Download 1 Continues to receive inadequate nutrition the existing cells are

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Continues to receive inadequate nutrition the existing cells are smaller in
size.
 Disease, trauma or unfavorable environmental factors may irreparably
alter the development of CNS.
 At 9 weeks the whole fetus moves in a jerky movement.
 By 16 weeks, fetal muscle movement is strong enough to activate
receptors on the maternal abdominal wall, the mother usually
interprets this as "the baby moving" and professionals refer it as
"quickening".
 The fetus is able to hear both internal and external sounds by the 5th
month of pregnancy.
Gastrointestinal system:
 The digestive system forms during the 4th week.
 Intrauterine nutrition and elimination occur through the placenta.
 During the second trimester, the fetus begins to swallow amniotic
fluid.
 The fetus receives its glucose, its main source of energy from the
mother. Maternal insulin doesn't pass to the fetus, the fetus secretes
insulin. The fetus synthesizes glycogen and forms his own fat rather
than receiving these nutrients in these forms from the mother.
Meconium: is a sterile, dark greenish brown, semisolid residue of bile
and embryonic secretions plus cellular waste (epithelial tissue) and hair
swallowed in utero.
Note: the presence of meconium in amniotic fluid before delivery usually
indicates fetal hypoxia.
Hepatic system:
 Liver function begins at about 4th week of gestation.
 Hematopoiesis starts at about the 6th week of intrauterine life; this
activity is primarily responsible for the rapid growth and relatively
large size of the liver during the 2nd month of gestation.
 Metabolic and glycogen store organ, secretes bile.
 Full liver function is not achieved well until after delivery.
Endocrine system:
 The fetal adrenal cortex produces cortisol, which may be important in
the initiation of labor.
 The thyroid gland is the first endocrine gland to develop in the fetus.
By the 4th week, it can synthesize thyroxin.
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 By the 12th week insulin can be extracted from the pancreas.
Reproductive system:
 By the end of the 9th week, male and female external genitalia appear
somewhat similar. At the 12th week, the external genitalia are well
developed enough to be easily distinguished.
 The fetal ovary has many primordial follicles and produces small but
increasing amounts of estrogen. Withdrawal bleeding follows rapid
drop of maternal estrogen following birth.
The Expectant Mother
Terminology:
 Gravida: a woman who is or has been pregnant without regard to
pregnancy outcome.
 Nulligravida: a woman who is not now and never has been pregnant.
 Primigravida: a woman pregnant for the first time.
 Multigravida: a woman who has been pregnant several times.
 Para: refers to past pregnancies that have reached viability.
 Nullipara: a woman who has never completed a pregnancy to the
period of viability.
 Primipara: refers to a woman who had completed one pregnancy to the
period of viability regardless of the number of infants delivered i.e. the
birth of twins increases parity by 1(not by 2), and regardless of the
infant being live or stillborn.
 Multipara: a woman who has completed 2 or more pregnancies to the
period of viability.
Manifestations of Pregnancy
I. Presumptive signs and symptoms:
1- Cessation of menses: pregnancy is suspected if more than 10 days
have elapsed since the time of the expected menses onset.
2- Breast changes:
a. breasts enlarge and become tender with visible veins.
b. nipples become larger and more pigmented.
c. colostrums, a thin milky fluid (in the second half of pregnancy).
d. Montgomery glands (secrete a fatty substance that lubricates
and protects the nipple and areola during breastfeeding ) may
appear "small elevations in the aereolae"
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3- Chadwick's sign: a bluish purple discoloration that appears on the
cervix, vagina, and vulva.
Chadwick's sign
4- abdominal striae (striae gravidarum) sometime appear on the
breasts, abdomen and thighs because of stretching, rupture and
atrophy of the deep connective tissue of the skin.
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5- nausea and vomiting (morning sickness), occurs mainly in the
morning, lasts and usually disappears near the end of the first
trimester.
6- quickening (sensation of fetal movement in the abdomen), occurs
between 16th and 20th week after the onset of last menses.
7-Frequency of urination:
- caused by pressure of expanding uterus on bladder.
- decreases when the uterus rises out of the pelvis.
- reappear when the fetal head engages in the pelvis at the end of
pregnancy.
8-Fatigue: characteristic of early pregnancy.
