tension becomes intolerable
Phase 2: Abusive incident ? Batterer highly abusive, incident occurs
�
Phase 3: Honeymoon period ? Loving, apologetic, promises chang
what are the risks to fetuses when a woman is the victim of battery during pregnancy?
Risk to the fetus includes increased rate of miscarriage, preterm birth, and stillbirth
�Rates of battery range from 4% to 8% and may be as high as 20% in some populations
�Incidence of intimate partner violence may escalate
�May happen for the first time
How can RN's be advocates for their pregnant abuse patients per ANA?
�Universal screening of all patients for IPV - follow up with a detailed assessment if a woman is a risk for abuse
�Documentation of the abuse
�Reporting of IPV - be aware of the laws regarding mandatory reporting
�Provide information regarding IPV and sa
what is the official diagnosis for infertility?
a diagnosis for couples who have not achieved a pregnancy after 1 year of regular, unprotected intercourse when the woman is less than 35yo
for women >35yo, the time is 6mo of regular unprotected intercourse
infertility affects about 10-15% of reproductiv
there are 4 goals when providing care to an infertile couple, what are they?
1. provide the couple w/ accurate info
2. assist in identifying the cause of infertility
3. provide emotional support
4. guide & educate about forms of treatment
there are several factors associated with female infertility, what are they?
- ovarian factors (developmental anomalies, primary/secondary anovulation, medications)
- tubal/peritoneal factors (developmental anomalies, reduced tubal motility, inflammation within the tube, tubal adhesions, disruption caused by tubal pregnancy, endom
How do we know if ovulation has taken place? (a physical observation)
Cervical mucous= spinnbarkeit... abundant, watery, stretchy/gummy discharge... "fertile mucous"� facilitates passage of sperm into uterus (Note: orgasm increases movement of sperm - will affect mucous)
in discussing the care management of female infertility, we use several diagnostic tests or exams. List these tests/exams
�Evaluation of the anatomy
�Detection of ovulation
�Hormone analysis
�Ultrasonography
�Endometrial biopsy
�Hysterosalpingography
�Laparoscopy
In discussing care management of female infertility, ovulation tests are done for what reason? Explain how they work
BBT, ovarian reserve testing, & detecting LH surge
Woman takes basal body temp (BBT) right away after waking up; as ovulation approaches, estrogen increases which drops temperature. When ovulation occurs, progesterone is produced, causing an increase in t
In discussing care management of female infertility, hormone analysis is a diagnostic test that we use. Explain what it is & how it works
�Ovarian reserve testing - day 3 of menstrual cycle a serum FSH and estradiol test is performed
�Detecting LH surge - rapid increase in LH 36 hours before ovulation - can be tested with urine or serum. Urine test can be done at home to help identify ideal
In discussing care management of female infertility, an endometrial biopsy is done for what reason?
to assess response of the uterus to hormonal signals that occur during the cycle
performed at the end of the menstrual cycle
In discussing care management of female infertility, a hysterosalpingography is done for what reason?
radiological examination that provided information about the endocervical canal, uterine cavity, and the fallopian tubes. Under fluoroscopic observation, dye is slowly injected through the cervical canal into the uterus. Able to detect tubal problems (adh
In discussing care management of female infertility, a laparoscopy is done for what purpose?
direct visualization and inspection of ovaries, fallopian tubes, and uterus - looking for abnormalities like endometriosis and scarring
What factors are associated with male infertility?
- hormonal factors
- testicular factors
- sperm transport factors
- idiopathic male infertility
in discussing care management of male infertility, what diagnostic tests/exams can we do?
- semen analysis
- hormone analysis
- scrotal analysis
true or false: infertility is a major life stressor & couples can often exhibit behaviors of the grieving process
true
it can also be expensive resulting in financial stress & other feelings like anger, guilt, frustration, feelings of failure - especially if one partner has the problem with infertility
true or false: Healthy lifestyle changes that result in a BMI within the normal range, moderate daily exercise, and abstinence from alcohol, nicotine, and recreational drugs are nonmedical treatment options for those with infertility problems
true
men also instructed to wear boxers & looser pants to decrease scrotal temp & prevent decrease in sperm count; avoid hot tubs & saunas
there are several pharmacological therapies for women experiencing infertility issues. these therapies are often directed at treating _______ ____ by either stimulating or enhancing ______ so more oocytes mature. This is often done with the medication ___
ovulatory dysfunction
ovulation
clomiphene citrate (Clomid)
metformin
(metformin is often the initial pharmacological treatment)
clomiphene citrate is indicated for what? describe its dosage & side effects
indicated for ovulation induction, treatment of luteal-phase inadequacy; ovulation stimulating medication.
