OB Session 7:

 

Vernix (the white stuff covering the skin) is less abundant the longer GA

 

Acrocyanosis – blue periphery and is normal

 

1st period of reactivity is before the baby falls back asleep. Lasts about an hour.

  • do a lot of mother to baby contact and feeding at this time.

 

The next period is the period of inactivity when the baby cannot really be woken up

 

L.A.T.C.H. score 0-10 10 being best.

Latch, Audible swallowing, Type of nipple, Hold

 

Normals: 110-160bpm, 30-60RR, 98-99F

 

Reasons that babies are bad at controlling temp:

  • Large body SA to Mass, thin epidermis, posture flexed, and need a higher ambient temp to keep their body temp up.
  • Can’t shiver
  • give the baby a layer more than you are wearing

 

Brown fat:

  • once depleted it does not come back
  • 2-7% of body weight
  • on chest and back

 

Blood glucose at 1 hour is ordinary

  • <40ish mg/dl is too low.
  • needs some sort of calories if this is the case.
  • syringe, cup feeding, gavage feed – g tube feeding directly into the stomach.
  • lavage is the cleaning out of the stomach
    • this will happen if the baby swallows bloody amniotic fluid.

 

before placing ID bads what should you do

  • double check identities
  • explain that there may be an alarm system associated with baby’s band to make sure that no one takes it.
  • dont take it off if the baby is still at the hospital

 

milia – don’t pick them

  • keratin cysts
  • they go away

 

stork bite

  • reddened area, may go away

 

epstein pearls

  • white round dots in the back of the throat
  • normal and goes away

 

natal tooth

  • painfull for breast feeding and could be a choking hazard

 

sucking blister in utero

 

polydactyly – extra finger

  • check the rest of the baby closely

 

Lanugo

  • body hair, that is fuzzy and falls off

 

Hair tuft at low back or sacral dimple point towards spina bifida

 

reflexes

  • rooting sucking
  • Moro
  • Palmar grasp
  • step
  • tonic neck
  • Galant
  • Plantar grasp
  • Babinski
  • Protective reflex – link to stanford website

 

Signs or effective breastfeeding

  • seisity
  • good latch
  • stool color change
  • stooling after feeds
  • eventual weight gain, after an initial weight loss of no more than 10% of initial body weight.

 

erythema toxicum

  • normal baby rash and goes away

 

before discharge

  • PKU test
  • car seat test
  • Hearing test
    • Hearing test can be failed due to fluid in the ear canal, need to see a pediatrician to fix this
  • education
  • total bilirubin (sometimes)

 

circumcision is an elective procedure

  • plasta bell, the plastic part is left on until it falls off naturally.
  • clamp types need petroleum jelly to prevent adherence to the diaper.

 

danger or warning signs for parents

  • lay baby on back to prevent SIDS

 

Cephalohematoma

  • does not cross suture line

Caput

  • can cross suture lines

 

Pseudo menstruation, from hormonal withdrawal

brick dust, uric acid excretion in boys and should only happen once.

 

syndactyly, webbed toes

 

slate grey spots – ok and go away

 

Nevus Flammeus – do not generally go away

 

Physiologic jaundice – happens after 24 hours and is OK

Pathologic Jaundice – happens before 24 hours and is bad

  • can be caused by ABO incompatibility

 

Hypoglycemia – <40 mg/dl

  • risk factors:
  • Neonate of DM mother

 

We treat HTN with Aldomet 250mg if the mother has bad HTN, not proteinuria if HTN before

  • HTN can cause Nephrotoxic issues

 

Preeclampsia – HTN after 20 week GA w/ proteinuria  

  • Volume overload and leaky vessels
  • HELLP – hemolysis, elevated liver enzymes, and low platelets
  • cause is mostly know, but thought to be from the placenta developing incorrectly, increased inflammatory response, with endothelial response and leaky.
  • only cure is delivering baby.
  • risk factor: 1st time, HTN or vascular Dx, big baby from DM
  • risks: DIC, abruptio
  • Mag sulfate is for the neural maturity of the baby
    • 4-6 gm loading dose
    • 2-3g/hr
    • Lab: 4-7 mEq/mL
    • monitor mag and RR
    • Pulmonary edema, resp depression and arrest,
    • Calcium gluconate IV is the antidote for MAG toxicity
    • should be on this for 24 hours postpartum, and still at risk for at least 6 weeks

