1. Define the following terms
a. Abortus
i. An embryo (0-8wks of intrauterine life) or fetus (8 weeks to delivery) that
is removed or expelled from the uterus at 20wks or less gestation and
1. Weighs 500g or less OR
2. Measures 25cm or less
b. Birth rate
i. Total number of live births (for a specific area and time) divided by the
total population (for the same area and time) multiplied by 1000
1. Usually reported as “______ per thousand/year.”
c. Maternal mortality rate
i. Number of maternal deaths during a given time per 100,000 live births
during the same time.
ii. Refers to a female death from any cause related to or aggravated by
pregnancy or its management during pregnancy and childbirth or within
42 days of termination of pregnancy, irrespective of the duration and site
of the pregnancy.
iii. Every day 2-3 women die of pregnancy complications in the US
iv. The US has the highest maternal mortality rate in the industrialized
world.
1. Texas has the highest rate in the world.
d. Perinatal mortality rate
i. Number of stillbirths plus the number of neonatal deaths per 1,000 live
births.
e. Stillbirth
i. An infant who, at birth, demonstrates no signs of life, such as breathing,
heartbeat, or voluntary muscle movement.
2. State those organizations responsible for establishing standards of care for the practice
of women’s health/obstetric/and newborn nursing and medicine.
a. Nurse practice acts
i. State boards of nursing
b. Hospital licensing laws
i. State and federal government bodies
c. Standards of practice for their practitioners
i. Professional and specialty organizations
d. Standards of care for their nurses through written policies and procedures
i. Individual institutions
3. Identify the primary organization for women’s health, obstetric and neonatal nurses.
a. American College of Obstetricians and Gynecologists
4. Describe the required educational background for a RN interested in becoming a
women’s health, obstetric or neonatal nurse.
5. Provide the full titles for the following abbreviations
a. MD: medical doctor
b. DO: doctor of osteopathy
6.
7.
8.
9.
c. NNP: neonatal nurse practitioner
d. CNM: certified nurse midwives
e. FNP/FNP-C: family nurse practitioner
f. WHNP/WHNP-C/WHCNP
g. PA/PA-C: physician assistant
h. APRN: advanced practice RN
i. DNP: doctorate nurse practitioner
Describe the educational background for all healthcare providers and direct entry
midwives who provide women’s health, obstetrics, and neonatal care.
List the duties of each of the professional categories listed above.
a. MD/DO
i. Diagnose, treat, and evaluate the treatment of medical diseases
ii. Prescriptive privileges
iii. Obstetrician, gynecologists, perinatologists, maternal-fetal medicine
specialists
iv. Family practice physicians
1. May choose to care for low-risk pregnant women
2. Uncomplicated vaginal delivery
3. Unable to perform OB/Gyn surgeries
v. Others:
1. Reproductive endocrinologist, gynecologic oncologists,
pediatricians, neonatologist, pediatric cardiologist, neurologist,
etc.
b. APRN/PA
i. APRN Obstetrics
1. Certified mid-wife
2. Family nurse practitioner
3. Women’s health nurse practitioners
ii. APRN’s in SC
1. Bachelor’s degree, NCLEX, current unrestricted license, master’s
degree in nursing.
Describe the educational background and job responsibilities of doulas
a. Education
i. No universally agreed upon requirements
ii. Many receive education from structured programs (2-3 days to several
weeks.)
1. available from several national organizations
b. Practice
i. Non-medical support and education for the woman and family
ii. Become experts in providing pregnant, laboring, and/or postpartum
women with physical comfort, emotional support, labor coaching, and
education.
1. Performs no medical functions
Compare and contrast the “medical model” vs. the “nursing model.”
