Reproductive & Sexual Health (part 1)

REPRODUCTIVE AND SEXUAL HEALTH ALEJANDRO S. MENDOZA, R.N., M.D.

REPRODUCTIVE AND SEXUAL HEALTH Source: Maternal and Child Health Nursing by Pillitteri et al. NURSING PROCESS OVERVIEW The primary role of the nurse concerning reproductive anatomy and physiology is education.

I. ASSESSMENT: Sexual assessment is not a routine part of every health assessment. However it should be included when appropriate, such as when discussing: - adolescent development - before providing family information - during pregnancy - following childbirth

REPRODUCTIVE AND SEXUAL HEALTH II. NURSING DIAGNOSIS: Common nursing diagnoses used in regards to reproductive health are: • Health seeking behaviors related to reproductive functioning • Anxiety related to inability to conceive after 6 months w/out birth control • Pain related to uterine cramping from menstruation • Sexual dysfunction related to as yet to unknown cause • Anxiety related to fear of contracting sexually transmitted dses. II. OUTCOME IDENTIFICATION AND PLANNING: • A major part of nursing are in this area is to empower over their bodies. • It may also be important to plan interventions to person’s gender identity or role behavior. • It essential to design care that demonstrates all lifestyle equality.

clients to feel control strengthen a acceptance of

REPRODUCTIVE AND SEXUAL HEALTH III. IMPLEMENTATION: To help clients understand reproductive functioning and sexual health throughout their life, specific teaching might include: –Explaining to a young boy that nocturnal emission are normal –Teaching a woman what is normal and abn. in relation to menstrual function –Explaining reproductive physiology to the couple who wishes to become pregnant –Teaching adolescent safer sex practices

IV. OUTCOME EVALUATION: Examples of outcome criteria might be: –Clients state he is no longer fearful of contacting STD –Clients state she is better able to control symptoms of premenstrual syndrome –Couple state they have achieved a mutually satisfying relationship –Client states he is ready to tell family about homosexual gender identity

REPRODUCTIVE AND SEXUAL HEALTH REPRODUCTIVE DEVELOPMENT •Intrauterine Development

•Gonad- is a body organ that produces sex cell ( ovary for females male).

and testis for

•Week 5- primitive gonadal tissue is already formed. In both sexes undifferentiated ducts, the mesonephric (wolffian) and the paramesonephric (mullerian) ducts are present.

two

•Week 7 or 8- in chromosomal males, gonadal tissue testes and begins the formation of testosterone: mesonephric (wolffian) ducts - develop to male reproductive organ paramesonephric (mullerian) ducts - regresses

differentiated into primitive

REPRODUCTIVE AND SEXUAL HEALTH •Week 10- if no testosterone is present gonadal tissue into ovaries mesonephric (wolffian) ducts- regresses paramesonephric (mullerian) ducts- develop to female reproductive organs ( oocytes are formed). •Week 12: (+) testosterone -penile tissue elongates -Urogenital fold on the ventral surface of the penis closes to form the urethra -scrotal tissue (-) testosterone -Urogenital fold remains open to form labia minora -labia majora

differentiated

REPRODUCTIVE AND SEXUAL HEALTH PUBERTAL DEVELOPMENT: Puberty is the stage of life at which the secondary sex changes Girls- age 10 to13 years Theory: must reach a critical weight of approx. 95lbs (43kgs) Boys- age 12 to 14 years The role of Androgen- hormones responsible for : •Muscular development •Physical growth •Increase sebaceous gland secretion (acne) “Testosterone -1° androgenic hormone” In girls, testosterone influences the development of labia majora, clitoris, and axillary & pubic hair latter termed as (adrenarche)

