lecture 1 - changes during pregnancy (224)

Which racial group consistently has the highest maternal mortality rate in the US?

black, non hispanic women

Why is it important to understand the maternal mortality for nursing care?

It highlights health disparities, risk assessment, and the need for culturally competent care

What is Antepartum?

Before birth - includes conception & pregnancy

What is intrapartum?

During birth - labor, delivery of baby, placenta

What does postpartum mean?

After birth - begins ~4 hours after placenta delivery and last 6 weeks

What are the main nursing priorities in the antepartum period?

• prenatal care

• teaching

• monitor for complications

• ensuring fetal growth

What are the main nursing priorities in the intrapartum period?

• Supporting Labor

• monitoring Fetal Heart Rate

• Assisting with delivery

• Preventing Hemorrhage

What are the main nursing priorities in the postpartum period?

• Maternal recovery

• Newborn care

• Bonding

• Breastfeeding support

• Monitoring for hemorrhage

• Infection

• POST PARTUM DEPRESSION

What is fertilization?

The process where a sperm cell joins with an egg cell to for ma new cell called a zygote

What is implantation?

When the zygote attaches itself into the lining of the uterus so pregnancy can continue 

What is the Embryonic period?

Weeks 2-8, the stage where cells are forming and differentiating into organs and body systems. This is where the embryo is MOST vulnerable.

What is the fetal period?

The stage where the baby grows, organs mature, and body systems develop to get ready for life outside the womb (Week 9-38)

At week 24, what is our survival rate?

That is typically the time where 50% of babies can survive outside the womb. that is called Age of Viability***

What is the placenta?

An organ that develops during pregnancy to connect the mother & fetus, it is used as a life support system for the fetus

What are some endocrine functions of the placenta?

Creates progesterone, keeps the uterus relaxed and prevents the uterus lining from shedding (period cycle)

What are some transfer functions of the placenta?

• Gas transfer

• Nutrient transfer

• Waste removal

• Antibody transfer

• Transfer of maternal hormones 

What are the two fetal membranes?

• Amnion

• Chorion

What is “Amnion”?

The inner membrane, closest to the fetus

What is “Chorion”?

The outer membrane, closest to the uterus

What is “amniotic fluid”?

Clear, slightly yellowish tint fluid that surrounds the fetus inside the amniotic sac during pregnancy. When the water breaks, this is what it is

What are the functions of amniotic fluid?

• Protects the fetus from trauma

• Temperature regulation

• Allows symmetric growth

• Prevents adhesions

• Provides space & movement, to help bring muscle and bone development

How many vessels are in the umbilical cord?

3 total, 2 arteries, 1 vein

What is the ductus venosus?

Shortcut that lets blood bypass the liver, goes straight to the inferior vena cava

What is foramen ovale?

Hole between right & left atria, allows blood to bypass the lungs

What is ductus arteriosus?

Connects pulmonary artery to aorta, lets blood bypass the lungs

What major change in circulation happens at birth?

Blood is oxygenated in the lungs instead of the placenta

What happens to the foramen ovale after birth?

Closes & becomes the fossa ovalis

What happens to the ductus arteriosus after birth?

Closes & becomes the ligamentum arteriosum

What happens to the ductus venosus after birth?

Closes and becomes the ligamentum venosum

Why are fetal circulatory shunts not needed after birth?

Because lungs take over oxygen exchange and the placenta is no longer connected

What are some presumptive indicators for confirmation of pregnancy?

• Amenorrhea (missed period)

• Fatigue

• N&V

• Urinary frequency

• Breast changes (darkened areolae, enlarged Montgomery glands)

• Quickening (mother feels first fetal movements)

• Uterine enlargement 

What are some probable indicators for confirmation of pregnancy?

