Fetal Development

FETAL DEVELOPMENT
Presentation by:Peggy Pannell RN, MSN

Learning Goals
* Normal Fetal Development
o From ovulation to birth
* Teratogen
o Definition and potential effects on development
Vocabulary
* Blastocyst
* Conception
* Ductus arteriosus
* Embryo
* Fertilization
* Fetus
* Foramen Ovale
* HCG
* Implantation
* L/S ration
* Gestational age
* Vernix
* Zygote
* Placenta
* Quickening
* Surfactant
* Teratogens
* Umbilical Cord

FERTILIZATION
* Begins with 46 pair of chromosomes, splits off to 23 then combine for a unique new 46 pair.

Stages and Time Frames
* Ovum
* Zygote
* Morula
* Blastocyst
* Embryo
* Fetus

IMPLANTATION
First weeks of human development:
Blastocyst embedded in endometrium.

PRIMARY GERM LAYERS
* Ectoderm
* Mesoderm
* Endoderm

GESTATIONAL AGE
* Gestational age=Time since last menstrual period (LMP)
* EDC, EDD, EDB
* 266 Days after fertilization
* 280 Days after onset of LMP

Nagele’s Rule
Trimester
1st = week’s 1-13
2nd = week’s 14 - 26
3rd = week’s 27 and on (38-40 WEEKS)

STAGES OF DEVELOPMENT
FETAL MEMBRANES
* Amnion
* Chorion

Decidua capsularis
Decidua basalis
Developing placenta
Yolk sac
Amniotic cavity
Intrauterine cavity
Decidua vera
Mucus plug (operculum)
Chorion (blends with placenta)
Amnion (blends with umbilical cord)

Umbilical cord (funis)
Lacunae in decidua basalis filled with maternal blood
Intrauterine cavity
Decidua capsularis
Decidua vera

1 Month
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
Third Trimester
At the end of 9 months:
* Baby is 19 to 20 inches long
* Weight is about 7 to 7 1/2 pounds
* The lungs are mature
* Baby is now fully developed and can survive outside the mother's body
* Skin is pink and smooth
* Baby settles down lower in the abdomen in preparation for birth and may seem less active

AMNIOTIC FLUID
* Clear, yellowish fluid surrounding the developing fetus.
* Average amount 1000 ml.
* Having < 300ml – Oligohydramnios, associated with fetal renal abnormalities.
* Having > 2 L – Hydramnios, associated with GI and other malformations.
* Protects Fetus
* Controls Temperature
* Supports Symmetrical Growth
* Prevents Adherence to amnion
* Allows Movement
* Source of oral fluid
* Acts as a excretion-collection repository

UMBILICAL CORD
Connecting link between fetus and placenta.
* Transports oxygen and nutrients to fetus from the placenta and returns waste products from the fetus to the placenta.
* Contains: 2 arteries and 1 vein supported by mucoid material (wharton’s jelly) to prevent kinking and knotting.
* Contains NO pain receptors.

PLACENTA
MOM
Baby
Produce protein hormones:
* Human chorionic gonadotrophin (HCG)- 8-10 days past conception, is basis for pregnancy test
* Progesterone
* Estrogen
* Human Placental Lactogen
* Sieve/filter – allows smaller particles through and holds back larger molecules. Passage of materials in either direction is effected by:
o Diffusion: gases, water, electrolytes
o Facilitated transfer: glucose, amino acids, minerals.
o Pinocytosis: movement of minute particle
* Mother transmits immunoglobulin G (IgG) to fetus providing limited passive immunity.
* Leakage: caused by membrane defect: may allow maternal and fetal blood mixing.

VIABILITY
RESPIRATORY SYSTEM
CARDIOVASCULAR SYSTEM
FETAL CIRCULATION
* HEPATIC SYSTEM
* MUSCULO-SKELETAL SYSTEM
GASTROINTESTINAL SYSTEM
RENAL SYSTEM
NEUROLOGICAL SYSTEM
ENDOCRINE SYSTEM
INTEGUMENTARY SYSTEM
IMMUNE SYSTEM
MULTIFETAL PREGNANCY
Teratogens
STAGES OF DEVELOPMENT

FETAL DEVELOPMENT.ppt

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Nursing Management During Pregnancy

