mcn power point

8/10/2019 MCN Power Point

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Physiologic and Psychologic Changes During

Pregnancy:

1. Presumptive Signs- those that are least indicative of pregnancy,taken as single entities, they could easily

indicate other conditions

- largely subjective

a. Breast changes

b. Nausea and vomitingc. Amenorrhea

d. Frequent urination

e. Fatigue

f. Uterine enlargementg. Quickening

h. Linea nigra

i. Melasma

j. Striae gravidarum


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MELASMA


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Sstri

STRIAE GRAVIDARUM


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2. Probable Signs-

a. Serum laboratory test

hCG- a hormone created by the chorionic villi inthe placenta.

*Reaches a measurable level (50mIU/ml) 7-

9 days after conception

*Peaks at about 100mIU/ml but by the 60th

-80thday after this it declines again and is

no longer detectable in the serum.

b. Chadwicks Sign- color change of the vagina from pink

to violetc. Goodellssign- softening of the cervix

d. Hegarssign- softening of the lower uterine segment


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CHADWICK S SIGN WITH LEUKORRHEA


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e. Sonographic evidence of gestational sac

f. Ballotement- when lower uterine segment istapped on a bimanual

examination, the fetus can be

felt to rise against theabdominal wall.

g. Braxton Hicks contractions- periodic

uterine tighteningh. Fetal outline felt by the examiner


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3. Positive Signs

a. Sonographic evidence of the fetal outline

b. Fetal heart audible

* 18-20 weeks of pregnancy audible by anordinary stethoscope 120-160 bpm

c. Fetal movement felt by the examiner- 20th-24th

weeks AOG


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PsychologicaL Changes During Pregnancy

1. Social Influences

2. Cultural Influences

3. Family Influences

4. Individual Influences


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The Psychological Tasks of Pregnancy:

First Trimester: Accepting the pregnancy- spends time

recovering from shock of learning they are

pregnant and concentrate on what it feels like

to be pregnant.

Second Trimester: Accepting the baby- moves through

emotions such as narcissism and introversion as they

concentrate on what will happen and what it feels

like to be pregnant.

Third Trimester: Preparing for parenthood


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EMOTIONAL RESPONSES TO PREGNANCY:

1. Ambivalence- interwoven feelings of wanting and not wanting

2. Grief

3. Narcissism-reaction to self-intrusion; self centeredness

4. Introversion vs. Extroversion

5. Body Image and Boundary

Body Image- the way your body appears to yourself

Body Boundary- a zone of separation you perceive between yourself

and objects or other people


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6. Stress

7. Couvade syndrome- men experiencing physicalsymptoms such as nausea,

vomiting etc. to some degree or

even more intensely than their

partners do.

8. Emotional lability

9. Changes in sexual desire

10. Changes in the expectant family


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PHYSIOLOGIC CHANGES OF PREGNANCY

A. Reproductive System

A1. Uterine Changes- increase in length, depth, widthweight, wall thickness and

volume

12thweek- uterus is firm and sphenoid under the

abdominal wall just above the

symphysis pubis

20th

-22nd

week- fundus is at the level of the umbilicus

36thweek- fundus is at the level of the xiphoid process

38th-40thweek- lowers


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*Increase of blood flow to the uterus- pre-pregnancy- 15-20

ml/min by the end of pregnancy- 500-750 ml/min 75 % of

which is going to the placenta

*Uterus is more anteflexed, larger, softer to touch than usual

*6th week of pregnancy- lower uterine segment just above thecervix becomes soft (HegarsSign)

* 12thweek of pregnancy- Braxton Hicks contractions begin

*16

th

-20

th

week of pregnancy- Ballottment may be noted*20th-24thweek- fetal outline may be palpated


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A2. Amenorrhea- due to suppression to FSH

Other possible reasons: uterine infection,

climate change, worry, chronic illness such assevere anemia or stress

A3. Cervical Changes- becomes vascular and edematous

- becomes soft in consistency (GoodellsSign) due to the high estrogen level

Operculum- mucus plug which acts to seal out bacteria during

pregnancy and to help prevent infection in the

fetus and membranes.


