Fetal Development and Tests for Fetal Wellbeing Chapter 13 1. What is the difference between mitosis and meiosis? 2. When does an oocyte become a zygote? 3. How many sperm are usually in an ejaculation? 4. How long to sperm live in the female reproductive system? I didn’t know some could reach the oocyte within five minutes! 5. Where does fertilization usually take place? 6. What are the germ layers: ectoderm, mesoderm and endoderm and what do each of these develop? 7. What are the embryonic period and the fetal period? 8. When is a baby most susceptible to the negative effects of teratogens? Also see brief discussion on page 331. Usually tri 1. Aka embryonic period. Everything is built by 8 weeks. At 6 weeks, an insult is more likely to casuse a fallocele. 9. What are the two fetal membranes called? Which one is closest to the baby? 10. Look at figure 13-6. If a mom got a severe infection between 5 and 6 weeks gestation, what kind of defect might the baby have at birth? Also check out Table 13-1 p. 328-330. 11. What are oligohydramnios and hydramnios? 12. What is the purpose of Wharton’s Jelly in the umbilical cord? 13. What is one of the early functions of the placenta? 14. Refresh your memory on fetal circulation (Fig. 13-9). 15. What is an L/S ratio? It has to do with the respiratory system. What are you if you are an XX or an XY? 16. Due to its immunological system, why is a preterm infant at greater risk for infection? 17. What are dizygotic twins and monozygotic twins? Chapter 29: Are you okay in there? Check out ATI Chapter 7 too! This is fetal testing not fetal screening. Some of these routine tests are risky. We are using indirect testing. Look at that one table and don‟t forget that sometimes tests are dangerous and sometimes we miss FLKs. Everyone wants a perfect baby, our tests are not perfect. 1. We know utero-placental insufficiency shows up as late decelerations in labor. What other serious things does it cause (check out Box 29-2 also)? Pg 765: list of things that cause uteroplacental insuff. Oligohydramnios: growth restriction, cord compression, defects—less than 300 mls. Early oligohydramnios means the kid isn‟t peeing enough and therefore might be a renal problem. Hydramnios or „polyhydramnios‟ mean the same thing: too much meaning more than 2 L. 2. Take a look at Box 29-1 (p. 764) How many of these are amenable by primary prevention? How can we as nurses, in roles "beyond the bed rails" contribute to prevention? 3. In general what are ultrasounds used for (Table 29-2)? Pg 768. Tell mom to have a full bladder—which sucks for her so be nice about it. 4. What’s the BPD? Bi parietal diameter—can measure this and abdominal girth and femur length. 5. What are symmetric and asymmetric IUGR? Which one’s “better’? Which would you rather have? IUGR: intrauterine growth restriction. Symetrical: means the kid is small all over from chronic insult of some sort: TOB, ETOH, fetal defects, etc. Better to be small all over. Asymmetrical: [used to call this „head sparing‟] means you‟re big in the head and not everywhere else. Causes: placental insuff, HTN, diet. The body catches up eventually, but it depends what the insult was. Twins: when there‟s twin-twin placental blood transfers you get one kid that‟s symmetrical IUGR. 6. What can fetal nuchal translucency be used for? What is an abnormal finding? A nucal fold is a little fold on the back of the neck if a kid has downs, also identifies trisomy 18. 7. Using Doppler Blood Flow analysis, which is not good: an elevation of S/D ratios or a decrease in S/D ratios? Looks at blood flow along umbilical artery. Not good: increase/elevation is not good b/c it means resistance, 8.What’s an AFI and what is normal? Look at a pocket, not overall fluid. What‟s not good: under 5 ml or over 20 ml in a pocket. As the placenta ages and the kid gets less nutrients, the kid makes less amniotic fluid. 9. Review biophysical profiles. What is it used for? Pg 772. Normal score: 8-10 [just like LATCH and APGAR]. There‟s 5 things they look at: breathing movements, gross body movement, tone (maturity and health), AFI, FHR, NST. Used to think these were so great, but Cochrane says that it‟s not a good predictor of morbidity and mortality. 10. What are some complications of having an amniocentesis? Infection, hemorrhage, PPROM, AFE. What do RN‟s do post procedure: assess them for about an hour, educate them about signs of trouble. Gotta know their Rh type b/c there could be blood mixing [we‟ll give them rhogam.] 11. What an AFP? Just know the basics! There is a longer description on page 777. 12. What’s chorionic villi sampling? 13.What is PUBS for? PUBS: precut umbilical blood sampling. 