By: Melissa D.

Sarmiento, RN, RM, MSN

THREE PERIODS OF FETAL GROWTH &
DEVT.
1. Pre- embryonic
2. Embryonic
3. Fetal


I. FERTILIZATION
Ampulla portion of the fallopian tube where
fertilization takes place
72 hours total critical time span during
which sexual relations must occur for
fertilization to be successful

1. ZONA PELLUCIDA
2. CORONA RADIATA

FIMBRIAE fine hairlike structures that lines the
openings of the fallopian tubes
FLAGELLA tail of the spermatozoa
HYALURONIDASE protective enzyme released
by
the spermatozoa and acts to dissolve the
layers of cell protecting the ovum
HYDATIDIFORM MOLE (H-MOLE) multiple
sperm enter the ovum that leads to
abnormal growth
FERTILIZATION IS NEVER CERTAIN, IT
DEPENDS ON THREE SEPARATE FACTORS
1. Equal maturation of both sperm and ovum
2. Ability of the sperm to reach the ovum
3. Ability of the sperm to penetrate the zona
pellucida and cell membrane
II. IMPLANTATION contact between the
growing structure and the endometrium
- occurs approximately 8-10 days after
fertilization

3-4 days zygote migrates towards the body of
the uterus
MORULA the zygote that reaches the body of
the uterus
BLASTOCYST structure that attaches to the
uterine endometrium leaving a fluid space
surrounding an inner cell mass
TROPHOBLAST cells in the outer ring

PARTS THAT WILL FORM THE PLACENTA
AND MEMBRANE
1. Blastocyst
2. Trophoblast

EMBRYOBLAST CELL portion of the structure
that
will form the embryo


APPOSITION process whereby the blastocyst
brushes against the rich uterine
endometrium in the secretory phase
ADHESION blastocyst attaches to the surface
of endometrium
INVASION blastocyst settles down into its soft
folds
EMBRYO the implanted zygote

III. EMBRYONIC
DECIDUA endometrium growing in thickness
and vascularity
3 SEPARATE AREAS OF THE DECIDUA
1. Decidua Basalis
2. Decidua Capsularis
3. Decidua Vera

About the 10
th
to 14
th
day of conception, the
blastocyst cells differentiate into the primary
germ layers
1. Ectoderm
2. Mesoderm
3. Endoderm


CHORION first and outermost membrane to
form
CHORIONIC VILLI miniature villi or probing
fingers on the surface of the chorion
- at term almost 200 villi will have formed
LAYER OF TROPHOBLAST CELL IN THE
CHORIONIC VILLI DIFFERENTIATION
1. Syncytiotrophoblast (Syncytial layer)
2. Cytotrophoblast (Langhans layer)


Begins to form at the time of implantation
A. THE PLACENTA
- arises out of trophoblast tissue
- 15-20 cm in diameter and 2-3 cm in
depth at term
- serves as the fetal lungs, kidneys, GI tract
and as a separate endocrine organ
throughout pregnancy

2 PARTS OF THE PLACENTA
1. maternal portion
2. fetal portion
CIRCULATION
As early as the 12
th
day of pregnancy, maternal
blood begins to collect in the intervillous spaces
of the uterine endometrium surrounding
chorionic villi
By the 3
rd
week, oxygen and other nutrients
and water diffuse from the maternal blood
through the cell layers of the chorionic villi to
the villi capillaries; nutrients are then
transported back to the developing embryo
COTYLEDONS 30 separate segments in a
mature placenta; makes the maternal side
of the placenta at term look rough and
uneven
100 MATERNAL UTERINE ARTERIES supply
the mature placenta


1. hCG
2. Estrogen
3. Progesterone
4. Human Placental Lactogen

B. UMBILICAL CORD formed from the fetal
membranes and provides a circulatory
pathway that connects the embryo to the
chorionic villi of the placenta
Transport oxygen and nutrients to the fetus
from placenta and to return waste products
from the fetus to the placenta
About 53 cm in length at term and about 2 cm
thick
WHARTONS JELLY a gelatinous
mucopolysaccharide which gives the cord body
and prevents pressure on the veins and arteries
that pass through it

