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Basic Components of Human Genetics
Genetics
● Branch of biological sciences that deals with transmission of characters from parents to
kid
o Bateson coined term in 1906→ derived from Greek word “gene” that means “to
become”
Genes: set of characteristics inherited by parents→ found in chromosome//contains DNA
Heredity: The transfer of character or traits from the parents to offspring
Variations: similarities & differences between character/traits among individuals of the same
species
● Send couples to genetic testing to see if they are going to produce offspring w/ these
diseases
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How Does Knowledge of Genetics Help Humans?
● Understanding cause of disease
o Addiction genes
o Genetic code for addiction (food, drugs, alcohol)
● Helps us understand how nml variation between individuals are brought about
● What works for you is genetic→ Ex: if Tylenol is the only thing that works for family
● Treatments based off genetic factors (chemotherapy)
● Prevent genetic illnesses & disorders through genetic testing & research
● Solve legal issues
o Paternity determined by analysis of blood groups & other inherited characteristics
Cytogenetics**
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Studies structure & function of the cell→ especially chromosomes
Start to see identification of chromosomal abnormalities (done early to catch early)
Concerned with the cytological and molecular basis of genetics
Examples:
o Down syndrome (trisomy 21)
o Edward syndrome (trisomy 18)
o Patau syndrome (trisomy 13)
o Chronic Myelogenous Leukemia (has a small chromosomes in WBC)
Biochemical Genetics
● Study of relationships between genes, protein and metabolism
● Study causes of some diseases→ what happens between genes & metabolism that
develops them
● Sees inherited diseases not r/t chromosomes (sickle cell, thalassemia, phenylketonuria &
galactosemia)
● Abnml relationship between genes & biochemicals→ evolve into depression, bipolar,
schizophrenia
o Need chemical to counteract chemical imbalances in brain so they can be nml
o Ex: Chemical imbalance of the metabolism of serotonin is thought to be inherited
and cause depression.
o Can change the way mental illness is approached.
Developmental Genetics
● Understand role of genes in development
● How your genes influence development→ process that gives rise to tissues, organs and
anatomy
● Process which brings about various changes in fertilized egg to make it into a complete
adult
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Physiological Genetics (Knowledge of Physiology)
● How do some genetic factors bring out certain things in individuals
● What are the factors that triggers a gene that may cause blood sugar
● What are the factors that work with physiology to produce these effects
● Knowledge of physiology explains effects produced by genetic factors of an individual
o Relationship of hereditary diseases & genetics
Immunogenetics
● Concerned with genetic aspects of immunity mechanisms
● How can we enhance people’s immunity to certain diseases
● How are some people more prone to get certain diseases and others not🡪 can we enhance
immunity?
Clinical Genetics
● Establish factors responsible for certain diseases like DM, Hemophilia (run on 7
chromosome), Alzhemiers
● Where does the causative factor come from that makes a disease come about?
● Study that analyzed Alzheimer's disease and how far it ran back in Colombia
Radiation Genetics→ Studies the effects of radiation on genes
Eugenics → Well Born
● Application of principles of heredity to the improvement of mankind→ we control our
genetics
● How far does this go?
o Sperm banks → Choose sperm that carry qualities you want (ex: boy, blue eyes)
o People will make sure they have either female or male and discard the gender they
didn’t want
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2 Categories of Eugenics→ “good” “well”
● Positive
o Encourages reproduction among genetically advantaged
o Used to prevent certain genetic diseases from being passed on
o Approaches
▪ Financial/political
▪ Targeted demographic analysis
▪ IVF or Egg transplants
● Negative
o Aimed to eliminate through sterilization or segregation
o Physically, mentally or morally undesirable
o Can eliminate certain populations when taken to an extreme
o Approaches→ Abortions/Sterilization/Family planning
Genetics to Genomics
● Genetics looking at single gene effect
● Genomics looking at all the interactions between all the genes and how they effect
humans
● (a: genomics looks at how all the genes interact with each other)
DNA Sequence
● Determining exact order of the base pairs in a segment of DNA
● Map-based (Gene Mapping)
o Method to produce the finished version of human genetic code
Ethical, Legal and Social Considerations of Genomics
● Fairness in the use of genetic information
● Psychological impact, stigmatization & discrimination
● Privacy and confidentiality
● Reproductive issues→ do you still reproduce if you find a possible negative gene?
Role of the Nurse
● Take detailed family history
● Construct pedigree (genogram) to identify genetic links between generations
● Assess hereditary & non-hereditary risk factors r /t genetic diseases or having a genetic
component
● Interpret genetic tests and laboratory data
● Manage and care for patients and families at risk for or affected by genetic diseases
● Provide genetic counseling & case mngmt for pts. w/ complex genetic health care needs
● Educate about testing but don’t decide for them
Prenatal Diagnostic Tests
● Ultrasound
● Chorionic villus sampling
⧫ Amniocentesis
⧫ Maternal serum testing
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Conception and Fetal Development
Steps of Fertilization (Conception)
● Several sperm try to penetrate corona radiata
● Several sperm attempt to penetrate zona pellucida
● Only ONE sperm enters the egg and nuclei fuse→ producing a zygote within hours
o Egg’s plasma membrane & zona pellucida becomes impermeable to prevent
polyspermy
o Polyspermy- more than one sperm fertilizing egg→ incompatible with life
● There is only a 12 hr window for egg to be in the right spot in tube to get pregnant
o Minimum of 20 million sperm in a mL of sperm for a egg to be fertilized
● Sperm lasts 48-72 hours
● Male sperm: fast, light & no staying power must fertilize quick→ if egg not there
won't fertilize
● Female sperm
o Heavy, slower & lasts longer and waits around for the egg if its not there yet
● An egg comes out 14 days after LMP
The First Form of Life
● At conception, the genetic material (nuclei) from each parent fuse
● A living cell called the zygote is formed within hours
Occurrence of Pregnancy
● When zygote begins dividing its called an embryo→ starts dividing before it implants
● Travels down oviduct & implants in endometrium (implantation/pregnancy)
o Can take up to 10 days
● Usually implants in posterior superior portion of uterus→ implants in the first place
it hits and that is where placenta will form
o If on the bottom can get placenta previa→ can’t deliver baby through placenta
● When implantation starts→ if HCG shows up in the blood→ positive pregnancy
o If implantation does not occur, a woman never knows fertilization took place
o Side effect of HCG is N/V
▪ Levels drop after 12 weeks so morning sickness stops
Embryonic Period
● Neural Tube: beginning of the spinal cord & brain in embryo
● Every single organ system is being established during this period (organogenesis)
● Embryonic period starts 2 weeks into pregnancy until week 8
o Susceptible to teratogens during this period because organs are forming.
