1. Prenatal Care – Module A
References:
Hogan, M. & Glazebrook. (2003). Maternal-newborn nursing: Reviews & rationales. Upper Saddle River, NJ: Prentice Hall.
Leifer, G. (2003). Thompson’s introduction to maternity and pediatric nursing. (4th ed.). Philadelphia: Saunders.
London, M., Ladewig, P., Ball, J., & Bindler, R. (2003). Maternal-newborn and child nursing.Upper Saddle River, NJ: Prentice Hall.
McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing. (2nd ed.). St. Louis: Elsevier-Saunders.
Rollant, P. & Piotrowski, K. (1996) Mosby’s review series: Maternity nursing. St. Louis: Mosby.
Silvestri, L. (2002). Comprehensive review for nclex-rn. (2nd ed.). Philadelphia: W. B. Saunders.
NUR 106
Spring, 2005

2. Anatomical Landmarks Female Male
Maternal-Child Nursing – McKinney, et al.
Review pictures on pages for female reproductive system.
Menstrual cycle -- p. 225
Review pictures on pages for male reproductive system.

3. External Structures

4. Internal Structures

5. Midsagital View

6. Uterus

7. Uterine Ligaments

8. Pelvic Bones

9. Female Pelvis

10. Pelvic Types Many women are combinations of above
Gynecoid and Anthropoid types are favorable for vaginal birth.
Android and platypelloid are not favorable for vaginal birth. Descent into pelvis is slow and difficult making labor more difficult; often results in c-section

11. Muscles of the Pelvic Floor

12. Male: External and Internal Structures
Seminal fluids secreted by the seminal vesicles, prostate, and bulbourethral glands nourish and protect the sperm, enhance their motility, and ensure that most sperm are deposited in the vagina during sexual intercourse.

13. Testis

14. Testis

15. Sperm
For normal sperm to form, a man’s testes must be cooler than his core body temperature.

16. Female Reproductive Cycle
Ovulation
Menstruation
Menarche
Climacteric
Menopause
At birth a woman has all the ova she will ever have. New ova are not formed after birth; almost all are depleted when she reaches the climacteric.
Girls often do not ovulate in early menstrual cycles, although it is possible for them to ovulate even before the first one. A sexually active girl can become pregnant before her first menstrual period.

17. Female Reproductive Cycle
The female reproductive cycle is often called the menstrual cycle. It includes changes in the anterior pituitary gland, ovaries, and uterine endometrium to prepare for a fertilized ovum. The character of cervical mucus also changes to encourage fertilization.
GnRH is secreted by the hypothalamus in response to the decreasing estrogen and progesterone level that occurs at the end of the menstrual cycle; stimulates the pituitary to secrete FSH and LH
FSH prepares the follicle
LH completes follicular maturation and stimulates ovulation, release of the maturing ovum from the ruptured follicle as well as the development of the corpus luteum
Estrogen: secreted from the maturing follicle and then in smaller quantities from the corpus luteum: stimulates the proliferation of the uterine endometrium to become thicker and more vascular; increases the motility of the fallopian tubes which allows the capture of the released ovum and propels it through the tube to the site of fertilization in the ampulla (outer third) of the tube; increases the motility of the uterus, which along with prostaglandin from sperm, facilitates the forward migration of sperm into the tube to the site of fertilization; stimulates the formation of a copious amount of thin, elastic, alkaline cervical mucus that is receptive to sperm and allows them to pass through the cervix into the uterus
Progesterone: the major hormone secreted by the corpus luteum, formed at the site of the ruptured follicle; continues the development of the endometrium into a secretory layer capable of providing a bed for the implantation and nourishment of the fertilized ovum; raises body temperature—an objective sign that ovulation has occurred; reduces the motility of the uterus to allow for implantation and adherence of the fertilized ovum
If fertilization occurs—corpus luteum continues to function as a result of HCG which is secreted by the implanted blastocyst (HCG found in maternal serum and urine is the basis for a + pregnancy test); corpus luteum maintains the pregnancy by secreting estrogen and progesterone until the placenta is mature enough to produce these hormones at sufficient levels in about 6 to 10 weeks
If fertilization does not occur—corpus luteum degenerates; levels of estrogen and progesterone fall—vasoconstriction occurs causing the endometrium to break down, slough off, and be discarded in the menstrual flow (day 1 of a new cycle); hypothalamus is stimulated to begin the menstrual cycle again

18. Conception and Fetal Development
Nine Month Miracle
Miracle of Life
Internet sites
Refer to various search engines like Yahoo.com or Altavista.com, Google.com, etc. and search prenatal development.

19. Conception Fertility Sexual intercourse Pregnancy
Sexual intercourse that takes place during the time of fertility (ovum viability) may result in fertilization and pregnancy

