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A. Fertilization B.

Stages of Fetal Growth and Development 3-4 days travel of zygote mitotic cell division begins *Pre-embryonic Stage a. Zygote- fertilized ovum. Lifespan of zygote from fertilization to 2 months b. Morula mulberry-like ball with 16 50 cells, 4 days free floating & multiplication c. Blastocyst enlarging cells that forms a cavity that later becomes the embryo. Blastocyst covering of blastocys that later becomes placenta & trophoblast d. Implantation/ Nidation- occurs after fertilization 7 10 days. Fetus- 2 months to birth. placenta previa implantation at low side of uterus Signs of implantation: 1. slight pain 2. slight vaginal spotting - if with fertilization corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed. 3 processes of Implantation 1. Apposition 2. Adhesion 3. Invasion C. Dicidua thickened endometrium ( Latin falling off) * Basalis (base) part of endometrium located under fetus where placenta is delivered * Capsularies encapsulate the fetus * Vera remaining portion of endometrium. C. Chorionic Villi- 10 11th day, finger life projections 3 vessels= A unoxygenated blood V O2 blood A unoxygenated blood Whartons jelly protects cord Chorionic villi sampling (CVS) removal of tissue sample from the fetal portion of the developing placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex missing digits/toes. E. Cytotrophoblast inner layer or langhans layer protects fetus against syphilis 24 wks/6 months life span of langhans layer increase. Before 24 weeks critical, might get infected syphilis F. Synsitiotrophoblast synsitial layer responsible production of hormone 1. Amnion inner most layer a. Umbilical Cord- FUNIS, whitish grey, 15 55cm, 20 21. Short cord: abruptio placenta or inverted uterus. Long cord:cord coil or cord prolapse b. Amniotic Fluid bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline. *Function of Amniotic Fluid: 1. cushions fetus against sudden blows or trauma 2. facilitates musculo-skeletal development 3. maintains temp 4. prevent cord compression 5. help in delivery process Normal amt of amniotic fluid 500 to 1000cc polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of fluid oligohydramnios- decrease amt of fluid kidney disease

Diagnostic Tests for Amniotic Fluid A. Amniocentesis empty bladder before performing the procedure. Purpose obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac; fluid is tested for: 1. Genetic screening- maternal serum alpha feto-protein test (MSAFP) 1st trimester 2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity 3rd trimester Testing time 36 weeks decreased MSAFP= down syndrome increase MSAFP = spina bifida or open neural tube defect Common complication of amniocenthesis infection Dangerous complications spontaneous abortion 3rd trimester- pre term labor Important factor to consider for amniocentesis- needle insertion site Aspiration of yellowish amniotic fluid jaundice baby Greenish meconium A. Amnioscopy direct visualization or exam to an intact fetal membrane. B. Fern Test- determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic fluid) C. Nitrazine Paper Test diff amniotic fluid & urine. Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid. 1. Chorion where placenta is developed

Lecithin Sphingomyelin L/S Ratio- 2:1 signifies fetal lung maturity not capable for RDS Shake test amniotic + saline & shake Foam test Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity Placenta (Secundines) Greek pancake, combination of chorionic villi + deciduas basalis. Size: 500g or kg -1 inch thick & 8 diameter Functions of Placenta: a. 1. 2. Respiratory System beginning of lung function after birth of baby. Simple diffusion GIT transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If mom hypoglycemic, fetus hypoglycemic Excretory System- artery - carries waste products. Liver of mom detoxifies fetus. Circulating system achieved by selective osmosis Endocrine System produces hormones 6. Human Chorionic Gonadrophin maintains corpus luteum alive. Human placental Lactogen or sommamommamotropin Hormone for mammary gland development. Has a diabetogenic effect serves as insulin antagonist Relaxin Hormone- causes softening joints & bones estrogen progestin

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It serves as a protective barrier against some microorganisms HIV,HBV

Fetal Stage Fetal Growth and Development Entire pregnancy days 266 280 days 37 42 weeks

Differentiation of Primary Germ layers * Endoderm 1st week endoderm primary germ layer Thyroid for basal metabolism Parathyroid - for calcium Thymus development of immunity Liver lining of upper RT & GIT * Mesoderm development of heart, musculoskeletal system, kidneys and repro organ * Ectoderm development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth First trimester: 1st month - Brain & heart development GIT& resp Tract remains as single tube 1. Fetal heart tone begins heart is the oldest part of the body 2. CNS develops dizziness of mom due to hypoglycemic effect Food of brain glucose complex CHO pregnant womans food (potato) Second Month 1. All vital organs formed, placenta developed 2. Corpus luteum source of estrogen & progesterone of infant life span end of 2nd month 3. Sex organ formed 4. Meconium is formed Third Month 1. Kidneys functional 2. Buds of milk teeth appear 3. Fetal heart tone heard Doppler 10 12 weeks 4. Sex is distinguishable Second Trimester: FOCUS length of fetus Fourth Month lanugo begins to appear fetal heart tone heard fetoscope, 18 20 weeks buds of permanent teeth appear Fifth Month lanugo covers body actively swallows amniotic fluid 19 25 cm fetus, Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks multi fetal heart tone heard with or without instrument Sixth Month eyelids open wrinkled skin vernix caseosa present

