N107 Essentials of Nursing Care: Reproductive Health Chapter 3: Needs of the Childbearing Family:...

N107 Essentials of Nursing Care: Reproductive HealthChapter 3: Needs of the Childbearing Family: Antepartal

Chapter Objectives

Understand the S&S of Pregnancy ID the physiological changes that take place

during pregnancy Know the discomforts of pregnancy and know

appropriate interventions to help with discomforts

Describe psychosocial changes in the expectant family

Chapter Objectives

Know what a nurse could tell a patient to promote self-care during pregnancy

Know when a pregnancy is at risk due to chronic health problems

Be knowledgeable of different medications used during pregnancy

Be familiar with diagnostic tests and possible medical interventions used during pregnancy

Be knowledgeable about the process of conception and implantation

Chapter Objectives

Know about embryonic/fetal development Understand the details and importance of

the umbilical cord and placenta Describe factors that influence fetal growth

and well-being Be knowledgeable of diagnostic test used

during pregnancy

Signs and Symptoms of Pregnancy

Antepartal – beginning of pregnancy to beginning of labor Pregnancy made possible by the hypothalamic stimulation of the anterior

pituitary hormones: follicle stimulating hormone (FSH), which stimulates follicle growth within the ovary, and luteinizing hormone (LH) which affects ovulation

3 categories of S&S of pregnancy Presumptive – those felt by the woman Probable – those changes observed by the examiner Positive Signs – those signs credited only to the presence of the fetus

Presumptive and probable could have other causes for their occurrences.

Positive signs are completely objective and cannot be caused by other pathologic states


Presumptive Signs Referred to as subjective Earliest is usually amenorrhea (in those with regular cycles) Morning sickness (can occur any time during day)

Due to elevated hCG levels and changed CHO metabolism hCG is biological marker on which all pregnancy test are based hCG can be detected in the blood as early as 6 days after conception (or

about 20 days since LMP) hCG secreted by trophoblast (outer layer of uterus)

Excessive fatigue Urinary frequency

Enlarging uterus putting pressure on bladder Symptoms decrease during 2nd trimester as uterus becomes an

abdominal organ Reappears during 3rd trimester as fetus descends into pelvic region


Presumptive Signs (Cont’d)Breast changes (enlargement, tenderness & tingling)

May occur prior to missing 1st menses Growth due to hormones and growth of secretory ductal

system. Tenderness and tingling most noticeable around nipple area

Quickening (fetal movements) Week 14 – 16 in a multigravida woman Week 18 or later in primagravida woman


Probable Signs (Objective) Observed through inspection or palpation Changes in pelvic organs caused by increased vascular

congestion Only physical signs detectable with the first 3 months of pregnancy

Goodell’s sign – softening of cervix Chadwick’s sign – deep red to purple bluish coloration of the mucous

membranes of cervix, vagina and vulva Hegar’s Sign – softening and compressibility of the lower uterine

segment McDonald's Sign – easy flexion of the fundus on the cervix Braun von Fernwald’s Sign – Softening and slight fullness of the

fundus near the area of implantation Piskacek’s Sign – a soft lateral bulge with corneal implantation


Probable Signs (Cont’d)Ultrasound or fetal stethoscope

Uterine soufflé (bruit) – sound of maternal blood flowing through uterine arteries to placenta

Synchronous with maternal pulse

Funic soufflé – caused by fetal blood coursing though the umbilical cord

Synchronous with fetal heart tone

Fetal heart tone – actual heartbeat of fetus


Other manifestations Facial chloasma, melasma (mask of pregnancy)

Blotchy, brownish hyperpigmentation of the skin over cheeks, nose & forehead

Accentuated by sun exposure

Linea nigra – pigmented line down midline of abdomen Striae gravidarum – stretch marks

Abdomen & buttocks

Ballotment – examiner pushes up against cervix with 2 fingers to elicit a passive rebound fetal movement.