REPRODUCTIVE AND SEXUAL HEALTH

Secondary sex characteristic of boys occurs in order: • increase in weight • growth of testes • growth of face, axillary, and pubic hair • voice changes • penile growth • increase in height • spermatogenesis Secondary sex characteristic of girls occurs in order: 1. growth spurt 2. increase in the traverse diameter of the pelvis 3. breast development (thelarche) 4. growth of pubic hair (adrenarche) 5. onset of menstruation (menarche 12.5 y/o ave.) 6. Ovulation occurs 1 – 2 years after menarche 7. growth of axillary hair (adrenarche) 8. vaginal secretion

FEMALE REPRODUCTIVE SYSTEM

THE CHILDBEARING CYCLE It is also known as the bag of water, it serves the ff purpose: •protects the fetus against blows or pressure on the mothers abdomen •protects the fetus against the sudden changes in To since liquid changes To more slowly than air. •protects the fetus from infection •provides free movement for the fetus DIAGNOSTIC FUNCTION: •AMNIOCENTESIS – removal of amniotic fluid to chromosomal abnormalities. •Meconium-stained amniotic fluid in non-breech sign of fetal distress.

diagnose presentation is a

THE CHILDBEARING CYCLE 2. Chorion -together with the deciduas basalis, gives rise to the placenta which starts to form at 8 weeks gestation. Before this time corpus luteum which produces the hormones necessary to maintain pregnancy.

Placenta serves the ff purpose. •Respiratory system (lungs) •Renal system (kidneys) •Gastrointestinal system (stomach and intestine) •Circulatory system •Endocrine system

THE CHILDBEARING CYCLE ENDOCRINE •Human Chorionic Gonadotropin (HCG) - orders the corpus luteum to keep on producing estrogen and progesterone, a. That is why there is amenorrhea during pregnancy. b. It is also the basis for pregnancy tests. •Human Placenta Lactogen -promotes the growth of the mammary glands necessary

for lactation.

•Estrogen and Progesterone •3 subtypes of Estrogen:

•Estrone(E1)- post menopausal women •Estradiol(E2)- non-pregnant •Estriol(E3)- pregnancy

The Childbearing Cycle Conception The penetration of one ovum (female gamete) by one sperm (male gamete) resulting in a fertilized ovum (zygote). Each gamete has haploid number (23). Zygote has a diploid number(46) with one of each pair from each parent. • •

Sex of child is determined at moment of conception by male gamete. If X-bearing male gamete unites with ovum, result is a female child (X + X). If Y- bearing male gamete unites with ovum, result is a male child (X + Y).

• Multiple pregnancies result from two or more fertilized ovum (fraternal or dizygotic) • Single fertilized ovum that divides- always same sex, only 1 chorion (identical or monozygotic)

Fetal Growth and Development: Measurements of length of pregnancy: •Days: 267-280

•Weeks:40, plus or minus 2 •Months (lunar):10 •Months (calendar):9 •Trimesters:3 •Estimated Due Date/Estimated Date of Confinement (Nagele’s rule); This calculation is an estimation only. Most women deliver: due date + or – 2 week. a. Add 7 days to the first day of the LMP b. Subtract 3 months. c. Add 1 year Example: 1st day of LMP= September 16, 1998 Add 7 days= September 23 Subtract 3 months= June 23

Add 1 year= June 23, 1999, will be EDD/EDC. •Sonogram dating used to confirm dates.

Fetal Growth and Development: Measurements of length of pregnancy: •Estimated Due Date/Estimated Date of Confinement –MCDONALD’S METHOD – Determines AOG in months by measuring from the fundus to the symphysis pubis (in cm) then divide by four. –BATHOLOMEW’S RULE – Estimate AOG by the relative position of the uterus in the abdominal cavity. •3rd mo: Fundus is slightly above symphysis pubis •5th mo: Fundus is at level of umbilicus •9th mo: below the process •8th mo and 10th mos: same level because of lightening

THE CHILDBEARING CYCLE Terms Used Denote Fetal Growth: NAME TIME PERIOD Ovum fr. ovulation – fertilization Zygote fr. fertilization – implantation Embryo fr. implantation to 5-8 wks Fetus fr. 5-8 wks – term Conceptus Developing embryo or fetus and placental structures the pregnancy

STAGES OF PRENATAL DEVELOPMENT: •Pre-embryonic stage – first 14 days after conception. -this stage is characterized by rapid growth and differentiation and establishment of embryonic germ layers and membranes.

