Infertility - A thin probe and biopsy forceps are introduced through cervix

- inability to conceive a child or sustain a pregnancy to birth - A biopsy specimen is taken from anterior or posterior
Infertile uterine wall
- If the woman has not become pregnant after at least a year of 3. Laparoscopy
unprotected sex
- Introduction of thin, hallow, lighted tube through a small
Subfertility
incision in abdomen, under the umbilicus, to examine position and
- When the couple are less able to conceive without additional
state of fallopian tubes and ovaries
help
Therapy for Uterine Concerns
Factors causing Female Subfertility
1. Progesterone vaginal suppositories
- Limited production of FSH/ LH which interfere w/ ova growth
- Luteal phase defect
- Anovulation
2. Myomectomy
- Problems of ova transport through fallopian tube to uterus
- Myoma or intrauterine adhesions
- Uterine factors
3. Surgery
- Cervical and vaginal factors
- Abnormal uterine formation
- Poor nutrition, increased body weight, and lack of exercise Testing for Vaginal and Cervical Concerns
- Tubal transport problem 1. Assessment of cervical mucus
- usually occurs because scarring has developed in the fallopian 2. Assessment of ability of sperm to survive in vagina and enter
tube uterus
Testing for Tubal Patency
Therapy for Vaginal and Cervical Concerns
1. Sonohysterosalpingogram
1. Low dose estrogen therapy
- sonographic examination of fallopian tubes and uterus using - To increase mucus production during days 5-10 of the woman’s
ultrasound contrast agent introduced into uterus through cycle
narrow catheter inserted into uterine cervix followed by 2. Antibiotic therapy
intravaginal scanning - Vaginal infection
- procedure is contraindicated if infection of vagina, cervix or REPRODUCTIVE LIFE PLANNING Includes all decisions an individual
uterus is present. or couple make about:
- Usually scheduled just following a menstrual flow - Whether and when to have children
2. Hysterosalphingogram - How many children to have
- Like Sonohysterosalpingogram except a radiopaque contrast - How they are spaced
medium is used and fallopian tubes are revealed by x ray Considerations in choosing Contraception Method
(catheter is utilized) - Personal Values
3. Transvaginal Hydrolaparoscopy - Ability to use method correctly
- installation of paracervical local anesthetic block - Effect of the method to sexual enjoyment
- followed by introduction of hysteroscope into an incision - Financial factors
behind the cervix through cul-de-sac of Douglas into the peritoneal - Term of the relationship
cavity. - Prior experience with contraception
Therapy for Lack of Tubal Patency - Future plans
1. Diathermy or steroids administration - Woman’s lifestyle and overall health
- Inflammation An ideal contraceptive should be:
2. Hysterosalpingography - Safe
- Adhesions - Effective
3. Canalization of the fallopian tubes - Compatible with spiritual and cultural beliefs and personal
4. Plastic surgical repair preferences
5. Laser surgery - Free of bothersome side effects
- Peritoneal adhesions or nodules - Convenient to use and easily obtainable
Testing for Uterine Concerns - Affordable and needing few instructions for effective use
1. Hysteroscopy - Free of effects on future pregnancies
Visual inspection of uterus through insertion of hysteroscope Assessment prior to Contraception Use
through vagina, cervix, and into uterus - Vital signs
- Done to evaluate uterine adhesion, malformations, other - Obstetric history
abnormalities such as fibroid tumors or polyps - Patient’s desires, needs, feelings and understanding of
2. Uterine endometrial biopsy contraception
- Examination of tissue removed from uterus to reveal - Sexual practices
endometrial problem such as luteal phase defect
- Done 2-3 days before an expected menstrual flow
NATURAL FAMILY PLANNING
- methods that involve no introduction or chemical or foreign
material into the body
- Also called “periodic abstinence methods”
1. Abstinence
- Refraining from sexual relations
- 0% failure rate (theoretical)
- Most effective way to prevent STIs
- Patients find it difficult to adhere (high failure rate)
2. Periodic abstinence
- Avoiding sexual contact on the days when a woman may
conceive
3. Lactation Amenorrhea Method
- When breast feeding there is a natural suppression of both
ovulation and menses
- Failure rate 1-5%
- A safe birth control method if:
- infant under 6 mos. of age
- infant exclusively breastfed (q4 at day, q6 at night)
- menses has not returned
4. Coitus Interruptus (Withdrawal Method)
- man withdraws at moment of ejaculation and spermatozoa are
emitted outside vagina
- 82% effective
- Ejaculation may occur before withdrawal is complete
- Few spermatozoa may be present in pre ejaculation fluid
- can lead to STIs
FERTILITY AWARENESS METHODS
- methods that rely on detecting when a woman will be capable
of impregnation (fertile) so she can use periods of abstinence
during that time
1. Calendar (Rhythm) Method
- Requires a couple of abstain from coitus on days of menstrual
cycle when woman is most likely to conceive.
- Woman keeps a diary of about 6 cycles to know her shortest
and longest cycles
- Subtract 18 from shortest and 11 from longest cycle
Failure is due to:
- irregular menstrual cycle
- Miscalculation
- Disregard to predicted fertile days
2. Basal Body Temperature
- Body temp (oral/ tympanic) is taken in resting state upon
waking before rising from bed before any activity
- BBT falls .5 F before ovulation, rises 1F during ovulation due to
rise in progesterone with ovulation
- slight dip in temp. followed by an increase = ovulation
- woman should refrain from having coitus for next 3 days
- recommended to combine this method with calendar method
- many factors can affect BBT
3. Billing’s Method (Cervical Mucus Method)
- Use changes in cervical mucus that occur naturally with
ovulation
- Before ovulation: cervical mucus is thick and does not stretch
- Just before ovulation: mucus secretion increases
- On the day of ovulation: copious, thin, watery, transparent,
slippery (egg white) and stretches
4. Spinnbarkeit Test
- Fertile on days: all the days when mucus is copious and for at
least 3-4 days afterwards
- should be conscientious about assessing vaginal secretions
every day
- Should be combined with calendar method for best results
5. Two-Day Method
- Uses cervical secretions as indicator of fertility
- pays attention each day to presence or absence of secretions
- If she notices any secretions today or yesterday, she considers
herself fertile today
- To prevent pregnancy, she avoids intercourse today
6. Symptothermal Method
- Combines cervical mucus and BBT methods
- takes temp. daily (watch for rise in temp. marks ovulation)
- analyze cervical mucus daily
- Observes for other signs of ovulation (mittelschmerz or if
cervix feels softer than usual)
- Abstain from sex until 3 days after rise in temp. or 4 days after
peak of mucus change
- More effective than either BBT or cervical mucus method
alone
7. Standard Days Method (Cycle beads)
- based on monitoring days menstrual cycle
- Appropriate for women with menstrual cycles between 26-32
days long.
- identifies days 8-19 as fertile days.
- tracks menstrual cycle and avoids unprotected sex on fertile
days
- can use Cycle Beads
- color-coded string of beads help track days of menstrual
cycle and days most likely to get pregnant
- White beads mark days when likely to get pregnant; Do not
have unprotected sex
- Brown beads mark days not most likely to get pregnant if
unprotected sex.
