Transcript Prenatal Care and Adaptations to Pregnancy

Prenatal Care and
Adaptations to Pregnancy
Chapter 4
Goals of Prenatal Care
Early & regular prenatal care is the
best way to ensure a healthy
outcome for both baby and mother.
Major goals of prenatal
care:
⁻Reducing risk factors & promoting good
health habits
⁻Teaching health habits
⁻Educate in self-care
⁻Provide physical care
⁻Prepare parents for responsibilities
Major role of Nurse
Include:
collecting data from pregnant
woman
identify & reevaluate risk
factors
provide nutrition counseling
promoting the family’s
adaptation to pregnancy
Prenatal Visits
Estimated date of delivery
(EDD) is calculated based on the
LNMP.
An ultrasound is done to confirm
EDD.
Recommended schedule for
prenatal visits in an
uncomplicated pregnancy is as
follows:
Routine lab tests
⁻Conception – 28 weeks= every 4
weeks
⁻29 – 36 weeks = every 2 to 3 weeks
⁻37 weeks to birth = weekly
Routine Assessments
Risk factors
V/S: B/P should be taken in same
area and in same position each time
for accurate comparison w/her
baseline
Weight
A sudden wt gain is often
associated w/gestational
hypertension
UA
Blood glucose screening between
24 & 28 weeks
Fundal height
Leopold’s maneuvers
FHR-Doppler transducer
Nutrition
Discomforts/problems
Definition of Terms
TPALM System: Used to Describe Parity
Gravida
T=number of term infants born after 37
weeks of gestation
Primigravida
Para
P=number of preterm infants born after
20 weeks or before 37 weeks
Primipara
A=number of pregnancies aborted
before 20 weeks
Abortion
L = number of children now living
Gestational age
M= Multiple births
Gravida = number of pregnancies
Para = TPALM
Kate
Anna
T=1
T=1
P=0
P=1
A=1
A=1
L=1
L=2
M=0
M=0
PARA = 10110
PARA = 11120
Nägele’s Rule
Example:
Determine the Estimated Date
of Delivery (EDD)
1.
1st
day of last normal
menstrual period (LNMP)
LNMP: 11-06-12
11-3 mos. = August
06
+7 days
2.
Count backward 3 months
13
EDD = Aug 13, 2013
3.
Add 7 days
4.
Correct year if necessary.
Avg. duration of a term
pregnancy is 40 weeks (280)
days after 1st day of LNMP plus
or minus 2 weeks.
Signs of Pregnancy
1.
Presumptive
2. Probable
3. Positive
Presumptive (suggestive signs)
Common symptoms during pregnancy but can often be
caused by other conditions.
Amenorrhea can be due to:
strenuous exercise,
changes in metabolism, endocrine dysfunction,
chronic disease,
certain medications,
Pigmentation changes can be caused by:
hormonal changes
radiation
sun exposure
birth control pills
certain medications
Urinary frequency may be caused by:
anorexia nervosa,
UTIs
early menopause
pelvic masses
Nausea/vomiting can be caused by:
Fatigue & drowsiness can be caused by:
illness
emotional problems
stress
GI upset
sudden changes in lifestyle
Brest Tenderness can also occur premenstrually
Quickening may be caused by:
abdominal gas
normal bowel activity
false pregnancy (pseudocyesis)
Probable (stronger evidence)
Braxton Hicks contractions may be
caused by:
Goodell’s/ Chadwick’s sign may by caused
by:
birth control pills
certain medications
hormonal imbalance
infection
McDonald’s sign and Hegar’s sign may
caused by:
uterine fibroids (benign tumors)
Ballottement may be caused by:
uterine or cervical polyps (small tumors)
Fetal outline may be mistaken for a
tumor
Abdominal striae may be caused by:
weight gain
hormonal imbalance
infection
Abdominal enlargement may be caused
by:
uterine or abdominal tumors
Positive pregnancy tests may by caused
by:
not following instructions for the EPT
precisely
antianxiety or anticonvulsant drugs
blood in urine
malignant tumors
premature menopause
Positive Signs
Caused only by a developing fetus
demonstration of fetal heart
activity
fetal movements felt by
examiner
visualization of fetus
w/ultrasound
Fetal heartbeat my be detected as
early as 10 weeks using a
Doppler device.
