Post-Partum/Puerperium (Immediately after birth and continues for about 6wks Monitor for signs of postpartum hemorrhage and

age and shock. If pre-eclamptic, assess BP q4hr It is considered normal to have slight fever (100.4F) for the first 24hr postpartum; temp greater than 101.4F indicates infection Pulse increases (rapid and thready pulse may be sign of PP hemorrhage) Urinary retention is likely to occur postpartum; encourage fluids and monitor I&O for the first 12hrs Encourage early ambulation; instruct Pt. to change position slowly, because postural hypotension is common postpartum Average weight loss: 12lbs. 5lbs water weight lost thru diuresis, lochial flow adds 2-3lbs Total wt. loss = approx. 19lbs. Breastfeeding Colostrum appears within 12hrs, and milk appears in ~72hrs postpartum. Breast become engorged by postpartum day 3 or 4 and should subside spontaneously within 24-36 hrs. Assess breasts for infection and assess nipples for irritation. Encourage use of bra between feedings.

Complications: Pain: assess for mastitis, abscess, milk plug, thrush, etc. Proper positioning of infant (football carry) will minimize soreness. Breast shields are used to prevent clothing from rubbing on nipples. Engorgement: missed or infrequent feedings, breast not emptied at feeding. Inadequate let down. Baby sleeping or not eager to feed. Apply moist heat for five minutes before breastfeeding. Use ice compress after each feeding to reduce swelling and discomfort. Avoid bottles and pacifiers while breasts engorged, because may cause nipple confusion or preference. Mastitis: Encourage rest and continuation of feeding or pumping. Administer prescribed antibiotics. Note: breast milk is not infected and will not harm infant. Cracked/Sore nipples: poor positioning, baby chewing or nuzzling onto nipple, baby sucking on end of nipple, baby chewing his/her way off nipple, baby overly eager to nurse, dry colostrum or milk causing nipple to stick to bra or breast pads, nipples not allowed to dry, nipple skin not resistant to stress, natural oils removed or keratin layers broken down by drying agents (soap, alcohol, shampoo, deodorant, etc.).

Abdomen and Uterus The uterus should be firm, about the size of a grapefruit, centrally located, and at the level of the umbilicus immediately postpartum. Deviation to the right may indicate distended bladder. If post-void uterus is still boggy, massage top of fundus with fingers held together and reassess q15min. Assess for bladder fullness (full bladder may inhibit uterine contractions and cause uterine bleeding). Have mother void if bladder is full. Hydronephrosis or enlargement of uterus: decrease bladder sensitivity to avoid damage to bladder, assess bladder 1-2hrs until mother voids. Mother and/or partner may be instructed to massage fundus. Auscultate bowel sounds and inquire daily about BMs Constipation is common from anesthesia and analgesics as well as fear of perineal pain. Increased fiber and fluid intake, along with early and routine ambulation, will help to reduce occurrence of constipation. Relaxation of muscles is due to Progesterone it relaxes. Any increase in blood flow is due to Estrogen. Complications of the uterus Endometritis: Infection of the uterus that involves endometrium, myometrium, or parametrium.

1. Caused by normal flora of vagina and cervix 2. Most common: E.Coli, staph, Group A or B Streptococcus 3. Risk Factors: PROM (premature rupture of membranes), post op C/S, Hx multiple pelvic exams, UTI, + GBS, DM, poor nutrition, poor health, catherization, prolonged labor. Treatment T=100.4x2. C/S * most common cause followed by UTI. S/S: fever, chills, malaise, abd. Pain, uterine cramping, and tenderness, foul-smelling lochia, tachycardia. LAB findings: Do CBC and blood cxs. WBC > 20,000 (indicates infection) 20,000=normal after delivery. Blood cx may be + for bacteremia. Send UA, urine cx; do lochia cx. Peritonitis: hard abdomen with absent bowel sounds, N/V, abd, distention, severe abd. Pain. TX: increase fluids po, hypothermia blankets, and ice packs to head/groin. Broad spectrum antibiotics. Ampicillin, cephalosporin, gentamycin, clindamycin for 2-3 days. Antipyretics and/or pain meds.

