Prenatal Care PDF

Unit 1: Prenatal Care Type Lecture Maternal and Child Course Nursing Notebook MCN Assignments Data Structures...

Unit 1: Prenatal Care Type Lecture Maternal and Child Course Nursing Notebook MCN Assignments Data Structures Pelvic Types 1. Gynecoid Pelvis Shape: Rounded and shallow with a wide pubic arch (around 90 degrees). Characteristics: Considered the typical female pelvis. It has a wide transverse diameter and a rounded inlet, ideal for childbirth. Clinical Significance: Most favorable for vaginal delivery due to its spacious dimensions. 2. Android Pelvis Shape: Heart-shaped or triangular, with a narrow pubic arch. Characteristics: Resembles a male pelvis, with a more funnel-shaped structure and a narrower pelvic inlet. Clinical Significance: May cause difficulties during labor as the narrow dimensions can lead to obstructed labor or require assisted delivery methods like forceps or cesarean section. 3. Anthropoid Pelvis Shape: Oval, with a longer anteroposterior diameter and a narrow transverse diameter. Unit 1: Prenatal Care 1  Characteristics: Elongated shape from front to back, often associated with tall women or those with a narrow pelvis. Clinical Significance: Although narrow transversely, the elongated shape is often favorable for vaginal delivery, especially for babies in the occiput posterior position. 4. Platypelloid Pelvis Shape: Flattened, wide, and shallow with a broad transverse diameter but a narrow anteroposterior diameter. Characteristics: Known as a "flattened pelvis," with the broadest pelvic inlet but shallow depth. Clinical Significance: Often associated with difficulties in labor as the baby's head may not engage easily, leading to a higher likelihood of needing a cesarean section. Unit 1: Prenatal Care 2  Female Reproductive Cycle Female Reproductive Cycle 1. Menstruation The regular shedding of the uterine lining (endometrium) that occurs in the absence of pregnancy. Occurs roughly every 28 days, though cycles can vary between 21 to 35 days in different individuals. The menstrual cycle includes the follicular phase, ovulation, and the luteal phase. Unit 1: Prenatal Care 3  Menarche is the first occurrence of menstruation. It marks the beginning of reproductive capability. 2. Ovulation The release of a mature egg from the ovarian follicle into the fallopian tube, typically occurring around day 14 of a 28-day cycle. Triggered by a surge in luteinizing hormone (LH) following a rise in estrogen levels. This is the most fertile time in the menstrual cycle, as the egg is viable for fertilization for about 12-24 hours. Sperm can live in the reproductive tract for up to 5 days, creating a fertile window around ovulation. 3. Climacteric The transitional phase leading to the end of a woman’s reproductive period, also known as perimenopause. Irregular menstrual cycles, hormonal changes (fluctuations in estrogen and progesterone), and symptoms such as hot flashes, mood swings, and sleep disturbances. This transition can last several years before reaching menopause. 4. Menopause The permanent cessation of menstruation, typically occurring between the ages of 45-55. Menopause is diagnosed after 12 consecutive months without a period. Significant drop in estrogen and progesterone levels. Symptoms: Hot flashes, vaginal dryness, mood changes, decreased bone density, and increased cardiovascular risks due to the reduction in estrogen. Contraception and Fetal Development 1. One Spermatozoon Enters the Ovum Unit 1: Prenatal Care 4  Fertilization begins when a single sperm cell (spermatozoon) successfully penetrates the outer layer of the ovum (egg), typically during or after ovulation. Once a sperm fuses with the ovum, a reaction occurs that prevents other sperm from entering, ensuring only one sperm fertilizes the egg. 2. Two Nuclei Containing the Parents’ Chromosomes Merge After fertilization, the nuclei of the sperm and the ovum (each containing 23 chromosomes) merge to form a single nucleus with a full set of 46 chromosomes. This fusion of genetic material results in a zygote, the first cell of the developing embryo, containing a unique combination of DNA from both parents. 3. Occurs in the Outer Third of the Fallopian Tube Fertilization typically occurs in the ampulla, the outer third of the fallopian tube. Following fertilization, the zygote begins to divide as it moves down the fallopian tube toward the uterus, where it will implant into the uterine lining. 4. Sex is Determined The sex of the embryo is determined at the moment of fertilization based on the type of sex chromosome carried by the sperm. The ovum always carries an X chromosome, while the sperm can carry either an X or Y chromosome. XX results in a female. XY results in a male. Process of Fertilization In sexual intercourse, 300 million sperm cells enter the vagina. Some may flow out of the vagina or die in its acidic environment. Unit 1: Prenatal Care 5  Sperm passes through the cervix - the opening into the uterus. There, cervix usually remains tightly closed, but it remains open for a few days as the woman ovulates. The sperm swim through the cervical mucus (thin, watery consistency). Millions of sperm die trying to make it through the mucus. Some remain behind and get caught in the folds of the cervix. Muscular uterine contractions assist the sperm on their journey towards the egg. Resident cells from the woman's immune system destroy the sperm, mistaking it for foreign invaders. Half of the sperm head toward the fallopian tube, the other half heads towards the tube containing the unfertilized egg. Tiny cilia inside the Fallopian tube push the egg toward the uterus. The sperm must go against this motion to reach the egg. Some get trapped in the cilia and die. Chemicals in the reproductive tract cause the membranes covering the head of the sperm to change. The sperm become hyperactive. The egg is covered with a layer of cells called the corona radiata. The sperm must push through this layer to reach the outer layer called the Zona Pellucida. Upon reaching the Zona Pellucida, they attach to specialized sperm receptors on the surface, triggering their acrosomes to release digestive enzymes, enabling the sperm to burrow into the layer. Inside the Zona Pellucida is a narrow fluid-filled space just outside the egg cell membrane, the first sperm to make contact will fertilize the egg. Unit 1: Prenatal Care 6  The sperm attaches to the egg cell membrane. Within minutes, their membranes fuse and the egg