Chapter 8 Physiological and Psychological Changes During Pregnancy Flashcards
1
Q
What does the pituitary gland do in preparation for pregnancy?
A
secretes hormones that influence ovarian follicular development, prompt ovulation, and stimulate the uterine lining to prepare for pregnancy and maintain it until the placenta becomes fully functional
-other pituitary hormones alter metabolism, stimulate lactation, produce pigmentation changes in the skin, stimulate uterine muscle contractions, prompt milk ejection from the breasts, allow for vasoconstriction to maintain blood pressure, and regulate water balance
2
Q
After conception, what happens to ovulation?
A
it ceases
3
Q
The corpus luteum produces what?
A
progesterone and estrogen (placenta produces these)
4
Q
Which hormone is primarily responsible for maintaining pregnancy?
A
progesterone
-“pro-pregnancy” hormone
5
Q
What happens once implantation occurs?
A
the trophoblast secretes human chorionic gonadotrophin (hCG) to prompt the corpus luteum to continue progesterone production until this function is taken over by the placenta
6
Q
The ovarian hormones responsibilities
A
ovarian hormones work in synchrony to maintain the endometrium, provide nutrition for the developing morula and blastocyst, aid in implantation, decrease the contractility of the uterus to prevent spontaneous abortion, initiate development of the ductal system in the breasts, and prompt remodeling of maternal joint collagen
7
Q
What provides hormones essential to the survival of the pregnancy and fetus?
A
the placenta
8
Q
What are the Placental hormones responsible for?
A
- prevent the normal involution of the ovarian corpus luteum
- stimulate production of testosterone in male fetus
- protect the pregnancy from the maternal immune response
- ensure that added glucose, protein, and minerals are available for the fetus
- prompt proliferation of the uterus and breast glandular tissue
- promote relaxation of the woman’s smooth muscle
- create a loosening of the pelvis and other major joints
9
Q
What is the effect of estrogen?
A
growth
- estrogen prompts hyperplasia and hypertrophy (growth of cells in number and size) during pregnancy
- because of effects of estrogen, breast tissue enlarges and becomes functional and the uterus expands, a process that allows for stretching of the muscles to accommodate the growing fetus
- estrogen also enhances uterine contractility to prepare the muscles for labor
10
Q
What is the effect of progesterone?
A
maintenance
- enables the pregnancy to thrive by its relaxation effect on the smooth muscle
- progesterone causes vasodilation and an increased blood flow to all body tissues
- it slows the gastrointestinal tract to ensure absorption of essential nutrients for fetal development
- relaxes the uterine muscle to prevent the onset of labor until term
- called the “pro-pregnancy” hormone
11
Q
Major pregnancy hormones
A
estrogen and progesterone
12
Q
Reproductive system effects of estrogen
A
- breast tissue enlargement
- uterine tissue enlargement
- increased uterine contractility
13
Q
Reproductive system effects of progesterone
A
- slowing of gastrointestinal tract
- relaxation of uterus and all smooth muscle
- vasodilation, increased blood flow
14
Q
What is considered the “home” for the growing fetus?
A
the uterus
15
Q
Braxton Hicks Contractions
A
- irregular and painless
- may begin at 16 weeks of gestation
16
Q
As pregnancy advances and the fetal size increases, what happens to the contractions?
A
become increasingly more frequent and intense and are easily felt by the woman
17
Q
Until late in the second trimester, what are the contractions purpose?
A
to prepare the uterine muscles for the synchronized activity necessary for effective labor
18
Q
Contractions in their normalcy
A
- irregular in frequency
- last for less than 60 seconds
19
Q
Contractions: When to call provider
A
- pattern of regular contractions is noted
- contractions are associated with bleeding, nausea, vomiting, or intense pain
20
Q
What does the increased blood flow from progesterone do for the body?
A
provides adequate circulation for endometrial growth and placental function
-the enhanced uterine circulation is important for ensuring adequate fetal nutrition and the removal of waste products
21
Q
After implantation, the endometrium lining the uterus is termed what?
A
decidua
22
Q
Decidua: Three layers
A
- Decidua vera
- Decidua basalis
- Decidua capsularis
23
Q
Decidua Vera
A
external layer, no contact with fetus
24
Q
Decidua Basalis
A
uterine lining beneath the site of implantation
25
Decidua Capsularis
endometrial tissue that covers the embryo
26
At 20 weeks, the fundus growth is at the level of
the umbilicus
27
At 36 weeks, the fundus should be at the level of what in growth?
the level of the xiphoid process
- "highest level"
- may feel SOB--> rest, if it does not get better call provider or get to hospital
28
What is one of the earliest signs of pregnancy?
discoloration, or bluish purple hue, that appears on the cervix, vagina, and vulva (Chadwick's sign)
29
Chadwick's sign
earliest signs of pregnancy
| -color change; discoloration or bluish purple hue, that appears on the cervix, vagina, and vulva
30
How do Chadwick's sign come about?
high levels of circulating estrogen cause stimulation of the cervical glandular tissue, which increases in cell number and becomes hyperactive
-increased blood flow and engorgement produces the bluish discoloration
31
Goodell's sign
- cervical softening
- stimulation from estrogen and progesterone produces cervical softening
- related to a decrease in the collagen fibers of the connective tissue, increased vascularity and edema, and slight tissue hypertrophy and hyperplasia
32
The Cervix, Before and After pregnancy
- Before: is firm, and texture resembles tip of nose
| - After conception: cervix softens and texture resembles that of an ear lobe
33
Operculum
mucus plug
-cervical mucus fills the endocervical canal and forms a mucus plug
-helps keep harmful agents out of the uterus
(estrogen and progesterone cause a proliferation of mucus-producing cervical glands)
34
Leukorrhea
increased whitish vaginal discharge
- results from hyperplasia of the vaginal mucosa and increased mucus production from the endocervical glands
- as due date approaches, cervical effacement and dilation cause a breakdown of the mucus plug (operculum), resulting in an increased vaginal discharge
- leukorrhea is normal during pregnancy
35
When to call provider about Leukorrhea?
