Antenatal Care Module 2023-2024 PDF

FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CL...

FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) MODULE 4- CARE OF THE MOTHER AND THE FETUS DURING PERINATAL PERIOD OVERVIEW During pregnancy, a woman’s body changes in many ways due to the effect of hormones. These changes can sometimes be uncomfortable, but most of the time they are normal and enable her to nourish and protect the fetus, prepare her body for labor, and develop her breasts for the production of milk. Knowing such information can help you protect the health of both women and their fetus for the next 9 months. In this module, you will learn about some of the psychological and physiologic changes that occur with pregnancy and the relationship of the changes to pregnancy diagnosis. By understanding the normal changes of pregnancy, you can analyze how the physiologic and psychological changes of pregnancy affect family functioning, and develop ways to make nursing care more family-centered. A basic knowledge of these changes and adaptations is also critical for Implementing nursing care, such as health teaching related to the expected changes of pregnancy wherein You can reassure the woman, detect and intervene more quickly if you notice any abnormalities. This module also examines the key events that take place during conception and fetal development. The birth of the newborn begins with conception (union of single egg and sperm) and continues throughout the period of fetal growth and maturation. During this time, many complex events take place: fertilization, implantation to the hormonally prepared uterus, development of the placenta, umbilical cord, amniotic fluid and amniotic membrane. While the fetus is growing, the mother’s body changes and adapts to the demands of the growing fetus. The role of the nurse is paramount in achieving mother’s optimal functioning to support the needs of the fetus. LEARNING OUTCOMES 1. After completing the module, you should be able to: 2. Assess mother and Child’s health status with the use of specific methods and tools to address existing health needs. 3. Formulate nursing diagnosis/es focusing on health promotion and disease prevention related to mother and child health. 1|P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) 4. Implement safe and quality nursing interventions addressing health needs affecting women from pregnancy to post-partum and children from perinatal to adolescent stage. 5. Conduct individual/group health education activities based on the priority learning needs of mother and child. 6. Evaluate with the client the health outcomes of nurse-client working relationship. 7. Institute appropriate corrective actions to prevent or minimize harm arising from adverse effects. 8. Manage resources (human, physical, financial, time) efficiently and effectively. 9. Use appropriate technology to support the delivery of care to the mother and child. 10. Adhere to protocols and principles of confidentiality in safekeeping and releasing of records and other information. 11. Integrate concepts of growth and development of fetus by gestational age in weeks and application of appropriate nursing care to the mother during childbearing years. 12. Assess fetal growth and development through maternal and pregnancy landmarks. 13. Formulate nursing diagnoses related to the needs of a fetus. 14. Implement nursing care to help ensure a safe fetal environment 15. Provide individual/group health education activities to promote fetal development. 16. Evaluate expected outcomes for the achievement and effectiveness of care. TOPIC OUTLINE: Care of the Mother during the Perinatal Period A. Prenatal Care 1. Care of Mother a) Assessment b) Process of conception 2. Antenatal visit a) Physiologic changes b) Common discomforts during 1st , 2nd and 3rd trimester c) Nutrition and Exercise d) Identifying danger signs and complications e) Common teratogens 2|P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) f) Developmental tasks during pregnancy g) Diagnostic procedures 3. Birthing Plan a) Nursing Diagnosis b) Planning and Intervention c) Evaluation d) Documentation B. Care of the Fetus 1. The Process of Conception 2. Embryonic and Fetal structures 3. Fetal development 4. Assessment of fetal growth and development 5. Nursing diagnosis: fetal growth and development 6. Nursing outcomes: fetal growth and development 7. Implementing nursing care 8. Evaluating nursing care CARE OF THE MOTHER PHYSICAL AND PSYCHOLOGIC CHANGES OF PREGNANCY REPRODUCTIVE SYSTEM OVARIES Ovulation stops with pregnancy because of the active feed- back mechanism of estrogen and progesterone produced by the corpus luteum early in pregnancy and by the placenta later in pregnancy. This feedback causes the pituitary gland to halt production of FSH and luteinizing hormone (LH). Without stimulation from FSH and LH, ovulation does not occur. The corpus luteum that was created after the ovulation that led to the pregnancy continues to increase in size on the surface of the ovary until about the 16th week of pregnancy, by which time the placenta takes over as the chief provider of progesterone and estrogen. The corpus luteum, no longer essential for the continuation of the pregnancy, regresses in size and appears white and fibrous on the surface of the ovary (a corpus albicans). 3|P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) VAGINA Under the influence of estrogen, the vaginal epithelium and underlying tissue become hypertrophic and enriched with glycogen; structures loosen from their connective tissue attachments in preparation for great distention at birth. This increase in the activity of the epithelial cells results in a white vaginal discharge throughout pregnancy, leukorrhea (a presumptive sign). An increase in the vascularity of the vagina, beginning early in pregnancy, parallels the vascular changes in the uterus. The resulting increase in circulation changes the color of the vaginal walls from the normal light pink to a deep violet (Chadwick’s sign), a probable sign of pregnancy. Vaginal secretions during pregnancy fall from a pH of greater than 7 (an alkaline pH) to 4 or 5 (an acid pH). This occurs because of the action of Lactobacillus acidophilus, bacteria that grow freely in the increased glycogen environment and by so doing increase the lactic acid content of secretions. This changing acid content helps to make the vagina resistant to bacterial invasion for the length of the pregnancy. This change in pH also, unfortunately, favors the growth of Candida albicans, a species of yeast-like fungi. CERVIX In response to the increased level of circulating estrogen from the placenta during pregnancy, the cervix of the uterus be- comes more vascular and edematous. Increased fluid between cells causes it to soften in consistency, and increased vascularity causes it to darken from a pale pink to a violet hue. The glands of the endocervix undergo both hypertrophy and hyperplasia as they increase in number and distend with mucus. A tenacious coating of mucus fills the cervical canal. This mucous plug, called the operculum, acts to seal out bacteria during pregnancy and therefore helps prevent infection in the fetus and membranes. Softening of the cervix in pregnancy (Goodell’s sign) is marked. The consistency of a nonpregnant cervix may be compared with that of the nose, whereas the consistency of a pregnant cervix more closely resembles that of an earlobe. This softening is so marked it is rated as a probable diagnostic sign of pregnancy. Just before labor, the cervix becomes so soft that it takes on the consistency of butter or is said to be “ripe” for birth (Kahn & Koos, 2007). 4|P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) UTERUS The most obvious alteration in a woman’s body during pregnancy is the increase in the size of the uterus to accommodate the growing fetus. Over the 10 lunar months of pregnancy, the uterus increases in length, depth, width, weight, wall thickness, and volume. Length increases from approximately 6.5 to 32 cm. Depth increases from 2.5 to 22 cm. Width expands from 4 to 24 cm. Weight increases from 50 to 1000 g. Early in pregnancy, the uterine wall thickens from about 1 cm to about 2 cm; toward the end of pregnancy, the wall thins to become supple and only about 0.5 cm thick. The volume of the uterus increases from about 2 mL to more than 1000 mL. The uterus can hold a 7-lb (3175-g) fetus plus 1000 mL of amniotic fluid for a total of about 4000 g at term. A woman becomes aware of her growing uterus early in pregnancy; by the end of the 12th week, the uterus is large enough to be palpated as a firm globe under the abdominal wall, just above the symphysis pubis. An important factor to assess regarding uterine growth is its constant, steady, predictable increase in size. By the 20th or 22nd week of pregnancy, for example, it should reach the level of the umbilicus. By the 36th week, it should touch the xiphoid process and can make breathing difficult. About 2 weeks before term (the 38th week) for a primigravida, a woman in her first pregnancy, the fetal head settles into the pelvis to prepare for birth, and the uterus returns to the height it was at 36 weeks. This event is termed lightening, because a woman’s breathing is so much easier it seems to lighten a woman’s load. When lightening will occur is not predictable in a multipara (a woman who has had one or more children). In these women, it may not occur until labor begins. A bimanual examination (one finger of an examiner is