Transcript Prenatal Care

Prenatal Care
The Healthy Client
Ana H. Corona, MSN, FNP-C
Nursing Instructor
February 2009
Process of Reproduction
 Fertilization refers to the joining together of the
ovum and sperm cells.
 Only one sperm is required for actual fertilization.
 The union between ovum and sperm occurs in the
outer third of the fallopian tube.
 The ovum and sperm = Zygote begins rapid cell
division and in 2 to 3 days becomes a structure
referred to as Morula.
 The morula is a rapidly growing structure and
reaches the uterus in approximately 4 days.
Process of Implantation
 The morula floats in the
uterus for 3 to 4 days
 The morula, now called
blastocyst burrows into
the uterine lining.
 The outer surface of the
blastocyst becomes
covered with finger-like
projections called
chorionic villi.
 Chorionic villi aid in the
process of implantation
into the endometrium
(decidua).
Decidua and Chorionic Villi
 The chorionic villi and the decidua form the
placenta.
3 phases of embryo and fetal development
1. Blastogenesis (day 0-4)
a. Zygote to Morula
b. Blastocyst
2. Embryonic Period (day 5-60)
a. Blastocyst to Fetus
b. Period of Differentiation
3. Fetal Stage (>day 60 to birth)
a. Period of Growth
Pregnancy Test
Measure hCG (human chorionic
gonadatropin)
95-98% accuracy
blood and urine tests
Estimated Date of Delivery
Nagele’s rule
Begins with 1st day of last menstrual
period, subtract 3 months, and add 7 days
McDonald’s Method
 Measure from top of
symphysis pubis over
curve of abdomen to
top of uterine fundus in
cm.
Helps determine
gestation week
Gives indication of IUGR,
twins, hydramnios
(excess amniotic fluid)
12-16 weeks, just above
the symphysis pubis
20-22 weeks, at
umbilicus
Presumptive, Probable and Positive Signs
of Pregnancy
Presumptive: amenorrhea, quickening
Probable: goodell’s sign, hegar’s sign,
braxton-hicks contractions, increased
pigmentation, ballottement, pregnancy test
Positive: hearing the fetal heartbeat (by
examiner)
Visualization of the fetus (ultrasound)
Examiner feeling fetal movement
Presumptive Signs & Symptoms of Pregnancy
 Presumptive signs and
symptoms of pregnancy
are those signs and
symptoms that are usually
noted by the patient.
 These signs and
symptoms are not proof of
pregnancy but will
suspicious of pregnancy.
 Amenorrhea
 Nausea and vomiting
 Enlargement & Breast
soreness
 Frequent urination
 Feeling tired
 Montgomery's tubercules
 Stretch marks
 Spider veins
 Quickening (fetal
movement)
 Colostrum from breasts
Quickening
This is the first perception of fetal
movement within the uterus.
It usually occurs toward the end of the fifth
month because of spasmodic flutter.
A multigravida can feel quickening as early
as 16 weeks.
A primigravida usually cannot feel
quickening until after 18 weeks.
Probable Signs
Noted by the clinician
upon examination of
the patient:
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Enlarged abdomen
Positive pregnancy test
Change in uterine shape
Softening of the cervix
(Goodell's sign)
Chadwick’s Sign
Enlarging uterus
Braxton Hicks contractions
Hegar’s Sign
Palpation of the baby
Ballottement
Goodell’s Sign
Goodell’s sign
The cervix is normally firm like the cartilage at
the end of the nose. The Goodell's sign is when
there is marked softening of the cervix (due to
invreasing vacularity and edema)
This is present at 6 weeks of pregnancy
Chadwick’s Sign
The vaginal walls and cervix have taken
on a deeper color (blue/violet) caused by
the increased vascularity because of
increased hormones.
It is noted at the sixth week when
associated with pregnancy.
It may also be noted with a rapidly growing
uterine tumor or any cause of pelvic
congestion.
Hegar’s Sign
 This is softening of
the lower uterine
segment just above
the cervix. the wall
feels tissue paper thin
during pelvic exam
 Uterus tilts forward
 Noted by the sixth to
eighth week of
pregnancy.
Braxton hicks contractions
 Painless uterine contractions occurring
throughout pregnancy.
