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186 Cards in this Set

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The first trimester lasts from ___ to ___ weeks (according to Varney/Frye).
The first trimester lasts from weeks one to twelve, according to Varney’s Midwifery. (Varney, 543)

The first trimester lasts from weeks one to fourteen, according to Holistic Midwifery. (Frye, 662)
What anatomical and physiological changes occur during the first trimester?
Uterus enlarges to just above the pubic bone
Ligaments that support the uterus begin to stretch, causing mild twinges, in some women.
Braxton Hicks contractions begin

Any of the following early signs of pregnancy may be present:
Elevated basal temperature, Implantation bleeding, Cessation of menses, Morning sickness, Irregular softening and enlarging of uterus (Braun von Fernwald’s sign), Increased urination, Breast tenderness, tingling, and heaviness, Darkening of the areola and nipple, Cervical and uterine softening (Goddell’s sign), Softening of the isthmus (Hegar’s sign), Softening of the uterus (MacDonald’s sign)
Increased ability to detect pulse in lateral fornices of the vagina, Violet-blue color of vaginal mucosa and cervix (Chadwick’s—or Jacquemier’s—sign), Irregular uterine contour because of non central implantation (Piskacek’s sign), Fetal heart heard with Doppler, Changes in skin pigmentation (lina negra), Stretch marks
(Frye, 667-669)

What common discomforts of pregnancy can occur in the first trimester?
Nausea (morning sickness) is commonly experienced in early pregnancy, usually subsiding by the twelfth-fourteenth week. Increased urination, breast changes, food cravings. Hormonally-induced mood changes, or swings. She may feel sick or that she is on an emotional roller-coaster.
What fetal growth and development occurs in the first trimester?
Fetal growth and development in the first trimester begins with conception, which results in the zygote (day one), which develops into the morula (day two), further develops into a blastocyst (day four) which then implants in the uterine endometrium (days six through nine).
The second trimester lasts from ___ to __ weeks (according to Varney/Frye).
The second trimester lasts from weeks thirteen to twenty-seven, according to Varney’s Midwifery. (Varney, 543)
The second trimester lasts from weeks fifteen to twenty-eight, according to Holistic Midwifery. (Frye, 737)
What anatomical and physiological changes occur during the second trimester?
Uterine enlargement becomes unmistakably present during the second trimester. The mother is able to feel the baby move. There is a general feeling of well-being, and excitement about the pregnancy, and beginning to look pregnant! Growth spurts are common, and it is during this time that blood volume begins to really expand, and reaches its peak. There can be an increase in vaginal discharge, and colostrum can be sometimes expressed.
What common discomforts can be experienced during the second trimester?
Toning contractions begin during the second trimester; usually, however, they are not painful. Hemorrhoids, if present, can become bothersome now that uterine enlargement has begun. Heartburn, indigestion, and constipation can also result from the enlarging uterus pushing on organs, and from the relaxing effect of pregnancy hormones on smooth muscle tissue. Round ligament pain can occur during this part of the pregnancy as the enlarging uterus pulls on them and stretches them.
What fetal growth and development occurs during the second trimester?(Summary)
The second trimester is a time of rapid growth for the baby. The fetus appears more human now; the eyes and ears are basically in position on the head where they will be at term, the head is erect, and scalp hair is beginning to develop a pattern. Slow eye movements occur. The lower limbs are well-developed, and begin coordinated movements, but most mothers cannot feel the movement because it is too mild.
What fetal growth and development occurs during the 16th week?
Sixteen weeks: The baby’s head is more proportionate to its body—rather small compared to the twelve week fetus’ head. The lower limbs are longer. The ears stand out from the head. By the beginning of this week, the skeletal tissue has continued to change into bone, and is clearly visible by x-ray. Within their still immature follicles, the baby girl’s ovaries (now differentiated) contain immature eggs. The baby lives in about 200-250 ml of amniotic fluid at this point, is 4 1/2 inches long from crown to rump, and weighs 3 1/2 to 4 ounces by the end of this week.
What fetal growth and development occurs during 17-18 weeks?
Fetal growth slows from seventeen to eighteen weeks but the crown rump length increases by about two inches, and brown fat is formed. Heat is produced in the brown fat to keep the baby warm; this is accomplished by oxidizing fatty acids. Brown fat (brown because of its high mitochondria content) is primarily found at the base of the neck, behind the sternum and in the area surrounding the kidneys.
What fetal growth and development occurs during 18-20 weeks?
At eighteen to twenty weeks, vernix covers the skin, and fine downy hair called lanugo helps hold the vernix on the skin to protect it from abrasions, chapping and hardening that could be the consequence of constant exposure to amniotic fluid. Vernix contains fatty secretions from the sebaceous glands on the skin and dead skin cells. By eighteen weeks, most mothers will feel fetal movement. The female fetus’ uterus is formed and the vagina canal has begun to form. In males, the testes are still at the posterior abdominal wall (where the female’s ovaries are located) but have begun to descend. At twenty weeks, the baby can hear sounds. The eyebrows and scalp hair are visible. The amniotic fluid has reached a volume of about 350 ml, and the crown rump length and weight are 6 1/2 inches, and 12 ounces, respectively.
What fetal growth and development occurs during 21-23 weeks?
At twenty-one weeks, the baby begins to dream, completely with rapid eye movements. At twenty-two weeks, the amnion and the chorion membranes have fused. The baby gains substantial weight from twenty- to twenty-five weeks, and for the remaining time in the pregnancy the baby’s size becomes more and more individualized. The baby is proportioned more like a full-term baby now, although still lean. Blink-startle responses have been observed when placing vibroacoustic noise on the mother’s abdomen at twenty-two to twenty-three weeks. Sink is wrinkled and more translucent, appearing a pink to red color because of the ready visibility of the blood in the capillaries.
What fetal growth and development occurs during 24-25 weeks?
At twenty-four weeks, the secretory epithelial cells in the lung walls begin to secrete surfactant, a surface-active lipid that keeps the developing alveoli of the lungs open, and unblocked. Fingernails are present. If given very high-tech care, babies born between twenty-two and twenty-five weeks can survive. The earlier the baby is born, the higher the risk of permanent disability such as cerebral palsy, if they survive. During the first year of life, those that survive very early birth may still die of respiratory complications because of immature lung development.
The third trimester lasts from weeks ___ to ___ (according to Varney and Frye).
The third trimester lasts from weeks twenty-eight to forty, according to Varney’s Midwifery.

The third trimester lasts from weeks twenty-nine to birth, according to Holistic Midwifery. (Frye, 781)
What anatomical and physiological changes occur during the third trimester?
Usually, by this point in pregnancy, all mothers look pregnant. Their body is getting more and more ready to bring forth the baby. Blood volume continues to build, ensuring that the placenta will grow large enough to keep the baby well-nourished, reaching a peak at around 30 weeks. The baby may drop, or settle into the pelvis. After that, the mother may find it easier to breath, but will have to go to the bathroom more often!
What common discomforts can accompany the third trimester?
The baby will be pressing on her bladder (especially if he or she has “dropped”), causing her to need to use the restroom often, or possibly causing her to leak some urine at times. She will usually find it easier to breath when the baby drops. She may have backache, more Braxton Hicks, and warm-up contractions, and begin to feel pelvic pressure; sometimes the baby will put pressure on nerves too—ouch! Varicosities, especially vulva ones, can be considerably uncomfortable at this point. Vaginal discharge may increase and thicken. As she nears the end, the mother will probably find it more and more difficult to sleep, move around—to do many normal, every-day things.
