Eriksons Stage Initiative vs. GuiltPreschool 4-5 years old Try new things Is it okay to do what I'm doing? Follow Interest Parents encourage trying new things but if constant reprimand for doing "silly" things guilt is created. Learning from the whole familyEriksons Stage industry vs inferiority5-12 years old Discover own interest different from others Recognition fosters development Negative Impact - too little recognition or not being approved of leads to inferiority. Neighbors and Schools Influence the most at this stageEriksons Stage 5 identity vs role confusionAges 13-19 years old different social roles - friends, student, citizens parents reduce structure to guide exploration of identity role confusion if parenting tries to conform child to their views. key to learning peers and role models.Eriksons Stage 6 - intimacy vs isolation20-40 years old Understand who we are Relationship Building Can we Love? Cant form relationships fosters isolation Confidence and Happiness to form relatinshp Friends and Partners are eseential to developmentEriksons Stage 7 - generativity vs stagnation40-60 Comfortable Leisure time creatively and contribute to society Generate the next generation to succeed Stagnation - Pessimistic views of society Home and Work influence the mostEriksons Stage 8 integrity vs despair65-Death Slow Down Compare to the rest of mankind Contentment and integrity over life experiences Despair is lacking contentment of life accomplishments Reflection of life accomplishments creates happiness, or sadness.Piaget's Cognitive TheoryDevelopmental Stage Theory - Theory about the nature and development of human intelligence; deals with the nature of knowledge itself and how humans gradually come to acquire, construct, and use it (known as Developmental Stage Theory)Piaget's stages of cognitive developmentsensorimotor preoperational concrete operational formal operationalCognition DevelopsSimple to complex Illogical to Logical Concrete to AbstractGrowth and Development - Speech at 12 monthsSays 2 or more words: mama and dada with meaningGross Motor Skills at 2monthsBegins to life headGross Motor Skills at 4 monthsRolls stomach to backGross Motor Skills at 6 monthsSits up by self using hands Rolls side to sideGross Motor Skills at 9 monthsPulls to stand or (3 Cs) Creeps Up Cruising CrawlingGross Motor Skills - 12 monthsStand without Support Postural Control improves First steps alone Throws a ballFine Motor Skills at 9months3 pincer grasp Grasps objects betterFine Motor Skills at 12months2 finger Pincer GraspSocial Sensory Development at 2monthssocial smileAge related landmarks at 2monthsposterior fontanel closes (2-3months)Age related landmarks at 4monthsSeperation AnxietyAge related landmarks at 6monthsBirth weight doubles Object permanence developed 6-8months 1st deciduous teeth 6-7months - fear of strangersAge related landmarks at 9monthsAnterior Fontanel closes between 12-18monthsAge related landmarks at 12monthsBirth weight is tripled Height increases by 50%Developmental Stages riskMost at risk for developmental delays with prolonged illnesses or hospitilizations as an infant Primarily impacts Trust vs. Mistrust and Sensorimotor stages of development.Parental Education between 6-12monthsDue to infants increased mobility - baby proof everything!!Immunizations at 2monthsB Dr. Hip B - Hep B D - Diptheria Tetanus & DTap (Pertusis) R - Rotavirus 1 H - Haemophilus I -Influenza P - Polio & PneumoccalImmunizations at 4monthsD - Diptheria Tetanus & DTap 2 R - Rotavirus H - Heemophilus I - IVP (Polio) P - PneumoccocalImmunizations at 6monthsB Dr Hip In B - Hepatitis B 3 D - Diphtheria Tetanus, Pertussis (DTaP) R - Rotavirus 3 H - Haemophilus influenzae meningitis (Hib) 3 I - (IVP) Polio 3 P - Pneumococcal (PVC) 3 IN - Influenza 1st can be given.Immunizations at 9monthsAny catchup of immunizationsImmunizations at 12monthsMAD HPV M - MMR 1 st Measles/German measles, Mumps Rubella A - Hepatitis A 1st D - Diphtheria Tetanus, pertussis (DTaP) 4 H - Haemophilus influenzae meningitis (Hib)4 P - Pneumococcal (PVC) 4 V - Varicella 1st (chickenpox)Family Teaching at 6weeks●Respond to cries. ●Frequent holding provides feelings of love & caring. ●Rocking & soothing baby are important. (6 weeks- 3½ months) ●Provide visual stimulation w/ toys, pictures, mobiles. ●Auditory stim. by talking & singing to baby ●Repeat sounds infant makesFamily Teaching 3.5 - 5 months●Play & talk regularly to/with baby. ●Give a variety of things to look at & touch (soft, fuzzy, rough & smooth), to provide tactile stimulation. ●Move baby around the hometo provide additional visual & auditory stim. ●Begin placing infant on floor to provide freedom of movement.Family Teaching 5--8months●Hold, cuddle, & respond to needs. ●Talk to infant. ●Put infant on floor more often to roll & move. ●Allow supervised tummy time. ●Fear of strangers is common at this age. Play games to help promote object permanence like peek-a-boo, or hide/seek. ●Provide play opportunities to stimulate next G & D stage.Family Teaching 8-12months●Review safety needs as child is becoming mobile in new ways. ●Accident-proof house. ●Give infant max access to living area. ●Supply infant w/toys. ●Stay close by for support in new/difficult situations. ●Continue to talk to infant to provide language stim. ●Developing more independence. ●Provide opportunities to develop gross & fine motor skills. ●May begin temper tantrums. ●Ensure