OB E1 - Normal Pregnancy PDF

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Summary

OB E1 – Antepartum Ch 10Time Span Ovum released from ovary  Passes into open fallopian tube  Starts journey downward toward the sperm for fertilization  Fertilization takes place in the ampulla of the fallopian tube (For conception to occur, a healthy ovum from the woman is released from the ova...

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OB E1 – Antepartum Ch 10

Time Span  Ovum released from ovary  Passes into open fallopian tube  Starts journey downward toward the sperm for fertilization  Fertilization takes place in the ampulla of the fallopian tube (For conception to occur, a healthy ovum from the woman is released from the ovary, passes into an open fallopian tube, and starts its journey downward. Sperm from the male is deposited into the vagina and swims approximately 7 in to meet the ovum at the outermost portion of the fallopian tube, the area where fertilization takes place.)

Stages of Fetal Development  Pre-embryonic stage: fertilization through second week o Fertilization; cleavage; morula o Blastocyst and trophoblast o Implantation (the trophoblast will implant in the endometrium of the uterus; implantation bleed could occur, and some women would mistake it as period) *See picture * (corpus luteum - is responsible for the production of the hormone progesterone during early pregnancy) o After all these things happen, there will be excessive mucus formed in the cervical canal with white discharge  kills any sperm that comes in and prevents bacteria from entering  Embryonic stage: end of second week through eighth week o Basic structures of major body organs and main external features  Fetal stage: end of the eighth week until birth

Embryonic Layers Once it embeds in the endometrium, the embryonic layers start forming  Endoderm: forms respiratory system, liver, pancreas, and digestive system  Mesoderm: forms skeletal, urinary, circulatory, and reproductive organs  Ectoderm: forms the central nervous system, special senses, skin, and glands

The amniotic cavity – baby side  Amniotic fluid serves as a cushion/shock absorber as the mom moves and keeps the baby warm The chorion cavity – maternal side

Functions of the Placenta      

Serving as the interface between the mother and fetus Making hormones to control the physiology of the mother Protecting the fetus from immune attack by the mother Removing waste products from the fetus Inducing the mother to bring more food/nutrients to the placenta Producing hormones that mature into fetal organs (corpus luteum produces a hormone that progesterone until the placenta takes over)  The oxygenated blood from the mother goes to the baby, and deoxygenated blood goes back to the mother Hormones Produced by the Placenta  Chorionic gonadotropin  Prolactin  Human placental lactogen (hPL) or human chorionic somatomammotropin (hCS)  Estrogen  Progesterone  Relaxin (Didn’t discuss in detail)

Umbilical Cord  Formed from the amnion  = Lifeline from the mother to the growing embryo  Contains one large vein and two small arteries  Wharton jelly surrounds the vein and arteries to prevent compression o 1 vein and 2 arteries o It’s very important  once the baby is born, we need to cut the umbilical cord to see if it does contain 1 vein and 2 arteries  it it’s not, then the baby could have some congenital abnormalities.  At term, the average umbilical cord is 22 in long and about 1 in wide o Complications can occur if having a very short or very long cord

Role of Amniotic Fluid     

Helps maintain a constant body temperature for the fetus Permits symmetric growth and development Cushions the fetus from trauma Allows the umbilical cord to be relatively free of compression Promotes fetal movement to enhance musculoskeletal development

Fetal Circulation  Blood from the placenta to and through the fetus and then back to placenta (see Figure 10.9)  Three shunts during fetal life: o Ductus venosus: connects the umbilical vein to the inferior vena cava o Ductus arteriosus: connects the main pulmonary artery to the aorta o Foramen ovale: anatomic opening between the right and left atrium

https://www.youtube.com/watch?v=-IRkisEtzsk - The oxygenated blood (where they picked up O2 from the placenta) leaves the placenta via the umbilical vein and goes to the ductus venosus (a bypass at the liver)  enters the heart through the inferior vena cava. - However, little goes into the right atrium and right ventricle (the little amount that goes into the pulmonary artery is just to keep the lung alive rather than picking up O2 because the lungs cannot do that yet)  most gets shunt through foramen ovale and leaves the heart to supply the body with Oxygenated blood again. - The blood at the pulmonary trunk will get shunted into the ductus arteriosus to the ascending and descending aorta  supplies the body with oxygenated

blood  then goes back to the placenta via the two umbilical arteries to get oxygenated in the placenta

OB E1 - Maternal Adaptation During Pregnancy, Ch11

Breathing may be affected because the diaphragm cannot be flattened as much as it normally does due to the big belly. Urinary frequency – very frequent in the first trimester; frequency goes away in the second trimester; frequent again in the third trimester. If just increasing thick white secretions  educate her that this is normal, just make sure to practice good hygiene

