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39 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. 40 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" 41 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. 42 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. 43 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. 44 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. 45 - 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. 46 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. 47 - 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 48 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. 49 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 50 - 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. 51 - 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. 52 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:▪ 53 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. 54 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 55 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