C. AMNIOTIC MEMBRANES (AMNION)
- second membrane lining the chorionic
membrane and forms beneath the chorion
Chorionic membranes outermost fetal
membranes; arises from the smooth chorion left
by the chorionic villi not involved in
implantation



D. AMNIOTIC FLUID
- constantly being newly formed by the
amniotic membrane
- 800 to 1,200 ml at term
HYDRAMNIOS excessive amniotic fluid
OLIGOHYDRAMNIOS reduction in the
amount
of amniotic fluid
Important protective mechanism for the fetus
Protects fetus from changes in temperature
Aids in muscular development
Protects umbilical cord from pressure


PREGNANCY IS CALCULATED TO LAST
AN AVERAGE OF 10 LUNAR MONTHS, 40
WEEKS OR 280 DAYS
Embryonic stage starts on day 15 and
continues approximately the 8
th
week or until
the embryo reaches a crown-to-rump (C-R)
length of 3cm (1.2in)
Embryonic disc becomes elongated and pear
shape with a broad cephalic end and a narrow
caudal end
Ectoderm has formed a long cylindric tube for
brain and spinal cord development
GIT created from the endoderm
Most advanced organ is the heart, a single
tubular heart forms just outside the body cavity
of the embryo
Days 21-32, somites form an either side of the embryos
midline, it is where the vertebrae of the spinal column
will develop
Prior to 28 days, arms and leg buds are not visible, but
the tail bud is present
Pharyngeal arches which will form the lower jaw,
hyoid bone and larynx develop
Pharyngeal pouches appears, form the eustachian tube
and cavity of the middle ear, the tonsils and the
parathyroid and thymus glands
Primordia of the ear and eye are present
End of 28 days, tubular heart is beating at a regular
rhythm
Optic cups and lens vessels of the eye form and
the nasal pits develop
Partitioning in the heart occurs with the
dividing of the atrium
Embryo has a marked C-shaped body
Arm and leg buds are well developed with
paddle-shaped hand and foot palate
Brain has differentiated into five areas and 10
pairs of cranial nerves are recognizable
Head structure are more highly developed and the trunk is
straighter than in earlier stages
Recognizable upper and lower jaws
External nares are well formed
Trachea has developed and its caudal end is divided for beginning
lung formation
Upper lip has formed, palate is developing
Ears are developing rapidly
Arms extend ventrally across the chest and both arms and legs
have digits (still webbed)
Slight elbow bend in the arms
Prominent tail will recede
Heart has more of its definitive characteristics
Fetal circulation begins to be established
Liver starts to produce blood cells
Embryo is rounded and nearly erect
Eyes have shifted and are closer together,
eyelids beginning to form
Beginning of all essential external and internal
structures are present
Clearly resembles a human being
Facial features continue to develop
Eyelids begin to fuse
Auricles of external ears begin to assume their final
shape, but still set low
External genital appear, but sex is not clearly
discernable
Rectal passage opens with the perforation of the anal
membrane
Circulatory system is well established through the
umbilical cord
Long bones beginning to form and the large muscles
are capable of contracting
Every organ system and external structures
that will be found in the full-term newborn is
present
Remainder of gestation is devoted to refining
structures and perfecting functions
End of 9
th
week, fetus reaches a C-R length of 5cm (2in) and weighs about
14g (0.5oz)
Head is large and comprises almost half of the fetus entire size
At 12 weeks, face is well formed with nose protruding, chin is small and
the ear acquiring a more adult shape
Sucking reflex has been observed
Tooth buds appear for all 20 childs baby teeth
Limbs are long and slender with well formed digits
Fetus begin to make tiny fist
Legs are still shorter and less developed than the arms
Urogenital tract complete
Well-differentiated genitals appear
Kidneys begin to produce urine
Red blood cells produced primarily by the liver
Spontaneous movements of the fetus occur
Fetal heart rates can be ascertained by electronic devices
Period of rapid growth
LANUGO or fine downy hair begins to develop
especially on the head
Blood vessels clearly visible
More muscle tissue and body skeleton developed
Active movement are present
Fetus stretches and exercises its arms and legs
Makes sucking motions, swallows amniotic fluid
and produces MECONIUM in the intestinal tract
Skeletal ossification is clearly identifiable by the
beginning of 16
th
week
Lanugo covers the entire body, prominent on
the shoulder
Nipples appear over the mammary gland
Head is covered with fine, wooly hair
Eyebrows and eyelashes beginning to form
Muscles are well-developed, fetus is active
Mother feels fetal movement (QUICKENING)
Fetal heartbeat audible through stethoscope
Hair is growing long
Eyebrows and eyelashes have formed
Eyes structurally complete and will soon open
Has a reflex hand grip (GRASP REFLEX)
End of 6 months, (STARTLE REFLEX)
Skin covering the body is reddish and wrinkled with
little subcutaneous fat
Thickened skin on the hands and feet with skin ridges
on palms and soles forming distinct foot and
fingerprints
Skin of entire body is covered with VERNIX CASEOSA
Alveoli in the lungs just beginning to form