What fetal growth and development occurs during the third trimester? (Summary)
At twenty-eight weeks to thirty-one weeks, the baby is covered with lanugo, and has well-developed scalp hair, eyelashes, partially opened eyes, and visible toenails. The lungs could breathe room air now, although many babies would still have difficulties this early. The nervous system can control rhythmic breathing movements, and control body temperature. The baby has enough body fat to smooth many wrinkles; white fat makes up about 3.5% of the baby’s weight. The spleen is essential for the formation of red blood cells, but by thirty weeks, that process is done by the bone marrow. In the male infant, the testes will start to descend between thirty and thirty-four weeks.
What fetal growth and development occurs during the 28-31st weeks?
During the twenty-ninth to the thirtieth week, the mother’s blood reaches it’s most expanded volume, especially if she had a nutritious diet that provided her body with the needed raw materials. The expanded blood volume is essential to cause sufficient placenta nourishment and growth so there is enough placenta to sustain the baby as he continues to grow and develop. At twenty-eight weeks to thirty-one weeks, the baby is covered with lanugo, and has well-developed scalp hair, eyelashes, partially opened eyes, and visible toenails. The lungs could breathe room air now, although many babies would still have difficulties this early. The nervous system can control rhythmic breathing movements, and control body temperature. The baby has enough body fat to smooth many wrinkles; white fat makes up about 3.5% of the baby’s weight. The spleen is essential for the formation of red blood cells, but by thirty weeks, that process is done by the bone marrow. By weeks thirty and thirty-one, the baby is easy to feel with palpation, and is beginning to fill the uterus more, while still able to freely move within the amniotic fluid. It will weigh at least 4.5 pounds at thirty-one weeks. In the male infant, the testes will start to descend between thirty and thirty-four weeks.
What fetal growth and development occurs during the 32nd week?
At thirty-two weeks, the pupils of its eyes respond to light. Usually, babies born from now on will usually survive life outside the womb.
What fetal growth and development occurs during the 36-37th week?
During weeks thirty-six and seven, the baby continues to steadily gain, and the lungs mature. The baby now has a firm grasp, and will orient towards light. Movements should not decrease in quantity, but the kind of movement will change. It is important to discuss this with clients so they are not alarmed. The baby is running out of room at this point, so they will feel more squirming, rolling, shifting movements rather than the kicking, stretching (aggressive movements) to which they have grown accustomed. By thirty-six weeks, nearly all babies have lungs mature enough to breathe room air with no problems, and will do well if born. By the end of thirty-six weeks, the baby’s skin is smooth and pink, and the arms and legs have a chubby appearance, with white fat now 8% of body weight.
What fetal growth and development occurs during the 38th week?
The head and abdomen circumference are about equal by thirty-eight weeks, and thereafter, the abdominal circumference may become larger. By weeks thirty-eight and nine, the baby should still be moving consistently, and amniotic fluid quantity should be normal. Baby’s skin is now bluish-pink. The head is the largest part of the fetus, the chest is prominent, and the breasts are slightly raised in both boys and girls. Usually, the testes will have descended into the scrotum. The baby is now fully capable of breathing independently, and sucking—the two most necessarily functions for a newborn baby outside the womb.
What fetal growth and development occurs during the 39th week?
Upon reaching thirty-nine weeks, the baby’s nervous system is able to carry out some integrated activities.
The pelvis is comprised of ____ bones.
What are those bones called?
The pelvis is comprised of four bones; two innominate bones, the sacrum, and the coccyx. (Varney, 1205)
Each innominate bone is comprised of three parts. What are they?
Each innominate bone is comprised of three parts: the pubis, the ischium, and the ilium. (Varney, 1205)
The _____ is the posterior and upper portion of the innominate bone and forms the _____ ______.
The ilium is the posterior and upper portion of the innominate bone and forms the false pelvis. (Varney, 1205)
The _______ is the medial and lower portion of the innominate bone and has the important bony landmark known as the ______ _____.
The ischium is the medial and lower portion of the innominate bone and has the important bony landmark known as the ischial spine. (Varney, 1205)
The ______ is the anterior portion of the innominate bone and is joined in front at the _________ _____.
The pubis is the anterior portion of the innominate bone and is joined in front at the symphysis pubis. (Varney, 1205)
The _____ __________ is the demarcation dividing the false and true pelvis.
The linea terminalis is the demarcation dividing the false and true pelvis. (Varney, 1206)
The true pelvis has three planes which are of obstetrical significance. What are they?
The true pelvis has three planes which are of obstetrical significance: a. the inlet, b. the midplane, and c. the outlet. (Varney, 1206)
The boundaries of the pelvic inlet are the _______ __________ posteriorly, the _____ __________ laterally, and the upper ________ _____, and the horizontal rami of the_____ _____ anterorly.
The boundaries of the pelvic inlet are the sacral promontory posteriorly, the linea terminalis laterally, and the upper symphysis pubis, and the horizontal rami of the pubic bones anteriorly. (Varney, 1206)
The ________ of the pelvis is the narrowest portion of the pelvis that the baby has to navigate because of the _______ ______.
The midplane of the pelvis is the narrowest portion of the pelvis that the baby has to navigate because of the ischial spines. (Varney, 1208)
The pelvic outlet's boundaries are the ___ of the ______ posteriorly, and the ________ _____ anteriorly.
The pelvic outlet’s boundaries are the tip of the sacrum posteriorly and the symphysis pubis anteriorly. (Varney, 1208)
Explain parallel, anterior, and posterior inclination of the symphysis pubis.
The symphysis pubis is normally parallel to the sacrum, which enables the anteroposterior diameter to be approximately the same for the pelvic inlet and outlet. If the symphysis pubis is inclined anterior, than the diameter of the inlet will be reduced, and the outlet enlarged; if the symphysis pubis in inclined posterior, then outlet’s diameter will be reduced, and the inlet enlarged. (Varney, 1208-1209)
The angle of the pubic arch should be at least ____ degrees.
The angle of the pubic arch should be at least ninety degrees. (Varney, 1208)
The anterior portion of the forepelvis should be _______, not _______ _______.
The anterior portion of the forepelvis should be rounded, not sharply angled. (Varney, 1209)
What percent of women's pelvises are gynecoid?
Forty-one to forty-two percent of women’s pelves are gynecoid. (Varney, 1209)
The platypelloid pelvis occurs in less than what percent of white and non-white women?
The platypelloid pelvis occurs in less than three percent of white and non-white women. (Varney, 1211)
The platypelloid pelvis is most common in which races, and occurs in approximately what percent of that group?
The platypelloid pelvis is most common in non-white races and occurs
in approximately 40.5 percent of that group. (Varney, 1211)
Which pelvic shape favors a posterior position of the fetus?
The shape of the anthropoid pelvis favors a posterior position of the fetus. (Varney, 1211)
Define "Menstruation".
Menstruation is the periodic shedding of the endometrial lining, consisting of blood, tissue fluid, mucus and epithelial cells. This shedding is caused by a sudden reduction in estrogens and progesterone when fertilization has not occurred. As the lining of the uterus is released, patchy areas of bleeding start from small areas of detaching tissue, a little at at a time. The uterine glands release their contents and collapse, adding their fluid to the flow. These secretions flow through the cervix and exit the body through the vagina. The menses last approximately five days, and 2/3 to 2 ounces of fluid—in some women considerably more—is discharged. When the flow is complete, the endometrium is very thin because the entire functionalis (or functional layer) has been shed, and the basalis layer, alone, remains. (Frye, 174)
List and briefly describe the phases of the menstrual cycle.