well-child visits kept & child up to date on immunizationGrowth and Development 18monthsVocabulary of 10-25wordsGrowth and Development 2 y/o2 word phrases Vocabulary of 200-300 words Carries conversation using up to 2 sentencesGrowth and Development 3 y/oVocabulary of 1,000 words egocentric language like to talk and sing questioning string multiple words togetherGrowth and Development 4 y/oVocabulary of 1,500 words time of rapid language growth uses communicative language detect speech problems before entering schoolGrowth and Development 5 years oldVocab of 3,000 words can count to 10 Find it funny to say "naughty words" Telegraphic speech at 3 yearsCognition at 3 y/oFollows instructions with 3 steps. ●Capable of symbolic thought. ●Fear of body mutilation - use age-appropriate words to explain procedures. ●Knows difference between "before" &"after" in clear instruction. (2-3 Years) ●Knows gender. ●Knows age. ●Can say first nameCognition at 4 years old●Have imaginary friends. ●View death as being temporary, reversible ● Fear of body mutilation - use ageappropriate words to explain procedures. ●Sees fantasy as truth, using magical thinking, transduction & animism. ●Still developing sense of time. Use benchmarks vs. exact times. ●Begins to understand justice & fairness. ●NO longer experience stranger anxiety. ●Experience less separation anxiety.Cognition 5 years old●Death seems reversible still. ●Fear of body mutilation - use age appropriate words to explain procedures. ●Unable to fully process abstract thoughts ●Sense of time improving. Help by sequencing events & using tools like calendars & clocks. ●Still experience some magical thinking.Personal Social G&D at 3 years oldDreams and Nightmares commonPersonal Social G&D 5 years old●Shows more independence. ●Able to perform basic self-care needs. ●Wants to please & be like friends.2 y/o PlayMake believe Play Spectator/Onlooker Behavior3 y/o PlayParallel Play 2+ years Still can not share4 y/o PlayAssosciate Play (3-4 years) starts to interact with others but not a lot may play without interacting (all playing on same piece of equipment)4-5 y/o PlayCooperative Play 4+ y/o Activity to mimic adult life Dress up clothes and role playImportant Age related landmarks12months --3 y/o ●Negativism, ●Dawdling ●Ritualism ●Temper Tantrums2 y/o Age related landmarks●Regression common in toddlers and preschoolers when facing stressful event3y/o Age related landmarksMagical thinking, imaginary friends common, Regression common when facing stressful events fear of body mutation use of age appropriate words to explain procedures4 y/o LandmarksFear of Body Mutilation Separation is easier Focuses on one aspect instead of the whole5 y/o LandmarksFear of body mutilation - explain proceduresStrenghtening Developmental stages (Age 2-4)Autonomy vs. Shame- Learns to perform tasks independently (Will). Parents most important. ●Allow to make simple decisions on their own (2 choices) for sense of control ●Allow them to carry out tasks on their own ●Avoid shaming 2) (Age 2 to 6-7) Pre-operational phase Egocentric point of view. Acts r/t punishStrengthening Developmental stages (Age 4-5)Initiative vs. Guilt- child develops a conscious & sense of right & wrong. Can feel guilty if they feel they misbehave (Purpose). Family most important. ● Age 2 to 6-7) Preoperational phaseStrengthening Developmental stages (Age 5-12)Industry vs. Inferiority Competes with others & enjoys task accomplishment (Competence). Neighbors & schoolSafety Ages 1-4 years oldAccidents, Baby Proofing: decrease risk of poisoningSafety Ages 2-5 years oldFront Facing Car seat - Rear middle with tether Baby Proofing - Poisoning, burns, animal bites, fractures Must be in proper size booster or wear a seat belt Booster seat - Age 5 (57 inches tall)Safety 4 years oldBe aware of foods that may cause allergic reactions (milk, nuts, and shellfish)Discipline 1-3 y/oChildren want and need limits without limits insecurity and fear can develop Avoid labeling Taking away a privelage is effective Time outs Ignore behavior and dont reactDiscipline 3-5 years oldTimeouts are effective, use approval and praise to reward positive behavior Toilet trainingImmunizations 3-5 y/oVERY DIM V - Varicella 2 (chickenpox) D - Diptheria I - Influenza M - MMRG&D 6-7 years oldSPEECH: 8,000-14,000 words begins to see death as COGNITION: Permanent and not reversible; can participate in self care including mgmt of chronic conditions MOTOR: Organized sports - Throw balls with some accuracy PERSONAL & SOCIAL: Sense of duty and accomplishment - Not succesful creates inferiority PLAY & TOYS: enjoys competition, organized clubs, build and constuct LANDMARKS: 20/20 vision, judgment guided by rewards and punishmentG&D 7-10 years old● Can sequence an event of own experience in order ● Can participate in selfcare, including management of chronic conditions ● Magical thinking ends. ● 7-9 years understands death is permanent & irreversible ● More adult like interests, enjoy outdoor activity, sports & competition. ● Use logical consequences, cause & effect, directly related to behavior ● Time of hormonal shifts; recognize & acknowledge changing feelings, respect & try to understand them. ● Keep your promises.G&D 11-15 years old● Has adult understanding about death. \● Acts on feelings more than thinking. ● Can participate in selfcare, including management of chronic conditions ● Coordination impairment