NU 330 - EXAM 2 - PP1 (Antepartum, Physical & Psychologic Changes of Preg.)

Gravida and Para

• Gravida: Number of times a woman has been pregnant

– Primigravida = first time pregnancy

• Gravida 1

– Multigravida = subsequent pregnancy(ies)

• Example: Gravida 4

• Para: number of pregnancies that reached 20.0

weeks; whether or not born alive

Gravida/Para = GTPAL

Para breaks down into “TPAL” to communicate pregnancy result:

• T = Term: Number of pregnancies delivered at or after 37.0 weeks gestation

• P = Preterm: Number of pregnancies delivered at or between 20.0 weeks and 36.6 weeks gestation

• A = Abortion: Number of pregnancies ending before 20.0 weeks gestation (includes spontaneous and mechanical abortions)

• L = Living: Number of current living children

– Multiples (twins, triplets, etc. are added in the living children tota

Signs of Pregnancy

• Subjective

• Objective

• Diagnostic

Presumptive Signs: A Woman's Subjective Experience

• Amenorrhea

• Nausea and vomiting (morning sickness)

• Extreme fatigue

• Breast changes (soreness, tingling)

• Urinary frequency

• Quickening: First recognition of fetal movement

-Primigravida; may first feel between 18-20 weeks or sooner

-Multigravida; may first feel between 16-18 weeks or soone

Probable Signs: An Examiner's Objective Findings

• Goodell’s sign (softening of the cervix)

• Chadwick’s sign (blue-purple discoloration of the cervix)

• McDonald's sign (flexing of uterine fundus within maternal abdomen, increase in fundal height)

• Enlargement and softening of uterus

• Braxton Hicks contractions

• Changes in skin pigmentation (linea nigra, straie gravadarium, chloasma)

• Positive pregnancy test per blood, urine

Positive Signs: Definitive Signs of Pregnancy

• Auscultation of fetal heartbeat by Doppler device

– Begins about 10–12 weeks' gestation

• Fetal movement palpable by examiner

– Palpable after about 20 weeks’ gestation

• Visualization of the fetus by ultrasound

– First trimester transabdominal or transvaginal ultrasound

▪ Gestational sac visible 4–5 weeks after Last Menstrual Period (LMP)

– Biparietal diameter predicts Estimated Date of Delivery (EDD) within 7–10 days

Estimated Date of Delivery (EDD)

• Nagele's Rule: How the estimated date of delivery (EDD or due date) or also known as estimated date of confinement

• 
  

(EDC) is calculated:

-Take the first day of the last menstrual period (LMP), count back 3 months, and then add 7 days (based on a 28 day cycle)

LMP (-) 3 months (+) 7 days = EDD

• EXAMPLE: LMP AUG 5th

• -3 months=May

• + 7 days=May 12th

• Not accurate for women

– With very irregular periods

– With amenorrhea due to breastfeeding

Ovarian Changes

• Ceases ovum maturation during pregnancy

• The next developing corpus luteum pauses it’s work

• Human chorionic gonadotropin (hCG) secretion maintains the corpus luteum

• The corpus luteum secretes progesterone until placental production of progesterone is sufficient (around gestational week 7)

Uterine Changes

• Increases in size from 2.5 ounces to 2.5 pounds

• Capacity increases from 10mL to 5000mL

• Estrogen & progesterone thickens the uterine wall during the first three months

• Hegar sign; softening of lower uterus (6-8 weeks) notedwith bimanual exam

• Braxton Hicks contractions:

– Irregular, painless contractions

– Can occur throughout pregnancy

– May be confused with true labor

Cervix Changes

– Closed and thick prior to and during first pregnancy

– Development of mucous plug

• Thick, sticky mucous sealing the endocervical canal

• Is a protective mechanism

• Expelled when cervix starts to thin and dilate

– Goodell sign

▪Softening of cervix at 4-6 weeks gestation

– Chadwick sign

▪Bluish-purple discoloration at 4-12 weeks

– Opens from 0-10cms during labor process

Vaginal Changes

• Thickening of mucosa

• Increase in vaginal secretions (due to estrogen), slightly more acidic = increased risk of yeast infections (candida albicans)

