NURS 4628 – Special Populations: Pregnancy & Prenatal Care (Module 1, Week 2)

Conception and Fertilization

• Marks the beginning of pregnancy.

• Female and male preparation are important.

• Fertilization is complete within 24 hours.

Implantation

• Occurs 6-10 days after conception.

• The fertilized egg (zygote) goes through cell division from 2 cells on day 2 to continued cell division on days 4-5.

• By day 9, the egg attaches to the uterine wall.

• Important: The site of implantation is crucial; it should be in the fundus of the uterus, not the fallopian tube (ectopic pregnancy).

• Implantation concludes the conception process.

• Implantation spotting can occur due to endometrial cells.

Fetal Development: 1st Trimester (Weeks 1-12)

• This is the most crucial time for fetal development.

• Body plan and early development occur.

• Heartbeat can be detected after week 5.

• Arms and legs begin to develop.

• Major organs like the heart, brain, pancreas, kidneys, and liver start to form.

• Eyelids form and fuse for iris development.

• Hair, fingernails, and toenails develop.

• External sex organs show the sex of the fetus at the end of the trimester.

Fetal Development: 2nd Trimester (Weeks 13-24)

• The fetus becomes more active and developed.

• Most joints and bones start to form.

• Skin is protected by fine hair and a waxy substance.

• Sleep cycles become more regular.

• Eyes open and blink; eyebrows and eyelashes form.

• The fetus breathes amniotic fluid to strengthen lungs.

• The mother feels the first movements (quickening) around 17-20 weeks.

Fetal Development: 3rd Trimester (Weeks 25-38)

• All organs fully form.

• The fetus responds to light and sound from outside the uterus.

• The fetus has periods of dreaming.

• Fine body hair thins, and scalp hair grows in.

• Bones grow and harden.

• Synapses between neurons form in large numbers.

• Lungs complete development.

• The fetus typically turns head-down, ready for exit.

Measuring the Uterus

• Measure from the fundus to the symphysis pubis.

• The number of centimeters roughly equals the number of weeks pregnant. For example, x \text{ cm} = x \text{ weeks pregnant}.

Cervical Changes During Pregnancy

• Chadwick's Sign: Bluish discoloration of the cervix.

• Goodell's Sign: Cervix softens.

• These changes are due to increased estrogen and progesterone, leading to increased blood flow.

• The cervix maintains its firmness to sustain the pregnancy.

Physiological Changes During Pregnancy

• Oxygen consumption increases.

• Chest breathing replaces abdominal breathing.

• Pregnancy-related dyspnea (shortness of breath) is common.

Gastrointestinal System

• Mouth: Excessive salivation, heartburn.

• Esophagus and stomach: Issues arise.

• Intestines: Constipation, address by increasing water and fiber intake.

• Liver and gallbladder: Can lead to gallstones.

Renal System

• Bladder: Increased frequency of urination; urinary stasis increases the risk of urinary tract infections (UTIs).

• Increased glomerular filtration rate (GFR) results in increased BUN, creatinine, and uric acid levels.

• Changes in kidney size and shape.

• Mild proteinuria may occur.

• Renal blood flow increases.

Fluid and Electrolyte Balance

• Total body water increases by 6.5-8.5L.

• Kidneys excrete water more efficiently early in pregnancy.

• Edema is seen later in pregnancy (dependent edema), which requires no treatment and improves with a side-lying position.

Integumentary System

• Skin: Circulation increases, leading to hyperpigmentation (melasma, linea nigra), stretch marks occur.

• Hair: Increased hair growth.

Musculoskeletal System

• Calcium demands increase.

• Postural changes: Pelvis tilts forward.

• Abdominal wall tone decreases, and abdominal muscles may separate.

• Realignment of the spine, and pelvic joints relax.

Endocrine System

• Pituitary gland: Prolactin prepares breasts for milk production.

• Thyroid gland: Hyperplasia and increased vascularity; changes in glucose levels.

