Normal PregnancyFall 2011Amie Bedgood RN, MSN

Physiological Changes in the Reproductive OrgansUterus

enlargement -- 2 ounces to 2 pounds rises out of pelvic area and displaces the

intestineschanges in tissue

increase in vascularityhypertrophy

isthmus of uterus softens-- Hegar’s signuterine souffle

Patient teaching Braxton-Hicks contractions

Cervixsoftens - Goodell’s signfills with a mucus plugincrease in discharge, leukorrhea

Vaginaincrease in vascularity - Chadwick’s signincrease in discharge, leukorrheapH rises and become more susceptible to

yeast infections

Perineumincreased vascularity and pressure causes

vulvar varicositiesWhat should the nurse teach regarding

decreasing the pressure in the perineal area?

Ovariescorpus luteum remains functioning and there

is NO ovulation or menstruation.

BreastsGrowth of alveolar tissue Nipples become more pigmented

Your patient states that her breasts are more full and have become very heavy. What teaching should the nurse include?

Cardiovascular System• Circulatory System

▫ Related to: cardiac enlargement vasodilation increase blood volume, hemodilution increase cardiac output – 30-50%

•Variations in common laboratory tests▫ Hgb – 12 – 16 g/dl – stays about the same▫ Hct -- 37% decreases RT hemodilution. There is an

increase of about 1500 cc . Over 1000 cc of that is plasma.

▫ RBC -- ~5.7million which is about a 17% increase

Nursing Care▫Avoid supine hypotension▫Arise slowly from a lying position▫Wear support hose to avoid varicose veins▫Avoid constipation to decrease formation of

hemorrhoids▫Instruct that palpitations may be felt and

are normal

Respiratory Changes▫ Related to:

Thoracic cage is pushed upward and the diaphragm is elevated as uterus enlarges

Oxygen consumption is increased to support fetus Lower thoracic cage widens to increase tidal volume

Nursing Care◦ Instruct due to shortness of breath and dyspnea may need to:

sleep in an upright position avoid eating large meals stop smoking! Nasal stuffiness is normal due to increase in hormones

Elimination:Gastrointestinal Changes•Nausea and Vomiting

▫Related to: increased levels of HCG changes in CHO metabolism fatigue

▫Nursing Care Avoid offending odors eat dry CHO (crackers) upon wakening Eat 5-6 small meals per day Avoid spicy, gas forming foods Drink carbonated beverages

Heartburn and Indigestion– Related to:

»slowing of motility and digestion due to progesterone

»relaxation of cardiac sphincter, regurgitation occurs

»stomach displaced upward and compressed by enlarged uterus

Nursing Care avoid large meals use good posture take low Sodium antacids

Constipation◦ Related to:

slowing of motility intestinal compression oral iron supplement

◦ Nursing Care Increase water and fiber in diet moderate exercise No laxatives or enema without a doctor’s permission

Hemorrhoids◦ Related to :

pelvic congestion straining with stool

◦ Nursing Care avoid constipation Apply topical agents to area

Elimination:Urinary SystemRenal Changes

◦ Related to: Kidneys increase in size and weight to due to increased

filtration needs Enlarged uterus presses on kidneys and ureters reducing

effective flow ureters dilate Urinary stasis occurs

Urinary frequency and urgency◦ Related to:

pressure of uterus on bladder first and last trimester Nursing care

Kegel’s exercises Limit fluid intake before bedtime Report dysuria or burning

IntegumentarySkin changes

◦ Increase pigmentation R/T increase in production of melanotropin face = chloasma breasts = areola darkens abdomen = linea nigra

◦ Spider nevi on face and upper trunk◦ Striae gravidarum

Regulatory Changes

• Joints, bones, and teeth▫ Softening of pelvic cartilage and exaggerated elasticity of

connective tissue▫ Posture changes▫ Leg cramps▫ Carpal tunnel syndrome▫ Teeth--there is no demineralization

• Endocrine▫ The placenta produces new hormones

• Exercise, Leisure▫ May attend regular prenatal exercise classes▫ Don’t take up a new sport▫ Travel--wear seat belt

Safety with Seat BeltsSafety with Seat Belts

Wear shoulder Wear shoulder belt belt over top of over top of abdomenabdomen

Wear lap belt lowWear lap belt lowover the hipsover the hips

Regulatory

•Employment▫Criteria for work:

safe environment for the fetus can woman carry out work commitments

without undue stress

•What other teaching is necessary regarding work and breaks?

