Pregnancy

A. Fertilization
1. Conception (fertilization)
a. Definition: union of sperm and ovum
b. Conditions necessary for fertilization
1. Maturity of egg and sperm
2. Timing of deposit of sperm
a. Lifetime of ovum is 24 hours
b. Lifetime of sperm in the female genital tract is 72 hours
c. Ideal time for fertilization is 48 hours before to 24 hours after ovulation
d. Menstruation begins approximately 14 days after ovulation
3. Climate of the female genital tract
a. Vaginal and cervical secretions are less acidic during ovulation (sperm
cannot survive in a highly acidic environment)
b. Cervical secretions are thinner during ovulation (sperm can penetrate more
easily)
c. Process of fertilization (7-10 days)
1. Ovulation occurs
2. Ovum travels to fallopian tube
3. Sperm travel to fallopian tube
4. One sperm penetrates the ovum
5. Zygote forms (fertilized egg)
6. Zygote migrates to uterus
7. Zygote implants in uterine wall
8. Progesterone and estrogen are secreted by the corpus luteum to maintain the lining
of the uterus and prevent menstruation until placenta starts producing these
hormones; (note: progesterone is a thermogenic hormone that raises body
temperature, an objective sign that ovulation has occurred)

d. Placental development
1. Chorionic villi develop that secrete Human Chorionic Gonadotropin (HCG). which
stimulates production of estrogen and progesterone from the corpus luteum
(production of HCG begins on the day of implantation and can be detected by the
sixth day)
2. Chorionic villi burrow into endometrium, forming the placenta
3. The placenta secretes HCG, human placental lactogen (HPL), and (by week three)
estrogen and progesterone
e. Fetal membranes develop and surround the embryo, fetus
1. Amnion: inner membrane
2. Chorion: outer membrane
3. Umbilical cord
a. Two arteries carrying deoxygenated blood to placenta
b. One vein carrying oxygenated blood to fetus
c. No pain receptors
d. Encased in Wharton’s jelly
e. Covered by chorionic membrane

f. Amniotic fluid
1. Production origins
a. Maternal serum during early pregnancy
b. Fetal urine in greater proportion during latter part of pregnancy
c. Replaced every 3 hours
d. 800-1,200 ml at end of pregnancy
2. Functions
a. Protection from trauma and heat loss
b. Facilitates musculoskeletal development by allowing for movement of the
fetus
c. Facilitates symmetric growth and development
 d. Source of oral fluid for fetus
g. Placental transfer of material to and from the fetus
1. Diffusion across membrane (for example: gases, water, electrolytes)
2. Active transport via enzyme activity (for example: glucose, amino acids, calcium,
iron)
3. Pinocytosis: minute particles engulfed and carried across the cell (for example:
fats)
4. Leakage: small defects in the chorionic villi cause slight mixing of material and
fetal blood cells
5. Nutrients and wastes are exchanged in the placenta, but the blood does not
intermingle

B. Fetal Development
1. Pre-embryonic: first two weeks
2. Embryonic: three to seven weeks
3. Fetal: eight to 40 weeks
a. Full term: 38 to 42 weeks
b. Preterm: less than 38 weeks
c. Post-term: more than 42 weeks
C. Terminology
1. Gravida

1. Definition: number of times pregnant, including present pregnancy

2. Variations: primigravida, multigravida
2. Para

a. Definition: number of pregnancies delivered after the age of viability, whether born alive
or dead
b. Variations: nullipara, primipara, multipara
3. Five-digit system
a. G: gravida
b. T: term infants
c. P: preterm
d. A: abortions
e. L: living

Signs of Pregnancy

1. Presumptive (subjective)
a. Amenorrhea: missed periods
b. Nausea and vomiting: morning sickness, probably due to HCG; usually lasts about 3 months
c. Fatigue: first trimester
d. Urinary frequency: caused by enlarging uterus pressing on bladder
e. Breast changes: tenderness and tingling, nipples pronounced, full feeling, increased size, areola
darker
f. Quickening: mother’s perception of fetal movement around 16-18 weeks: fluttering sensation

