N107 Essentials of Nursing Care: Reproductive Health

1. N107 Essentials of Nursing Care: Reproductive Health Chapter 3: Needs of the Childbearing Family: Antepartal

2. Chapter Objectives • Understand the S&S of Pregnancy • ID the physiological changes that take place during pregnancy • Know the discomforts of pregnancy and know appropriate interventions to help with discomforts • Describe psychosocial changes in the expectant family

3. Chapter Objectives • Know what a nurse could tell a patient to promote self-care during pregnancy • Know when a pregnancy is at risk due to chronic health problems • Be knowledgeable of different medications used during pregnancy • Be familiar with diagnostic tests and possible medical interventions used during pregnancy • Be knowledgeable about the process of conception and implantation

4. Chapter Objectives • Know about embryonic/fetal development • Understand the details and importance of the umbilical cord and placenta • Describe factors that influence fetal growth and well-being • Be knowledgeable of diagnostic test used during pregnancy

5. Signs and Symptoms of Pregnancy • Antepartal – beginning of pregnancy to beginning of labor • Pregnancy made possible by the hypothalamic stimulation of the anterior pituitary hormones: follicle stimulating hormone (FSH), which stimulates follicle growth within the ovary, and luteinizing hormone (LH) which affects ovulation • 3 categories of S&S of pregnancy • Presumptive – those felt by the woman • Probable– those changes observed by the examiner • Positive Signs – those signs credited only to the presence of the fetus • Presumptive and probable could have other causes for their occurrences. • Positive signs are completely objective and cannot be caused by other pathologic states

6. Signs and Symptoms of Pregnancy • Presumptive Signs • Referred to as subjective • Earliest is usually amenorrhea (in those with regular cycles) • Morning sickness (can occur any time during day) • Due to elevated hCG levels and changed CHO metabolism • hCG is biological marker on which all pregnancy test are based • hCG can be detected in the blood as early as 6 days after conception (or about 20 days since LMP) • hCG secreted by trophoblast (outer layer of uterus) • Excessive fatigue • Urinary frequency • Enlarging uterus putting pressure on bladder • Symptoms decrease during 2nd trimester as uterus becomes an abdominal organ • Reappears during 3rd trimester as fetus descends into pelvic region

7. Signs and Symptoms of Pregnancy • Presumptive Signs (Cont’d) • Breast changes (enlargement, tenderness & tingling) • May occur prior to missing 1st menses • Growth due to hormones and growth of secretory ductal system. Tenderness and tingling most noticeable around nipple area • Quickening (fetal movements) • Week 14 – 16 in a multigravida woman • Week 18 or later in primagravida woman

8. Signs and Symptoms of Pregnancy • Probable Signs (Objective) • Observed through inspection or palpation • Changes in pelvic organs caused by increased vascular congestion • Only physical signs detectable with the first 3 months of pregnancy • Goodell’s sign – softening of cervix • Chadwick’s sign – deep red to purple bluish coloration of the mucous membranes of cervix, vagina and vulva • Hegar’s Sign – softening and compressibility of the lower uterine segment • McDonald's Sign – easy flexion of the fundus on the cervix • Braun von Fernwald’s Sign – Softening and slight fullness of the fundus near the area of implantation • Piskacek’s Sign – a soft lateral bulge with corneal implantation

9. Signs and Symptoms of Pregnancy • Probable Signs (Cont’d) • Ultrasound or fetal stethoscope • Uterine soufflé (bruit) – sound of maternal blood flowing through uterine arteries to placenta • Synchronous with maternal pulse • Funic soufflé – caused by fetal blood coursing though the umbilical cord • Synchronous with fetal heart tone • Fetal heart tone – actual heartbeat of fetus

10. Signs and Symptoms of Pregnancy • Other manifestations • Facial chloasma, melasma (mask of pregnancy) • Blotchy, brownish hyperpigmentation of the skin over cheeks, nose & forehead • Accentuated by sun exposure • Linea nigra – pigmented line down midline of abdomen • Striae gravidarum – stretch marks • Abdomen & buttocks Ballotment – examiner pushes up against cervix with 2 fingers to elicit a passive rebound fetal movement. ID’d between week 16 - 18

11. Signs & Symptoms of Pregnancy • Positive signs of pregnancy (definitive) • Visualization of fetus via US • Weeks 5 – 6 • Fetal heart tones heard at 6 weeks • Fetal heart tones heard by doppler at 10 -17 weeks • Fetal heart tones heard by stethoscope at weeks 17 – 19 • Fetal movements palpated at weeks 19 - 22