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A4. Vaginal Changes

Estrogen- causes the vaginal epithelium and underlyingtissue becomes hypertrophic and enriched

with glycogen.

*Changes in color from pink to dark violet (Chadwicks

Sign)

*pH of vaginal secretions decreases from 7 to 4-5 due to

the action of Lactobacillus acidophilus and Doderlein

bacillus

A5. Ovarian Changes


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B. Breast Changes

*Estrogen- causes a feeling of fullness, tingling sensation and

tenderness* Hyperplasia of the mammary alveoli

* Areola darkens and its diameter increases from about 3.5 cm

to 5 or 7.5 cm (1.5-2-3 inches)

*There is formation of secondary areola, increase in vascularity,

blue veins become prominent over the surface of the breast,

sebaceous glands of the areola (Montgomery tubercles)

enlarge.

*16th week of pregnancy- colostrums is expelled from thenipples in a form of thin watery fluid which is high in protein

and considered to be a precursor of breast milk


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SYSTEMIC CHANGES

A. Integumentary System

A1. Striae gravidarum- pink or reddish streaks appearing on the sides of the

abdominal wall and sometimes on the thighs.

A2. Diastasis- separation of rectus muscle, bluish grooveat the site of the

separation

*At the 28thweek AOG the depression of the umbilicus becomes

obliterated and smooth.A3. Linea nigra- dark line running from the umbilicus to the symphysis pubis

A4. Melasma/ chloasma or the mask of pregnancy

A5. Vascular spiders- small, fiery-red branching spots commonly found on

the thighs.

A6. Increased perspiration

A7. Palmar erythema- due to increased estrogen level in the body


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B. Respiratory system

* NO change in vital capacity

* Tidal volume is increased by 30-40 %*Respiratory rate is increased by 1-2 cpm/minute (18-

20cpm/min)

* Residual volume- decreased by 20 %

* Plasma PCO2- decreased by 27-32 mHg

* PlasmaO2- increased to 104-108 mmHg

* Blood pH- increased to 7.40-7.45

*Respiratory minute volume- increased by 40%* Expiratory reserve- decreased by 20%

*Increased ventilation


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D. Cardiovascular System

D1. Blood volume increases by at least 30% and

possibly as much as 50%

Normal blood loss for NSVD- 300-400 ml

Normal blood loss for CS- 800-1000 ml

* The increase in blood volume peaks at the 28th-32nd

week

D2. Iron needs- 800 mg during pregnancy

True anemia- either a hemoglobin concentration of

less than 11.5 g/100 ml or a Hct of less than 30 %

D3. Folic acid- helps in preventing neural tube defects


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D4. Heart- increase in cardiac output by 25-50%

HR increases by 10 bpm

*Innocent heart murmurs may be heard r/t altered heart

position and decreased blood viscosity.* Palpitations are also common due to the stimulation of

SNS

D5. Regional blood flow- impaired to the lower extremities

D6. BP- does not normally rise

D7. Supine hypotension syndrome- light headedness,faintness and palpitations

Interventions: lie on the left side and rise from bed slowly


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D8. Blood Constitution

*Increase in circulating fibrinogen (as much as

50 %) due to increased level of estrogen

*Increase in clotting factors VII, VIII, IX, and X

and platelet count

*Increase in WBC* Decrease in total protein which may be a

cause of ankle edema

*Increase in body lipid by 1/3 and cholesterolby 90-100%


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E. Gastrointestinal system

*Slow intestinal peristalsis and emptying of the

stomach

*heartburn, constipation andf flatulence is common

*Nausea and vomiting is common due to increase l

level of hCG and progesterone or as a

systemic reaction to the increased level of estrogenand decreased level of glucose.

