PRENATAL CARE

1. CHAPTER 50 PRENATAL CARE

2. PRECONCEPTION EDUCATION AND CARE • Immunizations and disease status • Medications • Smoking, Alcohol, and Illicit Drugs • Genetic Risk Factors • Male Contributions

3. PRECONCEPTION EDUCATION AND CARE • Immunizations and disease status • Rubella and Hepatitis B should be completed before a pregnancy is begun. • Testing for infectious diseases (syphilis, hepatitis, HIV, chlamydia, gonorrhea, HPV, herpes simplex , and group B streptococcus) • Medications-Avoid teratogens prior to and during pregnancy • Avoid Smoking, alcohol, and illicit drug • Smoking-negative effects on pregnancy, major risk factors and low-birth weight infants. • No safe level of alcohol intake during pregnancy • Illicit drugs may cause fetal anomalies or disorders, newborn may experience withdrawal syndrome. Discontinue prior to and during pregnancy, and after birth if breastfeeding. • Genetic risk factors-review family history, genetic counseling, discuss risks • Male contributions-lower birth weight for infants of smoking fathers • Smoking affects spermatogenesis and sperm mobility • Male exposure to occupational chemicals has been associated with spontaneous abortion, stillbirth, preterm delivery, and small-for-gestational-age babies

4. PREGNANCY • Condition of carrying an offspring within body. • Fertilization (or conception)–occurs when a sperm and ovum unite. • Zygote–the fertilized ovum. • Implantation(5th day after fertilization)–embedding of the fertilized egg into the uterine lining.

5. AMNIOTIC FLUID-anatomy • 98% water • Contains glucose, protein, sodium, urea, creatinine • Slightly alkaline • Approximately every 3 hours the fluid is replaced. • Chorionic villa at the base of the implanted fertilized ovum. Amnion is the fetal side of the placenta, so it is smooth and shiny.

6. AMNIOTIC FLUID-functions • Equalizes the pressure around fetus. • Cushions fetus from external compression. • Provides constant temperature and fluid for fetus to swallow. • Allows freedom of movement for fetus. • Lubricates membranes and fetus.

7. FUNCTIONS OF THE PLACENTA • Transport • Endocrine • Metabolic

8. THE PLACENTA • Membranous vascular organ connecting fetus to mother. • Produces hormones to sustain pregnancy. (5 Hormones-hCG, hPL, estrogen, progesterone, and relaxin) • Supplies fetus with oxygen and food. • Provides nutrition to and transports waste products from fetus. • Fully functional by week 12.

9. THE UMBILICAL CORD • Structure connecting fetus to placenta. • Has two arteries that carry deoxygenated blood and one vein which carries oxygenated blood. (This is the one instance in which arteries carry deoxygentated blood and a vein transports oxygenated blood.) • Surrounded and protected by Wharton’s jelly.

10. FETAL DEVELOPMENT • Preembryonic or germinal stage–first 14 days after fertilization. • Embryonic stage–week 3 through week 8. • Fetal stage–week 9 until 38 to 40 weeks or full term. • Pregnancy calculated from first day of mother’s last menstrual period. • Development occus in a systematic manner from head to toe (cephalo-caudal), from proximal to distal (close to body-farthest from body), and from general to specific.

11. FETAL DEVELOPMENT • First trimester –first twelve weeks • Second trimester-weeks 13-27 • Third trimester-weeks 28-40 • Pregnancy generally lasts 10 lunar (28days) months, 40 weeks, 280 days. It is calculated from the first day of the mother’s last menstrual period (LMP). Table 50-1 identifies stages of fetal development

