CLAIRE GANTUANGCO 01-22-10

BSN-4C FPC MRS. ARENDAIN, RN,RM, MAN

Development
Main article: Prenatal development

9 weeks of gestation: condition at start of fetal stage

Artist's depiction of fetus 11 weeks after fertilization. The crown-rump length is 1.25
inches.[7]

The fetal stage commences at the beginning of the 9th week.[1] At the start of the fetal
stage, the fetus is typically about 30 mm (1.2 inches) in length from crown to rump, and
weighs about 8 grams.[1] The head makes up nearly half of the fetus' size.[8] Breathing-like
movement of the fetus is necessary for stimulation of lung development, rather than for
obtaining oxygen.[9]The heart, hands, feet, brain and other organs are present, but are only
at the beginning of development and have minimal operation.[10][11]

Fetuses are not capable of feeling pain at the beginning of the fetal stage, and will not be
able to feel pain until the third trimester.[12] At this point in development, uncontrolled
movements and twitches occur as muscles, the brain and pathways begin to develop.[13]

16 to 25 weeks after fertilization

A woman pregnant for the first time (i.e. a primiparous woman) typically feels fetal
movements at about 21 weeks, whereas a woman who has already given birth at least two
times (i.e. a multiparous woman) will typically feel movements by 20 weeks.[14] By the
end of the fifth month, the fetus is about 20 cm (8 inches).

26 to 40 weeks of gestation

Artist's depiction of fetus at 40 weeks after fertilization, about 20 inches (51 cm) head to
toe.

The amount of body fat rapidly increases. Lungs are not fully mature. Thalamic brain
connections, which mediate sensory input, form. Bones are fully developed, but are still
soft and pliable. Iron, calcium, and phosphorus become more abundant. Fingernails reach
the end of the fingertips. The lanugo begins to disappear, until it is gone except on the
upper arms and shoulders. Small breast buds are present on both sexes. Head hair
becomes coarse and thicker. Birth is imminent and occurs around the 40th week. The
fetus is considered full-term between weeks 35 and 40,[15] which means that the fetus is
considered sufficiently developed for life outside the uterus.[16] It may be 48 to 53 cm (19
to 21 inches) in length, when born. Control of movement is limited at birth, and
purposeful voluntary movements develop all the way until puberty.[17][18]

Variation in growth

See also: Birth weight

There is much variation in the growth of the fetus. When fetal size is less than expected,
that condition is known as intrauterine growth restriction (IUGR) also called fetal growth
restriction (FGR); factors affecting fetal growth can be maternal, placental, or fetal.[19]

Maternal factors include maternal weight, body mass index, nutritional state, emotional
stress, toxin exposure (including tobacco, alcohol, heroin, and other drugs which can also
harm the fetus in other ways), and uterine blood flow.

Placental factors include size, microstructure (densities and architecture), umbilical

blood flow, transporters and binding proteins, nutrient utilization and nutrient production.

Fetal factors include the fetus genome, nutrient production, and hormone output. Also,
female fetuses tend to weigh less than males, at full term.[19]

Fetal growth is often classified as follows: small for gestational age (SGA), appropriate
for gestational age (AGA), and large for gestational age (LGA).[20] SGA can result in low
birth weight, although premature birth can also result in low birth weight. Low birth
weight increases risk for perinatal mortality (death shortly after birth), asphyxia,
hypothermia, polycythemia, hypocalcemia, immune dysfunction, neurologic
abnormalities, and other long-term health problems. SGA may be associated with growth
delay, or it may instead be associated with absolute stunting of growth.

Viability
Main article: Viability (fetal)

Stages in prenatal development, showing viability and point of 50% chance of survival at
bottom. Weeks and months numbered by gestation.

