Maternal Adaptation During Pregnancy Chapter 11 & 12 Mary L. Dunlap MSN, Fall 2015

Presumptive Signs Amenorrhea- 4wks. Nausea and vomiting- 4-14 wks. Fatigue- 12wks. Urinary frequency- 6-12 wks. Breast enlargement- 6wks Breast tenderness -3-4wks Fetal Movement (Quickening)- 16-20 wks. Uterine enlargement- 7-12 wks. Hyperpigmentation- 16wks.

Probable Signs Chadwick’s sign- 6-8 wks. Goodell’s sign- 5 wks. Hegar’s sign- 6-12 wks. Ballottement- 16-28 wks. Abdominal enlargement- 14 wks. Braxton Hicks contractions 16-18 wks. Positive pregnancy test- 4-12 wks.

Positive Signs Auscultation of Fetal heart tones Palpation of Fetal movement Visualization by Ultrasound

Uterus Size increases to 20 times that of non-pregnant size Weight from 70 g to 1,100 to 1,200 g at term Walls thin to 1.5 cm, but strengthened with fibrous tissue Ascent into abdomen after 1st 3 months

Uterus Blood flow 500 ml/min Braxton Hicks contractions occur throughout pregnancy Mucous plug forms in cervix to protect the fetus

Uterus Fundal Height Uterus measured from the top of the symphysis pubis to the top of the fundus in cm Fundal height by 20 weeks’ gestation at level of umbilicus; 20 cm; reliable determination of gestational age until 36 weeks’ gestation

Cervix Cervical Softening(Goodell’s sign) due to vasocongestion Mucous plug formation Increased vascularity(Chadwick’s sign) Ripening about 4 weeks prior to birth

Vagina Chadwick sign bluish purple hue due to increased vascularity Thickening of mucosa Increased vaginal discharge Acidic environment prevents bacterial infection Yeast infection (candida) common during pregnancy-glycogen rich

Breast Enlarged & tender Increased alveoli Areola darken due to melanotropin Tubercles of Montgomery enlarge and secrete a substance to lubricate the nipple for breastfeeding Striae gravidarum (stretch marks) Colostrum can be expressed by 3rd trimester

Gastrointestinal System Gums Ptyalism ( excessive salivation) Reflux Heartburn Nausea & vomiting Constipation Hemorrhoids

Gastrointestinal System Stomach and intestine-Delayed stomach emptying, increase water absorption causes constipation Gallbladder-Predisposed to stone formation- due to decrease in muscle tone and increase in emptying time

Management of Nausea and Vomiting Plenty of fluids, avoid caffeine and carbonation Frequent, small meals, high protein, and carbohydrates Eat crackers to avoid an empty stomach Avoid noxious odors Limit stress

Management of Heartburn Avoid foods that cause symptoms Spread liquids throughout the day Stay upright after meals Don’t eat close to bedtime, extra pillows OTC calcium containing antacids Stop smoking

Management of Constipation Ample fluid intake Decrease cheese in the diet Diet high in fiber Stool softeners Exercise

Management of Hemorrhoids Maintain healthy and regular bowel habits Increase fiber to prevent straining Sitz bath Compresses soaked with witch hazel Reduce external hemorrhoids if possible

Cardiovascular System Heart Displaced up and to the left Hypertrophy due to increased blood volume, cardiac output Systolic murmurs common

Cardiovascular System Increase in blood volume (50% above prepregnant levels) Increase in cardiac output; increased venous return; increased heart rate Slight decline in blood pressure until midpregnancy, then returning to prepregnancy levels

Cardiovascular System Increase in number of RBCs; plasma volume > RBC leading to hemodilution (physiologic anemia) Increase in iron demands, fibrin & plasma fibrinogen levels, and some clotting factors, leading to hypercoagulable state

Supine Hypotension Syndrome Pressure from enlarged uterus decreases venous return from lower extremities Orthostatic hypotension

Respiratory System Diaphragm rises 4 cm Chest circumference increases by 2-3 in Increased tidal volume Increased oxygen consumption Congestion secondary to increased vascularity

Eyes, Ears, Nose, Throat Blurred vision Nasal stuffiness, congestion Increased mucus production Epistaxis Changes in tone and quality of voice

Urinary System Kidneys and ureters enlarge Ureters compressed at pelvic brim especially the right ureter Increased pyelonephritis UTIs common

