MATERNAL AND CHILD NURSING (NUR 362) Pregnancy Lecture 4 LECTURE 5

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) 13-27 Third trimester (late pregnancy) 28-40 LECTURE 5

GESTATIONAL AGE Nagele’s Rule Add 7 days to the first day of the last normal menstrual period, subtract 3 months and add 1 year. Example: 1st day of LNMP=December 16 2006 add 7 days = Dec. 23 2006 subtract 3 months = Sept 23 2006 add 1 year =Sept 23 2007, estimated due date (EDD) Johnson’s Rule: estimates the weight of the fetus in grams.

Sign and symptoms of pregnancy MATERNAL AND CHILD NURSING (NUR 362) Sign and symptoms of pregnancy 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 5

Sign and symptoms of pregnancy MATERNAL AND CHILD NURSING (NUR 362) Sign and symptoms of pregnancy 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 5

MATERNAL AND CHILD NURSING (NUR 362) Sign and symptoms of pregnancy 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 5

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Sign and symptoms of pregnancy MATERNAL AND CHILD NURSING (NUR 362) Sign and symptoms of pregnancy d. Breast changes Breast enlargement and vascular engorgement. Nipple and areola become blacker. Enlargement of the accumulated sebaceous glands of the areolas may be noted. e. Fatigue and dizziness LECTURE 5

MATERNAL AND CHILD NURSING (NUR 362) Sign and symptoms of pregnancy J . 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 5

MATERNAL AND CHILD NURSING (NUR 362) Sign and symptoms of pregnancy h. Basal body temperature (BBT) A persistent elevation of BBT for longer than 18 days may be presumptive evidence of pregnancy. LECTURE 5

Call the doctor if any of the following occur: Vaginal bleeding Sharp abdominal pain or cramping Loss of fluid from the vagina Severe or prolonged nausea or vomiting Frequent dizzy Painful urination High fever. Vaginal discharge that is irritating

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 5

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 5

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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 5

MATERNAL AND CHILD NURSING (NUR 362) Picture of gestational sac LECTURE 5

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 5

MATERNAL AND CHILD NURSING (NUR 362) Picture of normal fetus a．Pregnancy of 8w；b．Pregnancy of 18w BL-bladder；UT-uterus；GS-gestational sac LECTURE 5

Height of the uterine top MATERNAL AND CHILD NURSING (NUR 362) Height of the uterine top xiphoid LECTURE 5

Different methods of pregnancy diagnosis MATERNAL AND CHILD NURSING (NUR 362) Different methods of pregnancy diagnosis LECTURE 5

1 Month First Trimester At the end of four weeks: Baby is 1/4 inch in length Heart, digestive system, backbone and spinal cord begin to form. Placenta begins to develop The single fertilized egg is now 10,000 times larger than size at conception

Month 2 First Trimester At the end of 8 weeks: Baby is 1-1/8 inches long Heart is functioning Eyes, nose, lips, tongue, ears and teeth are forming Penis begins to appear in boys Baby is moving, although the mother can not yet feel movement

Month 3 Baby is 2 1/2 to 3 inches long Weight is about 1/2 to 1 ounce First Trimester At the end of 12 weeks: Baby is 2 1/2 to 3 inches long Weight is about 1/2 to 1 ounce Nails start to develop and earlobes are formed Arms, hands, fingers, legs, feet and toes are fully formed Eyes are almost fully developed Baby has developed most of his/her organs and tissues Baby's heart rate can be heard at 10 weeks with a special instrument called a Doppler

Month 4 Baby is 6 1/2 to 7 inches long Weight is about 6 to 7 ounces Second Trimester At the end of 4 months: Baby is 6 1/2 to 7 inches long Weight is about 6 to 7 ounces Baby is developing reflexes, such as sucking and swallowing and may begin sucking his/her thumb Tooth buds are developing Sweat glands are forming on palms and soles Fingers and toes are well defined Sex is identifiable Skin is bright pink, transparent and covered with soft, downy hair Although recognizably human in appearance, the baby would not be able to survive outside the mother's body

Month 5 Second Trimester At the end of 5 months: Baby is 8 to 10 inches long Weight is about 1 pound Hair begins to grow on baby's head Soft woolly hair called lanugo will cover its body. Mother begins to feel fetal movement Internal organs are maturing Eyebrows, eyelids and eyelashes appear

Month 6 Second Trimester At the end of 6 months: Baby is 11 to 14 inches long Weight is about 1 3/4 to 2 pounds Eyelids begin to part and eyes open sometimes for short periods of time Skin is covered with protective coating called vernix

Month 7 Third Trimester At the end of 7 months: Baby is 14 to 16 inches long Weight is about 2 1/2 to 3 1/2 pounds Fat layers are forming Organs are maturing Skin is still wrinkled and red If born at this time, baby will be considered a premature baby and require special care

Month 8 Third Trimester At the end of 8 months: Baby is 16 1/2 to 18 inches long Weight is about 4 to 6 pounds Overall growth is rapid this month Tremendous brain growth occurs at this time Most body organs are now developed with the exception of the lungs Movements or "kicks" are strong enough to be visible from the outside Kidneys are mature Skin is less wrinkled Fingernails now extend beyond fingertips

Month 9 Third Trimester At the end of 9 months: Baby is 19 to 20 inches long Weight is about 7 to 7 1/2 pounds The lungs are mature Baby is now fully developed and can survive outside the mother's body Skin is pink and smooth Baby settles down lower in the abdomen in preparation for birth and may seem less active

AMNIOTIC FLUID Clear, yellowish fluid surrounding the developing fetus. Average amount 1000 ml. < 300ml – Oligohydramnios, associated with fetal renal abnormalities. > 2 L – Hydramnios, associated with GI and other malformations.

