Exam 25 - Prenatal Care and Adaptions

Key Terms in Obstetrical History

• Ante: Before
• Antepartum: Before delivery
• Gravida: A woman who is or has been pregnant, regardless of duration or outcome
• Nullipara: A woman who has never completed a pregnancy beyond a spontaneous or elective abortion
• Primigravida: A woman pregnant for the first time
• Multigravida: A woman who has been pregnant more than once
• Para: Number of pregnancies progressed to 20+ weeks of gestation at delivery, whether the fetus was born alive or stillborn; Refers to the number of pregnancies, not fetuses
• Primipara: A woman who has given birth once after a pregnancy of at least 20 weeks
• Multipara: A woman who has given birth two or more times at 20+ weeks of gestation
• Abortion: Spontaneous or elective termination of pregnancy before the 20th week of gestation, based on the date of the Last Menstrual Period (LMP)
• Gestational Age: Number of complete weeks of fetal development, calculated in weeks from the first day of the last menstrual period
• Postpartum: Pertaining to the first 6 weeks after childbirth
• TPAL System:
  • T: Term infants
  • P: Preterm infants
  • A: Aborted pregnancies
  • L: Living children now

Goals for Prenatal Care

• Promote the health of the mother, fetus, newborn, and family
• Ensure a safe birth for mother and child by promoting good health habits and reducing risk factors
• Teach health habits that may be continued after pregnancy
• Educate in self-care for pregnancy
• Develop a partnership with parents and family for continuous and coordinated healthcare
• Provide physical care
• Prepare parents for the responsibilities of parenthood
• Attain these goals via an interprofessional team, creating an environment that allows for cultural and individual differences, while being supportive

Optimal Obstetric Care Includes

• Preconception care: Preparation for the impact the newborn will have on family dynamics.
• Prenatal care: Involves monitoring, care, and management of issues arising during pregnancy.
• Intrapartum care: Involves continuous presence and support of the parents by a labor and delivery nurse or doula during birth.
• Postpartum care: Involves supporting adjustment after birth. This includes encouragement to breastfeed, skin-to-skin contact, bonding, reduced separations/interruptions and follow-up care for the mother and newborn

Preconception Care

• Identifies risk factors that may be changed before conception, reducing negative impacts on pregnancy outcomes
• Involves discussion of pregnancy intention, access to care, use of multivitamins and folic acid, smoking, STIs, illicit drug use and mental health issues
• Education is provided on healthy weight, glycemic control, teratogenic medications, family history and chronic illnesses
• Maternal diet, exercise, smoking, stress, drugs, and environmental pollutants during pregnancy can affect the adult health of the developing fetus

Prenatal Care

• If care didn't begin prior to pregnancy, begin when a woman suspects she's pregnant
• The history includes:
  • Obstetric history: number/outcomes of past pregnancies, plus problems in the mother or infant
  • Menstrual history: Usual frequency, menstrual cycles, duration of flow, first day of Last Normal Menstrual Period (LNMP), and any spotting since LNMP
  • Contraceptive history: type used, whether oral contraceptives were taken before realizing pregnancy, whether an intrauterine device is still in place
  • Medical/surgical history: infections (hepatitis, pyelonephritis), surgical procedures, trauma involving pelvis or reproductive organs
  • Family history of woman and her partner: To identify risk factors (genetic defects, alcohol, drugs, tobacco) and incompatibility between mother and fetus
  • Psychosocial history of woman and her partner: to identify stability of lifestyle and ability to parent a child, significant cultural practices, or health beliefs affecting pregnancy
• Physical examination on first visit: evaluates general health, weight, vital signs, nutrition status, and physical/social problems
• Pelvic exam evaluates size, adequacy, and condition of pelvis and reproductive organs; assesses for signs of pregnancy
• Estimated Date of Delivery (EDD) calculated based on LNMP
• Routine lab work on first/second visit: Other lab work may be drawn at later visits/repeated throughout the pregnancy to establish baselines
• Recommended schedule for uncomplicated pregnancy:
  • Conception to 28 weeks: every 4 weeks.
  • 29–36 weeks: every 2–3 weeks.
  • 37 weeks to birth: weekly
• Early/regular prenatal care: reduces the number of low-birth-weight infants; reduces morbidity and mortality for mothers and newborns