• Abdominal enlargement

• Hegar’s sign (softening & compressibility of lower uterus)

• Chadwick’s sign (violet-bluish color of cerfix and vaginal mucosa)

• Goodell’s sign (cervical softening)

• Ballottement (rebound of unengaged fetus)

• Braxton Hicks contractions (irregular, painless contractions)

• Palpation of the fetal outline

• Positive pregnancy test

What is Hegar’s sign?

Softening/compressibility of the lower uterus

What is Chadwick’s sign?

Violet-blueish color of the cervix and vaginal mucosa

What is Goodell’s sign?

Cervical softening

What are some positive indicators for confirmation of pregnancy?

• Auscultation of fetal heart sounds

• Fetal movements felt by examiner

• Visualization of the fetus on ultrasound

THESE 100% MEAN SHE IS PREGNANT!

What are other ways to verify for pregnancies?

• Blood & urine pregnancy test

  • Detect human chorionic gonadotropin (hCG)

  • Higher or lower than expected levels may indicate multiple (twins, triplets) or complications

What is Naegele’s Rule?

Take the first day of the woman LMP (last menstrual period), subtract 3 months then add 7 days, then add 1 year. This will give the expected delivery date

What is fundal height?

The distance from the symphysis pubis to the fundus (top of the uterus)

The measurement in cm should correlate with gestational age (ex: 22 cm = 22 wks)

What is gravidity?

Number of pregnancies

What is Nulligravida?

A patient who has never been pregnant

What is Primigravida?

A client in their first pregnancy

What is Multigravida?

A client who has had two or more pregnancies

What is a parity?

Number of pregnancies in which the fetus reached 20 weeks of pregnancy

What is nullipara?

No pregnancy beyond the stage of viability

What is Primipara?

One pregnancy to stage of viability

What is Multipara?

Completed two or more pregnancies to stage of viability

What is GTPAL?

• Gravida (Total # of pregnancies)

• Term (pregnancies carried to >37 wks)

• Preterm (Pregnancies that ended >20wks but <37 wks)

• Abortions (Pregnances that ended before 20 weeks)

• Living (number of living children)

Where should the uterus be located at 12 weeks of pregnancy?

Above the symphysis pubis

Where should the uterus be located at 16 weeks of pregnancy?

Between the sympysis pubis and umbilicus

Where should the uterus be located at 20 weeks of pregnancy?

At the umbilicus

Where should the uterus be located at 36 weeks of pregnancy?

Lightening (the baby drops, moves to the pelvis)

What is a mucus plug?

Thick barrier in the cervical canal that helps prevent infection when pregnant 

What are some changes to the vagina & vulva during pregnancy?

• Increased vascularity

• Thickened mucosa

• Vaginal rugae become prominent

• Increased lactic acid production (lowers vagina pH)

  • Reduces bacterial infections

  • Increases risk for yeast infections (Candida)

What are some changes that happen to the ovaries during pregnancy?

Corpus luteum secretes progesterone

Ovulation stops during pregnancy

Estrogen production continues

What are some key changes in breast during pregnancy?

• Estrogen stimulates the growth of mammary ducts

• Progesterone promotes the growth of the lobes, lobules, and alveoli (milk producing glands)

• Size & color changes (breast enlarge, areolae darken)

• Colostrum secretion (thick yellowish-premilk rich in antibodies secreted late in pregnancy)

What are some key changes that happen to the heart during pregnancy?

• Heart muscle enlarges to handle workload

• Heart pushed up & left by the uterus

• Systolic murmurs are common

• Output increases 30-50%

• Heart rate increases 10-15 bpm

What can happen in blood volume while in pregnancy?

• Plasma volume increases (peak ~32 wks)

• RBC 20-30%, but plasma up more (physiologic anemia)

• Increased clotting factors (risk for DVT, PE)

What happens to your blood pressure while in pregnancy?

• ORTHOSTATIC HYPOTENSION

• Supine Hypotension

  • Teach pregnant woman should lie on their side, the uterus compresses vena cava when lying flat.

What is physiologic anemia?

When RBCs go up (20-30%) but plasma goes up (40-50%) creating dilution, making you anemic

What are some respiratory changes during pregnancy?

