Antepartum Flashcards
Cardiovascular System
Cardiac output increases 30-50% HR increases 15-20 BPM BP remains stable Compression of iliac veins and inferior vena cava Vena caval syndrome Dependent edema Varicose veins; hemorrhoids Increased risk for VTE
Cardiovascular System
↑ Total blood volume
↑Plasma volume > ↑Red blood cell volume =↓ Hgb & Hct
Physiologic anemia of pregnancy
Protective mechanism
Perfuse uterus
Hydrate fetal and maternal tissues
Fluid reserve for blood loss at birth and post-partum
↑White blood cell count
↑ granulocytes
↑Blood coagulation
↑Clotting factors + ↓coagulation inhibiting factors= hypercoagulability
Protective mechanism ↓ Fibrinolytic activity ↓ Risk of bleeding ↑ Risk of thrombus Post-cesarean
Respiratory System
Upper respiratory tract Nasal/sinus stuffiness; epistaxis; changes in voice Impaired hearing; earache; ear fullness Structural adaptions Diaphragm rises by up to 4 cm Chest circumference increases by 5-7 cm Pulmonary function Tidal volume increases by 40% Mild, chronic hyperventilation Reduced arterial carbon dioxide
Gastrointestinal System
Appetite and Mouth Fluctuations in appetite Food aversions and cravings Pica—may signify a dietary deficiency Gums edematous and bleed easily Esophagus, Stomach and Intestines Delayed gastric emptying, decreased peristalsis Heartburn; bloating; cramping; flatulence; constipation Hemorrhoids late in pregnancy Gallbladder distends Risk for gallstones
Renal System
Anatomic changes
Ureters dilate, elongate and become torturous
Urinary stasis; alkalotic=increased risk for UTIs
Enlarging uterus presses against the bladder
Bladder irritability; nocturia and urinary frequency
Functional changes
Increased GFR by 50%
Increased creatinine clearance
Reduced serum creatinine, BUN and uric acid levels
Renal System
Fluid and electrolyte balance
Increase in total body water of 6.5-8.5 L
Sodium is retained to maintain balance
Glycosuria
Because of the kidneys’ inability to reabsorb all the glucose filtered by the glomeruli
May indicate gestational diabetes
Increased excretion of protein and albumin
Proteinuria + hypertension=increased risk for adverse outcomes
Musculoskeletal System
Changes in posture and center of gravity (bottom picture)
Lordosis; back pain
Loosening of ligaments and separation of recti muscles (top pictures)
Waddling gait
Integumentary System
Skin ↑Melanotropin=Hyperpigmentation Melasma Linea nigra ↑Estrogen=↑blood flow to skin Angiomatas (vascular spiders) Palmar erythema Mechanical stretching Striae gravidarum (stretch marks) Hair and nails Accelerated growth Hirsutism
Breasts
Fullness, heightened sensitivity, tingling and heaviness
Blood vessels dilate and become visible
Areoles more pigmented and nipples more erect
Sebaceous glands secrete substances to lubricate and prevent infection
Mild tingling to sharp pain
Mammary glands grow in 2nd and 3rd trimester
Colostrum production begins at the end of the 1st trimester
Uterus
Changes in size, shape, and position Increases to 1200 grams at term Changes into an oval shape Assessed by measuring fundal height Can estimate weeks of gestation Changes in contractility Braxton-Hicks contractions Uteroplacental blood flow Depends on maternal blood flow to uterus Blood flow can be decreased by Low maternal BP Uterine contractions Supine positioning
Cervix, Vagina and Vulva
Cervix Goodell sign Friability Vagina Chadwick sign Leukorrhea Change in vaginal microbiome Vulva External structures are enlarged
Prenatal Care Management
Goal: promote health and well-being of the pregnant person, the fetus, the newborn and the family
Locations and team members
OB doctors, Family medicine MDs, CNMs, NPs, PAs, PH nurses, RD, Childbirth educators, doulas, lactation consultants, psychiatric, social work, case management
Clinic, public health locations, homes, birthing centers
Prenatal Care Management and Public Health