- Red bead marks first day of menstruation
8. Ovulation Detection
- Uses over the counter ovulation detection kit
- Detect surge in production of luteinizing hormone (LH); 36
hours before ovulation
- Not intended to be used as contraceptive aid
- Timing intercourse shortly after LH surge, can increase
probability of bringing sperm and egg together at time when
contraception is most likely to occur
9. Marquette Model
- teaches to identify fertile window and periods of infertility by
using electronic hormonal fertility monitor and cervical mucus
- allows to prevent or achieve pregnancy depending on family
planning needs
- electronic hormonal fertility monitor is a device that measures
levels of estrogen and luteinizing hormone (LH) in urine
- monitor is 98.8% accurate in identifying LH surge
 - monitor reports low, high, or peak fertility reading upon Fetal Growth and Development
scanning urine saturated strip - The embryonic stage begins in the third week after fertilization;
- benefits include objective measurement of hormones the fetal stage begins in the ninth week.
Effects of Natural Family Planning Methods 3 time periods
- no effects if women get pregnant and on future pregnancies 1. Pre-embryonic
- Provides spontaneity in couples sexual relations 2. Embryonic
- required days of abstinence make it unsatisfactory and 3. Fetal
unenjoyable Fertilization
- Also referred to as conception and impregnation
- Not for adolescents as they require great deal of thought and
- Union of an ovum and a spermatozoon
persistence
- Usually occurs in the outer third of the fallopian tube (ampullar
- For perimenopausal women (can’t use hormonal method) portion)
- For women delaying next pregnancy Name Time Period
BARRIER METHODS Ovum from ovulation to fertilization
- Placing chemical or latex barrier between cervix and Zygote From fertilization to implantation
advancing sperm
Embryo From implantation to 5-8 weeks
1. Spermicide
Fetus From 5-8 weeks until term
- Causes death of sperm and acidifies vagina
Conceptus Developing embryo and placental structures
2. Male Condoms
throughout pregnancy
- latex rubber/ synthetic sheath placed over erect penis before
Age of Earliest age at which fetuses survive if they
sex to trap sperm
Viability are born is generally accepted as 24 weeks or
3. Female Condoms
at the point a fetus weighs more than 500-
- latex or polyurethane sheath, prelubricated with spermicide
600g
4. Diaphragm
- circular rubber disk placed over cervix before sex to
Implantation
mechanically halt passage of sperm
- Contract between the growing structure and the uterine
5. Cervical Caps
endometrium
- soft rubber shaped like thimble, fits snugly over uterine cervix
- Occurs approx. 8-10 days after fertilization
6. Oral Contraceptives
- Usually occurs high in the uterus on the posterior surface
- Hormonal preparations containing estrogen and progestin or
Embryonic Fetal Structures
progestin alone
- Placenta
7. Estrogen/ Progesterone Transdermal Patch
- Membranes
- patch that slowly but continuously release combination of
- Fetal lungs, kidneys, digestive tract
estrogen and progesterone
Decidua or Uterine lining
8. Vaginal Estrogen/ Progesterone Ring
- Trophoblast cells
- Ring contains estrogen and progesterone
- HCG
- worn inside vagina; body absorbs hormones through vaginal - Uterine endometrium grows in thickness
lining Chorionic Villi
9. Subdermal Hormone Implants - Miniature villi resembling probing fingers
- delivery of steroid progestin from polymer capsules or rods Placenta
placed under skin - Latin for ‘pancake’
- hormone diffuses out slowly at stable rate, providing - Grows from a few identifiable trophoblastic cells at the beginning
contraceptive effectiveness for 1-5 years of pregnancy
10. Intramuscular Injections Function:
- progesterone via IM injection in either upper arm/ buttock - Circulation
- Depo-Provera stops ovulation - Endocrine function
11. Intrauterine Device - Human chorionic gonadotropin
- aka intrauterine contraceptive device - Progesterone
- small, T shaped device inserted into uterus - Estrogen
- one form of long-acting reversible birth control (LARC) - Human placental lactogen
SURGICAL METHODS - Placental proteins
- aka having tubes tied or tubal sterilization Amniotic Membranes
- Dual-walled sac with the chorion as the outermost part and the
- permanent birth control
amnion as the innermost part
- In tubal ligation, fallopian tubes are cut, tied or blocked - Chorionic frondosum (fetal), decidua basalis (maternal)
1. VASECTOMY Amniotic Fluid
- surgical procedure for male sterilization - 800-1200ml at term
- vasa deferentia are cut, tied or sealed to prevent sperm from - Hydramnios: more than 2000 ml
entering urethra thus preventing fertilization - Amniotic fluid index at least 5cm
- Appropriate amount ensures adequate kidney function Lecithin
Purposes: - Surge in the production at 35 weeks
- Shield fetus from pressure Sphingomyelin
- Protects fetus from changes in temp - Chief component in the early formation of surfactant
- Aids in muscular development Nervous System
- Protects umbilical cord from pressure, moisturizes it begins to develop early in pregnancy:
Umbilical Cord - Neural plate
- Formed from fetal membranes - Parts of the brain
- Transports oxygen and nutrients to the fetus from placenta - Brain waves detected by EEG
- Return waste products from fetus to the placenta - Eye and inner ear develop
- Comprising of 2 arteries and 1 vein (Smiley face) which is - By 24 weeks, ear is capable of responding to sounds, eyes exhibit
protected by Wharton’s Jelly pupillary reaction
- 400ml of blood given to baby Endocrine System
Origin and Development of Organ System - Fetal pancreas produces insulin needed by the fetus
- Stem cells - Thyroid and parathyroid glands play vital roles in fetal metabolic
- Zygote growth function and calcium balance
- Primary germ layers - Fetal adrenal glands supply a precursor necessary for estrogen
Origin of Body Tissue synthesis by the placenta
Ectoderm - Central nervous system CNS (brain, spinal Digestive System
(organ cord) - about the 4th week of uterine life, digestive tract separates from
system) - Peripheral nervous system PNS the respiratory tract
- Skin, hair, nails, tooth enamel - GIT is sterile before birth
- Sense organs Musculoskeletal System
- Mucous membranes of the anus, mouth, - First 2 weeks of fetal life = cartilage prototypes provide position
nose and support to the fetus
- Mammary glands - About the 12th week = ossification of the cartilage into bone
Mesoderm - Supporting structures (connective tissue, begins
(muscular) bones, cartilage, muscle, ligaments, Reproductive System
tendons) - Child’s sex is determined at the moment of conception by a
- Upper portion of urinary system (kidneys, spermatozoan carrying X or Y chromosome and can be
uterus) ascertained as early as 8 weeks by the chromosomal analysis or
- Reproductive system analysis of fetal cells
- Heart, lymph, circulatory system, blood cells Urinary System
Endoderm - Lining of pericardial, pleura, peritoneal - By the 12th week, urine is formed
(linings) cavities - By the 16th week, urine is excreted into the amniotic fluid
- Lining of the gastrointestinal tract, Integumentary System
respiratory tract, tonsils, parathyroid, - Skin of fetus appears thin and almost translucent until
thyroid, and thymus glands subcutaneous fat begins to be deposited underneath it by 36th
- Lower urinary system (bladder, urethra) weeks
Cardiovascular System Urinary System
- One of the first system to become functional in intrauterine life - IgG maternal antibodies cross the placenta into the fetus as early
- heartbeat may be heard with a Doppler as early as 10th to 12th as 20th week
week of pregnancy Milestones of Fetal Growth and Development
- After 28th week, consistent heart rate of 110 to 160 bpm End of 4th week gestation
