Maternal, Fetal, & Neonatal Physiology: A Clinical Perspective

721 Pages·2017·17.004 MB·English

by  Susan Blackburn

Maternal, Fetal,
&
Neonatal Physiology
A Clinical Perspective
This page intentionally left blank
FIFTH EDITION
Maternal, Fetal,
&
Neonatal Physiology
A Clinical Perspective
SUSAN TUCKER BLACKBURN,
PhD, RN, FAAN
Professor Emerita
Department of Family and Child Nursing
School of Nursing
University of Washington
Seattle, Washington
3251 Riverport Lane
St. Louis, Missouri 63043
BLACKBURN/MATERNAL, FETAL, & NEONATAL PHYSIOLOGY:
A CLINICAL PERSPECTIVE, FIFTH EDITION ISBN: 978-0-323-44934-2
Copyright © 2018 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
his book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent veriication of diagnoses and drug dosages should
be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or
contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 2007, 2000, and 1993.
Senior Content Strategist: Sandra Clark
Senior Content Development Manager: Laurie Gower
Associate Content Development Specialist: Laurel Shea
Publishing Services Manager: Jefrey Patterson
Senior Project Manager: Anne Konopka
Design Direction: Paula Catalano
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Contributors and Reviewers
Index
CONTRIBUTORS REVIEWERS
Ilana R. Azulay Chertok, PhD, MSN, IBCLC Cindy Bryant, BSN, RN-BC, CCRN-Neo
Professor, Associate Director of Nursing Research and Registered Nurse
Scholarship Texas Children’s Hospital
School of Nursing Houston, Texas
Ohio University
Athens, Ohio Tamara L. Bryant, RN, MSN
Postpartum Period and Lactation Physiology Program Chair
Associate of Nursing Program
Robin Webb Corbett, PhD, FNP-C, RNC Southern Regional Technical College
Associate Professor Thomasville, Georgia
Chair, Advanced Nursing Practice and Education
College of Nursing Cassie Flock, MSN, RN
East Carolina University Assistant Professor
Greenville, North Carolina Department of Nursing
Physiologic Basis for Reproduction Vincennes University
Vincennes, Indiana
Georgia R. Ditzenberger, NNP-BC, PhD
Neonatal Nurse Practitioner Sara B. Forbus, MSN, RN
School of Medicine Lecturer, Nursing Faculty
Department of Pediatrics/University of Wisconsin Medical School of Nursing
Foundation Old Dominion University
Meriter Hospital Norfolk, Virginia
University of Wisconsin – Madison
Madison, Wisconsin Carie Linder, APRN, NNP-BS
Clinical Product Surveillance Specialist Neonatal Intensive Care Unit
GE HealthCare Integris Baptist Medical Center
Madison, Wisconsin Oklahoma City, Oklahoma
Gastrointestinal and Hepatic Systems and Perinatal Nutrition
Carbohydrate, Fat, and Protein Metabolism Linda Macera-DiClemente, DNP(c), MSN, BA, RN
Calcium and Phosphorus Metabolism Lead Faculty
Department of Nursing
Tekoa L. King, CNM, MPH, FACNM Baker College of Auburn Hills
Deputy Editor Auburn Hills, Michigan
Journal of Midwifery & Women’s Health
Health Sciences Clinical Professor Christina Mahoney, RN, BSN, CCRN
School of Nursing Staff Nurse II
University of California San Francisco Neonatal Intensive Care Unit
San Francisco, California Boston Children’s Hospital
Fetal Assessment Boston, Massachusetts
Jacqueline H. Wolf, PhD Shelora Mangan, DNP, CNS, RNC-OB, EFM-C
Professor Perinatal Clinical Nurse Specialist
Department of Social Medicine Women and Newborn Services
Ohio University Legacy Health
Athens, Ohio Portland, Oregon
Postpartum Period and Lactation Physiology
v
vi CONTRIBUTORS AND REVIEWERS
Kristie K. Marbut, ARNP, MN, NNP-BC, CPNP Kathy Sheppard, PhD, MA, MSN, RN
Neonatal Nurse Practitioner Interim Dean and Professor of Nursing
Pediatrix Medical Group Department of Nursing
Tacoma, Auburn, Puyallup, Washington University of Mobile
Lecturer Mobile, Alabama
University of Washington
Seattle, Washington Julie Marie Anderson Symes, EdD, RN, IBCLC
University of Utah Nurse Faculty, Lecturer
Salt Lake City, Utah School of Health Sciences
Department of Nursing
Andrea C. Morris, DNP, RNC-NIC, CCRN, CNS University of South Dakota
Neonatal Clinical Nurse Specialist Rapid City, South Dakota
Neonatal Intensive Care Unit
Queen of the Valley Hospital, Citrus Valley Medical Center Valerie Wright, DNP, RN, CNE
West Covina, California Associate Dean of Nursing
Department of Nursing
Christina M. Rutledge, RN, MN, CNE Lincoln Land Community College
Module Leader Springfield, Illinois
Practical Nurse Course
AMEDD Center and School, Madigan Army Medical Center
Tacoma, Washington
Patricia Scheans, DNP, NNP-BC
Neonatal Nurse Practitioner, Clinical Support for Neonatal
Care
Women and Newborn Services
Legacy Health
Portland, Oregon
Preface
Accurate assessment and clinical care appropriate to the de- with low-risk and high-risk women and neonates with se-
