Transcript The Antepartum Period

The Antepartum Period
Objectives
Low-Risk Antepartum Period
 Nursing Care of the Antepartum Patient
 Signs and Symptoms of Pregnancy
 Prenatal Labs/Testing
 Physiologic Changes of Pregnancy
 Nutritional Needs
 Psychosocial Changes of Pregnancy
Documentation of Pregnancy History
 Gravida: a woman who is or has been pregnant
 Para: the number of pregnancies that reached
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viability (20 weeks)
Primigravida: a woman who is pregnant for the first
time
Primipara: woman who has delivered one viable fetus
Multigravida: a pregnant woman who has been
pregnant before
Multipara: a woman who has delivered more than
one viable fetus
Nulligravida: woman who has never been pregnant
Nullipara: a woman who has not carried a fetus to
variability
Classifying Pregnancy Status
 G= gravida
 P= para
(# of total pregnancies)
(# of pregnancies that reached viability)
“Para” can be further broken down:
T= term pregnancies
P= premature deliveries
(20-37 weeks)
A= abortions (< 20 weeks)
L= number of living children
Remember: G.T.P.A.L.
Determining GTPAL Status
 The patient is currently 32 weeks pregnant.
She has a 5 year old son who was delivered
at 38 weeks and a 3 year old daughter who
was delivered at 36 weeks. Before having her
children, the patient also experienced a
spontaneous abortion at 18 weeks gestation.
What is her GTPAL?
G__ T__ P__ A__ L__
Calculating the Date of Delivery Using
Naegele’s Rule
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Identify the first day of the last menstrual period
(LMP)
Subtract three months from this date
Add seven days
Example: First day of the LMP is June 14
June 14 less three months = March 14
March 14 + seven days = March 21
*The expected due date is March 21
Anna’s Rule
 Identify the first day of the last menstrual period
(LMP)
 Add 9 months (usual time for a baby to grow)
 Add 7 days (babies are usually late a week)
Example:
LMP = June 15
Add 9 months = March 15
Add 7 days = March 22
Estimated date of delivery is March 22
Calculating the Estimated Date of Delivery
 First day of last menstrual period: Sept. 14
Using either Naegele or Anna’s rule, what is
the estimated date of delivery (EDD)?
Signs of Pregnancy
 Presumptive Signs: those that suggest but do
not positively indicate pregnancy (subjective
signs)
 Probable Signs: strong indicators of
pregnancy, short of confirmation (objective
signs). Two or more are highly suggestive of
pregnancy. Detected at about 12th week
 Positive Signs: absolute confirmation of
pregnancy
Presumptive Signs of Pregnancy
 Amenorrhea: absence of menstruation
 Nausea/vomiting: due to metabolic and
hormonal changes
 Breast changes: enlargement, tingling,
increased sensation to touch, darkening of
nipples and areola
 Urinary frequency: due to pressure on
bladder from uterine enlargement
 Fatigue: due to increased metabolism
 Quickening: fluttering sensation when fetus
moves (16-20 weeks gestation)
Probable Signs of Pregnancy
 Pigmentation changes: linea nigra, chloasma (mask of
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pregnancy)
Abdominal enlargement: as uterus rises out of the pelvis (after
12 weeks)
Chadwick’s Sign: purplish color of cervix
Hegar’s Sign: softening of the lower uterus
Ballottement: detection of fetus floating in amniotic fluid
Braxton Hicks contractions: irregular, painless uterine
contractions
Goodell’s Sign: softening of a normally-firm cervix
Positive pregnancy test: Maternal blood or urine test for human
chorionic gonadotropin (hCG). (Testing one week after a missed
period usually provides more accurate information)
Ballottement
Hegar’s Sign:
A Softening of the Lower Uterus
 Mask of Pregnancy
(Chloasma)
Positive Signs of Pregnancy
 Detection of fetal heart tones
 Palpation of fetal movement
 Ultrasonic evidence of a fetus
Hydatiform Mole (Molar Pregnancy)
 Benign proliferating growth of the trophoblast in
which the chorionic villi develop into edematous,
cystic, vascular transparent vesicles that hang in
grapelike clusters without a viable fetus. Although
hCG is produced, this is a nonviable pregnancy
Pregnancy and Prenatal Care
 First trimester
 First day of LMP to week 13
 Second trimester
 14 weeks to 27 weeks
 Third trimester
 28 weeks to 40 weeks
*Full term pregnancy is 37-42 weeks
The FDA Categorization of Drug Risks to the Fetus:
"Category A" (safest) to "Category X" (known danger)
Category A
Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no
evidence of a risk in later trimesters), and the possibility of fetal harm appears remote.
