ATI-Women's health 41
ATI—Reproductive Cycle—Chapter 1 (1-19)
Infertility—no conception with unprotected sex for at least 12 months. Common factors—decreased sperm, ovulation DOs, tubal occlusions, and endometriosis. Meds used increase risk of multiple births > 25% Assessment (p13) Age, duration of infertility, OB hx (spontaneous abortions), Medical hx, surgical hx, sexual hx (coitus frequency, # past partners, hx STIs), occupational/environmental exposure risk, provide infor on assisted reproductive therapies (in vitro fert., embryo transfer, intrafallopian gamete transfer, surrogate partenting, adoption)
Genetic counseling—Identify clts in need of genetic counseling. Exp. Clt has Sickle cell trait, history of birth defects, <16 yrs and >35 yrs. Provide info on risk of occurrence, assist in construction of family medical histories of several generations, provide emotional support(denial, anger, grief, guilt, self blame), make referrals to support groups p13
Prenatal assessments thru—chorionic villus sampling, PUB (percutaneous umbilical blood sampling), and amniocentesis ---all have potential risks to fetus
Infertility Procedures:
Pelvic Exam—assess for vaginal or uterine anomalies
Hysterosalpinography—radiological check for patency of fallopian tubes, check for iodine and
seafood allergies.
Hysteroscopy—radiographic exam of uterus—defect, distortion, scar tissue
Laparoscopy—gas insufflation—visualize internal organs---general anesthesia used
Semen collection—used first, least invasive, 40% infertility RT men
Contraception Procedures
Vasectomy—infertility after approx. 20 ejaculations (1wk-several months)
Tubal ligation (salpingectomy)—from cutting, burning, or blocking
Hysterectomy—partial (uterus), complete (uterus, bilateral fallopian tubes and ovaries)
Contraception Assessment
BRAIDED—acronym for informed consent
B—benefits--advantages
R—risks--disadvantages
A—alternatives
I—inquires—clt ask questions
D—decisions
E—explanations—give info on selected method
D—documentation (info given U clts understanding)
Types of Contraception:
Abstinence
Adv.—most effective method, only safe sex if no genitalia contact
Disadv./Risks—required self-control, otherwise no risks
Coitus interruptus (withdrawl)—
Inst.—can have leakage of fluids from penis
Adv.—provides a form of Birth Control if no other option is available (?religious,area)
Disadv.—Lease effective method, no protections against STIs
Risks—men have to control ejaculation, fluid leakage from penis could contain sperm
Calendar Method(Rhythm)—based on sperm viable for 2-5 days & ovum for 1 day
Inst—record cycle for 6 months, subtract 18 days from # of days of shortest cycle,
Subtract 11 days from longest cycle. Fertile between these days of cycle.
Adv.—inexpensive, useful when used with other methods (BBT & cervical mucus)
Disadv.—not very reliable, requires record keeping & compliance of both partners
Risks—pregnancy from ovulation outside predicted days of cycle
Basal Body Temperature (BBT)—temp drops with ovulation
Inst.—take oral temp PRIOR to getting OOB each AM
Adv.—inexpensive, convenient, no side effects
Disadv.—inaccurate Temp interpretation (stress, fatigue, illness, alcohol, ambient temp)
Risks—unwanted pregnancy
Billings Method—cervical mucus thick/sticky, greatest stretch at ovulation (spinnbarkeit sign)
Inst.-handwash first, obtain mucus from vaginal introitus
Adv.—with practice self-eval can be very accurate, can determine ovulation during
lactation or menopause
Disadv.—women may feel uncomfortable with method
Risks—may in inaccurate if: mucous mixed w/ semen, contraceptive creams, or
discharge from infections
Condoms
Inst.—leave empty space at tip, hold rim on withdrawal, use with spermicidal cream for
Improved effectiveness.
