NCM 107: CARE OF MOTHER, CHILD, AND ADOLESCENT – OBSTETRICS

NURSING CARE DURING NORMAL PREGNANCY AND CARE OF THE DEVELOPING FETUS
STAGES OF FETAL DEVELOPMENT
1. Pre-embryonic (first 2 weeks, beginning with fertilization)
2. Embryonic (3-8 weeks)
3. Fetal (8 weeks to birth)
FETAL GROWTH TERMS
Name Time period
Ovum ovulation – fertilization
Zygote fertilization – implantation
Embryo implantation – 5-8 weeks
Fetus 5-8 weeks – term
Conceptus developing embryo and placental structures
Age of viability 24 weeks or >500-600g
FERTILIZATION: THE BEGINNING OF PREGNANCY
Fertilization – union of matured ovum and matured sperm
(conception, impregnation, fecundation)
 6 days (5 days before ovulation plus 24 hours afterward) – total
critical time span during which sexual intercourse must occur for
fertilization to be successful
 Occurs in the outer third of fallopian tube – ampullar portion EMBRYONIC AND FETAL STRUCTURES
 Ovum is extended from graafian follicle 1. Decidua – specialized endometrium of pregnancy
 Ovum is propelled into fallopian tube by fimbriae currents Layers:
 Reduction in cervical mucus viscosity
 Decidua basalis – directly under the embedded ovum;
 Species-specific reaction
forms the maternal side of the placenta
 All sperm that reach the ovum surround the protective layer of
corona cells  Decidua capsularis – pushed out by embedded and
 Once penetrated, the cell membrane changes its composition growing ovum
to become impervious to other sperm  Decidua vera – remaining portion which is not in
 Ovum and sperm fuse to form a zygote immediate contact with ovum
Functions:
CHARACTERISTICS OF SPERM FOR FERTILIZATION
1. Capacitation – the capacity to penetrate the ovum which  Most ideal site for implantation because of its rich
involves the removal of the protective layer of corona cells blood supply that ensures maximum placental growth
by hyaluronidase and development
2. Acrosome reaction – release of acrosin  It provides easy access to the birth of the baby at the
Zona reaction – formation of new barriers around the egg cell after it end of gestation as it is continuous with the birth canal
has been fertilized to prevent the entry of the sperms  It may prevent infections coming from the vagina and
Fertilization is never a certain occurrence because it depends on at cervix
least three separate factors:  Produces prolactin, relaxin, corticotropin-releasing
 Equal maturation of both sperm and ovum hormone (CRH), oxytocin, endothelin-1
 Ability of the sperm to reach the ovum
 Ability of the sperm to penetrate the zona pellucida and cell
membrane and achieve fertilization
IMPLANTATION
 After fertilization, zygote migrates toward the uterus (3-4 days)
 Mitotic cell division/cleavage begins
 First cleavage – 24 hours
 Continue at 1 every 22 hours
 16-50 cells by reaching uterus
 Next 3-4 days, blastocyst forms
 Trophoblast/Trophoderm – outer ring; gives rise to
placenta, fetal membranes, umbilical cord, and amniotic
fluid; “feeding layer”
Important functions:
o Absorb nutrients from the endometrium
o Secrete hCG to prolong corpus luteum life
Distinct layers (3rd week of gestation):
o Cytotrophoblast – develops into Langhan’s layer;
protects the fetus against syphilis until 2nd trimester 2. Chorionic villi – reach out from trophoblast cells into the
only (becomes less numerous) uterine endometrium to begin formation of the placenta
o Syncytiotrophoblast (syncytium) – originates from 3. Placenta – formed at 3rd month; fleshy, disk-like organ
cytotrophoblast; produces E, P, hCG, hPL
formed by union of chorionic villi and decidua basalis
12 days after fertilization:
o Chorion frondosum – in contact with decidua  Fetal side – smooth and glistening; covered by amnion
basalis; form fetal side of placenta; absorb  Maternal side – red and flesh-like
nutrients and oxygen from maternal blood stream;  3rd trimester (6 months) – span when mother still gives
dispose fetal waste products protection to the baby through transfer of IgG (passive
o Chorion laeve – not involved in implantation; immunity)