If thick white secretions with itching or odor  may be a vaginal infection and need treatment **Nurses need to know whether it is a minor disorder or a major one which needs intervention! Facial mask that may look like a symptom of lupus. Blood pressure should NOT go up during pregnancy  anytime a patient has any increase in her blood pressure, we need to get it investigated

Signs of Pregnancy  Chadwick’s sign

o Bluish-purple coloration of the vaginal mucosa and cervix (due to increase in vascularity)  Goodell’s sign o Softening of the cervix (See figure on the right)  Hegar’s sign o Softening of the lower uterine segment or isthmus

Signs and Symptoms of Pregnancy Presumptive signs (could be caused by other reason)  Fatigue (12 weeks)  Breast tenderness (3 to 4 weeks)  Nausea and vomiting (4 to 14 weeks)  Amenorrhea (4 weeks) o Stress, exercise, medications, birth control could cause amenorrhea  Urinary frequency (6 to 12 weeks) o UTI, drink excessive amount of fluids  Hyperpigmentation of skin (16 weeks) o Lupus, or other reason  Fetal movements (quickening) (felt between 16 to 20 weeks) o The first fetal movement felt by the mother o A woman who has had a baby before may feel a little earlier than a woman who’s never been pregnant before o Could be caused by gas  Uterine enlargement (7 to 12 weeks) o Fibroids, tumor could also cause this  Breast enlargement (6 weeks)

Probable signs  Braxton Hicks contractions (16 to 28 weeks) o = Spontaneous, irregular, and painless uterine contractions  Positive pregnancy test (4 to 12 weeks) o Measure the level of HCG

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o Could be other conditions causing the HCG to elevate; ex: hydatidiform moles, choriocarcinoma Abdominal enlargement (14 weeks) Ballottement (16 to 28 weeks) o = the examiner pushes against the woman’s cervix during a pelvic examination and feels a rebound from the floating fetus Goodell’s sign (5 weeks) Chadwick’s sign (6 to 8 weeks) Hegar’s sign (6 to 12 weeks)

Positive signs (ONLY THING CAN CONFIRM) we are only sure that the woman is pregnant with the doctor seeing, feeling, or hearing the baby.  SEEING - Ultrasound verification of embryo or fetus (4 to 6 weeks)  FEELING - Fetal movement felt by experienced clinician (20 weeks) o Where quickening is the fetal movement felt by the mother, which could be inaccurate (that’s why it’s a presumptive sign)  HEARING - Auscultation of fetal heart tones via Doppler (10 to 12 weeks)

Select Pregnancy Tests

Skipped

Reproductive System Adaptations Uterus Nonpregnant uterus is the size of a fist  Increase in size, weight, length, width, depth, volume, and overall capacity  Pear shape to ovoid shape  positive Hegar’s sign  Enhanced uterine contractility, Braxton Hicks contractions  Ascent into abdomen after first 3 months (first trimester) o Each 3 months = a trimester o In the first trimester, it’s in the pelvic area pressing on the bladder o After the first trimester, it will ascent into abdomen  Fundal height by 20 weeks’ gestation at level of umbilicus; 20 cm; reliable determination of gestational age until 36 weeks’ gestation o Doctor or nurse can assume the gestational age by this measurement based on the height of the fundus

o 12 weeks at the level of pelvis; 20 weeks at the level of umbilicus; 36 weeks at the level of the xiphoid process o If you feel the fundus in the midway between the pelvis and the umbilicus  16 weeks pregnant o The fundus reaches its highest level, at the xiphoid process, at approximately 36 weeks. Between 38 and 40 weeks, fundal height drops as the fetus begins to descend and engage into the pelvis ex: 36 weeks and 40 weeks about the same level

Cervix  Softening (Goodell’s sign)  Mucous plug formation  Increased vascularization (Chadwick’s sign)  Cervical ripening about 4 weeks before birth (at 36 weeks) Vagina  Increased vascularity with thickening  Lengthening of vaginal vault  Secretions more acidic, white, and thick = leukorrhea o Acidity helps to kill additional sperm and bacteria Ovaries  Enlargement until 12th to 14th week of gestation

o The corpus luteum helps with producing hormone until the placenta takes over  Cessation of ovulation Breasts  Increase in size and nodularity to prepare for lactation  increase in nipple size, becoming more erect and pigmented o Both the nipples and the areola become deeply pigmented o Tubercles of Montgomery becomes prominent, which are sebaceous glands that keep the nipples lubricated  Production of colostrum: o antibody-rich, yellow fluid that can be expressed after the 12th week o conversion to mature milk after delivery

