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

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

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

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

5. 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

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

7. 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

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

9. 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

10. 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

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

12. 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

13. 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

14. 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

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

16. 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

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

18. 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

19. 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

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

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

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

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

24. 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

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

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

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

28. Management of Edema Avoid long periods of standing Elevate feet
Exercise

29. 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

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

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

32. Endocrine System
Thyroid
Parathyroid
Pituitary
Adrenal

33. 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

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

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

36. 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

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

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

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

41. 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 p.334

42. 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

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

44. 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

45. 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

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

47. 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 mcg/day
Prenatal vitamin and mineral supplements

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

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

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

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

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

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

62. 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

63. 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

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

66. 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

67. 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

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

69. 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)

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

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

72. 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

74. 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

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

77. 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

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

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