velopmental and maturational stage of the mother, fetus, and lected health problems. Of special interest to those seeking
neonate depend on a thorough understanding of normal quick access to clinical information are boxes with recom-
physiologic processes and the ability of the caregiver to under- mendations for clinical practice that are included in each
stand the efects of these processes on pathologic alterations. chapter, referencing pages with relevant content that provides
Information on normal pregnancy and perinatal physiology the rationale underlying each recommendation. New to this
and its clinical implications can be found in various sources. edition is an appendix with deinitions of abbreviations fre-
hese sources are oten either fragmented, too basic in level, quently used in the text.
too focused on one phase of the perinatal period (and thus Advanced practice nursing must be based on a sound
lacking integration within the maternal-fetal-neonatal unit), physiologic base. hus I hope that this book will be a useful
or lacking in the clinical applications relevant to patient foundation reference for specialty and advanced practice
care. hus they do not adequately meet the needs of nurses in nurses in both primary and acute care settings, as well as for
specialty and advanced clinical nursing practice. graduate programs in maternal, perinatal, and neonatal nurs-
herefore the goal of the irst and subsequent editions of ing and nurse midwifery. his book may also hold appeal for
this book was to create a single text that brought together other health care professionals including physicians; physical,
detailed information on the physiologic changes that occur occupational, speech, and respiratory therapists; and nutri-
throughout pregnancy and the perinatal period, with empha- tionists involved in obstetrics and neonatology.
sis on the mother, fetus, and neonate and the interrelation-
ships among them. Maturational changes during infancy,
ACKNOWLEDGMENTS
childhood, and adolescence are also discussed. he purpose
of this book is not to provide a manual of speciic assessment he help and support of many individuals were critical in
and intervention strategies or to focus on pathophysiology— making this book a reality. hese include former and current
it is to present current information on the normal physiologic students, nursing staf, and colleagues who stimulated me to
adaptations and developmental physiology that provides the continue to expand my knowledge of perinatal and neonatal
scientiic basis and rationale underlying assessment and physiology and examine the scientiic basis for nursing inter-
management of the low-risk and high-risk pregnant woman, ventions with pregnant women and neonates. he women,
fetus, and neonate. Because the focus of this book is on neonates, and their families for whom I have cared and from
physiologic adaptations, the psychological aspects of perina- whom I have learned a great deal also stimulated develop-
tal and neonatal nursing are not addressed. hese aspects are ment of this book. hank you to Ilana Azulay Chertok, Robin
certainly equally as important but are not within the realm of Webb Corbett, Georgia Ditzenberger, Tekoa King, and
this text. Jacqueline Wolf for sharing their expertise in the chapters they
his book provides detailed descriptions of the physiologic contributed to this edition. Special thanks to Susan Skinner
processes associated with pregnancy and with the fetus and Elizabeth Posey for their assistance with manuscript
and neonate. he major focus is on the normal physiologic preparation. I am grateful for the eforts of the reviewers,
adaptations of the pregnant woman during the antepartum, whose constructive comments and suggestions helped in re-
intrapartum, and postpartum periods; anatomic and func- ining the content and in making this book more useful for
tional development of the fetus; transition and adaptation of the intended audience. My appreciation and thanks also goes
the infant at birth; developmental physiology of the neonate to the staf at Elsevier, particularly Laurel Shea, Associate
(term and preterm); and a summary of the maturation of each Content Development Specialist, and Anne Konopka, Senior
body system from infancy to adolescence. Clinical implica- Project Manager, for their assistance in the development and
tions of these physiologic adaptations as they relate to the production of this book. Finally I would like to thank my
pregnant woman, maternal-fetal unit, and neonate are also family for their support, guidance, and encouragement in all
examined. Each chapter describes the efects of normal physi- of my endeavors.