Determining Estimated Delivery Date

• Average term pregnancy is 40 weeks (280 days) from the first day of last normal menstrual period (LNMP); also called 10 "lunar" months of 28 days each or 9 calendar months
• Pregnancy is divided into three 13-week parts called trimesters

Nagele's Rule:

• Identify first day of Last Normal Menstrual Period (LNMP).
• Count backward 3 months.
• Add 7 days (update year if applicable).
• EDD can be determined with ultrasound using crown-rump length in first trimester. After 14 weeks gestation use the biparietal diameter, head circumference, abdominal circumference, and femur length

GTPAL System

• A standardized way to describe the outcomes of a woman's pregnancies on her prenatal record.
• Gravida: Indicates number of pregnancies, increasing by 1 each time a woman is pregnant
• Para: Indicates outcome of pregnancies, numbered increased only when a woman delivers a fetus of at least 20 weeks gestation

Para Breakdown:

• T: Number of term infants born (after at least 37 weeks)
• P: Number of premature infants born (after 20 weeks or before 37 weeks)
• A: Number of pregnancies aborted before 20 weeks (spontaneous or induced)
• L: Number of children now living

Presumptive Signs of Pregnancy: Indicators that suggest pregnancy, but may relate to unrelated conditions

• Amenorrhea (absence of menses):

  • Often one of first signs
  • Other causes must be ruled out such as strenuous exercise, changes in metabolism, and endocrine problems

• Nausea and Vomiting:

  • Begins at 4 weeks after LNMP, resolving around 20 weeks
  • Causes are believed to be from increased levels of hCG
  • Distaste for certain foods/odors
  • Symptoms can happen anytime of the day

• Breast changes and skin: results from the influence of estrogen and progesterone

  • Breast tenderness and tingling, striae as pink to brown lines may develop when breasts enlarge

• Deepening Pigmentation: happens primarily in dark-skinned women

  • Increased pigmentation of the face (chloasma or mask of pregnancy)
  • Linea nigra (line extending in the midline of the abdomen from just above the umbilicus to the symphysis pubis)
  • Darkening of areolae of the breast

• Urinary Frequency:

  • Common in early pregnancy due to increased blood supply to the pelvic area, which exerts pressure on bladder
  • Late in the third trimester, the presenting part descends into the pelvis for birth, causing frequency and urgency again

• Fatigue and Drowsiness:

  • Caused by increased metabolic needs of the woman and fetus
  • Significant sign in otherwise healthy women

• Quickening: First fetal movement felt by the mother at 16-20 weeks of gestation, feeling like faint abdominal fluttering and marks the midpoint of the pregnancy

Probable Indications of Pregnancy

• Provide stronger evidence, but other things could also cause these
• Goodell's Sign: Softening of the cervix and vagina caused by increased vascular congestion
• Chadwick’s Sign: Purplish or bluish discoloration of the cervix, vagina, and vulva, also from increased vascular congestion
• Abdominal Enlargement: Fairly reliable indicator if it corresponds with slow, gradual increase in uterine growth and amenorrhea
  • By the end of the 12th week, the uterine fundus may be felt just above the symphysis pubis, extending to the umbilicus between 20–22 weeks
• Hegar's Sign: Softening of the lower uterine segment, compressible to the thinness of paper
• Braxton-Hicks: Irregular, painless contractions that begin in the second trimester, becoming progressively more noticeable as term approaches and more pronounced in multiparas
• Ballottement: Maneuver where the fetal part is displaced by a light tap of the examining finger and rebounds quickly
• Palpation of Fetal Outline: May be identified by palpation after the 24th week
• Abdominal striae (stretch marks): Fine, pinkish white or purplish gray lines that some women develop when elastic tissue of skin has been stretched to capacity, Striae seen on breasts, thigh, abdomen and buttocks
• Pregnancy Tests: Done with maternal urine/blood to determine the presence of HCG
  • HCG is a hormone produced by the chorionic villi of the placenta and present in maternal blood and urine shortly after conception
    • Home pregnancy tests using hCG in urine are about 97% accurate (if followed precisely)
    • Professional pregnancy tests more accurate, highly reliable radioimmunoassay (IA) blood test accurate as early as one week after conception