Adv.—some protections against STIs
Disadv.—high rate of noncompliance, reduces spontaneity, must withdraw while erect
Risks—rupture/leakage, allergies to latex, use only water-soluble lubricants
Diaphragm and spermicide
Inst—get fitted, refitted q 2 yrs & with 15 wt. gain, stays in 6+ hrs after coitus, empty
Bladder prior to insertion, reapply spermicide with additional coitus
Adv.—no surgery needed, gives woman control over contraception
Disadv.—inconvenient, reduces spontaneity, additional cream needed with each coitus
Risks—NOT recommended for clts with history of TSS (toxic shock ) or UTIs
TSS is a bacterial infections. S/S: high fever, faint feeling, drop in BP, watery
diarrhea, headache, and muscle aches. Prevention: hand washing & removal of
diaphragm after 6 hrs
Combined Oral contraceptives—estrogen & progestin—suppresses ovulation, thickens mucus to
Block semen, alters uterine decidua to prevent implantation
Inst—prescription needed, consistent use required, has SE: chest pain, SOB, leg pain from a
possible clot, headache, eye problems, CVA, HTN; miss 1 pill-take 1 ASAP, miss
2—take 2 for 2 days, miss 3—skip doses for 4 days, restart new packet and use
alternate birth control
Adv—highly effective, can alleviate dysmenorrhea, reduces acne
Disadv—no STI protection, increase risks of thomoses, breast tendersness, stoke, nausea,
Headacheds, hormone-dependent cancers, can te teratogenic, exacerbates conditions
Affected by fluid retention (migraines, epilepsy, asthma, kidney/heart disease)
Risks—Do not use if >35yrs, or have history of any of the above, or smokes, decreased
effective with meds that affect liver enzymes (anticonvulsants & some antibiotics)
Minipill—oral progestins
Inst—take pill at same time daily, do not miss fill, use other form of control for 1st month
Adv—fewer side effects to combination oral contraceptives
Disadv—less effective in suppressing ovulation, increases ovarian cysts, no STI protection
Breakthrough bleeding, increases appetite
Risks: decreased effectivness with meds that affect liver enzymes (see above)
Emergency oral contraceptives (morning after pill) (high estrogen & progestin)
Inst—take within 72 hrs, take with antiemetic 1 hr prior, check for pregnancy if menstration
doesn't occur within 21 days, counsel on contraceptive methods & risky behavior
Transdermal Contraceptive patch—progesterone & ethinyl estrodiol
Inst—appy to dry skin on buttocks, abdomen, upper arm, torso (not breast area)
Adv.—consistent blood levels of hormone, avoids liver metabolism of med, not forget pill
Disadv.—No STI protection, same SE as oral contraceptives
Risks—same as oral contraceptives, avoid areas of skin rashes or lesions for application
Injectable progestins (Depo-Provera) IM injections q 11 – 13 weeks
Inst—injection during 1st 5 days of menstrual cycle & q 11 –13 wks thereafter
Adv—very effective, 4 shots/year, not impair lactation
Disadv—prolong amenorrhea/uterine bleeding, risk of thomboembolism, no STI protection
Risks—no not message injection site as may accelerate med absorption
Implantable progesin levonorgestrel (Norplant) surgicaql implantation of 6 capsules
Inst—avoid trauma to area of implantation (inner aspect of upper arm)
Adv—effective continuous contraception for 5 years, reversible
Disadv—irregular menstrual bleeding, no STI protection (use condom for STI protection)
Intrauterine device (IUD)—chemically active device, damages sperm, prevents implantation
Inst-monitor monthly after cycle to R/O migration or expulsion of device
Adv.—effective for 1-10 yrs, reversible, does not interfere with spontaneity
Disadv—increased risk for PID, uterine perforation, ectopic preg., No STI protection, report
abnormal bleeing, abdom. pain, pain w/coitus, foul discharge, fever, chills, change
in string length, or missing strings
Risk—CONTRAINDICATED if not in monogamous relationship and if never had child
Risk of bacterial vaginosis, uterine perforation, or uterine expulsion
Female Sterilization (bilateral tubal ligation)
Adv.—permanent contraception, sexual fxn unaffected
Disadv.—risks RT surgery, irreversible
Risks—ectopic pregnancy if pregnancy occurs
Male sterilization (vasectomy)
Inst—scrotal support & moderate activity post surgery, sterility delayed (20 ejaculations)
Adv—permanent, short/safe procedure, sexual fxn not impaired
Disadv—surgery, irreversible
Antepartum ATI p20f
Gestation—conception to birth
Fertilization—union of egg & sperm to form ZYGOTE—cell divisions separate into trophoblast (outer layer giving rise to placenta) & embryoblast ((inner core giving rise to embryo)
