test 1 maternity ch. 4,5,6,7,8,9,10 ch. 40 meds Flashcards
Intrapartum
During birth
Antepartum
Pre-birth/ prenatal
Postpartum
after birth
Prenatal care should begin
prior to conception , as soon as a woman suspects that she is pregnant.
Prenatal Hx includes
- obstetric Hx
- LNMP- usual amount and freq
- Contraceptive Hx
- Medical and surgical Hx
- family Hx
- health Hx
- psychology Hx
Pelvic exam to determine
size, adequacy, and condition of pelvis and reproductive organs assess signs of pregnancy.
Estimated Date of Delivery
calculated on LNMP , ultrasound confirms EDD
Asymptomatic Bacterium
12-16 weeks early treatment can prevent preterm labor.
First trimester Blood tests
Blood type and Rh factor CBC- anemia, abn blood cells, infx H&H- anemia VDRL RPR- syphilis Rubella titer- immunity to rubella TB screen- exposure to TB Hep B- carriers of Hep B HIV screen UA and cult- Infx, disease, diabetes, keytone levels PAP- Cervical CA Cervical culture- Group B streptocci, STI
2nd trimester blood tests
- Blood Glucose screen- 24-28 weeks gestational diabetes 135 mg/dL necessitate F/U
- Serum alpha fetoprotein- neural tube or chromosomal defect
- Ultrasound
2nd trimester if indicated
- Amniocentesis
16- 20 weeks gestation if problem suspected.
3rd trimester test if indicated
- real time ultrasound
- detects amount of amniotic fluid which can result in fetal problem
- confirms fetal gestational age, cephalopelvic disproportion
- in tandem amniocentesis to detect fetal lung maturity ( lecithin and sphingomyelin ratio)
- confirms presence of fetal abnormality that may need operation
Cervical fibronectin assay
determines risk of preterm labor when problem is suspected.
Fundal height
determine if fetus is growing as expected, volume of amniotic fluid is appropriate
Mothers weight
to determines if pattern of gain is normal: low pregnancy weight or inadequate gain are risk factors for preterm birth, low birth weight baby,. A sudden, rapid weight gain is often associated with gestational HTN.
Leopolds maneuvers
to assess the presentation and position of fetus by abdominal palpation.
Gravida
any pregnancy, regardless of duration, # of pregnancies
Nulligravida
a woman that has never been pregnant
Primigravida
Woman who is pregnant for the first time
Multigravida
woman who has been pregnant before, regardless of the duration.
Para
A woman who has given birth to one or more babies that have reached the age of viability 20 weeks. regardless of # of fetuses and if they are still living.
PrimiPara
A woman giving birth to her first baby (past the point of viability)
Multipara
Woman who has given birth to two or more children past the point of viabillity
Nullipara
woman who has not given birth to a baby past the point of viabillity
Abortion
Termination of pregnancy prior to 20 weeks
Gestational age
Prenatal age of fetus based on mothers LNMP
Age of viability
20 weeks where baby is capable of living outside of the uterus
TPALM
T # of Term infants born after 37 weeks
P # of Preterm infants born after 20 weeks
A # of Aborted pregnancies prior to 20 weeks
L # of Living children
M Multiple birth #
Nageles rule to determine EDD
- determine LNMP
- Count backwards 3 months
- Add 7 days
- correct the year
Presumptive signs of pregnancy
Amenorrhea
nausea- begins 6wk after LNMP and ends 1st trimester
Breast tenderness
deepening pigmentation- chloasma (mask), areolae,abd
urinary frequency
quickening- fetal movement detected by mom 16-20wk, marks the midpoint in pregnancy
Probable signs of pregnancy
Goodells-sign- softening of cervix& vagina/by ^vascular congestion
Chadwicks sign-Purple/blue discoloration of cervix, vagina, vulva caused by ^vascular congestion
Hegars sign- Sofetening of lower uterine segment
McDonalds sign- flex the cervix against the body of the uterus
Abdominal enlargement
Braxton hicks contractions
Ballottement
Striae-pink to brown lines occur as breast enlarge
Positive pregnancy test
Positive signs of pregnancy test
Audible FHR- 8 weeks ultrasound
Fetal movement felt by examiner
Ultrasound visualization of fetus
Trimesters
pregnancy is divided up into three 13 week segments
Abdominal and Uterine enlargement in pregnancy
- occurs irregularly at beginning of pregnancy, by the end of the 12th week uterine fundus may be felt just above the symphysis pubis and extends to the umbilicus between the 12th and 20th-22nd weeks.