pulls the sperm inside. This causes changes in the egg membrane, preventing other sperm from attaching to it. The egg releases chemicals that push other sperm away from the egg, creating an impenetrable fertilization membrane. As the reaction spreads, the Zona Pellucida hardens, trapping any sperm caught inside. Outside the egg, the sperm are no longer able to attach to the Zona Pellucida. Inside the egg, the tightly packed male genetic material spreads out. A new membrane forms around the male genetic material creating the male pronucleus. The genetic material reforms into 23 chromosomes. The female genetic material awakened by the fusion of the sperm with the egg finishes dividing, resulting in the female pronucleus which also contains 23 chromosomes. As the male and female pronuclei form, spider web-like threads called microtubules pull them toward each other. The two sets of chromosomes join together, completing the process of fertilization. At this moment, a unique genetic code arises — determining gender, hair color, eye color, and hundreds of other characteristics. This new cell, called the zygote, is gently swept by the cilia and the Fallopian tube toward the uterus, where it will implant in the richer uterine lining. Fertilization and Implantation Fertilization — process where a sperm cell from the male merges with an egg cell from the female to form a zygote. This typically occurs in the fallopian tube. The zygote then undergoes several cell divisions as it travels toward the uterus. Implantation — stage where the fertilized egg (now called a blastocyst) attaches itself to the uterine wall and begins to establish a connection with the mother’s blood supply. This is crucial for the development of the embryo into a fetus. Unit 1: Prenatal Care 7  1. Nidation Nidation is another term for implantation. It refers to the embedding of the blastocyst into the uterine lining (endometrium). During nidation, the blastocyst burrows into the endometrial lining, which allows it to receive nutrients and oxygen from the mother. This process is essential for the embryo's survival and growth. 2. Gradual Process Implantation is not instantaneous but a gradual process that unfolds over several days. After fertilization, the zygote travels down the fallopian tube and enters the uterine cavity. Here’s a general timeline: 1. Blastocyst Formation: Around 5 days after fertilization, the zygote has developed into a blastocyst, which consists of an inner cell mass (which will become the embryo) and an outer layer called the trophoblast (which will form the placenta). 2. Initial Contact: On days 6 to 7, the blastocyst begins to make contact with the uterine lining. 3. Attachment: Around days 7 to 8, the blastocyst starts to attach itself to the endometrial lining. 4. Invasion: Between days 9 and 10, the blastocyst is more deeply embedded into the uterine lining. The trophoblast cells invade the endometrium, establishing a connection with the maternal blood supply. 3. Occurs Between 6th/7th and 10th Days Implantation typically starts between the 6th and 7th days after fertilization and completes by the 10th day. This period allows the blastocyst to effectively adhere to and invade the endometrial lining. The timing is crucial because the uterine lining must be at the right stage of development to support the embryo. 4. Upper Part of Posterior Uterine Wall Implantation most commonly occurs on the upper part of the posterior uterine wall, which is the back portion of the uterus. This location is preferred because the upper part of the uterine cavity often has a thicker and more vascular endometrium, which provides a better environment for the embryo to implant and Unit 1: Prenatal Care 8  develop. The posterior wall is also less likely to be disturbed compared to the anterior wall, which can be subjected to more mechanical pressure. 5. Placenta Develops As implantation progresses, the trophoblast cells of the blastocyst begin to differentiate and form the placenta. The placenta is a crucial organ that forms during pregnancy, providing oxygen and nutrients to the developing fetus and removing waste products from the fetal blood. It also produces hormones necessary to maintain pregnancy, such as human chorionic gonadotropin (hCG). The placenta establishes a strong connection with the maternal blood vessels to facilitate the exchange of substances between mother and fetus. Placenta a vital organ that develops during pregnancy and plays a crucial role in supporting the growing fetus fully functional by week 12 Functions: 1. Respiration a. acts as the fetus's lungs by facilitating the exchange of oxygen and carbon dioxide between the mother and the fetus b. Oxygen from the mother's blood passes through the placenta and into the fetal bloodstream, while carbon dioxide, a waste product, moves from the fetal blood to the maternal blood for elimination. 2. Nutrition a. responsible for transferring nutrients from the mother to the fetus. b. allows essential nutrients like glucose, amino acids, fatty acids, vitamins, and minerals to pass through and nourish the developing baby. 3. Waste removal a. helps remove waste products produced by the fetus, such as urea and creatinine. Unit 1: Prenatal Care 9  4. Protection a. provides a protective barrier, filtering out many harmful substances and pathogens that could potentially harm the fetus. b. not an absolute barrier, and some substances, like certain medications, alcohol, and viruses, can still pass through. Umbilical Cord one vein, two arteries (AVA) Wharton's Jelly Wharton's jelly is a gelatinous substance found within the umbilical cord. It serves several important functions: 1. Structure and Support: Wharton's jelly is a soft, mucoid connective tissue that surrounds the umbilical blood vessels (two arteries and one vein) within the umbilical cord. Its primary function is to provide cushioning and support for these blood vessels, helping to protect them from compression and kinking, which could otherwise impede blood flow between the mother and the fetus. 2. Protection: By cushioning the blood vessels, Wharton's jelly helps maintain the integrity of the umbilical cord, ensuring a continuous and stable supply of oxygen and nutrients to the fetus. This protection is crucial for preventing complications like cord compression, which can affect fetal heart rate and overall well-being. 