Primary prevention Education about nutrition, physical activity, self-management of pregnancy discomforts, psychosocial impact of pregnancy Secondary prevention Screening for risk factors for early intervention Barriers to prenatal care and outcomes Preterm birth Low birth weight Infant mortality
Initial Prenatal Visit
Goal: To establish a trusting relationship with the patient and their family
Comprehensive health history of pregnant person, their partner, their families and any children
Menstrual history
Current pregnancy and OB history
Gravida and parity
Method of prior deliveries and anesthesia
Complications with prior deliveries
Medical and Surgical History
Preexisting conditions
Pap test results, history of STIs, contraceptive use
History of gynecological or abdominal surgeries
Initial Prenatal Visit
Nutrition Food allergies, eating disorders, pica or hyperemesis gravidarum Family history Genetic disorders, recent illness Current medications OTC, herbs, vitamins, supplements Substance abuse Tobacco, alcohol, illegal drugs Psychosocial history Emotional response to pregnancy, lifestyle, exercise Mental health—depression risk Abuse history or risk Intimate partner violence
Obstetric History Using 5-Digit System
G: Gravidity
Number of pregnancies (including current)
T: Term births
Births at 37 weeks, 0 days and beyond
P: Preterm
Pregnancies ended in pre-term birth
Births at 20 weeks, 0 days- 36 weeks, 6 days gestation
A: Abortion
Number of pregnancies that ended in miscarriage before 20 weeks
Includes spontaneous abortion or elective termination
L: Live at time of birth
Number of living children
Initial Prenatal Visit Assessments
Determine estimated date of birth Baseline weight and vital signs Head to toe assessment and pelvic exam Flu vaccine (in season) Initial lab tests Education Referrals
Routine Prenatal Visit Frequency and Assessments
FREQ
First month, usually in the first trimester
Monthly until 28th week of gestation
Bi-weekly from 28-36 weeks of gestation
Weekly from 36 weeks until birth
Increased frequency if pregnancy is high-risk
ASSESSMENTS Weight, Blood pressure Physical concerns Management of common discomforts Fetal development and well-being Fetal heart tones (FHT) Fundal height beginning in 2nd trimester Fetal movement at 16 weeks gestation
Lab Tests According to Gestational Age
24-28 weeks Antibody screening Rh factor CBC Assess for anemia Diabetes screening Glucose tolerance test 32-36 weeks CBC Repeat if indicated for anemia Gonorrhea and Chlamydia Repeat testing if indicated Group B Streptococcus Vaginal/rectal culture at 35 weeks; positive (+)=antibiotics in labor HIV and Syphilis Recommended by CDC to repeat in 3rd trimeste
Fundal height measurements
Measurement from pubic symphysis to the fundus (top of uterus)
Empty bladder first
Begin measurements at 20 weeks
Gestational age correlates with the measurement of the uterus in centimeters
Fetal Movement
Decreased movement can be an increased risk for adverse outcomes
Absence is correlated with fetal death
Teach patient to notify provider immediately if movement pattern changes or ceases.
Fetal Development: Ultrasound
1st Trimester
External ultrasound or transvaginal ultrasound
Confirms intrauterine pregnancy, fetal heart rate, fetal number and gestational age
2nd and 3rd Trimester
Evaluates fetal anatomy, amniotic fluid volume, placenta location and grading, fetal presentation (position)
Observation of fetal movement and breathing
Confirms gestational age, fetal viability or death
Patient and Family Education
Individualized
Assess previous knowledge and barriers to learning
Present most significant information first
Use visual aids and different modes of education
Always review warning signs
First visit and every visit afterwards
Warning Signs (Table 8.2)
First question is always: “How far along are you? or What is your due date?”