start taking day 5 of menses & take it continuously for 5 days
dosage: start w/ 50mg/day by mouth for 5 days beginning on the 5th day of menses; may
true or false: if a pt is given metformin to treat her PCOS (PCOS is insulin resistant so then you give them that to get them into ovulation) so must educate pt that if they aren't trying to get pregnant to have backup birth control
true
there are several different assisted reproductive therapies, name a few
- IVF-ET (ivf- embryo transfer)
- gamete intrafallopian transfer (GIFT)
- zygote intrafallopian transfere (ZIFT)
- ovum transfer (oocyte donation)
- therapeutic donor insemination (TDI)
- embryo hosting
- assisted embryo hatching
refers to study of a particular gene. It improves our ability to predict susceptibility, onset, progression and response to treatment.
genetics
basic physical units of inheritance that are passed from parents to offspring and contain the information needed to specify traits.
genes
the study of genetics is moving from genetics to genomics, what is genomics
the study of the entire genome (which is the entire set of genetic instructions found in a cell)
true or false: genetic counseling is standard practice in obstetrics
true
goal is to identify risk; genetic history obtained by using questionnaire or checklist; genetic counseling --> information, education, & support
the process of egg (ovum) formation. Gametogenesis is the female produces one mature ovum and three polar bodies.
oogenesis
Gametogenesis in the male produces four mature gametes, the sperm
spermatogenesis
results in the single-cell zygote and restoration of the diploid number of chromosomes
fertilization
____ is defined as the union of a single egg and sperm and marks the beginning of pregnancy. It is a sequential process that include the gamete (egg and sperm) formation, ovulation (release of the egg), union of the gametes (results in embryo) and implant
conception
Fertilization takes place in the outer third of the uterine tube. Between ________ days after conception the blastocyst embeds in the endometrium.
6 and 10 days
when the blastocyst embeds in the endometrium, the germ layers start forming. there are 3 primary germ layers, what are they?
ectoderm
mesoderm
endoderm
this primary germ layer is the upper layer of the embryonic disk ? epidermis, glands, nails, hair, central and peripheral nervous systems, lens of the eyes, and tooth enamel
ectoderm
this primary germ layer is the middle layer of the embryonic disk ? bones, teeth, muscles, dermis, connective tissue, cardiovascular system, spleen, and urogenital system
mesoderm
this primary germ layer is the lower level of the embryonic disk ? respiratory tract, digestive tract, liver, pancreas, urethra, bladder, and vagina
endoderm
true or false: pregnancy is an average of 10 LUNAR months, 9 calendar months, 40 weeks or 280 days from LMP - is calculated from the beginning of the last normal menstrual period to the time of birth
true
true or false: conception occurs approximately 2 weeks after the first day of the LMP. Post conception age of the fetus is 2 weeks less for a total of 266 days or 38 weeks. Post conception age is used in the discussion of fetal development.
true
intrauterine development is divided into 3 stages, what are they?
pre-embryonic, embryo, and fetus
____ is the time of implantation through 8 weeks
embryo
____ is 9 weeks until end of pregnancy; refinement of structures and function = less vulnerable; viability is the capability of the fetus to survive outside the uterus (infants who're 22-25wks of gestation are now considered on the threshold of viability)
fetus
there are 2 layers that comprise the amniotic sac, what are they?
amnion (inner layer) & chorion (outer layer)
amniotic fluid is the fluid contained within the amniotic sac
what are the primary functions of amniotic fluid?
�Cushion for mechanical injury
�Control temperature
�Permit symmetric growth
�Prevent adherence of embryo-fetus to amnion
�Allow for movement/musculoskeletal development
�Prevent cord compression
�Act as wedge during labor
�Fluid for analysis of fetal hea
how is amniotic fluid secreted?
�Embryo & trophoblast early in pregnancy,
�By 23-25 weeks fetal kidneys become major source for amniotic fluid. (Fetus swallows and inhales the amniotic fluid= matures lung /GI /Renal)
in regards to amniotic fluid, what is oligohydraminios?
(<500 mL); decreased amount of amniotic fluid could be from congenital renal problems
in regards to amniotic fluid, what is polyhydraminios?
(1,500-2,000mL)
increased amount of amniotic fluid = increased risk for chromosomal disorders, GI, cardiac, or neural tube disorders
the umbilical cord connects the fetus to the placenta; it has 3 vessels, describe what they are & their function
one large vein that brings oxygenated blood to the fetus
2 small arteries that carry deoxygenated blood away from the fetus
_____ is a specialized connective tissue that surrounds the blood vessels in the umbilical cord that helps prevent compression. Protects vessels from compression.
wharton's jelly
what is the purpose of the placenta?
metabolic and nutrient exchange between the embryonic and maternal circulation. Maternal-placental-embryonic circulation by Day 17
What are the parts of the placenta?