20. Genetics Chromosomes Autosomal Sex Chromosomal syndromes
Modes of inheritance
A human being’s physical characteristics are determined by the genetic material carried in the nucleus of each body cell
Abnormalities in chromosomes and defects in genes adversely affect fetal-newborn health and well being in a variety of ways and to varying degrees
Defective genes can be transmitted to the offspring of gene carriers whether or not the carriers have the disorder themselves
Genetic material is composed of chromosomes and genes, found in the nucleus of each body cell
Chromosomal abnormalities occur during the process of cellular division-replication as a result of advanced maternal age (>35) and exposure to teratogens—abnormalities in the number of chromosomes—more than or less than the required 46 [Down syndrome (trisomy 21); Turner’s syndrome (monosomy of the X chromosome XO); Klinefelter’s syndrome (trisomy of the sex chromosomes XXY); abnormality in the structure of chromosomes as a result of chromosomal breakage leading to translocation, addition, or deletion of genetic material [Cri du Chat syndrome—deletion of the short arm of chromosome5, resulting in an infant born with characteristics of a typical mewing-like cry, microcephaly, severe mental retardation, and abnormal facial characteristics
Transmission of defective genes: Single gene inheritance—autosomal dominant inheritance (the abnormal gene is dominant therefore the abnormality is expressed when the gene is present even if the other gene is the pair is normal [polydactyly, Huntington’s chorea, dwarfism]; when one parent is affected and one parent is normal, there is a 50% chance in each pregnancy that the offspring will be affected and a 50% chance that the offspring will not be affected; autosomal recessive inheritance – the abnormal gene is recessive, therefore the defect is only expressed when the other gene in the pair is the same abnormal recessive gene; if the second gene in the pair is normal the abnormality is not expressed but the person is a carrier of the abnormal gene, which can be transmitted to offspring [PKU, Tay-Sachs disease, SCA, cystic fibrosis]; two carriers of the recessive gene must each contribute the recessive gene for their offspring to express the abnormality; for EACH PREGNANCY there is a 25% chance the offspring will be unaffected, a 25% chance the offspring will be affected, and a 50% chance the offspring will be unaffected but a carrier of the abnormal gene; X-linked recessive inheritance—defective gene is carried on the X chromosome—females are predominately carriers, males predominately manifest the disorder when they receive the recessive gene from their mothers since there is no corresponding gene on their Y chromosome; they can transmit the defective gene only to their female offspring; females can only express the disorder if they receive a recessive gene from their mother and a recessive gene from their affected father [hemophilia, color blindness, Duchenne’s muscular dystrophy]; X-linked dominant inheritance—defective gene is carried on the X chromosome but since it is dominant it is expressed in both the male and the female offspring who inherit the defective gene carrying X chromosome; females are less severely affected than males since they also carry a normal gene in their second X chromosome [vitamin D-resistant rickets]

21. Patterns of Inheritance
Dominant
Recessive
X-linked
Single gene traits have mathematically predictable and fixed rates of occurrence. If a couple has a child with an autosomal recessive disorder, the risk that future children from the same couple will have the disorder is one in four (25%) at every conception. The risk for the disorder is the same at every conception, regardless of how many of the couple’s children are or are not affected.
A person affected with an autosomal dominant disorder has a 50% chance of transmitting the disorder to each of his or her children. Examples: Down syndrome; phenylkektonuria, cystic fibrosis;
Two healthy parents who carry the same abnormal autosomal recessive gene have a 25% chance of having a child affected with the disorder caused by this gene.
Parental consanguinity increases the risk for having a child with an autosomal recessive disorder.
One copy of an abnormal X-linked recessive gene is enough to produce the disorder in a male. X-linked disorders can be relatively mild, such as colorblindness, or they may be severe, such as hemophilia. Varying degrees of severity: Klinefelter syndrome; Turner syndrome; Double Y syndrome; Trisomy X
Abnormal genes can arise as new mutations that are then transmitted to future generations.
Dominance describes how one’s genetic composition is translated into the phenotype (observable characteristics). In the case of a dominant gene, one copy is enough to cause the trait to be expressed [ABO blood system – genes for type A and type B are dominant. Therefore a single copy of either of these genes is enough to be expressed in the person’s blood type]. Two identical copies of a recessive gene are required for the trait to be expressed. [The gene for blood group O is recessive – only if person receives a gene for blood group O from both parents will he be type O]. Dominance and recessiveness are not absolute for all genes. Some people with a single copy of an abnormal recessive gene (carriers) may have a slightly abnormal level of the gene product (eg and enzyme) but do not have the disease
Chromosome Abnormalities are either numerical or structural.
Numerical – entire single chromosome added [trisomy]; entire single chromosome missing [monosomy]; one or more added sets of chromosomes [polyploidy] usually results in early spontaneous abortion but is occasionally seen in a liveborn infant.
Structural – part of a chromosome missing or added; rearrangements of material within chromosome(s); tow chromosomes that adhere to each other; fragility of a specific site on the X chromosome [Fragile X syndrome is a structural chromosome abnormality that often causes mental retardation among males]
Multifactorial disorders result form an interaction of genetic and environmental factors. The genetic tendency toward the disorder is modified by the environment. For example, two embryos may have an equal genetic susceptibility for the development of a disorder such as spina bifida. However, the disorder will not occur unless an environment that favors its development, such as deficient maternal intake of folic acid, also exists. Multifactorial disorders represent some of the most common birth defects: many heart defects; neural tube defects such as anencephaly and spina bifida; cleft lip and palate; pyloric stenosis. Multifactorial disorders are not associated with a fixed risk of occurrence or recurrence in a family. The risks are an average rather than a constant percentage: number of affected close relatives; severity of the disorder in affected family members; sex of affected person(s); geographic location; seasonal variations

22. Nursing Responsibilities
Identify families at risk
Education
Liaison
Support / Crisis intervention
Continuity of care
Nursing Responsibilities for genetic counseling
Identify families at risk for genetic problems
Assist families in acquiring accurate information about the specific problem.
Act as a liaison between family and genetic counselor
Assist the family in understanding/dealing with information received.
Provide information on support groups.
Aid families in coping with this crisis.
Provide information about known genetic factors.
Assure continuity of nursing care to the family.