Involution of Uterus Immediately after delivery and within few hours, the uterus should rise to the level of the umbilicus and remain there for the first 24hrs. After this, it descends ~1cm/day while descending into the pelvic cavity. By day 10, it should no longer be palpable in the abdominal cavity. Factors that retard Uterine Involution Prolonged Labor: Muscles relax because prolonged labor time of contraction during labor. Anesthesia: muscles relax. Difficult birth: uterus is manipulated excessively. Grand multiparity: repeated distention of uterus during pregnancy and labor leads to muscle stretching, diminished tone, and muscle relaxation. Full bladder: as the uterus is pushed up and usually to the right, pressure on it interferes with effective uterine contraction. Incomplete expulsion of placenta or membranes: presence of even small amounts of tissue interferes with the ability of the uterus to remain firmly contracted. Infection: Inflammation interferes with the uterine muscles ability to contract effectively. Overdistention of uterus: over stretching of uterine muscles with conditions such as multiple gestations, hydramnios, or very large baby may set the stage for slower uterine involution. Involution occurs quicker when the baby breastfeeds because oxytocin is stimulated and causes the uterus to contact more quickly. Subinvolution of uterus Any slowing of descent is called subinvolution. Major complication after delivery involving PP bleeding > 500ml delayed return of uterus to its normal size and function. Normally descends 1cm/day PP S/S: larger than normal uterus, heavy flow, fatigue, back pain. TX: with methergine 0.2 mg po q4 x24hrs. Tx with AB as directed. Possible D&C. Methergine is an oxytocic medication which stimulates the uterus to contract, promotes involution process. Raises B/P, no smoking because constricts blood vessels and may lead to hypertension. Common causes: retained placenta and pelvic infection.

Perineum Episiotomy/laceration: Assess for swelling, bleeding, and infection. Healing starts 2-3wks after birth, complete healing may take up to 4-6months NSVD with MLE (normal vaginal delivery with midline episiotomy). Degrees of episiotomies and lacerations 1. 1st degree- from base of vagina to base of labia minora. 2. 2nd degree: from base of vagina to way down the perineum. 3. 3rd degree: entire perineum to anal sphincter. 4. 4th degree: entire perineum through anal sphincter and some of rectal tissue. Hemorrhoids: Encourage sitz baths to help reduce discomfort. Lochia: Amount, character, and color. Explain stages and duration of lochial discharge and instruct Pt. to report any odor. Lochia Rubra: 1-3 days postpartum, mostly blood and clots. Lochia serosa: 4-10 days postpartum, serosanguineous. Lochia Alba: 11-21 days postpartum, creamy white, scant flow. Menses: returns after 4-6 wks. after birth Complications of perineum Hematomas (collection of blood from bleeding vessels): may develop seen as area of swelling usually on one side of perineum. If small, blood absorbed in few days; apply ice and give analgesics. If large bleed, will return to OR for evacuation and vaginal packing for 12-18hrs. More associated with forceps delivery. Wound infection Common sites: incision, perineum S/S REEDA: erythema, ecchymosis, edema, purulent drainage, wound edges not approximated, pain, tenderness. Management: May remove some of staples or sutures and allow wound drain. Irrigation and packing of wound, broad spectrum AB, wound cx, blood cx, analgesics, warm compress.

Vaginal Bleeding Blood loss for NSVD Hct 37-47% Hct 32-42% HGB 12-16g/dL HGB 11.5-14g/dL

None pregnant Pregnant

HCT drops by 4pts for q250cc blood loss HGB drops by 1g/dL for q250cc blood loss Over 500cc blood loss is considered hemorrhage Normal blood loss is approximate 300cc. Postpartum Hemorrhage

