2 PRECONCEPTION EDUCATION AND CARE Immunizations and disease statusMedicationsSmoking, Alcohol, and Illicit DrugsGenetic Risk FactorsMale Contributions
3 PRECONCEPTION EDUCATION AND CARE Immunizations and disease statusRubella and Hepatitis B should be completed before a pregnancy is begun.Testing for infectious diseases (syphilis, hepatitis, HIV, chlamydia, gonorrhea, HPV, herpes simplex , and group B streptococcus)Medications-Avoid teratogens prior to and during pregnancyAvoid Smoking, alcohol, and illicit drugSmoking-negative effects on pregnancy, major risk factors and low-birth weight infants.No safe level of alcohol intake during pregnancyIllicit drugs may cause fetal anomalies or disorders, newborn may experience withdrawal syndrome. Discontinue prior to and during pregnancy, and after birth if breastfeeding.Genetic risk factors-review family history, genetic counseling, discuss risksMale contributions-lower birth weight for infants of smoking fathersSmoking affects spermatogenesis and sperm mobilityMale exposure to occupational chemicals has been associated with spontaneous abortion, stillbirth, preterm delivery, and small-for-gestational-age babies
4 PREGNANCY Condition of carrying an offspring within body. Fertilization (or conception)–occurs when a sperm and ovum unite.Zygote–the fertilized ovum.Implantation(5th day after fertilization)–embedding of the fertilized egg into the uterine lining.
5 AMNIOTIC FLUID-anatomy 98% waterContains glucose, protein, sodium, urea, creatinineSlightly alkalineApproximately every 3 hours the fluid is replaced.Chorionic villa at the base of the implanted fertilized ovum. Amnion is the fetal side of the placenta, so it is smooth and shiny.
6 AMNIOTIC FLUID-functions Equalizes the pressure around fetus.Cushions fetus from external compression.Provides constant temperature and fluid for fetus to swallow.Allows freedom of movement for fetus.Lubricates membranes and fetus.
7 FUNCTIONS OF THE PLACENTA TransportEndocrineMetabolic
8 THE PLACENTA Membranous vascular organ connecting fetus to mother. Produces hormones to sustain pregnancy. (5 Hormones-hCG, hPL, estrogen, progesterone, and relaxin)Supplies fetus with oxygen and food.Provides nutrition to and transports waste products from fetus.Fully functional by week 12.
9 THE UMBILICAL CORD Structure connecting fetus to placenta. Has two arteries that carry deoxygenated blood and one vein which carries oxygenated blood. (This is the one instance in which arteries carry deoxygentated blood and a vein transports oxygenated blood.)Surrounded and protected by Wharton’s jelly.
10 FETAL DEVELOPMENTPreembryonic or germinal stage–first 14 days after fertilization.Embryonic stage–week 3 through week 8.Fetal stage–week 9 until 38 to 40 weeks or full term.Pregnancy calculated from first day of mother’s last menstrual period.Development occus in a systematic manner from head to toe (cephalo-caudal), from proximal to distal (close to body-farthest from body), and from general to specific.
11 FETAL DEVELOPMENT First trimester –first twelve weeks Second trimester-weeks 13-27Third trimester-weeks 28-40Pregnancy generally lasts 10 lunar (28days) months, 40 weeks, 280 days. It is calculated from the first day of the mother’s last menstrual period (LMP). Table 50-1 identifies stages of fetal development
12 SYSTEM DEVELOPMENT Cardiovascular system Gastrointestinal system heart begins to beat on the 21st dayFirst system to function in the embryoMost malformations develop in first 6-8 weeksBlood cells develop day 14Gastrointestinal systemBegins to develop fourth weekFetus begins to swallow by 20th weekMeconium (fecal material stored in the fetal intestines) begins to form about week 16) *There should be no passage of meconium in utero. If the fetus encounters hypoxic stress, the anal sphincter may relax and meconium may be passed, causing meconium staining of the amniotic fluid.*Genitourinary systemBegins to form about week 3Begins to produce hypotonic urine about week 12Reproductive systemTestes can be seen about week 7 and begin to descend into the scrotum about 30 weeksOvaries develop in the abdomen and stay in the pelvic cavity (All the ova a female will ever have are in the ovaries at birth)Gender can be made through ultrasound by the end of week 12
13 SYSTEM DEVELOPMENT Integumentary system-skin protects Vernix caseosa protects the skinCreases form on palms, fingers and soles during week 11 and become permanent by week 17Skin color is genetically determinedLanugo appears during week 20, slowly disappears by birthTooth buds appear during week 6 (baby teeth) and week 10 (permanent teeth).Mammary glands develop during the sixth weekRespiratory systemLung buds week 6, bronchi forming by week 16Primitive lungs by week 23- not sufficient for gas exchange but lungs are capable of borderline support of extrauterine repsiration (age of viability- gestational age at which the fetus could live outside of the uterus is considered 24 weeks)Surfactant production begins between week and matures between weeksImmunologic systemBegins to develop between week 12 and 15Fetus produces small amounts of IgG, IgA, IgE before week 20Maternal IgG is actively transported actross the placenta to provide passive immunity against many infectious diseases
14 FACTORS AFFECTING FETAL DEVELOPMENT Quality of sperm, ovum, genetic codeTeratogens- any agent, such as radiation, drugs, viruses, or other microorganisms, capable of causing abnormal fetal development)Maternal malnutritionAcute and chronic diseasesAlcohol and drugsSmoking
15 PHYSIOLOGICAL CHANGES OF PREGNANCY Reproductive systemSize of uterusBraxton Hicks contractionsHegar’s SignCardiovascular systemBlood flow increases to uterusHeart rate increases by BPMCardiac Output increases by 30-50%B/P decreases, lowest during 2nd trimester, returns 3rd trimesterLower extremity edema, varicose veins of legs, vulva, or rectumSupine hypotensive syndrome-dizziness, clammy-pale skin, low b/p, decreased placental perfusionBlood volume increases by 30-50% and peaks at week 30Small increase in RBC, greater increase in PLASMA (shows lower hematocrit 34-40% known as physiologic anemia of pregnancy)WBC increases by week 8Plt, fibrin, fibrinogen, and coagulation VII, IX, X increases (increases the risk of venous thrombosis late in pregnancy)This summary slide added so that subsequent slide titles can be more explicit.