Positive Signs of Pregnancy: Only a developing fetus causes positive signs

• Fetal Heartbeat: May be detected by 10 weeks of gestation using a Doppler device; the mother's heartbeat must also be assessed at the same time
  • Fetal heart rate at term ranges from 110–160 BPM (higher in early gestation, slowing as term approaches)
  • Uterine Souffle: A soft, blowing sound auscultated over the uterus, caused by blood circulating through dilated uterine vessels, corresponding to maternal pulse
• A trained examiner can feel fetal movements in the second trimester; Examiner must distinguish from the mother's intestinal movements
• Identification of embryo or fetus by means of ultrasound photography of the gestational sac is possible at 4-5 weeks gestation, with 100% reliability; Ultrasound is often routinely performed around 20 weeks

Physiologic Changes in Pregnancy

• A woman's body undergoes dramatic changes as she houses/nourishes her growing child. These mostly reverse shortly after giving birth, involving every organ system in her body

Role of Microbiomes in Pregnancy

• Recent research showed that the microbiome (normal microbes in an individual's body) also play a role in maintaining pregnancy, in preparation for labor, and establishing a microbiome that is passed to the newborn
  • Development of an acidic environment in vagina to prevent vaginal infections and play a role in preventing preterm births
  • Microbes in mother's mouth spread by blood to the placenta: Explains the relationship between periodontal disease and preterm birth
  • Microbiomes in breast milk contribute to the establishment of a gut microbe in newborn and important to the health of the infant as they grow/develop

Endocrine System

• Hormones are essential to maintain pregnancy, the dramatic increase in hormones during pregnancy affects all body systems; Most hormones are produced by the corpus luteum initiallyand then later by the placenta
  • Estrogen:
    • Produced by ovaries and placenta
    • Responsible for enlargement of uterus, breasts, and genitals; Promotes fate deposit changes; Responsible for hyperpigmentation of skin; Promotes vascular changes; Promotes development of striae gravidarum; Alters sodium and water retention
  • Progesterone:
    • Produced by corpus luteum and ovary and later by the placenta
    • Maintains endometrium for implantation; Inhibits uterine contractions to prevent abortions; Promotes development of secretory ducts of breasts for lactation; Stimulates sodium secretion; Reduces smooth muscle tone causing constipation, heartburn, and varicose veins
  • T4:
    • Influences thyroid gland size and activity; also increases heart rate
    • Increases basal metabolic rate 23% during pregnancy
  • hCG:
    • Produced early in pregnancy by trophoblast
    • Stimulates progesterone and estrogen by corpus luteum to maintain pregnancy until the placenta takes over; Used in pregnancy tests to determine pregnancy state
  • hPL (chorionic somatomammotropin):
    • Produced by placenta
    • Affects glucose and protein metabolism; has a diabetogenic effect (allows increased glucose to stimulate pancreas and increase insulin levels)
  • MSH (Melanocyte-stimulating hormone):
    • Source: Anterior pituitary gland
    • Causes pigmentation of skin to darken (brown patches on face, dark line on abdomen, darkening moles/freckles, darkening nipples and areola)
  • Relaxin:
    • Produced by corpus luteum and placenta
    • Remodels collagen (causing connective tissue of symphysis pubis to be more moveable and cervix to soften); Inhibits uterine activity
  • Prolactin: Prepares the breasts for lactation
  • Oxytocin:
    • Produced by posterior pituitary gland
    • Stimulates uterine contraction, inhibited by progesterone during pregnancy; After birth, helps keep uterus contracted and stimulates milk ejection reflex during breastfeeding

