Maternal and Child Health Nursing *Bebe* Antepartum~ Current Trends and Issues Regionalized Care Highly specialized

ed care o E.g. Periantologist, neonatalogist, pediatric neurologist, edolescent allergy specialist, pediatric oncologist, neonatal and pediatric nurse practitioner, clinical nurse specialist Advances in Research o Became possible to save premature and low birth weight infancy o Surgical techniques to intervene on the fetus while in utero were developed o Techniques have been made it possible to detect and treat children born with congenital problems and disorders immediately after birth o Scientists studying ways to prevent and treat genetic disorders with gene therapy o Animal, human stem cell studies are being done to better understand and treat a variety of obstetric disorders o Progress have been made in understanding and treating infertility o Identification of genes that are responsible for the unique characteristics of Downs Syndrome o Therapies to treat intrauterine growth retardation (IUGR) Bioethical Issues A. Human Genome Project (HGP) was started in 1990 to study human genes and how they function 1. Identification of gene mutation in people who may be carriers of genetic disorders 2. Genetic testing and counseling 3. Predisposition to certain diseases that become evident in adulthood a. Ultrasound can reveal the grades of the fetus and certain abnormalities early in pregnancy b. Amniocentesis and Chorionic villus sampling show the entire genetic code of the fetus that can diagnose chromosomal abnormalities during the 1st trimester B. Surrogacy is an arrangement whereby a woman / a couple who is infertile contract with a fertile woman to carry a child 1. In vitro fertilization techniques 2. Artificial insemination with a sperm of the man / a sperm of an unknown donor Puberty Stage of life where secondary sex characteristics begin Androgen Hormone responsible for muscle development, physical growth and increase in sebaceous gland secretions for both male and female Estrogen Hormone that influences the development of the uterus, fallopian tube and vagina; fat distribution and hair patterns; breast development (thelarche); and an end to growth, because it closes the epiphyses of long bones Secondary Sex Characteristics Female Mature breasts Broader hips Pubic hair

Male 7. Male 1. 2. 3. 4. 5. 6.

Facial hair Broad shoulders Increased body hair Pubic hair grow up toward navel Mature genital organs Body more muscular Vaginal secretions Increase in weight Growth of testes Growth of face, axillary and pubic hair Voice changes Penile growth Increase in height

Secondary Sex Characteristics (Book ) Female 1. Growth spurt 2. Increase in the transverse diameter of the pelvis 3. Breast development 4. Growth of pubic hair 5. Onset of menstruation 6. Growth of axillary hair

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Spermatogenesis (production of sperm)

Anatomy And Physiology :-o Male Reproductive Organ External o o o Internal o o o o o o o Female Reproductive Organ External o o o Internal

Scrotum Supports the testes and helps regulate the temperature of sperm Testes Contains Leydig cells (testosterone) and seminiferous gland (spermatozoa) Penis Epididymis Vas Deferens Seminal Vesicles Ejaculatory Duct Prostate Gland Bulbourethral Gland Urethra

Mons Veneris Labia Minora Labia Majora 1. 2. Vaginal Canal Lined with epithelial cells a. LEUKORRHEA b. Organ for copulation; passageway of products of conception Uterus a. Body: Uppermost part; expands b. Isthmus: Common cut during cesarean c. Cervix: Lowest part. Passageway of the baby Fundus a. Uppermost convex part can be palpated to determine uterine growth Layers a) Endometrium Important in menstrual function influenced by estrogen and progesterone, site of implantation b) Myometrium Uterine Deviation a) Anteversion Fundus is tipped forward b) Retroversion Fundus is tipped back c) Anteflexion Body of the uterus is bent sharply forward at the junction with cervix d) Retroflexion Body is bent sharply back just above the cervix Fallopian Tube a. Conveys the ovum from the ovaries to the uterus and to provide a place for fertilization of the ovum by sperm b. Divided into four separate parts a) Interstitia lies within uterine wall b) Isthmus portion cut or sealed in tubal ligation c) Ampulla part where fertilization of ovum occurs (usually) d) Infundibulum Ovaries a. Produce, mature and discharge ova

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Menstrual Cycle (28 Day Cycle) As episodic uterine bleeding A response to cyclic hormonal changes Allows concepcion and implantation Bring ovum to maturity and renew uterine tissue bed Usually occur as early as 8 9 years old; late as age 17 Length of the cycle: 28 days, but may differ

Length on menstrual flow: 4 6 days (Average)

