Biophysical Aspects of Normal Pregnancy PDF

Biophysical Aspects of Normal Pregnancy  Learning outcomes Define terms related to pregnancy Identify the changes that take place within the uterus and body systems during pregnancy Explain Minor discomfort that occur during pregnancy Discuss Nursing Managem...

Biophysical Aspects of Normal Pregnancy  Learning outcomes Define terms related to pregnancy Identify the changes that take place within the uterus and body systems during pregnancy Explain Minor discomfort that occur during pregnancy Discuss Nursing Management for minor discomfort during pregnancy OUTLINE: Obstetrical History/ Assessment Signs and symptoms of Pregnancy Diagnostic Evaluation Maternal Physiological and Psychological Changes in each system Discomfort of Pregnancy  ANTEPARTUM PERIOD The antepartum period extends from conception to the onset of labor. During this time, care of the mother (client) and the fetus focuses on health maintenance and the prevention of complications. Nursing care during the normal antepartum period includes taking a through maternal history, performing a complete physical examination, and educating the client about antepartum health.  OBSTETRIC HISTORY/ ASSESSMENT GESTATION Time from fertilization of the ovum until the estimated date of confinement or estimated date of delivery About 280 days Nägele’s rule for estimating the date of confinement (deliver) McDonald’s rules uses fundal height (by tape measure) to determine the duration of pregnancy in either lunar months or weeks. (To use this rule, place a tape measure at the symphysis pubis and measure up and over the fundus.)  Nägele’s Rule for Estimating the Date of Confinement (Delivery) 1. Use of Nägele’s rule requires that the woman have a regular 28-day menstrual cycle. 2. Subtract 3 months and add 7 days to the first day of the last menstrual period; then add 1 year. Alternatively, add 7 days to the last menstrual period and count forward 9 First day of last menstrual period: September 12, 2014 months. Subtract 3 months: June 12, 2014 Add 7 days: June 19, 2014 Add 1 year: June 19, 2015 Estimated date of confinement (delivery): June 19, 2015  OBSTETRIC HISTORY Gravidity and Parity Gravidity – Gravida refers to a pregnant woman. – Gravidity refers to the number of pregnancies. – A nulligravida is a woman who has never been pregnant. – A primigravida is a woman who is pregnant for the first time. – A multigravida is a woman in at least her second pregnancy.  OBSTETRIC HISTORY Gravidity and Parity Parity – Parity is the number of births (not the number of fetuses, e.g., twins) carried past 20 weeks’ gestation, whether or not the fetus was born alive. – A nullipara is a woman who has not had a birth at more than 20 weeks of gestation. – A primipara is a woman who has had one birth that occurred after the twentieth week of gestation. – A multipara is a woman who has had two or more pregnancies to the stage of fetal viability.  OBSTETRIC HISTORY Many hospitals use the GTPAL or GTPALM system to document previous pregnancies: – G stands for the number of pregnancies (gravida). – T stands for the number of term infants born. (longer than 37 weeks’ gestation). – P stands for the number of preterm infants born (para) (before 37 weeks’ gestation). – A stands for the number of pregnancies ending in spontaneous or elective abortion. (before 20 weeks’) – L stands for the number of living children. Multiple gestation doesn’t change G (gravida) or P (para). – M stands for the total number of multiple pregnancies the client has experienced.  OBSTETRIC HISTORY Example: A woman is pregnant for the fourth time. She had one elective abortion in the first trimester, a daughter who was born at 40 weeks’ gestation, and a son who was born at 36 weeks’ gestation. She is gravida (G), 4; parity (number of births carried past 20 weeks), 2; term (T), 1 (the daughter born at 40 weeks); preterm (P), 1 (the son born at 36 weeks); abortion (A), 1 (the abortion is counted in the gravidity, but is not included in the parity because it occurred before 20 weeks); living children (L), 2. GTPAL = 4, 1, 1, 1, 2 = G4, T1, P1, A1, L2 Signs and Symptoms of Pregnancy  Presumptive Signs AMENORRHEA or slight, painless spotting of unknown cause in early gestation Breast enlargement and tenderness Fatigue Increased skin pigmentation Nausea and vomiting Quickening (the first recognizable movement of the fetus) Linea nigra ( dark line pigment on abdomen) Chloasma (Pigmentary skin change on the face) Striae gravidarum (red streaks on abdomen) Urinary frequency and