Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
The Antepartum Period Objectives Low-Risk Antepartum Period Nursing Care of the Antepartum Patient Signs and Symptoms of Pregnancy Prenatal Labs/Testing Physiologic Changes of Pregnancy Nutritional Needs Psychosocial Changes of Pregnancy Documentation of Pregnancy History Gravida: a woman who is or has been pregnant Para: the number of pregnancies that have delivered after 20 weeks. Primigravida: a woman who is pregnant for the first time Primipara: woman who has delivered one viable fetus Multigravida: a pregnant woman who has been pregnant before Multipara: a woman who has delivered more than one viable fetus Nulligravida: woman who has never been pregnant Nullipara: a woman who has not carried a fetus to variability Classifying Pregnancy Status G= gravida P= para (# of total pregnancies) (# of pregnancies that reached viability) “Para” can be further broken down: T= term pregnancies P= premature deliveries (20-37 weeks) A= abortions (< 20 weeks) L= number of living children Remember: G.(T.P.A.L.) Determining GTPAL Status The patient is currently 32 weeks pregnant. She has a 5 year old son who was delivered at 38 weeks and a 3 year old daughter who was delivered at 36 weeks. Before having her children, the patient also experienced a spontaneous abortion at 18 weeks gestation. What is her GTPAL? G__ T__ P__ A__ L__ Calculating the Date of Delivery Using Naegele’s Rule Identify the first day of the last menstrual period (LMP) Subtract three months from this date Add seven days Example: First day of the LMP is June 14 June 14 less three months = March 14 March 14 + seven days = March 21 *The expected due date is March 21 Signs of Pregnancy Presumptive Signs: those that suggest but do not positively indicate pregnancy (subjective signs) Probable Signs: strong indicators of pregnancy, short of confirmation (objective signs). Two or more are highly suggestive of pregnancy. Detected at about 12th week Positive Signs: absolute confirmation of pregnancy Presumptive Signs of Pregnancy Amenorrhea: absence of menstruation Nausea/vomiting: due to metabolic and hormonal changes Breast changes: enlargement, tingling, increased sensation to touch, darkening of nipples and areola Urinary frequency: due to pressure on bladder from uterine enlargement Fatigue: due to increased metabolism Quickening: fluttering sensation when fetus moves (16-20 weeks gestation) Probable Signs of Pregnancy Pigmentation changes: linea nigra, chloasma (mask of pregnancy) Abdominal enlargement: as uterus rises out of the pelvis (after 12 weeks) Chadwick’s Sign: purplish color of cervix Hegar’s Sign: softening of the lower uterus Ballottement: detection of fetus floating in amniotic fluid Braxton Hicks contractions: irregular, painless uterine contractions Goodell’s Sign: softening of a normally-firm cervix Positive pregnancy test: Maternal blood or urine test for human chorionic gonadotropin (hCG). (Testing one week after a missed period usually provides more accurate information) Ballottement Hegar’s Sign: A Softening of the Lower Uterus Mask of Pregnancy (Chloasma) Positive Signs of Pregnancy Detection of fetal heart tones Palpation of fetal movement Ultrasonic evidence of a fetus Hydatiform Mole (Molar Pregnancy) Benign proliferating growth of the trophoblast in which the chorionic villi develop into edematous, cystic, vascular transparent vesicles that hang in grapelike clusters without a viable fetus Although hCG is produced, this is a nonviable pregnancy Patient at greater risk of developing gynecological types of cancer. Therefore frequent PAP tests required X 2 years Pregnancy and Prenatal Care First trimester First day of LMP to week 13 Second trimester 14 weeks to 27 weeks Third trimester 27 weeks to 40 weeks *Full term pregnancy is 37-42 weeks Term Delivery Classifications Early Term: Between 37 weeks 0 days and 38 weeks 6 days Full Term: Between 39 weeks 0 days and 40 weeks 6 days Late Term: Between 41 weeks 0 days and 41 weeks 6 days Post term: Between 42 weeks 0 days and beyond The FDA Categorization of Drug Risks to the Fetus: "Category A" (safest) to "Category X" (known