Final AD - Antepartum Flashcards
Gestational DM nursing care and client edu?
Nursing care - Monitor Blood Glucose and Fetus
Client Education:
*Perform daily kick count
*Adhere. To the appropriate diet, including standard diabetic diet and restricted carbohydrate intake. Dietary counseling by a registered dietician should occur.
*Exercise
*Perform self-admin of insulin if needed
*Understand the need for postpartum lab testing to include OGTT and blood glucose levels.
Normal responses to pregnancy, Body image and Weight gain?
Physical and psychological changes, the pregnant client needs support from provider and family, 1st trimester psychological changes are not obvious, during the 2nd trimester rapid physical changes occur sue to the enlargement of the abd and breast. These changes can affect the client’s mobility. Skin changes also occur (stretch marks, hyperpigmentation). They might also find themselves losing their balance and feeling back of leg discomfort and fatigue. These factors may lead to a negative body image. The client might make statement of resentment toward the pregnancy and experience anxiousness for the pregnancy to be over soon.
Weight gain - (total =25-35 lbs) 2 to 4 lbs in 1st trimester and 1 lb/week in 2nd and 3rd trimester.
- Recommendations are based on pre-pregnancy weight
- Underweight: preterm labor, LBW, Intrauterine growth restriction (IUGR)
-Overweight: macrosomia and cephalopelvic disproportion (CPD), operative vaginal birth and emergency C-Section, PP hemorrhage, infection (wound, genital tract, and urinary tract), brain trauma, late fetal death, preeclampsia, and gestational DM.
Negel’s rule?
Month (month of period minus 3); Day (last day of period + 7); Year (+1 year)
Example: LMP = May 21st, 2019 (5-3 = 2 (February), 21+7 = 28th, 2019 +1 = 2020 – 02/28/20 = EDD
How to use a diaphragm?
*Round flexible device that covers the cervix.
*Must be fitted for size by HC provider
*Inserted into the vagina up to 6 H before intercourse
*Used with spermicidal jelly or cream
Physiological changes during pregnancy?
*Uterine changes (Size, shape, position) - fundus height is an important measure of fetal well being
*Uterine CTX - increase blood flow to uterus and strengthens muscles for birth process (Braxton Hicks) DO NOT CAUSE CERVICAL DILATION
*Hagar’s sign
*Lightening (fundal height decreases as fetus descends into the pelvis in preparation for delivery (38-40 weeks))
*Ballottement
*Quickening
*Cervical changes (Chadwick’s sign, Goodell’s signs, & mucus plug (operculum) seals endocervical canal - prevents ascent of bacteria from vagina to the uterus)
*Vaginal changes (pH of vaginal vault 3.5 (acidic), vaginal secretions increased (leukorrhea), and screening evaluate for pathology and presence of STD’s)
*Breast changes (Colostrum - may leak from nipple (precursor to milk – yellow in color), Breast size increased, and nipples and areola darken, and may have striae gravidarum (stretch marks)
*CV system changes (Blood Volume) - (Expansion of vascular volume up to 45-50%, Peak 32-34th week, and increase in vascular volume increase in RBCs - hemodilution - pseudoanemia of pregnancy (HGB below 11g/dL usually caused by iron deficiency anemia and folic acid and iron supplements to meet demands of increased blood supply and fetus))
*Cardiac Output (CO increased 25-50% (max at about 28 weeks), affected by maternal position Vena Cava syndrome)
*BP (DOES NOT increase during pregnancy: progesterone, prostaglandins, and relaxin effect. May even decrease in 2nd trimester. BP 140/90 is a danger signal of pregnancy, absolute value determination of gestational HTN, WATCH THE MAP when HTN.)
*Clotting factors increased (fibrinogen, clotting factors VII, VIII, IX, and X, and risk of blood clots.)
*Respiratory system changes (O2 consumption increased by 15-20%, Diaphragm elevated by enlarging uterus - thoracic cage widens to compensate so vial capacity is the same, breathing changes from thoracic to diaphragmatic, SOB may be experiences, and pregnancy is a state of Alkalosis, hyperventilation - decreased CO2 levels - alkalosis.
