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

 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 Mrs. Andrews complains of a whitish discharge. What is the teaching regarding vaginal discharges?

 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 ?

 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?

Cardiovascular Changes cardiac enlargement Vasodilation increase blood volume, hemodilution increase cardiac output – 30-50%

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.

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

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

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

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

Gastrointestinal Changes – Nursing Care avoid large meals use good posture Take low Sodium antacids -- n 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

Gastrointestinal Changes Constipation – Related to: slowing of motility intestinal compression oral iron supplement – Nursing Care Increase water and fiber in diet moderate exercise **Don’t take laxatives or enema without a doctor’s permission

Gastrointestinal Changes Hemorrhoids – Related to : pelvic congestion straining with stool – Nursing Care avoid constipation Apply topical agents to area

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?

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

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

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

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.

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

Confirmation of the Pregnancy Confirmation of the Pregnancy

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”.

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

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

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

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

Probable Signs of Pregnancy 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

Positive Signs of Pregnancy Auscultation of fetal heart tones Active fetal movement felt by Trained person Ultrasound showing fetal outline

Confirm the Pregnancy Pregnancy Tests All tests rely on detection of HCG Urine Hema- agglutination Inhibition Radioimmune assay Enzyme Radioreceptor Assay

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?

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

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.

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.

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

Calculation of Gravida and Parity Further Breakdown into TPAL – T = Term – P = Preterm – A = Abortions – L = Live births

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?

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?

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 ____________.

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?

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

 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?

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

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:

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

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

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

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. Teaching Health Behaviors

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

Exercise, Leisure, Travel – May attend regular prenatal exercise classes – Don’t take up a new sport – Travel--wear seat belt Wear shoulder belt over top of abdomen over top of abdomen Wear lap belt low over the hips

Teaching Health Behaviors Avoid exposure to teratogens – Alcohol – Smoking – Drugs n Immunizations - avoid live vaccines n Advise about use of prescription and over-the- counter drugs

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”

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”

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

Third Trimester Vulnerability – Worry that baby may be lost or harmed Increasing dependence Preparation for birth – Planning baby’s 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.”

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

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

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.