pt 2 Health Promotion & Maintenance Of The Maternity Patient

Medication safety and genetic considerations in pregnancy

  • Zoloft (sertraline) safety: questions arise about safety for the fetus or breastfeeding. The transcript emphasizes discussing these concerns with the physician; as a nurse or student, you provide support by compiling medical history and assisting, but final risk assessment and management are the doctor’s responsibility.
  • Genetic counseling and testing indications:
    • Maternal age > 35 is an indication for genetic counseling/testing.
    • Other indications discussed include scenarios where prior pregnancy outcomes or tests may guide management.
  • Cesarean birth context:
    • Prior cesarean birth can influence considerations about delivery planning; vaginal birth may be associated with different birth conditions, and prior birth mode can inform current planning.
  • Genetic testing outcomes:
    • Tests provide information to inform the provider and patient about potential risks and management options.
    • These tests do not automatically terminate a pregnancy; the information is used for planning and improving outcomes when the patient is ready to decide.
  • Note on terminology and patient communication:
    • The clinician emphasizes presenting risk information clearly and coordinating with the patient’s care team to optimize outcomes.

Pregnancy history and parity notation (GTPAL concepts)

  • Example discussion of a patient’s pregnancy history:
    • The patient had three pregnancies (G = 3 total).
    • Outcomes described: two pregnancies beyond 20 weeks (one full term, one preterm) and one abortion/miscarriage.
    • Living children: two.
  • Standard TPAL interpretation (to track pregnancy outcomes):
    • G=exttotalnumberofpregnanciesG = ext{total number of pregnancies}
    • T=exttermbirths(38weeksormoreperthesource;theslidenotes38+weeks)T = ext{term births (38 weeks or more per the source; the slide notes 38+ weeks)}
    • P=extpretermbirths(before38weeks)P = ext{preterm births (before 38 weeks)}
    • A = ext{abortions/miscarriages (< 20 weeks in common practice; note the source may discuss 20 weeks as a threshold)}
    • L=extlivingchildrenL = ext{living children}
  • Example from transcript (reconstructed): G3, T1, P1, A1, L2
    • Rationale: one full-term birth, one preterm birth, one abortion, two living children.
  • Important nuance discussed:
    • A pregnancy may be referred to by number of times the patient has been pregnant (gravidity). Patients may report a different number due to how miscarriages/abortions are counted; clinicians should reconcile patient-reported data with charted obstetric history.
  • Definitions of pregnancy counts:
    • Some sources consider a pregnancy ending before 20 weeks a miscarriage; after 20 weeks may be termed abortion depending on context, but many obstetric references use the term abortion/m miscarriage differently. The transcript indicates that the 20-week mark is a key distinguishing threshold in discussion.

Gestational age assessment, fundal height, and prenatal screening

  • Fundal height and gestational age:
    • The lecture notes give a relationship between fundal height and gestational age, e.g., fundal height roughly corresponds to weeks of gestation in the mid-to-late second trimester onward (e.g., ~20 weeks ≈ fundal height of ~20 cm; adjustments discussed around late pregnancy).
    • A typical expectation described: fundal height measurements increase as pregnancy progresses toward term.
  • Prenatal ultrasound and glucose screening:
    • Ultrasound is part of routine prenatal care to assess fetal development and positioning.
    • Glucose screening to check for gestational diabetes is typically performed around ~26 weeks gestation.
    • The transcript notes that some details will be covered in the prenatal lecture; this slide focuses on identification of when these tests occur.
  • Specific gestational milestones mentioned:
    • Seven weeks gestation: reference to measurement or positional expectations (text is garbled in the transcript; the intent is to discuss early anatomy/measurements).
  • Overall focus:
    • Use these measurements and screenings to inform care, plan management, and prepare for potential interventions.