Urinary System Increased blood flow to the kidneys by 50-80% Increase in GFR 40-60% starting the 2nd trimester Urinary frequency & incontinence Bladder tone relaxed, capacity and pressure increase

Management of Frequent Urination Most common early in pregnancy Notify HCP if pain or burning occur Kegel exercises- help to strengthen muscles

Musculoskeletal System Lordosis -compensatory curvature to help maintain balance→ back pain Ligaments soften due to Relaxin→ Pelvic discomfort & Unsteady gait Edema Led cramps

Management Round Ligament Pain Felt on one or both sides of the lower abdomen Good body mechanics Support belts Reassurance

Management of Edema Avoid long periods of standing Elevate feet Exercise

Management of Varicosities Support hose Avoid long standing, sitting, leg crossing Elevate legs when sitting Loose clothing and avoid knee-high hose Rest left lateral position

Management of Leg Cramps Adequate calcium Stretching exercises Drink plenty of fluids

Integumentary System Hyperpigmentation Striae gravidarum (stretch marks) Decline in hair growth Nails grow faster

Endocrine System Thyroid Parathyroid Pituitary Adrenal

Endocrine System Pancreas Early pregnancy ↓ in maternal glucose levels due to diversion across placenta to fetus for growth. Fetus also draws amino acids and lipids ↓mother’s ability to synthesize glucose as well as a ↓ in insulin production

Endocrine System Placenta hCG Human placental lactogen (hPL) Progesterone Estrogen Review table 11.3 p 323

Neurological System Decreased attention span Poor concentration Memory lapses Carpel tunnel syndrome Syncope

Management of Fatigue More common early in pregnancy Rest when tired Schedule a nap in the afternoon Alleviate stress Reassurance that the fatigue lessens after the first trimester

Immune System Enhancement of innate immunity Suppression of adaptive immunity Prevent maternal immune system from rejecting fetus

Maternal Emotional Responses Ambivalence Introversion Acceptance Mood Swings Change in Body Image

Maternal Role Transition Rubin’s tasks of pregnancy Incorporate pregnancy into identity Develop self-concept as a mother Develop relationship with her child

Maternal Role Tasks Seeking safe passage Securing acceptance of infant by others Seek acceptance of self in maternal role Committing to the unknown child- giving of oneself Box 11-4 p.334

Sexuality Due to physical changes causes stress on sexual relations Desire may change with each trimester Sexual positions may need to be altered Noncoital modes of sexual expressions utilized

Partners Reaction to Pregnancy Couvade syndrome Acceptance of roles Preparation for reality of new role

Pregnant Adolescent Normal adolescent developmental tasks conflict with tasks of pregnancy May not seek prenatal care Not future oriented- Grappling with the reality of pregnancy and the child Struggling for recognition as a parent Creating the role of involved father

Adaptation of Siblings Reactions influenced by age and level of involvement with pregnancy Toddlers- regressive Older children- may not grasp reality of a baby in the family Adolescents

Adaptation of Grandparents Age affects reaction Number and spacing of other grandchildren Perception of the role of grandparents

Nutritional Needs Balanced diet based on the food pyramid Ferrous Iron 30 mg/day Foods rich in iron if anemic (hemoglobin 10.5 or less) Folic acid 400-800 mcg/day Prenatal vitamin and mineral supplements

Dietary Recommendations Use of artificial sweeteners controversial Avoid fish with moderate/high levels of mercury 12 oz. of low level mercury fish weekly Dietary recommendations table 11.5 p.327 Diet plan through out pregnancy MyPyramid guide fig 11.5 p. 328 to Teaching Guidelines p331

Weight Gain in Pregnancy Individualized according to pre-pregnancy weight Weight assessed at every visit Weight loss is never normal Excessive weight gain requires evaluation

Weight Gain in Pregnancy Average weight gain is 27.5 lbs. 28-40 lb. for underweight women 25–35 lb. for normal weight women 15–25 lb. for overweight women 11-20 for obese Institute of Medicine 2009

Normal Distribution Of Weight 7.5 lbs. 4 lbs. 2 lbs. 1.5 lbs. 7lbs. 2lbs. 30 lbs. Infant birth weight Blood Volume Uterus Breast tissue Placenta Maternal fluid vol. Maternal fat tissue Amniotic fluid Total weight gain

