314-class one and two melone Flashcards
Contemporary issues
Millennium Development Goals Goal 4 Reduce child mortality Goal 5- Improve maternal health Integrative health Care – Complementary and alternative therapies. U.S. Health Care System – ACA, MA, MN Care Health Literacy Trends in Fertility and Birth Rate Increase in High Risk Pregnancies
Contemporary issues
Many will never work in L and D, postpartum – all RNs should have basic understanding of women’s health and reproductive health
So..we will focus during this part of 314 on: anatomy and physiology, normal pregnancy, labor/delivery/high risk conditions, newborn issues and a little about contraception.
When would you need to know this information if you are not a nurse on a L and D or postpartum floor?
We know that women’s health is closely related to population health – HP 2020 and MDG support importance of reproductive health care
HP 2020
MDGs
GOAL 4
Reduce Child Mortality
TARGET
1. Reduce by two thirds, between 1990 and 2015, the mortality rate of children under five
Quick Facts
* The number of children in developing countries who died before they reached the age of five dropped from 100 to 72
deaths per 1,000 live births between 1990 and 2008.
* Almost nine million children still die each year before they reach their fifth birthday.
* The highest rates of child mortality continue to be found in sub-Saharan Africa, where, in 2008, one in seven children
died before their fifth birthday.
Of the 67 countries defined as having high child mortality rates, only 10 are currently on track to meet the MDG target.
GOAL 5
Improve Maternal Health
TARGETS
1. Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
2. Achieve, by 2015, universal access to reproductive health
Quick Facts
* More than 350,000 women die annually from complications during pregnancy or childbirth, almost all of them —
99 per cent — in developing countries.
• The maternal mortality rate is declining only slowly, even though the vast majority of deaths are avoidable.
• In sub-Saharan Africa, a woman’s maternal mortality risk is 1 in 30, compared to 1 in 5,600 in developed regions.
• Every year, more than 1 million children are left motherless. Children who have lost their mothers are up to 10 times more
likely to die prematurely than those who have not.
Integrative Health care – body, mind, spirit Why is this an important part of reproductive health?
US Health Care system play an important role in outcomes: access to care and poverty associated with maternal and infant mortality and both are indicators of population health
ACA – increased focus on prevention
MA and MN care – higher guidelines for Pg women and children under 2 years.
Health literacy – limited health literacy impacts 1/3 individuals in the US
Trends in fertility and birth rates
Birth rate – Number of live births in one year per 1000 population
Fertility rate – Number of births in 1 year per 1000 women between 15 and 44
Maternal Mortality rate - # of maternal death due to complications of pregnancy per 100,000 live births. Sierra Leone has the highest maternal death rate at 2,000, and Afghanistan has the second highest maternal death rate at 1900 maternal deaths per 100,000 live births, Lowest rates included Ireland at 0 per 100,000 and Austria at 4 per 100,000. In the United States, the maternal death rate was 11 maternal deaths per 100,000 live births in 2005.[12] This rose to 13.3 per 100,000 in 2006.[13] “Lifetime risk of maternal death” accounts for number of pregnancies and risk. In sub-Saharan Africa the lifetime risk of maternal death is 1 in 16, for developed nations only 1 in 2,800.
Infant Mortality rate number of deaths of infants under 1 year per 1000 live births (see next slide)
Increase in High risk pregnancies-more incidences of preeclampsia, hypertension, twins
Health care Finally: Consider the family – pregnancy can be stressful, high risk pregnancy is often a crisis for the family; increase in high risk due to people with chronic health problems living longer and healthier lives. 25 weeks is the golden mark for babies to survive.
WHO Millennium Development Goals
Goal 4
Reduce child mortality by 2/3, children 5 and under
Goal 5
Reduce maternal mortality by ¾ and achieve universal access to reproductive health
Infant mortality
Health of the community affects women’s health and pregnancy outcomes.
Infant mortality is a common tool used to compare the health of a community or nation.
Infant mortality rate for the US is 6.3/1000 live births (2006?)-
It has improved but more slowly than other countries,
High technology has helped infants born younger and younger to survive,
but to make big strides emphasis will need to be on prevention: early, high quality prenatal care and preconception care and pregnancy prevention until the pregnancy is desired and planned
There is an interesting dichotomy.
prevention is key, technology = survival
Technology – use cautiously and examine the evidence. Nurses must not forget about the low tech care we give.
Move on to preconception care
2012 CDC statistics
The birth rate for teenagers aged 15-19 dropped 6% from 2011 to 2012, to 29.4 per 1,000 – the lowest rate ever reported for the U.S.