The lower limit of viability is approximately five months gestational age, and usually
later.[21]
Human fetus, age unknown

There is no sharp limit of development, age, or weight at which a fetus automatically

becomes viable. [22] According to data years 2003-2005, 20 to 35 percent of babies born at
23 weeks of gestation survive, while 50 to 70 percent of babies born at 24 to 25 weeks,
and more than 90 percent born at 26 to 27 weeks, survive. [23] It is rare for a baby
weighing less than 500 gm to survive.[22]

When such babies are born, the main causes of perinatal mortality is that the respiratory
system and the central nervous system are not completely differentiated.[22] If given
expert postnatal care, some fetuses weighing less than 500 gm may survive, being are
referred to as extremely low birth weight or immature infants.[22] Preterm birth is the most
common cause of perinatal mortality, causing almost 30 percent of neonatal deaths.[24]

Fetal pain
Main article: Fetal pain

Fetal pain, its existence, and its implications are debated politically and academically.
According to the conclusions of a review published in 2005, "Evidence regarding the
capacity for fetal pain is limited but indicates that fetal perception of pain is unlikely
before the third trimester."[12][25] However, there may be an emerging consensus among
developmental neurobiologists that the establishment of thalamocortical connections" (at
about 26 weeks) is a critical event with regard to fetal perception of pain. [26] Nevertheless,
because pain can involve sensory, emotional and cognitive factors, it is "impossible to
know" when painful experiences may become possible, even if it is known when
thalamocortical connections are established.[26]

Whether a fetus has the ability to feel pain and to suffer is part of the abortion debate.[27]
[28]
For example, in the USA legislation has been proposed by pro-life advocates that
abortion providers should be required to tell a woman that the fetus may feel pain during
the abortion procedure, and require her to accept or decline anesthesia for the fetus.[29]
Circulatory system
Main article: Fetal circulation

Diagram of the human fetal circulatory system.

The circulatory system of a human fetus works differently from that of born humans,
mainly because the lungs are not in use: the fetus obtains oxygen and nutrients from the
woman through the placenta and the umbilical cord.[30]

Blood from the placenta is carried to the fetus by the umbilical vein. About half of this
enters the fetal ductus venosus and is carried to the inferior vena cava, while the other
half enters the liver proper from the inferior border of the liver. The branch of the
umbilical vein that supplies the right lobe of the liver first joins with the portal vein. The
blood then moves to the right atrium of the heart. In the fetus, there is an opening
between the right and left atrium (the foramen ovale), and most of the blood flows from
the right into the left atrium, thus bypassing pulmonary circulation. The majority of blood
flow is into the left ventricle from where it is pumped through the aorta into the body.
Some of the blood moves from the aorta through the internal iliac arteries to the umbilical
arteries, and re-enters the placenta, where carbon dioxide and other waste products from
the fetus are taken up and enter the woman's circulation.[30]

Some of the blood from the right atrium does not enter the left atrium, but enters the right
ventricle and is pumped into the pulmonary artery. In the fetus, there is a special
connection between the pulmonary artery and the aorta, called the ductus arteriosus,
which directs most of this blood away from the lungs (which aren't being used for
respiration at this point as the fetus is suspended in amniotic fluid).[30]

Postnatal development

Main article: Adaptation to extrauterine life

With the first breath after birth, the system changes suddenly. The pulmonary resistance
is dramatically reduced ("pulmo" is from the Latin for "lung"). More blood moves from
the right atrium to the right ventricle and into the pulmonary arteries, and less flows
through the foramen ovale to the left atrium. The blood from the lungs travels through the
pulmonary veins to the left atrium, increasing the pressure there. The decreased right
atrial pressure and the increased left atrial pressure pushes the septum primum against the
septum secundum, closing the foramen ovale, which now becomes the fossa ovalis. This
completes the separation of the circulatory system into two halves, the left and the right.

The ductus arteriosus normally closes off within one or two days of birth, leaving behind
the ligamentum arteriosum. The umbilical vein and the ductus venosus closes off within
two to five days after birth, leaving behind the ligamentum teres and the ligamentum
venosus of the liver respectively.
 •

There's a lot more to getting pregnant

than just having intercourse sometime in the middle of your
cycle and hoping to see that positive pregnancy test instead
of your period.

I learned this the hard way.