o If she misses her period at the 2 week mark, she started embryonic period
o Should take folic acid supplements at 3-6 months before pregnancy to prevent
neural tube defects (spina bifida)
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Human Development Before Implantation
● Teratogenic effect- doesn’t happen until it implants to the wall of uterus
(endometrium)
● When it implants it embeds in endometrium- several layers start forming to develop
into human
Implantation
● Placenta takes over at 12 weeks after implantation
→ produces hCG, estrogen & progesterone (no more need for corpus luteum)
● Following implantation, the placenta originates from maternal and fetal tissues
● Placenta makes hCG to maintain corpus luteum in ovary until the placenta starts to
make its own progesterone & estrogen
● Physical S/S of pregnancy include:
o Amenorrhea
o Increased urination
o Morning sickness
o Increased size of breasts
o Darkening of areola
Fetal Development
● Three Stages
o Germinal – First 14 days/2 weeks after conception
▪ 3 germ layers develop
▪ Ectoderm, Mesoderm, Endoderm
o Embryonic period – Day 15 to 8 weeks
▪ Most vulnerable time is 2-8 weeks→ a
▪ Period of organ development
▪ Most vulnerable to teratogens
▪ Everything is established during this period
o Fetal Period (Fetus) – Week 9 to Birth/Delivery
▪ Refinement of structure/function & growth
▪ Makes everything work better, develop & get ready for delivery
Hormones
Estrogen
● “Congestion Hormone” → promotes uterine growth and Uteroplacental blood flow
● Promotes breast development (glands)
● Stimulates uterine contractility
o Don’t want too early so progesterone increases to counteract effects
● Estrogen doubles the amount of fluid (nose bleed, vaginal mucus inc)
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Progesterone
● Maintains endometrium & promotes breast development (alveoli)
● Counteract uterine contractility from estrogen→ that’s why it increases a lot
throughout pregnancy
● Look for rising levels of progesterone in early pregnancy→ good sign because we
know it's doing its job
● Works with Relaxin→ relaxes everything not just uterus
o Bigger feet, GERD & waddle
● (a. check fetal viability by progesterone level & FHR)
Human Chorionic Gonadotropin (HCG)
● Maintains the corpus luteum
● Chorionic Gonadotropin tells you you’re pregnant
● Present by day 8-10
o Reached maximal day 70, then drops back down
● Also develops males testes and scrotum
● Causes positive pregnancy test
● Drops after 1st trimester that’s why N/V usually disappears→ still there in low
amounts after
Human Placental Lactogen (HPL) or Human Chorionic Somatomammotropin (HCS)
● Shows up halfway through pregnancy at week 20
o Hormone works for kid not mom
● Promotes glucose transport to fetus
● “Parasite Hormone” demands a lot to try to make baby grow
● If mom didn’t eat still give baby glucose→ mom will get hypoglycemia
● Inadequate calcium intake
→ Will give whatever calcium mom has to baby and mom gets osteoporosis
● Moms get Gestational Diabetes because HPL doesn’t want insulin to work well bc it
needs sugar for kid
● Once the placenta is delivered, it goes back to normal. (Gestational diabetes)
● Stimulates breast development
Relaxin
● Works with Progesterone to increase pelvic flexibility so you belly is able to grow
● Relaxes ligaments in the foot, that’s why women get bigger feet
● Relaxes the cardiac sphincter, that’s why women get heartburn
● Relaxes the ligaments in the back, that’s why moms waddle
Prolactin
● Forms milk
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Development Before Birth
Processes of development
● Cleavage: cell division without growth (cleavage happens inside morula)
● Morphogenesis: shaping of embryo
● Differentiation: cells take on specific structure and function (organogenesis)
● Growth: increase in size of cells
● Fetal circulation
Stages of Development
● Morula- solid mass of cells resulting from cleavage- cleavage inside the morula
o (a: no fertilization yet during this stage)
● Blastocyst: ball of cells formed from morula
● Embryonic disk: inside of blastocyst where the embryo grows
● Gastrula: embryo composed of three tissues
o Ectoderm
o Mesoderm
o Endoderm are the foundation of body systems
o (Germ Layer Theory)
Neurula
● NS develops from ectoderm located above notochord
● This is when you get neural tube→ get spine and brain
o Neural folds turn into brain
o Somites turn into spine
● Induction: one tissue develops then another
→ that’s how group organ systems grow
● Must form first then circulates blood throughout the embryo to
● 6-8 weeks hear a heartbeat
o At 22 days neural tube forms and you can see flutter of the heart
● Folic acid is important bc neural tube is developing at this time→ defects happen
early
o TORCH viruses can cause defects in fetus & embryo early on
▪ Ex: Zika causes microcephaly
o Spina bifida
o Anencephaly
▪ Absence of major portion of the brain, skull & scalp
▪ Occurs when the end of the tube fails to close after the 23rd to the 26th
day after conception
o Microcephaly
▪ When the head is smaller in size than normal due to damage of
developing brain tissue
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Germ Layer Theory of Organ System Development
Extra-Embryonic Membranes
● Membranes that extend out beyond the embryo
● Food and oxygen goes to the fetus, the kid only sends back waste, they do not actually
meet.
● Things move by osmosis, (mom sends nutrients and child send back waste) at no point
is blood of mom and fetus interacting, it is all osmosis
● If mom and child had different blood types, they could consider the fetus as a foreign
object, and can react to it.
● If mom bleeds she gets rhogam immediately just in case blood mixed in the bleeding
episode.
● Amnion (inside) → provides fluid environment for developing embryo & fetus
o Amniotic fluid gives kid room to grow
▪ 600-800 mL but can be up to 1000 mL
o Made up of babies urine
▪ If not enough fluid check the babies kidneys (pees then drinks it)
o Ans: teach mom that amniotic fluid provides temperature stabilization
● Yolk Sac: first site of red blood cell formation
→ disappears after a while
● Chorion (outside): outermost membrane
o Develops from trophoblast→ contributes to the placental formation
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Fetal Circulation
● Umbilical cord stretches between placenta & fetus
o Has 2 umbilical arteries & 1 vein
● Placenta functions
o Waste from baby to placenta travels through arteries
o Nutrients from placenta to baby travels through vein
o Produce hormones to maintain pregnancy (estrogen, progesterone, HCG)
● Ductus venosus
o 1st part of fetal circulation
o Bypasses liver then goes to baby’s heart
o Bypass lungs bc don’t need them to breath yet→ then to the babies heart
● Foramen ovale: opening between the atriums so blood can go right through
● Ductus arteriosus: opening between aorta & pulmonary artery that allows blood to
bypass lungs
● When babies take 1st breathe pressure change in lungs will shut down bypass
● Umbilical vein carries blood and oxygen away from the placenta to the fetus.
● Produce hormones to maintain pregnancy (estrogen, progesterone, HCG)
● PFO:persistent foramen ovale (brother in law)
Placenta
● Exchanges gas and nutrients by osmosis
● Placenta weighs about 1 pound
o Fetal side→ smooth/shiny
o Maternal side→ dark/crusty
● Maternal & fetal circulation don’t merge
o No blood exchange (a: blood never mixes)
● Exchange of products occurs through osmosis
● No barrier to protect from bad things→ exchanges everything so careful with what
goes in body
o Know meds can get through- just don't know what it can cause
o Encourage waiting till organogenesis in embryonic stage is done to prevent
issues
o Antipsychotics/antidepressants cannot be taken – teratogenic
o Some anesthesia and antibiotics effect baby too
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Amniotic Fluid
● Initially diffused from maternal serum
→ later produced by fetal urine (fluid levels checks kidney fxn)
● Cushions fetus, allows for movement, prevents cord compression, provides oral fluid,
maintains temp
● Volume varies → 800-1200 mL at term→ Important assessment of fetal well-being
o Oligohydramnios: low fluid levels
→ (a. Check babies kidney function)
▪ Constriction, pressure on cord, no baby growth and no movement
▪ Managed with bed rest, FHR monitoring and hydration, delivery if fetal
distress
o Polyhydramnios/Hydramnios:excess fluid
▪ Problem because no room for baby to move
▪ Uterus can go into early labor bc uterus “feels” too big
▪ Cord can come down first before baby and can affect the brain and
cause cerebral palsy.
● Baby may not engage in pelvis if there’s “room to swim”
▪ Noted with gestational diabetes/fetus not swallowing enough fluid
▪ Ex: can cause cerebral palsy/hypoxic ischemic encephalopathy
Umbilical Cord
● Contains 2 arteries & 1 vein → in Wharton’s Jelly
● Provides connection between fetal circulation and maternal circulation
● At birth is 30-90 cm (22 in) long & 2 cm diameter
Embryonic Development
● Occurs from 2nd week - 8th week (organs being developed)
→ (a: this is most vulnerable period)
● Fetal development occurs from 3rd month (9th week) until delivery
● Right after fertilization
o Embryo divides & develops into blastocyst (hollow ball with inner cell mass)
o Surrounded by layer of cells (trophoblast) that becomes the Chorion
● Implantation
o Completed by the end of the 2nd week
● Embryo is a gastrula by the end of the 3rd week
o Forms after blastula→ 3 layers
● Placenta forms by the end of 4th week
● By the end of the 2nd month→ all organs have appeared & placenta is fully
functioning ( baby is size of a coffee bean)
o Embryonic development complete→ doesn’t mean it's okay to drink
o Can identify gender at 12 weeks (50% of body is head)
● The embryo is now recognizable as a human→ (8 weeks)
o Weighs 1 gram and is 1 inch long
o All the basic organs and body parts of a human being→ Tail is no longer
visible→ incorporated into the lower spine.
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Fetal Development (Growth and Refinement)
● Beginning of 3rd month→ head growth slows down & body length increases
● Ossification centers appear in bones
● Sex can be determined sometimes in 3rd month
→ XX = female // XY = male
Development of Male & Female Sex Organs
● Sex of an individual is determined at the moment of fertilization
o Indifferent tissue develops into ovaries or testes depending on action of
hormones
o No Y chromosome → female // Y chromosome→ male
● Hermaphrodite (both gonads)
→ usually parents will make it a girl bc easier to operate
Milestones by Month (Lunar)
10 Lunar months→ each month has 4 weeks
● 1st→ beginning of NS & GU system, skin, bones, lungs, heart, eyes, ears, and nose
form (organogenesis)
● 2nd → fetus bent with large head, sex differentiation & ossification begins (bone
formation)
● 3rd → fetal fingers & toes are distinct and placental & fetal circulation are complete
● 4th→ urine production begins, sex is differentiated, baby can hear & fetal heart beat
heard on doppler
o Nasal septum & palate close
th
● 5 → Lanugo- covers fetal body & fetal movements felt by mother
o Quickening: 1st fetal movement→ feels like gas bubbles
▪ Primigravidas feel it at 20 weeks
▪ Multigravidas feel it at 16-17 weeks (ans)
th
● 6 → red & wrinkled skin (red jello skin)
o Vernix caseosa present
o Responds to sound (moves/dances)
o Fetal breathing movements begin (not actually breathing)
th
● 7 → eyelids open but they don’t see anything yet
o Surfactant is produced
o Eyebrows and nails develop
th
● 8 → Subcutaneous fat develops (no longer looks like red jello)
● 9th & 10th
o Skin is pink and smooth
o Lanugo disappearing
o Slothing off of vernix
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Eighth & Ninth Month
● Fetus usually rotates so head is pointed down toward cervix
o 35 weeks→ head rotation toward cervix
o Baby usually goes into a vertex occiput position (head down for birth)
● Fetus is now at 530 mm (18 inches) in length & weighs 3,400 g (6-9 lbs)
o Weight does not distinguish how old an infant is.
