1. Adaptation to Pregnancy/ Chapter 7/Week1
Catherine Ramos Marin, MSN/Ed(C), WHCNP, RN

2. Physiology of Pregnancy
Fertilization
During sexual intercourse, the sperm carried in the ejaculatory semen of the male enters the vagina of the female.
Through flagellation, the sperm travel through the mucus of the cervical canal, enter the uterine chamber, and move into the ampulla, the outer third of the fallopian tube.
If the timing is such that an ovum has been produced and is also within the ampulla of the tube, fertilization may occur.

3. Physiology of Pregnancy
Fertilization (continued)
Fertilization takes place when the sperm joins or fuses with the ovum; this is called conception.
Once fertilization has occurred, the new cell is referred to as a zygote or fertilized ovum.
At the moment of fertilization, the sex of the zygote and all other genetic characteristics are determined and they do not change.

4. Physiology of Pregnancy
Implantation
The zygote moves through the uterine tube through ciliary action and some irregular peristaltic activity.
It requires about 3 or 4 days to enter the uterine cavity.
During this time, the zygote is in a phase of rapid cell division called mitosis; further changes result in formation of a structure called the morula.
The morula develops into a blastocyst.

5. Physiology of Pregnancy
Implantation (continued)
After the blastocyst is free in the uterine cavity for 1 or 2 days, the exposed cell walls of the blastocyst (called the trophoblast) secrete enzymes that are able to break down protein and penetrate cell membranes.
These enzymes allow the blastocyst to enter the endometrium and implant.
The action of the enzymes normally stops short of the myometrium but may cause slight bleeding; this is called implantation bleeding.
The bleeding may confuse some women who think they had a very light and short menstrual cycle.

6. Physiology of Pregnancy
Implantation (continued)
The condition of the uterine lining is critical if implantation of the zygote is to occur.
Implantation usually occurs in the fundus of the uterus on either the anterior or posterior surface.
If uterine conditions are not suitable, it is unlikely that implantation will occur.
If the intrauterine vascular or hormonal conditions cannot sustain the implanted embryo, a spontaneous abortion will occur; usually during the first 8 weeks of pregnancy.

7. Physiology of Pregnancy
Implantation (continued)
Ectopic pregnancy, in which implantation occurs outside of the uterine cavity, also poses serious problems.
During the first few weeks after implantation, primary villi appear; these villi are able to use maternal blood vessels as a source of nourishment and oxygen for the developing embryo.

8. Physiology of Pregnancy
Implantation (continued)
It is also during these first few weeks that the first stages of the chorionic villi occur.
Chorionic villi secrete human chorionic gonadotropin (hCG), a hormone that stimulates the continued production of progesterone and estrogen by the corpus luteum; this is the reason that ovulation and menstruation cease during pregnancy.
The chorionic villi become the fetal portion of the placenta.

9. Physiology of Pregnancy
Embryonic/Fetal Development
During this period, the fertilized ovum develops from the two original cells into a many-celled organism.
The zygote develops two distinct cavities.
Amniotic cavity: filled with amniotic fluid
Yolk sac: supplies nourishment until implantation
The mesoderm is located between the two cavities; it gives rise to all types of muscle, connective tissue, bone marrow, blood, lymphoid tissue, and all epithelial tissue.

10. Physiology of Pregnancy
Embryonic/Fetal Development (continued)
During the embryonic stage, the three primary cell layers differentiate into tissue and layers that form the placenta, embryonic membranes, and the embryo itself.
A simple heart begins beating, and rudimentary forms of all of the major organs and systems develop.
By the end of this stage, the embryo has acquired a human appearance.
Starting with the ninth week, the embryo is referred to as the fetus, and the fetal stage begins.

11. Physiology of Pregnancy
Embryonic/Fetal Physiology
Placenta
This disklike organ made up of about 20 sections called cotyledons and is present only during pregnancy.
At full term, the placenta looks like a large red disk with a diameter of 6 to 10 inches and a thickness of 1 inch; it weighs between 400 and 600 g (1 lb. to 1 lb. 5 oz).
Uterine side: dark red with a rough surface
Fetal side: smooth and shiny

12. Physiology of Pregnancy
Embryonic/Fetal Physiology (continued)
Placenta
It functions as an endocrine gland secreting hCG and the steroidal hormones estrogen and progesterone, which maintain pregnancy.
It is the site of exchange of nutrients, oxygen, and waste products between the fetus and the maternal circulation.
Placental barrier refers to the ability of the placenta to block the transfer of certain substances.
After delivery, the placenta is of no further use and is expelled.

