Week 2 Women's Health Pre-readings Summary Notes PDF

2.1: Antepartum/ Antenatal 2.1.2 Pregnancy: Overview of Pregnancy Pregnancy, or gestation, is the 40-week period during which one or more offspring develop inside a woman. If an ovum is fertilised by a sperm, the fertilised ovum begins to divide and becomes a fetus. During pregnancy, both es...

2.1: Antepartum/ Antenatal 2.1.2 Pregnancy: Overview of Pregnancy Pregnancy, or gestation, is the 40-week period during which one or more offspring develop inside a woman. If an ovum is fertilised by a sperm, the fertilised ovum begins to divide and becomes a fetus. During pregnancy, both estrogen and progesterone hormones rise, which causes several changes in nearly every organ system - there's an increase in blood volume, increased urinary output, shallow breathing, mood changes, nausea and changes in taste, darkening of the skin, breast changes, and the loosening of the ligaments. All of which help prepare for the delivery of a healthy baby. Terms Related to Pregnancy Status Key Terms Definition Para The number of pregnancies that have reached viability, regardless of whether the infants were born alive Gravida A woman who is or has been pregnant Primigravida A woman who is pregnant for the first time Primipara A woman who has given birth to one child past age of viability Multigravida A woman who has been pregnant previously Grand multipara A woman who has carried five or more pregnancies to viability Multipara A woman who has carried two or more pregnancies to viability Nulligravida A woman who has never been and is not currently pregnant 2.1.2 Pregnancy: 3 Ways to Calculate the Expected Date of Delivery (EDD) (1) Nagele’s rule (2) Gestational or (3) Ultrasound birth calculator or wheel Best method of dating a pregnancy To calculate the date of birth by this rule, count backwards 3 calendar months from the first date of the last menstrual period and add 7 days. For e.g., if the last menstrual period began on May 15, you would count back 3 months (April 15, March 15, February 15) and add 7 days to arrive at a date of birth of February 22. 2.1.2 Pregnancy: Assessment of Fetal Well-being Scan Type When conducted? Purpose Dating Scan In first 12 weeks of Confirm and see gestational sac pregnancy Fetal Anomaly 20 to 22 weeks of Physical anomalies Scan pregnancy Growth Scan 30 to 32 weeks of Growth (maturity, sex) pregnancy 2.1.3 Physiologic changes during pregnancy: Physiologic changes during pregnancy Involve the body's adaptations to support the developing fetus: Cardiovascular system Respiratory system Endocrine system Reproductive system Adapts by increasing Increases oxygen Boosts hormone Prepares the breasts for blood volume and consumption production of estrogen, future lactation cardiac output Gastrointestinal system progesterone, prolactin, Uterus enlarges to Decreases the reduces motility. oxytocin, human accommodate the growth of systemic vascular Kidneys work harder to chorionic gonadotropin, the developing fetus. resistance. eliminate maternal and and human placental Common changes include fetal waste, increasing lactogen. skin hyperpigmentation, urine output and cutaneous vascular changes, frequency. and striae gravidarum Musculoskeletal changes include postural and abdominal wall adaptations 2.1.5 : Common discomforts of pregnancy: Common discomforts of pregnancy Temporary symptoms due to the growth and development of the fetus. Important Factors 1. Enlargement of the uterus may compress or put pressure on different organs, causing these symptoms. Stomach: Heartburn Bladder: Increased urinary frequency Veins: hemorrhoids and varicose veins Nerves: leg cramps. 