ID’d between week 16 - 18

Signs & Symptoms of Pregnancy

Positive signs of pregnancy (definitive)Visualization of fetus via US

Weeks 5 – 6

Fetal heart tones heard at 6 weeksFetal heart tones heard by doppler at 10 -17 weeksFetal heart tones heard by stethoscope at weeks

17 – 19Fetal movements palpated at weeks 19 - 22

Physiological Changes During Pregnancy Uterine Growth

Response to hormonal stimulus High levels of estrogen and progesterone

Fundal height Uterus enlarges at predictable rate. Measurement used

to estimate the duration of pregnancy Palpable at symphis pubis between week 12 – 14 Palpable at umbilicus level at week 22 – 24 At level of xyphoid process at term

Lightening – fundal height decreases weeks 38 – 40 as fetus descends and engages the pelvis

Physiological Changes During Pregnancy

Braxton Hicks contractions – irregular painless contractions of the uterus that occur intermittently throughout pregnancy starting soon after 4th month

Contractions stimulate the movement of blood through the placenta and promote oxygen delivery to the fetus.

Increase in frequency during late pregnancy. Not true labor contractions

Physiological Changes During Pregnancy Breast Changes

Result of increased levels of estrogen and progesterone

Development of mammary glands is complete by mid pregnancy

Lactation does not occur until birth of baby and placenta

Estrogen levels decrease Colostrum

Creamy, white to yellow pre-milk fluid expressed from nipples as early as week 16

Physiological Changes During Pregnancy Skin

Changes thought to occur due to increased estrogen, progesterone and alpha-melanocyte-stimulating hormone levels

Sweat and sebaceous glands usually hyperactive Angiomas (telangiectasias) - Vascular spider nevi may

appear on the chest, neck, face, arms and legs. Of no clinical significance and disappear after pregnancy. Due to increased levels of estrogen

Palmar erythema – color changes which occur over the palmer surface of the hands. Due to increased levels of estrogen and progesterone

Physiological Changes During Pregnancy Hormones

Thyroid – moderate enlargement; increased vascularity T4 levels decrease in response to increased estrogen Oxygen consumption and basic metabolic rate (BMR) increase

as much as 20-25% secondary to fetal metabolic activity

Parathyroid Slight secondary hyperparathyroidism Plasma parathormone are elevated Coincides with fetal skeletal growth

The increased requirements for calcium and Vitamin D

Physiological Changes During Pregnancy

Pituitary Prolactin Prolactin responsible for initial lactation

Posterior Pituitary Releases oxytocin which promotes uterine

contractility and the stimulation of milk ejection from the breasts

Releases vasopressin which results in increased BP by vasoconstriction and has an antidiuretic effect to maintain water balance.

Physiological Changes During Pregnancy Adrenals Glands

Secrete increased levels of aldosterone by the early part of 2nd trimester in a protective response to the increased sodium excretion associated with progesterone.

Cortisol production increases which increases production of insulin but also increases mother peripheral resistance to insulin

This decreases mother’s ability to use her own insulin, thus ensuring ample supply of glucose for fetoplacental unit

Physiological Changes During Pregnancy Pancreas

Responsible for insulin production to lower glucose levels

The fetus requires ample amount of glucose for growth and development

The islet of Langerhans (beta cells) are stressed to meet the mother’s increased needs for insulin

Deficiency produces S&S of gestational diabetes

Physiological Changes During Pregnancy Hormones Required to Maintain Pregnancy

hCG Secreted early in pregnancy Stimulates progesterone and estrogen production by the corpus

luteum to maintain pregnancy until placenta has developed sufficiently enough to support it

Human Placental Lactogen Increases the amount of circulating free fatty acids for maternal

metabolic needs and decreases maternal metabolism of glucose to favor fetal grown

Physiological Changes During Pregnancy Hormones Required to Maintain Pregnancy

Estrogen Stimulates uterine development to provide a suitable environment

for the fetus while helping to develop the ductal system of the breast in preparation for lactation