AMNIOTIC FLUID functions Protects Fetus Controls Temperature Supports Growth Prevents Adherence to amnion Allows Movement Source of oral fluid Acts as a excretion

MATERNAL AND CHILD NURSING (NUR 362) Health education during pregnancy LECTURE 5

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 5

Normal Pregnancy Weight Gain MATERNAL AND CHILD NURSING (NUR 362) 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 5

Risks of Low Weight Gain MATERNAL AND CHILD NURSING (NUR 362) 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 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 5

MATERNAL AND CHILD NURSING (NUR 362) Proper nutrition Major Nutrients Carbohydrates Protein Fat Vitamins Minerals Water These nutrients, consumed in the correct amounts, help make a healthy baby. Eating nutritious foods from MyPyramid supplies these nutrients. Your doctor may prescribe a multi-vitamin and mineral supplement during pregnancy which you will need to take as directed in addition to eating a nutritious diet. Supplements are not a substitute for a healthful diet. However, they may be especially beneficial for teenagers, women who smoke or abuse alcohol or drugs, and strict vegetarians. LECTURE 5

Nursing Process Nursing Diagnosis Health-seeking behaviors Anxiety Risk for deficit fluid Constipation Disturbed body image Risk for altered sexuality patterns Disturbed sleep pattern Fatigue Risk for fetal injury

Health Promotion During Pregnancy Self-care needs Bathing Breast care Dental care Perineal hygiene Sexual activity Exercise Sleep

Health Promotion During Pregnancy First-Trimester Discomforts Breast tenderness Constipation Nausea, vomiting Fatigue Muscle cramps Hypotension Varicosities Hemorrhoids Heart palpitations Frequent urination Abdominal discomfort

Health Promotion During Pregnancy Middle to Late Pregnancy Discomforts Backache Headache Dyspnea Ankle edema

Discomforts associated with pregnancy 1. First trimester Nausea and vomiting (“morning sickness”) related to altered hormone levels and metabolic changes; advise small snacks of dry crackers before arising, small feedings of bland food, milk Urinary frequency and urgency without dysuria; fluid intake should not be restricted Increased vaginal discharge; manage with good hygiene (but no douching) and loose-fitting cotton underwear; report signs or symptoms of vaginitis

Breast soreness due to hormonal changes; suggest wearing a well-fitting, supportive brassiere Headache due to tension from emotional and physical stresses at any time during pregnancy; provide reassurance, suggest relaxation techniques; inform patient to report persistent and/or severe episodes

Second and third trimester Heartburn may be related to tension and vomiting in early pregnancy, progesterone-induced decreased motility and relaxation of the cardiac sphincter; displacement of the stomach by the growing uterus; encourage small, frequent meals and discourage overeating, ingesting fried/fatty foods, lying down soon after eating, use of sodium bicarbonate (would interfere with sodium balance)

Constipation related to progesterone-induced hypoperistalsis, compression/displacement of the bowel by the enlarging uterus, poor food choices, lack of fluids, and/or iron supplementation; advise bulk foods, fruits and vegetables, exercise, and generous fluid intake; avoid laxatives Hemorrhoids due to pelvic congestion related to pressure from enlarged uterus; suggest regulation of bowel habits, gentle reinsertion into rectum with use of lubricant, relief measures, e.g., ice packs, topical ointments, sitz baths, lying down with legs elevated

Uterine contractions (Braxton-Hicks) due to tension on the round ligaments as a result of displacement of the uterus; instruct patient to rest, change position or activity Backache due to increased spinal curvature; educate the patient on the importance good posture Faintness related to vasomotor lability or postural hypotension; instruct the patient to use slow, deliberate movements when rising, avoid prolonged standing and warm, stuffy environments; elastic hose may be needed

Leg cramps related to pressure on the nerves supplying the lower extremities aggravated by poor peripheral circulation or fatigue; instruct the patient to increase calcium and decrease phosphorus intake; encourage dorsiflexion of feet Ankle edema related to decreased venous return from lower extremities, instruct the patient to avoid wearing anything that constricts blood flow, elevate legs when sitting or resting, and dorsiflex feet when sitting or standing for any length of time; medical management if edema persists in AM, is pitting, involves the face, or associated with elevated BP, proteinuria, persistent headaches

Varicosities of extremities or vulva related to uterine compression of venous return, increased vein wall distensibility from progesterone-initiated relaxation, or inherited tendency; suggest elevating legs frequently, avoid sitting with legs crossed, standing/sitting for long periods of time, or wearing constrictive clothing; support/elastic stockings may be helpful.

Danger Signs of Pregnancy Abdominal or chest pain Pregnancy-induced hypertension Increase or decrease in fetal movement Vaginal bleeding Persistent vomiting Chills and fever Ruptured membranes

Teratogens Any factor that adversely affects fertilized ovum, embryo or fetus

Teratogenic Fetal Exposure Maternal infections: Toxoplasmosis, Rubella, Cytomegalovirus Herpes simplex virus, Syphilis Vaccines Drugs Alcohol Cigarettes

Teratogenic Fetal Exposure Environmental chemical Radiation Hyperthermia and hypothermia Maternal stress

MATERNAL AND CHILD NURSING (NUR 362) The End LECTURE 5