maternal_Care of Mother and Fetus during Perinatal Period: Prenatal Care

Care of the Mother: Prenatal Visits (1st visit)

As soon as woman missed her menstrual period & pregnancy is suspected

Care of the Mother: Prenatal Visits (Follow up visits)

*Once a month - first 28 wks
*Twice a month - 28-36wks
*Every week - 37-40 wks

Gravida

- indicates the NUMBER OF TIMES the mother has been pregnant, regardless of whether these pregnancies were carried to term. A current pregnancy, if any, is included in this count

Para

- indicates the number of viable (>20 wks) births. Pregnancies consisting of multiples, such as twins or triplets, count as ONE birth

What information should you obtain from Prenatal Clients?

*Obstetrical history
Gravida , Parity (20 weeks AOG)‏
T-infant born @ 37 wks or after , wt is 5 -8 lbs (2,500 - 4000 grams)‏
P-infant born before 37 wks , ended after 20 wks
A-(spontaneous/induced)-delivered before the end of 20 wks(5 month)‏
L-living children
M-multiple pregnancies-- para 1
*Medical and Surgical History,
*Family History
*Current problems

What are the purpose of Prenatal Care?

1. Establish a baseline of present health.
2. Determine the gestational age of the fetus.
3. Monitor fetal development and maternal
well being
4. Identify women at risk for complications
5. Minimize the risk of possible complications
by anticipating and preventing problems
before they occur.
6. Provide time for education about
pregnancy, lactation and newborn care

What are the components of Health history?

Data: Age, Marital Status, Family Setting, source of income, cultural values and practices relative to bearing and child rearing, education, employment background
A. Relevant data of previous pregnancies
B. History of present pregnancy:
LMP, EDC
*Estimating fetal Growth by:
-Naegele's Rule
-McDonald's Rule

What are the components of Initial Prenatal History?

A. Family History of Health Problems
B. Patient's medical history
C. Gynecologic History
D. Obstetrical History

McDonald's rule

Measurement of fundal height

Bartholomew's Tule

- position of uterus in abdomen

*12 wks, above symphysis pubis
*20 wks, umbilicus
*36 wks xyphoid process

Baseline height / weight and vital sign measurement

-sudden increased of BP and weight gain -gestational hypertension
-sudden increased in pulse or respiration-undetected bleeding

Weight gain during pregnancy

Roughly 20-30lbs/30-35lbs

Weight gain during pregnancy (1st Trimester)

2 to 4 lbs; 1 lb per month

Weight gain during pregnancy (2nd Trimester)

11-14 lbs; 0.9 lb per week

Weight gain during pregnancy (3rd Trimester)

8 to 11 lbs; 0.5 to 1 lb per week

T or F: Note: Pattern of weight gain is more important than amount of weight gain

T

Antenatal Visit PE

1. General Appearance and Mental Status
-hygiene, sad facial expression, the way they speak, check for sign of partner abuse ( marks from battering and ecchymotic spots)
2. Head and Scalp
- examine women's head for symmetry, normal contour, and tenderness .
- presence of hair (distribution, thickness, dryness/ oiliness)
dryness or sparseness of hair suggests poor nutrition
3. Eyes
- edema of the eyelids combined with a swollen optic disk suggests gestational hypertension
- Report spots before their eyes or diplopia suggests gestational hypertension
4. Nose
-increased level of estrogen cause nasal congestion or the appearance of swollen nasal membrane

Antenatal Visit PE

5. Ears
- nasal stuffiness may lead to blocked eustachian tubes
( fullness in the ears or dampening of sound )
6. Sinuses
- should feel nontender
headache suggests a danger sign until ruled otherwise.
7. Mouth, teeth and throat
-gingival (gum) hypertropy result from increased estrogen
-cracked corners of the mouth suggests Vit.A deficiency
-pinpoint lesion with erythematous base on the lips -suggests herpes infection.
- encourage good dental hygiene or yearly dental exam
8. Neck
-slight thyroid hypertropy may occur due to increased metabolic
rate -encourage a serving of seafoods at least once weekly to
supply enough iodine for the increased thyroxine production
-Use iodized salt

Antenatal Visit PE

9. Lymph nodes
-no palpable lymph nodes should be
present

10. Breast
- Areolae darken
- Secondary areola develop
-Montgomery tubercles in the areola become prominent
-Overall breast size increase
-Breast consistency firms
-Veins become prominent
Colostrum as early the16th week of pregnancy