• Pancreas: Insulin production changes.

• Adrenal glands: Significant changes in hormone levels.

• Placenta: Acts as an endocrine organ, secreting hormones.

Naegele's Rule for Calculating Expected Due Date (EDD)

• Uses the first day of the last menstrual period (LMP).

• Steps:

  1. Subtract 3 months from the LMP.

  2. Add 7 days.

  3. Add 1 year.

• Examples:

  • LMP: Oct 2, 2023 → July 9, 2024.

  • LMP: March 26, 2023 → Jan 2, 2024.

  • LMP: July 15, 2023 → April 22, 2024.

Maternal and Paternal Adaptation to Pregnancy

Maternal Tasks

• Seeking safe passage.

• Securing acceptance.

• Learning to give of self.

• Committing self to an unknown child.

• Identifying the mother’s role.

• Reordering personal relationships.

• Preparing for birth.

Paternal Tasks

• Grappling with the reality of pregnancy and child.

• Struggling for recognition as a parent.

• Identifying the father’s role.

• Reordering personal relationships.

• Committing self to an unknown child.

• Preparing for birth.

Factors Influencing Pregnancy

• Age.

• Multiparity.

• Social support.

• Absence of a partner.

• Socioeconomic status.

• Abnormal situations.

Prenatal Care

• Care of the mother during pregnancy.

• Regular visits with a healthcare provider are essential.

• Includes patient education.

• Barriers to care: Financial barriers (insurance) and location (meeting providers).

GTPAL

• GTPAL: A 5-digit system used to describe obstetric history.

  • G (Gravidity): Number of pregnancies (including current, live births, and stillbirths).

  • T (Term): Number of term births (≥37 weeks).

  • P (Preterm): Number of preterm births (before 37 weeks).

  • A (Abortions): Number of abortions or miscarriages (spontaneous or induced).

  • L (Living): Number of living children.

• G/P: A simpler, 2-digit system (Gravidity/Parity).

  • Gravidity: Number of pregnancies (live & abortion).

  • Parity: Number of pregnancies that have reached at least 20 weeks gestation and delivered.

Antepartum Assessment and Care

• Included in initial visit:

  • History.

  • Physical examination.

  • Laboratory data.

  • Risk assessment (one-on-one).

  • IPV (intimate partner violence) screening.

• Vaccinations: Tetanus shot, TDAP, and flu vaccine.

• Glucose screening (24-28 weeks).

• Group B Strep (GBS) screening (35-37 weeks); if positive, the mother will get antibiotics during labor to protect the baby.

• Follow-up visits occur every 4 weeks until 28 weeks, then biweekly until 36 weeks, then weekly until delivery.

Common Discomforts During Pregnancy

• Nausea and vomiting.

• Breast tenderness.

• Fatigue.

• Heartburn.

• Backache.

• Round ligament pain.

• Urinary frequency.

• Varicosities.

• Constipation and hemorrhoids.

• Leg cramps.

• Braxton Hicks contractions.

• Gingivitis, nasal stuffiness, and epistaxis.

Patient Education

• Prescription and over-the-counter drugs.

• Complementary and alternative therapies.

• Tobacco use.

• Alcohol.

• Illegal drugs.

• Nutrition.

• Exercise.

• Body mechanics.

Danger Signs During Pregnancy

• Burning with urination.

• Severe nausea and vomiting.

• Diarrhea.

• Fever or chills.

• Abdominal cramping and/or vaginal bleeding.

Nutritional Needs During Pregnancy

• 1st Trimester:

  • Fetal growth accelerates only slightly.

  • Weight gain: 2.2-4.4 lbs.

  • Nutritional needs increase.

• 2nd Trimester:

  • Fetal growth accelerates.

  • Weight gain: 1 lb per week.

  • Nutritional needs increase.

  • Add 340 cal/day.

• 3rd Trimester:

  • Fetal growth accelerates.