1. Define
a. Culture
i. The beliefs, attitudes and values shared by a group of people
b. Family
i. The primary institution in society that preserves and transmits culture
ii. Primary unit of socialization
1. Basic structural unit within a community
iii. Group of people who consider themselves a family
c. Diversity
i. A unique set of qualities that separate people as individuals, such as race,
gender, religion, sexual orientation, physical and mental abilities,
geographic locales, economic status, and many others.
d. Cultural diversity
i. A set of shared ideas about the way we live and behave toward others.
ii. An agreed upon set of rules about style, tradition, behavior, etiquette,
etc. combined with unique set of qualities that separate us as individuals
e. Cultural competence
i. The ability to provide high-quality health care to clients and their families
with diverse values, beliefs, and behaviors.
f. Family-centered maternity care
i. An approach to the delivery of maternity care that emphasizes the
importance of providing nursing care that focuses on biopsychosocial
needs of the patient (mother) and her family.
g. Cultural imposition
i. Nurses who do not practice cultural competence
ii. Imposing one’s own cultural beliefs and values onto another
2. Discuss the similarities and differences between the different types of family structures
a. Nuclear family
i. Traditional family with two parents of opposite sex with one or more
children
ii. 69% of American families
b. Married-blended family
i. Previously married parents who have divorced their former partners and
remarried each other.
1. May be children from both prior marriages that are now living as
one.
c. Nonbiologic-parent family
i. Families in which children live independently in foster or kinship care
(living with a grandparent.)
d. Cohabitating-parent family
i. Children live with two unmarried biologic or adoptive parents
e. Single-parent family
i. Children live with unmarried biologic or adoptive parent
3.
4.
5.
6.
7.
ii. More vulnerable than other family structure types to economic and social
instability
f. Alternative family
i. LGBTQ+
g. Multigenerational family
i. Family consisting of 3 or more generations—sandwich family.
Briefly summarize the history of family-centered maternity care
a. Childbirth moved from home to hospital in early 20th century
i. Increased risk for infection
ii. Increased rates of maternal mortality
iii. Removed involvement of family in childbirth
iv. Staff-centered model of maternity care
1. Doctors’ nurses made all decisions r/t care of the mother and
newborn.
2. Care highly regimented
3. Babies only brought to mothers q 4h for feeding—usually bottle.
4. Mothers stayed in hospital between 1-2 weeks following delivery.
v. 1970s changes start to put mother and baby back together
vi. 1980s concept of family-centered maternity care developed
Compare and contrast staff-centered vs. family-centered maternity care
a. FCMC
i. Birth is normal and healthy
ii. Care must be individualized
iii. Decision-making should be collaborative
iv. Education must reflect current, evidence-based knowledge
v. Info should be shared freely between patient and caregivers
vi. Supportive people present is beneficial
vii. Mothers are preferred caregivers
viii. Mothers and babies remain together
ix. Mother and baby should be cared for by same RN
x. Parents should have constant access to NICU
Explain the importance of providing family-center maternity care
a. Greater family satisfaction
b. Parents more adept at and self-assured in parenting skills
c. Enhanced maternal/newborn bonding
d. Babies tend to cry less
e. Breastfeeding more successful
f. Caregivers report greater job satisfaction
Identify ways in which you have behaved in an ethnocentric manner in the past
Identify the key components of culturally competent care
a. Personal insight into the reality that there is disparity between one’s own culture
and that of the client.
b. Ability of the nurse to understand the behaviors of clients form her/his own
unique cultural background and educate and promote healthy behaviors in a
cultural context that has meaning for the clients.
c. Someone who is competent
i. Take abstract knowledge and apply in a practical way
ii. Communicate respectfulness for a wide range of differences
1. Including nontraditional healing practices and alternative
therapies
iii. Recognize the important of different communication styles, problemsolving, concept of space and time, and desires to be involved with care
decisions. Anticipate the need to address varying degrees of language
ability and literacy.
d. Ethnocentrism
i. Universal belief that one’s own cultural norms (about values, beliefs,
thoughts, and practices) are the correct ones.