Progesterone Maintains the endometrium, inhibiting spontaneous abortion Helps development of acini & lobules of the breasts in preparation

for lactation Relaxin

Inhibits uterine activity Diminishes the strength of uterine contractions Aids in the softening of the cervix Has long-term effect of remodeling collagen

Physiological Changes During Pregnancy Other Hormones

Prostaglandins Lipid substances that occur in high concentrations in female

reproductive tract Present in the endometrium or lining of uterus during

pregnancy Present in the tissue around the ectopically located fertilized

ovum during pregnancy Exact functions unknown Decreased levels may contribute to HTN and pregnancy

induced HTN (PID)

Physiological Changes During Pregnancy Other Hormones

Mucus Plug Result of secretions from endocervical glands Plug seals the endocervical canal & prevents

invasion of bacteria or other substances into uterus Secretions favor the growth of yeast organisms

monilasis, a common vaginal infection during pregnancy

Physiological Changes During Pregnancy Metabolic

The expectant mother must meet her own tissue replacement needs, those of the fetus, and those preparatory for labor and lactation

Recommended weight gain Woman of normal wt = 25 – 35 pounds Overweight woman = 15 – 25 pounds Underweight woman = 28 – 40 pounds

Avg increases 3.5 – 5 pounds 1st trimester 12 – 16 pounds 2nd trimester 10 – 13 pounds 3rd trimester

Physiological Changes During Pregnancy Metabolic (Cont’d)

Water retention is a basic chemical alteration of pregnancy; caused by an increased level of steroid sex hormones, lowered serum protein and increased intracapillary pressure permeability. The extra water is needed for the fetus, placenta, and amniotic fluid, in addition to the mother’s increased blood volume, interstitial fluids, and enlarged organs.

Physiological Changes During Pregnancy BMR (Basic Metabolic Rate) is increased by

15-20% by termReflects increased oxygen demand of uterine-

placental-fetal unit as well as oxygen consumption from increased maternal cardiac work

High risk for heat intoleranceDuring early pregnancy may report feeling hot &

fatigued after slight exertion.Greater need for sleep

Physiological Changes During Pregnancy Cardiovascular System

Growing fetus pushes heart upward and left Blood volume increases throughout pregnancy; about

45% increase in 3rd trimester Cardiac hypertrophy

Increase in blood volume and cardiac output Both plasma and erythrocytes increase

Systemic Vascular Resistance & Pulmonary Vascular Resistance decrease enabling circulation to adapt to higher blood volume while maintaining normal vessel pressures

Physiological Changes During Pregnancy CV System (cont’d)

CO increases due to increased tissue demand for oxygen CO higher when lying in lateral recumbent position; lower

when in supine position CO increased with labor and birth Organ systems receive additional blood flow according to

their increased workload Heart rate increases about 10-15 BPM Palpitations and dysrhythmias may occur.

If no underlying pathology, no treatment required

Physiological Changes During Pregnancy CV (cont’d)

BP considerations Same position, same arm, correct cuff size

Dependent edema, varicose veins, hemorrhoids due to uterus compressing iliac veins and inferior vena cava increased venous pressure and reduced blood flow to lower extremities

More prone to postural hypotension


Venal Caval Syndrome (Supine hypotensive syndrome/autocaval compression)

Enlarging uterus putting pressure on the vena cava when in supine position

Interferes with blood return Significant decrease in BP with symptoms

Dizziness, pallor, clamminess Corrected by placing in left side-lying position


Blood volume increases 40-50% Peripheral vasodilation maintains normal BP

Total erythrocyte volume increases about 30% in women who receive iron supplementation; only 18% in those without iron supplementation

Plasma increase > RBC production decrease in Hematocrit (psuedoanemia)

Elevated erythrocyte production increases need for iron, because iron is necessary for the formation of hemoglobin (oxygen carrying component of erythrocytes)


Higher risk for hypercoagulation (clot formation)

Various clotting factors increase during pregnancy Fibrinolytic activity (dissolving actions of clots)

decreased Venous stasis DVT formation

Physiological Changes During Pregnancy Respiratory System

Maternal oxygen requirements increase Increase in BMR Need to add tissue mass in uterus and breast Fetus requires oxygen and needs to dispose of carbon monoxide