23. Teratogens Tobacco Alcohol Marijuana Cocaine Heroin Anticonvulsants
Anticoagulants
Acne medications
Teratogens are chemicals, agents, or factors that cause the production of physical defects in the developing embryo or increase the likelihood that a birth defect will occur. These substances are hard to pinpoint because the defect may not be apparent for several months after delivery. Teratogens are most harmful during the first weeks after conception, before the mother is aware that she is pregnant. Teratogens can adversely affect fetal-newborn health and well being according to the teratogen’s degree of toxicity or ability to harm, the amount of substance exposure; timing of the contact—critical periods of fetal growth and development; and the degree of fetal susceptibility to the teratogen
Types of teratogens:
Maternal infectious agents (viruses or bacteria) that cross the placenta and damage the embryo or fetus [TORCH]
Drugs and other substances used by the woman (therapeutic agents, illicit drugs, botanical preparations, tobacco, alcohol)
Pollutants, chemical, or other substances to which the mother is exposed in her daily life
Ionizing radiation
Maternal hyperthermia
Effects of maternal disorders, such as diabetes mellitus or phenylketonuria

24. Reproductive Ethics Maternal-fetal conflict Abortion
Intrauterine fetal surgery
Reproductive assistance
Embryonic stem cell research
Human genome project
Cord blood banking
Until recently the fetus was viewed legally as a non-person – now fetus is increasingly viewed as a client separate from the mother
Abortion – elective; and mandated contraception
Reproductive assistance – surrogate child bearing

25. Fertilization One spermatozoon enters the ovum
Two nuclei containing the parents’ chromosomes merge
Occurs in the outer third of the fallopian tube
Sex is determined

26. Multifetal Pregnancy Dizygotic twinning -- fraternal
Monozygotic twinning -- identical
Dizygotic twins arise from two ova that are fertilized by different sperm; associated with assisted reproductive techniques; advancing maternal age; may be hereditary in some families. The membranes and placentas are separate because they arise from two separate zygotes—may fuse during development if they implant closely
Monozygotic twins are conceived by the union of a single ovum and spermatozoon with later division of the concepts into two; have identical genetic complements and are of the same sex; occurs at random and is not associated with assisted reproductive techniques. The fetuses have two amnions (inner membranes) but a single chorion (outer membrane)

27. Implantation Nidation Gradual process
Occurs between 6th / 7th and 10th days
Upper part of posterior uterine wall
Placenta develops

28. Fertilization and Implantation

29. Amniotic Membranes Amnion (inner) Chorion (outer)
Enclose fetus in amniotic fluid
Protects fetus from infectious organisms

30. Amniotic Sac

31. Amniotic Fluid Clear, slightly yellow, alkaline fluid
Approximately 1 liter at term
Derived from
Maternal plasma
Cells of the amnion
Fetal fluids from lung, skin, fetal urine

32. Functions of Amniotic Fluid
Cushions fetus from trauma
Facilitates fetal movement
Facilitates symmetrical growth
Regulates intrauterine temperature
Provides source of oral fluid
Cushions umbilical cord
Receptacle for fetal substances
Cushions fetus from trauma
Facilitates fetal movement thereby enhancing the development of the musculoskeletal system
Facilitates symmetrical growth by preventing fetal entanglement in the membranes and allowing for unrestricted positioning
Regulates intrauterine temperature
Provides source of oral fluid
Cushions umbilical cord and prevents its compression [amnioinfusion]
Receptacle for fetal substances—fluid can be obtained and then analyzed to determine fetal health status by means of an amniocentesis

33. Placenta / Function Fully functional by week 12 Respiration Nutrition
Waste removal
Protection
Endocrine
Respiration: provides oxygen and removes carbon dioxide
Nutrition: supplies nutrients, fluid, vitamins, and minerals from the mother to sustain fetal growth and development
Waste removal: removes the by-products of fetal metabolism
Protection: creates a barrier that prevents exposure to some but not all harmful substances; allows passage of maternal antibodies
Endocrine: secretes estrogen, progesterone, HCG, and HPL (human placental lactogen), all essential for maintenance of the pregnancy

34. Placenta

35. Placenta After Delivery

36. Umbilical Cord One vein Two arteries Wharton’s jelly Amnion
Connects fetus to placenta – composed of the following:
One vein: carries oxygenated blood and nutrients to the fetus
Two arteries: return deoxygenated blood and wastes to the placenta
Wharton’s jelly: supports and separates the vessels
Amnion: membrane that covers the cord

37. Placenta and Cord

38. Umbilical Cord

39. 12 weeks

40. 18 Weeks

41. 4 Months

42. 5 Months

44. 30 Weeks

45. 40 Weeks

46. Fetal Development Preembryonic or ovum Embryonic Fetal
Preembryonic or ovum: period from conception until day 14; zygote develops into the blastocyst and implants itself into the endometrium
Embryonic: period from day 15 until 8 weeks; referred to an an embryo; critical stage for organ and external feature development—highly vulnerable to teratogens
Fetal: period from 9 weeks’ gestation until pregnancy ends; characterized by refinement of structure and function developed during the previous two stages; referred to as a fetus; less vulnerable to teratogens except for those that can interfere with the development of the brain and CNS
Use illustrations of the progress of fetal development as an effective prenatal teaching tool when working with pregnant women and their families (internet sites)

47. Fetal Circulation
Ductus venosus
Ductus arteriosus
Foramen ovale

48. Fetal Circulation

49. Factors Affecting Fetal Development
Exposure to teratogens
Maternal health habits and lifestyle
Paternal health habits and exposure to environmental influences
Maternal health habits and lifestyle can expose the fetus to teratogens or limit the amount of substances (nutrients) required for optimal growth and development; preconception care and counseling should be used to help women adopt a healthy lifestyle before attempting pregnancy; health and lifestyle practices that can adversely affect the fetus-newborn include poor nutrition, stressful lifestyle, poor hygiene or unsafe sex practices, environmental pollutants at home and in the workplace, and use of tobacco, alcohol, or cocaine
Paternal health habits and exposure of men to environmental influences are becoming the subject of increasing research – fertility in terms of sperm (number, viability, motility, morphology), quality of genetic material transmitted have already been shown to be adversely affected by the same health and lifestyle practices as above. Prospective fathers should receive preconception care and counseling to help them adopt a healthier lifestyle.