Reproductive System

• Uterus undergoes the most obvious changes
  • Before pregnancy, the uterus is a small, muscular, pear-shaped pelvic organ weighing 2 oz with a capacity of 10 mL. After pregnancy, gradually increases by adding myometrial cells during the first trimester and the size of individual cells during the second/third trimesters. At term, the uterus reaches the xyphoid process weighing 2.2 pounds with a capacity of about 5000 mL
• Cervix
  • Soon after conception, the cervix changes in color and consistency, with Chadwick's and Goodell's sign appearing
  • Secretion of thick mucus leads to a mucous plug that seals the cervical canal, preventing ascent of vaginal organisms into uterus. The plug is expelled with effacement (cervical thinning) and dilation (opening) near the onset of labor.
• Ovaries
  • The ovaries don't produce eggs during pregnancy
  • The corpus luteum remains on the ovary and produces progesterone to maintain the decidua for the first 6–7 weeks of the pregnancy until placenta takes over
• Vagina
  • Vaginal blood supply increases, causing a bluish color (Chadwick's sign)
  • Vaginal mucosa thickens and ridges (rugae) become prominent
  • Connective tissue softens to prepare for distention as baby is born
  • Vaginal secretions increase with high levels of glycogen, promoting overgrowth of Candida albicans, causing yeast infections; vaginal pH becomes more acidic to protect vagina/uterus from pathogenic microorganisms
  • The most common cause of vaginal discharge is bacterial vaginosis, which causes a milky white vaginal discharge (often no other symptoms). This infection is associated with preterm labor, and commonly treated with antimicrobials between 12–20 weeks of gestation
• Breasts
  • High levels of estrogen and progesterone prepare breasts for lactation
  • In the last few months of pregnancy, a thin yellow fluid called colostrum may be expressed from the breast
    • This "pre-milk" is high in protein, fat-soluble vitamins, and minerals, but low in calories, fat and sugar
    • Colostrum contains the mother's antibodies to diseases and is secreted for the first 2-3 days after birth

Respiratory System

• Oxygen consumption increases by 15% during pregnancy with deeper breathing, but respiratory rate increases only slightly (if at all)
• The expanding uterus exerts pressure upward on the diaphragm, causing it to rise about 1.6 inches In compensation, the rib cage flares, increasing chest circumference about 2.4 inches, and the client may experience dyspnea if the fetus descends into the pelvis
• Increased estrogen levels cause edema of mucous membranes in the nose, pharynx, mouth, and trachea leading to stuffiness, epistaxis, and changes in voice

Cardiovascular System

• Blood volume gradually increases to about 45% greater than the prepregnant state by 32-34 weeks of gestation; this increase provides blood for the exchange of nutrients/oxygen/waste products, needs of expanded maternal tissue, and reserve for blood loss at birth
• Cardiac output increases as more blood is pumped from the heart with each contraction, the pulse rate increasing by 10-15 BPM. Blood pressure does not increase with the higher blood volume due to decreased resistance to blood flow though the vessels. High blood pressure calls for attention.
• Supine hypotension syndrome occurs if woman lies on her back, allowing the heavy uterus to compress her inferior vena cava, reducing return of blood to the heart and circulation to the placenta (causing fetal hypoxia)
  • Symptoms may be faintness, lightheadedness, dizziness, and agitation. Prevent by displacing the uterus to side or left lateral position. If patient must lie flat, use a small rolled towel/wedge under her right hip will also help displace the uterus
• Orthostatic hypotension may occur when raising from recumbent position, decreasing cardiac output b/c venous return from the lower body suddenly drops. Patients may experience palpitations from increased thoracic pressure
• Dilution anemia (pseudoanemia): Although both plasma and red blood cells increase during pregnancy, the fluid part of blood increases more than RBC components
• White blood cell count also increases about 8% and returns to pre-pregnancy levels by the sixth day postpartum
• Increased levels of clotting factors VII, VIII, and X and plasma fibrinogen during second/third trimesters helps prevent excess bleeding if placenta separates, but also increases the possibility of thrombophlebitis during pregnancy
• Effects of exercise on the CV system must be reviewed before an exercise plan is implemented
• Venous pressure may increase in the femoral veins, given size/weight of the uterus, resulting in varicose veins (some women)