Fetal Circulation (read) - Length of embryo is about 0.75cm
Respiratory System - Weight is about 400mg
- At the 3rd week of uterine life, the respiratory and digestive tracts - Spinal cord is formed and fused at the midpoint
exist as a single tube. - Arms and legs are bud-like structures
- By the end of 4th week, a septum begins to divide the esophagus - Rudimentary eyes, ears and nose are discernible
from the trachea. At the same time, lung buds appear on the End of 8th week gestation
trachea - Length of fetus is 2.5cm (1 inch)
- Until the 7th week of life, the diaphragm does not completely - Weight is about 20g
divide the thoracic cavity from the abdomen - Organogenesis is complete
Developmental Milestones - The heart with septum and valves, beats rhythmically
- Surfactant is formed and excreted by the alveolar cells (24th - 32nd End of 12th week gestation
week aog) - Length of fetus is 7-8cm
- Specific lung fluid with a low surface tension and low viscosity - weight is about 45g
forms in alveoli to aid in expansion of the alveoli at birth - nail beds are forming on fingers and toes
- Spontaneous respiratory practice movements - sex is distinguishable on outward appearance
Surfactants (2:1)
End of 16th week gestation
- Length of fetus is 10-17cm, weight is about 55-120g
- fetal heart sounds are audible by an ordinary stethoscope
End of 20th week gestation
- Length of fetus is 25cm, weight is about 223g
- spontaneous fetal movements can be sensed by mother
(quickening)
- antibody production is possible
End of 24th week gestation
- Length of fetus is 28-36cm, weight is about 550g
- meconium is present as far as the rectum
- active production lung surfactant
End of 28th week gestation
- Length of fetus is 35-38cm, weight is about 1,200g
- lung alveoli are almost mature
- surfactant can be demonstrated in amniotic fluid
End of 32th week gestation
- Length of fetus is 38-43cm, weight is about 1,600g
- fetus responds to the movement to sounds outside the mother’s
body
- an active Moro reflex is present
End of 36th week gestation
- Length of fetus is 42-48cm, weight is about 1,800g
- most fetuses turn into a vertex (head down) presentation during
this month
End of 40th week gestation
- Length of fetus is 48-52cm
- weight is about 3,000g (7-7.5lbs), fetus kicks actively
- fetal hemoglobin begins its conversion to adult hemoglobin
- vernix caseosa begins to decrease
- creases on the soles of the feet cover at least two thirds of the
surface
Teratogens
- external agents such as viruses, drugs, chemicals and radiation
that can harm a developing embryo or fetus
- time when organ system or body part is at highest risk of effects
from teratogens is known as ‘sensitive period’
- effects of teratogens on a body part or organ system are worst
during the period when that structure is forming and growing
most rapidly
- the same defect can be caused by different teratogens
- a variety of defects can be caused by a single teratogen
- the longer the exposure or higher the ‘dose’ of the teratogen, the
more likely it is that serious harm will be done
- the long-term effects of a teratogen often depend on the quality
of the postnatal environment
Medications
- not all medications are safe while trying to conceive as well as
during pregnancy
- over the counter medications (antibiotics)
- prescription medications
- vitamins and supplements
- pregnancy risk categories for medications
- review all medications with a health care provider
Substance Use/ Abuse
- birth defects and learning defects
- safety issues impacting the ability to properly for an infant
- family dysfunction
- financial dysfunction
- financial stress
- potential for law enforcement involvement
- pregnancy may be a strong motivator for change
- refer for substance abuse evaluation/ counseling
Alcohol Intake
- fetal alcohol syndrome is a leading cause of preventable mental
retardation
- no level of alcohol is considered ‘safe’
- advise to abstain when attempting to conceive and as well as
during pregnancy
- refer for evaluation and treatment
Tobacco Exposure
- smoking in pregnancy is associated with preterm delivery and low
birth weight infants (vasoconstriction due to nicotine)
- smoking in the household is associated with sudden infant death
syndrome, childhood respiratory illness, asthma, and otitis media
- promote smoking cessation
Environmental Hazards
- chemical: lead, mercury, herbicides, pesticides
- physical: hyperthermia
- radiation: x-ray
- infectious: live vaccines, STDs, toxoplasmosis, cytomegalovirus,
parvovirus B19 (fifth disease) in dogs
- exposure at home, workplace and environment
- cultural considerations
Environmental Counseling
- avoid hot tubs, saunas, x-ray
- stay away from toxic materials like insecticides, solvents,
mercury, lead
- avoid cat litter, garden soil, raw meat
- frequent hand washing
- universal precautions for child care and health care
- cultural practices
Congenital Infections (TORCH)
1. Toxoplasmosis
- Caused by protozoan toxoplasma gondii
- Contracted by eating raw or undercooked meat or contact
with feces of infected cats
- maternal-fetal transmission
- often results in spontaneous abortion if contracted during the
first trimester
- sever neonatal disorders associated with congenital infection
include convulsions, coma, microcephaly, and hydrocephalus
Interventions:
- prevention
- have toxoplasma titer checked prenatally if cats live in the
household
2. Other Infections
- Rubeola (measles), Varicella (chickenpox), Mumps, Hepatitis,
PTB, Typhoid, Malaria, STD (Gonorrhea, Syphilis), Poliomyelitis
Syphilis
- Caused by treponema pallidum, a spirochete
- Crosses the placenta after 16 weeks gestation and infects the
fetus
- Langhan’s later in the chorion prevents fetal infection early in
pregnancy until the layer begins to atrophy between 16 to 18
weeks gestation
- No increase risk of anomalies, but spirochete may cause
inflammatory and destructive changes in the liver, spleen, kidney,
bone marrow
- If untreated, 25% will end in stillbirth, 40-50% of neonates born
will have symptomatic congenital syphilis
- Clients with syphilis have positive VDRL. Fluorescent treponemal
antibody absorption is more specific and are commonly
performed to confirm a positive VDRL.
Gonorrhea
- Causative organism is Neisseria gonorrhea
- Neonate can be exposed to organism during birth.
(recommended cesarian birth) This can result in sepsis or
ophthalmia neonatorum, which can cause permanent blindness
- Eye prophylaxis with erythromycin (Ilotycin) ointment within 4
hours after birth can decrease the risk of it
Chlamydia
- Most common sexually transmitted disease
- Caused by chlamydia trachomatis
- Can be transmitted to neonate during delivery and cause
neonatal conjunctivitis and pneumonia
- Eye prophylaxis with erythromycin ointment shortly after birth
can prevent neonatal conjunctivitis
- Silver nitrate has been used prophylactically in the past but it is
not effective against chlamydia trachomatis
3. Rubella (German Measles)
- 80-90% of fetuses exposed during the first trimester will be
affected either by spontaneous abortion or congenital
anomalies
- Clinical signs of congenital infections are congenital heart
disease, intrauterine growth restriction (IUGR) or fetal
undergrowth, hearing loss
- Infants born with congenital rubella syndrome are infectious
and should be isolated
4. Cytomegalovirus
- Respiratory or sexual transmission. Neonate can contract
during delivery through an infected birth canal.
- Most common cause of congenital viral infection, occurring in
1% of all newborns. Most (90 to 95%) of these infants are
asymptomatic at birth. The remaining 5 to 10% may
experience hemolytic anemia and jaundice, hydrocephaly or
microcephaly, pneumonitis, deafness and fetal or neonatal
death.