8. Practice culturally competent nursing care
a. American cultural values
i. Many subcultures and these may be based on one or more of the
following:
1. Country of origin, ethnicity, race, primary language
2. Gender
3. Educational level
4. Socioeconomic level
5. Religion
6. Region of the country
7. Sexual orientation
8. And more
b. Shared American cultural values
i. Free expression of both positive and negative feelings
ii. Maintenance of direct eye contact during communication
iii. Use of casual titles
iv. Preference for strong handshake
v. Active involvement of father of baby in pregnancy and birth
c. Because most of us are born in US we often forget that these values do not
extend to all cultures
1. Label all parts of the external female genitalia
2. Identify the location of the perineum
3. Label all internal female structures
4. Describe the vagina and list its functions
a. Fibromuscular
b. Collapsible tube with rugae
c. Extends from vulva to uterus
d. Lies between bladder and rectum
e. Ends at the cervix (opening to the uterus)
f. Functions
i. Birth canal
ii. Outflow tract for menses
iii. Female organ for intercourse
5. Describe the uterus and list its functions
a. Made up of smooth muscle
b. Sits in the middle of the pelvic cavity
6.
7.
8.
9.
c. Three parts
i. Upper part—corpus (body)
1. Uppermost part—fundus
ii. Middle part—isthmus—lower uterine segment
iii. Lower part—cervix
d. Functions
i. Cyclic menstruation
ii. Receives, implants, retains and feeds fertilized ovum/embryo/fetus
iii. Expulsion of fetus
Name the 3 layers of the uterus
a. Endometrium
i. Highly vascular layer in which conceptus implants itself 6-7 days after
fertilization
1. Stratum basalis
2. Stratum spongiosum
3. Stratum compactum
b. Myometrium
i. Muscular, middle layer
1. Extend all around uterus in 3 different directions
ii. Elastic muscles contract and expel the fetus during labor
iii. After delivery these muscles contract to seal maternal blood vessels that
run through the uterus
c. Perimetrium
i. Outermost layer
ii. Serosal layer
iii. Equivalent to peritoneum
Name the innermost layer of the endometrium
a. Stratum basalis
i. Basal layer
ii. Next to myometrium
iii. Permanent-never shed
Explain the purpose of the fallopian tubes
a. Passage between ovaries and uterus
b. Tube down which ovum (egg) moves trying to find the sperm
i. Fertilization usually occurs in upper segment
1. Usually, occurs within 12 hours of ovulation
ii. At the end of the tubules are the fimbriated ends
iii. Pull/wave ovum that just popped out of the ovary into the tubes
Describe the functions of the ovaries
a. Ovulation
i. The release of a mature ovum (Egg) from the ovary, usually at regular
intervals.
b. Hormone production
i. Estrogen, progesterone, androgens
10. Define the following terms
a. Menarche: first menstruation
b. Puberty: transition stage between childhood and sexually maturity
c. Menstruation: periodic uterine bleeding that begins approximately 14 days after
ovulation
d. Climacteric: transitional phase during which ovarian function and hormone
production decline
e. Menopause: the last period
11. List the 4 phases of the menstrual cycle
a. Phase 1—Menstrual Phase
i. Begins with day 1 of menstrual cycle
ii. First day of monthly bleed
1. Average duration is 5 days
iii. Levels of estrogen, progesterone, LH, and FSH are low
iv. Gonadropin-releasing hormone, from the hypothalamus is still
stimulating the anterior pituitary gland to release FSH which acts to
stimulate growth of ovarian follicles
1. Maturing follicles produce estrogen
b. Phase 2—Proliferative-follicular phase
i. 5th-7th day of menstrual cycle, a single follicle is dominant
ii. Blood estrogen levels (produced by the developing follicles) increase,
sending a message to the anterior pituitary to decrease the circulating
levels of FSH
1. Estrogen also stimulates endometrial growth
iii. By about the 14th day the continued increase in estrogen stimulates the
release of LH from anterior pituitary gland
iv. A massive release of LH from the anterior pituitary gland (The LH surge)
results in ovulation (approx. 9 hours later)
c. Phase 3—Secretory-Luteal Phase
i. Begins after ovulation
ii. Although estrogen levels being to fall, the corpus luteum continues to
produce estrogen and its increases its production of progesterone
1. Progesterone causes specific changes in the endometrium that
ready it for pregnancy, the conceptus
a. Secretory glands enlarge and increase their production
and secretion of glycogen-rich mucus
b. Arteries elongate and spiral through the endometrium,
providing an increased blood supply to the implanted
conceptus.