- Maternal part: decidual basalis & its circulation (red, fleshy) = dirty Duncan
- Fetal part: consists of chorionic villi & its circulation (covered by amnion=shiny/gray) = shiny Schultz
- Amnion & smooth chorion are arranged to show they're fused & cont
what are the functions of the placenta?
�Metabolic activities: produces glycogen, cholesterol and fatty acids for fetal use and hormone production, makes enzymes, stores glycogen and iron.
�Transport functions: transports nutrients, oxygen and CO2
�Endocrine gland functions: produces hormones f
there are structures that are unique to fetal circulation, what are they?
ductus venosus
foramen ovale
ductus arteriosus
the ductus venosus is a structure unique to fetal circulation, what is its function?
�most blood flows through the ductus venosus directly into the inferior vena cava, by-passing the liver, however, a small part enters the liver then the inferior vena cava via the hepatic veins. The oxygenated blood coming into vein from placenta will byp
the foramen ovale is a structure unique to fetal circulation, what is its function?
�allows blood to move from right to left atrium, then blood pours into left ventricle which pumps into the aorta. This structure allows some of the blood to bypass going through right ventricle, due to pulmonary resistance of fetal lungs, this particular
the ductus arteriosus is a unique structure to fetal circulation, what is its function?
allows lots of blood to pass from the pulmonary artery through to the descending aorta.
true or false: teratogen exposure most critical during the organogenesis (week 4-8weeks) = gross structural defects
true
Exposure to teratogens after 13 weeks of gestation = fetal growth restriction or reduction of organ size.
TORCH- toxoplasmosis, other infections (like hep a/b), rubella, cytomegalovirus, herpes
true or false: in regards to teratogens, The degree or types of malformation vary based on length of exposure, amount of exposure, and when it occurs during human development.
true
Give the definition of the following terms:
Gravida
Gravidity
Nulligravida
Primigravida
Multigravida
�Gravida: Woman who is currently pregnant
�Gravidity: Pregnancy
�Nulligravida: Woman who has never been pregnant and is currently not pregnant
�Primigravida: Woman pregnant for first time
�Multigravida: Woman who has had two or more pregnancies
_____ is the number of pregnancies in which fetus or fetuses have reached 20 weeks, not number of fetuses (e.g., twins) born. Whether the fetus is born alive or is stillborn (fetus who shows no signs of life at birth) after 20 weeks is reached does not af
parity
Give the definition of the following terms
Nullipara
Primipara
Multipara
�Nullipara: Woman who has not completed a pregnancy with fetus or fetuses who has reached 20 weeks or more of gestation
�Primipara: Woman who has completed one pregnancy with fetus or fetuses who has reached 20 weeks or more of gestation
�Multipara: Woman
Give the definition of the following terms:
Preterm
Late Preterm
Early term
Full term
Late term
Postterm
Viability
�Preterm: Pregnancy that has reached 20 weeks of gestation but before completion of 37 weeks of gestation
�Late preterm: Pregnancy that has reached between 34 weeks 0 days and 36 weeks 6 days gestation
�Early term: Pregnancy that has reached between 37 we
What is the GTPAL system for summarizing obstetric history?
G - gravida = total # of pregnancies
T - term deliveries 37 0/7 weeks or after
P - pre term deliveries between 20 and 36 6/7 weeks
A - abortion before 20 weeks or <500 gm
L - # of living children
what is the earliest biochemical marker of pregnancy?
human chorionic gonadotropin (hCG)
how do we diagnose pregnancy?
- urine test (ELISA; pregnancy tests based on recognition of hCG or Beta subunit of hCG which can be detected in serum/urine as early as 7-8 days after ovulation; most common testing done; urine pregnancy tests are qualitative but serum are quantitative)
What are presumptive signs of pregnancy?
what the woman reports/changes felt by the woman = subjective signs not diagnostic: Amenorrhea, nausea, vomiting, enlargement or tender breast, fatigue, urinary frequency, quickening (18-20 weeks) fetal movement
What are probable signs of pregnancy?
what the examiner determines from assessment/changes observed by an examiner = not diagnostic: Chadwicks sign (bluish-purple cervix @ 6-8 weeks), Goodell's sign (softening of cervix & vagina 8 weeks), Hegar's sign (softening of lower uterine segment @ 6 w
What are positive signs of pregnancy?
conclusive proof of pregnancy/signs attributed only to the presence of the fetus: Auscultation of fetal heart rate (10-12 weeks), ultra sound (noted cardiac movement at 4-8 weeks), observation and palpation of fetal movement (20 weeks)
the uterus changes in what ways during pregnancy?
changes in shape and position - increases in size from 40-50gms to 1100 to 1200gms - ovulation and menses cease during pregnancy
the cervix changes in what ways during pregnancy?
increases discharge and a sticky mucous plug closes cervix
�Chadwick's sign = bluish color of cervix and vagina from increased vascularity
�Goodell's sign = cervix softens
how does the vagina change in pregnancy?
connective tissue loosens and increase in vaginal secretions
what are some discomforts associated w/ reproductive changes in pregnancy?