50. Physiological Changes During Pregnancy
Uterus
Ligaments
Cervix
Chadwick’s
Goodell’s
Hegar’s
Breast
Montgomery tubercles
Skin
Changes stimulated primarily by estrogen and progesterone activity and mechanical factor of fetal growth
Uterus: thin soft-walled organ enlarges 500 times its prepregnant size
Ligaments
Cervix: changes apparent 6-8 weeks
Chadwick’s: color of cervix and vagina deepens to a reddish-purple
Goodell’s: cervix softens and becomes more friable (fragile)
Hegar’s: lower segment of uterus softens
Breasts: bilateral changes stimulated primarily by estrogen, progesterone, and HPL—begin at approximately 6 weeks gestation; gradual increase in size of breasts—glandular and duct tissue develops, alveoli hypertrophy; precolostrum (thin, clear fluid) is produced at approximately 6 weeks and colostrum (thick, yellowish, precursor to milk) during the 3rd trimester; circulation-vascularity increases; lactation is suppressed until estrogen-progesterone level falls after birth; Montgomery tubercles (sebaceous glands found in areola) enlarge; 2-3 trimester – full, heavy, enlarged, more erectile, striae gravidarum; pigmentation of nipples and areola deepens; sensitive or tender
Skin: chloasma (mask of pregnancy); linea nigra; striae gravidarum

51. Circulatory System Increases up to 50% Pseudoanemia
Iron requirements increased
Increase in size
Blood pressure changes
Fibrinogen increases
Mechanical circulatory effects
Blood volume increases beginning at about week and peaking at about week 20-26; 30-50% (or 1500 mL) increase in a single pregnancy; vascular network relaxes-dilates to accommodate volume; purpose of increase in volume—fill expanded vascular network-placenta, enlarged uterus, increased vascularity of body organs; protect maternal-fetal unit from hypotension related to impaired venous return; safeguard against blood loss during birth; hemodilution—most noticeable in second trimester; physiologic anemia related to hemodilution Hct should fall no lower than 33% (1st and 3rd trimesters) and no lower than 32% 2nd trimester – Hg should fall no lower than 11 g/dL-1st and 3rd trimester and no lower than 10.5 in 2nd trimester))cardiac output increases by 30-50%-peaks at 32 weeks and then declines; cardiac workload increases; heart enlarges slightly; hypercoagulability (increase in fibrin-fibrinogen, decrease in fibrolytic activity); blood pressure decreases 5-10 mm Hg systolic and diastolic during first and second trimester; returns to prepregnant baseline during 3rd trimester; postural hypotension with sudden change from supine to upright position; hypotension results in dizziness, lightheadedness, pallor, diaphoresis, anxiety; heart rate increases by beats per minute by approximately 14 to 20 weeks-persists until term; edema and varicose vein formation in lower extremities, around anus and vulva-perineum

52. Supine Hypotension Syndrome
Supine hypotension, vena caval syndrome—pressure of enlarging uterus on inferior vena cava when in the supine position

53. Respiratory System Thoracic cage Oxygen consumption increases
Hyperventilation
Respiratory alkalosis
Mucosal edema
Diaphragm is moved upward 4 cm (1.5”); ribs flare and expand; oxygen demand increases from increased maternal BMR, development of reproductive structures, and fetal growth and development; vascularity of upper airway and respiratory system increases from higher estrogen levels; respirations—slight increase in baseline respiratory rate (2/min); volume deeper (hyperventilation of pregnancy; thoracic breathing pattern; some shortness of breath and dyspnea even at rest—diminishes after lightening occurs; chest circumference expands 2-3 inches; nasal mucosa—swollen, moist reddened; nasal-sinus stuffiness, clear, watery discharge; inflammatory response to URIs is more severe; episodes of epistaxis; sense of fullness in ears with slight impairment of hearing and earaches; voice deepens; slight respiratory alkalosis, compensated by mild metabolic acidosis—decrease in PaCO2 of 5 mm Hg at about week 10

54. Digestive System Nausea / vomiting Constipation Flatulence / heartburn
Gallstones
Nausea and vomiting are common during the first trimester because of elevated HCG levels and changed carbohydrate metabolism. Poor appetite may occur because of the decreased gastric motility.Gum tissue may soften and bleed easily. Secretion of saliva may increase and even become excessive (ptyalism). Bloating and constipation due to elevated progesterone levels that cause smooth muscle relaxation resulting in delayed gastric emptying and decreased peristalsis. The enlarging uterus displaces the stomach upward and the intestines laterally and posteriorly; the cardiac sphincter also relaxes and heartburn may occur due to reflux of acidic secretions into the lower esophagus. The emptying time of the gallbladder is prolonged during pregnancy as a result of smooth muscle relaxation from progesterone also elevated levels of cholesterol in the bile – predisposes woman to gallstone formation. Alterations in taste and smell. Constipation as a result of decreased gastrointestinal motility or pressure of the uterus.