Elevated estrogen levels cause ligaments of rib cage to relax which allows increased chest

expansion Cause an increase in vascularization in upper respiratory tract

capillary congestion nasal & sinus congestion, nosebleeds, changes in voice, changes in respiratory center (a lower threshold for CO2)

During advanced pregnancy, increased awareness of the need to breathe evident; some complain of SOB; some complain of dyspnea at rest

Physiological Changes During Pregnancy Gastrointestinal (GI)

During pregnancy Appetite increases, intestinal secretions reduced,

liver function is altered, absorption of nutrients is enhanced, colon is displaced, GI motility decreases

Bowel sounds decrease, nausea and vomiting are common

An increase in blood flow and pressure on pelvic areas (later in pregnancy) places pregnant woman at increased risk for hemorrhoids

Physiological Changes During Pregnancy GI (cont’d)

Early in pregnancy Morning sickness (with or with vomiting)

Can occur at any time of day/night Usually appears 4-6 weeks & subsides after 1st trimester Triggered by sight or odors Appetite may be decreased hCG has depressant effect on appetite

Hyperemesis (severe vomiting) Should not continue beyond 1st trimester Should not be accompanied by fever, pain or weight loss If either occurs, medical intervention necessary


Morning sickness rarely has harmful effects on mother or fetus

Rising levels of estrogen cause selective increase in vascularity and connective tissue proliferation (gingivitis) and causes gums to bleed

Hiatal hernia Can occur after 7th month of pregnancy Usually due to displacement of stomach


increased progesterone production causes: Esophageal regurgitation, slower emptying of

stomach and reverse peristalsis from decreased tone and motility of smooth muscles

Increase in water absorption from colon constipation

Increased risk for gallstones

Physiological Changes During Pregnancy Genitourinary System(GU)

Affected by pressure from bladder, increased blood flow & increased filtration in the tubules

1st trimester Bladder irritability, nocturia, frequency due to growing uterus

placing pressure on bladder 2nd trimester

Bladder is pulled up and out of pelvis into abdomen 3rd trimester

Due to pressure from presenting part, impaired drainage of blood and lymph, bladder more susceptible to infection and trauma

Physiological Changes During Pregnancy GU (cont’d)

Susceptibility to infection Greater glucose content More alkaline (pH increased) Stagnated urine (takes longer to reach bladder)

Renal function Glomerular Filtration Rate (GFR) increases Renal Plasma Flow (RPF) increases Least efficient when in the supine position Most efficient in lateral recumbent position

Side lying increases renal perfusion, increases UOP, and decreases edema

Due to vena cava syndrome and compression of aorta, CO drops as does renal perfusion


Renal system can overstressed by excessive sodium intake or restriction or by using diuretics

Extra sodium is needed for both mother and fetus during pregnancy

Selective renal tubular reabsorption maintains sodium and water balance regardless of changes in dietary intake and losses

Severe hypovolemia and reduced placental perfusion are consequences of using diuretics during pregnancy


Glucose reabsorption is impaired Glucosuria varies in time and degree

Proteinuria does not usually occur in normal pregnancy except during labor or after birth

The amount of protein excreted does not indicate the severity of renal disease

Values of 1+ protein (per dipstick) is acceptable

Physiological Changes During Pregnancy Musculoskeletal

Alterations in posture and gait due to weight gain Spinal curvatures are re-aligned Lordosis develops

An increase in curvature of spine The head is held Lordly, like a King to maintain balance

Pelvic joints become more mobile and relaxed due to increased estrogen & other circulating hormones (relaxin)

This also allows an increase in pelvic dimensions preparing for labor and birth

Abdominal walls stretch and loose tone

Discomforts of Pregnancy

First TrimesterBreast ChangesUrgency/FrequencyLanguor & Malaise/FatigueNausea/Vomiting (Morning SicknessPtyalism (Excessive Salivation)Psychological Effects; Mood Swings; Mixed

