Transcript Slide 1

Antepartal Nursing
Ana H. Corona, MSN, FNP-C
Nursing Instructor
July 2008
Antepartal Nursing
• Period of pregnancy between conception
and onset of labor, used in reference to the
mother.
Pre-embryonic development
• Two week period that includes:
– Fertilization (conception)
– Implantation
• Miscarriage is a problem at this stage.
Embryonic Development
• 3-8 weeks
• major functions of this period:
– Cell multiples and grow
– Cells differentiate and grow
– By the end of week 8, all organ systems and
external structures are present.
• Primary germ layers develop
– Ectoderm (brain, nervous system)
– Medoderm (heart, bones)
– Endoderm (lungs, intestinal organs)
Embryonic Development
• Fetal membrane develops
– Amnion  inner lining  produces amniotic
fluid
– Chorion  outmost lining  chorionic villi
develop into placenta
• Amniotic fluid
– Function: shock absorber
– Amount: 1500ml or more
The Placenta
– Provides “food” and secretes hormones that
continue the pregnancy
– Circulation: Mom and baby’s circulation is
completely separate!
– Metabolic function
• Respiration
• Nutrition
• Excretion
• Storage
Umbilical Cord
• Lifeline to mom
– 2 arteries
• unoxygenated blood
– 1 vein
• oxygenated
– Wharton’s jelly
• Outer covering of umbilical cord (protects
cord)
Hormones
• Human chorionic gonadatropin (hCG)
• Supplied by corpus luteum
• Detected in mom’s blood 8-10 days after
conception
• Keeps corpus luteum active which
supplies:
– Estrogen
– Progesterone
• The placenta takes the place of the corpus
luteum around the 16th week of pregnancy
Hormones continue
• Human placental lactogen (hPL)
• Acts as a growth hormone
• Stimulates mom’s metabolism (mom needs extra
energy)
• Increases mom’s resistance to insulin (sends
more sugar to baby)
• Facilitates glucose transport across placental
membrane
• Stimulates breast development to prepare for
lactation.
Hormones
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Progesterone
Maintains endometrium
Decreases contractibility of uterus
Breast development
Estrogen (by 7 weeks)
Stimulates uterine growth and blood flow
between uterus and placenta
(uteroplacental)
• Breast development
An 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
Fetal Development
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Fetal period is 9 week to birth
Rapid growth and organ development
Some dates/terms related to fetal growth:
Integumentary
– Lanugo:
• Downy hair covering the body
• Appears at 13 weeks, disappears at 36 weeks
– Vernix caseosa
• Protects skin; most abundant in the creases (neck)
and flexor surfaces.
Fetal Development
• 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
Emotional Responses to Pregnancy
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Emotional responses to pregnancy
Ambivalence (contradictory feelings)
Grief
Self-centered; feels need to protect her body
Introversion or extroversion
Body image changes
Stress
Mood changes
Sexual desire changes
Couvade syndrome
– The father experiences the physical symptoms;
morning sickness or backache; the “empathy” belly.
Three Psychological tasks of
pregnancy
• 1st trimester: accepting the pregnancy
• 2nd trimester: accepting the baby
• 3rd trimester: preparing for parenthood;
nesting
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.
Pregnancy Tests
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Measure hCG (human chorionic
gonadatropin)
– 95-98% accuracy
– blood and urine tests
Estimated Date of Delivery
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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
Danger signs of pregnancy—call M.D.
• Sudden gush of fluid from vagina
• Vaginal bleeding (however, a little spotting can be normal
due to fluctuating hormones)
• Abdominal pain
• Apigastric pain (placenta may be tearing away from
uterine wall)
• Signs of toxemia/pre-eclampsia
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Dizziness, blurred vision, diplopia (double vision), see spots
Severe headache
Edema of the hands, face, legs, and feet
Muscular irritability, seizures
Oliguria (decreased urine output)
Dysuria (Painful or difficult urination)
Temp above 101 and chills (could mean sepsis)
Persistent vomiting
Absence of fetal movement (12 hours)
Prenatal Health Assessment
• hCG confirms pregnancy
• Complete health history
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genetic disorders
chronic illnesses
meds
obstetrical history
personal habits
• Complete physical exam
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VS
Weight/height
Pelvic exam
Assess size/shape of boney pelvis
Lab Tests
– Serology
– Hematocrit and hemoglobin
• N: 38-47% and 12-16 g/dl
– Sickle cell trait
– WBC
• N: 4,500-11,000
– ABO and Rh typing (indirect coombs)
• N: Rh neg
• Rationale: check for presence of Rh antibodies
– Rubella, Hep B, and Varicella titers
• N: Increased titer indicates immunity
– Urinalysis
• Abnormal color
• Protein, RBC’s, WBC’s
• Glucose: small vs. large amount
Subsequent Prenatal Visits
• Subsequent visits
– Physical assessment
– Measure fundal height
• Fetal heart tones
– Fetoscope
• 16 weeks, and almost always by 19 or 20 weeks
– Doppler
• 10-12 weeks
• Prenatal visits
– Q 4 weeks for 1st 28 weeks
– Q 2 weeks until 36 weeks, then
– Q 1 week until childbirth
Nutrition During Pregnancy
– Vitamin D and Folacin (folic acid) is increased
100%
– Iron is HUGE, need 433% due to that
pseudoanemia
• Pseudoanemia is a drop in hematocrit during
pregnancy. The increase in circulating blood volume
reflects an altered ratio of serum to RBC’s; plasma
volume increases by 50%, whereas the RBC count
increases by 30%.
• 2nd and 3rd trimesters need to increase
300 kcals/day
Fluids and Fiber
• Drink 8 glasses of fluid daily (water is best
fluid)
• No alcohol, limit caffeine
• Limit artificial sweeteners
• Fiber is good!