3. Composition: Wharton's jelly is composed of a gel-like matrix rich in mucopolysaccharides (such as hyaluronic acid and chondroitin sulfate) and proteoglycans. This composition gives it its characteristic jelly-like consistency and helps it maintain its cushioning properties. Unit 1: Prenatal Care 10  Amnion The amnion is a thin, transparent membrane that forms part of the amniotic sac (or amniotic cavity), which surrounds the developing fetus. It plays several vital roles: 1. Amniotic Sac: The amnion is one of the two layers of the amniotic sac, the other being the chorion. Together, these membranes enclose the amniotic cavity, which is filled with amniotic fluid. This fluid provides a protective cushion for the fetus and maintains a stable environment. 2. Fluid Production and Containment: The amnion is responsible for producing and containing the amniotic fluid. This fluid is essential for cushioning the fetus against external trauma, facilitating fetal movements, and allowing for proper fetal development. It also helps regulate the fetus's body temperature. 3. Protection: By lining the amniotic cavity, the amnion helps protect the fetus from physical impacts and prevents the adherence of the fetus to the uterine wall. It also acts as a barrier against infections and helps maintain the correct balance of fluids in the amniotic cavity. 4. Developmental Support: The amnion contributes to the development of the fetus by providing a constant volume of amniotic fluid, which is crucial for proper lung development and musculoskeletal development. The fluid also aids in the absorption of shock and reduces the risk of umbilical cord compression. Amniotic Membranes The amniotic membranes are critical structures in the uterus that create a protective environment for the fetus. They consist of two primary layers: 1. Amnion (Inner Layer) Unit 1: Prenatal Care 11  Location and Structure: The amnion is the innermost membrane that directly surrounds the fetus. It is a thin, transparent layer that lines the inner surface of the amniotic sac. Function: Fluid Production and Containment: The amnion plays a crucial role in producing and containing amniotic fluid. This fluid fills the amniotic sac and surrounds the fetus. Protection: By enclosing the fetus in amniotic fluid, the amnion provides cushioning, which protects the fetus from external trauma and helps absorb shocks. Facilitation of Movement: The amniotic fluid also allows the fetus to move freely, which is important for musculoskeletal development and overall growth. Temperature Regulation: The fluid helps maintain a stable temperature around the fetus, contributing to its thermal regulation. 2. Chorion (Outer Layer) Location and Structure: The chorion is the outermost membrane and surrounds the amnion. It is thicker than the amnion and is closely associated with the uterine wall. Function: Placental Formation: The chorion contributes to the formation of the placenta. It interacts with the maternal tissues to establish the connection necessary for nutrient and gas exchange between the mother and fetus. Protection: It acts as a protective barrier and helps anchor the amniotic sac to the uterine lining. Chorionic Villi: The chorion contains tiny, finger-like projections called chorionic villi that penetrate the uterine lining. These villi are crucial for nutrient and gas exchange between the maternal blood and fetal blood. Unit 1: Prenatal Care 12  3. Enclose Fetus in Amniotic Fluid Amniotic Sac: The amnion and chorion together form the amniotic sac, which encloses the fetus in a fluid-filled cavity. Functions of Amniotic Fluid: Cushioning: Amniotic fluid acts as a shock absorber, protecting the fetus from physical impacts and pressure. Development: It facilitates the movement of the fetus, which is important for the development of muscles and bones. Protection from Adhesion: The fluid helps prevent the fetus from sticking to the amniotic sac or the uterine wall. 4. Protects Fetus from Infectious Organisms Barrier Function: The amniotic membranes, particularly the chorion, help act as a barrier to protect the fetus from infectious organisms. The membranes are designed to minimize the risk of infection from bacteria, viruses, or other pathogens that may be present in the maternal environment. Immune Protection: While not entirely immune to all infections, the amniotic sac provides a physical barrier that helps reduce the risk of direct exposure to potential pathogens. The amniotic fluid itself also contains antibacterial properties that contribute to this protective role. Characteristics of Amniotic Fluid clear, slightly yellow, alkaline approximately 1 liter at term derived from: maternal plasma Unit 1: Prenatal Care 13  cells of the amnion fetal fluid from lungs, skin, fetal urine Functions of Amniotic Fluid Cushions fetus from trauma Facilitates fetal movement (necessary for musculoskeletal development) presence of amniotic fluid allows the fetus to move freely within the uterus. crucial for the development of the muscles and bones Facilitates symmetrical growth Amniotic fluid surrounds the fetus evenly, providing a uniform environment that supports balanced growth Regulates intrauterine temperature the amniotic fluid acts as an insulator, protecting the fetus from extreme temperature changes and helping to keep the intrauterine environment at a constant, optimal temperature for fetal development. Provides source of oral fluid The fetus swallows amniotic fluid, which is essential for the development of the digestive system. This fluid is absorbed and processed by the fetus, contributing to the maturation of gastrointestinal functions and aiding in the development of the gut. Cushions the umbilical cord The amniotic fluid surrounds the umbilical cord, preventing it from being compressed or pinched. This cushioning helps ensure a continuous supply of oxygen and nutrients from the placenta to the fetus and reduces the risk of umbilical cord complications that could affect fetal health. Receptacle for fetal substances Amniotic fluid collects and contains various substances released by the fetus, such as urine and skin cells. Unit 1: Prenatal Care 14  This helps prevent the accumulation of these substances within the uterus and maintains a clean environment for the fetus. Fetal Circulation (Summary) Blood enters the right atrium. This is the chamber on the upper right side of the heart. When the blood enters the right atrium, most of it flows through the foramen ovale into the left atrium. Blood then passes into the left ventricle. This is the lower chamber of the heart. Blood then passes to the aorta. This is the large artery coming from the heart. From the aorta, blood is sent to the heart muscle itself and to the brain and arms. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava. Very little of this less oxygenated blood mixes with the oxygenated blood. Instead of going back through the foramen ovale, it goes into the right ventricle. This less oxygenated blood is pumped from the right ventricle into the pulmonary artery. A small amount of the blood continues on to the lungs. Most of this blood is shunted through the ductus arteriosus to the descending aorta. This blood then enters the umbilical arteries and flows into the placenta. In the placenta, carbon dioxide and waste products are released into the mother's circulatory system. Oxygen and nutrients from the mother's blood are released into the fetus's blood. Physiologic Changes During Pregnancy 1. Chadwick’s sign — bluish/purplish discoloration of the cervix, vagina, and labia that occur due to increased blood flow to these areas. During pregnancy there is an increase in blood volume and circulation, particularly to the pelvic organs. 2. Goodell’s sign — Softening of the cervix due to increased blood flow and hormonal changes, particularly from progesterone. Unit 1: Prenatal Care 15  3. Hegar’s sign — softening of the lower uterine segment or isthmus. As the uterus expands to accommodate the growing fetus, the isthmus or the lower segment of the uterus becomes softer and more pliable. This softening allows the uterus to grow and adapt to the increasing size of the fetus. Circulatory System 1. Increases up to 50% — maternal blood volume increases by app. 30-50%. Increase in blood volume is essential for providing adequate oxygen and nutrients to the fetus and for accommodating increased blood flow through the placenta. 2. Pseudoanemia — decrease in hemoglobin concentration due to disproportionate increase in plasma volume compared to RBCs. 3. Iron requirements increased — increase significantly due to the increased blood volume and the need to support fetal development and placental growth. Needed to support additional RBCs. 4. Increase in size — size of the heart increases during pregnancy, particularly the left ventricle to accommodate the higher blood volume and increased workload 5. Blood pressure changes — BP typically decreases during the first and second trimester due to the effects of progesterone which causes vasodilation. BP often reaches lowest point during second trimester. 6. Fibrinogen increases — blood plasma protein essential for blood clotting. This prepares the body for potential blood loss during childbirth. Respiratory System 1. Thoracic Cage — expands during pregnancy 2. Oxygen consumption increases — higher oxygen demand to meet the needs of both the mother and the fetus Unit 1: Prenatal Care 16  3. Hyperventilation — increase in respiratory rate (hyperventilation) as the body attempts to meet the higher oxygen demands 4. Respiratory Alkalosis — an acid-base imbalance in the blood. It occurs when your carbon dioxide level is too low because of hyperventilation. The kidneys compensate for this alkalosis by excreting more bicarbonate, stabilizing the blood pH within a slightly alkaline range. 5. Mucosal Edema — Hormonal changes during pregnancy, particularly increased levels of estrogen, lead to mucosal edema, or swelling of the mucous membranes in the respiratory tract. Digestive System 1. Nausea/vomiting a. “morning sickness” b. experienced particularly in the first trimester c. thought to be related to rising levels of human chorionic gonadotropin (hCG) and estrogen 2. Constipation a. progesterone, a hormone that increases during pregnancy, relaxes the smooth muscles of the gastrointestinal tract. this slows down the movement of food through the intestines, leading to constipation b. as uterus expands, it exerts pressure on the intestines, further contributing to constipation 3. Flatulence (farting)/heartburn a. slowing of digestion can lead to increased gas production, causing flatulence and bloating b. the relaxation of the lower esophageal sphincter due to progesterone can cause stomach acid to flow back into the esophagus, resulting in heartburn. 4. Gallstones Unit 1: Prenatal Care 17  a. pregnancy can lead to the sluggish movement of bile from the gallbladder due to the relaxing effect of progesterone on smooth muscle. This can increase the risk of gallstone formation. b. pregnancy is associated with increased cholesterol levels, which can contribute to the formation of cholesterol-based gallstones. Urinary System 1. Kidneys a. Function increases i. During pregnancy, the kidneys' filtration rate increases by about 50% to handle the elevated blood volume and metabolic waste from both the mother and the fetus. This increased Glomerular Filtration Rate (GFR) leads to higher urine output. b. Renal threshold for sugar is reduced i. The renal threshold for glucose is lowered during pregnancy, meaning that glucose may spill into the urine more easily. This can result in glycosuria, where small amounts of sugar are present in the urine, even if blood sugar levels are normal. This is typically benign but should be monitored to rule out gestational diabetes. 2. Bladder and ureters a. Blood supply increased b. Pressure i. As the uterus expands, it exerts pressure on the bladder, reducing its capacity and leading to more frequent urination (known as urinary frequency). This pressure can also affect the ureters, which may become compressed, potentially slowing urine flow from the kidneys to the bladder. c. Atonia i. The hormone progesterone relaxes the smooth muscles of the urinary tract, leading to atonia (reduced muscle tone) in the bladder and ureters. This relaxation can slow the flow of urine and increase Unit 1: Prenatal Care 18  the risk of urinary stasis, which may contribute to urinary tract infections (UTIs). Integumentary System 1. Linea Negra — dark vertical line that appears on the abdomen. Primarily attributed to hormonal changes during pregnancy. Increased level of hormones such as estrogen and progesterone stimulate the production of melanin, the pigment responsible for skin color. 