12. SYSTEM DEVELOPMENT • Cardiovascular system • heart begins to beat on the 21st day • First system to function in the embryo • Most malformations develop in first 6-8 weeks • Blood cells develop day 14 • Gastrointestinal system • Begins to develop fourth week • Fetus begins to swallow by 20th week • Meconium (fecal material stored in the fetal intestines) begins to form about week 16) *There should be no passage of meconium in utero. If the fetus encounters hypoxic stress, the anal sphincter may relax and meconium may be passed, causing meconium staining of the amniotic fluid.* • Genitourinary system • Begins to form about week 3 • Begins to produce hypotonic urine about week 12 • Reproductive system • Begins to form about week 3 • Testes can be seen about week 7 and begin to descend into the scrotum about 30 weeks • Ovaries develop in the abdomen and stay in the pelvic cavity (All the ova a female will ever have are in the ovaries at birth) • Gender can be made through ultrasound by the end of week 12

13. SYSTEM DEVELOPMENT • Integumentary system-skin protects • Vernix caseosa protects the skin • Creases form on palms, fingers and soles during week 11 and become permanent by week 17 • Skin color is genetically determined • Lanugo appears during week 20, slowly disappears by birth • Tooth buds appear during week 6 (baby teeth) and week 10 (permanent teeth). • Mammary glands develop during the sixth week • Respiratory system • Lung buds week 6, bronchi forming by week 16 • Primitive lungs by week 23- not sufficient for gas exchange but lungs are capable of borderline support of extrauterine repsiration (age of viability- gestational age at which the fetus could live outside of the uterus is considered 24 weeks) • Surfactant production begins between week 20-24 and matures between weeks 35-37. • Immunologic system • Begins to develop between week 12 and 15 • Fetus produces small amounts of IgG, IgA, IgE before week 20 • Maternal IgG is actively transported actross the placenta to provide passive immunity against many infectious diseases

14. FACTORS AFFECTING FETAL DEVELOPMENT • Quality of sperm, ovum, genetic code • Teratogens- any agent, such as radiation, drugs, viruses, or other microorganisms, capable of causing abnormal fetal development) • Maternal malnutrition • Acute and chronic diseases • Alcohol and drugs • Smoking

15. Reproductive system Size of uterus Braxton Hicks contractions Hegar’s Sign Cardiovascular system Blood flow increases to uterus Heart rate increases by 10-15 BPM Cardiac Output increases by 30-50% B/P decreases, lowest during 2nd trimester, returns 3rd trimester Lower extremity edema, varicose veins of legs, vulva, or rectum Supine hypotensive syndrome-dizziness, clammy-pale skin, low b/p, decreased placental perfusion Blood volume increases by 30-50% and peaks at week 30 Small increase in RBC, greater increase in PLASMA (shows lower hematocrit 34-40% known as physiologic anemia of pregnancy) WBC increases by week 8 Plt, fibrin, fibrinogen, and coagulation VII, IX, X increases (increases the risk of venous thrombosis late in pregnancy) PHYSIOLOGICAL CHANGES OF PREGNANCY

16. PHYSIOLOGICAL CHANGES OF PREGNANCY • Respiratory system • Progesterone decreases airway resistance, allowing increase in oxygen consumption • Depth of respiration increases causing mild respiratory alkalosis, compensated by increased renal secretion of bicarb • Enlarged uterus pushes on diaphragm • Rib cage flares and the chest circumference expands to keep intrathoracic volume the same as when not pregnant • Estrogen causes edema and vascular congestion of the nasal mucosa • Musculoskeletal system • Relaxation of pelvic joints in preparation for delivery is caused by relaxin • Mother’s center of gravity changes due to increased size/weight of uterus • To compensate, the mother increases curve of the lumbosacral spine (lordosis) • May have waddling gait • Gastrointestinal system Urinary system • Nausea and/or vomiting “morning sickness” common early, usually disappear by week 12 • Smooth muscles relax causing delayed gastric emptying and decreased peristalsis • Enlarged uterus displaces stomach and intestines • Constipation • Relaxation of the cardiac spinchter may allow reflux of acidic gastric contents into esophagus, giving the mother heartburn