List and briefly describe the phases of the menstrual cycle. The menstrual cycle lasts, typically, 24-35 days, or an average of 28 days. There are three phases: menstruation, the preovulatory phase, and the postovulatory phase. Menstruation is the shedding of the functional layer of the endometrium down to the basal layer. The preovulatory phase is the time when fsh and lh stimulate the follicles of the ovaries to produce more estrogen which causes the endometrium to thicken to a depth of 4–6 mm. It is also know as the proliferate phase because of the proliferation of cells in the thickening endometrium, and is the phase that can vary most in length—usually 6–13 days in a 28 day cycle. The post ovulatory phase is the last, and most consistent in length; even in women who have irregular cycles, this phase of her cycles will tend to be regular in length. This period lasts from ovulation, to the onset of bleeding—it is usually 14 to 15 days long. lh encourages the development of the corpus luteum, which secretes increasing amounts of estrogen and progesterone. The progesterone triggers the endometrium to continue preparations to receive a fertilized ovum: stimulating the secretory endometrial glands, vascularizing the superficial endometrium, thickening the endometrial glycogen storage and increasing tissue fluid. (Holistic Midwifery; Frye, 174-177)
The ovarian cycle is regulated by which hormones from which gland?
The ovarian cycle is regulated by hormones from the anterior pituitary gland, specifically follicle stimulation hormone (fsh) and luteinizing hormone (lh). (Frye, 173)
Just before ovulation takes place the high levels of ___________ cause the anterior pituitary to release a surge of ___.
Just before ovulation takes place the high estrogen level causes the anterior pituitary to release a surge of lh. Refer to *”Holistic Midwifery”. (Holistic Midwifery; Frye, 176)
Name at least three changes that women may experience at ovulation.
Women may experience mittelschmerz, or midcycle pain, including off-center pain in the lower abdomen, caused by a rupturing follicle, spotting or breakthrough bleeding, bearing-down or dragging pains, general tenderness in the lower mid-abdomen and pelvic area. Increase in sexual desire, or libido, can be a symptom of ovulation, or completely unrelated. If examined under a microscope, cervical mucus (and saliva) will display a ferning pattern during ovulation. This can occur leading up to ovulation, but is most pronounced at the time of ovulation. Cervical mucus also becomes more slippery and stretchy during ovulation, a property called spinnbarkeit. The cervix will be softer, more open, and will take a higher position in the vagina at ovulation. (Varney, 475-476)
Define "climacteric".
Define climacteric. See “Varney’s Midwifery”,4th edition, chapter 13. “Climacteric” is a term used for the period of transition from the childbearing years to the post-childbearing years, generally a gradual seven-to-ten years long transition that ends with the last menstrual period. The cycle usually becomes quite irregular during this time, and women may experience such symptoms as hot flashes. (Varney, 335-336)
Fertilization is the fusion of what two gametes?
Fertilization is the fusion of a sperm and an ovum. (Varney, 556)
Describe the process of fertilization.
Fertilization usually happens in the fallopian tube’s ampulla, but can happen anywhere along the length. As the sperm have made their journey from the vagina to the fallopian tube, they undergo a final stage of maturation called capacitation, where the protective covering on their head comes off to allow enzymes carried in the acrosome (front part of the sperm’s head) to be activated. Although the sperm all seek for an egg-shaped object, very few sperm actually come in contact with the ovum. Those that do thrust themselves against the corona radiata and zona pellucida as they release enzymes. The corona radiata and the zona pellucida are two special outermost layers on a ovam—outside of and covering the cell membrane. The combined enzymes released from the acrosomes of the sperm bombarding the ovum cause the breakdown of the corona radiata and the zona pellucida, allowing access to the ovum, but to only one sperm. Only the sperm’s head enters the ovum—it sheds its tail. Once a single sperm has penetrated the ovum, the membrane changes, effectively preventing any more sperm from entering. At this time, the final meiotic division by the female chromosomes occurs, resulting in the formation of the female pronucleus. The sperm head enlarges, forming the male pronucleus, then both male and female pronuclei lose their membranes. This is when the genetic contents of sperm and ova fuze and become the nucleus of the newly formed zygote, the name for a fertilized ovum. (Varney, 557; Frye, 675)
What is a zygote?
A zygote is the result of the fusion of the female and male pronuclei from the ovum and sperm, and contains 46 chromosomes, 23 pairs. It is the first stage in the development of a newly-created baby, and it is at this point when the sex is determined by the male gamate, carrying a X or Y chromosome. (Varney, 556, Frye 675)
What is a morula?
The morula is the next stage of development after the zygote. About thirty hours after fertilization, the zygote travels down the fallopian tube toward the uterus as it begins to divide into two, then four, eight, sixteen, etc, cells; this is known as miotic cellular division, or cleavage. Successively smaller blastomere cells are the result of the continued exponentially divisions. These blastomere cells then change shape, and squeeze themselves together to form a compact ball of cells that looks like a raspberry. This is the morula. The word morula comes from the Latin morum, meaning mulberry. The morula enters the uterus after completing its four-inch journey down the fallopian tube.(Varney, 560; Frye, 675)
What is the blastocyst?
The blastocyst is a fluid-filled hollow ball, with the inner cavity called the blastocoel. As fluid increases within the blastocoel, it divides the blastomere into two sections. The thin outer layer of the blastocyst, the trophectoderm, is made of trophoblast cells and will become the chorion. (Varney, ; Frye, 676)
What are the three stages of human prenatal development?
The three stages (periods) of human prenatal development are: zygotic, embryonic, and fetal. (Varney, 556)
The fertilization and fusion of ovum and sperm produces what is called the _______.
After fertilization occurs, the fusion of the ovum and sperm produces what is
called the zygote. (Varney, 556)
The ovum and sperm each contain _____ chromosomes. The normal number of chromosomes in a human cell is _____.
The ovum and sperm each contain twenty-three chromosomes. The normal number of chromosomes in a human cell is forty-six. (Varney, 556)
Explain how the sex of the baby is determined by the male gamete.
The sperm determines the sex of a baby by whether it contains an X or a Y chromosome in its nucleus. When the sperm and ovum meet at fertilization, if the sperm contains an X (female) chromosome, it will combine with the X chromosome found in the nucleus of every ovum, and will result in a baby girl (XX). If however, the sperm contains a Y (male) chromosome, it will combine with the X chromosome, and result in a baby boy (XY). (Varney, 556, 560)
At day _____, the zygote becomes the _______, the Latin word for mulberry, because there are now enough cells that it resembles one.
Immediately following fertilization, the zygote begins meiotic cellular division.
At day three, it becomes the morula, the Latin word for mulberry,
because there are now enough cells that it resembles one. (Varney, 560)
The cells reorganize and fluid enters the center of the cellular mass; it is now called the _____________. (Hint: early baby development)
The cells reorganize and fluid enters the center of the cellular mass; it is now called the blastocyst. (Varney, 560)
The ______________________ implants in the uterine lining. Implantation is complete on the ______ or ______ day post-fertilization.
The embryo (or bilaminar embryo) implants in the uterine lining. Implantation is complete on the tenth or eleventh day post-fertilization. (Varney, 560)
The embryo produces three germ layers from which the baby’s body, the fetal membranes, the umbilical cord, and part of the placenta develop. List the three germ layers.
The three germ layers are the endoderm, mesoderm, and the ectoderm. (Varney, 560-561)
The endoderm develops into what? (Fetal development)
The endoderm develops into epithelial tissue for the trachea, bronchi, and lungs, liver, pancreas, bladder, and urachus, pharynx, thyroid, tympanic cavity, pharyngotympanic tube, tonsils, and parathyroid glands. (Varney, 560-561)
The mesoderm develop into what?