13. Physiology of Pregnancy
Embryonic/Fetal Physiology (continued)
Fetal Membranes
The amniotic sac is composed of two layers, both originating in the zygote.
The outer layer, the chorion, attaches to the fetal portion of the placenta.
The inner layer, the amnion, blends with the fetal umbilical cord.
These membranes appear to be very fragile, but in fact they are strong enough to contain the fetus and amniotic fluid even at full term.

14. Physiology of Pregnancy
Embryonic/Fetal Physiology (continued)
Umbilical Cord
The cord joins the embryo to the placenta; it originates in the fetal portion of the placenta and is normally attached near the center.
The cord is usually 20 to 22 inches long and less than 1 inch in diameter at the time of delivery.
The major part of the cord is a pale white, gelatinous-mucoid substance called Wharton’s jelly; it prevents compression of the blood vessels.
There are two arteries (carry deoxygenated blood) and one vein (carries oxygenated blood).

15. Physiology of Pregnancy
Embryonic/Fetal Physiology (continued)
Amniotic Fluid
Acts as a cushion against mechanical injury
Helps regulate fetal temperature
Allows the developing embryo/fetus room for growth.
Amount is about 30 ml at 10 weeks to 1 L at delivery

16. Transabdominal amniocentesis.
Figure 25-3
(Courtesy of Marjorie Pyle, RNC, LifeCircle, Costa Mesa, California.)
Transabdominal amniocentesis.

17. Amniotic Fluid

18. Amniotic Fluid-Related Complications
Hydramnios (polyhydramnios)- > 2000 ml of amniotic fluid (1% of all pregnancies), cause: unknown
2nd half of pregnancy: fetus normally begins to swallow amniotic fluid and urinate- swallowing mechanism defect?
Anencephaly: fetus is urinating excessively because of over stimulation of the cerebrospinal centers
>3000 ml : shortness of breath and edema of lower extremities
Fetal malformations, preterm birth, prolapsed umbilical cord

19. Physiology of Pregnancy
Fetal Well-being
A variety of technologic and assessment tools can be used to evaluate fetal well-being.
These tools are used to evaluate maternal and fetal health problems, fetal congenital anomalies, and fetal growth and maturity.
Ultrasonography
Maternal serum alpha-fetoprotein screening
Chorionic villus sampling
Nonstress test
Contraction stress test
Magnetic resonance imaging
Biophysical profile

20. Maternal Physiology Hormonal Changes
Estrogen and progesterone levels remain elevated for the first 8 weeks of pregnancy as a result of hCG.
After this time, the placenta takes over production and maintains necessary levels.
As long as these levels are high, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and ovulation are suppressed, as is menstruation.

21. Maternal Physiology Uterus
The uterus enlarges during pregnancy as a result of hormonal stimulus, increased vascularity, hyperplasia, and hypertrophy.
The nonpregnant uterus is pear-shaped and weighs about 50 g; by the third trimester, it is egg-shaped and has increased weight to 1000 g.
In a nonpregnant state, it is a pelvic organ; when the pregnancy reaches completion, the superior aspect of the uterus will be located at the level of the xiphoid process.

22. Maternal Physiology Breasts
There is hypertrophy of the mammary glandular tissue and increased vascularization, pigmentation, size, and prominence of nipples and areola.
Changes are caused by hormonal stimulation.

23. Maternal Physiology Maternity Cycle Antepartal or Prenatal Period
Begins with conception and ends with the onset of labor
Intrapartal or Perinatal Period
Begins with the onset of labor and ends with delivery of the placenta
Postpartal Period
Starts after the delivery of the placenta and lasts for approximately 6 weeks or until the reproductive organs return to the prepregnancy state

24. Maternal Physiology Maternity Cycle (continued)
Pregnancy spans 9 months, approximately 40 weeks
Divided into 3-month periods or trimesters.
First trimester: weeks 1 through 13
Second trimester: weeks 14 through 26
Third trimester: weeks 27 through term gestation (38 to 40 weeks)

25. Antepartal Assessment
genetic General Physical Assessment
Ideally, the woman has been receiving regular medical attention and is already known by the health care provider.
Unfortunately, many people do not receive regular, routine health care.
On the first visit, demographic data, such as age, occupation, marital status, and insurance information, are obtained; this helps the primary care practitioner identify potential areas of concern.
A basic family and personal medical history is obtained; it should include diseases.

26. Antepartal Assessment
Genetic Counseling
The most useful means of reducing the incidence of genetic disorders is by preventing their transmission.
With the accumulation of information about genetic disorders, the probability of recurrence in any given situation can be predicted with increased accuracy.
A personal medical history is taken and a review of systems is done.
Lifestyle patterns are assessed.
A basic physical examination is completed.