2. Striae Gravidarum (Stretch Marks) — stretching and tearing of the dermal layer of the skin. In accommodating the growing fetus, the skin stretches beyond its normal capacity. This stretching may cause the collagen and elastin fibers in the dermis to break, leading to the formation of stretch marks. Terminology 1. Gravida — woman currently pregnant or has been pregnant anytime in the past regardless of the outcome 2. Nulligravida — woman that has never been pregnant 3. Primigravida — woman who is pregnant for the first time 4. Multigravida — woman that has been pregnant more than once 5. Para — number of pregnancies that have reached viable gestational age (typically around 20 weeks) and resulted in the birth of one or more infants, regardless of whether the infants were born alive or stillborn. 6. Primipara — woman who has given birth to one viable offspring for the first time 7. Multipara — woman who has given birth to two or more viable offspring 8. Nullipara — woman who has never given birth to a viable offspring 9. Abortion — termination of a pregnancy before 20 weeks of gestation. Can be spontaneous (miscarriage) or elective (induced abortion) Unit 1: Prenatal Care 19  10. Gestational Age — age of the fetus or pregnancy calculated from the first day of the last menstrual period (LMP). Usually expressed in weeks and is commonly used to estimate the due date and assess fetal development 11. Fertilization Age (conception age) — age of the fetus or pregnancy calculated from the day of conception (fertilization). Typically about two weeks less than gestational age because gestational age is calculated from the first day of the LMP, which is approximately two weeks before conception occurs. Nomenclature G — number of pregnancies P — number of deliveries T — number of term deliveries P — number of preterm deliveries A — number of abortions L — number of living children M — number of multiple births Expected Date of Confinement/Delivery (EDC/EDD) First day of LMP - 3 months, + 7 days, + 1 year Signs of Pregnancy Presumptive (Subjective) 1. Amenorrhea (no period) 2. Nausea (with or without vomiting) 3. Breast enlargement and tenderness 4. Fatigue 5. Poor sleep Unit 1: Prenatal Care 20  6. Back pain 7. Constipation 8. Food cravings and aversions 9. Mood changes/”mood swings” 10. Heartburn (increased levels of progesterone leading to the relaxation of the lower esophageal sphincter causing stomach acid to flow back into the esophagus leading to heartburn) 11. Nasal congestion (increased levels of estrogen cause mucosal edema) 12. Shortness of breath 13. Lightheadedness 14. Elevated basal body temperature (BBT) 15. Spider veins 16. Reddening of the palms Probable (Objective) 1. Increased frequency of urination 2. Soft cervix 3. Abdominal bloating/enlargement 4. Mild uterine cramping/discomfort without bleeding 5. Increased skin pigmentation in the face, stomach, and/or areola Positive 1. fetal heartbeat 2. visualization of fetus (through an ultrasound) 3. positive hCG urine or blood Unit 1: Prenatal Care 21  Maternal Psychosocial Changes First Trimester 1. Ambivalent — During the first trimester of pregnancy, it is common for women to experience ambivalence, a mix of positive and negative emotions, as they begin to adjust to the reality of being pregnant. Second Trimester 1. Baby becomes real a. fetal movements are felt (known as “quickening”) b. growing baby bump and other physical changes c. emotional bonding with baby 2. Maternal introspection a. mother starts to reflect on their own upbringing and how they want to raise their child b. mother begins to emotionally and mentally prepare for the responsibilities of parenthood c. increased confidence and acceptance of their pregnancy Third Trimester 1. Begins to think of baby as separate a. As the due date nears, the mother increasingly sees the baby as a separate entity with its own identity 2. Restless a. Many women experience a "nesting" instinct during the third trimester, characterized by a strong urge to prepare the home for the baby. b. The physical discomforts of late pregnancy, such as back pain, difficulty sleeping, and the increased size of the abdomen, can contribute to Unit 1: Prenatal Care 22  feelings of restlessness. 3. Self-centered a. As the pregnancy progresses, the mother may become more focused on her own needs and well-being. b. There's a tendency to conserve energy and focus on self-care in preparation for the labor and postpartum period. c. heightened emotional sensitivity, where the mother becomes more attuned to her feelings and less tolerant of stressors or distractions. Paternal Psychosocial Changes First Trimester 1. Excitement over virility a. sense of pride over their ability to conceive a child 2. Financial concerns a. realization of impending fatherhood leads to concerns related to finances 3. Energetic a. excitement of fatherhood can make fathers feel more energetic and motivated to support their partner 4. Exhibit symptoms with wife a. Couvade Syndrome — fathers start to exhibit symptoms similar to their pregnant partner, such as nausea, weight gain, or mood swings Second Trimester 1. More confident a. fathers become more comfortable with the idea of becoming a father 2. Concerns about wife’s changes/introspection a. fathers become more aware of the physical and emotional changes their partner is experiencing Unit 1: Prenatal Care 23  b. fathers may start to engage in their own introspection, considering what kind of father they want to be Third trimester 1. Rivalry with fetus 2. Interest in himself 3. Fantasizes about child Factors Affecting Psychological Response Body image Personal characteristics Financial situation Cultural expectations Emotional security Support from significant others Changes in sexuality Role of the father and siblings Preparation for Parenthood Childbirth Education 1. provides information on pregnancy and childbirth to facilitate optimal decision- making 2. classes for special groups 3. importance of exercise during pregnancy 4. selection of birthing process 5. infant care First trimester Unit 1: Prenatal Care 24  1. Physical and psychosocial changes of pregnancy 2. Self-care in pregnancy 3. Protecting and nurturing the fetus 4. Choosing a care provider and birth setting 5. Prenatal exercise 6. Relief of common early pregnancy discomfort Goals of Prenatal Care 1. Safe birth/delivery 2. Health promotion 3. Self-care 4. Provide physical care 5. Provide anticipatory guidance Role of Nurse 1. Physical assessment 2. Identify and reevaluate risk factors 3. Teach self-care 4. Nutrition counseling 5. Promote family’s adaptation to pregnancy Prenatal Visits 1. Every 4 weeks for the first 28 to 32 weeks 2. Every 2 weeks from 32 to 36 weeks Unit 1: Prenatal Care 25  