1. Normal Pregnancy Fall 2011 Amie Bedgood RN, MSN

2. Physiological Changes in the Reproductive Organs 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-- Hegar’s sign uterine souffle Patient teaching Braxton-Hicks contractions

3. Cervix softens - Goodell’s 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

4.  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.

5.  Breasts  Growth of alveolar tissue  Nipples become more pigmented  Your patient states that her breasts are more full and have become very heavy. What teaching should the nurse include?

6. Cardiovascular System Circulatory System ▫Related to:  cardiac enlargement  vasodilation  increase blood volume, hemodilution  increase cardiac output – 30-50% Variations in common laboratory tests ▫Hgb – 12 – 16 g/dl – stays about the same ▫Hct -- 37% decreases RT hemodilution. There is an increase of about 1500 cc. Over 1000 cc of that is plasma. ▫RBC -- ~5.7million which is about a 17% increase

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

8. Respiratory Changes ▫Related to:  Thoracic cage is pushed upward and the diaphragm is elevated as uterus enlarges  Oxygen consumption is increased to support fetus  Lower thoracic cage widens to increase tidal volume Nursing Care ◦ Instruct due to shortness of breath and dyspnea may need to:  sleep in an upright position  avoid eating large meals  stop smoking!  Nasal stuffiness is normal due to increase in hormones

9. Elimination: 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

10. n Heartburn and Indigestion –Related to: »slowing of motility and digestion due to 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

11. Constipation ◦ Related to:  slowing of motility  intestinal compression  oral iron supplement ◦ Nursing Care  Increase water and fiber in diet  moderate exercise  No laxatives or enema without a doctor’s permission Hemorrhoids ◦ Related to :  pelvic congestion  straining with stool ◦ Nursing Care  avoid constipation  Apply topical agents to area

12. Elimination: Urinary System Renal Changes ◦ Related to:  Kidneys increase in size and weight to due to increased filtration needs  Enlarged uterus presses on kidneys and ureters reducing effective flow  ureters dilate  Urinary stasis occurs Urinary frequency and urgency ◦ Related to:  pressure of uterus on bladder first and last trimester Nursing care Kegel’s exercises Limit fluid intake before bedtime Report dysuria or burning

13. Integumentary Skin changes ◦ Increase pigmentation R/T increase in production of melanotropin  face = chloasma  breasts = areola darkens  abdomen = linea nigra ◦ Spider nevi on face and upper trunk ◦ Striae gravidarum

14. Regulatory Changes Joints, bones, and teeth ▫Softening of pelvic cartilage and exaggerated elasticity of connective tissue ▫Posture changes ▫Leg cramps ▫Carpal tunnel syndrome ▫Teeth--there is no demineralization Endocrine ▫The placenta produces new hormones Exercise, Leisure ▫May attend regular prenatal exercise classes ▫Don’t take up a new sport ▫Travel--wear seat belt

15. Safety with Seat Belts Wear shoulder belt over top of abdomen over top of abdomen Wear lap belt low over the hips

16. Regulatory Employment ▫Criteria for work:  safe environment for the fetus  can woman carry out work commitments without undue stress What other teaching is necessary regarding work and breaks?

17. Safety / Sensory Safety ◦ Clothing ◦ Bathing ◦ Immunizations - avoid live vaccines Eye Ear ◦ Clothing ◦ Bathing ◦ Immunizations - avoid live vaccines

18. Nutrition Increase in calories Increase in protein May have food cravings or Pica Nursing care: ◦ Teach to take prenatal vitamins and iron ◦ Teach about normal weight gain ~ 25 lbs.

19. THE PREGNANCY EXPERIENCE

20. 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”.

21. First Prenatal Visit What is the most important thing that the nurse can do at this first prenatal visit?

22. FIRST PRENATAL VISIT Most important intervention for the nurse is to: MAKE THE PATIENT WELCOME ! Why? (so the couple will continue with prenatal care)

23. Now that the couple has been welcomed to the clinic, one of the first things that must be done is to confirm that Mrs. A is pregnant.

24. 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?