2. Probable (objective)
a. Chadwick's sign: bluish coloration of the mucous membranes of the cervix, vagina, and vulva
b. Goodell's sign: softening of cervix; occurs beginning of the third month
c. Hegar's sign: softening of the isthmus of the uterus, between the body of the uterus and cervix;
occurs about the sixth week
d. Enlargement of abdomen: uterus just above symphysis at 8-10 weeks; at umbilicus at 20-22 weeks
e. Braxton-Hicks contractions: painless contractions occurring at irregular periods throughout
pregnancy; felt most commonly after 28 weeks
f. Uterine souffle: soft blowing sound; blood flow to placenta same rate as maternal pulse
g. Pregnancy test positive: HCG in serum and urine
 h. Ballottement: can push fetus and feel it rebound
i. Pigmentation changes: increased pigmentation, chloasma, linea nigra, and striae gravidarum
3. Positive
a. Fetal heartbeat: by Doppler at 8-10 weeks
b. Fetal movements: felt by examiner
c. Fetal outline: on sonogram

D. Assessment of Date of Delivery

1. Nagele's rule: first day of last menstrual period (LMP) minus three months plus seven days; in most
cases, add one year
2. Other parameters: fundal heights, quickening, sonograms

ADAPTATIONS TO PREGNANCY
ADAPTATIONS TO PREGNANCY TRIMESTER INTERVENTIONS
G.I:

- Nausea/vomiting 1 - Small frequent meals; eat crackers

or dry toast before getting up in the
morning; eat dry meals; drink liquids
between meals
- Exercise; increase fluid and fiber in
- Constipation,flatulence and heartburn 2, 3 diet; stool softeners if recommended
by physician
- Use soft toothbrush for dental care
- Bleeding gums 2, 3 - Avoid fatty foods
- Gallstones 2, 3 - Small frequent meals; avoid spicy,
fatty foods; no sodium bicarbonate as
- Heartburn 2, 3
antacid; antacids as recommended by
physician
Urinary Tract: 1, 3 - Void when first urge felt; wear a
- Frequency during first and third trimester pad if leaking
due to pressure on bladder 2, 3
- Increase fluid intake
- Glomerular filtration rate (GFR) increases
(glycosuria)
- Increase in urinary infections
Breasts: 1 - Wear good supportive bra
- Increase in size and nodularity, striae
1
- Tenderness and tingling
2
- Hypertrophy of Montgomery tubercles
2
- Darkening of areola
2, 3
- Colostrum secreted
Vagina: 1, 2, 3 - Report itching and burning to
- Epithelium undergoes hypertrophy and physician
hyperplasia 1
- Promote cleanliness by bathing
- Increased vascularity daily; avoid douching; avoid nylon
undergarments
- Increased pH; good for growth of Candida
(thrush)
- Increase in discharge; leukorrhea is
common
Respiratory System:
- Increase in volume of up to 40-50%
between 16-34th week
- Diaphragm is pushed upward; ribcage
flares out; breathing changers from
abdominal to chest
- Increase in oxygen consumption by 15%

ADAPTATIONS TO PREGNANCY

ADAPTATIONS TO PREGNANCY TRIMESTER INTERVENTIONS

Respiratory System (continued)
- Stuffiness, epistaxis, and changes in
voice occur as a result of increase estrogen 1 - Cool moist air may help; avoid
levels over-the-counter decongestants and
- Dyspnea 3 sprays
- Proper posture; sleep with head
propped up
Skin:
- Areola darkens
- Abdominal striae, linea nigra
- Diaphoresis
- Chloasma; mask of pregnancy 2, 3 Daily bathing; powder
- Vascular spider nervi; chest, neck, arms,
and legs
Metabolism/Nutrition:
- Basal metabolic rate increased by 20%
- Water retention; edema
2, 3 - Elevate legs and feet when sitting;
avoid prolonged standing; do not
wear garters or clothing with
restrictive bands around the legs;
- Weight gain; 20-25 lbs recommended avoid crossing legs at knees
- Adequate protein intake, especially for
teens
- Increase iron during last eight weeks
- Pica: craving for nonnutritive substance
2, 3 - Eat well-balanced diet
Perineum:
- Increased vascularity
- Venous congestion of the perineum
2, 3 - Kegal exercises
Cardiovascular:

- Cardiac output increases by 30%

- Blood volume progressively increases
and peaks around 30-40 weeks at 47%
above pre-pregnant state
- Plasma volume increases greater then
RBC and hemoglobin, resulting in
"pseudo anemia"
 - Pulse rate increases by 10-15
beats/minute; BP drops slightly in second
trimester due to peripheral dilatation
effects of progesterone; returns to normal
by third trimester

ADAPTATIONS TO PREGNANCY

ADAPTATIONS TO PREGNANCY TRIMESTER INTERVENTIONS

Cardiovascular (continued)
- Varicose veins may develop
2, 3 Elevate legs; avoid standing for
long periods of time; avoid
constrictive clothing
Uterus:
- Growth is influenced by estrogen
- 500 - 1,000 fold increase in capacity
- Cervical secretions form mucus plug
Endocrine:
- Increase in size and activity of thyroid
- Increase in size and activity of anterior
lobe of pituitary
- Increase in size and activity of adrenal
cortex
- Increase in production of relaxin causes Pelvic rock; good body mechanics;
2, 3
joint and back pain. supportive shoes