Gush of fluid from vagina
Pre-term labor (PROM)
Vaginal bleeding or abdominal pain
First trimester: miscarriage
Second or third trimester: placenta previa or placental abruption
Temperature >38.3˚C or persistent vomiting
Infection; dehydration
Visual disturbances, edema of hands/face, severe headache
Hypertensive conditions; preeclampsia
Decreased fetal movement
Fetal distress or demise
Health promotion
Medications/substances/alcohol/tobacco
Avoid use of substances that can affect the developing fetus
Exercise
30 minutes or more of exercise daily
Sexual activity
Ok to continue sexual relations during pregnancy without causing fetus any harm
Travel
Safe for travel up 36 weeks gestation
Avoid areas with Zika virus
Work
Avoid heavy lifting and exposure to chemicals, fumes, radiation and diseases
Encourage rest periods and brief walks to promote circulation
Nutrition during pregnancy
General rule
Gain 1 – 2 kg (2.2 to 4.4 lb) during first trimester
Gain 0.4 kg (1 lb) per week for last two trimesters
Recommended weight gain during pregnancy is based on pre-pregnancy body mass index (BMI)
Those of normal BMI (18.5-24.9): 25-35 lbs.
Underweight (BMI < 18): 28 to 40 lbs.
Overweight (BMI 25-29.9): 15 to 25 lbs.
Obese (BMI 30 or higher): 11 to 20 lbs.
Postpartum Period:
: from the time of birth until the reproductive organs return to their normal, nonpregnant state.
Critical transition period for woman, newborn, and family physiologically and psychologically
Maternal physiologic and psychological changes
Mother and family adjustment to new family member
Nursing Actions- Immediate PP (First 2 hrs)
Mother & Newborn attachment
Assist with breastfeeding
Spouse involved or other support
Placenta delivery (time, assessed for completeness)
Collection of cord blood
Administration of Pitocin
Assess Q 15 min for ~2 hours following birth
Vitals
Fundal height, firm vs boggy
Perineum , assist with repair, intact? edematous?
Lochia- color, amount (absent, scant, mod, heavy), clots present, free flow
Why do we encourage breastfeeding as soon as possible?
(stimulate release of oxytocin from the pituitary gland = strengthens and coordinates uterine contractions. CONTRACTIONS help compress blood vessels and promote hemostasis)
Placenta Delivery
Considered the 3rd Stage of Labor
Should be <30 mins after baby is delivered
Spontaneous or Assisted
Cord Blood Collection
pitocin
Exogenous oxytocin
Administered after placental delivery; IV or IM
Helps strengthen and coordinate uterine contractions
Breastfeeding is the natural way to increase oxytocin
PostPartum Assessment: Vital Signs
Normal Findings
Temp: up to 38° C (100.4 ° F). > 24 hrs afebrile (mild-r/t dehydration, milk “coming-in”)
Pulse: elevated x 1 hr then begins to decrease.
Resp: should decrease to normal prebirth by 6-8 wks
BP: no-slight alteration. Orthostatic hypotension can develop in 48 hours
Pain: afterpains, musculoskeltal, perineal, nipple pain
Reproductive System Adaptations
Uterus
Involution: contraction of muscle fibers; catabolism; regeneration of uterine epithelium
Lochia: rubra, serosa, alba
Afterpains
Cervix:
closure; now appearing as jagged slit-like opening.
Vagina: eventual thickening and return of rugae.
Perineum
Postpartum Period: Assessment
B: Breasts (size, contour, engorgement) U: Uterus (height of fundus, firmness) B: Bladder (voiding, bladder emptying) B: Bowels (bowel sounds, distention) L: Lochia (amount, color, odor) E: Episiotomy and perineum (lacerations, hematoma) E: Extremities E: Emotional status
B: Breasts
Normal filling day 2-3
May have engorgement
- on day 3-4
Treatment
Frequent nursing
Cold packs?
Cabbage leaves
Sore nipples? assess q shift
Breast
Breast
Clostrum present prior to birth (rich in protein & immunoglobulins)
Increased milk production begins 48-96 hours pp
Letdown reflex caused by oxytocin from posterior pituitary released by sucking
Engorgement occurs on 2-5th day
-transitional milk on 3-8th day
Mature milk is produced after
2 weeks
Breast care
Lactating Types of milk Positioning infant Breast engorgement Nipple care Fungal infection (thrush) Non-lactating Avoid stimulation Supportive bra
Common Postpartum Medications
Oxytocin (Pitocin) Rhogam Rubella Immunization: live vaccine Pain medication Ibuprofen (best for cramps/breastfeeding) Tylenol Depo Provera