The mesoderm becomes bone, connective tissue, muscles, skin dermis, the urogenital system: gonads, ducts, accessory glands, also serous membranes, heart, blood and lymph cells, spleen and adrenal cortex. (Varney, 560-561)
The ectoderm develops into what?
The ectoderm becomes the neurotube, central nervous system, retina, pineal body, the posterior part of the pituitary gland, cranial and sensory nerves and ganglia, medulla (inner part) of adrenal gland, pigment cells, cartilages, connective tissue, bulbar and conal ridges in the heart. The ectoderm also becomes the epidermis, hair, nails, tooth enamel, the anterior part of the pituitary gland, internal ear, eye lens, skin and mammary glands. (Varney, 560-561)
What is the function of progesterone in pregnancy and where is it produced?
Progesterone causes the uterine lining to be sustained and maintained in a state where it is suitable for implantation. It also stimulates mammary growth, specifically the growth and development of alveoli in the breasts, uterine enlargement and skin pigmentation in the first trimester, prevents the production of milk during pregnancy, and relaxes smooth muscle, including blood vessels. Progesterone contributes to an increase in the blood volume. The body uses blood cholesterol to make progesterone, and it is produced in the placenta, and, previous to that, in the corpus luteum. (Varney, 103, 199, 544, 547, 549-551, 1071)
What is the function of human gonadotropin in pregnancy?
Human gonadotrophin is a protein hormone that maintains the corpus luteum, in early pregnancy, which results in the maintenance of the endometrium, and therefore, the pregnancy is preserved. Another source is more specific on what hCG causes the corpus luteum to do that maintains the endometrium. It suggests that it ensures the maintenance of a healthy pregnancy by encouraging the corpus luteum to produce progesterone, which maintains the uterine lining, or endometrium. (Varney, 568)
According to Varney’s Midwifery, about ____ % of all women go through a period of disappointment, rejection, anxiety, depression, and unhappiness upon the diagnosis of pregnancy. (Varney, 553)
According to Varney’s Midwifery, about 80 percent of all women go through a period of disappointment, rejection, anxiety, depression, and unhappiness upon the diagnosis of pregnancy. (Varney, 553)
At what weeks is the baby's heart most likely to be affected by teratogens?
Heart: the middle of the third week through the end of the sixth;
the end of the sixth week through the eighth week. (Varney's, 562)
Note: I first listed the time period during which major defects are most likely to occur, and then listed the less sensitive period.
At what weeks are the baby's eyes most likely to be affected by teratogens?
Eyes: the middle of the fourth week through the end of the eighth week;
the end of the eighth week through the thirty-eighth week. (Varney's, 562)
Note: I first listed the time period during which major defects are most likely to occur, and then listed the less sensitive period.
At what weeks are the baby's limbs most likely to be affected by teratogens?
Limbs: weeks four and five;
the end of the fifth week through the eighth week. (Varney's, 562)
Note: I first listed the time period during which major defects are most likely to occur, and then listed the less sensitive period.
At what weeks are the baby's ears most likely to be affected by teratogens?
Ears: the middle of the fourth week through the end of the ninth week;
the middle of the ninth week until after thirty-two weeks. (Varney's, 562)
Note: I first listed the time period during which major defects are most likely to occur, and then listed the less sensitive period.
At what weeks is the baby's brain and CNS most likely to be affected by teratogens?
Brain and central nervous system: the third week through the thirty-second week;
week thirty-two through the end of the thirty-eighth. (Varney's, 562)
Note: I first listed the time period during which major defects are most likely to occur, and then listed the less sensitive period.
At what weeks are the baby's teeth most likely to be affected by teratogens?
Teeth: near the end of the sixth week through the eighth week;
the ninth week through the end of the thirty-eighth week. (Varney's, 562)
Note: I first listed the time period during which major defects are most likely to occur, and then listed the less sensitive period.
At what weeks is the baby's palate most likely to be affected by teratogens?
Palate: near the end of the sixth week through the eighth week;
the ninth week. (Varney's, 562)
Note: I first listed the time period during which major defects are most likely to occur, and then listed the less sensitive period.
At what weeks is the baby's external genitalia most likely to be affected by teratogens?
External genitalia: the middle of the seventh week to nearly the end of the ninth week;
near the end of the ninth week through the thirty-eight week. (Varney's, 562)
Note: I first listed the time period during which major defects are most likely to occur, and then listed the less sensitive period.
When is implantation complete?
Tenth or eleventh day (post-fertilization).
When is primitive placental circulation established?
Around the twelveth day (post-fertilization).
When is the beginning of the embryonic period?
Tenth or eleventh day (post-fertilization).
When does the heart begin to beat?
Fourth week (post-fertilization).
When is rapid development of the brain complete?
The fifth week (post-fertilization).
When do the nose, mouth and palate begin to develop?
The sixth week (post-fertilization).
When does urogenital development begin?
By the end of the eighth week (post-fertilization).
When does the embryonic period end?
The end of the eighth week (post-fertilization).
Where are all essential internal and external structures present in the developing baby?
By the end of the eighth week, which is also the end of the embryonic period (post-fertilization).
When do the baby's external genitalia have male or female characteristics?
By the end of the tenth week (post-fertilization).
When is the baby's sex clearly distinguishable? (This is not by sonogram.)
By the end of the twelfth week (post-fertilization).
When do the unborn baby's legs reach total length?
During the fifteenth to eighteenth week (post-fertilization).
When is the entire unborn baby's body covered with vernix?
By the eighteenth week (post-fertilization).
When can the baby's heart be heard with a fetoscope?
By the eighteenth week (post-fertilization).
When is the unborn baby completely covered with lanugo?
By the twenty-second week (post-fertilization).
When are buds for permanent teeth present in the unborn baby?
By nineteen to twenty-four weeks (post-fertilization).
When do the unborn baby's eyes begin to open and shut?
By twenty-four to twenty-six weeks (post-fertilization).
When does the fetus have control of rhythmic breathing motions?
By the thirtieth week (post-fertilization).
By when are the unborn baby's eyes open?
By the thirtieth week (post-fertilization).
When is the left testicle usually descended in baby boys?

When are both testicles descended?
By the thirty-fourth week (post-fertilization).

By the thirty-eight weeks (post-fertilization).
When are prominent chest and protuberant mammary glands present in the unborn baby?
By thirty-six to thirty-eight weeks (post-fertilization).
When is the baby's crown-rump length 4 1/2 inches with a weight of 3 1/2 to 4 oz?
By the end of the fourteenth week (post-fertilization).
When is a baby usually 6 1/2 inches long (crown-rump length), with a weight of 3/4 of a pound?
By the end of the eighteenth week (post-fertilization).
When is a baby usually 8+ inches long (crown-rump length), with a weight of 1 1/4 pounds?
By the end of the twenty-second week (post-fertilization).
When is a baby usually 12 inches long (crown-rump length), with a weight of 5 1/4 pounds?
By the end of the thirty-first week (post-fertilization).
When is a baby usually 14 inches long (crown-rump length), with a weight of 7 1/2 pounds?
By the thirty-eight week (post-fertilization).
The uterine endometrium is called what during pregnancy?
The uterine endometrium is called the decidua during pregnancy. (Varney's, 565)
Decidua comes from what Latin word, and what does it mean?
It comes from the Latin word “decidous” which means “a falling off”. (Varney, 565)
Each placental cotyledon consists of the main stem of a ________ _____ and all its branches.
Each placental cotyledon consists of the main stem of a chorionic villi and all its branches. (Varney, 565)
There are between ___ and ____ cotyledons.
