3 Physical Changes Antepartum Assessment PDF

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Chapter 12 – Physical and Psychologic Changes of Pregnancy  Student Learning Outcomes ◦ Identify the anatomic and physiologic changes that occur during pregnancy. ◦ Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. ◦ Compare presumptive (subjective), probable (objective), and positive changes of pregnancy. ◦ Discuss the emotional and psychologic changes that commonly occur in a woman and her partner. Chapter 13 – Antenatal Nursing Assessment  Student Learning Outcomes ◦ Summarize the essential components of a prenatal history. ◦ Identify factors related to the father’s health that should be recorded on the prenatal record. ◦ Describe the normal physiologic changes one would expect to find when performing a physical assessment of a pregnant woman. ◦ Explain the ways used to determine estimated due date, including Nägele’s rule, LMP, fundal height, quickening, FHTs. ◦ Relate danger signs of pregnancy to their possible causes. ◦ Describe expected subsequent prenatal visit assessments; including lab findings and screening tests  Preconceptual Counseling ◦ Up to half of all pregnancies unplanned ◦ By time most women know they are pregnant (2 weeks after missed period)  Fetal spinal cord formed  Neural tube is closed  Fetal heart is beating  All systems present ◦ Chronic disorders may impact fetus  DM, HTN, Epilepsy  Medications teratogenic ◦ Coumadin (crosses placental border) can change to heparin ◦ antibiotics (permanent hearing loss) ◦ tetracycline (permanent teeth staining) ◦ antipsychotics/sz (teratogenic) ◦ Genetic disorders  NTDs – neural tube defects  PKU – diet may be harmful in pregnancy ◦ Visit  Age (geriatric >35yo)  Personal/Reproductive history ◦ Problems w/ previous pg  FH – both mother and FOB  Lifestyle habits ◦ Weight/diet/exercise  Any pg woman can walk/swim  Better to begin exercise regimen pre-pregnancy ◦ Immunizations – screen for Hep B and HIV; MMR (can’t get during pg)  Rubella can be catastrophic during pg ◦ Smoking/Recreational drugs ◦ Domestic abuse ◦ Environmental exposure  Initial Prenatal Visit ~ week 8 ID risks to mom or baby – what can we do? ◦ Purpose of Prenatal Care ◦ Health History (complete) ◦ Physical exam ◦ Psychosocial exam ◦ Lab/Diagnostic tests – prenatal panel  May schedule ultrasound/other tests

Determination if low or high-risk pregnancy Teaching  1st step is to determine level of knowledge  Diet/exercise/health during pregnancy  Smoking cessation, etc.  Assess level of knowledge ***Determination of Due Date pg 256*** test question ◦ EDD, EDB, EDC (estimated due date/date of birth/date of confinement) ◦ Nägele’s Rule  LMP – 3 months + 7 days ◦ ◦

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Ex: LMP:  May 7, 2018 = Feb 14, 2019  July 21, 2018 = April 28, 2019  October 31, 2018 = August 7, 2019 Confirmation of Due Date ◦ Fundal Height   Pubic symphysis to fundus  # wks = # cms  24-36 weeks pg  Smaller = abnormality  Larger = multiples? ◦ Too much fluid? ◦ Big baby? DM? ◦ Would then get an ultrasound ◦ Quickening – helps to confirm the due date  Primip ~20th week  Multip ~16th week ◦ FHTs – fetal heart tones/heart rate  ~10-12 weeks by doppler down near symphysis pubis  Fundus is around symphysis pubis ~10-12 weeks Pregnant Client History ◦ Current Pregnancy  LMP (LNMP) ◦ Last (normal) menstrual period ◦ Could have thought implantation bleeding was period…  Pregnancy test @ home?  Pregnancy planned?  Discomforts ◦ Help those if possible ◦ N/V  Cramping/Bleeding ◦ Initial s/sx miscarriage ◦ Obstetrical History  G/P TPAL (next slide)  Year of pregnancies ◦ Ages of babies (names)  Loss of a child  Length of labor ◦

