Prenatal Care Part 2.pdf

Care of the Pregnant Mother and Preparation for Childbirth By Gina M. Dumawal RN, MAN  Maternal Adaptation Psychological Changes Social influences - personal experiences, experiences of friends and relatives, as well as that taught by childbirth educators. Cultural...

Care of the Pregnant Mother and Preparation for Childbirth By Gina M. Dumawal RN, MAN  Maternal Adaptation Psychological Changes Social influences - personal experiences, experiences of friends and relatives, as well as that taught by childbirth educators. Cultural influences - certain beliefs may place restrictions on her behavior and activities. Family influences - family in which a woman was raised can be influential to her beliefs about pregnancy because it is part of her cultural environment. Individual influences - ability to adapt—to being a mother without needing mothering, to loving a child as well as a husband, to becoming a mother of each new child—depends on her basic temperament.  Maternal Adaptation Diagnosis of Pregnancy Pregnancy is officially diagnosed based on symptoms reported by the woman and the signs elicited by a health care provider. Classification of signs and symptoms: > presumptive (subjective) - least indicative of pregnancy, cannot be documented by an examiner. > probable (objective) - objective signs, can be documented by an examiner. Laboratory tests Home pregnancy tests > positive (documented) signs of pregnancy Diagnosis of Pregnancy (cont’d)  Maternal Adaptation Physiological Changes 1. Reproductive system – ovaries, uterus, vagina & breasts. Ovaries – ovulation stops Uterus (2.5 lbs) *Increase in size: 12th week above the symphysis pubis. *Lightening: descend of the fetal head into the pelvis *Hegar’s sign: softening of the lower uterine segment *Braxton Hicks contractions: false labor/uterine tightening. >Effleurage: circular motion done with hands - relieve contractions Cervix *Goodell’s sign: softening of the cervix due to relaxin hormone. *Operculum/mucus plug: acts as a barrier Vaginal *Chadwick’s sign: purplish color of the vaginal wall. Breasts: changes due to the effects of estrogen & progesterone production which prepare the breast for lactation. *Fullness, tingling or tenderness *Darkened areola and prominent blue veins maybe seen *Secretion of colostrums by the 16th week  Maternal Adaptation Physiological Changes (cont.) 2. Integumentary System *Striae gravidarum (stretch marks), turns silvery after pregnancy. *Diastasis - separation of abdominal muscle. Loose tone. A dimple in between can be seen on abdomen. *Chloasma/melasma - increase pigmentation on the face. *Linea negra (linea alba) - dark line from symphysis pubis to umbilicus. 3. Cardiovascular system – cardiac output increases, 30-50% increase in total blood volume, increase clotting factors, increased chance of thrombophlebitis. *Supine hypotension/vena caval syndrome – feeling of lightheaded and palpitations. *Increase cardiac load; cause palpitation due to increase in blood vol. *B/P decreases in 2nd trimester due to lowered peripheral resistance. *Decreased regional blood flow causes edema and varicosities  Maternal Adaptation Physiological Changes (cont.) 4. Gastrointestinal system *Heartburn, constipation, flatulence; due to displacement of the stomach and slowed intestinal peristalsis. *Nausea & vomiting; caused by increased HCG & progesterone levels. *Hyperptyalism; cause by increased estrogen levels. 5. Renal/Urinary system * frequency of urination * Glomerular filtration rate increases sometimes resulting in glycosuria. Greater than a trace or 1+ is suspicious. >Glycosuria: spill/glucose in urine, 1+ means glucose amount in urine. *Pressure of the uterus & fetus on the ureters causes urinary stasis. *Pressure on the urethra results in poor emptying of the bladder which can cause UTI leading to kidney problems or preterm labor.  Maternal Adaptation Physiological Changes (cont.) 6. Respiratory System *Hyperventilation - as the fetus is developing, everything is moving upward & pushes the diaphragm up. *Shortness of breath *Nasal stuffiness due to increased estrogen levels. 7. Endocrine system – pituitary glands secretes prolactin and oxytocin, BMR increases *Thyroid enlargement causes increased BMR.(woman feels hot) *Parathyroid slight enlargement allows for better use of Calcium and vitamin D *Pancreas in the 1st trimester decreased insulin production, allows for more glucose availability for fetal growth. *Pituitary increased secretion of prolactin that prepares breast for lactation. *Adrenals increased glandular activity results in elevated corticosteroid and aldosterone level which suppresses inflammatory action and promotes sodium reabsorption.  