Exam 1 - Nursing Care During Pregnancy Flashcards
Human Chorionic Gonadotropin (hCG)
- the earliest biochemical marker of pregnancy
- Produced by the embryo soon after conception and later by the placenta
- Can be found in maternal blood and urine
- hCG level increases until it peaks at about 60-70 days of gestation
- *** HCG – earliest predictor (but not 100% sure) of pregnancy
- Guys who got + of pregnancy – need to be checked w cancer
– HCG number increases…… If the number is not climbing right, mom might have miscarriage…
Presumptive Signs of Pregnancy
- Least reliable indicators
- Subjective
– Example: Amenorrhea, N/V, fatigue, urinary frequency, breast and skin changes, fetal movement, quickening
Probable Signs of Pregnancy
– Objective findings
– Example: Abdominal enlargement, cervical softening, changes in uterine consistency, ballottement, braxton hicks, palpation of fetal outline, positive pregnancy tests, vaginal and cervical color changes
Positive Signs of Pregnancy
- Auscultation of fetal heart sounds
- 100% assurance of pregnancy
- 80 beats/min = could be MOM or dying baby
- 160 beats/min = baby - Fetal movements felt by examiner
- Visualization of embryo or fetus in ultra sound
- As early as 5 wks after missed period
Changes in Uterus
Grows in a predictable pattern
o Helps to confirm EDB (expected date of birth)
o Provides info about fetal birth
– 12 weeks extends out of pelvis
– 16 weeks, midway
– 20 weeks, @ umbilicus
– 36 weeks, highest level
– Drops from fetal descent after 36 weeks (lightening)
change in uterus:
LIGHTENING
fundus is highest when baby was at 36 THEN at 40 wks comes down to 32 – means baby is ready for delivery – BABY DROPS DOWN THE CANAL
change in uterus:
BRAXTON HICKS (4th month)
o Note *** False contraction or FALSE LABOR – feels like contracting but the cervix is not opening
o tell patient to time it…
o Empty bladder
o Drink fluid
o Lay down
o If contractions of >6 in an hour then call Dr or nurse !!
HEGAR SIGN
– softening of the lower segment of the uterus
UTERINE SOUFFLE
FUNIC SOUFFLE
SOUFFLE means heartbeat
o Babies upper back is where you hear baby’s heartbeat
BALLOTEMENT
– when the cervix is tapped, the fetus floats upward in the amniotic fluid. A rebound is felt by the examiner when the fetus falls back.
Changes in Cervix
-- Cervix becomes congested with blood (Chadwick’s sign) o Chadwick’s sign –TURNED BLUISH - Friable - Goodell’s sign - MUCOUS PLUG
MUCOUS PLUG
– yellowish that is plugged – to protect fetus from infection; so bacteria can’t invade the baby
GOODELL’s sign
– softening of cervix
Chadwick’s sign
–TURNED BLUISH bec congested w/ blood
Changes in Vagina and Vulva
o Increased vaginal vascularity causes bluish color (Chadwick’s)
o Leukorrhea – a vaginal white, thick discharge present is NORMAL
o Vaginal mucosa thickens and rugae prominent
o Increased amounts of glycogen cause the acidic environment that protects from bacteria but a good medium for yeast – that’s why pregnant mom usually gets yeast infection!!
o Vulva and perineum more pliable due to increased vascularity
Leukorrhea
– a vaginal white, thick discharge present is NORMAL
Changes in OVARY
– Corpus luteum secretes progesterone for first 6-7 weeks, placenta secretes it thereafter
– Progesterone must be present in adequate amounts from the earliest stages of pregnancy to maintain the pregnancy
– ** When it’s time for birth, the progesterone drops which starts the contraction process**
o Helps to suppress uterine cx
o Helps to prevent tissue rejection of the fetus
Changes in BREASTs
- Estrogen stimulates growth of mammary ductal tissue
- Progesterone promotes growth of lobules, lobes, and alveoli
- Become highly vascular
- Nipples increase in size
- Increased alveolar pigmentation
- Montgomery Tubercles
How to correct Inverted/Flat Nipple
- Use Breast Shells to Correct Inverted/ Flat Nipples
Changes in CARDIOVASCULAR:
INCREASE:
plasma vol, blood vol, clotting, CO, Kidney work, Varicose veins
Decrease: PVR
Remain: BP
- Heart enlarges slightly because of increased workload
- Heart is pushed upward as uterus enlarges
- Splitting of heart sounds is normal
- Total blood volume increases 40-50% bec mom will lose blood during delivery !