GI System Adaptations  Gums: hyperemic, swollen, and friable o Make sure to do good oral hygiene  Ptyalism = excessive spitting  Dental problems; gingivitis  Decreased peristalsis and smooth muscle relaxation  Constipation + increased venous pressure + pressure from uterus  hemorrhoids  Slowed gastric emptying  heartburn  Prolonged gallbladder emptying  Nausea and vomiting

Cardiovascular System Adaptations  Increase in blood volume (50% above prepregnant levels)  Increase in cardiac output; increased venous return; increased heart rate  Slight decline in blood pressure until mid-pregnancy, then returning to prepregnancy levels

 Increase in number of RBCs o plasma volume > RBC leading to hemodilution (physiologic anemia)  Increase in iron demands, fibrin, plasma fibrinogen levels, and some clotting factors, leading to hypercoagulable state o prenatal supplements needed

Respiratory System Adaptations  Breathing more diaphragmatic than abdominal due to increase in diaphragmatic excursion, chest circumference, and tidal volume  Increase in oxygen consumption  Congestion secondary to increased vascularity o Nasal congestion  do not use antihistamine during pregnancy; normal saline and nose drop is preferred

Renal/Urinary System Adaptations    

Dilation of renal pelvis; elongation, widening, and increase in curve of ureters Increase in length and weight of kidneys Increase in GFR  increased urine flow and volume Increase in kidney activity with woman lying down; greater increase in later pregnancy with woman lying on side

Musculoskeletal System Adaptations  Softening and stretching of ligaments holding sacroiliac joints and pubis symphysis o For women under 25, their pubis symphysis is still pliable  not as painful with giving birth  Postural changes: increased swayback and upper spine extension  Forward shifting of center of gravity  Increase in lumbosacral curve (lordosis); compensatory curve in cervicodorsal area  Waddle gait

Integumentary System Adaptations       

Hyperpigmentation; mask of pregnancy (facial melasma) Linea nigra Striae gravidarum Varicosities Vascular spiders Palmar erythema Decline in hair growth; increase in nail growth

Supine hypotensive syndrome (vena caval syndrome)  The gravid uterus compresses the vena cava when the woman is supine.  This reduces the blood flow returning to the heart and may cause maternal hypotension.  she will feel dizzy or even fall when she gets up  Educate the mom to lay side to side rather than on the back to reduce the vena calva syndrome

Pituitary Adaptations  Thyroid gland: slight enlargement; increased activity; increase in BMR

 Pituitary gland: enlargement; decrease in TSH, GH; inhibition of FSH and LH; increase in prolactin, MSH; gradual increase in oxytocin with fetal maturation until the baby is mature enough and contractions start  Pancreas: insulin resistance due to hPL and other hormones in second half of pregnancy (see Box 11.2)  Adrenal glands: increase in cortisol and aldosterone secretion  Prostaglandin secretion  Placental secretion: hCG, hPL, relaxin, progesterone, estrogen (see Table 11.3)

Nutritional Needs  Direct effect of nutritional intake on fetal well-being and birth outcome  Need for vitamin and mineral supplement daily  Dietary recommendations o Increase in protein, iron, folate, and calories (see Table 11.5) o Use of USDA’s Food Guide MyPlate (see Figure 11.5) o Avoidance of some fish due to mercury content

Maternal Weight Gain  Healthy weight BMI: gain about 25 to 35 lb o First trimester: 3.5 to 5 lb o Second and third trimesters: 1 lb/wk  BMI 25 (the mom is already overweight): 15 to 25 lb o First trimester: 2 lb o Second and third trimesters: 2/3 lb/wk The permission of weight gain during the pregnancy has to do with what weight she was prepregnant.

Nutrition Promotion  USDA Food Guide MyPlate  Client education (see Teaching Guidelines 11.1)

 Special considerations o Cultural variations o Lactose intolerance o Vegetarianism o Pica = abnormal craving; often is a result of something lacking in her diet.  make sure that the mom is not eating anything that could be dangerous for the baby.

Maternal Emotional Responses  Ambivalence o The realization of a pregnancy can lead to fluctuating responses, possibly at opposite ends of the spectrum o Ex: regardless of whether the pregnancy was planned, the woman may feel proud and excited by the news while at the same time fearful and anxious of the implications.  Introversion o focusing on oneself o The woman may withdraw and become increasingly preoccupied with herself and her fetus.  Acceptance  Mood swings  Changes in body image o Acene o Big belly

o overweight

Maternal Role Tasks    

Ensuring safe passage throughout pregnancy and birth Seeking acceptance of infant by others Seeking acceptance of self in maternal role to infant (“binding in”) Learning to give of oneself

Pregnancy and Sexuality    

Numerous changes, possibly stressing sexual relationship Changes in sexual desire with each trimester Sexual health and link to self-image If the mom is at risk for something, such as abortion  educate them to limit the sexual activity  If the sexual activity is happening with more than one partner  educate the mom to reduce the number of sexual partners.

