L2 CH11

what are the presumptive signs of pregnancy?

• the s/sx i think i might be pregnant, i feel it

• fatigue, breast tenderness, N/V, amenorrhea, urinary frequency, hyperpigmentation of skin, quickening (feels baby move in abd), uterine & breast enlargement

what are the probable signs of pregnancy?

• these are objective signs

• braxton hicks contractions (sporadic tightening of abd)

• positive pregnancy test

• abdominal enlargement

• ballottement (feels something bouncy on vaginal exam)

• goodell sign (softening of cervix)

• chadwick sign (bluish purple coloration of the vaginal mucosa & cervix)

• hegar sign (softening of the lower uterine segment or isthmus)

what are the positive signs of pregnancy?

• ultrasound verification of embryo or fetus

• fetal movement felt by experienced clinician

• auscultation of fetal heart tones via doppler

explain hormonal & physical maternal adaption: estrogen, progesterone, serum prolactin, oxytocin, human choronic somatommaotropin (human placental lactogen), relaxin (where are they produced & what do they do)

1. Estrogen

• Secreted by the corpus luteum until the placenta takes over

• Inhibits secretion of FSH & LH from anterior pituitary suppressing ovulation

• Stimulates growth of the maternal tissue: uterus, breast tissue, genitalia

• Relaxes joins & ligaments

• Increases vascularity 

2. Progesterone

• Secreted by the corpus luteum until the placenta takes over

• Inhibits secretion of FSH & LH from anterior pituitary suppressing ovulation

• Relaxes smooth muscle decreasing uterine contractility

• Maintains uterine lining

• Modulates immune function 

3. Serum Prolactin

• produced by AP

• Prepares breasts for lactation

4. Oxytocin

• produced by hypothalamus

• Stimulates contractions & milk ejection

5. Human choronic somatommotropin (human placental lactogen)

• produced by placenta

• Acts as growth hormone

• Decreases maternal metabolism of glucose

• Increases fatty acids for metabolic needs

6. Relaxin

• produced by corpus lutuem

• Relaxes muscles, bones, ligaments, joints, blood, vessels

• Softens & lengthens the cervix as childbirth begins 

• Highest levels in 1st trimester

how does the reproductive system: uterus adapt? what shape is it before pregnancy vs during? what does the baby do? what happens after 3 months?

• uterus is a size of a fist & it gets big enough to accommodate babies

• increases in size, weight, length, width, depth, volume, & overall capacity

• pear shape (before) → ovoid shape

• enhances uterine contractility; braxton hicks contractions

  • uterus contract often

• ascent into abd after first 3 months

  • enlarging uterus goes into abd cavity

• hegar sign- softening of lower segment of uterine lining (6 wks) related to increased vascularity

what should the fundal height be after 20 weeks of gestational age?

after 20 weeks of gestational age the height of the fundus should correspond aka 20 weeks should equal to 20 cm OR ± 2cm

how to measure fundal height?

• measure fundal height by locating symphysis pubis & measuring it to the fundus

• measured while lying supine

what information does the fundal height tells us?

• tells us gestational age & fetal well being

• if measurement is higher or lower than expected the provider may suspect growth restriction or macrosomic baby

how does the reproductive system: cervix adapt? what changes? what does cervix form?

• softens (goodell sign)

• forms mucus plug to protect fetus

• increased vascularization (chadwick sign) → bluish/purple discoloration

• ripens about 4 wks before birth (prepares for labor by softening)

how does the reproductive system: vagina adapt? how is the vagina more susceptible to edema & varicosities?

• increases vaginal mucosa

  • thicker d/t hormonal stimulation

• loosening of connective tissue

  • becomes softer to prepare for birth

• lengthening of vaginal vault

  • lengths as pregnancy progresses to accommodate changes

• increased vascularity

  • more blood flow & making it more sensitive → increased sexual interest

• increased congestion, relaxed vessels, heavy uterus → edema & varicosities of the vulva

• chadwick sign (appears 6-8 wks)

what is leukorrhea in the vagina? when does it occur? what does acidity have to do with this?