�Leukorrhea (thin milky white discharge)
�Increased yeast infections - advise to use cotton underwear, proper hygiene, avoid douching, notify MD of foul odor or puritis
�Braxton hicks contractions - occasional normal
is sexual activity okay during pregnancy?
yes unless advised by MD (may be restricted due to bleeding, rupture of membranes, or cramping) - advise that patient may wish to try alternative sexual positions.)
what changes in a woman's breasts during pregnancy?
Size: increase in glandular (progesterone) and duct (estrogen) development, veins more prominent�colostrum may be present by 3rd trimester
Striae gravidarum - may develop (stretchmarks)
Areolas - take on a darker color
Discomforts: tenderness/size increas
true or false: the cardiovascular system has significant adaptations during pregnancy
true
pulse rate increases by 10-15bpm at around 20wks (pulse of 60-90 is normal)
CO increases by 30-50% to supply kidneys & uterus (SV increases by 25-30%)
BP should be consistent w/ pre-pregnancy levels during 1st tri, drops 5-10pts during 2nd tri, & ret
what is supine hypotensive syndrome?
aka vena cava syndrome
weight of enlarging uterus impairs blood return through the vena cava resulting in hypotension and signs/symptoms dizzy & faint = don't lay on back to for prolonged periods
true or false: blood volume increases by 40-50% during pregnancy, but this increase in plasma volume is relatively larger than increase in RBCs thus woman experiences physiologic anemia
true
iron deficiency anemia (defined as Hgb less than 11.0 & Hct 33%)
true or false: pregnancy results in mild hypercoagulability, which decreases the risk of PP hemorrhage (but may increase risk for DVT)
true
increase in various clotting factors; platelets should be over 150,000. women are at 5-6x increased risk for thromboembolic disease
true or false: tidal volume increases as maternal O2 needs increase & diaphragm is elevated due to enlarging uterus
true to both
this can lead to dyspnea, nasal secretions & stuffiness, & epitaxis
urinary frequency is common in the ___ & ____ trimesters of pregnancy
1st & 3rd trimesters
(bladder tone decreases, pooling/stasis of urine, risk UTI increases, relaxation of smooth muscles)
increased risk of UTIs thus educate pt on empty bladder frequently & wipe front to back & immediately get help if s/sx of UTI
true or false: GFR increases by 50% in 1st tri & remains elevated until birth
true
what is melasma?
(also called chloasma or mask of pregnancy): blotchy, brownish hyperpigmentation o the skin over the checks, nose, and forehead. More common in women of darker complexion. Usually fades after birth.
what is linea nigra?
pigmented line extending from the symphysis pubis to the top of the fundus in the midline. Some women will have hair growth along the line.
what is striae gravidarum?
stretch marks" - reflect separation within the underlying connective (collagen) tissue of the skin. Usually occur over areas of maximum stretch such as abdomen, thighs, and breasts.
what is palmar erythema?
pinkish, red, diffusely mottled or well defined blotches seen over the palmar surfaces of the hands. Related to increased estrogen.
what is pruritus erythema?
mild pruritus that usually occurs over the abdomen. The most common specific dermatosis during pregnancy is polymorphic eruption of pregnancy (PEP) which is also called urticarial papules and plaques of pregnancy (PUPPP). This condition causes significant
what happens to a woman's musculoskeletal system during pregnancy?
lumbar lordosis
ligament changes (relaxin & progesterone loosen ligaments of pubic symphysis & sacroiliac joint to facilitate labor & birth)
waddling gate
diastasis recti (3rd tri, rectus abdominus muscles separate which allows ab. contents to protrude at
true or false: the gums can become spongy & swollen during pregnancy
true
They tend to bleed easily due increased levels of estrogen that causes increased vascularity and connective tissue proliferation. Women also report ptyalism = excessive salivation
what happens to the esophagus/stomach/intestines during pregnancy?
increased progesterone ? decreased tone and motility of smooth muscles ? results in esophageal regurgitation (reflux) ? slower emptying of the stomach ? reverse peristalsis = acid indigestion or heartburn (pyrosis) that begins early in the first trimester
true or false: the gastric emptying is decreased which decreases peristalsis & so the bowels are pushed up & back leading to constipation
true
Often called the "pregnancy hormone" because nausea and vomiting in early pregnancy may be caused by elevated hCG levels. This hormone helps to maintain the production of estrogen and progesterone until the placenta takes over the function.