55. Urinary System Kidneys Function increases
Renal threshold for sugar reduced
Bladder and ureters
Blood supply increased
Pressure
Atonia
Frequency – 1st and 3rd trimester due to pressure of the enlarging uterus on the bladder; decreased bladder tone is caused by hormonal changes; decreased bladder capacity; the ureters (especially the right ureter) elongate and dilate above the pelvic brim; renal function increases --glomerular filtration rate rises as much as 50% beginning in 2nd trimester; renal threshold for glucose may be reduced -- glycosuria is sometimes seen during pregnancy because of the kidneys’ inability to reabsorb all the glucose filtered by the glomerluli.

56. Joints, Bones, Teeth, and Gums
Pelvic cartilages
Gait
Uterus
Posture changes
Teeth
Gums
The joints of the pelvis relax because of hormonal influences. The result is a waddling gait. As the pregnant woman’s center of gravity gradually changes, the lumbar spinal curve becomes accentuated and her posture changes. This posture change compensates for the increased weight of the uterus anteriorly and frequently results in low backache. No demonstrable changes occur in the teeth of pregnant women. The dental caries that sometimes accompany pregnancy are probably caused by inadequate oral hygiene and dental care especially if the woman has problems with bleeding gums or nausea and vomiting – infections link to preterm labor!

57. Endocrine System Placenta HCG HPL Estrogen Progesterone Pituitary
Adrenal
Thyroid
Endocrine activities of the placenta are important to preserving a viable pregnancy and to the metabolic adaptations that must take place for the fetus to develop.
HCG
HPL secreted by the placenta
Estrogen
Progesterone
Pituitary gland enlarges – production of prolactin increases for breast development
Oxytocin is produced by the hypothalamus but the posterior pituitary stores and secretes the hormone
Adrenal gland does not change with pregnancy. Cortisol and aldosterone are two hormones secreted from the adrenal cortex that are important in pregnancy. Cortisol works at multiple sites in the body to promote the metabolism of carbohydrates, proteins, and fats. Increased levels of aldosterone may protect the pregnant woman from the excessive sodium loss that is attributed to elevated progesterone levels during pregnancy.
Thyroid gland enlarges slightly. Basal metabolic rate increases by 25% in pregnancy causing an increased pulse rate, heat intolerance, and elevated level of cardiac output.
Parathyroid gland secretes parathyroid hormone (responsible for calcium and phosphorus metabolism. PTH increases in pregnancy to meet the demands of the growing fetus for calcium. Total circulating calcium levels are decreased in pregnancy

58. Signs of Pregnancy Presumptive – Subjective Probable – Objective
Positive -- Diagnostic

59. Signs of Pregnancy: S, O, or D
Amenorrhea
Goodell’s sign
Fetal heart sounds
Urinary frequency
Positive pregnancy test
Nausea and vomiting
Enlargement of the abdomen
Quickening
Palpable fetal movements
Braxton Hicks contractions
Amenorrhea—subjective (presumptive)
Goodell’s sign—objective (probable)
Fetal heart sounds—positive (diagnostic)
Urinary frequency—subjective (presumptive)
Positive pregnancy test– objective (probable)
Nausea and vomiting—presumptive (subjective)
Enlargement of the abdomen—objective (probable)
Quickening—subjective (presumptive)
Palpable fetal movements—positive (diagnostic)
Braxton Hicks contractions—objective (probable)

60. How would you explain the differences between the subjective (presumptive), objective (probable), and diagnostic (positive) signs of pregnancy to an expectant mother?

61. Maternal Psychosocial Changes
First trimester
Ambivalent
Second trimester
Baby becomes real
Maternal introspection
Third trimester
Begins to think of baby as separate being
Restless
Self-centered
Pregnancy affects the pregnant woman, her family, and in some cases, specific members of her support system.
Ambivalence occurs early in pregnancy, even when the pregnancy is planned. Mother may experience dependence-independence conflict and ambivalence related to role changes. Father may experience ambivalence related to the new role he is assuming, the increased financial responsibilities, and sharing the wife’s attention with the child.
Acceptance: Factors that may be related to acceptance of the pregnancy are the woman’s readiness for the experience and her identification with the motherhood role
Emotional lability may be manifested by frequency in the change of emotional states or extremes in emotional states. These emotional changes are common, and the mother may feel that these changes are abnormal.
Body image changes –the changes in a woman’s perception of her image during pregnancy occurs gradually and may be either positive or negative; the physical changes and symptoms that the woman experiences during pregnancy contribute to her body image

62. Rubin’s Maternal Tasks
Seeking safe passage
Securing acceptance
Learning to give of self
Committing self to child
Seeking safe passage for herself and her fetus. This involves both health care by a professional and adhering to important cultural practices.
Securing acceptance of herself as a mother and for her fetus. Will her partner accept the baby? Does her partner or family have strong preferences for a child of a particular sex? Will a baby be accepted even if her or she does not fit the ideal? May review her relationship with her own mother.
Learning to give of self and to receive the care and concern of others. The woman will never again be the same carefree girl she was before her baby’s arrival. She depends on others in ways she has not experienced before.
Committing herself to the child as she progresses through pregnancy. Much of the emotional work of pregnancy involves protecting and nurturing the fetus.

