day 2 Flashcards
when to plan prenatal vists
Recommended course of visits (7-11)
- Pre-conception
- Initial visit after missed period and/or + test (first trimester)
- From ~ 12 weeks: once/month
- From ~28 weeks: every two weeks
- From ~36+ weeks: every week
comprehensive appt for pregnant mother
childbearing hx, nutritional requirements
Childbearing history
- Menstrual history / LMP
- Last PAP / Contraceptive type
- GTPAL
- Length of labour (9-18hrs typically)
- Type of birth (Vaginal, Forceps, Induction, Cesarean, Vacuum, Augmentation, VBAC)
- Birth weight ( 2500g – 4000g )
- Breastfed / duration
Health history
Nutritional requirements
- 2-3 extra food servings from any group
- 340 extra calories in 2nd trimester
- 452 extra calories in 3rd trimester
- Preconceptual folate – 400 μg
- During pregnancy – 600 μg / day
comprehensive appt for mother ctd
BMI, hx drug use/ herbal, fam hx
BMI
- check bmi for reccomended total weight gain during pregnancy
Hx of drug use/ herbal use
- Safety of herbal products (ex: avoid some herbal teas)
- Past & present use of prescribed meds, over-the-counter meds, vitamins, caffeine, nicotine, alcohol and illicit drugs
- nicotine
- Alcohol, misuse of prescription drugs & illicit drugs
- No safe level of alcohol established
- Cannabis
- Cocaine & opioids
Fam hx
- at risk populations, or genetic disorders that testing is available for
comprehensive appt for mother ctd
physical/sexual abuse, IPV, social / mental health considerations
social
- asses support/ environmental risks
mental health
- routine screening
- history
Physical/sexual abuse:
Screen all women
- Repetitive screening for current abuse
- Likelihood of IPV increases during pregnancy
- Privacy essential
- May require creative strategies
prenatal care assesments
physical exam, lab test, ultrasounds
Physical examination
- VS (esp. BP – be consistent), weight, edema
- Urine dipstick for glucose/protein.
- FHR, fundal height, gestational age, fetal movements
Laboratory tests
- Optional screening for chromosomal abnormalities (starting at 11-14 wks)
- Routine ultrasound between 18-22 weeks
- Bloodwork at 28 weeks: hemoglobin, hematocrit, glucose screen, Rh type and screen for antibodies
- At ~36 weeks: Cervical swab for Group B streptococcus (GBS); repeat STI testing prn
U/S Purposes
- To confirm GA
- To exclude a multiple gestation
- To examine the fetal anatomy
- To localize the placenta
prenatal genetic investigations
FTS, MSS, CVS, amniocentesis
FTS (First trimester screening)
- Performed between 11-14 weeks
MSS (Maternal serum screening or ‘Quad screening’ or ‘second trimester screening)
- Performed between 15-20 weeks
Chorionic villus sampling (CVS)
- 1st trimester / performed between 10-13 weeks
- Sample of chorionic villi tissue from the site of the developing placenta.
- Earlier results than amnio
Amniocentesis
- Performed between 15-20 wks
- Sample of 15-30 ml of amniotic fluid (10%)
ANP of uterus
enlargment and shape/position
stimulates by? blood volume? hegars sign? rests where?
enlargement
- Stimulated by high level of estrogen and progesterone
- 3rd month, enlargement results from growing fetus, placenta & amniotic fluid
- Fundus (upper portion) enlarges the most
- Uterine enlargement is determined by measuring fundal height
shape/position
- At 6 weeks, softening of the lower uterine segment (Hegar’s sign)
- Presses on bladder & causes urinary frequency
- Shape changes from pear to spherical to ovoid shape.
- Uterine walls strengthen & become more elastic during 2nd trimester
- Eventually displaces intestines and rests against the anterior abdominal wall – altering woman’s centre of gravity
ANP uterus ctd
contractility, blood flow
BH contractions uteroplacental blood flow,
Contractility
- Braxton Hicks contractions occur after the 4th month
- Are irregular
- Facilitate blood flow through placenta
- Confused with preterm labour, but cease with ambulation
- Does not cause cervical dilation
Uteroplacental blood flow
- At term – rate of blood flow through the uterus averages 450-650 mL/min
3actors that decrease uterine blood flow
- Low maternal arterial pressure
- Uterine contractions
- Maternal supine position
Cervical changes
goodells sign? due to what
Cervical changes
- At 6 weeks, softening of the cervical tip (Goodell’s sign)
- due to increased vascularization, hypertrophy and hyperplasia
- In nulliparas – cervix is rounded; after birth – cervix is oval
ANP vagina
estrogen, chadwicks sign, leukorrhea
Estrogen causes
- Thickening of vaginal mucosa
- Loosening of connective tissue
- Hypertrophy of smooth muscle
- Lengthening of vaginal vault
Chadwick’s sign
- refers to the deepened violet-bluish colour of the vaginal mucosa and cervix caused by increased vascularity
- evident at 6-8 weeks
Leukorrhea = whitish mucoid discharge.
- Mucous plug (operculum) protects against bacterial invasion
- closer to birth, mucous plug will be expelled when cervix thins (effaces) and dilates.