Physiology of Menstruation STRUCTURES INVOLVED A. Hypothalamus a. Release GnRH (Luteinizing Hormone Releasing hormone) B. Pituitary Gland a. FSH (Follicle Stimulating Hormone) Maturation of ovum b. LH (Luteinizing Hormone) Responsible for ovulation and growth of uterine lining C. Ovaries a. Contain primordial cell activated by the FSH to begin to grow and mature b. LH and Prostaglandin causes the graafian follicle to rupture and ovum os set free from the surface of ovary D. Cervix E. Uterus Menstrual cycle Phases of Menstrual Cycle (REMEMBER: P S I M) 1. Proliferative (6 14 Days) a. Happens immediately after menstrual flow b. Endometrium is approximately one cell layer in depth c. Gradual increase in estrogen, rapid proliferation of Endometrium to eightfold SIGNS OF OVULATION!! :-O!! (Lagowt XD) 1. Mittelshmerz = Certain degree of PAIN felt at the lower left / right iliac 2. Cervical Mucus Methods / Billings Method = Changes in cervical mucus secretion to clear, elastic and watery (most reliable sign) 3. Spinnbarkeitt Test This sign is characterized by cervical mucus that is thin, watery and transparent, abundant and highly stretchable. When dried and viewed under the microscope Secretory Phase (15 21 Days) a. Occur after ovulation b. Endometrium become corkscrew / twisted in appearance and dilated with glycogen mucin c. Increased amount of capillaries that causes rich, spongy velvet appearance of the lining Ischemic Phase (22 28 Days) a. Corpus luteum begins to regress after 8 10 days b. Decreased production of estrogen and progesterone c. Degeneration of uterine lining due to decreased progesterone d. The capillaries rupture with minute hemorrhages e. Endometrium sloughs off Menses a. Blood, mucin, endometrial tissue and microscopic unfertilized ovum are discharged from the uterus b. 30 80 mL of blood per menses c. The only external marker of the menstrual cycle

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Physiologic. (What? @_@) Ovum 48 Days It is the female sex cell / female gamete Regularly released by the ovary by ovulation Only one ovum reaches maturity every month Ovum has two layers of protective covering; a ring of fluid called ZONA PELLUCIDA and a circle called CORONA RADIATA Sperm (Andami neto grabe =))) Has 3 Parts: Head that contains chromatin materials; neck or mid-piece that provides energy and tail that is responsible for motility The functional life of spermatozoa is 48 72 hours (3 or 4 days after ejaculation). But can stay alive in the vagina for 5 7 days When the sperm reaches the uterus, it removes its protective covering called CAPACITATION, the outer covering of the head of the sperm cell disappears and tiny holes appear on it

When it meets the ovum at the fallopian tube, it secretes the enzymes HYALURONIDASE through the holes in its head which dissolves the outermost covering of the egg cell, the CORONA RADIATA (A process called Acrosome Reaction) When the RADIATA is dissolved, the sperm will again secrete another enzyme called ACROSIN to dissolve the portion of the ZONA PELLUCIDA and will enter the ovum Once the sperm cell has entered the ovum and their nucleus has fused together, fertilization is completed The plasma membrane of the ovum will undergo structural changes to prevent POLYSPERMY (or other sperm cells entering the ovum)

Concepcion / Fertilization Union of an ovum and spermatozoon Penetration of one female gamete (X ovum) and one male gamete (Y sperm) resulting in ovum Occurs in the outer third of the fallopian tube with a period of 48 72 hours Sex is determined by: 1. X bearing male units with and ovum (X + X) = Female 2. Y bearing male unites with an ovum (X + Y) = Male 3. Fertilized ovum 46 chromosomes Implantation Burrowing of the developed zygote into the lining of the uterus Occurs to 7 10 days while zygote develops into throphoblastic stage FETAL GROWTH and DEVELOPMENT~ A. Pre-Embryonic Stage 1. Cellular Multiplication a. Zygote Fertilized ovum Forms the future child and the special structure to support the intra-uterine life b. Morula Bumpy outward appearance of the zygote containing 16 50 cells after it reaches the body of the uterus c. Blastocyst Development of embryo cells are arranged on a single layer to form hollow sphere d. Trophoblast Third stage of development on the outer that will later form placenta and membrane e. Decidua Basalis Portion of the Endometrium underlying the embedded embryo and form which the maternal portion of the placenta is formed
Totipotent

Oocyte Sperm

Morula

Blastocyst

Human Fetus

Pluripotent Inner Mass Cells

UNIPOTENT Examples :

Circulatory System

Nervous System

Immune System

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Cellular Differentiation a. Fetal membrane Inner and outer chorion that hold the developmental fetus as well as the amniotic fluid b. Amniotic Fluid Clear, yellowish fluid that holds the developing fetus amounting to 700 1000 cc Protects the fetus by: 1. Allowing free movement 2. Maintaining temperature 3. Provide oral fluid Can be aspirated to detect various diagnosis and abnormalities during pregnancy c. Umbilical Cord Connecting link between the fetus and the placenta Contains TWO ARTERIES and ONE VEIN supported by mucoid material (Whartons Jelly) that prevents kinking and knotting d. Placenta 3 Organ after the 14 weeks Transient organ that allows passage of nutrients and waste material between mother and fetus Acts as the endocrine organ and barrier to protect the fetus against some drugs and infectious agents