27. Antepartal Assessment
Obstetric Assessment
Information about the woman’s gynecological, menstrual, and obstetric history is obtained.
The number of pregnancies and their outcomes are discussed.
Gynecological Examination
The gynecological examination is also performed at this time.
The nurse is often called on to prepare the necessary equipment and assist with this examination.

28. Determination of Pregnancy
Presumptive Signs
Amenorrhea
Nausea and vomiting
Frequent urination
Breast changes
Changes in shape of the abdomen
Quickening
Skin changes
Chadwick’s sign

29. Determination of Pregnancy
Probable Signs
Changes in the Reproductive Organs
Hegar’s sign
Goodell’s sign
Ballottement
Positive Pregnancy Test

30. Figure 25-4
(From Wong, D.L., Perry, S.E., Hockenberry-Eaton, M.J. [2002]. Maternal-child nursing care. [2nd ed.]. St. Louis: Mosby.)
Hegar’s sign.

31. Internal ballottement (18 weeks).
Figure 25-5
(From Wong, D.L., Perry, S.E., Hockenberry-Eaton, M.J. [2002]. Maternal-child nursing care. [2nd ed.]. St. Louis: Mosby.)
Internal ballottement (18 weeks).

32. Determination of Pregnancy
Positive Signs
Visualization
Fetal movement
Auscultation of fetal heartbeat

33. Determination of Pregnancy
Determination of the Estimated Date of Birth
Normal human pregnancy, counting from the first day of the last menstrual period, is about 280 days, 40 weeks, or 10 lunar months (slightly more than 9 calendar months).
Nägele’s rule
Start with the first day of the woman’s last menstrual period and count back 3 months; then add 7 days.

34. Determination of Pregnancy
Determination of the Estimated Date of Birth (continued)
If the woman does not keep a menstrual record, the primary care provider must then rely on observations such as quickening, estimation of fetal size by palpation, or ultrasonic tests, all of which can be unreliable.

35. Determination of Pregnancy
Obstetric Terminology
Terms used to describe the number of times a woman has been pregnant and given birth
Gravida: indicates a pregnant women
Primigravida: one pregnancy
Nulligravida: no pregnancies
Multigravida: multiple pregnancies
Primipara: one birth
Nullipara: no births
Multipara: multiple births
Abortion: indicating loss of a fetus before the age of viability

36. Antepartal Care Health Promotion
Pregnancy is a time in life when most women see the importance of regular medical supervision and are more willing to make changes in their habits than any other time.
Once pregnancy is diagnosed, prenatal care is instituted.
Early in pregnancy, the woman often begins to seek information and make choices regarding how and where she wishes to give birth.

37. Antepartal Care Health Promotion (continued)
Routine care during pregnancy begins with the initial examination and history.
Appointments are recommended once a month through the seventh month, once every 2 weeks for the next month, and then once every week until delivery.
Smoking and drinking alcoholic beverages during pregnancy are contraindicated.
Taking any medications or drugs during pregnancy, including over-the-counter drugs, should be avoided.

38. Antepartal Care Danger Signs During Pregnancy Visual disturbances
Headaches
Edema
Rapid weight gain
Pain
Signs of infection
Vaginal bleeding or drainage
Persistent vomiting
Muscular irritability or convulsions
Absence or decrease in fetal movement once felt

39. Antepartal Care Nutritional/Metabolic Health Pattern Pica
This is the craving and eating of substances that are not normally considered edible.
Substances such as clay or laundry starch are commonly ingested.
They are not toxic but may interfere with iron absorption, resulting in anemia.
Large amounts of clay may cause constipation.

40. Antepartal Care Common Discomforts Excessive salivation Nausea
Hyperemesis gravidarum
Pyrosis (heartburn)

41. Antepartal Care Skin Changes Linea nigra: dark line midline of abdomen
Chloasma: the mask of pregnancy
Striae gravidarum: stretch marks
Spider nevi: dilated capillaries on the skin
Palmar erythema: reddened palms
Hirsutism: excessive body hair

42. Antepartal Care Hygiene Practices
Bathing and showering during pregnancy should continue as part of routine hygiene.
Increased perspiration is common, and good personal hygiene is important to prevent body odor.
Some primary care practitioners restrict tub baths in the last month, because the cervix may have dilated.
Most primary care practitioners recommend that women avoid using hot tubs, sauna baths, and spas during pregnancy.

43. Antepartal Care Elimination Gastrointestinal System
Slowing of intestinal peristalsis can result in abdominal distention, flatulence, and constipation.
Hemorrhoids can result from straining and because the enlarged uterus puts pressure on the pelvic blood vessels.
Women with cholelithiasis may have problems as a result of increased cholesterol level.
Adequate fluid intake, dietary roughage, and exercise may help reduce problems with constipation.