urgency  Probable Signs Uterine enlargement Hegar’s sign: Compressibility and softening of the lower uterine segment that occurs at about week 6 Goodell’s sign: Softening of the cervix that occurs at the beginning of the second month Chadwick’s sign: Violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4 Ballottement: Rebounding of the fetus against the examiner’s fingers on palpation Braxton Hicks contractions (irregular painless contractions that may occur intermittently throughout pregnancy) Positive pregnancy test for determination of the presence of human chorionic gonadotropin  Positive Signs Fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation Active fetal movement felt by a trained provider (after about 20 weeks' gestation ) Ultrasound showing fetal outline Antepartum Diagnostic Testing  Diagnostic Evaluation Numerous tests are performed as part of antepartum care. The results can be used to confirm pregnancy and reveal maternal and fetal complication: Blood type, Rh and abnormal antibodies, identify whether the fetus is at risk for erythroblastosis fetalis or Hyperbilirubinemia Immunologic tests, such as rubella antibodies, detect presence of rubella; rapid plasma regain detects untreated syphilis; and hepatitis B surface antigen detects hepatitis B. Papanicolaou’s smear is done during the initial prenatal examination to screen for cervical neoplasia.  Maternal Physiological Changes in each System  Definition The changes that take place in the maternal organ system in response to pregnancy,to accommodate the pregnancy & to prepare the woman for labour  Physical changes during pregnancy Pregnancy divided into 3 trimester: 1st trimester: 1-2 -3 months 2nd trimester:4-5-6 months 3rd trimester: 7-8 -9 months Physiological Adaptations of Body System  Physiological Maternal Changes Cardiovascular system Circulating blood volume increases, plasma increases, and total red blood cell volume increases (total volume increases by approximately 40% to 50%). Physiological anemia occurs as the plasma increase exceeds the increase in production of red blood cells. Iron requirements are increased. Heart size increases, and the heart is elevated slightly upward and to the left because of displacement of the diaphragm as the uterus enlarges Retention of sodium and water may occur.  A) Supine position B) Side-lying position Supine hypotension can occur if a pregnant woman lies on her back. (A) The weight of the uterus compresses the vena cava, trapping blood in the lower extremities. (B) If a woman turns on her side, pressure is lifted off of the vena cava.  Physiological Maternal Changes Respiratory system 1. Oxygen consumption increases by approximately 15% to 20%. 2. Diaphragm is elevated because of the enlarged uterus. 3. Shortness of breath may be experienced.  Gastrointestinal system Mouth & teeth * Gums become hyperemic and have tendency to bleed Gastrointestinal tract – Smooth muscle relaxation occurs related to increased progesterone production.This can causes constipation , hemorrhoids and heart burn – Appetite usually increases , after a temporary decrease due to nausea and vomiting – Morning sickness , nausea & vomiting occur between 4-12 weeks of pregnancy  Urinary system During 1st and 2nd trimester, growing uterus put pressure on the bladder and produce urinary frequency. This pressure also impair the drainage of blood and lymph and cause infection and trauma.  Urinary Changes Kidneys grow and filter more blood as the blood volume increases Become more vulnerable to bladder and kidney infections Bladder becomes compressed causing frequent urination and incontinence  Endocrine system Basal metabolical rate increases The anterior lobe of the pituitary gland enlarges. The thyroid enlarges slightly, and thyroid activity increases. The parathyroid increases in size. Aldosterone levels gradually increase. Body weight increases. Water retention is increased, which can contribute to weight gain.  Weight Changes Metabolic changes, accompanied by fetal growth, result in an increase in weight of around 25% of the non- pregnant weight. Weight gain : Varies between 9-12 kg - Increased is the result of :- 1.Water retention 2. Effect of hormones 3. Products of conception  Reproductive systems Uterus – Uterus enlarges, increasing in mass from approximately 60 to 1000 g as a result of hyperplasia (influence of estrogen) and hypertrophy. – Size and number of blood vessels and lymphatics increase. – Irregular contractions occur. Relative Uterus Size During Pregnancy Figure 28.15  Reproductive System Cervix – Cervix becomes shorter, more elastic, and larger in diameter. – Endocervical glands secrete a thick mucous plug, which is expelled from the canal when dilation begins. – Increased vascularization and an increase in estrogen cause softening and a violet discoloration known as Chadwick’s sign, which occurs at about 4 weeks of gestation.  