• Patient education:

– Symptoms of infection (odor, yellowish-gray discharge, perineal itching)

– Wear cotton underwear

– Wipe from front to back

– Teach Kegel exercises

Breast Changes

• Increase in size (most in the first 20 weeks)

• Increased c/o tingling and heaviness (1st and 3rd trimester)

• Nipple and areola pigment can darken

• Straie gravadarium (stretch marks) can occur

• Follicles of Montgomery; enlarged sebaceous glands

• Colostrum; “first milk” (yellow)--present in 3rd trimester, some women’s breasts may leak, and can wear a breast pad or collection device

Respiratory System Changes

• Breathing changes from abdominal to thoracic

• Increased risk of hyperventilation and SOB

– Patient education: normal in pregnancy to be slightly SOB (especially in the 3rd trimester) with or after activity, encourage regular exercise

• Oxygen consumption increases

• Vascular congestion of nasal mucosa

– Patient education: Increased risk of epistaxis and nasal stuffiness, avoid vigorous nose blowing, normal part of pregnancy

Cardiovascular Changes

• Uterus exerts pressure on diaphragm

• Blood volume increases by 40-50% in 1st and 2nd trimesters and slows in 3rd trimester

• Pulse increases by 10-15 bpm during pregnancy

• BP decreases slightly in 1st and 2nd trimester (increased risk of postural hypotension); then BP rises to normal level in 3rd trimester; however elevated BP may occur in 3rd trimester (gest HTN, pre-eclampsia)

• Decrease in systemic and pulmonary vascular resistance

• Increase in cardiac output

• Stasis of blood flow in lower extremities-- dependent edema, varicose veins and hemorrhoids can occur

• Supine hypotensive syndrome

– Vena cava syndrome

• Total erythrocyte volume increases

– Normal slightly elevated WBC count

• Physiologic anemia of pregnancy

– Normal Hemoglobin in pregnancy: 12-16mg/dL

– Normal Hematocrit in pregnancy: 32-42%

*Prenatal vitamin and iron supplement added to increase RBC production and volume

Vena Cava 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

-Maternal hypotension can quickly lead to fetal deoxygenation or decelerations in the fetal heart rate.

-Recommend women in the third trimester avoid laying supine when possible. The best

position is left lateral

Gastrointestinal Tract Changes

Gastrointestinal Tract Changes

• Nausea and vomiting

– Morning sickness

• Nausea– 80% of pregnancies, vomiting– up to 40%

• Patient education: Eat small frequent meals, avoid greasy foods, eat crackers, toast, drink weak tea, sip seltzer water before arising in AM

– Hyperemesis Gravidarum

• Occurs in up to 3% of pregnancies

• Intractable vomiting during pregnancy

• Causes weight loss and volume depletion

• Ketonuria (ketones in urine)

• Treated with IV rehydration, vitamins, anti-emetic

• Hyperemia (softening and bleeding of gums)-- hormonal influence, increase in saliva

– Patient education: Use soft toothbrush, brush after each meal

• Heartburn— Due to relaxation of cardiac sphincter

– Patient education: TUMS ok, eat smaller more frequent meals, avoid lying down after meal, avoid greasy foods

• Gallstone formation: increased risk due to elevated cholesterol and smooth muscle relaxation

– Gallbladder emptying may be slow

– Patient education: If discomfort occurs, avoid greasy food

• Bloating and constipation-smooth muscle relaxation, delay in gastric emptying, decreased peristalsis; displaced stomach and intestines

– Patient education: Increase fiber in diet, eat easily digestible foods, smaller, more frequent meals

• Hemorrhoids: Due to constipation, pressure, and straining

– Patient education: Avoid straining to have a BM, increase fluids in diet, avoid constipation by increasing fiber in diet, avoid standing for long time

Weight Gain Recommendations:

Normal weight woman = 11.5 - 16 kg (25 - 35lb)

Healthy Food Choices:

• Carbohydrate sources-- Dairy, fruits, veggies, whole-grain breads and cereals

• Protein-- 60g/day

– Meat, fish, poultry, eggs, cheese

• Calcium and phosphorus--

– Calcium-- 1000mg/day (4 cups of milk or equivalent)

– Phosphorus— 700mg/day

– Milk, cheese, yogurt, calcium-fortified orange juice, nuts, dark green leafy veggies

• Iron--

– Needed for growth of fetus, placenta, and expanding

maternal blood volume

– Inadequate intake can lead to anemia

– Increase intake through prenatal vitamin

– Low iron increases risk for lower birth weight, preterm labor, postpartum hemorrhage

• Inadequate weight gain may increase risk for small-for- gestational-age neonate, preterm labor, preterm delivery

• Prenatal Vitamin is ESSENTIAL! Includes folic acid, which reduces risk of neural tube defects

Foods to Avoid in Pregnancy:

• In large amounts; shellfish, swordfish, mackerel, albacore tuna (high levels of mercury)

• Soft cheeses (ie: brie, unpasteurized blue cheese, can be a risk for listerosis)

• If not properly stored, cold lunch meats/deli meats (listeriosis risk)

• PICA; craving of non-nutritive substances

– May be symptom of anemia

Urinary System Changes

• Increased risk of urinary stasis and infection due to compression of ureters, hormonal changes, and perineal hygiene

• Glomerular filtration rate increases by 50%

• Patient education:

– s/s of UTI (burning, frequency, urgency, voiding small amounts)

– Increased frequency in 1st and 3rd trimester (pressure on bladder)

– Do Kegel exercises

Integumentary Changes

• Increased pigmentation

• Increased sweating

• Rate of hair growth decreases

• Increased production of melanin- stimulating hormone

– Linea nigra (line down middle of abdomen)

– Facial chloasma (melasma gravidarum)

– Straie gravadarium (stretch marks)

– Vascular nevi “spiders” (angiomas)

Musculoskeletal Changes

• Pelvic joints relax

– Loose waddling gait due to the relaxin hormone

– Changes center of gravity

• Lordosis: sway back posture; compensates for growing abdomen=possible lower backache

• Separation of rectus abdominis

• Patient education:

– Pelvic rock/pelvic tilt

– Monitor and adjust posture

– Daily exercise (under provider guidance

Neurological Changes

• Mid-frontal HAs common in 1st and 2nd trimester due to tension/hormonal changes

• Dizziness potential increased due to postural hypotension or hypoglycemia

• Sleep problems common in pregnancy

• Tingling sensations in hands--normal, most often related to hyperventilation or edema

- Eye Changes: Decreased intraocular pressure

Endocrine System and Hormones of Pregnancy

• hCG (human chorionic gonadotropin):

– Decreased level = Threatened abortion

– Increased level = Multiple pregnancy or hydaitiform mole (molar pregnancy; hCG-producing cells present but no fetus or placenta

Ectopic Pregnancy

Abnormal implantation of the fertilized ovum outside of the uterine cavity

-Symptoms: Lower abdominal pain, vaginal bleeding. If fallopian tube ruptures: Increased abdominal pain, referred shoulder pain, hemorrhage, and possible shock.

six key hormones in preg

The Placenta

• Develops at the uterine wall attachment site

• Completion of maternal-placental-fetal circulation occurs about 17 days after conception, performing metabolic and nutrient exchange between the fetus and the maternal circulation

• Two portions; maternal (vascular side) and fetal (shiny side)

The Umbilical Cord

-Consists of one large vein, two small arteries, and a substance called Wharton’s jelly which is a specialized connective tissue and helps to prevent compression of the arteries and vein

-There are no sensory endings in the cord

-True knots and nuchal cords (around the neck) are caused by fetal movements in utero

Psychologic Response to Pregnancy

• Changes affected by age, support system, maturity, coping mechanisms, mental and health status, planned or unplanned pregnancy

• Duvall’s Eight-Stage Family Life Cycle: Stage II: Birth of 1st child=new parent role=integration into family

• Rubin’s theory: Maternal role (tasks of pregnancy)

1. Safe Passage

2. Acceptance by others

3. Binding-in to the child

Mother’s Response to Pregnancy

• Emotional make-up influence-excited, surprised, planned or unplanned

• Sociologic/cultural: strong emphasis placed on family; mother revered in family

• Acceptance/rejection of pregnancy: introversion, mood swings, changes in body image, timing of pregnancy, worries about changes in relationship

– Ambivalence: c/o increased physical discomforts, depression, dissatisfaction with changing shape, delay in obtaining prenatal care

– Physical basis: hormonal shifts

– Transition period, changing roles?