Maternal Adaptation Physiological Changes (cont.) 8. Musculoskeletal System *Softening of pelvic ligaments & joint due to increased relaxin; this aids the birth process. *Lordosis is due to pregnant posture and gait causing backache. Emotional Responses to Pregnancy Common reactions include: > grief > narcissism (self centeredness) > introversion or extroversion > body image and boundary concerns > couvade syndrome (somatic experiences of father during pregnancy simulating those of the pregnant mother) > stress > emotional lability - mood swings > changes in sexual desire > changes in expectant family  Danger Signs of Pregnancy 1. Chills and fever - infection 2. Escape of fluid from vagina - PROM 3. Persistent vomiting beyond 3rd month = Hyperemesis Gravidarum 4. Abdominal pain > Early pregnancy – crampy with bleeding – abortion > Low quadrant pain radiating to shoulder – ectopic pregnancy > Hard, boardlike painful abdomen – abruption placenta > Sudden, sharp abdominal pain – uterine rupture 5. Vaginal bleeding > 1st trimester – Abortion > 3rd trimester – Placenta previa 6. Dysuria with burning sensation - UTI 7. Severe, persistent headache with vomiting 8. Swelling of hands and face 9. Dimness, blurring and doubling of vision (# 7, 8, and 9 = signs of PIH) 10. Marked change in intensity & frequency of fetal movement or absence of movement (6-8 hours) after quickening – fetal distress  Nursing Diagnoses Nursing diagnoses involving changes that occur w/ pregnancy: Anxiety related to unexpected pregnancy Altered breathing pattern related to respiratory system changes of pregnancy Disturbed body image related to weight gain with pregnancy Deficient knowledge related to normal changes of pregnancy Imbalanced nutrition, less than body requirements, related to early morning nausea  Pregnancy Needs and Discomforts Discomforts of Pregnancy First Trimester Breast Tenderness > wear a bra with a wide shoulder strap for support. > dress warmly to avoid cold drafts if cold increases the symptoms. Palmar Erythema or palmar pruritus probably caused by increase estrogen levels. > explain that this type of itching in early pregnancy is normal. > increase amount of fiber in diet > increase OFI, (8-oz glasses of water / day). Nausea, Vomiting, and Pyrosis (heartburn) Fatigue - because of increased metabolic requirements. > encourage increase amount of rest and sleep.  Discomforts of Pregnancy First Trimester Muscle Cramps – cause by low serum calcium levels, increase serum phosphorus levels and possibly, interference with circulation. > hyperextend involved leg and dorsiflex the foot/toes. > take magnesium citrate or aluminum hydroxide gel (Amphojel) - to lower the circulating phosphorus level. > increase calcium in the diet > avoid 1 position for a long time, elevate lower extremities frequently to improve circulation. Hypotension (Supine hypotension) - woman experiences an irregular heart rate & feeling of apprehension. > turn woman onto her side > always rest or sleep on their side not their back.  Discomforts of Pregnancy First Trimester Varicosities or tortuous leg veins due to weight of distended uterus, puts pressure on the veins returning blood from the lower extremities. > rest in Sims’ position or on back with the legs raised against the wall or elevated on a footstool for 15 to 20 mins 2x / day. > exercise to alleviate varicosities. > break up long periods of sitting or standing with a “walk break” at least 2x / day. > vitamin C may be helpful in reducing the size of varicosities because it is necessary for the formation of blood vessel collagen & endothelium. Hemorrhoids (varicosities of the rectal veins) - because of pressure on these veins from the bulk of the growing uterus. > daily bowel evacuation to relieve constipation > resting in a modified Sim’s position daily are both helpful. > assuming knee–chest pos. for 10 -15 mins - reduce pressure on rectal veins. > stool softener such as docusate Na (Colace) may be recommended for a woman who already has hemorrhoids. > promote comfort – sitz bath, warm compress > avoid spices.  