The fetal heartbeat can be
detected between the 18th and
20th week of gestation using a
fetoscope.
Fetal Heart Rate
At term ranges between a low of
110 to 120 beats/min and a high
of 150 to 160 beats/min.
The rate is higher in early
gestation & slows as term
approaches.
Identification of embryo
w/ultrasound photography is
possible as early as 4-5 week of
gestation.
Physiological Changes in Pregnancy
Endocrine system:
Most hormones are produced by
corpus luteum and later by placenta.
Placenta produces large amounts of
estrogen and progesterone to
maintain the pregnancy.
Other hormones produced are hCG
and human placental lactogen (hPL).
hPL  maternal insulin resistance
during pregnancy to provide the
fetus w/glucose needed for growth.
Reproductive System
Uterus
Small, muscular, pear-shaped
organ that weighs about 60 g ( 2
oz.) w/capacity of about 10 ml
At term the uterus reaches
xiphoid process & weighs about
1000 g (2.2 lb.) w/capacity of
about 5000 ml
Reproductive System
Cervix
Changes in color
Chadwick’s & Goodell’s signs
appear
Secretion of thick mucus leads to
formation of a mucous plug that
seals the cervical canal
Reproductive System
Ovaries
Do not produce ova (eggs) during
pregnancy.
The corpus luteum remains on
ovary & produces progesterone to
maintain decidua during first 6 to
7 weeks until placenta can
perform this function.
Reproductive System
Vagina
blood supply , causing bluish
color of Chadwick’s sign
connective tissue softens
secretions 
vaginal pH becomes more acidic
higher levels of glycogen
Breasts
 Levels of estrogen &
progesterone prepare breasts
for lactation
deeply pigmented areolae
tubercles of Montgomery become
prominent
last few months, thin yellow fluid
called colostrum may be
expressed from breasts
Colostrum =  in protein, fatsoluble vitamins & minerals, but
low in calories, fat, and sugar
Colostrum contains the mother’s
antibodies to diseases & is
secreted for first 2 to 3 days
after birth in breastfeeding
woman.
Respiratory System
Breathes more deeply, but
respiratory rate increases slightly
 Oxygen & carbon dioxide
exchange
Oxygen consumption  by 15%
Expanding uterus exerts upward
pressure on diaphragm, causing to
rise about 4 cm.
Rib cage flares, increasing chest
circumference about 6 cm (2.4
inches)
Dyspnea may occur until fetus
descends into pelvis (lightening)
Nasal stuffiness, epistaxis and a
sense of fullness in ears or earaches
occurs due to increased estrogen
levels.
Cardiovascular System
The uterus displaces the heart upward
and to the left.
Blood volume gradually  to about
45% greater than that of
prepregnant state by 32 – 34 weeks of
gestation.
The  provides added blood for
following purposes:
exchange of nutrients
needs of maternal tissue
reserve for blood-loss at birth
The pulse rate  by 10 – 15
beats/min, & basal metabolic rate
may  20%.
Blood pressure does not increase
w/higher blood volume. A B/P of
140/90 mm Hg or significant
elevation above baseline requires
attention.
Cardiovascular System
Supine hypotension syndrome
(aortocaval compression or vena
cava syndrome may occur if
woman lies on her back.
Supine position allows heavy
uterus to compress her inferior
vena cava or aorta, reducing
amt. of blood returned her heart,
causing fetal hypoxia.
Symptoms include: faintness,
lightheadedness, dizziness, and
agitation.
To relieve pressure, turn woman
preferably to left to displace
uterus.
If woman must remain in supine
position for procedures, the use of
a small towel roll placed under one
hip will also help prevent supine
hypotension syndrome.
Dilutional Anemia
Although both plasma (fluid) and
red blood cells (erythrocytes) ,
they do not  by same amt.
Fluid part of blood  more than
erythrocyte component, causing
dilutional anemia.
The white blood cell
(leukocyte) count also  about
8% (mostly neutrophils) &
return to prepregnancy levels by
about 6th day postpartum.
Clotting Factors
 Levels of clotting factors VII,
VIII, and X & plasma fibrinogen
during 2nd & 3rd trimester.
This prevents excessive bleeding
after delivery when placenta
separates from uterine wall.
