Normal Pregnancy

1
Normal Pregnancy
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Physiological Adaptation To Pregnancy
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Reproductive Organ Changes

• Uterus
• enlargement -- 2 ounces to 2 pounds
• rises out of pelvic area and displaces the
  intestines
• changes in tissue
• increase in vascularity
• hypertrophy
• isthmus of uterus softens -
• uterine soufflé
• Patient teaching
• Braxton-Hicks contractions

Hegars Sign
4

• Cervix
• softens - Goodells sign
• fills with a mucus plug
• increase in discharge, leukorrhea
• Vagina
• increase in vascularity - Chadwick's sign
• increase in discharge, leukorrhea
• pH rises and become more susceptible to yeast
  infections
• Mrs. Andrews complains of a whitish
• discharge. What is the teaching
• regarding vaginal discharges?

5

• Perineum
• increased vascularity and pressure causes vulvar
  varicosities
• What should the nurse teach regarding decreasing
  the pressure in the perineal area?
• Ovaries
• corpus luteum remains functioning and there is NO
  ovulation or menstruation.
• Mrs. Andrews asks why she stops having menstrual
  periods while pregnant. What is the nurses
  response ?

6

• Breasts
• Growth of alveolar tissue
• Nipples become more pigmented
• Mrs. Andrews states that her breasts are more
  full and have become very heavy.
• What teaching should the nurse include?

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Cardiovascular Changes

• cardiac enlargement
• Vasodilation
• increase blood volume, hemodilution
• increase cardiac output 30-50

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Cardiovascular Changes

• Blood Components and Variations in common
  laboratory tests
• RBC erythrocytes increase by 25 to 33 from
  acceleration in production 5.7million
• WBC leukocytes increase (5,000-15,000)
• Hgb 12 16 g/dl stays about the same
• Hct -- 37 decreases RT hemodilution. There is
  an increase of about 1500 ml. Over 1000 ml. of
  that is plasma.

9
Cardiovascular Care

• Nursing Care
• Avoid supine hypotension by side lying
• Arise slowly from a lying position
• Wear support hose and avoid constipation to
  decrease formation of varicose veins
• Instruct that palpitations may be felt and are
  normal

10
Respiratory Changes

• The body adjusts to meet the oxygenation needs
  by
• Thoracic rib cage is pushed upward and the
  diaphragm is elevated as uterus enlarges
• Lower thoracic cage widens to increase tidal
  volume
• Oxygen consumption is increased to support fetus
• Vasodilation of vessels in nose causing epistaxis
  and nasal stuffiness

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Respiratory Changes

• Nursing Care
• Instruct that because of shortness of breath and
  dyspnea may need to
• sleep in an upright position
• avoid overloading the stomach
• stop smoking!
• Nasal stuffiness is normal because of increase in
  hormones

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Gastrointestinal Changes

• Nausea and Vomiting
• Related to
• increased levels of HCG
• changes in CHO metabolism
• fatigue
• Nursing Care
• Avoid offending odors
• eat dry CHO (crackers) upon wakening
• Eat 5-6 small meals per day
• Avoid spicy, gas forming foods
• Drink carbonated beverages

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Gastrointestinal Changes

• Heartburn and Indigestion
• Related to
• slowing of motility and digestion because
• of progesterone
• relaxation of cardiac sphincter, regurgitation
  occurs
• stomach displaced upward and compressed by
• enlarged uterus

• Nursing Care
• avoid large meals
• use good posture
• Take low Sodium antacids --

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Gastrointestinal Changes

• Constipation
• Related to
• slowing of motility
• intestinal compression
• oral iron supplement
• Nursing Care
• Increase water and fiber in diet
• moderate exercise
• Dont take laxatives or enema without a
  doctors permission

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Gastrointestinal Changes

• Hemorrhoids
• Related to
• pelvic congestion
• straining with stool
• Nursing Care
• avoid constipation
• Apply topical agents to area

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• Review
• Mrs. Andrews says that she just mixes up some
  baking soda and that takes care of her
  indigestion.
• Is there any teaching that needs to be done in
  this situation?