Category B
Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled
studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other
than a decrease in fertility) that was not confirmed in controlled studies in women in the first
trimester (and there is no evidence of a risk in later trimesters).
Category C
Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal
or other) and there are no controlled studies in women, or studies in women and animals are not
available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.
Category D
There is positive evidence of human fetal risk, but the benefits from use in pregnant women may
be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a
serious disease for which safer drugs cannot be used or are ineffective).
Category X
Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence
of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant
women clearly outweighs any possible benefit. The drug is contraindicated in women who are or
may become pregnant!
Prenatal Labs and Tests
 CBC
 Serology/VDRL*/RPR*
(tests for syphilis)
 STD screening
(chlamydia, gonorrhea,
herpes)
 Pap smear (cervical
cancer screening)
 Antibody titers for
rubella and Hepatitis B
*VDRL=Venereal Disease Research Lab
*RPR=Rapid Plasma Reagin
 ABO/Rh typing
 Plasma glucose
 Urinalysis
 TB screening
 TORCH screening
 Alpha-fetoprotein (AFP)
 Group B Beta Strep
 HIV (with permission)
Rh Sensitization
 May occur when mother is Rh negative but fetus is Rh positive
 If the infant’s Rh+ blood enters the mother’s circulation, her
body perceives this foreign blood type as harmful. She creates
anti-Rh+ antibodies in response
 Although the current infant is not affected, the next pregnancy is
at risk. If that fetus also has Rh+ blood, the mother’s anti-Rh+
antibodies will attack the developing fetus, causing hemolysis
(break down) of its red blood cells. Known as erythroblastosis
fetalis
 Treatment? RhoGAM 300 mcg IM or IV is given prophalactally
at 28 weeks gestation and again within 72 hours of childbirth.
Remember this second dose is only given if the infant is Rh+
 RhoGAM is also given after abortion, ectopic pregnancy and an
amniocentesis as in each case blood could exchange and
trigger the Rh sensitization response
ABO Blood Incompatibilities
 More common than Rh incompatibility but less
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serious
Occurs when maternal blood type is O and fetal
blood type is A, B, or AB
O mothers naturally produce anti-A and anti-B
antibodies which cross the placenta
These antibodies will cause red blood breakdown in
the fetus with A, B, or AB blood types
Causes hyperbilirubinemia; phototherapy is the
treatment
T.O.R.C.H. Infections
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T= Toxoplasmosis
O= Other*
R= Rubella
C= Cytomegalovirus
H= Herpes
*Other includes gonorrhea, syphilis, varicella,
Hepatitis B, Group B strep and HIV
TORCH-Related Complications
 Congenital heart defects
 Physical fetal anomalies
 Intrauterine growth restriction (IUGR)
 Mental retardation
 Encephalitis
 Hydrocephalus
TORCH Infections
 TORCH infections place both mother and baby in
jeopardy due to the associated complications
 All TORCH infections can cross the placenta
 Prenatal complications include premature labor and
premature rupture of membranes
 Prenatal screening important since many infections
are asymptomatic
 Streptococcus (Group B) is a frequent cause of
sepsis in the mother/neonate
HIV/Aids in Pregnancy
 Fetus may contract HIV transplacentally, at birth or
through breast milk. Absolutely no breastfeeding for
these mothers!