– Financial considerations

– Fear of labor and birth

S.O.’s Response to Pregnancy

• Support impacts woman’s ability to accept pregnancy

• Planned or unplanned pregnancy?

• Financial concerns-can we live on one income?

• Change in relationship, roles?

• Couvade:

– Observance of rituals, taboos to signify transition to fatherhood

– Unintentional development of physical symptoms experiencing signs and symptoms

▪ Indicates higher degree of parental role preparation

Sibling’s Response to Pregnancy and New Baby + Grandparents Response

• Discuss what will change and what will stay the same

• Spend individual time with child after baby arrives

• Sibling classes prior to birth (3+ years of age and older)

• Consistency-- continue same people, places, things

• If need crib-- move several months prior to birth

• Avoid co-sleeping, teach safe sleep

• Delay toilet training due to possible regression?

• Bring to prenatal visits?

• Child present at birth??

Grandparents Response

• Change in life, feel older, excited, etc.

• Provide solicited and unsolicited advice

• Understand changes in parenting since they raised their own children

– Grandparent education/family-centered care

• Clarify roles of grandparents

– Gifts

– Babysitting

Prenatal Management

• No Risk Factors Identified:

– Every 4 weeks following initial visit (8-12 weeks) until week 30- 32 weeks

– Then every 2 weeks until week 36

– Then every week until delivery

– Over 41 weeks: twice a week (NST + provider visit)

• With Risk Factors:

– Every 2 weeks until 30-32 weeks, then every week until delivery

– Consider weekly or bi-weekly NST’s starting at 28 weeks

– May be more often depending upon risk factors

– May add frequent ultrasounds as we

Goals for Initial Assessment:

• Establish baseline (weight, VS, physical assessment)

• Gather a complete health history

• Current pregnancy dating with last menstrual period

• Any complaints of signs/symptoms (N&V, fatigue, etc.)

• Any complications (bleeding, cramping, etc.)

• Past pregnancy history (number, complications, # of living children, length of labor, spontaneous/planned abortions

• Gynecological history: last PAP, infection history, surgeries, age of menarche, regularity of periods, contraceptive history, infertility?

• Current medical history: blood type, exercise routine, meds, alcohol, tobacco, allergies, exposure to teratogens, immunizations, diagnoses (diabetes, cancer, etc.)

• Past medical history: childhood diseases and surgeries, past hospitalizations, exposure to HIV, etc.

• Family medical history: history of diabetes, heart problems, multiple gestations, mental illness, congenital birth defects, deceased family members

• Religion and cultural preferences: race/ethnic groups

• Occupational history: heavy lifting, exposure to chemicals

• Partner’s history: genetic, drugs and alcohol and smoking

• General info: age, education, economic level, concern for domestic violence, support systems, preference for delivery location, breast or bottle feeding, preferred newborn provide

Antepartum Testing (1st Trimester Lab Work)

• Rubella titer (immune or non-immune)

• Blood type (ABO and RH factor)

• Hepatitis B screen

• VDRL, RPR, or treponema

• HIV screen

• CBC: Hemoglobin: 12-16mg/dL, hematocrit: 32-42% (and also repeated in 3rd trimester)

• Illicit drug screen if at risk (done at 1st visit and intermittently throughout pregnancy if continues to be at risk for using)

• Urinalysis for protein; glycosuria, ketonuria, urine culture

• Pelvic exam with pap smear

Electronic Fetal Monitoring

• Doppler can first detect FHR between 10-12 weeks gestation

• Can be difficult to monitor FHR or obtain a reactive strip before ~28-30 weeks (EKG thingy)

Count baby kicks

-Count baby’s movements every day, once a day, near the same time each day.