Reproductive System Ovaries – A major function of the ovaries is to secrete progesterone for the first 6 to 7 weeks of pregnancy. – The maturation of new follicles is blocked. – The ovaries cease ovum production. Vagina – a. Hypertrophy and thickening of the muscle occur. – b. An increase in vaginal secretions is experienced; secretions are usually thick, white, and acidic.  Breasts 6 weeks : Develop ducts and glands 8 weeks : Bluish surface veins are visible.tense , warm , tender , enlarged dilated veins , nipple and darkling of primary areola 8-12 weeks: Primary areola become darker- Secondary areola 16-18 weeks : Colostrum expresses secreted in 3rd month , secondary areola appears Breast changes  Dermatological system Change in skin pigmentation occur during pregnancy. Area that increase the pigmentation are: Areola Nipples Vulva Perianal area Linea Nigra : Refers to the pigmentation or darkness in the linea alba.  Dermatological system Facial chloasma :Refers to irregular pigmentation of the cheeks, forehead and nose and is accentuated by sun exposure. Striae gravidarum :( Stretch Marks ) appear on the breasts and abdomen. This is caused by increased weakness of the connective tissue  Dermatological system Vascular spider nevi is small bright- red elevation of the skin and radiating from central body. It may develop on chest ,neck , face , arms and legs and caused by increase blood flow as result of increase of estrogen level.  Musculoskeletal system Alternation in posture can result in lordosis ( Waddling gait occur due to increased level of progesterone and relaxation hormone Lordosis helps counter balance the effect of the protruding abdomen and keeps the center of balance over the lower extremities. The increased curving can result in low backache Postural changes in pregnancy  Metabolic changes Increase metabolic rate Increase the demands for carbohydrate ,protein & minerals Water requirement is increased to supply fetus , placenta and amniotic fluid Immunological system Resistance to infection is decreased Maternal IgG level are decreased  Maternal Psychological Changes in each System  Psychological Maternal Changes Ambivalence Ambivalence occurs early in pregnancy, even when the pregnancy is planned. The mother may experience a dependence- independence conflict and ambivalence related to role changes. The father may experience ambivalence related to the new role that he is assuming, increased financial responsibilities, and sharing the wife’s attention with the child.  Psychological Maternal Changes Acceptance: Factors that may be related to acceptance of the pregnancy are the woman’s readiness for the experience and her identification with the motherhood role. Emotional lability Emotional lability may be manifested by frequent changes of emotional states or extremes in emotional states. These emotional changes are common, but the mother may think that these changes are abnormal.  Psychological Maternal Changes Body image changes The changes in a woman’s perception of her image during pregnancy occur gradually and may be positive or negative. The physical changes and symptoms that the woman experiences during pregnancy contribute to her body image.  Psychological Maternal Changes Relationship with the fetus The woman may daydream to prepare for motherhood and think about the maternal qualities that she would like to possess. The woman first accepts the biological fact that she is pregnant. The woman next accepts the growing fetus as distinct from herself and a person to nurture. Finally, the woman prepares realistically for the birth and parenting of the child. Common Minor Discomfort in Pregnancy  Nausea and Vomiting Related to: – Increased levels of HCG – Changes in CHO metabolism – Fatigue Intervention – Avoid offending odors – Eat dry crackers upon wakening – Eat 5-6 small, low-fat meals per day – Avoid spicy, gas forming foods – Drinking liquids between meals rather than at meals Pica Pica refers to eating nonfood substances, such as dirt, clay, starch, and freezer frost. The cause is unknown; cultural values, such as beliefs regarding the effect of a material on the mother or fetus, may make pica a common practice. Iron deficiency anemia may occur as a result of pica.  