Discomforts of Pregnancy First Trimester Heart Palpitations - probably due to circulatory adjustments necessary to accommodate her increase blood supply during pregnancy. > reassure women that palpitations are normal and to be expected occasionally. > gradual, slow movements help prevent heart palpitations frequently. Abdominal Discomfort > regnant women stand with their arms crossed in front of them because the weight of their arms resting on their abdomen relieves this discomfort. Frequent Urination - due to the pressure of the growing uterus on the anterior bladder. > occasional stress incontinence (involuntary loss of urine on coughing/sneezing) – do Kegel’s exercises (alternately contracting and relaxing perineal muscles) helps strengthen urinary control, directly strengthens perineal muscles for birth and decrease possibility of stress incontinence. > increase fluids to replace losses except bedtime > wear perineal pads to absorb leakage > report burning sensation  Discomforts of Pregnancy First Trimester Leukorrhea - whitish, viscous vaginal discharge or an increase in the amount of normal vaginal secretions due to high estrogen levels and increase blood supply to the vaginal epithelium and cervix in pregnancy. > daily bath/shower and proper hygiene > wearing cotton underwear can be helpful to reduce moisture > do not use tampons because this could lead to stasis of secretions and subsequent infection. > report abnormal color, odor & burning sensation leukorrhea > avoid douche  Discomforts of Pregnancy Middle to Late Pregnancy Backache > lumbar lordosis develops & postural changes to maintain balance leads to backache. > wear comfortable shoes (low to moderate heels) to reduce the amount of spinal curvature. > encourage a woman to walk with her pelvis tilted forward (putting pelvic support under the weight of the fetus) is also helpful. > use a firm mattress during sleep. > do exercises: squatting, pelvic rock - helps prevent and relieve backache. Headache > apparently due to expanding blood volume, which puts pressure on cerebral arteries. > resting with cold towels on their forehead and taking usual adult doses of acetaminophen usually furnishes adequate relief. > continuous sharp headache may be a danger sign of high BP during pregnancy.  Discomforts of Pregnancy Middle to Late Pregnancy (CONT.) Dyspnea - expanding uterus places pressure on the diaphragm, lung compression and shortness of breath result. > notice primarily at night if lying flat & definitely notice on exertion. > advise to sleep with head and chest elevated so the weight of the uterus falls away from her her diaphragm. > caution her to limit her activities during the day to prevent exertional dyspnea. Ankle Edema - probably caused by general fluid retention and reduced blood circulation in the lower extremities due to uterine pressure. > ankle edema is a normal occurrence of pregnancy (w/o proteinuria & hypertension). > rest in a left side-lying position to increase the kidney’s glomerular filtration rate and also allows good venous return. > avoid standing/sitting in one position for long periods > encourage frequent leg elevation > avoid wearing constricting clothing such as panty girdles or knee-high stockings because these impede lower extremity circulation and venous return.  Discomforts of Pregnancy Middle to Late Pregnancy (cont.) Braxton Hicks Contractions > Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again. > By middle or late pregnancy, the contractions become stronger, and a woman who tenses at the sensation may even experience some minimal pain, similar to a hard menstrual cramp, women should inform their primary care provider about them so that they can be evaluated. Common Teratogens and their Effects LEARNING OBJECTIVES: At the end of the lecture you should be able to: 1. Describe the frequency and significance of major and minor congenital malformations. 2. Discuss the etiology of congenital malformations and the importance of developmental timing of exposure. 3. Learn to recognize the most frequent genetic and environmental causes of congenital malformation syndromes and exposures to be avoided during and prior to pregnancy.  Common Teratogens and their Effects Terminology: Teratology - field of study that investigates the causes of birth defects. Teratogen - any substances that may produce physical or functional defects in the human embryo or fetus. ❖Types of Teratogens: 1. physical agents, 2. metabolic conditions, 3. infection, and 4. drugs and chemicals. Teratogenic Drugs Two principles governing drug intake during pregnancy: 1. Any drug or herbal supplement, under certain circumstances, may be detrimental to fetal welfare. 