Maternity: Prenatal Period and Uterus Changes

• Prenatal Period (antepartum) is a period of physical and psychological preparation for birth and parenthood.
• Gestation is the duration of pregnancy, with full term being 40 weeks or 280 days.
• Pregnancy is divided into 3 trimesters:
• 1st: first day of last menstrual period to 13 weeks and 6 days
• 2nd: 14 weeks to 27 weeks and 6 days
• 3rd: 28 weeks to 40 weeks and 6 days

Uterus Changes in Pregnancy

• Uterus changes in shape, size, and position during pregnancy
• Uterine weight and volume increase
• Uterus can be palpated above the symphysis pubis between 12-14 weeks, reaching the umbilicus by 20-22 weeks.
• Fundal height measures from the symphysis pubis to the top of the fundus, with the number in cm approximately equal to the weeks of gestation.
• Lightening is the decrease in fundal height around week 38-40 in preparation for birth.
• Braxton Hicks Contractions are irregular and painless uterine contractions after the fourth month of pregnancy; can be referred to as “false labor"
• Uteroplacental blood flow increases 10-fold as the uterus increases in size during pregnancy.
• Uterine souffle is the rushing sound of maternal blood flowing through the uterine arteries.
• Hegar sign is the softening and compressibility of the lower uterine segment between 6 weeks - 3 months experienced during pregnancy.

Cervix and Ovaries Changes During Pregnancy

• Cervix changes to a soft, elastic tissue that dilates for labor and birth.
• Goodell sign refers to the softening of the cervical tip that occurs around week 6.
• Friability means the tissue is easily damaged, so spotting may occur after vaginal examination or intercourse
• Formation of the operculum (mucous plug) acts as a barrier against bacterial invasion of the uterus.
• Ovulation doesn't occur during pregnancy.
• Amenorrhea is the absence of the menstrual period

Vagina Changes During Pregnancy

• Chadwick sign is the violet-blue color of the vaginal mucosa and cervix due to increased vascularity, evident at 6-8 weeks.
• Leukorrhea is a white/grayish vaginal discharge with a faint musty odor that occurs in response to cervical stimulation by estrogen and progesterone, but should NOT have odor, itching or burning.

Breast Changes Durign Pregnancy

• Breasts experience fullness, sensitivity, tingling, and heaviness early in pregnancy due to increased estrogen and progesterone.
• Nipples become more pigmented, areolae enlarge, and nipples become more erect.
• Lactogenesis Stage I occurs as milk ducts prepare for lactation with human placental lactocytes stimulating the secretion of colostrum during pregnancy.

Cardiovascular Changes During Pregnancy

• Total blood volume increases by 40-45% to meet the needs of the uterus and hydrate tissues.
• Cardiac output increases 30-50% due to increased stroke volume and heart rate.
• The blood pressure remains the same or slightly decreases.
• Supine hypotensive syndrome (vena cava syndrome) occurs when the vena cava is compressed when a woman lies on her back, potentially resulting in a drop in blood pressure, pallor, dizziness, breathlessness, tachycardia, nausea, and clammy skin; to resolve have the women lay on her side.
• Slight cardiac hypertrophy occurs, and the heart is displaced upward and rotated due to the enlarging uterus.
• Red blood cell mass increases
• Physiologic anemia of pregnancy occurs with a decrease in normal H&H values
• A pregnant woman is considered anemic if hemoglobin is less than 11 g/dL or hematocrit is less than 33%.
• Pregnancy is considered a hypercoagulable state in which women are 5-6x more likely for thromboembolic problems

Respiratory and GI Changes During Pregancy

• Maternal O2 consumption increases during pregnancy.
• Pregnancy-related dyspnea is common in the first or second trimester.
• Pyrosis (heartburn) occurs due to decreased tone and motility of smooth muscles
• Constipation is common during the 1st and 2nd trimesters due to smooth muscle relaxation and reduced peristalsis
• GI symptoms peak around 9 weeks
• Encourage small, frequent meals.

