Chapter 4 Prenatal Care and Adaptations to Pregnancy

Chapter 4 Prenatal Care and Adaptations to Pregnancy

Pregnancy • It’s Temporary • 3 Phases – Antepartum • Before birth (prenatal) – Intrapartum • During birth – Postpartum • After birth

Major Goals of Prenatal Care • Ensure a safe birth for mother and child by promoting good health habits and reducing risk factors • Teach health habits that may be continued after pregnancy • Educate in self-care for pregnancy • Provide physical care • Preparents for the responsibilities of parenthood

Prenatal Care • Early Prenatal Care • Should begin as soon as pregnancy is suspected! • Complete history and physical – Identify problems that may affect the woman and her developing fetus – Ensure healthy pregnancy and delivery of healthy infant

Role of the Nurse During Prenatal Care • • • Collecting data from pregnant woman Identifying and reevaluating risk factors Educating in self-care Providing nutrition counseling Promoting the family’s adaptation to pregnancy

Components of Prenatal Health History • Obstetric – # and outcomes of past pregnancies; problems in mother or infant • Menstrual – LNMP • Contraceptive – Type used • Medical and surgical – Infections, surgical procedures, trauma that involved pelvis or reprod. • Woman’s family – ID any genetic or other factors that may pose a risk for the preg • Partner’s family • Woman and partner’s to identify risk factors • Psychosocial – Stability of lifestyle and ability to parent a child; cultural influences

Physical Examination • • • Evaluate woman’s general health Determine baseline weight and vital signs Evaluate nutritional status Identify current physical/social problems Determines the estimated date of delivery (EDD) • Evaluate the size, adequacy, and condition of the pelvis and reproductive organs • Assess for signs of pregnancy

Recommended Schedule of Prenatal Visits—Uncomplicated Pregnancy • Conception to 28 weeks – every 4 weeks • 29 to 36 weeks – every 2 to 3 weeks • 37 weeks to birth – weekly • More often if complications arise • High-risk patients will be scheduled on a week-to-week basis, depending on need

Definition of Terms • • • Gravida – pregnancy Nulligravida – woman never pregnant Primigravida – woman pregnant 1 st time Para – birth to one or more children after 20 weeks Primipara – woman who has given birth for the 1 st time Multipara – • Nullipara – • • woman given birth to two or more children woman never given birth Abortion – spontaneous or induced termination of pregnancy before viability (20 wks) Gestational age – of fetus, calculated by LNMP Fertilization age – of fetus, from date of conception Age of viability – fetus capable of living outside of uterus (20 weeks)

TPALM • TPALM System T – number of term infants born (after 37 wks) P – number of preterm infants born (before 37 wks) A – number of pregnancies aborted (spontaneously or induced) L – number of children now living M – multiple birth (optional)

Determining the Estimated Date of Delivery • Average pregnancy is 40 weeks (280 days) after first day of LNMP, plus or minus 2 weeks – Nägele’s rule • • Identify first day of LNMP Count backward 3 months Add 7 days Update year, if applicable

Trimesters • Pregnancy divided into three 13 -week parts • Important to know what occurs during each trimester to both woman and fetus • Helps provide anticipatory guidance • Identify deviations from the expected pattern of development

Presumptive Signs of Pregnancy • • Amenorrhea Nausea Breast tenderness and tingling Deepening pigmentation – Chloasma, or “mask of pregnancy” – Breasts (darkening of areolae) – Abdomen (linea nigra) • Urinary frequency and urgency – Increased blood supply to pelvic area, exerts pressure on the bladder • Fatigue and drowsiness • Quickening – Fetal movement felt by the mother – First perceived at 16 -20 weeks of gestation as a faint fluttering in the lower abdomen

Probable Signs of Pregnancy • Goodell’s sign • Softening of the cervix • Chadwick’s sign • Purplish or bluish discoloration of the cervix, vagina, and vulva cause by increased vascular congestion • Hegar’s sign • Softening of the lower uterine segment • Mc. Donald’s sign • Flexing the body of the uterus against the cervix • Abdominal enlargement • Braxton Hicks contractions • Ballottement (tap on cervix causes quick rebound) • Fetal outline • Abdominal striae • Positive pregnancy test

Positive Signs of Pregnancy • Only 3 – Audible fetal heartbeat • Detectable at 10 weeks by Doppler • Detectable at 18 -20 weeks by Fetoscope – Fetal movement felt by examiner • Second trimester – Ultrasound visualization of fetus • 4 -5 weeks gestation with 100% reliability • Routinely done around the 20 th week of gestation

Effects of Pregnancy on the Reproductive System • Cervix – Changes in color and consistency – glands in cervical mucosa increase – Mucus plug formed (seals the cervical canal and prevents infection) • Ovaries – Produce progesterone to maintain decidua (uterine lining) during first 6 -7 weeks of gestation until placenta can take over task – No egg production • Vagina – Increased blood supply causes it to have a bluish color – Vaginal secretions increase, p. H more acidic – Higher glycogen level which promotes Candida albicans (yeast) • Breasts – Tubercles of Montgomery secrete substance to lubricate nipples

