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Chapter 14-15
Anatomy and Physiology of Pregnancy
Page 296

Physical Changes of Pregnancy


Reproductive System
Uterusfundus (upper portion), isthmus (lower segment), cervix (lower part)
Enlargement (measured by fundal height)

Blood Vessels/lymphatics increase


Braxton-Hicks Contractions
Quickening
Cervix
Mucous plug/Operculum
Goodells
Hegars
Chadwicks
Friability
Ballottement
Ovaries
Do not produce ovum
Corpus luteum persists approx. 10 weeks and produces
estrogen/progesterone until placenta can produce them

Vagina
Increased vascularization
Vaginal secretions-Vaginal cells high in
Chadwicks sign-Breasts
Size
Colostrum
Nipples, areola darken
May develop striae

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Chadwicks sign

Normal cervix color


Chadwicks sign

Cardiovascular
Heart displaced up, forward, left (diaphragm)
Blood volume increases progressively to 45 %
Physiologic Anemia of Pregnancy
Pulse rate increases 10 15 bpm
BP lowers in 2nd trimester, returns to normal 3rd
Cardiac output increases 30 to 50 % (20-24 wks)
WBC count increases (10,000-11,000 WBC/mm3)
Fibrin levels increase about 40%
Supine Hypotensive Syndrome (2nd/3rd trimesters)
vena cava syndrome

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Respiratory
Substernal angle increases (estrogen)
ribcage ligaments relax
Slight hyperventilation
O2 consumption increases 15 to 20 %
Elevated diaphragm causes SOB
Nasal stuffiness/epitaxis r/t edema, vascular
congestion (increased estrogen)
Urinary Tract (Renal)
Urinary frequency (1st and 3rd trimester)
Renal pelvis/ureters dilate
Increased GFR
Glycosuria r/t GFR increase
Proteinuria-usually doesnt occur during pregnancy
1+/lower acceptable during pregnancy

Endocrine
Increased vascularity (thyroid) BMR increases 25%
Pancreasincreased insulin production
(Estrogen/Progesterone/HPL/HCS decrease mothers ability to
utilize insulin effectively. This inability to use mothers insulin
ensures a generous glucose supply for the use of the fetus.

Integumentary System
Linea nigra/melasma (chloasma)/striae
Hormones of Pregnancy
Human Chorionic Gonadotropin (HCG)
Human Placental Lactogen (HPL)
Estrogen
Progesterone
Relaxin

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Hormones in Pregnancy
Hormone

Action

Effect

Human Chorionic
Gonadotropin (HCG)
Estrogen
Progesterone
Human Placenta Lactogen
Oxytocin
Relaxin
Prolactin
Prostaglandins

Signs of Pregnancypage 302


Presumptive (Subjective) Signs of Pregnancy

Probable (Objective) Signs of Pregnancy

Positive (Diagnostic) Signs of Pregnancy

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Ballottement

Psychological Adaptation to Pregnancy


Developmental Stage with its own developmental tasks
Adaptation influenced by:
Acceptance of pregnancy
Support system
Sociocultural background
Psychological responses include:
AmbivalenceNot me, Not now
Acceptance
Introversion
Mood Swings
Body Image Changes

Maternal Adaptation
of pregnancy parallels
the growing acceptance of the reality of a child
Nonacceptance of the pregnancy should not be equated with
rejection of the child. A woman may dislike being pregnant but
feel love for the child
Mood swings
Ambivalent feelings
2. Identifying with the mothering rolea mothers role begins
when she is a child and is being mothered herselfalso influenced
by social groups
3. Reordering personal relationshipsa womans own relationship
with her mother is significant in adaptation to pregnancy and
motherhood.
4. Establishing a relationship with the fetus
phase 1fetus part of mother, not separate
phase 2fetus distinct from herselfattachment grows
phase 3prepares for birth

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Maternal Tasks of Pregnancy


1. Seek safe passage
2. Securing Acceptance
3. Learning to give of self
4. Committing self to unborn child
Maternal Role:
Role-Play -- Fantasy -- Grief(giving up roles/image)

Paternal Tasks of Pregnancy/Adaptation

Today, father has a more active nurturing role


Father must also deal with realization of pregnancy
Father wants recognition as equal parent/participant
their pregnancy their baby
Shares some of the same feelings as mom
(ambivalence)