ologic adaptations on clinical assessment and interventions Susan Tucker Blackburn
vii
Contents
UNIT I
Follistatin, 37
Reproductive and Developmental Processes
Steroid Hormones, 37
Oocyte Maturation Inhibitor, 43
1 Biologic Basis for Reproduction, 1
Luteinization Inhibitor, 43
Chromosomes and Genes, 1 Gonadotropin Surge–Inhibiting Factor, 43
Chromosomes, 1 Relaxin, 43
Genes, 2 Feedback Systems, 43
DNA and RNA, 4 Reproductive Processes in the Female and Male, 44
Genomics and Epigenetics, 5 Oogenesis, 44
Cell Division, 6 Spermatogenesis, 45
Mitosis, 6 Puberty, 45
Meiosis, 7 Ovarian Cycle, 48
Gametogenesis, 8 Menstruation, 53
Oogenesis, 8 Endometrial Cycle, 53
Spermatogenesis, 10 Gestational Follicular Development, 56
Abnormal Gamete Development, 10 Male Reproductive Endocrinology, 56
Genetic and Chromosomal Disorders, 11 Climacteric, 57
Alterations in Chromosome Number, 11 Aging Male, 58
Alterations in Chromosome Structure, 13 Summary, 59
Gene Disorders, 14
3 Prenatal Period and Placental
Modes of Inheritance, 15
Physiology, 61
Autosomal Inheritance, 16
Sex-Linked Inheritance, 17 Overview of Pregnancy, 61
Multifactorial Inheritance, 17 First Trimester, 61
Nontraditional Modes of Inheritance, 18 Second Trimester, 62
Embryonic and Fetal Development of the Reproductive hird Trimester, 63
System, 19 Conception, 63
Development of the Primordial Germ Cells, 20 Ovulation, 63
Development of the Gonads, 20 Corpus Luteum, 65
Development of the Genital Ducts, 21 Sperm Transport, 65
Development of the External Genitalia, 22 Fertilization, 66
Anomalies of the Genital Tract, 24 Cleavage and Zygote Transport, 68
Clinical Implications, 25 Embryonic and Fetal Development, 69
Genetic Screening, 25 Regulation of Development, 69
Genetic Disorders and Pregnancy, 26 Mechanisms of Morphogenesis, 71
Summary, 26 Overview of Embryonic Development, 73
Overview of Fetal Development, 78
2 Physiologic Basis for Reproduction, 29
Intrauterine Environment, 79
Hypothalamic-Pituitary-Ovarian/Testicular Axis, 29 he Placenta and Placental Physiology, 79
Hormones, 29 Placental Development, 79
Hormone Activators, Receptors, and Messenger Placental Structure, 85
Systems, 29 Placental Circulation, 85
Hormone Storage, 30 Placental Function, 89
Hypothalamic and Pituitary Glands, 31 Umbilical Cord, 95
Reproductive Hormones in Females and Males, 33 Amnion and Chorion, 96
Luteinizing Hormone, 35 Amniotic Fluid, 96
Follicle-Stimulating Hormone, 35 Amniotic Fluid Volume and Turnover, 96
Activin, 35 Amniotic Fluid Production and Disposition, 97
Inhibin, 37 Composition of Amniotic Fluid, 97
viii
CONTENTS ix
Clinical Implications, 97 Human Milk, 151
Assisted Reproductive Technology, 97 Importance of Human Milk, 151
Assessment of the Embryo and Fetus, 99 Milk Production and Composition, 151
Alterations in Placenta, Umbilical Cord, and Amniotic Human Milk for the Preterm Infant, 155
Fluid, 102 Nutrition During the Postpartum Period and Lactation, 157
Multiple Gestation, 106 Common Breastfeeding Problems, 157