14. What’s a nonstress test (NST)? What would be a good result? Tests fhr, movement, reactivity, variability. What do NST, ctxST, and kick counts, and vibroacoustic tests all determine how much reserve the fetus has—we want their HR to go up a little and come down. If neurologically intact, it moves and HR goes up. If we give a ctx we expect HR to change in relation to that, and does it have enough reserves to recover after ctx. These are not perfect predictors. Reactive means: 2 or more accelerations up by 15 bpm for ____minutes within 20 minutes. Good if you‟re “reactive” 15. What is vibroacoustic stimulation? The buzzer 16. What’s a contraction stress test (CST)? What two methods are used? What would be a good result? Tests how kid tolerates ctx. Don‟t want late decels. Gold star: “negative.” Meaning neg for late decels—that‟s a good thing. These stress tests are poor predictors, and show false “hunkey dorey‟s” and also false “oh crap.” Tend to cause MORE “oh craps.” 17. What’s a student stress test (SST)? (just kidding!!) Anemias we can find: microcytic, beta thalassemia. Folic acid def anemia: makes macrocytes Antibody screens; RH. Usually do rhogam at 28 weeks if mom is RH negative. If mom was in MVA or in DV trauma we‟ll give rhogam. 10% of women have a bladder infection, but no symptoms and the immune system will fight it off. We do UA‟s on moms b/c they can‟t have the risk of pyelonephritis. TB: we can screen for that. TORCH test: it‟s in ATI. We don‟t do the whole thing any more. Toxoplasmosis: in cat feces—it‟s a virus, it survives cat guts. Prenatal teaching is good here, you don‟t want mom getting the virus for the 1st time during pregnancy—causes learning, hearing, visual disabilities. If you get it in 1st tri, 30% affect, but in 3rd tri 60% backwards from the norm. Most people are already immune to it. It‟s airborne after about 3 days in feces, so don‟t inhale. Also wear gloves when gardening. OTHER: gon, syph, chicken pox, heb b, HIV, 5ths disease. Gon: blindness in kiddo Chlamydia: Syphalis: babes will have neuro problems just like tertiary syphilis. We test people in 1st tri and high-risk people later on too. Need to treat and follow w/ serial syphilis tests. Varicella; less of this lately, but in tri 1 can cause fetal demise. Hep B: liver thing, pretty much vaccinating all kids GBS: causes pneumonia in newborns HIV: in pregnancy: can get passed to the baby and they can die. HIV is bad. Rapid HIV screen is being used when admitted to L&D. Mom has to be treated during pregnancy b/c it passes the placenta. 5ths: parvo-virus, carried in daycare by children, get generalized rashes, or the bitch-slap rash on the face. Causes trouble before 18 weeks. RUBELLA: causes blindness CMV: similar to mononucleosis. Transmitted thru blood, saliva, sex, feces, [daycare thing again], causes hearing loss, MR, dangerous in 1st 20 weeks. Women are usually asymptomatic. HERPES: 2 kinds, 1 and 2, used to say 1 was above the waist, but now we know that‟s really not true. H1 is not as bad as H2 for fetus or grownups. Herpes is something that most of us test positive for: 80% of pop, but not all those people have had outbreaks. Primary herpes is the first infection, usually a systemic infection. Secondary Herpes is reinfection—hangs out in nerve ganglion and comes back and goes away and comes back and goes away. Usually lesions come out on the same nerve segment. Primary infection is really the dangerous thing for fetuses: if 1st tri, the baby will die. If after tri 1, she‟s at risk for SGA and preterm labor, can have encephalitis. Stress does bring out herpes, but some women have less outbreaks when pregnant. At about 36 weeks we recommend women will use prophylactic antivirals to prevent shedding. Some hospitals will cut a CS if she‟s got an outbreak, others will deliver vaginally and treat baby with IV anti virals. We use the nuchal cord and then some other blood tests to identify some of these trisomies. Neural tube defect; usually spina bifida. AFP: if the ntd indicators are high, we recommend they go on and have an amniocentesis. Recommend all moms do blood tests: AFP, triple markers, etc. If mom is under 35, unless there‟s hx, we don‟t recommend amniocentesis or chorionic villi sampling. Why is 35 a magic age? At 35 there‟s an increase in congenital/chromosomal defects in general. The magic number at 35 the rate is 1/350 for having a funky kid. Major risk factor w/ amnicentesis is infection or rupture, sticking the kid, going thru placenta, PPROM. 35 is the magic age b/c the risk of an FLK is greater than the risks with amnio. If a mom doesn‟t plan to abort if the kid is funny, and asks why she should get the test, what do you say? You say: you probably want to deliver at a tertiary care center [UCSF], want to be able to plan your life and care for a kid, can help choose fetal surgery, prepare for neonatal surgeries, can plan grieving etc. Some parents choose comfort care with trisomy 18 and stuff. JK doesn‟t tell her patients that they should abort. Chorionic villi sampling: another big needle into ABD or thru cervix and get a little piece of chorion—tests stuff and in tri 1, but doesn‟t test spina bifida so you still need the AFP. Handles the triple marker too. There‟s a higher risk w/ CVS for miscarriage than w/ amnio. US: good for dating a pregnancy, check nuchal fold, limb deformities [at 18-20 weeks], gender, eye spacing, etc. People w/ triplets and twins, etc get more US‟s. People are said to have greater attachment to the kid they‟ve seen on a US. Work and enviro hazards: DV, dental, diet, ETOH, drugs, etc etc. Don‟t forget you get medical for dental care during pregnancy.