- discharge appears thicker
- becomes bloody or yellowish/green
- accompanied by foul odor
- causes itching, irritation, or pain in the vulvar or vaginal area
36
Changes in the Vagina and Vulva
- increased blood flow (hyperemia) produces a purple hue (Chadwick's sign)
- thickening of the vaginal mucosa develops
- rugae (vaginal folds) become more prominent
- leukorrhea results from increased cervical mucus along with elevated glycogen levels which produces rapid sloughing of tissue
- elevated glycogen create a vaginal environment more susceptible to the growth of Candida albicans; more susceptible to yeast infections
- pH of vaginal fluids becomes more acidic and decreases from 6.0 to 3.5 (help control the growth of pathogens in vaginal canal)
37
Vagina and Vulva Changes: Rugae
rugae (vaginal folds) deepen from hyperplasia and hypertrophy of the epithelial and elastic tissues
- this change allows for adequate stretching of the vaginal vault during childbirth
- as pregnancy progresses, this area becomes edematous from poor venous return caused by the weight of the gravid uterus
38
Vulvar hygiene
gentle external cleansing with plain soap and water
-douching, or internal cleansing should be avoided because it can alter the pH and allow pathogens to grow as well as disrupt the cervical mucus plug
39
Ovaries
after ovulation, the pituitary hormone luteinizing hormone (LH) stimulates the corpus luteum (functional cyst that remains on the ovary) to produce progesterone for 6 to 7 weeks
- once the placenta is developed and functional, it begins to take over the task of progesterone production
- the corpus luteum ceases to function and is gradually absorbed by the ovary
- the corpus luteal cyst enlarges while functioning and may reach the size of a golf ball before it begins to recede
- in some cases, the cyst may rupture, causing some pelvic discomfort associated with bleeding into pelvic cavity
- the pain should dissipate as the cyst and blood are absorbed
- if the pain is still persistent or if vaginal bleeding occurs, the nurse should advise the woman to seek medical care
40
Why does ovulation cease during pregnancy?
because of the high circulating levels of estrogen and progesterone, which inhibit pituitary release of follicle stimulating hormone (FSH) and LH
41
What Happens to the Breasts During Pregnancy?
estrogen and progesterone produce changes in the mammary glands
- breast enlargement, fullness, tingling, and increased sensitivity happen in early weeks of gestation
- superficial veins become more prominent
- nipples become more tender and more pronounced with darkening of the areola
- Montgomery tubercles (sebaceous glands) on and around the areola enlarge and provide lubrication for the nipple tissue
- striae gravidarum (stretch marks)
42
Montgomery tubercles
(sebaceous glands)
| on and around the areola enlarge and provide lubrication for the nipple tissue
43
Striae gravidarum
stretch marks
| -may develop as breast tissue stretches
44
Integumentary system changes
- darkening of the areolae
- appearance of linea nigra
- striae gravidarum
45
Pre-colostrum
- during second trimester
- a clear thin fluid
- found in acini cells, smallest part s of the milk glands
- becomes colostrum
46
Colostrum
creamy whitish-yellow liquid that may leak from the nipples as early as the 16th week of gestation
- contains antibodies, essential proteins, and fat to nourish the baby and prepare his intestines for digestion and elimination
- colostrum is converted to mature milk during the first few days after birth
47
What should the nurse discuss during prenatal care?
- need for changes in bra size
- options for infant feeding
- if breastfeeding, strategies to help prepare for successful breastfeeding
- process of lactation reviewed
- give list of lactation support resources
- soft cotton liners can be used to pad the bra if leaking of the nipples is troublesome
48
Integumentary system changes
estrogen, progesterone, and alpha-melanocyte-stimulating hormones cause many changes in the appearance
- may negatively affect woman's self-concept and body image
- number of pigmentation changes related to the influence of estrogen
- linea nigra
- chloasma (Melasma gravidarum)
- alterations in hair and nails
- striae gravidarum
- angiomas
- palmar erythema
49
Integumentary Changes: Pigmentation changes
- moles (nevi), freckles, and recent scars may darken or appear to multiply in number
- the nipples, areolae, axillae, vulvar area, and perineum darken in color
50
Integumentary Changes: Linea alba/ Linea nigra
linea alba is a light line that extends from the umbilicus to the mons pubis (and sometimes upward to the xiphoid process) darkens, becoming the linea nigra
-the linea is more noticeable in the woman with naturally darker complexion
51
Integumentary Changes: Cholasma
aka Melasma gravidarum
- forms the "mask of pregnancy"
- dark, blotchy brownish pigmentation change occurs around the hairline, brow, nose, and cheeks
- gives appearance of "raccoon eyes"
- fades after pregnancy but can recur after exposure to the sun
52
During Pregnancy what should the nurse educate the patient about when going outside?