Braxton hicks
irregular, painless uterine contractions start the 2nd trimester. give the sensation that abdomen is hard and tense, and may become strong enough to mimic true labor
Ballottement
Fetal part is displaced by light tap of examining finger
Fetal outline determination
by palpation after 24th week
Abdominal Striae
Stretch marks fine, pinkish, white, or purplish grey lines some women develop as elastic tissue of skin stretched to its capacity
Pregnancy test
HcG- hormone produced by chorionic villi of the placenta.
Radioimmuneassay (RIA) highly accurate pregnancy test 1 week after ovulation.
Physiologic changes Respiratory system
Expanding uterus exerts upward pressure on the diaphragm causing it to rise 4cm. to compensate, her rib cage flares, increasing the size of her chest. Dyspnea until fetus descends into the pelvis (lightening), reliving upward pressure on diaphragm.
Increased estrogen causes edema of mucus membranes of nose, pharynx, mouth, and trachea= nasal stuffiness,epistaxis(nosebleeds) changes in voice. fullness of ears
Physiologic changes Cardiovascular system
- growing fetus displaces heart upward to the left.
- blood volume gradually increases hypervole
Physiologic changes Reproductive system
Uterus- Temporary abdominal organ at end 1st trimester.
@ term weighs 100g (2.2lbs).capacity 500mL
Cervix- Changes color and consistency chadwicks and Goodells sign appear. ^Thickness &ammt cervical mucosa that forms mucous plug.
Ovaries- Dont produce eggs during preg. The corpus luteum (empty graffian follicle) remains and makes progesterone to maintain the decidua until 6-7 weeks until placenta takes over.
Vagina- Blood supply ^ chadwicks sign. Vaginal mucosa thickens and rugae form, connective tissue softens. Vaginal PH decreases ^ acidity, have higher levels of glycogen ^ candidias infx.
Breast- High lvls. estrogen&progest prepare breast 4 lactation Colostrum- 1st milk “premilk” high in protein, fat soluble vitamins, minerals low in calories and fatand sugar. contains antibodies for first 2-3 days
Estrogen
Produced by ovaries and placenta
responsible for enlargement of uterus, breast &genitals
Promotes vascular changes/ melanocyte stimulating hormone
promotes striae gravidarum
alters sodium and H2o retention
Progesterone
Produced by corpus luteum &ovary &later placenta
Maintains endometrium for implantation
Inhibits uterine contractility, preventing abortion
Promotes development of secretory ducts/ lactation
Stimulates sodium secretion
reduces smooth muscle tone (causing constipation, heartburn, vericosities)
Thyroxine T4
Influences thyroid glands size and activity and increases HR and BMR
Human chorionic gonadotropin HCG
Produced early in pregnancy by trophoblastic tissue
Stimulates Estrogen & Progesterone by corpus luteum to maintain preg. until placenta takes over.
Used in Preg tests
Human Placental Lactogen HPL
Produced by Placenta
Affects GLUCOSE and PROTEIN METABOLISM
Has diabetogenic effect allows increased glucose to stimulate pancreas and ^ insulin level.
Prolactin
Prepairs breast for lactation
Oxytocin
Produced Posterior pituitary gland
Stimulates uterine contraction
Is inhibited by progesterone during pregnancy
after birth helps keep uterine contracted
Stimulates milk ejaction reflex during breast feeding
Physiologic changes Cardiovascular system
Fetus displaces upward and to the left. Blood volume increases 45% greater than non pregnant state by 32-34 wks for 1. Exchange of nutrients, oxygen, waste within placenta. 2. needs of expanded tissue. 3. reserve for blood loss @ birth. Cardiac output is increased because more blood is pumped from the heart with each contraction, pulse rate ^ by 10-15BPM, BMR^20%
Supine HYPOtension syndrome AKA Aortocaval compression
Occurs when woman lies on her back, supine position allows the heavy uterus to compress her inferior vena Cava , reducing blood ammount of blood returned to her heart. Placenta circulation may also be reduced causing FETAL HYPOXIA. SYMPTOMS INCLUDE: faintness, lightheadedness, dizziness, agitation( TURN PT TO LEFT SIDE)
ORTHOSTATIC hypotension
when woman rises from recombinant position too quickly. resulting in faintness or lightheadedness
Palpation
Sudden increase in HR from increases in thoracic pressure, particularly if woman moves suddenly
Dilutional Anemia/Pseudo anemia
The fluid component of blood increases more than the erythrocyte component. As a result hematocrit levels drop from prepregnant 48-36% to 46-33%. Although not true anemia Hematocrit levels need to be rechecked
Clotting factors & thrombophlebitis
VII,VIII, X &plasma fibrinogen ^ in 2nd-3rd trimesters. Hypercoagulabillity state helps prevent excess bleeding after delivery after placenta seperates from uterine wall. CAREFULL assessment to see risk of venous stasis thrombophlebitis
Physiologic changes GASTROINTESTINAL
Fetal growth displaces stomach and intestine toward back and sides of abdomen. Ptyalism ^ salivary secretion sometimes effects taste and smell. mouth tissue ^ tenderness ^ bleeding. ^ appetite ^ thirst decreased acidity of gastric secretions; decreased emptying of stomach and motility. Bloated feeling/constipation/hemorrhoids ,Pyrosis heartburn relaxation of cardiac sphincter.