2. A woman of childbearing age & ability should not take any drug other than one prescribed by a physician or nurse-midwife to avoid exposure to a drug should she become pregnant. Common Teratogens and their Effects Timing The effect of teratogens The fetal brain develops depends upon the timing throughout pregnancy and of exposure. can be affected at any time. The first trimester of pregnancy is the critical Exposure to a teratogen period of organ and limb during the two weeks development in the fetus. following conception is unlikely to cause birth defects.  Common Teratogens and their Effects Sensitivity during Organogenesis: The probability of a structural defect is greatest during organogenesis. > 15 - 25 days after conception, the brain is most vulnerable. > 20 - 40 days after conception, the heart is most vulnerable. > 24 - 36 days after conception, the legs are most vulnerable. > 24 - 40 days after conception, the eyes are most vulnerable. Sensitivity during the Fetal Period: > Exposure is less likely to cause anatomical defects. > Exposure is more likely to stunt growth. > Exposure is more likely to create problems in organ functioning. Effects of Medication, Drugs or Substances during Pregnancy; 1. Interfering with normal fetal development and damaging the baby’s organs. 2. Damaging the placenta and putting the baby’s life at risk. 3. Bringing on premature labour and increasing the risk of miscarriage. Common Teratogens and their Effects ❑ The potential for harm to the pregnancy and unborn baby depends on a range of factors including: - type of drug/medication taken and how it is taken. - the dose of the drug/medication and how often it is taken, whether it is used alone or in combination with other drugs/medications. - gestational age of the baby. - other factors, such as maternal health and diet. ❑ Harmful Drugs, Substances and Medications; medicines illicitly used prescription drugs tobacco alcohol caffeine illegal drugs substances used as drugs  Common Teratogens and their Effects Smoking and alcohol during pregnancy smoking – increases risk of miscarriage and stillbirth, greater risk of low birth weight, prematurity and sudden unexpected death in infants. alcohol – frequent and heavy use of alcohol during pregnancy has been associated with miscarriage, babies who are small for gestational age and intellectual impairment in children (known as fetal alcohol syndrome). caffeine – heavy use (greater than 7cups of coffee/day) may be associated with an increased risk of low birth weight. Illegal Drugs and Pregnancy; amphetamines – increased risk of LBW, birth defects, prematurity. cannabis – increased risk of growth retardation, sleep problems, behavioural problems cocaine – increased risk of miscarriage, pre-term birth, growth retardation, stillbirth and birth defects (brain, heart, genitals and urinary system) heroin – increased risk of LBW, prematurity, fetal distress, stillbirth, blood-borne viral disease (hepatitis), infant withdrawal after birth. inhalants – increased risk of miscarriage, LBW, birth defects, and SUDI.  Common Teratogens and their Effects Radiation Produces a range of malformations depending on the stage of development of the embryo/fetus & the strength & length of exposure. Most damaging time for exposure and subsequent damage is from implantation to 6 weeks after conception. If exposure occurs before implantation, the zygote apparently killed. The nervous system (brain) and retinal innervation are most affected. Radiation of the pelvis should be avoided all during pregnancy. Hyperthermia Detrimental to growth because it interferes with cell metabolism, can occur from saunas, hot tubs, or tanning beds, from a work environment next to a furnace, such as in welding or steel making, or from a high maternal fever early in pregnancy (4–6 weeks). Women who use a hot tub at 40° C should not stay in it for longer than about 10 minutes at one time.  Common Teratogens and their Effects Teratogenic Maternal Stress An emotionally disturbed pregnancy could produce physiologic changes through its effect on the sympathetic division of the autonomic nervous system. If the anxiety is prolonged, the constriction of uterine vessels could interfere with the blood and nutrient supply to a fetus. Illness or death of one’s partner, marital discord & illness or death of another child are examples of stressful situations that might provoke excessive anxiety.  