 May begin about the 12th week of pregnancy
and becomes progressively stronger.
 These contractions will, generally, cease with
walking or other forms of exercise.
 Are distinct from of true labor contractions by the
fact that they do not cause the cervix to dilate
and can usually be stopped by walking.
Ballottement
 Demonstrated
during the
bimanual exam at
the 16th to 20th
week.
 The lower uterine
segment or the
cervix is tapped by
the examiner's
finger and left
there
 Fetus floats
upward, then sinks
back and a gentle
tap is felt on the
finger.
Leopold’s Maneuvers
 (A) The fundus is palpated to
determine which fetal part occupies
the fundus.
 (B) Each side of the maternal
abdomen is palpated to determine
which side is fetal spine and which is
the extremities.
 (C) The area above the symphysis
pubis is palpated to locate the fetal
presenting part and to determine how
far the fetus has descended and
whether fetus is engaged.
 (D) One hand applies pressure on the
fundus while the index finger and
thumb of the other hand palpate the
presenting part to confirm
presentation and engagement.
Positive Signs
Definitely confirmed as a pregnancy:
Fetal heart sounds
Ultrasound
X-ray
Actual delivery of infant.
Terms related to pregnancy
 Para: number of babies born after 22 weeks
 Gravida: A woman who is or has been pregnant
 Primigravida: a woman who is pregnant for the
1st time
 Primipara: A woman who has delivered one child
after 22 weeks
 Multigravida: A woman who has been pregnant
previously
 Multipara: A woman who has carried 2 or more
pregnancies after 22 weeks
 Nulligravida: A woman who is not pregnant and
is not currently pregnant.
Three Psychological tasks of
pregnancy
1st trimester: accepting the pregnancy
2nd trimester: accepting the baby
3rd trimester: preparing for parenthood;
nesting
Placenta
 Fleshy disk like organ.
 Reddish in color.
 It is formed from the
outer layers of the
blastocyst.
 It is completely formed
by the third month of
pregnancy.
 The umbilical cord
connects the fetus to
the placenta and is
normally 20 inches in
length and 3/4 inch in
diameter.
The maternal surface of a normal term placenta is seen
here. Note that the cotyledons that form the placenta are
reddish brown and indistinct.
Placental Function
 Transports oxygen, nutrients, and antibodies to
the fetus by means of the umbilical vein
 Removes carbon dioxide and metabolic wastes
from the fetus by the two umbilical arteries
 Serves as a protective barrier against harmful
effects of certain drugs and microorganisms
 Acts as a partial barrier between the mother and
fetus to prevent fetal and maternal blood from
mixing
 Produces hormones essential for maintaining the
pregnancy. (estrogen, progesterone, and human
chorionic gonadotropin (HCG)).
Important Point
Placental function depends on maternal
blood pressure
If there is interference with circulation with
the placenta, the following develops:
Vasoconstriction (blood flow to baby is
decreased)
Maternal hypertension
Maternal smoker
Cocaine abuse
Umbilical Cord
 Lifeline to mom
2 arteries
unoxygenated blood
1 vein
oxygenated
Wharton’s jelly
Outer covering of umbilical cord
(protects cord)
Fetal Membranes
Amnion Fluid
 Smooth, slippery,
glistening innermost
membrane that lines the
amniotic space.
 It is filled with fluid
 The fetus floats and
moves in the amniotic
cavity.
 At full term, this cavity
normally contains 500 cc
to 1000 cc of fluid (water).
Amnion Fluid Functions
 Protect the fetus from direct trauma.
 Separate the fetus from the fetal membranes.
 Allow freedom of fetal movement and permits
musculoskeletal development.
 Facilitate symmetric growth and development of
the fetus.
 Protect the fetus from the loss of heat and
maintains a relative, constant fetal body
temperature.
 Serve as a source of oral fluid for the fetus.
 Act as an excretion and collection system.
Chorion
This is the outer membrane.
It forms a large portion of the connective
tissue thickness of the placenta on its fetal
side.
It is the structure in and through which the
major branching umbilical vessels travel
on the surface of the placenta.
First Trimester
First three months of pregnancy: fertilized
ovum to an embryo.
All organs are formed.
The fetus becomes less vulnerable to the
effects of most drugs, most infections, and
radiation.