– Fights constipation
– Lowers cholesterol
Weight
• Recommended weight gain during
pregnancy:
– 25-40 lb
• 1st trimester
– gain 1 pound per month
• 2nd and 3rd trimesters
– gain 1 pound per week
• Watch for sudden large gains- could be
fluid
Physiological changes and discomforts in
pregnancy
• Uterus
• Hegar’s sign
– Softening of the lower uterine segment, a probable
sign of pregnancy that may be present during the 2nd
and 3rd month of pregnancy.
– The lower part of the uterus is easily compressed
between the fingers placed in the vagina and those of
the other hand over the pelvic area.
– Due to the softening of the uterus related to
increasing vascularity and edema and because the
fetus does not completely fill the uterine cavity at this
point, so the space is empty and compressible.
The Uterus
• Braxton Hick’s
– Changes in contractibility
– “False labor”; does not cause dilation and effacement of the
cervix.
• Effleurage (massage) and rest
• Ballottement
– A diagnostic maneuver in pregnancy. The fetus rebounds when
displaced by a light tap of the examining finger through the
vagina.
• Quickening
– Initial awareness of the movement of the fetus within womb
– Felt 16th-18th week
• 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
The Cervix
• Goodell’s sign
– Softening of the cervix (due to increasing
vascularity and edema)
• Chadwick’s sign
– Deep blue-violet color of the cervix and
vagina
• Mucus Plug “Operculum”
– The plug of mucus that fills the opening of the
cervix on impregnation
– Prevents bacteria from getting into uterus
The Ovaries
• No ovulation
• Corpus luteum increases until week 16;
then replaced by placenta
• Increased estrogen and progesterone
inhibit the release of LH and FSH.
The Vagina
• Chadwick’s sign
• Preparing for stretching during labor and birth:
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Connective tissue loosens
Hypertrophy
Lengthens
Luekorrhea
• White, thick secretions
• pH in vagina becomes more acidic
– fights off bacteria, but,
– promotes fungus/yeast infections
• bathe daily, wear absorbent cotton panties
• no crossing legs or douching
The Breasts
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Increase in fullness, heaviness, tenderness
Nipples darken
Thin and watery secretions
Montgomery’s tubercles
– Sebaceous glands in the areola surrounding the nipple of the
female breast
– Prevention of nipple cracking
• Blood vessels more visible
• Estrogen and progesterone cause these changes
• During 2nd and 3rd trimesters, most growth due to
mammary glands
– Wear a well fitting bra for breast tenderness
Cardiovascular
• Blood volume in mom increases by
1500ml or 40-50% above pre-pregnancy
levels.
– Changes due to hormones, meet woman’s
and growing fetus’ needs
– Cardiac output increases 30-50%
– Heart rate increases 10-15 BPM
– RBC’s increase, but cannot keep up with the
pace of the plasma volume; decreased
hemoglobin and hematocrit occur. This is
called pseudoanemia. Know it and love it.
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.
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).
• WBC are elevated in the 2nd and 3rd
trimester of pregnancy
– Could mask infection.
• Varicose veins
– Due to the compression of the iliac veins and
inferior vena cava by uterus; increases
venous pressure and decreases blood flow to
the legs.
• Interventions: Exercise, don’t cross legs; wear
support hose; keep legs and hips up; exercise feet.
Respiratory
• Increased tidal volume
• Increased oxygen consumption
• Slight elevation in respiratory rate (18-20 in
pregnancy; 12-20 is normal)
• Nasal stuffiness (1st trimester)
• SOB (not hubby, breath) 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.
Gastrointestinal
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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
GI continue
• Decreased motility  constipation (2nd half)
– Causes are due to the iron supplement most women
are on; displacement of the intestines.
• Interventions: Exercise qid, increase fluids/bulk, be regular
• Hemorrhoids (2nd half of pregnancy)
– Productions of relaxin
• Avoid constipation, prolonged standing, constricting clothing
• Use topical meds, warm soaks, anesthetic agents
• Flatulence (2nd half
– I don’t know why?
• Avoid gaseous foods, chew thoroughly, exercise.
Integumentary
• Increased skin pigmentation
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Melanocyte-stimulating hormone
Facial mask (melasma)
Linea ligra (dark line from pubis to umbillica)
Vascular spider nevi
Stretch marks on abdomen (striae gravidarum)
• Stretching ruptures small segments of connective tissue
– Rectus diastasis: Blue groove after pregnancy
• Abdominal wall separates
– Increased sweat glands (problems with perspirations
• Increased estrogen levels
– Palmar erythema
• Increased estrogen
– Use lotions
Renal
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Fluid retention: Aids with increased blood volume
Increased water absorption
Increased aldosterone
Increased diameter of uterers
Increased bladder capacity (urinary frequency and
urgency (symptoms disappear at 12 weeks, then reappear
3rd trimester)
– Estrogen and progesterone cause this
– Mom gets rid of own waste and fetus’; compression of the bladder
and uterers
– Ankle edema
• Decrease fluid intake in the evening, limit caffeine; empty bladder Q2h
to prevent distention and stasis; kegal exercises
• Avoid tight garments; elevate legs; do dorsiflexion of the feet while
standing or sitting for prolonged time
• May be slight (trace) spilling of glucose (glucouria)
Musculoskeletal
• 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 (late pregnancy)
– 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
Endocrine
• 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 continues
• Pituitary gland
– Oxytocin
– 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
Immune System
• Resistance to infection during each
trimester
• 1st trimester: 3-5 pounds
• 2nd trimester: 12-15 pounds
• 3rd trimester: 12-15 pounds