Gastrointestinal System

• Growing uterus displaces stomach/intestines toward back and sides of abdomen; Increased salivary secretions; Increased blood vessel development due to high estrogen levels makes the mucous membranes tender and bleed more easily
• The growing fetus increases maternal appetite and thirst, while decreased gastric secretions, slowed emptying of the stomach, and motility of intestines leads to bloating, constipation, and hemorrhoids. Relaxation of the cardiac sphincter causes heartburn.
• Altered glucose metabolism increases insulin resistance during pregnancy Allows greater use of glucose by the fetus and places the woman at risk of developing gestational diabetes
• Progesterone and estrogen relax muscle tone of the gallbladder, resulting in retention of bile salts (can lead to pruritus during pregnancy)

Urinary System

• Excretes waste products for both mother and fetus, thus, glomerular filtration rate increases. Renal tubules increases reabsorption of substances body needs
• Glycosuria/proteinuria are more common because water is retained to increase blood volume/dissolve nutrients provided to fetus
• Relaxing effects of progesterone cause the renal pelvis and ureters to lose tone, decreasing peristalsis in the bladder; diameter of ureters and bladder capacity increase, causing urine stasis, which makes pregnant women more prone to bladder infections
• Consuming 8 glasses of water per day reduces the risk of urinary stasis
• The enlarging uterus causes frequency, especially in first and third trimesters, and bladder can hold up to 1500 mL of urine. Changes in the renal system may take 6-12 weeks to return to normal after delivery

Fluid and Electrolyte Balance

• Sodium retention is influenced by many factors, including elevated hormones of pregnancy because the fetus uses a lot of the sodium
  • The remainder is in the maternal circulation and can cause maternal accumulation of fluid (edema)
• Fluid retention may cause problems if woman in labor is given oxytocin because it has an antidiuretic effect, resulting in water intoxication
  • Report agitation and delirium (signs of water intoxication); An accurate I&O should be recorded during labor and immediate postpartum phase

Integumentary and Skeletal Systems

• In addition to pigmentation changes already discussed early in pregnancy, sweat and sebaceous glands become more active to dissipate heat from the woman and fetus, and small red elevations of skin with lines radiating from the center (spider nevi) may occur; The palms of the hands may become deeper red, and most skin changes are reversed shortly after birth
• As the child grows, the woman's posture changes (the anterior part of her body becomes heavier with expanding uterus, and lordotic curve in her lumbar spine becomes more pronounced)
  • Clients often experience low backaches/rounding of the shoulders in later pregnancy
  • Pelvic joints relax with hormonal changes, and fetal presenting part enters pelvic brim causing a "waddling gait" due to slight separation of the symphysis pubis
  • Change in center of gravity and joint instability predispose her problems with balance; Safety interventions a part of prenatal education

Nutritional Needs

• Important during pregnancy and lactation; a high correlation exists between maternal diet and fetal health
• To ensure that deficiencies do not occur during the critical first week, the nurse explains to women of childbearing age the value of eating a well-balanced diet
• A personalized portion-sized diet plan that includes individualized advice on activity level is available online
  • Women who follow this guide before pregnancy will be well-nourished at the time of conception
• U.S. Department of Agriculture site provides specific recommendations for pregnant women (See page 60); Each food group is given an amount to be eaten per day based on trimester
  • Calorie increase of about 340 cal/day in second trimester and 450 cal/day in the third provides for the growth of fetus, placenta, amniotic fluid, and maternal tissues

Nursing Interventions for Nutrition during Pregnancy

• Determine age, parity, present weight, prepregnant nutritional status, and food preferences/intolerances
• Determine socioeconomic and cultural factors that may influence food choices
• Review specific nutritional needs, provide written materials and modify information based on culture/food intolerances
• Teach the purpose of and maintain a food diary
• Maintain and review the patient's actual weight at each visit

