 Hormones

 Topic Focus
 Case Studies
 GTPAL
o G–
o P – (outcomes for pregnancies)
o G4P3 – pregnant 4 times 3 kids
o GTPAL
 Gravita – how many pregnancies
 Paritiy – what was the outcome – how many kids you have
o Term
o Preterm
o G4 (pregnant 4 times), T (3 terms) P (no preterm) A1 (no miscarriage) 4
(adopted)
 Can put a little disclaimer (1 died at 6 weeks)
 Triplets – pregnant 3 times
 G3P
 T2
 3 preterm
 5 living children
 currently pregnant – 5th pregnancy,, 2 term babies, 1 preterm, and 1 misscariage
 term 37 weeks*
 G5T2P1A1L3
 G1P2 – had twins (twins)
 G – number of times pregnant including current pregnancy

Hormones play a role

 Menstral cycle
 Entering into adolescence
 Contraception
 Pregnancy
 Older woman/menopause

Estrogen – when enter puberty – responsible for secondary sex characteristics – first half of the
cycle – gonadotropin releasing hormone is the hormone that stimulates the production of
estrogen as well as FSH and leutinizing hormone

*estrogen marks first part of cycle – one ovulates, then progesterone kicks in, second half is
progesterone

in contraception – we alter the balance between estrogen and progesterone, by adding it in

small doses – upset negative feedback system, when estrogen low progesterone high, when
add hormone back in we are disrupting that system. Estrogen is in any kind of combined –
rarely use it alone – leads to clotting, hyperplasia, want to use it in balance with progesterone

Estrogen – in pregnancy – does many of same things during adolescence, causes breast
enlargementment for baby, causes vascularity in any pink tissue, the reason – vascularity of
cervix, gums, inside of nose, so women get nose bleeds, bleeding gums, all because estrogen
made system more vascular* also makes all of the lining thicker bc made of thicker – makes
woman at risk for clots. That’s why pregnancy is a stage of clotting, never give estrogen for
someone with a case of clots

In menopause – progesterone is the first hormone to change. When level drop, we have an
overabundance of estrogen, so progesterone drops, too much estrogen, what happens when
too much, lining of uterus gets real thick and messy. In 40s, progesterone levels dropped, get
killer periods. Some women want to have some estrogen and progesterone back into system,
estrogen also causes most of cardiovascular of menopause – changes in lipids

If put back a little of estrogen and progesterone – you increase the risk, esterogen increases risk
of stroke, increases risk of hyperplasia of uterus as well,

In perimenopausal period – just give some progesterone, patch, cream* it will put enough back
into the system to get rid of messy periods. Another way perimenopausal – mirena an IUD, or
the rod that secretes progesterone. A lot safer to give a little progesterone. Estrogen post
menopausally – risk benefit situation

Only person give just esterogen to – someone without a uterus

Soy – a phytoestrogen – fake estrogen. People eat tofu, soy to build estrogen and get rid of hot
flashes, menopausal symptoms

Progesterone we can use alone

Improve skin, make vagina not tight and uncomfortable, (estrogen and progesterone), 6
months replacement therapy ok.

Estrogen catches up and gets the message and you stop making it and you don’t get a period

PROGESTERONE –

Menstral cycle – the second half of cycle – people feel PMSy, bloated, cranky, hungry, when
loaded with progesterone. Contraception use by itself or in combination. By itself best example
is depopravera – big side effect people gain weight – big dose of progesterone – also causes
bone loss, good for teens for a couple of years, women who approach run into problems with it

Other forms just progesterone – mirena, implenade (nexplanaon) – nice methods

Progesterone in pregnancy – called the hormone in pregnancy – it does SMOOTH MUSCLE
RELAXATION – uterus a big muscle, perceives foreign body, tires to cramp it out, but because
progesterone have smooth muscle relaxation keeps uterus cramping out baby. IF RELAXATION
OF SMOOTH MUSCLE IN RELAXATION GET CONSTIPATION!! A side effect. In pregnancy, every
one of hormones does something to help pregnancy

What is hormone, how support pregnancy, what are the side effects, so what are we going to
teach mom about making it better

Estrogen –
Progesterone -
Melanin –
Prolactin -
HCG –

What does each hormone do in pregnancy, how support pregnancy, what are side effects and
what am I going to teach mom

Progesterone in older women in menopause, heavy duty bleeding periods, perimenopausally,

HCG – supports the corpos luteum – corpus luteum spot from whence an egg is released –
corpos luteum makes progesterone and estrogen until placenta is working. But majorly what it
does ACTS AS A MARKER – rises rises to day 70 peaks – so if you have a pregnancy so you are
concerned if it is healthy and normal, need to see a rise of HCG! WOMAN comes to clinic, 7
weeks pregnant, what would you do? Take hcg, come back in 2 days, if rising, just spotting. If
not rising, flat or dropping she is having a miscarriage

Side effect of HCG is nausea and vomiting

So what are you going to teach mom? – separating fluids and liquids. Potato chips and
lemonaid. Not having an empty stomach. Women want to go in and sleep don’t want to do
that. 10 weeks. By 12 weeks will feel better

LH – fsh triggers estrogen and Lh eventually that leads to ovulation. Get a big rise in LH. So
when someone going through menopause, their FSH levels are HIGH because their pituitary is
saying ovaries, come on, ovulate already, keeps releasing more FSH.