Pregnancy
9 calendar months
10 lunar months
280 days
40 weeks
Definition of terms/time of each:
Antepartum
Gestation
Intrapartum
Postpartum

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Pregnancy divided into trimesters:


1st trimester

0-3 months

2nd trimester

4-6 months

3rd trimester

7-9 months

Antepartal Terms
Term
Preterm
Postterm
Viability

Prenatal Assessment Terminology


G/P
GTPAL

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Pregnancy and Birth History


G number of pregnancies including current
pregnancy
T number of pregnancies delivered at 37
weeks or later
P number of pregnancies delivered
between 20 and 37 weeks
A number of pregnancies ending in
spontaneous or therapeutic abortion
L number of currently living children

Gravida
Primigravida
Multigravida
Nulligravida
Para
Primipara
Multipara
Nullipara
Grand Multipara

Numerical Documentation of Pregnancy


G_____P_____A_____

G_____T_____P_____A_____L_____

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A woman is in her 28th week of her first


pregnancy.

G_____P_____A______

G_____T_____P_____A_____L_____

Mrs. Smith is pregnant. She tells you that she had


twins two years ago at 38 weeks, a miscarriage at 10
weeks last year and a baby girl (36 weeks gestation)
three years ago. Record her history as:

G_____P_____A_____
G_____T_____P_____A_____L_____

Sandy has come to the clinic for her first prenatal


visit. You are asked to record her obstetrical history.
She states she lost a baby last year at 14 weeks, had a
first trimester abortion when she was 15, had one son
born at 35 weeks gestation, and one daughter at
39 weeks.
G_____P_____A_____
G_____T_____P_____A_____L______

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Ms. John is pregnant now. She states she has no


other children.
G_____P_____A_____

G_____T_____P_____A_____L_____

Nageles Rule
Subtract 3 months from 1st day
of last menstrual period
Add 7 days

EDC-estimated date of confinement


EDB-estimated date of birth
EDD-estimated date of delivery

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Antepartal Assessment

Personal Information about the


Woman
Relationship status
Educational level
Race or ethnic group
Housing stability
Economic level
Any history of abuse
Emotional/mental health history

Personal Information about the


Woman (contd)
Support systems available to her
Overuse or underuse of healthcare system
Personal preferences about birth
Plans for care of child following birth
Feeding method for the baby

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Assessment: First Prenatal Visit


History
Past Medical History
Current Medical History
Social/Employment History
Family Medical History
Reproductive History: date, course of pregnancy,
l&d, pp
Current OB/GYN History: LMP, any
complications, contraception use, STDs, age
at menarche, date of last pap smear, exam,
risk exposure
Weight Pattern
Nutritional Assessment: dietary recall
Exercise Program
Allergies
Use of over the counter, prescription, illicit drugs

Complete Physical Exam


Vital Signs
Weight/Height
Skin/ Head/Chest/Lungs/Heart
Breasts
Abdomen
Extremities
Pelvic Area

Laboratory Assessment
Blood:
CBC: hematocrit, hemoglobin
Blood type/RH (RhIG/RhoGAM 28 wks for Rh-)
RDR/VDRL (Syphilis)/HIV screening
Antibody Screen: , Varicella, toxoplasmosis,
Rubella Titer
Tuberculin Test
Hepatitis B Screen
Sickle Cell
Quad Screen (15-21 wks) neural tube defects,
trisomy 18 (MSAFP), page 336
Urine
Urinalysis/Culture if necessary
Protein/Glucose/ketones
Pap Smear
Culture: Chlamydia, gonorrhea
Group B streptococcusbetween 35/37 weeks

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Screening Tests
Throughout pregnancy
Gestational diabetes mellitus (GDM)
Hemoglobin (Hgb) and hematocrit (Hct)
Group B streptococcus (GBS)
Hemoglobin electrophoresis
Varicella immunity
Purified protein derivative of tuberculin (PPD)

Planning
Safe, Effective Care
Physiological & Psychosocial Integrity
Health Promotion & Maintenance
Implementation
Record Gravida & Para
EDC,EDB,EDD Calculation
Physical Exam