Glucose metabolism is altered ^ insulin resistance, this allows fetus to use more glucose places mom @ risk GDM
Gallbladder retention of bile salts=pruritis =itching
Physiologic changes Urinary system
Excreates waste for mom and fetus. ^glomerular filtration^ reabsorption by renal tubules of substances body needs to concerve but may not be able to keep up with the high load of substances filtered by glomeruli ( glucose,) therefire glycosuria & proteinuria are more common during pregnancy.
Relaxing effects of Progesterone cause loss of tone in renal pelvis, ureters, decreased peristalsis to bladder. diameter of ureters and bladder sze decrese because progesterone leading to urine stasis ^ risk UTI.
*8 glasses H2O daily
Frequency of urination due to fetus
Physiologic changes Fluid and electrolyte balance
^glomerular filtration rate ^ sodium filtration by 50%, ^ tubular reabsorption by 99%. ^ sodium retention can cause EDEMA, big problem if mom is given pitocin which has antidiuretic effect leading to H2O Intoxication. AGItation and Delirium are possible S&S of water intox. should be recorded a& reported. I&O should be kept during labor and postpartum .
Pregnancy blood is slightly more alkaline, mild alkalemia is enhanced by hyperventilation that often occurs during preg. status does not effect normal preg,
Identify nutritional needs for pregnancy and lactation
Begin PRIOR to conception &continue during pregnancy
adequate amounts docosahexanoic acid omega # fatty acid DHA, optimal for fetal brain development 20mg/kg DHA a day, Fish mackerel, atlantic and sockeye salmon, halibut, flounder, egg yolk, red meat, poultry, canola oil, soybean oil 2-3 servings wk. FRYING foods takes away DHA. EXCESS vitamin C can inhibit absorption B12
Discuss the importance and limitations of exercise in pregnancy
Mild to moderate beneficial, vigorous avoided. Maternal cardiac status and fetal reserve determine exercise during all trimesters. Hx of exercise practice is 1st step in nursing process. goal Maintenance of fitness not improvement or weight loss .recommended exercises pelvic tilt, tailor sitting position, proper stretch, proper squat, back massage with tennis ball, step aerobics. MONITOR TEMP WTH EXERCISE.
when exercise is allowed to exceed the ability of the cardiovascular system to respond, blood may be diverted from the uterus FETAL HYPOXIA may result exercise ^ catacholamine which placenta may not be able to filter results in fetal bradycardia & hypoxia & labor. exercise takes away vital blood flow to uterus,viscera, placenta. Moderate exercise is advised several x week from 8th week to delivery. Intensity judged by TALK TEST ( should be able to complete a sentence w/out the need to take a breath)
Review immunizations during pregnancy
No live virus vaccines. No products containing thimerosal risk of mercury poisoning. No bacille calmette guerin BCG , HPV, live attenuated influenza (LAIV) in nasal spray, N measles, mumps, (rubella MMR- avoid getting pregnant for 1 month after getting vaccinated).
