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First Trimester Week 0-12 Gestational Age
First Trimester Week 0-12 Gestational Age
Month 1
o Ovulation and conception
o During week 4 some home pregnancy tests will detect
o Embryo is two cells
Month 2
o Signs of preg: extreme fatigue, frequent urinartion, morning
sickness, and hormonal fluctuations
o Babys heart is beating
o Brain is formed
Month 3
o Embryo becomes fetus
o Decreased morning sickness
o Fetus size of plum
Women looking forward to changes that will be more noticeable
Prenatal monthly for first 7 months
Common discomforts
o N/V, breast tenderness, urinary frequency, UTI, fatigue, Braxton
Hicks contractions
Nutrition
o Patient should gain 1-2 kg during first trimester
Vitals
o B/P at prepregnancy range
Diagnostic Procedures
o Internal transvaginal ultrasound useful in clients who are obsess
and those in first trimester to detect: ectopic pregnancy,
abnormalities, and establish gestational age.
Causes of bleeding
o Spontaneous abortion
o Ectopic pregnancy
2-8
o majority of birth defects occur
10-12
o FHR can be heard by Doppler
Second Trimester week 12-28 gestational age
Month 4
o Babys bones are hardening and will now show up on Xray
o Baby is about 5 inches long and weighs about 5 ounces
Month 5
o Begin to feel baby kick
o Baby’s hearing starts to develop
o Common discomforts: backaches, indigestion, heartburn,
headaches, water retention, dizziness, constipation
Month 6
o Marks halfway mark in pregnancy!
o At end of this month baby is almost formed
Month 7
o Possible occurrences of Braxton Hicks contractions
o Brain is beginning to process sights and sounds
o Baby is about 13 inches long
Viability
o 20 weeks whether born or alive
Vitals
o BP decreases 5-10 mmHg during second trimester
Common discomforts
o heartburn, constipation, hemorrhoids, backaches, varicose veins
and LE edema
Nutrition
o Should gain approximately 0.4 kg (1lb)per week in last two
trimesters
o An increase of 340 calories is recommended during 2 nd trimester
Diagnostic Procedures
o Abdominal ultrasound is more useful after first trimester with gravid
uterus is larger
o 10-12 CVS can be performed
Causes of bleeding
o GTD
After 12 weeks
o fundal height
After 14
o Amniocentesis
16- 20
o Quickening
o FHR heard by ultrasound stethoscope
o Begin assessing fetal movement
15-22
o Maternal serum alpha-feto protein screening occurs. Used to rule
out Down Syndrome (low level) and neural tube defects (high level)
16-18
o Quad screen, a more reliable indicator of AFP, inhibin-A, a combo
analysis of HCG, and estriol
20
o BP returns to prepregnancy baseline
o Pulse increases 10-15 minutes and remains increased
o More distinguishable splitting of S1 & s2
18-32
o measurement of fundal height (approximates gestational age)
24-28
o Indirect Coombs Test for Rh- and not sensitized mothers repeated
Third Trimester week 28-40 gestational age
Month 8
o Baby is fully formed and putting on weight
o Baby’s lungs almost fully developed
Month 9
o Common discomforts: Braxton Hicks, pelvic pressure, difficulty
sleeping
Prenatal appointments every 2 weeks in the 8 th month & every week in the
last month
Term
o 38 weeks or more
Preterm
o 20 up to 37 weeks
Nutrition
o Should gain approximately 0.4 kg (1lb)per week in last two
trimesters
o An increase of452 calories is recommended
Common discomforts
o urinary frequency, UTI, fatigue, heartburn, constipation, backaches,
leg cramps, varicose veins and LE edema, increased intensity and
frequency of Braxton Hicks contractions
Diagnostic Procedures
o May be used in conjunction with abdominal scanning to evaluate for
preterm labor
o Nonstress Test performed
Causes of bleeding
o Placenta previa, abruptio placenta
36
o Top of uterus and fundus will reach xiphoid process
35-37
o GBS test
PostPartum
Nutrition
o Breastfeeding- an additional intake of 330 calories/day is
recommended during 1st 6 months
Additional intake of 400 calories a day during second 6
months
Folic acid- 500 mcg
Nursing Actions/Education throughout Pregnancy
Nutrition
Diagnostic Procedures
Ultrasound
Types:
o External abdominal U/S
Useful in first trimester with uterus gravid is larger
o Internal transvaginal U/S
Useful in obese clients and those in first trimester to detect
ectopic preg, ID abnormalities, & establish gestational age
o Doppler US blood flow analysis
Useful in IUGR and poor placental perfusion, and as an
adjunct in pregnancies at risk due to HTN, DM, multiple
fetuses, or PTL
Education:
o Advise client to drink 1-2 quarts of fluid prior to fill the bladder, lift
and stabilize uterus, displace bowel, and act as an echolucent to
better reflect waves
o Supine position with wedge placed under right hip to displace
uterus (prevent supine hypotension)
Education for transvaginal-
o Lithotomy position
o Pressure may be felt
Infections
HIV/AIDS
TORCH infections
Group B streptococcus B Hemolytic
Chlamydia
Gonorrhea
Candida Albicans
Medical Conditions
Incompetent Cervix (Recurrent premature dilation of cervix)
Hyperemesis Gravidarum
Anemia
Gestational DM
Gestational HTN
Stages of Labor
o First Stage
Duration: 12.5 hr
Begins with: Onset of labor
Ends with: Complete dilation
Maternal characteristics: Cervical dilation 1 cm/hr for
primigravida, and 1.5 cm/hr multigravida (on average)
o Latent Phase
Duration:
Primigravida: 6 hr
Multigravida: 4 hr
Begins with:
Cervix 0 cm
Irregular, mild to moderate contractions
Frequency 5-30 min
Duration 30-45 seconds
Ends with: Cervix 3 cm
Maternal characteristics: Some dilation and effacement,
talkative and eager
o Active Phase
Duration:
Primigravida: 3 hr
Multigravida: 2 hr
Begins with:
Cervix: 4 cm
More regular, moderate to strong contractions
Frequency 3-5 min
Duration 40-70 seconds
Ends with:
Cervix dilated 7 cm
Maternal characteristics:
Rapid dilation and effacement
Some fetal descent
Feelings of helplessness
Anxiety and restlessness increase as contractions
stronger
o Transition
Duration:
20-40 min
Begins with:
Cervix 8 cm
Strong to very strong contractions
Frequency 2 to 3 min
Duration 45-90 seconds
Ends with: Complete dilation at 10 cm
Maternal characteristics:
Tired, restlessness, irritable
Feeling out of control, “cannot continue!”