possible d/t growth spurts ● By 14-16 yrs., precise hand/eye coordination is fully developed. ● Continues to develop & refine identity. ● Seeks out intimate relationships. ● Body image is closely related to self-esteem - Need careful guidance & understanding with managing chronic conditions (need to fit in with their peers) ● Activity that promotes social identity. ● Games of all kindG&D 15-18 years old● Frontal cortex (brain's rational part) responds to situations with good judgment & awareness of consequences, is last to mature. An immature frontal cortex explains teenage behaviors, such as poor judgment, impulsivity, & risk taking behaviors. **Increased risks as they try to separate self identity from their parents ● Can participate in selfcare, including management of chronic conditions ● Body image exerts an enormous influence on self-identity ● Develops sense of moral judgment & system of values/beliefs. ● Peer group & role models extends tremendous power (seeking-self-identity). Need careful guidance & understanding with managing chronic conditions (need to fit in with their peers) ● May turn to peers for information rather than parents/adults - less reliable information (sex, contraception, drugs, smoking, vaping, etc.) ● More adult like activity tailored to personal interests. ● Stop growing about 2-2 1/2 years after onset of menses. - Identity vs. Role Confusion ● Set clear & realistic expectations, with consistent follow through - BSE & TSE for health promotionDuvall's Family StagesStage 1 - Marriage, independent Home, joining families Stage 2 - Families with Infants Stage 3 - Families with pre-k Stage 4 - Families with school children Stage 5 - Families with teenagers Stage 6 - Families as launching centers Stage 7 - Middle Aged Families Stage 8 - Aging FamiliesFamily InfluencesFamily Structure, family functioning, familial roles, parenting styles, limit setting and disciplineSociocultural Sphere of InlfuencesBronfenbrenners Ecologic Framework: Schools, peer cultures, social roles, co-cultural, subcultural, communities Broader Sociocultural Influences: Race/Ethnicity, social class, religion, mass mediaNormal vs. Abnormal DevelopmentDevelopmental delay, developmental regression, developmental arrest, global delays (cog and physical)Pervasive Developmental DelayPDD - usually ID by age 3, socialization delays, communication delays, cognitive delays. Autism, Asperger's, NOSDevelopmental Risk FactorsSocial Deteminants of Health - Socioeconomic status, food security, access to healthcare, early childhood brain development, household living conditions, residential segregation, social support, culture/social norms/languages, access to mass media/techForms of PlayUnoccupied, solitary, spectator/onlooker, parallel play, assosciate play, cooperative play Unoccupied - birth to 3mo Solitary - birth to 2 y/o Spectator - 2 y/o Parallel Play - 2+ y/o Assosciate Play - 3-4y/o Cooperative Play (4+ y/o)Developmental Influences of PlayFunctions: physical, emotional, cognitive, social, moral development Social Development: Explore feeling, develop self discipline, expression of self, work out emotionsCulutural CompetenceCultural Humility Commitment to self reflection and critique, adressing power imbalances, mutually beneficial Open mindedness, no judgement, acceptance, gaining client perspective, holistic approach to planning careHolistic Caring PrinciplesCreating Intention (Presence and Energy - self care) Holistic Communication - Listening to their story (self assessment) Building Relationships - Patient/Family Perceptions (self reflection)Maternity Nursing-Complex FieldsCultural, Ehtical, legal, values, spirituality, life and deathHistory of Maternal NursingColonial America - Anxiety and fear due to death common Early 1900s - Physician assisted birth (midwives for those who could not afford Dr.) 1950s - Intro to natural birth practices 1960s-70s - Home births, prepared births, father involvement, and nurse midwives Current - Return of midwives, childbirth choices for mother and family.Factors affecting Maternal Child HealthFamily, genetics, society, global society, culture, health status and lifestyle, access to health care, improvement diagnosis and treatments, empowerment of healthcare consumers.Defining the FamilyPrimary unit of socialization, potent support system for its members, family plays a pivotal role in health care decisions, family centered care is the target of health delivery for maternal and newborn nurseFamily Organization and StructureNuclear Family, extended family, multigenerational family, no parent families, married-blended families, cohabitating-parent families, single-parent families, homosexual families (LGBT)Interrelated concepts of Culturehealth disparities, fatigue, mood and affect, communication, coping, family dynamics, spiritualityCommon attributes of cultureCulture is learned, culture is chaning and adapting, shared beliefs values and behaviors = How does this affect the family and roles within a family.Cultural Beliefs around childbearingAsian, hispanic, african america, somalian, native americans, muslimWomens Health over the LifespanPrimary, seconadary, tertiaryCommon Lab and Diagnostic Testing: Genetic RiskAlpha-fetoprotein, aminocentesis, chronic villus sampling, percutaneous umbilical blood sampling, fetal nuchal translucency, ultrasound, cell free fetal DNA.GeneticsStudy of heredity and its variation disorders