More Symptoms During Pregnancy

• Nausea and vomiting: “morning sickness” (hyperemesis gravidarum)
• Ptyalism: excessive salivation
• Epulis: gingival granuloma gravidarum that bleeds easily
• Pica: non-food cravings
• Abdominal discomfort

Urinary and Skin Changes During Pregnancy

• Kidneys enlarge during pregnancy
• Pregnant women are more susceptible to UTIs
• Protein and albumin urinary excretion increases
• Pregnant women with hypertension and proteinuria are risk for preeclampsia
• Melasma is “mask of pregnancy”, a brown hyperpigmentation of the skin over the face
• Linea nigra is a pigmented line extending from the symphysis pubis to the fundus in the midline
• Striae gravidarum are stretch marks that appear during the second half of pregnancy
• Angiomatas or "vascular spiders" are tiny star-shaped pulsating end arterioles usually found on the neck, thorax, face, and arms
• PUPPP is pruritic urticarial papules and plaques of pregnancy

Musculoskeletal and Neurologic Changes During Pregnancy

• Increased risk for falls due to changed center of gravity
• Diastasis abdominis occurs when the rectus abdominis muscles separate
• Lordosis occurs in pregnancy
• Pregnant women are more prone to headaches, but NEVER dismiss a headache!
• Lightheadedness, faintness, and syncope (fainting) are common during early pregnancy
• Alterations in sleep time, heightened olfactory sense or carpal tunnel syndrome can also occur

Endocrine, Immune, and Fetal Changes During Pregnancy

• Endocrine changes are essential for pregnancy maintenance, fetal growth, and postpartum recovery.
• Maternal immune system functions protect the pregnant woman against infection while preventing rejection of the fetus.
• Ballottement is the passive movement of the unengaged fetus and occurs between 16 and 18 weeks gestation.
• Quickening is the first recognition of fetal movements felt by mom.
• Nulliparous moms feel it around 18 weeks.
• Multiparous moms feel it as early as 14-16 weeks.

Pregnancy Tests

• Human chorionic gonadotropin (hCG) is the earliest biological marker.
• Pregnancy tests are based on the recognition of hCG.
• HCG begins with implantation, detected 7-10 days after conception, and peaks at day 60-70.
• HCG levels > 25 IU/L are diagnostic for pregnancy.
• For at-home pregnancy tests, use a first-voided morning urine specimen.
• If the test at the time of the missed period is negative, repeat the test in 1 week if you still have not had a period.
• False negatives can be due to improper collection, promethazine, and diuretics.
• False positives can be due to anti-convulsives or tranquilizer medications.

Signs of Pregnancy

• Presumptive signs are felt by the woman and may indicate pregnancy such as breast changes, amenorrhea, nausea and vomiting, urinary frequency, fatigue and quickening
• Probable signs strongly suggest pregnancy such as Goodell's sign, Chadwick's sign, Hegar's sign, positive urine and serum pregnancy tests, Braxton Hicks contractions and ballottement
• Positive signs indicate proof of pregnancy such as an ultrasound, fetal heart tones, visualization of fetus and fetal movement felt or visible by an examiner.

Obstretical Terms

• Gravida is the number of pregnancies, including the current one.
• Primigravida is a woman pregnant for the first time.
• Multigravida; is a woman who has had 2+ pregnancies.
• Nulligravida; is a woman who has never been pregnant.
• Parity is the number of pregnancies in which the fetus(es) have reached 20 weeks gestation or more.
• Primipara is a woman who has completed one pregnancy and has reached 20 weeks or more.
• Multipara is a woman who has completed 2+ pregnancies to 20 weeks gestation or more.
• Nullipara is a woman who has not completed a pregnancy and has not reached 20 weeks or more gestations.
• Viability is the capacity to live outside the uterus, usually 22-25 weeks is on the threshold of viability and infants born this young are vulnerable to brain injury if they survive.
• Preterm is a pregnancy that has reached 20 weeks and 0 days gestation, but ends before 37 weeks 0 days of gestation.
• Early Term is a pregnancy that has reached between 37 weeks, 0 days and 38 weeks, 6 days of gestation.
• Full term is a pregnancy that has reached between 39 weeks, 0 days and 41 weeks, 6 days.
• Late term is a pregnancy that has reached between 41 weeks, 0 days and 41 weeks, 6 days of gestation.
• Postterm is a pregnancy that has reached 42 weeks, 0 days and beyond of gestation.