• leukorrhea: white/slight gray mucoid/discharge

• occurs in response to cervical stimulation by estrogen & progesterone → forms mucus plug AKA OPERCULUM → a barrier against bacterial invasion during pregnancy

• vaginal secretions become more acidic & protects against some bacteria but leaves the women susceptible to yeast infections

how does the reproductive system: ovaries adapt? (when does it enlarge until & what does it stop

• enlargement until 12th to 14th wk of gestation

• cessation of ovulation

how does the reproductive system: breasts adapt?

• increases in size & nodularity

• increase in nipple size → more erect & pigmented (darker)

• production of colostrum by 16 wks

  • antibody rich, yellow first milk (first breast milk after birth)

• montgomery tubercles (more pronounced, the small bumps around nipple)

  • sebaceous & sweat glands lubricate, anti-infective, protect nipples during breastfeed

• increased vascularity

what are the gastrointestinal system adaptations? (think about the mouth, stomach, gut)

• morning sickness

  • d/t rising hCG & estrogen

• decreased GI peristalsis

  • progesterone relaxes smooth muscle → constipation

• hemorrhoids

  • enlarging uterus increases pressure on pelvic area → constipation/straining → swollen veins

• ptyalism (excessive salivation)

• bleeding gums (red, swollen, friable)

  • pregnancy causes increased vascularity & blood flow → more likely to bleed

  • gingivitis

• heart burn

  • progesterone relaxes lower esophageal sphincter → stomach acid goes up ALSO keep in mind how stomach is pushed upwards

what are the cardiovascular system adaptations? (how much does blood volume, HR, cardiac output increase by, what decreases, what also happens)

• blood volume increases by 40-50%

• HR increases by 10-15 BPM

• cardiac output increases by 30-50%

• blood pressure decreases initially until about 32 wks when it returns to pre-pregnant level d/t vasodilation of blood vessels & progesterone relaxation

• hypercoagulation of pregnancy

• dependent edema

what are blood components are impacted by maternal changes? (what increases, decreases, stays the same)

• increases

  • RBC (makes more O2 for the fetus)

  • plasma volume (results from hormonal factors, water & sodium retention)

    • more plasma = less RBC (dilution)

  • fibrin, plasma, clotting factors → why pregnancy is a hypercoagulable state

• stays the same

  • hemoglobin

• decrease: hematocrit (% of total BV)

what are pregnant people at risk for in the cardiac aspect? what do 95% of women develop d/t cardiac hypertrophy?

• CV diseases

• they develop murmurs, palpitations, arrhythmias

what causes cardiac hypertrophy in pregnancy?

• displaced by the enlarging uterus which pushes up the diaphragm & shifts the heart

• increase in blood volume → heart works harder → mild increase in heart size

what is the physiological anemia of pregnancy? why does this happens & when is it the most dramatic? when is a person considered anemia during the 1st or 3rd trimester or 2nd trimester? what about hematocrit count to be considered anemic?

• increase blood volume > increase RBCS

  • huge increase in blood volume & RBC can’t keep up

• happens b/c of hemodilution & most dramatic in the 2nd trimester

• 1st or 3rd trimester: <11 g/dL → anemic

• 2nd trimester <10.5 g/dL or a HCT of 32% or less

what is supine hypotension (inferior vena cava syndrome)? how can we prevent this?

• when a pregnant woman lies on her back & presses down on the inferior vena cava causes BP to drop

• if BP drops, the fetus won’t get enough blood

• prevent this by keeping pregnant women' off their backs during birth so fetus gets enough blood

what are the respiratory system adaptations? (how are they breathing, what increases, what does increased vascularity cause, what is the role of estrogen & progesterone)

• breathing more diaphragmatic than abdominal d/t increase in diaphragmatic excursion, chest circumference, tidal volume → thoracic breathers relying more on chest

  • as uterus enlarges it pushes diaphragm up

  • chest expands more → rib cage relaxes (estrogen) to expand easily, decreased resistance (progesterone) so easier to breathe

  • incr. tidal volume b/c mom takes in more air w/ each breath

• increase oxygen consumption (20-40%), RR, CO2 blown off

  • increase oxygen needs for mom & baby

• increase secretion of bicarb from the kidneys → can cause respiratory alkalosis

• congestion secondary to increased vascularity (capillary engorement)