2. Pregnancy hormones may cause nausea and vomiting, as well as back pain. First Trimester Second Trimester Third Trimester Urinary frequency or Backache Return of first trimester incontinence Varicosities of the vulva and discomforts Fatigue legs Shortness of breath and Nausea and vomiting Hemorrhoids dyspnea Breast tenderness Flatulence with bloating Heartburn and indigestion Constipation Dependent edema Nasal stuffiness, bleeding Braxton Hicks contractions gums, epistaxis Cravings 2.1.6 : Prenatal Care Definition and Terms Used Key Terms Definition Key Terms Definition Antenatal Period Conception to Labour Trimester 1 Week 1 to end of week 12 Pregnancy Duration 40 weeks (1st day of LMP to labour) Trimester 2 Week 13 to end of week 27 Trimester 3 After week 28 Common signs & symptoms experienced throughout pregnancy Presumptive signs (subjective) Probable Signs (Objective) Positive Signs (Objective) Breast tenderness (3 to 4 weeks) Positive pregnancy test (4 to 12 weeks) Ultrasound verification of embryo Nausea and vomiting (4 to 14 Goodell’s sign -softening of the cervix or fetus (4 to 6 weeks) weeks) (5 weeks) Auscultation of fetal heart tones Amenorrhea (4 weeks) Chadwick’s sign- bluish-purple coloration via Doppler (10 to 12 weeks) Breast enlargement (6 weeks) of the vaginal mucosa and cervix Fetal movement felt by Urinary frequency (6 to 12 weeks) (6 to 8 weeks) experienced clinician (20 weeks) Uterine enlargement (7 to 12 Hegar’s sign- softening of the lower weeks) uterine segment or isthmus Fatigue (12 weeks) (6 to12 weeks) Hyperpigmentation of skin (16 Abdominal enlargement (14 weeks) weeks) Braxton Hicks contractions Fetal movements (quickening) (16 (16 to 28 weeks) to 20 weeks) Ballottement (16 to 28 weeks) 2.1.6: Prenatal Care Prenatal Visit Schedule & Assessments Recommended prenatal visits frequency for a Key Assessments: successful pregnancy outcome: Weight and BP compared to baseline values Every 4 weeks until week 28 Urine testing for protein, glucose, ketones, and nitrites Every 2 weeks from week 28 to 36 Fundal height Every week from 37 weeks to birth. Quickening/fetal movement Fetal heart rate First Trimester Second Trimester Third Trimester Determine gestational age and Monitor blood pressure for hypertensive Continue ultrasounds at each visit estimated delivery date disorders of pregnancy to assess fetal growth, amniotic Record detailed medical and Analyse urine for urinary tract infections fluid levels, fetal lie, and obstetric history or proteinuria presentation Perform genetic screenings Conduct ultrasounds at each visit to Repeat STD screenings Determine ABO and Rh status assess fetal growth, abnormalities, and Screen for group B streptococcus, Screen for infections amniotic fluid levels or GBS (after 36 weeks) (e.g. HIV, syphilis, chlamydia, viral Screen for gestational diabetes (weeks hepatitis) 24-28) Document immunity against Administer anti-Rh immune globulin, or diseases like rubella and varicella RhoGAM to Rh-negative clients who have not been sensitised (28 weeks) 2.1.6: Prenatal Care Danger Signs of Pregnancy Vaginal bleeding Abdominal or chest pain Persistent vomiting Hypertension, excessive weight gain, eye changes, Chills and fever edema Ruptured membranes Increase or decrease in fetal movement Common pregnancy compilations that require medical attention and action: 1. Bleeding during pregnancy 2. Gestational Diabetes 3. Pregnancy-induced Hypertension (PIH) Common causes in early pregnancy bleeding First Trimester Second Trimester Third Trimester  Spontaneous abortion/ Gestational trophoblastic disease Placenta previa miscarriage (hydatidiform mole) Abruptio placentae Threatened Premature cervical dilatation Preterm labor Inevitable Disseminated intravascular coagulation Complete (DIC) Missed Incomplete Ectopic pregnancy Abdominal pregnancy 2.1.6: Prenatal Care Spontaneous abortion/ miscarriage Cause Nursing assessment Unknown and highly variable Vaginal bleeding First trimester commonly due to fetal Cramping or contractions genetic abnormalities Vital signs, pain level Second trimester more likely related to Patient’s understanding maternal conditions Medical Management of Spontaneous abortion/ miscarriage Threatened Inevitable/Incomplete Missed Avoiding strenuous Misoprostol orally to induce < 14 weeks: D & C activity/bedrest, avoid contractions > 14 weeks: Prostaglandin coitus for 2 weeks; Suction curettage/ D&C suppository or oral Medication: /Dilation & evacuation Misoprostol to dilate the Progesterone if inadequate cervix, then oxytocin luteal function infusion or administration of mifepristone 2.1.6 : Prenatal Care Nursing Management of Spontaneous abortion/ miscarriage Cause Support Vaginal bleeding Physical and emotional Pad count Stress that woman is not the cause of the Passage of