Follow-Up Visits
Frequency
every 4 weeks for the first--every 2 weeks until --every week --

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Subsequent Prenatal Visits to include:


Teaching, Teaching, Teaching
Overall health status: discomforts, signs/symptoms
Medication additions/changes/psychological/
psychosocial needs
Warning signs of pregnancy
MOM:
VS, weight, edema, signs of preterm labor
FETUS:
FHTs, fetal movement, fundal height for growth,
Fetal position and presentation

Physical Exam:
Fetal Heart Tones

Can be assessed using a fetoscope (A) by 16


weeks or by Doppler ultrasound device (B) by
about 10 weeks

Figure 15-3

A cross-sectional view of fetal position when McDonalds method is used to assess fundal height.

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Olds, London textbook

Follow-Up Visits
1st trimester: every 4 weeks
VS, weight, urine (glucose, protein, ketones), fetal heart
tones, discomfort of pregnancy, nutritional assessment,
adjustment to pregnancy, assess for warning signs,
education, fetal heart tones
2nd trimester: every 4 weeks:
above plus AFP 16 weeks (QUAD SCREEN), Indirect
Coombs Test (28 weeks), ultrasound, fetal movement,
prenatal classes, education, assess for warning signs,
discomforts
3rd trimester: every 2 weeks/every week: (RhoGam if
needed 28-32 weeks
above plus gestational diabetes screen, 24-28 weeks
Culture for Group B Strep (37 weeks), Assess for signs
of labor,

Weight Gain
First Trimester:
Second Trimester:
Third Trimester

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Danger Signs
Vaginal Bleeding

miscarriage,
placenta previa
abruptio placentae

Persistent Vomiting

hyperemesis
gravidarum

HA, blurred vision

HTN, PIH

Fluid from vagina

ROM

Elevated Temperature

Infection

Abdominal Pain

premature labor
abruptio placenta

Danger Signs, continued


No fetal movement

fetal death, obesity

Edema of hands, face PIH


Dysuria

URI

Epigastric Pain

Severe
preeclampsia

Signs of Impeding Labor:


1. Uterine contractions, increasing in
frequency, intensity, duration
2. Bloody Show
3. Expulsion of mucous plug
4. Rupture of membranes

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Signs of Preterm Labor


Painful menstrual-like cramps
Dull low backache
Suprapubic pain or pressure
Pelvic pressure or heaviness
Change in character or amount of vaginal
discharge
Diarrhea

Signs of Preterm Labor (contd)


Uterine contractions felt every 10 minutes
for 1 hour
Leaking of water from vagina

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Discomforts of Pregnancy

350

1st trimester
nausea and vomiting
urinary frequency
fatigue
breast tenderness
increased vaginal discharge
nasal stuffiness
excess salivation

Discomforts, continued
2nd and 3rd trimester
heartburn
ankle edema
varicose veins
hemorrhoids
constipation
backache
leg cramps

text, 349

Self-Care Education
Travelpage 362
Difficulty Sleeping
Sexpage 366
Clothing
Bathing
Employment
Exercisepage 363
Dental Carepage 366

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Teratogenic Substances
OTC Medications herbs, allergy meds
Alcohol
Tobacco
Marijuana, Cocaine

Special Needs of:


Women over 35 years
Pregnant Adolescents
Women over 36 risk of Downs syndrome
Asked to submit to more medical
procedures
Adolescent mothers, see text 422U.S.A.
has highest adolescent birth rate in the
industrialized world, but has declined since
1991about 4 in every 10 girls

Special Needs of the Pregnant


Adolescent
Review Developmental Tasks of
Adolescencepage 380
Review Adolescents Response to
Developmental Tasks of Pregnancy
page 384
Emancipated Minorpage 387
Trusting Relationship vital

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Contraception
Stop oral contraceptives 2-3 months prior
to conception
Have IUD removed 1 month prior to
conception
Use barrier methods of contraception
while waiting

Childbirth Options
Chapter 13

Pregnancy/Birth Options
Health Care Provider
Physician
Midwife
Birth Setting
Birth Center
Hospital
Labor support person
Significant other
Doula
Nurse