II. Probable signs and symptoms:
1. Enlargement of the abdomen.
2. Changes in shape, size and consistency of the uterus.
- uterus enlarges, elongates and decreases in thickness as
pregnancy progress.
- Hegar's sign, lower uterine segment softens at 6-8 weeks.
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3. changes in cervix:
- Goodell's sign: softening of the cervix at 6-8 weeks.
- with inflammation and carcinoma during pregnancy, the cervix
may remain firm.
4. intermittent contractions of the uterus (Braxton Hick's
contraction): painless, palpable contractions occurring at irregular
intervals. May appear early at the 16th week.
5. Ballottement: a sinking and rebounding of the fetus in its
surrounding amniotic fluid in response to sudden tap on the uterus,
occurs near midpregnancy (16-28 weeks).
6. positive hormonal tests for pregnancy, response of HCG in
maternal blood (4-12weeks) and urine (6-12 weeks).
III. positive signs:
1. fetal heart sounds by ultra sound (6 weeks) or fetal stethoscope at
20-24 weeks.
2. visualization of the fetus by ultrasound at 6 weeks or X-ray at 16
weeks.
3. Fetal parts palpated at 24 weeks- Fetal movements are palpable at
22 weeks and visible are late pregnancy.
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Physiological and psychological changes of pregnancy
“Maternal adaptations to pregnancy”
All changes in a mother’s body during pregnancy are due to:
1. The effects of specific hormones.
2. The growth of the fetus inside the uterus.
3. The mother’s physical adaptation to the changes that are occurring.
These changes enable the mother to nurture the fetus, prepare her body for
labor, develop her breasts and by down stores of fat to provide calories for
production of breast milk during puerperium. By understanding the normal
changes, the nurse can detect abnormality.
The woman’s psychological state is also affected by hormonal changes.
The changes interact with other external factors and influence her transition to
motherhood.
Changes being soon after fertilization.
 Physiological changes in the reproductive system:
1.the uterus:
 The uterus develops to provide a nutritive and protective environment in
which the fetus will develop and grow.
-Progesterone and estrogen initially produced by the corpus lutetium cause the
deciduas become thicker, richer and more vascular at the fundus and in the
upper body of the uterus. The deciduas provides a glycogen- rich environment
for the blastocyst until the trophoblastic cells begin to form the placenta.
- Estrogen is responsible for the growth of uterine muscle.
- Enlargement during pregnancy involves muscle to accommodate its
contents.
- Increase in weight, from 60 g to 900-1100g.
- Increase in size from 7.5x5x2.5cm to 30x23x20 cm.
- Braxton – Hicks contractions are necessary for the uterus to strech,
usually painless, last approx. 60 seconds, begins at 8 weeks gestation,
continue throughout pregnancy and later changes in intensity to
became contractions of labor.
- Estrogen causes development of new blood vessels to meet the
needs of the functioning placenta.
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- The uterus changes to a globular shape to anticipate fetal growth
and also to accommodate increasing amounts of liquid and
placental tissue. This causes pressure on other pelvic organs.
- At 12 weeks the fundus of the uterus may be palpated abdominally
above the symphysis pubis.
- By 20 weeks gestation, the fundus has reached the umbilicus.
- By 36 weeks, the fundus has reached the xiphoid.
- During the last 3 weeks, the uterus descends slightly because of
fetal descent into pelvis. Walls of the uterus become thinner.
2. The cervix:
- It acts as an effective barrier against infection, it also retains
pregnancy.
- Under the influence of progesterone, endocervical cells secrete
mucus, which becomes thicker and more viscous during
pregnancy.
A clot of very thick mucus obstructs the cervical canal, which
provides protection from ascending infections.
Estrogen increases cervical vascularity and if viewed through a
speculum, the cervix looks purple.
- In late pregnancy softening of the cervix occurs in response to
increasing painless contractions. Progestron also play a role in
cervical softening in readiness for the onset of labor.
3. the vagina:
Estrogen causes muscle layer hypertrophy and changes the
surrounding connective tissue which allows the vagina to become
more elastic and enabling it to dilate during labor. The epithelium
has a marked desquamation of the superficial cells which increases
the amount of normal white vaginal discharge called leukorrhea.