Feelings


Second TrimesterSkin changesSpider Nevi (TelangiectasiasPalmar ErythemaPruritusPalpitationsSupine Hypotension (Vena Cava Syndrome)Orthostatic Hypotension


2nd Trimester (Cont’d)Food CravingsHeartburn/IndigestionConstipationFlatulence/Bloating/BelchingVaricose VeinsLeukorrheaHeadaches


2nd Trimester (Cont’d)Carpal Tunnel SyndromeAcrodysesthesia (Numbness/Tingling of

FingersRound Ligament Pain/TendernessJoint Pain/Backache/Pelvic Pressure

Hypermobility of Joints


Third TrimesterRespiratory Discomforts InsomniaPsychological Responses/Mood Swings

Mixed Feelings/AnxietyHyperemia, Hypertrophy, Bleeding

TendenciesReturn of GU Symptoms


3rd Trimester (Cont’d)Perineal Discomfort and PressureBraxton Hicks ContractionsLeg CrampsMarked EdemaNasal Stuffiness

The Expectant Family

Psychosocial Changes Pregnancy represents a turning point in the affected

individuals’ lives Support system Altered routines and family dynamics Financial issues

Will expectant mother work during pregnancy? Will expectant mother work after baby is born? Who will provide childcare if mother does work? Will housework & care for the child at home be divided?


Emotional Responses Ambivalence, introversion, mood swings & changes in

body image Ambivalence may be related to many things (See

page 73) Indirect evidence of ambivalence

c/o prolonged or frequent depression Physical discomforts Body image Excessive mood swings Difficulty accepting life changes resulting from pregnancy


Emotional Responses (cont’d)Women with unplanned or unwanted

pregnancies experience: Increased depression Increased stress Decreased support from the father Decreased overall satisfaction with life


Emotional Responses Women with planned pregnancies

tend to be happier Experience less physical discomforts Tolerate discomforts associated with 3rd trimester

Introversion is common during pregnancy Mood swings Need increased love and affection from partner Concerns about body image

Personality traits, values, social network responses and attitude toward pregnancy are thought to influence her body image


Role Transition Four psychological tasks the expectant mother

undertakes to maintain her intactness and that of her family while also incorporating her new child into the family system:

Prenatal care Seeking partner’s acceptance and support Preparing herself to protect fetus and child once born Learning to delay immediate gratification to meet the needs

of another


The Expectant Father May experience ambivalence and stress also

Reality of new role Financial issues Unexpected events Health of baby His role during labor and birth

The successful father: Likes children Excited about fatherhood Want to nurture Have parenting confidence Share experience of pregnancy and childbirth with their parents


The Expectant Father 1st trimester

Confused by woman’s mood swings Resentful of attention given to mother-to-be

2nd trimester Feel more involved by feeling fetal movements See fetus on US Plans parenting style

3rd trimester Afraid of hurting unborn child during intercourse Have increased anxiety over outcome of partner and baby during

labor and birth

Promotion of Self-Care During Pregnancy Estimated Date of Birth

AKA Estimated Date of Confinement (EDC) Due Date Most common method = Nagele’s Rule

LMP – 3 months + 7 days LMP (5/8/2011) – 3 months = 2/8/11 2/8/11 + 7 days = EDC of 2/15/2012

Rule can be adjusted for those who have irregular menstrual cycles

Fundal Height (See page 77)

Promotion of Self-Care During Pregnancy Nutrition/Supplements

Pregnant woman need additional 300 kilocalories per day during 2nd & 3rd trimesters

Lactating mother needs additional 500 kilocalories per day Factors that increase nutrient needs:

Uterine-placental unit Maternal blood volume and constituents, Maternal mammary changes Metabolic needs (BMR increases)

Daily food plan should include all food groups + Vitamins + Minerals See page 77-80 PICA (non food sources) or non-nutritional food should be avoided

as much as possible Nurse should be non-judgmental when assessing for PICA

Promotion of Self-Care During Pregnancy Teratogenic Substances

Substances that cause abnormal development of the embryo Alcohol fetal alcohol syndrome