ANP breasts
estrogen/progesterone, visible changes
Increased estrogen & progesterone
- Feeling of fullness
- Heightened sensitivity
- Heaviness
Blood vessels
- dilate due to increased blood supply / often become visible
visible changes
- Nipples & areolae become more pigmented
- Mammary gland growth accounts for breast enlargement in 2nd & 3rd trimesters
- Lactation is inhibited until the decrease in estrogen after birth
- Colostrum may be expressed as early as 16 weeks
Cardio system
size, position, sounds, pulse rate, BP changes
size
- Slight cardiac hypertrophy (enlargement) due to increased blood volum d and cardiac output
- Heart returns to normal size after birth
Heart position
- Heart is elevated upward and rotated forward to the left
Heart Sounds
- Increased loudness of 1st & 3rd heart sounds
- systolic and diastolic murmurs can be heard (20 weeks & resolves after birth)
Pulse Rate
- increases 10- 15 beats/min during 2nd trimester & persists until term
blood pressure
- Decrease in systolic (slight) and diastolic (5-10mmHg ) pressure in 1st trimester
- Lowest during 2nd trimester
- gradually increases to pre-pregnancy levels during 3rd trimester
cardio ANP
Cardiac output and SHS
Cardiac output
- Increases from 30-50% above non-pregnant levels by 32 weeks gestation
- Then declines to ~ 20% increase above non-pregnant levels by 40 weeks gestation
Supine hypotensive syndrome
- d/t pressure from enlarging uterus on inferior vena cava when woman lying supine
- Decreased cardiac output, hypotension & decreased placental circulation
- Ask woman to lie on her left side!
resp system
oxygenation, progesterone/estrogen changes, diaohragm changes
oxygenation
- ↑ need for O2
- Pulmonary function is not impaired by pregnancy although diseases of respiratory tract may be more serious during pregnancy
Progesterone & estrogen
- result in a lowered threshold for CO2 (ie: and increased sensitivity to CO2)
Estrogen increases:
- Relaxation of rib cage ligaments = ↑ chest expansion
- Upper respiratory tract becomes more vascular = can cause nasal stuffiness, epistaxis
diaphragm
- rises ~ 4cm d/t increased chest circumference
- Chest breathing replaces abdominal breathing
Renal system changes
structural, functional, electrolyte imbalances
Structural changes
- Dilation of the kidneys & ureter ⇒ urinary stasis
- Urinary frequency in 1st & 3rd trimesters due to increased bladder sensitivity & compression (but dysuria is not normal)
Functional changes due to pregnancy hormones
- ↑ blood volume
- Increased blood flow to kidneys
- Increased glomerular filtration rate (GFR)
- ↑ risk of urinary tract infections
Fluid & electrolyte balance
- Increased renal tubular resorption rate (to prevent excessive sodium loss)
- edema in 3rd trimester is normal (resolves with side-lying position
MSK anp changes
Physical changes
- increasing weight cause changes in posture & center of gravity shifts forward
- Increased lordosis (lumbosacral curve)
- Increased curvature of the thoracic area (d/t weight of breasts)
- Low backache
- Increased mobility of the pelvic joints
- ‘Waddling’ gait is common
GI anp changes
esophagus/stomach/intestines, apetite
Esophagus, stomach & intestines
- Pyrosis (‘heartburn’) caused by ↑ progesterone
- Hiatal hernia-
- Iron absorption increased (fetus prioritized)
- Constipation from - slower stomach emptying time, ↓ intestinal motility and smooth muscle relaxation → increased water reabsorption from the colon
appetite
- Nausea & vomiting during 1st trimester (rarely harmful)
- Appetite usually increases by 2nd trimester
- Changes in senses of taste & smell
- Cravings / Pica
What triggers labour
Progressive uterine distension
Increasing intrauterine pressure
Hormones produced by fetal hypothalamus, pituitary and adrenal cortex;
Increased concentrations of estrogen, oxytocin and prostaglandins
Decreasing progesterone levels
horomones of birth
prostoglandins, endorphins, oxytocin, catecholamines, relaxin
Prostoglandins
- Softening of the cervix
- positive feedback loop w oxytocin
Endorphins
- Natural high when released in response to the pain
Oxytocin
- Stimulates uterine contractions
- Also the horomone of love and bonding
- Artificial oxytocin does not cross blood brain barrier only acts on uterus
Catecholamines
- Stress horomones (EPI, cortisol)
- In case of danger (oposes oxytocin)
Relaxin
- Helps the joints of the pelvis relax → better mobility
- Works everywhere in the body so it relaxes all joints → waddle walk
stage 1 of labour
dialation, nsg assesment, physical exam + VS
- Cervix dilates from 4 to10 cm & Effaces from 0% to 100%
- Duration 3-6 hours (variable, usually longer in primipara than multipara)
nursing assesment
- amniotic fluid –> COAT → colour (should be clear), odor (should smell like semen), amount (1L → not necessarily gonna lose all at once), Time
Physical exam
- Brief systems assessment, VS (in between contractions), pain assessment
- Fetal well-being: Leopold’s, FHR, fetal activity
- Lab and diagnostic test results (+strep –> penicillin)
- Maternal VS q 30-60 min, temp q 4 hours until ROM then q 1-2hrs;
- amniotic fluid (nitrizine pH or ferning test).
fetal surveilance
IA, frequency and EFM
IA (intermittent auscultation)
- recommended method for healthy mom and term baby 37-0 and 41-3 weeks gestation in spontaneous labour
- IA may be used for women who are 41-4 weeks gestation to 42-0 weeks, provided there is a normal non-stress test and normal amniotic fluid volume
frequency
- Active phase – every 15-30 minutes
- Latent (passive)– every 15 minutes
- Active (pushing) – every 5 minutes (or after every ctx)
EFM
- EFM is recommended for pregnancies at risk of adverse perinatal outcome
- Only recommended when there is a presence of risk factors