 

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Nursing Care of Child Bearing Families Session 5:

 

Session 5

 

starting the labor process

  • we don’t really know what starts labor
    • uterine distention
    • aging of the placenta
    • hormones
    • fetal adrenals
    • psychological

 

  • signs of labor
    • lightening – fetus dropping into the pelvis
      • days to weeks before labor
    • bloody show
    • weight loss, from loose stools
    • burst of energy and nesting

 

  • stages of labor
    1. Stage 1: onset of regular contractions
  • latent: 0-3 cm
    • duration of 6-8hr
    • contractions 5 – 30 mins and irregular
  • active: 3-8cm
    • 3-6hr
    • contractions: 3-5 mins and regular and moderate to strong
  • transition: 7-10cm
    • duration: 20-40 min
    • contractions: 2-3 min regular and strong

 

  1. Stage 2: full dilation to the delivery of baby
    1. Pushing with contractions
  2. Stage 3: time between baby born, and the placenta coming out. (20-30) min
    1. retained placenta is over 30 minutes
    2. signs of placental detachment
      1. change of uterus shape
      2. gush of blood
      3. urge to push again, more contractions
    3. prevention of hemorrhage
      1. pitocin – 10-40 units IV
      2. methergine – 0.2 mg IM
        1. do not give if HTN in pt
      3. hemabate – 250 mcg IM
        1. prostaglandin
        2. contraindicated in asthma (bronchoconstriction)
      4. cytotec (misoprostol)- 600- 800 mcg PO
        1. synthetic prostaglandin
        2. do not give vaginally if she is actively bleeding
  3. Stage 4: 0-4hrs after delivery, bonding and breastfeeding

 

episiotomy can be done when…

  • shoulder dystocia
  • fetal distress

 

nullipara women go through 12-18 hr of labor on average 

multipara women have shorter labor time on average

 

  • things we can do to help as a student
    • hygiene
      • chux, washcloth, mouthwash

 

false pregnancy

  • no cervical change

true pregnancy

  • water broke (things to confirm this)
    • ferning seen under a microscope
    • also higher ph than urine

SROM – spontaneous rupture of membranes

AROM – artificial rupture (HOOK)

PROM – Pre labor

pPROM – preterm pre labor

Malodorous fluid- infection in the fluid

 

GBS

    • group beta strep
    • 10 – 30% of women colonized

 

  • universal screening at 35-37 weeks
  • the screen stays negative for about five weeks after negative test.
  • Pen 6million units
  • WHAT, WHY, HOW do we check, and how do we treat.

 

  • then every four hours after

Nursing care of child Bearing Families Session 4:

Accelerations are always good

  • at least 15 bpm increase and at least 15 second duration

Decelerations

  • early
    • gradual onset
      • time it takes to go from baseline to nadir (bottom) is at least 30 seconds
    • Gradual return to baseline
    • can be OK
    • on time with contractions, and head compression (not and issue)
  • Late
    • Gradual onset
    • after a contraction (timing is late) resolves after contraction has ended.
    • associated with lack of blood flow to the baby from the placenta.
      • placental insufficiency
  • Variable
    • Abrupt onset
      • less than 30 seconds from baseline to the nadir
    • From cord compression
  • Prolonged deceleration
    • longer than 2 minutes and less than 10
    • decrease of at least 15 bpm

Category 1

  • Baseline rate: 110-160 bpm.
  • Baseline FHR variability: moderate
  • Late or variable decelerations: absent
  • Early decelerations: present or absent
  • Accelerations: present or absent

Category 2

  • Not 1 or 3

Category 3

  • Absent baseline FHR variability and any of the following: –
    • Recurrent late decelerations
    • Recurrent variable decelerations
    • Bradycardia
  • OR just
  • Sinusoidal pattern

Labor and delivery

Secondary powers

  • physiologic pushing
    • grunting
    • more O2 throughout mom and baby
    • may take more time
    • cannot feel this Ferguson’s reflex when on an epidural
  • Closed glottis pushing
    • Take a deep breath and push
    • less O2 throught

effacement is the thinning of the cervix

dilation is the opening of the cervix

                         

Nursing Care of Child Bearing Families Study guide #1:

Things to know for test one in Nursing care of childbearing families:

Contractions – Duration is the length of a wave, intensity can only be measured by an IUPC not an external monitor, And frequency is the length of time from the start of one wave to the start of the next.

baseline variability – How much the heart rate moves from the baseline

  • absent – flat line
    • associated with sleep
  • minimal – less than or equal to 5 bpm of variance from baseline
  • Moderate – best rhythm(best parasympathetic/sympathetic teeter-totter), 6-25 bpm variance from baseline
  • Marked variability – more than 25 bpm from base, usually does not last long

Accelerations are always good and show that the baby is reacting to stimulus

  • greater than 15 seconds and shorter than 2 min

folic acid, – start taking in healthy amounts of folic acid before you get pregnant, 500mg is the goal amount to take in each day.

  • neural tubes do not close correctly if there is not enough folic acid resulting in spina bifida, anencephaly, cleft palate, premature and/or low birth weight, and miscarriage.

weight gained in pregnancy – 1st trimester weight gain is 3-5 lbs

  • .5 – 1 lbs per week after 1st trimester
  • How much weight a person should gain determined by pre pregnancy BMI
    • Underweight BMI <18.5: 28-40 lbs.
    • Normal BMI 18.5-24.9: 25-35 lbs.
    • Overweight BMI  25-29.9: 15-25 lbs.
    • Obese BMI greater than 30: 11-20 lbs.

hormones:

  • progesterone – Hormone of pregnancy, dominant in ovarian cycle in the luteal phase (days 15-28)
  • estrogen – subtle dark skin on face and linea alba from estrogen
    • Estradiol
      • in the reproductive years
    • Estriol
      • only during pregnancy
    • Estrone
      • Menopause
  • HCG – Human chorionic gonadotropin, produced by the placenta only, pregnancy test for this.  
  • oxytocin starts labor through contractions, lactation, bonding, and orgasm. Positive feedback loop.
  • prolactin – enable production of milk, and produced by the pituitary gland
  • relaxin – produced in the placenta and the ovaries, and relaxes the ligaments in the pelvis to allow for the baby to pass through more easily.
  • human placental l (HPL) – produced by the placenta, allows more glucose to get to the baby from the mother’s blood stream by blocking the mother’s cells from using the glucose.

don’t lie women flat on her back or it will occlude the vena cava causing a drop in BP, also it may be harder for the mother to breathe due the shifting of organs allowing for less space for the lungs to expand.

changes in blood values and know the risk factors from lab values (HCT, and Hemoglobin),

  • hypercoagulable
  • left shift in WBC’s (elevated count)
  • Anemia
    • fetus starts to store Iron from the mother at twenty weeks
  • Decrease in HCT and Hemoglobin, treat the HCT if it drops below 11.
  • Increase in the GFR in the kidneys due to the increased blood volume.

Maternal mortality in the US and infant mortality in the US are ranked very low when compared to other developed countries, and this is due to minimal prenatal care.

Know the broad System changes that occur in a pregnant woman’s body.

Know the leopolds – so the lie of the baby and how to describe the positions: oblique, transverse, breach, cervical. 

Gs and Ps,  

  • Gravidity – # of pregnancies including the current one.
  • Parity – # of births after 20 weeks
  • Nulligravida – never been pregnant
  • Nullipara – never given birth
  • Primigravida – first time to give birth
  • Primipara – has given birth to a less than 20 week old fetus one time.
  • TPAL
    • Term – # of births after 37 6/7 weeks
    • PreTerm – # of births between 20 and 37 6/7 weeks
    • Abortion – # of miscarriages, spontaneous or therapeutic abortions
    • Living children – self explanatory

TORCH infections

  • Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes
  • these infections need to be treated in pregnant women especially, because they correlate highly with congenital defects.

Chadwick’s sign is the darkening of the labia, cervix and vagina. this comes from the increased blood flow associated with pregnancy.  

Hegar’s sign is the separation of the cervix from the uterus upon palpation, and the softening of the uterus.

fetal development milestones,

  • Heartbeat at 6 weeks on ultrasound, can be heard at 10 week GA for the doppler.
  • Fetal movement at 18-22, it is sooner in women who have been pregnant previously, (multips)

Umbilical cord anatomy – two arteries carrying DEoxygenated blood AWAY from the fetus, and one vein carrying OXYgenated blood TO the fetus.