At 6 months, fetal skin is still red, wrinkled and
covered with vernix caseosa
Brain is developing rapidly and nervous system is
complete enough to provide degree of regulation
of body functions
Eyelids can open and close under neural control
Nails are present on fingers and toes
In male, testes begin to descend into the scrotal sac
Respiratory and circulatory systems have
developed

At 30 weeks, pupillary light reflex is present
Fetus is gaining weight from an increase in body
muscle and fat
CNS has matured enough to direct rhythmic
breathing movements and partially controlled
body temperature, lungs are not yet fully mature
Bones fully developed but soft and flexible
Fetus begins to store iron, calcium and phosphorus
Active MORO REFLEX
Fetus begins to get plump
Less wrinkled skin covers the deposits of
subcutaneous fats
Lanugo begins to disappear and nails reach the
edge of the fingertips
By 35 weeks fetus has a firm grasp and exhibits
spontaneous orientation to light
Infant born at this time has a good chance of
survival but require some special care
considered full term
Skin has a smooth polished look
Only lanugo left is on the upper arms and shoulders
Hair on head is coarse about 1 inch long
Vernix caseosa with heavier deposit in the creases and folds
of the skin
Body and extremities are plump with good skin turgor
Chest is prominent but still a little smaller than the head
Mammary glands protrude in both sexes
Fingernails extend beyond fingertips
Testes are in the scrotum
Fetal assumes position of comfort (LIE)
Extremities and head are well-flexed
Postterm labor labor that occurs after 42 weeks gestation
Gravida any pregnancy, regardless of duration, including present
pregnancy
Nulligravida a woman who has never been pregnant
Primigravida a woman who is pregnant for the first time
Multigravida a woman who is in her second or any subsequent
pregnancy
Para birth after 20 weeks gestation regardless of whether the infant is
born alive or dead
Nullipara a woman who has had no births at more than 20 weeks
gestation
Primipara a woman who has one birth at more than 20
weeks gestation regardless of whether the infant was born alive or
dead
Multipara a woman who has had two or more births at more than 20
weeks gestation

Stillbirth an infant born dead after 20 weeks gestation
Gestation the number of weeks of pregnancy
since the first day of the last menstruation
Abortion birth that occurs before the end of 20 weeks
of gestation
Term the normal duration of pregnancy
Antepartum time between conception and the onset of
labor
Intrapartum time from the onset of labor until the birth of
the infant and the placenta
Postpartum time from the delivery of the placenta and
membranes until the womans body returns to a non-pregnant
condition
Preterm or premature labor labor that occurs after 20
weeks but before completion of 37 weeks gestation



LMP last menstrual period
EDC expected date of confinement
EDB estimated date of birth
EDD expected date of delivery
AOG age of gestation
NAGELES RULE standard method used to
predict the length of pregnancy
Mc Donalds Rule a symphysis-fundal height
measurement
NAGELES RULE

FOR LMP JAN. TO APRIL
-3MONTHS +7 DAYS
FOR LMP MAY TO DEC.
+9 MONTHS + 7 DAYS + 1 YEAR
LMP = DEC. 29, 2012
DAY OF VISIT = AUG. 16, 2013
DEC = 2
JAN = 31
FEB = 28 AOG = 230 7 = 32 WEEKS & 6 DAYS
MAR = 31
APR = 30 AOG = 32 4 = 8 MONTHS & 6 DAYS
MAY = 31
JUNE = 30
JULY = 31
AUG = 16
___
230 DAYS