placed in the vagina, the other hand on the abdomen) can demonstrate that, with pregnancy, the uterus feels more anteflexed, larger, and softer to the touch than usual. At about the sixth week of pregnancy (at the time of the second missed menstrual period), the lower uterine segment just above the cervix becomes so soft that when it is compressed between examining fingers on bimanual examination, the wall cannot be felt or feels as thin as tissue paper. This extreme softening of the lower uterine segment is known as Hegar’s sign. 5|P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) During the 16th to 20th week of pregnancy, when the fetus is still small in relation to the amount of amniotic fluid present, ballottement (from the French word balloter, meaning “to toss about”) may be demonstrated. On bimanual examination, if the lower uterine segment is tapped sharply by the lower hand, the fetus can be felt to bounce or rise in the amniotic fluid up against the top examining hand. Uterine contractions begin early in pregnancy, at least by the 12th week, and are present throughout the rest of pregnancy, becoming stronger and harder as the pregnancy advances. They may be felt by a woman as waves of hard- ness or tightening across her abdomen. An examining hand may be able to feel a contraction as well, and an electronic monitor will be able to measure the frequency and length of such contractions. These “practice” contractions, termed Braxton Hicks contractions, serve as warm- up exercises for labor and also increase placental perfusion. BREASTS She may experience a feeling of fullness, tingling, or tenderness in her breasts because of the increased stimulation of breast tissue by the high estrogen level in her body. As the pregnancy progresses, breast size increases because of hyperplasia of the mammary alveoli and fat deposits. The areola of the nipple darkens, and its diameter increases from about 3.5cm (1.5in) to 5 or 7.5cm (2or3in). There is additional darkening of the skin surrounding the areola in some women, forming a secondary areola. As vascularity of the breasts increases, blue veins may become prominent over the surface of the breasts. The sebaceous glands of the areola (Montgomery’s tubercles) enlarge and become protuberant. The secretions from these glands 6|P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) are what keeps the nipple supple and helps to prevent nipples from cracking and drying during lactation. By the 16th week (during the second trimester), the breasts begin to produce colostrum. This is the precursor of breastmilk. It is a yellowish secretion from the nipples, which thickens as pregnancy progresses. It is extremely high in protein and contains antibodies (special proteins produced by the mother’s immune system) that help to protect the newborn baby from infection. RESPIRATORY SYSTEM A local change that often occurs in the respiratory system is marked congestion, or “stuffiness,” of the nasopharynx, a response to increased estrogen levels. As the uterus enlarges during pregnancy, a great deal of pressure is put on the diaphragm and, ultimately, on the lungs. This can displace the diaphragm by as much as 4 cm upward. This crowding of the chest cavity causes an acute sensation of shortness of breath late in pregnancy, until lightening relieves the pressure. A woman’s vital capacity (the maximum volume exhaled after a maximum inspiration) does not decrease during pregnancy because, they can still expand horizontally. Residual volume (the amount of air remaining in the lungs after expiration) is decreased up to 20% by the pressure of the diaphragm. Tidal volume (the volume of air inspired) is increased up to 40% as a woman draws in extra volume to increase the effectiveness of air exchange. Total oxygen consumption increases by as much as 20%. Increased ventilation (mild hyperventilation) to blow off excess CO2 begins early in pregnancy. At full term, a woman’s total ventilation capacity may have risen by as much as 40%. This increased ventilation may become so extreme that a woman develops a respiratory alkalosis or exhales more than the usual CO2. To compensate, kidneys excrete plasma bicarbonate in urine. This results in increased urination or polyuria, an early sign of pregnancy. The cumulative effect of these respiratory changes is often experienced by a woman as chronic shortness of breath. Although her breathing rate is more rapid than usual (18–20 breaths per minute), this is normal for pregnancy. The total respiratory changes and the compensating mechanisms that occur in the respiratory system can be described as compensate for blood loss at birth, the total circulatory blood volume of a woman’s body increases by at least 30% (and possibly as much as 50%) during pregnancy. 7|P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) CARDIOVASCULAR SYSTEM Cardiac output increases 25 to 50% over nonpregnant output with an increase in 10 beats per minute. Because the diaphragm is pushed upward by the growing uterus late in pregnancy, the heart is shifted to a more trans- verse position in the chest cavity, a position that may make it appear enlarged on x-ray examination. Some women have audible functional (innocent) heart murmurs during pregnancy, probably because of the altered heart position. Palpitations in the early months of pregnancy are probably caused by sympathetic nervous system stimulation; in later months, they may result from increased thoracic pressure caused by the pressure of the uterus against the diaphragm. Pulmonary and peripheral vascular resistance decreases lowering the blood pressure throughout the first and second trimesters as the placenta expands rapidly. During the third trimester, the blood pressure rises again to first-trimester levels. During the third trimester of pregnancy, blood flow to the lower extremities is impaired by the pressure of the expanding uterus on veins and arteries. This resistance to blood flow in the venous system can lead to edema and varicosities of the vulva, rectum, and legs. Supine hypotensive syndrome or vena cava syndrome results as the gravid uterus compresses the vena cava resulting in decreased blood flow from the lower extremities. A woman experiences this hypotension as lightheadedness, faintness, and palpitations. Supine hypotension syndrome can easily be corrected by having a woman turn onto her side (preferably the left side), so that blood flow through the vena cava increases again. Blood volume increases over prepregnant levels. The increase in blood volume occurs gradually, beginning at the end of the first trimester. It peaks at about the 28th to the 32nd week and then continues at this high level throughout the third trimester. Because the plasma volume increases faster than red blood cell production, the concentration of hemoglobin and erythrocytes may decline, giving a woman a pseudoanemia early in pregnancy. A woman’s body compensates for this change by producing more red blood cells, creating near normal levels of red blood cells again by the second trimester. Either a hemoglobin concentration of less than 11 g/100 mL or a hematocrit value below 33% in the first or third trimester of pregnancy or a hemoglobin concentration of less than 10.5 g/dL (hematocrit 32%) in the second trimester is considered true anemia, for which iron therapy above normal supplementation is advocated (Arnett & Greenspoon, 2007). 8|P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) RENAL SYSTEM In the first trimester, the gravid uterus presses on the bladder causing urinary frequency. This is relieved in the second trimester as the uterus moves into the abdominal area and this returns in the third trimester as the presenting part presses on the bladder. During pregnancy, urinary output gradually increases (by about 60% to 80%). The specific gravity of urine decreases. The glomerular filtration rate (GFR) and renal plasma flow begin to increase in early pregnancy to meet the increased needs of the circulatory system. By the second trimester, both the GFR and the renal plasma flow have increased by 30% to 50%, and they remain at these levels for the duration of the pregnancy. This rise is consistent with that of the circulatory system increase, peaking at about 24 weeks. This efficient GFR level leads to a lowered blood urea nitrogen (BUN) and low creatinine levels in maternal plasma. INTEGUMENTARY SYSTEM As the uterus increases in size, the abdominal wall must stretch to accommodate it. This stretching (plus possibly increased adrenal cortex activity) can cause rupture and atrophy of small segments of the connective layer of the skin. This leads to pink or reddish streaks (striae gravidarum) appearing on the sides of the abdominal wall and sometimes on the thighs. During the weeks after birth, striae gravidarum lighten to a silvery-white color (striae albicantes or atrophicae), and, although permanent, they become barely noticeable. Occasionally, the abdominal wall has difficulty stretching enough to accommodate the growing fetus, causing the rectus muscles to actually separate, a condition known as diastasis. The umbilicus is stretched by pregnancy to such an extent that by the 28th week, its depression becomes obliterated and smooth because it has been pushed so far outward. In most women, it may appear as if it has turned inside out, protruding as a round bump at the center of the abdominal wall. Extra pigmentation generally appears on the abdominal wall. A narrow, brown line (linea nigra) may form, running from the umbilicus to the