Massage mothers fundus (Abdomen) or encourage breastfeeding if appropriate to stimulate uterine contractions. Control external bleeding with direct (external) pressure. Place mother in trendelenburg position. Establish 2nd large-bore IV and titrate to SBP >90mm Hg. Management: 20-30 units of Pitocin to 1000cc RL; start infusion @fast rate or Methergine 0.2 mg po q4h x 24hr. Monitor B/P before giving may increase BP Remove clots and/or retained placenta; D&C or hysterectomy. IV RL, transfusion with whole blood. Precipitous delivery: means that the baby is born quickly can cause PP hemorrhage Late PPH Appears from 24 hr. to over a month after delivery Usually caused by retention of small piece of tissue Tissue undergoes necrosis during period after delivery and finally sloughs off, causing bleeding at site. D/C teaching: teach mom s/s PP hemorrhage and to contact MD if increase bleeding. Tx: remove pieces of retained placenta instrumentally by dilation and curettage (D&C) Uterine Prolapse Relaxation of the uterine muscle; uterus protrudes from vagina; ligaments which support uterus and vagina are over stretched and do not return to normal Occurs after many vaginal births or large infants; menopause d/t decreased estrogen Tx: for severe prolapse: hysterectomy or for milder prolapse: pessary

Lower extremities Thrombophlebitis: Unilateral swelling, decreased pulses, redness, heat, tenderness, and positive Homans sign (calf pain or tenderness on dorsiflexion of foot). Leg exercises and early ambulation help minimize occurrence of venous stasis and clot formation. DVT Emotional Status Explain to mother and to family that her emotions may shift from high to low and these changes are considered normal result of the tremendous hormonal changes occurring postpartum. Assess parent-infant bonding and family support system. Taking in phase: women talk about delivery, excitement about delivery. Taking hold phase: patient asks questions, being responsible, might worry about technique of breastfeeding. Letting go phase: Is when patient goes home. Bonding: an expression of maternal love and attachment towards new infant. Enface position: when mother is holding baby and looking face to face. Factors interfering with bonding Difficult labor Separation at birth (NICU) Other maternal feelings of PP period Abandonment Disappointment Postpartum blues: consist of a transient period of depression that occurs during the first few days of puerperium. Is drop of estrogen and progesterone different from postpartum depression usually happens on 3rd day.

New Born Assessment Baby should be pink (for dark-skinned Pts., assess oral mucosa, conjunctivae, palms, soles of feet, etc.) and have a loud, vigorous cry. Suction nose and mouth to clear excess secretions, mucus. (first mouth then nose) Stimulate breathing with vigorous rubbing and drying. Dry baby and maintain warmth (wrap in blanket, warmer, etc.). First temp. after birth is done rectal Identification of Newborn Safety Place ID bands on baby, mother and significant other immediately after delivery. Record babys footprints and mothers thumb print in chart. Always transport newborn in bassinette. Only staff with proper identification may take newborn from mother. Alarm is placed on infant depending on hospital procedure leg, cord, etc. Apgar and Vital signs Assess and document APGAR at 1 and 5min after delivery. Note: some hospitals also require a 10minute Apgar score. Hands and feet at birth will be blue, this is normal it is called acrocyanosis Apgar score 9/9 common where infant receives 2 on HR, Resp. effort, reflexes, and muscle tone but only gets 1 on color d/t acrocyanosis (bluish discoloration) of hands and feet d/t newly established circulation at 1 and 5 minutes. Score of 4 or less indication that infant most likely needs resuscitative efforts: PPV (positive pressure ventilation = bag & mask) Score 4-6 may indicate that infant needs suctioning and oxygen therapy. 10/10 is highest score; not common. Means no acrocyanosis present at birth

APGAR score Appearance (color) Pink torso and extremities2 Pink torso, blue extremities..1 Blue all over.0 1 minute 5 minutes 1 minute 5 minutes

Pulse (heart rate) >100.2 <100.1 Absent..0

Grimace (irritability/reflexes) Vigorous cry.2 Limited cry1 No response to stimulus.0

1 minute

5 minutes

Activity (muscle tone) Actively moving2 Limited movement.1 Flaccid0

1 minute

5 minutes

Respiratory Effort Strong loud cry..2 Hypoventilation, irregular..1 Absent0

1 minute

5 minutes

Totals. 1 minute 8-10 normal; 4-6 moderate depression; 0-3 aggressive resuscitation Assess and record VS RR: 50-70 HR: 140-180

5 minutes

Preterm

SBP: 40-60

T: 36.8-37.5 C 98.2-99.5 F

Newborn

RR: 30-60

HR: 110-160

SBP: 60-90

T: 36.8-37.5 C 98.2-99.5 F

Note: bath is given to baby when he/she reaches 98.0 R if newborn has higher HR its because of extra fluid.