When I was trying to conceive, I found out that there was a

lot that I didn't know. Which led me to making a lot of big
mistakes which were actually preventing me from getting
pregnant.

For one thing, I had the timing all wrong. I thought I

ovulated 14 days after the start of my period, but later
learned that this is a big mistake that many women make.
For most women, ovulation does not occur 14 days after
their period starts even though many women think this is
true. That's because most women do not have a perfect 28
day cycle.

And would you believe I was using lubrication that I later

found out can kill sperm!! That certainly wasn't helping me
to get pregnant, was it?

I also had my husband "save up" his sperm thinking this

would make him more fertile when my ovulation day came,
and it turns out this actually makes him less fertile, and
reduces the chance of pregnancy. Who knew??

Avoid Common Mistakes!

Oh, I could go on and on about all the mistakes I was
making.

Luckily, after spending months researching, I uncovered

many possible mistakes which can get in the
way of getting pregnant, and I made a lot of changes based
on what I learned.

And guess what, I conceived my two little "bundles of joy"

(not at the same time!) soon after I made
some changes!

I wrote a little report to inform other women about the

common mistakes I discovered which will
reduce your chances of getting pregnant. I bet you'll be
surprised to find that you're making at
least a few yourself!!

You can get your free copy of the "7 Mistakes Report" by
clicking here. Consider it my gift to you...

I sincerely hope it helps you have your own

little "bundle of joy."

Baby dust to you...

--Beth
GINA G. DALUMPINES 01-23-10
BSN-4C FPC MRS. ARENDAIN,RN, RM,MAN

OBSTETRICS & GYNECOLOGY

Maternal Physiology Changes During Pregnancy

The physiologic,biochemical,and anatomic changes that occur during pregnancy are

extensive and may be sistemic or local..Teleologic alterations during pregnancy mantaina
healthy enviroment for the fetus without compromising the mother`s
health.Although,sometimes determine small disconfort to the mother.

Gastrointestinal Tract

During pregnancy, nutritional requirements,including those for vitamins and minerals, are
increased, and several maternal alterations occur to meet this demand.The mother`s
appetite usually increases, so that food intake is greather, some women have a decreased
appetite or experience nausea and vomiting.These symptoms may be related to relative
levels of human chorionic gonadotrophin(hCG).

Oral Cavity

Salivation may seem to increase due to swallowing difficulty associated with nausea
,and ,if the pH of the oral cavity decreases, tooth decay may occur.Tooth decay during
pregnancy,however, is not due to lack of calcium in the teeth.Indeed,dentalcalciumis
stable and not mobilized during pregnacy as is bone calcium.

The gums may become hipertrofic, hiperemic and friable;this maybe due to increased
systemic estrogen. Vitamin Cdeficiency also can cause tenderness and bleeding of the
gums.The gums shoud return tonormal in the early puerperium

Gastointestinal Motility

Gastrointestinal motility may be reduced during pregnancy due to increased levels of

progesterone, which in turn decrease the production of motilin, ahormonal peptide that is
known to stimulate smooth muscle in the gut.Transit time of food throughout the
gastrointestinal tract may be so much slower that more water than normal is reabsorbed,
leading to constipation.

Stomach and Esophagus

Gastric production of hidrocloric acid is variable and sometimes exaggrated, especially

during the first trimester. More commonly, gastric acidity is reduced. Production of the
hormone gastin increases significantly, resulting in increased sthomac volume and
decreased stomach pH. Gastric production of mucus may be increased. Esophageal
peristalses is deceased, accompanid by gastric reflux because of the slower emptying
time and dilatation or relaxation of the cardiac sphincter. Gastric reflux is more prvalent
in later pregnancy owing to elevation of the stomach by the enlarged uterus.Besides
leading to heartburn, all of these alterations as well as lying in the supine lithotomy
position, make the use of anesthesia more hazardous because of the increased possibility
of regurgitation and aspiration.

Small and Large Bowel ann Appendix

The large and small bowel move upward and laterally,the appendix is displaced
superiorly in the right flank area. These organs return to the normal positions in the early
puerperium.