GTPAL

• Tool that summarizes obstetrical history
• G: gravida which is the number of pregnancies, including this one
• T: term which is the number of pregnancies that ended in term births (37 weeks, 0 days and beyond)
• P: preterm which is the number of pregnancies that ended in preterm births (between 20 weeks, 0 days and 36 weeks, 6 days gestation)
• A: abortion which is the number of pregnancies that ended in miscarriage (spontaneous abortion) or elective termination (therapeutic abortion) before 20 weeks or weighed less than 500 g at birth
• L: living children which is the number of children living currently

Estimated Delivery Date

• Estimated Date of Birth is determined based on the date of the woman's last menstrual period and the first accurate ultrasound examination
• Naegele rule: subtract 3 calendar months and add 7 days to the first day of the woman's last menstrual period, assuming the woman has a 28 day cycle and that fertilization occurs on the 14th day
• For example, if the first day of LMP was January 20, 2023, the due date will be October 27, 2023
• Ultrasound is the MOST ACCURATE assessment of the EDB based on ultrasound measurement of the embryo or fetus during the first trimester

Adaptation to Pregnancy

• Material adaptation is a process of social and cognitive learning during which women begin adapting to the maternal role
• Accepting the pregnancy results in ambivalent feeling, even if it is a wanted pregnancy
• Next is Identifying with a role followed by, Reordering personal relationships and finally The "mother-child" progressing through 3 phases ending with the woman prepared for birth
• Partner adaptation causes father to adapt to changes in the relationship as they prepare for the child
• Acceptance of the pregnancy has 3 phases
• Announcement phase is where they, accept the biologic fact of pregnancy
• Moratorium phase is what men become more introspective and engage in discussions about philosophy of life, religion, childbearing and child-rearing practices
• Focusing phase is when they negotiating with his partner the role he is to play in labor and preparing for parenthood
• LGBTQ adaptations must be respectful such as who are is carrying the baby
• Sibling adaptations dependent on the age of the other children and needs
• Grandparent adaptations are excited at the idea of a new baby

Prenatal Visits

• Should promote the health and well-being of the pregnant woman, her fetus, the newborn, and the family
• Has the first visit around 8-9 weeks of pregnancy Monthly unit 28 weeks Every two weeks from 28-36 weeks Weekly after 36 weeks until birth
• Initial visit takes the longest and is the most detailed
• includes a comprehensive health history emphasizes current pregnancy, previous pregnancies, the family, a psychosocial profile, a physical assessment, diagnostic testing, and an overall risk assessment

The Aim of Initial Prenatal Visits

• Goal is to identify any risk of antepartum, intrapartum, postpartum, or neonatal complications.
• Reasons for seeking care include current pregnancy and desire for it, reproductive and sexual history, health history, medications, herbals, family history and nutritional history
• A physical examination should be completed to find height, weight, vitals with pressure, then lab tests that note Hemoglobin and Hematocrit, CBC, blood type, Rubella titer, TB skin test, and urinalysis Follow ups
• Interviews can be briefer and less intensive
• Always do physical assessments such as BP and weight or fundal height.
• The fetal assessment include growth, and heart tones

Gestational and Genetic Testing

• Note the date when FHTs were first auscultated and first felt
• Urine specimen: for glucose, protein, nitrates, and leukocytes
• Rh antibody screening at 28 weeks
• glucose tolerance test at 24-28 weeks
• Group B Strep (GBS) at 36 weeks
• Genetic screening offer for chromosomal abnormalities based age