2. If fertilization/pregnancy or implantation do not occur, the corpus
luteum regresses (starts to disintegrate), levels of estrogen and
progesterone fall, and menstruation occurs on day 1 of menstrual
cycle.
3. If fertilization and implantation do occur, the corpus luteum
continues to produce hormones to maintain a beginning
pregnancy (and prevent menstruation)
d. Phase 4—Ischemic Phase
i. Only added by some authors
ii. Can also be called premenstrual phase
1. Occurs in the last day or two of the secretory phase of the
menstrual cycle
2. Blood supply to endometrium is cut off, and the new, glycogenrich endometrium dies and is sloughed off (during Phase 1 of the
menstrual cycle)
12. For each of the phases of the menstrual cycle, describe
a. Phase 1
i. Which days each begins and stops
1. Days 1-5
ii. Hormonal changes
1. Levels of estrogen, progesterone, LH, and FSH are low
2. Gonadropin-releasing hormone, from the hypothalamus is still
stimulating the anterior pituitary gland to release FSH which acts
to stimulate growth of ovarian follicles
3. Maturing follicles produce estrogen
iii. Endometrial changes
1. Vasoconstriction of upper 2 layers of endometrium causes
shedding of those 2 layers
2. Basal layer always maintained
3. Endometrial layer restored about 4th day of cycle
b. Phase 2
i. Which days each begins and stops
1. Days 6-13
ii. Hormonal changes
1. Requires estrogen that is produced by ovarian follicles
2. Several follicles are developing
iii. Endometrial changes
1. 8-10-fold thickening endometrium
c. Phase 3
i. Which days each begins and stops
1. Day after ovulation to day 26
ii. Hormonal changes
1. After ovulation, larger amounts of progesterone produce by
corpus luteum
iii. Endometrial changes
1. Endometrium becomes edematous, thick, and vascular
a. By end of secretory phase, endometrial lining feels like
heavy, soft velvet
b. Blood and glandular secretions
c. Ready for implantation and nourishment of conceptus
d. If an ovum was fertilized, implantation occurs 7-10 days
following ovulation
13. Describe the function of the corpus luteum in the maintaining a new pregnancy
1. Describe the basic process of fertilization
a. Once an ovum has been released from the ovary—and if there has been
unprotected sex—the sperm do their best to get to the ovum (this takes
between 5 minutes to 6 hours)
b. Usually occurs in the fallopian tube
c. Once fertilization occurs, no other sperm can enter the egg
d. Fertilized egg begins to divide rapidly
e. Day 4, the fertilized egg is separating into a fluid-filled cavity and a cellular
