copyright 2005 thomson delmar learning. thomson and delmar learning are trademarks used herein under...

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license.

PRENATAL CARE

CHAPTER 50


PRECONCEPTION EDUCATION AND CARE

Immunizations and disease status Medications Smoking, Alcohol, and Illicit Drugs Genetic Risk Factors Male Contributions


PRECONCEPTION EDUCATION AND CARE

Immunizations and disease status Rubella and Hepatitis B should be completed before a pregnancy is

begun. Testing for infectious diseases (syphilis, hepatitis, HIV, chlamydia,

gonorrhea, HPV, herpes simplex , and group B streptococcus) Medications-Avoid teratogens prior to and during pregnancy Avoid Smoking, alcohol, and illicit drug

Smoking-negative effects on pregnancy, major risk factors and low-birth weight infants.

No safe level of alcohol intake during pregnancy Illicit drugs may cause fetal anomalies or disorders, newborn may

experience withdrawal syndrome. Discontinue prior to and during pregnancy, and after birth if breastfeeding.

Genetic risk factors-review family history, genetic counseling, discuss risks

Male contributions-lower birth weight for infants of smoking fathers Smoking affects spermatogenesis and sperm mobility Male exposure to occupational chemicals has been associated with

spontaneous abortion, stillbirth, preterm delivery, and small-for-gestational-age babies


PREGNANCY

Condition of carrying an offspring within body.

Fertilization (or conception)–occurs when a sperm and ovum unite.

Zygote–the fertilized ovum. Implantation(5th day after fertilization)–

embedding of the fertilized egg into the uterine lining.


AMNIOTIC FLUID-anatomy 98% water Contains glucose, protein, sodium, urea,

creatinine Slightly alkaline Approximately every 3 hours the fluid is

replaced. Chorionic villa at the base of the implanted

fertilized ovum. Amnion is the fetal side of the placenta, so it is smooth and shiny.


AMNIOTIC FLUID-functions

Equalizes the pressure around fetus. Cushions fetus from external

compression. Provides constant temperature and fluid

for fetus to swallow. Allows freedom of movement for fetus. Lubricates membranes and fetus.


FUNCTIONS OF THE PLACENTA

Transport Endocrine Metabolic


THE PLACENTA

Membranous vascular organ connecting fetus to mother.

Produces hormones to sustain pregnancy. (5 Hormones-hCG, hPL, estrogen, progesterone, and relaxin)

Supplies fetus with oxygen and food. Provides nutrition to and transports waste

products from fetus. Fully functional by week 12.


THE UMBILICAL CORD

Structure connecting fetus to placenta. Has two arteries that carry deoxygenated blood

and one vein which carries oxygenated blood. (This is the one instance in which arteries carry deoxygentated blood and a vein transports oxygenated blood.)

Surrounded and protected by Wharton’s jelly.


FETAL DEVELOPMENT Preembryonic or germinal stage–first 14 days

after fertilization. Embryonic stage–week 3 through week 8. Fetal stage–week 9 until 38 to 40 weeks or full

term. Pregnancy calculated from first day of mother’s

last menstrual period. Development occus in a systematic manner

from head to toe (cephalo-caudal), from proximal to distal (close to body-farthest from body), and from general to specific.


FETAL DEVELOPMENT First trimester –first twelve weeks Second trimester-weeks 13-27 Third trimester-weeks 28-40 Pregnancy generally lasts 10 lunar

(28days) months, 40 weeks, 280 days. It is calculated from the first day of the mother’s last menstrual period (LMP). Table 50-1 identifies stages of fetal development


SYSTEM DEVELOPMENT Cardiovascular system

heart begins to beat on the 21st day First system to function in the embryo Most malformations develop in first 6-8 weeks Blood cells develop day 14

Gastrointestinal system Begins to develop fourth week Fetus begins to swallow by 20th week Meconium (fecal material stored in the fetal intestines) begins to form about week