Antenatal Visit PE

11. Heart
- ranges from 70 to 80 beats / min in pregnant woman
- no accessory sounds or murmurs should be present.
- teach woman to rest or sleep on their side ( left side)-to
keep their uterus from compressing their vena cava(a
cause of supine hypotension syndrome as well as heart
palpitations).
12. Lungs
-diaphragmatic excursion (diaphragm movement ) is lessened
because the diaphragm cannot descend fully as usual because
of the distended uterus.
13. Back
- lumbar curve is accentuated and standing so that they can
maintain body posture in the face of increasing abdominal size
( Lordosis -the pride of pregnancy )
14. Rectum
- hemorrhoid tissue commonly occurs from uterine pressure
on pelvic veins.

Antenatal Visit PE

15. Extremities and skin
- palmar erythema or itching early in pregnancy due to
high estrogen level
- subclinical jaundice (jaundice that is not yet apparent
by a color change) from reabsorbed bilirubin because of
slowed intestinal peristalsis
- assess for varicosities (filling time of toenails should be
under 5 seconds) and edema caused by impaired venous
return from the lower extremities
- Edema more than ankle swelling may be a danger sign
of pregnancy.
- waddling gait late in pregnancy may cause pain if the
cartilage at the joint becomes so unstable that it moves
from walking.

Measurement of fundal height and FH sound

*Bartholomew's Rule- position of uterus in the abdomen
-12 wks, above symphysis pubis
- 20 wks, umbilicus
- 36 wks xyphoid process
*lightening- uterus returns 4cm below
the xiphoid at 40 weeks

*Fetal heart sound -120 to 160 beats / min
heard at 10 to 12 weeks using a doppler
technique
18 to 20 weeks using a regular
stethoscope

Internal Pelvic Measurement

Give actual diameters of the inlet and outlet in which the fetus must pass
Lithotomy position(on her back with her thighs flexed and her feet resting in the examining table stirrups) - used for pelvic exam

Types of pelvis

1. gynecoid
2. android
3. anthropoid
4. platypelloid

Methods in measuring Internal Pelvic

1. Fingers are introduced vaginally and pressed inward and upward until the middle finger touches the sacral prominence. With the other hand, the part of the examining hand where it touch the symphysis pubis is marked. After withdrawing the hand , the distance between the tip of the middle finger and the mark point on the glove is measured.

*If more than 12.5 cm, the pelvis is rated as ADEQUATE for child birth.( the diameter of fetal head that must pass that point averages 9cm in diameter.

Methods in measuring Internal Pelvic (True conjugate/conjugate vera)

The usual depth of the symphysis pubis
(1.5 - 2cm) is subtracted to the diagonal conjugate measurement.
Average is 10.5-11 cm.

Methods in measuring Internal Pelvic (Ischial Tuberosity diameter)

- the narrowest diameter
- most apt to cause a misfit
- a pelvimeter / ruler is used to measure the medial or lowermost aspect of the ischial tuberosity at the level of the anus.
-11 cm is considered adequate

Diagonal conjugate

-Distance between anterior surface of sacral prominence & posterior surface of inferior margin of symphysis pubis
-Should be 10.5 cm-11cm to be adequate

True conjugate/conjugate vera

-Distance between anterior surface of sacral prominence & posterior surface of inferior margin of the SP
- [ 1.5 - 2 cm(usual depth of sp) is subtracted from DC ]
= 10.5-11.0 cm

Transverse diameter

- Distance bet. Ischial tuberosities or the transverse diameter of the outlet
Adequate measurement: 11 cm ( fetal head 9cm)

What are the internal measurements of pelvis?

- diagonal conjugate
- true conjugate/conjugate vera
- transverse diameter

Leopold's maneuver

A systematic method of observation and palpation to determine fetal presentation and position.

Types of Leopold's Maneuver

*First Maneuver (Fundal Grip)
- to determine presenting part at the fundus
*Second Maneuver
- to determine fetal back
*Third Maneuver
- to determine position and mobility of the presenting part
*Fourth Maneuver ( Pelvic Grip)
- to determine fetal descent and attitude

4 steps of obstetric palpation

1. Upper part of uterus
2. Lateral part of uterus
3. Presentation; Engagement (gina kaptan kuno abi ang head ka fetus)
4. Further confirmation (kapti ang head with one hand and the other sa upper part ka uterus)

What are the psychosocial/psychological changes that occur with pregnancy?