• Oxygen consumption increases

• Hyperventilation (could lead to compensated respiratory alkalosis)

Hormonal Effects:

• Progesterone - relaxes ligaments around ribs, chest expands more easily

• Estrogen - Increases vascularity, more nasal congestion

Physical effects of uterus

• Enlarged uterus pushes diaphragm upward, making lungs have less room so feel SoB

What are some musculoskeletal changes during pregnancy?

• Calcium storage

  • Fetal demands for calcium increase

• Postural changes

  • Baby’s weight shift center of gravity - progressive lordosis (increased curve in lower back)

• Abdominal wall

  • Diastasis recti - Seperation of the rectus abdominis muscles

  • Can cause weakened core and abdominal bulge 

What are some Gastrointestinal changes during pregnancy?

• Ptyalism (excessive salivation, spitting)

• Esophagus - Relaxed cardiac sphincter (causes reflux)

• N&V relating to hormonal changes and displaced organs

• Large & small intestines

  • Displaced

  • Slowed

• Liver & gallbladder

  • Displaced or blocked

    • leading to possible gallstones

What are some urinary system changes during pregnancy?

• Bladder

  • Hormonal urinary frequency

    • Progesterone relaxes smooth muscles, leading to more frequent urination

  • Physiologic urinary frequency

    • Uterus presses on bladder, esp in the 1st & 3rd trimester causing frequent urination

• Kidneys & Ureters

  • Filtration rate increases due to

    • hormones

    • blood volume

    • metabolic demands 

What are some skin (integumentary) changes during pregnancy?

Melasma / Cholasma (mask of pregnacy) - dark patches on face

Linea nigra - dark vertical line down the abdomen

• Connective tissue

  • Striae gravidarum - stretch marks from skin stretching and hormone changes 

What are some immune system changes in pregnancy

• Autoimmune conditions

• Infection resistance - overall immune function is altered, INCREASING SUSCPECTIBILITY TO INFECTIONS

• antibodies cross the placenta (gives passive immunity)

• NO LIVE VIRUS VACCINES! COULD HARM FETUS***

What are some endocrine changes during pregnancy?

• Pituitary gland

  • Prolactin (prepares breast for milk production)

  • Oxytocin (stimulates uterine contractions during labor & milk let-down during breastfeeding)

• Thyroid gland

  • Rise in T4 (to speed up metabolism)
    

• Parathyroid glands

  • Calcium homeostasis

• Pancreas

  • Fluctuations in insulin production

  • Insulin resistance (lower fasting glucose, higher post-meal glucose)

THIS CAUSES GESTATIONAL DIABETES ^^

What are some psychosocial adaptations in pregnancy?

• Age

• Multiparity (First time moms vs multi pregnancies)

• Social support

• Presence of partner

• Socioeconomic status

• Obstetrical history

What are some maternal psychological responses by the FIRST trimester?

• Uncertainty

• Ambivalence (mixed feelings, happy/anxious)

• Self-Focused (main concern is her body and coping with changes)

What are some maternal psychological responses by the SECOND trimester?

• Physical evidence of pregnancy (baby bump)

• Fetus becomes the focus

• Narcissism & introversion (focused on her & the baby)

• Body image changes

• Changes in sexuality (may increase or decrease) 

What are some maternal psychological responses by the THIRD trimester?

• Vulnerability & increased dependence

• Preparation for birth (surge of energy, organizing and preparing for baby’s arrival)

What does paternal adaptation mean?

How fathers/partners adjust to pregnancy and prepare for parenthood.

What are some paternal adaptations that partners do?

• Developmental processes

  • Reality of pregnancy & child (Father adjust to being a parent)

  • Struggle for recognition; may feel less included or overlooked

• Role of involved father

  • Parenting information

  • Couvade syndrome (some father experience pregnancy-like symptoms) nausea, weight gain, fatigue 

What needs to be included in the initial prenatal visit?