However, this changes  possibility
of thrombophlebitis during
pregnancy and postpartum period.
Gastrointestinal System
Uterus displaces stomach &
intestines toward back & sides of
abdomen.
The woman’s appetite & thirst  as
fetus grows.
Gastric secretions .
Emptying of stomach & motility of
intestines are slowed.
Women feel bloated, may experience
constipation & hemorrhoids.
Glucose metabolism is altered by hPL
to increase insulin resistance during
pregnancy.
This allows more glucose use by
fetus but also places woman at risk
for development of gestational
diabetes mellitus.
Urinary System
Excretes waste products for both mother &
fetus
Glomerular filtration rate of kidneys .
Renal tubules  reabsorption of substances
that body needs to conserve but may not be
able to keep up w/high load of some
substances filtered by glomeruli (e.g.
glucose).
Therefore glycosuria and proteinuria are
more common during pregnancy.
Water is retained for  blood volume &
dissolving nutrients for fetus.
Progesterone causes renal pelvis & ureters to
lose tone, resulting in  peristalsis to
bladder.
The relaxing effects of progesterone causes
the bladder and diameter of ureters to ,
causing urine stasis..
The urine stasis and nutrient-rich urine
makes the woman more susceptible to
urinary tract infection.
Teach woman to drink at least 8 glasses of
water each day ( if not contraindicated) to
reduce risk for UTIs..
Fluid & Electrolyte Balance
Filtration of sodium by glomerular
filtration rate increases by 50%
but tubular resorption rate results
in 99% reabsorption of sodium.
Much sodium is used by fetus, but
remainder is in maternal
circulation and can cause
accumulation of water (edema).
Pitocin may further exacerbate
fluid retention because it is an
antidiuretic and can cause water
intoxication.
Integumentary and Skeletal Systems
Temporary changes are caused by high
levels of hormones.
In addition to pigment changes, the sweat
& sebaceous glands become more active
to dissipate heat from woman and fetus.
Spider nevi may occur.
Palms of hands may become deeper red.
Most skin changes are reversed after birth.
Joint instability
Woman’s posture changes. The anterior
part of body becomes heavier and lordotic
cure in her lumber spine becomes more
pronounced.
Women often experience low backaches,
aching in the cervical spine & upper
extremities.
The pelvic joints relax (relaxin)
w/hormonal changes during late
pregnancy. A woman often has a
“waddling” gait because of slight
separation of the symphysis pubis.
Nutrition for Pregnancy and Lactation
An adequate dietary intake of
docosahexaenoic acid-omega 3
fatty acid (DHA) is essential for
optimal brain development of the
fetus and infant.
Dietary sources of DHA include:
fish, salmon, halibut, tuna,
flounder, egg yolk, red meat,
poultry, canola oil & soybean oil.
Avoid frying these foods as this
detracts from DHA content.
Weight Gain
Guidelines for weight gain during
pregnancy are based upon the
woman’s prepregnant weight and
BMI.
Current IOM recommended weight
gains during pregnancy w/single
fetus are as follows:
Normal weight women: 25-35 lb.
(11.5-16 kg)
Underweight: 28-40 lb. (12.5-18
kg)
Overweight: 11-25 lb. (5-11.5 kg)
Obese: 11- 20 ( 5-9 kg)
Weight Gain
Pattern: General recommendation
weight gain up 4.4 lb. (2kg)
during the first trimester and………
approximately 1 lb. (0.44
kg)/week during the rest of
pregnancy
Factors contributing to
weight gain.
Nutritional Requirement During
Pregnancy
Caloric  of 300 kcal/day is
recommended to provide growth of
fetus, placenta, amniotic fluid, and
maternal tissues.
Caloric intake must be nutritious
and include four nutrients in
pregnancy.
Protein,
calcium,
iron, and
folic acid
Protein
An intake of 60g/day is
recommended.
Protein sources:
Meat, fish, poultry, and dairy
products.
Calcium
Calcium requirements  by 50%
in pregnancy & lactation.
DRI is 1200 mg
Food sources: Dairy products
Other sources: enriched cereals,
legumes, nuts, dried fruits,
broccoli, green leafy vegetables,
and canned salmon & sardines that
contain bones.