17. PHYSIOLOGICAL CHANGES OF PREGNANCY • Integumentary system • Skin pigment changes (nipples, areola, vulva, perineal area darken) • Linea nigra-pigmented line on the abdomen • Chloasma “mask of pregnancy” –darkening of forehead and around the eyes • Striae gravidarum “stretch marks”- reddish streaks found on the abdomen, thighs, buttocks, and breasts (may cause itching) • Endocrine system • APG (prolactin-initial milk production) • PPG (oxytocin-uterine contractions and ejection of milk from the breasts “let-down reflex” after delivery) • hPL-insulin antagonist-stress on islets of Langerhans-may show signs of gestational diabetes • Slight increase in size of thyroid, increase capacity to bind thyroxin(important for fetal neural development during first trimester) Causes increased PBI • Metabolism-increases • Mother must meet her needs as well as the needs of the developing fetus

18. PHYSIOLOGICAL CHANGES: REPRODUCTIVE SYSTEM • Uterus • Before pregnancy, it is a small, pear-shaped, thick-walled, muscular organ weighing 60g. At the end of pregnancy, it is a large, thin-walled organ weighing 1,000g. Its capacity increased from 10mL to 5L. • Cervix • Secretes a thick, sticky mucus -forms a plug • plug prevents microorganisms from entering through the vagina • During labor, cervix dilates-plug is expelled • Goodell’s sign (softening of the cervix) noted at 8 weeks • Chadwick’s sign (a purplish-blue color of the cervix and vagina)8weeks • Ovaries • Ovulation does not occur during pregnancy • Corpus luteum produces estrogen and progesterone until week 8 • Vagina • Estrogen causes loosening of connective tissue and increae in vaginal secretions • Acidic secretions prevent bacterial infections • Increased glycogen in cells may enhance growth of trichomonas vaginalis or candida albicans • Breasts • Enlargement, nipples more erect, areolas darken, Montgomery’s tubercles enlarge • Colostrum, antibody rich yellow fluid secreted last trimester & first 2-3 days after birth-gradually changes to milk

19. PHYSIOLOGICAL CHANGES: CARDIOVASCULAR SYSTEM • Blood flow increases. • Heart rate increases. • Blood pressure decreases. • Supine hypotensive syndrome may occur. • Physiologic anemia of pregnancy may occur.

20. PHYSIOLOGICAL CHANGES: RESPIRATORY SYSTEM • Progesterone decreases airway resistance. • The enlarging uterus presses upward on the diaphragm. • Estrogen causes edema and vascular congestion in the nasal mucosa.

21. PHYSIOLOGICAL CHANGES MUSCULOSKELETAL SYSTEM • Relaxin relaxes the pelvic joints. • Mother’s center of gravity changes. • May cause the woman to have a waddling gait. • See figure 50-7, view how the mother’s posture changes due to the growing fetus

22. PHYSIOLOGICAL CHANGES: GASTROINTESTINAL SYSTEM • Nausea and/or vomiting common before 12 weeks. • Delayed gastric emptying and decreased peristalsis. • Stomach and intestines are displaced. • Constipation and heartburn also common.

23. PHYSIOLOGICAL CHANGES: URINARY SYSTEM • Enlarging uterus presses on bladder in first and third trimester. • Ureters relax and dilate. • Glomerular filtration rate rises. • Glycosuria may develop if kidneys are unable to reabsorb glucose.

24. PHYSIOLOGICAL CHANGES: INTEGUMENTARY SYSTEM • Several skin pigment changes occur. • Linea nigra–pigmented line on the abdomen from umbilicus to pubis. • Chloasma–the “mask of pregnancy.” • Striae gravidarum– “stretch marks.”

25. PHYSIOLOGICAL CHANGES: ENDOCRINE SYSTEM • Prolactin is responsible for initial milk production. • Oxytocin causes uterine contractions and ejection of milk from the breasts. • Greater insulin production is required. • Thyroid often increases in size.

26. PHYSIOLOGICAL CHANGES: METABOLISM • The metabolic rate of the mother increases during pregnancy as demands of the growing fetus increase. • Mother must meet her own and the fetus’s nutritional needs.