16) *There should be no passage of meconium in utero. If the fetus encounters hypoxic stress, the anal sphincter may relax and meconium may be passed, causing meconium staining of the amniotic fluid.*

Genitourinary system Begins to form about week 3 Begins to produce hypotonic urine about week 12

Reproductive system Begins to form about week 3 Testes can be seen about week 7 and begin to descend into the scrotum about

30 weeks Ovaries develop in the abdomen and stay in the pelvic cavity (All the ova a

female will ever have are in the ovaries at birth) Gender can be made through ultrasound by the end of week 12


SYSTEM DEVELOPMENT Integumentary system-skin protects

Vernix caseosa protects the skin Creases form on palms, fingers and soles during week 11 and become

permanent by week 17 Skin color is genetically determined Lanugo appears during week 20, slowly disappears by birth Tooth buds appear during week 6 (baby teeth) and week 10 (permanent teeth). Mammary glands develop during the sixth week

Respiratory system Lung buds week 6, bronchi forming by week 16 Primitive lungs by week 23- not sufficient for gas exchange but lungs are

capable of borderline support of extrauterine repsiration (age of viability- gestational age at which the fetus could live outside of the uterus is considered 24 weeks)

Surfactant production begins between week 20-24 and matures between weeks 35-37.

Immunologic system Begins to develop between week 12 and 15 Fetus produces small amounts of IgG, IgA, IgE before week 20 Maternal IgG is actively transported actross the placenta to provide passive

immunity against many infectious diseases


FACTORS AFFECTING FETAL DEVELOPMENT

Quality of sperm, ovum, genetic code Teratogens- any agent, such as radiation,

drugs, viruses, or other microorganisms, capable of causing abnormal fetal development)

Maternal malnutrition Acute and chronic diseases Alcohol and drugs Smoking


PHYSIOLOGICAL CHANGES OF PREGNANCY Reproductive system

Size of uterus Braxton Hicks contractions Hegar’s Sign

Cardiovascular system Blood flow increases to uterus Heart rate increases by 10-15 BPM Cardiac Output increases by 30-50% B/P decreases, lowest during 2nd trimester, returns 3rd trimester Lower extremity edema, varicose veins of legs, vulva, or rectum Supine hypotensive syndrome-dizziness, clammy-pale skin, low

b/p, decreased placental perfusion Blood volume increases by 30-50% and peaks at week 30 Small increase in RBC, greater increase in PLASMA (shows

lower hematocrit 34-40% known as physiologic anemia of pregnancy)

WBC increases by week 8 Plt, fibrin, fibrinogen, and coagulation VII, IX, X increases

(increases the risk of venous thrombosis late in pregnancy)


PHYSIOLOGICAL CHANGES OF PREGNANCY Respiratory system

Progesterone decreases airway resistance, allowing increase in oxygen consumption

Depth of respiration increases causing mild respiratory alkalosis, compensated by increased renal secretion of bicarb

Enlarged uterus pushes on diaphragm Rib cage flares and the chest circumference expands to keep intrathoracic

volume the same as when not pregnant Estrogen causes edema and vascular congestion of the nasal mucosa

Musculoskeletal system Relaxation of pelvic joints in preparation for delivery is caused by relaxin Mother’s center of gravity changes due to increased size/weight of uterus To compensate, the mother increases curve of the lumbosacral spine (lordosis) May have waddling gait

Gastrointestinal system Urinary system Nausea and/or vomiting “morning sickness” common early, usually disappear

by week 12 Smooth muscles relax causing delayed gastric emptying and decreased

peristalsis Enlarged uterus displaces stomach and intestines Constipation Relaxation of the cardiac spinchter may allow reflux of acidic gastric contents

into esophagus, giving the mother heartburn


PHYSIOLOGICAL CHANGES OF PREGNANCY Integumentary system

Skin pigment changes (nipples, areola, vulva, perineal area darken) Linea nigra-pigmented line on the abdomen Chloasma “mask of pregnancy” –darkening of forehead and around the

eyes Striae gravidarum “stretch marks”- reddish streaks found on the

abdomen, thighs, buttocks, and breasts (may cause itching) Endocrine system

APG (prolactin-initial milk production) PPG (oxytocin-uterine contractions and ejection of milk from the

breasts “let-down reflex” after delivery) hPL-insulin antagonist-stress on islets of Langerhans-may show signs

of gestational diabetes Slight increase in size of thyroid, increase capacity to bind

thyroxin(important for fetal neural development during first trimester) Causes increased PBI

