maternal child health nursing module 3. objectives discuss pregnancy and fetal well-being discuss...
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Physiological changes of pregnancy
Uterus Hormones stimulate increased vascularity,
growth of new muscle and tissue (hyperplasia) and growth of existing muscle and tissue (hypertrophy)
Grows from 2 ounces (50 grams) to 2.2 pounds (1,000 grams); rises from low pelvis to base of ribcage
Enlargement a “probable sign” of pregnancy Hegar’s sign: softening of isthmus, also
“probable”
Physiological changes of pregnancy Cervix
Softening called “Goodell’s sign”, a probable sign of pregnancy
Ovaries Suppressed ovulation
Vagina Chadwick’s sign: blue, violet or
purple darkening of vagina, cervix, perhaps vulva
Physiological changes of pregnancy
Breasts Hypertrophy of mammary glands Increased vascularization, size,
pigmentation and changes in areolas and nipples
Colostrum forms in late pregnancy and may leak even before birth of baby
Need adequate support
Pregnancy: cardiovascular
FON p 792, box 25-5 10-15 bpm increase Blood pressure decreases slightly in second
trimester and returns to pre-pregnancy levels in third
Blood volume: 40%-50% increase H&H: decreased due to blood volume Increased RBC mass WBCs increase 2nd, 3rd trimesters Cardiac output: 30%-50% increase
Pregnancy: respiratory
FON p 792 box 25-6 Rate may increase 02 consumption 15%-20% greater Total lung capacity may be slightly
decreased In 3rd trimester, high fundal position may
make short of breath. Lightening refers to the baby’s drop into the pelvis before birth and often allows easier breathing
Pregnancy: musculoskeletal
Increased weight and outgrowth of womb alter mom’s posture
Exaggerated spinal curves (lordosis): aching, numbness, weak upper extremities
Estrogen and relaxin soften connective tissues, symphysis pubis and hip joints, allowing growth and change but also stretching supportive fibers
Pregnancy: gastrointestinal
Peristalsis slows Gas, constipation, abdominal distension and discomfort
Hemorrhoids from constipation, pressureIron supplements
May have higher cholesterol, cholelithiasis
Pregnancy: urinary
In first trimester, hormones and enlarging uterus irritate bladder -> frequency
Later, weight of uterus puts pressure on bladder
Kegels can help prevent urinary incontinence
Ureter and kidney dilation, bladder trauma can lead to increased infections
Pregnancy: integumentary
Darkened pigmentation Areola, nipples, vulva, perianus, linea alba
Linea nigra Darkening of areola may allow newborn to
better visualize target area during breastfeeding
Chloasma or butterfly Striae gravidarum: stretch marks Spider nevi, palmar erythema, hirsutism
Pregnancy: endocrine
Elevated estrogen, progesterone Triggered by HCG from corpus luteum
weeks 1-10 Maintained by placenta thereafter Prevent follicle-stimulating hormone (FSH),
luteinizing hormone (LH) and ovulation Prolactin, oxytocin
Pituitary gland origin Role in contraction (oxytocin),
breastfeeding (both)
Pregnancy: metabolism
Metabolism generally increases to meet energy needs of mother and fetus Affected by prenatal nutrient/energy state Maternal energy stores may be altered by
larger baby Mom needs up to 500 extra Kcalories,
depending on trimester or breastfeeding status Number of infants Underlying maternal needs
Signs of pregnancy
Presumptive – possibly mean pregnancy Amenorrhea Nausea, vomiting Frequent urination Breast changes Abdominal changes Quickening (16-18 weeks) Skin changes Chadwick’s sign
Signs of pregnancy
Probable (indicate high likelihood) Changes in reproductive organs (uterine
enlargement with softening of isthmus (Hegar’s sign), cervix (Goodell’s sign)
Ballottement (palpating presence of fetal by rebound)
Positive pregnancy tests (accuracy depends on collection technique)
Signs of pregnancy
Positive Visualization of fetus
X-ray or ultrasound Fetal movement observation by
health care provider Auscultation of fetal heartbeat
10-12 weeks by Doppler/ultrasound
18 weeks fetoscope
Psychological adaptation to pregnancy
Developmental tasks Pregnancy validation
Accepting the pregnancy (1-13 weeks) Fetal embodiment
Woman thinks of herself as “mom” and thinks of the fetus as part of herself (14-27 weeks)
Fetal distinction Mom prepares for delivery, thinks of fetus as
separate from herself (28 weeks – delivery) Role transition
Woman/wife/girlfriend -> Mom Partners’ tasks
Similar transition to parent role
Factors: psychological response Body image Financial situation Cultural expectations
Status, work Emotional security Support from significant others
Prenatal education and care
Prenatal care Begins before conception and continues
during pregnancy It may take weeks before a woman realizes
she’s pregnant Neurological development significant in first
few weeks Women not preventing pregnancy should
prepare for it
Anticipatory guidance self-care Pregnancy can be a great time to teach
health promotion, as women often are eager to protect their pregnancies Pap smears, breast self exams Nurses can help women separate fact and
fiction
