WK5A: Care of the Mother during the Perinatal Period

Gravida

Number of pregnancy regardless of duration as long as the mother becomes pregnant even abnormal.

Para/Parity

number of viable pregnancy or the total number of pregnancies in which the fetus has reached the age of viability and subsequently delivered whether dead or alive at birth.

Viability

Ability of the fetus to live outside the uterus at the earliest possible gestational age.

Primigravida

Woman who is pregnant for the first time

Primi/para

Woman who has given birth to one child past age of viability; woman who has completed one pregnancy to age of viability and subsequently delivered the fetus, whether alive or dead at birth.

Multigravida

Woman who has been pregnant previously; 2 or more pregnancy

Grand multigravida

woman who has had six or more pregnancies

Multipara

Woman who has carried two or more pregnancies to viability; woman who has carried two or more pregnancies of stage of viability and subsequently born alive or dead.

Nulligravida

Woman who has never been and is not currently pregnant

Nullipara

woman who has not carried a pregnancy beyond 20 weeks

Grand multipara

woman who has had 6 or more viable deliveries, whether, the fetuses were alive or dead

PRINCIPLES IN IDENTIFYING PARITY

1. Number of pregnancies is counted and not the number of fetuses.

2. Abortion is not included in parity count

3. Live birth or stillbirth is counted in parity count.

OB SCORING = TPALM

• T - Term

• P - Pre-term

• A - Abortion

• L – Number of Currently Living Children

• M – Multiple Pregnancy

Term

Number of full-term infants born 37 weeks

Pre-Term

Number of preterm infants born 20 – 36 weeks

Abortion

termination of pregnancy before the age of viability (less than 20 weeks)

NAGELE’S RULE

Use to determine expected date of delivery (EDD or EDB). It is important to determine the mother’s last menstrual period (LMP).

NAGELE’S RULE = If Jan – March

+9 (month) +7 (day)

NAGELE’S RULE = If Apr– Dec

-3 (month) +7 (day) +1 (year)

MC DONALD’S RULE

Use to determine age of gestation (AOG) in weeks using FUNDIC HEIGHT

MC DONALD’S RULE FORMULA = AOG in WKS

AOG in WKS = FUNDIC HEIGHT x 8/7

MC DONALD’S RULE FORMULA = AOG in MONTHS

AOG in MONTHS = FUNDIC HEIGHT x 2/7

BARTHOLOMEW’S RULE

Use to determine age of gestation by proper location of fundus at abdominal cavity

BARTHOLOMEW’S RULE = < 12 weeks

not palpable/pelvic cavity

BARTHOLOMEW’S RULE = 3 months

above symphysis

BARTHOLOMEW’S RULE = 5 months

level of umbilicus

BARTHOLOMEW’S RULE = 7 months

bet. Umbilicus and xyphoid

BARTHOLOMEW’S RULE = 9 months

touching/below xyphoid

BARTHOLOMEW’S RULE = 10 months

level of 9 months due to lightening; about 4 cm

LEOPOLD’S MANEUVER

1st to 4th Maneuver

1st MANEUVER

• Purpose: to determine the fetal presentation/lie through fundal palpation

• If palpated a round, hard and movable – BREECH presentation

• If palpated round, soft and immovable - HEAD/CEPHALIC presentation

2nd MANEUVER

• Purpose: to determine the back of fetus to hear the fetal heart sound

  • If smooth hard and resistant surface - FETAL BACK

  • If angular nodulations - KNEES AND ELBOWS

3rd MANEUVER

• Purpose: to determine the degree of engagement by palpating the lower uterine segment

• If the presenting part is movable: NOT ENGAGED

  • If the presenting part is immovable: ENGAGED

    • HARD: HEAD

    • SOFT, GLOBULAR, LARGE: BUTTOCKS

4th MANEUVER

• Purpose: to determine the fetal attitude–relationship of fetus to each part or degree of flexion by grasping the lower quadrant of abdomen. It is done only if the fetus is in cephalic presentation.

