MATERNAL AND CHILD NURSING (NUR 362) Reproductive Health Nursing NUR 324 Lecture 2 Part 1+2 Pregnancy LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) The Whole Period of Pregnancy Can Be Divided Into Three Stages (Trimesters ): Trimesters Weeks First trimester (early pregnancy) 1-12 Second trimester (middle pregnancy) 13-28 Third trimester (late pregnancy) 29- 40 LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) The Whole Period of Pregnancy Can Be Divided Into Three Stages (Trimesters ): LECTURE 3

Regular visits during pregnancy MATERNAL AND CHILD NURSING (NUR 362) Regular visits during pregnancy Prenatal visits Q 4 weeks for 1st 28 weeks Q 2 weeks until 36 weeks, then Q 1 week until childbirth LECTURE 3

Important Estimates of Pregnancy MATERNAL AND CHILD NURSING (NUR 362) Important Estimates of Pregnancy These are tools used in calculating the gestational age of the growing fetus and its Expected Date of Birth (EDB) Nagele’s Rule: Computation of expected date of birth. Formula: Last Menstrual Period in Day / Month / Year (+7) (-3) (+1) = Expected Date of Birth Johnson’s Rule: estimates the weight of the fetus in grams. LECTURE 3

The Diagnosis of the First Trimester MATERNAL AND CHILD NURSING (NUR 362) The Diagnosis of the First Trimester 1. History and symptoms A. Cessation of menstruation This is the first frequent symptom of pregnancy, although a few women may have slight bleeding after conception. But amenorrhea is not only due to pregnancy but also other reasons. Women of breast feeding may be pregnant before the recovery of menses. LECTURE 3

1.The history and symptoms MATERNAL AND CHILD NURSING (NUR 362) 1.The history and symptoms B. Nausea and vomiting Also called morning sickness because they occur upon arising. These symptoms appear one or two weeks after the period is missed and last until 10th to 12th week, its severity varies from mild nausea to persistent vomiting (e.g. Hyperemesis gravidarum). LECTURE 3

1.The history and symptoms MATERNAL AND CHILD NURSING (NUR 362) 1.The history and symptoms C. Urinary symptoms Increased frequency of urination is due to increased circulation associated with the effect of estrogen and progesterone on the bladder, combined with pressure by the gradually enlarged uterus on the bladder. LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) 2. Signs Breast changes Breast enlargement and vascular engorgement. Nipple and areola become blacker. Enlargement of the accumulated sebaceous glands of the areolas may be noted. LECTURE 3

Changes of the reproductive organs MATERNAL AND CHILD NURSING (NUR 362) Changes of the reproductive organs Vagina: The vaginal wall become discoloration as the pelvic blood vessel becomes congested. Cervix: Cyanosis and a gradual softening due to congestion. LECTURE 3

Changes of the reproductive organs MATERNAL AND CHILD NURSING (NUR 362) Changes of the reproductive organs Uterus: enlargement and softening. The isthmus of the uterus is also soft and can be compressed between the fingers palpating vagina and abdomen (Hegar’s sign). After the 12th week, the fundus of the uterus is usually palpable above the symphysis pubis. LECTURE 3

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C. Supplementary examination MATERNAL AND CHILD NURSING (NUR 362) C. Supplementary examination Pregnancy test The laboratory test for pregnancy are based on the identification of human chorionic gonadotrophin (hCG), which can be detected as early as 7-9 days after fertilization by high sensitive technique. The samples may be blood or urine. LECTURE 3

Basal body temperature (BBT) MATERNAL AND CHILD NURSING (NUR 362) Basal body temperature (BBT) A persistent elevation of BBT for longer than 18 days may be presumptive evidence of pregnancy. LECTURE 3

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MATERNAL AND CHILD NURSING (NUR 362) Ultrasonography There are trans-vaginal and abdominal Ultrasonagraphys. A gestational sac can usually be identified at 5-6 weeks after the beginning of the last period. LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) Ultrasonography Fetal heart beating can be detected by about 7th week and the fetus itself can be seen by about the 8th week. Doppler is also an ultrasound technique, which diagnoses the pregnancy by revealing the heart beating. LECTURE 3

The diagnosis of the second and the third trimester pregnancy MATERNAL AND CHILD NURSING (NUR 362) The diagnosis of the second and the third trimester pregnancy Symptoms Abdominal enlargement and fetal movement generally occurs after the 18th to 20th week of gestation. LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) Signs The uterus continues to enlarge Fetal movement (quickening) can usually be seen or heard after 18th week of gestation LECTURE 3

Height of the uterine top MATERNAL AND CHILD NURSING (NUR 362) Height of the uterine top xiphoid LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) Signs Fetal heart sound can be heard at rate varies from 120 to 140 beats per minute. The fetal body can usually be palpated by the 18th to 20th week of gestation unless the patient is too fat, the abdomen is tender or there is an excessive amount of amniotic fluid. LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) Fetal heart LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) Other Examinations X-ray. It is rarely used recently because the harmfulness to the fetus. Fetal electrocardiogram. A fetal electrocardiogram can first be recorded at about the 12th week of pregnancy. LECTURE 3

Different methods of pregnancy diagnosis MATERNAL AND CHILD NURSING (NUR 362) Different methods of pregnancy diagnosis LECTURE 3

Fetal lie & fetal Presentation MATERNAL AND CHILD NURSING (NUR 362) Fetal lie & fetal Presentation Fetal lie: the relationship between the long axis of the mother and the long axis of the fetus. (longitudinal lie and transverse lie) Fetal presentation: the portion of the fetus that descends into pelvis first. LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) LECTURE 3