Urinary urgency and frequency Usually occurs in the first and third trimesters Caused by pressure of the uterus on the bladder Interventions – Limiting fluid intake in the evening – Voiding at regular intervals – Sleeping side-lying at night – Wearing perineal pads, if necessary – Performing Kegel exercises  Heartburn Occurs in the second and the third trimesters Results from increased progesterone levels, decreased gastrointestinal motility, esophageal reflux, and displacement of the stomach by the enlarging uterus Interventions – Eating small, frequent meals – Sitting upright for 30 minutes after a meal – Drinking milk between meals – Avoiding fatty and spicy foods – Consulting with the HCP about the use of antacids  Backache Usually occurs in the second and the third trimesters Caused by an exaggerated lumbosacral curve resulting from an enlarged uterus Interventions – Obtaining rest – Using correct posture and body mechanics – Wearing low-heeled, comfortable, and supportive shoes – Sleeping on a firm mattress  Shortness of breath Can occur in the second and the third trimesters Results from pressure on the diaphragm from the enlarged uterus Interventions – Taking frequent rest periods – Sitting and sleeping with the head elevated or on the side – Avoiding overexertion  Leg cramps Usually occur in the second and the third trimesters Result from an altered calcium-phosphorus balance and pressure of the uterus on nerves or from fatigue Interventions – Getting regular exercise, especially walking – Dorsiflexing the foot of the affected leg  Constipation Usually occurs in the second and the third trimesters Results from an increase in progesterone production, decreased intestinal motility, displacement of the intestines, pressure of the uterus, and taking iron supplements Interventions – Eating high-fiber foods such as whole grains, fruits, and vegetables – Drink no less than 2000 mL per day. – Exercising regularly, such as a daily 20-minute walk – Consulting with the health care provider about interventions such as the use of stool softeners, laxatives, or enemas  Ankle edema Usually occurs in the second and the third trimesters Results from vasodilation, and increased venous pressure below the uterus Interventions – Elevating the legs at least twice a day and when resting – Sleeping in a side-lying position – Wearing supportive stockings or support hose – Avoiding sitting or standing in one position for long periods  ANTEPARTUM PERIOD Nursing Diagnoses Ineffective health maintenance Risk for deficient fluid volume Nursing Planning and Goals The results of the client’s health history and physical and diagnostic examinations will be within normal limits. The client will be to describe the warning signs of pregnancy complications. The client will verbalize acceptance of the body changes of early pregnancy. The client will discuss concerns about her pregnancy related to personal and family psychosocial needs. The client will return for routine follow-up visits.  ANTEPARTUM PERIOD Nursing Evaluation The results of the client’s health history and physical and diagnostic examinations are within normal limits. The client describes the warning signs of pregnancy complications and the importance of reporting them. The client identifies sources of emotional and material support that will adequately meet personal and family needs during this pregnancy. The client has made an appointment for her next visit. Nutrition  Nutrition General guidelines An increase of about 300 cal/day is needed during pregnancy. Calorie needs are greater in the last two trimesters than in the first. An increase of about 500 cal/day is needed during lactation.  Nutrition General guidelines A diet high in folic acid and folic acid supplements is recommended. A diet high in folic acid is necessary for all women of childbearing age to prevent neural tube defects and orofacial clefts in the fetus. At least 8 to 10 (8-oz) glasses of fluid are needed each day, of which 4 to 6 glasses should be water. Sodium is not restricted unless specifically prescribed by the HCP.  References Silvestri, L.A. (2014), “Saunders Comprehensive Review for the NCLEX-RN Examination” Elsevier Publishing Nettina, S. (2010) “Lippincott Manual of Nursing Practice.” 9th Edition. Wolters Kluwer Health. Lippincott Williams & Wilkins. Springhouse Review for NCLEX-RN 6th edition. 2006. Lippincott Williams and Wilkins. For images taken from https://www.google.com.sa Perry S, Hockenberry M, Lowdermilk D, Wilson D: Maternal-child nursing care, ed 4, St. Louis, 2010, Mosby.