Effects of Pregnancy on the Respiratory System • • Oxygen consumption increases by 15% Diaphragm rises ~4 cm (1. 6 inches) Causes ribs to flare Dyspnea can occur until fetus descends into pelvis (lightening) • Increased estrogen causes edema or swelling of mucous membranes of nose, pharynx, mouth, and trachea • Woman may complain of nasal stuffiness, epistaxis, and voice changes

Effects of Pregnancy on the Cardiovascular System • Blood volume increases by ~45% than prepregnant state • Increase provides for – Exchange of nutrients, oxygen, and waste products within the placenta – Needs of expanded maternal tissue – Reserve for blood loss at birth • Pulse rate increases by 10 to 15 beats/min • Orthostatic hypotension • Palpitations (increased thoracic pressure)

Supine Hypotension Syndrome

More Normal Effects • Gastrointestinal System – stomach and intestines are displaced – ^ salivary secretions – ^ appetite & thirst – constipation & hemorrhoids – Heartburn – glucose metabolism altered – gallbladder retains bile salts • Urinary System – excretes for two! – glycosuria & proteinuria are more common • retention leads to ^ UTI, – frequency • Integumentary & Skeletal Systems – sweat & oil glands more active (spider nevi) – posture changes • lordotic curve ^, backaches, ^ risk for falls.

Nutrition • Does she need to “eat for 2” ? • • Women of normal weight: 25 to 35 pounds Underweight women: 28 to 40 pounds Overweight women: 11 to 25 pounds Obese women: 11 to 20 punds • High correlation between maternal diet and fetal health • Pattern of weight gain: 4. 4 lbs first trimester, just under one lb. per week after that

Nutrition Requirements • Increase k. Cal by 300 per day – should include: • Protein— 60 g/day • Calcium— 1200 mg/day • Iron— 30 mg/day • Folic acid— 400 mcg (0. 4 mg)/day • Best Sources?

Special Nutrition Considerations • Pregnant adolescent – May need an additional 200 kcal/day in addition to the recommended 300 kcal/day for normal pregnancy in order to meet her own growth needs and that of the developing fetus • • • Sodium intake Vegetarian Pica Lactose intolerance Cultural preferences Gestational diabetes mellitus

Nutrition During Lactation • About 500 more calories than nonpregnant woman • Protein intake 65 mg/day • Continue ^ calcium & iron • 8 to 10 glasses of fluid (non-caffeine) • Omit foods that may cause fetal gastric upset

Nursing Guidance for Exercise • Goal of exercise during pregnancy should be maintenance of fitness, not improvement of fitness or weight loss • Combined with balanced diet is beneficial • Eating 2 to 3 hours before exercise or immediately after is recommended • Avoid marked changes in depth of water (such as scuba diving) and/or altitude • Avoid becoming overheated, increase fluid intake • Intensity of exercise should be modified based on the “talk test” • Elevated temperature: can impact fetal circulation and cardiac function

Travel During Pregnancy • Air travel generally safe • Avoid sitting for extended periods of time • Avoid locations that increase the risk of exposure to infectious diseases • Bring a copy of obstetric records • Obtain information about nearest health care facility • Encourage hand hygiene and dietary precautions • Provide the “recipe” for oral rehydration formula

Common Discomforts in Pregnancy • • • Fatigue Nasal stuffiness Nausea Heartburn Constipation Hemorrhoids EDEMA OF FACE IS NOT NORMAL ! • • • Vaginal discharge Backache Varicose veins Leg cramps Edema of the lower extremities • Dyspnea

Impact on Mother • According to Rubin, 4 maternal tasks the woman accomplishes during pregnancy – Seeing safe passage for herself and her fetus – Securing acceptance of herself as a mother and for her fetus – Learning to give of self and to receive the care and concern of others – Committing herself to the child as she progresses through pregnancy

Impact on the Father • Cultural values influence the role of fathers • Do not assume that a father is uninterested if he takes a less active role in pregnancy and birth • 3 Phases 1. Announcement phase 2. Adjustment phase (finances) 3. Focus phase (father figure)

Impact on Teen Moms • Lots of issues! • Must break the news to the family – often they wait until late in pregnancy • • Financial problems are common What about the relationship with baby’s father? Low self-esteem Drug and/or alcohol abuse? – Help the young woman finish the growing-up process while taking on the role of new mom • The pregnant adolescent must cope with 2 of life’s most stress-laden transitions simultaneously: – Adolescence & parenthood

Other Special Situations • The Older Couple – Usually adjust well because it is planned – Some issues: ^ multiple births, ^ birth defects • The Single Mom – Need emotional support from someone – Social acceptance? • The Single Dad – Reactions can be unpredictable – range from joy to rejection – Often rejected by mother

Prenatal Education • Should progress according to the nursing process: – Assess • the history and cultural needs – Diagnose • the knowledge deficit – Plan • the goals and priorities – Outcomes identification • clarifies expected outcomes – Teach (intervene) • the facts and rationales – Evaluate • knowledge gained and goals achieved

Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 33