THE CHILDBEARING CYCLE B. Embryonic stage –fr. 15 days to 8 wks after conception

-is the period of differentiation of tissues into organs. 3 primary germ layers of the embryo: 1. Endoderm – lining of the GIT, respiratory tract, tonsils, thyroids, bladder and urethra 2. Mesoderm – (bones, dentin of teeth, connective tissue, cartilage, muscles and tendons), circulatory system, reproductive system, kidneys and ureters. 3. Ectoderm –nervous system, skin, tooth enamel, hair, nails, mucus membrane of mouth and anus. C. Fetal stage – from 5- 8 weeks to birth – every structure is present that will be found in the full term neonate.

Fetal Growth and Development: FOCUS OF DEVELOPMENT 1.First trimester- Organogenesis 2.Second Trimester – period of continued fetal growth and development 3.third trimester – period of most rapid growth and development because of rapid deposition of subcutaneous fats. Markers in Fetal development Date Development 4 weeks -germ membranes appear by the 2nd week -fetal membranes appear by the 2nd week -nervous system appears by the 3rd week (dizziness is said to be the earliest sign of pregnancy because of the depletion of the mothers glucose which the embryo needs for the proper brain development. Hypoglycemia therefore is the cause of dizziness) -All systems in rudimentary form; heart chambers formed and heart is beating. -Embryo length =0.4 cm; weight = 0.4g.

Fetal Growth and Development: Markers in Fetal development Date Development 8 weeks -Same distinct features in face; head large in proportion to rest of body; some movement length =2.5 cm, weight =2 g. -all vital organs are formed by the 8th week (organogenesis) -placenta develops -sex organs (ovaries/testes) are formed by the 8th week -meconeum is formed by 5th to 8th wk -visible on ultrasound 12 weeks -Sex distinguishable; ossification in most bones; kidneys secrete urine; able to suck and swallow Length=6-8cm, weight =19g.

Fetal Growth and Development: Markers in Fetal development Date Development 16 weeks -More human appearance; earliest movement likely to be felt by mother; meconium in bowel; scalp hair develops. Lt.= 11.513.5 cm., weight 55 to 120 gms -lanugo (fine downy hair on the body) appears buds of permanent teeth form -heart beats audible with fetoscope -rapid skeletal development visible on x-ray -Sex differentiation is completed

Fetal Growth and Development: Markers in Fetal development continue Date

Development

20 weeks Vernix caseosa and lanugo appear; movement usually felt by mother Quickening occurs; heart rate audible;bones hardening. Vernix caseosa appears Lt=16-18.5 cm.,wt300 g Lanugo covers entire body 24 weeks Body well proportioned; skin red and wrinkled; hearing established. Lt=23 cm., wt= 600 g. 28 weeks Infant viable, but immature if born at this time. Body less wrinkled; appearance of nails. Lt= 27 cm., wt= 1100g 32 weeks Subcutaneous fat begin to deposit; L/S ratio in lungs now 1.2 : 1 . Skin smooth and pink. Lt= 31 cm., wt =1800-2100 g. 36 weeks Lanugo disappearing; body usually plump; L/S ratio usually 2:1; definite sleep/wake cycle. Lt= 35 cm., wt= 2200-2900 g 40 weeks Full-term pregnancy; Baby is active, with good muscle tone; strong suck reflex; if male testes in scrotum; little lanugo. Length >40 cm., weight= 3200g or more

Fetal Growth and Development: FETAL CIRCULATION The oxygen is delivered from the placenta. The placenta is also

- the source of nutrition and - the site of waste excretion. Temporary Structures involved in fetal circulation: •Placenta •Umbilical cord •Ductus venosus – (vein to a vein) connects the umbilical vein to the inferior vena cava. Allows the oxygenated blood from the placenta to bypass the liver. •Foramen ovale – temporary opening between atria that allows the majority of blood entering form the IVC to pass across in to the left atrium. •Ductus arteriosus (artery to an artery) – channel between fetal aorta and main pulmonary artery. It closes during normal respiration. Allows the blood to bypass the fetal lungs. •Hypogastric arteries – They return the blood to the placenta.