- Disease is usually progressive through infancy and childhood.
5. Herpes (HSV)
- Maternal symptoms include vesicles on the genitalia that are
usually painful. Fetal symptoms include fever or hypothermia,
jaundice, seizures, poor feeing. 50% develop vesicular skin
lesions.
- There is no known cure
- Virus can be lethal to fetus and is transmitted during birth.
Cesarean delivery is indicated if mother has active lesions at
the time of delivery.
Psychological Response to Pregnancy
1. Role changes – transition to parenthood for first-time parents
means making adjustments to previous patterns in life;
accommodating subsequent children also requires adjustment
of family roles
2. Financial changes – employment changes, childcare expenses,
need for larger housing space, all factors in parenthood changes
3. Fear and anxiety – present in most pregnancies, though source
may vary; for some, finances may be biggest concern; for
others; social support may be greatest source of anxiety
Developmental Task
First trimester – Accepting the pregnancy
Woman’s responses
- Often ambivalence and disbelief, pregnancy seems unreal, mood
swings due to hormonal changes
Partner’s Responses
- Ambivalence
- Excited yet may be overwhelmed
Second trimester – Accepting the fetus
Woman’s responses
- Quickening makes pregnancy seem real
- Narcissism and introversion
- Role playing
- Body image changes, concern about partner’s support
Partner’s Responses
- May feel ‘left out’
- Will be absorbed in work
- Sexual issues may arise
Third trimester – Preparing for the baby and end of pregnancy
Woman’s responses
- Pride in pregnancy (lordosis)
- Prepares clothing, sleeping arrangement for the baby
- Anxiety about delivery, concern about health of baby
- Often surge of energy near end of pregnancy just prior to labor
when woman prepares home for new baby
Partner’s Responses
- Interested in attending prenatal classes
Emotional Responses
Developmental tasks
Maternal psychological tasks (based on Rubin’s work)
- Ensuring safe passage for fetus
- Seeking acceptance of fetus by others
- Assumption of the mother role
- Learning to give of oneself on behalf of one’s child
Paternal psychological response
- Pride in pregnancy
- Ambivalence – concerns about readiness for responsibilities of
parenthood
- Stress – may feel pressure for added financial support
- Concerns and fears – change in marital relationship, health of
baby and partner
Grandparents
- Often great source of support
- Role vary widely, due to factors like proximity, age and availability
of grandparents, their ease with role
Siblings’ response
- Sibling rivalry occurs when new baby introduced in family
- Preparation for new baby in developmentally appropriate way for
sibling useful in decreasing rivalry
- Parents need to be realistic about stress of new baby on other
children and be prepared to help them through transition;
anticipate some regression in siblings
- Older sibling still needs some ‘alone time’ with parents after new
baby arrives
Emotional Responses that can Cause Concern in Pregnancy
1. Grief
- Maybe result of giving up on a previous role
- Will not be ‘irresponsible and carefree’
- Must incorporate her new role to overcome this
2. Narcissism
- Self-centered
- May criticize partner
- May reduce risky activities to protect herself and the baby
- Nurses must be sensitive to the woman’s needs depending
on the stage of her pregnancy
3. Introversion vs Extroversion
- Introversion – means turning inward, concentrating on
oneself and one’s body
- Extroversion – some pregnant women are more active,
appears healthier during pregnancy
4. Body Image and Boundary
- Body image – the way you perceive yourself
- Body boundary – zone of separation you perceive between
yourself and the objects or other people
- Pregnancy may change her concept of body boundaries to
protect her pregnancy
5. Stress
- Major change brings about stress
- Stress may make it difficult for the woman to make decisions.
Be aware of surroundings and manage her time.
6. Depression
- Feeling of sadness marked by loss of interest in usual things,
feeling of guilt, disturbed sleep, low energy, poor
concentration (common among adolescents)
- Check if taking antidepressants which are teratogenic
- Determine support system
7. Couvade Syndrome
- Traditionally, observance of certain rituals and taboos for
father during transition to parenthood
- Now also refers to development of physical symptoms of
pregnancy usually seen in pregnant woman such as weight
gain and nausea
Sexual desires of the pregnant woman
- Affected by women’s previous experience
- She may be worried or may have decreased desire for sex
- First trimester – decrease in libido
- Second trimester – increased blood flow to pelvic organs may
increase libido and sexual pleasure
- Third trimester – may still be high or may decrease
--------------------------------------------------------------------------
Fertilization
Mitosis
- Process of cellular division
- Results in daughter cells that are exact copies of the original
cell
- Identical to parent cell and to each other
- Contain a full set of chromosomes or genetic material
- Referred to as diploid cells
- Somatic cells continue to reproduce and replace each other
Meiosis
- Type of cell division that reproductive cells called gametes
(sperm and ova) – each cell contains half genetic material of
parent cell (haploid)
Oogenesis
- Process that produces the female gamete, called an ovum
(egg), that begins to develop early in the fetal life of the female
- There’s is enough ova good for 35 years
- Ovaries begin to develop early in the fetal life of the female
 - All ova that female will produce in her lifetime are present at
birth – ovary gives rise to oogonial cell, which develop into
oocytes
- During puberty, mature primary oocyte continues through first
meiotic division in ovary
- Haploid cells released at ovulation
Spermatogenesis
- Production of the male gamete, or sperm, during puberty
- The spermatogonium (primordial germ cell)
- Begins with complete set of genetic material – diploid number
of chromosomes
- Cell replicates before it enters first meiotic division
- Cell is now primary spermatocyte
- During second meiotic division, divide to form four spermatids,
each with haploid number of chromosomes
Preparation for Fertilization
- Preparation is the first component of fertilization
- Ovum released into fallopian tube – viable for 24 hours
- Sperm deposited into vagina – viable for 48 to 72 hours (highly
fertile for 24 hours)
- Sperm must undergo capacitation and acrosomal reaction
- Sperm penetration causes a chemical reaction *
Fertilization
Mitosis
- Process of cellular division
- Results in daughter cells that are exact copies of the original
cell
- Identical to parent cell and to each other
- Contain a full set of chromosomes or genetic material
- Referred to as diploid cells
- Somatic cells continue to reproduce and replace each other
Meiosis
- Type of cell division that reproductive cells called gametes
(sperm and ova) – each cell contains half genetic material of
parent cell (haploid)
Oogenesis
- Process that produces the female gamete, called an ovum
(egg), that begins to develop early in the fetal life of the female towards to the ovum
- There are enough ova good for 35 years
- Ovaries begin to develop early in the fetal life of the female
- All ova that female will produce in her lifetime are present at
birth – ovary gives rise to oogonial cell, which develop into
oocytes
- During puberty, mature primary oocyte continues through first
meiotic division in ovary
- Haploid cells released at ovulation
Spermatogenesis
- Production of the male gamete, or sperm, during puberty
- The spermatogonium (primordial germ cell)
- Begins with complete set of genetic material – diploid number
of chromosomes
- Cell replicates before it enters first meiotic division
- Cell is now primary spermatocyte
- During second meiotic division, divide to form four spermatids,
each with haploid number of chromosomes
Preparation for Fertilization
- Preparation is the first component of fertilization
- Ovum released into fallopian tube – viable for 24 hours
- Sperm deposited into vagina – viable for 48 to 72 hours (highly
fertile for 24 hours)
