Physiologic Adaptations to Pregnancy 4th Lecture PDF

Antepartum: Nutrition & Physiologic Adaptations to Pregnancy 1 Outlines Diagnosis of pregnancy  Signs & Symptoms of pregnancy Physiologic changes in body systems Endocrine system Cardiovascular system Respiratory system Reproductive system Musculoskeletal system Integumentary system Nutrition...

Antepartum: Nutrition & Physiologic Adaptations to Pregnancy 1 Outlines Diagnosis of pregnancy  Signs & Symptoms of pregnancy Physiologic changes in body systems Endocrine system Cardiovascular system Respiratory system Reproductive system Musculoskeletal system Integumentary system Nutrition & Eating Strategies Psychological Adaptation and Developmental Tasks of Pregnancy Nursing care for common discomfort during Pregnancy. Objectives: At the end of the session, the students will be able to: 1. Differentiate among presumptive, probable, and positive signs of pregnancy. 2. Describe the main physiological changes which occur in a mother during a normal pregnancy 3. Discus maternal adaptations to pregnancy and the support the fetus influence maternal nutritional requirements. 4. Describe the main psychological changes during a normal pregnancy. 5. Explain common disorders during pregnancy and implement nursing care for those woman. Signs of pregnancy  Presumptive signs-these signs suggest pregnancy (generally subjective data).  Probable signs-indicate that the woman is most likely pregnant (objective data).  Positive signs- definite evidence that a woman is pregnant (diagnostic) Presumptive Signs & Symptoms ( Subjective) Those changes felt by the woman but are not conclusive for pregnancy.  1- Amenorrhea sudden cessation of a previously regular menstruation . It is due to high level of estrogen and progestrone without withdrawal.  Presumptive Signs & Symptoms ( Subjective) 2- Gastro-intestinal symptoms: A- Nausea, with or without vomiting usually at the morning (morning sickness )are met with in about 50% of pregnant women. They may be the first indication for the occurrence of pregnancy, rarely lasts more than three months . B- Appetite changes(longing or pregnancy pica) Craving for certain types of foods and refusal of others types. Presumptive signs of pregnancy cont. 3- breast sensitivity: Breast changes: fullness, tingling, heaviness, pigmentation of nipples & areolae and is caused by hormone-induced growth of secretory ductal system in the breasts. 4- urinary symptoms: urinary symptoms, particularly frequency, occur in the first trimester and are caused by the pressure of the enlarging uterus on the bladder. Presumptive signs of pregnancy cont. 5- fatigue: Some women experience fatigue very early after conception and complain of not being able to get enough sleep. The fatigue is caused by the many hormonal changes of early pregnancy. 6-Weight gain: the amount of weight gain during first trimester is usually small and weight gain can be attributed to many factors other than pregnancy. 7-Quickening: Quickening, the subjective perception of fetal movement or feeling of life, can be felt by most women between 16 -20 weeks of gestation. Probable Signs & Symptoms ( Objective)  Those changes observed by an examiner but could be caused by a condition other than pregnancy (still not conclusive for pregnancy) Uterine enlargement, Abdominal enlargement  Softening of the lower uterine segment at about 6 wk (Hegar’s), softening of cervix at about 6 wk (Goodell’s), & cervix takes on bluish coloring (Chadwick's) signs from increase vascularity  Ballottement (at 16-28 wks)  Braxton Hick’s contractions (after 16 wks)  Laboratory tests for pregnancy (Positive pregnancy test-serum or urine) These depend on presence of human chorionic gonadotrophin (HCG) in maternal serum and urine.  Positive Signs & Symptoms      Those signs that can be attributed only to the presence of the fetus (conclusive for pregnancy) Fetal heart tone detected by US or stethoscope Fetal movement visible or palpated by examiner Visualization of fetus by ultrasound or x-ray Abdominal enlargement in relation to size of uterus Physiologic changes in body systems • • • • • • Endocrine system Cardiovascular system Respiratory system Reproductive system Musculoskeletal system Integumentary system Endocrine Changes with Pregnancy  Carbohydrate Metabolism First half: tendency to hypoglycemia (Progesterone & Estrogen).  Second half: tendency to hyperglycemia(HPL).  “Typical” FBS less than in non-pregnant state The patient may feel warmer or experience "hot flashes“ caused by increased hormonal level and basal metabolic rate. Fluctuating hormone levels lead to moodiness Increase BMR lead to woman feel fatigue. Fluctuating hormone & level of sugar in blood lead to morning sickness  • • • • 1. Increase in body weight by 9-12 kg 2. Retention of water, sodium, potassium and chloride. This explains the diuresis which occurs in the first 2 days after delivery. 3. Protein metabolism: There is nitrogen retention 4. Carbohydrate metabolism: 5. Fat metabolism:. 6. There is increased demand for calcium, iron and all vitamins. Moodiness in Pregnancy (1, 2, 8, 9 month) Fluctuating hormone levels lead to more susceptible to moodiness. Near the end of pregnancy, altered body image, fatigue and concerns about the upcoming labor can add to the moodiness. Health Education  Allow time to cry  Seek out support from friends and family. Have at least one person that can share concerns with.  Slow down schedule; be sure to give mother enough time to rest.  Extra careful about eating well, poor nutrition will only make it worse.  Morning Sickness in Pregnancy (1st trimester)  Nausea and Vomiting in pregnancy can actually occur at any time of day, it may be due to the rapid fluctuations in blood sugar levels, or a reaction to changing hormones. About half of all pregnant woman experience morning sickness. Health Education      Eat smaller frequently meal to keep blood sugar levels constant Avoid foods that trigger nausea. Keep crackers near bed to eat before get up. Try drinking fluids after meal, not during. Rare cases of severe morning sickness with vomiting called hyperemesis gravidarum can cause serious complications: dehydration, electrolyte imbalances, weight loss Often requires hospitalization Fatigue in Pregnancy (1st & 3rd trimester)     Metabolism has increased significantly as body builds the baby, so body's energy demands have greatly increased. The changing hormone levels the extra effort it takes to carry around the extra weight. the difficulty sleeping at night. Health Education    Supplement with vitamins to regain energy; rest times during the day. Sometimes 10 minutes of abdominal breathing with feet up can be as good as a long nap. Drink plenty of water. One of the effects of dehydration is to make you tired. Exercise helps keep energy levels higher during pregnancy. Effects of Pregnancy on the Cardiovascular System  Blood volume: It is increased during pregnancy reaching its maximum at 32 weeks  Cardiac output increases about 25-50% percent during the first and second trimester to accommodate for hypervolemia.  Pulse rate increases by 10 to 15 beats/min Blood pressure declines from pre-pregnant levels for first 22 weeks and then returns to pre-pregnant level.  Venous Return  The expanding uterus restricting physical movement and interfering with the return of blood flow & lead to poor return of blood from extremities and weak vessel wall. This results in swelling of the feet and legs ( varicose veins) & Fainting The pregnant uterus compresses the vena cava and descending aorta when the women is in a supine position & blood flow to the heart is decreased and maternal hypotension can occur (Orthostatic hypotension (Supine hypotensive syndrome) Nursing implications. 1. Advise women to rest frequently & elevate her feet and legs while sitting. 2. The women is encouraged to lie on her left side to prevent compression of the vena cava and descending aorta  Faintness in Pregnancy (1st & 3rd trimester)  blood volume increases during pregnancy, and the high progesterone levels relax blood vessels to prevent high blood pressure. However, the relaxed and slack vessels can slow down the circulation enough that cause faint when stand up suddenly. In addition to that, when overheating, blood vessels dilate. If this happens to already relaxed blood vessels, dizzy, light-headache or faint occurs. Health Education    Cooler showers and have snacks if necessary Deep abdominal breathing to get blood fully oxygenated. Plan activities in such a way that can move around and rest. CHANGES OF THE RESPIRATORY SYSTEM DURING PREGNANCY  Inspiration increases allowing a greater intake of O2 (resp. rate 18-20)  Diaphragm elevates leads to Shortness of breath (Dyspnea) (Diaphragm rises 4 cm) until fetus descends into pelvis  Increased estrogen causes edema or swelling of mucous membranes of nose, pharynx, mouth, and trachea lead to woman may complain of nasal stuffiness, epistaxis, and vocal changes Effects of Pregnancy on the Reproductive System      Increased blood supply in vagina causes it to have a bluish color (Chadwick sign ). Vaginal discharge increased (Operculum: mucus plug fill the cervical