Self-Management

• Always have nutrition and avoid risky exercise
• Stop exercise immediately if experience SOB, dizziness, headache, numbness, tingling, chest pain, regular uterine contractions, dec. fetal activity, vaginal bleeding, weakness, calf pain/swelling
• Do NOT give live vaccines to pregnant women (varicella, MMR, rotavirus)
• Kegel Exercises increase tone
• Recommend air travel is up to 36 weeks wear support stocking and ambulate

Maternal and Fetal Nutrition

• First trimester is crucial in terms of embryonic and fetal organ development
• Folic acid decreases neural tube defects
• Women who are or can become pregnant should take 0.4 mg of folic acid supplements everyday and consume dietary sources of folate Including liver, legumes, beans, lentils, asparagus, spinach, papaya, breakfast cereal, wheat germ
• BMI of Normal weight (18.5-24.9): advised to gain 25-35 lbs Underweight (<18.5): advised to gain 28-40 lbs Overweight (25-29.9): advised to gain 15-25 lbs Obese (>30): advised to gain 11-20 lbs
• In the first trimester weight is at 0.9 - 1.8 kg (2 - 4 lb) Then approximately 0.45 kg (1 lb) per week for underweight 3 Kg (0.6 lb) per week for overweight 5 lb per week for obese
• Nutrients the promote fetal growth is Protein, good fats such as avocados, nuts and carbs

Other Considerations During Pregnancy

• Avoid alcohol
• Less than 200mg a Caffeine
• Safe artificial when using moderation
• Nutritional Risks in Pregnancy, Adolescence, frequent gestations, history of low birth weight infants
• Food Safety Avoid: shark, swordfish, mackerel, tilefish
• limit:tuna to 6 oz/week of albacore or white tuna
• Eat fully cooked foods!
• Heat lunch meats, hot dogs to steaming
• Avoid soft cheeses, store-made salads, egg salads, etc.

Nutrition Discomforts

• Nausea/vomiting: eating starchy foods, small meals
• Increasing activity, high foods with fluid
• Pyrosis: avoid fluids with meals
• Lactose intolerance: eat legumes with calcium
• Vitamin C inc, Absorption take on an Empty stomach within 13 hr do not double dose

The Assessment of High-Risk Pregnancy

• Biophysical, Psychosocial,Sociodemographic, Environmental The daily fetal movement count “kick count” indication baby health To increase evaluation nonstress test The ultrasound the most diagnostic valuable

Assess Fetal Movement

• The daily fetal movement count is a way used to assess the condition of the fetus.
• Good fetal movement indicates fetal well-being → normal fetal “kick count” should be 10+ movements in a 2 hour period.
• Fewer than 3 kicks in 1 hour warrants further evaluation
• Fetal alarm signal: fetal movement completely stops for 12 hours

Ultrasound Uses

• First Trimester: transvaginal ultrasound for obese women to confirm viability.
• Second and Third Trimesters: abdominal ultrasound to has a full bladder.
• Types: 2-D ultrasounds are most common in OB.
• Levels: Standard or Limited or Specialized

Ultrasound

• First Trimester for confirm pregnancy,viable,gestanional age
• Second Trimester for establish dates
• Third Trimester: amniotic fluid test

Radiologic Techniques

• MRI: used for obstetric and gynecologic diagnosis that assess soft tissues and the function
• Biophysical profile for acute and chronic markers of fetal disease Fetal breathing Variable to beat to beat Ammonic fluid > 2 Non reactive Highest possible on the BPP 10 by 10 interpretation by weekly to biweekly

Biochecmical Assessment

• Involves biologic exam and chrmjial assessment
• The procedures needed include, amniocentesis, and chorionic villus sampling
• For genetic screening: genetic disorders and hemolytic diagnosis
• For long development is done later in the prenancy

