Prenatal Changes and Adaptations to Pregnancy PDF

Normal Prenatal Changes and Assessments Objectives 1.Describe the physiologic and psychological changes that occur during pregnancy. 2.Compute gravidity, parity, and estimated date of delivery. 3.Describe preconception, initial, and subsequent antepartum assessments. Objectives 1.Identify the proces...

Normal Prenatal Changes and Assessments Objectives 1.Describe the physiologic and psychological changes that occur during pregnancy. 2.Compute gravidity, parity, and estimated date of delivery. 3.Describe preconception, initial, and subsequent antepartum assessments. Objectives 1.Identify the process of role transition. 2.Explain the maternal tasks of pregnancy. 3.Discuss factors that influence psychosocial adaptation to pregnancy such as age, parity, social support, absence of a partner, socioeconomic status, and abnormal situations. Patient: Sally Smith 25 year-old, G2 P0 Married Waitress , works 8-10 hr days LMP February 20th, 2012 Thinks she might be pregnant In the office - missed her period Is Sally Pregnant?? Presumptive Indicators Probable Indicators Positive Indicators Presumptive indicators Amenorrhea Nausea and vomiting Unexplained Fatigue Urinary frequency Excessive Salivation (ptyalism) Breast and skin changes Fetal movement (quickening) Probable Indicators Abdominal enlargement Positive Pregnancy Test –Human Chorionic Gonadotropin Changes in the cervix –Chadwick’s sign (blue cervix, vulva) –Hegar’s sign (softening of cervix) –Goodell’s sign (softening of the cervix 6 – 8 weeks) Probable Indicators, Cont Changes in the uterus –Braxton Hicks contractions –Fetal outline Leopold’s Maneuver –Uterine souffle soft blowing sound on auscultation –Pregnancy tests Human Chorionic Gonadotropin Urine & Serum Positive indicators –Auscultation of fetal heart tones (110 -160 bpm) –Fetal movement felt by examiner –Visible on ultrasound –Visible on x-ray, MRI, etc. First Prenatal Visit Confirmation of pregnancy Calculate estimated due date Obstetrical History – Menstrual history – Contraceptive history – Medical and surgical history – Family history – Partner’s health history – Psychosocial history First Prenatal Visit Confirmation of Pregnancy –Urine and/or Serum –Human Chorionic Gonadotropin Calculate EDD (need LMP) –Naglee’s Rule –- 3 months –+ 7 days G Gravida Number of pregnancies P Para T P Term Number of pregnancies ≥ 21 weeks gestation 38 - 42 weeks gestation Preterm ≤ 37 weeks gestation A Abortions Fetal loss ≤ 20 weeks L Live births Current number of living children Sally Smith Currently Pregnant 1st trimester Therapeutic Abortion (TAB) age 17 G____P___ T___P___A___L____ Sally’s Last Menstrual Period (LMP) February 20, 2012 What is the estimated date of delivery? Minus 3 months Plus 7 days Year? = = = First Prenatal Visit Describe physical changes Sally will have during her pregnancy Schedule of visits Lab work that will be ordered at this first visit Teaching Reproductive Changes Uterus –10 - 12 weeks slightly above pubic bone –16 weeks midway between pubic bone and umbilicus –20 wks @ umbilicus –> 20 weeks, each +1cm = 1 week –“Drops” at 36 weeks (lightening) Reproductive Changes Cervix Enlargement of space with thick mucous plug Mucous plug cervix Vagina Reproductive Changes – Vagina and vulva Edematous; bluish color, folds prominent Ovaries Secrete progesterone for 1st 6 - 7 weeks Ovulation stops Placenta Temporary endocrine gland during pregnancy Produces large amounts of estrogen & progesterone by 10 to 12 weeks of pregnancy Maintains the growth of the uterus Breasts Increase in size; vascularity Nursing Implication/care? Areolae darker Breasts begin to produce colostrum (16th week), –Thin dark yellow fluid Circulatory System Blood Volume: Increases gradually by 30 – 50% Causes decreased concentration of RBC & HGB Body compensates by end of pregnancy showing normal RBC, HGB Circulatory System Cardiac Output: Increases by 30% during 1st and 2nd trimester Reflected in increased HR – 10 beats per minute No change in blood pressure Circulatory System Venous Return: Inhibited Swelling of the feet and legs in the last months of pregnancy Vena cava syndrome (supine hypotension) Patient may feel dizzy, nauseated, or weak Respiratory Oxygen Consumption: ­ 15 - 20% during pregnancy –½ used by fetus; ½ used by uterus –Respirations deeper –RR rises to compensate for increased maternal O2 consumption –Patient c/o feeling out of breath – Temperature Slight increase in body temperature Returns to normal at approx 16th week of gestation Patients may feel warmer or experience "hot flashes" Selected Hormonal Changes Ø Parathyroid Gland – increases in size slightly – meets increased requirements for calcium needed for fetal growth Ø Posterior Pituitary Ø Near term, oxytocin secreted to initiate labor Ø Anterior Pituitary Ø At birth prolactin secreted – stimulates breast milk production Hormonal Changes Progesterone – Inhibits smooth muscle in the uterus from contracting – Increased levels affect other smooth muscle in the body Estrogen – ­ vascularity of mucous membranes in upper respiratory tract – Edema in nose; pharynx, larynx, and trachea – Nasal & sinus stuffiness; epistaxis; and voice changes Gastrointestinal System Mouth – ­ estrogen → hyperemia → gingivitis & bleeding gums – Vascular hypertrophy of gums – Darkened in color; ptyalism; no change in teeth Esophagus – lower esophageal tone ↓ from ­ progesterone – GERD and pyrosis (Hearburn) Gastrointestinal System Stomach & small intestine Enlarged uterus displaces stomach & intestines – ↓ GI tone and motility from progesterone – ­ Gastric Emptying Time – ­ Nausea & Vomiting – Risk for ↓ Nutrients to fetus Gastrointestinal System Gallbladder –Gallbladder hypotonia w/ ­GET –Thicker bile; ­ risk for gallstones Gastrointestinal Peristalsis – slowed RT progesterone – Enhances absorption of nutrients – Slow emptying may increase nausea & heartburn (pyrosis). – Relaxation of the cardiac sphincter may increase risk of heartburn – Movement through large intestines slowed increases risk of constipation. Urinary system 1st through 3rd trimester ­ pressure on bladder →­frequency and urgency; nocturia Bladder walls hypertrophied (thin) from estrogen Risk of trauma during childbirth Urinary system – Kidneys and Ureters –Kidneys workload increases, GFR ­ 50% –Removal of maternal & fetal waste –Increased urinary output –Risk for urine stasis & pyelonephritis in right kidney RT uterine pressure on the right ureter Skin Integument –Circulation ­ during pregnancy –Chloasma hyper-pigmentation –Linea nigra (negra) dark line from umbilicus to symphysis pubis Integument Connective tissue –Striae gravidarum Hair and nails – Hair grows more rapidly and less falls out Musculoskeletal System Postural changes –Pelvic instability –Wide stance –Waddling gait –Leaning backward to maintain balance –Progresses lordosis – leads to backache Abdominal Wall – Abdominal rectus muscles stretch – May separate – Diastasis recti Endocrine Pituitary gland – Prolactin—(anterior pituitary) produces milk – Oxytocin—stimulates contractions of uterus – Inhibited during pregnancy by progesterone – ­ PP to prevent hemorrhage Thyroid gland – ­ thyroid hormones; slight ­ size of thyroid → ­ BMR—20-30% during pregnancy – Returns to normal after delivery Endocrine Parathyroid glands – Fetus demands ­ CA & Phosphorous – Maternal parathyroid hormone ­ – Bones protected by calcitonin & estrogen Endocrine Pancreas– Insulin – fetal glucose demand & pregnancy hormones leads to lower maternal glucose levels – Maternal blood glucose levels ­ & insulin sensitivity ↓ – Insufficient insulin secretion = GDM Endocrine Adrenals - regulate kidneys – Cortisol ­ – Aldosterone ­ Placental hormones – Human Chorionic gonadotropin (HCG) – Estrogen – Progesterone – Human placental lactogen (HPL) – Relaxin Initial Prenatal Visit Vital signs Height & weight Urinalysis Blood work STD testing Physical exam Prenatal Education Goals of Prenatal Education Providers of Education Class Participants Choices for Childbearing Preconception classes Early pregnancy classes Exercise classes Childbirth preparation classes Refresher courses Cesarean birth preparation classes Vaginal birth after cesarean birth (VBAC) Breastfeeding classes Parenting classes Postpartum classes Methods of pain management - Education, Relaxation, Conditioning Classes for family members Siblings, Grandparents Prenatal Panel Usual Testing Additional Per History Hemoglobin/ hematocrit Rh Factor B Blood type Rubella screen Varicella Hepatitis B surface antigen Cystic Fibrosis screen HIV test tuberculosis Hepatitis C Tay Sach’s screen Sickle Cell prep screen Schedule of Visits Monthly x 7 months Every 2 weeks during month 8 Then, weekly until delivery Subsequent Visits Schedule of visits Vital signs Weight Urinalysis Glucose screen Fundal height Leopold’s maneuvers Fetal heart tones Fetal activity Pelvic Examination Common Discomforts of Pregnancy Nausea and vomiting Heartburn Backache Uterine ligament pain Urinary frequency Varicose veins Hemorrhoids Constipation Leg cramps Education: Health Behaviors Nutrition Bathing Hot tubs and saunas Douching Breast care Clothing Exercise Education: Health Behaviors Sleep and rest Employment Maternal safety Sexual activity Travel Immunizations Teaching Lifestyle Changes Over the counter (OTC) drugs Tobacco Alcohol Illegal drugs A Studies note no risk to fetus in 1st trimester No evidence of risk later in pregnancy B Studies have failed to demonstrate risk to fetus e. g. Amoxicillin, Acetaminophen C Studies show adverse effect on fetus Discuss risk versus benefit D Evidence of fetal risk, benefit may outweigh risk e. g. Phenytoin X Fetal risk clearly outweighs benefit e. g. Accutane Adaptation Maternal Psychological Responses First Trimester Uncertainty Ambivalence Self as Primary Focus Maternal Psychological Responses Second trimester Physical evidence of pregnancy Fetus as primary focus Narcissism and introversion Body image Changes in sexuality Third trimester – Vulnerability – Dependency – Preparation for birth Maternal Role Transition Maternal Role Mimicry Role-play Fantasy Looking for a role fit Grief work Maternal Tasks Seeking safe passage Securing acceptance Learning to give of self Committing to maternal role Paternal Adaptation Recognition as a parent Creating the role of involved father Cultural Influences on Childbearing Differences within cultures – Health beliefs – Communication techniques – Time orientation Culturally competent nursing care – Assessment – Negotiation