canal help prevent infection, Higher glycogen level, which promotes Candida albicans (yeast) growth Palpation of the fetus’ sac – ballottement Goodell’s Sign  softening of cervix due to engorgement with blood  apparent by 6 weeks after conception Vaginal discharge in Pregnancy (2nd & 3rd trimester) Cervix produces fluids during pregnancy that help to keep the vaginal canal clean and infection free. This increased moisture and the change in acid levels of the vagina make the area easily susceptible to infection; also makes the skin of the perineum brittle and susceptible to tearing during baby is born. Health Education  Wear cotton panties. Prevent tight clothing. This forces the fluids back up to the vagina.  Cleansing with warm water and a cloth only. If get infection, contact caregiver right away to start treatments.  Uterus During Pregnancy      Becomes temporary abdominal organ; Uterine lower segmant’s softens (Hegar’s sign) Increased pressure of uterus on bladder = increased frequency of urination, one of the earliest symptoms of pregnancy Muscle cells increase in size and number. Increase in the number of blood vessels and blood vessels increase in size. Braxton-Hicks contractions: irregular, painless contractions of uterus that begin in 1st trimester and increase in frequency and strength as pregnancy progresses. Braxton-Hicks contractions: Health education      Changing activity Eat something. Your body can start contractions if the baby needs food. Drink water. Dehydrations can start contractions. Ignore them and go about your regular routine. Relax and do abdominal breathing. Frequent Urinations (2, 3, 8, 9 month) The pressure of the growing uterus and a heightened metabolic rate cause increased frequency of urination Health Education  Do kegal exercise.  Keep drinking water.  Go to the bathroom regularly, don't try to hold it.  If you feel a burning or stinging sensation when you urinate, seek the advice of your caregiver.  Don't sit with legs crossed or wear tight, restrictive clothing. These things may encourage a back-up in urinary tract causing an infection. Sleepless Nights in Pregnancy (3rd trimester)     When body is large and cannot find a comfortable position in bed, sleep becomes difficult. In addition to the physical discomfort of the growing baby, you may wake up several times a night to use the bathroom. Try pelvic rocking just before go to bed. It pulls the uterus into a better position so the bladder is not as compressed. Use lots of pillows to support back and legs. Try propping upper body up more by using more pillows. 26 Breast during Pregnancy     High levels of estrogen and progesterone prepare breasts for lactation & Maximal development of mammary glands result in breast soreness; tenderness; and enlargement May have darkening of areola and development of secondary areola Montgomery’s tubercles secrete substance to lubricate nipples & become more prominent. By 10th week, begin production of colostrum, a thin, yellow, high-protein substance (first nutrition for newborn) Breast Soreness in Pregnancy (1, 2, 8, 9 month) • Growth and development of the mammary glands can cause the surrounding area to be sensitive to the touch, or sore. This is normal Health Education • Stand in the shower and let the warm water massage your breasts. • Be sure to wear a bra with good support. • Try wearing a bra at night, the extra support may feel better. Skeletal Changes during Pregnancy    29 Lordosis: curvature of the lower spine occurs during pregnancy to maintain balance & Altered center of gravity. It is due to the increase in size of the uterus and pressure on the abdominal wall. Relaxin : General softening of the ligaments of the sacroiliac and pelvis allows joints to widen & reduces risk of broken bones during labor Abdominal muscles may separateDiastasis recti adbominis Backache in Pregnancy (3rd trimester) the changing center of gravity by pulling the shoulders back, & wearing shoes with a heel will further exaggerate this arching, causing worse backaches.  The ligaments that hold the uterus in place are attached to the back. As the uterus grows, this added cause backaches.  When baby begins to descend into the pelvis, the head can cause pressure on the pelvis & felt as a backache. Health education 1. Try pelvic rocking, it stretches the muscles of the back and realigns the uterus. 