There are between fifteen and thirty cotyledons. (Varney, 565)
Together the _______ and the __________ constitute the fetal membranes which enclose and contain the fetus in the amniotic fluid.
The amnion and the chorion. (Varney's, 556)
Describe the anatomy of the placenta.
The placenta is an amazing, well-designed organ with a wide area for the exchange of nutrients, oxygen, and other materials, supplying the baby with everything it needs, yet without allowing maternal and fetal blood to mix. The mother’s contribution to the placenta is the decidua basalis, which has three layers, the compact surface layer (the zona compacta), the spongy middle layer (spongy because of decidual cells and capillaries; the zona spongiosa), and the base layer which remains after the decidua is shed after birth to rebuild the endometrium (the zona basalis). Burrowed into the decidua basalis are the chorionic villi, which are fed by the rich blood supply in the basalis, and reach from there to the cotyledons. The cotyledons—between fifteen and thirty of them—make up most of the placenta; they are nodes, irregularly shaped, and incompletely separated by placental septa. The placenta septa are spaces between cotyledons that minimize blood exchange between cotyledons—preventing pathology or infarcts from spreading from one to another. Each cotyledon has a main branch of a chorionic villus with its numerous branches, and infinitely more sub-branches. Inside the cotyledons, and between the chorionic villi, is the intervillous space, a large blood sinus that extends from the chorionic plate to the decidua basalis. The chorionic plate comprises trophoblast—next to the intervillous space—and mesoderm internally, which is fused to the amnion after the first trimester. The amnion and chorion are both the fetal membranes, enclosing and protecting the fetus and amniotic fluid with a sterile, sealed barrier. The chorionic plate has branches of the umbilical arteries and the umbilical vein running between its internal and external layers, which then enter the chorionic villi, which enter the intervillous space.
Explain fetal circulation.
Fetal circulation comes to the placenta by way of the two umbilical arteries, bringing the deoxygenated blood back. The umbilical arteries subdivide and branch at the chorionic plate, and enter the chorionic villi, where they further divide, and form an extensive network of capillaries and veins at the end divisions. It is here, inside the chorionic villi, at the capillary-veinous network, that this amazing transfer of material occurs. (Varney, 564-568)
How is fetal circulation kept separate from maternal circulation?
The umbilical arteries subdivide and branch at the chorionic plate, and enter the chorionic villi, where they further divide, and form an extensive network of capillaries and veins at the end divisions. It is here, inside the chorionic villi, at the capillary-veinous network, that this amazing transfer of material occurs—maternal and fetal materials diffuse across the placental membrane composed of the trophoblast, connective tissue in the chorionic cilli, and the endothelium of the fetal capillaries. The blood returning to the fetus goes by the branches of the umbilical vein, as they converge and eventually become the one vein, carrying oxygenated blood to the baby. This process works exactly the same way as the umbilical arteries carrying blood away from the fetus, only in the opposite direction. Maternal blood flow in the placenta is separate from the rest of maternal circulation. Oxygenated blood enters the intervillous space via the endometrium’s spiral arteries under tremendous pressure—the exact pressure dictated by the mother’s blood pressure. This causes a spurting fountain of blood to reach into and across the intervillous spaces to the chorionic plate. When it hits the chorionic plate, it is distributed laterally by the boundary, flowing over all the branches of the chorionic villi slowly enough to allow the exchange of materials between fetal and maternal circulation. Deoxygenated blood leaves the intervillous spaces by venous openings which empty into the spiral veins in the endometrium. (Varney, 564-568)
List the functions of the placenta.
The placenta is an essential life-line for the unborn baby. It is responsible for oxygen-carbon dioxide exchange, transferring essential nutrients, excreting metabolic waste, providing needed metabolic processes, passing maternal antibodies to the baby for protection, and synthesizing hormones essential to maintaining a healthy pregnancy. It is the only disposable organ in the body. (Varney, 567)
What does the umbilical vein carry?
The umbilical vein carries the oxygenated blood to the fetus. (Varney's, 567)
What does the umbilical artery carry?
The umbilical artery carries the deoxygenated blood from the fetus to the placenta. (Varney's, 567)
List the hormones the placenta synthesizes, produces, and secretes.
Both protein and steroid hormones. In early pregnancy, the placenta synthesizes, produces, and and secretes hCG, or, Human chorionic gonadotropin. It is produced by both the cytotrophoblast, and the syncytiotrophoblast. These hormones maintain the corpus luteum, which supports the endometrium by producing progesterone and thus, the pregnancy is preserved. Other hormones synthesized, produced and secreted by the placenta: Human placental lactogen (hPL), Estrogens, progesterone, and possibly a thyroid-stimulating hormone (chorionic thyrotropiun). (Varney, 567)
What does HCG accomplish?
HCG preserves pregnancy by causing a maintained uterine lining that nourishes the developing baby.
What do high levels of estrogen and progesterone cause during pregnancy?
Breast changes, skin pigmentation, and uterine enlargement in the first trimester.
Estrogen specifically promotes the development of the duct system in the breast; progesterone stimulates the alveolar system of the breasts to further develop. Progesterone also causes the relaxation of smooth muscle fibers, which includes blood vessel walls, and sphincters.
Chorionic somatomammotropin (human placental lactogen or hPL) does what?
Stimulates breast growth, lactogenic changes, and a number of metobolic changes.
True or False?
Viral infections may pass through the placental membranes and infect the fetus without infecting the placenta.
True. (Varney, 568)
What are vitamins?
Vitamins: organic nutrients required in tiny amounts to maintain growth and normal metabolism. They coexist and work together with minerals. (Frye, 205)
What are minerals?
Minerals: inorganic substances which may appear in combination with each other or with organic compounds which are required for physiological processes; muscle response, neurological transmissions, digestion, and the utilization of nutrients from foods. They are needed for hormone production, and they assist in fluid balance and normal pH in the body. (Frye, 205)
What are enzymes?
Enzymes: chemicals which have numerous essential functions within the body. Enzymes have two parts, a protein molecule and a coenzyme which is often responsible for the delivery of nutrients to the cells and elimination of wastes from the cells. They also play a major role in growth, metabolism, cellular reproduction and digestion. (Frye, 205)
What are antioxidants?
Antioxidants: also called “free radical scavengers”, antioxidants are a group of vitamins, minerals, and enzymes that protect our body from the formation of free radicals—groups of atoms, or single atoms, that can cause cell damage, impaired immune function, and contribute to infectious or degenerative disease. Antioxidant enzymes: superoxide dismutase (SOD), methione reductase, catalase, and glutathione peroxidase. Antioxidant vitamins: A, E, C, Beta-carotene, hesperidin, and the “vitamin-like” coenzyme Q10. Antioxidant minerals: selenium. Antioxidant amino acids: L-Cysteine, L-Glutathione. Protein-rich foods, oils (vegetable, EPO, black currant seed and borage), barley grass, wheat grass, broccoli, Brussels sprouts, cabbage, and most green plants, mackerel, salmon and sardines are all sources of antioxidants. (Frye, 210)
How much protein is needed during pregnancy?
Frye recommends 80 to 100 grams of protein daily to meet the pregnant woman’s unique needs for tissue-building and blood volume expansion.
Sources:
Meat and dairy
Vegetable foods also contain all the amino acids.
Some women, with diets of high-quality vegetable protein, and optimally-functioning digestive systems will have more biologically available protein (percentage-wise) than women who get their protein from animal or highly-processed sources, and may do very well with less than 80 to 100 grams of protein. As always, the midwife should monitor the baby’s growth and the mother’s blood volume expansion to ensure that the supply of protein and other essentials are being provided by the mother’s diet.