Safety / SensorySafety

◦Clothing◦Bathing◦Immunizations - avoid live vaccines

EyeEar

◦ Clothing◦ Bathing◦ Immunizations - avoid live vaccines

Nutrition

Increase in caloriesIncrease in protein

May have food cravings or Pica

Nursing care:◦ Teach to take prenatal vitamins and iron

◦ Teach about normal weight gain ~ 25 lbs.

THEPREGNANCYEXPERIENCE

Situation

•Mr. and Mrs. Andrews visit the clinic and tell the nurse that Mrs. A has “missed two menstrual periods, has urinary frequency,

and is tired all of the time”.

First Prenatal Visit

•What is the most important thing that the nurse can do at this first prenatal visit?

FIRST PRENATAL VISIT

•Most important intervention for the nurse is to:

MAKE THE PATIENT WELCOME !

Why? (so the couple will continue with prenatal

care)

Now that the couple has been welcomed to the clinic, one of the first things that must be done is to confirm

that Mrs. A is pregnant.

•Mrs. A says that she used a home pregnancy test and the results were positive.

•What are some of the advantages and disadvantages of using home pregnancy testing?

Home Pregnancy Testing• Advantages

▫ Easily available▫ Uncomplicated ▫ Convenient▫ Have a greater than 97%

accuracy▫ Minimal time

• Disadvantages▫ Must be able to follow

the directions as described or can lead to improper collection and errors in performing or reading the test

▫ False-positive results – anticonvulsants, aspirin,

tranquilizers, marijuana▫ False-negative results –

diuretics, promethazine▫ Laboratory errors

•What other types of pregnancy tests might be utilized to confirm the pregnancy?

Confirm the PregnancyAll tests rely on detection of HCG

EnzymeImmunoassay Tests

Radioimmune assay Tests

UrineHema-agglutinationInhibitionTests

Presumptive Signs

•Cessation of Menstruation•Breast changes -- tenderness•Nausea and Vomiting•Frequent Urination•Quickening•Chadwicks sign•Increased pigmentation of the Skin•Fatigue

Probable Signs

•Enlargement of the Abdomen•Hegar’s Sign -- softening of the isthmus

of the uterus•Goodell’s Sign --softening of the cervix•Braxton-Hicks contractions•Ballotment•Outline of the fetus by abdominal

palpation•Positive Pregnancy Test

Positive Signs

•Ausculation of fetal heart tones

•Active fetal movement felt by a trained provider

•Ultrasound showing fetal outline

•It is confirmed that Mrs. Andrews is pregnant.

•The nurse will continue with the assessment of physiological and psychological needs of the family.

•Assessment begins at the initial visit and continues throughout pregnancy.

Legal Implication•Nurses must exercise caution when

discussing obstetric history with the expectant mother in the presence of her family or significant other. Although the antepartum record may indicate a previous pregnancy or childbirth, she may not have shared this Information with her family, and probing questions could jeopardize her right to privacy.

• The confidentiality of the pregnant woman must always be protected.

Health History Assessment• Collect information about:

▫ Obstetric History -- Current and past pregnancies▫ Menstrual History▫ Family history--genetic and environmental factors

that affect health▫ Medical history-- diabetes, heart

• Perform Physical Examination including a Pelvic Examination (Pap test, measurements, cervical culture)

• Perform Laboratory Studies▫ CBC, Type & Cross, RPR, Rubella, Hepatitis, HIV

Calculation of Gravida and Parity•Obstetrical Status

▫Gravida = number of times pregnant regardless of duration or outcome

▫Parity = number of deliveries after the age of viability (20 weeks).

** It is not the number of babies that come out, but the number of deliveries of a pregnancy

Calculation of Gravida and Parity•Further Breakdown into TPAL

▫T = Term▫P = Preterm▫A = Abortions▫L = Living children

Check Yourself !The nurse obtained the following data

from Mrs. Andrews. She has five year old twins that delivered at 35 weeks, a three year old son that delivered at 39 weeks, had a miscarriage last year at 12 weeks gestation.

What is her gravida and parity?What is her gravida and parity using the

TPAL system?