THE CHILDBEARING CYCLE Fetal Circulation •Arteries in cord and fetal body carry deoxygenated blood. •Vein in cord and those in fetal body carry oxygenated blood •Ductus venosus connects umbilical vein and inferior vena cava; bypassing portal circulation; closes after birth •Foramen ovale allows blood to flow from right atrium to left atrium, bypassing lungs. Closes functionally at birth because of increased pressure in left atrium; anatomic closure may take several weeks to several months. •Ductus arteriosus allows blood flow from pulmonary artery to aorta, by passing fetal lungs; closes after delivery.

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY Reproductive System A. External structures: enlarged due to increased vascularity B. Ovaries: 1. No ovulation during pregnancy 2. Corpus Luteum persists in early pregnancy until development of placenta is complete. C. Fallopian tubes: elongate as uterus rises in pelvic and abdominal cavities.

D. Vagina –Increased vascularity (Chadwick’s sign) –Estrogen-induced leukorrhea –Change in pH (less acidic) may favor overgrowth of yeast like organisms –Connective tissue loosens in preparation for distention of labor and delivery.

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY Reproductive System continue…

E. Cervix –Softens and loosens in preparation for labor and delivery (Goodell’s sign). –Mucous production increases and plug (Operculum) is formed as bacterial barricade. F. Uterus –Hypertrophy and hyperplasia of muscle cells. –Development of fibroelastic tissue that increases ability to contract –Shape changes from pearlike to ovoid –Rises out of pelvic cavity by 16th week of pregnancy –Increased vascularity and softening of isthmus (Hegar’s sign) –Mild contractions (Braxton Hick’s sign) beginning in the fourth month through end of pregnancy.

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY Reproductive System continue… G. Breasts –Increased vascularity; sensitivity and fullness –Nipples and areola darkens –Nipples becomes more erectile –Proliferation of ducts and alveolar tissue evidenced by increased breast size. –Production of colostrums by the second trimester

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY Cardiovascular System

–Blood volume expands as much as 50% to meet demands of new tissue and increased needs of all systems. –Progesterone relaxes smooth muscle, resulting in vasodilatation and accommodation of increased volume. –RBC volume increases as much as 30%; may be slight decline in hematocrit as pregnancy progresses because of this relative imbalance (physiologic anemia). –Stroke volume and cardiac output increase. –WBC’s increased. –Greater tendency to coagulation. –Blood pressure may drop in early pregnancy; should not rise during last half of pregnancy. –Heart rate increases; palpitation possible –Blood flow to uterus and placenta is maximized by side-lying position. –Varicosities may occur in vulva and rectum as well as lower extremities.

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY Respiratory System –Increased vascularity of mucous membranes of this system gives rise to symptoms of nasal and pharyngeal congestion and fullness in the ears.

–Shape of thorax shortens and widens to accommodate the growing fetus –Slight increase in respiratory rate –Dyspnea may occur at end of third trimester before engagement or “lightening” –Increased respiratory volume by 40 to 50 %. –Oxygen consumption increases by 15%.

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY Renal System –Kidney filtration rate increases as much as 50%. –Glucose threshold drops; sodium threshold rises. –Water retention increases as pregnancy progresses. –Enlarging uterus causes pressure on bladder resulting in frequency of urination, especially during first trimester; later in pregnancy relaxed ureters are displaced laterally, increasing possibility of stasis and infection. –Presence of protein (not an expected component of maternal urine) indicates possible renal disease or pregnancy-induced hypertension.