● Full-terms have best chance of survival
o Near terms have breathing, digestion, growth problems
o Will see near terms in NICU even if good size
▪ Size and weight doesn’t mean anything
Twins
● Fraternal twins are genetic
● Fraternal twins
o 2 eggs fertilized→ 2 placentas→ each have their own sac & fluid
● Identical twins
o 1 egg fertilized→ splits into 2 babies→ can share/fuse placenta
o Both genetically the same because the same egg
Teratogens
● Teratogenic effects usually happen during embryonic period but can still occur in
fetal period
o Tetracycline causes teeth discoloration in children
o Smoking causes vasoconstriction (small babies) and can lead to SIDS
o Fetal Alcohol Syndrome (flat nose, wide set eyes)
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Antepartum Assessment & Care
How to Calculate Estimated Date of Delivery (EDD) *
● Nagele’s rule: Last menstrual period (LMP) → 3 months + 7 days → adjust year
accordingly
o Ex: LMP- Sept 26 2019 – 3 months + 7 days is June 33, 2020 → July 3, 2020
o Ex. LMP- April 6, 2020 – 3 months + 7 days is January 13, 2021
● If month is January, February or March→ + 9 months + 7 days & adjust year
accordingly
o Ex: Feb 15, 2019→ + 9 + 7 is Nov 22, 2019
● Months with 31 days
o January, March, May, July, August, October, December
● Months with 30 days
o April, June, September, November (30 days until June SAN)
● Month with 28 days→ February
● Pregnancy is 10 lunar months (4 weeks each) = 40 weeks
Nursing Interventions Utilized in Pregnancy
● Client Education → things occur in nml pregnancy that is abnml for non-pregnant
people
o SOB, heartburn, fatigue, nausea, lower extremity edema→ teach that this is nml
o Teach what to look out for that is NOT normal
o 95% of clients are normal, 5% is what you have to look out for.
● Monitoring for potential complications→ know what’s normal and what’s not normal
Uterine Changes
● Weighs 1 pound and grows 4x its size
● Practice for labor→ Braxton hicks starts at 12 weeks
o Fake contractions aren’t felt because uterus is little
o Know the difference between BH & real contractions
o BH don’t cause cervical dilation & contractions stay in the front
Cervix & Vagina
● Hegar's sign: softening of uterine isthmus→ neck of uterus gets flexible
● Goodell’s Sign: softening of cervix causing it to turn bluish purplish (Chadwick’s sign)
● Chadwick’s Sign: blue/purple discolor caused by the Goodell’s sign bc ↑ blood flow
● Hypertrophy of epithelium
● Increased mucus discharge and moisture as a result of estrogen (congestor)
o Increased discharge, mucous, increases mucus, (stuffy nose, nosebleeds, )
o Bloating
● Mucus plug: barrier to infection that develops bc vagina is not a sterile neighborhood
o (a: normal to see bluish discoloration & increase mucus discharge are normal
findings
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Ovaries
● Stop producing eggs after fertilization
● Corpus luteum forms to produce hormones & keeps pregnancy going
o Sticks around to send out estrogen and progesterone, HCG (human chorionic
gonadotropin) → HCG keeps pregnancy going until the placenta can take over
Changes in Breast Volume Based on Baby’s Gestational Age
● 7 weeks→ 293 mL
● 19 weeks→ 381 mL
● 31 weeks→ 398 mL
● Can keep growing after she delivers and starts to develop milk
o Breast changes are due to estrogen, progesterone and prolactin
o Will complain of tenderness
o May see superficial veins due to increased blood flow & blood amount
o Colostrum develops at 12 weeks
Respiratory Changes
● Hyperventilation: due to uterus pushing on diaphragm
● Increased tidal volume→ breathing for 2
o Wider horizontally/shorter vertically across abdomen
o Causes more thoracic breathing
● Decreased airway resistance causes more oxygen to get in
o (a: teaching different breathing methods)
o If mom’s SOB baby still needs enough O2→needs to learn different breathing
● Breathing changes from abdominal to thoracic
Cardiovascular Changes
● Blood volume increased by 45% → increase in cardiac output by the Week 20
o Note a Pulse increase by 10 bpm above baseline
● Decrease systemic & pulmonary vascular resistance→ want stuff to get where it needs to
go
● VS changes
o Pulse increases
o 2nd trimester→ BP decreases because of increase in volume
o 3rd trimester→ BP goes back up to baseline
o Never normal for BP to go above baseline during pregnancy
▪ Potential preeclampsia, moles, anxiety (temporary increase)
▪ If normal→ 110/70 1st trimester, then drop to 90/60 in 2nd trimester
(cardiovascular changes), then goes back up to 128/80→ not normal (???)
● Vena caval syndrome
o Postural hypotension caused by uterus pressing against vena cava
o Happens when mom lays completely supine, then sits up may be light headed
o Body/Husband pillows→ find different positions to keep mom off back
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Physiologic Anemia of Pregnancy
● 50% increase in blood volume & blood products but you can't tell bc there’s more
plasma volume
o Ex: coy pond→ increase fluid & cells that are watered down bc of so much
plasma volume
● H/H will be very low→ don’t send for transfusions→take iron (takes 1 month to kick in)
o Hgb: 12–16 g/dL for women
o Hct: 37%–47% for women
● Not anemia because cells are there they are just watered down by the amount of plasma
volume
● Don’t take iron with prenatal because the body cannot absorb that much at one time
o Separate by meals→ spread out so more chance to absorb iron
o Body can only absorb 18 mg of iron per sitting
● Take iron supplement with citric acid juice (V8, OJ, grapefruit juice)
Gastrointestinal Changes
● Progesterone + Relaxin relax cardiac sphincter→ stays open a little and baby kicks
stuff back up (GERD)
o Standup so gravity can help move the stuff back down
o Acid reflux- elevate angle at which sitting, watch what you're eating, smaller
meals, eat little talk a little pick, pick, talk a little more.