Maternal alcohol use spontaneous abortion Smoking IUGR

Increase risks for preterm labor, premature rupture of membrane (PROM), abruption placentae, placenta previa and fetal death R/T decreased placental perfusion

Illegal or Controlled Substance Abuse IUGR and developmental delay

Focus for mother with any detrimental habit should be Good Nutrition

Promotion of Self-Care During Pregnancy Teratogenic Substances

Congenital anomaly Condition present at birth

Known human teratogens Drugs, chemicals, infections, radiation, DM, PKU Greatest impact during periods of rapid

differentiation Embryonic period (days 15 – 60) Fetus unable to use maternal reserves, subsequently all

nutrients come directly from mother’s diet

Promotion of Self-Care During Pregnancy Activity and Exercise

Consult physician before starting an exercise regimen Exercise should be moderate and consistent Fluid intake should be increased before during and

after exercise to prevent dehydration Dehydration preterm labor

Aerobic exercise recommended with maternal HR<or= 140

Do NOT proceed to fatigue or exhaustion decrease uterine profusion &/or fetoplacental deoxygenation

Promotion of Self-Care During Pregnancy Screenings and Lab Test

Numerous Labs, blood type & Rh, rubella, TB, urine, renal

function, pap smear, STD/HIV. Alpha-fetoprotein is done at 16 weeks Triple Marker Test (Triple Screen) Group B Streptococci


HIV (Human Immunodeficiency Virus) causes Acquired Immune Deficiency Disease [AIDS] Should be tested during prenatal period Pregnancy is discouraged Common presenting problems

Chronic vaginitis & candidiasis (thrush) Treatment started prior to 14th week of pregnancy has shown a

66% decrease in lateral transmission to fetus with caesarian section

Treatment is Zidovudine (AZT) Fetus will test positive for HIV antibody for up to 18 months even if

not infected HIV can be transmitted through breast milk


TORCH Infections Toxoplasmosis Other infections Rubella Virus Cytomegalovirus Herpes simplex Virus


TORCH Infections Toxoplasmosis Cause

Consumption of infected raw or undercooked meat or handling infection cat litter

Can cause spontaneous abortions &/or congenital infections Diagnosis: Serologic testing Treatment: Pyrimethamin and sulfadiazine

Can reduce risk to fetus by 60%


TORCH Infections Other Infections

Hepatitis A, B, C, D Causes:

Hep A – feces Hep B – blood products & body fluids Hep C – direct blood contact (IV drug users,

receivers of blood products) Hep D – same as Hep B;


TORCH Infections Rubella (German Measles)

Cause: contact with droplets Clinical Signs

Heart Dz, IUGR, cataracts Complications: spontaneous abortions, heart damage,

cataracts, mental retardation Infants are infectious and require isolation Prevention: Rubella vaccine (prenatal assessment)

Serious fetal consequences; vaccination not warranted during pregnancy


TORCH Infections Cytomegalovirus

Cause: Herpes Virus Transmitted by respiratory droplets or body fluids (less likely) Women who have + titer usually have chronic or recurrent

infections Not normally harmful to mothers with intact immune systems

Treatment: No known treatment Complications: Primary cause of congenital infection in fetus and

neonate Most common infectious cause of mental retardation Most at Risk: women who work or have children in daycare, mental

health facilities or certain health care settings


TORCH Infections Herpes Simplex Virus (HSV)

Type I – contact with oral secretions Type II –contact with genital secretions

Treatment: Acyclovir Prevention of lateral transfer: Cesarean birth within 4 hours of

ruptured membranes Neonate and fetal effects are profound Good hand washing especially if lesions are present

Healthcare providers with oral lesions present should practice good hand hygiene and wear masks when in contact with newborns

Anyone with skin lesions should not give direct care until lesions are dried and crusted.

N107 Essentials of Nursing Care: Reproductive Health Chapter 3: Needs of the Childbearing Family:...

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