2. Have someone massage, or just put pressure on your lower back. 3. Avoid shoes with heels  Gastrointestinal System during Pregnancy   Growing uterus displaces stomach and intestines Decreased gastric acid secretions  Delayed gastric emptying and slow in intestinal movement lead to nausea & constipation- hemorrhoids & flatulence  Heartburn is R/T relaxation of the cardiac sphincter of the stomach which permits reflux Health education to resolve Heartburn    Eat small frequent meals. This will decrease the pressure on digestive system and may make digesting easier. Also prevent dips in blood sugar. Drink more water and eat adequate amounts of fiber to help move the food through the digestive system. Walking is a natural way to aid digestion. If you are finding yourself frequently sick after eating, talk to your caregiver. You may have developed a lactose intolerance (having problems after eating dairy foods) or be having gall bladder problems (uncomfortable after eating fatty foods). Health education for Constipation As a miner discomfort      Constipation is avoided by vegetables, milk, regulation of the bowels, exercises and laxatives if necessary. Avoid the use of liquid paraffin for a long time as it interferes with absorption of fat soluble vitamins A and D. Try pelvic rocking or going for a walk. Both will stimulate the digestive system. Check your diet, are you getting enough fiber and water? Try eating raw fruits. Put a low stool under you feet in the bathroom. This will put you in more of a squat position which opens the outlet of the pelvis by as much as 15%. Hemorrhoids in Pregnancy (3rd trimester)  Def: varicose veins of the rectum. May experience them from straining too hard when using the bathroom. They can be uncomfortable or itchy. Health education 1. Put a low stool under your feet while you use the toilet. 2. Adequate water and fiber in diet. 3. Avoid constipation, which will cause to push harder when going to the bathroom. 4. Try walking as natural stimulants for the bowel. 5. Ice the sore area for some comfort and relief. CHANGES OF THE SKIN DURING PREGNANCY  Linea Nigra. A dark line that runs from the umbilicus to the symphysis pubis.  Mask of Pregnancy (Chloasma). The brownish hyper pigmentation of the skin over the face and forehead. It begins about the 16th week of pregnancy and gradually increases  Striae Gravidarum (Stretch Marks 6-9m). It reflects a separation within underlying connective tissue of the skin. This occurs over areas of maximal stretch--the abdomen, thighs, and breasts. Nutrition      The mothers nutritional status can affect the outcome of her pregnancy Adequate weight gain is required for fetal growth and development; accepted weight gain is 12.5 to 16 kg  Ist trimester-0,4/month nd & 3rd trimester  0,4 per week in 2 Recommended increases over usual caloric intake is 300 per day during pregnancy and 500 per day during breastfeeding. Women who are under Wt should gain slightly more than average: 0.5kg/month Women are obese should gain less than average 0.3kg. Eating Strategies  Nausea, vomiting, heart burn, and constipation are common discomforts of pregnancy. Strategies that are recommended to deal with some of these issues include:  Small, frequent meals and snacks  Adequate fluid & fiber intake  Avoiding an empty stomach  A low-fat, high- carbohydrate diet  Nutritional education: Encourage Read food labels & Protein versus sugary foods  Don't focusing on how much weight are gaining, focus on eating well and getting adequate exercise. INSTRUCTIONS TO THE PREGNANT MOTHER A) Diet During Pregnancy 1. Proteins: More proteins are needed and the amount is 2 g/kg body weight daily. Half of the amount must contain the essential amino acids (animal proteins). Protein deficiency may cause anaemia and oedema. 2. Fats: Should be restricted to avoid abnormal gain in weight. 3. Carbohydrates: The amount is not changed. 4.Vitamins: All the vitamins are needed in increased amounts during pregnancy: 5. Minerals: a) Iron: Deficiency leads to anaemia of the mother. The fetus obtains his needs of iron even if the mother is iron deficient. Daily requirement 3-6 mg  up to 50% of pregnant women develop iron deficiency anaemia. Iron supplementation is started after the first trimester when nausea disappears. b) Calcium: Deficiency leads cramps, muscle twitches or pain in pelvic bones and back. The pregnant woman needs 1.2-1.5g ( 1200-1500mg) calcium/day. One liter of milk contains 1 g calcium. c) Iodine: Deficiency may lead to congenital goitre and goitre of the mother. Common questions for which you will need to have an answer          Sleep Activity and exercise Sexual activity Bathing and swimming Clothing Dentition Immunizations Travel Breast Sleep Eight hours at night and 2 hours rest in the afternoon. Activity and Exercises moderation should