Facial features are forming and the fetus
becomes human in appearance.
External sex organs are visible, but
positive sex identification is difficult.
First Trimester
Well-defined neck, nail beds beginning,
and tooth buds form.
Rudimentary kidneys excrete small
amounts of urine into the amniotic sac.
There is movement but just not strong
enough to be felt.
The fetus is about 2.9 inches long and
weighs about 14 grams.
Second Trimester
 During these months (4th, 5th, and 6th) the fetus
grows fast. At the end of the second trimester,
the fetus…
 Fetal heart tone (FHT) can be heard with a
stethoscope.
 Skin is wrinkled, translucent, and appears pink.
 Sex is obvious.
 Looks like a miniature baby.
 Skeleton is calcified.
 Birth survival is possible, but the fetus is
seriously at risk.
Third Trimester
At the end of the third trimester (7th, 8th,
and 9th month), the fetus:
Skin is whitish pink.
Hair in single strands.
Testes are in the scrotum, if a male child.
Bones of the skull are firmer, comes closer
at the suture lines.
Lightening occurs.
Fetus is about 20 inches long and weighs
about 3300 grams.
Fetal Development – fetal period 9 week - Birth
 Cardiovascular
Heart beat heard at 10 weeks by Doppler
Heard at 16 weeks via fetoscope
 Respiratory
Surfactant matures by 36th week
 Surfactant permits expansion of the lungs
 GI system
Meconium (tarry stool)
 Urinary system
By 5th month, fetus urinates into amniotic fluid
2nd half of pregnancy: urine makes up major part of
amniotic fluid
 Sexual
Can identify male/female by 16th week
Fetal Circulation
 The fetus receives oxygen through the placenta
because the lungs do not function as organs of
respiration in the uterus.
 The umbilical vein transports blood rich in oxygen
and nutrients from the placenta to the fetal body.
 About 1/2 of the blood passes into the liver and
the rest enters a shunting vessel called the
ductus venosus that bypasses the liver.
 The ductus venosus travels a short distance and
joins the inferior vena cava.
Fetal Circulation
The oxygenated blood from the placenta is
mixed with deoxygenated blood from the
lower parts of the fetal body.
This blood continues through the vena
cava to the right atrium.
As the blood relatively high in oxygen
enters the right atrium of the fetal heart, a
large proportion of it is shunted directly
into the left atrium through an opening in
the atrial septum called the foramen
ovale.
Fetal Circulation
 The more highly oxygenated blood that enters the
left atrium through the foramen ovale is mixed
with a small amount of deoxygenated blood
returning from the pulmonary veins.
 This mixture moves into the left ventricle and is
pumped into the aorta.
 The rest of the blood entering the right atrium, as
well as the large proportion of the deoxygenated
blood entering from the superior vena cava,
passes into the right ventricle and out through the
pulmonary artery.
Fetal Circulation
Most of the blood in the pulmonary artery
bypasses the lungs by entering the
ductus arteriosus, which connects the
pulmonary artery to the descending
portion of the aortic arch.
Fetal Circulation
Circulation after Birth
 The umbilical vein is obliterated and becomes
the round ligament of the liver.
 The umbilical arteries are obliterated and
ultimately become ligaments.
 The ductus venosus is obliterated and
becomes a ligament.
 Anatomic closure is completed at the end of 2
months.
 The ductus venosus is superficially embedded in
the wall of the liver.
Circulation after birth
The ductus arteriosus is obliterated and
becomes a ligament.
Functional closure takes 3-4 days;
anatomic closure is completed by 3
weeks.
The constriction seems to be stimulated by
a substance called Bradykinin, which is
released from the lungs during their initial
expansions.
Circulation after Birth
 The foramen ovale closes after the umbilical
cord is tied and cut.
 A large amount of blood is returned to the heart
and the lungs.
 With the lungs now functioning, there is equal
pressure on both atria as the vessels constrict.
 Failure of the foramen ovale to close
spontaneously results in an atrial septal defect,
which may or may not require surgery later
Fetal Circulation after Birth
Integumentary System: Vernix Caseosa
 This is a soft, white, cheesy, yellowish cream on the
infant's skin at birth. It is caused by the secretions of the
sebaceous glands of the skin. It offers protection from the
watery environment of the uterus and serves as a natural
moisturizer.