Implantation—Zygote implants into endometrium (called deciduas after inplantation) 6-10 days after conception. Usually at uterine fundus
Chorionic villi—fingerlike projections from the trophoblasts that extend into maternal blood vessels of deciduas. Place of oxygen & nutrition and waste exchange
Ovum stage (<14) –from cellular replication (morula), blastocyst formation, and differentiation into three primary germ layers (endoder/ entoderm, mesoderm, ectoderm)
Embryo stage (day 15 to 8 wks)—most critical for development, greatest risk from teratogens. Women should avoid lg groups of people to limit exposure to infections, Handwashing important
Layers of Embryo:
Endoderm/entoderm: inner most layer of cells that become internal organs (such as intestines), epithelium of respiratory tract and other organs
Mesoderm: middle layer that becomes CT, bone marrow, muscles, blood, lymph tissue, epithelial tissue, bones/teeth
Ectoderm: outer layer that develops into skin, nails, glands, CNS, PNS (peripheral NS)
Fetal Stage: (9wks to birth) viability possible >500g and 20 weeks, good chance viability >32 wks. Viability dependent on oxygenation capabilities and CNS function
4 wk—fetal heartbeat starts, body flexed, C-shaped with arm and leg buds present
8 wk—all body organs formed, 1st indication of musculoskeletal ossification
8-12wk—FHR can be heard with Doppler
12wk—sex of fetus can be determined, blood forming in marrow, kidneys able to secrete urine
16wk—face looks human, meconium present, heart muscle well-dev. Sensory organs differentiated.
20wk—preimitive Resp mov't begin, HR heard with fetoscope, quickening occurs, brain grossly
formed, vernix caseosa (protective cheese-like coating on skin) & lanugo (fine, downy hair)
24wk—body lean, but well-proportioned, lecithin (respiratory marker) begins to appear in amniotic
fluids, ability to hear.
28wk—brown fat present, eyes begin to open & close, weak suck reflex
32wk—subQfat increase, has fingernails/toenails, sense of taste present, hears sounds outside womb
38+wk—skin pink, body rounded, lanugo on shoulders & upper body only, vernix caseosa scant,
fetus receives antibodies from mother
Fetal circulation—blood oxygenated from placenta, fetal liver not in use as all nutrients from placenta
3 shunts reroute most of circulated blood past fetal lungs and liver
Ductus arteriosus—connects pulmonary artery with aorta (bypass lungs)
Foramen ovale—intra-atrial opening shunts blood from Rà L (bypass lungs)
Ductus venosus—shunts blood from unbilical vein to inferior vena cava (bypass liver)
Placenta—produces hormones needed to maintain pregnancy & performs metabolic fxns of respiration,
nutrition, excretion, and storage
Amniotic fluid—suspends the embryo/fetus and serves:
--maintain constant Temp., source of oral fluid, repository for waste, cushion to prevent injury,
allow fetal mov't & musculoskeletal devel., prevent umbilical cord compression, prevent
amnion ( inner membrane of the placenta) from adhering to the fetus.
Umbilical cord—2 arteries carry deoxygenated blood away, 1 vein carries oxygenated & nutrition to
fetus. Wharton's Jelly—surrounds cord & prevents pressure from interfering with fetal circulation.
Risk factors that can negatively impact fetal development & lead to complications:
Preterm LaboràRDS (resp. distress syndrome)
Premature rupture of membranesà fetal infection
Ectopic pregnancy
Ployhydramniosàfetal congenital anomalies & abnormal fetal presentation
Oligohydramniosà interuterine fetal death, cord compression, IUGR
Nuchal cordà fetal asphyxia
Maternal diabetesàlarge for gestational age fetus
Rh or ABO isoimmunizationà fetal hemolytic DO (erythroblastosis fetalis)
Maternal age <16 or >35-à chromosomal anbnormalities.
Teratogenic effects in utero (maternal substance abuse, chemicals, radiation exposure, infections)
Smokingà IUGR
Poor nutritionà congenital anomalies (folic acid deficiency), IUGR
Multifetal pregnancyà (dizygotic-2 ova & monozygotic-1 ova split) à abnormal attachment of
placenta, incomplete splitting of mono, tangling of cords, circulatory problems, IUGR;
3+ fetuses: restriction of blood flow available for each fetus & restrict uterine spaceàIUGR
Uteroplacental insufficiencytà IUGR, fetal distress, neonatal morbidity, fetal death
Therapeutic & Diagnostic Procedures
Abdominal & transvaginal Ultrasound—assess fetal growth & development, fetal maturity
Biosphysical profile—assess amniotic fluid volume index, fetal breathing mov'ts, body mov'ts, fetal
muscle tone, fetal heart reactivity.
