NURS 2700 MAT week 1-3 - Lecture notes 1-3 PDF

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NURS 2700: MIDTERM EXAM NOTESCHAPTER 10: ANATOMY AND PHYSIOLOGY OF PREGNANCYOBSTETRICAL TERMINOLOGYGravida: a woman who is pregnantGravidity: pregnancyMultigravida: a woman who has had two or more pregnanciesMultipara: a woman who has completed two or more pregnancies to 20 weeks of gestation or...

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NURS 2700: MIDTERM EXAM NOTES CHAPTER 10: ANATOMY AND PHYSIOLOGY OF PREGNANCY OBSTETRICAL TERMINOLOGY  Gravida: a woman who is pregnant  Gravidity: pregnancy  Multigravida: a woman who has had two or more pregnancies  Multipara: a woman who has completed two or more pregnancies to 20 weeks of gestation or more  Nulligravida: a woman who has never been pregnant and is not currently pregnant  Nullipara: a woman who has not completed a pregnancy with a fetus or fetuses beyond 20 weeks of gestation  Parity: number of pregnancies in which the fetus or fetuses have reached 20 weeks of gestation, not the number of fetuses (e.g., twins) born o Parity is not affected by whether the fetus is born alive or is stillborn (i.e., showing no signs of life at birth)  Primigravida: a woman who is pregnant for the first time  Primipara: a woman who has completed one pregnancy with a fetus or fetuses who have reached 20 weeks of gestation  Viability: Capacity to live outside the uterus, occurring about 22 to 25 weeks of gestation  Term: a pregnancy from the beginning of week 37 of gestation to the end of week 40 plus 6 days of gestation  Preterm: a pregnancy that has reached 20 weeks of gestation but prior to completion of 36 weeks of gestation  Early Term: a pregnancy between 37 weeks and 38 weeks 6 days  208  Full Term: a pregnancy between 39 weeks and 40 weeks 6 days  Late Term: a pregnancy in the 41st week  Post Term: a pregnancy after 42 weeks The five-digit system, separated by hyphens, provides information about the woman's obstetrical history  First digit represents gravidity (number of all pregnancies)  Second digit represents the total number of term births (at 37 or more weeks' gestation)  Third indicates the number of preterm births (after 20 weeks to 37 weeks' gestation)  Fourth identifies the number of abortions (miscarriage or elective termination of pregnancy)  Fifth is the number of children currently living o Actual number of children born during each pregnancy The acronym GTPAL (gravidity, term, preterm, abortions, living children) may be helpful in remembering this system of notation PREGNANCY TESTS  Human chorionic gonadotropin (hCG) is the earliest biological marker for pregnancy  Pregnancy tests are based on the recognition of hCG or a beta (β) subunit of hCG  Production of β-hCG begins as early as the day of implantation and can be detected as early as 7 to 10 days after conception  The level of hCG rises until it peaks at about 60 to 70 days of gestation and then declines until about 80 days of gestation  It remains stable until about 30 weeks and then gradually increases until term  Higher than normal levels of hCG may indicate: o ectopic pregnancy o abnormal gestation (e.g., fetus with Down syndrome) o multiple gestation o an abnormally slow increase or a decrease in hCG levels may indicate impending miscarriage  Both serum and urine tests can provide accurate results  A 7- to 10-mL sample of venous blood is collected for serum testing  Most urine tests require a first-voided morning urine specimen because it contains levels of hCG approximately the same as those in serum  A positive test result is indicated by a simple colour change reaction or a digital reading  Most common error in performing home pregnancy tests is doing the test too early in pregnancy before a significant rise in hCG level; this can cause a false-negative result

CHAPTER 21: MATERNAL PHYSIOLOGICAL CHANGES Postpartum period is the interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state  Referred to as puerperium or fourth trimester  Lasts approximately 6 weeks REPRODUCTIVE SYSTEM AND ASSOCIATED STRUCTURES Uterus Involution Process  Return of uterus to nonpregnant state  Begins immediately after expulsion of the placenta  Contraction of the uterine smooth muscle  End of third stage - uterus midline (approx. 2cm below the umbilicus) and fundus resting on sacral promontory  Within 12 hours - fundus may rise to approx. 1cm above the umbilicus  After 24 Hours - uterus is about the same size as it was at 20 weeks of gestation  Fundus descends 1-2cm every 24 hours  Uterus should not be palpable abdominally after 2 weeks  Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus  Prenatal uterine growth results from both hyperplasia and hypertrophy o Hyperplasia: increased number of muscle cells