The nurse should reassure the patient about the
normalcy of leukorrhea during pregnancy and instruct
her to call her health care provider if the discharge
appears thicker; becomes bloody or yellowish/green;
is accompanied by a foul odor; or if it causes
itching,irritation, or pain in the vulvar or vaginal area.
The vagina is more vascular, appearing reddish purple in color.
The pH of vaginal secretions is 3.5-6 because of increased
production of lactic acid from glycogen in the vaginal epithelium
by lactobacilus acidophilus which prevent infection but
unfortunately, it increase the susceptibility of other infections such
as candida albicans.
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4. The ovaries:
- Ovulation ceases during pregnancy, maturation of new follicles is
suspended.
- One corpus luteum functions during early pregnancy (first 8 weeks)
producing mainly progesterone.
Notes:
- The placenta blood flow 450-650 ml/min at term.
The blood flow to the uterus constitutes 2% of cardiac output in
nonpregnant woman and increases to 17% at term of pregnancy.
▪ skin changes:
- Increased activity of the melanin- stimulation hormone causes deeper
pigmentation during pregnancy.
- Some develop deeper, patchy coloring on the face which resembles a
mask and is known as chloasma. (The heightened pigmentation fades
after pregnancy but can recur after exposure to the sun).
- Many notice a pigmented line running from the pubis to the umbilicus
and sometimes higher, called the linea nigra.
- The perineum darkens in order to enable it to stretch during the birth of
the baby.
- In some women the areas of maximum stretch become thin and stretch
marks, striae gravidarum appear as red stripes during pregnancy. It
appears in the skin of the abdomen, breast and thighs.
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- The increased blood supply to the skin leads to sweating. Women often
feel hotter in pregnancy. “This may be caused by a progesterone
induced vasodilation".
- Vascular spiders are tiny, branched, slightly raised and pulsatingend
arterioles, usually found on the neck, chest, face, and arms.
- Oily skin and acne may occur during pregnancy.
- Increased adrenal steroid levels cause the connective tissue to lose
strength and become more fragile. This change can cause striae
gravidarum, or “stretch marks” on the breasts, buttocks, thighs, and
abdomen. Striae appear as reddish, wavy, depressed streaks that will
fade to a silvery white color after birth but they do not usually
disappear completely.
▪ Breasts changes:
Estrogen and progesterone produce a number of changes in the mammary
glands. Breast enlargement, fullness, tingling, and increased sensitivity
occur during the early weeks of gestation. The superficial veins become
more prominent from the vascular relaxation effects of progesterone.
- They are tender and tingle in early pregnancy.
- Increase in size by the second month (hypertrophy of mammary
alveoli).
- Nipples become larger, more deeply pigmented and more erectile.
- Colostrum may be expressed by the second trimester, colostrums has
more protein and minerals but less sugar and fat than that of mature milk.
Aereolae become broader and more deeply pigmented. This pre-milk
substance contains antibodies, essential proteins, and fat to nourish the
baby and prepare his intestines for digestion and elimination.
- Glands of Montgomery scattered through the aereolae a number of
small elevations (hypertrophic sebaceous glands).
▪ Changes in the cardiovascular system:
- Due to an increase in blood volume and increase in workload, the
heart may increase in size.
- The heart may be displaced upwards and to the left because of the
increasing pressure from the growing uterus.
- Blood volume increases by 40% to 45% and is due primarily to an
increase in plasma and erythrocyte volume.
- Most of the increased blood flow is directed to the uterus to nourish
the fetus.
- The increased need for oxygen requires the pregnant woman to
increase her iron intake.
- During pregnancy, the woman’s hematocrit values may appear low
due to the increase in total plasma volume (on average, 50%). Since
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the plasma volume is greater than the increase in erythrocytes (30%).
This alteration is termed “physiological anemia of pregnancy” or
pseudoanemia.”
- The hemodilution effect is most apparent at 32 to 34 weeks. The mean
acceptable hemoglobin level in pregnancy is 11 to 12 g/dL of blood.
- The number of leukocytes also increases and the average white blood
cell count ranges from 5000 to 15,000 /mm3. During labor and
postpartum these levels may climb as high as 25,000/mm3.
- Cardiac output increases, and peaks around the 20th to 24th week of
gestation at about 30% to 50% above pre-pregnancy levels. It remains
increased for the duration of the pregnancy.