63. Paternal Psychosocial Changes
First trimester
Excitement over virility
Financial concerns
Energetic
Exhibit symptoms with wife
Second trimester
More confident
Concerns about wife’s changes / introspection
Third trimester
Rivalry with fetus
Interest in himself
Fantasizes about child

64. Factors Affecting Psychological Response
Body image
Personal characteristics
Financial situation
Cultural expectations
Emotional security
Support from significant others
Changes in sexuality
Role of the father and siblings

65. Preparation for Parenthood
Preconception
Childbearing decisions
Prenatal education
Childbirth preparation
Preconception counseling
Childbearing decisions: care provider, birth plan, birth setting, labor support person, siblings at birth
Content of classes based on needs for each trimester
Methods: Lamaze (psychoprophylactic): body conditioning exercises, relaxation exercises; breathing techniques, disassociation relaxation; effleurage; massage; education

66. Childbirth Education
Provides information on pregnancy and childbirth to facilitate optimal decision making
Classes for special groups
Importance of exercise during pregnancy
Selection of birthing process
Infant care
Topics should be timed to the progress of pregnancy
Special classes: Grandparents, siblings, adolescents, elective c-section deliveries
Exercise is an important topic for childbirth education; women should be encouraged to participate in regular (3 times/week) exercise during pregnancy. Maintains muscle tone and bowel function; fewer complications during labor and delivery. Pelvic tilt, partial sit-ups; Kegel exercises, and exercises to stretch the inner-thigh muscles are especially helpful.
Classes on preparation for the birth process provide information on selection of birthing method and relaxation techniques

67. First Trimester Physical and psychosocial changes of pregnancy
Self-care in pregnancy
Protecting and nurturing the fetus
Choosing a care provider and birth setting
Prenatal exercise
Relief of common early pregnancy discomforts

68. Second Trimester Planning for breast-feeding Sexuality in pregnancy
Relief of common later-pregnancy discomforts

69. Third Trimester Preparation for childbirth Development of a birth plan
Relaxation techniques
Postpartum self-care
Infant stimulation
Infant care and safety

70. Goals of Prenatal Care Safe birth Health promotion Self-care
Provide physical care
Provide anticipatory guidance
Ensure a safe birth for mother and baby by promoting good health habits and reducing risk factors
Teach health habits that may be continued after pregnancy
Teach self-care for pregnancy
Provide physical care (wholistic)
Prepare parents for the responsibilities of parenthood

71. Risk Factors / Reproductive Outcomes
Maternal age
Parity
Socioeconomic status
Ethnicity
Geographic factors
Behavioral and Lifestyle risks
Health risks
Previous pregnancies
During the prenatal assessment, the woman is screened for risk factors. Risk factors are any findings that suggest the pregnancy may have a negative outcome.
Maternal age: young adolescents (pg associated with increased maternal and neonatal morbidity and mortality – obstetric and social complications are enormous)
Older than 35 – increased risks for mom and fetus
Parity: higher risks for grand multips; may not seek early prenatal care; multiple gestation; history of habitual spontaneous abortion; spontaneous premature rupture of membranes
Socioeconomic status: low income associated with low birth weight; younger age; later prenatal care
Undernutrition: lack essential nutrients; anemic; Vit A,C and riboflavin deficient – affects fetal development; causes low birth weight
Hypertensive disorders (PIH)
Ethnicity: non-whites have more problems; mortality greater
Geographic factors
Addictive disorders: alcohol, street drugs
Socioeconomic status (again)
Teratogenic foods, additives, exposures,
Stress
STDs
Multiple sex partners
Abuse and domestic violence
Preexisting medical disorders such as diabetes, heart conditions, thyroid disorders, anemia

72. Role of Nurse Physical assessment Identify and reevaluate risk factors
Teach self-care
Nutrition counseling
Promote family’s adaptation to pregnancy

73. Prenatal Visits Every 4 weeks for first 28 to 32 weeks
Every 2 weeks from 32 to 36 weeks
Every week from 36 to 40 weeks
Minimum number of visits = 11 or considered limited or no prenatal care

74. Terminology Gravida Nulligravida Primigravida Multigravida Para
Primipara
Multipara
Nullipara
Abortion
Gestational age
Fertilization age
Para: number of pregnancies that have progressed to 20 or more weeks at delivery, whether the fetus was born alive or was stillborn; refers to the number of pregnancies, not the number of fetuses.
Abortion: a spontaneous or elective termination of pregnancy before the 20th week of gestation based on the date of the LMP. Spontaneous often called miscarriage.
Gestational age: prenatal age of the developing baby (measured in weeks) calculated from the first day of the woman’s last menstrual period. Also called menstrual age, about 2 weeks longer than the fertilization age.

75. Nomenclature G = number of pregnancies T = number of term deliveries
P = number of preterm deliveries
A = number of abortions
L = number of living children
M = number of multiple births

76. First Day of Last Menstrual Period
Nägele’s Rule
First Day of Last Menstrual Period
Minus 3 months
Plus 7 days

77. Identify the causes and interventions for each discomfort of pregnancy:
Heartburn
Hemorrhoids
Urinary frequency
Nausea / vomiting
Leg cramps
Vaginal discharge
Fatigue
Backache
Constipation
Varicose veins
Edema
Dyspnea

78. Why is a positive pregnancy test not a positive sign of pregnancy?

79. Routine Lab Tests Blood grouping Rh factor and antibody screen CBC
H & H
VDRL, RPR, or STS
Rubella titer
TB skin test
Hg electrophoresis
HIV screen
Hepatitis B screen UA
PAP test
Cervical culture
MSAFP
Maternal blood glucose