- Plasma volume increases by 50% – which sometimes causes Pseudoanemia or FALSE ANEMIA because the increase in plasma dilutes the RBC w/c shows low Hct and low Hgb.
- Physiologic anemia, pseudoanemia of pregnancy
- Clotting factors increase
- CO increases by 30-50%
- PVR decreases
- Blood pressure remains stable
- Kidneys have to work harder to eliminate maternal and fetal wastes
- 500-800ml/min of blood circulated to the uteroplacental circuit
- Varicose veins common due to pressure of uterus obstructing blood return from legs
Supine Hypotensive Syndrome
o lying supine occludes the vena cava and descending aorta
o side lying position corrects supine hypotension
RESPIRATORY changes
- O2 consumption increases by 15-20%
- RR remains unchanged, but woman breaths deeper through mild hyperventilation
- Tidal volume and minute volume increase by 40%
- Progesterone & Estrogen
- The more o2 take in the more O2 to the baby
- bec of Progesterone and Estrogen == that’s why O2 increases
- Progesterone & Estrogen
– These are 3rd trimester changes
GI changes:
• Nausea common in first trimester
– If nausea absent, increased appetite may be present
• Estrogen causes hyperemia of gums and mouth
• Ptyalism: increased salivation
• Reduced lower esophageal sphincter tone
• Progesterone decreases tone and motility of GI tract
• Decreased emptying time by small intestine
• Gall bladder hypotonic which could lead to gall stones (or right after they had the baby)
• Liver function mildly altered
** Sometimes loosing the nausea is not good,, might lose the baby too bec progesterone causes the N/V
** Gingivitis can lead to premature labor
Changes in Urinary: BLADDER
Frequency and urgency of urination 1st trimester (normal) due to:
o Hormonal influences
o Increase in uterine size
Frequency and urgency of urination 3rd trimester:
o Due to large uterus pressing on bladder
- Bladder capacity doubles by term as the bladder relaxes –so we can hold more longer
- Bladder more susceptible to trauma and infection
- Pay close attention to s/s bladder infection b/c could lead to preterm labor!
- Women who are prone to UTI needs a lot of teaching
Changes in Urinary: KIDNEYS and URETER
– Progesterone
o Dilation of renal pelvis and ureters
– Flow of urine through ureters partially obstructed by uterus
o Dilation helps flow
o Stasis can lead to bacterial growth
– Renal plasma flow and GFR increases
– Flow highest when woman in side-lying position (left side to promote blood flow)
– Glycosuria is common bec filtered load of glucose exceeds ability of renal tubules to reabsorb it
- Mild spilling of protein is NORMAL (bleeding might see protein)
- Note:
o These can cause infection
o Hydrate to flush and prevent infection
Changes in INTERGUMENTARY
– Increased metabolic rate causes: sweating and the feeling of warmth
– Hyperpigmentation: estrogen, progesterone, and melanocyte-stimulating hormone (melasma, chloasma, mask of pregnancy, linea alba
– Increased vascularity may cause angiomas on face (not cancerous tumors)
- Striae gravidarum – stretch marks
- Hair and nail growth increases
Changes in MUSCULOSKELETAL System
• Calcium stored to meet later needs of fetus
• Does not deplete mother’s stores
• Postural changes
o Due to change in center of gravity
• Widening of symphysis pubis
o Allows more room for head to deliver
o Causes pain in some
• Abdominal Wall weakens and may separate
• Note:
o Mom’s Ca level should NOT be changed !!