gradually degenerates eventually forming the Functions:
chorionic membrane; “bald chorion”  Transfer of gases
 Embryoblast/Endoblast – inner cell mass; form embryo  Transport of nutrients
 Implantation occurs at approx. 8-10 days after fertilization  Excretion of wastes
 Blastocyst sheds residue of corona and zona pellucida and
 Transfer of heat
settles in the soft folds of endometrium (8 days after ovulation)
 Blastocyst burrows deeply into endometrium and connects to  Hormone production
its blood system  Provider of antibodies
 Capillaries rupture on the day of implantation because of the  Protective barrier
implanting of trophoblast cells – implantation bleeding
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 Circulation: Knots of the cord:
 12th day of pregnancy – mother’s blood begins to  True knots – fetus passes through a loop of cord
collect in the intervillous spaces of the uterine  False knots – wharton’s jelly containing a loop of
endometrium surrounding the chorionic villi umbilical vessels
 3rd week – oxygen and other nutrients (glucose, amino  Loops of the cord – cord coil around the fetal body and
acids, fatty acids, minerals, vitamins, water) are neck
transported to the developing embryo  Nuchal cord – when cord coil is around the neck
 Fetal alcohol syndrome (FAS)
 Utero-placental blood flow – 50mL/min. (10 weeks); TERMS
500-600mL/min. (at term) 1. Gravidity
Endocrine functions:  Gravida – refers to a pregnant woman
 Human chorionic gonadotropin (hCG)  Gravidity – refers to number of pregnancies
 Progesterone, estrogen  Nulligravida – a woman who has never been pregnant
 Human placental lactogen (human chorionic  Primigravida – a woman who is pregnant for the first
somatomammotropin) time
4. Amniotic membranes  Multigravida – a woman in at least her second
 Chorion – envelops the embryo; serves as protective pregnancy
and nutritive covering; provides support to the 2. Parity
amniotic membrane  Parity – number of births (not the number of fetuses)
 Amnion – most internal of the fetal membranes; carried past 20 weeks gestation, whether or not the
contains cells that produce water (amniotic fluid); fetus was born alive; term for previous pregnancies
secretes phospholipids that plays an important role in that terminated after the infant was viable whether
prostaglandin synthesis alive or dead
5. Amniotic fluid – medium which the fetus and cord float  Nullipara – a woman who has not had a birth at more
inside the amniotic membrane; not static than 20 weeks gestation
 350-500mL is produced and replaced each hour  Primipara – a woman who has had one birth that
 Normal amniotic fluid volume: 500-1200mL occurred after the 20th week of gestation
 Polyhydramnios – excessive amniotic fluid (>2000mL)  Multipara – a woman who has had two or more
 Oligohydramnios – little amniotic fluid pregnancies resulting in viable offspring
 99% water and 1% solid particles
 Contains albumin, urea, uric acid, creatinine, lecithin, Teratogens – any factor, chemical or physical, that adversely affects
sphingomyelin, bilirubin, minerals, and suspended the fetal development
materials such as desquamated epithelial cells and Factors influencing the amount of damage a teratogen can cause:
vernix caseosa 1. Strength – rays of sun in small amount is alright but frequent
 Clear and colorless to straw-colored exposure may be bad; increased dose/amount = increased
o Green/meconium – fetal distress teratogenic effect
o Yellow/golden – blood/Rh incompatibility 2. Timing – if teratogen is introduced before implantation,
o Gray – infection either zygote is destroyed or unaffected
o Bloody – vasa previa  2nd – 8th week – vulnerability to injury
o Brownish/coffee/tea – fetal death  Syphilis and toxoplasmosis can cause abnormalities
 7.0-7.25 pH; reaction is neutral to alkaline in organs that are originally formed normally
 Specific gravity – 1.005-1.025 3. Affinity – to specific tissue
Production:  Lead attacks and disabled nervous tissue
 Mother – transudation from maternal circulation  Thalidomide causes limb defects