Prenatal care: initial visit
History, demographics Estimated due date (EDD)
Nagele's rule Start with first day of LMP, count back 3
months, add 7 days Most babies born 10 days before or after this
date Useful if Mom’s menstrual cycle regular
Gestation calculation wheel Two wheels preprinted with dates and events
that can show EDD
Prenatal care: initial visit
Estimated due date (EDD) Woods Method or Nichols Rule
Primigravida (28-day cycle): LMP + 12 mo – 2 mo and 14 days
Multigravida (28-day cycle): LMP + 12 mo – 2 mo and 18 days
Cycles >28 days: EDD + (days in cycle – 28 days) = new EDD
Cycles < 28 days: EDD – (28 days-days in cycle) = new EDD
Mittendorf’s Observations
Prenatal care: initial visit
Fundal heightFrom weeks 18-
30, the height of the fundus in centimeters about equal to weeks’ gestation
Requires skill and experience for accuracy
Prenatal care: initial visit
Ultrasound High-pitched sound waves bounced off fetus and
tissues are received back by monitor and made into pictures (sonogram) or pattern (FHR monitor)
Doppler refers to a hand-held version that works similarly – picks up fetal heartbeat
Fetal heartbeat Detected by auscultation (fetal stethoscope),
Doppler or sonogram Quickening
Mom feels baby’s movements – starts about 16-18 weeks gestation
Prenatal care: physical exam Vital statistics
Are vital signs appropriate to trimester and general health?
Head to toe exam Gives baselines and also opportunities to
note changes Pelvic exam
Screens and tests may be done, structural abnormalities noted and reassurances given
Descriptive terms
Abortion : termination of pregnancy <20 weeks Spontaneous: unintentional loss of pregnancy
(miscarriage) Threatened: cramping, bleeding, spotting but
closed cervix and no tissue passed Inevitable: S/S, cervix opens Incomplete: S/S, dilation, tissues passed Complete: S/S, tissues and fetus passed, cervix
closes and bleeding stops Missed: fetus dies in utero but is retained, can
lead to sepsis Recurrent: two or more abortions
Descriptive terms
Induced abortion: intentional loss of pregnancytherapeutic: to preserve health of
motherElective: reasons other than health of
mother (fetal abnormality, social reasons)
Gravida: pregnancy Nulligravida: never been pregnant Multigravida: pregnant more than once
Descriptive terms
Para: birth Nullipara: never carried pregnancy past age
of viability Multipara: more than one pregnancy past
age of viability Preterm: born at 0-36/6 late preterm: 34-36/6 weeks Term: 37-41 weeks Post term: 42 or more weeks
Defining parity
FON p 788, box 25-5 G – gravidity: number of pregnancies,
including present one T – term births: number of births at or after
37 weeks’ gestation P – preterm births: number of births before
37 weeks A – abortions : number of pregnancies
interrupted before age of viability L – living children: not including present
pregnancy
Screening tests
Ultrasonography High-frequency sound waves gestational age Presence of normal fetal development or
abnormal developments Status and location of placenta and cord
Maternal serum alpha-fetoprotein screen (msAFP) Can indicate possible presence of chromosomal
problems (Down’s syndrome) if dates are correct
Maternal blood test
Screening tests
Chorionic villus sampling Genetic test of placental tissue Done at 8-12 weeks to avoid fetal injury
Amniocentesis Done around 16th week to determine fetal status May be done later to determine lung maturity
Non-stress test Fetal monitoring without added stimulus
Contraction stress test Fetal monitoring after stimulating contractions;
done after 32nd week
Screening tests
MRI Images soft tissues and blood vessels without
use of contrast medium Clearer than ultrasound
Biophysical profile Assessed fetal well-being by measuring
Non-stress test resultsFetal breathing movementsFetal muscle toneFetal movementsAmniotic fluid volume
Prenatal care: return visits
Subjective Objective
blood pressures Weight
Abnormal gain may mean increased fluid volume/edema
Uterine size Measurements smaller or larger than expected
for gestational age may indicate problem Edema
Visible edema may indicate rising blood pressures
Prenatal care: return visits
Fetal heartbeat Is it within normal range for gestational age? By term, normal range will be about 120-160
beats/minute Temporary increases/decreases normal with fetal activity
Labs Blood: anemia, infection, etc Urine: infection, glucose/protein spilling
Fetal position As baby nears 37th week of pregnancy, usually turns
head down Head-down position best for vaginal birth Leopold’s maneuvers
Leopold’s maneuvers
Abdominal palpation
Gently done – should not be uncomfortable or painful
With practice, examiner can determine location of fetal head, buttocks and body position
Discomforts vs warning signs Discomforts:
Cause Interventions Client education
Warning signs Cause Interventions Client education
Discomforts of pregnancy
FON p 792 Table 25-4 When evaluating complaints, consider stage
of pregnancy, history, related activities Shortness of breath: 1st trimester vs 3rd
Urinary frequency and urgency Normal or s/s possible UTI?