o Prone to fall bec of change in stature… center of gravity changes
Changes in NEUROLOGIC System
- Sensory changes in legs caused by compression of pelvic nerves
- Dorsolumbar lordosis may cause pain related to nerve traction or compression
- Edema may cause carpal tunnel syndrome
o CARPAL TUNNEL SYNDROME–main s/s: pain spares the pinky - Numb hands caused by stooped shoulder stance
- Light-headedness or faintness usually caused by CV changes
- Muscle cramps may be caused by hypocalcemia or hypomagnesemia
o Pain in legs and muscles means low Ca and Mg
Changes in Endocrine : PITUITARY
o FSH and LH are suppressed
• FSH and LH are not needed bec pt is already pregnant
o Prolactin released
Changes in Endocrine : THYROID Gland
o Enlarges due to increased vascularity
o Hormones increase, but level off at end of first trimester
Changes in Endocrine : PARATHYROID
– Calcitonin decreased to allow for calcium needs during pregnancy
Changes in Endocrine : PANCREAS
– Hypoglycemia common
• Hypoglycemia – need small freq meal
– Tissue sensitivity to insulin decreases r/t hPL
Changes in Endocrine : ADRENALS
o Aldosterone and cortisol levels elevate
Placental Hormones
- hCG
- Estrogen
- Progesterone
- hPL – human placental lactogen
- Relaxin → changes cavity shape → changes gait
Other Changes:
WEIGHT
FLUID
HEMODILUTION (dilution of RBC)
- Weight gain: fetus, placenta, and fluid make up less than half of weight gain during pregnancy
- Women with normal BMI should gain 25-35 lbs
- Water needs increase = 3L / day
- Hemodilution causes dependent edema
- Carpal Tunnel Syndrome from fluid retention
- Problems with carbohydrate metabolism
Preconception Visit
- Complete history and examination
- Screening for rubella, varicella, and hepatitis B
- FOLIC ACID needs before and during pregnancy
Note:
o Can’t get Rubella vaccine while pregnant – need to be immune before pregnancy – can’t give live vaccine to pregnant
o Boost folic acid before getting pregnant
Initial Prenatal Visit
- Verify pregnancy
- Evaluate physical health
- Assess growth of fetus
- Establish baseline data
- Establish trust
- Evaluate psychosocial needs
- Negotiate plan of care
- Note:
o Initial visit more entail
HISTORY to get on 1st visit
Obstetric: GTPAL Gravida, para Menstrual History EDD: Naegele’s Rule, gestational wheel Contraceptive History Medical and Surgical History Family History Partner’s Health History Psychosocial History
GTPAL
– Gravida: # of pregnancies
– Term: at least 37 weeks gestation
– Preterm: > 20 weeks but < 37 weeks
– Abortion: < 20 weeks, either spontaneously or electively
o SAB- spontaneous abortion (no control of her own)
o EAB- elective abortion
o TAB – therapeutic abortion
– Living: number of living children
Initial Physical Exam
- Vital Signs
- Cardiovascular
o Venous congestion
o Edema - Musculoskeletal
o Posture and gait
o Height and weight
o Pelvic Measurements
o Abdomen - Skin
- Neurologic: DTR
- Endocrine: Thyroid
- GI: mouth, intestine
- Urinary: protein, glucose, ketones, bacteria
- Reproductive: breasts, internal and external reproductive
- Laboratory
Urinalysis
checks for:
Protein, gluccose , nitrates, glucosite, ketones (for dehydration)
Fundal Height
o The number of weeks = the number of centimeters (normal)
o Distance from upper border of symphysis pubis and top of the fundus
– at 20 wks, right on the unbilical
Leopold’s maneuvers
palpating to feel where the head, back, hands and feet
–to know where to auscultate the heart of baby
Signs of Labor
o 6 contraction/ hr o Pelvic pressure o Leakage of fluid o Bleeding o 104 F – infection causes labor
Ultrasound screen
at 12-20 weeks
Glucose screen
at 24-28 weeks
o to check if mom has gestational DM (GDM)
How? • Light breakfast • Drink nasty syrup • After 1 hr, Draw blood • if positive for DM, will test again • If 2 out of 2 are positive, means MOM is diabetic
Isoimmunization
???