Human chorionic gonadotropin (hCG)
maintains pregnancy by relaxing smooth muscles and decreasing uterine contractility; ? risk of spontaneous abortion (SAB - miscarriage)
progesterone
promotes enlargement of the genitals, uterus, and breasts, increases vascularity, and relaxes pelvic ligaments and joints
estrogen
prepares breasts for lactation
serum prolactin
stimulates uterine contractions and stimulates milk ejection from breasts
oxytocin
what is the breakdown of trimesters?
1st= weeks 1-13
2nd= weeks 14-26
3rd= weeks 27-40
describe naegele's rule in EDB
- Determine first day of last menstrual period (LMP), subtract 3 months, add 7 days plus 1 year
- Alternatively add 7 days to LMP and count forward 9 months
how do we use fundal height to estimate date of birth?
measure fundal height (in cm from symphysis pubis) - gestational age (18-32 in weeks) is estimated to be equal to fundal height (in cm) - 20 weeks gestation should be measure at umbilicus - obesity can affect measurements. Gestational age = fundal height
phenomenon when some men experience pregnancy-like symptoms such as nausea or weight gain.
with regards to paternal adaptation to pregnancy, what is this?
couvade syndrome
the stage of absorbed or occupied; participating in labor, witnessing birth, and holding his new baby can have a profound effect on the father.
with regards to paternal adaptation of pregnancy, what is this?
engrossment
true or false: Prenatal care can significantly reduce infant and maternal morbidity and mortality rates by early detection and treatment of potential problems.
true
true or false: Prenatal care is sought routinely by women of middle or high socioeconomic status
true
emphasis on preventative care & optimal self-care
there are several barriers to prenatal care, list a few
- inadequate finances
- lack of transportation
- unpleasant clinical personnel
- inconvenient clinical hours
- personal & cultural attitudes
Women in poverty or lacking health insurance may not have access to public or private care. Elaborate further
�Lack of culturally sensitive care and communication interferes with access to care
�Immigrant women may not seek prenatal care
�Birth outcomes are less positive with higher rates of maternal and newborn complications
�Problems with low birth rate and inf
Prior to pregnancy, there should be a preconception screening (interventions aiming to identify medical, behavioral, and social risks to a woman's health). What does this comprise of?
- routine physical
- health screenings (risk screenings) (pap smear (if indicated), blood type and Rh, CBC, urine analysis, STI (HBsAg, HIV, chlamydia/gonorrhea, syphilis), and glucose (if at risk))
- anticipatory guidance
goal is to modify risk factors t
as a part of a preconception screening, there are several anticipatory guideline topics that are brought up. name some
- nutrition (maintain healthy weight as obesity increases risk for infertility, antepartum complications, complications during childbirth, prolonged labor/difficult delivery, postpart. hemorrhage, & poor wound healing post C-section)
- medications (note m
in an uneventful pregnancy visits are scheduled _____ until ___ weeks, every ____ weeks starting at 28 weeks, and then every ____ starting at 36 weeks.
scheduled monthly until 28 weeks, every 2 weeks starting at 28 weeks, and then every week starting at 36 weeks.
what does the initial prenatal visit consist of?
everything discussed in preconception health care visit: History, physical exam, risk factors, anticipatory guidance, laboratory tests, and ultrasound (to confirm pregnancy and determine pregnancy dating)
PLUS lab tests (urine dipstick/culture, blood type
what do each subsequent prenatal visits after the initial consist of?
�weight, blood pressure, urine dipstick (protein, glucose), fundal height, Leopold's maneuver, fetal heart tones (FHT), assessment of fetal movement (once patient has started feeling fetal movement), and possible cervical exam check (starting at 36 weeks)
what are some danger signs in pregnancy?
severe edema/facial edema (a sign of preeclampsia)
bleeding, absence of fetal movement, fever, sudden gush of fluid (or a trickle, could be a premature rupture of membranes), fever, dizziness, epigastric pain,
�Provide education on maternal and fetal changes and on self-management. Some self-management topics include: Nutrition, dental health, physical activity, immunizations, substance abuse, normal discomforts, recognizing potential complications, safety, pre
prenatal education principles
in the 1st trimester, what type of education should mom receive?
�discomforts, changes, fetal development, lifestyle (exercise, oral hygiene, nutrition)
in the 2nd trimester, what type of education should mom receive?
�changes, danger signs, preterm labor, PIH, breastfeeding, birth plan, classes
in the 3rd trimester, what type of education should mom receive?
