Chapter 4 Prenatal Care and Adaptations to Pregnancy

Pregnancy It’s Temporary 3 Phases –Antepartum Before birth (prenatal) –Intrapartum During birth –Postpartum After birth

Major Goals of Prenatal Care Ensure a safe birth for mother and child by promoting good health habits and reducing risk factors Teach health habits that may be continued after pregnancy Educate in self-care for pregnancy Provide physical care Prepare parents for the responsibilities of parenthood

Prenatal Care Early Prenatal Care Should begin as soon as pregnancy is suspected! Complete history and physical –Identify problems that may affect the woman and her developing fetus –Ensure healthy pregnancy and delivery of healthy infant

Role of the Nurse During Prenatal Care Collecting data from pregnant woman Identifying and reevaluating risk factors Educating in self-care Providing nutrition counseling Promoting the family’s adaptation to pregnancy

Components of Prenatal Health History Obstetric –# and outcomes of past pregnancies; problems in mother or infant Menstrual –LNMP Contraceptive –Type used Medical and surgical –Infections, surgical procedures, trauma that involved pelvis or reprod. Woman’s family –ID any genetic or other factors that may pose a risk for the preg Partner’s family Woman and partner’s to identify risk factors Psychosocial –Stability of lifestyle and ability to parent a child; cultural influences

Physical Examination Evaluate woman’s general health Determine baseline weight and vital signs Evaluate nutritional status Identify current physical/social problems Determines the estimated date of delivery (EDD) Evaluate the size, adequacy, and condition of the pelvis and reproductive organs Assess for signs of pregnancy

Recommended Schedule of Prenatal Visits—Uncomplicated Pregnancy Conception to 28 weeks –every 4 weeks 29 to 36 weeks –every 2 to 3 weeks 37 weeks to birth –weekly More often if complications arise High-risk patients will be scheduled on a week-to-week basis, depending on need

Definition of Terms Gravida –pregnancy Nulligravida –woman never pregnant Primigravida – woman pregnant 1 st time Para –birth to one or more children after 20 weeks Primipara –woman who has given birth for the 1 st time Multipara – woman given birth to two or more children Nullipara – woman never given birth Abortion –spontaneous or induced termination of pregnancy before viability (20 wks) Gestational age –of fetus, calculated by LNMP Fertilization age –of fetus, from date of conception Age of viability –fetus capable of living outside of uterus (20 weeks)

TPALM TPALM System T – number of term infants born (after 37 wks) P – number of preterm infants born (before 37 wks) A – number of pregnancies aborted (spontaneously or induced) L – number of children now living M – multiple birth (optional)

Determining the Estimated Date of Delivery Average pregnancy is 40 weeks (280 days) after first day of LNMP, plus or minus 2 weeks –Nägele’s rule Identify first day of LNMP Count backward 3 months Add 7 days Update year, if applicable

Trimesters Pregnancy divided into three 13-week parts Important to know what occurs during each trimester to both woman and fetus Helps provide anticipatory guidance Identify deviations from the expected pattern of development

Presumptive Signs of Pregnancy Amenorrhea Nausea Breast tenderness and tingling Deepening pigmentation –Chloasma, or “mask of pregnancy” –Breasts (darkening of areolae) –Abdomen (linea nigra) Urinary frequency and urgency –Increased blood supply to pelvic area, exerts pressure on the bladder Fatigue and drowsiness Quickening –Fetal movement felt by the mother –First perceived at weeks of gestation as a faint fluttering in the lower abdomen

Probable Signs of Pregnancy Goodell’s sign Softening of the cervix Chadwick’s sign Purplish or bluish discoloration of the cervix, vagina, and vulva cause by increased vascular congestion Hegar’s sign Softening of the lower uterine segment McDonald’s sign Flexing the body of the uterus against the cervix Abdominal enlargement Braxton Hicks contractions Ballottement (tap on cervix causes quick rebound) Fetal outline Abdominal striae Positive pregnancy test

Positive Signs of Pregnancy Only 3 –Audible fetal heartbeat Detectable at 10 weeks by Doppler Detectable at weeks by Fetoscope –Fetal movement felt by examiner Second trimester –Ultrasound visualization of fetus 4-5 weeks gestation with 100% reliability Routinely done around the 20 th week of gestation

Effects of Pregnancy on the Reproductive System Cervix –Changes in color and consistency –glands in cervical mucosa increase –Mucus plug formed (seals the cervical canal and prevents infection) Ovaries –Produce progesterone to maintain decidua (uterine lining) during first 6-7 weeks of gestation until placenta can take over task –No egg production Vagina –Increased blood supply causes it to have a bluish color –Vaginal secretions increase, pH more acidic –Higher glycogen level which promotes Candida albicans (yeast) Breasts –Tubercles of Montgomery secrete substance to lubricate nipples