44. Antepartal Care Elimination Urinary System
Frequency of urination is a common complaint.
The mother must excrete not only her own waste products but also those of the fetus.
Early in pregnancy, the enlarging uterus irritates the bladder by putting pressure on it; this continues until the uterus rises into the abdominal cavity.
Later in pregnancy, when the presenting part descends into the pelvis, the pressure and symptoms return.

45. Antepartal Care Activity/Exercise
Normal activity should continue throughout an uncomplicated pregnancy.
Fatigue is a common complaint during pregnancy.
Changes in balance and posture occur as the fetus increases in size; to compensate for the shifting center of gravity, the lumbodorsal curve increases (lordosis).
Hormonal influence on the pelvic bones, resulting in joint relaxation, can lead to a waddling gait.
Leg cramps are a common occurrence.

46. Antepartal Care Rest/Sleep
Early in pregnancy, few changes in sleep patterns are experienced.
As the size of the abdomen increases, it may become increasingly difficult for the woman to find a position of comfort.
The supine position is not recommended as a woman approaches her due date; this may cause excessive pressure on the aorta and vena cava and may result in decreased circulation for the fetus.
Rest periods during the day with the feet elevated should be encouraged.

47. Figure 25-7
(From McKinney, E.S., James, S.R., Murray, S.S., Ashwill, J.W. [2005]. Maternal-child nursing. [2nd ed.]. Philadelphia: Saunders.)
During third trimester, pillows supporting abdomen and back provide a comfortable position for rest.

48. Antepartal Care Sexuality/Reproductive System Breast Changes
Breast changes begin early in pregnancy; there may be tingling and a feeling of fullness.
Generally, the breasts increase in size in preparation for lactation.
The nipples and areola darken.
Colostrum may be secreted by the nipples in late pregnancy.

49. Antepartal Care Sexuality/Reproductive System Sexual Activity
Unless there are complications in the pregnancy or the bag of water has ruptured, there is no physiological reason to limit sexual activity during pregnancy.
Many women experience a decrease in desire as a result of hormonal changes and the multiple discomforts that may be occurring.
Discussion of various coital positions and sexual activity that does not include intercourse is appropriate.

50. Antepartal Care Vaginal Bleeding
Vaginal bleeding at any time during pregnancy should be reported to the physician at once.
Sexual activity should cease until the cause of the bleeding is determined and should be resumed only when the physician determines that no danger exists.

51. Antepartal Care Coping/Stress Tolerance
All of the physical and hormonal changes of pregnancy place additional stress on the woman.
Mood swings and ambivalence are common as the woman works through her fears and comes to grip with the reality of pregnancy and how the pregnancy will affect her life.
Listening and allowing the woman adequate time to verbalize her fears can also help reduce anxieties.

52. Antepartal Care Role/Relationship
Pregnancy introduces a totally new role, that of a mother.
Culture will have much to do with how the woman will define her role.
Dynamics also change between the woman and the baby’s father, particularly with the first pregnancy. The woman is no longer just a wife or girlfriend; she is also a mother.

53. Antepartal Care Self-Perception/Self-Concept
Rapid changes in body shape and size can lead to changes in self-image.
Many women feel that they are not attractive when they are pregnant.
They may also feel a loss of control related to the changes taking place.

54. Antepartal Care Cognitive/Perceptual
Although sensory changes are uncommon with pregnancy, blurring or diplopia may indicate problems with pregnancy-induced hypertension.
Prenatal education is important.

55. Preparation for Childbirth
Childbirth Preparation Classes
Some classes are general in nature, whereas others are targeted toward specific groups such as adolescents, those having cesarean or vaginal birth after cesarean delivery, siblings, or grandparents.
Common methods of prepared childbirth include
Dick-Read
Bradley
Leboyer
Lamaze

56. Entire family participating in a childbirth preparation course.
Figure 25-8
(From Lowdermilk, D.L., Perry, S.E. [2004]. Maternity & women’s health care. [8th ed.]. St. Louis: Mosby.)
Entire family participating in a childbirth preparation course.

57. Preparation for Childbirth
Cultural Variations in Prenatal Care
It is imperative that the practitioner determine and explore cultural practices and beliefs with the patient.

58. Nursing Process Nursing Diagnoses Body image, disturbed
Nutrition: less than body requirements
Injury, risk for
Activity intolerance
Incontinence, stress urinary
Constipation
Sleep pattern, disturbed
Fatigue

59. Nursing Process Nursing Diagnoses (continued) Knowledge, deficient
Family processes, interrupted
Fear
Parenting, risk for impaired