Metabolism-increases Mother must meet her needs as well as the needs of the developing

fetus


PHYSIOLOGICAL CHANGES: REPRODUCTIVE SYSTEM Uterus

Before pregnancy, it is a small, pear-shaped, thick-walled, muscular organ weighing 60g. At the end of pregnancy, it is a large, thin-walled organ weighing 1,000g. Its capacity increased from 10mL to 5L.

Cervix Secretes a thick, sticky mucus -forms a plug plug prevents microorganisms from entering through the vagina During labor, cervix dilates-plug is expelled Goodell’s sign (softening of the cervix) noted at 8 weeks Chadwick’s sign (a purplish-blue color of the cervix and vagina)8weeks

Ovaries Ovulation does not occur during pregnancy Corpus luteum produces estrogen and progesterone until week 8

Vagina Estrogen causes loosening of connective tissue and increae in vaginal

secretions Acidic secretions prevent bacterial infections Increased glycogen in cells may enhance growth of trichomonas vaginalis or

candida albicans Breasts

Enlargement, nipples more erect, areolas darken, Montgomery’s tubercles enlarge

Colostrum, antibody rich yellow fluid secreted last trimester & first 2-3 days after birth-gradually changes to milk


PHYSIOLOGICAL CHANGES: CARDIOVASCULAR SYSTEM

Blood flow increases. Heart rate increases. Blood pressure decreases. Supine hypotensive syndrome may occur. Physiologic anemia of pregnancy may

occur.


PHYSIOLOGICAL CHANGES: RESPIRATORY SYSTEM

Progesterone decreases airway resistance.

The enlarging uterus presses upward on the diaphragm.

Estrogen causes edema and vascular congestion in the nasal mucosa.


PHYSIOLOGICAL CHANGES MUSCULOSKELETAL SYSTEM

Relaxin relaxes the pelvic joints. Mother’s center of gravity changes. May cause the woman to have a

waddling gait. See figure 50-7, view how the mother’s

posture changes due to the growing fetus


PHYSIOLOGICAL CHANGES: GASTROINTESTINAL SYSTEM

Nausea and/or vomiting common before 12 weeks.

Delayed gastric emptying and decreased peristalsis.

Stomach and intestines are displaced. Constipation and heartburn also common.


PHYSIOLOGICAL CHANGES: URINARY SYSTEM

Enlarging uterus presses on bladder in first and third trimester.

Ureters relax and dilate. Glomerular filtration rate rises. Glycosuria may develop if kidneys are

unable to reabsorb glucose.


PHYSIOLOGICAL CHANGES: INTEGUMENTARY SYSTEM

Several skin pigment changes occur. Linea nigra–pigmented line on the

abdomen from umbilicus to pubis. Chloasma–the “mask of pregnancy.” Striae gravidarum– “stretch marks.”


PHYSIOLOGICAL CHANGES: ENDOCRINE SYSTEM

Prolactin is responsible for initial milk production.

Oxytocin causes uterine contractions and ejection of milk from the breasts.

Greater insulin production is required. Thyroid often increases in size.


PHYSIOLOGICAL CHANGES: METABOLISM

The metabolic rate of the mother increases during pregnancy as demands of the growing fetus increase.

Mother must meet her own and the fetus’s nutritional needs.