Organic food will provide more nutrients than conventional food, regardless of the protein sources. (Frye, 220)
How should a mother adjust her diet for a multiple pregnancy?
Add an addition 500 calories and 30 grams protein for each additional baby,
Add 220 calories and 20 grams of protein for each activity or stress factor.
Eat small meals frequently!
High-protein, high-calorie, high-nutrition foods should be emphasized. No empty calories!
Daily natural multi-vitamin and mineral supplement; she may need to take two or three time the recommended dose, depending on the number of babies. The supplement she takes should be high in iron, and her diet should reflect this need as well. She can also take extra Vitamin C, bioflavonoids, and easily assimilable calcium. (Frye, 231, 894-895)
What is the purpose of protein?
Protein (specifically amino acids) is used by the body to build tissue, and, in the absence of sufficient calories, is burned for energy. The increased need for protein during pregnancy includes the expansion of the mother’s blood supply, the rapid growth of the baby, and placental growth, amniotic fluid, uterine and breast growth, and storage for labor and birth. This is true even during the embryonic period, because protein is being used to form the baby’s very earliest cells, the foundation upon which the baby’s lifelong health will depend. (Frye, 217-220, 226)
Explain why sodium is/is not important for a healthy pregnancy.
Sodium is important! It is used for the baby, amniotic fluid, to expand the blood supply, and for increased breast and uterine tissue. Sodium is crucial to proper fluid balance in the body and works with albumen to maintain proper circulating blood volume.
What can happen if a pregnant mother gets too little sodium?
Restricted blood supply, high blood pressure, impaired kidney function, decreased urine volume and increased excretion of serum uric acid. Avoid table salt with chlorine, especially if high blood pressure is a concern.
What are good sources of sodium?
Sea weeds, celery and dairy foods, along with sea salt are good natural sources of sodium. Avoid table salt with chlorine.
How can iron-deficiency anemia be corrected?
Minimal correction or support of low iron is supplied by using cast iron skillets and combining foods rich in iron and vitamin C (which aids in iron absorption) in the same meal. General therapy may include nettle leaf infusion, dark green vegetables, prunes, grape juice, organic iron supplements, and yellow dock tincture. (Frye, 251, 1007)
True or False: Cigarette smoke contains 68, 000 toxic substances?
True. (Frye, 267)
What happens to fetal hemoglobin when the mother smokes?
It is artificially elevated. This is because the carbon monoxide rapidly enters the blood stream, firmly attaches itself to the red blood cells, and prevents oxygen uptake. The carbon monoxide leads to an approximately 20% decrease in the unborn baby's blood levels of oxygen. (Frye, 266)
Nicotine causes what effects in mother and the unborn baby?
Nicotine causes the constriction of blood vessels, which contributes to hypertension. The rapid drop in uterine and placental blood flow caused by constriction of the mother’s blood vessels causes the baby’s heart rate to rise in an attempt to make up for the reduction in oxygen. It is dangerous to the baby to have insufficient oxygen, especially during labor when contractions intermittently diminish blood flow to the uterus. This constriction of maternal blood vessels beneath the placenta lasts up to fifteen minutes after the cigarette is extinguished.
What changes does smoking cause to a pregnant mother's placenta, and what dangers does this hold for the baby?
The placenta of a mother who smokes will be larger, more friable, and have less blood vessels and a decreased nutrient and oxygen exchange rate when compared to a non-smoker’s placenta. A decreased supply of nutrients and oxygen, combined with restricted blood flow (from the nicotine causing a hypertensive state) is bad news for the baby. Reduced oxygen and nutrient supply means there is an increase risk if the smoking mother carries past her due date.
What negative impact does smoking have on the circulatory system/blood besides lower oxygen uptake?
Hardening of the arteries (arteriosclerosis) and clots are more common in smokers because cholesterol and platelet adherent properties are both increased by smoking. This will aggravate platelet problems in women who have insufficient expansion of their blood volume.
What impact does smoking have on an unborn baby's weight?
Maternal smoking contributes to a decreased fetal weight (in an unhealthy way). Babies born to smokers are, on an average, half a pound lighter than those born to non-smokers, and the more a woman smokes the greater reduction in birth weight is observed. Mother who quit by the fourth month will experience a great reduction in the risk of a small-for-dates infant. With a mother that smokes, the fetal head diameter will be less than average after 18 weeks.
What diet or other recommendations can you make for a mother in your care who is quitting smoking?
Encourage her that regardless of when she quits during pregnancy, it will still benefit her and the baby. Only 48 hours after she quits, her blood will provide 8% more oxygen to her baby!
Try replacing the smoking with something else comforting: a warm bath, reading a good book, calling a friend, getting a massage, or some other productive thing she enjoys.
Light aerobic exercise can help her body with the cleansing that will inevitably occur with quitting. It also stimulates the body to produce endorphins, but in a much healthier way than smoking.
Have her eat two large and varied servings of fresh vegetables daily, and whole grain legumes; whole grains, nutritional yeast, and pumpkin seeds are also good things for her as she quits smoking. B and C vitamin supplementation is very good. Warm milk has tryptophan which is a precursor to the neurotransmitter serotonin—this decreases the anxiety and tension that can occur with the detoxification process, and encourages sleep. To detoxify, red clover infusion and lemon juice are good. Chamomile, valerian, and skullcap can be safely used to calm nerves. Wintergreen infusion or St. John’s Wort tincture can help with relieving muscle tension.
List five negative outcomes associated with drinking alcohol during pregnancy.
Spontaneous abortion, low-birth-weight babies, children with learning disabilities, infant mortality, and birth defects known collectively as Fetal Alcohol Syndrome. (Frye, 274)
Describe Fetal Alcohol Syndrome.
Prenatal or postnatal weight gain or head circumference growth delay; Abnormal features of the face and head (including at least two of the following): small head, eyes, or short eye openings, a narrow lip without center groove, short upturned nose or flattened midfacial area. Males may have abnormal testes. Abnormalities of the central nervous system, with signs of brain dysfunction, delays in behavioral development, and/or cognitive impairment. (Frye, 275)
What is a teratogenic agent?
A teratogenic agent is one which causes defects or malformation in the embryo. Most teratogenic agents can affect the human embryo only during a short time period, which has elapsed by the eighth week, although damage may occur at any time. (Frye, 274-276, 282-283)
Is there a safe amount of alcohol a pregnant mother can consume?
There is no known "safe" amount of alcohol that the pregnant mom may consume. (Frye, 276)
What about vaccines during pregnancy?
They are not recommended unless the risk of exposure clearly outweighs the potential risks of the vaccine. The main concern is how the vaccine will affect the fetus, whose immune system is still quite immature.
List the seventeen behaviors that may help you identify potentially abusive partners.
Jealousy, controlling behavior, quick involvement, unrealistic expectations, isolation, blames others for their problems, or feelings, hypersensitivity, cruelty to children or animals, “playful” use of force in sex, verbal abuse, rigid gender roles, Dr. Jekyll and Mr. Hyde, past battering, threats of violence, breaking or striking objects, and any use of force during an argument. (Frye, 301-303)
What is meant by TPALM?
TPALM is a system that allows gynecological history details to be easily noted. The letters in this acronym are replaced by numbers.
T- babies born at term
P- babies born prematurely
A- abortions; spont. or induced (any preg ending before 20 weeks)
L- currently living children
M- multiples
What does "presumptive signs of pregnancy" mean, and what are they?