80. Prenatal Laboratory Tests: Normal or Abnormal ?
Hemoglobin 13.6 g/dL
Hematocrit 35%
Rubella titer 1:6
WBC 6,200/ mm3
Sickle Cell screen negative
Refer to norms for pregnancy!!
Hemoglobin 13.6 g/dL: OK – normal in pregnancy [decreased from norms during pregnancy—may decrease to 11.5 later in pregnancy due to hemodilution]
(Nonpregnant = 12-16)
Hematocrit 35%: OK normal in pregnancy [decreased from norms during pregnancy—33% lowest acceptable due to hemodilution] (Nonpregnant = 36-48)
Rubella titer 1:6: Non-immune [>1:10 indicates immunity <1:10 immunize after birth of infant]
WBC 6,200/L: OK – rises to 18,000/mm3 by late pregnancy – mostly neutrophils [5,000-12,000/ mm3 normal during pregnancy – rises during labor and postpartum up to 25,000/ mm3]
Sickle Cell screen negative: OK

81. Prenatal Self-Care Measures
Breast tenderness
Leg cramps
Nausea
Constipation
Backache

82. Risk Factors Definition Social / Personal
Preexisting medical disorders
Obstetric considerations
Problems associated with current pregnancy
During the prenatal assessment, the woman is screened for risk factors. Risk factors are any findings that suggest the pregnancy may have a negative outcome either for the woman or her unborn child.
Social/Personal: low income level and/or low educational level; poor diet; multiparity >3; weight <100 lbs; weight >200 lbs; age <16 or >35; smoking; use of addicting drugs; excessive alcohol consumption
Preexisting medical conditions: diabetes mellitus; cardiac disease; anemia; HTN; thyroid disorder (hypo or hyper); renal disease
Obstetric considerations: stillborn; habitual abortion; cesarean birth; Rh or blood group sensitization; large baby
Current pregnancy: rubella in first or second trimester; cytomegalovirus; Herpes virus; syphilis; abruptio or placenta previa; PIH; multiple gestation; polycythemia; spontaneous premature ROM; STDs;
Maternal age: young adolescents (pg associated with increased maternal and neonatal morbidity and mortality – obstetric and social complications are enormous)
Older than 35 – increased risks for mom and fetus
Parity: higher risks for grand multips; may not seek early prenatal care; multiple gestation; history of habitual spontaneous abortion; spontaneous premature rupture of membranes
Socioeconomic status: low income associated with low birth weight; younger age; later prenatal care
Undernutrition: lack essential nutrients; anemic; Vit A,C and riboflavin deficient – affects fetal development; causes low birth weight
Ethnicity: non-whites have more problems; mortality greater

83. Prenatal Diagnostic Studies
Ultrasound
Estriol: Increases with fetal growth
Amniotic Fluid
Amniocentesis
Lecithin / sphingomyelin ratio
Fern test
Nitrazine test
Kick test
Chorionic villus sampling
Alpha feto protein level
Ultrasound: used to identify a yolk sac, a fetal heart before it is audible le with Doppler, the sex of the fetus, and internal structures of the developing fetus. Routine use is usually limited to pregnancy confirmation; assessment of fetal development and well-being; sex determination if indicated or desired; and overall fetal size as term approaches. Further use are indicated in cases of unusual findings that suggest deviations from a normal prenatal course [fundal height inconsistent with calculated dates of pregnancy – large or small; inability to find fetal heart beat]
Estriol: Increases with fetal growth
Amniotic Fluid
Amniocentesis
Lecithin / sphingomyelin ratio
Fern test: confirms ruptured membranes – requires speculum exam
Nitrazine test: amniotic fluid alkaline [compare to urine pH]
Kick test: fetal movement counting—daily maternal assessment of fetal activity by counting the number of movements within a specified time period—correlates with fetal well-being—the frequency of fetal movement peaks at 32 weeks gestation and gradually decreases as the pregnancy approaches 40 weeks. A number of factors can influence fetal movement: time of day, glucose loading, and maternal smoking, alcohol, or medication consumption. Decreased fetal movements may be associated with chronic as opposed to acute states of fetal distress. As the fetus experiences intrauterine compromise, the decreased activity leads to decreased oxygen requirements manifested as altered growth and oxygenation patterns. Fetal movement counting should be done at the same time each day, preferably after a meal or when the fetus is most active. Neither an ideal number of fetal movements not an ideal interval for fetal movement counting has been established. In general, a count of less than three fetal movements within 1 hour necessitates further evaluation with a NST or BPP
Chorionic villus sampling: a procedure to obtain fetal cells in the first trimester of the developing pregnancy—reflects the chromosomes, enzymology, and DNA content of the fetus—does not determine the presence of a neural tube defect
Alpha feto protein level: basis for screening for neural tube defects (elevated) and trisomy 21 (decreased levels)—optimal time for testing is 16 to 18 weeks gestation. Screening test—not diagnostic

84. Level I Ultrasound Basic Detect gestational sac (5 weeks after LMP)
Identify number of fetuses
Document fetal life
Detect gross fetal structural anomalies
Estimate gestational age
Determine fetal position
Locate the placenta
Estimate amniotic fluid volume
Evaluate maternal pelvic masses

85. Level II Ultrasound Evaluate gestational age Measure fetal growth
Perform specific examinations of the brain, heart, kidney, and cord insertion
Quantify amniotic fluid volume
Determine placental location
Performed after 18 weeks

86. List two advantages of prenatal ultrasound assessment for the mother and fetus.
Confirms pregnancy
Makes it real
Reassuring
Noninvasive, nondamaging , painless

87. Tests of Fetal Well-Being
Ultrasound
Amniocentesis
Nonstress Test (NST)
Contraction Stress Test (CST)
Breast Self-Stimulation Test (BSST)
NST: a noninvasive test using an external fetal monitor to note fetal response, oxygenation, and autonomic functioning. A reactive NST exists when two fetal heart rate accelerations of 15 bpm lasting for 15 seconds occur in a 15 to 20 minute period. Accelerations may occur spontaneously after fetal movement or other stimulation methods. A nonreactive test fails to demonstrate these accelerations and may indicate a need for further testing.
CST: Use of the external fetal monitor to evaluate the fetal response to the stress of contractions. The challenge is to achieve three moderate-intensity contractions lasting seconds in 10 minutes and note the fetal response. Contractions are achieved by client nipple stimulation (BSST) or IV administration of an oxytocin piggyback drip. The desired response is referred to as a negative test. The occurrence of repetitive late decelerations is referred to as a positive test and indicates the need for intervention, usually delivery.