symphysis pubis and separating the abdomen into right and left hemispheres. Darkened areas may appear on the face as well, particularly on the cheeks and across the nose. This is known as melasma (chloasma), or the “mask of pregnancy.” These increases in pigmentation are caused by melanocyte-stimulating 9|P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) hormone, which is secreted by the pituitary. With the decrease in the level of the hormone after pregnancy, these areas lighten and again disappear. Vascular spiders or telangiectases (small, fiery-red branching spots) are sometimes seen on the skin of pregnant women, particularly on the thighs. These probably result from the increased level of estrogen in the body. They may fade but not completely disappear after pregnancy. The activity of sweat glands increases throughout the body during pregnancy. Women notice this as an increase in perspiration. Palmar erythema (redness and itching) may occur on the hands from the increased estrogen level. Fewer hairs on the head enter a resting phase because of overall increased metabolism, so scalp hair growth is increased. MUSCULOSKELETAL SYSTEM Relaxation of the pelvic joints results in the classic “waddling” gait often seen in pregnancy. Physiologic lordosis develops as the curvature of the lumbar spine increases to compensate for the weight of the gravid uterus, which may lead to backache. Calcium and phosphorus needs are increased during pregnancy, because the fetal skeleton must be built. As pregnancy advances, there is a gradual softening of a woman’s pelvic ligaments and joints to create pliability and to facilitate passage of the baby through the pelvis at birth. This softening is probably caused by the influence of both the ovarian hormone relaxin and placental progesterone. Excessive mobility of the joints can cause discomfort. A wide separation of the symphysis pubis, as much as 3 to 4 mm by 32 weeks of pregnancy, may occur. This makes women walk with difficulty because of pain. NEUROLOGIC SYSTEM Few changes with a typical pregnancy. Pressure on the sciatic nerve may occur later in pregnancy due to fetal position. GASTROINTESTINAL SYSTEM During pregnancy, the muscles in the walls of the gastrointestinal system relax slightly, and the rate at which food is squeezed out of the stomach and along the intestines is slowed down. During the first trimester, human chorionic gonadotrophin (hCG) increases and can 10 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) cause nausea and vomiting known as morning sickness. This common feeling of nausea usually subsides after the first 3 months, after which time a woman may have a voracious appetite. Although the acidity of stomach secretions decreases during pregnancy, heartburn may result from reflux of stomach contents into the esophagus, caused by upward displacement of the stomach by the uterus, and a relaxed cardioesophageal sphincter, caused by the action of relaxin, an enzyme produced by the ovary. At about the midpoint of pregnancy, this pressure may be sufficient to slow intestinal peristalsis and the emptying time of the stomach, leading to increased heartburn, constipation, and flatulence. Relaxin may contribute to decreased gastric motility; this natural slowing can be helpful, because the blood supply may be reduced to the gastrointestinal tract (i.e., blood is drawn to the uterus). Progesterone also has an effect on smooth muscle, such as that in the intestine, making the gastrointestinal tract less active. A woman who has had gallstones may have an increased tendency to stone formation during pregnancy as a result of the increased plasma cholesterol level and additional cholesterol incorporated in bile. Pressure from the uterus on veins returning from the lower extremities can lead to hemorrhoids. Some pregnant women notice hypertrophy at their gumlines and bleeding of gingival tissue when they brush their teeth. There may be increased saliva formation (hyperptyalism), probably as a local response to increased levels of estrogen. ENDOCRINE SYSTEM Follicle stimulating hormone (FSH) and Luteinizing hormone (LH) greatly decreased due to increase in estrogen and progesterone levels of the placenta. There is increased production of growth hormone and melanocyte-stimulating hormone (which causes skin pigment changes). Late in pregnancy, the posterior pituitary begins to produce oxytocin, which will be needed to aid labor. Prolactin production is also begun late in pregnancy, as the breasts prepare for lactation. The thyroid gland enlarges in early pregnancy to such an extent that the basal body metabolic rate increases by about 20%. The parathyroid glands, which are necessary for the metabolism of calcium, also increase in size during pregnancy. Adrenal gland activity increases in pregnancy as increased levels of corticosteroids and aldosterone are produced. The increased level of aldosterone aids in promoting sodium reabsorption and maintaining 11 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) osmolarity in the amount of fluid retained. The pancreas increases production of insulin in response to the higher levels of glucocorticoid produced by the adrenal glands. PSYCHOSOCIAL CHANGE First Trimester Task: Accepting the pregnancy Description Woman and partner both spend time recovering from shock of learning they are pregnant and concentrate on what it feels like to be pregnant. A common reaction is ambivalence, or feeling both pleased and not pleased about the pregnancy. The first task of a woman and partner during the first trimester is to accept the reality of the pregnancy. Receiving confirmation of pregnancy, at her health care provider’s office, makes the mother feel “more pregnant.” Home pregnancy test kits have helped women in this regard by confirming pregnancy as early as the first missed menstrual period. Until it is verified by a home test or a health care visit, however, the uncertainty of the symptoms makes pregnancy only a vague theoretical possibility that leaves room for denial. Often women immediately experience something less than pleasure and closer to disappointment or anxiety at the news that they are pregnant or a feeling of ambivalence. Ambivalence toward pregnancy does not mean that positive feelings counteract negative feelings so the woman is left feeling nothing toward her pregnancy. Instead, it refers to the interwoven feelings of wanting and not wanting that can exist at high levels. When talking to pregnant women, emphasize that this ambivalence is normal. Otherwise, if a poor outcome should result, a woman may recall her ambivalence and feel guilty. Partners also experience ambivalence, sometimes more so than pregnant women. The feeling of ambivalence can be compounded if partners are afraid to voice their concerns. This happens if they do not want to intensify the pregnant woman’s anxieties by appearing anxious themselves. Partners may also feel ambivalent if they are not well prepared for parenthood or have had little experience with children. Second Trimester Task: Accepting the baby 12 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) Description Woman and partner move through emotions such as narcissism and introversion as they concentrate on what it will feel like to be a parent. Role- playing and increased dreaming are common. During the second trimester, the psychological task of a woman is to accept that she is having a baby, a second step from accepting the pregnancy. This change usually happens at quickening, or the first moment a woman feels fetal movement. With quickening, however, the fetus assumes a separate identity. She begins to imagine how she will feel at the birth, when the physician or midwife announces, “It’s a boy!” or “It’s a girl!” She begins to imagine herself as a mother, per- haps teaching her child the alphabet or how to ride a bicycle. This anticipatory role-playing is an important activity for mid- pregnancy. It leads her to a larger concept of her condition and helps her realize that not only is she pregnant but also there is a child inside her. As a woman begins to actively prepare for the coming baby, a partner may feel as if he is left standing in the wings, waiting to be asked to take part in the event. To compensate for this feeling, a partner may become overly absorbed in his work, striving to produce something concrete on the job or to earn enough money to demonstrate that he, too, is capable of creating something. This preoccupation with work may limit the amount of time a partner spends with his family, just when the pregnant woman most needs emotional support. Third Trimester Task: Preparing for the baby and end of pregnancy Description: Woman and partner prepare clothing and sleeping arrangements for the baby but also grow impatient with pregnancy as they ready themselves for birth. During the third trimester, couples usually begin “nestbuilding” activities, such as planning the infant’s sleeping arrangements, buying clothes, choosing a name for the infant, and “ensuring safe passage” by learning about birth. Couples at this point are interested in attending prenatal classes or preparation for childbirth classes. It is helpful to ask a couple what 13 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) specifically they are doing to get ready for birth to see if they are interested in taking such a class and to document how well prepared they will be for the baby’s arrival. Many men experience physical symptoms such as nausea, vomiting, and backache to the same degree or even more intensely than their partners during a pregnancy. These symptoms apparently result from stress, anxiety, and empathy for the pregnant woman. This is common enough that it has been given a name: couvade syndrome. The more the partner is involved in or attuned to the changes of the pregnancy, the more symptoms a woman’s partner may experience. THE ANTEPARTAL PERIOD ASSESSMENT Classification of Pregnancy: I. Gravida- number of time pregnant, regardless of duration, including the present pregnancy. 