 Fetus – active secretion from the epithelium of the  Tetracycline causes tooth enamel deficiencies and
amniotic membrane, transudation from fetal possibly long bone deformities
circulation, fetal urination (late pregnancy)  Rubella virus affect many organs like eyes, ears,
Removal: heart, and brain
 Absorption through the amnion to the maternal Specific teratogens:
circulation 1. Rubella (German measles) – effects to baby include
 Fetal swallowing – controls fluid volume deafness, cataracts, mental and motor retardation, cleft lip
Functions: and palate, abortion, cardiac effects (patent ductus
 Keeps fetus at even temperature arteriosus and pulmonary stenosis), SGA
 Cushions fetus against possible injury 2. Sexually transmitted diseases
 Provides medium which fetus can move easily  Syphilis – congenital syphilis (damage occurs 16-18
 Acts as hydrostatic wedge easing the pathway of fetus weeks), untreated beyond 18 weeks results to
during delivery deafness, cognitive impairment, fetal death
 Prevents adhesion between the sac and embryo o Newborn with congenital syphilis has extreme
 Can be a basis to determine fetal maturity and fetal rhinitis, syphilitic rash
genetic make-up o Infection usually leads to spontaneous abortion
 Source of oral fluid  Herpes simplex – cause congenital anomalies and
6. Umbilical cord – connects the placenta with the umbilicus spontaneous abortion
of the fetus; AVA; 50-55 cm (20 in.) in length, 2 cm in o Organism may cross the placenta
diameter o Fetus is contaminated after membranes rupture
 Short cord may lead to: or with vaginal delivery
o Intrapartum hemorrhage due to premature  Gonorrhea
separation of the placenta o Fetus is contaminated at time of delivery
o Delayed descent of fetus during labor o Maternal infection may result in postpartum
o Inversion of the uterus infection of the neonate
 Long cord may lead to: o Risks to the neonate include ophthalma
o Cord presentation and cord prolapse neonatorum, pneumonia, and sepsis
o Coiling of cord around the neck 3. Toxoplasmosis – contact with cat’s stool or cat litter; causes
o True knots of the cord CNS damage, hydrocephalus, microcephaly, intracerebral
 Wharton’s jelly – gelatinous tissue; no nerve endings calcification, and retinal deformities
 It may be prolapsed, revealed, concealed

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 4. AIDS – repeated exposure to virus during pregnancy Fetal circulation:
through unsafe sex practices or IV drug use can increase  Umbilical vein – carries oxygenated blood toward fetal
the risk of transmission to the fetus heart
 Perinatal administration of zidovudine (ZDV) may be  Umbilical artery
recommended to decrease the transmission of HIV  Ductus venosus – discharges oxygenated blood into
virus from mother to fetus the fetal liver
ORIGIN AND DEVELOPMENT OF ORGAN SYSTEMS  Ductus arteriosus
1. Stem cells  Foramen ovale – atrial septum
 Totipotent stem cells – zygote cells during first 4 days  O2 saturation – 80%
 Pluripotent stem cells – slated to become specific
body cells (nerve, brain, or skin cells)
 Multipotent – are so specific they cannot be deterred
from growing into a particular body organ (spleen,
liver, or brain)
2. Zygote growth
3. Primary germ layers
 Rubella infection – capable of infecting all germ layers
 Organogenesis – most vulnerable to invasion by
teratogens
Germ layer Body portions formed
Ectoderm  CNS (brain and spinal cord)
 PNS
 skin, hair, nails, and tooth enamel
 sense organs
 mucous membranes of anus, mouth, and nose
 mammary glands
Mesoderm  supporting structures of the body (connective
tissue, bones, cartilage, muscle, ligaments, and
tendons)
 upper portion of the urinary system (kidneys and
ureters)
 reproductive system
 heart, lymph, and circulatory systems and blood
cells
Endoderm  lining of the pericardial, pleura, and peritoneal
cavities
 lining of the GI tract, respiratory tract, tonsils,
parathyroid, thyroid, and thymus glands Fetal Hgb:
 lower urinary system (bladder and urethra)  2 alpha and 2 gamma chains