*Subclinical jaundice may be experienced

*Hypertrophy of the gumlines and possible bleeding

of the gingival tissue*Decreased pH in the mouth


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F. Urinary System

*Glomerular filtration rate- increased by 50 %* Renal plasma flow- increased by 25-80 %

* BUN- decreased by 25%

* Plasma creatinine level- decreased by 25%

* Renal threshold for sugar- decreased to allowspillage

* Bladder capacity- increased by 1000 ml

* Diameter of ureters- increased by 25%

* Frequency of urination- increased in the 1sttrimester and the last two weeks of

pregnancy to 10-12 times/day


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ANKLE EDEMA


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G. Skeletal System

* Ca and Ph needs are increased

* There is softening of pelvic ligaments and joints which

causes the waddling gait

H. Endocrine System

*Placenta- produces hCG, estrogen, progesterone, hPL,

relaxin and prostaglandinsEstrogen- causes breast changes and palmar erythema

Progesterone- maintains endometrium inhibiting uterine

contractions;aids in the preparation of the

breasts for lactation.Relaxin- secreted primarily by the corpus luteum

- inhibits uterine contractions; softens the cervix

and the collagen in joints


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hCG- secreted by the trophoblast in the placenta

stimulates estrogen and progesterone synthesis until the

placenta can take its role.hPL- also known as human chorionic somatomammotropin hormone

- serves as the antagonist to insulin, freeing fatty acids for

energy

Prostaglandin- affects smooth muscle contractility to such an

extent they may be the trigger that initiates labor at

term

*Pituitary gland- halted FSH and LH release because of increased

levels of estrogen and progesterone

- late in pregnancy it produces oxytocin

- produces prolactin which prepares the breasts for

lactation


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*Thyroid and parathyroid glands- glands enlarges and

BMR increases by 20%

*Protein based-iodine, butanol-extractable iodine,and thyroxine are all elevated as well.

* Adrenal glands- increased function due to increased

level of corticosteroid and

aldosterone.

- aids in suppressing inflammatory

reaction , helps in regulating theglucose metabolism in the woman

Increase in aldosterone aids in promoting sodium

reabsorption


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Estimating Pelvic Sizepelvic pelvimetry and fetal

sonography

*Estimation should be done at least by the 24thweek ofpregnancy because by this time there is danger that the fetal

head will reach a size that will interfere with safe passage

and birth if pelvic measurements are small

TYPES OF PELVES:

1. Android

2. Anthropoid

3. Gynecoid

4. Platypelloid


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Common Measurements:

1. Diagonal conjugate- distance between the anterior

surface of the sacralprominence and the anterior

surface of the inferior margin of

symphysis pubis

-considered to be the most usefulmeasurement for the estimation

of pelvic size.

-suggests the anteroposterior

diameter of the pelvic inlet* Measured while the client is in a lithotomy position

>12.5 cm- adequate for childbirth (average fetal head

is 9 cm)


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3. Ischial tuberosity diameter- distance

between the ischial tuberosity or thetransverse diameter of the outlet. Made

at the medial or lowermost aspect of the

ischial tubersities at the level of the anus(11 cm)


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LEOPOLDS MANEUVER


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LEOPOLDS MANEUVER


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DISSCOMFORTS DURING THE FIRST TRIMESTER

1. Breast Tenderness

2. Palmar Erythema

3. Constipation

4. Nausea Vomitting and Pyrosis

5. Fatigue

6. Muscle cramps- due to decreased Calcium and increased Phosphorus

7. Hypotension

8. Varicosities- Let client rest in Simsposition or with legs raised for 15-20

min 2x a day


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9. Hemorrhoids- modified Simsposition or knee chest position

for 10-15 min.

-apply Witch hazel or cold compress to relieve

pain

10. Heart palpitations

11. Frequency of urination- reduce caffeine intake and practiceKegelsexercise

12. Abdominal discomfort

13. Leukorrhea- a whitish vaginal discharge or increased vaginal

secretions brought about by increased

estrogen level and blood supply to the vaginal

epithelium and cervix.