Weight Gain

• The suggested weight gain is based on Body Mass Index (BMI), which considers the height and weight
  • Normal BMI for women is between 18.5-24.9
• Current guidelines for weight gain during pregnancy with a single fetus:
  • Normal weight women: 25-35 lb
  • Underweight women: 28-40 lb
  • Overweight women: 15-25 lb
  • Obese women: 11-20 lb
• Women should gain up to 4.4 lb during the first trimester, then approximately 1 lb per week during rest of pregnancy
• Women should understand weight gain distribution between uterus, fetus, placenta, amniotic fluid, breasts, blood volume, extravascular fluid and reserves

Nutritional Requirements

• Protein is needed for metabolism and to support the growth/repair of the maternal and fetal tissues with an intake of 60 g/day
  • The best sources of protein are meat, poultry, fish and dairy products; beans, lentils and legumes, breads, cereals, seeds, and nuts in combination with plant/animal protein provide amino acids necessary for building tissues
  • Avoid Albacore tuna/swordfish/shark/king mackerel given high mercury, and raw meat and eggs for contamination
• Increase calcium requirements nearly 50% to 1000mg/day, mainly from dairy products, enriched cereals, legumes, nuts, dried fruit, broccoli, green leafy vegetable, canned salmon, and sardines
  • Supplements necessary for women who don't drink milk or eat sufficient amounts of equivalent products; Required for individuals under the age of 25 because bone density is incomplete
  • Take separately from iron with adequate Vitamin D to enhance absorption
• Heavy demand for iron in pregnancy given fetal storage for needs in first 3-6 months of life (pregnant women increases erythrocyte production)
  • A recommendation is 30 mg/day for pregnant women, from heme (red/organ meats, best absorption) and nonheme (plants)
  • Sources: Molasses, whole grains, iron-fortified cereals/breads, dried fruits, dark green leafy vegetables
  • Supplements are ordered beginning second trimester after morning sickness decreases for hard to get it from the diet.
  • They should be taken on an empty stomach, but if not tolerated, with food. DO NOT take with coffee/tea/high calcium foods; Vitamin C helps with absorption

Vitamins and Minerals

• Adequate vitamin intake is necessary. Prenatal vitamins are routinely prescribed, but high intake of certain vitamins can result in fetal anomalies, so B6 and ginger are often used for nausea relief
• Vitamin D is important for normal placental implantation, fetal growth, and development. Egg yolk, salmon, cod liver oil, and fortified milk are good sources; Metabolized with 5-10 minutes of sun exposure on the arms/legs/face 2-3 times a week, deficiency related to multiple sclerosis as an adult
• Folic Acid is a water-soluble B vitamin, essential for red/white blood cell formation and maturation in bone marrow that can reduce incidence of neural tube defects (spina bifida/anencephaly) when taken before conception
  • Sources include liver, lean beef, kidney, lima beans, dried beans, potatoes, whole wheat bread, peanuts and fresh dark green leafy vegetables
• Pregnant women should drink 8-10 8oz glasses of fluid mostly water
  • Avoid caffeinated drinks. Intake Women at risk for having insufficient amniotic fluid have had successful outcomes by increasing fluie
• Sodium is necessary for maintaining normal levels in plasma/bone/brain/muscle; DO NOT restrict, and avoid additional intakes
• Special considerations apply to pregnancy in adolescents (resistance, ambivalence and inconsistency) where inadequate weight gain and nutrient deficits is likely to occur
  • Consider the girl’s growth and nutritional needs, body image, and peer pressure; Promote the adolescent to find nutritious food that allows her to socialize; WIC and food-stamp programs may be necessary
• Vegetarian or Vegan Diets
  • Focus on protein-rich foods (soymilk, tofu, tempeh, beans), prenatal vitamins, and consult with a registered dietician
• Pica
  • Refers to craving/ingestion of non-food substances (clay, starch, raw flour, cracked ice); Interfere with iron absorption, cause fecal impaction, and harm necessary nutrients
  • Difficult to break, nurses to educate, nonjudgmentally, about the importance of good nutrition
• Lactose intolerance
  • Deficiency of an enzyme that digests the sugar milk with the clinical symptoms including abdominal distention, flatulence, nausea, vomiting and loose stools
  • Can be managed with a calcium supplement
• Cultural Preferences:
  • Some people believe certain foods include a dominant trait that affects the "humoral balance" in the body
  • Nutritional education must include these beliefs