• COMPLETE HISTORY

  • Menstrual history (to calculate Naegele’s Rule)

• Obsteric history

• Gynecologic/contraceptive history

• Medical & surgical history

• Family history

• Psychosocial history (SCREEN FOR DOMESTIC VIOLENCE)

• Physical exam

  • full systems

  • vital signs (BP!)

  • lab work

What do you need to look for in Obstetric History?

• Gravida, Para

• Details of previous pregnancies

  • length of gestations

  • birth weights

  • labor experience

  • anesthesia use

  • complications

• Methods of infant feeding

• Birth plan

When should you schedule for an UNCOMPLICATED pregnancy

• Schedule for uncomplicated pregnancy

  • 16-28 wks (every 4 wks)

  • 29-36 wks (every 2 wks)

  • 36 wks to birth (weekly visits)

What should be assessed in every prenatal assessment visit?

• Vital signs (especially BP!)

• Weight

• Urine

• Fundal height (check fetal growth)

• Leopold’s maneuvers

• Fetal heart rate

• Signs of labor

• Ultrasound screening (as indicated)

• Glucose screen (around 24-28 wks)

• Isoimmunization screening

• Pelvic exams

When should a patient start paying attention and tracking fetal kick counts?

After 20 weeks

How do you track kick fetal counts?

Woman lies on her side, hands on the largest part of the abdomen, and focuses on fetal movements

If movements are fewer than expected, additional testing may be needed.

What are some common discomforts of pregnancy?

• GI-related

  • Nausea & vomiting

  • Heartburn

  • Constipation

  • Hemorrhoids

• Urinary & fatigue

  • Urinary frequency

  • Fatigue

• Breast & respiratory

  • Breast tenderness

  • Shortness of breath

• Circulatory & muscoskeletal

  • Backache

  • Leg cramps

  • Varicosites (varicose veins)

• ENT (head and nasal)

  • Gingivitis

  • Nasal stuffiness

  • Epistaxis (nosebleeds)

• Pregnancy-specific

  • Braxton Hick contractions

  • Supine hypotension

What are some danger signs for the FIRST trimester of pregnancy?

• Dysuria (may indicate infection)

• Severe vomiting (risk of dehydration)

• Diarrhea

• Fever or chills

• Abdominal cramping

• Vaginal bleeding

What are some danger signs for the SECOND AND THIRD trimester of pregnancy?

everything on the first

AND

• Gush of fluid from vagina

• Changes in fetal activity (no movement/decreased)

• Severe headache, blurred vision, facial edema

• Kussmaul Respirations

• Pale, clammy skin, weakness, tremors

What are some high BMI risks relating to pregnant women?

• Macrosomia (large baby)

• IUGR (intrauterine growth restriction, small baby)

• Spontaneous abortion

• Gestational diabetes

• Gestational hypertension & preeclampsia

• Prolonged labor Cesarean birth

• Postpartum hemorrhage

• Wound complications

What is the approximate weight gain you get during pregnancy?

• 1-4 lb during the first trimester

• 1lb a week in 2nd & 3rd trimester

TOTAL: 25-35 lbs

What are some nutritional requirements for pregnant woman?

• Increase calories

• Increase protein

FOLIC ACID!

• Neural tube defects

• 400-600 mg

• Iron supplements

  • RBC production

• Calcium

• Maintain sodium intake

• Limit caffeine, NO ALCOHOL!

What are some nutritional risk factors that can occur for patients?

• Socioeconomic status

• Nausea/vomiting of pregnancy

• Anemia

• Abnormal pre-pregnancy weight

• Eating disorders

• WEIRD food cravings

  • Pica (craving weird foods or nonfoods)

What is some nutritional patient teaching we have relating to nutrition in pregnant women?

• Nausea

  • Eat small frequent meals

  • Avoid alcohol, caffeine fried/fatty/spicy

• Constipation

  • Increase fluids

  • Increase physical activity

  • Increase fiber