1. Primagravida – pregnant for the first time 2. Multigravida – pregnant for second or subsequent time II. Para – number of pregnancies that lasted more than 20 weeks, regardless of outcome ⚫ Nullipara—a woman who has not given birth to a baby beyond 20 weeks’ gestation ⚫ Primipara—a woman who has given birth to one baby more than 20 weeks’ gestation. ⚫ Multipara—woman who has had two or more births at more than 20 weeks’ gestation… twins or triplets count as 1 para. ⚫ TPAL M— para subdivided: Term, Premature births, Abortions, and Living children, Multiple pregnancy o Term – 38 – 42 weeks o Postdate / Post term - >42 weeks o Preterm – 21 to 37 weeks o Abortion - < 20 weeks 14 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) DIAGNOSIS OF PREGNANCY The medical diagnosis of pregnancy serves to date when the birth will occur and also helps predict the existence of a high-risk status. If a pregnancy was planned, the diagnosis produces a feeling of intense fulfillment and achievement. If it was not planned or not desired, it can result in an equally extreme crisis state. Pregnancy is officially diagnosed on the basis of the symptoms reported by the woman and the signs elicited by a health care provider. These signs and symptoms are traditionally divided into three classifications: presumptive or subjective, probable or objective, and positive or documented. Presumptive (Subjective) Signs of Pregnancy Presumptive signs of pregnancy are those that are least indicative of pregnancy; taken as single entities, they could easily indicate other conditions (Rojas, Wood, & Blakemore, 2007). These findings, discussed in connection with the body system in which they occur, are experienced by the woman but cannot be documented by an examiner. Probable (Objective) Signs of Pregnancy In contrast to presumptive signs, probable signs of pregnancy are objective so can be documented by an examiner. Although they are more reliable than presumptive signs, 15 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) they still are not positive or true diagnostic findings. They are also discussed in connection with the body system in which they occur. Positive Signs of Pregnancy There are only three documented or positive signs of pregnancy: 1. Demonstration of a fetal heart separate from the mother’s The fetal heart can be shown to be beating on ultrasound as early as the sixth to seventh week of pregnancy. Ultrasonic monitoring systems that convert ultrasonic frequencies to audible frequencies (Doppler technique) can detect fetal heart sounds as early as the 10th to 12th week of gestation. Echocardiography can demonstrate a heartbeat as early as 5 weeks. It is audible by auscultation of the abdomen with an ordinary stethoscope only at about 18 to 20 weeks of pregnancy. 2. Fetal movements felt by an examiner Fetal movements may be felt by a woman as early as 16 to 20 weeks of pregnancy. Those felt by an objective examiner are considered much more reliable because a 16 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) woman could mistake the movement of gas through her intestines for fetal movement. Fetal movements can be felt by an examiner at the 20th to 24th week of pregnancy unless a woman is extremely obese. 3. Visualization of the fetus by ultrasound High-frequency sound waves projected toward a woman’s abdomen are useful in diagnosing pregnancy. If a woman is pregnant, a characteristic ring, indicating the gestational sac, will be revealed on an oscilloscope screen as early as the fourth to sixth week of pregnancy. This method also gives information about the site of implantation and whether a multiple pregnancy exists. By the eighth week, a fetal outline can be seen so clearly within the sac that the crown-to-rump length can be measured to establish the gestational age of the pregnancy. Seeing the fetal outline on an ultrasound is clear proof for a couple that a woman is pregnant if they had any doubt up to that point. INTERVENTIONS Prenatal care The purposes of prenatal care are to: 1. Establish a baseline of present health 2. Determine the gestational age of the fetus 3. Monitor fetal development and maternal well being 4. Identify women at risk for complications 5. Minimize the risk of possible complications by anticipating and preventing problems before they occur 6. Provide time for education about pregnancy, lactation, and newborn care A. TIME FRAME 1. First visit: may be made as soon as woman suspects she is pregnant; frequently after first missed period. 17 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) 2. Subsequent visit: Every mon. until the 8th mon., every 2 weeks during the 8th month and weekly during the 9th mon more frequent visits are scheduled if problem arise B. CONDUCT OF THE INITIAL VISIT Screening includes an extensive health history, a complete physical examination, including a pelvic examination, and blood and urine specimens for laboratory work. Manual pelvic measurements can be taken to determine pelvic adequacy. 1. Extensive collection of data about client in all pertinent areas in order to form basis for comparison with data collected on subsequent visits and to screen for any high- risk factors. a. Menstrual history: menarche, regularity, frequency and duration of flow, last period. b. Obstetrical history: all pregnancy, outcome, complications, contraceptive use, sexual history. c. Medical history: include past illnesses, surgeries; current use of medication d. Family history/ psychosocial data e. Information about the father-to-be may also be significant f. Current concerns 18 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) 2. Complete physical examination, including internal gynecologic exam and bimanual exam MEASUREMENT OF FUNDAL HEIGHT AND FETAL HEART SOUNDS At about 12 to 14 weeks of pregnancy, the uterus becomes palpable as a firm globular sphere over the symphysis pubis. It reaches the umbilicus at 20 to 22 weeks and the xiphoid process at 36 weeks, and then often returns to about 4 cm below the xiphoid because of “lightening” at 40 weeks. If a woman is past 12 weeks of a pregnancy, palpate the fundus location, measure the fundal height (from the notch above the symphysis pubis to the superior aspect of the uterine fundus), and plot the height on a graph such as the one shown in. Plotting uterine growth at each visit this way can help detect any unusual variation in fetal growth. If an abnormality is detected, further investigation with ultra- sound can be done to determine the cause of the unusual in- crease or decrease in growth. Auscultate for fetal heart sounds (120 to 160 beats per minute). These can be heard at 10 to 12 weeks if a Doppler technique is used but not until 18 to 20 weeks if a regular stethoscope is used. Palpate for fetal outline and position after the 28th week as a further estimation of fetal size and growth. 19 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) A) Auscultation of the fetal heartbeat using a fetoscope. (B) A Doppler ultrasound device can be used to monitor fetal heart rate intermittently in low-risk labor PELVIC EXAMINATION A pelvic examination reveals information on the health of both internal and external reproductive organs. Equipment required is a speculum (a metal or plastic instrument with movable flat blades; a spatula for cervical scraping, a clean examining glove, lubricant, a glass slide or liquid collection device for the Pap smear, a culture tube, two or three sterile cotton- tipped applicators or cytobrushes for obtaining cervical cultures, a good examining light, and a stool at correct sitting height. Pelvic examinations have the reputation of being painful and causing a loss of modesty. Allow a woman the opportunity to talk with the person performing the examination while sitting up, before being placed in a lithotomy position (on her back with her thighs flexed and her feet resting in the examining table stirrups) as this can enhance her sense of self-esteem and control if she meets her examiner first while upright rather than in a lithotomy position. Before a pelvic examination, ask a woman to void to reduce her bladder size and then lie in a lithotomy position. Make sure her buttocks extend slightly beyond the end of the examining table. Place a pillow under her head to help her relax her abdominal muscles. Properly drape her with a draw sheet over her abdomen that extends over her legs. Give 20 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) explanations of what is happening or what the examiner is doing as needed. Conversation with the examiner over her head is not helpful. Suggesting that a woman breathe in and out (not hold her breath as she is likely to do) is another technique to help her relax (holding her breath pushes the diaphragm down and makes the pelvic organs tense and unyielding). 