12. Physiological Changes During Pregnancy • Uterine Growth • Response to hormonal stimulus • High levels of estrogen and progesterone • Fundal height • Uterus enlarges at predictable rate. Measurement used to estimate the duration of pregnancy • Palpable at symphis pubis between week 12 – 14 • Palpable at umbilicus level at week 22 – 24 • At level of xyphoid process at term • Lightening – fundal height decreases weeks 38 – 40 as fetus descends and engages the pelvis

13. Physiological Changes During Pregnancy • Braxton Hicks contractions – irregular painless contractions of the uterus that occur intermittently throughout pregnancy starting soon after 4th month • Contractions stimulate the movement of blood through the placenta and promote oxygen delivery to the fetus. • Increase in frequency during late pregnancy. • Not true labor contractions

14. Physiological Changes During Pregnancy • Breast Changes • Result of increased levels of estrogen and progesterone • Development of mammary glands is complete by mid pregnancy • Lactation does not occur until birth of baby and placenta • Estrogen levels decrease • Colostrum • Creamy, white to yellow pre-milk fluid expressed from nipples as early as week 16

15. Physiological Changes During Pregnancy • Skin • Changes thought to occur due to increased estrogen, progesterone and alpha-melanocyte-stimulating hormone levels • Sweat and sebaceous glands usually hyperactive • Angiomas (telangiectasias) - Vascular spider nevi may appear on the chest, neck, face, arms and legs. Of no clinical significance and disappear after pregnancy. Due to increased levels of estrogen • Palmar erythema – color changes which occur over the palmer surface of the hands. Due to increased levels of estrogen and progesterone

16. Physiological Changes During Pregnancy • Hormones • Thyroid – moderate enlargement; increased vascularity • T4 levels decrease in response to increased estrogen • Oxygen consumption and basic metabolic rate (BMR) increase as much as 20-25% secondary to fetal metabolic activity • Parathyroid • Slight secondary hyperparathyroidism • Plasma parathormone are elevated • Coincides with fetal skeletal growth • The increased requirements for calcium and Vitamin D

17. Physiological Changes During Pregnancy • Pituitary Prolactin • Prolactin responsible for initial lactation • Posterior Pituitary • Releases oxytocin which promotes uterine contractility and the stimulation of milk ejection from the breasts • Releases vasopressin which results in increased BP by vasoconstriction and has an antidiuretic effect to maintain water balance.

18. Physiological Changes During Pregnancy • Adrenals Glands • Secrete increased levels of aldosterone by the early part of 2nd trimester in a protective response to the increased sodium excretion associated with progesterone. • Cortisol production increases which increases production of insulin but also increases mother peripheral resistance to insulin • This decreases mother’s ability to use her own insulin, thus ensuring ample supply of glucose for fetoplacental unit

19. Physiological Changes During Pregnancy • Pancreas • Responsible for insulin production to lower glucose levels • The fetus requires ample amount of glucose for growth and development • The islet of Langerhans (beta cells) are stressed to meet the mother’s increased needs for insulin • Deficiency produces S&S of gestational diabetes

20. Physiological Changes During Pregnancy • Hormones Required to Maintain Pregnancy • hCG • Secreted early in pregnancy • Stimulates progesterone and estrogen production by the corpus luteum to maintain pregnancy until placenta has developed sufficiently enough to support it • Human Placental Lactogen • Increases the amount of circulating free fatty acids for maternal metabolic needs and decreases maternal metabolism of glucose to favor fetal grown

21. Physiological Changes During Pregnancy • Hormones Required to Maintain Pregnancy • Estrogen • Stimulates uterine development to provide a suitable environment for the fetus while helping to develop the ductal system of the breast in preparation for lactation • Progesterone • Maintains the endometrium, inhibiting spontaneous abortion • Helps development of acini & lobules of the breasts in preparation for lactation • Relaxin • Inhibits uterine activity • Diminishes the strength of uterine contractions • Aids in the softening of the cervix • Has long-term effect of remodeling collagen

22. Physiological Changes During Pregnancy • Other Hormones • Prostaglandins • Lipid substances that occur in high concentrations in female reproductive tract • Present in the endometrium or lining of uterus during pregnancy • Present in the tissue around the ectopically located fertilized ovum during pregnancy • Exact functions unknown • Decreased levels may contribute to HTN and pregnancy induced HTN (PID)

23. Physiological Changes During Pregnancy • Other Hormones • Mucus Plug • Result of secretions from endocervical glands • Plug seals the endocervical canal & prevents invasion of bacteria or other substances into uterus • Secretions favor the growth of yeast organisms  monilasis, a common vaginal infection during pregnancy

24. Physiological Changes During Pregnancy • Metabolic • The expectant mother must meet her own tissue replacement needs, those of the fetus, and those preparatory for labor and lactation • Recommended weight gain • Woman of normal wt = 25 – 35 pounds • Overweight woman = 15 – 25 pounds • Underweight woman = 28 – 40 pounds • Avg increases • 3.5 – 5 pounds 1st trimester • 12 – 16 pounds 2nd trimester • 10 – 13 pounds 3rd trimester

25. Physiological Changes During Pregnancy • Metabolic (Cont’d) • Water retention is a basic chemical alteration of pregnancy; caused by an increased level of steroid sex hormones, lowered serum protein and increased intracapillary pressure permeability. The extra water is needed for the fetus, placenta, and amniotic fluid, in addition to the mother’s increased blood volume, interstitial fluids, and enlarged organs.