o Hypertrophy: enlargement of the existing cells After birth, decrease in hormone causes autolysis o Autolysis: self-destruction of excess hypertrophied tissue  Subinvolution: failure of the uterus to return to a nonpregnant state o Common causes are retained placenta fragments and infection Contractions  Oxytocin, released from the pituitary gland, strengthens and coordinates these uterine contractions o Compress intramyometrial blood vessels and promote homeostasis  1 to 2 postpartum hours, uterine contractions may decrease intensely and become uncoordinated o Exogenous oxytocin is administers intravenously or intramuscularly immediately after expulsion of placenta  Breastfeeding immediately after birth increases release of oxytocin o Decreases blood loss o Reduces risk for postpartum hemorrhage  First-time mothers uterine tone is good o Fundus remains generally firm o Perceives only mild uterine cramping  Subsequent pregnancies o Periodic relaxation o Vigorous contractions o May cause uncomfortable cramping; afterpains (afterbirth pains) o Persists throughout the early puerperium  Afterpains more noticeable after births in which the uterus was overdistended o Large baby, multifetal gestation, polyhydramnios o Breastfeeding and exogenous oxytocin medications intensify these afterpains because both stimulate uterine contractions Placental Site  Immediately after the placenta and membranes are expelled, vascular constriction and thromboses reduce the placental site to an irregular nodular and elevated area  Upward growth of endometrium caused sloughing of necrotic tissue and prevents the scar formation characteristic of normal wound healing  Enables to resume its usual cycle of changes and permit implantation and placentation in future pregnancies  Endometrial regeneration is completed by day 16, except at the placental site  Regeneration at the placental site usually is not complete until 6 weeks after birth Lochia  Postbirth uterine discharge  Initially bright red (lochia rubra) and may contain small clots  First two hours after birth, discharge should be similar to a heavy menstrual period o Lochia should steadily decrease after  Lochia Rubra: mainly blood and decidual and trophoblastic debris o Flow pales, becoming pink or brown (serosa) after 3-4 days  Lochia Serosa: old blood and serum, leukocytes and tissue debris o Duration is 22-27 days  Lochia Alba: leukocytes decidua, epithelial cells, mucus, serum and bacteria o Can persist for approx. 4-8 weeks after birth o Commonly after 10 days, drainage becomes yellow to white  Oxytocin medication => flow of lochia is scant until medication wears off  Caesarean birth => Amount of lochia is usually less o Blood and fluids suctioned out or uterine lining is wiped before closing incision  Ambulation => flow of lochia increases o Lochia tends to pool in the vagina when woman is lying in bed o Gush of blood when she stands o Gush should not be confused with hemorrhage  Continued flow of lochia serosa or alba by 3-4 weeks can indicate endometritis o Fever, pain, or abdominal tenderness associated with discharge  Lochia should smell like normal menstrual flow  Offensive odour usually indicates infection  Not all postpartal vaginal bleeding is lochia o Unrepaired vaginal or cervical lacerations Cervix  Soft immediately after birth  Ectocervix (portions of the cervix that protrudes into the vagina) appears bruised and has some small lacerations  Cervical os closes gradually  Cervix up to the lower uterine segment remains edematous, thin and fragile for several days after birth  By 2nd or 3rd day, the cervix is dilated 2-3cm  By 1 week, approx. 1cm dilated  External cervical os appears jagged slit that is often described as a fish mouth o Never regains prepregnancy appearance  Lactation delays the productions of cervical and other estrogen-influenced mucus and mucosal characteristics 

Vagina and Perineum  Estrogen deprivation is responsible for the thinness of the vaginal mucosa and the absence of rugae  Greatly distended, smooth-walled vagina => decrease in size, regains tone  Rugae reappear within 3 weeks  Hymen remains as small tags of tissue that scar and form the myrtiform caruncles  Mucosa remains atrophic in lactating woman, at least until menstruation resumes  Thickening of vaginal mucosa => return of ovarian function  Estrogen deficiency => decrease vaginal lubrication  Localized dryness and coital discomfort (dyspareunia) until ovarian function returns or menstruation resumes  Introitus is erythematous and edematous  Most episiotomy or laceration repairs are visible if the woman is lying on her side with her upper buttock raised or in a lithotomy position  Signs of infection: pain, redness, warmth, swelling or discharge  Loss of approximation: separation of edges of the incision  Initial healing occurs within 2-3 weeks, 4-6 months to completely heal  Hemorrhoids (anal varicosities) are commonly seen o May evert while the woman is pushing during birth o Experience associated symptoms such as itching, discomfort, and bright red bleeding upon defecation o Decrease in size within 6 weeks  Pelvic Muscle Support o Supportive tissues of pelvic floor may require 6 months to regain tone o Kegel exercises strengthen perineal muscles and encourage healing Abdomen      