- With the increased vascular volume and cardiac output, vasodilation
(related to progesterone-induced relaxation of the vascular smooth
muscle) prevents an elevation in blood pressure.
- The woman’s pulse rate frequently increases up to 10 to 15 beats per
minute to facilitate effective circulation of the increased blood
volume.
- Because of the relaxed vascular resistance and stasis of blood in the
lower extremities, there is an increased risk of varicose veins and
hemorrhoids.
- The nurse should instruct the woman to elevate her lower extremities
by lying on her left side with the feet higher than her heart for 15 to 20
minutes daily to improve venous return from the lower extremities.
- The pregnant woman may experience supine hypotension syndrome,
or vena caval syndrome (faintness related to bradycardia) if she lies
on her back. The pressure from the enlarged uterus exerted on the
vena cava decreases the amount of venous return from the lower
extremities and causes a marked decrease in blood pressure, with
accompanying dizziness, diaphoresis, and pallor.
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Changes in the respiratory system
- The tidal volume (amount of air breathed in each minute) increases
30% to 40%. This change is related to the elevated levels of estrogen
and progesterone. Estrogen prompts hypertrophy and hyperplasia of
the lung tissue. Progesterone decreases airway resistance by causing
relaxation of the smooth muscle of the bronchi, bronchioles, and
alveoli.
- These are necessary in order to maximize maternal oxygen intake and
provide efficient carbon dioxide excretion for the mother and through
her for the fetus.
- Diaphragm is elevated during pregnancy chiefly by enlarged uterus,
but chest circumference increases by 6 cm.
- Maternal oxygen requirements increase in response to increased
metabolic rate.
- Increased respiratory rate and reduced PCO2 probably induced by
progesterone and estrogen to a lesser on respiratory center.
- EYES Blurred vision, the most common visual complaint in pregnant
women, is caused by corneal thickening associated with fluid retention
and decreased intraocular pressure.
- NOSE An increase in mucus production results from the combined
effects of progesterone (increased blood flow to the mucus membranes
of the sinus and nasal passages) and estrogen (hypertrophy and
hyperplasia of the mucosa). Nasal stuffiness and congestion (rhinitis
of pregnancy) and epistaxix may occur.
Changes in the gastrointestinal system:
- Gums may become hyperemic and softened and inflamed (gingivitis)
and may bleed easily under the effect of estrogen. Dental problems
occur because of leading to dietary changes and food cravings.
-
- Craving for unnatural substances such as coal is termed pica
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- Progesterone relaxes smooth muscle; gastric emptying and peristalsis
are slowed in order to maximize the absorption of nutrients. More
water is reabsorbed from the bowel and bloating and constipation can
occur.
- Heartburn is common and is associated with gastric reflux due to the
relaxation of cardiac sphincter. (Eating small meals, avoiding lying
down after meals for at least 1 hour, and limited use of antacids can
alleviate some of these symptoms).
- Constipation is a result of sluggish gut motility .
- It can exacerbate hemorrhoids which may exist as a result of the
relaxing effect of progesterone’s action on the smooth muscle of vein
wall and the pressure exerted by the enlarged uterus on pelvic veins.
- Nausea and vomiting occur mainly during early pregnancy, possibly,
due to raised hCG levels and altered carbohydrate metabolism.
- Changes in taste and smell, due to alterations in the oral and nasal
mucosa, can further aggravate the gastrointestinal discomfort.
- Patients should be encouraged to drink at least 8 to 10 glasses of water
each day, add fiber to their diets to produce bulk, and exercise to
encourage peristalsis. They should be taught to avoid straining with
bowel movements. Warm sitz baths may be helpful for hemorrhoid
discomfort.
Changes on urinary system
- During the first trimester, the bladder is compressed by the weight of
the growing uterus. The added pressure, along with progesteroneinduced relaxation of the urethra and sphincter musculature, leads to
urinary urgency, frequency, and nocturia.
- These signs and symptoms disappear during the second trimester and
most of the third trimester. They reappear in the last 2-3 weeks when
the presenting part of the fetus descends into the pelvis.
- Ascending infection (UTI) occur more frequently in pregnancy due to
relaxation of the smooth muscle of the bladder and urinary sphincter,
changes that allow bacterial ascent into the bladder.