Presumptive signs of pregnancy are those that the woman notes as changes in her body, which are commonly but not exclusively associated with pregnancy. Mother’s sense of pregnancy, Amenorrhea, breast changes, color changes in the vaginal mucus membranes, increased pigmentation and pigmentation changes in the skin, nausea and vomiting, quickening, urinary frequency, and fatigue are all presumptive signs of pregnancy. (Frye, 360)
What does "probable signs of pregnancy" mean, and what are they?
Probable signs of pregnancy are those that are usually due to pregnancy but may also be present in certain other conditions. They are not absolute indications that a pregnancy is the cause of their appearance. Abdominal enlargement, changes in the shape, size and consistency of the uterus, changes in the cervix, intermittent uterine contractions, ballottement or outlining of the fetus, and a positive hormonal pregnancy test are all probable signs of pregnancy. (Frye, 360)
What does "positive signs of pregnancy" mean, and what are they?
Positive signs of pregnancy are those which leave no doubt that the changes occurring in the mothers’ body are indeed due to a pregnancy in progress. Most of the positive signs of pregnancy cannot be detected until the fourth month (around the thirteenth week or so). Hearing and counting the fetal heart rate, feeling fetal movements on palpation, ultrasound or X-ray confirmation of pregnancy are all positive signs of pregnancy. (Frye 360)
How might you be able to tell if a woman has been pregnant before without her telling you?
Breasts more flabby and soft (more pronounced nipples if she breastfed).
Areolar pigmentation that occurs with pregnancy may persist in brunettes.
Abdominal tone and skin more relaxed and looser.
Uterine wall less rigid, with rounder shape, baby easier to palpate.
Possibly silvery-white stretch marks (unless she has had weight gain/loss outside of pregnancy).
Vulva may gape, is more open.
Labia minora may appear stretched, larger, more relaxed.
Scars from perineal tears.
(But sexual abuse as a child can also cause changes in external genitals.)
VE: vagina feels more roomy, os transverse split that admits fingertip. (Previous abortion or IUD can also cause transverse split).
What is important to consider when calculating a due date?
Average cycle length and regularity
First day of last two periods (normal?)
Date she thinks she conceived
Contraceptive use? Kind?
Date she first felt movement
Date when FHT were heard with
doppler, fetoscope?
Fundal height, fetal size
What is meant by a "baseline" FHR?

What is the normal range for FHTs?
The baseline fetal heart rate is the rate at which a normal healthy fetus' heart beats when at rest. (Frye, 373)
The normal range for FHTs is 120-160 bpm. (Frye, 373)
Define bradycardia.
Bradycardia occurs when the heart rate falls below 120 bpm. It may happen for an unknown cause, and occur when the baby is fine, but will not drop below 100 bpm. When there is fetal compromise, the heart rate will usually be below 100.
Define tachycardia.
Tachycardia is an elevation of the fetal heart rate of over 160 bpm. There may be periods of tachycardia in a healthy baby during fetal movement, especially if the baby’s baseline is high to begin with, but if it is sustained, it can be due to a variety of factors that compromise the baby.
Define acceleration (in reference to FHTs).
Acceleration is a temporary increase in the fetal heart rate above the normal baseline because of fetal activity or because of temporary, harmless stress such as the mother being excited or exercising.
What is variability (in reference to FHR)?
Variability is the normal fluctuation of the fetal heart rate. In a fetus that is well supplied with oxygen, the space or interval between each beat is rarely the same—this causes the baseline to appear irregular. Short-term or beat-to-beat variability usually ranges between three and eight beats per minute around an imaginary average heart rate. Fluctuation or long-term variability of three to five beats per minute usually occurs in a repeating cycle three to five times per minutes. There may be minimal variability in a sleeping baby, but if this happens continually it usually reflects a central nervous system unable to respond to stress—a compromised situation for the baby. (Frye, 373-376)
What is deceleration (in reference to FHR)?
Deceleration is a brief period of bradycardia. (Frye, 373-376)
What is reactivity (in reference to FHR)?
Reactivity is a type of variability and is defined as how much the heart rate responds to fetal rest or movement as well as to other stress such as uterine contractions. Normally the baby’s heart rate increases in speed when the baby is active, and slows down to normal baseline when the baby is at rest. Ideally, the baby’s heart rate will accelerate at least 15 beats per minute above normal baseline for 15 to 30 seconds at least twice in ten minutes, or at least five times in 20 minutes. This frequency reflects health and neurological maturity, although reactivity as defined above is not always detectable in healthy young fetuses. If little or no variability occurs during fetal movement, the baby is said to have a nonreactive heart rate. (Frye, 373-376)
How would you determine the best location to listen for FHTs on the woman's abdomen (in early pregnancy, later in pregnancy)?
In early pregnancy, you should listen just above the pubic bone.
As the baby grows larger, palpate to determine position, and listen just below the anterior shoulder through the baby's back (traditionally thought to be the easiest).
How can you determine placental location (besides with a sonogram)?
Around the twentieth week of pregnancy, start trying to find the placenta location. Starting at the pubic bone, listen over each side, then over the anterior surface of the uterus and over the fundus. The soft blowing sound of the placenta is referred to as the placental souffle, and it may be somewhere between the maternal and fetal pulse, or almost the same rate as the mother’s pulse. (Frye, 379-380)
What are the benefits of palpating the pregnant mother's abdomen?
Palpation gives you several important bits of information. If palpation is done over the entire course of the pregnancy, it can give a good idea whether uterine/fetal growth is adequate, and healthy, and allows you to estimate fetal weight. Palpation also gives information on where the baby is in the uterus (in early pregnancy), and the baby’s position and lie (and whether or not the head is engaged) in later pregnancy. You can also assess the amount of amniotic fluid, and where pockets of it are located. During labor, it can help you assess the strength of contractions, and rule out certain complications if you have a concern about them (a placental abruption would cause the uterus to be woody-hard to the touch and potentially exceedingly tender.) (Frye, 387-418)
The amniotic fluid provides ___________ and _____________ for the baby, and affords the fetus _____ to move around normally.
The amniotic fluid provides cushioning and hydration for the baby, and affords the fetus space to move about and grow normally. (Frye, 401)
What is the normal volume of amniotic fluid at term?
One to three pints is a normal amount of amniotic fluid near term. (Frye, 401)
How do you assess amniotic fluid volume?
Fluid thrill is used to access the volume of amniotic fluid, or to determine if there is an abnormal amount of amniotic fluid, such as with polyhydramnios. It requires two people, or assistance from the mother herself. The outer edge of someone’s hand should be pressed into the midpoint of the woman’s abdomen, over the navel point, with fingertips pointing at the mother’s chin or feet. The midwife then places a hand on one side of the mother’s abdomen, to stabilize it, and flicks the other side. If a distinct vibration or “fluid thrill” is felt, this is indicative of excess fluid. This evaluation can be checked in several locations to find pockets of fluid. (Frye, 401-402)
What can be learned from measuring fundal height?
Measuring fundal height helps determine if fetal growth and amniotic fluid levels are normal, and can also assist in confirming dates. (Frye, 403-404)
Why might you want to measure abdominal girth?