Abdomen protrudes during first days after birth During first 2 weeks, abdominal wall is relaxed Takes about 6 weeks for abdominal wall to return almost to its prepregnancy state Skin regains most of its previous elasticity, some striae may persist Return of muscle tone depends on previous tone, proper exercise and the amount of adipose tissue With or without overdistention because of a large fetus or multiple fetuses, abdominal wall muscles separate; diastasis recti abdominis o Persistence of separation may be disturbing but becomes less apparent with time

ENDOCRINE SYSTEM Placental Hormones  Dramatic decrease of hormones produced  Decrease in human chorionic somatomammotropin, estrogens, cortisols, and placental enzymes insulinase reverse the diabetogenic effects of pregnancy o Lower blood sugar levels o Type 1 diabetic mothers will require much less insulin for several days  Estrogen and progesterone levels drop after expulsion of placental o Lowest levels 1 week after birth o Decreased estrogen associated with diuresis of excess extracellular fluid accumulated during pregnancy o Estrogen start to increase 2 weeks after  Human chronic gonadotropin (hCG) disappears quickly from maternal circulation Pituitary Hormones and Ovarian Function  Prolactin levels in blood rise progressively throughout pregnancy  Prolactin level increase even more after birth  In mothers who breastfeed, prolactin levels are at the highest during the first month  Influenced by frequency and duration of breastfeeding  In nonlactating women, prolactin levels decline after birth o Reach prepregnant range by third postpartum week  Lactating and nonlactating women differ considerably in the timing of their first ovulation and when menstruation resumes  Nonlactating women o Ovulation occurs as early as 27 days after birth o Resume menstruating by 12 weeks after birth  Lactating women o Ovulation occurs in about 6 months o Prolactin levels affect resumption of ovulation and return of menses o Due to uncertainty, needs to consider contraceptive options early in postpartum period  First menstrual flow is usually heavier than normal URINARY SYSTEM Diminishing steroid levels after childbirth may partly explain the reduced renal function. Kidney function returns to normal within 1 month after birth Urine Components  Renal glycosuria disappears by 1 week  Lactosuria may occur in lactating women  Blood urea nitrogen increases during puerperium as autolysis of the involuting uterus occurs  Proteinuria resolves by 6th week

 Ketonuria may occur in women with an uncomplicated birth or after prolonged labour with dehydration Postpartal Fluid Loss  Profuse diaphoresis often occurs, especially at night (first 2-3 days)  Caused by: o Decreased estrogen levels o Removal of increased venous pressure in lower extremities o Loss of remaining pregnancy-induced increase blood volume Urethra and Bladder  Increase bladder capacity  Effects of conduction anaesthesia (epidural or spinal) combine to cause a decrease urge to void  Pelvic soreness caused by the forces of labour, vaginal lacerations, or the episiotomy reduces or alters voiding reflex  Decreased voiding and postpartal diuresis ay result in bladder distension  Excessive bleeding can occur if bladder is distended GASTROINTESTINAL SYSTEM Appetite  Often hungry  Usually can tolerate regular diet Bowel Evacuation  May not occur for 2-3 days  Decreased muscle tone in the intestines  Often anticipates discomfort during bowel movement due to perineal tenderness; episiotomy, lacerations, or hemorrhoids  May resist to defecate  Need to be encourages to increase fluid and fibre intake to prevent constipation and discomfort  Stool softeners may be required  Operative vaginal birth and anal sphincter lacerations are associated with an increased risk of postpartum anal incontinence o Often incontinent of flatus than of stool  Caesarean birth => build-up of flatus => abdominal pain  Movement => enhance movement of intestinal system BREASTS Breastfeeding Mothers  Colostrum: early milk, a clear, yellow fluid, may be expressed from the breasts  Initially feel soft and gradually become fuller and heavier as the colostrum transitions to milk o 72-96 hours after birth o Often referred to as "milk coming in"  May feel warm, firm and somewhat tender  Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples  As milk glands and ducts fill, may feel nodular or lumpy  Some experience engorgement, but with frequent breastfeeding and proper care this is a temporary condition that typically lasts only 24-48 hours Nonbreastfeeding Mothers  Generally feel nodular in contrast to the granular feel of the breast in nonpregnant women  Nodularity is bilateral and diffuse  Prolactin levels drop rapidly  Colostrum is present for first few days after birth  Second or third day; milk production begins => tissue tenderness  Third or fourth day: engorgement may occur o Resolves spontaneously an discomfort decreases within 24-36 hours  Distended (swollen), firm, tender, and warm to the touch o Temporary congestion of veins and lymphatics rather than by an accumulation of milk => distention  Breast binder or well-fitted supportive bra, ice packs, fresh cabbage leaves or mild analgesics may be used to relieve discomfort  Nipple stimulation should be avoided CARDIOVASCULAR SYSTEM Blood Volume  Several factors: blood loss, amount of extravascular water mobilized and excreted  Hypervolemia: increase in blood volume over prepregnancy values near term  Average blood loss or a vaginal birth of a single fetus ranges from 300ml to 500ml (10% of blood volume)  Caesarean is about 500ml to 1000ml  Plasma volume decreases further as a result of diuresis  Three postpartum physiological changes protect the woman by increasing the circulating blood volume: o Elimination of uteroplacental circulation reduces the size of the maternal vascular bed by 10-15% o Loss of placental endocrine function removes the stimulus for vasodilation o Mobilization of extravascular water stored during pregnancy occurs Cardiac Output  Pulse rate, stroke volume, and cardiac output increases throughout pregnancy  Cardiac output remains increased for at least 48 hours after birth due to increased stroke volume o Caused by return of blood to the maternal systemic venous circulation