Average age increased (25.8) as did birth rate in age 30-44
Preconception care
-Health Promotion
Nutrition
Folic Acid, Healthy diet/weight
Exercise and Rest
Substance use/abuse
Alcohol and other drugs
smoking
Risk reducing sexual practices
Family and social needs
-Risk factor assessment
Chronic diseases
Diabetes, hypertension, thyroid diseasePreconception care
What is preconception care?
one of the most important health care opportunities that - rarely used.- pregnancies often not planned or families not aware they can make pregnancy healthier.
Should happen every health care encounter
Components (from book 4-1)
Even asking about plans in future can be preconception care
Focus on chronic health conditions, nutrition, exercise, immunizations/infections, lifestyle
preconception and prenatal period focuses on optimizing mom and baby’s health.
One big concern for babies is teratogens.
Teratogens: things that can affect interfere with growth and development of an embryo, fetus or baby.
drugs, Xrays, viral diseases (CMV, Rubella), bacterial diseases (gonorrhea and Chlamydia-newborn), parasites (toxoplasmosis), lead or chemicals, lack of nutrients (folic acid). We will talk more about teratogens when we get into fetal development.
List from slide some aspects of pcc
Preconception care can prevent problems in pregnancy, acknowledges -families self care and health promotion; de-medicalizing pregnancy.
The fewer risks going into a pregnancy, the better.
PKU- a bunch of metabolic diseases, diet restrictions that can come up.
smoking during pregnancy
Smoking causes-low birth rate, umbilical cord is smaller so decreased blood flow and decreased nutrients. Placenta can be calcified so nutrients are not as good.
genetics
Autosomal dominant – one copy of allle is needed for expression of trait. 50% chance in offspring, male and female equally affected.
Autosomal recessive – 2 copies of allle is needed for expression of trait. 25% chance in offspring, male and female equally affected.
Genetic Disorders
Autosomal recessive-PKU, galactosemia, Sickle cell anemia, Cystic fibrosis
Autosomal dominant-Huntingtons disease, Marfan syndrome, achondroplasia
Aneuploidy
Down Syndrome (trisomy 21)
Sex Chromosome-
Turners syndrome-(monosomy X -45X)
Klinefelter syndrome- (trisomy XXY)
genetic disorders notes
Review genetic inheritance –use the reading guide to help you. Important for nurses to recognize the importance of Genetics and Genomics
should be able to construct a basic family pedigree – a part of early prenatal care
Provide education and information related to specific genetic conditions
recognize own attitudes and values in genetic counseling
tailor genetic needs based on culture, religion, level of knowledge, literacy and preferred language.
refer to specialized services a s needed.
DNA forms chromosomes and chromosomes contain genes. Ganes interact with other genes and the environment –
Alleles code for traits
Dominant traits are expressed when only one copy of the allelle is present.
Recessive traits need 2 copies (one from each parent) to be present in order to be expressed.
Chromosomal abnormalities occur in - 0.6% of newborns
6% stillbirths
60% of spontaneous abortions (miscarriage)
Autosomal recessive disorder-both parents carriers, they have a 1-4 chance of having a child with the disorder. But it is always 1-4, regardless of how many children they have had. Examples CF, Tay-Sachs, sickle cell anemia, PKU
Autosomal dominant: Commonly, any person who has a autosomal dominant disorder, has a parent with it as well. Generally, it is heterogeneous in one and homogeneous (normal) in the other. Each child would then have 50% chance of getting the disease. Marfan syndrome, Huntington disease, achondroplasia (dwarfism)
X linked recessive – females homozygous or heterozygous, males only one X so homozygous. Men receive affected X from mom, can pass to daughter but not to son. Daughters carriers, unless get an affected X from mom as well. (examples: hemophilia, color blindness and Duchenne muscular dystrophy are x=linked recessive.)
Abnormality of chromosomal number (most common is Down Syndrome - 47, XX +21 or 47 XY+ 21) also trisomy 13 and 18. Anaploidy – number of chromosomes is not an exact replication. Most common chromosomal abnormality and the most common of these is Trisomy 21 (Down Syndrome) Extra 21st chromosome
1 in 73 newborns has DS. Increasing with maternal age, because it occurs with the maturing of the ovum.
1/1200 age 25 1/350 age 35 1/30 age 45 but can happen at any age. 80% of children are born to mothers under 35. Improved care last 30-40 years. May life span increased to 50-60- years.
Sex Chromosome abnormalities:
Most common female: (turners syndrome-missing a X chromosome-45X) most miscarry. (Turners assoc with ht defect, short stature, decreased ovarian function) – embryos with only a “Y” chromosome can’t survive.
Most common male: Klinefelter syndrome (trisomy XXY)
Normal would be to get x from mom and x or y from dad. – usually infertile and very tall.