affect all without regard to socioeconomic, race, color family history importantGenetics and ChromosomesHuman Cells: 46 chromosomes Autosomal: 22 pairs, one from each parent Sex Chromosomes: 1 pair XX or XYAutosomal Chromosome AbnormalitiesUnequal Distribution of genetic material Monosomic- 45 chromosomes trisomic - 47Sex Chromosome AbnormalitiesMonosomy X (turners syndrome)Turner SyndromeA chromosomal disorder in females in which either an X chromosome is missing, making the person XO instead of XX, or part of one X chromosome is deleted.Trisomy XXYKlinefelter syndromeKlinefelter syndromeA chromosomal disorder in which males have an extra X chromosome, making them XXY instead of XY.Patterns of genetic transmissionunifactorial or multifactorialMaternal Mortalitydeath of a mother during pregnancy, childbirth or within 42 days of delivery Population most affected: Non-Hispanic BlackCultural aspects to Birthsome beliefs are that colustrum is dirty and want a bottle untill colostrum clears. Multiple cultures have different beliefs on post birth and birthing process - asian, hispanic, african american, somalian, native americans, muslimWomens Health Prevention StrategiesPrimary - educcation secondary - screening (pap, breast exam, HIV) tertiary - support groups for increase quality of lifeAlpha-fetoprotein (AFP)A blood test that measures the level of alpha-fetoprotein in the mothers' blood during pregnancy as an indicator of possible birth defects in a fetus.AminocentesisPrenatal diagnostic technique that involves inserting a needle to obtain a sample of amniotic fluid that surrounds the fetus. sample of fluid which contains fetal cells, diagnostic, but high riskchronic villus sampling (CVS)A technique for diagnosing genetic and congenital defects in a fetus by removing and analyzing a sample of the fetal portion of the placenta.Percutaneous Umbilical Blood Sampling (PUBS)Procedure for obtaining fetal blood through ultrasound-guided puncture of an umbilical cord vessel to detect fetal problems such as inherited blood disorders, acidosis, or infection; also called cordocentesis.Fetal nuchal translucency (FNT)-An intravaginal ultrasound that measures fluid collection in the subcutaneous space between the skin and the cervical spine of the fetus -To identify fetal anomalies; abnormal fluid collection can be associated with genetic disorders (trisomies 13, 18, and 21), Turner syndrome, cardiac deformities, and/or physical anomalies. When the FNT is greater than 2.5 mm, the measurement is considered abnormal. -Performed between 10 and 14 weeks' gestationUltrasoundmonitors fetal growth throughout pregnancy and produces images of the fetusCell fraction fetal DNADuring prenatal cell-free DNA screening, DNA from the mother and fetus is extracted from a maternal blood sample and screened for the increased chance of specific chromosome problems, such as Down syndrome, trisomy 13 and trisomy 18. This screening can also provide information about fetal sexRisk and BenefitsInvasive or less invasive of fetal harm - first trimester 0-13weeks - No abortion past 13weeks Assess continuously for preparation to care for high risk delivery throughout genetic testing.Ballottementa sharp upward pushing against the uterine wall with a finger inserted into the vagina for diagnosing pregnancy by feeling the return impact of the displaced fetusChadwick's SignBluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion. Cervical ripening Early sign of preganancy Increase in elasticity and strengthDIETARY REFERNCE INTAKES (DRIs)Vitamin and Mineral Supplements Prenatal Vitamins - No evidence of folic acid iron and folic acid need to be supplemented due to Dietary intakeinsufficient to meet needs. Must form new blood cells to prevent anemia folic acid reduces risk for neural tube defectsGoodell SignCervix begins to soften due to inflence of estrogen, and endocervical glands increasing in size - Increased mucous - Forms mucous plugHegar SignThining of the uterus due to need for anterflexion - Increase urinary frequency by placing pressure on bladderLinea NigraDeep pigmented line from umbilicus to the pubic area.Physiologic Anemia of PregnancyDilution of RBCs - decreased HgB and HCT Need for iron supplement for adoption throughout pregnancy due to increased metabolic needs Increase perfusion of organs and increased excretion of kidney wastePicaEating non-food items compulsivity Soil - Causes iron deficiency Clay - Constipation and Parasite Infection Ice - Iron Deficiency - tooth fractures Laundry Starch - Replaces protein metabolism and deprives fetus of aminos.QuickeningSensation of fetal movement - mother acknowledges fetus as seperate •Decreased asphyxia or hypoxia •Kick countsTrimesterEach trimester requrie numerous adaptions take place that facilitate growth of the fetus. 