during pregnancy the skin becomes photosensitive, and sunburn may occur in a shorter exposure time than usual
- importance of regular sunscreen
- decreased sun exposure time
53
Integumentary Changes: Striae Gravidarum
increased adrenal steroid levels cause the connective tissue to lose strength and become more fragile
- causes "stretch marks"
- on breasts, buttocks, thighs, and abdomen
- appear as reddish, wavy. depressed streaks that will fade to a silvery white color after birth, but do not usually disappear completely
54
Integumentary System Changes: Angiomas
"vascular spiders"
- tiny, bluish, end-arterioles that occur on the neck, thorax, face, and arms
- may appear as star-shaped or branched structures that are slightly raised and do not blanch with pressure
- more common in Caucasian women
- appear most often during the second to fifth month of pregnancy and usually disappear after birth
55
Integumentary Changes: Palmar erythema
color changes over the palmar surfaces of the hands
| -presents as a diffuse, reddish-pink mottling of the palms
56
Integumentary Skin Changes: Other skin changes
- increased blood flow, along with high levels of circulating hormones can produce inflammatory pruritis and acne vulgaris, seen in the first trimester
- hyperactivity of the sweat and sebaceous glands may cause excessive perspiration, night sweats, and skin changes that range from extreme dryness to extreme oiliness
57
Anticipatory guidance for Integumentary changes
- offer reassurance
- recommendations of daily bathing, liberal use of lotions or oils for dry skin, regular use of deodorant, and limited sun exposure with diligent use of sunscreen
58
Neurological System Changes
- decreased attention span
- poor concentration
- memory lapses during and shortly after pregnancy
- reduced sleep efficiency
- carpal tunnel syndrome
- syncope
59
Neurological System Changes: Carpal tunnel syndrome
manifested by pain and paresthesia (a burning, tingling, or numb sensation) in the hand that radiates to the elbow
- the pain occurs in one (usually the dominant) or both hands and is intensified with attempts to grasp objects
- usually subsides after the pregnancy (and the accompanying edema) has ended although some may require surgical treatment if symptoms persist
- usually develops during third trimester
60
How does Carpal tunnel syndrome occur?
edema from vascular permeability can lead to a collection of fluid in the wrist that puts pressure on the median nerve lying beneath the carpal ligament
-causes pain and paresthesia (burning, tingling, or numb sensation) in the hand that radiates to the elbow
61
Neurological System Changes: Syncope
transient loss of consciousness and postural tone with spontaneous recovery
62
How does Syncope Occur during pregnancy?
- attributed to orthostatic hypotension and/ or inferior vena cava compression by the gravid uterus
- occur as increased intra-abdominal pressure from the growing uterus places pressure on the vagus nerve
- coughing, straining during bowel movements, and upward pressure from the growing fetus can trigger a vasovagal response that produces faintness or loss of consciousness
63
Warning signs that often precede syncope that the nurse should teach the client
light-headedness, sweating, nausea, yawning, and feelings of warmth
- if light-headedness or other warning signs are experienced, instruct to assume a lying or sitting position
- a left side-lying position is preferred to avoid compression of the vena cava (which can lead to supine hypotension) from the gravid uterus
64
What happens to the heart during pregnancy?
the growth of the fetus exerts pressure on the diaphragm, and the heart is pushed upward and laterally to the left
-cardiac hypertrophy results from the increased blood volume and cardiac output
-exaggerated first and third heart sounds and systolic murmurs are common findings (usually asymptomatic and require no treatment)
>if symptoms, may experience palpitations, chest pain, SOB, or a decreased tolerance to activity (should see healthcare provider)
-systolic murmurs usually resolve within the first 2 weeks postpartum after the plasma volume level return to normal
65
Cardiovascular system changes
- increase in maternal blood volume (begins in 1st trimester and peaks at term)
- iron
- leukocytes, proteins, platelets, immunoglobulins
- cardiac output
66
Cardiovascular System Changes: Blood volume
increase in maternal blood volume (begins in 1st trimester and peaks at term)
- due to an increase in plasma and erythrocyte volume
- additional erythrocytes, needed because of the extra oxygen requirements of the maternal and placental tissue, ensure an adequate supply of oxygen to the fetus
- elevation of erythrocyte volume remains constant during pregnancy
- mostly goes to the uterus, blood flow to maternal kidneys is increased and enhances excretion of maternal and fetal waste
- dilation of capillaries and increased blood flow to the skin assist the woman in eliminating the extra heat generated by fetal metabolism
- extra blood volume decreases during first 2 weeks postpartum
- fluid loss in the first 3 postpartum days through maternal diuresis
67
Cardiovascular System Changes: Iron
iron is necessary for the formation of hemoglobin, the oxygen carrying component of the erythrocyte.