Nursing Care of Child Bearing Families Session: 4

I this is the fourth session of the class and we discussed some of the changes that a woman will face during the pregnancy, and started talking about the fetal heart monitor and how to read it. The next post for this class will be a review guide of the information that may be on the next text. Happy studying.

-Peter

Session 4

Normal phys changes in pregnancy

  • hematologic
    • increase in plasma and RBC
      • blood is diluted
      • Hbg goes down as well as Hct
      • fetus is storing iron so there may not be as much going to make RBC
    • immunocompromise
      • increased WBC
  • MSK
    • loose joints and tendons from relaxin
  • Vena Cava syndrome
    • lean to her left side so there is decreased pressure on the vena cava

Fetal assessment

All women should be offered genetic testing

Amniocentesis

  • .5% chance of loss

CVS – chorionic villi sampling

  • does not detect neural tube defects
  • 1% chance of loss

electronic fetal monitoring

  • know how to read these will
  • the purpose is to prevent fetal hypoxic ischemic injury
  • vocabulary
    • common language so that there are fewer miscommunications
    • frequency – the start of one contraction to the start of another
      • dark vertical lines are a minute on the EFM
    • duration
      • length of time of the contraction
    • Intensity: of contractions
      • cannot tell the intensity from an external monitor
      • must palpate, and get subjective data to get contractions
      • IUPC – intrauterine pressure catheter measures the intensity as well
    • Category 1
    • Category 2
    • Category 3
    • Montevideo units -MVU total intensity of each contraction (from baseline)added up in a 10 min period. 200 MVU is the pressure needed for 90% of labors to move forward.  
    • normal fetal HR is 110-160
      • make sure you compare this to the mother’s pulse to be sure that you are not reading the mother’s pulse as the baby’s
      • listen to FHR during the contraction through doppler and for 30 seconds after contraction
    • US transducer
      • placed in area of max intensity of FHR
      • use gel when applying
    • Tocotransducer
      • has a button on the bottom
    • Fetal scalp electrode
      • fetal ECG from a spiral electrode hooking gently into baby’s skin
    • Intrauterine Pressure catheter
      • measures frequency, duration and STRENGTH of contractions.
    • Meconium fluid is baby poop
    • autonomic nervous system
    • Vagus stimulation will slow down HR and increase peristalsis to cause meconium
    • Placenta produces estrogen, progesterone, hPl, and hCG
    • tachysystole is rapid contractions with small rest periods
    • FHR baseline to the nearest 5 BPM
    • variability
      • absent – flat line
        • associated with sleep
      • minimal – less than or equal to 5 bpm of variance from baseline
      • Moderate – best rhythm(best parasympathetic/sympathetic teeter-totter), 6-25 bpm variance from baseline
      • Marked variability – more than 25 bpm from base, usually does not last long
      • Accelerations are always good
        • greater than 15 seconds and shorter than 2 min

Nursing care of child bearing Families Session 3:

This is OB session 3, we finally came around to more involved information, and there is more information that needs to be known in this session. Happy studying!