Infant Reflexes Reflexes Babinski Galant Stimulation Stroke sole of foot. Stroke along spine. Response Toes open/fan upward Back arches toward stimulus. Grasping (palmar) Moro (startle) Place object in palm. Loud noise. Grasping objects. Rapid outward extension of arms followed by a return to midline. Parachute Suspended in prone position (as if falling). Plantar Rooting Stroke ball of foot. Stroke cheek. Extension of extremities. Toes curl downward. Turns toward stimulus. Sucking Stroke area around mouth. Stepping Hold infant upright with feet on surface Stepping movements 4-8wks Begins to suck. 0-4mo 0-12mo 0-4mo 8mo-adult 0-6mo 0-2mo Age 0-12mo 0-6mo

Measurements Weight: Normal is 6-10 lbs. Length: Normal is 18-22 in. Head circumference: Normal is 13-14 in. (33-35cm) Chest circumference: Normal is 12-13 in. (30-33cm)

Physical Assessment Note: Perform regular, head-to-toe assessment, similar to an adult, but note the following areas specific to newborn assessment. Appearance: Baby should be pink (for dark-skinned babies, assess oral mucosa, conjunctivae, palms, soles of feet, etc.), have a loud vigorous cry, and be well flexed with full ROM and spontaneous movements. Fontanels: Anterior is diamond shaped, 2-3 cm at widest point and 3-4 cm long (closes at 12-18 months); posterior is triangular, ~0.5 cm at widest point (closes at 2-3months). Depression indicates dehydration. Bulging > Hydrocephalus (fluid brain tissue) Molding: Skull may be oddly shaped with overlapping cranial bones. Mouth: Inspect mouth for cleft lip and/or cleft palate. Heart Murmur: Soft murmur considered normal in first few days. Breathing: Abdominal breathing normal in newborns. Inspect chest for shape, symmetry, position, development of nipples and breast tissue. Breast engorgement may be present. Grunting: expiratory not normal TTN may exist transient tachypnea of NB RR= 70-80 Umbilical cord: Should have one vein and two arteries. Should be clamped, may or may not be pulsating, and no sign of bleeding. Fetal circulation the vein is oxygenated & artery is deoxygenated (AVA) Extremities: Legs and arms equal length to each other and all fingers and toes accounted for. Limp arm may have nerve damage (birth injury) aka brachial plexus palsy. Observe palm: simian crease (single); not usual 3. Associated with trisomy 21. Syndactyly: webbing of fingers/toes. Polydactyly: > than 10 fingers or toes. Sole creases; mature infant 2/3rds or full sole w. creases; premature infant: < 2/3rds or none. Acrocyanosis: Bluish discoloration of hands and feet. Lasts for 24-48hrs. mucous obstruction may cause central cyanosis Male genitalia: Testes palpable in scrotum or inguinal canal. May be in process of descending. If one or both are undescended = cryptorchidism. Agenesis (no testes) or closed scrotal sac. Normal length of penis =~2cm long. Urethral opening aka urinary meatus; abnormal dorsal surface epispadias, ventral surface Hypospadias. Female genitalia: Large labia minora and vaginal discharge of blood (pseudomenstruation) or mucus considered normal. Hymenal tag or small piece of pink tissue protrudes between labia. Scalp: If internal fetal monitoring used, scalp may have pinpoint hole at point of insertion. Skull sutures: may override at birth d/t pressure from delivery process.

Level: sutures indicate probable cesarean delivery with less pressure on skull. Sutures should never be wide opened or fused shut; both need further evaluation. Cradle cap: reddish colored patches on scalp Hair: Well-nourished, full-term 40wks thicker hair; premature infants 33-34wks finer hair. Eyes: usually blue or gray d/t scleral thinness. Permanent color between 3-12 months of age. Iris does not develop color til 3-6 months. Lacrimal tear glands: not fully mature til 3mos. Edema: sometimes found on eyelids of newborn Pupils Reaction to light: Pupils round and equal; should constrict-normal response to light; indicates 3rd cranial nerve intact. Both pupils should constrict at the same time= consensual constriction. Use term PERL = pupils equal and reactive to light. Should be dark; white pupil suggests congenital cataracts or blindness.