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Urinary Changes

• Renal Changes
• Related to
• Kidneys increase in size and weight to enable
  greater filtration
• Enlarged uterus presses on kidneys and ureters
  reducing effective flow.
• ureters dilate
• Urinary stasis

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Urinary Changes

• Urinary frequency and urgency
• Related to
• pressure of uterus on bladder
• When is this more common?
• Nursing care
• Kegels exercises
• Limit fluid intake before bedtime
• Report dysuria or burning

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Skin and Hair Changes

• Skin
• Increase pigmentation RT increase in production
  of melanotropin
• face chloasma
• breasts areola darkens
• abdomen linea nigra
• Spider nevi on face and upper trunk
• Striae gravidarum
• Hair
• Increase in hair growth

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Musculoskeletal Changes

• Joints, bones, and teeth
• Softening of pelvic cartilage and exaggerated
  elasticity of connective tissue can lead to
  unstable gait
• Posture changes
• Leg cramps
• Carpal tunnel syndrome
• Teeth--there is no demineralization
• Nursing Care
• Wear low heel shoes for support
• Exercises
• Walk leading with the heel of the foot
• Wrist supports until after delivery assist with
  pain related to carpal tunnel syndrome. Goes
  away after delivery.

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Hormones

• Endocrine
• The placenta produces new hormones
• Human chorionic gonadotropin maintain pregnancy
• Human placental lactogen antagonist of insulin
• Estrogen stimulates development of uterine
  lining
• Progesterone maintains pregnancy
• Relaxin aids in softening the cervix

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Confirmation of the Pregnancy
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Situation

• Mr. and Mrs. Andrews visit the clinic and tell
  the nurse that Mrs. A has missed two menstrual
  periods, has urinary frequency, and is tired all
  of the time.

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First Prenatal Visit

• What is the most important thing that the nurse
  can do at this first prenatal visit?

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FIRST PRENATAL VISIT

• Most important intervention for the nurse is to
• MAKE THE PATIENT WELCOME !
• Why?
• (so the couple will continue with prenatal care)

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• The nurse will gather data regarding presumptive,
  probable, and positive signs of pregnancy.

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Presumptive Signs of
Pregnancy

• Cessation of Menstruation
• Breast changes -- tenderness
• Nausea and Vomiting
• Frequent Urination
• Quickening
• Chadwick's sign
• Increased pigmentation of the Skin
• Fatigue

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Probable Signs of Pregnancy

• Enlargement of the Abdomen
• Hegars Sign -- softening of the isthmus of the
  uterus
• Goodells Sign --softening of the cervix
• Braxton-Hicks contractions
• Ballotment
• Outline of the fetus by abdominal palpation
• Positive Pregnancy Test

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Positive Signs of Pregnancy

• Auscultation of fetal heart tones
• Active fetal movement felt by Trained person
• Ultrasound showing fetal outline

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Confirm the Pregnancy
All tests rely on detection of HCG
Pregnancy Tests
Urine Hema- agglutination
Inhibition
Enzyme Radioreceptor Assay
Radioimmune assay
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• Mrs. A says that she used a home pregnancy test
  and the results were positive.
• What are some of the advantages and disadvantages
  of using home pregnancy testing?

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Assessment and Nursing Care
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Health History Assessment

• Collect information about
• Obstetric History -- Current and past pregnancies
• Menstrual History
• Family history--genetic and environmental factors
  that affect health
• Medical history-- diabetes, heart
• Perform Physical Examination including a Pelvic
  Examination (Pap test, measurements, cervical
  culture)
• Perform Laboratory Studies
• Hgb., Hct, Type, Rh, CBC, Rubella, Hepatitis,
  HIV

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• Now that the couple has been welcomed to the
  clinic and the history is complete, it is time to
  confirm that Mrs. A is pregnant.

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• It is confirmed that Mrs. Andrews is pregnant.
• The nurse will continue with the assessment of
  physiological and psychological needs of the
  family.
• Assessment begins at the initial visit and
  continues throughout pregnancy.

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Calculation of Gravida and Parity

• Obstetrical Status
• Gravida number of times pregnant regardless of
  duration or outcome
• Parity number of deliveries after the age of
  viability (20 weeks).
• It is not the number of babies that come out,
  but the number of deliveries of a pregnancy

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Calculation of Gravida and Parity

• Further Breakdown into TPAL
• T Term
• P Preterm
• A Abortions
• L Live births

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Check Yourself !

• The nurse obtained the following data from Mrs.
  Andrews. She has five year old twins that
  delivered at 35 weeks, a three year old son that
  delivered at 39 weeks, had a miscarriage last
  year at 12 weeks gestation.
• What is her gravida and parity?
• What is her gravida and parity using the TPAL
  system?

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• Mr. and Mrs. Andrews are both excited about the
  pregnancy. It is her first so she is considered
  a Gravida 1, Para 0.
• They ask the nurse When is the baby due?
• How will you calculate this?

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Calculation of E. D. C.