1st Trimester - Woman focuses on self - Acceptance 2nd Trimester - Attachment - Fetal Movement - Seperate 3rd Trimester - Concern, longing, questioningBraxton HicksTightening and pulling on top of uterus - differ from labor contractions (felt in back) Last 30secs to 2 minutes due to influence of oxytocin Real Labor = Longer than 30seconds and 4-6x/hourEssential Oils to help with DeliveryLavendar, Peppermint to reduce nausea and vomitting during laborOBpredictable and follows developmentAnatomy Impacts PregnancyAt time of conception problems cant be reversed cross section views previous surgeries and 2* intention woundsMidline episiotomyStarts at the posterior vaginal entrance and is directed straight back toward the rectum Vagina --> RectumLateral episiotomyMidline to the outside - to the left or to the right; takes forever to healAnatomy of Motheranatomy of reproductive systempelvic anatomyUterus AnatomyFemale Reproductive Cycle±Ovarian Cycle (Preparation) °Midcycle-Ovulation occurs ±Endometrial (Uterine) Cycle (Menstruation) ±Hormonal Changes-regulate cycles ±Cyclical Changes in the Breast ±No FERTALIZATION=Menstruation °Shedding of uterine lining °Beginning and end of monthly cycle The menstrual cycle results from a functional hypothalamic-pituitary-ovarian axis and a precise sequencing of hormones that lead to ovulation. Menstruation Perimenopause Menopause-1 year without a menstrual cycleMenstrual Cycle HormonesFollicular Phase: Ovulation Luteal Phase: at ovulation until menstrual phase Ovulation: 14 days before menstruationProstaglandin:mediators of inflammation, regulatory properties, but not hormones-responsible for menstrual cramps myometrial stimulate & vasoconstrictorProgesteroneRelaxes & Inhibits LH & FSH This hormone is often called the hormone of pregnancy because of its calming effect (reduces uterine contractions) on the uterus, allowing pregnancy to be maintained. Secreted by the corpus luteum, maintains uterus lining. Inhibits secretion of LH & FSH *Calming effect on pregnancy •maintains the endometrium, decreases the contractility of the uterus, stimulates maternal metabolism and breast development, provides nourishment for the early conceptus.EstrogenEgg is Ready - Secreted by the ovaries to mature follicle, promotes thickening of the uterine lining. Inhibits secretion of FSH, stimulates pituitary to secrete •causes enlargement of a woman's breasts, uterus, and external genitalia; stimulates myometrial contractility.Luetenizing HormoneLoose folicle in fallopian tube - connects within 24 hours (egg life), and sperm live up to 24-72hours. Sperm is the key to unlock egg and genetics LH surge causes final development and rupture of mature follicle. Ruptured follicle forms corpus luteum Promotes estrogen secretion by developing follicle approximately day 10 to 14FSH (follicle stimulating hormone)Fires ovary to produce Stimulates ovary to produce immature follicles (oocyte/egg) Stimulates estrogen secretion by follicle cells *starts on day 1 of menstrual cycleFollicular PhaseAnterior Pituatary - FSH, LHLuteal PhaseEstrogen Progesterone Occurs within the OvaryFallopian Tubes•Create Currents •Carry OvumCervix•Mucous needed to facilitate sperm movementCellular Divison & Conception±Meiosis-mature egg (ovum) released from ovarian follicles ±High levels of estrogen move ovum through the fallopian tube ±Ovum available 24 hours ±Sperm viable 2 to 3 days ±Union of gametes (egg & sperm)=EmbryoConception2 weeks after first day of LMPPregnancy TestsHuman chorionic gonadotropin (hCG) is earliest biochemical marker of pregnancy Pregnancy tests based on recognition of hCG or β subunit of hCG Can be detected in serum or urine as early as 7 to 8 days after ovulationOvumTravels to fallopian tube for preparedness of pregnancy COMPLICATIONS: Ectopic Pregnancy - must be terminated and lead to fallopian tube damage Abdominal Pregnancy - Too acidic for viable pregnancyWhat part of the uterus is the strongest?Top part of uterus is the strongestSample of UterusEndometrial Reese AUterusIs the environment to be receptive to pregnancy - must test for porgesteroneProgesterone SupplementDecreases risk for miscarriageWhat must occur in placenta?Must be devlopled to create a viable supplementPregnancyLasts 40 weeks. 1st Trimester - 0-12 2nd Trimester - 13-26 3rd Trimester - 27-40weeksAge of Viability22-25weeks - Ability for fetus to be able to live. Must assess: - lung maturity and CNS function - lungs must make surfactant - CNS must be mature to support autonomic function If pregnancy makes to 20weeks = viable pregnancy - Counts as delivery and live birth - if death occurs it requires a funeral - dating of pregnancy no always accurateSigns of Pregnancy3 days after conception Subjective - presumptive, perceived by mother Objective - Probable, measures HcG Positive - Only accurate - lab work, ballottement, chadwicks, heagar - medically confirming pregnancy with DT.Fetal Developmentfirst two weeks the uterus prepares 3 weeks uterus is formedYolk SacWhen sperm and egg come together and forms nutrition for embryoCrown Rump LengthDetermines how many weeks embyro is along we add 2 weeks of age due to development screen pregnancy at reproductive age due to high risk of exposure to tetragensTetrogensHarmful to baby - causes problems alcohol, cigarettes, environmental factors Neural Tube DefectsPlacentaChorion vs. Amnion Side Guides the fetus to wallow and breath waster to stimulate lung function Room for movement to allow muscular structures to developpolyhydramniosexcessive amniotic fluidoligohydramniostoo little amniotic fluidUmbilical CordWortens Jelly - 2 arteries and 1 vein - Can indicate kidney dysfunction Important assesementChronic Villifingerlike projections of the chorion that extend into the uterine lining - diffusion of material occursUterine ArterySupplies blood to uterus and oxygen to placentaUmbilical Cord Purposetransport waste and lifewastes CO2 returned to placenta oxygen --> placenta > baby > CO2 from baby > placenta > uterus Contractions reduce O2 transfer