• Full Flexion if the fetal chin touches chest

Psychological Changes of pregnancy

• The environment in which she was raised

• The messages about pregnancy her family communicated to her as a child

• The society and culture in which she lives as an adult

• Whether the pregnancy has come at a good time in her life

5 Psychological Changes of Pregnancy

1. Social Influences

2. Cultural Influences

3. Family Influences

4. Individual Differences

5. Partners Adaptation

Social Influences

• The woman and her partner feel during pregnancy and prepared to meet the challenges are related to them:

  • a. Cultural background

  • b. Personal beliefs

  • c. Experiences reported by friends and relatives

  • d. Current plethora of information available

Social Influences = Nurse’s Role

• 1. Teaching the woman about their health care option

• 2. Continue to work with other health care provider to “demedicalize” childbirth

Cultural influences

• Cultural beliefs and taboos can place restrictions on a woman’s behavior and activities regarding her pregnancy

• During prenatal visits, ask the woman and her partner if there is anything, they believe that should or should not be done to make the pregnancy successful and keep the fetus healthy.

Cultural Influences = Nurse’s Role

• 1. Supporting these beliefs shows respect for the individuality of a woman and her knowledge of good health.

• 2. Find a compromise that will assure a woman that these are not really harmful to a fetus but that still respects these beliefs

Family Influences

• Woman and her siblings were loved and seen as a pleasant outcome is more likely to have a positive attitude towards her pregnancy

• A woman who views mothering a positive activity is more likely to be pleased when she becomes pregnant than one who does not value mothering

• Negative Influences - woman and her siblings were blamed for the breakup of a marriage or a relationship.

Individual Differences

A woman’s ability to cope with or adapt to stress plays a major role in how she can resolve any conflict and adapt

Individual Differences = Nursing Role

• 1. Assessing and counselling pregnant woman

• 2. Fill the role of an attentive listener

Partner’s Adaptation

The more emotionally attached a partner is to a pregnant woman, the closer the partner’s attachment is apt to be to the child.

Factors that affect the pregnant woman’s decision making

• a. Cultural

• b. Past experience

• c. Relationships with the family members

Emotional responses that can cause concern in Pregnancy

• Grief

• Narcissism

• Introversion versus Extroversion

• Body image and Boundary

• Stress

• Depression

Confirmation of Pregnancy

• A medical diagnosis of pregnancy serves to date when the birth will occur and helps predict the existence of a high-risk status

• Pregnancy was diagnosed on symptoms reported by a woman and the signs elicited by a health care provider

Signs and symptoms of Pregnancy

• Presumptive Signs (Subjective Symptoms)

• Probable Signs (Objective Symptoms)

• Positive Signs of Pregnancy

Probable Signs (Objective Symptoms)

are findings and can verified by an examiner

Presumptive Signs (Subjective Symptoms)

are findings in connection with the body system in which they occur and are experienced by the woman but cannot be documented by an examiner

3 Positive Signs of Pregnancy

• a. Sonographic evidence of fetal outline. – fetal outline can be seen and measure by sonogram

• b. Fetal movement felt by examiner

• c. Fetal heart audible – doppler ultrasound reveal heartbeat (10th – 12th week of gestation

10 Presumptive Signs (Subjective Symptoms)

• a. Breast changes

• b. Nausea and vomiting

• c. Amenorrhea

• d. Frequent urination

• e. Fatigue

• f. Uterine enlargement

• g. Quickening

• h. Linea Nigra

• i. Melasma

• j. Striae Gravidarum

Quickening

fetal movement felt by woman

Linea Nigra

line of dark pigment forms on the abdomen

Melasma

dark pigmentation forms on face

Striae Gravidarum)

red streaks forms on abdomen

8 Probable Signs (Objective Symptoms)

• Chadwick’s sign

• Goodell’s sign

• Hegar’s sign

• Sonographic evidence of gestational sac

• Braxton Hick’s contraction

• Fetal outline felt by examiner through palpation

• Ballottement

• Laboratory Tests – blood serum and urine specimen to detect the presence of human chorionic gonadotrophin (hCG)

4 Laboratory Tests

• a. Serum pregnancy test – hCG appear as early as 24 – 48 hrs. after implantation and reach a measurable level about 50 unit/ml 7-9 days after conception

• b. Urine sample – concentrated such as a first urine in the morning

• c. Home Pregnancy Test -it takes 2-3 mins. to complete and have a high degree of accuracy

• d. Early prenatal care – is the best safeguard to ensure successful pregnancy.

Chadwick’s sign

color change of the vagina from pink to violet

Goodell’s sign

softening of the cervix

Hegar’s sign

softening of the lower uterine segment

Braxton Hick’s contraction

periodic uterine tightening

Ballottement

the fetus can feel through bimanual examination

RECOMMENDED WEIGHT GAIN DURING PREGNANCY

• weight gain of 11.2 to 15.9 kg (25 to 35 lb) is recommended

• approximately 0.4 kg (1 lb) per month during the first trimester and then 0.4 kg (1 lb) per week during the last two trimesters

• excessive if it is more than 3 kg (6.6 lb) a month during the second and third trimesters

• less than usual if it is less than 1 kg (2.2 lb) per month during the second and third trimesters.