- the increased need for oxygen requires the pregnant woman to increase her iron intake
- fetal need for iron is greatest at the last 4 weeks of pregnancy, when fetal iron stores are amassed (gathered)
68
Cardiovascular Changes: Hemoglobin and Hematocrit levels
- hematocrit values may appear low because of the increase in total plasma volume (on average, 50%)
- because the plasma volume is greater than the increase in erythrocytes (30%), the hematocrit (measure of red blood cell concentration in the plasma) decreases by about 7%----> termed "physiological anemia of pregnancy" or "pseudoanemia"
- the acceptable hemoglobin level in pregnancy is 11 to 12 g/dL of blood
69
Cardiovascular changes: Physiological anemia of pregnancy or Pseudoanemia
the hematocrit (measure of red blood cell concentration in the plasma) decreases by about 7%
- because the plasma volume is greater than the increase in erythrocytes (30%)
- may experience fatigue
- teach patient to hydrate by drinking 6 to 8 glasses of water each day and ensure a diet high in protein and iron
70
What should the nurse teach the patient when the patient experiences "physiological anemia of pregnancy" or "pseudoanemia"
-stay hydrated by drinking 6 to 8 glasses of water each day
-ensure a diet high in protein and iron
>although gastrointestinal absorption of iron in enhanced during pregnancy, most women must add supplemental iron to meet the needs of the expanded erythrocytes an those of the growing fetus
71
Cardiovascular changes: Leukocytes
- increases
- normal range: 5000-15000/mm3
- During labor and postpartum: may climb up to 25000/mm3
- reason unclear
72
Cardiovascular Changes: Proteins
- plasma proteins increase
- decrease in protein concentrations (like albumin) because of the hemodilution effect during pregnancy
- decreased plasma albumin leads to a drop in osmotic pressure, which causes bodily fluids to move into the second space, producing edema
73
Cardiovascular Changes: Platelet and fibrinogen
-platelet count does not change significantly
-fibrinogen (clotting factor) volume increases as much as 50%
>leads to increase in sedimentation rate
-Blood factors VII, VIII, IX, and X are increased; causing hypercoagulability
>the hypercoagulable state, coupled with venous stasis (poor blood return from lower extremities) puts woman at risk for venous thrombosis, embolism, and when complications are present, disseminated intravascular coagulation (DIC)
74
Cardiovascular Changes: Immunoglobulins
(IgA, IgG, IgM, IgD, and IgE)
- are unchanged
- immunoglobulins protect the body from a variety of bacterial, viral, and parasitic infections
- IgG, IgA, and IgM are primarily involved in immunity
- Circulating levels of maternal IgG are decreased during pregnancy because of transfer across the placenta
- IgG, the only immunoglobulin transported across the placenta, is active against bacterial toxins
- fetus does not acquire IgG until the last 4 weeks of pregnancy
75
Cardiovascular Changes: Cardiac Output
- increases and peaks around the 20th to 24th week of gestation, 30 to 50%
- remains increased for duration of pregnancy
- with increased vascular volume and cardiac output, vasodilation (related to progesterone-induced relaxation of the vascular smooth muscle) reduces BP in the mid trimester
- woman's pulse rate increases up to 10 to 15 bpm to facilitate effective circulation of the increased blood volume
76
Blood Pressure during pregnancy
- during first trimester= same
- decreases around 20 weeks gestation
- after 20 weeks, the vascular volume expands and the blood pressure increases to reach pre-pregnancy levels by term
- because of the relaxed vascular resistance and stasis of blood in lower extremities= increase risk of varicose veins and hemorrhoids
77
What should the nurse teach when dealing with a risk for varicose veins and hemorrhoids due to the relaxed vascular resistance and stasis of blood in the lower extremities?
-elevate lower extremities by lying on her left side with the feet higher than her heart for 15 to 20 minutes daily to improve venous return from the lower extremities
-daily walks enhance circulation and improve intestinal peristalsis for regular bowel function
-drink at least 8 to 10 glasses of water each day and include roughage in their diet
>these help prevent constipation and straining with bowel movements, which increase likelihood of hemorrhoids
78
Interventions to teach the patient with Carpal tunnel syndrome
- elevation of the hands at night may help reduce edema
- may need to wear a "cock-up splint" to prevent the wrist from flexing, an action that puts additional pressure on the median nerve
79
Supine Hypotension Syndrome or Vena Caval Syndrome
-if patient lies on her back
-the pressure from the enlarged uterus exerted on the vena cava decreases the amount of venous return from the lower extremities and causes a marked decrease in blood pressure, with accompanying dizziness, diaphoresis, and pallor
>place woman on her left side
80
How to relieve symptoms from supine hypotension syndrome or Vena Caval Syndrome
place woman on her left side
81
What is another condition that occurs in pregnancy and results from stagnation of blood in the lower extremities?
Orthostatic Hypotension
-if the woman stands for too long or arises too quickly, gravity causes the blood to flow to the lower extremities, decreasing blood flow to the brain
>arise slowly from a lying or sitting position
>while standing, keep her feet moving to encourage adequate venous return from the lower extremities and avoid lying flat on her back
82
Respiratory System Changes
- increased tidal volume
- increased oxygen consumption
- elevated diaphragm
- increased chest circumference
83
Respiratory System Changes: Tidal volume
-the tidal volume (amount of air breathed in each minute) increases 30-40%
-change is related to elevated levels of estrogen and progesterone
-estrogen prompts hypertrophy and hyperplasia of the lung tissue
-progesterone decreases airway resistance by causing relaxation of the smooth muscle of the bronchi, bronchioles, and alveoli
>these alterations produce an increase in oxygen consumption by 15-20% along with an increase in vital capacity (the maximum amount of air that can be moved in and out of the lungs with forced respiration)
84
What should the nurse do when the patient verbalizes an increase awareness of the need to breathe and perceive this sensation of dyspnea?
-offer reassurance and educate about normal alterations and symptoms
-under normal circumstances, resting with the head elevated while taking slow, deep breaths causes an improvement in symptoms
>lung diseases including asthma and emphysema may be aggravated by the normal physiological changes as the oxygen demands of the pregnancy increase--> if symptoms persist contact healthcare provider
85
Respiratory System Changes: Elevated diaphragm
the enlarging uterus creates an upward pressure that elevates the diaphragm and increases the subcoastal angle
- chest circumference may increase by 2.4 inches (6 cm)
- the "up and down" capacity of the diaphragmatic movement is reduced (because of increasing pressure from the growing fetus), lateral movement of the chest and intercostal muscles accommodate for this loss and keep pulmonary functions stable
86
Eye Changes
blurred vision
-caused by corneal thickening associated with fluid retention and decreased intraocular pressure
-begin during first trimester
-persist throughout pregnancy
-regress by 6 to 8 weeks postpartum
>nurse teaches this because changes are only temporary; corrective lens prescription should not be changed until pregnancy has been completed
87
Nose Changes
- increase in mucus production results from combined effects of progesterone (increased blood flow to the mucus membranes of the sinus and nasal passages) and estrogen (hypertrophy and hyperplasia of the mucosa)
- nasal stuffiness and congestion (rhinitis of pregnancy)
- edema (effect of estrogen) of the nasal mucosa, along with vascular congestion (effect of progesterone) may cause epistaxis (nosebleeds)
88
What should the nurse teach a patient about changes of the nose during pregnancy and what interventions to take?