  • estrogen increases blood flow & vascularity → nasal stuffiness/congestion, bloody noses, voice changes, susceptible to respiratory infections

what hormone is responsible for more air inhaled with each breath? how does tidal volume, vital capacity, inspiratory volume, expiratory volume, & total lung capacity change? (is it increased, decreased, or unchanged)

• progesterone is the hormone

• increased

  • tidal volume (more air in & out), inspiratory volume (takes in more air)

• decreased

  • expiratory volume (less air exhaled)

• unchanged

  • vital capacity, total lung capacity

what is the renal/urinary system adaptations? (what happens to the kidney, what increases, what happens if you lie on the back vs on the side, what are they at risk for)

• dilation of renal pelvis; elongation, widening, & increase in curve of ureters

  • d/t relaxation from progesterone

• increase in length & weight of kidneys

  • d/t increase blood flow

• increase in GFR, increase urine flow & volume

  • increase in blood flow causes kidneys to filter more

• increase in kidney activity when woman lies down

  • lying down brings blood flow to the heart

• greater increase in later pregnancy with woman lying on side

• prone to UTI & pylenephritis since urine sits there d/t dilation & lengthening

what are the muscloskeletal adaptions? (what happens, what gait, what are they at risk for)

• softening & stretching of ligaments holding sacroiliac joints & pubis symphysis

  • prepare for child birth

• postural changes: increased swayback & upper spine extension

• forward shifting of center of gravity → at risk for falls

• increase in lumbosacral curve (lordosis), compensatory curve in cervicodorsal area → back pain

• waddle gait

what is diastasis recti abdominis? is it dangerous? what should we do?

• when muscles in abd stretch & lose tones

• not dangerous

• do more exercises after baby is born

what are the integumentary system adaptions? (what changes in the skin, what declines & increases)

• hyperpigmentation; mask of pregnancy (facial melasma/chlosma) → dark patches of skin that resolves after pregnancy

• linea nigra (dark vertical line in the middle of the abd)

• striae gravidarum (stretch marks)

• varicosities (swollen twisted vessels) d/t increases blood volume

• vascular spiders (damaged vessels)

  • estrogen dilates vessels

• palmar erythema (itchy palms)

  • incr. estrogen → increase blood

• decline in hair growth

• increase in nail growth d/t faster metabolism

what happens to the endocrine system: thyroid gland, pituitary gland, pancreas, adrenal gland, prostaglandin, placental secretion?

1. thyroid

• slight enlargement, increased activity & BMR (basal metabolic rate)

2. pituitary

• enlargement

• decrease in TSH (thyroid stimulating hormone) & GH

• inhibits FSH & LH

• increase prolactin & MSH(melanocyte stimulating hormone), gradually oxytocin w/ fetal maturation

3. pancreas

• insulin resistance d/t hPL & other hormones in second half of pregnancy (don’t respond to insulin as strongly)

  • more glucose in body & tries to compensate by producing more insulin

4. adrenal

• increase in cortisol & aldosterone secretion (causes more sodium & water retention)

5. prostaglandin

• increases near labor to aid cervical ripening & uterine contractions

6. placental

• secretes hCG, hPL, relaxin, progesterone, estrogen

what are the goals of nutrition & pregnancy?

• optimize maternal & fetal health

• lowering the number of low birth weight babies

• optimizing maternal weight gain (not too much or too little)

• ensuring mom receives adequate nutrtients

• identify risk factors for obesity & diabetes

how much would should you gain when you are pregnant? what if you are a normal weight (BMI 18.5-24.9), how much weight should you gain?

• depends on BMI

• gain 25-35 lbs

how many additional calories do we need? what vitamins need to be increased?

• additional 300 calories

• increase folic acid (600 mcg), calcium, iron

why are prenatal vitamins prescribed routinely? why does iron, folic acid, calcium need to be increased?

• prescribed as a safeguard to less than optimal diets

• iron & folic acid requirements are too big to be met through diet alone

  • iron is essential for fetal growth & brain development, prevent maternal anemia

  • folic acid is essential before & early into pregnancy to prevent neural tube defects

  • calcium is essential for development of fetal bones & teeth, supports maternal bone health

what are the recommended doses for iron, folic acid, and calcium? what are the dietary sources for each?