3. Laboratory work, including CBC, urinalysis, pap test, blood type and Rh, rubella titer, testing for sexually transmitted diseases (STD), other test as indicated (e.g. TB test, hepatitis viral studies, EKG, etc C. Conduct of subsequent visit 1. Continue collection of data, especially weight, blood pressure, urine screening for glucose and protein, evaluation of fetal development through auscultation of fetal heart rate (FHR) and palpitation of fetal outline, measurement of fundal height as correlation for appropriate progress of pregnancy. 2. Prepare for necessary testing. a. Have client void (clean catch) b. Collect baseline data on vital signs c. Collect specimen d. Monitor client and fetus after procedure e. Provide support to client f. Document as needed 21 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) INTERVENTIONS Nutrition during Pregnancy A. Weight gain Recommended Weight Gain During Pregnancy A weight gain of 11.2 to 15.9 kg (25 to 35 lb) is recommended as an average weight gain in pregnancy. If a woman is at high risk for nutritional deficits, a more precise estimation of adequate weight gain can be calculated. This is done by computing body mass index (BMI), the ratio of weight to height. Women who are high or low in weight for their height (BMI below 18.5 or above 25 kg/m2) need to have their expected outcomes for weight gain adjusted. Weight gain in pregnancy occurs from both fetal growth and accumulation of maternal stores and occurs at approximately 0.4 kg (1 lb) per month during the first trimester and then 0.4 kg (1 lb) per week during the last two trimesters (a trimester pattern of 3-12-12). As a general rule, in the average woman, weight gain is considered excessive if it is more than 3 kg (6.6 lb) a month during the second and third trimesters; it is less than usual if it is less than 1 kg (2.2 lb) per month during the second and third trimesters. 22 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) B. SPECIFIC NUTRIENT NEEDS Components of Healthy Nutrition for the Pregnant Woman Energy (Calorie) Needs The DRI of calories for women of childbearing age is 2200. An additional 300 calories, or a total caloric intake of 2500 calories, is recommended to meet the increased needs of pregnancy. In addition to supplying energy for a fetus, this increase provides calories to sustain an elevated metabolic rate in the woman from increased thyroid function and an increased workload from the extra weight she must carry. Advise women to obtain calories from complex carbohydrates (cereals and grains) rather than simple carbohydrates (sugar and fruits) because these are more slowly digested so help regulate glucose and insulin levels. Protein Needs The DRI for protein in women is 46 g/d. During pregnancy, the need for protein increases to 71 g daily. If protein needs are met, overall nutritional needs are likely to be met as well (with the possible exceptions of vitamins C, A, and D) because of the high incorporation of 23 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) other nutrients with protein foods. Extra protein is best supplied by meat, poultry, fish, yogurt, eggs, and milk, because the protein in these forms contains all nine essential amino acids, or is complete protein. Milk is a rich source of protein. Fat Needs Only linoleic acid, an essential fatty acid necessary for new cell growth, cannot be manufactured in the body from other sources. Vegetable oils are a good source. In addition, using vegetable oils (e.g., safflower, corn, olive, peanut, and cottonseed) that have a low cholesterol content rather than animal oils (butter) is recommended for all adults as a means of preventing hypercholesterolemia and coronary heart disease. Women should also try and ingest omega-3 oils, found primarily in fish, omega-3–fortified eggs, and the newer omega-3– fortified spreads. Vitamin Needs Requirements for both fat-soluble and water-soluble vitamins increase during pregnancy to support the growth of new fetal cells (see Table 13.1). Folic acid is necessary for red blood cell formation. Without adequate folic acid, a megaloblastic anemia (large but ineffective red blood cells) may develop. For this reason, as well as its 24 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) importance in preventing neural tube defects, women should eat foods high in folic acid such as vegetables and fruit and should take a prenatal vitamin that contains a folic acid supplement of 0.4 to 1.0 mg. When cautioning women about vitamin use, advise them not to leave prenatal vitamins within the reach of small children. Mineral Needs Minerals are necessary for new cell building in a fetus. Calcium and Phosphorus. The skeleton and teeth constitute a major portion of a fetus. Tooth formation begins as early as 8 weeks in utero. Bones begin to calcify at 12 weeks. To supply adequate calcium and phosphorus for bone formation, pregnant women need to eat foods high in calcium and vitamin D (necessary for calcium to be absorbed from the gastrointestinal tract and to enter bones). The recommended amount of calcium during pregnancy is 1300 mg. If a woman cannot drink milk or eat milk products such as cheese, she can be prescribed a daily calcium supplement. Iodine. Iodine is essential for the formation of thyroxine and, therefore, for the proper functioning of the thyroid gland. As thyroid function increases during pregnancy, a woman needs to ingest enough iodine during pregnancy to supply this increased need. If iodine deficiency occurs, it can cause hypothyroidism and thyroid enlargement (goiter) in a woman. The DRI for iodine is 220 g daily during pregnancy. Seafood is the best source of iodine. It is suggested that women use iodized salt rather than plain salt to ensure a healthy iodine intake. Iron. A fetus at term has a hemoglobin level of 17 to 21 g per 100 mL of blood, a level that is necessary to oxygenate the blood during intrauterine life. Iron is needed to build this high level of hemoglobin. In addition, after week 20 of pregnancy, a fetus begins to store iron in the liver to last through the first 3 months of life, when intake will consist mainly of milk, typically low in iron. In addition to supplying these high fetal needs, a woman needs iron to build an increased red cell volume for herself and to protect against iron lost in blood at birth. The DRI for iron for pregnant women is 27 mg. An average diet supplies about 6 mg of iron per 1000 calories. If a woman eats a 2500-calorie diet daily, her daily intake, there- fore, is about 15 mg iron. Therefore, dietary supplementation with 15 mg iron per day helps ensure that adequate iron is ingested and absorbed. The foods richest in iron (e.g., organ meats; eggs; green, leafy vegetables; whole grains; enriched breads; dried fruits). Iron absorption increases 25 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) in an acid environment, so eating iron-rich foods or swallowing iron pills with ascorbic acid (found in orange juice) may increase absorption. Oral iron compounds turn stools black or blackish green. The compounds can be irritating to the stomach or cause constipation in some women. If this happens, urge women not to stop taking the iron compound but to always take the iron pills with food and increase fluid intake or fiber to relieve the constipation. Some women may need a prescribed stool softener such as docusate sodium (Colace); this stool softener is not associated with teratogenic action, so it can be taken safely during pregnancy. Fluoride. Because fluoride aids in the formation of sound teeth, a pregnant woman should drink fluoridated water. In an area where the water is not fluoridated either naturally or artificially, supplemental fluoride may be recommended. Fluoride in large amounts causes brown-stained teeth, so a woman should not take the supplement more often than prescribed or if tap water in her area is already fluoridated. Sodium. Sodium is the major electrolyte that acts to maintain fluid in the body: when sodium is retained rather than excreted by the kidneys, an equal or balancing amount of fluid is also retained. Retaining enough fluid during pregnancy in the maternal circulation is important to ensure a pressure gradient to allow optimal exchange of nutrients across the placenta. Unless a woman is hypertensive or has heart disease with required sodium restriction when she enters pregnancy, she should continue to add salt to foods as usual during pregnancy. Zinc. Zinc is necessary for the synthesis of DNA and RNA. The DRI for zinc during pregnancy is 12 mg, or an increase of 3 mg over prepregnancy needs. Most people who take in adequate protein also take in adequate zinc because zinc is contained in foods such as meat, liver, eggs, and seafood. It is also a component of prenatal vitamins to help ensure an adequate intake. Fluid Needs Extra amounts of water are needed during pregnancy to promote kidney function because a woman must excrete waste products for two. Two or three glasses of fluid daily over and above the three servings of milk recommended by the food pyramid is a common recommendation during pregnancy (a total of six to eight glasses daily). Fiber Needs Constipation can occur during pregnancy from slowed peristalsis because of the pressure of the uterus on the intestine. Eating fiber rich foods, foods consisting of parts of the plant cell wall resistant to normal digestive enzymes such as broccoli and asparagus, are a 26 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) natural way of preventing constipation, because the bulk of the fiber left in the intestine aids evacuation. Fiber also has the advantage of lowering cholesterol levels and may remove carcinogenic contaminants from the intestine. Therefore, encourage women to eat plenty of fresh fruits and