MATERNAL AND CHILD NURSING (NUR 362) LECTURE 3

Nutrition During Pregnancy Special interest nutrients include: Vitamin B12 Folic Acid Iron Calcium Lecture 4

Recommended Weight Gain Underweight 28-40 lbs Normal weight 25-35 lbs Overweight 15-25 lbs Obese ~ 15 lbs Twins 35-45 lbs Triplets 50 lbs Prenatal weight gain within these ranges from the Institute of Medicine is associated with better pregnancy outcomes. Women with a BMI of <19.8 are at high risk of delivering a low birth weight infant if their weight gain is inadequate. Women who lose weight or gain less than 6 kg are more likely to deliver an infant that is small for gestational age. Excessive weight gain in women with a BMI > 26 also places the child at risk of being large-for-gestational age, which in turn, has been associated with excess body fat during childhood. Excessive weight gain contributes more to postpartum weight retention and less to fetal growth in normal weight and overweight women. Being overweight or underweight prior to pregnancy is associated with a greater risk of complications. Overweight and/or obese women are at a higher risk for medical complications like premature births, pregnancy-induced hypertension, gestational diabetes, and complications during labor. The recommended weight gain from conception to 20 weeks is only about 2-5 pounds total weight gain. From 20 weeks to delivery the average weight gain is 1 pound per week. Following these recommendations is associated with better pregnancy outcomes. Low weight gain in either the second or third trimester increases the risk of intrauterine growth retardation. Low weight gain in the third trimester is also associated with preterm delivery. Ask question: Where do those extra pounds go?.......Go to next slide 1 pound = about 0.45 kilograms Lecture 4

Normal Pregnancy Weight Gain Breast 1-1.5 lbs Blood 3-4.5 lbs Extra water 4-6 lbs Uterus 2.5-3.0 lbs Placenta/amniotic fluid 3.5-5.5 lbs Baby 7-8 lbs Fat stores 4-6.5 lbs Total 25-35 lbs Normal weight gain is important to the development of the baby. Impaired intrauterine growth and development of the infant may result in cardiovascular, metabolic, or endocrine disease in adult life. Maternal obesity increases the risk of gestational diabetes, cesarean deliveries, complications during delivery, congenital defects, and childhood obesity. Women who gain excessive amounts of weight are more likely to be overweight or obese after the baby is born. Lecture 4

Risks of Low Weight Gain Low weight gain in second or third trimester increases risk of intrauterine growth retardation Low weight gain in third trimester increases risk of preterm delivery Higher weight gains and greater postpartum weight retention is common if mother is still growing (teenager) The timing of weight gain during pregnancy is also important. Regardless of pre-pregnancy weight, women with low weight gain in the second or third trimester increases the risk of growth retardation of the fetus. Low weight gain in the third trimester is also associated with an increased risk of a preterm delivery. Lecture 4

Special Interest Nutrients Special interest nutrients include: Vitamin B12 Folic Acid Iron Calcium Lecture 4

Vitamin B12 Generally adequate amounts are obtained through animal products Fish, eggs, milk, meats, etc. Vegans that do not have any animal products in their diet need supplementation Works with folic acid in cell growth and is essential to the normal development of the infant In most cases, even modest amounts of fish, meat, eggs, or milk products, along with body stores, easily meet Vitamin B12 needs. A deficiency is rare in women who consume these foods. Strict vegetarians who don’t eat any foods of animal origin may need daily Vitamin B12 supplements to prevent a deficiency. A deficiency of vitamin B12 increases the risk of having a stillborn baby. Lecture 4

Folic Acid A supplement taken 1-3 months prior to conception and during first 6 weeks gestation reduces the risk of neural tube defects, cleft palate/lip 400 micrograms per day of synthetic folic acid needed per day (pregnant women and those of childbearing age) Needed for rapidly dividing cells, protein metabolism, and formation of red blood cells RDA Non-pregnant 400 micrograms per day Pregnant 600 micrograms per day (400 micrograms should be in synthetic form) Pregnant smoker up to 3-4 times more is required to reach the same blood levels The Public Health Service recommends that all women of childbearing age who are capable of becoming pregnant take 0.4 milligrams (400 micrograms) of folic acid daily. Lecture 4

Iron Needed for the formation of red blood cells 15 milligrams a day for woman during childbearing years recommended Iron supplement (30 mg/day) recommended for pregnant women Pregnant women who make wise food choices can meet most of their nutrient needs, except for iron. Iron supplements are recommended during the second and third trimesters of pregnancy. Low iron stores increase the risk for anemia. Lecture 4

Calcium Is used in the formation of fetal bones Will be absorbed from maternal bones if not enough calcium in diet Calcium absorption increases with Vitamin D Recommended amounts of calcium during Pregnancy 1200-1500 mg per day Due to increased absorption of calcium during pregnancy, calcium requirements during pregnancy are similar to the non-pregnant state for most pregnant women. However, pregnant adolescents and women at risk of pregnancy-induced hypertension might benefit from higher calcium intakes. Milk and some soy milks are fortified with vitamin D. Vitamin D is produced by exposure of the skin to sunlight. Women who do not consume milk products or calcium-fortified foods may need to take a calcium and vitamin D supplement. The inclusion of vitamin D in the supplement is especially important in northern locations during the winter, because exposure to sunlight may not be enough to maintain levels of vitamin D in the body. Lecture 4