Summary, 110 Social and Cultural Barriers to Breastfeeding, 158
Summary, 159
4 Parturition and Uterine Physiology, 115
6 Fetal Assessment, 162
Uterus, 115
Uterine Structure, 115 Physiology of Fetal Heart Function, 162
Uterine Growth, 116 Autonomic Control of Fetal Heart Rate, 162
Myometrium, 116 Fetal Acid-Base Physiology, 163
Myometrial Cell Structure, 116 Uteroplacental Circulation and Gas Exchange, 163
Changes During Pregnancy, 118 Uterine Blood Flow in the Intervillous Space, 164
Cervix, 118 Umbilical Blood Flow, 165
Structure of the Cervix, 119 Placental Area, 165
Changes During Pregnancy, 119 Transfer of Oxygen and Carbon Dioxide, 165
Cervical Ripening and Dilation, 119 Fetal Response to Hypoxia, 166
Rupture of Fetal Membranes, 121 Acute Fetal Hypoxia, 166
Parturition, 121 Chronic Fetal Hypoxemia, 166
Initiation of Labor, 122 Severe Asphyxia: Hypoxic-Ischemic Encephalopathy and
Endocrine and Other Factors, 124 Neonatal Encephalopathy, 167
Myometrial Contraction, 128 Newborn Umbilical Cord Gas Analysis, 168
Coordination of Uterine Contractions, 129 Characteristics of the Fetal Heart Rate, 169
Clinical Implications for the Pregnant Woman and Beat-to-Beat Variability, 169
Her Fetus, 131 Accelerations, 170
Maternal Position During Labor, 131 Alterations in Fetal Heart Rate, 170
Maternal Pushing Eforts During the Second Periodic and Episodic Fetal Heart Rate Decelerations, 171
Stage, 132 Sinusoidal Pattern, 172
Preterm Labor and Birth, 133 Fetal Heart Rate Pattern Evolution, 172
Altering Uterine Motility and Cervical Ripening, 135 hird Trimester Fetal Assessment Techniques, 173
Dystocia, 137 Fetal Movement, 174
Postterm Labor, 137 Nonstress Test, 174
Summary, 137 Vibroacoustic Stimulation, 175
Contraction Stress Test, 175
5 Postpartum Period and Lactation
Amniotic Fluid Index, 175
Physiology, 142
Biophysical Proile, 175
Involution of the Reproductive Organs, 142 Umbilical Artery Doppler Velocimetry, 176
Uterus, 142 Clinical Implications: Intrapartum Fetal Assessment and
Cervix, Vagina, and Perineum, 143 herapeutic Interventions, 176
Physical Activity and Sexual Function, 144 Electronic Fetal Monitoring, 176
Endocrine Changes, 144 herapeutic Interventions, 177
Estrogen and Progesterone, 144 Summary, 177
Pituitary Gonadotropin, 145
7 Pharmacology and Pharmacokinetics
Prolactin, 145
During the Perinatal Period, 180
Oxytocin, 145
Resumption of Menstruation and Ovulation, 145 Pharmacokinetics, 180
Anatomy of the Mammary Glands, 146 Pharmacogenetics and Pharmacogenomics, 181
Physiology of Lactation, 147 Pharmacokinetics During Pregnancy, 182
Embryogenesis, 147 Drug Use During Pregnancy, 182
Mammogenesis, 148 Alterations in Drug Absorption, Distribution, Metabolism,
Lactogenesis, 148 and Excretion During Pregnancy, 183
Prolactin Patterns During Lactation, 149 Alterations in Drug Absorption, Distribution,
Oxytocin Release During Lactation, 150 Metabolism, and Excretion During the Intrapartum
Mammary Involution, 151 and Postpartum Periods, 187