Uterine, cervical, and placental changes during pregnancy

  • Uterine size and capacity:
    • Pre-pregnancy uterus: approximately 2.5 ounces.
    • At term: approximately 1,100–1,200 grams (about 2.4–2.6 pounds).
    • Capacity: from about 10 mL to over 5,000 mL as pregnancy progresses.
  • Fetal engagement and abdominal dimensions:
    • Near term, fetal head engagement (often cephalic) reduces maternal pelvic pressure; the position affects symptoms and comfort.
  • Blood flow and exchange:
    • As the uterus enlarges, maternal blood flow to the uterus and placenta increases dramatically, especially toward the end of pregnancy, to support fetal exchange.
    • The amount of placental exchange expands due to the larger surface area.
  • Positioning considerations:
    • Maternal position becomes crucial to facilitate adequate uteroplacental blood flow.
    • Supine positioning can alter hemodynamics; left lateral decubitus or other positions may be encouraged to optimize return and placental perfusion.
  • Hormonal and vascular changes:
    • Estrogen increases vascularity of the mucous membranes and genital tract.
    • Chadwick sign: bluish-purple coloration of the cervix due to increased vascularization, indicating high estrogen and vascular changes; associated with infection protection and other vascular adaptations.
  • Cardiovascular adaptations:
    • Increased cardiac output (CO) to support the growing demands of pregnancy.
    • Heart rate may rise by about riangleHR ≈ 15–25 bpmriangle HR \,\approx\, 15\text{--}25\text{ bpm} during pregnancy.
  • Respiratory changes:
    • Estrogen increases vascularity and mucous membranes of the respiratory tract, often contributing to congestion and dyspnea sensations.
  • Supine hypertension note (as described in transcript):
    • The lecturer mentions supine hypertension in the context of position; typical obstetric physiology emphasizes the risk of reduced venous return in the supine position (supine hypotension syndrome). Clinically, encourage side-lying positions to enhance venous return and uteroplacental perfusion.

Endocrine and organ system changes during pregnancy

  • Gastrointestinal changes (primarily progesterone effects):
    • Decreased lower esophageal sphincter (LES) tone leading to heartburn/GERD.
    • Slower gastric emptying contributing to reflux symptoms.
  • Small intestine and nutrient absorption:
    • Small intestinal absorption may be increased due to hormonal changes; constipation can occur from slowed motility.
  • Hepatic and protein parameters:
    • Liver may show changes in serum proteins; possible elevations in alkaline phosphatase and other markers as pregnancy progresses, with shifts in albumin and protein production.
  • Renal and urinary changes:
    • Kidneys and ureters enlarge and change shape; urine flow can be partially obstructed, especially on the right side, increasing urinary stasis risk.
    • Higher risk of urinary tract infections (UTIs) during pregnancy.
    • Proteinuria can be seen and is not necessarily diagnostic of a UTI; clinical context matters (e.g., Prima Xa, etc. are not elaborated in depth in this slide).

Common discomforts and nursing interventions during pregnancy

  • Role of nursing interventions:
    • Encourage use of evidence-based remedies and coordinate with physicians to address common discomforts (e.g., sleep disturbances, nausea, heartburn).
  • Nausea and vomiting (early pregnancy):
    • Morning sickness or hyperemesis gravidarum can occur in early pregnancy and may persist.
    • Recurrent vomiting can lead to dehydration and may require medical evaluation.
    • Practical strategies discussed:
    • Keep crackers at the bedside and eat a small amount before getting up to reduce nausea.
    • Ginger and peppermint are commonly cited remedies; prenatal vitamins at bedtime may help.
    • Acupuncture point PC6 (just above the inner wrist crease) can help with nausea.
    • Hyperemesis gravidarum as a medical emergency:
    • If signs of dehydration persist or vomiting is severe, clinical evaluation and IV fluids/medications may be required.
  • Small, frequent meals and reflux management:
    • Eat small, frequent meals to manage reflux and nausea.
    • Avoid foods or drinks that worsen heartburn (e.g., coffee, carbonated beverages).
    • Peppermint gum is helpful for heartburn and nausea for some patients.
    • Avoid eating or drinking right before bed; wear loose clothing; remain upright after meals.
  • Round ligament pain and posture:
    • As the uterus grows, the round ligaments stretch, causing discomfort; teach reassurance and coping strategies.
    • Encourage posture changes and gradual activity to minimize discomfort.
  • Fetal movement and movement counseling:
    • The instructor references fetal movement and position changes as part of ongoing assessment (exact guidance on counts is not fully detailed in the transcript).