�labor and birth, infant care, feeding, classes, birth plan, infant care, postpartum
____ are labor and postpartum companions that are trained to provide physical, emotional, and information support to women and their partners during labor, birth, and the postpartum period. The doulas does not become involved with the clinical tasks. Some
doulas
is a tool with which parents can explore their childbirth options and choose those that are most important to them. The plan must be viewed as tentative because the realities of what is feasible may change as actual labor and birth unfold. It should be co
birth plan
true or false: the first trimester is crucial for embryonic and fetal organ development & thus healthful diet before conception ensures that adequate nutrients are available for developing fetus
true
this vitamin intake is important in the periconceptual period
folate or folic acid
why is folate/folic acid so crucial in the periconceptual period??
neural tube defects are more common in infants of women with poor folic acid intake.
Proper closure of the neural tube is required for normal formation of the spinal cord and the neural tube begins to close within the first month of gestation often before
All women of childbearing age should take ____ mg (___ mcg) of folic acid every day in addition to consuming sources of folate. what foods contain folate?
0.4 mg (400 mcg) of folic acid
liver, chicken, turkey, lamb, beef, legumes, peas, beans, lentils, breakfast cereals, vegetables (broccoli, greens, spinach), pasta, rice, bread, egg, corn
what factors contribute to nutrition needs in pregnancy?
�Development of uterine-placental-fetal unit
�Increased maternal blood volume and constituents
�Maternal mammary development
�Increased metabolic rate
For women with single fetuses, current recommendations are that women with normal BMI should gain _____ during pregnancy
11.5-16kg (25-35lbs)
in the 1st tri: 2-4lbs
then 1lb per week
true or false: The recommendation for overweight and obese woman is to gain less during the pregnancy.
true
Recommended energy (kcal) intake:
�1st trimester = ___ kcals/day
�2nd trimester = ____ kcals/day
�3rd trimester = ____ kcals/day
1800
2200
2400
is the practice of consuming nonfood substances (clay, dirt, laundry starch) or excessive amounts of food that is low in nutritional value (cornstarch, baking powder, or baking soda). Women with this have been found to have lower hemoglobin levels. Cravin
pica
what is the energy intake upped to during lactation?
increase 450kcal
�Needs for energy (calories), protein, calcium, iodine, zinc, the B vitamins, and vitamin C remain greater than nonpregnant needs
what are some biophysical factors that are common in high-risk pregnancy?
genetic disorders, nutritional and general health status, and medical or obstetric related illness (poorly controlled diabetes mellitus and disorders)
what are some psychosocial factors that are common in high-risk pregnancy?
disturbed interpersonal relationships, emotional distress, inadequate social support, unsafe cultural practices, and substance abuse.
what are some sociodemographic factors that are common in high-risk pregnancy?
low income, lack of prenatal care, age (adolescent or older mother), parity, marital status, and ethnicity
what are some environmental factors that are common in high-risk pregnancy?
hazards in the workplace, infection, drugs and environmental pollutants.
what is a daily fetal movement count & how is it obtained?
�Daily fetal movement counts (aka "fetal kick" counts) - the presence of movements is generally a reassuring sign of fetal health
�
Mother palpates abdomen and counts the number of times baby moves
�
If less then 10 movements /2 hour calls MD
�
Any decrea
confirmation and dating of pregnancy, detect multiple gestation, fetal heart activity, fetal growth, fetal anatomy, fetal genetic disorders, fetal anomalies, bleeding issues, placenta location, placenta issues (placenta previa or abruption), and additiona
ultrasound
uses high-frequency sound waves; fluid is clear and bone is bright white
levels= standard, limited, & specialized
can e transvaginal or external abdominal
done at first & then 20wks to check organs
�screening tool used to identify fetuses at risk for further genetic testing
�Done between 11weeks - 13 weeks 6 days
�NT: <2.5-3mm (normal)
�May detect up to 90% of cases of genetic disorders (downs syndrome, trisomy 18) and cardiac anomalies
what screeni
nuchal translucency
�Screening tool to measure amniotic fluid levels to assess placental function
�US used to measure pockets of fluid in 4 quadrants
�Average fluid: 8-24 cm
what test is this?
amniotic fluid index (AFI)
�Oligohydramnios (< 5 cm): indicates congenital anomalies (renal decrease in O2 to kidneys leads to decrease of renal function) and premature rupture of membranes
�Polyhydramnios (> 24 cm): may indicate gastrointestinal and cent
�Gold standard for assessment of fetal condition; uses real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.
�Assess 5 characteristics - zero or 2 points
�Max scor
bio-physical profile (BPP)
Less than 4 requires repeating later in the day or delivering the baby
Usually done at end of pregnancy; done on high risk pts who would be high risk b/c of diabetes or BP issues, could also be done on pt 41 weeks into pregnancy
on a BPP, what are the 5 components we are assessing?
what is a normal score? what score is abnormal? what score is strongly suspect?