Accepting the Pregnancy
Accepting the Baby
Preparing for baby and end of pregnancy

Accepting the pregnancy

Woman and partner both spend time recovering from shock of learning they are pregnant and concentrate of what it feels like to be pregnant. Common reaction is ambivalence

Accepting the baby

*Woman and partner move through emotions such as narcissism and introversion as they concentrate on what it feel like to be a parent.
*Role playing and increased dreaming are more common.

Preparing for baby and end of pregnancy

*Woman and partner prepare for clothing and sleeping arrangements for the baby but also grow impatient with pregnancy as they ready themselves for birth.

Nesting

- a ritual performed by pregnant women in ridding the house, the "nest", from anything potentially harmful to the soon to be born child.

Emotional Responses to pregnancy

Ambivalence
Grief
Narcissism
Introversion/Extroversion
Stress reaction
Emotional Lability
Couvade Syndrome

Ambivalence

- Normal Response;
- Discomforts of pregnancy caused mixed feelings. - She may make comments such as: "I thought I wanted a baby, but now I'm not so sure."

Grief

Commonly occurs as a result of change in the woman's role

Narcissism

-Woman focuses on self and changing body
- Signifies an effort by the woman to protect her body
and the fetus

Introversion/extroversion

- Woman focuses on self or become more out going

Stress reaction

- Pregnancy interferes with ability to perform daily
tasks such as caring for other family members; support
systems can alleviate some stress

Emotional lability

-mood changes; influenced by hormones;
- avoiding fatigue and reducing stress can
help

Couvade Syndrome

-Partner may experience discomforts such as nausea, vomiting, fatigue, similar to or
possibly more intense than those that the
pregnant woman experiences

Maternal Physiology Changes during pregnancy

Uterus
Hegar's sign
Ballottement
Braxton Hick's contractions
Ovaries
Cervical changes (Goodell's sign)
VAginal Changes (Chadwick's)
Changes in breast

Uterus changes during pregnancy

*length increases from approximately 6.5 to 32cm
*depth increases from 2.5 to 22 cm
*width expands from 4 to 24 cm
*weight increases from 50 to 1000g
* early in pregnancy uterine
-wall thickens about 1 cm to 2 cm
* towards the end of pregnancy
- only about 0.5 cm thick
*the volume of the uterus
-increases from about 2ml to
more than 1000ml
-the uterus can hold a 7 lb (3175) fetus + 1000ml amniotic fluid = total of 4000g @ term
-uterus feels more ante flexed, larger and softer to the touch


(B4 PREGNANCY)
-uterine blood flow is 15 to 20 ml/min, by the end of pregnancy as much as 500 to 750 ml/ min which 75 % goes to the placenta.

Hegar's sign

Softening of lower uterine segment

Lightening

-Uterus returns to height it was @ 36 wks
-seems to lighten woman's load

Ballottement

—> 16th - 20th of pregnancy
- if the lower uterine segment is TAPPED SHARPLY by the lower hand , the fetus can be felt to bounce or rise in the amniotic fluid up against the top examining hand.

Braxton Hicks Contractions

- "practice" contractions felt by a woman as waves of hardness or tightening across her abdomen

changes in ovaries during pregnancy

- Ovulation stops with pregnancy because of the active feedback mechanism of estrogen & progesterone produced by the corpus luteum early in pregnancy and by the placenta later in pregnancy. this feedback causes the pituitary gland to halt production of FSH & LH ,thereby ovulation will not occur.
- Amenorrhea

Amenorrhea

- (absence of menstruation) occurs with pregnancy because the suppression of FSH by rising estrogen levels

Cervical changes during pregnancy

* The cervix of the uterus becomes more vascular
and edematous, it darkens from a pale pink to a violet hue

*endocervix undergo both hypertrophy and hyperplasia

*operculum- mucous plug in the cervix

*Goodell's sign

Goodell's sign

- softening of the cervix
*non pregnant cervix- nose
*pregnant cervix- earlobe
*just before labor- soft as butter,
said to be ripe for birth

Operculum

- mucous plug forms to seal out bacteria
- help prevent infection in fetus & membranes