- Sperm must undergo capacitation and acrosomal reaction
- Sperm penetration causes a chemical reaction that blocks more
sperm penetration
Fertilization
- Union of ovum and spermatozoon
- Usually occurs in the outer third of the fallopian tube (ampulla)
- Also called conception, impregnation, fecundation
- Zygote – fertilized ovum
- 46 chromosomes: 22 pairs of homologous autosomes, 1 pair of
sex chromosomes, 23 pairs
- Sex determination: XX – female, XY – male
- Aberrations in the number chromosomes result in abnormal
offspring or spontaneous abortion
Moment of Fertilization
- Sperm penetration causes chemical reaction that blocks more
sperm penetration
- Sperm enters ovum, chemical signal prompts secondary oocyte
to complete second meiotic division
- True moment of fertilization occurs as nuclei unite
- Chromosomes pair up to produce diploid zygote
- Each nucleus contains haploid number of chromosomes (23)
- Union restores diploid number (46)
- Zygote contains new combination of genetic material
- Sex of zygote determined at moment of fertilization
- two chromosomes of twenty-third pairs (sex chromosomes) –
either XX (female) or XY (male) determines sex of individual
Corona Radiata – circle of cells around the ovum
Nucleus – contains 23 chromosomes and genetic material in DNA
Zona Pellucida – ring of mucopolysaccharide fluid
Acrosome- in the head of sperm that helps to penetrate the ovum
Species-specific reaction – the mechanism sperms are drawn
Capacitation – the removal of the plasma membrane, which
exposes the acrosomal covering of the sperm head
Acrosomal Reaction – is the deposit of hyaluronidase in the
corona radiata, which allows the sperm head to penetrate the
ovum

Implantation
- when the developing zygote burrows into the endometrium,
which has undergone changes to provide for its nourishment
and is now called the decidua
- usually occurs in the upper part of the uterus about 7-10 days
after fertilization
- also called nidation
Apposition – blastocyst brushes against the decidua
Cleavage – rapid mitotic division that zygote undergoes
Blastomeres – when the zygote divides and multiplies into cell
groupings

Adhesion – blastocyst attaches to the surface of the decidua

Cytotrophoblast – inner layer of chorionic villi, functions to
protect the growing embryo of fetus against infection
- Langhan’s Layer – protection for syphilis, develops during 2nd
trimester, disappears at week 20-24
Syncytiotrophoblast – outer covering, responsible for the
production of various placental hormones like HCG, HPL, Estrogen,
Progesterone
Morula – small mass of 100 cells
- Syncytial layer – secretion of hormones
Embryoblast – group of cells that will eventually form the embryo
Invasion – blastocyst settle down into the soft folds of decidua
Trophoblast – outer ring that later form the placenta and
Chorionic Villi – probing ‘fingers’ formed from the trophoblast
membranes
layer of blastocyst
Blastocyst – the inner solid cell mass when a cavity forms in the
Decidua capsularis – portion that covers the blastocyst
morula
Decidua basalis – portion that is directly under the blastocysts
Decidua vera – portion that lines the rest of the uterine cavity
 - Syncytiotrophoblast
- Fetal membranes: amnion, chorion
Amnion – formed from the ectoderm and is the thin protective
membrane that contains the amniotic fluid and embryo, the ‘bag
of waters’
Chorion – thick membrane that develops from trophoblast and
encloses the amnion, embryo and yolk sac
Amniotic fluid
- Cushions the fetus against mechanical injury, controls the
embryo’s temperature, allows symmetrical external growth,
prevents adherence to the amnion, permits freedom of
Embryonic Development
movement
Embryo
- Fluid formed by the amnion
- from weeks to two months
- Constantly new formed and reabsorbed by the fetus
- period of organogenesis
- Ave. amount: 800-1200cc at term
- Significant events the occur during embryonic stage include:
- Ph = 7.2 slightly alkaline
- Fetal heart beginning to beat at 4 weeks
Protects fetus:
- Establishment of fetal circulation at 6 weeks
- Allows free movement
Cell Differentiation
- Provides oral fluid
- 10 to 14 days (ectoderm, mesoderm, and endoderm) from
- Aids in muscular development
which all tissues, organs, and organ system develop
- Protects the umbilical cord against pressure
- Embryonic membranes form at implantation, chorion, amnion
- Hydramnios – more than 2000cc aka polyhydramnios
- Amniotic fluid: created when amnion and chorion grow and
- Oligohydramnios – less than 300cc
connect and form amniotic sac to produce fluid
Diagnostic Tests for Amniotic Fluid
- Yolk sac: develops as part of blastocyst, produces primitive
- Amniocentesis – aspiration of amniotic fluid for examination
RBC, soon incorporated into the umbilical cord
- If done 12-13 weeks - to assess chromosomal aberrations or
other disorders
- If done > 35 weeks – to determine fetal lung maturity
- L/S ratio= 2:1 fetal lung maturity
- Advise to report: fetal hyperactivity/ hypoactivity, vaginal
bleeding, chills, fever
- Possible complication: placental, cord and bladder puncture
- Amnioscopy – visual inspection of the amniotic fluid through
the cervix and membranes with an amnioscope; used to detect
meconium staining
- Fern test
- Nitrazine Paper test – urine or amniotic fluid
- Cervical Test

Umbilical Cord
- Develops from amnion
- Body stalk attaches embryo to yolk sac, fuses with
embryonic portion of placenta
- Provides pathway from chorionic villi to embryo
- Contains two arteries which carry deoxygenated blood from
fetus to placenta, and one vein that carry oxygenated blood
from placenta to fetus
- Surrounded by Wharton’s Jelly (specialized connective tissue)
to protect vessels
- Function: provides circulatory pathway to embryo
Fetal Environment - About 20 inches in length and about ¾ inch in dm
- Decidua - Blood velocity: 350 ml/min at term
- Chorionic villi Wharton’s Jelly
- Cytotrophoblast
 - Specialized connective tissue, helps prevent compression of - Umbilical Arteries – carries unoxygenated blood
umbilical cord in utero
Placenta
- Formed by the union of chorionic villi and decidua basalis
- Placental development
- Begins at third week of embryonic dev
- Develops at site where embryo attaches to uterine wall
- Function: metabolic and nutrient exchange between embryonic
and maternal circulations
- Transmit immunoglobulin G (IgG) – passive immunity
- Hormones produced: HCG, HCS/HPL
- 2 parts:
Maternal portion
- consists of decidua basalis and its circulation
- surface appears red and flesh-like
Fetal Portion
- consists of the chorionic villi and their circulation
- the fetal surface of the placenta is covered by the amnion
- appears shiny and gray
Placental Perfusion
Influenced by: Physiologic Changes of Pregnancy
- Maternal BP Confirmation of Pregnancy
- Conduction of maternal blood vessels - Presumptive indicators
- Uterine contractions inhibiting effect - Probable signs
- Maternal position - Positive indicators
Fetal Circulation Presumptive Indicators
FHT/ FHR monitoring - Amenorrhea
- Assesses fetal heart rate abnormality - Nausea and vomiting
- N: 120-160 bpm - Fatigue
- Done in between contraction - Urinary frequency
- 3rd month doppler - Breast and skin changes
- 4th month fetoscope - Vaginal and cervical color changes
- 5th month stethoscope - Fetal movement
- Early – fetal head compression (mirror image) Probable Indicators
- Variable – cord compression - Abdominal enlargement
- Late – placental insufficiency (reverse mirror) - Cervical softening
External FHT monitoring - Changes in uterine consistency
- Less precise information collected - Ballottement (upward and lowering motion)
- Maybe affected by maternal movements - Braxton Hicks contractions – palpation of the fetal outline
- Non-invasive – can be widely used - Pregnancy tests
- Little danger associated
Internal FHT monitoring Positive Indicators
- More precise - Auscultation of fetal heart sounds
- Cervix must be fully dilated and membranes ruptured - Fetal movements felt by examiner
- MD applies scalp electrode and uterine catheter - Visualization of the fetus
- Sterile technique Changes in Body Systems:
- Can yield short term variability Reproductive System
Fetal Circulation Bypass Uterus
- Umbilical vein – carries O2 blood - Growth