be encouraged. The usual activities and home work are allowed. Violent exercises are avoided. In the last month, the woman is asked to walk for an hour daily to help engagement of the head. Sexual activity (Coitus) no problem as long as pregnancy progresses normally. It is avoided if there is tendency to abortion or preterm labour. Bathing and swimming The bath is given by shower. Tub and sea bathing are avoided for fear of ascending infection. Clothing Should be loose. Avoid high heels which increase lumbar lordosis, and backache, and increase the risk of falling as well as ankle injury. Care of the Teeth Regular cleansing and if necessary a dentist is consulted. Immunizations: should probably avoid live virus vaccines Traveling Safe during the first half of pregnancy, but it is restricted in later months. It is not allowed if there is a tendency to abortion or preterm labour. Air travel is better than train or car for long distances. Breast • Crusts or dried secretion over the nipples are washed by warm water and soap or boric lotion. • The nipples are drawn for a short time daily by the thumb and finger and painted with a lubricant during the last 6 weeks. 44 Psychological Adaptation and Developmental Tasks of Pregnancy 1st Trimester  Ambivalence : it referee to the inter women feeling of wanting not wanting that always exist at a high level, it is important to emphasize that is normal  Narcissism: self centered is early reaction to pregnancy 2nd Trimester  Accepting reality of pregnancy  Resolving feelings about her own; defining herself as a mother, 3rd Trimester  Active preparation for childbirth and baby; Emotional liability (mood swing). Normal Antepartum: First Trimester Key Nursing Activities  Screen for factors; assess for complications of pregnancy  Encourage healthy behaviors (e.g: nutrition, exercise, rest)  Continually assess maternal & fetal well-being  Treat or teach self-care for minor discomforts of pregnancy  Teach s & s that require reporting to health care provider Normal Antepartum: Second Trimester Key Nursing Activities • Encourage healthy behaviors (nutrition; exercise, rest) • Continue to assess maternal & fetal well-being • Implement or teach self-care treatments for minor discomforts of pregnancy • Screen for risk factors denoting complications of pregnancy • Teach & reinforce s & s of complications to report to the healthcare provider Normal Antepartum: Third Trimester Key Nursing Activities • Continue to assess maternal & fetal well-being • Assess for & teach comfort measures for any new discomforts • Review s & s of complications that need to be reported to the care provider • Teach signs of labor onset and the difference between true and false labor • Provide information about infant care • Plan for discharge following the birth. Taking Care of Yourself For your baby's sake and yours, its important to take especially good care of yourself during your pregnancy. Follow the basics: • Don't smoke, drink alcohol, or take drugs. • Get enough rest. • Eat a healthy diet. Nursing Diagnosis         Health-seeking behaviors related to interest in maintaining optimal health during pregnancy Anxiety related to minor discomfort of pregnancy Risk for fluid volume deficient related to nausea and vomiting Constipation related to reduced peristalsis during pregnancy Disturbed body image R/T change of appearance Risk for ineffective sexuality patterns R/t fear of harming fetus during pregnancy. Disturbed sleep pattern R/t frequent need to empty bladder during night (or huge uterus) Fatigue R/t metabolic changes of pregnancy. Nursing intervention in antenatal period maintaining optimal health during pregnancy  Teach about exercise & Promote exercise.  Maintain Adequate sleep & Encourage rest.  Teach relaxation technique & breathing technique.  Manage nutritional status &Teach about diet.  Assess body image & Support positive body image.  Teach about pregnancy &Teach about effective parenting.  Assess family coping & Support family coping process.  Teaching About the Danger Signs of Pregnancy.  Follow-Up Visit Intervals and Assessments of pregnancy. Warning signs during pregnancy  Bleeding or leaking fluid from the vagina  Blurry or impaired vision  Unusual or severe stomach pain or backaches  Frequent, severe, and/or constant headaches  Contractions, where your stomach muscles tighten, before 37 weeks that happen every 10 minutes or more often  Decrease in baby's movements after 28 weeks  Dizziness & Excessive vomiting and diarrhea  Fever or chills  Pain or burning with urination  Swelling of face, fingers, and feet 52