products of conception loss Pain level Verbalisation of feelings Preparation for procedures Grief support Medications Referral to community support group 2.1.7 : Hyperemesis gravidarum Definition Cause Signs and symptoms Diagnosis Severe nausea and Unknown cause Weight loss History and physical vomiting that occurs Most likely occurs in Nausea examination during pregnancy susceptible Persistent vomiting Laboratory and urine individuals because several times a day testing. of hormonal changes Signs of dehydration, that occur during the fluid and electrolyte gestational period imbalances. Treatment Nursing Care Depending on the severity, it may involve dietary Priority goals include: changes that decrease the frequency and severity of initiating measures to reduce vomiting vomiting or antiemetics. maintaining fluid and electrolyte balance Supportive treatment, including intravenous fluid providing emotional support. replacement, vitamin and mineral supplementation, Client and family teaching focuses on dietary or total parenteral nutrition might be necessary modifications to reduce risk of nausea and vomiting, and signs and symptoms to watch out for and report to a healthcare provider. 2.1.8 : Pre-gestational conditions: Gestational Diabetes Mellitus (GDM) Definition Type Chronic disease in which GDM, 90%:any degree of glucose metabolism is impaired glucose intolerance with onset by lack of insulin or by or first recognition during ineffective insulin utilisation pregnancy Type1 and Type2 (pre- gestational diabetes) Influences on Mothers Influences on Fetus Spontaneous miscarriage: 15-30% Fetal death Pregnancy-induced hypertension: 3-5times Congenital anomalies Increased rates of CS and postpartum Macrosomia (>4,500g) hemorrhage: macrosomic baby Fetal growth restriction UTIs increase Polyhydramnios (>2000ml) 2.1.9 : Preeclampsia and eclampsia: Nursing Pre-eclampsia Eclampsia Definition: Definition: Elevated blood pressure after 20 weeks of Progression of pre-eclampsia to generalised gestation or during postpartum, with proteinuria or seizures not caused by other factors end-organ damage Seizures can occur before, during, or after labour Mechanism: Complications: Increased peripheral vascular resistance due to heightened sensitivity to vasoconstrictor Placental abruption Intrauterine growth molecules and reduced vasodilating molecules, HELLP syndrome restriction leading to decreased perfusion to organs (e.g. Stroke Preterm birth placenta, kidneys, liver, brain) Low birth weight Fetal death Symptoms: Treatment: High blood pressure (systolic > 140 mmHg and/or Ultimate Treatment: diastolic > 90 mmHg) Delivery of the baby and placenta Proteinuria Visual changes Nursing Care Goals: Peripheral and pulmonary edema Control blood pressure, prevent complications, Headache, confusion provide emotional support Decreased urinary output Epigastric pain Client and Family Education: Understanding the condition, plan of care, and symptoms to report immediately 2.1.9: Preeclampsia and eclampsia: Nursing Pregnancy Induced Hypertension (PIH) Definition Risk Factors Vasospasm occurs during pregnancy in both Multiple pregnancy small and large arteries Primigravida: 40 yrs Incidence: 6-8% of all pregnancies, Poor nutrition responsible of 15% of maternal death Hydramnios Diabetes mellitus Chronic hypertension Chronic renal disease PIH Manifestations Hypertension Proteinuria Edema: generalised edema Insevere cases, headache, blurred vision, nausea, vomiting, even convulsion and coma Severity of clinical manifestations determine the management and treatment 2.1.9: Preeclampsia and eclampsia: Nursing Types of PIH Type of PIH Mild pre-eclampsia Severe pre-eclampsia Eclampsia Overview BP≥140/90mmHg BP≥160/110mmHg/ A seizure or coma Systolic/diastolic BP: Diastolic BP 30 mmHg occurs due to cerebral 30 /15 mmHg more more edema May with mild proteinuria (1+ or 2+) or Proteinuria (3+ or 4+), Fetal hypoxia: fetal edema >5 g/ 24 hours urine mortality rate 25% Edema: different levels Antepartum/intrapartu Headache, blurred m/postpartum vision, nausea and eclampsia vomiting Medical Bed rest, daily BP monitoring, and Hospitalization - Seizure management, Management fetal movement counts oxytocin and IV IV magnesium