Pregnancy and Partner  Family-centered emphasis  Partner’s reaction to pregnancy and changes o Couvade syndrome, ambivalence o Acceptance of roles (second trimester) o Preparation for reality of new role (third trimester)

Pregnancy and Siblings  Age-dependent reaction  Sibling rivalry with introduction of new infant into family  Sibling preparation imperative

OB E1 - Nursing Management During Pregnancy, Ch12

Goals of Preconception Care  Promote the health and well-being of a woman and her partner before pregnancy o = giving people the option so they can make the right decision  Identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management intervention  CDC guidelines for vaccination

Period of Greatest Environmental Sensitivity  The period of greatest environmental sensitivity and consequent risk for the developing embryo  between days 17 and 56 after conception

Preconception Care      

Immunization status Underlying medical conditions Reproductive health care practices Sexuality and sexual practices Nutrition Lifestyle practices o Ex: if the mother is a nurse and has to stand for a long time for her job  educate the mom to elevate her legs when she is sitting down; take breaks; use compression stocking  Psychosocial issues o Nurses need to know  Who is going to be your main support?  Medication and drug use  Support system

Risk Factors for Adverse Pregnancy Outcomes             

Isotretinoins Alcohol misuse Antiepileptic drugs Diabetes (preconception) Folic acid deficiency HIV/AIDS (See Box 12.2) Hypothyroidism Maternal phenylketonuria Rubella seronegativity Obesity Oral anticoagulant STI Smoking

First Prenatal Visit    

Establishment of trusting relationship Focus on education for overall wellness Detection and prevention of potential problems Comprehensive health history, physical examination, and laboratory tests

Comprehensive Health History  Reason for seeking care o Suspicion of pregnancy o Date of last menstrual period o Signs and symptoms of pregnancy o Urine or blood test for hCG  Past medical, surgical, and personal history  Woman’s reproductive history: o menstrual, obstetric, and gynecologic history

Menstrual History  Menstrual cycle o Age at menarche o Days in cycle o Flow characteristics o Discomforts o Use of contraception  Date of last menstrual period (LMP)  Calculation of estimated or expected date of birth (EDB) or delivery (EDD) o Nagele rule  Use first day of LNMP 11/21/20  Subtract 3 months 8/21/20  Add 7 days 8/28/20  Add 1 year 8/28/21 = EDB o Gestational or birth calculator or wheel (see Figure next page) o Ultrasound is best method of dating a pregnancy

Obstetric History  Gravida: the amount of time a woman has been pregnant o Gravida I (primigravida): first pregnancy o Gravida II (secundigravida): second pregnancy, etc. o Ex: if a woman got pregnant one time but did an abortion  still count as 1 gravida/pregnancy  Para: a woman who has produced one or more viable offspring carrying a pregnancy 20 weeks or more, if the baby comes out before 20 weeks  it’s abortion not para o Primipara: one birth after a pregnancy of at least 20 weeks (“primip”)

o Multipara: two or more pregnancies resulting in viable offspring (“multip”) o Nullipara: no viable offspring; para 0 = never carried a baby beyond 20 weeks o Ex: gravida = 6, para = 0  she's been pregnant six times, but none of them have surpassed 20 weeks  Terminology o G (gravida): includes the current pregnancy o T (term births): the number of pregnancies ending >37 weeks’ gestation, at term o P (preterm births): the number of preterm pregnancies ending >20 weeks or viability but before completion of 37 weeks o A (abortions): the number of pregnancies ending before 20 weeks or viability o L (living children): number of children currently living

Ex 1: 23-year-old. Currently pregnant at 35 weeks, has had one miscarriage of twins at sixteen weeks, one abortion. G = 3; T = 0; P = 0; A = 2; L = 0 Ex 2:

G = 6; T = 2; P = 2; A = 1; L = 3 Ex 3:

G = 7; T = 2; P = 2; A = 2; L = 3 Ex 4:

G = 3; T = 0; P = 1; A = 1; L = 1

Ex 1:

G = 2; P = 0 Ex 2:

G = 9; P = 7 Ex 3:

G = 4; P = 2 KEEP IN MIND: When doing GP  P (para) regardless the baby lives or die, look for AFTER 20 weeks is still count  G: total number of pregnancies When doing GTPAL, have to separate the per- term and full term Physical Examination  Vital signs  Head-t...