-Peter

Session 3

    • Gestational age starts from the first day of the last menstrual period.
      • the fetal age is about two weeks after that: the time to ovulation.
    • any infections can cause preterm labor, so these infections will be treated more aggressively than in a nonpregnant woman
    • advanced maternal age is greater than 35 and paternal age is greater than 50
    • SAB = spontaneous abortion or miscarriage
    • hCG human chronotropic gonadotropin
    • KNOW THE SIGNS OF PREGNANCY
      • Presumptive
        • subjective things that point towards pregnancy but are not diagnostic
          • ie amenorrhea, QUICKENING (movement of baby)
      • Probable
        • objective: changes in uterus size, braxton hicks, enlargement of abdomen, subtle dark skin on face and linea alba from estrogen, pregnancy test, palpation of fetal outline.
      • Positive
        • Fetal heart beat, movement, ultrasound of fetal.
    • Pregnancy term
      • 10 lunar months each 28 days (40 weeks)
        • 38 weeks to 42 due to ovulation variability
      • 266 days after ovulation
      • 280 after LMP
    • Abortion
      • more than 20 weeks and less than 37 6/7 weeks
    • Dating pregnancy
      • EDD/EDC/EDB- estimated date of…
      • Naegele’s rule
        • one year minus three months plus 7 days
          • +- two weeks (due month)
        • LMP 7/4/13: 7-3= 4 + 7days =april 11 2015
        • LMP 2/1/13: EDD 11/8/13
        • LMP 10/31/13: 10-3=7(july) + 7 days = august 7 14
      • think of it like a “Due month” not day. Due to the date +- 2 weeks
      • Don’t change the due date after it is calculated.
        • this helps us know that a baby is growing to fast or too slow.
    • get a good health history
      • previous preg
      • STI
      • + normal health history
      • DM, thyroid, clotting Dx, HTN
      • C sections are sugery
    • NSVD – normal spontaneous vaginal delivery
    • GA – gestational age
    • PPD – postpartum depression
    • epis – episiotomy, cutting the posterior perineum to allow for the baby’s head (not often done)
    • abruption is when the placenta tears from the uterine wall.
    • VBAC – vaginal birth after cesarean
      • risk of uterine rupture due to the previous scar of C section
    • Labs:
  • RH factor, blood type, ABS
    • CBC with hgb/hct/ plt
    • chlamydia, gonorrhea
    • wet prep for vaginal discharge
    • bacterial culture
    • TORCH – infections: toxoplasmosis, other, rubella, cytomegalovirus, herpes
  • Lab changes that are normal
    • increased WBC with left shift
    • increased fibrinogen
    • some anemia due to iron deficiency
    • increased alkaline phosphatase
    • Lower BUN and Creatinine due to more urine (from more blood circulation)
    • trace protein and glu in urine
    • Blood types
      • the actual blood does not cross the placenta (in a perfect world)
      • Rh + baby has a Rh- mom
        • the first baby has the mom make antibodies aginst the Rh factor, but does not harm baby
        • the second baby that is Rh + will be attacked by the IgG and identified by the antibodies.
        • Rh immune Globulin (rhogam) given to Rh – women who have not yet been sensitized by a Rh-baby.
          • IM or IV
          • it is a very small dose of Rh anti-D antibodies, this trick the woman’s body into thinking that there are enough antibodies so the mom’s body does not make any more.
          • given at 26-28 weeks, and postpartum if the baby is Rh +
          • given in the first pregnancy so the mom is never sensitized and doesn’t make her own antibodies.
            • given after any sign or chance of bleeding
          • do not give to a mom who has been sensitized
            • it will show up in the blood test with the Rh + antibodies (the Rhogam will not last long into a blood test of the next baby)
      • TORCH infections
  • PREVENT!
      • can cause fetal death
      • do not eat raw or uncooked meat
      • toxoplasmosis
        • watch for cats that go outside, there is a risk for toxoplasmosis in their poop.
      • Parovirus
        • high risk in day care workers
    • Evaluation of risk
      • BMI – the amount of weight that a person should gain goes down with increase in mom’s weight
      • head to toe exam
      • uterine exam
      • for how the uterus feels, and how far it is up from the symphysis pubis to the umbilicus  
    • Clinical pelvimetry
      • false pelvis is the iliac crest
      • true pelvis is below the iliac crest
      • the mid pelvis is the most narrow (ischial spines)
    • 1st trimester weight gain is 3-5 lbs
      • .5 – 1 lbs per week after 1st trimester
    • Heart rate symptoms
      • headache, scotoma, vaginal bleeding, loss of fetal movements,
    • fetal wellbeing
      • Heartbeat at 6 weeks on ultrasound, 10 week GA for the doppler
      • fetal movement at 18-22, it is sooner in women who have been pregnant previously, (multips)
      • fetal kick counts measure fetal wellbeing
      • US are usually completed in the 2nd or 3rd trimester
        • for presentation, fetal #
        • GI issues: can see an omphalocele, or gastroschisis (organs outside of the body)
        • Cardiac issues: transposition, 2 chamber heart
    • visit every four week from 26 to 38 weeks every 2 weeks till 40, and every week after that.
    • when traveling make sure there is a good medical center, and bring your medical records
      • walk around a lot to prevent DVT
    • die hair ok, massage by a trained person for pregnant women, no hot tubs, pedicure ok, can still have sex.
    • work changes: may need extra breaks, put feet up.
    • can pain room with safe paint without fumes
  • Layers of the pregnancy
  • Fetus, amnion, chorion (synonymous with placenta)
  • chorionic villi exchange the blood products with the mother’s blood vessels.
  • chorionic villi come from the trophoblast and the trophoblast line the chorionic villi
    • by 10 weeks all of the systems/organs have formed
    • Heartbeat at 6 weeks on ultrasound, 10 week GA for the doppler
    • fetal movement at 18-22, it is sooner in women who have been pregnant previously, (multips)
    • Breathing of the fluid starts around, 16 weeks (visible at 24-40 weeks)
  • 2 arteries and a vein and are in the umbilical cord, three total
  • the arteries carry the DEoxygenated blood away from baby
  • the vein carries OXYgenated blood to the baby
  • wharton’s jelly is inside the cord and keeps the cord from kinking
    • Placenta
      • maternal part is the ….
      • the fetal par is the chorionic
      • hormone function
        • produces: hPL, HCG estrogen, progesterone
  • Gravidity – any pregnancy (have to count current pregnancy!!!!)
  • parity – the # of births after 20 weeks regardless of outcome  (twins = 1 as well)
  • Nulligravida – never been pregnant
  • primapara – given birth to a fetus less than 20 week GA
  • multigravida – multiple pregnancies
  • TPAL
  • Term – # babies >37 6/7 weeks
  • Preterm – # babies < 37 6/7 weeks
  • Abortions – Miscarriages, or therapeutic
  • Living children –
  • the format for this will look like G1P1
    • one pregnancy, and one birth
  • G3P1112
    • 3 pregnancies, one full term baby, one preterm, one abortion, 2 living children.

