Prenatal Care – Module A

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Prenatal Care Module A

• NUR 106
• Spring, 2005

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Anatomical Landmarks

• Female
• Male

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External Structures
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Internal Structures
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Midsagital View
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Uterus
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Uterine Ligaments
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Pelvic Bones
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Female Pelvis
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Pelvic Types
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Muscles of the Pelvic Floor
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Male External and Internal Structures
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Testis
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Testis
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Sperm
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Female Reproductive Cycle

• Ovulation
• Menstruation
• Menarche
• Climacteric
• Menopause

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Female Reproductive Cycle
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Conception and Fetal Development

• Nine Month Miracle
• Miracle of Life
• Internet sites

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Conception

• Fertility
• Sexual intercourse
• Pregnancy

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Genetics

• Chromosomes
• Autosomal
• Sex
• Chromosomal syndromes
• Modes of inheritance

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Patterns of Inheritance

• Dominant
• Recessive
• X-linked

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Nursing Responsibilities

• Identify families at risk
• Education
• Liaison
• Support / Crisis intervention
• Continuity of care

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Teratogens

• Tobacco
• Alcohol
• Marijuana
• Cocaine
• Heroin
• Anticonvulsants
• Anticoagulants
• Acne medications

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Reproductive Ethics

• Maternal-fetal conflict
• Abortion
• Intrauterine fetal surgery
• Reproductive assistance
• Embryonic stem cell research
• Human genome project
• Cord blood banking

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Fertilization

• One spermatozoon enters the ovum
• Two nuclei containing the parents chromosomes
  merge
• Occurs in the outer third of the fallopian tube
• Sex is determined

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Multifetal Pregnancy

• Dizygotic twinning -- fraternal
• Monozygotic twinning -- identical

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Implantation

• Nidation
• Gradual process
• Occurs between 6th / 7th and 10th days
• Upper part of posterior uterine wall
• Placenta develops

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Fertilization and Implantation
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Amniotic Membranes

• Amnion (inner)
• Chorion (outer)
• Enclose fetus in amniotic fluid
• Protects fetus from infectious organisms

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Amniotic Sac

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Amniotic Fluid

• Clear, slightly yellow, alkaline fluid
• Approximately 1 liter at term
• Derived from
• Maternal plasma
• Cells of the amnion
• Fetal fluids from lung, skin, fetal urine

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Functions of Amniotic Fluid

• Cushions fetus from trauma
• Facilitates fetal movement
• Facilitates symmetrical growth
• Regulates intrauterine temperature
• Provides source of oral fluid
• Cushions umbilical cord
• Receptacle for fetal substances

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Placenta / Function

• Fully functional by week 12
• Respiration
• Nutrition
• Waste removal
• Protection
• Endocrine

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Placenta
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Placenta After Delivery
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Umbilical Cord

• One vein
• Two arteries
• Whartons jelly
• Amnion

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Placenta and Cord
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Umbilical Cord
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12 weeks
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18 Weeks
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4 Months
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5 Months
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(No Transcript)
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30 Weeks
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40 Weeks
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Fetal Development

• Preembryonic or ovum
• Embryonic
• Fetal

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Fetal Circulation

• Ductus venosus
• Ductus arteriosus
• Foramen ovale

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Fetal Circulation
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Factors Affecting Fetal Development

• Exposure to teratogens
• Maternal health habits and lifestyle
• Paternal health habits and exposure to
  environmental influences

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Physiological Changes During Pregnancy

• Uterus
• Ligaments
• Cervix
• Chadwicks
• Goodells
• Hegars
• Breast
• Montgomery tubercles
• Skin

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Circulatory System

• Increases up to 50
• Pseudoanemia
• Iron requirements increased
• Increase in size
• Blood pressure changes
• Fibrinogen increases
• Mechanical circulatory effects

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Supine Hypotension Syndrome
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Respiratory System

• Thoracic cage
• Oxygen consumption increases
• Hyperventilation
• Respiratory alkalosis
• Mucosal edema

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Digestive System

• Nausea / vomiting
• Constipation
• Flatulence / heartburn
• Gallstones

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Urinary System

• Kidneys
• Function increases
• Renal threshold for sugar reduced
• Bladder and ureters
• Blood supply increased
• Pressure
• Atonia