16 PHYSIOLOGICAL CHANGES OF PREGNANCY Respiratory systemProgesterone decreases airway resistance, allowing increase in oxygen consumptionDepth of respiration increases causing mild respiratory alkalosis, compensated by increased renal secretion of bicarbEnlarged uterus pushes on diaphragmRib cage flares and the chest circumference expands to keep intrathoracic volume the same as when not pregnantEstrogen causes edema and vascular congestion of the nasal mucosaMusculoskeletal systemRelaxation of pelvic joints in preparation for delivery is caused by relaxinMother’s center of gravity changes due to increased size/weight of uterusTo compensate, the mother increases curve of the lumbosacral spine (lordosis)May have waddling gaitGastrointestinal system Urinary systemNausea and/or vomiting “morning sickness” common early, usually disappear by week 12Smooth muscles relax causing delayed gastric emptying and decreased peristalsisEnlarged uterus displaces stomach and intestinesConstipationRelaxation of the cardiac spinchter may allow reflux of acidic gastric contents into esophagus, giving the mother heartburn
17 PHYSIOLOGICAL CHANGES OF PREGNANCY Integumentary systemSkin pigment changes (nipples, areola, vulva, perineal area darken)Linea nigra-pigmented line on the abdomenChloasma “mask of pregnancy” –darkening of forehead and around the eyesStriae gravidarum “stretch marks”- reddish streaks found on the abdomen, thighs, buttocks, and breasts (may cause itching)Endocrine systemAPG (prolactin-initial milk production)PPG (oxytocin-uterine contractions and ejection of milk from the breasts “let-down reflex” after delivery)hPL-insulin antagonist-stress on islets of Langerhans-may show signs of gestational diabetesSlight increase in size of thyroid, increase capacity to bind thyroxin(important for fetal neural development during first trimester) Causes increased PBIMetabolism-increasesMother must meet her needs as well as the needs of the developing fetus
18 PHYSIOLOGICAL CHANGES: REPRODUCTIVE SYSTEM UterusBefore pregnancy, it is a small, pear-shaped, thick-walled, muscular organ weighing 60g. At the end of pregnancy, it is a large, thin-walled organ weighing 1,000g. Its capacity increased from 10mL to 5L.CervixSecretes a thick, sticky mucus -forms a plugplug prevents microorganisms from entering through the vaginaDuring labor, cervix dilates-plug is expelledGoodell’s sign (softening of the cervix) noted at 8 weeksChadwick’s sign (a purplish-blue color of the cervix and vagina)8weeksOvariesOvulation does not occur during pregnancyCorpus luteum produces estrogen and progesterone until week 8VaginaEstrogen causes loosening of connective tissue and increae in vaginal secretionsAcidic secretions prevent bacterial infectionsIncreased glycogen in cells may enhance growth of trichomonas vaginalis or candida albicansBreastsEnlargement, nipples more erect, areolas darken, Montgomery’s tubercles enlargeColostrum, antibody rich yellow fluid secreted last trimester & first 2-3 days after birth-gradually changes to milk
19 PHYSIOLOGICAL CHANGES: CARDIOVASCULAR SYSTEM Blood flow increases.Heart rate increases.Blood pressure decreases.Supine hypotensive syndrome may occur.Physiologic anemia of pregnancy may occur.
20 PHYSIOLOGICAL CHANGES: RESPIRATORY SYSTEM Progesterone decreases airway resistance.The enlarging uterus presses upward on the diaphragm.Estrogen causes edema and vascular congestion in the nasal mucosa.