Lanugo
 This is a long, soft growth of fine hair on the
infant's shoulders, back, and forehead. It
disappears early in postnatal life.
Respiratory System: Age of Viability
 By 24 weeks the lung cells
begin to produce a
substance called
surfactant.
 Surfactant: A substance
composed of lipoprotein
 Secreted by the alveolar
cells of the lung
 Serves to maintain the
stability of pulmonary
tissue by reducing the
surface tension of fluids
that coat the lung.
Maternal: Blood Pressure
First trimester: no change
Second trimester: systolic and diastolic
decrease 5-10 mm Hg
3rd trimester: Returns to first trimester
levels.
Supine hypotension syndrome can occur
in the 2nd half of pregnancy (vertigo,
decreased BP).
Palpitations and murmurs can cause an
issue for these issues.
Patient Teaching
Encourage mom to take naps, have partner
assist with housework, get to bed early, and
good nutrition.
Teach mom that that these symptoms are
normal.
If mom feels faint, tell her to lower head
between legs, lie down, rise slowly, avoid
standing long periods.
Avoid lying on back, instruct to lie on side
(due to compressed inferior vena cava).
Physiologic Anemia of Pregnancy
Blood volume increases gradually by 30 to
50 percent (1500 ml to 3 units).
RBC’s increase, but cannot keep up with
the pace of the plasma volume
Decreased hemoglobin and hematocrit
occur.
This is called pseudoanemia.
This explains why the need for iron is so
important during pregnancy.
Respiratory System
Slight elevation in respiratory rate (18-20 in
pregnancy; 12-20 is normal)
Nasal stuffiness (1st trimester)
SOB 2nd trimester
Dyspnea
Estrogen causes upper respiratory tract to
become more vascular. As capillaries fill, edema
develops in the nose.
Interventions: Use cool air vaporizer
NO SPRAYS
Proper position; semi-Fowlers when sleeping.
Musculoskeletal System
Changes in gravity
Calcium and phosphorus needs increase
Later in pregnancy, gradual softening of
pelvic ligaments and joints
Lordosis
Caused by relaxin and progesterone
Leg cramps and backache (late pregnancy)
Good nutrition, rest with legs elevated, wear warm
clothing.
During leg cramp, pull toes up toward the leg while
pressing down on the ankle
Use proper body mechanics; avoid high heels
Gastrointestinal System
 Nausea and vomiting (1st trimester)
 Gingivitis
 Increased saliva
 Increased gastric acid (heartburn/pyrosis)
Causes are due to the cardiac sphincter relaxes;
increased progesterone; gastric displacement; hCG
levels
 Interventions: Avoid greasy, highly seasoned food, eat small
meals frequently, eat dry toast or crackers before arising.
Warm sprite and ginger ale can be helpful.
 Sit upright 1 hour after eating
 Sodium bicarb after eating
 6-8 glasses of water every day
Colostrum
A thin white fluid, the first milk secreted at
the termination of pregnancy
Contains antibodies that confer passive
immunity to the newborn.
High in carbs, protein, and antibodies
Nutrients
Laxative effect
Integumentary System
 Linea Nigra: hormone
induced pigmentation
- dark line that runs
from the umbilicus to
the symphysis pubis
and may extend as
high as the sternum.
 It is a hormoneinduced pigmentation.
Chloasma
Mask of Pregnancy. Brownish
hyperpigmentation of the skin over the
face and forehead.
It begins about the 16th week of
pregnancy and gradually increases, then it
usually fades after delivery.
Striae Gravidarum – stretch marks
 May be due to the
action of the
adrenocorticosteroids.
 A separation within
underlying connective
tissue of the skin.
 Occurs over areas of
maximal stretch--the
abdomen, thighs, and
breasts.
 May never completely
disappear.
Lightening
The descent of the presenting part of the fetus
into the pelvis. Feels as if the baby is
“dropping”.