- offer reassurance and educate about normal changes
- increase oral fluid intake helps to keep the mucus thin and easier to mobilize
- use caution when blowing her nose
- avoid probing the nasal cavities with a cotton swab
- use of nasal sprays designed to relieve congestion should be avoided because of their rebound effect that causes the congestions to worsen
- normal saline nasal sprays may be used sparingly to moisten nasal passageways
89
Throat changes during pregnancy
- hyperemia (congestion) occurs from increased blood flow and relaxation of smooth muscle
- swallowing may be difficult if food is not chewed well
90
What is roughage?
fiber
- part of plant-based foods
- grains, fruits, vegetables, nuts, and beans
91
Gastrointestinal System Changes
- nausea and vomiting in the first trimester related to rising levels of hCG and altered carbohydrate metabolism
- changes in taste and smell due to alterations in oral and nasal mucosa; can further aggravate GI discomfort
- gingivitis (inflammation of the gums) because of increased blood supply to the gums, along with estrogen related hypertrophy and edema
- epulis gravidarum
- ptyalism
- pyrosis
- relaxation of the esophagus
- sluggish large intestine
- liver; altered liver function tests
- relaxation of the gallbladder; lead to cholestasia, cholelithiasis, and cholecystitis
- pruritis gravidarum
92
GI system Changes: Gingivitis and Nursing Interventions
- inflammation of the gums
- occurs frequently because of the increased blood supply to the gums; along with estrogen related tissue hypertrophy and edema
- Interventions: stress importance of regular dental maintenance and its effect on good maternal nutrition even if the gums may bleed from routine oral hygiene
93
GI system Changes: Epulis Gravidarum
red, raised nodules that appear on the gum line
- bleed easily
- regress within 2 months after childbirth
- if excessive bleeding, local excision may be necessary
94
GI System Changes: Ptyalism
excessive saliva production often with a bitter taste
-stimulation of the salivary glands from eating starch or decreased unconscious swallowing when nauseated may contribute
>limited relief with the use of chewing gum and lozenges
>eat small, frequent meals
>avoid starchy foods such as potatoes, bread, and pasta
95
GI System Changes: Relaxation of the esophagus
the effect of progesterone on smooth muscle causes relaxation of the esophagus
-movement of food is slowed and the gastroesophageal, or cardiac, sphincter (circular muscle located at the top of the stomach) weakens
>this prevents efficient closure when the stomach is emptying and allows the reflux of stomach contents into the esophagus, producing heartburn, or pyrosis
96
Pyrosis and its intervention
heartburn
-happens with the changes of GI system; relaxation of esophagus
-results from irritation to the esophageal lining by gastric secretions and acids
>Interventions: eating small meals, avoiding lying down after meals for at least 1 hour, and limited use of antacids
97
Why does Nausea and Vomiting Occur During Pregnancy?
"morning sickness"
-high levels of hCG and relaxation of the stomach, esophagus, and gastroesophageal sphincter
-food remains in the stomach longer for enhanced digestion and moves more slowly through the small intestine to allow for complete absorption of nutrients
-because the large intestine is also sluggish from the effects of progesterone on the smooth muscle, more water is reabsorbed from the bowel, and bloating and constipation can occur
>straining at defecation may cause or exacerbate hemorrhoids
98
Hemorrhoid interventions
- dink at least 8 to 10 glasses of water each day
- add fiber to produce bulk
- exercise to encourage peristalsis
- avoid straining with bowel movements
- warm sitz baths
99
GI System Changes: Liver
- the liver, which breaks down maternal toxins, must deal with fetal waste products and toxins
- additional workload can lead to altered liver function tests, especially if accompanied by hepatic vessel vasoconstriction associated with preeclampsia
- stasis of bile in the liver (intrahepatic cholestasis) occasionally occurs late in pregnancy and cause severe itching (pruritus gravidarum)
100
GI System Changes: Gallbladder
-gallbladder, storehouse for bile, is composed of smooth muscle and becomes relaxed, resulting in inefficient emptying
>lead to stasis of bile (cholestasia) or inflammation and infection (cholecystitis)
>the progesterone-induced prolonged emptying time, combined with elevated blood cholesterol levels, may predispose woman to gallstone formation (cholelithiasis)
-pain in the epigastric region after ingestion of a high-fat meal is major symptom of these conditions
-pain is self-limiting and usually resolves within 2 hours
101
Urinary system Changes
- frequency, urgency, and nocturia
- more susceptible to ASB and UTI
- elongation and dilation of ureter
- glomerular filtration rate and renal plasma flow are increased
- increased glucose excretion in urine
102
Urinary System Changes: frequency, urgency, nocturia
-during the first trimester, the bladder, is compressed by the weight of the growing uterus; the added pressure along with progesterone-induced relaxation of the urethra and sphincter musculature, leads to urinary urgency, frequency, and nocturia
in the second trimester, when the uterus becomes an abdominal organ, bladder pressure is largely relieved, along with most of the frequency and urgency
-third trimester, the fetal presenting part descends into the pelvis; increased pressure is again exerted on the bladder, and symptoms of frequency, urgency, and nocturia return
103
Urinary System Changes: Susceptible to ASB or UTI
ascension of bacteria into the bladder can cause asymptomatic bacteriuria (ASB) or UTI's
-occur more frequently in pregnancy because of relaxation of the smooth muscle of the bladder and urinary sphincter, changes that allow bacterial ascent into the bladder
104
Urinary System Changes: Ureters
composed of smooth muscle, are also affected by progesterone
-elongation and dilation (usually of right ureter) occurs
-peristalsis that normally facilitates the movement of urine from the kidneys to the bladder is reduced
>this change coupled with pressure on the ureters from the enlarging uterus, causes an obstruction of urine flow
-the stagnant urine becomes a medium for the growth of microorganisms
105
What should the nurse teach the patient that is undergoing changes with the ureters and to prevent stasis of urine and the bacterial contamination that leads to infection?