Iron
The fetus must store and adequate
supply of iron to meet the needs of
the first 3 to 6 months after birth.
An  of erythrocytes also  the
need for iron.
DRI is 30mg/day beginning in 2nd
trimester.
Taking iron on empty stomach
improves absorption.
Vitamin C may enhance
absorption.
Should not be taken w/coffee or
tea or w/high-calcium foods such
as milk.
Folic Acid
Water-soluble B vitamin essential
for formation & maturation of red
& white blood cells in bone
marrow.
Can reduce incidence of neural
tube defects.
DRI is 400 mcg (0.4 mg)/day.
Food sources: liver, lean beef,
kidney, lima & dried beans,
potatoes, whole wheat bread,
peanuts & fresh, dark green,
leafy vegetables.
Fluids
Recommended fluid intake
should be:
 8-10 (8oz) glasses of fluid
preferably water.
Sodium
Essential for maintaining normal
sodium levels in plasma, bone,
brain, and muscle because both
tissue & fluid expand during the
prenatal period.
Avoid foods high in sodium,
such as lunch meats and chips
during pregnancy.
Pregnant Adolescent
Gynecological age: number of
years between the onset of
menses & date of conception.
Planning nutrition interventions.
Peer group
Inadequate weight gain
Fast food restaurants
Pica
Craving for & ingesting of nonfood
substance such as:
clay
raw flour
cracked ice
starch
eating cigarette ashes
Frequent ingestion in large
amounts can interfere w/iron
absorption, and large amts. may
cause fecal impaction.
Difficult habit to break.
Gestational Diabetes
Calories should be distributed
throughout day to maintain
adequate and stable blood
glucose levels.
Glycemic control during 1st & 2nd
trimesters is most important to
prevent macrosomia and
stillbirths.
Nutritional Requirements During Lactation
During lactation caloric intake
should be about 500 calories
more than nonpregnant
woman.
Exercise During Pregnancy
Mild to moderate exercise is
beneficial during normal
pregnancy.
Vigorous exercise should be
avoided.
Cardiac Output
When exercise  the ability of
cardiovascular system to respond,
blood may be diverted from uterus,
causing fetal hypoxia.
Strong & prolonged exercise causes
blood flow to be distributed to
skeletal muscles and skin and away
from viscera, uterus, and placenta.
For this reason, moderate exercise
is preferred because it will not
cause decreased oxygen supplies to
the fetus.
Traveling During Pregnancy
Because of  levels of clotting
factors & plasma fibrinogen, the
woman should be counseled to
avoid long periods of sitting due to
increased risk of developing
thromboembolism.
Special oral rehydration solutions
should be available.
Comfortable shoes for walking
during plane ride.
Available space to move feet
while sitting on plane seat.
Common Discomforts in Pregnancy
Nurse should teach measures to
relieve discomforts.
Nausea/vomit:
Eating dry toast or
crackers before getting out of
bed in AM.
Drinking fluids between
meals.
Eating small, frequent meals.
Avoid fried, greasy, or spicy
foods and foods w/strong odors
Common Discomforts During Pregnancy
 Vaginal discharge
 Fatigue
 Backache
 Constipation
 Varicose veins
 Hemorrhoids
 Heartburn
 Nasal stuffiness
 Dyspnea in late pregnancy
 Leg cramps
 Edema of lower extremities
Pregnancy: Impact on the mother
First Trimester: Behavior
characteristics
Sonogram photos
Conflicting feelings (ambivalence)
Woman focuses on self
Experiences fatigue and sleepiness
Unstable (labile) emotions
Impact on Father
First Phase:
Announcement begins when
pregnancy is confirmed.
Seeing fetus on ultrasound
Second Phase: revising financial
plans
Third Phase: participating in
labor
Impact on Pregnant Adolescent
Assess the girl’s developmental &
educational level & support
systems.
Critical variable is age.
They have a difficult time
considering the needs of others,
such as the fetus.
The nurse helps the adolescent girl
to complete the developmental
tasks of adolescence while
assuming the new role of
motherhood.
She must cope w/two of life’s most
stress-laden transitions
simultaneously: adolescence and
parenthood.
Impact on the Older Couple
 “Elderly Primips”-women who
become pregnant for the first
time after age 35 years.
Questions?