PRESUMPTIVE SIGNS OF PREGNANCY see pg 1433 Amenorrhea __________________________________________________________

Nausea and vomiting___________________________________________________ Breast changes________________________________________________________ Urinary frequency_______________________________________________________ Excessive fatigue______________________________________________________ Abdominal enlargement_________________________________________________ Quickening________________________


PROBABLE SIGNS OF PREGNANCY see pg 1433 Goodell’s sign______________________ Hegar’s sign_______________________ Chadwick’s sign____________________ Uterine enlargement_________________ Braxton-Hicks contractions____________ Increased pigmentation______________ Ballottement_______________________


PREGNANCY TEST

Measures hCG in either urine or blood. Blood is positive 8 days after conception. Urine is positive 10–14 days after

conception. A pregnancy test is a probable sign of

pregnancy.


POSITIVE SIGNS

Hearing the fetal heartbeat. Visualization of the fetus through

ultrasound. Examiner feeling fetal movement.


DEVELOPMENTAL TASKS OF PREGNANCY Pregnancy validation

Validate and accept pregnancy Mood swings with hormonal changes

Fetal embodiment Incorporates growing fetus into body image Physical changes in body Self-involvement, depression, or regression-having difficulty

Fetal distinction Fetal movement felt-sees fetus as separate being May daydream about baby and being a mother

Role transition Time to prepare, childbirth classes, prepare nursery, explore parenting nesting

Partners’ tasks Accept they (as a couple) are pregnant Accept changes physical and psychological in partner Fetal distinction when hears heartbeat or feels movement


FACTORS AFFECTING PSYCHOLOGICAL RESPONSE Body image

“fat” “ugly” “so good” “beautiful” Feel a lack of control or limited

Financial situation Anxiety, nutrition, medical care

Cultural expectations Conflicts, expectations

Emotional security Planned, secure Unexpected, uncertainty

Support from significant others Father/partner (couvade) Siblings Grandparents


GOALS OF PRENATAL CARE

Healthy, prepared mother, minimal discomforts

Potential problems or complications Identified as early as possible

Safe delivery of a healthy infant Prepared father, partner Prepared siblings and grandparents


PRENATAL CARE

Initial visit Initial history Estimating duration of pregnancy Physical examination-client’s ht/wt, pelvic,

fundal ht Screening tests-see table 50-3 pg 1439 Return visits


ANTICIPATORY GUIDANCE Environmental hazards-chemicals, xray exams, heat

from saunas/hot tubs Discomforts of pregnancy-table 50-4 Warning signs-table 50-5 Nutrition-

well balanced diet, add 300kcalories a day when pregnant and 500kcalories when breastfeeding.

Add 2 servings milk and one meat serving Multivitamin, calcium, iron, & folic acid Pica may develop Nutritional risk –

• Adolescence, due to demands for own growth & pregnancy• Inadequate nutritional intake• Low income• Smoking, alcohol abuse, drug addiction• Depression• See pg 1443


SELF-CARE

Breast care Good support Keep clean

Personal hygiene Daily bathing

Activity/rest Regular physical activity Adequate rest

Clothing Attractive, loose fitting Low heeled-shoes

Employment Assess risks/benefits

Travel Discuss with doctor

Dental care Regular hygiene Avoid xrays

Sexual activity NO NEED TO LIMIT IN A

HEALTHY PREGNANCY!! Sexual desire may increase in

2nd trimester Consider position changes Allow men to discuss feelings


NURSING DIAGNOSES

Activity intolerance Anxiety Breathing pattern, ineffective Body image disturbance Constipation Fatigue Family coping


NURSING DIAGNOSES (continued)

Fear Fluid volume deficit Excess fluid volume Ineffective health maintenance Health seeking behaviors Ineffective coping Risk for injury


NURSING DIAGNOSES (continued)

Deficient knowledge Noncompliance Imbalanced nutrition Impaired physical mobility Sexual dysfunction Disturbed sleep pattern


NURSING INTERVENTIONS

Must be individualized and specific for the client.

Focused on teaching the client and providing anticipatory guidance.

copyright 2005 thomson delmar learning. thomson and delmar learning are trademarks used herein under...

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