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DISCOMFORTS DURING MIDDLE AND LATE

PREGNANCY

1. Backache- Pelvic rocking and tilting exercise

2. Headache

3. Dyspnea

4. Ankle edema

5. Braxton Hicks Contractions


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Danger Signs of Pregnancy:

1. Vaginal bleeding

2. Persistent vomiting

3. Chills and fever

4. Sudden escape of clear fluid from the

vagina

5. Abdominal or chest pain


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6. PIH

6a. rapid wt. gain (over 2 lbs/week in the 2nd

trimester and 1lb/week in the 3rdtrimester)

6b. Swelling of the face and the fingers

6c. Flashes of light or dots before the eyes6d. Dimness or blurring of vision

6e. Severe continuous headache

6f. decreased urine output

7. Increased or decreased fetal movement


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VARICOSITIES


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HEMORRHOIDS


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ELASTIC STOCKINGS


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LEFT SIDE LYING POSITION


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SQUATTING


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TAILOR SITTING


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PREVENTION OF EXPOSURE TO

TERATOGENSTeratogen- any factor, chemical

and physical thatadversely affects the

fertilized ovum,

embryo or fetus.


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Maternal Infection

TO- TOxoplasmosis

* a protozoan infection spread through uncooked

meat, and through handling cat stool in soil or cat

litter.

* Effect to fetus: CNS damage, hydrocephalus,

microcephaly, intracerebralCalcification and retinal deformities.

*Dx: Serum analysis

*Tx: sulfonamides- but this can lead to increased

bilirubin in the newbornPyrimethamine- antiprotozoal drug but an

antifolic acid drug at the

same time


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R Rubella


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R- Rubella

*otherwise known as German measles

*Effect to fetus: deafness, mental or motor

challenges, cataract, cardiac

defects (PDA or pulmonary

stenosis), retarded

intrauterine growth,thrombocytopenic purpura,

dental and facial clefts.

*Dx. Rubella titer- > 1:8 suggests immunity< 1:8 susceptible to viral

invasion

Greatly increased- suggests recent infection


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RUBELLA

C- Cytomegalovirus (CMV)


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C- Cytomegalovirus (CMV)

* a member of the herpes virus family

*MOT: Droplet

* Effect to the fetus: neurologically

challenged (hydrocephalus, microcephaly

spasticity with eye damage [optic atrophy

and chorioretinitis]) deafness, chronic liverdisease, skin covered with large petechiae

(blueberry muffin lesions)

*Dx. Isolation of CMV antibodies in theserum

* No treatment


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CHILD AFFECTED WITH CMV

H- Herpes simplex


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H Herpes simplex

*1sttrimester- congenital anomalies or

spontaneous miscarriage

*2nd or 3rd trimester- premature birth, intrauterinegrowth retardation and

continuing infection

Other viral infection

RubeolaCoxsackievirus

Mumps

Varicella (chickenpox)

Poliomyelitis

Influenza

Viral hepatitis

Parvovirus B19- causative agent of Erythema infectiosum (5th


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Parvovirus B19 causative agent of Erythema infectiosum (5

dise. ) attacks the RBC

-associated with fetal death in early pregnancy

and anemia and congenital heart defect in late pregnancy

Syphylis- caused by Trepenoma pallidum

*causes damage to the fetus after the 16th-18thweek of

intrauterine life when the cytotrophoblastic layerof the

placental villi has atrophied* causes deafness, cognitive challenge, osteochondritis and

death

*Dx. VDRL and rapid plasma regain- remains high for more than

2oo days*infants born of a mother with syphilis- remains to be (+) up to

3 mos. even if the dse has

already been treated.

*Tx. Benzathine penicillin


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SYPHILIS


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Lyme disease- Borrelia burdorferi

*Tx. Tetracycline or doxycycline-

not safe for pregnant womenPenicillin- drug of choice


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TRICHOMONIASIS & VAGINITIS


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AMELIA


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PHOCOMELIA

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