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o Rapid decrease in uterine blood flow o Mobilization of extravascular fluid Stroke volume, cardiac output, end-diastolic volume and systemic vascular resistance remain elevated for 12 weeks until the 24th week after birth

VITAL SIGNS AFTER CHILDBIRTH NORMAL FINDINGS

DEVIATIONS FROM NORMAL FINDINGS AND PROBABLE CAUSES

During the first 24 hours temperature may increase to 38°C as a result of dehydrating effects of labour. After 24 hours the woman should be afebrile.

A diagnosis of puerperal sepsis is suggested if an increase in maternal temperature to 38°C is noted after the first 24 hours after childbirth and recurs or persists for 2 days. Other possibilities are mastitis, endometritis, urinary tract infections, and other systemic infections.

Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. It then begins to decrease at an unknown rate to a nonpregnant rate.

A rapid pulse rate or one that is increasing may indicate hypovolemia as a result of hemorrhage or an increased temperature.

The respiratory rate should rapidly decrease to within the woman's normal prebirth range.

Hypoventilation (respiratory depression) may occur after an unusually high subarachnoid (spinal) block or epidural narcotic after a Caesarean birth.

Blood pressure is altered slightly, if at all. Orthostatic hypotension, as indicated by feelings of faintness or dizziness immediately after standing up, can develop in the first 48 hours as a result of the splanchnic engorgement that may occur after birth.

A low or decreasing blood pressure may indicate the existence of hypovolemia secondary to hemorrhage; however, it is a late sign, and other symptoms of hemorrhage are usually seen first. An increased reading may result from excessive use of vasopressor or oxytocic medications. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is needed. If a woman states she has a headache, hypertension must be ruled out as a cause before analgesics are administered.

Temperature

Pulse

Respirations

Blood Pressure

Blood Components  Hematocrit and Hemoglobin: moderately drops for 3-4 days, then begins to increase, and reaches nonpregnant levels by 8 weeks o Can be lower than normal; blood loss increases or hypervolemia of pregnancy was less than normal  White Blood Cell count: leukocytosis averages approx. 12 x 10^9/L o First 10-12 days: 20 and 25 x 10^9/L are common o Neutrophils most numerous o Leukocytosis may obscure the diagnosis of acute infections at this time  Coagulation Factors: clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium o When combined with vessel damage and immobility, the hypercoagulable state causes increased risk of thromboembolism o Encouraged to move around asap o Some may require anticoagulants o Fibrinolytic activity increases o Factors I, II, VIII, IX, and X decrease o Fibrin split products, probably released from the placental site, can also be found in maternal blood Varicosities  Varicosities of the legs (varices) and around the anus (hemorrhoids) are common  Even the less common vulvar varices, regress (empty) rapidly immediately after birth RESPIRATORY SYSTEM  Immediate decrease in intra-abdominal pressure => allows for greater excursion of the diaphragm  Decreased pressure on diaphragm + reduced pulmonary blood flow => chest wall compliance increases  Rib cage elasticity takes months to recover  Costal angle may not completely return back

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Loss of placenta => Decline in progesterone => PaCO2 levels rise Basal metabolic rate returns within 1-2 weeks

NEUROLOGICAL SYSTEM  Result from a reversal of maternal adaptations to pregnancy  Result from trauma during labour and childbirth  Eliminati...