- drink at least 8 to 10 glasses of water each day
| - empty bladder every 2 to 3 hours and immediately after intercourse
106
Urinary System Changes: GFR and renal plasma flow
increased because of hormonal changes, blood volume increases, the woman's posture, physical activity level, and nutritional intake
-GFR increases 50% in second trimester
-alteration prompts an increase in renal tubular reabsorption
>there is a increased load of glucose presented to the renal tubules; glucose excretion increases in virtually all pregnant woman
-it may be a normal finding but glucosuria (glucose in urine) should be investigated to rule out gestational diabetes because the quantitative urine glucose does not accurately reflect blood glucose levels
107
Endocrine System Changes: Thyroid Gland
-size upon palpation increases (caused by increased circulation from the progesterone-induced effects on the vessel walls and by estrogen-induced hyperplasia of the glandular tissue)
-increased levels of T4 continue to be elevated until several weeks postpartum
>increased T4-binding capacity is noted by an increase in the serum protein-bound iodine (PBI)
-these changes in thyroid regulation cause a increase in the basal metabolic rate (BMR) of up to 25% by term
(BMR is amount of oxygen consumed by the body over a unit of time)
>Maternal effects of the increase BMR are: heat intolerance, elevation in pulse rate, elevation in cardiac output
-within a few weeks of birth thyroid function returns to normal
108
Endocrine System Changes: Parathyroid Glands
these glands regulate calcium and phosphate metabolism
- increase in size from estrogen-induced hyperplasia and hypertrophy
- maternal concentrations of parathyroid hormone increase as the fetus requires more calcium for skeletal growth during second ad third trimesters
- daily intake of calcium--> 1200 to 1500 mg
109
Endocrine System Changes: Pituitary gland and FSH and LH
- anterior lobe of the pituitary gland, stimulated by the hypothalamus, increases in size and in weight
- pregnancy is possible because of the actions of FSH (stimulates growth of Graafian follicle) and LH, which prompts final maturation of the ovarian follicles and release of the mature ovum
- If conception occurs, elevated levels of estrogen and progesterone suppress production of FSH and LH
- during pregnancy, ovarian follicle maturation may continue, but ovulation does not occur
110
Endocrine System Changes: Prolactin
produced by the anterior pituitary gland
- responsible for initial lactation
- increases 10-fold during pregnancy
- elevated levels of estrogen and progesterone inhibit lactation by interfering with prolactin-binding to the breast tissue
- may also play a role in fluid and electrolyte shifts across the fetal membranes
111
Endocrine System Changes: Oxytocin
produced in the posterior lobe of the pituitary gland
- causes uterine contractions
- high levels of progesterone prevent contractions until close to term
- also stimulates milk ejection from the breasts, or the "let down" reflex
112
Endocrine System Changes: Vasopressin
produced in the posterior lobe of the pituitary gland
-causes vasoconstriction
>vasoconstriction leads to an increase in maternal blood pressure and exerts an antidiuretic effect that promotes maternal fluid retention to maintain circulating blood volume
-the increased blood volume, along with changes in plasma osmolarity (the fluid-pulling capacity of the plasma to retain fluids) controls the release of vasopressin
113
Endocrine System Changes: Adrenal Glands; Cortisol
-located above the kidneys, change little
-the adrenal cortex produces cortisol, a hormone that allows the body to respond to stressors
>cortisol is increased because of decreased renal secretion (an alteration prompt by high estrogen levels)
>cortisol regulates protein and carbohydrate metabolism and believed to promote fetal lung maturation and stimulate labor at term
-make take u to 6 weeks for maternal cortisol levels to return to normal
114
Endocrine System Changes: Adrenal Glands; Aldosterone
by the second trimester, the adrenal cortex secretes increased levels of aldosterone
>aldosterone is a mineral corticoid that causes the renal reabsorption of sodium
-this alteration promotes the reclaiming of water and helps to enhance circulatory volume
115
Endocrine System Changes: Pancreas
pancreas secretes insulin produced by the beta cells of the islets of Langerhans
-pregnancy prompts an increase in the number and size of the beta cells
>these changes are responsible for the alterations that occur in carbohydrate metabolism during pregnancy
116
Musculoskeletal System Changes
-postural changes
>lumbar lordosis
>"pregnancy waddle"
-calcium needs
117
Musculoskeletal System Changes: Lumbar Lordosis
as the weight of the uterus shifts upward and outward, a lumbar lordosis (anterior convexity of the lumbar spine) develops
-alteration compensates for the changing center of gravity and allows centering to remain over the woman's legs
-low back pain usually accompanies
>separation of the rectus abdominis muscles along with an increase in intra-abdominal pressure from the growing uterus may exacerbate an abdominal wall hernia
118
Musculoskeletal System Changes: "pregnancy waddle"
Relaxin, a hormone produced by the placenta, along with progesterone, causes a laxity of the ligaments
- these changes, coupled with the change in maternal center of gravity, result in an unsteady gait and a greater tendency towards falls
- gait takes on appearance of "pregnancy waddle" as the bones of the pelvis shift and move
119
Interventions for Pregnancy waddle and low back pain
- maintain good posture
- keep abdominal muscles toned through exercise
- sitting in a firm chair and the use of a small pillow or blanket rolled and placed in the lumbar region for support can decrease low back pain
120
Musculoskeletal System Changes: Calcium stores
mobilization of calcium stores occurs to provide for the fetal calcium needs necessary for skeletal grown
- the total maternal serum calcium decreases, but the ionized calcium level remains unchanged from the prepregnant state
- increase in circulating maternal parathyroid hormone stimulates an increased absorption of calcium from the intestines and decreases the renal loss of calcium to maintain calcium levels
121
What should the nurse tell the patient about Calcium intake during pregnancy?