Screening For Genetics

• Maternal Assays (blood tests); is used as a screening tool, Alpha-fetoprotein
• Multiple marker screens: fetal chromosomal abnormalities -Quad Test: used to screen fetuses with trisomy 21 and trisomy 18 measures four maternal serum markers
• Coombs test: is screening tool for Rh incompatibility, and cellular. Deoxyribonucleic acid Screening
• Nonstress Test (NST): for external monitor at least 2 accelerations within 20min periods

• 32 weeks gestation: lasting at least 15 seconds and peaking at least 15 bpm

• < 32 weeks gestation; lasting at least 10 seconds and peaking at least 10 bpm

Contraction Stress Test:

• Done ONLY if mom could deliver immediately if necessary;
• Contractions and exogenous oxytocin or nipple stimulation are used
• Negative (desired): at least three uterine contractions in a 10 minute period, with no late or variable deceleration
• Positive (abnormal): warrants hospital admission for further evaluation

The Nursing Roles

• Patient education
• Counseling for the family
• Planning and implementations

Maximizing Comfort

• Neurologic Origins: originating from internal or external origins from muscle
• Factors is the pain response physiologic,anxiety and comfort

Comfort Management

• Cutaneuous Strategies-therapeutic and walking
• Sensory stimulation Aromatherapy-breathing techni and music
• Breathing Techniques Music-inagery points

Pain Management

• Anesthesia-opioid can give labor

Labor is

• viseral vs the somatic

17: Maximizing Comfort for the Laboring Woman

• Pain highly individualized: sensory and emotional components
• Neurologic origins of pain:
  • Visceral: pain originating from internal organs, e.g. uterine pain
  • Somatic: of the skin, tissue, muscle pain, e.g. vaginal pain
• Factors influencing pain response: anxiety, culture,experience
• Gate-control theory: sensations( hot. cold, counterpresssure) to offset labor

Nonpharmacologic Pain Management

• Cutaneuous Stimulation: heat/cold, touch, acupressure, water therapy. Contraindicated if: preterm, continuous monitoringmaternal fever
• Sensory stimulation: Aromatherapy, breathing

Methods of Breathing

• Cleansing Breath: in through the nose and out through the mouth
• slow placed: breathing 6-8 beats

Analgesics

used to releaved and induce sleep used to enhance anessthia

• Valuum(benzoz) use

Anesthesia

Nerve conduction analgesic

Nerve Block

• Local perineal infiltration:
• Pudendal block
• Spinal blockade: where the solution is with CFS spinal effects
• Side Effects:hypotonion, inffectivness and head aches
• Nitrous oxide: laughing gas

Analgesia

labor and contractions: is

• Nonphara: is used to access the pain
• Parmacologic: is informed conset

18: Fetal Response During Labor

• Uterine Activity: Provides on contactions and FHR

Fetal Compromise

• Goal: to maintains flow
• Due to;
• altertions with circulation
• Placenta cord is around
• Is intermitted auscultation easy acess and less invasive Electeonic featal monitor is to asses adequaccy

Internal Fetal Monoring

the head must in down position mom is at 2-3 cm in membranes there are 3 catergies

• Normal,inermidate,abmalormatl

FHR

• Finds a basline.10bpm normal basline is 110-160
• Contacrtion range is shorts and long and there is 4 FHR variables
• Absent-undetectable minimal and bad Moderate -wanted

Variables

Cord Comopress

• Early comp-heads and compression Placinal utero indefficency Late deceleration are similar from early Need vasopressor

Contraction Monitoring and the Womb

• Contractions are observed for intensity and length. Contraction greater than 2 indicate birth is needed
• Contraction is observed but not responding, needs a c-section
• Nurse will educate, reassure, counsel, assess and plan