Fetal development, fetal position, and maternal comfort considerations

  • Fetal positioning and engagement:
    • Head-down (cephalic) presentation is typically aimed for late gestation to facilitate delivery and reduce maternal pressure.
  • Maternal comfort and orientation:
    • Emphasis on maternal position to optimize uteroplacental blood flow and fetal oxygenation.
  • Counseling around common third-trimester discomforts:
    • Reassure patients that common symptoms like round ligament pain are expected due to the growing uterus.
    • Provide strategies for managing discomfort and recognizing when to seek care.

Definitions and terminology for pregnancy outcomes (viability, abortion, term, etc.)

  • Important outcome thresholds mentioned in the transcript:
    • Miscarriage: generally < 20 weeks.
    • Abortion (context-dependent): can refer to pregnancy termination or pregnancy loss after 20 weeks in some discussions; the transcript notes that the abortion pill and similar events may be categorized this way and that the status of the fetus can influence terminology.
    • Term pregnancy: described in the transcript as > 38 weeks (per the source book); other obstetric references use ≥ 37 weeks for term.
    • Preterm: pregnancy before 38 weeks.
  • Clarification from the transcript:
    • The distinction between abortion and miscarriage can depend on gestational age and treatment context; some discussions in the transcript emphasize that certain outcomes after 20 weeks may be labeled as abortion in particular contexts.

Quick reference: numbers, thresholds, and formulas from the transcript

  • Term threshold given in the transcript:
    • \text{Term} > 38\ \text{weeks}
  • Preterm threshold:
    • \text{Preterm} < 38\ \text{weeks}
  • Fetal growth and uterine capacity statistics:
    • Pre-pregnancy uterus weight: approximately 2.5 oz2.5\ \text{oz}
    • Term uterus weight: 1100 to 1200 g1100 \text{ to } 1200\ \text{g}
    • Term uterus capacity: > 5000\ \text{mL}
  • Fundal height correlation (concept):
    • Fundal height (cm)≈Gestational age (weeks)\text{Fundal height (cm)} \approx \text{Gestational age (weeks)} (noting this is a general relationship described in the lecture; accuracy varies with gestational progression)
  • Cardiac output change during pregnancy:
    • ΔHR≈15–25 bpm\Delta\text{HR} \approx 15\text{--}25\ \text{bpm}
  • Fetal movement and engagement reminders:
    • The transcript indicates fetal movement assessment and position changes as ongoing aspects of prenatal monitoring, though precise counts or schedules are not specified here.

Summary and practical implications

  • Always tailor information to the patient’s context, including genetic risk, prior pregnancy outcomes, and current pregnancy status.
  • Use structured history tools (like GTPAL) to clarify parity and outcomes, especially when patient reporting may differ from chart data.
  • Monitor and manage common pregnancy-related discomforts with lifestyle modifications, dietary adjustments, and targeted therapies (e.g., antiemetics for hyperemesis gravidarum, acid-reflux strategies).
  • Recognize the physiological changes across organ systems (uterine growth, cardiovascular adjustments, respiratory mucosal changes, GI and renal adaptations) and how they influence symptoms and care planning.
  • Reinforce the importance of appropriate positioning to optimize maternal-fetal perfusion; educate about signs of potential complications requiring urgent evaluation (dehydration, persistent vomiting, reduced fetal movement).
  • Be prepared to discuss medication safety with obstetric care providers, particularly regarding antidepressants like sertraline, balancing maternal mental health with fetal safety; emphasize that such decisions require physician input and are not made by nurses in isolation.