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Joints, Bones, Teeth, and Gums

• Pelvic cartilages
• Gait
• Uterus
• Posture changes
• Teeth
• Gums

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Endocrine System

• Placenta
• HCG
• HPL
• Estrogen
• Progesterone
• Pituitary
• Adrenal
• Thyroid

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Signs of Pregnancy

• Presumptive Subjective
• Probable Objective
• Positive -- Diagnostic

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Signs of Pregnancy S, O, or D

• Amenorrhea
• Goodells sign
• Fetal heart sounds
• Urinary frequency
• Positive pregnancy test
• Nausea and vomiting
• Enlargement of the abdomen
• Quickening
• Palpable fetal movements
• Braxton Hicks contractions

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How would you explain the differences between the
subjective (presumptive), objective (probable),
and diagnostic (positive) signs of pregnancy to
an expectant mother?
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Maternal Psychosocial Changes

• First trimester
• Ambivalent
• Second trimester
• Baby becomes real
• Maternal introspection
• Third trimester
• Begins to think of baby as separate being
• Restless
• Self-centered

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Rubins Maternal Tasks

• Seeking safe passage
• Securing acceptance
• Learning to give of self
• Committing self to child

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Paternal Psychosocial Changes

• First trimester
• Excitement over virility
• Financial concerns
• Energetic
• Exhibit symptoms with wife
• Second trimester
• More confident
• Concerns about wifes changes / introspection
• Third trimester
• Rivalry with fetus
• Interest in himself
• Fantasizes about child

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Factors Affecting Psychological Response

• Body image
• Personal characteristics
• Financial situation
• Cultural expectations
• Emotional security
• Support from significant others
• Changes in sexuality
• Role of the father and siblings

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Preparation for Parenthood

• Preconception
• Childbearing decisions
• Prenatal education
• Childbirth preparation

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Childbirth Education

• Provides information on pregnancy and childbirth
  to facilitate optimal decision making
• Classes for special groups
• Importance of exercise during pregnancy
• Selection of birthing process
• Infant care

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First Trimester

• Physical and psychosocial changes of pregnancy
• Self-care in pregnancy
• Protecting and nurturing the fetus
• Choosing a care provider and birth setting
• Prenatal exercise
• Relief of common early pregnancy discomforts

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Second Trimester

• Planning for breast-feeding
• Sexuality in pregnancy
• Relief of common later-pregnancy discomforts

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Third Trimester

• Preparation for childbirth
• Development of a birth plan
• Relaxation techniques
• Postpartum self-care
• Infant stimulation
• Infant care and safety

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Goals of Prenatal Care

• Safe birth
• Health promotion
• Self-care
• Provide physical care
• Provide anticipatory guidance

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Risk Factors / Reproductive Outcomes

• Maternal age
• Parity
• Socioeconomic status
• Ethnicity
• Geographic factors
• Behavioral and Lifestyle risks
• Health risks
• Previous pregnancies

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Role of Nurse

• Physical assessment
• Identify and reevaluate risk factors
• Teach self-care
• Nutrition counseling
• Promote familys adaptation to pregnancy

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Prenatal Visits

• Every 4 weeks for first 28 to 32 weeks
• Every 2 weeks from 32 to 36 weeks
• Every week from 36 to 40 weeks

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Terminology

• Gravida
• Nulligravida
• Primigravida
• Multigravida
• Para
• Primipara

• Multipara
• Nullipara
• Abortion
• Gestational age
• Fertilization age

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Nomenclature

• G number of pregnancies
• T number of term deliveries
• P number of preterm deliveries
• A number of abortions
• L number of living children
• M number of multiple births

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Nägeles Rule

• First Day of Last Menstrual Period
• Minus 3 months
• Plus 7 days

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Identify the causes and interventions for each
discomfort of pregnancy

• Heartburn
• Hemorrhoids
• Urinary frequency
• Nausea / vomiting
• Leg cramps
• Vaginal discharge

• Fatigue
• Backache
• Constipation
• Varicose veins
• Edema
• Dyspnea

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Why is a positive pregnancy test not a positive
sign of pregnancy?
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Routine Lab Tests

• Blood grouping
• Rh factor and antibody screen
• CBC
• H H
• VDRL, RPR, or STS
• Rubella titer
• TB skin test

• Hg electrophoresis
• HIV screen
• Hepatitis B screen
• UA
• PAP test
• Cervical culture
• MSAFP
• Maternal blood glucose

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Prenatal Laboratory Tests Normal or Abnormal ?