Nose: infants obligatory nose breathers. Note size shape and presence of nasal discharge or stuffiness. Clean nose with bulb syringe and saline drops. Observe flaring; may indicate progressive respiratory distress.

Ears: Note position of ears in relation to eyes. Low set ears signify chromosomal disorder. Pinna should be fully formed and formed. Term infant: pinna recoils easily Preterm infant: < 36wks-relatively shapeless and flat; little cartilage. Slow recoil. Skin tag: harmless; may be associated w. kidney disease. Hearing test done before newborn D/C home; if infant fails test, it is repeated. If fails 2nd time, hearing eval. Done as outpatient.

Neck: Normal newborn neck short, chubby w. creased skin folds. Head support necessary. Inspect for masses, limitation of movement and webbing. Clavicles: Straight, palpate each clavicle for intactness; feel for crepitus commonly found in larger infants delivered vaginally. Spine: 2 curves: dorsal=upper back and sacral= lower. Assess for intact spine without masses or openings. Well aligned from top to base. Small indentation at base of spine may suggest pilonidal

dimple

May be pilonidal sinus (opening); represents possible spina

bifida occulta. Requires surgical repair ASAP d/t infection.

Tuft hair present at base of spine = Nevus pilosus; poss. Assoc. w. spinal cord anomalies. Anus and rectum: assess rectal patency (NBN) with 1st temp; lubricate thermometer. If rectum not patent, called imperforate anus; covered by thin membrane. Surgery immediately. Tonic Neck: turn head to one side; extends arm towards direction of head with flexion of opposite arm. Sleep/awake behaviors

Predictable Behavior during 1st few hours after delivery: 1st 4hrs after delivery 1st period of reactivity: alert, active state; awake, crying, sucking. Then sleep phase 4-6hrs 2nd period of reactivity 2-3hrs. Sleep/awake states during day. Sleep states:

1. Deep sleep 2. Light sleep Awake states Drowsy: eyes open and close; can return to sleep state or wake completely; infant arousable. Quiet alert: eyes open; body at ease; most attentive to environment; focused on every detail; great pleasure for parents. Active alert: much body activity; periods of fussiness; pre-crying state. Crying: infants communication signal; response unpleasant stimuli from environment: hunger, cold, discomfort. Can console him-self; may need to be consoled. Behaviors Ballard Assessment Scale: developed 1970s to assess gestational maturity; takes 2-3 minutes to do Assess physical & neuromuscular maturity. Useful in differentiating between SGA infant & miscalculated due date. Used in hospitals. SGA infant is mature gestationally. Full term infant gets score of ~ 3.3 in each category. Compare infants in NICU to those in NBN.

MEASUREMENTS: 5-10% WEIGHT LOSS IS ACCEPTABLE! EXAMPLE: BABY IS: 8LBS 3 OUNCES AT DISCHARGE: 7 LBS 9 OUNCES 8LBS 3 OUNCES= 131 OUNCES ** DO 10% OF ORIGINAL WT (13.1%) *** 7 LBS 9 OUNCES= 121 OUNCES ** DO 10% OF DISCHARGE WT (12.1%)*** _______________ 10 OUNCES 10 OUNCES IS LESS THEN THE 13.1% BABY CAN GO HOME!!!

Best ways to breastfeed newborn

Football hold is a good position to breastfeed newborn after having a C-section. Routine Newborn Medication and Labs

Eyes: Medicated with antibiotic ointment per hospital policy. (Erythromycin) eliminates gonorrhea/chlamydia. Scant purulent drainage will develop after ointment; d/t irritation from med. Lasts 24hr.