to babyFetal CirculationFetal lungs don't perform gas exchange liver does not need to filter blood - bloodflow is shunted & follows path of least resistance Umbilical Veins - oxygen to fetus Umbilical Arteries - wastes back to placenta blood doesn't go to lungs ductous venoses - liver ductous arteriouses - heart valve to lungsBlood flow in fetusumbilical vein > liver > Bypass D.V. > RA > RV >Pulmonary Aorta but shunt valley > LV > Aorta > umbilical arteries veins return blood to heart = oxygenated arteries have deoxygenatedPhysilogical Adaption throughout PregnancyAnemia due to iron deficiencies - helps moms accomodate for blood loss due to increase plasma within body and natural adaption GFR increases = uterus dilates Melanin Increase = Hyperpigmentation Stria VaricositiesReccomendations for Lactating MothersIncrease need for fluid Increase iron during pregnancy due to RBC Increase Iron Side Fx = NauseaModifiable Risk Factorssubstance abuse, support, addiction, nutrition, obesityClassification of pregnancyGTPAL Score Gravida - Number of times pregnant Term - Children to term Para - Pregnancies over 20 weeks Abortions - Pregnancy terminated or under 20weeks Living If term and Abortions = each other mean not pregnant Still birth over 20 weeks - counts as pregnancyGestational AgeLate Preterm - 34-36 weeks Early Term - 37-38 weeks Full Term - 40 weeks Late Term - 40-41 weeks Post Term - 41+ weeksPrenatal CareAssess: UA, BP, Weight, Fundal Height, Fetal HR, Fetal Movement, Emotional Status.benefits of routine screening and diagnosticsdetermine risksIntrapartumpredictable amount of time but time it takes is different Primipara - longer labor Multipara - shorter laborLabor StagesFirst stage - cervix dilating Latent - 0-6cm Active - 6-10cm Contractions 0-8cm are less painful, 9-10cm increased pain due to fetus in pelvisSecond stage of LaborDelivery of baby can push at 10cmThird Stage of Labordelivery of placenta4th stage of LaborMother's recovery after birth of baby and placenta - Extrouterine environment 1-4 hours is most vulnerablePreliminary Signs of LaborCervical Changes, increase vacularity, bloody show or mucous plug changes mother reports "baby has dropped" "more energy" "decreased SOB"Spontaneous Rupture of MembranesTime everything - its go time -not within 24 hours from first sign of labor = induction protective environment compromised = increased risk for infectionTrue LaborChanges in cervixFactors that Affect LaborCan cause risks for L&D Passageway Powers Passenger Position Psychological ResponsePelvic ShapesCan cause complications of birthing Gynecoid - normal shape Cartilage (pubic symphysis) is flexible and aid descending of the babyFetal PosititionIs in relation to ischial spines Furthest Up to Furthest Down -3 -2 -1 0 - Head Felt +1 +2 +3 +4 - OutProbable signs of pregnancysigns of pregnancy are those that can be detected on physical examination by a health care provider. Common probable signs of pregnancy include softening of the lower uterine segment or isthmus (Hegar sign), softening of the cervix (Goodell sign), and a bluish-purple coloration of the vaginal mucosa and cervix (Chadwick sign). Other probable signs include changes in the shape and size of the uterus, abdominal enlargement, Braxton Hicks contractions, and ballottement (the examiner pushes against the woman's cervix during a pelvic examination and feels a rebound from the floating fetus).fetal development1.Zygotic stage: Union of sperm and egg through the second week. 2.Blastocyst: specialized cells that form into embryo and amnion (placenta & cord) 3.Embryonic stage: Day 15 to through week 1.Measure crown rump length-accurate dating 2.Rapid changes and cell growth, vulnerable to environmental teratogens 4.Fetal stage: Differentiation and structures specialize by end of the eighth week until birth.Yolk Sac LayersEmbryo: All tissues and organs develop from 3 layers 1.Ectoderm—forms the central nervous system, special senses, skin, and glands. 2.Mesoderm—forms the skeletal, urinary, circulatory, and reproductive organs. 3.Endoderm—forms the respiratory system, liver, pancreas, and digestive system. Yolk sac provides nutrients until placenta is fully functional, becomes part of the primitive digestive sac-gone by 5th or 6th weekEDD - Estimated due dateEDD: Naegels Rule: Add 7 days to first day of LMP then subtract 3 monthsEmbryonic StageThe embryo is floating in amniotic fluid, surrounded by the protective fetal membranes (amnion and chorion).What is the Placenta?±Maternal-placental perfusion: Day 17-embryonic heartbeat ±Membranes °Chorion: maternal side, umbilical blood vessels °Amnion: fetal side, cord, covers placenta, filled with fluid ±Amniotic Fluid-transparent, straw colored °Fetal fluid from respiratory and GI tract °Temperature regulation, cushion, practice breathing, barrier °Prevents tangling with cord or membranes It is developed by end of 2nd weekWhartons Jelly°Wharton's jelly-connective tissue coating the cord, prevents compressionPlacenta FunctionsThe main functional units of the placenta are the chorionic villi within which fetal blood is separated by only three or four cell layers (placental membrane) from maternal blood in the surrounding intervillous space. Maternal arteries=deliver nutrients to placenta Maternal vein=remove fetal waste There is no MIXINGRelaxin•is a potent vasodilator and regulates maternal hemodynamics. It acts synergistically with