 Current maternal treatment is oral zidovudine (AZT)
during pregnancy and IV AZT during labor. Newborn
also treated with AZT
 Although maternal antibodies may be present at birth
in some babies, the antibody tests will usually convert
to negative before 18 months of age
HIV/AIDS: Nursing Interventions
 Reduce invasive procedures (AROM, fetal
scalp electrodes, IUPCs)
 Bathe baby as soon as possible after
delivery. If baby is unstable, wash injection
sites with soap and water, then cleanse with
alcohol
 Delay injections, heel-sticks until after bath
 Medical personnel should wear eye shields,
gowns, masks and double glove during the
birth
Group B Strep Infection
 Usually not harmful to mother but can cause
serious complications if transferred to infant
 Vaginal/rectal area swabbed
 Woman screened at 35-37 weeks gestation
because the pathogen can come and go
during pregnancy
 If positive, mother is treated with IV antibiotics
while in labor. Must have two separate doses
administered at least 4 hours before birth to
be considered treated
Alpha-fetoprotein (AFP)
 Substance produced by the fetal liver
 Elevated levels in maternal serum may
indicate neural tube defect in the fetus
 Decreased levels may indicate Down
Syndrome (Trisomy 21) in fetus
 Abnormal levels will necessitate further
testing. Amniotic fluid will be assessed; more
accurate
 In what situation would elevated AFP levels
be considered normal?
Domestic Violence
 Pregnant women more abused than general
population
 Most likely related to the partner feeling a sense of
lack of control/power
 Essential to screen throughout the entire pregnancy
 Important to ASK the questions:
1) “In your current relationship, do you feel safe?”
2) “Within the last 6 months have you been hit,
slapped, kicked, or punched?”
3) “Do you fear for your own safety or the safety of
your children?”
Substance Abuse
 Alcohol
 Tobacco
 Marijuana
 Cocaine
 Amphetamines
 Heroin
 Other prescribed or ilicit drugs
Substance Abuse
 If the nurse suspects the patient is a drug
user, her urine is sent for a drug screen
 After delivery, infant’s first meconium is sent
to the lab for a meconium drug screen
 Notify Social Services if infant drug screen is
positive. CPS involvement is mandatory
 Narcan SHOULD NOT be given to mother on
methadone or heroin as it may precipitate
drug withdrawal
Clinical Manifestations of Newborn
Narcotic Withdrawal
 Hyperactivity
 Disorganized,
 Persistent shrill cry
vigorous suck
 Poor feeding
 Vomiting
 Drooling
 Diarrhea
 Flushing, sweating
 Tachypnea (>60 bpm)
 Tremors
 Increased muscle
tone
 Sneezing, hiccups,
yawning
 Short, unquiet sleep
 Fever
Fetal Alcohol Syndrome
Fetal Alcohol Syndrome
 Symptoms:
 Microcephally
 Growth retardation
 Short palpebral
fissures
 Maxillary hypoplasia
 Smooth philtrum
 Nursing Interventions:
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Decrease environmental
stimuli
Provide gavage feedings
if neonate has
uncoordinated sucking
and swallowing
Long Term Implications of FAS
 Mental retardation
 Poor coordination
 Facial abnormalities
 Behavioral deviations (irritability)
 Cardiac and joint abnormalities
Routine Prenatal Care
Prenatal Visits
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Blood pressure
CBC
Weight
Abdominal exam
Assess fetal heart rate (FHR)
Assess fetal position
Prenatal Testing
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Non-stress test (NST)
Contraction stress test (CST)
Ultrasound (US)
Biophysical profile (BPP)
Alpha-fetoprotein (AFP)
Amniocentesis
Amniotic fluid index (AFI)
Chorionic villi sampling (CVS)
Measuring Fundal Height
Measuring Fundal Height to Determine Gestational Age
Non-Stress Test (NST)
 NST used to evaluated fetal status without uterine contractions
 Monitors FHR with fetal movement, which should accelerate 15
beats per minute for 15 seconds. Then would be considered
“reassuring”
Contraction Stress Test (CST)
 With CST, the uterus is made to contract artificially with the use
of pitocin or nipple stimulation
 Fetal heart monitoring evaluates the respiratory function
(oxygen/ carbon dioxide exchange) of the placenta
 Determines if fetus could withstand labor
 This test is no longer commonly used
Amniocentesis:
Amniotic Fluid Removed From Amniotic Sac
Genetic information
Sex of fetus
Chromosomal abnormalities
Determine health or maturity
of fetus