N/V
Urge to push
Increased rectal pressure and feelings of needing to
have a BM
Increased bloody show
Most difficult part of labor
Sources of pain:
Internal visceral pain that may be felt as back or leg
pain, caused by
o Dilation, effacement, and stretching of cervix
o Distention of lower segment of uterus
o Contractions of uterus with resultant uterine
ischemia
o Second Stage
Duration:
Primigravida: 30 min-2 hr
Multigravida: 5-30 min
Begins with:
Full dilation
Progresses to intense contractions every 1-2 min
Ends with: Birth
Maternal characteristics: Pushing results in birth of fetus
Pain:
Somatic and occurs with fetal descent and expulsion.
Caused by
o Pressure and distension of vagina and
perineum described as “burning, splitting, and
tearing”
o Pressure and pulling on pelvic structures
(ligaments, fall tubes, ovaries, bladder, and
peritoneum)
o Laceratons of soft tissue
o Third Stage
Duration: 5-30 min
Begins with: Delivery of neonate
Ends with: Delivery of placenta
Maternal characteristics:
Placental separation and expulsion
Schultze presentation: shiny fetal surface of placenta
emerges first
Duncan presentation: dull maternal surface of
placenta emerges first
Pain:
Pain with expulsion of placenta is similar to pain
experienced during the first stage. Caused by
o Uterine contractions
o Pressure and pulling of uterine structures
o Fourth Stage
Duration: 1-4 hour
Begins with: Delivery of placenta
Ends with: Maternal stabilization of VS
Maternal characteristics:
Achievement of VS homeostasis
Lochia scant to moderate rubra
Pain:
Caused by distention and stretching of vagina and
perineum incurred during the second stage with a
splitting, burning, and tearing sensation
Maternal VS q 15 min for first hour then according to
protocol
Assess fundus and lochia q 15 min for first hr….
Massage uterine fundus and or administer oxytocies as
prescribed to maintain uterine tone to prevent hemorrhage
Assess perineum and provide comfort measures as needed
Encourage voiding to prevent bladder distension
bonding
Pain Control
non pharmalogical
o Gate control theory of pain
Sensory strategies
Cutaneous strategies
Effleurage: light gentle circular stroking of pts
abdomen with fingertips in rhythm with breathing
during contractions
Sacral counterpressure: consistent pressure applied
by support person using heel of hand or fist against
sacral area to counteract pain in lower pact
Hydrotherapy increases endorphin levels
o Frequent maternal position changes to promote relaxation and pain
relief: semi-sitting, squatting, kneeling, kneeling and rocking back
and forth, supine position only with placement of wedge under one
of hips to tilt uterus and avoid hypotension
Pharmacological
o Analgesia
Opiod analgesics
Sedatives (barbituates) such as secobarbitual,
pentobarbitual, and phenobaritual, NOT USED
DURING BIRTH, BUT DURING ACTIVE OR LATENT
PHASE TO RELIEVE ANXIETY AND INDUCE SLEEP
Adverse effects of sedatives:
o Neonate respiratory depression secondary to
med crossing plcenta and affecting fetus.
Should not give 12-24 hr
o Unsteady walking
o Inhibition of ability to cope with labor
Meperidine hydrochloride (Demerol), fentanyl
(sublimaze), butorphanol (stadol), and nalbuphine
(Nubain) act in CNS to decrease perception of pain
without loss of consciousness. IV or IM.
o Butorphanol and nalbuphine provide pain releft
without causing significant respiratory
depression
o Adverse effects:
Prior to administering, ensure labor is established,
perform V exam and cervical dilation at least 4 cm
and fetus well engaged
Administer antiemetics
Monitor maternal VS, uterine contraction pattern, and
continue FHR monitoring
Naloxone (Narcan)
Opioid antagonist for reversal of opioid reduced
respiratory depression
Ondansetron (Zofran)
o Epidural and spinal regional analgesia
Consist of Fentanyl (Sublimaze) and sufentanil (Sufenta)
which are short acting opiods that are administered as a
motor block into the epidural or intrathecal space without
anesthesia. Produce regional anagsic providing rapid pain
relief while allowing pt to sense contractions and maintain
ability to bear down
Adverse effects
Pharmacological Anesthesia
o Regional blocks
Most common
Pudendal block
Consists of local anesthetic administered
transvaginally into the space in front of the pudendal
nervea
Additional