- Ureters are dilated, glomarular filtration increased, glycosuria may be
evident, proteinuria doesn’t occur normally.
Skeletal changes:
- Progesterone and relaxin (a hormone produced by the placenta)
encourage relaxation of ligaments and muscles, reaching maximum
effect during the last weeks of pregnancy.
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- This relaxation allows the pelvis to increase its capacity in readiness to
accommodate the fetal presenting part at the end of pregnancy and in
labor.
- Unstable pelvic joints result in the rolling gait sometimes seen in
pregnant women.
- Alteration in posture and walking due to an increase in weight which
result in back pain.
Changes in the endocrine system:- - Human placental lactogen (hPL), placental hormone promotes
lipolysis , increases plasma free fatty acids and thereby provides
alternative fuel sources for the mother. HPL, estrogen and
progesterone produced by the placenta oppose the action of insulin
during pregnancy.
- Note this happens to elevate the maternal circulating blood glucose
level since the fetus is dependent on glucose for body and brain
growth.
- The anterior pituitary gland is enlarged. ACTH, melanocytestimulating and thyrotropic hormone increase their activity.
- FSH and LH are inhibited by progesterone and estrogen.
- Thyroid gland is moderately enlarged because of hyperplasia of
glandular tissue and increase vascularity leading to increased BMR.
- Adrenal gland secretions (corticosteroid) considerably increased and
may be one of the reasons for glycosuria in pregnancy.
- Excretion of sodium is increased in the presence of progesterone and
elevated level of aldosterone.
Metabolic changes:- Maternal weight:
Continuing weight increase in pregnancy is considered to be one
favorable indicator of maternal adaptation and fetal growth.
Expected increase:
1 Kg in first 20 weeks.
0.5 Kg per week until term.
12.0 Kg approximates total.
Many factors influence weight gain. The degree of maternal edema,
smoking, amount of amniotic fluid, and size of the fetus must all be taken
into account.
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Water metabolism:
-Average woman retains 6.5 liter of water during pregnancy. Production
of aldosterone increase which will increase water retention.
- Many woman experience edema of the legs at the end of pregnancy.
▪ Protein metabolism:
- At term, fetus and placenta contain 500g of protein.
- Approx. 500g more of protein are added to the uterus, breasts and
maternal blood in the form of hemoglobin and plasma proteins.
Total increase: 1000 grams.▪ Fat metabolism: increase in plasma concentrations of lipid and
lipoproteins.
▪ Carbohydrate metabolism:
- Pregnancy is potentially diabetogenic.
- Normal pregnancies induce a state of peripheral resistance to insulin by
hPL, estrogen and progesterone.
Duration of pregnancy:
- Average length is 280 days or 40 weeks from the first day of the last
normal menstrual period.
- Duration may also be divided into three equal parts or trimesters of
slightly more than 13 weeks or 3 calendar months each.
- Estimated date of confinement (EDC) is calculated according to Nagele
rule by adding 7 days to the date of the first day of the last menstrual
period and counting back 3 months.
Antenatal (prenatal) Care
"Nursing care during pregnancy"
The prenatal period is a preparatory one, both physically in terms of fetal
growth and maternal adaptation and psychologically in terms of
parenthood. Prenatal is a time of intense learning for the parents and for
those close to them, as well as a time for development of family unity.
Regular prenatal visits ideally begin soon after the first missed menstrual
period, offer opportunities to ensure the health of the expectant mother
and her infant.
Aims of antenatal care:▪
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1. To support and encourage a family's healthy psychological adjustment
to childbearing.
2. To promote an awareness of the sociological aspects of childbearing
and rearing and the influences that these may have on the family.
3. To monitor the progress of pregnancy in order to ensure maternal
health and normal fetal development and provide management or
treatment as required.
4. To recognize deviation from the normal and provide management or
treatment as required.
5. To ensure that the woman reaches the end of her pregnancy physically
and emotionally prepared for her delivery.
6. To help and support the mother in her choice of infant feeding to
promote breast feeding in a sensitive manner and give advice about
preparation for lactation when appropriate.
7. To offer the family advice on parenthood either in a planned program
or on an individual basis.
8. To build up a trusting relationship between the family and their
caregiver which will encourage them to participate in and make
informed choices about the care they receive.