o Lemon ice helps
o Extra water or milk can settle stomach
o Real grapefruit and pineapple not juice (high fiber, brings things down with it)
o Eat slowly so it has time to get down→ eat a little talk a little
● System slows bc baby pushes intestines and there is no room to move
o Stool spends more time in & more water gets taken out→ causes constipation
o Exercise
▪ No adding new exercise just simply walk around
o Increase fiber and fluids
▪ Skip dessert→ cake, pastries and deserts causes increased flatulence
o Constipation causes hemorrhoids
▪ Come from pushing stool)🡪 inc fluids to soften stool
Urinary Changes
● Increased bladder pressure
o Uterus & bladder fight for space & uterus wins→ bladder empties frequently
o 1st trimester & 3rd trimester→ urinary frequency bc fighting for space d/t pressure
o 2nd trimester→ uterus moves into pelvis so bladder has a little more room
● Increased glomerular filtration rate due to increased volume
o Sometimes will get TRACE glycosuria not unusual→ 1 or greater is abnormal
▪ HCS/HPL (causes insulin to be less effective & leads to glucose in stream)
o Protein in urine is never good→ sign of preeclampsia
● Increased renal plasma flow due to increased volume
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Skin & Hair Changes
● Facial Chloasma: mask that comes out when they go in the sun (goes away)
● Striae gravidarum (stretch marks): genetic (fade but don’t fully disappear)
o Cocoa butter doest work
● Linea nigra: due to moms hormones (fades and disappears)
● Hair growth: slower but doesn’t fall out as much & longer thicker nails because of
prenatal vitamins
● Spider veins→ d/t pressure on the uterus on the circulation to the extremities
Musculoskeletal Changes
● Relaxin + Progesterone relaxes lower back→ increased lumbar sacral curve causing
waddle
o Feet grow (permanent) and get wide (temporary)
● Pelvic tilt & belly dancing relieves pain in lumbar sacral area
● Diastasis recti abdominis
o Separation of muscles during pregnancy for uterus→ can feel when palpating
fundus
Changes of Pregnancy
● Presumptive (Subjective): 6 signs only she can feel
o Nausea, urinary frequency, tender breast, fatigue, missed period
(amenorrhea), quickening (flutters)
o Can find other reasons as to why these things are happening→ not necessarily
pregnancy
● Probable (Objective): Can be caused by other things but probably pregnant
o Positive pregnancy test, weight gain, Braxton hicks, abd enlargement, changes w/
uterus, skin changes
o Increased breast size, chadwicks, goodelles, abdominal enlargement, uterine sulae
(pulse)
o Allotment- when u push in it goes back to where it was originally
o Uterine soufflé- sound of placental pulse (whoosh) matches moms pulse- can
also be an enlarged uterine artery and not fetal heartbeat
o Blood test increase HCG (a: Mammary Gland)
● Positive (Diagnostic)
o Ultrasound
o Fetal HR
o Fetal movement
▪ See stomach moving (baby kicking)
o EKG evidence
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Psychological Tasks of Pregnancy
● Ensuring safe passage through pregnancy, labor & deliver
o Take prenatal, attend class & dr’s appointments, eating healthy, prenatal visit, tour
of unit before labor
● Seeking acceptance of this child by others→ easy when mom is right age w/ right
partner
o Young/older mom – harder to seek acceptance of that child by others
● Seeking of commitment and acceptance of self as a mom to the infant
o Binding-in
● Learning to give of oneself on behalf of one’s child
o Ready to change life for baby (sacrifice for child)
Initial Nursing Examination (Slide 17)
● Client history
● LMP: Last Menstrual Period
● Problems/Complications:
● Any discharge?--> Increase in vaginal mucous bc of estrogen
o Clear/mucus is good, Itching and burning is not good
o Is she bleeding, spotting, cramping, extra discharge?
o History of UTIs, vaginal infections, are the prime reason for membrane rupture.
● Concerns/questions
● Past pregnancy
● Gynecologic history
● Religious History/Cultural History
● Occupational
● Partner’s history
Initial Prenatal Physical Exam
● VS→ must know baselines to be prepared for any problems/complications
● Height & Weight
● Urinalysis→ blood, sugar and protein
● Blood testing
o CBC, rH & Blood Type, VDRL for STDs
o Rubella, Hep B, HIV, PPD, Vit D levels, Varicella, Syphilis
● UltraSound (make sure everything is okay, size and dates, etc.)
● Pap smear, CVS, Genetic screenings
Psychosocial Assessment
● Determine attitude about pregnancy, teaching needs, support systems, living conditions
● Further evaluation
o Marked anxiety, apathy, fear, anger.
o Isolated home environment//Language barriers
o Cultural practices that may endanger child (binding of abdomen)
o Long term family problems (abusive) (Family apgar to identify family issues you
may need to cope with)
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Fetal Assessment at Visits
● **Know where to mark X on fundus per week**
● Fetal HR→ 1st trimester can go up to 200
● Fundal height→ measure from top of symphysis pubis to top of fundus
w/ measuring tape
o Fundal height is assessed against gestational age
▪ If you get a fundal height of 22 cm but she is only 16
weeks pregnant, can indicate (multiple pregnancies,
polyhydramnios, or a molar pregnancy (hydatidiform
mole)
▪ Molar Pregnancy: when the placenta takes over (huge uterus)
o Baby’s lift out of pelvis in 10-12 weeks
o Expect fundus to be at the umbilicus at about 20 weeks(halfway mark)
o At 16 weeks its half way from symphysis pubis & umbilicus
o From 20-38 weeks rises 1 cm a week (38 weeks→ 38 cm away from symphysis
pubis)
o 40 weeks is lower than 38 weeks because she’s engaged and experiences lightning
Nutrition During Pregnancy
● Calories: must eat and extra 300 when pregnant and 800 when breastfeeding
● 1st trimester→ gain 5-6 lbs
○ A Lot of the sugar is being used by fetus for organogenesis
nd
● 2 & 3rd trimesters → should gain 1 lb a week
● Half the plate should be non starchy vegetables and fruit
● Quarter of plate: protein
○ Protein should increase from 44g to 74g a day
○ Shouldn’t eat raw fish, white albacore, salmon, swordfish→ very high in mercury
○ Deli meat/cold cuts (listeria)
○ More emphasis on vegetables than fruits, fiber, helps.
○ Avoid sugar free foods
● Quarter of plate: whole grains & starchy vegetables
● 2-3 servings of dairy
● Maximum of 200-300 mg of caffeine per day)
● Exercise 30 min a day
● 6 small meals a day to maintain sugar level
● Avoid processed sugar, heavy fats & soda
● Calcium: 1200-1500 mg/day
● No unpasteurized cheeses→ (feta, blue, goat)
● No alcohol, raw fish (mercury), raw eggs, deli meat
● 300 mg of caffeine tops
● Wash vegetables well to prevent salmonella and e. Coli
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Weight Gain During Pregnancy
● Normal BMI, 19-24 should gain 25-35 lbs (1st trimester can gain 5-6 lbs/week then 1lb a
week in 2nd and 3rd trimester)
​ → If she gained 10 lbs in a week could be an indicator of preeclampsia (monitor weight
gain)
● Underweight woman should gain 28-40 lbs
● Overweight woman gain 15-25 lbs
● Obese women 11-20 lbs
Ultrasound Examination
● Transvaginal→ done in (1st trimester) before the uterus gets above symphysis pubis
● Transabdominal→ once uterus lifts out of the pelvis
o Prep: drink a quart water to distinguish between baby and bladder
o Bladder should be full
● Nursing implications:
o Provide opportunity to ask questions
● Used to check
o Position of baby
o Fetal HR
o Measurements (lengths of legs, arms, baby length)
o Placenta location (is it attached, location)
o Amount of fluid
o Movement or lack thereof
o How many babies are there
o Gender eventually
o Organ/Brain development
o Physical characteristics (eyes, ears, arms, legs)
o Breathing patterns
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Doppler Flow Studies
● Blood flow analysis of umbilical arteries & veins→ analysis via ultrasound
o Measures velocity of flow, umbilical vessels and other fetal blood vessels
● Get picture & heart beat
o Some people only have 1 vein and 1 artery and are missing 2nd artery
First Trimester Tests
● Ultrasounds
o Nuchal translucency: measuring of the neck
▪ Thickness of neck could be sign of down syndrome
o Nasal bone determination
▪ If nuchal translucency and nasal bone is normal may not need
amniocentesis to test for chromosomal abnormalities
● Serum tests
o Plasma Protein A: elevated plasma protein would indicate pregnancy issues
o HCG-low HCG levels are abnormal and could signify the need for HCG
injections.