calcium intake is of major importance during pregnancy
- increase dietary calcium through consumption of dairy products, calcium-fortified orange juice, and dark green leafy vegetables
- calcium supplementation may be advised for patients who are vegetarian or lactose intolerant
- cramps or "charley-horses" can be extremely painful and are caused by poor circulation to the extremities; also associated with imbalances in calcium and phosphorus
122
Immediate relief of cramping in the calves and lower extremities include
- instructing the woman to stand and lean forward to stretch the calf muscle
- have someone gently push toes back toward her shin and hold for several seconds
- daily walks can help because ambulation improves circulation to the muscles
- increasing or decreasing calcium intake may also help
123
Nursing Diagnoses related to Physiological Adaptations to Pregnancy
- deficient knowledge r/t normal physiological changes of pregnancy
- constipation r/t changes in gastrointestinal tract occurring in pregnancy
- imbalanced nutrition; more than body requirements r/t excessive intake of calories
- imbalanced nutrition; less than body requirements r/t inadequate information about nutritional needs during pregnancy
- activity intolerance r/t fatigue from the physiological changes of pregnancy
124
First Trimester Education: Physiological changes of Pregnancy and Related Discomforts
- pain and tingling in breasts
- nausea and vomiting (morning sickness)
- urinary frequency
- fatigue
- mood swings
125
Second Trimester Education: Physiological changes of Pregnancy and Related Discomforts
- enlargement of the abdomen
- skin pigmentation
- striae gravidarum
- vascular spiders
- constipation
- heartburn or gastric reflux
- leg cramps
- groin pain from round ligament stretching
- leukorrhea
126
Third Trimester Education: Physiological changes of Pregnancy and Related Discomforts
- Dyspnea
- leg and feet cramps
- constipation
- indigestion, heartburn, gastric reflux
- pedal edema
- fatigue
- vaginal discharge
- urinary frequency
- Braxton-hicks contractions vs true labor
127
First Trimester Education: Danger Signs to Report
- vaginal bleeding
- abdominal cramping or pain
- severe or prolonged vomiting
128
Second Trimester Education: Danger Signs to Report
- vaginal bleeding
- burning or painful urination
- fever, increased pulse rate
- decreased or absent fetal movements
- unrelenting nausea and vomiting
- abdominal pain or cramping
- swelling of the face or fingers
- headaches
- visual disturbances
- epigastric pain
129
Third Trimester Education: Danger Signs to Report
- visual disturbances
- headache
- hand a facial edema
- fever
- vaginal bleeding
- abdominal pain; uterine contractions
- premature rupture of the membranes
- decreased or absent fetal movement
130
First Trimester Education: General Health Teaching
- schedule of return visits for routine prenatal care
- general hygiene
- comfort measures
- anticipatory guidance
- sexual activity restrictions
- physical activity, exercise, and rest
- nutritional guidance
- avoidance of alcohol, fetal alcohol effects
- effects of smoking and smoking cessation strategies if indicated
131
Second Trimester Education: General Health Teaching
- reinforcement and reiteration of previous teaching
- comfort measures
- anticipatory guidance
- choices of prenatal education classes
- signs and symptoms of preterm labor
132
Third Trimester Education: General Health Teaching
- signs/symptoms of labor/preterm labor
- when to call the healthcare provider, when to go to the birthing center or hospital
- comfort measures
- anticipatory guidance
- reinforcement and reiteration of previous teachings
- encouragement to attend a labor and birth class
133
"tasks of Pregnancy"
Rubin described specific tasks that a women must accomplish to integrate the maternal role into her personality
-to be successful the woman must incorporate the pregnancy into her total identity
>must accept the reality of the pregnancy and integrate it in her self-concept, accept the child, reorder relationships, learn to give of herself for the child, and seek safe passage through the pregnancy, labor, and birth
134
Tasks of Pregnancy: Acceptance of Pregnancy
"Binding-in"
- First trimester: woman's focus centers on physical discomforts (fatigue, nausea, etc.) and needs rather than developing child
- Second Trimester: feels fetal movement (quickening), most likely seen baby on ultrasound and heart heartbeat, and begins to conceptualize the child as an individual within her
- Third Trimester: as due date approaches, the mother wants the child and wants the pregnancy to be over; she is tired and needs emotional and physical support from family and friends
135
Tasks of Pregnancy: Acceptance of Child
acceptance must come from mother as well as others
- a positive response from those closest helps foster her acceptance of the child
- In Second Trimester: the immediate family needs to exhibit behaviors consistent with relating to the child as a sibling, son, or daughter
- Third Trimester: woman must develop an unconditional acceptance of the child, or she and others may reject him for not meeting their expectations
136
Tasks of Pregnancy: Reordering Relationships
- needed to allow for the child to fit into the existing family structure and learn to give herself to the unknown child
- mom becomes reflective and examines what things in her life may be given up or changed for the infant
- if first child, may grieve the loss of her carefree life
- during the last few weeks of pregnancy, the woman must work through doubts of ability to be a good mother; positive support from family and friends
137
Tasks of Pregnancy: Seeking Safe Passage through pregnancy, labor, and birth
-First Trimester: focuses on own discomforts and places her needs before those of the fetus (symptoms of fatigue, nausea, and breast tenderness can be overwhelming)
-Second and Third Trimesters: develops an increasing sense of the value of her infant; begins to conceptualize her fetus as a separate being (fetal distinction), and accepts changing body image
>becomes vulnerable during 7th month and worried about impending labor and birth
>as due date approaches, woman's fears bout labor diminish as she sees childbirth as an "end point"; participation in childbirth preparation classes can assist in dealing with the anxiety and fears often surrounding labor and birth
-feelings of uncertainty or ambivalence (mixed feelings) are normal
138
When caring for expectant women, the nurse should never assume what?