27. PRESUMPTIVE SIGNS OF PREGNANCY see pg 1433 • Amenorrhea_______________________ ___________________________________ • Nausea and vomiting________________ ___________________________________ • Breast changes_____________________ ___________________________________ • Urinary frequency___________________ ____________________________________ • Excessive fatigue___________________ ___________________________________ • Abdominal enlargement______________ ___________________________________ • Quickening________________________

28. PROBABLE SIGNS OF PREGNANCY see pg 1433 • Goodell’s sign______________________ • Hegar’s sign_______________________ • Chadwick’s sign____________________ • Uterine enlargement_________________ • Braxton-Hicks contractions____________ • Increased pigmentation______________ • Ballottement_______________________

29. PREGNANCY TEST • Measures hCG in either urine or blood. • Blood is positive 8 days after conception. • Urine is positive 10–14 days after conception. • A pregnancy test is a probable sign of pregnancy.

30. POSITIVE SIGNS • Hearing the fetal heartbeat. • Visualization of the fetus through ultrasound. • Examiner feeling fetal movement.

31. DEVELOPMENTAL TASKS OF PREGNANCY • Pregnancy validation • Validate and accept pregnancy • Mood swings with hormonal changes • Fetal embodiment • Incorporates growing fetus into body image • Physical changes in body • Self-involvement, depression, or regression-having difficulty • Fetal distinction • Fetal movement felt-sees fetus as separate being • May daydream about baby and being a mother • Role transition • Time to prepare, childbirth classes, prepare nursery, explore parenting • nesting • Partners’ tasks • Accept they (as a couple) are pregnant • Accept changes physical and psychological in partner • Fetal distinction when hears heartbeat or feels movement

32. FACTORS AFFECTING PSYCHOLOGICAL RESPONSE • Body image • “fat” “ugly” “so good” “beautiful” • Feel a lack of control or limited • Financial situation • Anxiety, nutrition, medical care • Cultural expectations • Conflicts, expectations • Emotional security • Planned, secure • Unexpected, uncertainty • Support from significant others • Father/partner (couvade) • Siblings • Grandparents

33. GOALS OF PRENATAL CARE • Healthy, prepared mother, minimal discomforts • Potential problems or complications Identified as early as possible • Safe delivery of a healthy infant • Prepared father, partner • Prepared siblings and grandparents

34. PRENATAL CARE • Initial visit • Initial history • Estimating duration of pregnancy • Physical examination-client’s ht/wt, pelvic, fundal ht • Screening tests-see table 50-3 pg 1439 • Return visits

35. ANTICIPATORY GUIDANCE • Environmental hazards-chemicals, xray exams, heat from saunas/hot tubs • Discomforts of pregnancy-table 50-4 • Warning signs-table 50-5 • Nutrition- • well balanced diet, add 300kcalories a day when pregnant and 500kcalories when breastfeeding. • Add 2 servings milk and one meat serving • Multivitamin, calcium, iron, & folic acid • Pica may develop • Nutritional risk – • Adolescence, due to demands for own growth & pregnancy • Inadequate nutritional intake • Low income • Smoking, alcohol abuse, drug addiction • Depression • See pg 1443

36. Breast care Good support Keep clean Personal hygiene Daily bathing Activity/rest Regular physical activity Adequate rest Clothing Attractive, loose fitting Low heeled-shoes Employment Assess risks/benefits Travel Discuss with doctor Dental care Regular hygiene Avoid xrays Sexual activity NO NEED TO LIMIT IN A HEALTHY PREGNANCY!! Sexual desire may increase in 2nd trimester Consider position changes Allow men to discuss feelings SELF-CARE

37. NURSING DIAGNOSES • Activity intolerance • Anxiety • Breathing pattern, ineffective • Body image disturbance • Constipation • Fatigue • Family coping

38. NURSING DIAGNOSES (continued) • Fear • Fluid volume deficit • Excess fluid volume • Ineffective health maintenance • Health seeking behaviors • Ineffective coping • Risk for injury

39. NURSING DIAGNOSES (continued) • Deficient knowledge • Noncompliance • Imbalanced nutrition • Impaired physical mobility • Sexual dysfunction • Disturbed sleep pattern

40. NURSING INTERVENTIONS • Must be individualized and specific for the client. • Focused on teaching the client and providing anticipatory guidance.