M/B Unit 1

the right to self determination

all persons equally valued

Obligation to do good

Do no harm

equal and fair treatment of others

obligation to keep promises

obligation to tell the truth

the greatest good for the individual

• by full term should be 800-1200 cc
• 1st trimester produced by amniotic membrane, 2 & 3rd by fetal kidneys
• Purpose is to protect fetus from pressure or blows, thermal regulation, aids in muscular development by allowing movement, protects umbilical cord

• too much amniotic fluid
• 1500-2000 cc

• Less than 500cc amniotic fluid at term
• often due to fetal kidney issues or decrease in placental function

• maternal "decidua" (term for uterine lining)
• fetal- chorionic villi
• Nutrients and O2 are exchanged, fully functional at 12 weeks
• Some harmful substances can't cross, some can
• Secretes hormones
• MATERNAL AND FETAL BLOOD DON'T MIX

• Actually 2 membranes:
• Chorionic membrane - outermost fetal membrane
• Amniotic membrane - closest to fetus
• so adherent, seems like one

• also called amniotic membrane
• Produces amniotic fluid and phospholipid that forms prostaglandins
• May be part of trigger for labor

• connects fetus to placenta
• has 1 vein that carries oxygenated blood to fetus
• has 2 arteries that carry deoxygenated blood back to mom
• usually inserted in center of placenta
• vessels surrounded by Wharton's jely

• surrounds vessels in umbilical cord
• prevents cord from collapsing

• amenorrhea
• breast changes
• N/V
• uterine enlargement
• frequency urination
• quickening
• fatigue

• basal body temp elevated
• ballottement
• Ultrasound (sonographic)
• serum lab test
• urine home test
• changes in skin & mucus: Chadwicks sign, Goodell's sign, Hegar's Sing, Linea nigra

a sharp upward pushing against the uterine wall with a finger inserted into the vagina for diagnosing pregnancy by feeling the return impact of the displaced fetus

• ultrasound visualization - p 4 weeks
• Fetal heart sounds - 10 - 12 weeks
• Fetal movement felt by examiner

lack of menstration

fetal movement

• color change in vagina and cervix
• more bluish

softening of cervix

softening of lower uterine segment

• Estimated date of delivery
• Naegele's rule:
• count back 3 months from first day of last menstrual period, then add 7 days

number of pregnancies that reached viability, regardless whether infants were born alive or not

pregnancy that reaches 20 weeks

woman who is or has been pregnant

woman who is pregnant for first time

woman who has given birth to 1 child past age of viability

woman who has been pregnant previously

woman who has never been and is not pregnant

• also called melasma
• tan or dark skin discoloration, usually on cheeks, upper lip, chin and forehead
• "Butterfly mask"

separation of stomach muscles

syndrome in which father also experiences N/V, weight gain, increased frequency to pee

• also called fundal height
• measure of size of uterus, used to assess fetal growth and development
• measured from top of uterus to top of pubic symphysis
• roughly corresponds to gestational age, 1 cm per week btwn 20 and 31 weeks

assessing for placental sufficiency

• taken btwn 14 and 20 weeks
• tests for chromosomal defects

inspection through tiny tube inserted by amniocentesis for biopsy, some surgery

• Non-stress test
• 2 accelerations of 15 bpm x 15 sec in 20 mins
• screening tool that uses electronic fetal monitoring to assess fetal well-being

• bleeding
• preterm labor
• rupture

the presence of regular contractions, at intervals of 10 mins of < 1 hr, WITH CERVICAL CHANGE, and/or rupture of membranes after 20 weeks and before 37

if baby is lost before 20 weeks

thick layer of modified mucus membrane that lines the uterus during pregnancy and is she with afterbirth

meds given to try and stop labor

if baby comes before 34 weeks, given to baby to help lungs

when you flex mom's ankles, the feet don't just smoothly relax back - will beat back

• causes spontaneous abortions
• Due to: trauma, anatomical abnormalities, Diethylstilbestrol taken by mother, infections, inflammation, or hormonal effects
• Treatment is cerclage, if cervix is 3cm or les and membranes are intact

• is a smooth muscle relaxant
• given so mom doesn't seize (in HTN)
• Also given in preterm labor to help stop labor

• Treatment for incompetent cervix
• Type of purse string suture placed cervically to reinforce a weak cervix
• *If she starts contracting, must be undone or she will rip

• also known as intra-amniotic infection
• is an inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection.
• It typically results from bacteria ascending into the uterus from the vagina and is most often associated with prolonged labor.

a hormone-secreting structure that develops in an ovary after an ovum has been discharged but degenerates after a few days unless pregnancy has begun.