sulphate Hospitalization - IV magnesium magnesium sulphate; and antihypertensive sulphate during labour preparation for birth agents Birth once seizures controlled 2.1.9: Preeclampsia and eclampsia: Nursing Nursing Management of patient with PIH Nursing assessment Nursing management Risk factors Home management for mild preeclampsia BP Hospitalisation for severe preeclampsia; quiet Nutritional intake environment, sedatives, seizure precautions, anti- Weight hypertensives, assessing for *Magnesium Sulphate Edema; urine for protein toxicity and signs of labour Other laboratory tests if indicated Seizure management for eclampsia; fetal monitoring; uterine contraction monitoring; preparation for birth Follow-up postnatal care *Common signs of Magnesium Sulfate toxicity – flushing, nausea, headache, generalized muscle weakness; – loss of deep tendon reflexes, respiratory depression, oliguria, slurred speech  Antidote – Calcium gluconate 2.2: Intrapartum 2.2 Intrapartum Care Learning Outcome Determine components of labour: passenger, passage and power Distinguish stages of Labour Understand nursing Assessment of Women in Labour: Principles of Care Identify different methods of pain relief in labour Passenger 2.2.1 : Stages of Labour 1st Stage 2nd Stage Initial Examination and Care Time from full dilatation of the cervix to delivery of the Welcoming the mother and her partner / family fetus or fetuses Respect choices (e.g. cultural, personal)/ Birth Plan Subdivided into two phases: History taking (present labour & past hx) Passive (no maternal urge to push, fetal head is General & abdominal assessment still relatively high in pelvis) Vaginal examination (cervix, forewaters, station, Active (strong maternal urge to push, fetal head position, moulding, pelvic capacity) is low –causing ‘bear down’ reflex) Cleanliness and Comfort (clothing, bath / shower, bowel preparation) Management and Care Documentation / Records (partogram, Coach on ‘pushing’ cervicograph, midwifery/nurses notes, obstetric Perineal cleaning records, IMR) Episiotomy (if necessary) Birth Cutting and clamping the umbilical cord 2.2.1 : Stages of Labour 3rd Stage 4th Stage Expulsion of the placenta Immediate Newborn and Postpartum Care Placental separates from the uterine wall when the Lie baby on mother’s abdomen: skin to skin contact, uterus contracts after the infant is delivered. eye contact, explore baby. Encourage bonding / attachment: touch & cuddling. Signs: Assist with breastfeeding: baby usually roots for the a gush of blood nipple (breast crawl) Lengthening of the umbilical cord Uterine fundus becomes firmer and globular Major complication: hemorrhage- Blood loss > 500 ml. Retention of the placenta: if placenta not expelled by 1 hr after delivery Usually last for 5 to 30 minutes from the delivery of the baby. Active management: an oxytocic injection (IM Syntometrine or IV Syntocinon) to help expedite uterine contractions (control bleeding) and expel the placenta. 2.2.2 : Pain management during labour: Nursing Common Pharmacological Pain Relieves during Labour Nitrous oxide gas Pethidine injection Epidural analgesia Self-administered, using a hand- Opioid, Intramuscular injection. Was It is the most effective relief. held face mask widely used in many birth centers. Perform by anesthetist. inexpensive, easy to administer Maternal side effects: Nausea, vomiting Expensive. and safe for both mother and and sedation. Side Effects: fetus. Fetal side effects: Respiratory Frequent: depression. Cross placenta, fetus peak hypotension, itching, nausea ~2-3 hrs, baby should deliver 4 hrs and vomiting, spinal headache, fever. However, pethidine injection has became disfavoured in view of its side effects and the Infrequent: availability of epidural analgesia. Fits, breathing difficulties, nerve damage, death Intrapartum Summary 3 Components of labor: Power, Passenger & Passage 3 stages of labor 1st stage- the cervical dilatation 2nd stage- the interval between full cervical dilatation and delivery of the baby 3rd stage- interval between delivery of the baby to the expulsion of the placenta Pain management is the main challenge for labour care. Epidural analgesia is the commonly used form of pain relieve in local context.