3. Every week from 36 to 40 weeks Routine Lab Tests 1. Blood grouping a. identifies mother’s blood type 2. Rh factor and antibody screen a. checks if mother is Rh-positive or Rh-negative b. checks for antibodies that could affect the baby 3. CBC a. evaluates overall health by measure RBCs and WBCs, hemoglobin, hematocrit, and platelets 4. Hemoglobin and Hematocrit (H&H) a. measures the levels of hemoglobin and the percentage of RBCs, assessing for anemia 5. VDRL, RPR, or STS a. test screen for syphilis, an infection that could be passed on to the baby if untreated 6. Rubella Titer a. checks immunity to rubella (German measles), if the mother is not immune, exposure during pregnancy could cause birth defects 7. Tuberculosis (TB) skin test a. Screens for tuberculosis 8. Hemoglobin electrophoresis a. identifies hemoglobinopathies like sickle cell disease or thalassemia, both of which can be passed to the baby 9. HIV screen Unit 1: Prenatal Care 26  a. detects HIV infection, reducing transmission to baby 10. Hepatitis B screen a. tests for hepatitis B infection 11. Urinalysis (UA) a. screens for urinary tract infections, diabetes, and kidney conditions 12. PAP test a. screens for cervical cancer 13. Cervical culture a. detects sexually transmitted infections like chlamydia and gonorrhea 14. Maternal Serum Alpha-Fetoprotein (MSAFP) a. part of the quad screen, checks for neural tube defects and other abnormalities in the baby 15. Maternal blood glucose a. screens for gestational diabetes, a type of diabetes that develops during pregnancy Assessment of Fetal Well-Being Fetal Position positioning of the baby as it develops back curved head bowed limbs bent and drawn up to torso Fetal Presentation part of the fetus that is leading/closest to the pelvic inlet of the birth canal Unit 1: Prenatal Care 27  cephalic presentation: baby’s head is positioned to enter the birth canal first breech presentation: baby’s buttocks or feet are positioned to enter the birth canal first, may necessitate a cesarean delivery Unit 1: Prenatal Care 28  frank breech: buttocks first with legs extended complete breech: buttocks first with legs flexed footling breech: one or both feet first Unit 1: Prenatal Care 29  Engagement baby’s head (or presenting part) settles into pelvis before birth known as “lightening” or “dropping” Leopold’s Maneuver performed after 24 weeks gestation when fetal outline can be palpated named after Christian Gerhard Leopold Uterine Growth During Pregnancy McDonald’s Rule measures fundal height (FH) measures the size of the uterus assesses fetal growth and development Unit 1: Prenatal Care 30  measured from the top of the mother’s uterus (fundus) to the top of the mother’s pubic symphysis. This measurement reflects the size of the uterus and indirectly the growth of the fetus. Formula: Greater FH than expected Gestational Age multiple pregnancy, miscalculated due date, Large for Gestational Age (LGA) infant, hydramnios (excess amniotic fluid), Hydatidiform mole (molar pregnancy — a condition where abnormal tissue grows in the uterus instead of a fetus) Lesser FH than expected Gestational Age Small for Gestational Age (SGA), pregnancy length miscalculated or an anomaly in developing, Intrauterine Growth Restriction (IUGR — a condition where the fetus is not growing at the expected rate) Bartholomew’s Rule of 4’s measures AOG determines the position of the uterus in the abdominal cavity - uterus is about the size of a small 4 weeks almond or a large egg - remains within the pelvis 8 weeks - uterus begins to enlarge - uterus can be palpated above the pubic Unit 1: Prenatal Care 31  symphysis (joint at the front of the pelvis) - uterus rises above the pubic symphysis, can be felt around the level of the pubic 12 weeks bone - size of a grapefruit - uterus can be felt midway between the 16 weeks pubic symphysis and the umbilicus (belly button) - uterus reaches level of umbilicus - fundal height (distance between the 20 weeks pubic symphysis to the top of the uterus) can be measured more accurately - uterus continues to grow 24 weeks and beyond - fundal height usually corresponds closely to the gestational age in weeks Computing Age of Gestation (AOG) Prenatal Diagnostic Studies Common 1. Ultrasound — uses high-frequency sound waves to create images of the baby, placenta, and amniotic fluid Unit 1: Prenatal Care 32  a. Biophysical profile i. combines ultrasound with a nonstress test to assess fetal well-being ii. evaluates the following: 1. fetal heart rate — using the nonstress test 2. fetal movement — using ultrasound 3. fetal tone — fetal muscle tone 4. fetal breathing movements — via ultrasound 5. amniotic fluid volume — via ultrasound b. Amniotic fluid level c. Sex/Gender i. identified through ultrasound ii. typically around 18-20 weeks of gestation 2. Kick Test a. monitors fetal activity by counting the number of kicks or movements the fetus makes in a given period 3. Contraction Stress Test a. assess how fetus responds to contractions b. evaluates fetal heart rate response to uterine contractions c. mother is given oxytocin or encouraged to have natural contractions through nipple stimulation, fetal heart rate is monitored 4. Nonstress Test a. measures fetal heart rate in response to fetal movements 5. Amniocentesis a. diagnostic test used to obtain amniotic fluid for testing b. used to assess for genetic disorders, chromosomal abnormalities, and fetal lung maturity Unit 1: Prenatal Care 33  Others 1. Lecithin/sphingomyelin ratio 2. Fern test 3. Nitrazine test 4. Alpha feto protein level Assessing Fetal Movement Level 1 Ultrasound basic detects gestational sac (5 weeks after LMP) identify number of fetuses document fetal life — visualizes fetal movement and heart activity detects gross fetal structural anomalies estimates gestational age — estimates how far along pregnancy is determines fetal position locates the placenta — ensures that the placenta is not covering the cervix estimates amniotic fluid volume evaluate maternal pelvic masses Level 2 Ultrasound evaluates gestational age measures fetal growth specific examinations of the brain, heart, kidney, and cord insertion quantify amniotic fluid volume determine placental location Unit 1: Prenatal Care 34  performed after 18 weeks Level 1 Ultrasound (Basic or Routine Ultrasound) Timing: Typically performed between 18-20 weeks of pregnancy. Purpose: It is a standard anatomy scan that checks for basic features like: Gestational age and growth. Fetal heart