N106

1. N106 Nursing Care of the Expanding Family

2. Outline • Issues & Trends • Menstrual Cycle • Conception • Fetal Development

3. Issues and Trends • Family Centered • Role of Nurse • Legal and Ethical • Cultural Influence • Client Teaching

4. Ovarian and Endometrial Cycles . Menstrual Cycle

5. Conception Sperm penetration of an ovum

6. the fertilized ovum from conception to implantation

7. Fetal Development • Ovum (pre-embryonic stage) – first 2 weekszygotemorulablastocyst • Embryonic stage – weeks 3 to 8 • Fetal stage – 8 weeks to birth

8. Figure 3–12 The actual size of a human conceptus from fertilization to the early fetal stage. The embryonic stage begins in the third week after fertilization; the fetal stage begins in the ninth week. Source: Adapted from Marieb, E. N. (1998).

9. Foramen ovale Ductus arteriosus Ductus Venosus Figure 3–11 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilical vein. After circulating through the fetus, the blood returns to the placenta through the umbilical arteries. The ductus venosus, the foramen ovale, and the ductus arteriosus allow the blood to bypass the fetal liver and lungs.

10. Outline • Terminology • Pregnancy dating • Signs of Pregnancy • Normal Physical Changes of Pregnancy • Psychological Changes • Nutrition • Medication Admin

11. Terminology • Gravida - # of times a uterus has held a pregnancy • Primigravida and Multigravida • Para - # of times a uterus held a pregnancy past 20 wks – Primiparity and Multiparity • Abortion – less than 20 weeks – miscarriage • Viability – past 24 weeks – Federal /State • Preterm – 20-37 weeks • Term – 38-42 weeks • Post term – after 42 wks • BOW – bag of waters • Bloody show – when cervix starts to dilate

12. Pregnancy dating • Nagele’s rule – add 7 days to first day of LMP and count back 3 months • McDonald’s rule – fundal height = week of gestation +/- 2-4 weeks • Sonogram – early US at 7-13 weeks after LMP most accurate for dating pregnancy

13. McDonald’s method is used to assess fundal height.

14. The TPAL approach

15. Signs and symptoms of pregnancy • Presumptive • Probable • Positive auscultation of FHTfetal movement felt by examinerfetus visualized by US

16. Physiologic changes with Common Discomforts • Reproductive • Cardiac • Respiratory • Gastrointestinal • Renal • Integumentary • Endocrine • Musculoskeletal • Neurological

17. uterus cervix vagina ovaries breast heart heart sound pulse blood volume cardiac output peripheral vasodilatation B/P blood components Reproductive and Cardiac

18. Vena caval syndrome.

19. Thoracic circumference Diaphragm Oxygen consumption Tidal volume Gingivitis and bleeding gums Heartburn Nausea Constipation Gallstones Respiratory and Gastrointestinal

20. Endocrine/ hormones • Human Chorionic Gonatropin (HCG) • Human Placenta Lactogen (HPL) • Relaxin • Estrogen • Progesterone • Oxytocin • Prolactin

21. Physiologic changes • Renal • Integumentary chloasmalinea nigrastriae gravidarum • Musculoskeletallordosisdiastasis recti • Neurological

22. Psychological changes • First trimester – disbelief & ambivalence focus: self-centered R/T physiologic changes • Second trimester – introspective focus: baby; fetus becomes real • Third trimester - pride and anxiety focus: labor / delivery & baby’s well-being

23. Nutrition • Affects size of baby • Wt gain 3.5 lbs during 1st trimester than 1 lb/wk • Total 25-35 lbs • Folic acid – prevent neural tube defects • Iron supplements – 30 mg daily • Additional 300 cal/day • Lactating requires 2700-2800 cal/day and 3000cc of fluids /day • Post partum 2200 to 2300 well balanced

24. Healthful eating Largest portion - grains, rice, bread, and pastaSmallest portion - fats, oils, and sweets,

25. Medication Administration • Most medications cross placenta to fetus • Medications during PG can harm fetus • Pain meds in labor cross placenta • Newborn meds are Vitamin K & Erythromycin • PostPartum meds are oxytocics & analgesics

26. Prenatal Education • Early pregnancy classes • Childbirth Preparation classes • Methods of childbirth BradleyLamaze

27. Assessment during Pregnancy • Prenatal appointmentsmonthly first 6 monthsq 2 weeks in 7 & 8 monthweekly last month • Vag exam initial visit and 2-3 wks a EDC • Assessment each visitwt, B/P, P, R, fundal ht, FHT

28. Danger Signs of Pregnancy • Vaginal Bleeding • Rupture of membranes • Swelling of the fingers, face, eyes • Headache • Visual disturbances • Persistent abdominal pain • Chills and fever • Painful urination • Persistent vomiting • Change in fetal movements