Mc Donalds Rule distance from the uterine
fundus to the symphysis pubis is equal to
AOG between the 20
th
and 31
st
week of
pregnancy
APPROXIMATE HEIGHT OF FUNDUS AT
VARIOUS WEEK OF PREGNANCY:
Over the symphysis pubis 12 weeks
Level of umbilicus 20 weeks
At the xiphoid process 36 weeks
Multiple pregnancy
A miscalculated due date
A large for gestational age infant
Hydramnios
H-mole

Intrauterine growth restriction
Miscalculated length of pregnancy
Anomaly (anencephaly)

FETAL MOVEMENT
QUICKENING fetal movement felt by the
mother

METHOD OF ASSESSING FETAL MOVEMENT
1. Sandovsky Method
2. Cardiff Method
FETAL HEART RATE
Counted and heard as early as 10
th
to 11
th

weeks of pregnancy by using Ultrasonic
Doppler techn ique
Audible through stethoscope at 18-20 weeks
120-160 beats/min

FETAL TACHYCARDIA sustained rate of 161
bpm or above
MARKED TACHYCARDIA 180bpm or above
Early fetal hypoxia
Maternal fever
Maternal dehydration
Beta-symphatomimetic drugs
Amnionitis
Maternal hyperthyroidism
Fetal anemia
FETAL BRADYCARDIA is a rate less than
120bpm
CAUSES:
Late fetal hypoxia
Maternal hypotension
Prolonged umbilical cord compression
Fetal arrhyhtmia
Uterine hyperstimulation
Abruptio placenta
Uterine rupture
Vagal stimulation in the second stage



Any agent that can cause development of
abnormal structures in an embryo
Substances that affect the normal growth and
development of the fetus
TOBACCO specific mechanism of smokings
effect on the fetus is not known
Effects:
Low birth weight
Risk of spontaneous abortion
Preterm birth
PROM
Placenta previa
Abruptio placenta
Higher morbidity

Greatest Risks:
Intrauterine growth restriction or prematurity
Intrauterine distress
Neonatal neurobehavioral abnormalities

ALCOHOL
Effects:
a. heavy drinkers FAS
b. moderate drinkers lowered birth weight,
neurologic effects
c. occasional drinkers does not carry any
known risk
CAFFEINE
Effects:
- increased risk of decreased birth weight has been
found in infants of mothers who consume at least
600mg of caffeine daily

DRUGS
Vit. A derivatives craniofacial, cardiac, CNS
anomalies
Analgesics (ASA, NSAIDs) prolonged pregnancy,
maternal bleeding, patent ductus arteriosus
Antineoplastics multiple anomalies


Anticonvulsants Phenytoin (Dilantin) neural tube
defects, fetal anomalies
Anticoagulants (Warfarin) fetal bleeding or anomalies
Antidepressants cardiovascular anomalies
Antischizophrenic (Lithium) hydramnios
Antithyroid (Methimazole) hypothyroidism in fetus
Antibiotics (sulfonamides) hyperbilirubinemia in
newborn
Antibiotics (Tetracycline) teeth and bone deformities
Antihelmintics (Lindane) limit exposure to 2 doses
ACE inhibitors oligohydramnios
Softdrinks, chocolates low birthweight

Hypoglycemics profound hypoglycemia in
newborn
Radiopharmaceuticals destroy thyroid of
fetus
Narcotics CNS anomalies, growth retardation
Tranquilizers growth retardation, CNS
dysfunction, hypotonia, respiratory depression
Vaccines (live) possible infection in fetus


1. Toxoplasmosis CNS damage,
hydrocephalus, microcephaly, intracerebral
calcification and retinal deformities
2. Rubella deafness, mental and motor challenges,
cataracts, cardiac defects, IUGR, dental and
facial clefts, cytopenic purpura
3. Herpes Simplex (Genital Herpes) severe
congenital anomalies, spontaneous miscarriage,
premature birth, IUGR, continuing infection at
birth
4. Syphillis congenital anomalies, congenital
syphillis
1. Metal and chemical hazards (pesticides, carbon
monoxide, formaldehyde, lead) cognitive or
neurological abnormalities
2. Radiation
- exposure before implantation, the zygote is
killed
- causes nervous system, brain and retinal
damages
3. Hyperthermia abnormal fetal brain development,
seizure disorders, hypotonia, skeletal
deformities
PRESUMPTIVE (SUBJECTIVE) CHANGES
A. Amenorrhea
B. Nausea & vomiting
C. Urinary frequency
D. Changes in the breast
E. Quickening
F. Fatigue
G. Uterine enlargement
H. Linea nigra
I. Melasma
J. Striae gravidarum