21 PHYSIOLOGICAL CHANGES MUSCULOSKELETAL SYSTEM Relaxin relaxes the pelvic joints.Mother’s center of gravity changes.May cause the woman to have a waddling gait.See figure 50-7, view how the mother’s posture changes due to the growing fetus
22 PHYSIOLOGICAL CHANGES: GASTROINTESTINAL SYSTEM Nausea and/or vomiting common before 12 weeks.Delayed gastric emptying and decreased peristalsis.Stomach and intestines are displaced.Constipation and heartburn also common.
23 PHYSIOLOGICAL CHANGES: URINARY SYSTEM Enlarging uterus presses on bladder in first and third trimester.Ureters relax and dilate.Glomerular filtration rate rises.Glycosuria may develop if kidneys are unable to reabsorb glucose.
24 PHYSIOLOGICAL CHANGES: INTEGUMENTARY SYSTEM Several skin pigment changes occur.Linea nigra–pigmented line on the abdomen from umbilicus to pubis.Chloasma–the “mask of pregnancy.”Striae gravidarum– “stretch marks.”
25 PHYSIOLOGICAL CHANGES: ENDOCRINE SYSTEM Prolactin is responsible for initial milk production.Oxytocin causes uterine contractions and ejection of milk from the breasts.Greater insulin production is required.Thyroid often increases in size.
26 PHYSIOLOGICAL CHANGES: METABOLISM The metabolic rate of the mother increases during pregnancy as demands of the growing fetus increase.Mother must meet her own and the fetus’s nutritional needs.
27 PRESUMPTIVE SIGNS OF PREGNANCY see pg 1433 Amenorrhea __________________________________________________________Nausea and vomiting________________Breast changes_____________________Urinary frequency_______________________________________________________Excessive fatigue___________________Abdominal enlargement______________Quickening________________________
28 PROBABLE SIGNS OF PREGNANCY see pg 1433 Goodell’s sign______________________Hegar’s sign_______________________Chadwick’s sign____________________Uterine enlargement_________________Braxton-Hicks contractions____________Increased pigmentation______________Ballottement_______________________
29 PREGNANCY TEST Measures hCG in either urine or blood. Blood is positive 8 days after conception.Urine is positive 10–14 days after conception.A pregnancy test is a probable sign of pregnancy.
30 POSITIVE SIGNS Hearing the fetal heartbeat. Visualization of the fetus through ultrasound.Examiner feeling fetal movement.
31 DEVELOPMENTAL TASKS OF PREGNANCY Pregnancy validationValidate and accept pregnancyMood swings with hormonal changesFetal embodimentIncorporates growing fetus into body imagePhysical changes in bodySelf-involvement, depression, or regression-having difficultyFetal distinctionFetal movement felt-sees fetus as separate beingMay daydream about baby and being a motherRole transitionTime to prepare, childbirth classes, prepare nursery, explore parentingnestingPartners’ tasksAccept they (as a couple) are pregnantAccept changes physical and psychological in partnerFetal distinction when hears heartbeat or feels movement
32 FACTORS AFFECTING PSYCHOLOGICAL RESPONSE Body image“fat” “ugly” “so good” “beautiful”Feel a lack of control or limitedFinancial situationAnxiety, nutrition, medical careCultural expectationsConflicts, expectationsEmotional securityPlanned, secureUnexpected, uncertaintySupport from significant othersFather/partner (couvade)SiblingsGrandparents
33 GOALS OF PRENATAL CARE Healthy, prepared mother, minimal discomforts Potential problems or complications Identified as early as possibleSafe delivery of a healthy infantPrepared father, partnerPrepared siblings and grandparents
34 PRENATAL CARE Initial visit Initial history Estimating duration of pregnancyPhysical examination-client’s ht/wt, pelvic, fundal htScreening tests-see table 50-3 pg 1439Return visits
35 ANTICIPATORY GUIDANCE Environmental hazards-chemicals, xray exams, heat from saunas/hot tubsDiscomforts of pregnancy-table 50-4Warning signs-table 50-5Nutrition-well balanced diet, add 300kcalories a day when pregnant and 500kcalories when breastfeeding.Add 2 servings milk and one meat servingMultivitamin, calcium, iron, & folic acidPica may developNutritional risk –Adolescence, due to demands for own growth & pregnancyInadequate nutritional intakeLow incomeSmoking, alcohol abuse, drug addictionDepressionSee pg 1443
36 SELF-CARE Breast care Personal hygiene Activity/rest Clothing Good supportKeep cleanPersonal hygieneDaily bathingActivity/restRegular physical activityAdequate restClothingAttractive, loose fittingLow heeled-shoesEmploymentAssess risks/benefitsTravelDiscuss with doctorDental careRegular hygieneAvoid xraysSexual activityNO NEED TO LIMIT IN A HEALTHY PREGNANCY!!Sexual desire may increase in 2nd trimesterConsider position changesAllow men to discuss feelings