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Third trimester: Period of most rapid growth. FOCUS: weight of fetus Seventh Month development of surfactant lecithin Eighth Month lanugo begin to disappear sub Q fats deposit Nails extend to fingers Ninth Month lanugo & vernix caseosa completely disappear Amniotic fluid decreases Tenth Month bone ossification of fetal skull

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Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus A. Drugs: Streptomycin anti TB & or Quinine (anti malaria) damage to 8th cranial nerve poor hearing & deafness Tetracycline staining tooth enamel, inhibit growth of long bone Vitamin K hemolysis (destr of RBC), hyperbilirubenia or jaundice Iodides enlargement of thyroid or goiter Thalidomides Amelia or pocomelia, absence of extremities Steroids cleft lip or palate Lithium congenital malformation Alcohol lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by microcephaly Smoking low birth rate Caffeine low birth rate Cocaine low birth rate, abruption placenta

B. C. D. E.

TORCH (Terratogenic) Infections viruses CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus. T toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meat O others. Hepa A or infectious heap oral/ fecal (hand washing) Hepa B, HIV blood & body fluids Syphilis R rubella German measles congenital heart disease (1st month) normal rubella titer 1:10 <1:10 less immunity to rubella, after delivery, mom will be given rubella vaccine. Dont get pregnant for 3 months. Vaccine is terratogenic C cytomegalo virus H herpes simplex virus II. Physiological Adaptation of the Mother to Pregnancy

A. Systemic Changes 1. Cardiovascular System increase blood volume of mom (plasma blood) 30 50% = 1500 cc of blood - easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis due to hyperemia of nasal membrane palpitation, Physiologic Anemia pseudo anemia of pregnant women

Normal Values Hct 32 42% Hgb 10.5 14g/dL Criteria 1st and 3rd trimester.- pathologic anemia if lower HCT should not be 33%, Hgb should not be < 11g/dL 2nd trimester Hct should not <32% Hgb Shdn't < 10.5% pathologic anemia if lower Pathogenic Anemia - iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women.

- Assessment reveals: Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia Nursing Care: Nutritional instruction kangkong, liver due to ferridin content, green leafy vegetable-alugbati,saluyot, malunggay, horseradish, ampalaya Parenteral Iron ( Imferon) severe anemia, give IM, Z tract- if improperly administered, hematoma. Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs after, black stool, constipation Monitor for hemorrhage Alert:

Iron from red meats is better absorbed iron form other sources Iron is better absorbed when taken with foods high in Vit C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs

Edema lower extremities due venous return is constricted due to large belly, elevate legs above hip level. Varicosities pressure of uterus - use support stockings, avoid wearing knee high socks - use elastic bandage lower to upper Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position side lying with pillow under hips or modified knee chest position Thrombophlebitis presence of thrombus at inflamed blood vessel - pregnant mom hyperfibrinogenemia - increase fibrinogen - increase clotting factor - thrombus formation candidate outstanding sign (+) Homan's sign pain on cuff during dorsiflexion milk leg skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens Mgt: 1.) 2.) 3.) 4.) 5.) 6.)

Bed rest Never massage Assess + Homan sign once only might dislodge thrombus Give anticoagulant to prevent additional clotting (thrombolytics will dilute) Monitor APTT antidote for Heparin toxicity, protamine sulfate Avoid aspirin! Might aggravate bleeding.

2. Respiratory system common problem SOB due to enlarged uterus & increase O2 demand Position- lateral expansion of lungs or side lying position. 3. Gastrointestinal 1st trimester change Morning Sickness nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon - small freq feeding. Vomiting in preg emesisgravida. Metabolic alkalosis, F&E imbalance primary med mgt replace fluids. Monitor I&O

constipation progesterone resp for constipation. Increase fluid intake, increase fiber diet - fruits papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha. Except guava has pectin thats constipating veg petchy, malungay. - exercise -mineral oil excretion of fat soluble vitamins * Flatulence avoid gas forming food cabbage * Heartburn or pyrosis reflux of stomach content to esophagus - small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanical increase salivation ptyalsim mgt mouthwash *Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for comfort 4. Urinary System frequency during 1st & 3rd trimester lateral expansion of lungs or side lying pos mgt for nocturia Acetyace test albumin in urine Benedicts test sugar in urine Musculoskeletal

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Lordosis pride of pregnancy Waddling Gait awkward walking due to relaxation causes softening of joints & bones Prone to accidental falls wear low heeled shoes Leg Cramps causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 cause while pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab. Vit D for increased Ca absorption dorsiflexion B. Local Changes Local change: Vagina: V Chadwicks sign blue violet discoloration of vagina C Goodel's sign change of consistency of cervix I Hegar's change of consistency of isthmus (lower uterine segment) LEUKORRHEA whitish gray, mousy odor discharge ESTROGEN hormone, resp for leucorrhea OPERCULUM mucus plug to seal out bacteria. PROGESTERONE hormone responsible for operculum PREGNANT acidic to alkaline change to protect bacterial growth (vaginitis)