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY Intergumentary System : –Increased pigmentation of nipples and areolas. –Possible appearance of chloasma (mask of pregnancy); darkening of the areas on forehead and cheekbones –Appearance of linea nigra, darkened line bisecting abdomen from symphysis pubis to top of fundus. –Striae (stretch marks): separation of underlying connective tissue in breasts, abdomen, thighs and buttocks; fade after delivery. –Greater sweat and sebaceous gland activity.

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY Musculoskeletal System: –Alterations in posture and walking gait caused by change in center of gravity as pregnancy progresses.

–Increased joint mobility as a result of action of ovarian hormone (relaxin) on connective tissue. –Possible headache –Occasional cramps in calf may occur with hypocalcemia.

Neurologic System –Few changes with a typical pregnancy –Pressure on sciatic nerve may occur later in pregnancy due to fetal position.

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY Gastrointestinal System –Bleeding gums and hypersalivation may occur. –Tooth loss due to demineralization should not occur. –Nausea and vomiting in 1st trimester due to rising levels of HCG. –Appetites usually improves. –Cravings/desires for strange food combinations may occur. –Progesterone-induced relaxation of muscle tones leads to slow movement of food through GI tract; may result in heat burn –Constipation may occur as water is reabsorbed in large intestine. –Emptying time for gallbladder may be prolonged; increased incidence of gallstones.

PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY

Endocrine System

–Pituitary: FSH and LH greatly decreased; oxytocin secreted during labor and after delivery; prolactin responsible for initiation and continuation of lactation. –Progesterone secreted by corpus luteum until formation of placenta. –Principal source of estrogen is placenta synthesized from fetal precursor. –HPL produced by placenta; similar to growth hormone, it prepares breasts for lactation: also affects insulin/ glucose metabolism; may overstress maternal pancreas –Ovaries secrete Relaxin during pregnancy –Slight increase in thyroid activity and basal metabolic rate (BMR). –Pancreas may be stressed due to complete interaction of glucose metabolism, HPL and cortisol, resulting in diminished effectiveness of insulin and demand for increased production.

PSYCHOLOGIC CHANGES OF PREGNANCY Psychosocial changes: A. First trimester

–Mother needs accurate diagnosis of pregnancy –Works through characteristic ambivalence of early pregnancy –Mother is self-centered, baby is part of her –Grandparents are usually the first relatives to told of the pregnancy.

B. Second trimester

–Mother demonstrates growing realization of baby as separate and needing person. –Fantasizes about unborn child.

C. Third trimester –“Nesting” activity appears as due date approaches –Desire to be finished with pregnancy. –Anxiety over “safe passage” for self and baby through labor and delivery. –Reactions of father-to-be may parallel those of mother (e.g ambivalence, anxiety). “COUVAGE SYNDROME” 5. Preparation of siblings varies according to their age and experience.

THE ANTEPARTAL PERIOD ASSESSMENT Classification of Pregnancy: I. Gravida- number of time pregnant, regardless of duration, including the present pregnancy. –Primagravida-pregnant for the first time –Multigravida- pregnant for second or subsequent time II. Para-number of pregnancies that lasted more than 20 weeks, regardless of outcome –Nullipara—a woman who has not given birth to a baby beyond 20 weeks gestation –Primipara—a woman who has given birth to one baby more than 20 weeks gestation. –Multipara—woman who has had two or more births at more than 20 weeks gestation… twins or triplets count as 1 para. –TPAL—para subdivided : Term, Premature births, Abortions, and Living children