mass—now called the blastocyst
2. Define
a. Zygote
i. A fertilized egg
b. Morula
i. Fertilized egg that is dividing rapidly—a solid ball of cells
c. Blastocyst
i. When the fertilized egg changes into a fluid-filled cavity and cellular mass
d. Embryo
e. Fetus
3. Discuss implantation of blastocyst into uterine endometrium
a. Day 7-10 after conception
i. Implantation bleeding may occur
b. Trophoblastic cells of blastocyst begin secreting enzymes which allow the
blastocyst to burrow into the tick, vascular endometrium
c. Once implantation occurs the endometrium is now referred to as the decidua
4. Describe the process of placental development from trophoblastic cells to chorionic villi
to fully formed placenta
a. Chorionic villi grow into blood-filled spaces of the decidua
i. Villi are becoming the placenta
ii. Vascular and function to obtain nutrients and oxygen from the maternal
bloodstream
1. They also dispose of fetal waste and carbon dioxide
5. Define the length of a full-term pregnancy in days, weeks, and lunar months.
a. 280 days
b. 40 weeks
c. 10 lunar months
i. Each lunar month lasts exactly 4 weeks
d. 9 calendar months
6. List and escribe the 3 stages of intrauterine development
a. Stage 1
i. Ovum or pre-embryonic
ii. Conception- day 14
iii. Cellular replication, blastocyst formation, intiital development of
embryonic membranes, establishment of primary germ layers
b. Stage 2
i. Embryonic stage
ii. Day 15- 8 weeks
iii. Most crucial part of development
1. All organs and systems forming
2. Most vulnerable teratogens
a. Substances or exposures that can cause abnormal
development of the conceptus
c. Stage 3
i. Fetal stage—from the 8th week until delivery
7. Identify the two separate layers of fetal membranes
a. Chorion—outer sac
i. Develops from trophoblast
ii. Contains chorionic villi on its surface
iii. Covering of fetal side of placenta
b. Amnion—inner sac
i. Inner membrane
ii. Develops from inner cells of blastocysts
c. Membranes enlarge with the growth of the fetus
d. Eventually the amnion and chorion encounter each other
8. List the functions of amniotic fluid
a. Maintain constant (fetal) body temperature
b. Source of oral fluid
c. Collects some wastes
d. Cushions fetus from blunt trauma
e. Allows freedom of movement so muscles and skeletal system can develop
f. Essential for lung development
g. Prevents compression on umbilical cord
h. Prevents membranes from sticking to fetus
9. Quantify the amount of amniotic fluid present within the fetal membranes (bag of
water) at term
10. Describe the function of the yolk sac
a. Transfers maternal nutrition and oxygen (diffused through chorion) to embryo
i. With beating of embryonic heart and development of placenta, yolk sac
and no longer needed
ii. At about 4 weeks, some of the yolk sac is drawn into the fetus to become
a primitive digestive tract
iii. The remainder separates and disintegrates
11. Explain the anatomy of the umbilical cord
a. 2 arteries and 1 vein
i. Vein carries oxygenated blood from placenta to fetus
ii. Arteries carry unoxygenated blood from fetus back to placenta
12. Explain the function of Wharton’s jelly
a. Type of connective tissue inside cord that protects blood vessels of cord from
compression (which may interfere with fetal circulation)
13. List all discussed functions of the placenta
a. Fetal nourishment
b. Removal of fetal waste products
c. Endocrine gland
i. Production of hCG
1. Produced by trophoblastic cells which will form into the placenta
2. Detected in maternal serum 8-10 days after conception
3. Levels peak at about 8 weeks then decrease
4. Used to maintain corpus luteum
ii. Production of human chorionic somatomammotropin (hCS)
1. Also known as human placental lactogen
2. Similar to growth factor
3. Increases resistance to insulin
4. Facilitates glucose transport across placental membrane
5. Stimulates breast development in preparation for lactation
iii. Production of progesterone
1. Initially produced by corpus luteum, but approximately 7-9 weeks,
the placenta eventually takes over the function
2. Maintains endometrium, relaxes uterus, serves to develop breast
alveoli
iv. Production of estrogen
1. Proliferation of breast glandular tissue
2. Stimulates uterine growth and uteroplacental blood flow
3. Stimulates myometrial contractility
d. Organ of respiration of fetus
i. Provides fetus with oxygen and removes carbon dioxide
ii. Fetus will practice breathing movements
e. Metabolism
i. Synthesis of glycogen, cholesterol, and fatty acids
14. List situations that decrease blood supply to placenta/fetus
15. Identify the names and purposes of fetal shunts
a. Ductus venosus
i. Shunts blood past the liver into the vena cava
ii. Closes when umbilical cord cut and blood flow from placenta stops
b. Fetal cardiac shunts
i. Foramen ovale
1. Opening between the right and left atrium
2. Allows some oxygenated blood from right atria to bypass lungs
ii. Ductus arteriosus
1. Opening between the pulmonary artery and aorta
2. Allows some oxygenated blood from the right ventricle to bypass
lungs
iii. Close as blood flow to lungs increases after birth—process begins at birth
and is fully completed within hours to months.