- Ductus Venosus – circulatory pathway that allows blood to - Pattern of growth
bypass the liver - Contractility
- Foramen Ovale – opening between the interstitial septum that - Uterine blood flow
directs blood from the right atrium to left - Length: 6.5 cm – 32 cm
- Ductus Arteriosus – tubular connection that shunts the blood - Depth: from 2.5cm – 22cm
away from the pulmonary circulation - Width: from 4cm – 24cm
 - Weight: from 50g – 1000g Cervix
- Increased vascularity, hyperplasia (limited) and hypertrophy - Tissue changes from increased estrogen (vascularity)
- Capacity increases from 2 mL to more than 1000 mL - Cause increased number of cells and hyperactivity of cervix
- Mainly from enlargement of cells, not increase in number of - Estrogen-stimulated changes
cells - Mucous plug: Seals endocervical canal, Protects uterus
- Muscle fibers increase in length and width from ascending Microorganisms “Show”
- Braxton Hicks contractions Goodell’s sign
- irregular, often painless contractions felt during pregnancy - Softening of cervix
(4th month)
- become more noticeable in 3rd trimester (false labor)
- later may be confused with true labor
- shape: from a pear chape to globular to ovoid
- deviated to the right (rectosigmoid colon pushes it)

Chadwick’s sign
- Bluish discoloration from increased vascularity
Operculum
- Mucus plug

Circulatory Requirements
- Blood flow
- Enlarged uterus, developing placenta, and growing fetus lead to
increased blood flow to uterus (from 15-20 ml per minute to
500-750 ml per minute)
- 75% goes to the placenta Vagina and Vulva
- By end of pregnancy one-sixth of maternal blood flow goes to - Increased secretions, thickening of mucosa due to estrogen
uterus or 17% (Leukorrhea)
- Maternal blood carried by the myometrial arteries - Rich glycogen content favors the growth of candida albicans
- Intervillous spaces - Acidic pH (pH 4 or 5 due to Lactobacillus acidophilus)
- Chorionic villi - Prevents bacterial infection but favors growth of yeast
- Fetus organisms
- Metabolic waste from fetus diffuse into venous structures of - Increased vascularity
the mother - Vaginal rugae become prominent
Hegar’s Sign - Increased production of lactic acid
- Softening of the lower uterine segment Ovaries
- Progesterone must be present in adequate amounts
- Corpus luteum of the ovaries secretes progesterone and then
later by the placenta
- Ovulation ceases during pregnancy Because the feedback loop
is halted by increase estrogen and progesterone
Breasts
- Size: enlarge and become more nodular (estrogen and
progesterone effects), more and larger glands
- Appearance: Veins more prominent, Nipples erectile, areola
darken
- Colostrum: Antibody-rich yellow secretion (16th week), May leak
in last trimester, Montgomery tubercle active
 - Linea nigra
- Cutaneous vascular changes palmar and plantar erythema,
vascular spiders

Endocrine System
Placental hormones
- Human Chorionic Gonadotropin (HCG)
- Estrogen
- Progesterone
Hair and Nails
- Human chorionic somatomammotropin (hCS)
- Hair follicles are in resting phase but resumes activity after
- Relaxin
childbirth
Pituitary gland
Respiratory System
- Prolactin: Milk production, Insulin antagonist
Hormonal factors
- Oxytocin: Uterine contraction
- Progesterone – decreased airway resistance by 50%
Thyroid gland
- Increased sensitivity to CO2 causes the woman to
- Rise in total thyroxine (T4) and thyroxine binding globulin--
hyperventilate as compensatory action
causes increased BMR
- Estrogen – increased vascularity of mucous membrane
- Can cause increase emotional lability, tachycardia
(congestion)
Parathyroid glands
Physical Effects of the Enlarging Uterus
- Increased to maintain calcium homeostasis
- Lifting diaphragm by 4 cm upwards to the right
Pancreas
- Relaxation of the ligaments around the ribs
- Fluctuations in insulin production
- Increased in pressure
- Insulin resistance due to HCS, prolactin, estrogen,
- Oxygen consumption increases by 20%
progesterone, prolactin
Adrenal glands
- Cortisol are higher due to estrogen, This regulates CHO and
CHON metabolism
- Aldosterone regulates the absorption of sodium
Changes in Metabolism
Weight gain
- Recommended is 11.5-16 kg (25-35 lbs.)
Water metabolism
- Increased water needs
Edema
- Due to fluid shifts and poor venous return
Carpal tunnel syndrome
Carbohydrate metabolism
--------------------------------------
Integumentary System
Connective Tissue
- Abdominal stretching causes rupture and atrophy of small
segments of the connective tissues leading to streaks, called
Striae gravidarum – stretch marks
Abdominal Muscles
- Diastasis Recti – stretching of the abdominal wall which cause
the rectus abdominis muscle to separate
Skin
- Hyper pigmentation due to increased estrogen, progesterone
and MSH
- Melasma “mask of pregnancy”
Shortness of Breath – increased RR due to:
- Residual volume decreased by 20%
- Tidal volume increased by 4-%
- Tidal oxygen consumption increased by 20% -
progesterone may increase pCO2 level by 40% -
hyperventilation
Cardiovascular System
Heart
- Increased workload due to increased volume
- More blood flow to uterus and kidneys, potential for
dependent edema in lower extremities as well as varicosities in
legs, vulva and rectum (hemorrhoids)
- Slight hypertrophy due to increased blood volume which
returns to normal after childbirth
- Heart is pushed upwards and rotated to the left
- Transient murmurs in the pulmonic valve heard but is normal
- The muscles of the heart (myocardium) enlarge 10% to 15%
during the first trimester
- Alteration of heart sounds
Blood Volume
- Increases rapidly in second trimester – RBC, WBC, plasma,
platelets
- Plasma – volume increases by 30-50%
- Due to vasodilation, effect of E and P, prostaglandin
stimulation, renin-angiotensin
- Purposes: transport nutrients, increased need for maternal
tissues, reserve for mother in ease of bleeding
Physiologic Anemia of Pregnancy
- Caused by larger increase in plasma volume (50%) than in
erythrocyte volume (30%) if with iron treatment; only 18% if
without iron treatment)
- Also called pseudoanemia
- Leukocytes – increased production throughout pregnancy,
averaging 5000 to 12,000/mm3
- Fibrin and Fibrinogen Levels
- Increased during pregnancy
- Increase risk for thrombosis
- Erythrocytes
- Volume increased by 20% -30%
- Needed to transport addition O2 required
- Needs more iron intake to support RBC and fetal needs
- Hemodilution: Physiologic Anemia
- Iron Deficiency Anemia: Hg. < 11./dl. (first trimester and
third); < 10.5g/dl second trimester
- Cardiac Output
- Output increases 30-50%
- Increased stroke volume, with resulting increase in HR by
15-20 bpm
- Systematic vascular resistance decreases due to:
- Vasodilation
- Addition of the utero-placental unit
- Increased heat production
- Decreased sensitivity to angiotensin II
- Endothelial prostacyclin and endothelial derived relaxant
factor such as citric oxide
- Blood pressure (slight decrease then return to normal at
term)
- Effects of position
- Supine hypotension (reduced cardiac output by 25-30%)
- Blood Flow
- Altered to include the utero placental unit
- Renal plasma flow increases up to 30%
- Skin requires increased circulation
- Blood flow to the breasts increases
- Expanding uterus partially obstructs blood return from veins
in the legs
Gastrointestinal System
GI System
- Appetite – increased to consume additional calories for her
baby
- Mouth – effects of estrogen causes hyperemia of the gums
(Gingivitis)
- Esophagus – lower esophagus sphincter tone decreases due to
progesterone, causes reflux (pyrosis)
- Large and small intestines – increased emptying time, allowing
more time for nutrient absorption
- Calcium, iron, some amino acids, chloride are better
absorbed. Decreased absorption of B vitamins
- Feeling bloated and constipation
- Liver and gall bladder- liver pushed upward and backwards,
gallbladder has decreased emptying time, predisposes to gall
stones
Changing Nutritional Requirement of Pregnancy
- Energy requirements and weight gain
- Energy requirements are increased due to fetal tissue
development and increased maternal stores
- First trimester weight gain is 3-4 lbs. then for the remainder
of the pregnancy, 1 lb per week for a total of 23-40 lbs.