• the cotyledons are the approximately 15-25 separations or sections of the decidua basalis of the placenta, separated by placental septa.
• Each cotyledon consists of a main stem of a chorionic villus as well as its branches and subbranches etc.
• Think of little trees in each space...

• Toxoplasmosis
• Other (Heb B)
• Rubella
• Cytomegalovirus
• Herpes

Detected from TORCH blood screen

• Single celled parasite; transplacental transmission
• Done by blood screen
• *AVOID raw meat and contact with cat feces
• Tx: sulfadiazine or pyrimethamine after 1st trimester

often asymptomatic but can cause fatigue, muscle pain, pneumonitis, myocarditis, lymphadenopathy

• severity varies with gestational age.
• Can lead to:
• spontaneous abortion
• low birth weight
• hepatosplenomegaly
• anemia
• neurological disease

Transmitted direct w blood/body fluid

• Infant receives HBIG (Human B Immune Globulin) and Hep vaccine at delivery
• Screening recommended in prego

HBV can be given in preganancy

• almost half are asymptomatic
• Other have low fever, nausea, preterm labor/delivery

• have 90% chance becoming chronically infected, HBV carrier,
• 25% risk developing liver disease

German measles, Transplacental

• Tx: primary approach is immunization.
• If woman is prego & no immun, should NOT receive vaccine until after delivery and advised not to get pregnant for 3 mons

• Rash
• Lymph node enlargement
• slight fever
• HA and malasie
• Just don't feel well

• Anomalies include:
• Deafness
• eye defects
• CNA anomalies
• severe cardiac malformations

• Type of herpes infection
• Transmitted by droplet or transplacentally

May result in low birth weight, IUGR, hearing impairment microcephaly, and CNS abnormalities

No treatment available

• Herpes Simplex Virus
• Chronic lifelong infection; contact at delivery & ascending infection
• Mom: painful genital lesions, which may be external or internal
• Baby: Mortality of 50-60% if neonatal exposure to active primary lesion related to neuro complication of massive infection sepsis and neuro complications
• NO CURE
• C-section will protect neonate from exposure if active lesion

In the developing fetus, the ductus arteriosus, also called the ductus Botalli, is a blood vessel connecting the pulmonary artery to the proximal descending aorta.

• shunts a portion of the left umbilical vein blood flow directly to the inferior vena cava.
• it allows oxygenated blood from the placenta to bypass the liver

• Pregnancy outside of uterus - 95% in tubes
• Higher with STD, tubal surgeries, prev ectopic prego, endometriosis, altered hormones, contraceptive failure from intra-uterine devices, smoking

term used for developing human from time of implantation through 8 weeks of gestation

the fusion of gametes to initiate the development of a new individual organism.

term used for developing human from 9 weeks gestation to birth

• Structure in fetal circulation
• is an opening btwn right and left atria
• blood high in oxygen is shunted to left atrium via the foramen ovale

embedding of the blastocyst into the endometrium of the uterus

• term used to describe the descent of the fetus into the true pelvis
• occurs approx 2 weeks before term in first-time pregnancies

used by women in labour to help them focus during contractions and it can assist with moving the baby down the birth canal.

• smooth muscle relaxant
• preparing breasts for lactation
• inhibiting uterine contractility

heartburn

• Decreased ability for mom to complete school
• Increased risk of HTN in preo
• 64% teen moms live in poverty
• Increase risk for STD
• Increased risk for baby health issues: prematurity, low birth weight, respiratory distress
• Kids of teens increase interaction with law
• Teen birth rate in US decreasing, but still higher than other countries
• 25% of teen moms will have 2nd child within 24 months

• Smoking (causes preterm delivery, LBW and stillbirth)
• substance abuse
• Obesity (BMI >30)
• preeclampsia
• gestational diabetes
• wound infection
• economic status
• age
• race
• ethnicity

• Majority if injuries/legal issues in ob:
• inability to recognize or appropriately respond to intrapartum fetal compromise
• Inability to timely c-section (30 mins from decision to incision)
• Inability to approp initiate resuscitation of depressed neonate
• Inapprop use of oxytocin or misoprostol leading to uterine rupture, fetal intolerance of labor or death
• Inapprop use of forceps/vacuum or preventable shoulder dystocia

• Monozygotic twins
• are from one zygote that divides in first week of gestation
• Are genetically identical, similar in appearance
• ALWAYS SAME GENDER