Preconception Care Goal promotion of the health and well-being of a women and her partner prior to pregnancy Identify & modify biomedical, behavioral and social risks to a pregnancy Review Pregnancy Risk factors box 12.2 p. 341 & 342

Nurse’s Role- First Visit Goal explain purpose of prenatal care and establish specific goals for that patient Build positive, nonthreatening trusting relationship Therapeutic communication- avoid medical /technical terminology Detection and prevention of potential problems

Initial Prenatal Visit Obtain baseline History/Physical Laboratory test Assess for risk factors Focus on prenatal education Breast surgery/cancer/lumps/biopsies History of rape or abuse Infertility Surgeries Abortions Hx of STD’s Cervical pathology Hx DVT’s

Nurse’s Role Pregnant Adolescent Assessment- closely monitor for iron deficiency anemia, STD’s, preeclampsia and high risk behaviors Knowledge regarding personal care of infant Promote optimal nutrition

Nurse’s Role Older Gravida Identify chronic medical conditions Identify detrimental lifestyle habits Screening for fetal chromosomal abnormalities

Focus of History/Physical Nutrition Lifestyle practices Psychosocial issues Medication & drug use Support systems Evaluate for history of domestic violence

Focus of History/Physical Immunization status- Rubella Underlying medical conditions Reproductive healthcare practices Sexuality& sexual practices

Initial Laboratory Test Blood type and RH Antibody screen (Coombs’ test) CBC Rubella titer HIV ? A1C

Initial Laboratory Test Hepatitis B Syphilis ( RPR/VDRL) Sickle cell Pap smear GC and Chlamydia culture Urinalysis

Return Visit Schedule Visit schedule Every 4 weeks up to 28 weeks Every 2 weeks from 29 to 36 weeks Every week from 37 weeks to birth

Return Visit Assessments Education Blood pressure Weight Fundal height Fig 12.5 p. 354 Urine testing Fetal heart tones 12.1 procedure p.355 Assess for fetal movement Box 12.4 p. 355

Screening Tests Glucose screen- done 24-28 wks Triple screen- 16-18 wks Group B strep- vaginal culture after 35 wks PPD

Obstetric Terms Gravida: number of times a women has been pregnant & outcome doesn’t matter Primigravida pregnant for the first time Multigravida women pregnant for at least 3rd time

Obstetric Terms Para: the number of pregnancies not fetuses that have been carried to 20 weeks or more Primipara: one birth after 20 weeks (Primip) Multipara: two or more births after 20 weeks (Multip) Nullipara: no viable offspring; para 0

Obstetric History G- Gravida P- Para T- Term births P- Preterm births A- Abortion L- number of living children

Expected Date of Delivery Duration of pregnancy 280 days or 40 weeks Naegele’s rule Add seven days to the first day of the LMP and then subtract three months (can be off by two weeks)

Expected Date of Delivery Indicators of gestational age FHT Procedure 12.1 p.355 Fetal movement Box 12.4 p.355 Fundal height Fig. 12.5 p. 354 Ultrasound Fig 12.6 p. 356

Assessment of Fetal Well-Being Ultrasound Doppler flow studies AFP Nuchal Translucency Screening Amniocentesis

Assessment of Fetal Well-Being Chorionic Villus Sampling (CVS) Percutaneous Umbilical Blood Sampling (PUBS) Nonstress test (NST) Contraction stress test (CST) Biophysical profile Kick Counts

Danger Signs in Pregnancy Vaginal bleeding Edema of the face and hands Severe headache Vision changes Abdominal pain Chills and fever Persistent vomiting Fluid from the vagina

Nursing Management Refer to teaching Guidelines and Nursing care plans through out this chapter when developing your own care plans.

Nursing Diagnosis Deficient Knowledge (Pregnancy related changes) Risk for imbalanced Nutrition: Less than body requirements Fatigue/Activity intolerance Sexual dysfunction Interrupted Family process Risk for Disturbed Body Image

Perinatal Education Education focus is broader then just Childbirth preparation. Topics include: Breast-feeding Infant care, growth, development Maternal Exercise

Childbirth Education Goal- promote a positive childbearing experience and be active participants Topics – Maternal changes Comfort measures Labor and birth process Relaxation/pain management