Adaptations to Pregnancy and Prenatal Care - Practice Flashcards

Uterine, Cervical, Ovarian, and Breast Adaptations

• Uterus: Grows in strength and size, increased blood flow; palpable at 12 weeks, at umbilicus by 20 weeks. Fundal height (FH) in cm approx. equals gestational weeks after 20 weeks.

• Cervix: Chadwick’s sign (bluish-purple), Goodell’s sign (softening), mucus plug forms.

• Vagina: Increased vascularity and discharge; loosening of connective tissue.

• Ovaries: Corpus luteum secretes progesterone until placental takeover; ovulation ceases.

• Breasts: Stimulated by estrogen (ductal tissue) and progesterone (lobes, lobules, alveoli); visible veins, striae gravidarum, darkened areolae, Montgomery tubercles; colostrum present by 12–16 weeks.

Cardiovascular Changes

• Overall ↑ cardiac workload, ↑ myocardial mass, systolic murmur common.

• Cardiac output (CO) ↑ up to ~50% (CO = SV \times HR);

• Blood volume ↑, leading to physiologic anemia due to plasma rise outpacing red cell mass.

• Intervillous, uteroplacental, renal, and skin blood flow ↑.

• SVR ↓; BP mostly stable; HR ↑ ~15–20 bpm.

• Supine hypotension syndrome risk; lateral tilt or left uterine displacement favored.

• Hematologic: Iron supplementation needed; leukocytosis common; hypercoagulable state ↑ VTE risk.

Respiratory Changes

• Oxygen consumption ↑ ~20% (half for uterus/fetus/placenta).

• Chest wall changes: rib cage relaxation, substernal angle widens, thoracic circumference ↑ ~5–7 cm; breathing becomes more thoracic.

• Dyspnea and hyperventilation common; tidal volume ↑ ~30–40%; respiratory rate stable.

• Partial pressure of CO_2 ↓ (respiratory alkalosis), renally compensated.

• Hormonal influences: progesterone/prostaglandins relax smooth muscle; estrogen causes nasal hyperemia/epistaxis.

Gastrointestinal Changes

• Intestines: Delayed gastric emptying; ↑ absorption of micronutrients and water (can lead to constipation).

• Mouth: Gingival hyperemia, gingivitis, ptyalism (excessive salivation).

• Esophagus: Progesterone relaxes smooth muscle, ↓ lower esophageal sphincter tone → pyrosis (heartburn).

• Liver/Gallbladder: Progesterone causes hypotonic gallbladder, thicker bile → ↑ gallstone risk; alkaline phosphatase rises.

Urinary Changes

• Bladder: ↑ urine frequency, nocturia, potential stress urinary incontinence.

• Kidneys/Ureters: Enlarge; urinary stasis, dilation (pelviectasis) → ↑ UTI risk.

• Functional changes: Renal blood flow ↑ 50–80%; GFR ↑ ~50%; some products resorbed less efficiently.

Integumentary Changes

• Hyperpigmentation: Chloasma, melasma, linea nigra, darkening of nipples/areolae/nevi.

• Vascular changes: Estrogen-induced vasodilation, spider angiomas, palmar erythema.

• Connective tissue: Striae gravidarum (stretch marks) appear, not preventable.

• Hair: Longer growth phase; postpartum telogen effluvium common, resolves in 6–12 months.

Musculoskeletal Changes

• Calcium storage: Fetal demand ↑, intestinal absorption ↑; maternal bone density preserved.

• Postural changes: Pelvic ligament mobility ↑; pelvic symphysis softens by 28–30 weeks (causing pain, waddling gait).

• Lordosis ↑; diastasis recti (abdominal wall separation) may occur.

Endocrine Changes

• Prolactin: Stimulates milk production.

• Oxytocin: Stimulates uterine contractions and milk ejection reflex; prevents postpartum hemorrhage.

• Pancreas: Glucose levels 10–20% higher; ↑ insulin production; GDM risk.

• Thyroid: Gland enlarges; T4 ↑ initially then normalizes; maternal hormones crucial for fetal brain development; BMR ↑ ~25%.

• Parathyroid: Maintains blood calcium, may enlarge.

• Placental Hormones: hCG (stimulates corpus luteum for progesterone/estrogen); Estrogen (uterine growth, breast ducts, hyperpigmentation); Progesterone (maintains endometrium, smooth muscle relaxation, breast support, ↑ fat stores); Relaxin (inhibits uterine activity, softens CT); Human chorionic somatomammotropin (hCS) (causes maternal insulin resistance).