that the pregnancy was planned or wanted
-instead, facilitate discussion of uncertainties or concerns with the patient and her family to facilitate acceptance of pregnancy
139
Why do pregnant women often feel closer to their own mothers as the pregnancy progresses?
this deeper relationship with her mother begins as one of dependency and progresses to one in which she identifies with her mother as a peer
>if mother is not available, she may reach out to another valued maternal figure for identification and support
140
Developmental Tasks and Pregnant Adolescent
-tasks associated focus on growth and maturity
-include: developing personal value system, choosing a vocation or career, developing personal body image and sexuality, achieving a stable identity, attaining independence from parents
>conflicts may arise when these tasks are overshadowed by tasks of pregnancy
-the adolescent may not seek prenatal care unless pressured by authority figures or peers
-not future oriented
-may not be able to readily accept the reality of the unborn child
-bodily changes often feel awkward because sense of identity is still incomplete
-acceptance of pregnancy by others may be hindered
-adolescents parents may assume the role of the parent; which limits the young mothers involvement with the newborn and her ability to fully give of herself
141
Paternal Involvement During Pregnancy
- "observer"- father is passive and detached
- "expressive"- expectant father attempts to experience the pregnancy as much as possible
- "instrumental"- father is the caretaker
142
Couvade
observance of certain rituals and taboos by the male to signify his transition into fatherhood
-affirms the mans psychosocial and biophysical relationship to his partner and the child
143
Nursing Interventions for Adaptation of siblings and grandparents
- engage child in family discussions about anticipated birth, encouraging the child to feel fetal movements, and listening to the fetal heartbeat, sharing age-appropriate educational materials, and allowing him to attend sibling preparation classes
- have child attend prenatal visits to listen to the baby's heartbeat, and possibly view the fetus during ultrasound examinations
144
Maternal Adaptations for a single mother interventions
- if the woman has no involved significant other, she will need the presence of a strong support person to help her adapt to the pregnancy and the demands of parenting
- during prenatal visits, the nurse should ensure that the woman is given the opportunity to discuss her future plans for the child
- after assessing woman's needs, nurse can make referrals to appropriate community resources that may include prenatal classes, physiological counseling, pastoral care, or social services
145
Nurse Interventions for Cultural Influences and Psychosocial Adaptations
- nurse should explore cultural influences with the patient and her family
- by acknowledging and documenting specific beliefs and needs, the nurse can help guide the woman and her family through the prenatal and intrapartal care system more effectively
- through open discussion, erroneous or conflicting beliefs can be addressed, and a plan can be developed to ensure a satisfactory, positive experience for the child bearing year
146
Hazards of High-tech management on maternal adaptation
- the technology-focused society of today can lead to an increase in level of anxiety and number of stressors
- moral and ethical dilemmas may arise from positive diagnostic tests
- full enjoyment of pregnancy may not be possible as the woman focuses on each test and its result; "tentative pregnancy"
- conflict of interest develops between the technology and the woman's trust of her own instincts
- stressors interfere with the ability to move through the tasks of maternal role development and delay preparation for parenting
147
Societal and Cultural Influences on family adaptations
nurse's role is to assess each patient's beliefs and develop a plan of care that is individualized and incorporates the woman's customs while providing comprehensive and safe care
148
Nursing Assessment of psychosocial changes
- must include a thorough history including the family background, past obstetric events, and the status of the current pregnancy
- each prenatal visit provides an opportunity to ask the patient about her pregnancy experience since her last visit, address current concerns, and offer anticipatory guidance of what to expect from the present visit to the next appointment
- health education should be focused according to the current trimester and evaluated by the patients or couples ability to verbalize the content presented, their efforts to seek assistance and support with psychological concerns, and indicators of satisfactory coping with the physiological transitions that are occurring
149
Nursing Diagnoses r/t psychosocial adaptations to pregnancy
- risk for disturbed body image r/t anatomical and physiological changes of pregnancy
- ineffective role performance r/t taking on new roles; changes in roles
- risk for situational low self-esteem r/t pregnancy complications, changes in body image, roles
- ineffective sexuality patterns r/t changes in libido during pregnancy
- interrupted family processes r/t developmental stressors of pregnancy or loss
- anxiety r/t fear of the unknown
- readiness for enhanced family coping r/t opportunity for growth/mastery
- risk for impaired parenting r/t lack of knowledge, skills, support
- health-seeking behaviors; developmental tasks needed to prepare for parenthood
- dysfunctional grieving r/t stillbirth, ill or preterm newborn, loss of the ideal perfect child, loss of pregnancy, or loss of desired labor or birth
150
What are the major hormones produced by the placenta during pregnancy?
- Estrogen ("growth")
| - Progesterone ("maintenance")
151
What system of the body undergoes the greatest changes in size and function?
The reproductive system
| -every organ within this system is affected by or focused on the needs of the growing fetus
152
What Systems in the body experiences dramatic changes in structure and function as a result of the hormonal changes of pregnancy?
Every system
153
Why is pregnancy considered a time of turmoil? (a state of great disturbance, confusion, or uncertainty)
time in a woman's life that affects her ability to deal with stress and cope with the changes that will occur over the many months
-changes affect both woman, partner, and other family members
154
What exerts a powerful influence on the woman and her family's progress through the pregnancy and can enhance or interfere with routine prenatal care?
ethnocultural, familial, and spiritual beliefs
155
What is the nurses responsibility in prenatal care?
ensure that the patient and her family understand the physiological and psychosocial changes that occur because of pregnancy and equip them with strategies to cope with these changes