Vitamin K injection: Given to prevent hemorrhage. IM within 1st hr. dose =0.5mg to 1.0 mg. site vastus lateralis TB syringe is 1ml which is used for babies TB syringe measures 0.1-1.0. PKU (phenylketonuria): Should be obtained 24 hrs. after feeding begins. Normal serum blood level is < 4mg/dL. Sample is obtained from heel stick. Coombs test: Done if mothers blood is Rh negative. Determines if mother has formed harmful antibodies against her fetus RBCs and transferred them to her baby via placenta. Heel-stick sample. Immunizations: Physician may order first hepatitis B vaccine (Hep-B) to be given soon after birth, before discharge. Hemoglobin: 15-20g/dl Hct: 43-61% Blood volume: 80-110ml/kg. or 300ml. WBC: 10-30,000 mm Glucose: 45-60mg/dl (normal) do heel stick < 45-50 hospital protocol & feed infant with oz formula. Repeat heel stick within hour. Send serum blood glucose as per hospital protocol.

Subconjunctival hemorrhage: results from pressure during birth that ruptures conjunctival capillary.

Transient strabismus: newborns occasionally cross-eyed during first 6wks; not able to focus. Constant strabismus <6wks, further assessment needed. Strabismus >6wks, referral needed.

Epsteins pearls: small, round, white cysts. Note symmetry of mouth. If not symmetrical may indicate cranial nerve injury.
Note size and shape of tongue and length of frenulum membrane.

Supranumery teeth aka natal teeth.

Milia: pinpoint white papules on nose of newborn. Disappears 2-4 wks.

Lanugo: fine hair covering newborns upper arms, shoulder, and back that decreases as gestational age increases. 37-39wks. NB more lanugo than 40wk and 41-42wk ~ none.

Vernix Caseosa: white, cream cheese like substance serves as skin lubricant. Infants > 40wks. Almost no vernix. Lack of protective vernix promotes temporary skin desquamation or peeling.

Erythema neonatorum (toxicum): NB rash; reddened rash with flea bite apperance. Can be present shortly after birth or can appear 2wks later. Disappears by 3 day.
rd

Stork Bites- aka telangiectasia: pink spots found on nape of neck, nose, upper eyelids, upper lip. Disappear within 1-2yrs.

Mottling: Generalized red and white discoloration of skin of exposed infants with fair complexion.

Mongolian Spot: Collections of pigmented cells (melanocytes) that appear as patches across infants sacral area and buttocks. Tend to occur in newborns of Asian, African, or Southern European descent.

Capillary hemangiomas:

3types, all are vascular.

Nevus Flammeus aka port wine stain: macular (flat), purple or dark red lesions, present at birth. Usually found on face and thighs. Can be removed with laser surgery.

Strawberry hemangiomas: raised areas formed by immature capillaries and endothrlial cells. Occurs typically in term infant; can present few weeks > birth. Possible cause: increase estrogen levels of pregnancy. Shrink by age 10. Surgery not rocommended; risk of infection.

Cavernous Hemangiomas: raised; resembles strawberry hemangioma but larger. Can be surgically removed; does not fade with time.

Cephalohematoma: collection of blood between skull bone and periosteum; Does not cross suture line.

Cephalohematoma is a collection of blood under the periosteum of a skull bone "very tough tissue covering that encapsulates bones" Because of its location, it is impossible for Cephalohematoma to cross suture lines. If more than one bone is affected, there will be a separation between the two areas at the suture line as seen in this photo at the left where the sagittal suture separates the bilateral parietal cephalohematomas.

Caput succedaneum: localized swelling over presenting part. Crosses suture line.
Unlike Cephalohematoma; a caput succedaneum is caused by the mechanical trauma of the initial portion of scalp pushing through a narrowed cervix. The swelling may be on any portion of the scalp, may cross the midline (as opposed to a Cephalohematoma), and may be discolored because of slight bleeding in the area. There may also be molding of the head, which is common in association with a caput succedaneum.

Infant Mortality Neonatal mortality: number of deaths of infants less than 28 days old per 1000 live births; mostly due to congenital anomalies and prematurity Fetal Death: is death in utero at 20weeks or more gestation.