 More concentrated and has greater O2 affinity
 17.1 g/100mL
 Hct – 53%
5. Respiratory system
 Respiratory and digestive tracts exist as a single tube
(3rd week of intrauterine life)
 Spontaneous respiratory practice movements begin
as early as 3 months gestation and continue
throughout pregnancy
 Surfactant – formed and excreted by the alveolar cells
of the lungs (24th week of pregnancy)
 28th week of gestation is believed to be the practical
lower limit of prematurity or the earliest gestation age
at which a fetus can survive outside a woman’s womb
6. Nervous system
 Neural plate and neural crest (3rd week)
 All parts of brain (none are completely mature)
 Brain waves on EEG (8th week)
 Ear – capable of responding to sound (24 weeks)
4. Cardiovascular system – one of the first systems to
 Eyes – exhibit a pupillary reaction
become functional in intrauterine life
 Morning sickness may be interpreted as a sign of
 Simple blood cells → network of blood vessels (as
pregnancy because this symptom is brought about by
early as the 16th day of life and beats as early as the
a depletion in maternal blood glucose levels
24th day)
 This results from the embryo’s intake of glucose from
 Heart septum develops (6th or 7th week)
the mother which is necessary for the rapid
 Heart valves develop (7th week) development of the nerve tissues during the 3rd and 4th
 Heartbeat – heard with Doppler (10th-12th week) week of life
 ECG – (11th week, but more accurate at 20th week) 7. Endocrine system
 HR of fetus – affected by O2 level, activity, and  Fetal pancreas produces insulin needed by the fetus
circulating blood volume  Thyroid and parathyroid glands – fetal metabolic
 HR stabilizes (28th week) – 110-160 beats/min. function and calcium balance
 Fetal circulation differs from extrauterine circulation  Fetal adrenal glands – supply a precursor (estrogen
 Oxygen exchange and excretion of carbon dioxide synthesis)
takes place through 2 umbilical arteries and 1 vein of
the placenta and not to the lungs

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 8. Digestive system
 Respiratory and digestive tracts exist as a single tube
(3rd week of life)
 Separates from respiratory tract (4th week)
 Atresia (blockage) or stenosis (narrowing) – common
fetal anomalies
 6th week – intestines become too large; pushed into
base of umbilical cord until 10th week
 Omphalocele – if any intestine remains outside the
abdomen in the base of the cord
 Gastrochisis – when the midline fusion is incomplete
 It grows very fast so that by 5th – 8th week, meconium
is already formed in the intestines
 Meconium – black or dark green and sticky in texture;
the end-product of fetal metabolism made up of bile,
mucoproteins, fats, cellular waste,
mucopolysaccharides, and some vernix caseosa
9. Musculoskeletal system
 Quickening – seen on ultrasonography at 11th week,
but felt at 16th-20th week
 A fetus cannot be visualized by x-ray until a degree of
ossification has taken place
 Ossification of bone tissue in the 3rd month and
continue all throughout fetal life
 Fetal x-ray is a teratogenic factor which can cause
damage to the developing fetus early in pregnancy
10. Reproductive system
 Child’s sex – determined at 8 weeks (chromosomal
analysis) or at 10 weeks (fetal cell analysis)
 6th week – gonads form
11. Urinary system
 Urine – formed at 12 weeks and excreted into amniotic
fluid by 16th week
 At term, fetal urine is excreted at a rate of up to
500mL/day
 Kidneys are non-functional before birth even if they
are already present in rudimentary form as early as 4th
week of fetal life
12. Integumentary system
 Skin appears thin and almost translucent until
subcutaneous fat begins to be deposited underneath
it at about 36 weeks
 Lanugo – soft downy hairs that covers the skin
13. Immune system
 IgG cross the placenta into the fetus as early as the
20th week and certainly by the 24th week to give fetus
temporary passive immunity
 Fetus only becomes capable of active antibody
production in late pregnancy

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