Teratogen

1. Definition: nongenetic factor producing malformations of the fetus; greatest effect on those cells
undergoing rapid growth, thus time is important
2. Types
a. Chemical agents (for example: insecticides)
b. Radiation
c. Drugs: for example: alcohol, tetracycline (Sumycin), chemotherapeutic agents, phenytoin
(Dilantin), narcotics, nicotine, megavitamins, warfarin (Coumadin), lead, lithium, carbamazepine
(Tegretol), and mercury
d. Bacteria and viruses
1. Syphilis
a. Spirochete does not cross placenta until after 18th week; treat as soon as possible;
can treat later since penicillin does not cross placenta
b. Can cause late abortions, stillbirths, and congenitally infected infants
2. Gonorrhea: causes injury to eyes at birth (ophthalmia neonatorum)

3. T.O.R.C.H.- severe effects on the fetus

a. Toxoplasmosis: protozoan contracted by ingesting raw meat or feces of infected animal (for
example: cats); pregnant women should not change cat litter boxes
b. Rubella: first trimester most serious; causes congenital heart problems, cataracts, hearing loss;
clients cannot receive the rubella vaccine during pregnancy as it is a live virus; if they receive the
 immunization in the post-partum period, they must understand that they should not become
pregnant for at least three months
c. Cytomegalovirus (CMV): member of the herpes family; causes congenital and acquired infection;
principal organs affected: liver, brain, and blood
d. Herpes simplex virus, Type 2 (HSV-2)
1. Transmitted to infant vaginally in intrauterine cavity or during delivery; do not deliver
vaginally if active lesions are present
2. Affects blood, brain, liver, lungs. CNS, eyes, skin
3. Perinatal mortality: 96%; 50% of survivors have neurological or visual abnormalities
4. Chlamydia: causes conjunctivitis and pneumonia in the newborn
5. AIDS
a. Transmitted via breast milk
b. 30% chance of transmission in utero or during deliver
c. Treatment of mother with zidovudine (AZT) while pregnant can reduce chance of transmission to
fetus to approximately 8%

Emotional and Psychological Adaptations to Pregnancy

Development Tasks of Pregnancy

1. First trimester: accept the biological fact of pregnancy; it is common to feel ambivalent early in pregnancy
2. Second trimester: accept growing fetus as a baby to be nurtured
3. Third trimester, prepare for the birth and parenting of the child

Prenatal Care

A. Assessment
1. Complete history
2. Lab work: complete blood count (CBC), blood type and Rh, Rubella, VDRL/FTA-ABS/RPR,
hepatitis B surface antigen, HIV antibody (with client's consent), alpha fetal protein (AFP)
3. Vital signs, weight, urine test for protein and glucose
4. Physical exam: fundal height, fetal heart rate (FHR), fetal activity
5. Internal exam
a. Adequate pelvic outlet, signs of pregnancy (First visit)
b. Cervical changes, especially in last weeks (for example: "ripe cervix")
c. Vaginal smear for Neisseria gonorrhea, chlamydia, group B strep, human papillomavirus
(HPV) cultures, and pap test
6. Psychosocial assessment

B. Health Teaching
1. Nutrition
2. Discomforts
3. Danger signs (The nurse must be able to differentiate potential complications from the normal
discomforts or physical adaptations of pregnancy)
a. Bleeding
b. Rupture of membranes (ROM)
c. Contractions (Braxton-Hicks contractions usually go away when position is changed)
d. Signs of pregnancy induced hypertension (P1H), toxemia
1. Edema of hands and face, sudden weight gain
2. Headache, blurred of vision, spots before eyes, dizziness
3. Decrease in urinary output
e. Burning on urination
f. Fever
g. Significant decrease in fetal activity
4. Childbirth education and alternative methods of birth
a. Read method (Grantly Dick-Read)
1. Natural childbirth
2. Abdominal breathing
3. Fear-tension-pain cycle
b. Lamaze method
1. Prepared childbirth
2. Labor coach
3. Chest breathing
c. Leboyer
1. Birth without violence
2. Concerned with possible negative effect a traumatic birth can have upon an infant
d. Birthing chairs
e. Alternate positions
f. Birthing rooms
g. Birthing centers
h. Delivery by midwife
i. Home births
5. Rest and exercise