Occurrence and recurrence chance. Importance of families understanding that risk remains the same – two parents with heterozygous recessive gene 25% chance of affected child, autosomal dominant in one parent, normal other parent – 50%, x-linked chance depends on sex of child.
Genetic Counseling
Genetic counselors often recommended with high risk pregnancies:
After age 35
Previous child with mental retardation, inherited disorders or birth defect
Genetic disease diagnosed by newborn screening
Baby die in infancy or 2-3 miscarriages
Lifestyle
Couples who are close relatives
US or blood tests indicate increased risk
genetic counseling notes
Genetic counseling; Generally master’s degree in genetic counseling. Not uncommon for couples to want to see one, however, nurses need to know the basics of genetics to those who don’t, and possibly to know when couples should seek genetic counseling.
Common reasons for seeking Genetic counselors Couples concerned they have genetic disorder
Pregnancy after age 35
Have one child with mental retardation, inherited disorder or a birth defect
Infant who has a genetic disease diagnosed by newborn screening
Had had a baby die in infancy or have had 2-3 or more miscarriages
People who feel they may be at increased risk due to lifestyle, job, medical history: medications, drugs, chemical exposure, radiation exposure, infections
Concerns about diseases that affect certain ethnic groups
Couples who are close relatives (first cousins)
Ultra Sounds or blood tests indicate may be increased risk of complications or birth defects
Role of Genetic counselor
Look at family history, medical background
Set up blood tests, exams, amniocentesis
Explain “risks” or try to put it in perspective
Explain information.
Provide information; do not tell people what to do with the information.
SCASpinoCerebellar Ataxia
Type II
Autosomal dominant – mutated genes located on non-sex gene
Often parents do not know that carry gene until their children begin to show signs of having disorder
SCASpinoCerebellar Ataxia notes
Onset varies in the different types of ataxia – for type 2- onset is usually in 3-4th decade with duration of 10 years
First ataxia gene was identified in 1993. Genetic testing available 2008
Fetal Development
3 stages
3 trimesters
Length of Pregnancy
Focus: from slide:
Length of pregnancy and development
LMP: First day of last menstrual period,
Fertile: generally about 2 weeks after first day of LMP (if 4 week cycles)
Ovulation and most fertile time: About 14 days before start of next menstrual cycle.
Pregnancy considered 40 weeks, but first 2 weeks, not actually pregnant, so pregnancy is actually 38 weeks.
In that 40 weeks the development is divided into the three stages:
Ovum or preembryonic: Conception until day 14
Cellular replication, blastocyst formation, embryonic membranes, primary germ layers
Embryo: day 15 -8 weeks after conception (3 cm- 1 inch in length)
greatest vulnerability to teratogens-organ systems and external structures are present.
Fetus: 9 weeks- end of pregnancy
Pregnancy divided into trimesters:
1st trimester: week 1-13, -embryonic plus 2 weeks as fetus. Morning sickness, tired, embryo is forming-major organs developing-no smoking most critical time of development
2nd trimester : week 14-27
3rd trimester: week 28-40. (end of pregnancy)
Uterus and ovaries
Day 14-Ovulation
Day 14-20-Fallopian Tube
Day 18-20-Uterus
Day 20-24-Implantation
Female reproductive – just so we are on the same page
Closer to delivery, cervix shortens.
Implantation -6-10 days after conception
No + pregnancy test yet.
Endometrium now called “decidua”
Implantation occurs in uterus
Watch video part 4 &5
Morning sickness, nausea to smells
Embryonic (3rd week -9th week since conception)
Ectoderm
Skin, glands, nails, hair, NS
Mesoderm
Bones and teeth, muscles, CVS, GU system
Endoderm
Lining of respiratory and digestive tracts
Glandular cells of organs (pancreas, liver)
Embryonic (3rd week -9th week since conception)
Embryo:-app. Day 15 –week 9
Primary Germ layers form-3 weeks after conception-5 weeks after LMP
Embryonic develop comes from 3 layers:
Ectoderm: skin, glands, nails and hair, nervous systems
Mesoderm: Bones and teeth, muscles, cardiovascular system, urogenital system
Endoderm: lining of respiratory and digestive tracts, glandular cells of associated organs: pancreas, urethra, bladder, vagina, liver
Embryonic development
Organ development
blood vessels, blood cells, heart, liver, biliary tract, respiratory system, kidneys, neurologic system, endocrine: thyroid, sex differentiation, musculoskeletal, integumentary
Effects of Teratogens
Embryonic development
Slide 16: Teratogens most harmful during embryonic development
Most organs and body parts formed during this time:-cepholo-caudal, brain and spinal cord, eyes, limbs, nose, ears
Placenta, umbilical cord,
blood vessels, blood cell formation (3rd week)
Heart (begins to beat in 3rd week)
GI system –developing by folding
Liver and biliary tract develop during 4th week
Hematopoiesis-begins during 6th week
Respiratory system begins development during embryonic period-4th week
Kidneys: form during 5th week
Neurologic: 3rd week begins, open neural tube 4th week, developed by folding, develops head to toe manner, nerve fibers through body by 8th week
Endocrine: thryroid- 3-4th week, secretion of thyroxine during 8th week
Reproductive: sex differentiation during 7th week
Musculoskeletal: fourth week
Integumentary: begins development in 4th week
Use this to look at teratogens
Teratogens: environmental substances or exposures that result in functional or structural disability
Drugs, chemicals, infections, radiation, maternal conditions such as diabetes and PKU
Greatest effect on the fetus during the period of rapid growth and differentiation
Embryonic period: days 15-60
During first 2 weeks-generally no effect or lead to miscarriage
Teratogens are: dose dependent, cause damage specific to development that is occurring and exposure can occur through mucous membrane during birth and placenta during fetal development.