• dizygotic twins
• result from fertilization from 2 eggs
• May be same or differing gender

• Risk to both mom and fetuses increases w # of fetuses
• Preterm labor and delivery rate 50% higher
• premature/prolonged rupture of membranes related to over distention of uterus
• HTN tend to develop earlier and more severe
• Gest. diabetes
• antepartum hemorrhage
• Abruptio placenta and placenta previa
• anemia
• PE and C-section all more common with twins

• increased morbidity and mortality
• preterm delivery
• increased LBW
• increase of intrauterine growth restriction and discordant growth
• elevated hcg

Monoamniotic twins have a fetal mortality rate of 50-60% due to entangling of umbilical cords

• premature prolonged rupture of membranes
• HTN & preeclampsia
• Gest diabetes
• hemorrhage, abruptio placenta, placenta previa
• anemia
• PE for mom
• C-section
• increase in fetal morbidity and mortality due to sharing uterine space and placental circulation
• increase of LBW and IUGR

• most common genetic disease of people of African descent
• causes disruption of red blood cells

• most common in european ancestry
• causes thick mucus in bronchial tree and pancreatic ducts

• people of jewish ancestry
• degeneration of nervous system, results in death by age 2

• Phenylketonuria
• lack of enzyme to metabolize milk
• caused by genetic mutation
• Leads to severe mental and physical retardation
• can be prevented by use of diet, beginning at birth, that limits phenylalanine

uncontrolled muscle contractions btwn 30 and 50 yrs of age followed by mental deterioration

• Lack of factor 8 
• impairs clotting
• may be controlled with factor 8 from donated blood

• replacement of muscle with adipose tissue and scars
• often fatal before age 20 due to involvement of cardiac muscle

• A = safest
• B = no risks shown in humans
• C = not enough research
• D= adverse reactions
• X = NEVER take in preganacy

• High levels of oxygenated blood enter fetal circulatory system from placenta via umbilical cord
• ductus venosus connects umbilical vein to inferior vena cava, allowing majority of oxygenated blood to enter right atrium
• Foramen ovale is opening in right and left atria, blood high in O2 shunted to left atriam
• Ductus arteriosus connects pulmonary artery with descending aorta; majority of O2'd blood shunted to aorta w smaller amounts going to lungs
• Afterwards, ductus arteriosus constricts in response to higher blood oxygen levels and prostaglandins

2 in t0 babies with single umbilical artery have health problems, including heart kidney or digestion problems and genetic conditions

• Fetal alcohol syndrome
• Spontaneous abortion, abruptio, low birth weight

• G = Graviad (# of pregnancies)
• T = Term (37 wks)
• P = Pre-term (20-36 wks)
• A = Abortion ( therapeutic or miscarriage before 20 wks)
• L = living children

• Increased renal blood flow
• Rate of formation increased
• Reabsorption of sodium, chloride, water
• Increased glomerular filtration
• Increased urinary tract infections
• Urinary frequency
• Decreased blood urea nitrogen & plasma creatinine level, renal threshold for sugar

• Occurs when mom lays on back after 20 wks, compresses vena cava
• Characterized by pallor, bradycardia, sweating, nausea, hypotension, dizziness
• Teach mom to rest on side, preferably left side

• Screened for in prenatal visit with permission
• Tx with at least 3 antiretroviral drugs during pregnancy reduces incidence of transmission to fetus to less than 2%

• Risk of transmission is 20-25%
• If untreated, preterm delivery,
• preterm PROM (rupture of membranes)
• IUGR (Intrauterine growth restriction)

• Avoid instruments during birth
• leave membrane intact
• avoid scalp electrode
• avoid episiotomy and assisted delivery
• provide and reinforce education
• provide emotional support

• Underweight: 20-40 lbs (BMI of <1835)
• Normal weight: 25-35 lbs (BMI 18.5-24.9)
• Moderately overweight: 15-25 lbs (BMI 25-29.9)
• Very Overweight/obese: 11-20 lb (BMI >30)
• Recommended 2-4 lbs first trimester, 1 lb per week thereafter

• CBC, Hgb, Hct, platelets
• blood type and RH

• serology (RPR) for syphilis
• rubella screening
• Hep B
• HIV is offered but not standard
• PPD (Tuberculosis)

urinalysis

• To prevent any complications in pregnancy that could harm the baby or fetus
• Rhogam, ABX for group B strep, HIV medication, Rubella vaccination after birth
• Low platelets = no epidural, treat anemia