Maternal Biochemical Assessment
Maternal → always a double and triple check method
● Alpha-fetoprotein (AFP): done at 16-18 weeks
o Screens for NTD (neural tube defect) & trisomies
o Done at 16-18 weeks
o If high can indicate NTD, or multiple pregnancies
▪ Test is sensitive to week that it is performed→ must know gestational age
▪ Anencephaly: born without brain or just a brain stem
▪ Meningocele: can be high or low
▪ Encephalocele: outpouching of the brain
▪ Craniorachischisis: sutures prematurely attach
o If low can indicate increased risk for chromosomal abnormalities
o If abnormal results you get triple or quadruple marker
● Triple marker test→ AFP, hCG test, and unconjugated Estriol (UE)
o Done at 16-18 weeks
o Unconjugated Estriol is produced out of fetus’s liver & in the placenta
▪ Low UE means increased risk of down syndrome
o High hCG means increased risk of down syndrome
o AFP: high indicated NTD or multiple pregnancy while low indicates
chromosomal abnormalities
● Four Markers→ AFP, unconjugated Estriol, hCG test and inhibin A
o Done at 14-22 weeks
o High inhibin A + other 3 are indicators for down syndrome (more accurate)
o If abnormal results→ high or low→ do amniocentesis
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Fetal Biochemical Assessment
Amniocentesis→ (genetic disorders) lab test on amniotic fluid where you can check
chromosomes in mom's blood
● US transducer→ used to identify where the pocket of fluid is to do amniocentesis
● Done early in 2nd trimester when testing for genetic abnormalities if triple or quad
screen is abnormal
● Done 2nd time during 3rd trimester if mom is high risk & must deliver early→ checks for
fetal maturity
o For women with high risk issues (preeclampsia, diabetes) they may be induced
for an early delivery)
● Four things to check for genetic disorders & fetal maturity
o L/S ratio→ lecithin-sphingomyelin ratio
▪ Phospholipids that make up majority of surfactant used to assess lung
maturity
▪ 2:1 ratio indicates lung maturity
▪ Women who are diabetic need 3:1 ratio
▪ Can give corticosteroid if babies ratio is low (betamethasone or
dexamethasone)
o Phosphatidylglycerol→ PG+ is enough body mass available for baby to survive
in the world→ usually PG + after 35 weeks of pregnancy
o Amniotic creatinine→ indicates kidney function
o Meconium→ should NOT have meconium in fluid
● Test for chromosomal abnormalities at 35 y/o
● Risk of complications = 1%
o Infection, premature, premature rupture of membrane
● Risk of having chromosomal abnormality
o Under 35 = less than 1% // Over 35 = 1.6%
● Benefits outweigh the risk if greater than 35 years old → take age into consideration
● Done to ensure mom has proper resources to take care of this child- encourage test
Chorionic Villus Sampling (CVS) → Done at week 6-8 when placenta is developing (done very
early in pregnancy)
● Tests specifically for chromosomal abnormalities in high risk women
● Genetics studies done earlier results in more risk
● Genetic studies done on the chorionic villus if they think there’s a huge issue
● Can sample fetal blood (percutaneous umbilical blood sampling)
Percutaneous Umbilical Blood Sampling
● Done if there’s a reaction in babies blood with mom's blood type to check for antigen
antibody reactions going on
● Sample of fetal blood taken from umbilical cor
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Electronic Fetal Monitoring
● Done in last trimester bc that is when u feel baby’s movement most
Nonstress Test→ done on admission to antepartum
● Done to see how baby’s heartbeat is reacting to its own movement
● When baby moves mom pushes a button and we see if the HR went up when baby moves
o Heart rate should increase when moving
● Want: 3 accelerations at 15 beats per min lasting 15 secs every time baby moves
o Note that fetal hr inc above baseline for 15 beats then goes back down to baseline
o Reactive is good→ means baby is well oxygenated
o Non reactive→ may want to do contraction stress test
Contraction Stress Test: very rare to do→ done during 3rd trimester
●
●
●
●
Stimulate 3 contractions in 10 min & see how baby reacts to 3 contractions
Invasive→ uses Pitocin IV
Noninvasive→ massage breast & roll nipples for 30 mins
Nonreactive→ shows no decels with contractions
o If no accelerations or decelerations the kid is in trouble.
Biophysical Profile *be able to list 5 areas*
Real time Ultrasound→ measures 5 parameters score 2 for each:
● 1. Fetal breathing movement: sees if baby is practicing- not really breathing
● 2. Gross body movements: how well body is moving
● 3. Fetal tone : is it flexed
● 4. Reactive fetal HR: done with non-stress test
● 5. Qualitative amniotic fluid volume (AFV)
● Gives us idea of how well kid is doing
● If need to get kid out preterm do biophysical profile (BPP) results tell us how well this
kid is doing inside
o Normal = 8-10
o Equivocal = 6
o Abnormal = < 4, will need to get the kid out of there.
o Commonly done on high risk pregnancies.
Normal schedule for seeing OB
● 1st & 2nd trimesters if she’s normal→ go every 4 weeks until 28 weeks
● 3rd trimester 28-36 weeks → every two weeks
● At 36 weeks start going every week until she delivers
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Psychosocial Assessment:When to worry?
● Mom not coming to appointment
● Anxiety?--> Calling every 5 seconds
● Losing weight
● Living situation
● Language barriers
Check-ups Done at Every Prenatal Visit
● Urinalysis, VS, weight, edema & fetal HR
o Check for preeclampsia (especially in 3rd trimester bc highest risk)
o Classic signs of Preeclampsia: increased BP, protein in urine and edema, weight
gain (shows up around 28 weeks)
● Glucose tolerance test ~24 weeks checks for GD bc that’s when HPL hormone comes in
o If gtt is above 140, will follow up with a glucose challenge test, and follow it up .
● Group B Strep Screen (If positive, will put her on antibiotics during labor//ROM)
Go to hospital: Danger Signs of Pregnancy (C.R.A.M.P.S U.P.)
● Cramping
● Abdominal cramping/pain may be premature labor (time contractions if >36 weeks)
● Rupture of membranes
● Gush of fluids=Is the baby moving? Then go to hospital, a prolapsed cord, baby
comes down against its own cord could mean it's fixated.
● Absence of Fetal movement
● My baby isn’t moving, when was the last time you felt it move, if 30 mins ago , okay
but if 3 hrs ago, have her come in.
● Muscle irritability
● Can be a sign of impending seizures, it’s a precursor for convulsions as well as
epigastric pain or preeclampsia
● Pain (epigastric, abdominal, uterine)
● Spotting or vaginal bleeding
● Placenta Previa: bleeding every time cervix opens she bleeds(bright red, non
painful),
● Placenta abruptio is painful and dark blood)
● Urine frequency/Oliguria/Dysuria
● Oliguric not going to the bathroom too often can mean renal impairment, retention
● Burning/UTI’s
● Persistent vomiting: hypothalamus stimulates and ADH is released, right next to Oxytocin
in the brain.
● Fever: temp above 101, signs of infection
● Blurred vision, dizzy, spots in front of her eyes, signs of retinal edema which is related to
preeclampsia
● Severe Headache where she cant lift head off of pillow can be a sign of High BP
(preeclampsia)
● Edema in face and hands (above waist)
● Dysuria
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Normal Discomforts of Pregnancy
● Nausea/Vomiting: Crackers by bedside, ginger ale (small frequent dry meals) avoid
carbonated drinks
● Polyuria- peeing a lot
o Less fluids at night, sip on fluids, change position w/ body pillow so uterus lifts
off bladder
● Breast Tenderness
o Supportive bra, ice packs
● Vaginal discharge (note color)
o Cotton panty liner→ no nylon- fluid stays & causes infection
o No douche
● Nosebleed→ Humidifier (vaporizer), head facing down, pressure on nasal kiesselbach’s
plexus (nose bridge)
● Ptyalism: excessive salivation production
o Chew gum, sour or sugar free candy, hydration, mouth wash(mouth care)
● Pyrosis- heartburn
o Drink water/milk, sit up right after eating, eat slowly, no spicy foods, don’t eat
right before bed
o Grapefruit and pineapple help digestion bc high fiber
● Ankle Edema: Normal finding in 2nd & 3rd trimester
o Elevate legs unless heart disease, don’t cross legs when sitting
o Stockings→ if u get up it’ll swell so lay down 15 min to go dec swelling than put
stockings on
o Moderate sodium diet
● Varicose veins: very genetic → supportive stockings
● Constipation: High fiber, fluids, exercise
● Hemorrhoids: sitz bath, ice pack, witch hazel on gauze pad (tucks), reinsertion
● Backaches: good body mechanics (pelvic tilts) , is belly getting tight?
o If just back ache can do 1hr ice/1 hr heat
o Good body mechanics, bend at the knees.
● Leg cramps→ Dorsiflex foot (point toe to knee), heat pads for fast relief(vasodilation)
o Diet- low calcium (milk) & high phosphorous (soda) cause cramps- (check
potassium too)
▪ Phosphorus dried fruit and sodas
● Fainting: normal, especially if getting up quickly (postural hypotension) Avoid
prolonged sitting or standing, teach them how to rise slowly, don’t lie on back
● Flatulence: pastries, cruciferous vegetables are gas forming, chewing slowly, is helpful
● Carpal tunnel:may need physical therapy, and splint to relax area
● Dyspnea/SOB: Semi-fowlers position
● Quickening→ Monitor baby movement→ min 12 movements a day
o Hr after eating u should feel them moving
o If no movement ask when was the last time bc they have sleep wake cycles so
they may be asleep
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Self Care
● Bathing
o Can take tub bath unless bleeding, membrane rupture or hx of premature labor
o Somebody should be in house to help them out
▪ Risk for falls
o Bathe with warm water(tepid) not hot
● Work
o Can work all the way up until labor unless they have complications
o Sitting for long time at work should be get up in certain periods of time to stretch
(set timer)
o Can’t work if have balance problems
● Travel→ Can travel until third trimester
o No cruise after 24 weeks
o No plane in 3rd trimester
o Bus/train/car→ must take breaks to walk around every couple of hrs
▪ Pack an overnight bag just in case and for emergency deliveries.
o Set parameters for travel
▪ What to do if they go into labor
● Exercise: encouraged exercises
o Walking, yoga, kegels (30-50min/day)
o decreases urinary incontinence, helps with expanding when they have a baby,
tightening up like going to the bathroom, hold for count of 4, hold it let it
go,1234,
o Finished the marathon then had the baby. Can swim if water has not broken.