Vaginal changes during pregnancy

*Chadwick's
*Vaginal secretions during pregnancy fall from a
pH of greater than 7 ( alkaline pH)
*pH 4 or 5 (an acid pH) owing to INCREASED
production of lactic acid from glycogen in the
vaginal epithelium by lactobacillus acidophilus.
*vaginal epithelium and underlying tissue become
hypertrophic and enriched with glycogen which
results in a white vaginal discharge throughout
pregnancy

Chadwick's sign

- increase in circulation changes
- the color of the vaginal walls from the normal
light pink to deep violet

Changes in the breast

-feeling of fullness, tingling or tenderness in her breast because of high estrogen level
-areola of the nipple darkens and its diameter increases from about 3.5cm to 5 or 7.5 cm.
-darkening of the skin surrounding the areola in some women, forming a secondary areola.
-Montgomery's tubercles enlarge and become protuberant.
-by 16th week, colostrum can be expelled from the breasts

striae gravidarum

—often develop- pink or reddish, slightly depressed streaks in the skin of abdomen, breast, and thighs. (Become glistening silvery lines after pregnancy.)

Systemic changes during pregnancy (integumentary)

- striae gravidarum
-diastasis
- linea nigra
- melasma/chloasma
- vascular spider/telangiectases
- palmar erythema
- scalp hair growth is increased due to increased metabolism

Linea nigra

- a narrow brown line may form running from the umbilicus to the symphysis pubis and separating the abdomen into right and left hemisphere

Melasma/Chloasma

-"the mask of pregnancy"- darkened areas may appear on the face (cheek and across the nose)

Diastasis

rectus muscles separate to accommodate the growing fetus.(after pregnancy it appear as a bluish groove at the site of separation)
-umbilicus appear as if it has turned inside out, protruding as a round bump at the center of the abdominal wall.

Vascular spider/telangiectases

- (small, fiery red branching spots) on the thigh, result from increased level of estrogen

Palmar erythema

- (redness and itching) occurs on hands due to increased estrogen level

Systemic changes during pregnancy (respiratory)

*Increased activity of sweat glands- increase in respiration
*(RR 18 to 20 breaths/min)
-marked congestion or stuffiness of the nasopharynx due to increased estrogen
-crowding of the chest cavity causes shortness of breath late in pregnancy, until lightening relieves the pressure
-tidal volume (volume of air inspired) is increased up to 40% as a woman draws in extra volume to increased the effectiveness of air exchange.
-total oxygen consumption increases by as much as 20%
-increased mild hyperventilation to blow off excess CO2 shifted to her by the fetus to prevent the mother's ph level becoming acidic
-to exhale more than the usual CO2 the woman may develop respiratory alkalosis, to compensate kidney excrete plasma bicarbonate in urine. This result in polyuria .

Systemic changes during pregnancy (temperature)

— body temp increases slightly because of progesterone as the placenta takes over the function of the corpus luteum at about 16 weeks, the temp usually decreases to normal

Systemic changes during pregnancy (cardiovascular system)

*Blood volume
Increased total circulatory blood volume by at least 30% or 50%
Blood loss NSVD - 300 to 400 ml
Blood loss CS - 800 to 1000 ml

*BP decreases in 2nd trimester
*pseudoanemia
*decreased gastric acidity
*megalohemoglobinemia
*neural tube disorders in fetus

Pseudoanemia

— a condition where the plasma volume increases faster than RBC production, thereby hemoglobin and erythrocytes concentration declines on the first trimester.
- increased need of iron about 800mg

Decreased gastric acidity

- occurs during pregnancy due to impaired iron absorption
- increased need of folic acid

Megalohemoglobinemia

- large nonfunctioning RBC

T or F: During the physiologic changes in pregnancy, encourage woman to eat (spinach, asparagus, legumes)

T

Systemic changes during pregnancy (heart)

*heart rate increases by 10 beats/ min
*diaphragm is pushed upward by the growing uterus late in pregnancy, the heart is shifted to a more transverse position in the chest cavity.
*palpitation of the heart in the early months of pregnancy are probably caused by sympathetic nervous system stimulation,
*in later months result from increased thoracic pressure caused by the pressure of the uterus against the diaphragm.