progesterone to maintain pregnancy, causes relaxation of the pelvic ligaments, softens the cervix in preparation for birth (Roberts & Myatt, 2019).Human placental lactogen (hPL)modulates fetal and maternal metabolism, participates in the development of maternal breasts for lactation, and decreases maternal insulin sensitivity to increase its availability for fetal nutrition.Chorionic gonadotropin (CG)•preserves the corpus luteum and its progesterone production so that the endometrial lining of the uterus is maintained; this is the basis for pregnancy tests.Aspects special to fetal circulation±Shunts in heart and liver bypass most oxygenated blood ±Lungs do not perform gas exchange °Ductus venosus-blood mostly bypasses liver to go to vena cava °Foramen ovale-opening between atria °Ductus arteriosus-extra artery that diverts blood pumped from right ventricle into aorta to bypass lungsBlood flow in fetal heartOxygenated blood enters through 1. fetal vein to liver-splits small amt blood into 2. liver and ductus venous which empties into 3. vena cava-mixes with deoxygenated blood from legs and abdomen 4. heading to right atrium-flows through foramen ovale (opening between atria) 5. left atria and mixes with small amount of blood returning from lungs 6. Left atria to left ventricle-pumped out aorta-blood pumped 7. right ventricle mixes with blood from left ventricle in aorta by way of the ductus arteriosusReproductive development in fetus°Testes descend after week 28 °Ovaries produce eggs by week 16Cardiovascular Physiological Adaptionphysiologic anemia of pregnancy extra volume not as much extra cells •Increase heartrate 25% •Increase cardiac output 30 to 50% •Increased plasma and blood volume •1.5 Liters or 50% increaseRespiratory Physiological Adaption•Space •Extra red cells to saturateRenal/Urinary Physiological Adaption•Adapt to increased blood flow •Dilation of renal pelvis, kidneys and ureters, increases fragility •Increased GFRMusculoskeletal Physiological Adapion•Changes in posture and gait •Ligaments soften •Joints increased movabilityInfluence of Dietary Intake on FetusInadequate: Low birth weight Preterm birth Congenital anomalies Excessive: Fetal macrosomia Labor dystocia Neonatal hypoglycemiaRecommendations for Weight Gain throughout pregnancyGain between 15 and 40 lb in a gradual and steady manner depending on prepregnancy weight as follows: • Underweight (BMI >18.5) total weight gain range = 28-40 lb • Normal weight (BMI = 18.5-24.0) total weight gain range = 25-35 lb • Overweight (BMI = 25-29) total weight gain range = 15-25 lb • Obese (BMI = 30 or higher) total weight gain range = 11-20 lb (HMD, 2009)Risk Factors for Adverse Pregnancy Outcomes• Isotretinoins: Use of isotretinoins (e.g., Accutane) in pregnancy to treat acne can result in serious birth defects such as cleft palate, congenital heart defects, hearing loss, and microcephaly. • Alcohol misuse: No time during pregnancy is safe to drink alcohol, and harm can occur early, before a woman has realized that she is or might be pregnant. Fetal alcohol syndrome and other alcohol-related birth defects can be prevented if women cease intake of alcohol before conception. • Antiepileptic drugs: Certain antiepileptic drugs are known teratogens (e.g., valproic acid). Recommendations suggest that before conception, women who are on a regimen of these drugs and who are contemplating pregnancy should be prescribed lower dosages of these drugs. • Diabetes (preconception): The threefold increase in the prevalence of birth defects among infants of women with type 1 and type 2 diabetes is substantially reduced through proper management of diabetes. • Folic acid deficiency: Daily use of vitamin supplements containing folic acid (400 mcg) has been demonstrated to reduce the occurrence of neural tube defects by two thirds. • Hepatitis B: Vaccination is recommended for men and women who are at risk for acquiring hepatitis B virus (HBV) infection. Preventing HBV infection in women of childbearing age prevents transmission of infection to infants and eliminates risk to the woman of HBV infection and sequelae, including hepatic failure, liver carcinoma, cirrhosis, and death. • HIV/AIDS: If HIV infection is identified before conception, timely antiretroviral treatment can be administered, and women (or couples) can be given additional information that can help prevent mother-to-child transmission. • Rubella seronegativity: Rubella vaccination provides protective seropositivity and prevents congenital rubella syndrome. • Obesity: Adverse perinatal outcomes associated with maternal obesity include neural tube defects, preterm delivery, diabetes, cesarean section, and hypertensive and thromboembolic disease. Appropriate weight loss and nutritional intake before pregnancy reduce these risks. • Sexually transmitted infections (STIs): Chlamydia trachomatis and Neisseria gonorrhoeae have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain. STIs during pregnancy might result in fetal death or substantial physical and developmental disabilities, including intellectual disability and blindness. Early screening and treatment prevent these adverse outcomes. • Smoking: Preterm birth, low birth weight, and other adverse perinatal outcomes associated with maternal smoking in pregnancy can be prevented if women stop smoking before or during early pregnancy. Because only 20% of women successfully control tobacco