vegetables, especially green, leafy vegetables, to provide fiber. Foods to Avoid or Limit in Pregnancy Alcoholic beverages should not be ingested by a pregnant woman because of their potentially teratogenic effects on a fetus. Other foods to be avoided are those that contain food additives, because the effect of many of these is unknown. Excess Seafood Women should eat up to 12 ounces (2 to 3 meals) of seafood or shellfish a week for their omega-3 and iodine content. Fish such as shark, swordfish, king mackerel or tilefish are high in mercury contamination, however, so should be avoided (Genuis, 2008). Five types of fish that are low in mercury are shrimp, canned light tuna, salmon, pollock, and catfish. Foods with Caffeine Caffeine is thought of by many women as just an incidental ingredient in beverages. Actually, it is a central nervous system stimulant capable of increasing heart rate, urine production in the kidney, and secretion of acid in the stomach (Rolfes, Pinna, & Whitney, 2009). A daily intake of caffeine of two or three cups of coffee has not been associated with low birth weight, but drinking over three cups is associated with an increased rate of early miscarriage (Applebee, 2008). To limit their caffeine intake, women may need to limit not only the amount of coffee they drink but also other sources of caffeine such as chocolate, soft drinks, and tea. Decaffeinated coffee, as the name implies, contains almost no caffeine. Chocolate sources tend to be low in caffeine, however, compared with coffee. Soft drinks do not naturally contain caffeine; it is added to improve their flavor. To limit the amount of caffeine consumed, encourage pregnant women to choose caffeine- free types. Artificial Sweeteners Artificial sweeteners are used to improve the taste and to limit the caloric content of foods. It is probably safest for pregnant women to reduce their intake of these. For instance, although the sweetener aspartame has been approved by the U.S. Food and Drug 27 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) Administration for consumption and is apparently safe during pregnancy, large amounts of the compound should be avoided by pregnant women until its safety is thoroughly confirmed. The use of saccharine is not recommended during pregnancy because it is eliminated slowly from the fetal bloodstream. C. Dietary supplements: many health care providers supplement the pregnant woman’s diet with an iron-fortified multivitamin to ensure essential levels 28 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) D. Special concerns ⚫ religious, ethics, and cultural practices that influence selection and preparation of foods ⚫ Pica (ingestion of non-edible or nonnutritive substances) During pregnancy, some women report an abnormal craving for nonfood substances (termed pica from the Latin word for “magpie,” a bird that is an indiscriminate eater). The most common form of pica in the past was a craving for laundry starch. Today, women are more apt to report cravings for clay, dirt, cornstarch, or ice cubes (Mills, 2007). Although some of these items can do no harm in themselves, the ingestion of large quantities of nonfood substances can leave a woman deficient in protein, iron, and calcium, nutrients essential for a healthy pregnancy outcome. ⚫ Vegan vegetarians- no meat products, may need B12 supplement There are many different types of vegetarians: lacto-ovo-vegetarians (no animal flesh or fish is eaten, but dairy products and eggs are), lactovegetarians (no meat, fish, or eggs are eaten, but dairy products are), and vegans (nothing derived from an animal is eaten). Special concerns for pregnant vegetarians include lack of vitamin B12 (meat is 29 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) the chief source of this) and an inadequate intake of calcium (recommend dark-green vegetables as sources) and vitamin D (fortified milk and sunlight are the main sources of this). Urge women who are vegetarians to take a daily prenatal supplement, like all women, to ensure adequate iron and folic acid. ⚫ Adolescence A pregnant adolescent needs a high caloric intake (2500 calories per day) to supply energy for her high level of activity and growth. The nutrients most often lacking from a typical adolescent diet tend to be calcium, iron, folic acid, and total calories. Good nutrition can be a problem with pregnant teenagers because of the dual demands of consuming enough food to provide for fetal growth and their own continuing growth. Often adolescents, in their search for identity, avoid foods that their parents see as important for them (e.g., milk, warm cereal, vegetables, or fruit) and indulge instead in foods such as soft drinks, potato chips, and French fries. To help an adolescent plan nutritional intake for pregnancy, respect her right to reject traditional foods as long as what she does eat includes sufficient nutrients. ⚫ Heavy smoking, alcohol consumption, drugs In addition to specific teratogenic fetal effects, these substances can lead to general nutrition problems because a woman is ingesting these substances rather than eating nutritious foods. Cigarette smoking by a pregnant woman has been shown to cause fetal growth restriction. In addition, a fetus may be at greater risk for being stillborn and, after birth, may be at greater risk than others for sudden infant death syndrome. Low birth weight in infants of smoking mothers results from vasoconstriction of the uterine vessels, an effect of nicotine. Evidence over the years has shown that when women consume a large quantity of alcohol during pregnancy, their babies show a high incidence of congenital deformities and cognitive impairment. Women during pregnancy should be screened for alcohol use because an infant born with fetal alcohol syndrome (FAS) not only is small for gestational age but can be cognitively challenged. The infant typically has a characteristic craniofacial deformity including short palpebral fissures, a thin upper lip, and an upturned nose. It is impossible to define a safe level of alcohol consumption. Women are best advised, therefore, to abstain from alcohol completely. 30 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) Any drug or herbal supplement, under certain circumstances, may be detrimental to fetal welfare. Therefore, during pregnancy, women should not take any drug or supplement not specifically prescribed or approved by their physician or nurse- midwife. The classic example of a teratogenic drug is thalidomide, once liberally prescribed for morning sickness thalidomide caused amelia or phocomelia (total or partial absence of extremities). Minoxidil (Rogaine), a drug taken by both men and women to restore hair growth, is an example of another drug that is documented to cause fetal deformities. The use of recreational drugs during pregnancy puts a fetus at risk in two ways: the drug may have a direct teratogenic effect, and intravenous drug use risks exposure to diseases such as HIV and hepatitis B. Narcotics such as meperidine (Demerol) and heroin have long been implicated as causing intrauterine growth restriction (IUGR). Cocaine, particularly its crack form, is potentially harmful to a fetus because it causes severe vasoconstriction in the mother, compromising placental blood flow and perhaps dislodging the placenta. Its use is associated with spontaneous miscarriage, preterm labor, meconium staining, and IUGR. ⚫ Extremes in weighing scale – low prepregnant weight and obese Underweight is defined as a state in which a woman’s weight is 10% to 15% less than the ideal weight for her height, or a BMI of less than 18.5 kg/m2. Most women who are underweight tire easily because they have an accompanying iron deficiency anemia. Even when underweight women gain excessive weight during pregnancy, they still tend to have a higher- than-usual incidence of low-birth-weight infants, probably because of depleted nutrient stores at the pregnancy’s beginning. A woman is considered overweight if she is 20% above ideal weight or has a BMI over 25 kg/m2. She is considered obese if she weighs more than 200 lb, she is 50% above ideal bodyweight for height, or her BMI is above 30 kg/m2. Obesity in pregnancy is serious because it is associated with an increased incidence of gestational diabetes and pregnancy-induced hypertension. Obesity becomes a problem during pregnancy for a variety of reasons: 31 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) Pregnancy causes circulatory volume to increase 20% to 50% and metabolism to increase to meet the demands of the pregnancy, placing additional stress on a possibly already overworked body. Hypertension and thrombophlebitis are more likely to occur. It is often difficult to hear fetal heart tones in an obese woman; palpating for position and size of a fetus at birth is also difficult. Obese women are at an increased risk for giving birth to infants with macrosomia (excessive fetal growth); this increases the incidence of cesarean births in this population. Performing a cesarean birth, if necessary, may be difficult because of the excessive adipose tissue that must be incised to reach the uterus. Gestational diabetes is more apt to develop; the pregnancies of obese women are more apt to be prolonged, leading to postmature infants. Ambulating during pregnancy and immediately afterward is more difficult because of the increased energy expenditure necessary, increasing the risk for complications such as thrombophlebitis and pneumonia. When a women weighs over 300 lb or has a BMI over 40 kg/m2, she