When High risk of INFX the following vaccinations may be given Hep A&B, inactivated flu, meningococcal MCV-4 pneumococcal polysaccharide vaccine PPV, inactivated polio, rabies, tetanus diphtheria after 29 wks gestation Japanese encephalitis & anthrax. Vaccines in bottles with natural rubber tops not given to latex allergy
Weight Gain
Low weight gain ^ risks preterm labor,
Weight gain based on pre-pregnancy weight/BMI
Gen recommendation mom gain 4.4lbs (2kg) during first trimester, and approx 1lb (0.44kg) per wk for the rest of pregnancy
BMI 18.5-24.9 normal weight BMI greater than 30 obese
Normal weight women gain 25-35 lbs
underweight- 28-40 lbs
overweight 11-25
Obese- 11-20
TWINS
Norm- 37-54
Over- 31-50
Obese 25-42
Adolescent should gain upper part of recommended range
nutritional needs for pregnancy and lactation
Calorie increase 300kcal/day banana, carrot, piece of whole bread and a glass of whole low fat milk. half roast beef sandwich on wheat bread and salad.
PROTEIN, IRON, CALCIUM, FOLIC ACID
Protein
needed for metabolism and support growth and repair of maternal tissues and fetal tissues. 60g/day
Meat, fish, poultry and dairy products, beans, lintels, legumes, breads and cereals Peanut butter and bread. seeds and nuts corn,
Calcium
^ requirements by 50%, 1200mg dairy products, enriched cereals, legumes, nuts, dried fruits, brocoli, green leafy vegitables, canned salmon & sardines, Ca supplements for non dairy people or those under 20 yo take separately from iron supplements.
IRON FeSO4
Fetus heavy demand for Iron because fetus must store adequate supply to meet first 3-6 months after birth. in addition mom ^ production of erythrocytes. DRI 15mg/day non pregnant 30 mg/day preg FeSO4 supplements 2nd trimester after morning sickness dissipates DONT take with coffee or tea or high calcium foods such as MILK. Take on empty stomach. Heme red organ meats, Non heme plant products Heme products absorbed in body better. non heme molasses whole grains, iron fortified cereals and breads dried fruits dark green leafy vegetables.
Folic Acid
Water based B vitamin essential for formation and maturation of both RBC and WBC in bone marrow, decreases risk for neural tube defects such as spina bifida and anecephaly. DRI 400mcg (0.4mg) per day. Food sources Liver, lean beef, kidney,lima beans, dried beans, potatoes, whole wheat bread, peanuts, fresh dark green leafy vegetables.
Fluids q
8-10 oz glasses of fluid each day most of which should be water. caffeine and drink high in sugar limited, caffeine diuretic. No more than 2 cups coffee daily
woman @ risk 4 low amniotic fluid Oligohydramnios should drink 8-12, 8 oz glasses daily
Sodium
Sodium intake essential for maintaining normal sodium levels in plasma, bone, brain, &muscle because tissue expands during pregnancy. Foods high in sodium LUNCH meats & chips Avoid.
Gynecological Age
of years between onset of menses and date of conception. Pregnant adolescent who conceives soon after first menses greater nutritional need than more sexually mature. Inadequate weight gain and nutrient deficiencies more common in preg adolescent. Girls continuing growth & growth of fetus make it difficult to meet needs. Special risk pressure to eat junk food and appearance feeling “FAT” , fast food recommend Salad chicken,tacos, baked potatoes, and pizza Smaller adolescent needs additional 200kcal on top of 300 kcal daily
Vegetarian and vegan
Focus on protein rich foods such as soy milk, tofu, tempeh, and beans supplement diet with prenatal vitamins
PICA
Craving and ingestion of nonfood substances such as clay, starch, raw flour, cracked ice
Starch= impedes iron absorption
Clay=fecal impaction
Lactose intolerance
deficiency in lactase enzyme that digests the sugar in milk ^ risk for Calcium deficiency native americans, hispanic, african, asian descent ^ risk
symp abdominal distention, flatulence, nausea, vomiting, loose stools Ca supplement can have aged cheeses, yogurt, fermented milk products , buttermilk lactaid
Cultural preferences FOOD
classifications of “hot” and “cold” hot foods mangoes, peanuts, ice cream, tea, cereal grains, hard liquor
cold foods- milk, green leafy veg, fresh water fish, chicken, bananas, & citrus
Gestational DM
1st Dx during pregnancy not prior, calories should be evenly distributed during day among 3 meals and 3 snacks to maintain adequate and stable BGL. Preg mom is susceptible to hypoglycemia during NIGHT while mom sleeps. FINAL HS meal High in PROTEIN and COMPLEX CARB. control of BGL esp important in 1st and 2nd trimesters to prevent new born macrosomia. WOmen with uncontrolled DM and fasting BGL greater than 500mg/dl ^ chances of stillborn
Breast feeding nutrition
500 calories more than non pregnant RDA maternal protein 65mg/day CA-1200mg day FeSO4-30mg/day fluids 8-10 8oz glasses day limit caffeine 2 cups daily continue vit suppléments No ETOH, No drugs w/out DR consent
MAternal elevated temperature
exercise can elevate maternal temp and result in decreased fetal circulation and cardiac function. maternal body temp should not exceed 38C (100.4F)
-No Hot tubs