FETAL GROWTH AND DEVELOPMENT Receive immunoglobulin that provide limited passing immunity from the mother Produces the following hormones 1. hCG (Human Chorionic Gonadotrophin) Its role is to prevent the disintegration of the corpus luteum of the ovary and thereby maintain progesterone production that is critical for a pregnancy 2. HCS / HPL (Human Placental Lactogen / Human Chorionic Somatomammotropin) Modifies the metabolic state of the mother during pregnancy to facilitate the energy supply of the fetus Prepares breast for lactation, promotes mammary gland growth 3. Estrogen and Progesterone B. Embryonic Stage Day 15 to 8 weeks (2 months) Age of embryo in weeks

6th week Heart, Upper and Lower Limbs 7th, 8th, and 9th week Central Nervous System 8th week Palate; ears 9th week Eyes 10th week Teeth; external genitalia

Organ Systems are derived from these germ layers 1. Ectoderm Outer layer, produces skin, nail, nervous system, tooth enamel 2. Mesoderm Middle layer 3. Endoderm Inner layer, produces lining of GIT and respiratory tracts, endocrine Fetal Circulation 1. 2. 3. 4. 5. Umbilical vein Ductus venosus Inferior vena cava Right atrium Foramen Ovale 6. 7. 8. 9. Left atrium Ductus Arteriosus Aorta Umbilical Arteries

Milestone of Fetal Development~ @_@ 1 month (1 4 weeks) The rudimentary heart appears as a prominent bulge on the anterior surface Arms and Legs are bud-like structures Head folds forward and becomes prominent 2 months (5 8 weeks) Organogenesis is complete Facial features are definitely discernable Sonogram shows a gestational sac, diagnostic of pregnancy 3 months (9 12 weeks) Spontaneous movements are possible, but, too faint to be felt Sex is distinguishable by outward appearance Heartbeat is heard using Doppler Technology; bone ossification 4 months (13 16 weeks) Fetal heart sounds are audible with an ordinary stethoscope Lanugo is well formed Actively swallows amniotic fluid, urine is present in amniotic fluid Sex can be determined by ultrasound Quickening felt (multipara) 5 months (17 20 weeks) Spontaneous movement can be sensed by mother Brown fat (aids in temperature regulation) begins to be formed Vernix caseosa (serves as protective skin covering) begins to form Quickening felt (primipara) 6 months (21 24 weeks) Passive antibody transfer from mother to fetus Active production of surfactant Hearing is demonstrated by response to sudden sound Eyebrows and eyelashes are well defined 7 months (25 28 weeks) Lund alveoli begin to mature Testes begin to descend into the scrotal sac Blood vessels of the retina are thin and extremely susceptible to damage from high oxygen concentration 8 months (29 32 weeks) Subcutaneous fats started to be deposited Birth position may be assumed Iron stores are beginning to be developed 9 months (33 36 weeks) Additional amount of subcutaneous fats are deposited Sole of the foot has only crisscrosses creases Amount of Lanugo begin to diminish Most babies turn into a vertex / head-down 10 months (37 40 weeks) Fetus kicks actively that causes discomfort to the mother Creases on the soles of the feet cover at least 2/3 of the surface Lightening is experienced by primiparas Common Teratogens Any factor (chemical or physical) that adversely affects the fertilized ovum, embryo or fetus Any substance, agent, of process that blocks normal growth of the fetus, causing one or more developmental abnormalities in the fetus

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Maternal Infection ToRCH o Toxoplasmosis Protozoan infection, spread through contact with uncooked meat cat litter Fetus: Hydrocephalus, micocephaly, intracerebral deformities and retinal deformities

Dx: Serum analysis Tx: Sulfonamides, anti-protozoal agents Rubella Fetus: deafness, mental and motor challenges, cataract, cardiac defects, restricted intrauterine growth, dental and facial clefts Dx: Rubella titer Tx: Advise the mother to avoid contact to children with rashes Cytomegalovirus Transmitted through droplet infection Fetus: neurological challenges / eye damage; after birth childs skin may be covered by petechild rashes (blue-berry muffin lesions) Tx: Handwash and avoid crowds of young children Herpes Simplex Virus

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1st trimester Severe Anomalies / spontaneous miscarriage

2nd / 3rd trimester, premature birth, intrauterine growth restriction and continual infection Cesarean delivery is advisable to reduce risk of this route infection Syphilis Treponema pallidum Fetus: deafness, cognitive challenge, Osteochondritis and fetal death Newborn: Congenital anomalies, extremities, syphillic rash, Hutchinson teeth (oddly shaped teeth) Dx: Serologic screening (VDRL) Vaccine For pregnant women, only one vaccine is available (TETANUS TOXOID) Drugs o Recreational drugs o Narcotics Alcohol o Fetal Alcohol Syndrome o Neurologic damage (alcohol decreases Vit. B) o Small for gestational age; cognitively challenged Cigarette o Fetus: Low birth weight, maybe at risk to have sudden infant death syndrome Environment o Metal and chemical hazards o Radiation o Hyperthermia and hypothermia o Maternal Stress

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At least we made it this far - Relient K \m/