Intimate Partner Violence Epidemic in households across the country; more women killed by intimate partners than any other criminal act. Screen pregnant women and those in for GYN visits on every visit (new recommendations). IPV increases during pregnancy Trusting relationship with nurse = disclosure. Provide tools to escape the violence Cultural Influences in Womens Health Ethnicity: social identity associated with shared behaviors and patterns Culture: shared values, beliefs and expected behaviors Cultural values: norms/values set by specific culture Stereotyping: expecting someone to act a certain way based on his/her culture/race Race: bio similarities and genetic traits Acculturation: adaptation to a new cultural norm (may have negative consequences- e.g. Asians living in US now have obesity/GI problems) Assimilation: a group completely changes their identity. Ethnocentrism: belief that ones culture is the best. Cultural competence: the skills and knowledge necessary to appreciate respect and effectively work with individuals from different cultures. Remember that like Asians believe postpartum is cold condition and will only drink hot things and treat with heat. YIN-YANG

Anatomy OS: cervical opening Ovaries are influenced by the FSH (follicle stimulating hormone), LH (lutenizning hormone), and gonadotropic hormones. Ovulation occurs after LH surge, follicle ruptures and ovum released waits to be fertilized. Corpus luteum: Ruptured graaffian follicle secretes progesterone during second half of menstrual cycle. FSH: anterior pituitary stimulates development of graaffian follicle LH: anterior pituitary gland stimulates ovulation and development of corpus luteum. If cycle is longer than 28 days count two weeks back and that will be ovulation cycle. Progesterone: hormone of pregnancy inhibits uterine contractions and relaxes smooth muscles to cause vasodilation allowing pregnancy to be maintained. Placenta is primary source of progesterone. Uterus is sensitive to estrogen and progesterone. If ovum is fertilized and implants in endometrium the fertilized egg begins to secret HCG (human chronic gonadotropin) Ovarian cycle Follicular phase: 1-14 days, Luteal phase: 15-28 days Uterine (menstrual cycle)- Menstrual phase 1-6 days, proliferative phase- 7-14 days, Secretory phase- 15-26days, Ischemic phase- 27-28days.

Conception-Fetal development First trimester- fetus most susceptible to damage from external source including: teratogens, (causing birth defects. i.e. Alcohol, some Rx and recreational drugs), Infections (rubella or cytomegalovirus), radiation (x-rays, radiation therapy, or accidental exposure to radiation), and nutritional deficiencies.

The first trimester is the beginning of pregnancy and is the most important period as well. The delivery date is usually 280 days after the first day of last period. This is, however, not accurate for a woman with a 28-day cycle. There are three trimesters in pregnancy. The first trimester is the period starting from 1st to 12th week. During this period the pregnant woman should be extra cautious and give extra care to both herself and the baby.

Second Trimester

The second trimester of pregnancy starts from the 13th week and continues up to the 28th week. It is most enjoyable period as the discomforts of each pregnancy begin to wear off.

Third Trimester

The period from 29th to 40th week of pregnancy is called the third trimester. The expectant mother feels excitement and joy in anticipation of seeing the baby and at the same time the fear of labor and process of painful delivery

4th wk: fetal heart begins to beat. (0.75-1cm) 8th wk: organs are formed. L:2.8 cm (1in) Wt.:4g 8-12wks: fetal heart tones may be herd by Doppler, sex organs formed, fingers, toes developed. L: 7-8cm. Wt.: 28g 16wks: sex can be seen, starting to suck and swallow. Nails on fingers and toes, swallows amniotic fluid. Lanugo formed. L:10-17cm. Wt.: 55-120g 20wks: heartbeat herd with fetoscope. Develops schedule; sleeping, sucks thumb, and kicking. Hands grasp, vernix caseosa begins to form; Assumes favorite position in utero. Lanugo keeps oil on skin; + fetal movement (quickening). L: 25cm. Wt.: 223g 24wks: Increased activity, Fetal respiratory movement begins, regular sleep time. L: 28-36cm. Wt.: 650g (1lb 10oz) 28wks: Eyes open & close, makes breathing motions, surfactant begins to be formed, and testes descend, can hiccup, cry, and hear your voice. L: 14in. Wt.: 2lbs 32wks: Skin pink; covered with vernix; lanugo begins to disappear. More subcutaneous fat laid down. Appears less red and wrinkled; Brain is growing; Lungs immature; L: 18in (38-43cm); 5lbs (1600g); Gains ~1b/wk. 38-40wks: full term at 37th wk; fills uterus; gets antibodies from mother. Gains 2 lbs.; mostly fat. L: 20in (48-52cm); Wt.: 7 lbs. (3000g)