• breast tissue increase in size and nodularity as milk glands and ducts grow
• nipples more erect
• areola darker
• colostrum as early as 16 weeks

• increase in insulin resistance
• increase in estrogen, progesterone, Human Placental lactogen, hCG, relaxin, and oxytocin

• N/V - thought to be due to hCG and Progesterone
• Increased salivation (ptyalism)
• bleeding gums due to increased vascularity
• heart burn
• constipation and hemorrhoids from pressure of uterus

• striae gravidarum
• diastasis
• oily skin and acne
• hair and nail growth
• hot flashes
• facial flushing
• increased prespiration

• enlarging uterus causes shift in center of gravity
• Lordosis - low back pain
• Relaxation and increased mobility of joints = waddle gait
• diastasis rectus and round ligament pain

• Compulsion to ingest non food substances 
• interferes with good nutrition and can lead ot anemia
• Blood test done for iron and zinc, as could be deficient

• eat small, frequent meals
• avoid spicy and high fat foods
• plenty of rest
• drink plenty of fluids

• Nausea during pregnancy appears to be linked with increase of Hcg and progesterone, and maybe estrogen increase and glucose decrease
• Both nausea and these hormones peak at same time 4-8 weeks preg
• N/V usually lasts through first trimester, but can extend through other trimesters

• Intractable vomiting in preg
• Caused by an interplay of hormones, psychology and metabolism
• Treatment is rest, parenteral fluids, antiemetics, and vit B6
• Signs: maternal weight loss of 5% or more, dehydration, ketonuria, acetonuria, and/or electrolyte imbalance

• meat
• dairy
• nuts
• eggs
• beans
• fish

• Beans
• nuts 
• dark leafy greens
• hemp
• non-dairy milks (soy & almond)
• quinoa 
• tofu
• lentils

• vaginal spotting or bleeding
• leaking fluid from vagina
• unusual abd pain, cramping, pelvic pressure, persistent back ache
• persistent or excessive N/V
• persistent HA or blurred vision
• marked swelling of hands/feet/face
• painful/burning urination
• foul smelling vaginal discharge
• chills/fever
• decreased fatal movement in 3rd trimester

• 400 mcg/day
• prevents neural tube defects

• 30 mg/day - essential for making extra blood that mom and fetus need
• also helps move oxygen from lungs to rest of body
• prevents anemia

• 1000 mg/day
• helps baby build strong teeth and bones
• helps with development of muscles, heart, and nerves
• development of normal heart rhythm

• 400 IU
• necessary for metabolism and absorption of calcium and phosphorus
• essential for bone health
• deficiency is linked to preeclampsia

• DVT's
• varicose veins

• Hook up FHR monitors for at least 40 mins and look for accelerations of at least 15 beats for 15 sec twice or more in 20 mins
• IN fetus <32 weeks; two accels at least 10 beats above baseline for 10 sec in 20 mins

Reactive NST means normal

• Used for elaluating fetal well being for high risk pregnancies including:
• hypertension
• diabetes
• multiple gestation
• trauma/bleeding
• womans report of decreased fetal movement
• placental abnormalities

• Eat something, lay on side and palpate for kicks
• In one hour more than k kicks is reassuring, in tow hours more than 10 kicks is reassuring
• should be done daily after 28 weeks to assess fetal well being and could identify potentially hypoxic fetuses

• can be done to check surfactant levels in preterm babies, genetic testing, assessment of hemolytic disease or intrauterine infection
• Done by inserting long needle guided by ultrasound into pocket of amniotic fluid through stomach and withdrawing sample
• Done btwn 14-20 weeks for genetic testing

• Explain procedure, full bladder may be required
• Provide comfort measures and emotional support
• Nurse should assess FHR and maternal well being,
• instruct not lift anything heavy for 2 days
• Report abd pain or cramping, leaking of fluid, bleeding, decreased fetal movement, fever of chills
• administer RhoGAM as ordered for RH-neg to prevent antibody formation

• Biophysical profile
• an ultrasound assessment of fetal reflexes and activities that are CNS controlled and sensitive to fetal hypoxia

• breathing movements
• gross body movement
• fetal tone
• amniotic fluid volume
• heart rate reactivity observed for 30 min in addition to NST in high risk preg

• each component gets a score of 2 if present and 0 if absent, 
• 8/10 is reassuring
• 6/10 is equivocal and may need to deliver depending on gestation age
• 4/10 delivery is recommended and is correlated with chronic asphyxia
• 2/10 or less means immediate delivery