dependency during pregnancy, cessation of smoking is recommended before pregnancy.Nursing Interventions to prevent adverse pregnancy outcomesNursing Interventions ±Preconception education ±Nutrition education ±Lifestyle education ±Medication & Substance Use ±Reproductive life planNaegle's rule - estimate due dateNagele's Rule for Calculating the Estimated Due Date (EDD)1.Use the first day of the last normal menstrual period: 10/14/20 2.Add 7 to the number of days: 21 3.Subtract 3 from the number of months: 7/14/20 4.Adjust the year by adding 1 year: 7/21/21 5.Estimated due date (+ or − 2 weeks) = July 21, 2020.GravidThe state of being pregnantGravida/GravidityThe total number of times a woman has been pregnant, regardless of whether the pregnancy resulted in a termination or if multiple infants were born from a pregnancyNulligravidaA woman who has never experienced pregnancyMultiparaA woman who has had two or more pregnancies of at least 20 weeks' gestation resulting in viable offspring, commonly referred to as a "multip"PrimiparaA woman who has given birth once after a pregnancy of at least 20 weeks, commonly referred to as a "primip" in clinical practiceNuliparaA woman who has not produced a viable offspringParityRefers to the number of pregnancies, not the number of fetuses, carried to the point of viability, regardless of the outcomeParaThe number of times a woman has given birth to a fetus of at least 20 gestational weeks (viable or not), counting multiple births as one birth eventMultigravidaA woman pregnant for at least the third timeSecundigravidaA woman pregnant for the second timePrimigravidaA woman pregnant for the first timeGestational Age Pre-Term vs. EarlyPreterm: 20 weeks to 36 weeks 6 days Early term: 37 weeks to 38 weeks 6 days gestationPrenatal Care - Nursing Interventions±Urinalysis ±Blood pressure ±Weight ±Fundal height ±Fetal heartrate ±Fetal movement ±Emotional status First Visit: •Complete history •Reproductive history •Physical examRoutine Screening and Diagnostics - 1st Trimester• Urine or serum pregnancy test • CBC with differential • Blood Type & Rh factor • Rubella titer • Hepatitis B titer • Syphilis test (RPR or VDRL) • HIV test • Urinalysis and culture • Pap screening • Gonorrhea & chlamydia cultures • Nuchal translucency screening • Amniocentesis as needed • Emotional well-beingRoutine Screening and Diagnostics - 2nd TrimesterCBC 24-26 weeks gestation • 1-Hour glucose tolerance test • 3-Hour glucose tolerance test • MSAFP screen • Amniocentesis as needed • Emotional well-beingRoutine Screening and Diagnostics - 3rd TrimesterGroup B strep testing at approximately 36+ weeks of gestation • Screening and diagnostic ultrasound • Emotional well-being • Biophysical Profile • Non-stress Test • UltrasoundTreatment Rh PregnancyAgglutinogens: immune response if recognize a foreign body When antibodies are present in the plasma (one blood type) are recognized by antigens on RBC=reaction called agglutination (clumping) in the blood Development of maternal sensitization to Rh antigens. A, Fetal Rh-positive erythrocytes enter the maternal system. Maternal anti-Rh antibodies are formed. B, Anti-Rh antibodies cross the placenta and attack fetal erythrocytes.RhogamUsed to prevent an immune response to Rh positive blood in people with an Rh negative blood type Suppresses immune response in non-sensitized women with Rh-blood type who have been exposed to Rh+fetal blood cells Standard dose: 1 vial (300 mcg) IM in deltoid or gluteal muscle; microdose: 1 vial (50 mcg) IM in deltoid muscle; Rho(D) immune globulin (Rhophylac) can be given IM or IV (available in prefilled syringes).Assessment of Fetal WellbeingFetal Movement, Fetal Heartrate, Ultrasound, Alpha Fetoprotein, marker screenings, aminocentesis, chorionic villus samplingFetal Heart Rate Range110-160 bpmUltrasound Purpose•Early-crown rump •Heartbeat •Nuchal translucency 11 to 14 weeks •Doppler flow-blood flow in placenta and fetusAlphafetoprotein (AFP)Alpha-fetoproteinbiomarker screening, maternal serum 12 to 14 weeks (AFP) is a glycoprotein produced initially by the yolk sac and fetal gut, and later predominantly by the fetal liver. Increased levels neural tube defect, low downs syndromeMarker ScreeningsMarker Screenings (quad screening): using more than one test to determine risk, more specific if AFP is high or low chromosomal anomalies, neural tube defects, pregnancy complications-determines if further testing is neededchorionic villus sampling (CVS)embryonic sample, genetic disordersA biophysical profile (BPP)uses a real-time ultrasound and NST to allow assessment of various parameters of fetal well-being that are sensitive to hypoxia. Body movements: three or more discrete limb or trunk movements Fetal tone: one or more instances of full extension and flexion of a limb or trunk Fetal breathing: one or more fetal breathing movements of more than 30 seconds Amniotic fluid volume: one or more pockets of fluid measuring 2 cm NST: normal NST = 2 points; abnormal NST = 0 pointsDiscomforts of pregnancy1st Trimester: •Breast •Urinary •Fatigue •Nausea 2nd Trimester: •Heartburn •Constipation •Food craving •Round ligament 3rd Trimester: •Insomnia •Anxiety •Braxton hicks •Ankle edema •Shortness of breathProviders and Education throuhgout Pregnancy±Perinatal Care Provider-Delivery Setting ±Childbirth Education ±Birth Plan ±Doulas

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