Gestational Diabetes

• Diagnosed during pregnancy with calories evenly distributed in 3 meals and 3 snacks
• GDM mother are susceptible to nighttime hypoglycemia given fetal use of glucose if mother sleeps
• Registered dietician may supervise to manage glycemic control to prevent abnormally large newborns (stillborn baby)

Nutrition for Lactation

• The mother should have about 500 calories more than nonpregnant women; Indicator is a stable maternal/increasing newborn weight
• Continue protein/calcium/iron/vitamin supplements (matched to the infant's demand of mother’s supply)
• Fluids sufficient to relieve thirst and replace fluids losses via breastfeeding should be taken (8-10 caffeine-free glasses)
• Drugs should be taken only with HCP advice (secrete in breastmilk)

Exercise During Pregnancy

• Mild/moderate exercise is beneficial during normal pregnancy; vigorous exercise should be avoided. Must gather history and education with the goal to maintain fitness, not weight loss
  • Elevated maternal temperatures can decrease fetal circulation/function but should not exceed 100.4o F (i.e., hot tubs, saunas), and heat exposure is associated with neural tube defects
  • Hypotension (exercise positioning and orthostatic) can decrease blood flow to the fetus causing fetal hypoxia, and cardiac output is altered during exercise. Increased workload/venous pooling result in decreased output, prolonged/strenuous exercise leads to blood diverted from viscera, uterus, and placenta, and moderate exercise is preferred
• Exercise can cause changes in oxygen consumption and hormones (increase in risk of problems or premature labor)
• Moderate exercise several times/week from the 8th week through delivery is advised for better self-image, less musculoskeletal discomfort, and return to prepregnancy weight: Warmup/cool-down, avoid overheating, drink liquids, beginning exercise program
  • Balanced meal 2-3 hours before/after exercise. Avoid scuba/sky diving, horse back riding/skiing, and modify intensity with the “talk test”
  • Safe Exercises include; pelvic tilt, tailor-sitting, proper stretching, participate in step aerobics

Common Discomforts

• Smoking has a deleterious effect on neural development, relationship to psychiatric disorders, affects developing eggs, and is associated with preterm birth
  • Do not replace smoking with nicotine patches given a risk of long-term lung problems
    • Patient education regarding smoking/drug use should happen early in pregnancy
• Travel is generally safe up to 36 weeks gestation with precautions given increased clotting factor levels (avoid sitting for long periods) and infection risks with hand hygiene/dietary precautions essential given diarrhea
  • Encouraging High Potassium foods, medical follow ups; comfy shoes, mosquito nets, and insect repellant with DEET is usually safe after first trimester

