Pregnancy and Psych Meds: Assessment and Breastfeeding

Assessment of Childbearing Women

Physiological and Anatomical Changes

• Pregnancy brings about various physiological and anatomical changes in the body, mainly influenced by estrogen and progesterone hormones.
• Changes occur in the skin, hair, and nails, including:
  • Stretch marks (striae gravidarum) on the abdomen, breasts, thighs, and buttocks
  • Hyperpigmentation on the face (chloasma) and abdomen (linea nigra)
  • Darkening of areolae, nipples, axillae, umbilicus, and perineum
  • Vascular changes, such as spider nevi and palmar erythema
  • Acne vulgaris (unpredictable response)

Skin Changes

• Breast changes:
  • Tingling sensations and tenderness
  • Enlargement of breast and nipple
  • Hyperpigmentation of areola and nipple
  • Enlargement of Montgomery tubercles
  • Prominence of superficial veins
  • Development of striae
  • Expression of colostrum in the second and third trimesters
• Skin changes:
  • Darkening of scars and moles
  • Gingival bleeding and hypertrophy

Cardiovascular System

• Increase in cardiac output and maternal blood volume by 40% to 50%
• Heart rate increases by 10 to 15 beats per minute
• Systolic murmurs may be heard

Peripheral Vascular System

• Physiologic anemia (pseudoanemia) commonly develops
• Clients may experience dizziness and lightheadedness due to increased blood volume
• Arterial blood pressure stabilizes and symptoms resolve in the third trimester

Abdomen

• Abdominal muscles stretch as the uterus enlarges
• Diastasis recti abdominis may occur (permanent separation of rectus abdominis muscles)
• Lower pelvic discomfort may result from stretching of the ligaments, especially the round ligaments

Genitalia

• Uterus changes:
  • Weighs approximately 44 g before conception
  • Can hold approximately 10 mL of fluid
  • Grows to weigh approximately 1,000 g and hold 5 L of amniotic fluid during pregnancy
• Uterine changes:
  • Ovulation ceases
  • Uterine endometrium thickens
  • Number and size of uterine blood vessels increase
  • Uterus should be palpated at the top of the symphysis pubis at 10 to 12 weeks' gestation

Anus and Rectum

• Constipation is a common problem during pregnancy
• Progesterone decreases intestinal motility
• Iron supplementation can contribute to constipation
• Hemorrhoids may develop due to pressure on the venous structures

Musculoskeletal System

• Not mentioned

Neurologic System

• Pain or tingling feeling in the thigh: Caused by pressure on the lateral femoral cutaneous nerve
• Carpal tunnel syndrome: Caused by pressure on the median nerve
• Leg cramps: Caused by inadequate calcium intake
• Dizziness and lightheadedness: In early pregnancy, caused by blood pressure slightly decreasing due to vasodilation and decreased vascular resistance; in later pregnancy, caused by compression of the vena cava and aorta

Collecting Subjective Data

• Questions to ask the client:
  • Weight changes and normal weight before pregnancy
  • Fever or chills since the last menstrual period
  • Nasal "stuffiness" and nosebleeds
  • Throat problems
  • Nausea or vomiting
  • Bowel habits
  • Urinary tract symptoms
  • Vaginal bleeding, leakage of fluid, or discharge
  • Breast pain, lumps, or fluid leakage
  • Problems at home or work
  • Depression or feelings of sadness
  • Thoughts of suicide
  • Professional counseling history

Personal Health History

• Questions to ask the client:
  • Age at the time of delivery
  • Genetic relationships to the baby's father
  • Number of times pregnant
  • Pregnancy history, including child's name, birth date, birth weight, sex, gestational age, and type of delivery
  • Complications during previous pregnancies
  • Neonatal complications
  • Perinatal or neonatal losses
  • Abortions (spontaneous or elective)
  • Hydatidiform mole or ectopic pregnancy
  • Regular menstrual periods
  • Last menstrual period
  • Bleeding or spotting since the last period
  • Birth control methods used
  • Reproductive surgery or abnormal Pap smear results### Personal Health History
• Infections:
  • Infections during pregnancy need treatment
  • Partner's history of STI and treatment is important
  • Vaginal infections (e.g., bacterial vaginosis, yeast infection) require treatment
  • Metronidazole may be used in the second or third trimester
• Blood Type and Rh Factor:
  • Rh-negative mothers should receive Rho immunoglobulin at 28 weeks' gestation
  • Importance of knowing blood type and Rh factor for preventing isoimmunization
• Medical Problems:
  • Identification of medical problems is crucial during pregnancy
  • Certain medical conditions put the mother at high risk for complications
  • Examples: heart trouble, rheumatic fever, hypertension, diabetes, lung problems, etc.
• Medications and Allergies:
  • Identification of medication allergies is necessary to prevent complications
  • Discussion of medications taken during pregnancy is important

Family History

• Birth Defects and Inherited Diseases:
  • Identification of birth defects or inherited diseases in the family is important
  • Examples: cleft lip or palate, hemophilia, mental retardation, etc.
  • Cystic fibrosis screening should be offered to all clients during preconceptual counseling
• Cardiovascular Disease:
  • Cardiovascular disease may be inherited
  • Family history of heart trouble or rheumatic fever before age 50 years is important