Nursing Management During Pregnancy
presentation from:Los Angeles Valley College

Preconceptual Counseling
* Why is it important?
* Medical- past or current problems
* Sexual- STI
* Reproductive-AB or losses
* Psychosocial-support system
* Counseling- Folic acid, iron, wgt. SA, violence diseases, genetics

Taking History
* Current pregnancy- any problems
* Past pregnancy-problems, type of delivery,newborn info
* Current/past medical hx
* Family-Religion-Culture
* Age-old vs. young
* Identify high risk problems early

Vocabulary
* Nagle’s rule minus three months + 7days
* Ab- before 20 weeks
* Nullipara- no births before 20 weeks
* Primpara -one birth after 20 weeks
* Gravida- pregnancy regardless of duration
* P- after 20 weeks before 37 wks
* Living- number of living children

Head to Toe
* Head and Neck- Evaluate thyroid, dental
* Chest- HR, murmur, SOB, breast exam
* Abdomen- check fundal hgt
* Extremities- varicosities, edema, calfs
* Pelvic exam-Lesions, discharge, hematomas
* Pelvimetry- gynecoid, assess for adequate pelvis
* Labs- CBC, Rh, Rubella, Hepatitis, HIV, VDRL,RPR

Prenatal Care Visits
Fetal Movement
* Used to determine fetal well being
* Cardiff- lie or sit, count 10 fetal movements
* Call healthcare provider if more than 1 hour
* Sadovsky- lie on left after eating.
* Should feel 4 movements in 1 hr
* Count movements second hr.
* Call HCP if criteria not met


Assessment of Fetal Well Being
* UTZ- Low risk assessment tool
* Doppler Flow-Eval for absent or reversed diastolic flow
* AFP-16-18wks Eval for NTD or Down’s
* Marker Screening test- AFP ,unconjugated estriol, hCG and Inhibin A- more accurate
* Amniocentisis—chromosomes and metabolic defect



Assessment of Fetal Well Being
* Nsg-Consent, risk of AB, empty bladder
* Assess for FHT and UC- Rhogam?
* Give labor precautions
* CVS-Tissue sample- Get results sooner
* Nsg- same as amniocentisis
* PUBS- blood collected from fetus
* High Risk- Monitor fetus
* NSG-FKC- S/S of infection, cramping

Assessment of Fetal Well Being
* NST- Fetal Movement = Fetal Well Being
* Reactivity= 2 accelerations above baseline lasting 15 seconds within 20 minutes
* Nsg- Apply monitors, give marker, displace uterus to left lateral
* Need for NST determined by risk factors
* CST- Ability of fetus to tolerate stress and fetal reserve
* Decrease in oxygenation with uc’s
* Initiate 3 ucs in 10 minutes
* Eval. FHR for variations
* Negative results are GOOD
* Positive - 50% of ucs = late decelerations

Biophysical Profile
Promotion of Self-Care

* Treat holistically-promote well being
* Personal Hygiene/Dental Hygiene
* Breast Care- Sears or J.C. Penny
* Clothing- loose comfortable
* Balance exercise with rest
* Pelvic Tilt and Kagel’s
* Sleep- use pillows- limit fluids
* Sexual activity- encourage intimacy
* Employment- evaluate risk factors
* Travel- move q 2 hrs
* Immunizations- no live vaccines
* OTC meds- should consult HCP

Classifications of Drugs
* A- controlled studies- no fetal risks
* B- use frequently- r/t little harm
* C- likely to cause harm risk vs. benefits
* D- fetal risk benefits outweigh risk
* X risks outweigh benefits

Promotion of Self Care
* Urinary frequency-need 2000 cc/day. Limit 2-3 hrs before bed
* Fatigue- feel best 2nd trimester
* N/V- Avoid foods and smell. Crackers, sit up, rise slowly- S/S of dehydration
* Constipation- increase fiber-Do not strain
* Nasal- epitaxis-use air vaporizer
* Cravings- Weight? Avoid sodium/sugar

Promotion of Self Care Second Trimester
* Backache- Good body mechanics
* Leg cramps-increase calcium/magnesium
* Ankle edema- common- legs above heart
* Hemorrhoids- avoid straining
* Constipation- bulk in diet- prune juice
* Flatulence- avoid carbonation, cheese