Happens around the 36th week
Mucus Plug
The plug of mucus that fills the opening of
the cervix
Prevents bacteria from getting into uterus
Endocrine System
 Placental hormones
Estrogen: breast/uterine enlargement
Progesterone: maintains endometrium; inhibits
uterine contractibility; lactation
hCG: stimulates corpus luteum to produce
estrogen and progesterone until placenta takes
over.
hPL (Human placental Lactogen): antagonist to
insulin (frees fatty acids for energy so glucose
is available)
Relaxin: Inhibits uterine activity; softens cervix
and collagen in joints.
Prostaglandins: May trigger labor
Endocrine System
 Pituitary gland
Oxytocin - loosens joints and ligaments starting at
about 4 months. Initiates labor
Prolactin: lactation
 Thyroid increases in size
Increased BMR
Better use of calcium and vitamin D
 Adrenal glands
Aldosterone
 Pancreas:
Insulin; additional glucose available for fetus
Physical Examination
 Screening Tests:
 CBC
 Blood type
 Rh factor
 Coomb’s test
 Rubella titer
 Blood glucose
 VDRL
 Cervical/Vaginal cultures
 Hepatitis B Surface
Antigen
 Antibody titer Hb, ag
 HIV
 Tuberculosis screening
 Urinalysis
 Alpha-Fetoprotein AFP
Identify 5 assessments of the pregnant
female during return office visits
 Blood Pressure
 Weight total weight gain (25-35 lbs)
 Week 1 - 12 = 2-4 lbs
 Week 13 – 40 = 1 lb a week
 Uterine Size
 Edema
 Fetal position (Leopold’s Maneuvers)
 Fetal Heartbeat
 Laboratoy test (urinalysis)
Schedule for return office visits of the
healthy pregnant female
First 28 weeks=every 4 weeks
Week 29-36=every 2 weeks
Week 37 to delivery=each week
Amniocentesis
 Is a method for assessing
fetal maturity and well
being
 Amniotic fluid is withdrawal
of by insertion of a needle
through the abdominal and
uterine walls after 14
weeks gestation.
 The chromosome analysis
of these cells can be
performed to determine
abnormalities.
 Other studies can be done
directly on the amniotic
fluid including
measurement of alphafetoprotein.
Amniocentesis Risks
 Complications are less than 1percent for the mother and
the fetus. Possible risks are:
 (a) Maternal.
 1 Hemorrhage.
 2 Infection.
 3 Labor.
 4 Inadvertent damage to the intestines or bladder.
 (b) Fetal.
 1 Death.
 2 Hemorrhage.
 3 Direct injury from the needle.
 4 Abortion.
 5 Premature labor.
Abortion Types
Spontaneous categorized as
Threatened, inevitable, incomplete,
complete or missed.
The most common complication of
pregnancy Spontaneous abortions can
be classified further as sporadic or
recurrent.
Incomplete abortion is the partial
expulsion of the products of conception
before the 20th week of gestation.
Spontaneous Abortions
A.
B.
C.
D.
Threatened
Inevitable
Incomplete
missed
Related Factors
1st Trimester pregnancy loss: Genetic
anomalies; hormonal abnormalities; and
infectious, immunologic, and
environmental factors.
2nd Trimester pregnancy loss: Anatomic
factors, Factor XIII deficiency and a
complete or partial deficiency of fibrinogen
are associated with recurrent spontaneous
abortions.
Threatened or Spontaneous Abortions
 A threatened
miscarriage or
spontaneous
abortion occurs in
approximately 10%
of pregnancies
between 7 and 12
weeks of gestation.
 Symptoms include
vaginal bleeding,
abdominal cramps,
and low back pain.

Missed Abortion – the clinical situation in
which a pregnancy is present but is no
longer developing normally. This can
manifest as an anembryonic gestation
(empty sac or blighted ovum) or with fetal
demise prior to 20 weeks' gestation. The
cervical os is closed.
Complete Abortion - When the
embryonic and placental components
have been expelled completely, it is called
a complete abortion.
Incomplete Abortion
Occasionally, some part of the gestational
tissue (embryo+early
placenta+membranes) may be retained
within the uterus during the process of
abortion while other parts may be
expelled.
Inevitable Abortion
If the treatment of threatened abortion is
not adequate or timely, the abortion may
become inevitable.
In this type of abortion, besides pain and
bleeding there is also dilation of the cervix
of the uterus and the process of expulsion
of the fetus cannot be stopped.