PROBABLE (OBJECTIVE) CHANGES
A. Changes in pelvic organs
1. Goodells Sign
2. Chadwicks Sign
3. Hegars Sign
4. Mc Donalds Sign
B. Enlargement of the abdomen
C. Braxton Hicks Contractions
D. Uterine Souffle
E. Palpation of fetal outline
F. Ballotement
G. Presence of hCG in serum laboratory test
H. Sonographic evidence of gestational sac

POSITIVE (DIAGNOSTIC CHANGES)
A. Fetal heartbeat audible
B. Fetal movement felt by examiner
C. Visualization of fetus by ultrasound
examination (evidence of fetal outline)
Vaginal bleeding
Persistent vomiting
Chills and fever
Sudden gush of clear fluid from the vagina
Abdominal or chest pain
PIH
Increase or decrease in fetal movement
A major strategy for helping to reduce the number
of low-birthweight babies born yearly.
Essential for ensuring the overall health of
newborns and their mothers.
1. Health history
Demographic data
Chief concern
- LMP, result of pregnancy test
- use of pregnancy test
- signs of early pregnancy
- discomforts of pregnancy
- danger signs of pregnancy
- ask if pregnancy was planned
2. History of Past Illnesses/Past Medical History
- history of kidney disease, HPN, STI, diabetes,
thyroid disease , recurrent seizures, gallbladder
disease, UTI, varicosities, phenylketonuria, TB
and asthma
- childhood diseases like chickenpox, mumps,
measles, German measles, or poliomyelitis
- ask about allergies and any past surgeries
- surgical procedures and presence of bleeding
disorders or tendencies


3. History of Family Illnesses/Family Medical
History
- cardiovascular and renal diseases, cognitive
impairment, blood disorders, or any known
genetically inherited diseases or congenital
anomalies
- occurrence of multiple births
- occurrence of caesarian births and causes
4. Social Profile
- current nutrition, elimination, sleep, exercise,
recreation, and interpersonal interactions
5. Gynecologic History
Age of menarche
Usual cycle (interval, duration, amount of
menstrual flow)
Presence of discomforts
Monthly perineum self-examination
Past surgery on reproductive tract
Family planning methods used
Sexual history
Assess possibility of stress incontinence
Pap Smear
Previous infections
6. Obstetric History
Review pregnancy briefly
Previous miscarriage or abortions
GTPAL or GTPALM, TPAL/FPAL Score

G number of times she has been pregnant
T number of full-term infants born
P number of preterm infants
A number of spontaneous or induced
abortion
L number of living children
M multiple pregnancies
7. Current Medical History
Weight
Blood type and Rh factor
Any medications presently taken
Previous or present use of alcohol
Drug use or abuse
Drug allergies and other allergies
Potential teratogenic insults
Presence of diabetes, HPN, cardiovascular disease,
renal problems, thyroid disease
Record of immunization

8. Review of systems
9. Physical Examination
Baseline data
System assessment
Pelvic examination
- pregnant women should remain in a lithotomy
position for a short time to prevent
thromboembolism and supine hypotension
syndrome



10. Laboratory Assessment
Blood assessment
Urinalysis
TB
Ultrasound
11. Nutritional status
- woman must eat adequately to supply
enough nutrients to the fetus
- woman will not have to increase the
quantity of food but they will have to
increase the quality of food they eat

Systematic way to evaluate the
maternal abdomen
Preparation:
Empty the bladder
Lie on her back with her feet on the
bed and her knees bent