*Pulmonary congestion (increased vascularity of upper respiratory tract - engorgement and edema of mucosa (nose, oropharynx, larynx, and trachea), symptomatic nasal congestion, and epistaxis is common)
*Early changes are related to increase in estrogen and progesterone levels
*Estrogen and prolactin have an inverse relationship. When placenta delivered then prolactin becomes dominant.
*Oxytocin responsible for milk letdown and prolactin responsible for production
*Basal Metabolism and Acid base balance (basal metabolism rate increased 10-20% by term, increase in O2 demand of the uterine-placental-fetal unit, and acid base balance - respiratory alkalosis compensated by mild metabolic acidosis)
*Renal system changes (Urinary frequency in 1st trimester (again in 3rd trimester r/t lightening), High risk for UTI (symptomatic or asymptomatic), Glycosuria occurs at <160 mg/dL in pregnancy, this is lower levels than non-pregnant women, ALL PREGNANT CLIENTS are screened for gestation DM at 24-28 weeks (high risk pts tested earlier))
*Skin changes (Linea nigra, Striae gravidarum, Chloasma, Palmar erythema (darker red palms rt hyperemia), and Accutane for acne)
*Musculoskeletal (postural and gait changes - lumbar lordosis as center of gravity shifted forward. Lumbar and dorsal curves accentuated results in low back pain, and typical “waddling gait” as relaxin hormone relaxes pelvic points. Pubic symphysis and sacroiliac joints loosen due to relaxin to allow passage of the baby, muscle cramps or tetany r/t hypocalcemia (or hypokalemia or hypomagnesia)
*Neurological changes (changes in sensorium (lightheaded or dizzy) - R/O postural hypotension/hypoglycemia, Carpal tunnel syndrome, edema, and compression of medial nerve in risk, Lordosis (back sway), and hypocalcemia can cause cramps and tetany.
*GI changes (N/V - early subjective sign of pregnancy, may be related to hormonal changes, subsides past 1st trimester) and R/O hyperemesis gravidarum if persists longer than 1st trimester, Reflux and constipation r/t relaxation of smoot muscle of esophagus, stomach and intestines, Pyrosis is common (heartburn) - passive regurgitation, Hemorrhoids r/t constipation and increased pressure on blood vessels in the rectum, Gallbladder sluggish, along with increased secretions of cholesterol may predispose to gallstones, and Pica - craving non-nutritive substances.
*Endocrine (HCG, human placental lactogen, relaxin, estrogen and progesterone, and prolactin)
Psychosocial changes during pregnancy?
Psychosocial Adaptations
Body Image Changes
Anxiety
Trauma History
Developmental and family changes
Education for IPVs and nursing assessment?
Abuse is a violation of rights
Facilitation of access to protective and legal services is first step
Support and community resources.
STIs
Pelvic pain
Substance abuse
Depression
PTSD
Suicide
Nursing assessment - Assess for IPVs
Regular screening of ALL women for history/risk of IPV
Most important – validate that they have been heard…….
Establish safety (now and future)
Observe for injuries – old/new
Associated health conditions warranting further assessment:
-HA
-GI problems
-Chronic pain
-Arthritis
Explain the effects UTIs during this period
*Symptoms of UTI frequency with urgency, dysuria, and hematuria.
*Urinary Tract infection (UTI) is the most common bacterial infection in pregnancy. The three most common clinical syndromes associated with UTI are asymptomatic bacteriuria, acute cystitis, and acute pyelonephritis. Asymptomatic and untreated bacteriuria has been associated with several complications during pregnancy including low birthweight, intrauterine death, pre-eclampsia, and maternal anemia.
Teens and pregnancy – why are they at high risk
Pregnancy complications are the leading cause of death for girls aged 15 to 19 years old.
Prenatal and medical behavioral risk factors include:
*PTL and birth, especially when combined with low socioeconomic status, single parent, smoker, illicit drug use, pre-pregnant weight less than 100 lbs, poor weight gain during pregnancy, and inadequate prenatal care.
*Anemia
*Preeclampsia/eclampsia
*Related exposure to STIs
*Chronic or asymptomatic UTIs
*Acute pyelonephritis
*IUGR/Low birth weight infants
*Social issues: poverty, unmarried status, low educational levels, smoking, and drug use.