Placenta implants low on interior of uterine wall, near or over os

• will have bright red painless bleeding
• can be emergency needing c-section

• Risks include previous previa, prior c/s, multiparity, abortion, advanced maternal age, GDM or HTN, smoking, uterine anomalies
• VAGINAL EXAM CONTRAINDICATED
• TX: expectant management if mild with no s/s of shock, not in labor and less than 36 weeks with reassuring FHR
• Hospitalized on bed rest, monitored for bleeding and fetal wellbeing

• Premature separation of placenta; either partial or complete
• S/S - sudden onset intense abd pain, dark red vaginal bleeding, strong almost continuous contractions, uterine tenderness, board like uterus, fetal distress and signs of hypovolemic shock

• PIH, h/o previous abruption, abd trauma, smoking, meth and cocaine, premature rupture of membranes, thrombophilia, uterine abnormalities
• If deteriorating maternal or fetal status, immediate c-section
• If maternal status is stable and fetus is premature, hospitalization, close monitoring, steroids

• 1st trimester: wk 1 - 1k 12
• 2nd trimester: wk 13 - wk 27
• 3rd trimester: wk 28 - birth

• Assess vitals before beginning and every 5-15 mins during loading dose, then 30-60 mins till stable
• Assess DTR's every 2 hrs
• Monitor strict intake/output as pt with oliguria or renal disease at risk for toxic
• Monitor serum levels (therap level 5-7 mg/dL)
• Keep calcium gluconate immediately available

• A noncancerous tumor that develops in the uterus as a result of a nonviable pregnancy.
• Tests will include ultrasound and blood hCg
• Tx includes a D&C, possibly hysterectomy, and continued hCg monitoring

• Higher with h/o STD
• tubal surgeries
• previous ectopic preg
• endometriosis
• altered hormones 
• contraceptive failure from intrauterine device
• SMOKING!!

S/S: abdominal tenderness, spotting or bleeding

Diagnose: transvaginal ultrasound for misplaced gestational sac, falling progesterone levels and/or plateauing hCg levels

• Laparoscopy to remove affected tube
• OR
• methotrexate for hemodynamically stable pt with unruptured mass <4cm

• Estrogen: stimulates enlargement of breast and uterus
• Progesterone: facilitates implantation, decreases uterine contractility
• Human placental lactogen: promotes fetal growth by regulating glucose available to fetus
• Chorionic gonadotropin: stimulates corpus luteum to continue to secrete progesterone and estrogen till placenta can secrete

• hydrate
• embolism stockings
• keep moving, be active
• watch your weight 
• don't strain (prevent constipation)

• Q4 weeks to 28 weeks
• Q2 weeks 28-36
• Q week till delivery

weight, BP, Urine for protein and glucose (checking for preeclampsia, and DM)

Fetal: fundal height, fetal heart tones, fetal movement counts (3rd trimester)

• 16-18 wk: Maternal serum alpha (quadruple screed), includes Hcg and estidoiol
• 24 wk: repeat Hct/Hgb
• 28 wk: glucose screening
• 28 wk: antibody titers for Rh neg mom, Rhogam is neg at 28 weeks
• 36 wk:Group B strep

• Most women are typically asymptomatic carriers
• Sx include abnormal vag discharge, UTI and chorioamnionitis

Transmission rate is low, but infection can result in invasive GBS with permanent neurological sequalae

• Screening involves vaginal and rectal swab cultures at 35-37 wk gestation
• If positive at 35-37 week or status is unknown, treat with abx in labor to prevent neonatal transmission
• Penicillin or ampicillin IV

• Accepting pregnancy
• Id motherhood role
• re-order relationship with partner
• prepare for labor
• fear of loss of control of self-esteem in labor
• Nurse can help by teaching and reassuring of "normal symptoms"

• Varying levels of airway obstruction, bronchial hyperresponsiveness and bronchial edema
• Uncontrolled increased risk of preeclampsia, HTN, and hyperemesis gravidarum

Risk to newborn includes hypoxia, preterm birth and LBW

• Maternal age >25
• Precious big babies, infant with anomalies
• Previous preg or fam hx with GDM
• recurrent monilial vaginitis (yeast inf)
• obesity
• HTN
• Glycosuria on 2 successive visits
• high fasting glucose

• Early in preg can cause SAB or congenital anomalies
• IUGR
• delay fetal lung maturity
• cardiomyopathy
• can lower intelligence, motor impairment, tendency to develop childhood obesity & type II DM in life

• asside from reg dm tx, 
• betamethazone is given to help mature fetal lungs in PTL