19: Nursing Care of the Family During Labor and Birth

• Regular contradictions leading to the first phase
• First Stage: Regular contractions and ends with cervical effacement
• Latent Phase: Characterized by the beginning of the active phase
• Active Phase: 6 - 10 cm dilated
• True Labor: Cervical Dilation

Labor and Amniotic Labor

• Regular every Minutes
• Walking intensifes
• Can be felt in lower back
• False Labor Braxton hICKS
• Can feel higher
• Can be stop after

Labor and Emergency

• EMTALA protect pregnant regardless
• Assessment is a big part of this because it start with woman
• Always start woman age and height
• Gather woman informartion

Interview and Sterile

• Labor Triage and Spontaneous Rupture of Membranes
• Bloody Show to see if mucous nature inc or dec Is there any status

Psycossil Factors

• General behaviors in the type of
• Verbal interactions
• Cultural always speak what they need is

Examing for the Cord

• What is the pressure
• First ask mom to empty and then
• Fetal Strip Interpretation

Vaginal Exam

look for dilataions and STERILE

Lab Test

the analysis the test for fluid Uteral Hygiene is needed Clear liquids

Ambulation

• In 125 ml hr
• Keep them empty
• The lower and elevate is a good position
• Encourage mothers

Second and Third Stage

• A 10 dial with contraction is needed
• In 10dial is complete that we neeed Bear down with the open stage so that the 6-8 contraction is avoided
• Make sure to Contractions the entire stage Bear up against it

Birth and Medical Process

• Crowning occur
• C-section helps but isnt good at all
• Apply pressurre as needed
• Assess is needed

Perioneal Trauma

• The Lasteration
• 3,4 degree involve with the sphincte

Post Anehthsiac Recovery

A person will have to do recieced unit

• Activity Resperation Color and vs

Anal Anatomy Changes

• Assessment fundal heights Priority: test
• Invlution-retunr to pregnant
• Subinvolution- failuure

After Baby is Born

• 14 days to return to locaiton Hemo stasis
• oxytocin stimulation
• increase the oxy
• Placenta siite
• lochia stage birth weeks

20: Postpartum Anatomic and Physiologic Changes

• Main point is return to the pre pregnancy to return to a non- pregnant state
• Lochia is the Postbirth uterine Discharge blood vaginal after birth Cervical change there can be rupture is diffuculty

Pregnancy Change and Signs

• Pelvic support and Kegel Breasts,progesterone First 24hrs of the milk Full to lumpys Engorgement elevated Vial Signs inc rapidly with with

Body System

• Repressurasion within the normal reange Hyopventation on needed Blood presser after birth

Other Organs

and the melasma

• muscolskel 6weeks

Organs and Head

• Head aches are common
• careful assessments
• The Rebound and immune system and then they have
• name and age and medications

Post Birth Signs to Keep In Mind

consistent 8c vs

• Pulse
• repirations clear Days with in breast
• and firm midline Varginal Minimal and edges needs

Baby Has No Sence

and the baby is not there

• emotional excited and if not it is depreesionsionsing

Prevent

with the bleeding need toning The uteraning prevent

• the vagina can result inn atony or lacereations
• a lot of blood lost can indicate inntervations
• massage if
• women at risk if there
• epitoioy pain will feel to high

Comfort Level For Mom

and the interveaetions

• massage
• encrouge from
• opioid and breast feeds in with CNS

Promoting Rest

• they dont get the reest The aeds and pain relief
• always assess and do excersie Encourage the and high fiber foods

Promotiong For New Preganancts

for Rubella

• vaccine
• TDAP AND Rh iniminzation

Phycosisocial

assess memtal and there will unlwliing to work and disconect with all.

Adapt To Familiy

• is adapting well
• that affect with partner
• sexual needs
• if not seek help

22: Transition to Parenthood

• Bonding
• Mutuality
• Attathemnto

High Risk in Family

• Fators High high or poor family member

Medication

• The Acetoaminophen for pain cautions is liver with the
• with Colace to relax with
• Demoplast is a burn pain it can with the spray