antepartal notes spring 15 student

8/9/2019 Antepartal Notes Spring 15 Student

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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/3rdtrimesters)

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 SOBNasal stuffiness/epitaxis r/t edema, vascular

congestion (increased estrogen)

Urinary Tract (Renal)

Urinary frequency (1st and 3rdtrimester)

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

ProgesteroneRelaxin


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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

Page 302


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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 beginswhen 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)

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)

Paternal Tasks of Pregnancy/Adaptation

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

pregnancyT number of pregnancies delivered at 37weeks or later

P number of pregnancies deliveredbetween 20 and 37 weeks

A number of pregnancies ending inspontaneous 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 birthPlans for care of child following birth

Feeding method for the baby


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Assessment: First Prenatal VisitHistory

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 ScreenSickle 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 Visits1st trimester: every 4 weeks

VS, weight, urine (glucose, protein, ketones), fetal hearttones, 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), IndirectCoombs Test (28 weeks), ultrasound, fetal movement,prenatal classes, education, assess for warning signs,discomforts

3rd trimester: every 2 weeks/every week: (RhoGam ifneeded 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

Page 340


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Danger Signs

Vaginal Bleeding miscarriage,placenta previa

abruptio placentae

Persistent Vomiting hyperemesisgravidarum

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 vomitingurinary 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 366Clothing

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

AdolescentReview 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 tochildbearing family (text, pg. 438)

Doulasnonprofessional trained to

provide labor support, does not get

involved with clinical tasks

Birth Centers

LDR, LDRP, home bi rths

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 andphosphorus

Vitamin E

Fat absorption

Vitamin K

Synthesis of prothrombin

B Vitamins

Thiamine

Riboflavin

NiacinFolic acid

Vitamin B6Vitamin B12


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Folic Acid

Increase intake of folic acid to prevent

neural tube defects

Sources:

(need 24 hour recall)

Mercury WarningHigh levels of mercury can harm the

fetus developing nervous system

Sources: shark, swordfish, marlin, king

mackerel, albacore/white tuna

Nutrition, continuedProblems: LBW, SGA, IUGR1st half of pregnancygains reflect maternal tissue2nd half of pregnancy reflect fetaltissue gains

Prenatal vitamins/minerals

Folic acid Calcium, magnesium, vitamin Dbone health

Iron

Picaconsuming nonfood substances Clay, dirt, laundry starch

Causes: nutritional deficiencies, stress, low socioeconomic


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NutritionWeight Gain25 to 35 pounds weight gain during pregnancy

3-4 pounds in first trimester12 pounds in second trimester

12 pounds in third trimesterUnderweight 28-40 pounds

Overweight 15-25 pounds

Obese 15 pounds (Institute of Medicine)

Lactating women should consume 3000 ml offluids per day

Nutritional Assessment and

Education24 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 foodsInclude 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

QuestionsAnyone?

antepartal notes spring 15 student

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