•Mr. and Mrs. Andrews are both excited about the pregnancy. It is her first so she is considered a Gravida 1, Para 0.

•They ask the nurse “When is the baby due”?

•How will you calculate this?

Calculation of E. D. C. Nagele’s Rule

First day of last Menstrual Go back 3 months Add 7 days

Mrs. Andrews tells you her last menstrual period began on July 18.

Her baby is due on ____________.

TEST YOURSELF

•Mrs. B. began her menses onJanuary 21. What is her E.D.C.using Nagele’s Rule?

•Mrs. C. started her menses onJune 27. What is her E.D.C. using Nagele’s Rule?

Problem Solving

•If Mrs. Andrews did not know the first day of her last menstrual period, what method

of calculation would you use?

McDonald’s Rule Use Fundal height measurement, measure

from the symphysis to the top of the fundus.

Months = measure cm. X 2/7 Weeks = measure cm. X 8/7

Mrs. Andrew’s fundal height is 7 cm. How far along is she?

Assessment

•The nurse continues with assessment of Mrs. Andrews and gathers data regarding presumptive, probable, and positive signs of pregnancy

Conclusion of Visit

•You are completed with Mr. and Mrs. Andrews first prenatal visit.

•Before they leave, it is important to discuss the following topics:

Conclusion of Visit

•Patient Teaching

•Diet Counseling

•Referrals

•Danger Signals

•Date of next visit

Danger Signals• Vaginal Bleeding• Fluid from the Vagina• Abdominal Pain• Increased Temperature• Dizziness, Blurred vision or Double Vision• Persistent Vomiting• Edema• Headache• Dysuria• Absence of Movement of the Baby

Psychosocial Adaptions

Psychological Tasks of PregnancyMr. Andrews says they were excited about

having the baby but he had just taken a new job and was concerned.

Is this Normal?

The First Trimester

• Major Feelings are:

▫ Disbelief / Uncertainty Much time is devoted to the attempt to

determine for sure whether she is pregnant

▫ Ambivalence Feelings fluctuate between acceptance and

rejection of the pregnancy

The First Trimester

• How the Nurse Can Assist the Woman to Adjust:

▫ Assist her to confirm that she is Pregnant▫ Recognize that she is self-centered▫ Focus on Current Events▫ Provide opportunities for her to discuss

concerns▫ Guide her to appropriate community resources

The Second Trimester

•The Major Task is to:• Perceive the Fetus as • a Growing Infant• be able to say:

•“I am Going to have a Baby”

The Second Trimester

• Major Feelings are:▫ Woman feels well and good about herself▫ Concerned with producing a healthy baby▫ Self- Centered and Introverted▫ Visualizes the infant as a separate being▫ Views body image changes as positive sign

that the baby is doing O.K.

The Second TrimesterWays Health Care Worker can assist the

woman to adjust:◦ Take advantage of the Prime Time for Teaching Individual Care

Nutrition Clothing Exercise

Baby Care◦ Confirm that the baby is Growing and Doing Well◦ Praise her on following Prenatal

Recommendations

The Third Trimester

The Major Task is toPrepare for the end of Pregnancy and she need to be able to say

“I am Going to Be a Parent”

The Third Trimester• Major Feelings are:

▫ Vulnerable Fears loss of the baby Fantasies about harm coming to the baby

▫ Dependent Needs satisfaction that partner / support

person is there ▫ Concerned with how to cope with labor and

delivery▫ Need to Prepare for Parenthood

The Third Trimester

• Ways in which the Health Care Worker can assist the woman to adjust:▫ Assure her of the baby’s well- being▫ Be a Good Listener▫ Nurture her▫ Provide with information about childbirth

classes▫ Assist her with contacting appropriate

agencies that may assist in caring for the infant after birth

What would the nurse base her response?

Sexual Changes

•First trimester – decrease in sex drive

•Second trimester – return of sex drive“Baby Moon”

•Third trimester – decrease in sex drive

•Exceptions – those women who are prone to preterm labor.

Factors that affect psycosocial adaptations

•Age•Multiparity•Social support•Absence of a partner•Socioeconomic status•Abnormal situations

Barriers to prenatal care

•Financial•Systemic•Attitudinal

Cultural Influences

•Health beliefs•Communication•Time orientation

Teen pregnancy

•How is it different?•What will the nurse need to focus on with

the pregnant teen?

The end!!!!