Nursing Care of Child Bearing Families Session 1+2:

Its the first session of OB! This is a great start to the class, and the first two sessions honestly started off somewhat slowly due to forces out of our control. The notes are short due to this, and there is a lot of information that is not a part of this, and it should only be supplemental for your studying.

-Peter

OB/GYN

Session 1

the U.S. is 50 out of 50 for industrialized nations for Maternal mortality

  • no consistent prenatal care

Labor induced is not the safest birth type

  • 50% increase in the chance of a c-section

39-42 weeks is the normal term of pregnancy

Childbirth in the U.S. is NOT safer now than ever before.

95% of deliveries in the 1800-1900 are at the home, and usually done by midwives.

1912 Flexnar report’s take power away from midwives, given to doctors.

1920’s medicated births

  • increase in infant mortality rates during/after this but due to birth injury and fever.

1935  antibiotics for fever

Session 2

Attendants

  • FOC is father of child
  • Doula – a medical information/positional/emotional resource that is on call 2 weeks before the due date up until the birth and some time after.

ethical issues –  maternal/fetal conflict, assisted reproductive tech, abortion, stem cell research, when to resuscitate a preterm on the edge of viability

The pregnancy related mortality ratio is going up in the US and is 31st in developed countries.

  • need access to prenatal care

A low birth weight baby can be full term or otherwise

Do not assume that a pregnant woman knows specific information about pregnancy

  • no drinking is ok during pregnancy

Morbidity and mortality

  • Maternal
  • Infection, Hemorrhage, HTN, Embolism
  • Neonatal/Fetal
  • Congenital anomalies, short gestation/low birthweight, SIDS, Consequences of maternal Dx, Unintentional injuries.

pre birth cervix looks like a doughnut with a dot/hole (os) in the middle. after pregnancy the hole tends to look like a slit.

effacement – the distance between the internal and external os decreases

Ligaments hold up the uterus (round ligament) and stretch to accommodate the weight and size

  • can cause pain.

retroverted uterus – uterus pointed backwards.

symphysis pubis – cartilage connection of the pelvis in the anterior

More than one ductal opening on the nipple. 15-20.

estrogen types

  • Estradiol
    • in the reproductive years
  • Estriol
    • only during pregnancy
  • Estrone
    • Menopause

Progesterone

  • hormone of pregnancy

FSH – stimulates the follicle and that allows the egg to mature

LH – Converts the empty follicle that produced the egg into the corpus luteum, which supports

Ovarian cycle

  • follicular Phase days 1-14
  • growth of follicle
  • estrogen dominance
  • LH surge releases the egg
  • variable amount of time
  • Luteal Phase 15-28
  • Progesterone dominance

Menstrual cycle

  • Menstrual cycle (bleeding)
  • Proliferative phase
    • estrogen dom
  • Secretory phase
    • Progesterone dom
  • ischemic phase if no pregnancy