*Increased chance of experiencing IVPs
Describe gravidity and parity based on 6-digit system (GTPALM)
Gravida: # of times the patient is pregnant including a current pregnancy
Para: # of times the uterus in emptied (not # of babies)
Term: # of deliveries were 37 to 40 weeks’ gestation
Preterm: # of deliveries were 20.0 to 36.6 weeks gestation
Abortions: # of times uterus was emptied prior 20 weeks (are not viable)
Multiples: # of deliveries that contained more than 1 infant being delivered
Gravidity: # of pregnancies –
*Nulligravida - a client who has never been pregnant
*Primipara - a client in 1st pregnancy
*Multigravida - a client who has had 2 or more pregnancies
Embryotic stage?
3 weeks - Heart starts beating, and blood circulates
4 weeks - 2 chambers form a 4-chamber heart and respiratory system begins
5 weeks - umbilical cord develops
8 weeks - gender distinguishable
Fetal stage?
9 weeks - fingers, toes, eyelids, nose, and jaw evident
12 weeks - placenta complete, organ system complete, thumb sucking, and fetus urinates in amniotic fluid (11 weeks)
16 weeks - meconium in bowel
20 weeks - hearing developing, quickening (mom feels FM). Lanugo covers the body, and wake/sleep cycles evident.
24 weeks - circulation visible, rapid brain growth, hiccups, vernix caseosa is thick, Lecithin (L) present
28 weeks - eyes open and close, process sight and sounds, taste buds developing, and hair on head
32 weeks - fingernails, toenails, and fingerprints present, SubQ fat develops, vigorous FM, and L/S ratio = 1:2:1 (lung maturity = 2:1)
36 weeks - lanugo disappearing, amniotic fluid decreased, and L/S ratio > 2:1\
40 weeks - fetal development complete
fetal circulation?
*Shunts allow most O2 blood to the brain
*Maternal and fetal blood DO NOT normally mix.
*Ductus Venosus - shunts around liver. Placenta does the work of liver for fetus.
*Foramen Ovale - Right to left shunt… blood transfers from the right atrium through foramen ovale to left atria. Valve allowing blood flow directly from the right to left atrium.
*Ductus Arteriosus - shunts around lungs… just enough to keep viable
*Fetal circulation supplies the highest levels of O2 and nutrients to the head, neck, and arms which enhances cephalocaudal (head-to-rump) development of embryo/fetus.
*The fetal lungs do not function for respiratory gas exchange, so the ductus arteriosus creates a circulatory pathway bypassing the lungs.
*Blood cells and heart functioning at 3 weeks, heart is fully developed at 8 weeks.
*Oxygenation - pulmonary surfactant: lecithin/sphingomyelin (LS) ratio of 2:1 at maturity, lung movement can be seen by 11th week, and lungs are fully mature about week 34.
Presumptive Signs of Pregnancy?
Changes that the client experiences that make them think that they might be pregnant. These changes might be subjective CM or objective findings. Signs also might be a result of physiological factors other than pregnancy (peristalsis, infections, stress, etc.)
*Amenorrhea
*Fatigue
*N/V
*Urinary Frequency
*Breast Changes (Darkened areolae, enlarged Montgomery’s Glands)
*Quickening (slight fluttering movements of the fetus felt by the client, usually between 16 to 20 weeks)
*Uterine Enlargement
Probable Signs of Pregnancy?
Changes that make the examiner suspect a client is pregnant (primarily related to physical changes in the uterus). Signs can be caused by physiological factors other than pregnancy (pelvic congestion, tumors)
*Abdominal enlargement (related to changes in uterine size, shape, and position)
*Hagar’s signs (softening and compressibility of lower uterus)
*Chadwick’s signs (deepened violet-blush color of cervix and vaginal mucosa)
*Goodell’s sign (softening of cervical tip)
*Ballottement (rebound of unengaged fetus)
*Braxton Hicks CTX (false CTX that are painless, irregular, and usually relieved by walking)
*Positive Pregnancy Test
*Fetal Outline (felt by examiner)