THE ANTEPARTAL PERIOD ASSESSMENT

Determination of Pregnancy Diagnosis of pregnancy is based on pregnancy-related physical and hormonal changes and are classified as presumptive, probable or positive A. Presumptive Signs and Symptoms (Subjective) These changes may be noticed by the mother/health care provider but are not conclusive for pregnancy. –Amenorrhea (cessation of menstruation) –Nausea and vomiting –Urinary frequency –Fatigue –Breast changes –Weight change –Skin changes –Vaginal changes including leukorrhea –Quickening

THE ANTEPARTAL PERIOD ASSESSMENT Determination of Pregnancy

B. Probable Signs and Symptoms (Objective) These changes are usually noted by the health care provider but are still not conclusive for pregnancy. –Uterine enlargement –Changes in the uterus and cervix from increase vascularity –Ballottement: fetus rebounds against the examiner’s hand when pushed gently upwards. –Braxton Hick’s contractions: occurs early in pregnancy, although not usually sensed by the mother until the third trimester –Laboratory test for pregnancy –Most tests rely on the presence of HCG in the blood or urine of the woman –Easy, inexpensive, but may give false readings with any handling error, medications or detergent residue in laboratory equipment.

THE ANTEPARTAL PERIOD ASSESSMENT Determination of Pregnancy B. Probable Signs and Symptoms (Objective) continue: 8. Exception is the radioimmunoassay (RIA) which tests for the beta subunit of HCG and is considered to be so accurate as to be diagnostic for pregnancy 9. Changes in skin pigmentation. C. Positive Signs and Symptoms: These signs emanate from the fetus; are noted by the health care provider; and are conclusive for pregnancy –Fetal heartbeat: detected as early as eighth week with an electronic device; after 16th week with more conventional auscultatory device. –Palpitation of fetal outline –Palpitation of fetal movements –Demonstration of fetal outline by either ultrasound (after sixth week) or xray (after 12th week).

THE ANTEPARTAL PERIOD ANALYSIS

–Nursing diagnoses for the antepartal period may include: –Knowledge deficit: information on the following topics needs to be given and reinforced –Alteration in nutrition potential: individualized nutritional information will be needed –Activity intolerance: need for additional rest and benefits of a moderate exercise program –Anxiety –Constipation, potential –Body image disturbance –Alteration in comfort –Individual coping, ineffective –Powerlessness

–Noncompliance –High risk for fluid volume deficit –Health-seeking behaviors

THE ANTEPARTAL PERIOD

PLANNING AND IMPLEMENTATION Goals –Establish a diagnosis of pregnancy –Gather initial data to form the basis for comparison with data collected as pregnancy progresses. –Identify high risk factors. –Propose realistic and necessary intervention. –Promote optimal health for mother and baby, providing any needed information –Provide needed information for prepared childbirth

Interventions Prenatal care A. Time frame –First visit: may be made as soon as woman suspects she is pregnant; frequently after first missed period. –Subsequent visit: Every mon. until the 8th mon., qo 2 wks during the 8th mon and wkly during the 9th mon more frequent visits are scheduled if problem arise

THE ANTEPARTAL PERIOD Interventions Prenatal care continue: B. Conduct of initial visit 1. Extensive collection of data about client in all pertinent areas in order to form basis for comparison with data collected on subsequent visits and to screen for any high-risk factors. a. Menstrual history: menarche, regularity, frequency and duration of flow, last period. b. Obstetrical history: all pregnancy, outcome, complications, contraceptive use, sexual history. c. Medical history: include past illnesses, surgeries; current use of medication d. Family history/ psychosocial data e. Information about the father-to-be may also be significant f. Current concerns.