As noted previouly, motility is generally decreased an gastrointestinal tone is decreased.

Gallblader

Gallblader function is also altered during pregnancy because of the hypotonia of the
smooth muscle wall. Emptying time is slowed and often incomplete. Bile can become
thick, and bile stasis may lead to gallstone formation.

Liver

There are no apparent morphologic changes in the liver during normal pregnancy, but
there are functional alterations. Serum alkaline phosphatase activity can double, probably
because of inceased placental alkaline phosphatase isoenzimes. Thus, a decrease in the
albumin/globulin ratio occurs normally in pregnancy.

Kidneys and Urinary Tract

Renal Dilatation

During pregnancy , each kidney increases in leagth by 1-1,5cm, with a concomitant

increase in weight.The renal pelvis is dilated.The ureters are dilated above the brim of the
bony pelvis.The ureters also elongate, widen, and become more curved.Thus there is an
increase in urinary stasis, this may lead to infection and may make tests of renal function
difficult to interprete.

The absolute cause of hydonephrosis and hydroureter in pregnancy is unknown, there

may be several contributing factors:1-Elevated progesterone levels may contribute to
hypotonia of the smooth muscle in the ureter. 2-The ovarian vein complex in the
suspensory ligament of the ovary may enlarge enough to compress the ureter at the brim
of the bony pelvis, thus causing dilatation above that level. 3-Dextorotation of the uterus
during pregnancy, may explain why the right ureter is usually more dilated than the left.
4-Hyperplasia of smooth muscle in distal one-third of the ureter may cause reduction in
the luminal size. Renal Function

The glomerular filtration rate(GFR) increases during pregnancy by about 50% .The renal
plasma flow rate increases by as much as 25-50%. Urinary flow and sodium excretion
rates in late pregnancy can be alterated by posture, being twice as great in the lateral
recumbent position as in the supine position.

Even thought the GFR increased dramaticallyduring pregnancy, the volume of the urine
passed each day is not increased. Thus, the urinary system appears tobe even more
efficient during pregnancy.

With the increase inGFR, there is an incease in endogenous clearence of creatinine.The

concentration of creatinine in serum is reduced in proportion to increase in GFR, and
concentration of blood urea nitrogen is similarly reduced.
Glucosuria during pregnancy is not necessarily abnormal, may be explained by the
increase in GFR with impairment of tubular reabsortion capacity for filtered
glucose.Increased levels of urinary glucose also contribute toincreased susceptibility of
pregnant women to urinary tract infection.

Proteinuria changes litlle during pregnancy and if more than 500mg/24h is lost,a desease
process shoud be suspected

Levels of the enzime renine, which is produced in kidney, increase early in the first
trimester, and continue toarise until term. This enzime acts on its substrate
angiotensinogen, to first form angiotensin1 and then angiotensin2, which acts as a
vasoconstrictor.Normal pregnant are resistent to the pressor effect of elevated levels of
angiotensin2 but those suffering from preeclampsia are not resistant, this is one of the
some theories to explain this desease.

Blader As the uterus enlarges, the urinary blader is displaced upward and flattened in the
anterior-posterior or diameter.Pressure from the uterus leads to inceased in urinary
frequency. Blader vascularity increases and muscle tone decreases, incresin capacity up
to 1500ml.

Hematologic System

Blood Volume `

Perhaps the most striking maternal phisiologic alteration occurring during pregnancy is
the increase in the blood volume. The magnitude of the increases varies according to the
size of woman, the number of pregnancies she has had, the number of infants she has
delivered, and whether there is one or multiple fetuses.The increases in blood volume
progress until term;the average increase in volume at term is 45-50%. The increase is
needed for extra blood flow to the uterus, extra metabolic needs of fetus, and increased
perfusion of others organs, especially kidneys. Extra volume also compensate for
maternal bllod loss delivery. The average blood loss with vaginal delivery is 500-600ml,
and with cesarean section is 1000ml.