● Sex
o Can have sex
o 1st trimester usually don’t want sex because of N/V
o Women are more interested in having sex in 2nd trimester
o Nurse must be open/comfortable talking about sex, no missionary (vena cava), no
nipple rolling
o No sex if bleeding, ruptured membrane or history of premature labor
Complications of Pregnancy
Characteristic Causes of High-Risk Pregnancies
● Related to the pregnancy itself
o Teenagers and elderly, is considered high risk
● Medical condition or injury complicating pregnancy
● Environmental hazards
● Behaviors/Lifestyles
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Pregnancy Complicated by Medical Conditions
● Diabetes Mellitus
o Type 1→ insulin dependent (pancreas doesn’t make enough insulin)
o Type 2 → insulin resistance (family predisposition)
▪ may go on a little insulin during pregnancy
o Gestational DM→ shows up halfway through pregnancy- glucose intolerance d/t
pregnancy
● Hormones (estrogen/progesterone), insulinase (enzyme) & inc prolactin levels have 2
effects:
o Increased cell resistance to insulin
o Increased speed of insulin breakdown
o Pregnancy can make diabetes worse. Will cause blood glucose to increase
Effects of Diabetes in Pregnancy
Maternal Effects
● Spontaneous abortion:especially if not controlled w/ insulin- sugar becomes teratogenic
● Gestational hypertension can lead to preeclampsia
o BP 140/90 and above w/o proteinuria. Preeclampsia has protein in the urine.
● Preterm labor/premature rupture of membranes bc of infection
● Hydramnios/Polyhydramnios: excessive amniotic fluid
● More prone to infections (vaginitis, UTI): irritates the lining and causes premature labor.
● Large for gestational age fetus (LGA) “BFK”
o Presence of extra sugar→ take hx, ask mom how big are their kids, it gives insight
on how they process sugars and are at risk for diabetes down the road.
● Ketoacidosis
Fetal/Neonatal Effects
● If sugar is out of control in the 1st trimester (embryonic period, 2nd-8th week ) Sugar acts
as teratogen and can end up causing congenital birth defects (pregestational diabetes)
o Gest diabetes shows up when HCS/HPL kicks in at 24 weeks
● Congenital abnormalities
● Macrosomia-BFK (large kid)
● Intrauterine growth restrictions (IUGR)- tiny babies due to vascular complication in
the placenta(d/t diabetes)
● Birth injury bfk→ shoulder dystocia some test to see if can deliver preterm to dec risk
o BFK getting through the vagina, ends up with injuries, clavicular fractures, palsy
o Small babies as well (preterm) may have injuries from not being able to
withstand pressure.
● Delayed lung maturity→ LS ratio 2:1 for nml ppl but for diabetics 3:1
● Neonatal: hypoglycemia, hypocalcemia, hyperbilirubemia & polycythemia
o Check BSL for LGA (BFK) and SGA-hypoglycemia
o Hypocalcemia
o Hyperbilirubinemia: liver problems not breaking down bilirubin, end up jaundice
o Polycythemia
● Perinatal death
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Gestational Diabetes
● If mom has low insulin than HPL kicks in & drops it more→ causes Gest Diabetes
o Always ask how big was baby in medical history because BFK can indicate DM
down the road
o check for glucose tolerance test, if failed then glucose challenge test.
● If mom cant inc insulin production → will have periods of hyperglycemia
● Fetus constantly taking glucoses from mom→ hypoglycemia b/w meals & at night
● 2nd & 3rd trimester→ fetus at high risk for organ damage from hyperglycemia
o At this time fetal tissue increases tissue resistance to maternal insulin action
o Teratogenic effects continue into 2nd & 3rd trimester
● When baby is born they can be hypoglycemic→ usually infuse 50% sugar water into
scalp vein
Treatment of GD
● (3 prong approach, medication, diet, exercise)
● Diet
o Eat 6x a day to keep sugar levels at a constant, count carbs
● Monitoring blood glucose levels
● Ketone monitoring in urine
● Exercise→ walking
● Fetal assessment → check for fetal movement
● Probably will get biophysical profile & non-stress test
● If want to deliver kid early→ will have late amniocentesis
Care During Labor GDM Mom
● May need to give mom insulin pump in labor
● IV infusion of dextrose (not a lot of sugar in there) may be needed (D5W has 200
calories)
● Regular insulin
● Assess blood glucose levels hourly & adjust insulin as needed
o After delivery sugar dec for 24 hrs
o Go through a postpartum honeymoon, they don’t need coverage, question it,
expect gestational diabetics to become nondiabetic because pregnancy is over.
o If maintain diabetes probably an undiagnosed diabetic
Care of Neonate of a GDM Mom
● Can get hypoglycemia, resp distress (pale. lethargic, flaring, retraction & grunting)
o Need a 3:1 L/S ratio in order to have mature lungs
● Injury related to macrosomia→ look for clavicular fractures, facial palsy, paralysis
● Blood glucose monitored closely for at least 1st 24 hrs after birth
o 40-80 normal BSL in infants
o Look for trends, want consistency.
● Breastfeeding should be encouraged
o Want to feed the infant immediately in delivery room (d/t risk for hypoglycemia)
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Heart Disease
● Manifestations
o Increased levels of clotting factors
o Increased risk of thrombosis
● If moms heart can’t handle inc workload→ will develop CHF
● Fetus suffers from reduced placental blood flow
● #1 reason for HD in young women → Mitral valve prolapse
● Nml to be tired, anemic, feel pressure on diaphragm as baby grows→ but can also be a
sign of Heart Disease
o Help mother manage fatigue
o Can't do anything about pressure (baby's position) or anemia (can't change plasma
volume)
o Can prevent infection (sepsis can lead to bacterial endocarditis)
o Can reposition→ cannot put legs over head
● Women will go on Lovenox as prophylaxis during pregnancy until they deliver
Signs of CHF During Pregnancy
● Persistent cough** → biggest & most worrisome sign
● Moist lung sounds: always listen to lungs for peripartum cardiomyopathy
o Can happen at 9th month of pregnancy to 5 months postpartum
o Caused by left ventricular dysfunction🡪 can end up on heart transplant list if
severe
o If mom gets through pregnancy- problem will resolve in a couple of months
o Hard to get through bc its hypofunction of left ventricle
o Maintain mom on Lasix (to get rid of water) and digoxin
o Main complaint: unable to get up without being out of breath
● Overly fatigue or fainting/dyspnea on exertion, orthopnea, palpitations
● Severe pitting edema (3-4+) of the lower extremities or generalized edema
● Palpitations
● Changes in fetal HR→ indicates hypoxemia or growth restriction
● SOB is NOT normal→ teach pt to call if trouble breathing occurs
Treatment
● Under care of both obstetrician & cardiologist→ Priority care is limiting physical
activity (avoid fatigue)
● Drug therapy→ beta-adrenergic blockers (olol’s), anticoagulants, diuretics
o Can put mom on prophylactic abx to prevent bacterial endocarditis
● Vaginal birth is preferred bc less risk for infection/respiratory complications
o Epidural, and equipment, forceps or vacuum suction pulling kid out without her
pushing, she should not be pushing.
● Peripartum cardiomyopathy happens to women who have no hx of cardiac problems and
have all the symptoms of CHF.
● Peripartum cardiomyopathy dysfunctioning left ventricle, all symptoms of CHF. It can
start in the 9 month of pregnancy or 5 months postpartum→ will be put on digoxin/ lasix.
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Anemia
● Reduced ability of the blood to carry oxygen to the cells
● Nutritional types→ Iron deficiency & Folic acid deficiency
● Important to do H&H and CBCs.