maternal heat exposure 1 trimester =neural tube defects & miscarriage
Types of classes childbearing families
7
factors influence woman’s comfort during labor
7
methods of childbirth preparation
7
advantages and limitations non pharmacological methods of pain management during labor
7
Nursing role in non-pharmacological pain management during labor
7
Advantages and limitations pharmacological pain management
7
Each type of pharmacological pain management nursing role for each
7
Preventive health care for women
Women over 40 mammogram- Q1-2 years
Women 20 yearly DR breast exams and SBE
women over 18 PAP test- sched b/t menses no sex 48 hrs prior
Vular Self examination- over 18 yoa monthly to determine tumor or lesion, ulcers, inflammation, changes in color
decrease occurrence of vertebral Fx
decreased STI
Amenorrhea
Amenorrhea- Absence of menses. 1. Primary amenorrhea failure to menstruate by 16 and 14 yoa if no 2ndary sex characteristics 2. Secondary- cessation of menstruation for @ least 3 cycles or 6 months in a woman with previously est menstruation
Tx thorough Hx, physical exam, lab tests, preg test in sex active women Thin women low fat = low estrogen athletes, anorexia, bulimia=therapy for eating disorder
other Tx Endocrine imbalance correction
Identify methods to reduce a woman’s risk for antepartum complications.
5
Discuss the management of concurrent medical conditions during pregnancy.
5
Recognize and treat hypovolemic shock.
5
Describe environmental hazards that may adversely affect the outcome of pregnancy.
5
Describe psychosocial nursing interventions for the women who has a high-risk pregnancy and for her family.
5
Danger signs pregnancy
Sudden gush of fluid from the vagina Vaginal bleeding Abdominal pain Persistent vomiting Epigastric pain Edema of face and hands Severe, persistent headache Blurred vision or dizziness Chills with fever over 38.0° C (100.4° F) Painful urination or reduced urine output
Hyperemesis Gravidarum
Manifestations
Excessive nausea and vomiting/ inability to retain food/fluids - significant weight loss
Lasting longer than first 11-12wks
Loss of weight/ inablility to gain
Electrolyte imbalances & acid base imbalance- dehydration dry mucus membranes poor skin turgor scant concentrated urine, high serum hematocrit level
Tx: Dr. rules out other causes, correct dehydration oral/iv fluids, Antiemetic Zofran 6-8mg, TPN if severe
Teaching: severe risk to fetus
Ectopic Pregnancy
Manifestations
Lower abdominal pain and may have light vaginal bleeding
If tube ruptures
May have sudden severe lower abdominal pain
Vaginal bleeding
Signs of hypovolemic shock
Shoulder pain may also be feltTreatment
Pregnancy test
Transvaginal ultrasound
Laparoscopic examination
Priority is to control bleeding
Three actions can be taken
No action
Treatment with methotrexate to inhibit cell division
Surgery to remove pregnancy from the tube
Hydatidiform Mole (cont.)
Manifestations Bleeding Rapid uterine growth Failure to detect fetal heart activity Signs of hyperemesis gravidarum Unusually early development of GH Higher-than-expected levels of hCG A distinct “snowstorm” pattern on ultrasound with no evidence of a developing fetusTreatment Uterine evacuation Dilation and evacuation Recurrent checks for hCG levels
Care of the Pregnant Woman with Excessive Bleeding
Document blood loss
Closely monitor vital signs, including I&O
Observe for Pain
Uterine rigidity or tenderness
Verify that orders for blood typing and cross-match have been carried out
Monitor intravenous infusionPrepare for surgery, if indicated
Monitor fetal heart rate and contractions
Monitor laboratory results, including coagulation studies
Administer oxygen by mask
Prepare for newborn resuscitation
Bleeding Disorders of Late Pregnancy
Placenta previa
abrupto placentae
Placenta previa
Abnormal implantation of placenta
Bright red bleeding occurs when cervix dilates, resulting in painless bleeding
Three degrees
Marginal
Partial
Total
Increased risk for hemorrhage as term approaches
Abrupto placentae
5
List the goals of prenatal care
Ensure a safe birth for mother and child by promoting good health habits and reducing risk factors
Teach health habits that may be continued after pregnancy
Educate in self-care for pregnancy
Provide physical care
Prepare parents for the responsibilities of parenthood
Calculate the expected date of delivery and duration of pregnancy
Average pregnancy is 40 weeks (280 days) after first day of LNMP, plus or minus 2 weeks Nägele’s rule Identify first day of LNMP Count backward 3 months Add 7 days Update year, if applicable
presumptive signs of pregnancy
Amenorrhea Nausea Breast tenderness Deepening pigmentation Urinary frequency Fatigue and drowsiness Quickening
probable signs of pregnancy
Goodell’s sign Chadwick’s sign Abdominal enlargement Braxton Hicks contractions Ballottement/fetal outline Abdominal striae Positive pregnancy test
positive signs of pregnancy
Audible fetal heartbeat
Fetal movement felt by examiner
Ultrasound visualization of fetus
Discuss the importance and limitations of exercise in pregnancy.