29. Fetal Assessment

30. LabsAlpha-fetoprotein screening (MSAFP) Ultrasound glucose tol test (GTT) AmniocentesisL/S ratio and PG Nonstress test (NST) Contraction stress test (CST) Ante-partal Fetal Assessment

31. Amniocentesis

32. Reactive NST Figure 14–5 Example of a reactive nonstress test (NST). Accelerations of 15 bpm lasting 15 seconds with each fetal movement (FM). Top of strip shows FHR; bottom of strip shows uterine activity tracing. Note that FHR increases (above the baseline) at least 15 beats and remains at that rate for at least 15 seconds before returning to the former baseline.

33. Nonreactive NST Figure 14–6 Example of a nonreactive NST. There are no accelerations of FHR with FM. Baseline FHR is 130 bpm. The tracing of uterine activity is on the bottom of the strip.

34. CST Figure 14–8 Example of a positive contraction stress test (CST). Repetitive late decelerations occur with each contraction. Note that there are no accelerations of FHR with three fetal movements (FM). The baseline FHR is 120 bpm. Uterine contractions (bottom half of strip) occurred four times in 12 minutes.

35. Complications Antepartal • Gestational Diabetes • Hemorrhage - abortion • Hyperemesis Gravidarum • PROM – premature rupture of membranes • Preterm labor • Pregnancy Induced Hypertension PIH • Substance abuse • Infections – TORCH

36. Gestational Diabetes • Develops during pregnancy • Risk factors: obesity, <25 yrs, family history, chronic hypertension, large birth wt, previous gestational diabetes • Screening: between 24-28 weeks a 50 g, 1 hour glucose challenge test (GCT) if 140 or above recommend 3 hour oral glucose tolerance test (OGTT) • Increased for PIH and fetal macrosomia

37. Therapeutic Management • Diet – 2200 -2400 calories per day • Exercise – Moderate exercise for active women, regular activity for sedentary women • Blood glucose monitoring – if FBG >95 or PPBG >120 start on insulin • Fetal surveillance – 28 weeks ultrasound, amniocentesis, NST, CST, BPP

38. Insulin Therapy • First trimester – insulin needs lower • Second and Third trimester – increased insulin due to placental hormones • During labor – based on blood glucose levels • Post Partum – insulin not needed due to abrupt cessation of placental hormones

39. Hyperglycemia fatigueflushed hot skindry mouth, excessive thirstfrequent urinationrapid respheadachedepressed reflexes Hypoglycemiashakinesssweatingcold, clammy skinpallordisorientationirritabilityheadachehungerblurred vision Teaching Self-Care – S&S

40. Spontaneous Abortion • Incidence • Threatened • Inevitable/imminent • Complete • Incomplete • Missed • Recurrent

41. Threatened The cervix is not dilated, and the placenta is still attached to the uterine wall, but some bleeding occurs.

42. Imminent The placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has increased.

43. Incomplete . The embryo or fetus has passed out of the uterus, but the placenta remains.

44. Ectopic Pregnancy • Pregnancy outside the uterine cavity • S & S of PG • Rupture at 6-12 weeks • Severe pain • Vaginal tenderness and shock • Treatment – salpingectomy if rupturedlinear salpingostomy if tube is intact • Care – assess for bleeding and pain, prepare for surgery, emotional support

45. Various implantation sites in ectopic pregnancy. The most common site is within the fallopian tube, hence the name “tubal pregnancy.”

46. Complications of pregnancy Hyperemesis gravidarum

47. Hyperemesis Gravidarum • Persistent, uncontrolled vomiting • Cause unknown may be high hCG or psychological problem – hydatidiform mole • S&S: Nausea and vomiting, weight loss, fatigue, signs of dehydration, signs of starvation • TX: antiemetics, IV fluids, quiet environment ,sedation, counseling • Care: Allow to verbalize

48. Reducing nausea and vomiting • 1) small portions q 2-3 hours • 2) attractively presented • 3) eliminate strong odors • 4) low-fat foods, • 5) easily digested carbohydrates, such as fruit, breads, cereal, rice and pasta • 6) soups and liquids taken between meals • 7) sitting upright to reduce gastric reflex

49. Complications of Pregnancy Premature Rupture of Membranes

50. Premature rupture of membranes (PROM) • Diagnose – Nitrazine or fern test • Gestational age - more than 36 wks deliver if – ripe cervix, abnormal FHT, meconium stained fluid, possible infection, abnormal presentation Tx – walking, Prostaglandin • Gestational age between 32-35 weeksdeliver if – mature fetal pulmonary status, abnormal FHT, possible infection • Strategies – tocolytics, steroids, antibiotics