26. Physiological Changes During Pregnancy • BMR (Basic Metabolic Rate) is increased by 15-20% by term • Reflects increased oxygen demand of uterine-placental-fetal unit as well as oxygen consumption from increased maternal cardiac work • High risk for heat intolerance • During early pregnancy may report feeling hot & fatigued after slight exertion. • Greater need for sleep

27. Physiological Changes During Pregnancy • Cardiovascular System • Growing fetus pushes heart upward and left • Blood volume increases throughout pregnancy; about 45% increase in 3rd trimester • Cardiac hypertrophy • Increase in blood volume and cardiac output • Both plasma and erythrocytes increase • Systemic Vascular Resistance & Pulmonary Vascular Resistance decrease enabling circulation to adapt to higher blood volume while maintaining normal vessel pressures

28. Physiological Changes During Pregnancy • CV System (cont’d) • CO increases due to increased tissue demand for oxygen • CO higher when lying in lateral recumbent position; lower when in supine position • CO increased with labor and birth • Organ systems receive additional blood flow according to their increased workload • Heart rate increases about 10-15 BPM • Palpitations and dysrhythmias may occur. • If no underlying pathology, no treatment required

29. Physiological Changes During Pregnancy • CV (cont’d) • BP considerations • Same position, same arm, correct cuff size • Dependent edema, varicose veins, hemorrhoids due to uterus compressing iliac veins and inferior vena cava  increased venous pressure and reduced blood flow to lower extremities • More prone to postural hypotension

30. Physiological Changes During Pregnancy • CV (cont’d) • Venal Caval Syndrome (Supine hypotensive syndrome/autocaval compression) • Enlarging uterus putting pressure on the vena cava when in supine position • Interferes with blood return • Significant decrease in BP with symptoms • Dizziness, pallor, clamminess • Corrected by placing in left side-lying position

31. Physiological Changes During Pregnancy • CV (cont’d) • Blood volume increases 40-50% • Peripheral vasodilation maintains normal BP • Total erythrocyte volume increases about 30% in women who receive iron supplementation; only 18% in those without iron supplementation • Plasma increase > RBC production  decrease in Hematocrit (psuedoanemia) • Elevated erythrocyte production increases need for iron, because iron is necessary for the formation of hemoglobin (oxygen carrying component of erythrocytes)

32. Physiological Changes During Pregnancy • CV (cont’d) • Higher risk for hypercoagulation (clot formation) • Various clotting factors increase during pregnancy • Fibrinolytic activity (dissolving actions of clots) decreased • Venous stasis DVT formation

33. Physiological Changes During Pregnancy • Respiratory System • Maternal oxygen requirements increase • Increase in BMR • Need to add tissue mass in uterus and breast • Fetus requires oxygen and needs to dispose of carbon monoxide • Elevated estrogen levels • cause ligaments of rib cage to relax which allows increased chest expansion • Cause an increase in vascularization in upper respiratory tract •  capillary congestion  nasal & sinus congestion, nosebleeds, changes in voice, changes in respiratory center (a lower threshold for CO2) • During advanced pregnancy, increased awareness of the need to breathe evident; some complain of SOB; some complain of dyspnea at rest

34. Physiological Changes During Pregnancy • Gastrointestinal (GI) • During pregnancy • Appetite increases, intestinal secretions reduced, liver function is altered, absorption of nutrients is enhanced, colon is displaced, GI motility decreases • Bowel sounds decrease, nausea and vomiting are common • An increase in blood flow and pressure on pelvic areas (later in pregnancy) places pregnant woman at increased risk for hemorrhoids

35. Physiological Changes During Pregnancy • GI (cont’d) • Early in pregnancy • Morning sickness (with or with vomiting) • Can occur at any time of day/night • Usually appears 4-6 weeks & subsides after 1st trimester • Triggered by sight or odors • Appetite may be decreased • hCG has depressant effect on appetite • Hyperemesis (severe vomiting) • Should not continue beyond 1st trimester • Should not be accompanied by fever, pain or weight loss • If either occurs, medical intervention necessary