25. Home Pregnancy Testing Advantages ▫Easily available ▫Uncomplicated ▫Convenient ▫Have a greater than 97% accuracy ▫Minimal time Disadvantages ▫Must be able to follow the directions as described or can lead to improper collection and errors in performing or reading the test ▫False-positive results – anticonvulsants, aspirin, tranquilizers, marijuana ▫False-negative results – diuretics, promethazine ▫Laboratory errors

26. What other types of pregnancy tests might be utilized to confirm the pregnancy?

27. Confirm the Pregnancy All tests rely on detection of HCG Enzyme Immunoassay Tests Radioimmune assay Tests Urine Hema- agglutination Inhibition Tests

28. Presumptive Signs Cessation of Menstruation Breast changes -- tenderness Nausea and Vomiting Frequent Urination Quickening Chadwicks sign Increased pigmentation of the Skin Fatigue

29. Probable Signs Enlargement of the Abdomen Hegar’s Sign -- softening of the isthmus of the uterus Goodell’s Sign --softening of the cervix Braxton-Hicks contractions Ballotment Outline of the fetus by abdominal palpation Positive Pregnancy Test

30. Positive Signs Ausculation of fetal heart tones Active fetal movement felt by a trained provider Ultrasound showing fetal outline

31. 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.

32. Legal Implication Nurses must exercise caution when discussing obstetric history with the expectant mother in the presence of her family or significant other. Although the antepartum record may indicate a previous pregnancy or childbirth, she may not have shared this Information with her family, and probing questions could jeopardize her right to privacy. The confidentiality of the pregnant woman must always be protected.

33. 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 ▫CBC, Type & Cross, RPR, Rubella, Hepatitis, HIV

34. 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

35. Calculation of Gravida and Parity Further Breakdown into TPAL ▫T = Term ▫P = Preterm ▫A = Abortions ▫L = Living children

36. Check Yourself ! 4 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. 4 What is her gravida and parity? 4 What is her gravida and parity using the TPAL system?

37. 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?

38. Calculation of E. D. C.  Nagele’s 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 ____________.

39. TEST YOURSELF Mrs. B. began her menses on January 21. What is her E.D.C. using Nagele’s Rule? Mrs. C. started her menses on June 27. What is her E.D.C. using Nagele’s Rule?

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

41.  McDonald’s 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. Andrew’s fundal height is 7 cm. How far along is she?

42. Assessment The nurse continues with assessment of Mrs. Andrews and gathers data regarding presumptive, probable, and positive signs of pregnancy

43. 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:

44. Conclusion of Visit Patient Teaching Diet Counseling Referrals Danger Signals Date of next visit

45. 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

46. Psychosocial Adaptions

47. Psychological Tasks of Pregnancy Mr. Andrews says they were excited about having the baby but he had just taken a new job and was concerned. Is this Normal?

48. The First Trimester Major Feelings are: ▫Disbelief / Uncertainty  Much time is devoted to the attempt to determine for sure whether she is pregnant ▫Ambivalence  Feelings fluctuate between acceptance and rejection of the pregnancy

49. The First Trimester How the Nurse Can Assist the Woman to Adjust: ▫Assist her to confirm that she is Pregnant ▫Recognize that she is self-centered ▫Focus on Current Events ▫Provide opportunities for her to discuss concerns ▫Guide her to appropriate community resources

50. The Second Trimester The Major Task is to: Perceive the Fetus as a Growing Infant be able to say: “I am Going to have a Baby”

51. The Second Trimester Major Feelings are: ▫Woman feels well and good about herself ▫Concerned with producing a healthy baby ▫Self- Centered and Introverted ▫Visualizes the infant as a separate being ▫Views body image changes as positive sign that the baby is doing O.K.

52. The Second Trimester Ways Health Care Worker can assist the woman to adjust: ◦ Take advantage of the Prime Time for Teaching  Individual Care  Nutrition  Clothing  Exercise  Baby Care ◦ Confirm that the baby is Growing and Doing Well ◦ Praise her on following Prenatal Recommendations

53. The Third Trimester The Major Task is to Prepare for the end of Pregnancy and she need to be able to say “I am Going to Be a Parent”

54. The Third Trimester Major Feelings are: ▫Vulnerable  Fears loss of the baby  Fantasies about harm coming to the baby ▫Dependent  Needs satisfaction that partner / support person is there ▫Concerned with how to cope with labor and delivery ▫Need to Prepare for Parenthood

55. The Third Trimester Ways in which the Health Care Worker can assist the woman to adjust: ▫Assure her of the baby’s well- being ▫Be a Good Listener ▫Nurture her ▫Provide with information about childbirth classes ▫Assist her with contacting appropriate agencies that may assist in caring for the infant after birth

56. What would the nurse base her response?

57. Sexual Changes First trimester – decrease in sex drive Second trimester – return of sex drive “Baby Moon” Third trimester – decrease in sex drive Exceptions – those women who are prone to preterm labor.

58. Factors that affect psycosocial adaptations Age Multiparity Social support Absence of a partner Socioeconomic status Abnormal situations

59. Barriers to prenatal care Financial Systemic Attitudinal

60. Cultural Influences Health beliefs Communication Time orientation

61. Teen pregnancy How is it different? What will the nurse need to focus on with the pregnant teen?

62. The end!!!!