Physiologic Changes of Pregnancy

They can categorize as local (confined to the reproductive organs) or systemic (affecting the entire body)

4 Reproductive System Changes

1. Uterine Changes

2. Cervical changes

3. Vaginal Changes

Uterine Changes

• increase the size of the uterus to accommodate the growing fetus. The uterus increases in length, depth, width, weight, wall thickness and volume

• Braxton Hick’s contraction

• Amenorrhea

• Hegar’s signs

• Ballottement

Cervical changes

becomes more vascular and edematous

Vaginal Changes

increase vascularity of the vagina

Ovarian Changes

active production of estrogen and progesterone

Uterine Changes = Length

from 6.5 - 32 cm;

Uterine Changes = Width

from 4cm to 24 cm;

Uterine Changes = Weight

increases from 50g to 1000g;

Uterine Changes = Depth

increases from 2.5 cm to 22 cm

Uterine Changes = Uterine Wall

thickens from 1cm to 2cms

Uterine Changes = Volume

increases from 2 ml. to more than1,000 ml. can hold a total of 4000g at term (7-lb (3.175 g.) fetus, 1,000 ml. amniotic fluid

Fundus height at 20-22nd week

reaches the level of the umbilicus

Fundus height at 36th week

touches the xiphoid process

Fundus height at 38th week

fetal head settles into the pelvis

Hegar’s signs = Uterus

extreme softening of the lower uterine segment

Ballottement

the fetus can be felt to bounce or rise in the amniotic fluid

Goodell’s sign = Cervix

softening of the cervix

Chadwick’s sign - Vagina

changes in color from light pink to a deep violet

Breast changes

• Feeling of fullness, tingling or tenderness because of increased estrogen level

• Breast size increase because of the growth in mammary alveoli and in fat deposit

• Areola of the nipple darkens and the diameter increases from about 3.5 cm (1.5 inches) to 5cm or 7 cm (2 or 3 inches)

Respiratory system

• Shortness of breathing is common

• Marked congestion or stuffiness – due to increase estrogen

Immune system

• IgG production decreases

• WBC simultaneously increases

Muscular system

• Calcium and Phosphorus needs are increased

• Gradual softening of the pelvic ligaments

• Wide separation of the symphysis pubis

Urinary System

• Glomerular Filtration rate increases

• BUN and Plasma Creatinine decreases

• Renal threshold for sugar decreases

• Frequent urination in 1st trimester, normalizes in 2nd trimester, frequent urination in 3rd trimester

Gastrointestinal system

• Slow emptying time of the stomach

• Nausea and vomiting

• Decreased pH of the saliva

• Hemorrhoids is common due to constipation, pressure of the uterus, slow peristalsis

Cardiovascular system

• 30-50% increase in the total cardiac volume

• Physiologic Anemia of pregnancy may occur

• Increases heart rate

• Palpitations is common

• Edema and varicosities of the lower extremities

Endocrine changes

• Increased thyroid and parathyroid hormone production

• Palmar erythema

• Insulin production is decreased early during pregnancy and increases after the 1st trimester

• Prolactin, Melanocyte-stimulating hormone, and human growth hormone of the pituitary gland increase,

• ESTOGEN AND PROGESTERONE produced

• Placenta as a transient endocrine organ

• Colostrum can be expelled as early as 16 weeks

• Increase vascularity

• Enlarge and protuberant nipples

First Trimester: Accepting the Pregnancy

woman and partner both spend time recovering from shock of learning they are pregnant and concentrate on what it feels like to be pregnant. A common reaction is ambivalence, or feeling both pleased and not pleased about the pregnancy.

Ambivalence

refers to the interwoven feelings of wanting and not wanting feelings which can be confusing to an ordinarily organized woman

Health care plan: First Trimester

• Routine sonogram – to assess for growth anomalies and can be a major step in promoting acceptance because women can see a beating heart or fetal outline or can learn the sex of their fetus.

• First prenatal visits - hearing their pregnancy officially diagnosed at a first prenatal visit is another step toward accepting a pregnancy

Second Trimester: Accepting the Baby

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

Third trimester: Preparing for parenthood

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