Lecithin/sphingomyelin ratio
(L/S ratio) to determine lung
maturity. Ratio of 2:1 confirms
fetal lung maturity
*Ultrasound used with this
procedure to help prevent injury to
the fetus
*Bladder should be full when done at
<20 weeks gestation; bladder should
be empty when done at >20 weeks
gestation
Chorionic Villi Sampling
 Sample of tissue (chorionic villi) from the
edge of the placenta
 Detects genetic disorders; done at 8-12 wks
 Aspiration catheter or biopsy forcep is
introduced through cervix
 Guided/monitored by
ultrasound
Biophysical Profile (BPP)
(Confirms Fetal Well-Being and Placental Functioning)
Variable
Normal
(Score=2)
Abnormal
(Score=0)
Fetal
Breathing
Movements
Gross Body
Movements
Fetal Tone
Reactive FHR
Qualitative
Amniotic Fluid
Volume (AFV)
Score of 8-10
is optimal
Score of 0-6 is
ominous
Physiological Changes of Pregnancy
Pregnancy affects all the major systems:
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Reproductive
Musculoskeletal
Cardiovascular
Respiratory
Gastrointestinal
Urinary
Endocrine
Metabolic
Reproductive System
Uterus: enlarges (X 20); irregular, painless contractions occur
Ovaries: ovulation stops due to high levels of placental
estrogen and progesterone
Vagina: becomes softer, mucosa thickens, vascularity
increases, vaginal discharge increases and becomes
more acidic
Breasts: increases in size and become full and tender, areola
darken; colostrum is excreted
Cervix: softens (Goodell’s Sign), becomes congested with
blood (Chadwick’s Sign), mucus plug forms
Uterine Enlargement During Pregnancy
Musculoskeletal System
 Relaxation of joints due to relaxin hormone
 Widening of symphysis pubis
 Waddling gait
 Lordosis
 Increased back strain
Cardiovascular System
 Blood volume increases by 30-50%
 Pulse rate increases by 10-15 beats/minute
 Clotting factors increase which helps prevent
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hemorrhage however increases risk of DVT
RBC mass increases (plasma portion
faster…therefore causing physiological anemia)
BP basically remains essentially unchanged due to
peripheral vasodilation related to progesterone
500-1,000 mLs of blood to the uterus per minute!
Supine hypotension a major problem
Hgb < 11g/dL Hct < 33% indicates anemia
Normal Hematologic Values
NORMAL HEMATOLOGIC VALUES
Nonpregnant
Pregnant
Hemoglobin
(HGB)
12–16 g/dL
11.5–15 g/dL
Hematocrit
(HCT)
36–48%
33–36.5%
White blood
cells (WBC)
4-10.6
6-20
Cardiovascular
The pregnant uterus
compressing the aorta and
the inferior vena cava
(aortocaval compression).
Patient in supine position.
Uterine displacement with
wedge under hip to relieve
aortocaval compression.
Aortocaval Compression
Respiratory System
 Oxygen consumption increases by about 20%
 Dyspnea is common
 Nosebleeds and nasal stuffiness are common and
related to estrogen
 Rib cage widens
 Respiratory depth increases
Gastrointestinal System
 Gums appear red and swollen and bleed easier,
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caused by elevated levels of estrogen
Nausea and vomiting occurs in 50% of women and
common in the first trimester
Delayed gastric emptying and reduced tone of
esophageal sphincter allows reflux, producing
heartburn. Caused by progesterone
Decreased motility in large intestine causes
constipation and hemorrhoids
Gallbladder emptying time prolonged—may lead to
gall stone formation
Increased thirst and appetite
Urinary System
 Frequent urination is common, particularly in
the first and third trimesters
 Urinary stasis predisposition to urinary tract
infection (UTI)
 Increased renal plasma flow
 Glucosuria may occur; normal finding
Bladder Changes
Neurological System
 Loss of consciousness
 Headaches
 Reflexes (DTRs)
 Light-headedness/fainting
may be due to:
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Hormones
B/P
Blood sugar
Cardiac problems
Anemia
Endocrine System
 Placenta becomes an endocrine organ and
produces large amounts of hormones
 Heat intolerance due to vasodilatation, fetal
and maternal heat production
 Thyroid gland 25% larger during pregnancy;
basic metabolic rate increase 25%
 Oxytocin and prolactin are secreted by the
pituitary gland
Endocrine System: Placental Hormones
 1) Estrogen: increases vascularity. Level remains
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high during pregnancy
2) Progesterone: Relaxes all smooth muscle.