- Underweight when got pregnant – 28-40 lbs. weight gain
- Overweight when got pregnant – 15-25 lbs.
- Failure to gain weight or gained less than 16 lbs. will have
an increased risk of having LBW neonate
- Woman who gains too much weight has an increased risk of
delivering macrosomic neonate (4,000 gms)
- Caloric requirement in the first trimester – negligible
- Second and third trimester – 300 kilocalories more than
required during pregnant state
- Protein – increased due to growth and repair of fetal tissue,
placenta, uterus, breasts, and maternal blood volume
 - 1,000 gms of additional protein during pregnancy - Fetal demands for calcium increase in the third trimester
- Mineral – sufficient amount to prevent deficiencies in the Postural Changes
growing fetus and maternal stores - Changes are progressive, effects of relaxin ‘waddling gait’
- Iron – 1,000 mgs. For the formation of hemoglobin
- Calcium – not increased above pre-pregnancy level of
1,000md/day
- Phosphorous – no need to increase during pregnancy but if in
excess can inhibit calcium absorption
- Zinc – needed to provide for fetal growth and during lactation
for milk production
- Iodine – needed for normal thyroid activity, to avoid cretinism
caused by iodine deficiency
- Vitamins
- B9 (Folic acid) – needed to prevent neural tube defects,
found in dark green and leafy vegetables, legumes, citrus
fruits, and berries
- Vitamin A – if taken above 10,000 IU or 3,000 mcg can - Lordosis of spine, exaggerated curvature of lumbar
cause birth defects, if too little can stunt fetal growth, - Back pain
cause impaired dark adaptation and night blindness Sensory Organs
- Vitamin C – essential in formation of collagen - Eye – corneal edema (do not use contact lenses)
- Vitamin B6 – necessary for healthy development of the - Sensitivity to light
fetus nervous system - Movement of involuntary muscles, eye twitching
- Vitamin B12 – needed to and red blood cells, maintain - Ear – changes in mucous membrane causes blocked Eustachian
healthy nerve cells Tube – poor hearing
Urinary System Antepartum Assessment and Care
Bladder Objective
- Urinary frequency and urgency - To ensure that pregnancy ends in the birth of a healthy infant
- Bladder capacity doubles by term and bladder tone is without impairing the health of the mother
decreased Preconception and Interconception
- Ideally before conception
- Identify problems
- Provide education to help achieve a healthy pregnancy **
Initial Prenatal Visit
- Establishment trust and rapport with family
- Verify or rule out pregnancy
- Evaluate woman’s physical health
- Assess the growth and health of the fetus
- Establish the baseline data
- Evaluate the psychosocial needs
- Assess the need for counselling or teaching
- Negotiate a plan of care
A. History
- Obstetric History
- Gravida, para (GPTPAL)
- Length of previous gestations
- Weight of infants at birth
- Labor experiences
- Anesthesia
- Maternal complications
Kidneys and Uterus - Methods of infant feeding
- Size and shape of kidneys changes - Special concerns
- Due to increased renal blood flow: increased GFR - Menstrual history and estimated date of delivery (EDD)
- Functional changes in kidneys - Nagele’s rule (-3+7+1)
Musculoskeletal System - Gynecological and contraceptive history
Calcium storage - Medical and surgical history
 - Family history - Walk around periodically to limit prolonged standing or
- Partner’s health history sitting
- Psychosocial history - Avoid excessive overtime
B. Physical Exam - Wear support stockings
- Vital signs - Empty the bladder every two hours
- Cardiovascular Musculoskeletal Neurologic Integumentary - Pack or purchase nutritious food
Endocrine Gastrointestinal Urinary Reproductive Clothing
Subsequent Assessments - Loose, non-constrictive to prevent impairment in circulation
- Schedule foe uncomplicated pregnancy - Avoid garters, panty legs or knee-high stockings
- Conception to 28 weeks: every 4 weeks - Moderate to low-heeled shoes to decrease pelvic tilt, curvature
- 29 to 36 weeks: every 2 weeks of the lower back, backache and falls
- 37 weeks to birth: weekly Personal hygiene
- Vital signs Weight Urine Fundal height Leopold’s maneuvers - Increased bmr
- Fetal heart rate Fetal activity Signs of labor Ultrasound screen - Sweating is increased due to excretion of maternal and fetal
- Glucose screen Isoimmunization Pelvic examination waste
Antepartum Assessment and Care: Multifetal Pregnancy - Daily bath is recommended, change clothes
- Maternal physiologic change is greater with multiple fetuses Bathing
- There is increased workload for the heart - Tub bathing is not recommended during the 3rd trimester
- Respiratory difficulty increases (ascending infection)
- Early diagnosis - Avoid hot soaks or tub bath for a long period to prevent fetal
- Special antepartum classes hyperthermia or birth defects
- More frequent visits and ultrasounds Breast care
- Teach signs of preterm labor - Well-fitting firm supportive brassiere with wide straps to
RECENT spread the breast weight across the shoulders
D – diet - If planning to breastfeed, the most suitable bra is the one that
E – employment, travel is open in front
C – Clothing - Start in 16th week aog, colostrum may be secreted, hence wash
P – personal hygiene: bathing, breast & perineal care, dental care breast with water only, pat dry with towel daily to prevent
A – activity: exercise nipple sore, cracking, fissure, or infection mastitis
R – rest, relaxation, sleep - A square gauze pad may be inserted inside the bra to absorb
A – antenatal visits the secretions
P – physiological and psychological concerns; prepared childbirth Dental care
I – immunizations - Adequate brushing using soft bristled brush
Diet - Preventive dental cleanings and annual exams are safe and
- Caloric requirement recommended
- 2nd and 3rd trimester: additional 300 cal/day - Dental x-ray is not recommended unless very necessary for
- Folic acid 400 ug daily; prevent neural tube defects; avocado, dental health
asparagus, arugula, broccoli, peas, banana, lentils, cauliflower, - Abdomen must be shielded with a lead apron
brussels, papaya, okra, citrus fruits, soybeans, pinto beans Physical activity
- Iron 30-60 mg daily - Decreases the risk of pregnancy related complications
Employment - Avoid vigorous and stressful activity
- Take short, frequent breaks - Fatigue may increase the amount of morning nausea
- Cut back on activities - Benefits:
- Keeping stress under control - Lowers cholesterol