• Nageles Rule
• First day of last Menstrual
• Go back 3 months
• Add 7 days
• Mrs. Andrews tells you her last menstrual period
  began on July 18.
• Her baby is due on ____________.

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TEST YOURSELF
Mrs. B. began her menses on January 21. What is
her E.D.C. using Nageles Rule?
Mrs. C. started her menses on June 27. What is
her E.D.C. using Nageles Rule?
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Problem Solving

• If Mrs. Andrews did not know the first day of her
  last menstrual period, what method of calculation
  would you use?

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• McDonalds Rule
• Use Fundal height measurement, measure from the
  symphysis to the top of the fundus.
• Months measure cm. X 2/7
• Weeks measure cm. X 8/7
• Mrs. Andrews fundal height is 7 cm. How far
  along is she?

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Assessment of Pelvic Adequacy

• Clinical Pelvimetry via ultrasound can be
  performed to determine if the pelvis is of
  adequate size to allow for a normal vaginal
  delivery.
• Manual measurement via examiner

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Conclusion of Visit

• You are completed with Mr. and Mrs. Andrews first
  prenatal visit.
• Before they leave, it is important to discuss the
  following topics

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Conclusion of Visit

• Danger Signals
• Patient Teaching
• Diet Counseling
• Referrals
• Date of next visit

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Danger Signals

• Vaginal Bleeding
• Fluid from the Vagina
• Abdominal Pain
• Increased Temperature
• Dizziness, Blurred vision or Double Vision
• Persistent Vomiting
• Edema
• Headache
• Dysuria
• Absence of Movement of the Baby

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Patient Teaching
Review interventions on how to overcome the
Common Discomforts of pregnancy and Health
Behaviors with each subsequent visit .
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Teaching Health Behaviors
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Teaching Health Behaviors

• Employment
• Criteria for work
• is work environment safe for the fetus
• can woman carry out work commitments without
  undue stress
• What other teaching is necessary regarding work
  and breaks.

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• Mrs. Andrews says that she is employed as a bank
  teller on a full time basis.
• She asks whether she can continue to work
  throughout her pregnancy

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• Exercise, Leisure, Travel
• May attend regular prenatal exercise classes
• Dont take up a new sport
• Travel--wear seat belt

Wear shoulder belt over top of abdomen
Wear lap belt low over the hips
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Teaching Health Behaviors

• Avoid exposure to teratogens
• Alcohol
• Smoking
• Drugs
• Immunizations - avoid live vaccines
• Advise about use of prescription and
  over-the-counter drugs

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Psychosocial Adaptation To Pregnancy
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Maternal Responses
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First Trimester

• Uncertainty
• Incorporation and integration of the fetus as an
  integral part of the woman.
• Ambivalence
• Self as primary focus
• Baby not perceived as a reality.
• Fetus is not perceived as a separate object
• Interest and concern about their bodily and
  emotional changes.

Psychological Task - Needs to be able to say I
am Pregnant
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Second Trimester

• Fetus as primary focus
• Sees fetus as a separate object and not an
  extension of self.
• Picture the fetus as a newborn infant.
• Assign sex and describe with specific
  characteristics.
• Narcissism and Introversion
• Wants to do the right things to protect herself
  and her baby
• Body Image

Psychological Task - Needs to be able to say I
am going to have a baby
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Changes in Sexuality

• First Trimester
• nausea, fatigue, fear of miscarriage interfere
  with sexual feelings
• Second trimester
• freedom from worry of getting pregnant so enjoy
  sex
• Increase in sexual responsiveness
• Third Trimester
• Suggest alternate positions for sex
• Sexual response varies widely

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Third Trimester

• Vulnerability
• Worry that baby may be lost or harmed
• Increasing dependence
• Preparation for birth
• Planning babys arrival at home.
• Decide on method of feeding.
• Acceptance of demands baby will make on parents.
• More confident in knowledge about labor and
  delivery.
• Interest in child care and planning for the
  future.

Psychological Task - Needs to be able to say I
am going to be a parent.
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Paternal Responses

• Readiness for fatherhood is more likely if there
  is a stable relationship between partners
• May be more difficulty for males to adapt to role
  as father because they are often neglected when
  the focus is on the woman
• Need the same support as the woman

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Cultural Influences
In working with clients of other cultures, health
professionals should be open to and respectful of
other beliefs
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Maternal Nutrition
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Nutrition in Pregnancy

• Increase in calories
• Increase in protein
• Adequate intake of minerals and vitamins
• May have food cravings or Pica
• Nursing care
• Teach to take prenatal vitamins and iron
• Teach about normal weight gain 25 lbs.