Topics to focus on –

 GO THROUGH TOPIC OUTLINE ON FRONT PAGE OF CANVASS – OPEN SLIDES and see if
you can answer
 In older women - ** the schedule – those are our topics, take a look at slides, good
guide, not only source of info
 Slides = the most effective means of contraception? VASECTOMY, gets an edge. You can
check it for effectiveness. The only one you can actually say give me a sperm sample
want to see if alive
 Case study on contraception – if you are working at planned parenthood as center aid,
education – someone comes in who is, she would like birth control pills renewed,
smoker, family history of stroke, wants her combined oral contraceptives. Would you go
with it? GIVE ONE THAT IS PROGESTERONE ALONE OR NO HORMONE, and is older –
setting her up for clotting risk if giving her estrogen. Condoms* bag of condoms. But if
give a bag of condoms, have to think about first slide – making choices in contraception
– looking at medical history, quirks, culture, 5 factors to consider when choosing birth
control method – REVIEW THAT! Think of an example of each one. Personal quirk – not
liking fingers in vagina. Medical history – stroke
 75 questions. Slides and class are your guide. Articles if said read article and really good,
then read it and worry about it. Review the immunizations for older people***** and
screening tests for older women***** health promotion. Really clear guidelines, when
you should have a dexa scan, when to have a mammogram
 case study on older woman = a 59 yr old women comes to clinic, a new sexual partner,
she comes for STD screening and protection. What kidns of screening does she need?
Health screening, what would you suggest in terms of immunizations, anything
particular to a 59 yr old woman?
o Flu shot
o Mammogram – 59 – 40 do every other year, 50 every year
o Dexa scan offer after 65 unless fracture
o Pap smear – esp bc new partner – cut off for papsmear is 75. PAP – wont ask bc
changes too frequently. Used to do it frequently. New partner? If new partner,
they’ve had 59 years of sex, a lot of exposure, need std screening, and maybe
condoms*
o Colonosocopy done at 50 and every 10 years if normal
o Do lipids – what happens to lipds, hdl decrease and ldl increase after
menopause, assuming post menopause, change in lipids in wrong direction*
o If concerned about STI – can be screened for chlaymidia, ghonoorea
 The lipids we want to see elevated are hdl and ldl, changes post menopausally, at risk
for cardiovascular disease
 *the slide on what you do week by week – SHE IS GIVING THE INFORMATION
 what is GBS – group beta strep – screen women at 36 weeks.* somewhere between 10-
30% of women have it. If someone is positive we don’t treat in pregnancy unless gbs
urinary tract infection. If positive, give them antibiotics in LABOR so don’t transfer to
baby, take a peak of slide – JUNO getting ultrasound and the weeks of what you do at
each time and the email she sent out!!
 First stage of labor up until fully dialated
 Second stage – fully dialated pushing and delivering baby
 Third stage delivery of placenta
 Fourth stage immediately post partum
 o Early, active, transition PHASES
o Early phase – more by woman’s behavior than cervix. Early phase of first stage,
women can walk around, get a massage, they are comfortable, cervix is a
marker, but people can be 5cm and still comfortable
o Active labor, comes next – contractsions, closer logner and stronger, when most
people come to hostpital, they want some intervention, by then, whirlpool,
shower, epidural whatever is your choice. Walking around, breathing massage
but harder to be effective
o Transition – 7-8cm to ready to push, the hardest time, most intense, its when
people say no puedo, I want to die, I hate you, its really intense. But its short.
 Pushing for first time mom can last up to 2 hours. Second time mom is up
 Delivery of placenta – when its time to deliver – if the placenta falls off uterine wall,
gush of blood , and chord lengthens, placenta falls down, and you know its time to push
it out
 Antesthesia or analgesia or showers in early labor, walking around, hydrotherapy, some
women have no anesthesia during whole labor, other women have interventions for
pain management.
 Analgesia – morphine, demoral
 Anesthesia – epidural. Don’t want to give epidural too early or put out fire. At least
active phase if want epidural otherwise labor will stop

REVIEW IMMUNIZATIONS AND SCREENING FOR OLDER WOMEN

Treatment of hot flashes – the best treatment – drinking large amounts of cold liquid**
dressing in layers, and staying away from things that trigger them. Spicy food, alcohol, identify
what your triggers are**

RISK OF TUMMY ROLL OR GAINING WEIGHT – weight in terms of 20 lbs over childbearing years,
and postmenopausally, happens right around the middle. Weight in that placement – increased
risk for stroke. If lose secondary sex characteristics, breasts get small, lose some muscle mass,
might lose weight. MORE AT RISK FOR STROKE.