● Genetic disorders:
o Sickle cell: worrying about clotting crisis- dehydration/infection can cause crisis
o Thalassemia
Nutritional Anemia
● Easily fatigued, pale skin & mucous membranes, SOB, pounding heart, rapid pulse
● Lethargy, depression, insomnia, HA, pallor, angina, impaired cognition & immune
system, anorexia, cold intolerance
Iron Deficiency Anemia
● RBC’s are small (microcytic) & pale (hypochromic)
● Prevention: iron supplements (625 mg /day split)
o Don’t take with prenatal b/c body can't absorb that much at one time
● Treatment: oral dose of elemental iron→ takes a month for iron to kick in
o Continue therapy for about 3 months after anemia has been corrected
o Sources of iron: lean red meat, chicken, turkey, eggs & cereals
Folic Acid Deficiency Anemia
● Large immature RBCs (megaloblastic anemia)
● Folate→ essential for growth & development→ risk of neural tube defects if deficient
● Anticonvulsants, oral contraceptives, sulfa drugs & alcohol
o Decreases folate absorption from meals
● Prevention→ daily supplement of 400 mcg (0.4 mg)
o Start taking 6-8 months before getting pregnant
● Tx: Folic acid treatment → 1 mg/day
o Dose may be higher for moms who had previous kid with a neural tube defect or
twins
Nursing Care for Anemic Mom’s During Pregnancy
● Teach mom which foods are high in iron & folic acid
● Teach how to take supplements:
o Not with milk or antacids
o Take with Vit. C
o Stool may get dark green/blackish
● Moms with sickle cell require close care:
o Teach to prevent dehydration & activities that cause hypoxia
▪ (inc fluid intake ) 10-12 glasses/day
▪ Use of instrumentation to decrease pushing
o Teach to avoid high exposure to infections & promptly report any sign of
infection
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Infections
● TORCH→ used to describe infections that can be devastating to fetus/newborn:
o Toxoplasmosis
o Other infections
o Rubella (rubella vaccine has live virus→ teratogenic)
o Cytomegalovirus (Syphilis)
o Herpes/HIV
Viral Infections
● Can get flu & pertussis shot when pregnant bc virus isn’t alive
o CANNOT get rubella vaccine
● Adenovirus- conjunctivitis with sore throat
Cytomegalovirus (CMV)
● Mom usually don’t have symptoms- found when TORCH titer is done
o By than severe brain & eye damage or chronic liver disease causing blueberry
muffin lesions
● If infant is infected may develop:
o Mental retardation, seizures, blindness, deafness, dental abnormalities &
petechiae (bb muffin)
● Diagnosis → CMV titer
● Treatment🡪No effective treatment is known- offer therapeutic abortion if dx early in
pregnancy
● Cannot breastfeed
Fifth Disease
● Common in kids- rash on face means virus is over
● If mom gets in 1st trimester → will cause blood issues and miscarriage
Rubella
● Mild viral disease that is destructive to developing fetus→ malaise, low fever and rash
● In early pregnancy can disrupt formation of major body systems
● 1st trimester→ lots of defects (80% rate in 1st trimester) & 30% chance of spontaneous
abortion
o Need to wait 3 months and then be tested for titers. Not given during pregnancy.
o Will be offered the vaccine after pregnancy and will give depotpavera as a
contraceptive to make sure the woman doesn’t give birth.
● In later pregnancy can cause damage to organs that are already formed
● If u get rubella vaccine prior to pregnancy must not get pregnant for at least 3
months (a)
● If baby is born with rubella can pass it on to other kids so isolate baby
● Effects on embryo or fetus:
o Microcephaly (small head), mental retardation, congenital cataracts, deafness,
cardiac effects
o Intrauterine growth restriction (IUGR) → small baby
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Herpes Virus
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Type 1: likely to cause fever, blisters or cold sores
Type 2: likely to cause genital herpes
Anyone with cold sore is not allowed on unit until its resolved
After primary infection→ virus is dormant in nerves & can reactivate at any time
Initial infection during 1st half of pregnancy can cause spontaneous abortion, IUGR &
preterm labor
If baby gets herpes during delivery they can die within 1 week of delivery
Infant can be infected in 2 ways
o Virus ascends into uterus after membrane rupture
o Infant has direct contact with infected lesions during vaginal delivery
Neonatal herpes
o Localized or disseminated (widespread)
o High mortality rate
Treatment & nursing care
o Avoid contact with lesions
o May need C-section if mom has active herpes when membranes rupture & labor
begins
o Mom & baby don’t need to be isolated as long as direct contact with lesions is
avoided
o Some use of acyclovir
Do immunoglobulin assay titers to diagnose
Hepatitis B
● Transmitted by blood, saliva, vaginal secretions, semen, breast milk & can cross placenta
● Infects fetus transplacentally or by contact with blood/vaginal secretions during delivery
● If mom has Hep B upon delivery→ baby gets single dose hep b immune globulin & hep
b vaccine (ans)
● If baby is infected, high risk of liver cancer & cirrhosis
● Cannot breastfeed
HIV Nursing Care
● Some born positive then convert to negative if mom takes antiretroviral cocktail & baby
continues it once born
● Educate moms on how to reduce risk of transmission to her fetus/infant
● Moms with AIDs are more susceptible to infection
● Breastfeeding is contraindicated
● If PACT taking during pregnancy and baby put on for several months can convert to
negative status, do not want breastfeeding if HIV+ because it can be transferred through
breast milk
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Non-Viral Infections
Toxoplasmosis (Cats)
● Parasite acquired by contact with cat poop or raw meat(burger) → given through placenta
● Mom may not know she has it→ may have cervical lymphadenopathy & fatigue
● Congenital toxoplasmosis includes possible signs
o Low birth weight, enlarged liver & spleen, jaundice, anemia, inflammation of eye
structures (retinal deformities) & neurological damage
● Treatment
o Can try sulfonamides but they are teratogenic
o Offer mom therapeutic abortion
● Prevention:
o Cook all meat thoroughly/well done
o Wear gloves while gardening
o Wash hands and all kitchen surfaces after handling raw meat
o Avoid uncooked eggs and unpasteurized milk
o Wash fresh fruits and veggies well
o Avoid liter→ don’t have to get rid of cat
Group B Streptococcus (GBS) Infection
● Leading cause of perinatal infection with high mortality rate→ very deadly to infant
● Must do vaginal culture on every mom to test if positive
o If positive, prophylactic antibiotics as soon as in labor
● Organisms found in moms rectum, vagina, cervix, throat or skin
● Inc risk of exposure to baby if long labor or PROM
● GBS inc risk of maternal postpartum infection
o S/S: fever within 12 hrs after delivery, rapid HR, abdominal distention
● Treatment: give abx→ penicillin usually ampicillin
o 2 gram dose of ampicillin followed by 1g every 4 hrs.
o If shes has never been tested, she is treated as if positive
o 101 and 102 F (elevated temps ) dealy to infant
Sexually Transmitted Infections (STI’s)
● Infections: Syphilis, gonorrhea, chlamydia, trichomoniasis & condylomata acuminata
o If positive for any of these will start antibiotics.