Lifestyle and Health Practices

• Substance Abuse:
  • Daily alcohol intake puts the fetus at risk for fetal alcohol syndrome
  • Smoking correlates with an increased incidence of perinatal mortality, preterm delivery, and other complications
  • Cocaine use during pregnancy increases the rate of spontaneous abortions and abruptio placentae
• Nutrition and Diet:
  • Maternal nutrition has a direct relationship to maternal-fetal well-being
  • Importance of consuming a balanced diet with sufficient vitamins and minerals
• Exercise and Activity:
  • Daily exercise is highly recommended during pregnancy
  • Lifting heavy weights during pregnancy has been shown to increase spontaneous abortion

Toxic Exposure

• Chemical and Radiation Exposure:
  • Assessment of toxic exposure can identify potential teratogens to the fetus
  • Importance of proper handling of cat litter to prevent toxoplasmosis

Physical Assessment

• Blood Pressure:
  • Importance of accurate measurement of blood pressure during pregnancy
  • Elevated blood pressure may indicate chronic hypertension, hydatidiform mole pregnancy, or thyroid storm
• Temperature:
  • Normal temperature range during pregnancy is 97°–98.6°F
  • Elevated temperature may indicate infection
• Height and Weight:
  • Importance of establishing a baseline height and weight during pregnancy
  • Normal weight gain during pregnancy is 25-35 pounds### Physical Assessment: Head and Neck
• Inspect and palpate the neck: normal findings include smooth, non-tender, small cervical nodes may be palpable
• Abnormal findings: hard, tender, fixed, or prominent nodes may indicate infection or cancer

Physical Assessment: Eyes

• Inspect eyes: normal findings include pupils equal and round, reactive to light, and accommodate
• Abnormal findings: narrowing of arterioles or AV nicking may indicate hypertension

Physical Assessment: Ears

• Inspect the ears: normal findings include clear tympanic membranes and visible landmarks
• Abnormal findings: red and bulging tympanic membrane with pus may indicate infection

Physical Assessment: Mouth, Throat, and Nose

• Inspect the mouth: normal findings include hypertrophy of gingival tissue, bleeding may occur due to brushing teeth or dental examinations
• Abnormal findings: epulis nodules may be present, representing benign changes of the gum that may spontaneously resolve after pregnancy
• Inspect the throat: normal findings include pink, no redness or exudate
• Abnormal findings: red throat, exudate present, and tonsillary hypertrophy indicate infection

Physical Assessment: Thorax and Lungs

• Inspect, palpate, percuss, and auscultate the chest: normal findings include increased anteroposterior diameter, thoracic breathing, and slight hyperventilation
• Abnormal findings: dyspnea, rales, rhonchi, wheezes, and unequal breath sounds may indicate respiratory distress

Physical Assessment: Breasts

• Inspect and palpate the breasts and nipples: normal findings include venous congestion, prominence of veins, and breast size increase
• Abnormal findings: nipple inversion, localized redness, pain, and warmth could indicate mastitis, and breast cancer may cause bloody discharge and skin retraction

Physical Assessment: Heart

• Auscultate the heart: normal findings include normal sinus rhythm and soft systolic murmurs
• Abnormal findings: irregular rhythm, progressive dyspnea, palpitations, and markedly decreased activity tolerance may indicate cardiovascular disease

Physical Assessment: Peripheral Vascular

• Inspect face and extremities: normal findings include dependent edema in the third trimester
• Abnormal findings: calf pain, positive Homans’ sign, generalized edema, and diminished pedal pulses may indicate thrombophlebitis

Physical Assessment: Abdomen

• Inspect the abdomen: normal findings include striae, linea nigra, and uterine size corresponding to gestational age
• Palpate the abdomen: normal findings include the uterus palpable beginning at 10-12 weeks' gestation
• Abnormal findings: abnormal masses palpable in the abdomen may indicate uterine fibroids or hepatosplenomegaly

Physical Assessment: Fetal Movement

• Palpate for fetal movement after 24 weeks: normal findings include fetal movement felt by the mother by approximately 18-20 weeks
• Abnormal findings: if fetal movement is not felt, the estimated delivery date may be wrong or intrauterine fetal demise may have occurred

Physical Assessment: Fundal Height

• Measure fundal height: normal findings include uterine size approximately equal to the number of weeks of gestation
• Abnormal findings: measurements beyond 4 cm of gestational age may indicate multiple gestation, polyhydramnios, fetal anomalies, or macrosomia, and measurements smaller than expected may indicate intrauterine growth retardation

Physical Assessment: Fetal Position

• Using Leopold's maneuvers, palpate the fundus, lateral aspects of the abdomen, and the lower pelvic area: normal findings include a longitudinal lie, cephalic, breech, or shoulder presentation
• Abnormal findings: a longitudinal lie, cephalic, breech, or shoulder presentation may indicate complications in fetal position

Physical Assessment: Fetal Heart

• Determine the location, rate, and rhythm of the fetal heart: normal findings include a fetal heart rate ranging from 120-160 beats/min
• Abnormal findings: inability to auscultate fetal heart tones with a fetal Doppler at 12 weeks may indicate retroverted uterus, uncertain dates, fetal demise, or false pregnancy