16. Compare and contrast monozygotic and dizygotic twins
a. Monozygotic
i. One fertilized ovum split into two distinct individuals
1. Genetically identical
2. Number of sacs and placentas depends on when the conceptus
split into two
3. Split at 13th-15th day of life→conjoined twins
ii. Dizygotic
1. Two ova (eggs) are released from ovary, and each are fertilized by
separate sperm.
2. No different genetically than siblings
3. Can be same or different sex
4. The two ova can be fertilized by sperm from the same man or
sperm from two different men
5. Likelihood of having dizygotic twins increases with maternal age
17. Describe the potential pregnancy/newborn effects maternal use/abuse of the following
substances can have
a. Alcohol
i. Miscarriage
ii. Fetal alcohol spectrum disorders
1. Present at 24 hours of life
2. Newborn symptoms
a. Lethargy
b. Seizures
c. Poor sucking reflex
d. Abdominal distention
e. Respiratory difficulty
b. Cigarette smoking
i. IUGR (intrauterine growth restriction)
ii. Decreased birthweight
1. 6oz less on avg
iii. Increased rates of perinatal and infant mortality
iv. Increased frequency of
1. Preterm labor
2. Preterm rupture of membranes
3. Placental abruption
4. Placenta previa
5. Stillbirth
v. Exposure to 2nd and 3rd increase risks of
1. Ear infections
2. Asthma, bronchitis, and other respiratory infections
3. SIDS
c. Marijuana
i. May be associated with IUGR or preterm birth
d. Cocaine and methamphetamine
i. Causes severe maternal vasoconstriction which may→violent
contractions with rapid birth and/or placental abruption
ii. Vasoconstriction can also→SGA and/or preterm birth
iii. IV use increases risk of Hep B and HIV
iv. Newborns may display
1. Tremors
2. Irritability
3. Hyperactivity to stimuli
4. Poor feeding
v. Long term effects
1. Delays in gross and fine motor movement
e. Opiates
i. Associated with increased risk of
1. Preeclampsia
2. Placental abruption
3. IUGR
4. Miscarriage
5. PROM (preterm rupture of membranes)
6. Infections
7. PTL
ii. Newborns of women who have used narcotics at risk of
1. LBW
2. Stillbirth
3. SIDS
18. Discuss the possible clinical manifestations of neonatal abstinence syndrome
a. Opiates
i. Excessive and/or high-pitched crying
ii. Seizures
iii. Hyperactive reflexes
iv. Sleep problems
v. Increased muscle tone
vi. Stuffy nose, sneezing
vii. Irritability
viii. Sweating
ix. Poor feeding
x. Tremors
xi. Vomiting
xii. Diarrhea
b. Modified Finnegan Neonatal Abstinence Score
i. Assess 21 of the most common signs of withdrawal syndrome
ii. Score >8 treatment is needed
c. Benzos
i. Signs not seen until postpartum 7-21 days
ii. More severe signs and duration of withdrawal
iii. Common signs and symptoms
1. Hypo- hypertonia
2. Excessive or poor suck
3. Emesis
iv. Severe side effects may need treatment with phenobarbital
19. Discuss client education “bullets” re: some concerning intrauterine infections
a. Rubella
i. Very serious for fetal health
ii. Congenital rubella syndrome
1. Hearing loss (most common)
2. Visual defects such as glaucoma and cataracts
3. Cardiac defects
4. Several others
5. Death
b. Cytomegalovirus
i. May be transmitted from infected person by
1. Saliva
2. Urine
3. Feces
4. Blood
5. Mucus
6. Sexually
ii. In the herpes family of viruses
iii. Most common congenital infection at birth
iv. Most dangerous if infected in the first half of pregnancy
v. Affected newborns
1. Hepatosplenomegaly
2. Thrombocytopenia with petechiae
3. IUGR
4. Microcephaly
5. Chorioretinitis
6. Hearing loss
7. Mental retardation
8. Seizures
vi. Options for treatment
1. Elective abortion
2. Treatment with antiviral
a. Ganciclovir, foscarnet, cidofovir, valganciclovir
3. Hyperimmune globulin