Schedule of Prenatal Visit Age of Gestation Schedule From the time pregnancy is monthly detected to 32wks 2x a month 32 to 37wks (alternating wks) 37wks to EDC weekly Post - term 2x a week  Preparation for Childbirth Classes Focus mainly on explaining the birth process rather than pregnancy and ways to prevent or reduce the pain of childbirth. Common goals of preparation are to: prepare a woman and her support person for the childbirth experience. help women reduce and manage pain with both pharmacologic and non- pharmacologic methods. Help increase a couple’s overall enjoyment of and satisfaction with the childbirth experience. Include several exercises to ready the body for labor, as well as methods of pain prevention or relief in labor.  Prenatal Exercises Prenatal Yoga aimed at helping a woman to relax and manage stress. focus on gentle stretching and deep breathing. Yoga breathing techniques can be used in labor to help both relaxation and pain management.  Prenatal Exercises Perineal and Abdominal Exercises strengthen pelvic and abdominal muscles and make these muscles stronger and more supple. ❖ Do not exercise if any danger signs of pregnancy are present, and never exercise to a point of fatigue. 1. Tailor Sitting - stretches perineal muscles without occluding blood supply to the lower legs.  Prenatal Exercises Perineal and Abdominal Exercises (cont.) 2. Squatting - stretches perineal muscles, can be a useful position for 2nd stage labor. 3. Pelvic Floor Contractions (Kegel Exercises) - perineal muscle- strengthening exercise, can help in the postpartum period to reduce pain and promote perineal healing.  Prenatal Exercises Perineal and Abdominal Exercises (cont.) 4. Pelvic Rocking - helps relieve backache during pregnancy and early labor by making the lumbar spine more flexible. 5. Abdominal Muscle Contractions - help strengthen abdominal muscles during pregnancy. Strong abdominal muscles can also contribute to effective 2nd-stage pushing during labor. Ex: practice “blowing out a candle.” A woman takes a fairly deep inspiration then exhales normally.  Methods for Managing Pain in Childbirth Discomfort during labor can be minimized; 1. if they are informed about what is happening and prepared with breathing exercises to use during contractions. 2. if the abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall with contractions. 3. Pain perception can be altered by distraction techniques or by the gating control theory of pain perception.  Methods for Managing Pain in Childbirth 1. The Bradley (Partner-Coached) Method - by Robert Bradley woman’s partner should play an important role during pregnancy, labor and the early newborn period. reduces pain in labor by abdominal breathing. encouraged to walk during labor. 2. The Psychosexual Method - by Sheila Kitzinger in England includes a program of conscious relaxation and levels of progressive breathing that encourage a woman to “flow with” rather than struggle against contractions.  Methods for Managing Pain in Childbirth 3. The Dick-Read Method - Grantly Dick-Read, English physician. the premise is that fear leads to tension which leads to pain. reduced fear through education about childbirth & relaxation. reduced pain by focusing on abdominal breathing during contractions. 4. Lamaze Philosophy - popularized by a French physician, Ferdinand Lamaze. originally termed as psycho-prophylactic method - focuses on preventing pain in labor by use of the mind. women can learn to use controlled breathing to reduce pain during labor.  Methods for Managing Pain in Childbirth The Lamaze Philosophy 1. Labor should begin on its own, not be artificially induced. 2. Women should be able to move about freely during labor, not be confined to bed. 3. Women should receive continuous support during labor. 4. No routine interventions (IVF) are needed. 5. Women should be allowed to assume a non-supine position for birth. 6. Mother and baby should be housed together following birth, with unlimited opportunity for breastfeeding.  Methods for Managing Pain in Childbirth Premises related to the gating control method of pain relief: 1. Familiarization with what will happen during labor & the nature of contractions can decreased tension. 2. Concentration on breathing patterns, use imagery or focusing on a specified object to block incoming pain sensations. 3. Conditioned reflexes in response to a stimulus to displace pain during labor. ❖ Gating Theory of Pain Control - gate control mechanisms in the substantia gelatinosa, capable of halting an impulse at the level of spinal cord so the impulse is never perceived at the brain level as pain.  Methods for Managing Pain in Childbirth The Lamaze Method 1. Conscious Relaxation - learning to relax body parts so that a woman does not remain tense. place a comforting hand on the tense body area or tell her to relax that area to achieve complete relaxation. 