Red BloodCels The increase in red blood cel mass is about 33%. Since plasma volume
increases early in pregnancy and faster than red blood cell volume, the hematocrit falls
until the end of the second trimester, when the increase in the red blood cells is
synchronized with the plasma volume increase. The hematocrit then stabilizes or may
increase slightly near term.
Iron

With the increase in red blood cells, the need for iron for the production of
hemoglobin,naturally increases. If supplemental iron is not added to the diet, iron
deficiency anemia will result. Maternal requiriments can reach 5-6mg/d in the latter half
of pregnancy. If iron is not readly available, the fetus uses iron from maternal stores.
Thus, the production of fetal hemoglobin is usually adequate even if the mother is serely
iron deficient. Therefore anemia in the newborn is rarely a problem; instead, maternal
iron deficiency more commonly may cause preterm labour and late spontaneus abortion,
incresing the incidence of infant wastage and morbidity.

White Blood Cells

The total blood leukocite count increases during pregnancy from a prepregnancy level of
4300-4500/mL to 5000-12000/mL in the last trimester, althought counts as hight as
16000/mL have been observed in the last trimester.Counts as hight as 25000-30000/mL
have been noted in anormal patient during labor. Lymphocite and monocyte numbers stay
essencially the same throughout pregnancy; polymorphonuclear leucocytes are the
primary contributors to the increase.

Clotting Factors

During pregnancy, levels of several essential coagulation factors isincrease.Thereare

marked increases in fibrinogen and factor8. Factors VII, IX, X, and XII also increased but
to alesser extend.

Fibrinolytic activity is depressed during pregnancy and labor, although the precise
mechanism is unkown. The placenta may be partially responsible for this alteration in
fibrinolytic status.Plasminogen levels increase concomitantly with fibrinogens levels,
causing an equilibrationof clotting and lysing activity.

Clearly, coagolation and fibrinolytic sistems undergo major alterations during pregnancy.
Understanding these physiologic changes is necessary to manange two of the more
serious problems of pregnancy: hemorrage and thromboembolic desease, both caused by
disorders in the mechanism of hemostasis.

Cardiovascular System

Position and Size of Heart

As the uterus enlarges and the diaphragm becomes elevated, the heart is displaced
upward and somewhat to the left with rotation on its long axis, so that the apex beat is
moved laterally. Cardiac capacity increases by 70-80mL; this may be due to increased
volume or hyperthophy of cardiac muscle.The size of the heart appears to increase by
about 12%

Cardiac Output

Cardiac output increases approximately 40% during pregnancy, reaching its maximum at
20-24 week’s gestation and continuing at this level until term. The increase in output can
be as much as1,5L/min over the non pregnant level. Cardiac output is very sensitive to
changes in body position. This sesitivity increases with leghthening gestation,
presumably because the uterus impinges upon the inferior vena cava, thereby decreasing
blood return to the heart.

Blood Pressure

Systemic blood pressure declines slightly during pregnancy. There is a little change in
systolic blood pressure, but ddiastolic pressure is reduced (5-10mmHg) from about 12-26
weeks.Diastolic pressure increases thereafter to prepregnancy levels by about 36 weeks.

The obstruction posed by the uterus on the inferior vena cava and the pressure of fetal
presentig part on the commom illiac vein can result in decreased blood return to the heart.
This decreases cardiac output, leads to a fall in blood pressure, and causes edema in the
lower extremities.

Peripheral Resistence Peripheral resistence equals blood pressure divided by cardiac

output. Because blood pressure either decreases or remain the same during pregnancy and
cardiac output increases appreciably, there is good evidence that peripheral resistence
declines markedly. The elevated venous pressure returns toward normal if the woman lies
in the lateral recumbent position.
Effects of the Labor on the Cardiovascular System
When a patient is the supine position, uterine contractions can cause a 25% increase in
maternal cardiac output, a 15% decrease in heart rate, and a resultant 33% increase in
stroke volume. However when the laboring patient is inthe later recumbent position, the
hemodinamic parameters stabilize , with only a 7,6% increase in cardiac output, a 0,7%
decrease in heart rate, and a 7,7% increase in stroke volume. These sgnificant differences
are atributable to inferior vena caval occlusion caused by the gravid uterus. During
contractions, pulse pressure increases 26% in the supine position but only 6% in the
lateral recumbent position. Central venous pressure increases in direct relationship to the
intensity of uterine contraction and increased intra abdominal pressure. Additionally,
cardiopulmonary blood volume increases 300-500mLduring contractions. At the time of
delivery, hemodynamic alterations vary with the anestesic used.