rate. Basic anatomy: Brain, heart, spine, limbs, and organs. Placenta location and amniotic fluid levels. Level of Detail: Provides a general overview but is not designed to diagnose detailed or complex conditions. Level 2 Ultrasound (Detailed or Targeted Ultrasound) Timing: Usually done at the same time as a Level 1 scan, around 18-22 weeks, but can be performed later if necessary. Purpose: A more comprehensive scan aimed at detecting specific problems or more detailed anomalies in the fetus. It may be recommended for: High-risk pregnancies. Suspected abnormalities from Level 1 ultrasound. Families with genetic conditions or history of birth defects. Older maternal age or specific health conditions. Level of Detail: It provides greater detail, focusing on the fetus's anatomy, including the brain, heart, kidneys, face, and spine. It may involve 3D or 4D imaging and can look more closely at the baby’s development. Assessing Maternal Wellbeing Urine Test: Benedict’s Test (Sugar in Urine) Color Presence of Sugar Unit 1: Prenatal Care 35  Blue None Green/Yellow Traces of Reducing Sugar Orange Red Moderate amount of Reducing Sugar Brick Red Large amount of Reducing Sugar Danger Signs of Pregnancy chills and fever C cerebral disturbances — severe headaches, dizziness, confusion A abdominal pain blurred vision blood pressure — significant increases B or decreases bleeding swelling S sudden escape of fluid — premature rupture of membranes (water breaking) Maternal Weight Gain Distribution Fetus, Placenta, Amniotic Fluid 11 lbs Uterus 2 lbs Increased blood volume 3 lbs Breast tissue 3 lbs Maternal stores 5-10 lbs Total 25-35 lbs Normal 25-35 lbs Overweight 35-40 lbs Underweight 15-25 lbs Nutrition During Pregnancy Unit 1: Prenatal Care 36  choose food from food guide pyramid increase of 300 calories per day calorie needs greater in last two trimesters encourage diet in high folic acid with supplements calcium needs increase nearly 50% — supports development of baby’s bones and teeth heavy demand for iron for fetal stores — body requires more iron to support increased blood volume and to provide fetal stores of iron 8-10 glasses of water per day Vegetarianism ample and complete proteins from dairy products and eggs brown rice and whole weat, legumes, nuts, cooked and fresh vegetables and fruits vitamin B12 supplement Unit 1: Prenatal Care 37  Lactose Intolerance abdominal distention, discomfort, nausea, vomiting, loose stool, cramps may tolerate milk in cooked form cheese and yogurt — better tolerated because they contain less lactose lactase may be prescribed — enzyme supplements that help digest lactose lactase-treated milk — milk with lactose broken down for better digestion lactose-free products Pica non-nutritive eating — eating food with no nutritional value associated with poverty and inadequate diets iron deficiency anemia — the craving for non-food substances may be a way for the body to compensate for iron or other nutrient deficiencies Supplements During Pregnancy Iron Supplements helps woman’s body make more RBCs carries oxygen to the baby for its development Folic Acid prevents birth defects that affect the baby’s spinal cord and brain Calcium prevents mother from losing bone density as the baby uses calcium for its own bone growth Iodine Unit 1: Prenatal Care 38  critical for a woman’s healthy thyroid function during pregnancy iodine deficiency may cause: miscarriage stillbirth stunted physical growth severe mental disability deafness Is Sex Safe During Pregnancy? Penetration and intercourse’s movement WON’T harm the baby baby is protected by mother’s abdomen and the uterus’ muscular walls baby is cushioned by amniotic sac’s fluid contractions of orgasm aren’t the same as labor contractions Safety Precautions: avoid sex in the final weeks of pregnancy hormones in semen called prostaglandins stimulate contractions or induce labor For some women, desire fades during pregnancy. Others feel more deeply connected to their sexuality and are more aroused when they’re preggers. It’s normal for sexual desire to come and go as the mother’s body changes. First Trimester — nausea, fatigue, or breast tenderness may kill sex drive Unit 1: Prenatal Care 39  Second Trimester — libido may kick into high gear, increased blood flow enhances orgasms Third Trimester — sex may feel uncomfortable as birth approaches Active Recall Pelvic Types 1. Gynecoid 2. Android 3. Anthropoid Unit 1: Prenatal Care 40  4. Platypelloid Where does fertilization occur? Outer third of the fallopian tube Where is sex determined? Outer third of the fallopian tube Where does implantation occur? Upper part of the posterior uterine wall Where does the placenta develop? Upper part of the posterior uterine wall When does implantation occur? Between the 6th/7th and 10th days By what week is the placenta fully functional? Week 12 Unit 1: Prenatal Care 41  Functions of the placenta 1. Respiration 2. Nutrition 3. Waste Removal 4. Protection 5. Endocrine: hCG, hPL, somatomamotropin Components of the umbilical cord 1. Two arteries 2. One vein 3. Wharton’s Jelly 4. Amnion Inner amniotic membrane Amnion Outer amniotic membrane Chorion Functions of the amniotic membranes 1. encloses the fetus in amniotic fluid 2. protects fetus from infectious organisms Where is amniotic fluid derived from? 1. maternal plasma 2. cells of the amnion 3. fetal fluid from skin, lungs, and fetal urine Characteristics of amniotic fluid 1. clear, slightly yellow, alkaline 2. approximately 1 liter at term Functions of amniotic fluid Unit 1: Prenatal Care 42  1. cushions fetus from trauma 2. facilitates symmetrical growth 3. facilitates movement 4. regulates intrauterine temperature 5. provides source of oral fluid 6. cushions umbilical cord 7. receptacle for fetal substances Bluish-purplish coloration of the vaginal mucosa and cervix Chadwick’s sign Softening of the cervix Goodell’s sign Softening of the lower uterine segment or isthmus Hegar’s sign Positive signs of pregnancy 1. Fetal heartbeat 2. Visualization of fetus 3. Positive hCG urine or blood Rubin’s Maternal Tasks 1. Seeking safe passage 2. Securing acceptance 3. Learning to give of self 4. Committing of self to child Maternal Psychosocial Changes First trimester — ambivalent Second trimester — baby becomes real, maternal introspection Third trimester — thinks of baby as a separate being, restless, self-centered Unit 1: Prenatal Care 43  Paternal Psychosocial Changes First Trimester — excitement over virility, financial