Braxton-Hicks contractions vs labor contractions
Edema Nausea/vomiting
Warning signs
FON p 790 Box 25-9 Visual disturbances Headaches Edema , rapid weight gain Pain s/s infection Vaginal bleeding, drainage Persistent vomiting
Warning signs (cont’d)
Muscular irritability or convulsions Absence or decrease in fetal movement
Kick count: fewer than 10 movements in 2 hours should be evaluated
Pregnancy: self care
Breast care Breast self-exam Support
Personal hygiene Increased perspiration Safety, mobility and the bathtub
Tub baths after cervical dilation Teaching about douching
Interrupted flora
Pregnancy: self care
Activity and rest Fatigue may limit Should be able to talk during exercise Safety for changing balance 3rd trimester changes Non-contact activities Changes in rest and sleep patterns
Pregnancy: self care
Nutrition What not to eat
Mercury (large predatory fish)Harmful bacteria and viruses
Raw or undercooked fish, shellfish, meats, eggs, poultry, processed meats, refrigerated pates and meat spreads
Pregnant women have less resistance to certain bugs like salmonella and listeria
Stick to pasteurized foods (dairy, juices)Unwashed fruits and vegetables
Large quantities of liver (too much vitamin A)
Pregnancy: self care
What not to eat (cont’d) Too much caffeine Any alcohol unless recommended by health
care provider Some herbal teas and supplements
Anticipatory guidance
Environmental hazards Discomforts Warning signs Nutrition Medications
Pregnancy categories
Childbirth education classes
Fear-tension-pain syndrome (Grantly Dick-Read)
Bradley (husband-coached) Lamaze (psychoprophyllaxis) Mongan HypnoBirthing (profound self-
relaxation) Hospital routine classes Pregnancy and newborn care classes
Assessment: fetal well-being
Ultrasound Transabdominal Endovaginal
Non-stress test Monitor
FAST & VST Measure fetal response to acoustic stimulation
Fetal biophysical profile Breathing, movement, tone, fluid assessment,
reaction
Assessment: fetal well-being
Fetal movements 10 movements in 2 hours indicates fetal
well-being Stimulate movement by eating, drinking
Biochemical assessment (maternal blood test) msAFP: chromosomal Estriol: development Human placental lactogen: developmental
Assessment: fetal well-being
Amniocentesis 1st trimester: detect chromosomal problems 3rd trimester: fetal health, maturity
Chorionic villi sampling 1st trimester: infection, cell abnormalities
Contraction stress test How fetus responds to contractions
Assessment: fetal well-being
Electronic fetal monitoring External
Ultrasound and transducer over abdomen Reflects FHR, cxns onto monitor screen Requires complex interpretation skills
Internal Attaches to fetal scalp May give clearer FHR pattern Connects to same monitor
Interpretation AWHONN
Hyperemesis gravidarum
Disorder distinct from “morning sickness” Vomiting causes electrolyte, metabolic,
nutritional imbalances and dehydration Requires evaluation and care
Rehydration, possibly IV nutrients Lab values reflect electrolyte, hydration
status Nursing care: IV, medications, educate
about disorder, medication side effects, fetal safety
Bleeding complications
Abortion/miscarriage Ectopic pregnancy
Fertilized egg implants out of uterus, usually in fallopian tubes
Life-threatening once fetus grows large enough to cause damage
Hydatidiform mole Fertilized egg growing without nucleus or
placenta Abnormally high HCG levels
Bleeding complications
Placenta previa Placenta growing too close to cervix Stress during pregnancy, labor and/or
delivery breaks blood vessels Fetal hypoxia
May resolve if uterine muscles pull placenta out of path as pregnancy grows
Indication for C-section delivery if present at time of delivery
Bright red blood, painless – after 20 weeks Sonogram: placenta location, fetal life
Bleeding complications
Abruptio placenta Premature placental separation
Partial or total Risk factors: trauma, chronic HTN, PIH, DM,
cocaine use, etc. S/S of total or severe partial: sudden severe
abdominal pain, rigid abdomen Monitor FHR Emergency C-section required Sonogram: placental location, fetal life Avoid vaginal/rectal exam