is classified as morbidly obese. During a pregnancy, she presents with a series of special care problems as she is even more prone to complications of pregnancy such as gestational or type 2 diabetes, hypertension, back pain, and thrombophlebitis than obese women. She is prone to sleep apnea so may feel tired over and above normal pregnancy fatigue. Hearing fetal heart sounds and palpating for fetal position can be difficult. Because exercise is difficult, a woman may be pre- scribed support hose to aid lower leg circulation and help avoid thromboembolic complications. Pregnancies tend to be pro- longed with a high rate of cesarean birth. In addition, morbidly obese women may need special care equipment furnished for them such as a larger hospital bed, examining gown, wheelchair, and straps for fetal monitoring equipment than usual. Sexual Activity ⚫ Sex is contraindicated in the following situations: ⚫ Spotting or bleeding ⚫ Incompetent cervical os 32 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) ⚫ Ruptured BOW ⚫ Sexual Positions ⚫ Side by side ⚫ Rear entry ⚫ Side lying, facing each other ⚫ Exercise is contraindicated ⚫ PIH ⚫ PROM ⚫ PTL (preterm labor) ⚫ Incompetent cervix ⚫ Vaginal bleeding ⚫ Recommended Exercises ⚫ Squatting and Tailor Sitting ⚫ strengthen perineal muscles ⚫ increase circulation in the perineum ⚫ make pelvic joints more pliable 33 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) ⚫ Pelvic Rock ⚫ Maintains good posture ⚫ Relieves abdominal pressure and low backache pain ⚫ Strengthens abdominal muscles following delivery ⚫ Modified knee-chest position ⚫ Relieves pelvic pressure and cramps in the thighs or buttocks; relieves discomfort from hemorrhoids ⚫ Kegel’s Exercise ⚫ Pelvic muscle exercises/Contract pubococcygeus muscle 34 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) ⚫ Strengthen the muscles of the pelvic floor, providing support for the pelvic organs and control muscles surrounding the vagina and urethra ⚫ Relieves congestion and discomfort in pelvic region; tones up pelvic floor muscles DISCOMFORTS OF EARLY PREGNANCY: FIRST TRIMESTER Early pregnancy symptoms can often cause discomfort in an expectant woman. Providing empathic and sound advice about measures to relieve these discomforts helps promote overall health and well-being. Although these symptoms are classified as minor, they may not seem minor to a woman who wakes up each morning feeling nauseated, wondering if she will ever feel like herself again. Also, each of these symptoms has the potential to lead to problems that are more serious. Breast Tenderness Breast tenderness is often one of the first symptoms noticed in early pregnancy; it may be most noticeable on exposure to cold air. If the tenderness is enough to cause discomfort, encourage a woman to wear a bra with a wide shoulder strap for support and to dress warmly to avoid cold drafts if cold increases symptoms. Palmar Erythema Palmar erythema, or palmar pruritus, occurs in early pregnancy and is probably caused by increased estrogen levels. Explain that this type of itching in early pregnancy is normal before she spends time and effort trying different soaps or detergents or at- tempting to implicate certain foods she has eaten. Calamine lotion can be soothing. Constipation As peristalsis slows and the weight of a growing uterus presses against the bowel, constipation can occur. Encourage her to evacuate her bowels regularly (many women neglect 35 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) this first simple rule); increase the amount of fiber in her diet by eating raw fruits, bran, and vegetables; and to drink at least eight 8-oz glasses of water daily. Enemas also should be avoided because their action might initiate labor. Over-the-counter laxatives are also contraindicated. If dietary measures and attempts at regular bowel evacuation fail, a stool softener, such as docusate sodium (Colace), or evacuation suppositories, such as glycerin, may be prescribed. Some women have extensive flatulence accompanying constipation. Recommend avoiding gasforming foods, such as cabbage or beans, to help control this problem. Nausea, Vomiting, and Pyrosis At least half of pregnant women experience other gastrointestinal symptoms such as nausea, vomiting, and pyrosis (heartburn). Fatigue Fatigue is extremely common in early pregnancy, probably because of increased metabolic requirements. Much of it can be relieved by increasing the amount of rest and sleep. Muscle Cramps Decreased serum calcium levels, increased serum phosphorus levels, and, possibly, interference with circulation commonly cause muscle cramps of the lower extremities during pregnancy. This problem is best relieved if a woman lies on her back momentarily and extends her involved leg while keeping her knee straight and dorsiflexing the foot until the pain disappears. Hypotension Supine hypotension is a symptom that occurs when a woman lies on her back and the uterus presses on the vena cava, impairing blood return to her heart. A woman experiences an irregular heart rate and a feeling of apprehension. The method of relieving the problem is simple: if a woman turns or is turned onto her side, pressure is removed from the vena cava, blood flow is restored, and the symptoms quickly fade. To prevent the syndrome, advise pregnant women to always rest or sleep on their side, not their back. If they can only fall asleep 36 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) on their back, they should insert a small firm pillow under their right hip to cause the weight of their uterus to shift off their vena cava. Varicosities Varicosities, or the development of tortuous leg veins, are common in pregnancy because the weight of the distended uterus puts pressure on the veins returning blood from the lower extremities. This causes pooling of blood and distention of the vessels. The veins become engorged, inflamed, and painful. Although usually confined to the lower extremities, varicosities can extend up to and include the vulva. Urge such women to take active measures to prevent varicosities beginning in early pregnancy; if left until the second trimester, the best they will be able to accomplish is relief of pain from already formed varicosities. Resting in a Sims’ position or on the back with the legs raised against the wall (a small firm pillow under their right hip) or elevated on a footstool for 15 to 20 minutes twice a day is a good precaution. (Fig. 12.5). Caution women not to sit with their legs crossed or their knees bent and to avoid constrictive knee-high hose or garters. 37 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) Hemorrhoids Hemorrhoids (varicosities of the rectal veins) occur commonly in pregnancy because of pressure on these veins from the bulk of the growing uterus. Daily bowel evacuation to relieve constipation and resting in a modified Sims’ position daily are both helpful. At day’s end, assuming a knee–chest position (Fig. 12.6) for 10 to 15 minutes is an excellent way to reduce the pressure on rectal veins. A stool softener such as docusate sodium (Colace) may be recommended for a woman who already has hemorrhoids. Applying witch hazel or cold compresses to external hemorrhoids can help relieve pain. Replacing hemorrhoids with gentle finger pressure can also be helpful. Frequent Urination Frequent urination occurs in early pregnancy because of the pressure of the growing uterus on the anterior bladder. The sensation may last for about 3 months, sometimes beginning as early as the first or second missed menstrual period, disappear in midpregnancy when the uterus rises above the bladder, and return again in late pregnancy as the fetal head presses against the bladder. Kegel exercises (alternately contracting and relaxing perineal muscles; helps strengthen urinary control, directly strengthens perineal muscles for birth, and decreases the possibility of stress incontinence. 38 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) Abdominal Discomfort Some women experience uncomfortable feelings of abdominal pressure early in pregnancy. Women with a multiple pregnancy may notice this throughout pregnancy. Typically, pregnant women stand with their arms crossed in front of them because the weight of their arms resting on their abdomen relieves this discomfort. Leukorrhea Leukorrhea, a whitish, viscous vaginal discharge or an increase in the amount of normal vaginal secretions, occurs in response to the high estrogen levels and the increased blood supply to the vaginal epithelium and cervix in pregnancy. A daily bath or shower to wash away accumulated secretions and prevent vulvar excoriation usually controls this problem. Wearing cotton underpants and sleeping at night without underwear can be helpful to reduce moisture and possible vulvar excoriation. Caution women not to use tam- pons because this could lead to stasis of secretions and subsequent infection. Advise women to contact their physician or nurse-midwife if there is a change in the color, odor, or character of this discharge as these suggest infection. Nursing Diagnoses and Related Interventions Nursing Diagnosis: Health-seeking behaviors related to learning more about the minor discomforts of late pregnancy such as Braxton Hicks contractions. Acute abdominal pain related to sudden postural change in position Anxiety related to shortness of breath resulting from expanding uterine pressure on diaphragm Deficient knowledge related to beginning signs of labor Pain related to almost constant backache Outcome Evaluation: Client states that she feels confident in self-managing the minor discomforts of late pregnancy. 