This is a screening tool of limited value which can only be used after the thirty-forth week of pregnancy with women of average size. To measure abdominal girth, encircle the woman’s belly with a tape measure at the level of the navel. The measurement is usually about two inches less than the week of pregnancy. If the abdominal girth remains the same on three or more occasions after thirty-four weeks, or decreases by 1 inch or more on two or more occasions, this can possibly indicate oligohydramnios, intrauterine growth restriction, or fetal demise. A large finding may indicate polyhydramnios (which causes an abdominal girth in excess of 1000 cm before term and may vary a little from visit to visit because of fluctuation in fluid volume), or multiples, or a large baby, which all will increase the abdominal girth. The girth measurement however, can be inaccurate if the woman body build is large, or different, regardless of her weight. I would consider measuring abdominal girth if I was concerned about too much or too little fluid, multiples (if the mother didn’t really want a sonogram), or the other conditions it can help diagnose. If I were to use abdominal girth measurements, though, I would like to get a baseline measurement before thirty-four weeks to get an idea of the normal measurement for the particular mom. (Frye, 406)
List possible reasons for a high fundal height for dates.
Baby carried high in uterus, baby is breech, placenta previa, fibroids, especially in the fundus or inlet, multiples, very large baby, lots of amniotic fluid or polyhydramnios, mother that carries baby all in front, or a very short mother, very shallow pelvic shape. (Frye, 406-407, 410)
List possible reasons for a low fundal height for dates.
Baby lying transverse, baby in oblique lie, baby’s upper pole leaning sidewise, baby well engaged, uterine retroversion (early pregnancy, small-for-dates baby, mother carries baby deeply inside her, or is tall, minimal amniotic fluid or oligohydramnios, intrauterine growth restriction, different pelvic shape, fetal demise. (Frye, 406-407, 410)
Why is it important to be able to accurately assess the fetal size and growth?
Why is it important to be able to accurately assess the fetal size and growth? This enables us to encourage the mother to make changes to diet, nutrition, and lifestyle to improve her health, but also the health of her baby, and possibly the outcome of the pregnancy. Knowing the fetal size and growth enables us, without resorting to sonograms every time, to know for the most part, that baby is getting enough nutrition, oxygen, and is doing well. If a baby feels small for dates, using all your screening tools (palpation, head size, fundal height, etc), and good nutrition changes do not cause it to “catch up”, other tests can be done (including a sonogram) to see what might be the problem (remember that it could simply be the norm for this mother to feel small). Make sure you take all the following into consideration before ordering a number of tests: accuracy of dates, head size, the amount of amniotic fluid, mother’s body shape, mother’s abdominal tone, uterine growth from previous pregnancies, maternal impression of fetal size, previous babies’ size at birth, rate of fundal growth from visit to visit (steady growth, even if measuring small is a good sign), and very importantly, maternal nutrition and stress levels. (Frye, 410-413)
What are the components of an integrated physical exam?
Observation of her general appearance: gait, general appearance, mental status
Check height, body frame and weight
Assess vital signs: pulse, blood pressure, respiration, temperature (if indicated)
Observe head and palpate lymph notes of the arms, face, and neck.
Examine the head: skull, facial features, mouth, eyes and ears
Palpate the thyroid
Check for varicosities of the legs
Assess for edema
Assess reflexes
Examine the torso and listen to the lungs
Examine the back and check for CVA tenderness
Listen to the heart
Perform a breast exam
Perform an abdominal exam: check for rectus diastasis, palpate liver and spleen
Check the lymph notes in the groin
Perform a pelvic exam (Frye, 414)
What vital signs should be checked at each visit, and what are the normal ranges for these?
Pulse: 60-90 beats per minute (typical is a rise of 10 to 15 points above the woman’s non-pregnant normal).
Blood pressure: There is generally a lowering of the blood pressure during the second trimester, and a rise in the third. Normal blood pressure ranges from the low end of 90/60 to 140/90 (the cut-off for high blood pressure).
Respirations: Normal is 14 to 20 breaths per minutes.
Temperature: The normal oral temperature range is 97.6-99.6 degrees Fahrenheit. The normal rectal temperature range is 98.6-100.6 Fahrenheit. The normal axillary temperature range is 96.6-98.6 Fahrenheit. The average for each of these is 98.6, 99.6, and 97.6, Fahrenheit, respectively. (Frye, 420-426, 1010)
What is the purpose of obtaining a thorough and accurate history and physical exam?
What is the purpose of obtaining a thorough and accurate history and physical? A thorough medical history and physical exam gives you a good idea of what areas of concern may arise during the pregnancy, what areas of diet, nutrition and lifestyle may need attention in order to prevent any complications she had before, or areas of concern that could occur in future. It can help you determine where she is constitutionally weak. You may also uncover emotional issues, or other areas of her life that will impact her pregnancy, labor and the birth, which will need her attention. In midwifery, we are concerned with caring for the entire person. There are good reasons to do the medical history in person rather than sending it with your client as a take-home sheet to fill out. It can be very helpful to ask for more detail as she explains what medical issues she or family have had, and the discussion can be very enlightening and give you much more information than you might otherwise glean. This is also the most personal way to do it. (Frye, 549, 564-565)
What prenatal lab work does Frye recommend?
Pregnancy test (if needed)
Complete blood count (CBC): red blood count, white blood count, differential (counting the different types of white blood cells), hemoglobin and hematocrit, platelet count
Blood type and factor with an antibody screen
Rubella titer
Hepatitis B surface antigen
Urine analysis
Syphilis screening
HIV testing, if desired after discussion
Liver or Chem profile
Tuberculosis screening (Frye, 579)
Why is breast assessment important during the antepartum period?
It is very helpful to assess the breasts early on in pregnancy to get an idea of the normal, and then be able to observe the changes that occur with normal pregnancy, and educate the mother about these changes so she is not concerned or alarmed by them. On the other hand, if abnormal growths or lumps are present, the high levels of progesterone and other hormones can cause increased or accelerated growth that should be discovered and seen by a specialist. (Frye, 444)
When would you notice an elevated basal temperature if a mother became pregnant?
From conception on.
When would spotting (if it occurs with implantation) occur?
During the third or fourth week of pregnancy.
When might morning sickness begin?
The fourth week of pregnancy.
When will the uterus become divided longitudinally, with one side becoming more elastic and enlarged?
During the fifth week of pregnancy.
By which week of pregnancy might the mother notice that she has to use the restroom more often due to increased pressure on her bladder, and more blood flow in that area? (In early pregnancy)
By six weeks of pregnancy.
When might the newly-pregnant mother begin to notice breast changes (tingling, increased blood flow, heavier feeling, darkening of nipple and areola, prominence of oil glands on the areola)?
Around six to eight weeks of pregnancy.
When can cervical and uterine softening occur in the newly-pregnant mother?
Anywhere from six to ten weeks of pregnancy, or sometimes later.
By when is the newly-pregnant mother's uterus enlarged when examined internally?
By seven weeks of pregnancy.
When is there increased pulsation in the vaginal lateral fornices, and when does the mucosa turn from pink to a violet-blue color?
By eight weeks of pregnancy.
When can the uterus be palpated abdominally, just above the pubic bone?
At twelve weeks of pregnancy.
If there is a non-central implantation, when will the uterus feel irregular in contour (in early pregnancy)?
At eight to twelve weeks of pregnancy.
When will skin changes occur---especially in darker-skinned women (in early pregnancy, specifically the lina negra)?
Around twelve weeks of pregnancy.
If vulval varicosities are present, when will they become apparent?
By around ten weeks of pregnancy.
When can the fetal heart be detected by doppler, and fetoscope, respectively?
Ten to twelve weeks of pregnancy, with a doppler.
Fifteen weeks at the earliest, with a fetoscope.
What is Braun von Fernwald’s sign?
Irregular softening and enlarging of uterus.
What is Goddell’s sign?
Cervical and uterine softening.
What is Hegar’s sign?
Softening of the isthmus.
What is MacDonald’s sign?
Softening of the uterus.
What is Chadwick’s (or Jacquemier’s) sign?
Violet-blue color of vaginal mucosa and cervix.