THE ANTEPARTAL PERIOD Interventions Prenatal care continue: B. Conduct of initial visit 2. Complete physical examination, including internal gynecologic exam and bimanual exam

3. Laboratory work, including CBC, urinalysis, pap test, blood type and Rh, rubella titer, testing for sexually transmitted diseases (STD), other test as indicated (e.g. TB test, hepatitis viral studies, EKG, etc

THE ANTEPARTAL PERIOD Interventions Prenatal care continue: C. Conduct of subsequent visit 1. Continue collection of data, especially weight, blood pressure, urine screening for glucose and protein, evaluation of fetal development through auscultation of fetal heart rate (FHR) and palpitation of fetal outline, measurement of fundal height as correlation for appropriate progress of pregnancy. 2. Prepare for necessary testing. a. Have client void (clean catch) b. Collect baseline data on vital signs c. Collect specimen d. Monitor client and fetus after procedure e. Provide support to client f. Document as needed

THE ANTEPARTAL PERIOD Interventions

Nutrition during Pregnancy A. Weight gain –Variable, but 25 lb usually appropriate for average woman with single pregnancy –Woman should have consistent, with only 2-3 lb in first trimester, then average 12 oz gain every week in second and third trimesters. –Gain mostly reflect maternal tissue in second half of pregnancy B. Specific nutrient needs –Calories: + 300 kcal/day. Never < 1800 kcal/day. –Protein: + 30g/day to ensure intake of 74-76g/day –Carbohydrates: –Fats: –Iron: –Calcium: 1200mg/day –Sodium: –Vitamins:

THE ANTEPARTAL PERIOD Interventions Nutrition during Pregnancy C. Dietary supplements: many health care providers supplement the pregnant woman’s diet with an iron-fortified multivitamins to ensure essential levels

D. Special concerns –religious, ethics, and cultural practices that influence selection and preparation of foods –Pica (ingestion of non-edible or nonnutritive substances) –Vegan vegetarians- no meat products, may need B12 supplement –Adolescence –Economic deprivation –Heavy smoking, alcohol consumption, drugs –Previous reproductive problems

THE ANTEPARTAL PERIOD Interventions Education for Parenthood –Provision of information about pregnancy, labor and delivery, the postpartum period, and lactation –Usually taught in small groups, may be individualized. –Topics can be grouped into early and late pregnancy, labor an delivery, and post delivery/newborn care. –Emphasis placed on both physical and psychosocial changes seen in childbearing cycle. –Preparation for childbirth: intended to provide knowledge and alternative coping behaviors in order to diminish anxiety and discomfort, and promote cooperation with the birth process,

THE ANTEPARTAL PERIOD Interventions

Determination of Fetal Status and Risk Factors A. Fetal diagnostic tests 1. Used to •Identify or confirm the existence of risk factor's •Validate pregnancy •Observe progress of pregnancy •Identify optimum time for induction of labor if indicated •Identify genetic abnormalities 2. Types •Chorionic vili sampling (CVS): earliest test possible on fetal cells; sample obtained by slender catheter passed through cervix to implantation site.

THE ANTEPARTAL PERIOD Interventions Determination of Fetal Status and Risk Factors A. Fetal diagnostic tests

2. Types continue… •Ultrasound: use of sound and returning echo patterns to identify intrabody structures. Useful early in pregnancy to identify gestational sac(s); later uses include assessment of fetal viability, growth patterns, anomalies and adnexal masses. Used as an adjunct to amniocentesis; safe for fetus (no ionizing radiation). •Amniocentesis: location and aspiration of amniotic fluid for examination; possible after the 14th week when sufficient amount is present. Used to identify chromosomal aberrations, sex of fetus, levels of alpha-fetoprotein and other chemicals indicative of neural tube defects and inborn errors of metabolism, gestational age, Rh factor.

THE ANTEPARTAL PERIOD Interventions Determination of Fetal Status and Risk Factors A. Fetal diagnostic tests 2. Types continue: •X-ray: can be used late in pregnancy (after ossification of fetal bones) to confirm position and presentation; not used in early pregnancy to avoid possibility of causing damage to fetus and mother. •Alpha-fetoprotein Screening: Maternal serum screens for open neural tube defects. Alpha-fetoprotein is glucoprotein produced by fetal yolk sac, GI tract, and liver. Test done between 16 and 18 weeks gestation •Creatinine level: estimates fetal renal maturity and function, uses amniotic fluid •Bilirubin level: high early in pregnancy; drops after 36 weeks gestation; uses amniotic fluid.