The initial visit (booking visit):
The visit should take place as soon as possible after pregnancy had been
confirmed. Advice should be given early because the fetal organs are
almost completely formed by the 12th week of pregnancy.
Objectives for the booking visit:
1. to assess levels of health by taking a detailed history and to employ
screening test appropriate.
2. To ascertain baseline recordings of weight, height, blood pressure
and hemoglobin level in order to assess normality. These findings
are used for comparison as the pregnancy progresses.
3. To identify risk factors by taking accurate details of past and
present obstetric and medical history.
4. To provide an opportunity for the woman and her family to express
any concerns they might have regarding this pregnancy or previous
obstetric experiences.
5. To give advice on general health matters and those pertaining to
pregnancy in order to maintain maternal health and healthy
development of the fetus.
6. To begin building a trusting relationship in which realistic plans of
care are discussed.
Nursing care follows the nursing process:
Assessment includes detailed health history, physical examination and
screening laboratory tests.
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Health history
1. Personal or demographic information
o Client’s name and information
o Phone number
o Age: if over 35 years, risk factors for genetic and medical
problems increases.
o Increased risk for hypertension (PIH), anemia, and
prematurity in young women.
o Education: is learning a problem. Is she able to follow
instructions.
o Usual responsibilities: what are her daily activities, who can
help her if there is a problem.
o Husband and family: husband name, do they have means of
transportation, how closely they are related (genetics)
2. Woman’s present obstetric history (current pregnancy):
o Gravidity and parity: one obstetric abbreviation commonly
employed in maternity centers is often more detailed. It
consists of 5 digits. The firs digit presents the total number
of pregnancies including the present one. The second digit
represents the total number of deliveries. The third indicates
the number of premature babies. The fourth identifies the
number of abortions. The fifth is the number of children
currently living. GTPAL
o Example: if the woman pregnant only once with twins
delivered at the 35th week and the babies survived. The
abbreviation that represents this information is 1-2-2-0-2.
o During her next pregnancy, the abbreviation is 1-2-2-0-2.
o Note: according to the 2 digits system, the abbreviation that
represent the information above will be 1-1, 2-1
o Date of last menstrual period. Estimated date of
confinement, signs and symptoms of pregnancy, rest and
sleep pattern (regularity of sleep)
o Activity and employment, plans for continued employment.
o Diet history, weight gain, eating patterns, social and cultural
dietary habits.
o Psychosocial status, woman’s and family’s reaction to this
pregnancy, support system.
3. Woman’s menstrual history:
o Menarche
o Length and regularity of menstrual period.
4. Past obstetric history: for each previous pregnancy, record the
following information: you are looking for a pattern of problems or
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non-problems to help you predict what may happen during the current
pregnancy.
a. Data of previous pregnancies.
i. Year: if within the last year, note the month
ii. Consider nutrition and recovery if recent or increased
number of birth
iii. Still breast feeding.
b. Gestational age: any known cause for abnormal gestation.
i. If stillbirth or abortion, document gestational age, if
genetics results were obtained.
c. Birth weight: appropriate for gestational age. Pattern of large
for gestational age (LGA) or small for gestational age
(SGA).
d. Duration of labor: spontaneous of induced
e. Abortions
f. Type of birth: vaginal or CS (why CS)
g. Place of birth: hospital, clinic or home.
h. Maternal and fetal complications
i. Received prenatal care, weight gain, infection, ….
j. Administration of anti D immunoglobulin to Rh negative
5. Medical history: in additional to the usual questions appropriate to
a health history, the following are specific to the pregnant woman.
o Kidney: recurrent UTI (may lead to premature labor)
o CV: systolic ejection murmur common in pregnancy,
varicosities in legs, other areas, DVT.
o Essential hypertension (predispose pregnancy-induced
hypertension and increase the risk for antepartal
hemorrhage)
o Heart disease, blood transfusion.
o Diabetes: if previous large babies, consider blood sugar with
other prenatal blood tests in the initial blood visits.
o Infections
o Thyroid problems and medications.
o Transfusions. Previous transfusion may lead to HB virus or
HIV. Document any objection to transfusion.
o Operations. What, when and where.
o Surgery of reproductive organs
o Allergies, food, medication, bronchial asthma.
6. Family history