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Childbirth Education
Birth Planchoose options r/t childbirth
experience that are important to
childbearing family (text, pg. 438)
Doulasnonprofessional trained to
provide labor support, does not get
involved with clinical tasks
Birth Centers
LDR, LDRP, home births

First Trimester Class Material

Second Trimester Class Material

Third Trimester Class Material

Factors Influencing Prenatal Nutrition


General nutritional status before pregnancy
Maternal age
Maternal parity

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Nutritional Requirements:
Calories
Protein
Carbohydrates
Primary source of energy
Fiber
Fats
Energy
More completely absorbed during pregnancy

Minerals
Calcium and phosphorus
Mineralization of fetal bones and teeth
Energy and cell production
Acid-base buffering

Iodine
Essential for brain development

Minerals (contd)
Sodium
Metabolism
Regulation of fluid balance

Zinc
Protein metabolism
Synthesis of DNA and RNA
Fetal growth
Lactation

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Minerals (contd)
Magnesium
Cellular metabolism
Structural growth

Iron
Oxygen-carrying capability

Vitamins
Vitamin A
Growth of epithelial cells, metabolism

Vitamin D
Absorption, utilization of calcium and
phosphorus

Vitamin E
Fat absorption

Vitamin K
Synthesis of prothrombin

B Vitamins
Thiamine
Riboflavin
Niacin
Folic acid
Vitamin B6
Vitamin B12

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Folic Acid
Increase intake of folic acid to prevent
neural tube defects
Sources:

(need 24 hour recall)

Mercury Warning
High levels of mercury can harm the
fetus developing nervous system

Sources: shark, swordfish, marlin, king


mackerel, albacore/white tuna

Nutrition, continued
Problems: LBW, SGA, IUGR1st half of pregnancy

gains reflect maternal tissue2nd half of pregnancy reflect fetal


tissue gains

Prenatal vitamins/minerals
Folic acid Calcium, magnesium, vitamin D
bone health
Iron
Picaconsuming nonfood substances
Clay, dirt, laundry starch
Causes: nutritional deficiencies, stress, low socioeconomic

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NutritionWeight Gain
25 to 35 pounds weight gain during pregnancy
3-4 pounds in first trimester
12 pounds in second trimester
12 pounds in third trimester
Underweight 28-40 pounds
Overweight 15-25 pounds
Obese 15 pounds (Institute of Medicine)

Lactating women should consume 3000 ml of


fluids per day

Nutritional Assessment and


Education
24 hour recall obtained
Eat a variety of good foods (fruits/veg)
whole grains, protein
8-10 glasses of water daily
Appropriate weight gain

Effects of Maternal Nutrition


on Fetus
Deficiencies can interfere with cell and
organ growth
If deficiencies occur during cell division
permanent consequences
If deficiencies occur during cell
enlargement reversible

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Nutritional Counseling
for the Adolescent
Positive approach
Suggest nutrient-rich foods
Include other family members involved in
meal preparation
Involve expectant father
Emphasize benefits to her and her baby
Peer classes

Postpartum Nutrition
Assess new mothers weight, labs, clinical
signs
Weight loss at birth
Rate of weight loss
Evaluate weight
Assess clinical symptoms

Nutritional Care of
Formula-Feeding Mothers
Dietary requirements return to
prepregnancy levels
Understanding of nutrition
Refer to dietitian if excessive weight gain

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Nutritional Care of Breastfeeding


Mothers
Nutrient needs increase during
breastfeeding
Increase caloric intake by 200 kcal/day over
pregnancy level
Protein intake 65 mg/day for first 6 months
and then 62 mg/day thereafter
Calcium intake should be 1000 mg/day
Iron intake
Maintain adequate fluid intake

Nursing Care Management


Nursing assessment and diagnosis
Data collection
Diet history
Formulate nursing diagnoses from data
analysis

Nursing Diagnoses
Imbalanced Nutrition: Less than Body
Requirements
Imbalanced Nutrition: More than Body
Requirements
Readiness for Enhanced Knowledge

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Nursing Plan and Implementation


Health promotion education
Clear presentation
Develop plan with pregnant woman

Plan with woman


Guidance
Community-based nursing care

Evaluation
Food journal
Writing weekly menus
Returning for weekly weighing
Periodic hematocrit assessment
Referral to dietitian

Questions
Anyone?

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