THE ANTEPARTAL PERIOD Interventions Determination of Fetal Status and Risk Factors A. Fetal diagnostic tests 2. Types continue: •L/S ratio: uses amniotic fluid to ascertain fetal lung –lung surfactants lecithin and sphingomyelin.

maturity

–At 35-36 weeks , ratio is 2:1, indicative of mature levels; once ratio of 2:1 is achieved, newborn less likely to develop respiratory distress syndrome. –Phosphatidylglycerol (PG) is found in amniotic fluid after 35 weeks.

•Fetal movement count: teach mother to count 2-3 times daily, 30-60 minutes each time, should feel 5-6 movements per counting time. Mother should notify care giver immediately of abrupt change or no movement

THE ANTEPARTAL PERIOD Interventions

Determination of Fetal Status and Risk Factors A. Fetal diagnostic tests 2. Types continue: •PUBS (Percutaneous Umbilical Blood Sampling): Uses ultrasound to locate umbilical cord. Cord blood aspirated and tested. Used in second and third trimesters. •Biophysical exams: a collection of data on fetal breathing movements; body movements, muscle tone, reactive heart rate, and amniotic fluid volume. A score of 0-2 is given in each category and the summative number interpreted by the physician. Primary suggested use to identify fetuses at risk for asphyxia.

THE ANTEPARTAL PERIOD Interventions Determination of Fetal Status and Risk Factors B. Electronic Monitoring 1. Nonstress test (NST) a. Accelerations in heart rate accompany normal fetal movement b. In high risk pregnancies, NST may be used to assessed FHR on a frequent basis in order to ascertain fetal well-being. c. Non-invasive

THE ANTEPARTAL PERIOD Determination of Fetal Status and Risk Factors B. Electronic Monitoring 1. Nonstress test (NST)

THE ANTEPARTAL PERIOD Interventions Determination of Fetal Status and Risk Factors B. Electronic Monitoring 2. Contraction stress test A. Based on a principle that healthy fetus can withstand decreased O2 during contraction, but compromised fetus cannot. B. Types:

•Nipple stimulated CST: massage or rolling of one or both nipples to stimulate uterine activity and check effect on FHR •Oxytocin challenge test (OCT): infusion of calibrated dose of IV oxytocin “piggy Backed” to main IV line; controlled by infusion pump; amount infused increased every 15-20 minutes until three good uterine contractions are observed within 10-minute period. •CST never done unless willing to deliver fetus

2. Contraction stress test (CST)

THE ANTEPARTAL PERIOD Interventions Methods of Childbirth Read method The so-called “natural” childbirth method. Underlying concept: knowledge diminishes the fear that is key to pain. Classes include information as well as practice in relaxation and abdominal breathing techniques for labor.

Lamaze method Psychoprophylactic method based on utilization of Pavlovian conditioned respond theory. Classes teach replacement of usual response to pain with new, learned responses (breathing, effleurage. Relaxation) in order to block recognition of pain and promote positive sense of control in labor Bradley method Husband-coached childbirth. A modification of the Read method emphasizing working in harmony with the body.

THE ANTEPARTAL PERIOD EVALUATION: •Maternal /fetal assessment data remain within acceptable limits: fetus maintains growth and development pattern appropriate to gestational age (evidenced by maternal weight gain, normal increments in fundal heights, fetal activity level, other antepartal tests). •No complications of pregnancy are evident. •Pregnant woman receives prenatal care (initial and subsequent visits) •Maternal blood pressure, weight gain and other lab tests findings are within normal range. •Pregnant woman/family have received adequate educational instruction. •Pregnant woman/family express understanding of childbirth experience and begin transition to role of parenting. •Any necessary testing procedures carried out completely and correctly; client/ fetus in stable condition.