Maternal cardiac status and fetoplacental reserve should be the basis for determining exercise levels during all trimesters of pregnancy
It is important to assess the exercise practices of the woman
Goal of exercise during pregnancy should be maintenance of fitness, not improvement of fitness or weight lossElevated temperature: can impact fetal circulation and cardiac function
Hypotension: can reduce blood flow to the fetus
Cardiac output: peripheral pooling decreases cardiac reserves for exercise
Hormones: changes in oxygen consumption and epinephrine, glucagon, cortisol, prolactin, and endorphin levels
Other factors: moderate exercise has many benefits—more positive self-image, a decrease in musculoskeletal discomfort during pregnancy, and a more rapid return to prepregnant weight after deliveryThe maternal temperature should not exceed 100.4° F.
What activities are restricted in pregnancy due to their potential to elevate the mother’s body temperature? Hot tubs and saunas are to be avoided.
Maternal exposure to elevated temperatures during the pregnancy has been associated with miscarriage and neural tube defects.
Safety concerns mandate the type of exercise recommended for pregnancy. Certain positions can cause supine hypotension syndrome or promote orthostatic hypotension. What activities could be associated with these concerns?
During pregnancy, the length of continuous time spent exercising must be evaluated. Prolonged exercise sends an elevated amount of blood to the skeletal muscles. What impact does this have on the pregnancy? This increase will reduce the amount of blood being circulated to the uterus. Women who have been exercising prior to the pregnancy are the best candidates for continuing in an approved exercise regimen.
Review immunizations during pregnancy.
Live virus vaccines are contraindicated during pregnancy
Avoid pregnancy for at least 1 month after receiving an MMR vaccine
Select immunizations are allowable during pregnancy, such as influenza vaccine and H1N1 vaccine
Recommended Schedule of Prenatal Visits—Uncomplicated Pregnancy
Conception to 28 weeks—every 4 weeks
29 to 36 weeks—every 2 to 3 weeks
37 weeks to birth—weekly
Certain laboratory and/or diagnostic tests are performed at various times throughout the pregnancy
Routine Assessments at Each Prenatal Visit
Risk factors: review known and assess for new
Vital signs and weight: determine if gain is normal
Urinalysis: protein, glucose, and ketone levels
Blood glucose screening
Fundal height: fetal growth/amniotic fluid volume
Leopold’s maneuvers: assess presentation/position
Fetal heart rate
Nutrition intake
Any discomforts or problems since last visit
Effects of Pregnancy on the Reproductive System
Uterus
Becomes temporary abdominal organ
Capacity is 5000 mL (fetus, placenta, amniotic fluid)
Cervix
Changes in color and consistency, glands in cervical mucosa increase
Mucus plug formed to prevent ascent of organisms into uterus
Ovaries
Produce progesterone to maintain decidua (uterine lining) during first 6-7 weeks of gestation until placenta can take over task
Effects of Pregnancy on the Reproductive System (cont.)