• iron (27 mg)

  • red meat, poultry, seafood, beans, lentils, fortified cereals/breads, nuts, green leafy veggies

• folic acid (400-800 mcg)

  • much higher if prior pregnancy had neural tube defect

  • prenatal vitamins

• calcium (1000 mg/day)

  • milk, yogurt, cheese, fortified plant milks, calcium fortified juices, dark greens, tofu, broccoli, bokchoy

what info should the nurse gather during nutritional assessment

• usual intake

• diet modifications

• food allergies

• meds/supplements

• cultural practices

• adequacy of resources (do they have food, are they getting enough)

what are the special considerations for nutrition?

• cultural variations

  • don’t assume everyone follows the same diet

  • consider what foods they usually eat, religious restrictions, fasting practices

• gluten free diets

• lactose intolerance

• vegetarianism

• pica

  • eating dirt, clay, raw starch, paper, toilet paper, charcoal, baby powder, chalk, ashes, ice, freezer frost, etc

what are the 3 main substances pregnant people with pica eat? what can it cause?

• soil or clay (geophagia)

  • causes iron deficiency anemia & low gestational weight gain, constipation, can be toxic & cause parasitic infection or hypokalemia

• ice (pagophagia)

  • cause iron deficiency anemia, tooth fractures, jaw pain, freezer burn injuries, low gestational weight gain

• laundry starch (amylophagia)

  • iron deficiency, abd discomfort, poor glucose control, excessive weight gain

what is not recommended to eat when pregnant? why?

• artificial sweeteners

  • not evident but can cause high birth weight, increased preterm birth risk, altered childhood preference for sweets, increases rate of higher weight

• fish high in mercury → damages baby’s developing brain

• food borne illnesses (listeria) → from raw or unpasteurized milk

• caffeine → low birth weight, miscarriage

• alcohol (can’t drink) → fetal alcohol spectrum disorder

what are some nutritional considerations for pregnancy? (what type of diet, what are we limiting, yes or no alcohol, how much caffeine to limit, how much oz of low mercury fish to eat, how much water to drink)

• increase consumption of fruits & veggies (half plate)

• consume dairy (fat free, low fat, yogurt, cheese), protein

• choose whole grains instead of refined

• limit added sugar, saturated fats, sodium

• read nutrition labels to make healthy choices

• follow food safety tips to prevent food borne illnesses

• choose higher in fiber foods

• no alcohol

• limit caffeine to less than 200-300 mg/day

• eat 8-12oz of low mercury fish weekly, one being oily fish

• consider 76 oz of water daily

what are the psychosocial adaptation of pregnancy? (what happens in 1st, 2nd, & 3rd trimester, also throughout)

• ambivalence (1st tri)

  • mixed feelings about pregnancy, worried abt health, changes, becoming parent, etc

• introversion (1st & 3rd tri)

  • more focused on pregnancy & role as parent

  • 3rd tri is more about birth & baby

• acceptance (2nd tri)

  • pregnancy starts to feel more real b/c of physical signs such as fetal movement, validity

• mood swings (throughout)

• changes in body image (throughout), but stressful

  • weight gain, breast enlargement, abd growth, skin changes, etc

what is rubin’s maternal role tasks?

• ensure safe passage throughout pregnancy & birth

• seeking acceptance of infant by others

• seeking acceptance of self in maternal role to infant (binding in)

• learning to give of oneself

how can pregnancy impact sexuality, partner, & siblings?

1. sexuality

• many changes, possibly stressing sexual relationship

• change in sexual desire w/ each trimester

  • 1st tri: less interested in sex d/t fatigue or fear or disturbing embryonic development

  • 2nd tri: interest increases b/c of stability

  • 3rd: enlarging abd is uncomfy during sex

• sexual health & link to self image

2. partner

• family centered emphasis

• partner’s reaction to pregnancy & changes

  • couvade syndrome, ambivalence (they feel the physical & emotional s/sx of pregnancy)

  • acceptance of roles (second tri)

  • prepare for reality of new role (3rd tri)

3. sibling

• age dependent reaction

• sibling rivalry w/ introduction of new infant into family

• sibling preparation imperaitve