36. Physiological Changes During Pregnancy • GI (cont’d) • Morning sickness rarely has harmful effects on mother or fetus • Rising levels of estrogen cause selective increase in vascularity and connective tissue proliferation (gingivitis) and causes gums to bleed • Hiatal hernia • Can occur after 7th month of pregnancy • Usually due to displacement of stomach

37. Physiological Changes During Pregnancy • GI (cont’d) • increased progesterone production causes: • Esophageal regurgitation, slower emptying of stomach and reverse peristalsis from decreased tone and motility of smooth muscles • Increase in water absorption from colon  constipation • Increased risk for gallstones

38. Physiological Changes During Pregnancy • Genitourinary System(GU) • Affected by pressure from bladder, increased blood flow & increased filtration in the tubules • 1st trimester • Bladder irritability, nocturia, frequency due to growing uterus placing pressure on bladder • 2nd trimester • Bladder is pulled up and out of pelvis into abdomen • 3rd trimester • Due to pressure from presenting part, impaired drainage of blood and lymph, bladder more susceptible to infection and trauma

39. Physiological Changes During Pregnancy • GU (cont’d) • Susceptibility to infection • Greater glucose content • More alkaline (pH increased) • Stagnated urine (takes longer to reach bladder) • Renal function • Glomerular Filtration Rate (GFR) increases • Renal Plasma Flow (RPF) increases • Least efficient when in the supine position • Most efficient in lateral recumbent position • Side lying increases renal perfusion, increases UOP, and decreases edema • Due to vena cava syndrome and compression of aorta, CO drops as does renal perfusion

40. Physiological Changes During Pregnancy • GU (cont’d) • Renal system can overstressed by excessive sodium intake or restriction or by using diuretics • Extra sodium is needed for both mother and fetus during pregnancy • Selective renal tubular reabsorption maintains sodium and water balance regardless of changes in dietary intake and losses • Severe hypovolemia and reduced placental perfusion are consequences of using diuretics during pregnancy

41. Physiological Changes During Pregnancy • GU (cont’d) • Glucose reabsorption is impaired • Glucosuria varies in time and degree • Proteinuria does not usually occur in normal pregnancy except during labor or after birth • The amount of protein excreted does not indicate the severity of renal disease • Values of 1+ protein (per dipstick) is acceptable

42. Physiological Changes During Pregnancy • Musculoskeletal • Alterations in posture and gait due to weight gain • Spinal curvatures are re-aligned • Lordosis develops • An increase in curvature of spine • The head is held Lordly, like a King to maintain balance • Pelvic joints become more mobile and relaxed due to increased estrogen & other circulating hormones (relaxin) • This also allows an increase in pelvic dimensions preparing for labor and birth • Abdominal walls stretch and loose tone

43. Discomforts of Pregnancy • First Trimester • Breast Changes • Urgency/Frequency • Languor & Malaise/Fatigue • Nausea/Vomiting (Morning Sickness • Ptyalism (Excessive Salivation) • Psychological Effects; Mood Swings; Mixed Feelings

44. Discomforts of Pregnancy • Second Trimester • Skin changes • Spider Nevi (Telangiectasias • Palmar Erythema • Pruritus • Palpitations • Supine Hypotension (Vena Cava Syndrome) • Orthostatic Hypotension

45. Discomforts of Pregnancy • 2nd Trimester (Cont’d) • Food Cravings • Heartburn/Indigestion • Constipation • Flatulence/Bloating/Belching • Varicose Veins • Leukorrhea • Headaches

46. Discomforts of Pregnancy • 2nd Trimester (Cont’d) • Carpal Tunnel Syndrome • Acrodysesthesia (Numbness/Tingling of Fingers • Round Ligament Pain/Tenderness • Joint Pain/Backache/Pelvic Pressure Hypermobility of Joints

47. Discomforts of Pregnancy • Third Trimester • Respiratory Discomforts • Insomnia • Psychological Responses/Mood Swings Mixed Feelings/Anxiety • Hyperemia, Hypertrophy, Bleeding Tendencies • Return of GU Symptoms

48. Discomforts of Pregnancy • 3rd Trimester (Cont’d) • Perineal Discomfort and Pressure • Braxton Hicks Contractions • Leg Cramps • Marked Edema • Nasal Stuffiness

49. The Expectant Family • Psychosocial Changes • Pregnancy represents a turning point in the affected individuals’ lives • Support system • Altered routines and family dynamics • Financial issues • Will expectant mother work during pregnancy? • Will expectant mother work after baby is born? • Who will provide childcare if mother does work? • Will housework & care for the child at home be divided?

50. The Expectant Family • Emotional Responses • Ambivalence, introversion, mood swings & changes in body image • Ambivalence may be related to many things (See page 73) • Indirect evidence of ambivalence • c/o prolonged or frequent depression • Physical discomforts • Body image • Excessive mood swings • Difficulty accepting life changes resulting from pregnancy