1. First maneuver
Facing the woman, palpate the upper abdomen
with both hands.
Note the shape, consistency, and mobility of
the palpated part.
Fetal head is firm and round and moves
independently of the trunk. The buttocks feels
softer, and it moves with the trunk.
4. Fourth Maneuver.
Facing the womans feet, place both hands on
the lower abdomen and move hands gently
down the sides of the uterus toward the pubis.
Note the cephalic prominence or brow.
2. Second Maneuver
Moving the hands on the pelvis, palpate the
abdomen with gentle but deep pressure.
The fetal back on one side of the abdomen feels
smooth, and the fetal extremities on the other side
feels knobby.
3. Third Maneuver
Place one hand just above the symphysis pubis.
Note whether the part palpated feels like the fetal
head or the breech and whether it is engaged.
NURSING DIAGNOSES IN EARLY PREGNANCY
Health-seeking behaviors related to interest in using
herbal medicines to relieve discomforts of pregnancy
Disturbed body image related to breast and abdominal
enlargement in pregnancy
Constipation related to reduced peristalsis in
pregnancy
Fatigue related to increased physiologic need for sleep
and rest during pregnancy
Acute pain related to frequent muscle cramps
secondary to physiologic changes of pregnancy
Disturbed sleep pattern related to frequent need to
empty bladder during night

1. Breast tenderness
2. Palmar erythema
3. Constipation
4. Nausea, vomiting and pyrosis
5. Fatigue
6. Muscle cramps
7. Hypotension
8. Varicosities
9. Hemorrhoids
10. Frequent urination
11. Abdominal discomforts
12. Leukorrhea

Health seeking behaviors related to
discomforts of middle to late pregnancy
Acute pain related to sudden postural change
in pregnancy
Anxiety related to shortness of breath resulting
from expanding uterine pressure on
diaphragm
Deficient knowledge related to occurrence of
Braxton Hicks contractions in late pregnancy

1. Backache
2. Headache
3. Dyspnea
4. Ankle edema
5. Braxton Hicks contractions
LOCAL CHANGES
- involves the uterus, ovaries, vagina and breasts

1. Uterine changes
a. increase in size (length,
depth, width, weight, wall thickness and
volume)
length 32cm
Depth 22cm
Width 24cm
Weight 1,000g
Thickness early pregnancy 2cm; end of pregnancy 0.5cm
thick
Volume more than 1,000ml


b. Stretching of muscle fibers of the uterus
c. Hegars Sign
2. Amenorrhea
3. Cervical changes
more vascular and edematous
Darken to violet
Goodells Sign
Cervical hypertrophy and hyperplasia
Mucus filled cervical canal



4. Vaginal changes
Hypertrophic vaginal epithelium
Increase in vascularity
Change in vaginal secretion pH
5. Ovarian changes
Halt in FSH and LH production
Increase in size of the corpus luteum at the surface of the ovary
until 16
th
week
6. Changes in the breast
Feeling of fullness, tingling, or tenderness
Increase breast size
Darkened and increase diameter of the areola
Prominent blue veins
Supple nipple
Breast secretes milk



SYSTEMIC CHANGES
1. Integumentary system
Striae gravidarum
Protruding umbilicus
Linea nigra
Melasma
Vascular spider
Increase perspiration
Palmar erythema
Increased scalp hair growth



2. Respiratory system
Marked congestion of the nasopharynx
Shortness of breath
Total O2 consumption increase by as much as 20%
3. Cardiovascular system
Increased circulatory blood volume
Needs iron supplementation
Increase cardiac output and heart rate
Decrease BP at 2
nd
trimester and rises at third trimester
Impaired blood flow at lower extremities
Supine hypotension syndrome
Increased circulating fibrinogen


4. Gastrointestinal system
Heartburn, constipation and flatulence
Hemorrhoids
Nausea and vomiting
Some women with hypertrophy of gumlines
Hypertyalism
5. Urinary system
Fluid retention
Gradual increase in urinary output
Increase urinary frequency


6. Skeletal system
Increased calcium and phosphorous needs
Gradual softening of the pelvic ligaments and joints
pride of pregnancy
7. Endocrine system
Placenta
Halt in FSH and LH production
Increase production of melanocyte stimulating hormone
Enlarged thyroid gland
Increase production of insulin
Adrenal glands activity increases
8. Immune system
Decreased immunologic competency