concerns, energetic, exhibit symptoms with wife Second Trimester — more confident, concerns about wife’s changes/introspection Third Trimester — rivalry with fetus, interest in himself, fantasizes about child Factors affecting psychological response 1. Body image 2. Personal characteristics 3. Financial situation 4. Cultural expectations 5. Emotional security 6. Support from SO 7. Changes in sexuality 8. Role of the father and siblings Goals of prenatal care 1. Safe birth 2. Health promotion 3. Self-care 4. Provide physical care 5. Provide anticipatory guidance Role of the nurse 1. Physical assessment 2. Identify and re-evaluate risk factors 3. Teach self care 4. Nutritional counseling Unit 1: Prenatal Care 44  5. Promote family’s adaptation to pregnancy Positioning of the baby as it develops Fetal position Specifies which anatomical part of the fetus is leading/is closest to the pelvic inlet of the birth canal Fetal presentation Baby’s head settles into your pelvis before birth Engagement When is Leopold’s maneuver performed? 24 weeks AOG when fetal outline can be palpated Leopold’s maneuver is named after? Christian Gerhard Leopold FH greater than AOG 1. multiple pregnancies 2. miscalculated due date 3. LGA infant 4. hydramnios — too much amniotic fluid 5. H-mole/ hydatidiform mole FH less than AOG 1. SGA 2. pregnancy length miscalculated 3. anomaly in developing 4. IUGR This determines the position of the uterus in the abdominal cavity Bartholomew’s Rule of 4’s Where is the uterus at: Unit 1: Prenatal Care 45  12 weeks fundus over symphysis pubis 16 weeks halfway between symphysis pubis and umbilicus 20 weeks umbilicus 36 weeks xyphoid process; lightening and engagement What is the ideal AOG 37-40 weeks Common Prenatal Diagnostic Studies 1. Ultrasound a. Biophysical profile b. Amniotic fluid level c. Sex/gender 2. Kick Test 3. Contraction Stress Test 4. Nonstress Test 5. Amniocentesis Other Prenatal Diagnostic Studies 1. Lecithin/sphingomyelin ratio 2. Fern test 3. Nitrazine test 4. Alpha feto protein level Danger signs of pregnancy C — cerebral disturbances, chills and fever Unit 1: Prenatal Care 46  A — abdominal pain B — bleeding, blood pressure, blurred vision S — swelling, sudden escape of fluid This supplement helps the woman make more RBCs Iron This supplement prevents birth defects that affect the baby’s spinal cord and brain Folic Acid This supplement prevents the mother from losing bone density as the baby uses calcium for its own bone development Calcium This supplement is critical for a woman’s healthy thyroid function during pregnancy Iodine Iodine deficiency can cause: 1. Miscarriage 2. Stillbirth 3. Stunted physical growth 4. Severe mental disability 5. Deafness This hormone found in semen can cause contractions or induce labor Prostaglandins Amnion (Inner layer) 1. Production of amniotic fluid 2. Protection 3. Allows fetus to move freely Unit 1: Prenatal Care 47  4. Temperature regulation Chorion (outer layer) — thicker than amnion 1. Placental formation 2. Protection — anchors amniotic sac to uterine lining 3. Chorionic Villi — penetrates the uterine lining, nutrient and gas exchange between maternal and fetal blood Characteristics of Amniotic Fluid clear, slightly yellow, alkaline app. 1 liter at birth derived from: maternal plasma cells of the amnion fetal fluid from lungs, skin, and fetal urine Functions of the amniotic fluid: 1. Cushions fetus from trauma 2. Facilitates fetal movement 3. Symmetrical growth 4. Cushions umbilic cord — protects it from being compressed or pinched 5. Provides source of oral fluid — development of digestive system 6. Receptacle for fetal substances — maintains clean environment for fetus Chadwick’s sign — bluish/purplish discoloration Goodell’s — softening of the cervix Unit 1: Prenatal Care 48  Hegar’s — softening of lower uterine segment or isthmus Changes in circulatory system 1. maternal blood volume increases by 30-50% 2. pseudoanemia — decrease in hemoglobin concentration bec of disproportionate increase in plasma volume compared to RBCs 3. greater iron requirements 4. heart increases in size, particularly the left ventricle 5. bp decreases during first and second trimester 6. fibrinogen increases — blood plasma protein essential for blood clotting, prepares body for potential blood loss during childbirth Changes in respiratory system 1. thoracic cage expands 2. oxygen consumption increases to meet demands of both mother and fetus 3. hyperventilation — body attempts to meet higher oxygen needs 4. respiratory alkalosis — kidneys compensate for the lowered carbon dioxide levels (bec of hyperventilation) by releasing more bicarbonate, stabilizing the blood pH within a slightly alkaline range Changes in digestive system 1. morning sickness/nausea a. thought to be because of increasing levels of hCG b. first trimester 2. constipation a. because of progesterone which relaxes the smooth muscles of the gastrointestinal tract, slows down movement of food Unit 1: Prenatal Care 49  b. uterus puts pressure on intestines as it expands 3. Flatulence — farting a. slowing of digestion = increased gas production b. relaxation of lower esophageal sphincter can cause stomach acid to flow back into the esophagus causing heartburn c. gallstones i. due to sluggish movement of bile from the gallbladder because of the effects of progesterone on the smooth muscles. ii. increased risk of gallstone formation iii. increased cholesterol levels Changes in kidneys 1. filtration rate of kidneys increases by about 50% 2. lowered threshold for sugar, sugar spills into urine causing glycosuria (small amounts of sugar present in urine) Changes in bladder and ureters 1. uterus puts pressure on bladder as it expands, leading to more frequent urination 2. Atonia in the bladder and ureters reduced muscle tone due to progesterone, relaxes smooth muscles of the urinary tract can increase the risk of urinary stasis I LOVE YOOU MORE fetal movements are felt — quickening Unit 1: Prenatal Care 50  Couvade syndrome — father exhibits symptoms similar to their pregnant mother Goals on prenatal care 1. safe birth/delivery 2. health promotion 3. self care 4. provide physical care 5. provide anticipatory guidance Role of nurse 1. physical assessment 2. identify and reevaluate risk factors 3. teach self care 4. nutritional counseling 5. promote family’s adaptation to pregnancy 28 - 32 weeks — every 4 weeks 32-36 weeks — every 2 weeks 36 - 40 weeks — every week Unit 1: Prenatal Care 51