�Breathing - one episode of breathing motion for 30 seconds in 30 min
�Fetal movement - limb movement 3 or more in 30 min
�Fetal tone - extremity extension and return (one or more)
�Amniotic fluid - 2 cm in 2 planes perpendicular to each other
�Nonstress
using ultrasound guidance a needle inserted into uterine sac to sample amniotic fluid for genetic testing or fetal long maturity
what is this test?
Amniocentesis
�L/S ratio >2:1 indicates fetal lung maturity
�L/S ratio <2:1 indicates immaturity and risk for respiratory distress syndrome
�L/S ratio needs to be 3:1 in diabetes to indicate fetal lung maturity
when is an early amniocentesis done & why?
Done at 14-20 weeks for genetic abnormalities in women at risk loss; determines chromosome disorders, gender, neural tube defects. Possible risks: vaginal bleeding, rupture of membranes (ROM), infection, and fetal loss.
when is a late amniocentesis done & why?
Done for lung maturity to assess PG (phosphatidylglycerol- present-absent) and L/S (lecithin/sphingomyelin�ratio 2:1) may not be present until after 35 wks. Risks: preterm delivery, trauma, bleeding, and infection
�Assessment of a portion of the developing placenta (chorionic villi) which is aspirated through a thin sterile catheter
�Used for chromosomal, metabolic, or DNA testing - checks for genetic disorders & metabolic disorders (cystic fibrosis) - results in 2
chorionic villus sampling
�Screening tool used to detect neural tube defects
�80% to 85% of open NTDs and abdominal wall defects can be detected early
�Recommended for all pregnant women
Blood sample is obtained 16-18 weeks gestation and sent to lab for analysis
an elevated level
alpha-fetoprotein (AFP) test
Advantage = easy test and can indicate further testing
Risk = high false positive rate = anxiety
Nursing actions teach about test, provide support to parents
passive monitoring of FHR for at least 20 minutes, marking fetal movements. Test preferably done after a carbohydrate load and can be done weekly or bi-weekly. Typically performed in the third trimester to monitor the response of the FHR to fetal movement
non-stress test (NST)
results:
�Reactive: 2 accelerations of 15 bpm lasting 15 seconds over 20 minutes
�Non-reactive (NR): criteria not met. If NR = continue monitoring, add vibroacoustic stimulation (VAS), repeat next day, if still NR or abnormal then fu
stimulates uterine contractions (UC's) either by supplementing oxytocin or by performing nipple stimulation. Monitors the FHR response to contractions (decreased placental blood flow) to determine how the fetus will tolerate the stress of labor. Provides
contraction stress test (CST)
Must have 3 UC's (lasting 40-60 seconds) in 10 minutes while monitoring FHR.
�Negative: No late decelerations with UC's (we want this)
�Positive: repetitive late decelerations with greater that 50% of UC's
there are several preexisting conditions that for some women represent significant risks with pregnancy, what are they?
- gestational diabetes mellitus
- CV disorders (increased intravascular volume, decreased systemic vascular resistance, CO changes during l/d, intravascular changes that occur just after delivery)
- substance abuse
this is any degree of glucose intolerance with onset or recognition during pregnancy. Insulin needs low in first trimester. During the 2nd half of pregnancy, woman need more insulin because placental secretion of hPL, prolactin, glycogen, and increased le
gestational diabetes mellitus (GDM)
Risk factors: obesity, PCOS, prior history of gestational diabetes, persistent glycosuria, strong family history of diabetes, prior macrosomic infant, prior stillborn infant; chronic hypertension
when should a pregnant woman be screened for gestational diabetes?
if low risk, 24-28wks gestation
if high risk, as early as possible in the pregnancy
what is the maternal risk of diabetes mellitus?
�Preeclampsia and hypertensive disorders
�Risk of infection: vaginitis and UTI risk (due to poor glucose control)
�Increased risk of polyhydramnios- due to fetal anomalies; may see oligohydramnios at the end of pregnancy due to decreased placental perfusi
what are the fetal risks of diabetes mellitus?
�LGA infant = macrosomia due to hyperglycemia or IUGR due to decreased maternal perfusion
�Over distension of uterus can lead to preterm premature rupture of membranes (PPROM), preterm labor (PTL), hemorrhage
�Asphyxia related to hyperglycemia and leads t
what are the neonatal risks of diabetes mellitus?
�Birth injury form macrosomia/dystocia/cesarean
�Respiratory distress syndrome due to fetal lung immaturity
�Hypoglycemia due to hyperinsulinemia from infant need to overcome mothers hyperglycemia can also lead to temp instability
�Prematurity
how do we screen for gestational diabetes mellitus?
�Routine dipping of urine for glycosuria at all prenatal visits
�Signs and symptoms of diabetes: hunger, thirst, frequent urination, blurred vision, and excessive weight gain
�For low risk patients an initial screening test of a 1 hour 50 gm glucose test
what are some outcomes as a result of a pregnant woman having CV disorders?