Nursing Intervention for Discomforts

• See Table 4.6*
• Nausea & Vomiting
  • Avoid an empty stomach.
  • Eat small, frequent meals, dry crackers, or toast 30 minutes to one hour before rising.
  • Avoid greasy, odorous, or gas-forming foods.
  • Drink fluids in between meals; May lead to hyperemesis gravidarum
  • Acupressure wrist bands or diclegis maybe prescribed
• Breast Tenderness Caused by increased vascular supply and hypertrophy of breast tissue
  • Wear a supportive bra to alleviate tingling and tenderness. May occur during first trimester. Avoid soap to nipples to prevent cracking.
• Urinary Frequency Caused by pressure of uterus in both the first and third trimesters
  • Progesterone relaxes smooth muscles of the bladder
  • Practice Kegel exercises and avoid when urge is felt
  • Limit caffeine; decrease fluids in evening especially if nocturia
• Vaginal Discharge Caused by increased production of mucus from endocervical glands due to high estrogen
  • Should remain clean and dry
  • Bathe/shower daily avoid tight underwear
• Heartburn Caused by increased production of progesterone causing relaxation of esophageal sphincter
  • Sit up, avoid overeating avoid greasy and gassy foods .Liquid Antacids
• Constipation & Flatulence Caused by progesterone causing a sluggish bowel with increased water absorption resulting in hard stool.
  • Pressure
    • Increase Fluid, Roughage, bowel movements
      • Avoid oil
• Hemorrhoids occur due to enlargement of pelvis, constipation, and descent of fetal head into the pelvis
  • Use ointment, pads or suppositories. Sit baths; Increase fiber
• Backaches
  • Maintain good posture, squat when picking up objects, exercise. Rest
• Round Ligament Pain: Abdominal ligaments stretched by enlarging uterus causes pain in lower abdomen after sudden movements.
  • Avoid jerky and quick movements; pillows/body mechanics
• Leg Cramps: vessel circulation and muscle fatigue: imbalance in Calcium and phosphorus
  • Stretch and dorsiflex foot: evaluate calcium intake
• Headache Tension & Fatigue: volume and heart rate causes dilation and distention of cerebral vessels.
  • Relax, meals, support, medication may be used to treat
• Varicose Veins Progesterone & Enlarging uterus causes pressure of the veins: vulva and rectum legs
  • Prolonged Sitting - Rest feet Elevate - Support hose no tights -Stimulate venous return

Psychological Adaptations

• Pregnancy creates a variety of confusing feelings for all members of the family
• Identify and manage the concerns to have a positive outcome for pregnancy
• Identify barriers to care: This include that is health insurance coverage, financial problems, knowledge deficit concerning community resources, lack of transportation, housing, and domestic violence

Impact on Mother: 4 maternal tasks

1. Safe passage for herself and fetus
2. Acceptance of herself and the fetus
3. Self giving and receiving from others.
4. Committing to the child thru labor and the pregnancy.

Psychosocial Adaptations in the First trimester

• May have a hard time believing
• Ambivalence and conflicting Feeling
• Focuses on herself
• Reassure moodiness will stabilize

Second Trimester Psychological Adaptations in the

• The fetus becomes real
• Take role as expectant mother
• Narcissism body and health
• Learns what it means to be a parent

Third Trimester Psychosocial Adaptations

• Dramatic Changed Body
• Mood Swinga
• Prepares for the infant the pregnancy the end
• Discomforts
• Needs family understanding and support

Psychological Adaptation impacts the Father

1.Similar feelings and expectations as moms 2.Begins new stage of parenthood -Announcement of pregnancy is shared -Adjustment to finances and new role to come -In Focus and participates -Make lifestyle changes

Special Group Adaptations & Impact

• Pregnant Adolescents -Conflict w unplanned Pregnancy -Needs to prepare for mother hood -Nurse must assess to assist with motherhood -Anticipate resistive - Ambivalence -Inconsistency
• Elder Mother -Adjusts well with pregnancy -Higher Risk group -Couples are at ease being parents

Single Mother

• Special Needs -Nurse must be able supportive and not judgmental -Help achieve the pregnancy
• Impact From 1.Single father a. May show support and involvement b. May delay plans for the marriage 2. Grand Parents a. Many may not be excited to be becoming b.First grand child causes greatest excitement c. Distances

Nurse Can Negotiate Difficult Situations

Single Father

a. Nurse Can Negotiate Difficult Situations

Impact For Siblings

• Preparation is important for the new baby arriving
• Special attention

Steps for Prenatal Education

1. Interactive Process
2. Healthy mom and child
3. Positive attitudes and perceptions
4. Learning with positive reactions
5. Select Proper foods
6. Perform Exercises

• Nurse in involved throughout to Evaluate through* 1: History 2CulturalNeeds 3InadequateKnowledge 4:Plan Goals 5: Identify and clarify the outcome 6:Teach facts

Methods of ChildBirth preparation

• Dick Read Breaks cycle of tension and pain
• Bradley Method- First to make the father Part of Labor
• Lamaze: Relaxation Thru Childbirth.
  • Learn the tension techniques
  • Thru Body Senses