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◦ Each typically shorter than last Type of delivery ◦ Vaginal, c/s, VBAC (why c/s?)  Anesthesia ◦ What did she have? How did she tolerate it? ◦ Epidural?  Complications ◦ L&D, pregnancy, PP ◦ Risk factors Obstetrical History ◦ Gravida - # pregnancies  Number of times a woman has been pregnant, regardless of duration, including present pregnancy ◦ Para (parity) – # pregnancies @ age of viability  Birth after 20 weeks’ gestation or infant weigh > 500 gm; regardless infant born dead or alive  NOT including current pregnancy ◦ TPAL:  T = Number of term births: 37-42 weeks  P = Number of preterm births: 20-completion of 36 weeks  A = number of pregnancies ending before 20 weeks (Spontaneous or Elective) ◦ Spontaneous = miscarriage ◦ Elective = abortion  L = number of currently living children ◦ ***Examples of G/P TPAL – short answer test question***  A woman had her pregnancy confirmed today. Obstetrical history includes babies delivered at 41, 35, 39 weeks. All are living. She miscarried at 10 weeks’ gestation 3 years ago. G/P TPAL status? ◦ 5/3 2113  Ultrasound confirms a viable pregnancy at 12 weeks’ gestation. First pregnancy terminated in VIP (voluntary interruption of pregnancy) at 14 weeks gestation. Next pregnancies ended at 36 and 43 weeks’ gestation, all children are living. G/P TPAL status? ◦ 4/2 1112  A woman is in the office today for her initial prenatal visit. Her obstetrical history includes healthy triplets (2 boys and 1 girl) delivered at 36 weeks, a boy at 40 weeks’ gestation and spontaneous abortion at 8 and 15 weeks. G/P TPAL status? ◦ 5/2 1124 ◦ Adopted children/foster children are NOT included in G/P TPAL Client History ◦ GYN History  Age of menarche  Method of birth control  Last pap smear/results  Previous gyn surgery (FT, uterus, Cx) ◦ Fallopian tube increases risk of ectopic pregnancy ◦ Uterus increases risk of uterine rupture @ incision point ◦ Cervical surgery can interfere with dilation and effacement of cervix  Scar tissue won’t allow to dilate/efface well/easily  STIs ◦ When, what type, was she treated? ◦ Current Medical History  Weight – see what she’s starting at  Blood type – Rh pos or neg  Medications  SADs – smoking, alcohol, illegal drug use  Teratogenic exposure – where she lives/works ◦ Exposure to pollution/radiation?  Immunizations UTD (up to date)? 

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Past Medical History  Chronic illnesses  Surgeries/hospitalizations  Blood transfusions ◦ Why? What happened?  Childhood diseases ◦ Family History  Chronic illnesses  Mental illness  Genetic disorders  Multiple births  Parents and siblings A&W (alive and well) ◦ Religious beliefs  Not allowing blood transfusions? ◦ Cultural beliefs  Foods they will/won’t eat  Won’t allow male HCP in the room…  Some dispose of colostrum… ◦ Occupation – exposures, ability to lift certain weights… ◦ Father of Baby’s (FOB) History  Age – increased risk of chromosomal issues w/ increased age  General health  SADs  Blood type (Rh factor)  Genetic disorders  Occupation  Involved? Prenatal High-Risk Screening (Table 13-1; Page 247-248) ◦ Age 35 ◦ Weight 200 ◦ Low income ◦ Nutrition ◦ SADs – smoking, alcohol, drugs ◦ Work exposure to toxins ◦ Chronic illnesses ◦ STI’s ◦ Previous pg. complications ◦ Previous stillbirth ◦ Multiple pg ◦ Rh sensitization (next slide) ◦ Infection exposure during pregnancy ◦ Bleeding problems – can indicate placental problems ◦ Previous c/s (cesarean sections) Rh Sensitization ◦ Does not impact 1st pregnancy ◦ All pg women tested for blood type, RhD antigen, antibody screen at 1 st prenatal visit ◦ Rh- mom and Rh+ dad probably will have Rh+ baby  Rh antigen may cross placenta site at delivery and invade maternal bloodstream  If mixing of mother and fetal blood  Mom forms antibodies to Rh+ blood; may affect next pregnancy ◦ When this happens: Rh isoimmunization/sensitization ◦ RhoGAM® given as prophylaxis for Rh- mom to prevent formation of antibodies  During pregnancy (28 to 30 weeks)  After birth of each Rh+ newborn ◦ Will give RhoGAM w/in 72 hours of delivery of 1st baby ◦ May have Coombs’ test to detect antibodies Initial Prenatal Assessment pg 250 ◦ Physical Exam  VS ◦