�Increased incidence of miscarriage
�Preterm labor and birth more prevalent
�Intrauterine growth restriction is more common
�Incidence of congenital heart lesions increased in children of mothers with congenital heart disease
what is the 4Ps Plus tool in regards to screening for substance abuse (in pregnancy)
�Parents: Did either of your parents ever have a problem with alcohol or drugs?; Partner: Does your partner have a problem with alcohol or drugs?; Past: Have you ever had any beer or wine or liquor?; Pregnancy: In the month before you knew you were pregna
_______ disorders of pregnancy are the most common medical complication reported during pregnancy
�Significant contributor to maternal and perinatal morbidity and mortality
hypertensive
gestational htn is defined as?
BP>140/90 that develops after 20 weeks gestation but there is no proteinuria; 25% to 50% of these woman may develop preeclampsia
preeclampsia is defined as?
�hypertension BP>140/90 that develops after 20 weeks gestation
with proteinuria
a*. It can be further characterized as ether mild or severe.
_______ is the onset of convulsions/seizures attributed to preeclampsia - high risk for cerebral hemorrhage, aspiration, death
eclampsia (not common)
what is chronic htn defined as in pregnancy?
�elevated BP before 20 weeks gestation (pre-existing disease); blood pressure >140/90 before pregnancy or before 20weks gestation or remains >12 weeks postpartum; 25% of these women are at risk for development of preeclampsia
what is chronic htn superimposed preeclampsia defined as in pregnancy?
a patient who has chronic hypertension who develops preeclampsia symptoms including proteinuria
the risk factors for preeclampsia are?
�Family history
�Multifetal pregnancy
�African-American race
�Obesity
�Before 19 and after 40 years old
�Preexisting medical or genetic conditions
what is the pathophysiology of preeclampsia?
�Progresses along a continuum from mild to severe
�Caused by disruptions in placental perfusion and endothelial cell dysfunction
�Placental itching
�Generalized vasospasm
�Reduced kidney perfusion
preeclampsia complications maternally include?
-Seizure (eclampsia)
-Intracerebral hemorrhage
-Increased intraocular pressure
-Thrombocytopenia/DIC
-Renal failure
-Hepatic failure
-Abruption
preeclampsia complications to the fetus/newborn include?
-Preterm birth /RDS
-IUGR
-Low birth weight
-Stillbirth
-Decreased placental perfusion
-Sedation related to medications
what is HELLP syndrome?
�Laboratory diagnostic variant of severe preeclampsia involves hepatic dysfunction, characterized by:
�Hemolysis (H)
�Elevated liver enzymes (EL)
�Low platelets (LP)
associated w/ risk factors of pulmonary edema, acute renal failure/liver hemorrhage or fa
what are the 1st & 2nd line drugs used to control htn in pregnant women?
1st line: hydralazine, labetalol hydrochloride, methyldopa
2nd line: nifedipine
also use mag sulfate to prevent seizures w/ severe preeclampsia/HELLP/eclampsia
also steroids such as beamethasone for fetal lung maturity
a SAB (miscarriage) is classified as such how? (S/sx)
<20weeks & fetal weight <500g
Symptoms: vaginal bleeding, cramping-can be like a heavy period, loss of amniotic fluid, patient stating that she doesn't feel pregnant anymore
Diagnosis-ultrasound - either abdominal or transvaginal to assess gestational sac
Mechanical defect in the cervix that results in painless cervical dilation in the second trimester of pregnancy. Cause unknown but related to trauma of cervix.
Risk factors: history of recurrent and unexplained spontaneous abortions, multiple gestation, p
cervical insufficiency
�In L&D perform cerclage (Shirodkar-Barter operation-more invasive; sutures cervix to keep it closed, remove it at 35/36 weeks) or McDonald's suture (more infections) procedures�remove at term
an abnormal implantation of a fertilized egg outside the womb. Leading pregnancy-related cause of 1st trimester maternal deaths and is responsible for 6% of all maternal deaths
what is this & what are its risk factors?
ectopic pregnancy
risk factors: Previous ectopic pregnancy, Pelvic inflammatory disease (PID), tubal surgery (such as a tubal ligation), IUD (intrauterine device), age extremes, smoking, endometriosis, ovulation-inducing drugs
Classic symptoms: abdominal
a premature separation of a normally implanted placenta; s/sx include severe sudden abdominal pain, rigid board like abdomen (internal bleeding), vaginal bleeding may or may not be present, hypovolemic
abruptio placentae (placenta abruption)
risk factors: previous abruption, abdominal trauma, cocaine use, methamphetamine use, uterine anomalies, hypertensive disorders
�Maternal complications/risks: blood loss 500 to >1500 , shock, hypotension, tachypnea,