Amniocentesis—assess for genetic abnormalities or fetal lung maturity
Daily fetal kick counts—3x/day, count > 3 mov'ts / 60 minutes. No mov'ts in 12 hrs-notify Dr.
Complications of fetal development
Genetic abnormalities—defective genes, Inherited DOs, chromosone anomalies, multiple
pregnancy, ABO incompatibility
Congenital anomalies—malformations that are present at birth
IUGR (intrauterine growth restriction)—failure of fetus to grow at an expected rate
Fetal death or neonatal death
Monitoring for abnormal diagnostic fetal assessments (decreased fetal mov'ts, abnormal FHR pattern, abnormally excessive or inadequate fetal growth for duration of pregnancy, encourage early & ongoing adherence or Drs recommendations and prescriptions.
Antepartum—Normal Physiological Changes of Pregnancy ATI p.33-44
Presumptive Signs of Preg—changes felt by the woman that makes her think she's pregnant
Amenorhea, M/V, fatigue, Urinary frequency, Breast changes, Quickening(Mov't felt at 16-20 wks), uterine enlargement, linea nigra, chlosasma (mask of preg), striae gravidarum, darkened areola
Probable signs—changes observed by the examiner that makes the examiner think she's pregnant
Abdominal enlargement RT changes in uterine size, shape, or position; cervical changes, Hegar's sign (softening and compressibility of lower uterus), Chadwick's sign (deepened violet-bluish color of vaginal mucosa RT increased vascularity of area), Goodell's sign (softening of cervical tip), Ballottement (rebound of unengaged fetus), Braxton Hicks contractions (painless, irregular contractions relieved by walking), positive pregnancy fest, fetal outline felt by examiner.
Positive signs—signs that can only be explained by pregnancy
Fetal heart sounds, fetal mov't palpated by experienced examiner, visual of fetus w/ultrasound
Calculation of Delivery Date:
Nagele's Rule: subtract 3 months and add 7 days + 1 year to first day of LMP (or add 9mo.+7days)
McDonald method: measure fundal height in cm from 24-34 wks + 2 weeks (cm x 8, divided by 7)
Gravity—number of pregnancies
Nulligavida—never pregnant Primigravids—first pregnancy Miltigravida—2+ pregnancies
Parity—# of pregnancies in which the fetus reaches viability, whether born alive or not.
GTPAL=Gravidity, term births (38+ wks), preterm births, abortions/miscarriages, living children
Psysiological Stgatus of Pregnant client:
Reproductive- uterus increases in size, and changes shape and position; Ovulation/menses cease
Cardiovascular-CO (cardiac output) & blood volume increase; HR increases
Respiratory-maternal O2 need increase; during 3rd trimester chest size may enlarge
Musculoskeletal—body alterations and wt. increase necessitate an adjustment in posture. Pelvic
joints relax.
Gastrointestional- N/V (may be hormonal, or increased pressure of stomach / intestines)
Renal- GFR increases; urinary frequency is common
Endocrine-placenta à an endocrine organ- (hCG, progesterone, estrogen, etc) to maintain preg.
Serum & Urine Pregnancy tests—presence of hCG(human chorionic gonadotropin) earliest biochemical marker for preg. (6-11 days in blood ; 26 days in urine) after conception following implantation;
--hCG begins w/implantation and peaks 60-70 days gestation, then declines until 140 days, then increases until term.
--Higher hCG levels indicate multifetal preg., ectopic preg, hydatidiform mole (gestational trophoblastic disease) or abnormal gestation such as Down syndrome.
--Slow increases or abnormal decreases may indicate threatened abortion
--Some meds may cause false + or — preg. results (anticonvulsants, diuretics, tranquilizers)
--urine samples should be first-voided moring specimens
Expected Vital signs
Blood pressure: same as prepreg. range 1st trimester and after 20 weeks. 5-10mmHg during 2nd trimester. Position can affect BP-supine à ¯ BP due to pressure of uterus on vena cava and result in fetal hypoxia (known as: supine hyptensive syndrome of supine vena cava syndrome) S/S are: dizziness, lightheadedness, pale/clammy skin. Use wedge under one hop to alleviate pressure