• Hemoglobin 13.6 g/dL
• Hematocrit 35
• Rubella titer 16
• WBC 6,200/ mm3
• Sickle Cell screen negative

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Prenatal Self-Care Measures

• Breast tenderness
• Leg cramps
• Nausea
• Constipation
• Backache

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Risk Factors

• Definition
• Social / Personal
• Preexisting medical disorders
• Obstetric considerations
• Problems associated with current pregnancy

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Prenatal Diagnostic Studies

• Ultrasound
• Estriol Increases with fetal growth
• Amniotic Fluid
• Amniocentesis
• Lecithin / sphingomyelin ratio
• Fern test
• Nitrazine test
• Kick test
• Chorionic villus sampling
• Alpha feto protein level

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Level I Ultrasound

• Basic
• Detect gestational sac (5 weeks after LMP)
• Identify number of fetuses
• Document fetal life
• Detect gross fetal structural anomalies
• Estimate gestational age
• Determine fetal position
• Locate the placenta
• Estimate amniotic fluid volume
• Evaluate maternal pelvic masses

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Level II Ultrasound

• Evaluate gestational age
• Measure fetal growth
• Perform specific examinations of the brain,
  heart, kidney, and cord insertion
• Quantify amniotic fluid volume
• Determine placental location
• Performed after 18 weeks

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List two advantages of prenatal ultrasound
assessment for the mother and fetus.
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Tests of Fetal Well-Being

• Ultrasound
• Amniocentesis
• Nonstress Test (NST)
• Contraction Stress Test (CST)
• Breast Self-Stimulation Test (BSST)

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Danger Signs in Pregnancy

• C Chills and fever
• Cerebral disturbances
• A Abdominal pain
• B Blurred vision
• Blood pressure
• Bleeding
• S Swelling
• Sudden escape of fluid

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Nutrition During Pregnancy

• Choose foods from food guide pyramid
• Increase of 300 calories / day
• Calorie needs greater in last two trimesters
• Encourage diet high in folic acid with
  supplements
• Calcium needs increase nearly 50
• Heavy demand for iron for fetal stores
• Drink 8 to 10 glasses of water / day

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Food Guide Pyramid

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Vegetarianism

• Need ample and complete proteins from dairy
  products and eggs
• Protein from brown rice and whole wheat, legumes,
  nuts, cooked and fresh vegetables and fruits
• Vitamin B12 supplement

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Lactose Intolerance

• Abdominal distention, discomfort, nausea,
  vomiting, loose stool, cramps
• May tolerate milk in cooked form
• Cheese and yogurt
• Lactase may be prescribed
• Lactase-treated milk
• Lactose-free products

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Pica

• Non-nutritive eating
• Associated with poverty and inadequate diets
• Iron deficiency anemia

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Weight Gain

• Normal 25 -- 35 pounds
• Underweight 28 -- 40 pounds
• Overweight 15 -- 25 pounds

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Uterine Growth During Pregnancy
F
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Uterine Growth During Pregnancy
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What is the average pattern of weight gain during
each trimester of pregnancy?
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Maternal Weight Gain Distribution

• Fetus, placenta, amniotic fluid 11 pounds
• Uterus 2 pounds
• Increased blood volume 3 pounds
• Breast tissue 3 pounds
• Maternal stores 5-10 pounds
• Total 25-35 pounds

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Medications

• Prenatal vitamins
• Iron supplements
• Folic Acid
• Antacids

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Case Study

• A client, who is a primigravida in her second
  trimester, has come in for a scheduled prenatal
  visit. When the nurse asks how things are going,
  the client replies, Not very well. It seems
  like Im just falling apart. I have heartburn
  after I eat, my ankles swell, Im constipated all
  the time, and I think I may be getting
  hemorrhoids.