Embryonic and Fetal Development
Umbilical cord in 5th week of gestation from connecting stalk Amniotic fluid initially maternal in origin Fetal Membranes Chorion and amnion
Embryonic and Fetal Development notes
In addition to the embryonic development, other important structures are starting to form during the embryonic stage – and continue to develop throughout pregnancy.
Umbilical cord: in 5th week develops from connecting stalk. Two arteries and one vein: Arteries carry blood from baby to placenta (low Oxygen), vein carries blood from placenta to baby (high oxygen)
Protected by wartons jelly
10-30 inches long (average about 20-24 inches)
Amniotic fluid: initially from fluid from mom’s blood.
Infant swallows it, flows in and out of lungs, urinates into it
Sources: maternal blood, fetal lungs and GI tract, fetal urine.
Normal volume changes with gestation - 30ml-week 10, 1000 ml at 38 weeks. At term 700 to 1000 ml is normal.
Functions to: keep temperature stable for baby, cushions fetus, movement, keeps membranes away from fetus-symetric growth,
Question to students: if we know that babies swallow amniotic fluid, and we know they urinate into the amniotic fluid-what are some things that we might associate with increased or decreased amniotic fluid?
Oligohydramnios: fetal renal abnormalities (
Placenta
Placenta Structure Begins at implantation Maternal/placental/embryo circulation by day 17 Structure complete in first trimester, getting larger through week 20 Placenta Function Endocrine hCG hCS or hPL Progesterone Estrogen Metabolic Oxygen, CO2 Nutrient Stores No blood transport –only nutrients and waste
placenta notes
Placental structure-begins at implantation-made up of cotyledons-15-20 per placenta
Maternal/placenta/embryo circulation in place by day 17 (about 5 weeks after lmp)-embryonic heart starts to beat about the same time
Blood circulating between embryo and chorionic villi-mom providing O2 and taking away CO2 and waste
By 8th week genetic testing can be done on chorionic villi-
Structure of placenta complete by week 12, continues to grow wider until week 20
Placental function: endocrine gland-early function: four hormones:
hCG (used in pg tests)-8-10 days after conception-facilitates adequate estrogen by supporting corpus luteum
human Chorionic Somatomammotripin (hCS) or human placental lactogen: stimulates maternal metabolism: insulin resistance, glucose transport across placental membrane, stimulate breast development.
Progesterone: maintains the endometrium, decreases uterine contractility, breast alveoli and maternal metabolism
estrogen (by week 7)-stimulates uterine growth and uteroplacental blood flow, breast tissue proliferation, myometrial contractility
Metabolic functions: Respiration, nutrition, excretion and storage:
Oxygen diffuse from mom to baby through placental membrane, CO 2 diffuses from baby to mom-fetal lungs
Stores: carbs, proteins, calcium and Fe, other nutrients passed as well as water-nutrients passed through active and passive transport
fetus has high need for glucose
fetal waste products excreted by maternal kidneys
No blood is directly transported through placenta-the separation is quite thin (one cell thickness) so leaking can occur-possible way to develop antibodies to fetal RBC
Higher pressure in maternal circulation than fetal, pushes blood flow to allow exchange of nutrients
If maternal pressure is disturbed, causes problems for baby: High blood pressure: -> vasoconstriction-> decreased uterine blood flow
Low blood pressure: also decreases uterine blood flow.
viruses, drugs, bacteria can also cross into the fetal circulation
Embryo Week 6
Beginning of forebrain and Limb buds Heart beating (5th week) Liver and biliary tract, respiratory system begins to develop
Embryo week 7
Finger rays
Kidneys
developing
Embryo Week 9
Sex differentiation
Embryo Week 10
Weight = “4 paper clips”,
3 cm length