Pulmonary System

Anatomic and Physiologic Changes

Pregnancy produces anatomic and physiologic changes that affect respiratore

performance. Early in pregnancy, capillary dilatations occurs throughout the respiratory
tract, leading to engorgement of the nasopharinx, larinx, trachea, and bronchi. This
causes the voice to change and makes breathing though the nose difficult. Respiratory
infections and preeclampsia aggravate these symptoms. Chest X-rays reveal increased
vascular makings in the lungs.

As the uterus enlarges, the diaphragm is elevated as much as 4cm, and the ribe cage is
displaced upward and widens, increasing the lower toracic diameter by 2cm and the
toracic circunference by up to 6cm. Elevation of the diaphragm does not impede its
movement.Abdominal muscles have less tone and are less active during the pregnancy,
causing respiation to be more rather than less diaphragmatic.

Lung Volumes and Capacities

Alterations occurring in lung volumes and capacitiesduring pregnancy include the

following:Dead volumes increases owing to relaxationof the musculature of conducting
airways. Tidalvolumes increases gradually(35-50%)as pregnancy progesses. Total lung
capacity is reduced (4-5%) by the elevation of the diaphragm. Funtional residual
capacity, residual volume, and respiratore reserve volume all decrease by about
20%.Larger tidal volume and smaller residual volume cause increased alveolar
ventilation (about 65%) during pregnancy.Inspiratory capacity increases 5-10%.

Functional respiratore changes include a slight increase in respiratory rate,a 50% increase
in minute ventilation, a 40% increase in tidal volume, and a progressive increase in
oxigen consuption of up to 15-20% above nonpregnant levels by term. With the increase
in respiratory tidal volume associated with a normal respiratore rate, there is an increase
in respiratore minute volume of approximately 26%. As the respiratore minute volume
increases, “hiperventilayion of pregnancy”occurs, causing a decrease in alveolar CO2 .
This decrease lowers the maternal blood CO2 tension; however alveolar oxigen tension is
maintened within normal limits.Maternal hyperventilation is considered a protective
measure that prevents the fetus from the exposure to excessive levels of CO2.. Effects of
Labour on thhe Pulmonary System

There is a further decrease in functional residual capacity (FRC) during the early phase of
each uterine contractin, resulting from redistribution of blood from the uterus to the
central venous pool. Because this decrease in FRC occurs without a concomitant change
in dead space, there is little residual diluition and, therefore, presumably more efficient
gas exchange.
Metabolism

As the fetus and placenta grow and place increasing demands on the mother, phenomenal
alterations in metabolism occur.The most obvious physical changes are weight gain and
altered body shape. Weight gain is due not only to the uterus and its contents but also to
increase breast tissue, blood and water volume in the form of extravascular and
extracellular fluid. Deposition of fat and protein and increased cellular water are added to
the maternal stores. The average weight gain during pregnancy is 12,5Kg.

During normal prgancy, approximately 1000g of weight gain is attributable to protein.

Half of this is found in the fetus and the placenta, with the rest being distribute as uterine
contractile protein, breast glandular tissue, plasma protein, and hemoglobin. Plasma
albumin levels are decreased and fibrinogen levels increased.

Total body fat incresas during pregnancy, but the amount varies with total weight gain.
During the second half of pregnancy, plasma lipids increase , but triglycerides,
cholesterol and lipoproteins decreasesoon after delivery. The ratio of low density
lipoproteins to high density lipoproteins increases during pregnancy.