2. Cleansing Breath - woman breathes in deeply & then exhales deeply. limits the possibility of either hyperventilation or hypoventilation, that could happen with rapid breathing patterns. 3. Consciously Controlled Breathing - provides distraction as well as prevents the diaphragm from descending fully and putting pressure on the expanding uterus.  Methods for Managing Pain in Childbirth The Lamaze Method 4. Effleurage. French for “light abdominal massage,” done with just enough pressure to avoid tickling. Serves as distraction technique and helps limit local discomfort. 5. Focusing or Imagery. (sometimes called “sensate focus”). A photograph, graphic design or just something that appeals to her. She concentrates on it during contractions. Other women use imagery by imagining they are in a calm place. 6. Second-Stage Breathing - suggest that women breathe any way that is natural for them, except holding their breath during this stage of labor. Preparation for Labor and Delivery  The Birth Setting ❖ Choosing the Appropriate Setting uncomplicated pregnancies - hospitals, birthing centers, homes. high-risk pregnancies - hospitals where immediate emergency care will be available. ❖ Choosing a Birth Attendant and Support Person ❖ Hospital Birth Receive accurate and up-to-date information about the benefits and risks of all procedures, drugs, and tests suggested for use during pregnancy, birth, and the postpartum period, with the rights to informed consent and informed refusal. Advantages and Disadvantages of Hospital Birth ❖ Disadvantages Separation of the family for at least one night Mother may not feel as much in control of the childbirth experience as she may wish. Care may be fragmented, particularly if a woman’s physician is not present during the entire labor & birth or if labor nurses change shifts in the middle of labor.  The Birth Setting ❖ Alternative Birthing Centers (ABCs) - wellness-oriented childbirth facilities at least within an easy distance of a hospital. The birth attendants tend to be nurse-midwives. Women are encourage to express her own needs & wishes during the labor process. Women remain in an ABC from 4 to 24 hours after birth. Advantages and Disadvantages of ABCs ❖ Advantages A woman is encouraged to be prepared to control the discomfort of labor. A woman is encouraged to be knowledgeable about the labor process. A woman is encouraged to breastfeed. Family integrity can be maintained because family members may accompany a woman to the birthing center. A woman is attended by skilled professionals during labor & birth. Emergency care is immediately available. Extended high-risk care is easily arranged.  The Birth Setting Advantages and Disadvantages of ABCs ❖ Disadvantages Extended high-risk care is not immediately available. A woman may be fatigued after birth because of brief health care setting stay. She must independently monitor her postpartal status because of brief health care setting stay. ❖ Home Birth May be supervised by a physician, but nurse-midwives are the more likely choice as birth attendants in this setting. They choose home birth so that they: > can have their baby close by after birth. > can have more control over the childbirth experience. > can give birth in familiar, low-cost surroundings.  The Birth Setting Advantages and Disadvantages of Home Birth ❖ Advantages Woman is encouraged to be knowledgeable on birth process. Woman has the greatest freedom for expressing her individuality. There is no separation of the family at birth. A skilled professional can attend the birth. ❖ Disadvantages Adequate equipment is unavailable. Abrupt change of goals is necessary if hospitalization is required. A woman and support person may become exhausted because of the responsibility placed on them. A woman must independently monitor her postpartal status.  Alternative Methods of Birth Leboyer Method - Frederick Leboyer ,French obstetrician. the birthing room is darkened & kept pleasantly warm soft music is played or at least harsh noises are kept to a minimum. Infant is handled gently; the cord is cut late and the infant is placed immediately after birth into a warm-water bath. Hydrotherapy and Water Birth Birthing centers allow women to labor in warm showers or give birth in spa tubs of warm water. Baby is born underwater then immediately brought to the surface for a first breath. Risk uterine infection in the mother aspiration of contaminated bath water by a newborn maternal chilling when leaving the water. End of Slides