  • Weight gain: 1 lb per week.

  • Nutritional needs increase.

  • Add 450 cal/day.

Key Nutrients

• Folic Acid: Crucial for neurological development.

• Protein: Essential for basic growth.

• Iron: Reduces maternal anemia.

• Calcium: Important for the developing fetus.

• DHA: Essential for fetal neuro and eye development.

• Adequate fluid intake.

PICA

• Consumption of non-food items (ice, clay, cornstarch, dirt).

• Associated with women having lower hemoglobin or iron deficiency.

Factors Affecting Pregnancy

• Biophysical.

• Psychosocial.

• Sociodemographic.

• Environmental.

Biophysical Assessment

• Daily fetal movement count (kick counts).

• Ultrasonography (abdominal).

Biochemical Assessment

• Amniocentesis (after 14 weeks).

• Chorionic Villus Sampling (CVS) for neural tube defects.

• Maternal assays.

Electronic Fetal Monitoring (EFMs)

• Non-stress test (NST): Performed quickly and easily in an outpatient setting.

• Contraction stress test (CST):

  • Nipple-stimulation.

  • Oxytocin-stimulation.

Diabetes Mellitus

• Type 1 Diabetes.

• Type 2 Diabetes.

• Gestational Diabetes: Diagnosed in the 2nd and 3rd trimesters.

Risk Factors for Gestational Diabetes

• Overweight or obesity (BMI > 25).

• Maternal age.

• Gestational diabetes in a previous pregnancy.

• History of abnormal glucose tolerance level.

• History of diabetes in a close relative.

• Hypertension.

• Ethnicity.

Diagnosis and Management of Gestational Diabetes

• Diagnosis:

  • Glucose screening test (between 24-28 weeks).

  • Glucose tolerance test (for high-risk women or if GCT results are elevated).

• Management:

  • Glucose control (diet, exercise, glucose level monitoring, pharmacological therapy).

  • Fetal surveillance.

Hypoglycemia Symptoms

• Shakiness (tremors).

• Sweating.

• Pallor; cold, clammy skin.

• Disorientation, irritability.

• Headache.

• Hunger.

• Blurred vision.

Hyperglycemia Symptoms

• Fatigue.

• Flushed, dry skin.

• Dry mouth, excessive thirst.

• Frequent urination.

• Rapid, deep respirations; odor of acetone on the breath (fruity breath).

• Drowsiness, headache.

• Nausea/vomiting.

• Abdominal pain.

Anemia

• Increases the workload of the heart and stresses ventricular function.

Types of Anemia

• Iron deficiency (most common).

• Folic acid deficiency (megaloblastic anemia).

• Sickle cell anemia.

• Thalassemia.

Substance Abuse

• Warning signs: No prenatal care, sporadic care, non-compliance.

• Screenings/Legal: Urine drug screen at the initial visit.

Hyperemesis Gravidarum (HG)

• Persistent nausea and vomiting beyond the 16th week of pregnancy.

• Significance: Weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria.

• Risk factors: Not specified in the transcript.

• How to help: Reducing nausea and vomiting, maintaining nutrition and fluid balance, providing emotional support.

• Potential Complications: Prematurity, small for gestational age, low birth weight.

Ectopic Pregnancy

• Implantation of the pregnancy outside of the uterus.

• Risk factors: STIs (PID), tubal infections and damage, contraceptive devices, scarring from previous surgeries.

• Symptoms: Unilateral pain, delayed menses, vaginal spotting/bleeding, referred shoulder pain, symptoms of hemorrhage.

• Treatment options: Medical management, surgical management.

• Goal: Prevent hemorrhage.

Placenta Previa

• Implantation of the placenta in the lower uterine segment.

• Classification: Complete, marginal, low-lying.

• Symptoms: Painless, bright red vaginal bleeding, soft/relaxed/non-tender abdomen, fundal height greater than expected, malpresentation of fetus.