Bleeding complications
Disseminated intravascular coagulation (DIC) Disrupted clotting cascade: the body’s
response to bleeding overproduces clotting elements, tying up the supply in many tiny clots in small blood vessels. The clots obstruct blood flow and oxygenation of tissues, organs. The rest of the blood is free to bleed out
Underlying disorders: abruptio placentae, incomplete abortion, HTN, infection, prolonged retention of dead fetus
Bleeding disorders
DIC: Bleeding in lungs: dyspnea, chest pain,
restlessness, cyanosis, frothy and bloody mucus coughed up
Excess bleeding from small wounds/sites IV sticks, B/P cuff petechiae, shave nicks, IM sites,
catheter insertion, nosebleed, bleeding gums Labs: H&H (anemia), decreased fibrinogen and
platelet counts, prolonged PT, PTT times noted. Tx: IV blood and clot components, 02 by face
mask, woman on side Consider delivery
Bleeding disorders
DIC Monitor: V/S, FHR, bleeding, I&O (renal
status), status of underlying disorder and response to treatments
May prepare for emergency C-section, advanced neonatal support and NICU care/transport
Postpartum hemorrhage Excessive bleeding after delivery
Nursing care: bleeding complications
Stabilize bleeding IV fluids, fundal massage, treat hypovolemic
shock Prepare for surgery if necessary Pain management Recognize and get help in emergency Post-operative care Teaching considerations: fertility,
expectations, self-care, pregnancy progression
Pregnancy-induced hypertension
May occur during or after pregnancy Mild pre-eclampsia
140/90 B/P or increased >30 mm/Hg systolic/15 mm Hg/diastolic with previous normal B/P
Edema: hands, face, ankles Weight gain up to 3 lbs/month (2nd
trimester) and 1 lb/week (3rd trimester) Urine output at least 20.8 mL/hour (500
mL/24 hours)
Pregnancy-induced hypertension
Severe pre-eclampsia High B/P, edema also to abdomen and sacrum,
dramatic weight gain, increased albuminuria, urine output drops below 500 mL/24 hours
Eclampsia Seizures, coma
Magnesium sulfate May be used IV with careful control of amount Calcium gluconate should be kept at bedside
to treat toxicity
Pregnancy-induced hypertension
HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets Development of pre-eclamptic and
eclamptic states Pain in RUQ, lower chest, epigastric, severe
edema May have normal blood pressures Hypoglycemia very dangerous for mother May need blood transfusion Prepare for needs of preterm newborn
Nursing care: HTN
Monitor V/S, FHR, pregnancy status, medication side effects
Give antihypertensives, supportive care IV, pre/post C-section care
Do not give pain medication if unexplained pain present until assessment done by healthcare provider to avoid masking problem
Maternal diabetes mellitus
Type 1 or 2 before pregnancy Gestational diabetes develops during
pregnancy Effects of pregnancy on diabetes: poorer
glucose control, can only use insulin Effects of diabetes on pregnancy: UTIs,
poor blood/oxygen supply to baby, ketoacidosis, neonatal hypoglycemia, risk neonatal RDS, macrosomia
Maternal heart disease
Rheumatic heart disease Streptococcus infection scarring
Congenital heart defects Cardiac work increased
Mitral valve prolapse May or may not have symptoms
Peripartum cardiomyopathy Uncommon, seen in late pregnancy or early
postpartum S/S similar to CHF
Maternal heart disease
Hypertensive heart disease Rise in obesity in pregnant population Cardiac system unable to adjust to
pregnancy: edema, hypertension, cyanosis, tachycardia, irregular rhythms, chest pain, dyspnea, fatigue, decreased cardiac output, pulmonary edema, may hear abnormal lung sounds
Maternal phenylketonuria
PKU: a genetic disease in which phenylalanine cannot be broken down.
Recessive inherited disorder Phenylalanine can build up in brain and
nervous system -> delayed development, neuromuscular problems, small head size
“musty” odor noted on skin, breath, urine if untreated
Treatment involves strict diet High maternal levels can cause fetal defects