Promotion of Self Care Third Trimester
* SOB-pressure on diaphragm, sit up, avoid large meals- Lightening
* Constipation- hydration- fruits and vegetables
* Heartburn- sit up, avoid large meals
* Ankle edema- eval for PIH
* Braxton Hicks- Cervix preparing for labor

Diet

* 30 mg ferrous sulphate/600mcg of folic acid
* Normal weight gain 25-35 pounds
* Alterations in weight- thin vs. obese
* Culture variations
* Special Diets- Lactose Intolerant- Vegans
* Use Dieticians
* Evaluate for Pica

Perinatal Education
* Knowledge = Better Birth Experience
* Lamaze- psychophrophylactic- Breathing controls pain
* Bradley-Enjoy process of childbirth-no pain medications
* Dick Read- Break cycle of Fear-Tension-Pain

Birth Options
* Hospital Based Care-Birthing Suites – Family Centered Care
* Birthing Center- No Rush- Midwife
* Home Birth- Must be low risk
* Choosing a health care provider
* Doula- Continuous support during labor and birth

Breast vs. Bottle
* Breast is best
* Bonding
* Less infection
* Promotes involution
* Less allergies
* Less obesity
* More digestible
* Bottle
* Need more to get same nutrition
* Expensive
* Less digestible
* No microwave
* Do not prop bottle
* Father can feed

Danger Signs of Pregnancy
Class activities
GTPAL
Maslow
Diet

Nursing Management During Pregnancy.ppt

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Antepartum Fetal Testing

Antepartum Fetal Testing: Examining the Evidence
Presentation lecture by:Jay J Bringman, MD
University of Tennessee Health Sciences Center, Memphis

Objectives
* Understand physiology behind antepartum fetal testing
* Review evidence for antepartum fetal testing
* Indications for testing
* Review what test to use
* What to do with an abnormal test
* When to start and the frequency in which to test

Cerebral Palsy
* Case-control study of term infants weighing >2500g in Australia
* Case: neonate with diagnosed moderate or severe neonatal encephalopathy in first week of life
* Control: term neonate without diagnosis of neonatal encephalopathy
* Evaluated role of preconceptional, antepartum and intrapartum factors in neonatal encephalopathy
* Strongest antepartum risk factor for NE is IUGR; OR 38.2 (9.4-154.8)
* Other risk factors:

Physiologic basis for antenatal testing
* Fetal testing designed to assess for fetal hypoxia

Non-stress test physiology
* Afferent signals:
* When stimulated, send afferent impulses to brain to increase FHR
* Efferent signals increase FHR
* If movement and accelerations observed, reasonable to conclude the afferent and efferent limbs intact and cardioregulatory neurons adequately oxygenated

NST: How to do it
* Patient in lateral tilt position
* Tracing observed for 40 minutes
* Accelerations peak (but do not necessarily remain) at least 15 BPM above baseline
* Last for 15 seconds
* Reactive: 2 or more accelerations within 20 m period
* Nonreactive: one that lacks sufficient accelerations over 40 minute period
* No contraindications

The preterm fetus
* Frequently nonreactive
Evidence for use of NST
Randomized trials
Caveats
NST versus VAS
NST and nonrandomized data
Caveat for observational data
Contraction stress test
CST interpretation
Biophysical profile
What score tells you…

* Normal acute variables and AFI
* Normal pH and blood gases secondary to compensation
* Abnormal blood gases and normal AFI
* Abnormal acute and abnormal blood gases
* Goal is to recognize asphyxia and deliver prior to morbidity and mortality

Cesarean delivery
IOL for abnormal testing
Induction of labor
Nonrandomized data
Biophysical profile
Fetal movement assessment
Indications for antepartum monitoring
Maternal and Fetal Indications
Which test to use?
* Most evidence points to use of NST as first line test
* Imperative to remember that it should not be used a sole test
* Other tests should be used in situation of nonreassuring testing such as BPP or CST
* NST can be used in conjunction with Doppler studies in IUGR

What to do if test is abnormal?
* True false-positive test results not known
o Test introduced without rigorous evaluation of utility
* Abnormal result in context of clinical situation
o Did maternal condition change?
o Abnormal test usually followed by other test
+ 90% of NRNSTs followed by negative CST
o If NRNST followed by positive CST, delivery warranted in morphologically normal fetus

Abnormal BPP
When to start?
How frequently?

Antepartum Fetal Testing.ppt

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