- Talk it out - Reduces risks for osteoporosis
- Practice relaxation techniques - Increases energy level
- Taking proper job precautions - Maintains body weight
High risk occupation - Decreases the risk of heart disease
- Exposure to toxic substances - Increases self-esteem and well-being
- Lifting heavy objects - Exercises:
- Long period of standing or sitting - Mild to moderate exercise 3 times weekly for 30 min
- Interventions: - 5 min warm up, 20 min active, 5 min cool down
- Make use of the lunch time to rest - Walking is best form of exercise
- Rest by lying on your left side or sitting with your legs - Instructed to eat protein and complex carbohydrates prior
elevated to exercise
 - Drink water before and after exercise - Interventions: wear supportive bra
- 2nd to 3rd trimester: avoid exercising in supine Palmar Erythema
- Avoid prolonged standing - Caused by increased level of estrogen
Kegel’s exercise - Intervention: reassurance, calamine lotion
- Strengthens perineal and pubococcygeal muscles Morning sickness
- Sit, stand, or lying down pull up, tighten pelvic floor for 10 sec - Caused by increased level of HCG
and relax for 10 sec, this is one cycle, do 10 cycles 3 times/ day - Interventions: eat dry carbohydrates, avoid hypoglycemia, stay
Tailor sitting on bed till feeling subsides
- Strengthens thighs and stretches perineal muscles Pyrosis of heart burn
Squatting - Regurgitation of gastric contents into the lower esophagus
- Stretches the muscles of the pelvic floor - Caused by increased level of progesterone, decreased GI
Pelvic rocking/ pelvic tilt motility, growing uterus compressing the stomach
- relieves backache - Interventions: small frequent feeding, proper posture, do not
Activity lie down immediately after eating, avoid fatty food, gas
Sexual activity forming food, amphogel, Maslow, Tagamet, ranitidine may be
- no sexual restrictions, passive prescribed
- changes in sexual position may be needed Constipation
- if with history of preterm birth, seek advice - Caused by decreased GI motility, growing uterus compressing
Travel the stomach
- no restrictions on travel - Interventions: encourage regular bowel movement, increased
- by land: stop every 2 hours, walk for 10 min to improve fluid intake, increased fiber, adequate exercise, do not use
circulation to lower extremities and relieve stiffness and mineral oil as laxative
muscle aches Fatigue
- wear both lap and shoulder belts - Caused by increased metabolic demand
- long distance trip: train or plane - Interventions: encourage adequate rest and sleep, have at
- plane: safe till 36 weeks others require < 7 months least one-hour break per day
- by air: no restrictions as long as airplane has well-pressurized Muscle cramps
cabin - Caused by decreased calcium, increased phosphorus, cold legs
- some do not permit pregnant women with aog of more than 7 - Interventions: dorsiflexing the foot of the affected leg, avoid
months cold legs, calcium supplements
** Supine Hypotension
Immunization - Caused by compression of the inferior vena cava by the
- Tdap vaccines (starting 3rd trimester) enlarged uterus
- Inactivated influenza vaccines (any trimester) - Interventions: left lateral position, avoid sudden change in
- Measles mumps rubella (MMR) vaccine should be given a position
month or more before pregnancy Varicosities
Danger signs - Caused by pressure of the enlarged uterus on the veins
- Bleeding causing pooling of blood on the lower extremities
- Severe nausea and vomiting - Interventions: raising the lower extremities for 15-20 min,
- Decrease fetal movement wearing supportive stockings before rising up, avoid
- Abdominal cramping constrictive garments, avoid prolong sitting or standing,
- Severe headache adequate intake of vit c (formation of blood vessel collagen
- Visual disturbances and endothelium) vit a
- Edema of hands feet face Hemorrhoids
- Fever - Caused by pressure of the enlarged uterus on the rectal veins
- Rupture bow or leaking bow - Interventions: regular bowel movement, avoid constipation,
- dysuria assume a knee-chest position for 10-15 min
Subsequent Assessments (antenatal visits) - Applying cold compress
- schedule for uncomplicated pregnancy: - Applying witch hazel or hydrocortisone-pramoxine as
- conception to 28 weeks: every 4 weeks prescribed
- 29-36 weeks, every 2 weeks Heart palpitations
- 37 weeks after birth- weekly * - Caused by increased in blood volume
Breast tenderness - Interventions: reassurance, gradual movement or change in
- Caused by: increased breast size related to estrogen and positions, adequate rest, further assessment
progesterone Backpain
 - Caused by changes in the center of gravity (lordosis-pride of
pregnancy)
- Interventions: wear low-moderate heeled shoes, squat when
picking up objects, use body mechanics when lifting objects,
use firm mattress, further assessment
Frequency of Urination
- Caused by pressure of the bladder
- Interventions: encourage to void at regular intervals, limit
intake of caffeine containing beverages, adequate fluid intake,
further assessment
Dyspnea
- Caused by pressure of the uterus on the diaphragm
- Interventions: adequate rest, limit activities, rest or sleep with
head elevated
Ankle Edema
- Caused by pressure of the uterus on the blood vessels
supplying the lower extremities, pooling of blood on the lower
extremities
- Interventions: rest in LLP (to increase kidney glomerular
filtration rate and venous return), elevate legs for 30-60 min
BID (pm and hs), avoid constrictive garments, avoid prolonged
standing or sitting
Braxton Hicks Contraction
- Occurs as early 8th-12th week AOG
- “Practiced contractions”
- Usually painless uterine contractions
- Not a sign of true labor
- Interventions: further assessment
Promoting Fetal Health and Well-being
Prevent exposure to teratogens
Stage of fertilization and implantation – abortion
Embryonic stage (1st trimester) – congenital defects
Fetal stage – minor deformities
Types of teratogens
Chemical
- Mercury, lead, drugs tetracycline, immunoprim (anti-cancer
drug)
- Tobacco – IUGR (due to vasoconstriction), still birth, SIDS
Physical
- Partner’s violence
Biological
- Virus: rubella
- Protozoan: syphilis
- Live virus vaccines: measles, HPV human papilla virus, mumps,
rubella, poliomyelitis (sabin)
- Herbs: American ginseng (congenital defect), green tea (alters
B9 absorption)
- Alcohol: craniofacial deformities, vit. B deficiency, neurological
defect
Thermal
- Hot (interferes with cell metabolism)
Stress
- SAMR response
Chapter 12