Vagina
Increased blood supply causes it to have a bluish color
Vaginal secretions increase, pH more acidic
Higher glycogen level which promotes Candida albicans (yeast) growth
Breasts
High levels of estrogen and progesterone prepare breasts for lactation
Tubercles of Montgomery secrete substance to lubricate nipples
“Premilk” is expressed and is high in protein, fat-soluble vitamins, and minerals
Low in calories, fats, and sugar
Effects of Pregnancy on the Respiratory System
Oxygen consumption increases by 15%
Diaphragm rises ~4 cm (1.6 inches)
Causes ribs to flare
Dyspnea can occur until fetus descends into pelvis
Increased estrogen causes edema or swelling of mucous membranes of nose, pharynx, mouth, and trachea
Woman may complain of nasal stuffiness, epistaxis, and voice changes
Effects of Pregnancy on the Cardiovascular System
Blood volume increases by ~45% than prepregnant state
Increase provides for
Exchange of nutrients, oxygen, and waste products within the placenta
Needs of expanded maternal tissue
Reserve for blood loss at birth
Pulse rate increases by 10 to 15 beats/minOrthostatic hypotension
Palpitations
Dilutional anemia (a.k.a., pseudoanemia)
Increased clotting factors in second and third trimesters
Increases risk of thrombophlebitis
Supine Hypotension Syndrome
Occurs if woman lies flat on her back Allows heavy uterus to compress inferior vena cava Reduces blood returned to her heart Can lead to fetal hypoxiaSymptoms Faintness Lightheadedness Dizziness Agitation Turning to one side relieves pressure on inferior vena cava, preferably the left side
Effects of Pregnancy on the Gastrointestinal System
Growing uterus displaces stomach and intestines
Increased salivary secretions
Oral mucosa may become tender and bleed more easily
Appetite and thirst may increase
Gastric acid secretions decrease
Delayed gastric emptying and intestinal movement
Progesterone and estrogen relax muscle tone of gallbladder
Leads to retained bile salts
Can cause pruritus during pregnancy
Gestational Diabetes
If already diabetic, highly susceptible to hypoglycemia at night! Teach to have an evening snack
Uncontrolled BS can lead to macrosomia and possibly still birth.
Effects of Pregnancy on the Urinary System
Excretes waste products of woman and fetus
Glomerular filtration rate of kidneys increases
Glycosuria and proteinuria more common
Water retention due to increased blood volume and dissolving nutrients provided for fetus
Progesterone causes renal pelvis and ureters to lose tone, leads to urinary stasis
Woman more susceptible to UTIs
99% of sodium is reabsorbed, leads to fluid retentionIn the first and last trimester, the woman will experience frequent urination related to pressure by the uterus on the bladder.
Additional changes in pregnancy respond to the needs of the growing fetus.
As cardiac output and the volume of circulating blood increase, the kidneys also have an increase in workload. The kidneys work to filter this increased blood volume.
As the body strives to keep up with the volume, the woman might “spill” glucose and protein into the urine.
Effects of Pregnancy on the Integumentary and Skeletal Systems
Striae
Spider nevi
Sweat and sebaceous glands become more active
To dissipate heat from woman and fetus
Posture changes
Low back aches
Relaxation of pelvic joints
Waddling gait
Change in center of gravity
Balance may become an issueStriae (stretch marks) will fade after the pregnancy, but they won’t totally disappear.
Safety education is vital to the pregnant woman. As balance changes and becomes affected, she might face difficulty with stairs and getting in and out of the bathtub.
Nutrition for Pregnancy and Lactation
Women must be educated that they are not “eating for two.”
The intake must be evaluated for both caloric content and value to the growing fetus.
Weight Gain
Women of normal weight: 25 to 35 pounds (11.5 to 16 kg)
Obese women: 11 to 20 pounds (5 to 9 kg)
Overweight women: 31 to 50 pounds (14 to 22.7 kg)
Multifetal pregnancy: twins—woman should gain 4 to 6 pounds in first trimester, 1½ pounds per week in second and third trimesters, for a total of 37 to 54 pounds
Nutrition Requirements for Pregnant Women
Increase kCal by 300 per day, and should include
Protein—60 g/day
Calcium—1200 mg/day
Iron—30 mg/day
Folic acid—400 mcg (0.4mg)/day
Lactation increase another 200kCal (500kCal over non-pregnant recommendation)
FDA Pregnancy Risk Category for Drugs
Category A: no risk demonstrated to the fetus in any trimester
Category B: no adverse effects in animals; no human studies available
Category C: Only prescribed after risks to the fetus are considered. Animal studies have shown adverse reaction; no human studies available
Category D: Definite fetal risks, but may be given in spite of risks in life-threatening situations
Category X: Absolute fetal abnormalities. Not to be used anytime during pregnancyWhen administering medications to the pregnant patient, these categories must be taken into consideration.
What actions should be taken by the nurse when adverse reactions in pregnancy are associated with a prescribed medication?