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Initial visit – prenatal labs  CBC, blood type, Rh factor  Antibody screen (Indirect Coombs) ◦ Name during pg (after pg)  Rubella titer ◦ 10 cm Physical Changes/Initial Exam – Cervix, Vagina, Ovaries ◦ Cervix:  r/t  vascularity Chadwick’s sign ◦  Purple/blue ◦ Goodell’s sign  Softening of cervix  Mucous plug ◦ Thick mucus produced by endocervical glands ◦ Acts as a barrier/protective ◦ Vagina:  Hypertrophy and hyperplasia of epithelium ◦ Chadwick sign  Bluish color  Leukorrhea increases  Acidic (3.5-6 pH) – controls growth of pathogens ◦ Ovaries:  Anovulation  Suppression of FSH and LH r/t  estrogen and progesterone  Corpus luteum active until 10-12 weeks ◦ hCG maintains the CL CL produces? ◦  progesterone Physical Changes/Initial Exam – Breast ◦ Anatomy – 3 types of tissue ◦  in size (hypertrophy and hyperplasia) ◦ Symmetric enlargement  If one getting much larger than other, could point to CA ◦ Nipple and areola larger and darker ( pigmentation)  Montgomery follicles – antiseptic/moisturizer ◦ Superficial veins dilate ◦ Colostrum – developed after 12th week 

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 May leak during last trimester  Thick/yellow Contains much of IgA antibodies  ◦ Striae gravidarum ◦ CBE – clinical breast exam Physical Changes/Initial Exam – Cardiovascular System ◦ Blood volume 45% (about 1600 mL)  Begins at 6 wks, peaks at 28 to 34 wks   perfusion to placenta, uterus, kidneys, etc.  All maternal/doesn’t go to baby Increased blood volume is protective ◦  Increase uterine vascularity of enlarging uterus  Adequately hydrating maternal and fetal tissues Fluid reserve for intrapartum blood loss  ◦ Up to 500 mL blood loss normal (200-300 mL normal) vaginal birth ◦ Up to 1000 mL c/s ◦ Progesterone produces vasodilation   systemic and pulmonary vascular pressure/resistance ◦ Vasodilation to accommodate extra blood volume  B/P  slightly, returns to normal 3rd trimester Hypertension never normal during pregnancy ◦  Orthostatic hypotension common in pg Physical Changes/Initial Exam – Cardiovascular System ◦ Due to increase blood volume:   heart rate (10-15 bpm); RRR (regular rate and rhythm)  Palpitations   cardiac output 30-50%  BP – initially decreases; gradually increases by 28 weeks; at prepregnant level at term  Heart slightly enlarges ◦ Also may move/shift ◦ Diaphragm pushing heart up  Grade II systolic murmur (90% of pregnant women) – heard best at LSB ◦ Normal during pregnancy  S1 and S2 splitting, S3 louder ◦ Valves closing far enough apart, hear two sounds ◦ All benign  As fetus grows: diaphragm pushes heart up and to left ◦ PMI may move  Increase development of varicose veins ◦ Pressure on femoral veins ◦ More venous stasis ◦ Physiologic anemia of pregnancy  Major part of increase in blood volumes is in plasma  RBC increase, but not at same rate ◦ Why does this occur if blood volume   Plasma volume  45%, RBCs  20-30%  Hct 37-47% (...