39 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) Discomforts of Middle to Late Pregnancy At about the 20th to 24th weeks, the midpoint of pregnancy, a woman is usually ready for further health teaching that relates to the new developments that will occur in the latter half of pregnancy. As she starts to view the child within her as a separate person, she becomes interested in discussing and making plans for the signs and symptoms of beginning labor, birth, and the infant’s care. The midpoint of a pregnancy is also a good time to describe the new minor symptoms that may occur and to review the precautionary measures to prevent constipation, varicosities, and hemorrhoids, as these in- crease in intensity late in pregnancy. Backache As pregnancy advances, a lumbar lordosis develops and postural changes necessary to maintain balance lead to backache. Wearing shoes with low to moderate heels reduces the amount of spinal curvature necessary to maintain an upright posture. Encouraging a woman to walk with her pelvis tilted forward (putting pelvic support under the weight of the fetus) is also helpful. In addition, applying local heat may aid in relieving backache. To avoid back strain, advise women to squat rather than bend over to pick up objects. Headache Many women experience headache during pregnancy, apparently from their expanding blood volume, which puts pressure on cerebral arteries. Trying to reduce any possible causative situations, such as eye strain or tension, may lessen the number of headaches they experience. Resting with cold towels on their forehead and taking usual adult doses of acetaminophen usually furnishes adequate relief. Caution women that if a headache is unusually intense or continuous, they should report it to their primary care provider. A continuous sharp headache may be a danger sign of high blood pressure during pregnancy. Dyspnea As the expanding uterus places pressure on the diaphragm, lung compression and shortness of breath result. A woman will notice this primarily at night if she lies flat. She also 40 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) will definitely notice it on exertion. To relieve nighttime dyspnea, advise her to sleep with her head and chest elevated so the weight of the uterus falls away from her diaphragm. Ankle Edema Most women experience some swelling of the ankles and feet during late pregnancy, most noticeably at the end of the day. As long as proteinuria and hypertension are absent, ankle edema of this nature is a normal occurrence of pregnancy. It is probably caused by general fluid retention and reduced blood circulation in the lower extremities because of uterine pressure. This simple edema can be relieved best by resting in a left side-lying position because this increases the kidney’s glomerular filtration rate and also allows good venous return. Sitting for half an hour in the afternoon and again in the evening with the legs elevated is also helpful. Caution women to avoid wearing constricting clothing such as panty girdles or knee-high stockings because these impede lower extremity circulation and venous return. Braxton Hicks Contractions Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again. Early in pregnancy, these sensations, termed Braxton Hicks contractions, are not noticeable. By middle or late pregnancy, the contractions become stronger, and a woman who tenses at the sensation may even experience some minimal pain, similar to a hard menstrual cramp. Although these contractions are not a sign of beginning labor, women should inform their primary care provider about them so that they can be evaluated. A rhythmic pattern of even very light but persistent contractions could be a beginning sign of labor. HIGH RISK MOTHER 1. Pregnancy: a) lack of prenatal care b) under 18 y.o. or over 35 years of age c) conception within 2 months of previous delivery d) first / fifth or subsequent delivery e) pre-pregnant weight 20% or more or less than normal f) minimal or no weight gain g) fetal anomaly h) labor and delivery complication - e.g. eclampsia, precipitous delivery i) history of spontaneous abortion 41 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) Danger Signs of Pregnancy a) Epigastric Pain b) Severe continuous headache c) Blurring/dimness of vision or flashes of light or dots/spots before the eyes d) Edema lower legs, hands and face e) Rupture Membrane f) Bleeding from the vagina g) Persistent vomiting h) Abdominal Pain i) Fever/Chills j) Absence/Cessation of fetal movement THE ANTENATAL PERIOD Education for Parenthood 1. Provision of information about pregnancy, labor and delivery, the postpartum period, and lactation 2. Usually taught in small groups, may be individualized. 3. Topics can be grouped into early and late pregnancy, labor and delivery, and post- delivery/newborn care. 4. Emphasis placed on both physical and psychosocial changes seen in childbearing cycle. 5. Preparation for childbirth: intended to provide knowledge and alternative coping behaviors in order to diminish anxiety and discomfort, and promote cooperation with the birth process Determination of Fetal Status and Risk Factors A. Fetal diagnostic tests 1. Used to ⚫ Identify or confirm the existence of risk factor's 42 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) ⚫ Validate pregnancy ⚫ Observe progress of pregnancy ⚫ Identify optimum time for induction of labor if indicated ⚫ Identify genetic abnormalities 2. Types ⚫ Chorionic vili sampling (CVS): earliest test possible on fetal cells; sample obtained by slender catheter passed through cervix to implantation site. ⚫ Ultrasound: use of sound and returning echo patterns to identify intrabody structures. Useful early in pregnancy to identify gestational sac(s); later uses include assessment of fetal viability, growth patterns, anomalies and adnexal masses. Used as an adjunct to amniocentesis; safe for fetus (no ionizing radiation). ⚫ Amniocentesis: location and aspiration of amniotic fluid for examination; possible after the 14th week when sufficient amount is present. Used to identify chromosomal aberrations, sex of fetus, levels of alpha-fetoprotein and other chemicals indicative of neural tube defects and inborn errors of metabolism, gestational age, Rh factor. ⚫ X-ray: can be used late in pregnancy (after ossification of fetal bones) to confirm position and presentation; not used in early pregnancy to avoid possibility of causing damage to fetus and mother. ⚫ Alpha-fetoprotein Screening: Maternal serum screens for open neural tube defects. Alpha-fetoprotein is glucoprotein produced by fetal yolk sac, GI tract, and liver. Test done between 16 and 18 weeks gestation ⚫ Creatinine level: estimates fetal renal maturity and function, uses amniotic fluid ⚫ Bilirubin level: high early in pregnancy; drops after 36 weeks gestation; uses amniotic fluid. ⚫ L/S ratio: uses amniotic fluid to ascertain fetal lung maturity ⚫ lung surfactants lecithin and sphingomyelin. ⚫ At 35-36 weeks , ratio is 2:1, indicative of mature levels; once ratio of 2:1 is achieved, newborn less likely to develop respiratory distress syndrome. 43 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) ⚫ Phosphatidylglycerol (PG) is found in amniotic fluid after 35 weeks. ⚫ Fetal movement count: teach mother to count 2-3 times daily, 30-60 minutes each time, should feel 5-6 movements per counting time. Mother should notify care giver immediately of abrupt change or no movement ⚫ PUBS (Percutaneous Umbilical Blood Sampling): Uses ultrasound to locate umbilical cord. Cord blood aspirated and tested. Used in second and third trimesters. ⚫ Biophysical exams: a collection of data on fetal breathing movements; body movements, muscle tone, reactive heart rate, and amniotic fluid volume. A score of 0-2 is given in each category and the summative number interpreted by the physician. Primary suggested use to identify fetuses at risk for asphyxia. B. Electronic Monitoring 1. Nonstress test (NST) A nonstress test measures the response of the fetal heart rate to fetal movement. Position a woman and attach both a fetal heart rate and a uterine contraction monitor. Instruct a woman to push a button attached to the monitor (similar to a call bell) whenever she feels the fetus move. This will create a dark mark on the paper tracing at these times. When the fetus moves, the fetal heart rate should increase about 15 beats per minute and remain elevated for 15 seconds. It should decrease to its average rate again as the fetus quiets. If no increase in beats per minute is noticeable on fetal movement, poor oxygen perfusion of the fetus is suggested. A nonstress test usually is done for 10 to 20 minutes. The test is said to be reactive if two accelerations of fetal heart rate (by 15 beats or more) lasting for 15 seconds occur after movement within the chosen time period. The test is nonreactive if no accelerations occur with the fetal movements. The results also can be interpreted as nonreactive if no fetal movement occurs or if there is low short-term fetal heart rate variability (less than 6 beats per minute) throughout the testing period. 44 | P a g e NUR 1208 – MODULE 4: ANTENATAL CARE Prepared by MCN FEU Faculty Lecturers 2023 = 2024  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING DEPARTMENT OF NURSING 2Nd SEMESTER – AY 2023 – 2024 NCM 107 CARE OF MOTHER & CHILD, ADOLESCENT (WELL CLIENT) If a 20-minute period passes without any fetal movement, it may mean