Weight and Fluid Changes

• Weight gain: Recommended 25–35 lb (11–16 kg) for normal BMI.

• Edema: Physiologic swelling from pelvic vein compression, hemodilution; dependent edema common.

• Carpal tunnel syndrome: Fluid retention compresses median nerve; resolves postpartum.

Other Pregnancy Changes

• Eyes: Corneal edema, transient visual changes.

• Ears: Estrogen-induced mucous changes can cause muffled hearing.

• Immune system: Immune modulation to tolerate fetus; ↑ susceptibility to some infections.

Confirmation of Pregnancy

• Presumptive signs: Subjective (amenorrhea, nausea, fatigue, quickening, Chadwick’s sign, abdominal enlargement).

• Probable signs: Objective, but not definitive (Hegar’s sign, Ballottement, Braxton Hicks, positive pregnancy test).

• Positive signs: Definitive (ultrasound visualization of fetus, fetal heart sounds, fetal movements felt by examiner).

Preconception & Interconception Care

• Preconception: Assess health, habits, review meds, lifestyle counseling, vaccinations (rubella, varicella), avoid teratogens; 800 μg folic acid (4 mg if history of NTD) at least 1 month before conception.

• Interconception: Identify new problems, discuss prior complications, plan next pregnancy timing.

Antepartum Care: History and Assessment

• Obstetric history: Gravida (pregnancies), Para (pregnancies reaching ≥20 weeks); GTPAL (Gravida, Term, Preterm, Abortions, Living).

• Menstrual history: Naegele’s rule to estimate EDD (LMP - 3 \ months + 7 \ days).

• GYN history: STDs, contraception, IUD removal.

• Initial visit includes medical, surgical, family, genetic history.

• Exam findings: Vital signs, fundal height, FHR (110–160 bpm), linea nigra, bowel sounds, Leopold’s maneuvers.

• Labs: Type and Screen, CBC, STD screenings (HIV, syphilis, hepatitis B, GC/CT), genetic screening, Pap test, glucose challenge test (24–28 weeks).

Antepartum Care: Schedule and Tests

• Visit frequency: Every 4 weeks until 28 weeks; every 2 weeks until 36 weeks; weekly until birth.

• Ultrasounds: Viability (6–10 weeks), nuchal translucency (12–14 weeks), anatomy (20 weeks), growth (36 weeks).

• Vaccinations: Influenza, Tdap, hepatitis, COVID, RSV.

• Multifetal pregnancy: Higher risks (SAB, anemia, HTN, GDM, preterm labor), requires increased surveillance.

Common Discomforts and Psychological Aspects (Antepartum)

• Discomforts: Nausea/vomiting, heartburn, backache, round ligament pain, urinary frequency, varicosities, constipation, leg cramps, edema.

• Psychological responses: First trimester (uncertainty); Second trimester (quickening, introversion); Third trimester (vulnerability, birth preparation).

• Parental tasks: Maternal (safe passage, acceptance, self-giving); Paternal (recognition, involvement, couvade).

Barriers to Prenatal Care and Cultural Influences

• Barriers: Financial, systemic (transportation, scheduling), attitudinal (staff judgment), unrecognized pregnancy.

• Cultural influences: Health beliefs, decision-making, modesty, views on birth, communication (language, eye contact, touch).

Chapter 14: Nutrition for Childbearing

• Weight gain (by BMI):

  • Underweight (< 18.5): 28–40 lb (~1 lb/week in 2nd/3rd).

  • Normal weight (18.5–24.9): 25–35 lb (~1 lb/week).

  • Overweight (25–29.9): 15–25 lb (~0.6 lb/week).

  • Obese (> 30): 11–20 lb (~0.5 lb/week).

• Pattern: 1.1–4.4 lb in first trimester; then ~0.8–1 lb/week.

• Implications: Inadequate gain → low birth weight; excessive gain → macrosomia, C-section.

• Nutritional requirements: ↑ calories (2200–2900/day); protein ~71 g/day in late pregnancy.

• Supplements: Folic acid (neural tube defect reduction: 400–800 μg preconception, 600 μg pregnancy, 4 mg if prior NTD).

• Iron: Needed for ↑ maternal RBCs and fetal stores; Hgb < 11 g/dL (1st/3rd), < 10.5 g/dL (2nd) indicates anemia. Absorption enhanced by Vitamin C; inhibited by milk/coffee.