Weight – really is a big deal – a lot of reproductive cancers, alcohol, weight for reproductive
cancers. Women beyond childbearing years – get to where weight should be and keep it there

KNOW CATEGORY 1, 2, 3 IN EXTERNAL FETAL MONITORING –

- Category 1 – variability is good, not seeing any decelerations

- Category 2 –
- Category 3 – ominous – lots of late decelearations
Best barometer of fetal wellbeing is VARIABILITY. Want baby’s heart line to be scraggled – baby
who is hypoxic is no variability

Good variability and no decelerations**

Early deceleration – takes a dip – and bottom line is contraction – early deceleration it mirrors
the contraction – when contraction is over so is the deceleration. That just means head
compression, the baby is moving down. If I see, GREAT! This woman is making progress. Not
bad

Late decelerations – are those that take place slightly after the contraction, or resolve after the
contraction. Deceleration takes place AFTER THE CONTRACTION. It resolves after the
contraction – it means – uterplacental insufficiency!!! The placenta is not getting fed the way it
needs to. Maybe mom has hypertension, maybe placenta old and poopy. When you see – when
you stress the baby heart rate doesn’t come up all the way

Cord compression = VARIABLE deceleration** not a lot of amniotic fluid, happen randomly, may
or may not, see that, just change mom’s position to get pressure off the cord.

STUDY VEAL CHOP

**Category 3 – repeated late decelerations or bradycardia – heart rate low. General range
should be 110-160. If you see bradycardia and late decelerations, oo get baby out of there!

- Risk for intimate partner violence** pregnancy is greatest risk for both homicide and
intiate partner violence. In readings – poverty a risk factor for intimate partner violence
and being an adolescent. Being transgender is greater risk for intimate partner violence

One more case study –

Labor – patient comes into labor floor, contractin every 5 min, complaing pain in back and
abdomen, you check cervix, she is 6 cm dialated, 100% effaced, and at +1 station. So we would
call that 6/100/+1 – she is uncomfortable, she is walking around rubbing back, and contraction
are close and strong. What stage of labor? Shes in the active phase of STAGE 1. Its her first
baby, so how long can we expect her labor to last in total. Whole length of labor – average for
first time mom – 14/16 hours – it’s long

What would you suggest for pain management for someone in this phase of labor – how about
getting in tub, how about hot shower. Think least invasive to most invasive. If I can get her to be
comfortable and get her to pushing staying in hot shower, will be better for her. Epidurals can
cause hypotension, can give epidural fever, many women have back aches after epidural. Get
her in shower, keeping her moving, if it doesn’t work – women self report 1) hydrotherapy and
epidural –
First time mom – can expect mean of 16 hours start to finish, in early phase of first stage, she
might be comfy, might not be uncomfortable until here. Shes been at home laboring coping
very well

Average length for more than one – half of what first child was. Number 2 baby is the speedy
one

46-52 – average age of menopause

active phase of first stage.

Menopause – TRY LEAST INVASIVE TO MOST – have woman drink tons of cold water, and then
in time, if need to go to black cohosh to control hot flashes, and then if really miserable talk
about hormones.

Case studies – go over them – a way of applying the information. Some general knowledge
questions and application questions

General knowledge – the average length of labor for first time mom – a) 6 hrs
What is the recommendation for calcium and vitamin d over 60? – 1200 and 800 dosage**

Application – your client wants to increase calcium intake in interest of preventing

osteoporosis, which of recommendations would you make? Wants to prevent osteoporosis
a) Engage in hardcore exercise and increase calcium in diet
b) Engage in weight bearing exercise and take calcium 1200 every day – walking, yoga,
biking,

Moderate – still exercise and still talk. Calcium and vitamin d 1200 calcium, 800 of vitamin D –
they help each other. Drink lots of milk, eat cheese (would upset lipids though)

- Look at specifically, and an and, usually one is right and one is wrong. If you can get
down to two potentials, you are probably going to get it right
Select all that apply – not all of the following except.

 Early labor – marked – stage 1 first stage – closed cervix to 10 cm to push

o Divided into early
o Active
o transition

general theme – contractions get closer together and stronger. You are going to do efm
module. SIM lab assignments = the EFM module* know your sim stuff, makes it make sense.

**if you understand rather than memorize you do better.