88. Danger Signs in Pregnancy
C = Chills and fever
Cerebral disturbances
A = Abdominal pain
B = Blurred vision
Blood pressure
Bleeding
S = Swelling
Sudden escape of fluid
Vaginal bleeding with or without discomfort
Rupture of membranes
Swelling of the fingers (rings tight) or puffiness of the face or around the eyes
Continuous pounding headache
Visual disturbances (blurred vision, dimness, spots before the eyes
Persistent of severe abdominal pain
Chills or fever
Painful urination
Persistent vomiting
Change in frequency or strength of fetal movements

89. Nutrition During Pregnancy
Choose foods from food guide pyramid
Increase of 300 calories / day
Calorie needs greater in last two trimesters
Encourage diet high in folic acid with supplements
Calcium needs increase nearly 50%
Heavy demand for iron for fetal stores
Drink 8 to 10 glasses of water / day

90. Food Guide Pyramid Dairy: Pregnant and lactating – at least 3 servings
Vegetables and fruits: at least 5 servings – include at least 1 vitamin C source, 1 vitamin A source; at least 1 folic acid source; at least 2 others 3 fruit servings; 4 vegetable servings
Whole grains: at least 7 9 servings
Protein: 7 oz (seven 1 oz servings or two 3.5 oz servings) 3 servings
Fats: 3 tsp unsalted fat use sparingly

91. Vegetarianism
Need ample and complete proteins from dairy products and eggs
Protein from brown rice and whole wheat, legumes, nuts, cooked and fresh vegetables and fruits
Vitamin B12 supplement
Legumes: beans, split peas, and lentils
Nuts in large quantities

92. Lactose Intolerance
Abdominal distention, discomfort, nausea, vomiting, loose stool, cramps
May tolerate milk in cooked form
Cheese and yogurt
Lactase may be prescribed
Lactase-treated milk
Lactose-free products

93. Pica Non-nutritive eating Associated with poverty and inadequate diets
Iron deficiency anemia

94. Weight Gain Normal: 25 -- 35 pounds Underweight: 28 -- 40 pounds
Overweight: pounds

95. Uterine Growth During PregnancyF

96. Uterine Growth During Pregnancy

97. What is the average pattern of weight gain during each trimester of pregnancy?
The average expected weight gain during pregnancy is 2 to 4 pounds in the first trimester, and approximately 1 pound per week in the second and third trimesters

98. Maternal Weight Gain Distribution
Fetus, placenta, amniotic fluid 11 pounds
Uterus pounds
Increased blood volume pounds
Breast tissue pounds
Maternal stores pounds
Total pounds
Remember: Appropriate pregnancy weight gain averages 25 to 35 pounds for women with a normal pre-pregnant weight.
10-13 pounds in the first 20 weeks
About 1 pounds per week after the 20th week

99. Medications
Prenatal vitamins
Iron supplements
Folic Acid
Antacids

100. Case Study
A client, who is a primigravida in her second trimester, has come in for a scheduled prenatal visit. When the nurse asks how things are going, the client replies, “Not very well. It seems like I’m just falling apart. I have heartburn after I eat, my ankles swell, I’m constipated all the time, and I think I may be getting hemorrhoids.”
From: Hogan & Glazebrook
What questions should the nurse ask the client regarding the problems described? The nurse should assess for factors possibly affecting the GI system system such as the client’s dietary intake, especially with regard to fruit and vegetables, fiber and spicy foods; use of stool softeners, laxatives, or antacids; and timing of food intake. Factors affecting lower-extremity swelling such as rest and activity patterns should be assessed.
What objective data should the nurse collect regarding the problems described? With regard to GI function, the nurse should inspect the anus for the presence of hemorrhoids. Lower extremities should be assessed for varicose veins. The client should also be assessed for signs and symptoms of PIH such as elevated blood pressure, protein in the urine, and swelling other than in the lower extremities.
What nursing diagnoses are appropriate for this client? Mild anxiety, Body image disturbance, Constipation, Risk for aspiration, or Altered comfort.
What teaching is needed in this situation? The nurse should assure the client that all of these symptoms, while not life threatening, can affect her function and comfort, are commonly associated with pregnancy, and can be treated. To manage heartburn, the client could avoid lying down after eating, avoid fatty or fried foods, eat smaller and more frequent meals, and take a low-sodium antacid, if needed. To minimize constipation and the development of hemorrhoids, the woman could increase her fluid intake to at least 2000 mL per day; increase her intake of fruits, vegetables, and fiber; participate in daily exercise; allow sufficient time for bowel function ; and use stool softeners, if needed. To decrease or prevent ankle edema, the client could avoid prolonged standing or sitting, dorsiflex the feet frequently, avoid tight bands or garters around the legs, and elevate the feet and legs during frequent rest periods.
How should the nurse follow-up with this client? The nurse should encourage the client to call the healthcare provider’s office if these symptoms are not relieved by the measures suggested. When the woman returns for her next prenatal visit, these problems should be assessed and, if needed, further management should be considered.