Maintains the endometrium and prevents abortion by
relaxing uterine muscles
3) Human Chorionic Gonadotropin (hCG): Hormone
measured in pregnancy tests. Stimulates the corpus
luteum to produce estrogen and progesterone until
the placenta can assume that function
4) Human Placental Lactogen: Acts as a insulin
antagonist; increases availability of glucose for fetal
growth and development
5) Relaxin: Softens connective tissue and relaxes
pelvic joints
Metabolic Changes
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Protein demands increase
Carbohydrate demands increase
Glycosuria may be present
Iron needs increase
Water requirements increase
Metabolic Changes and Weight Gain
 Fluid retention common
 Dependent edema
 Lower extremities
 Weight gain should be
approximately 25-35 pounds
 Clients should gain 1 pound per
week in the 2nd and 3rd trimesters
Nutritional Needs of Pregnancy
 Must eat nutritious, well-balanced meals
 Prenatal vitamins usually prescribed. Megadoses of
Vitamin A and D found to be teratogenic to fetus
 Pica: Unexplained urge to eat non-nutritive
substances such as dirt, starch, ice, clay, freezer
frost. Thought to be related to an iron deficiency
 Nausea and vomiting are also common. Related to
hCG and estrogen. Ginger has been found to be a
safe anti-emetic for pregnant women
Nutritional Concerns
 Should not consume soft cheeses as they
harbor listeria monocytogenes, the organism
that causes listeriosis
 Maternal effects of listeriosis includes
meningitis, pneumonia and sepsis
 Increased risk of delivering stillborn babies
 Another concern? Fish…mercury poisoning
Specific Nutritional Needs
 Protein 60-65 grams/day
 Calcium 1,200 mg/day
 Average of 2,500 calories/day; only 300
additional daily calories required during
pregnancy. (A breastfeeding mother requires
500 extra calories daily)
 Before conception: Folic acid 400 mcg/day
which helps prevent neural tube defects such
as spina bifida. During pregnancy 600 mcg
per day is recommended
Dietary Sources of Folic Acid
 Liver (chicken, turkey, goose, lamb, beef)
 Fortified cereals and breads
 Spinach
 Broccoli
 Peas
 Beans
Danger Signs in Pregnancy
Danger Sign
Possible Cause
Gush of fluid from vagina
Rupture of membranes
Vaginal bleeding
Placenta abruption, previa, bloody
show
Abdominal pain
Premature labor, placenta abruption
Temperature > 101.0 F
Infection
Persistent vomiting
Hyperemesis gravidarum
Visual disturbances
Hypertension, preeclampsia
Generalized edema
Hypertension, preeclampsia
Severe headache
Hypertension, preeclampsia
Epigastric pain
Preeclampsia, HELLP
Dysuria
Urinary tract infection
Decreased fetal movement
Compromised fetal well-being
Mother’s Psychological Response
to Pregnancy
 Ambivalence
 Acceptance
 Introversion
 Mood swings
 Changes in body image
Rubin’s (1984)
Developmental Tasks of Pregnancy
 Ensuring safe passage through pregnancy,
labor and birth
 Seeking acceptance of this child by others
 Seeking commitment and acceptance of self
as mother to the infant (binding in)
 Learning to give of oneself on behalf of one’s
child