Effects of Pregnancy on the Respiratory System Oxygen consumption increases by 15% Diaphragm rises ~4 cm (1.6 inches) Causes ribs to flare Dyspnea can occur until fetus descends into pelvis (lightening) Increased estrogen causes edema or swelling of mucous membranes of nose, pharynx, mouth, and trachea Woman may complain of nasal stuffiness, epistaxis, and voice changes

Effects of Pregnancy on the Cardiovascular System Blood volume increases by ~45% than prepregnant state Increase provides for –Exchange of nutrients, oxygen, and waste products within the placenta –Needs of expanded maternal tissue –Reserve for blood loss at birth Pulse rate increases by 10 to 15 beats/min Orthostatic hypotension Palpitations (increased thoracic pressure)

Supine Hypotension Syndrome

More Normal Effects Gastrointestinal System –stomach and intestines are displaced –^ salivary secretions –^ appetite & thirst –constipation & hemorrhoids –Heartburn –glucose metabolism altered –gallbladder retains bile salts Urinary System –excretes for two! –glycosuria & proteinuria are more common retention leads to ^ UTI, –frequency Integumentary & Skeletal Systems –sweat & oil glands more active (spider nevi) –posture changes lordotic curve ^, backaches, ^ risk for falls.

Nutrition Does she need to “eat for 2” ? Women of normal weight: 25 to 35 pounds Underweight women: 28 to 40 pounds Overweight women: 11 to 25 pounds Obese women: 11 to 20 punds High correlation between maternal diet and fetal health Pattern of weight gain: 4.4 lbs first trimester, just under one lb. per week after that

Nutrition Requirements Increase kCal by 300 per day –should include: Protein—60 g/day Calcium—1200 mg/day Iron—30 mg/day Folic acid—400 mcg (0.4mg)/day Best Sources?

Special Nutrition Considerations Pregnant adolescent –May need an additional 200 kcal/day in addition to the recommended 300 kcal/day for normal pregnancy in order to meet her own growth needs and that of the developing fetus Sodium intake Vegetarian Pica Lactose intolerance Cultural preferences Gestational diabetes mellitus

Nutrition During Lactation About 500 more calories than nonpregnant woman Protein intake 65 mg/day Continue ^ calcium & iron 8 to 10 glasses of fluid (non-caffeine) Omit foods that may cause fetal gastric upset

Nursing Guidance for Exercise Goal of exercise during pregnancy should be maintenance of fitness, not improvement of fitness or weight loss Combined with balanced diet is beneficial Eating 2 to 3 hours before exercise or immediately after is recommended Avoid marked changes in depth of water (such as scuba diving) and/or altitude Avoid becoming overheated, increase fluid intake Intensity of exercise should be modified based on the “talk test” Elevated temperature: can impact fetal circulation and cardiac function

Travel During Pregnancy Air travel generally safe Avoid sitting for extended periods of time Avoid locations that increase the risk of exposure to infectious diseases Bring a copy of obstetric records Obtain information about nearest health care facility Encourage hand hygiene and dietary precautions Provide the “recipe” for oral rehydration formula

Common Discomforts in Pregnancy Fatigue Nasal stuffiness Nausea Heartburn Constipation Hemorrhoids EDEMA OF FACE IS NOT NORMAL ! Vaginal discharge Backache Varicose veins Leg cramps Edema of the lower extremities Dyspnea

Impact on Mother According to Rubin, 4 maternal tasks the woman accomplishes during pregnancy –Seeing safe passage for herself and her fetus –Securing acceptance of herself as a mother and for her fetus –Learning to give of self and to receive the care and concern of others –Committing herself to the child as she progresses through pregnancy

Impact on the Father Cultural values influence the role of fathers Do not assume that a father is uninterested if he takes a less active role in pregnancy and birth 3 Phases 1.Announcement phase 2.Adjustment phase (finances) 3.Focus phase (father figure)

Impact on Teen Moms Lots of issues! Must break the news to the family –often they wait until late in pregnancy Financial problems are common What about the relationship with baby’s father? Low self-esteem Drug and/or alcohol abuse? –Help the young woman finish the growing-up process while taking on the role of new mom The pregnant adolescent must cope with 2 of life’s most stress-laden transitions simultaneously: –Adolescence & parenthood

Other Special Situations The Older Couple –Usually adjust well because it is planned –Some issues: ^ multiple births, ^ birth defects The Single Mom – Need emotional support from someone – Social acceptance? The Single Dad – Reactions can be unpredictable – range from joy to rejection – Often rejected by mother

Prenatal Education Should progress according to the nursing process: –Assess the history and cultural needs –Diagnose the knowledge deficit –Plan the goals and priorities –Outcomes identification clarifies expected outcomes –Teach (intervene) the facts and rationales –Evaluate knowledge gained and goals achieved

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