Amnioinfusion
Oligohydramnios
Umbilical cord compression
Reduction of recurrent variable decelerations
Dilution of meconium-stained amniotic fluid
Replaces the “cushion” for the umbilical cord and relieves the variable decelerationsAn amnioinfusion is the instillation of fluids into the uterus by means of an intrauterine-pressure catheter (IUPC).
Discuss the nursing care required for the patient undergoing an amnioinfusion.
Amniotomy
The artificial rupture of membranes Done to stimulate or enhance contractions Commits the woman to delivery Stimulates prostaglandin secretion Complications Prolapse of the umbilical cord Infection Abruptio placentaePrior to an amniotomy, a series of assessments must be completed. What are the needed assessments?
What are the needed assessments amniotomy
Observe for complications post-amniotomy
Fetal heart rate outside normal range (110-160 beats/min) suggests umbilical cord prolapse
Observe color, odor, amount, and character of amniotic fluid- Woman’s temperature 38° C (100.4° F) or higher is suggestive of infection- Green fluid may indicate that the fetus has passed a meconium stoolThe rupture of membranes may be accompanied by complications:
Prolapsed umbilical cord
Infection
Abruptio placentae
What are the signs and symptoms of each of the identified complications?
Explain why the rupture of membranes could yield these results.
Audience Response Question #1
You are assessing characteristics of amniotic fluid post-amniotomy. You observe the color of the fluid to be green tinged. This can indicate the potential for:
1. Pre-term delivery
2. Vaginal infection
3. Cervical trauma
4. Fetal distress
Induction
Induction is the initiation of labor before it begins naturally
Augmentation
Augmentation is the stimulation of contractions after they have begun naturally
Indications for Labor Induction
Gestational hypertension
Ruptured membranes without spontaneous onset of labor
Infection within the uterus
Medical problems in the woman that worsen during pregnancyFetal problems such as slowed growth, prolonged pregnancy, or incompatibility between fetal and maternal blood types
Placental insufficiency
Fetal death
Contraindications to Labor Induction
Placenta previa
Umbilical cord prolapse
Abnormal fetal presentation
High station of the fetusActive herpes infection in the birth canal
Abnormal size or structure of the mother’s pelvis
Previous classic cesarean incision
Pharmacological Methods to Stimulate Contractions
Cervical ripening
Prostaglandin in a gel or vaginal insert is applied before labor induction to soften the cervix
Laminaria is an alternative to cervical ripening by swelling inside the cervix
Oxytocin induction and the augmentation of labor
Used to initiate or stimulate contractions
Most commonly used methodCervical softening assists with efforts to induce labor.
Oxytocin does not have cervical ripening properties.
Review the steps taken to administer prostaglandin and laminaria.
Benefit of Augmentation
Usually requires less total oxytocin than induction
Uterus is more sensitive to the drug when labor has already begun
Nonpharmacological Methods to Stimulate Contractions
Walking
Stimulates contractions
Eases pressure of the fetus on the mother’s back
Adds gravity to the downward force of contraction
Nipple stimulation of labor
Causes the pituitary gland to secrete natural oxytocin
Complications of Oxytocin Induction and Augmentation of Labor
Most common is related to Overstimulation of contractions Fetal compromise Uterine rupture Water intoxication Inhibits excretion of urine and promotes fluid retention
Episiotomy and Lacerations
Episiotomy—controlled surgical enlargement of the vaginal opening during birth
Lacerations—uncontrolled tear of the tissues that results in a jagged wound
Indications for an Episiotomy
Better control over where and how much the vaginal opening is enlarged
An opening with a clean edge rather than the ragged opening of a tear
Note: Perineal massage and stretching exercises before labor may be an alternative to an episiotomy
Forceps Extraction
Provides traction and rotation of the fetal head when the mother’s pushing efforts are insufficient to accomplish a safe delivery
Forceps may also help the physician extract the fetal head through the incision during a cesarean birth
Vacuum Extraction Birth
Uses suction applied to the fetal head so the physician can assist the mother’s expulsive efforts
Used only with occiput presentationForceps or vacuum extraction is used at the end of the second stage of labor.
Why would forceps or vacuum extraction be utilized?
Discuss additional criteria that must be present for the use of forceps or vacuum extraction.
Risks of Forceps or Vacuum Extraction
Trauma to maternal or fetal tissues
Mother may have a laceration or hematoma in her vagina
Infant may have bruising, facial or scalp lacerations or abrasions, cephalhematoma, or intracranial hemorrhage