• Diagnosis: Patient history, transvaginal ultrasound.

• Potential complications: Hemorrhage, abnormal placental detachment.

• Treatment: Determined by delivery type.

Placental Abruption

• Premature separation of the placenta from the uterus.

• Risk factors: Maternal hypertension, cocaine use, blunt abdominal trauma, maternal battering, smoking, history of placental abruption, history of PROM, multifetal pregnancy.

• Classic symptoms: Sudden onset of uterine pain with dark red vaginal bleeding, board-like abdomen, contractions, fetal distress, hypovolemic shock, non-reassuring signs on EFM strip.

• Diagnosis: Based on clinical presentation.

• Management: Depends on many factors; fluid resuscitation, oxygen 10L via mask, assess urine output. Immediate delivery is the management of choice if term. Can be vaginal or cesarean.

Hypertension During Pregnancy

• Classifications:

  • Gestational hypertension.

  • Preeclampsia.

  • Eclampsia.

  • Chronic hypertension (preexisting).

Preeclampsia

• Pregnancy-specific; develops after 20 weeks; no prior diagnosis of HTN; elevated blood pressure with proteinuria.

• Management goal: Maintain pregnancy to at least 37 weeks.

• Mnemonic: P (proteinuria), R (rising BP), E (edema).

Assessment for Edema and DTR

• Edema is graded on a scale from 1+ (2mm) to 4+ (8mm).

• Reflexes are graded from 0 (no response) to 4+ (very brisk, hyperactive, with clonus).

Management of Preeclampsia

• Activity and diet restrictions.

• Monitoring of fetal activity.

• Blood pressure monitoring.

• Keep all follow-up appointments.

• Hospital precautions: Severe headache, abdominal pain, contractions, spotting, and/or decreased fetal movement.

Eclampsia

• Continuous fetal monitoring.

• Assessment of mother.

• Bedrest.

• Labs.

• Foley catheter for strict intake and output monitoring.

• Darkened room.

• Seizure precautions.

• Antihypertensive medications.

• IV magnesium sulfate.

• Treatment: Delivery.

Symptoms of Impending Eclampsia

• Persistent headache.

• Blurred vision.

• Photophobia.

• Epigastric pain.

• Hyperreflexia.

• Altered mental status (AMS).

Interventions for Eclampsia

• Control external stimuli.

• Administer magnesium sulfate.

• Seizure management.

HELLP Syndrome

• H (Hemolysis occurs).

• EL (Liver enzyme levels increase).

• LP (Low Platelet Count).

Rh Incompatibility

• Rh- woman conceives an Rh+ child.

• Prevention: Administration of RhoGAM.

Miscarriage (Spontaneous Abortion)

• Symptoms: Uterine bleeding, uterine contractions (cramping), abdominal pain.

• Risk factors, diagnostics/procedures, and expected medications are not specified in the transcript.

Types of Spontaneous Abortions

• Threatened abortion: Vaginal bleeding occurs.

• Inevitable abortion: Membranes rupture, and the cervix dilates.

• Incomplete abortion: Some products of conception have been expelled, but some remain.

Cervical Insufficiency

• May be acquired or congenital.

• Diagnosis: OB history, speculum examination, measurement of cervical length via US.

• Treatment: Cervical cerclage placement.

Trauma During Pregnancy

• Causes: Blunt abdominal trauma, penetrating abdominal trauma, thoracic trauma.

• Primary assessment: CABDs (Circulation, Airway, Breathing, Disability).

• Secondary assessment: Assessment of mother and fetus.

Signs and Symptoms of Shock

• Increased pulse rate.

• Falling blood pressure.

• Increased respiratory rate.

• Weak, diminished, or “thready” peripheral pulses.

• Cool, moist skin; pallor; or cyanosis (late sign).

• Decreased urinary output (<30 mL/hr).

• Decreased hemoglobin and hematocrit levels.

• Change in mental status (restlessness, agitation, difficulty concentrating).