-Start at 28.0 weeks gestation

-Set a timer and record the time it takes to feel 10 movements

-Call or go to the hospital if a change in usual movements is noted

Rh Factor

• If mom Rh- and mate Rh+ = 60% chance of Rh+ baby

– If Rh- maternal and Rh+ fetal blood mixes, this could stimulate the production of antibodies within the maternal circulatory system (Rh iso-immunization) that can cross the placenta and destroy fetal RBCs

• Maternal antibody testing (indirect coombs) at 28 weeks

• If mom is Rh negative (A-, B- AB- O-), she should receive IM or IV injection of Rhogam or Rhophylac at the following times:

– At 28 weeks gestation and after amniocentesis, pregnancy loss, and within 72 hours after delivery only if the neonate blood type is Rh + or unknown blood type

– Neonatal blood work: If neonate has a + indirect coombs, monitor for anemia and elevated bilirubin

Rh Isoimmunization

This is the process that we try to protect against by giving Rhogam or Rhophylac to the Rh negative mother (when indicated)

Diabetic Screening

• “Glucose Tolerance Test”

• Performed between 24-28 weeks of pregnancy

• Procedure: Fasting BS drawn (fasting blood sugar target level is < 95 mg/dL), then mother drinks Glucola (50g oral glucose solution). Blood is drawn again at 1 and 2 hours after finishing entire drink.

• 1 hour blood sugar target level is <140 mg/dL

• 2 hour blood sugar target level is <120 mg/dL

• If levels are above target, diagnosed with Gestational Diabetes Mellitus

– Diet Controlled (initial diagnosis and treatment plan)

– Insulin Controlled (if then need to prescribe insulin to keep blood sugars stable)

Gestational Diabetes

Gestational Diabetes

• Gestational diabetes treatment plan

– Referral to diabetic educator

– Minimal follow-up needed after delivery: condition usually resolves

– Pregnancy is now considered high risk

• Increase frequency of prenatal visits

• Increase frequency of ultrasounds to monitor fetal well being and fetal growth

• Start non-stress tests at 28 weeks gestation to monitor fetal well being

• Increased risk of developing type 2 diabetes later in life

• These same risks and plans apply to patients with Type 1 and Type 2 diabetes

Non-Stress Test (NST)

• The hallmark of outpatient antenatal testing for fetal well- being

– Can begin at or after 28.0 weeks gestation

• Outpatient procedure using external fetal monitor (EFM)

• Reactive = 2 accelerations lasting at least 15 seconds each, reaching at least 15 beats above baseline, occurring during a 20 minute time frame

• Non-reactive = no or insufficient accelerations; continue to monitor; notify provider, may order a BPP (biophysical profile)

*Example of a reactive non-stress test (N ST). Accelerations of 15 beats/min lasting 15 seconds with each fetal movement (F M). Top of strip shows fetal heart rate (FHR); bottom of strip shows uterine activity tracing. Note that F HR increases (above the baseline of 130 bpm) at least 15 beats and remains elevated for at least 15 seconds before returning to baseline.

*Non-stress test = there are no uterine contractions causing stress

Biophysical Profile (BPP)

BATMN
• NST & Ultrasound with a score of 0 to 2 for each:

– Breathing movements of fetus

– Amniotic fluid volume

– Tone of fetus (flexed or extended)

– Movements (gross body)

– Non-Stress Test (reactive=2, non- reactive=0)

Height of the fundus at various weeks of pregnancy

-Can be difficult to evaluate uterine size in obese women, multiple gestations, or in presence of uterine fibroids

-McDonald Method = fundal height

-Centimeters correlate with weeks of gestation

-Lower than normal = off on dates vs. SGA baby

-Higher than normal = multiple pregnancy, LGA baby, hydatiform mole, or hydramnios?

Referrals for Support and Education

• Young Parents Network (YPN)

• Women, Infants and Children Nutrition program (WIC)

• Childbirth Education Classes

• Pre-Pregnancy Classes

• LaLeche League (breastfeeding support)

• Birthright

• Lactation Consultants, Doulas