• Calcium: Dairy primary source; Vitamin D aids absorption.

• Sodium: Moderation recommended.

• Food precautions: Avoid high-mercury fish, raw/undercooked meats/eggs, unpasteurized products, deli meats unless steaming, pate, unwashed produce.

• Nutrition after birth:

  • Lactating: +~330 kcal/day (first 6 months); +~400 kcal/day (6–12 months); 8–10 cups fluids/day; limit caffeine; avoid alcohol for 2 hours post-intake.

  • Nonlactating: No extra calories; gradual weight loss (~1–1.5 lb/week) after 3 weeks.

Chapter 15: Prenatal Diagnostic Tests

• Indications: Detect anomalies, monitor fetal well-being, establish dating.

• Ultrasound: First trimester (TVUS) for IUP, dating, viability; Second/Third trimester (transabdominal) for anatomy, growth, AFI, position. Doppler ultrasound assesses blood flow.

• Alpha-Fetoprotein (AFP): Screens for chromosomal abnormalities/NTDs (16–18 weeks).

• Multiple-Marker/Quad Screen: Screens for chromosomal abnormalities (MSAFP, hCG, unconjugated estriol, inhibin A at 16–18 weeks).

• Chorionic Villus Sampling (CVS): Early diagnostic for chromosomal/DNA abnormalities (10–13 weeks); risks include pregnancy loss (~2.5%).

• Amniocentesis: Diagnostic for chromosomal/DNA, fetal Rh status, lung maturity (L/S ratio); later in pregnancy; risks include contractions, bleeding.

• Percutaneous Umbilical Blood Sampling (PUBS): Fetal blood sampling for specific diagnoses (e.g., Rh disease); higher risk.

• Noninvasive Prenatal Screening (NIPS): Cell-free fetal DNA in maternal blood (after 10 weeks); screening, not diagnostic.

• Antepartum Fetal Surveillance Goals: Determine health, guide intervention, reduce morbidity/mortality.

Nonstress Test (NST) and Fetal Surveillance

• Purpose: Detect fetal well-being via FHR accelerations with movement (intact CNS, oxygenation).

• Procedure: External fetal monitoring. Reactive NST: ≥2 FHR accelerations (≥15 bpm for ≥15 sec if ≥32 weeks; ≥10 bpm for ≥10 sec if <32 weeks) within 20 minutes. Nonreactive NST lacks required accelerations.

• Vibroacoustic Stimulation: Uses sound to shorten NST time, stimulates fetal response.

Contraction Stress Test (CST)

• Purpose: Assess fetal reserve under stress (induce contractions, observe FHR).

• Contraindications: High risk PTL/PROM, uterine surgery, placenta previa.

• Interpretation: Negative (reassuring) – no late decelerations; Positive – late decelerations with ≥50% contractions.

Biophysical Profile (BPP)

• Purpose: Evaluate fetal well-being including neurologic function/oxygenation.

• Components: Fetal tone, gross body movements, fetal breathing movements, NST, Amniotic Fluid Index (AFI).

• Scoring: Each component 0 or 2 points (max 10). 8–10 reassuring; 6 equivocal; ≤4 abnormal.

Kick Counts (Fetal Movement Monitoring)

• Maternal awareness of fetal movements; typically 5–10 movements/hour acceptable. Report decreased movements.

Nursing Process (Overview)

• Assessment, Diagnosis, Planning, Implementation (education like avoiding hot tubs/douching, exercise, work adjustments, rest, snacks, travel immunizations; avoiding teratogens), Evaluation.

Signs and Symptoms Requiring Immediate Attention (Critical Warning Signs)

• Vaginal bleeding or fluid leakage, facial/finger swelling, severe headaches, visual disturbances, severe abdominal/epigastric pain, chills/fever, painful urination, persistent vomiting, altered fetal movement, PTL signs (contractions, cramps, low back pain, pelvic pressure, watery discharge), uterine tachysystole.

Psychological and Family Adaptations

• Pregnancy involves psychosocial transition, identity changes, relationship shifts.

• Parental tasks emphasize safety, bonding, birth preparation.

• Support networks and cultural beliefs influence coping.

Cultural and Ethical Considerations

• Recognize diverse beliefs about pregnancy, nutrition, risk, decision-making.

• Provide culturally sensitive care; respect modesty, language, traditional practices while ensuring safety.