Peripheral blood flow

-blood flow to the lower extremities is impaired by the pressure of the expanding uterus on veins and arteries leads to edema and varicosities of the vulva, rectum and legs

Supine hypotension syndrome

-when a pregnant woman lies supine ,the weight of the growing uterus presses the vena cava against the vertebrae, obstructing blood flow from the lower extremities.
-woman experiences hypotension, as lightheadedness ,faintness, and palpitations.
-may cause fetal hypoxia
-can be corrected by having a woman turn on her side (left side)

Systemic changes during pregnancy (GI system)

*nausea and vomiting /morning sickness-due to increased HCG and progesterone
*as the uterus increases in size, it PUSHES the stomach and intestines toward the back and sides of the abdomen, this pressure slow intestinal peristalsis and the emptying time of the stomach leading to heartburn, constipation and flatulence
*relaxin / progesterone may contribute to decreased gastric motility
*decreased emptying of bile from the gallbladder can lead to reabsorption of bilirubin into the maternal bloodstream which lead to generalized itching
*increased tendency to stone formation dueto increased plasma cholesterol level and cholesterol incorporated in bile
*hypertrophy of the gums and bleeding of
gingival tissue
*Hyperptyalism

Hyperptyalism

- increased saliva formation due to increased estrogen level

Systemic changes during pregnancy (urinary system)

*Glycosuria is evident due to increase in glomerular filtration without increase in tubular re-absorptive capacity for filtered glucose.

Systemic changes during pregnancy (skeletal system)

*The increasing mobility of sacroiliac, sacrococcygeal, and pelvic joints during pregnancy is the result of hormonal (progesterone) changes.
-This mobility contributes to alteration of maternal posture and to back pain.
*Lordosis- the pride of pregnancy

Systemic changes during pregnancy (endocrine system)

*placenta produces estrogen, progesterone, HCG, human placental lactogen, relaxin, prostaglandin
*Pituitary gland-a major change in the PT is the halt in production of FSH and LH because of high estrogen and progesterone levels produced by placenta.
*increased production of growth hormone and melanocyte-stimulating hormone, late in pregnancy oxytocin and prolactin.

Hormones involved in physio changes in pregnancy

*estrogen
*progesterone
*HCG
*hPL
*Relaxin
*Prostaglandin
*prolactin
*growth hormone & melanocyte
*oxytocin

Estrogen

- cause breast and uterine enlargement.
- Palmar erythema-redness and itching of the palms- occur early in pregnancy as a response to high circulating estrogen level.

Progesterone

— major role in maintaining the endometrium, inhibiting uterine contractility, and aiding in the development of breasts for lactation.

HCG

— secreted by trophoblast cells early in pregnancy. It stimulates progesterone and estrogen synthesis in the ovaries until the placenta can assume the role.

HPL

— known as human chorionic somatomammotropin, serves as an antagonist to insulin, making insulin less effective, and allow more glucose to become available for fetal growth.

Relaxin

-- secreted by corpus luteum of the ovary and placenta. Responsible for helping to inhibit uterine activity and to soften the cervix and collagen in joints. Softening of the cervix allows for dilatation at birth; softening of collagen allows for laxness in the lower spine , which helps enlarge the birth canal.

Prostaglandin

-- affect smooth muscle contractility to such extent they may be the trigger that initiates labor at term.

Growth hormone & melanocyte stimulating hormone

- causes skin pigment changes.

Prolactin

-- begins late in pregnancy and helps breasts prepare for lactation.

Oxytocin

- produced by posterior pituitary which is needed to aid labor.

Changes in Thyroid and parathyroid

*levels of protein- bound iodine, butanol-extractable iodine, and thyroxine are all elevated
*emotional lability, tachycardia, palpitation, and increased perspiration may lead to a mistaken diagnosis of hyperthyroidism.
*parathyroid gland necessary for metabolism of calcium also increased

Changes in adrenal gland

-increased level aid in suppressing an inflammatory reaction or help reduce the possibility of a woman's body rejecting the foreign protein of the fetus.
-help regulate glucose metabolism
-Aid in promoting sodium reabsorption and maintaining osmolality in the amount of fluid retained

Changes in pancreas

-secretes an increased level of insulin, it appears to be not effective
-to ensure against hypoglycemia ,diet high in calories and should never go longer than 12 hours between meals

Systemic changes during pregnancy (immune system)

- Decreased immunoglobulin to prevent a woman's body from rejecting the fetus. Immunoglobulin G(IgG) is decreased which make a woman prone to infection

T or F: A simultaneous increase in WBC count may help to counteract this decrease in the IgG response

T