Pelvic exam
Pelvic exam during last 4 weeks of pregnancy
Pregnancy Milestones in an Uncomplicated Pregnancy
5-6 wks – 1st see the heart fluttering on Ultra Sound
10-12 wks – FHR heard on fetoscope/doppler
16-20 wks – Quickening
16-18 wks – MFSFAP – Maternal Serum Alfafetal Protein
– to screen for neural tube defects & Trisomy 21
20 wks – ultrasound
20-24 wks – Viability
26-28 wks – GDM testing
34-36 wks – fetal lung maturity; w/ enough surfactant
36 wk – GBS screening
GBS Screening
GBS Screening:
– Group Beta Hemolytic Streptococcus
o Normal vaginal/cervical flora in some women
o Can cause sepsis in newborn
o Can lead to infection in mother
– Screened for prenatally at 36 weeks gestation by swabbing the cervix and rectum and culturing the specimen
– Women who are GBS Positive should receive antibiotics during labor (at least 2 IV doses are required and must be given at least 4-6 hours before the baby is born to be effective)
o Penicillin or Clindamycin
* Once the water bag breaks (can break in months before delivery), mom gets antibiotic
Multifetal Pregnancies
Multifetal Pregnancies
- More likely in woman with personal or family history, older mothers, infertility therapy
- Greater weight gain and more rapid uterine growth
- Degree of maternal physiologic change greater with multiple fetuses
- More frequent antepartum visits
- Educate early and often about s/s of PTL (preterm labor)
Teachings
– Bathing important
– No Hot tubs or saunas
– No Douching
– Breast care
– Comfortable Clothing
– Exercise/Kegels
– Sleep and Rest
– Dental Care
* periodontal disease related to Preterm Births
* LBW, and increased risk for preeclampsia
– Sexual activity – no limit
– Nutrition
– Employment
o Maternal safety
o Exposure to teratogens
– Immunizations (live vaccines contraindicated)
– Sleeping Positions – side lying is good for circulation
Preventing UTIs
- UTIs common during pregnancy and may be asymptomatic
- A cause of Preterm Labor
- Ask if mom is prone to UTI –
- Need to test bec sometimes asymptomatic
Discomforts Related to Pregnancy
- NAUSEA & VOMITING – due to increased hCG and estrogen
- HEARTBURN bec esophageal sphincter is relaxed
- BACKACHE
- Round Ligament Pain
– can’t take motrin while pregnant – tylenol better
o More common on right side - URINARY FREQUENCY – normal if no burning, urgency, or s/s of UTI
- VARICOSITIES
- HEMORRHOIDS – no sitting on the toilet for a long time bec it’s going to get worst
- CONSTIPATION
- LEG CRAMPS
o Low Mg levels are cause
o Imbalance of calcium and phosphorus
o dorsiflex your foot to relax the muscle
Recognizing Preterm Labor
– UTERINE CONTRACTIONS of 6X in an hr (every 10 min)
– Painful or Painless contractions
– Persistent or Intermittent Low Backache
– Lower abdominal cramping
– Suprapubic pain or pressure
– Pelvic pressure or heaviness
– Change in vaginal discharge
– Urinary Frequency
o UTIs
– Bloody Spotting or Leaking of fluid from vagina
Goals of Perinatal Education
- Helps parents become knowledgeable consumers
- Helps parents take and active role in their health, pregnancy, and birth
- Helps parents to acquire coping techniques to deal with pregnancy, childbirth, and parenting
Providers of Education
- Registered Nurses
- Others certified to become perinatal educators
- Doulas
Types of Classes
Preconception Early Pregnancy Exercise Childbirth Preparation Refresher Courses C-Section Preparation Classes VBAC Vaginal Birth After Cessarian – VBAC Prone to complications Breastfeeding Parenting Postpartum Siblings Childbirth Preparation Classes
Methods of Pain Management
Education
Relaxation
Conditioning
Methods of Childbirth Prep Classes
Dick-Read Method
Bradley Method
LeBoyer Method
Lamaze Method –
Lamaze Method
Lamaze Method: Exercises Relaxation Techniques Cutaneous Stimulation Mental Stimulation Special Techniques Breathing Techniques