● Vaginal changes during pregnancy increased risk of transmission
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Pregnancy-Related Complications
Hyperemesis Gravidarum (Excessive N/V)
● Electrolyte/acid-base imbalance
● Significant weight loss→ get initial weight
● Dec turgor & urine output due to dehydration
● High hematocrit
● Treatment
o Correct hydration & inadequate nutrition (IV & sometimes TPN)
o Give room temp water- not too hot/cold, or coca-cola, ginger
o Give water shots instead of full glass
o Rule out other causes of N/V: gastroenteritis, liver/gallbladder, pancreatic
disorders
● Dehydration→ causes fetal death in 1st trimester
● Patient education:
o Reduce factors that trigger N/V (ex: certain smells)
o Keep accurate I&O’s
o Can administer vitamins via IV
o Frequent, small meals:
▪ Easily digested carbohydrates
▪ Eliminate foods with strong odors
▪ Drink liquids between meals
▪ Put vitamins in IV
Classification of Hypertensive Disorders
● Gestational HTN- never had htn before & start to get high BP (over 140/90)
o seen in 2nd trimester (20 weeks)
● Preeclampsia: inc BP >140/90 + protein in urine
o Mild: 1-2 + protein
o Severe: 3-4+ protein in the urine and BP 160/110
● Eclampsia: have preeclampsia + seizure activity
● Chronic HTN: HTN, prior to pregnancy, doesn’t have proteinuria
● Chronic HTN w/ superimposed preeclampsia→ chronic htn starts to spill protein
● It is NEVER normal for BP to go up, know baseline
o Huge problem if BP inc by 30 in systolic & 15 in diastolic
● Diagnosing factor is protein in urine→ determine if just htn or if preeclampsia
Risk Factors for Gestational HTN & Preeclampsia
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First pregnancy (primigravida) for mom or dad (highest risk)
Obesity, family history, anemic
> 40 or < 19 y/o
Multifetal pregnancy (twins, triplets, quadruplets)
Chronic HTN, renal disease & DM
Men that fathered a preeclampsia pregnancy
Pregnancy from assisted reproductive techniques (IVF)
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Manifestations of Preeclampsia
● HTN→ 140/90
● Edema above waist: especially periorbital (face) & swelling of hands
o (a: generalized edema)
o Measure severity of edema by pressing area & measuring depth of pit
o Daily weight to check for fluid retention
o Retinal edema- will complain of blurry visions or spots in vision (glistening
retinas)
● Proteinuria (a: BP and +1 protein)
● Central NS: severe HA associated w/ brain swelling & potential cerebral hemorrhages
o Severe unrelenting HA usually means impending seizure
o Hyperactive deep tendon reflexes (normal is +2)
● Eyes: spots caused by arterial spasms
o Glistening retinas→ pt sees spots due to retinal edema
● Urinary tract
o Oliguria, proteinuria
● Respiratory system
o Some fluid in lungs→ watch breathing & listen to lung sounds
● GI & liver: epigastric pain
o Caused by hepatomegaly, ischemia, and necrosis
o Big sign of seizures
● Blood clotting
o (a) HELLP Syndrome: hemolysis, elevated LFT’s, & low platelets
o Pt will have petechiae, hematuria, anemia, and be pale
o DIC: clotting factors not where they have to be→ woman can bleed out
● Vasospasms of arteries
● The cause of GH is unknown🡪 cure is delivery of the fetus
● Complications d/t GH:
o Abruptio placentae
o Fetal growth restriction (IUGR)
o Preeclampsia
o Prematurity
o Stillbirth
● Lab test used to diagnose GH:
o Hgb & Hct→ detects hemoconcentration to indicate severity of GH
o Platelets counts→ thrombocytopenia
o Urine for protein(24 hrs) → confirms GH when hypertension is present, if
above 500g for 24 hrs it’s a problem,
o Serum creatinine: elevated Cr & oliguria (suggestive of preeclampsia)
o Serum uric acid: elevated, suggest preeclampsia
o Serum Transaminase: if elevated confirms liver involvement
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Management of Preeclampsia
● Depends on severity of hypertension & maturity of fetus
● Treatment focuses on:
o Maintaining blood flow to moms vital organs & placenta
o Preventing convulsions→ seizures will damage placenta
o Safe delivery of fetus
o Goal is to keep mom alive
▪ If home decreased stress, visitors, calm feet up and relax (unless heart
conditions)
Conservative Treatment
● Activity restriction→ keep away from nursing station want them in quiet room with no
light
o Maintain pt in small dark private rm away from stimulus- less stimulus means
decreased risk of seizure
● Maternal assessment of fetal activity (12 movements in a day minimum)
● BP monitoring→ especially at home
● Daily weight (to check if retaining fluid)
● Checking urine for protein: may collect 24 hr protein test→ want to see if < 500g
Drug Therapy
Magnesium Sulfate IV: prevents seizures but doesn’t lower BP
● Must have baseline BP, magnesium level & deep tendon reflexes before admin
● Want reflexes to drop from 4 to 2→ not 0 because that also means toxicity
● Pt will be drowsy with normal DTR & respiratory status→ means levels are therapeutic
● Inhibits uterine contractions (risk for pp hemorrhage) → use w/ oxytocin if pts in labor
● Teach to call right away if getting twitches, blurry vision & peeing less
● Nursing Care
o Remain in bed tilted on left side to increase O2 to fetus
o Continuous O2 Sat & BP monitoring, full neuro checks (monitor LOC) q2-4 hrs
o Padding on side rails
o Vitals q15 min for 4 hrs after initial admin→ then q1h
o Strict I&O→ urine output monitored q1h: usually has foley bc bedrest
o Periodic mg serum blood levels to monitor for toxicity
● S/S of deterioration
o Increased HTN (>160/100)
o Facial twitching & hyperactive DTR’s
o Decreased urine output (<30 mL/hr)
o Complaints of severe unrelenting headache & visual disturbances
o Epigastric pain, absent DTR, respirations <12 breaths/min
o Serum mg level > 8
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Calcium Gluconate
● Antidote for Mag Sulfate (BURP) toxicity (fill-in)
● Must have on hand ready to admin if needed→ ideally kept at bedside
● BURP (no patellar reflex)
Antihypertensives
Bleeding Disorders of Late Pregnancy
Placenta Previa
● Placenta develops in lower portion of uterus instead of upper portion
(abnml implantation)
● Scab every time cervix opens get painless bright red bleed from where
placenta covers cervix
● Put mom in left side-lying trendelenburg position in bed
● Some low-lying and Marginal moms can deliver vaginally (not covering cervix)
depending on how much room they got to the opening- placenta will usually pull up
during pregnancy as uterus grows
● Partial & total need C-section→ can't deliver through placenta
● (a) If they have csection you go over breathing techniques with them bc its surgery
● (a) question the pitcoin, don’t give for previa
Abruptio Placentae
● Premature separation of normally implanted placenta (violently rips itself off uterus)
● Dark blood w/ pain, enlarged uterus & board-like abdomen
● Dark blood bc by the time blood comes down from the top it's clotted up
● Concealed Bleeding-Sometimes don’t see bleeding bc placenta is high up🡪 causes
concealed bleeding- makes fundus go up (may just have pain)
o Check fundal height→ mark on belly where fundus is & monitor if it moves up
● Partial placental Abruption Will see dark red bleeding and need to do a pad count as
you would a previa. Won't need to do a fundal height cause you can see it
Placenta Previa:Complications/Risks
● Infection bc of vaginal organisms→ placenta is exposed to vaginal area (no vag exams)
● Postpartum hemorrhage: lower segment of uterus has fewer muscle fibers so don’t
contract as well after delivery of placenta
● Fetus may have severe blood loss at birth→ results in hypovolemia, shock or anemia
● Fetus may not be able to engage in pelvic inlet bc placenta is in the way (usually
transverse or breech)
● Treatment: Goal is to maintain fetus in-utero until lungs have matured (34 weeks)
o Deliver fetus if bleeding is significant enough to cause danger to mom or baby
even if preterm
o Avoid supine hypotension: put mom on left side-lying trendelenburg
o (a) turn lady on side after getting hypotension d/t lying flat during leopalds
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Abruptio Placentae:Complications/Risks
● Predisposing factors
o HTN/Preeclampsia, cigarette smoking, poor nutrition, blows to abdomen, history
of abruptio placentae
o Clotting problems- clots in placenta cause premature aging make it separate- dec
O2 & lose baby
o Cocaine/Alcohol use → spasms uterine arteries
o Folate deficiency
● Neonate will present with severe anemia, hypovolemia or shock
● Signs and Symptoms
o Bleeding accompanied by abdominal/lower back pain
o Bleeding usually concealed behind placenta→ blood will be dark red
o Uterus is tender and extremely firm (hard as a rock)
o Fetal monitoring strip reflects dec HR & irritable contraction pattern
Disseminated Intravascular Coagulation (DIC)
● Pathologic form of coagulation causing decreased clotting factors
o Causes generalized bleeding
● Usually associated with abruptio placentae, Eclampsia, intrauterine fetal demise, amniotic
fluid embolism, and hemorrhage
OB Drug Calc
Pitocin (Oxytocin)
● Given by IV/IM
● Used for 2 reasons
o Induction: get labor started
o Augmentation: to speed up contractions, make it stronger
● Side effects: hypo/hypertension, dysrhythmia, abruptio placenta, decreasing uterine
blood flow, convulsions, nausea, vomiting, Asphyxia for fetus.
o Keep checking her BP, O2 stat and pulse, abdominal rigidity(separation of
placenta from wall of uterus)
o Can cause placenta to separate prematurely (abruptio placenta), asphyxia
(fetal distress)
o Vital signs, FHR (accelerating, decelerating (late), distress can be directly related
to Pitocin (strengthens contractions), it causes it to peak, then drop back down. \
o Pressure is elevated
o Intake and Output
o Tetanic contractions: contractions that don’t stop
o Oxygen decrease in fetus: late decel or poor variability
o Cardiac arrhythmia
o Irregularity in fetal heart rate
o Nausea and vomiting
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Magnesium Sulfate (MgSO4)
● Stops premature labor or anticonvulsants
● The myometrium of the uterus is responsible for uterine contractions during labor and is
composed of smooth muscle cells.
● Magnesium Sulfate inhibits the action potentials in these smooth muscle cells by
blocking Ca2+ channels in these cells. (used to stop premature labor)
● This inhibitory action is responsible for the relaxation of the smooth muscle cells and
decreases uterine contractibility.
● Preeclampsia can lead to eclampsia (uncontrolled convulsions and dangerous
hypertension).
● Magnesium Sulfate acts as an anticonvulsant by inhibiting ACH release at the
neuromuscular junction , thereby reducing muscular contraction.
○ BURP (Toxicity)
▪ BP DECREASE
▪ URINE OUTPUT DECREASE
▪ RESPIRATORY RATE DECREASE
▪ PATELLAR REFLEX ABSENT
o If toxicity occurs: stop MgSO4 infusion and administer antidote of calcium
gluconate (10 mL of 10% solution slowly intravenously over approx 10 minutes).
▪ Mag needs to be therapeutic to be effective.
● Bolus then maintenance rate/hr
● Check therapeutic levels.