danger) Category A Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no evidence of a risk in later trimesters), and the possibility of fetal harm appears remote. Category B Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters). Category C Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus. Category D There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective). Category X Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant! Prenatal Labs and Tests CBC Serology/VDRL*/RPR* (tests for syphilis) STD screening (chlamydia, gonorrhea, herpes) Pap smear (cervical cancer screening) Antibody titers for rubella and Hepatitis B *VDRL=Venereal Disease Research Lab *RPR=Rapid Plasma Reagin ABO/Rh typing Plasma glucose Urinalysis TB screening TORCH screening Alpha-fetoprotein (AFP) Group B Beta Strep HIV (with permission) Rh Sensitization May occur when mother is Rh negative but fetus is Rh positive If the infant’s Rh+ blood enters the mother’s circulation, her body perceives this foreign blood type as harmful. She creates anti-Rh+ antibodies in response Although the current infant is not affected, the next pregnancy is at risk. If that fetus also has Rh+ blood, the mother’s anti-Rh+ antibodies will attack the developing fetus, causing hemolysis (break down) of its red blood cells. Known as erythroblastosis fetalis Treatment? RhoGAM 300 mcg IM or IV is given prophalactally at 28 weeks gestation and again within 72 hours of childbirth. Remember this second dose is only given if the infant is Rh+ RhoGAM is also given after abortion, ectopic pregnancy, abdominal trauma and an amniocentesis as in each case blood could exchange and trigger the Rh sensitization response ABO Blood Incompatibilities More common than Rh incompatibility but less serious Occurs when maternal blood type is O and fetal blood type is A, B, or AB O mothers naturally produce anti-A and anti-B antibodies which cross the placenta These antibodies will cause red blood breakdown in the fetus with A, B, or AB blood types Causes hyperbilirubinemia; phototherapy is the treatment T.O.R.C.H. Infections T= Toxoplasmosis O= Other* R= Rubella C= Cytomegalovirus H= Herpes *Other includes gonorrhea, syphilis, varicella, Hepatitis B, Group B strep and HIV TORCH-Related Complications Congenital heart defects Physical fetal anomalies Intrauterine growth restriction (IUGR) Mental retardation Encephalitis Hydrocephalus TORCH Infections TORCH infections place both mother and baby in jeopardy due to the associated complications All TORCH infections can cross the placenta Prenatal complications include premature labor and premature rupture of membranes Prenatal screening important since many infections are asymptomatic Streptococcus (Group B) is a frequent cause of sepsis in the mother/neonate HIV/Aids in Pregnancy Fetus may contract HIV transplacentally, at birth or through breast milk. Absolutely no breastfeeding for these mothers! Current maternal treatment is oral zidovudine (AZT) during pregnancy and IV AZT during labor. Newborn also treated with AZT Although maternal antibodies may be present at birth in some babies, the antibody tests will usually convert to negative before 18 months of age HIV/AIDS: Nursing Interventions Reduce invasive procedures (AROM, fetal scalp electrodes, IUPCs) Bathe baby as soon as possible after delivery. If baby is unstable, wash injection sites with soap and water, then cleanse with alcohol Delay injections, heel-sticks until after bath Medical personnel should wear eye shields, gowns, masks and double glove during the birth Group B Strep Infection Usually not harmful to mother but can cause serious complications if transferred to infant Vaginal/rectal area swabbed Woman screened at 35-37 weeks gestation because the pathogen can come and go during pregnancy If positive, mother is treated with IV antibiotics while in labor. Most agencies’ policy state the patient must have two separate doses administered at least 4 hours before birth to be considered treated Alpha-fetoprotein (AFP) Substance produced by the fetal liver Elevated levels in maternal serum may indicate neural tube defect in the fetus Decreased levels may indicate Down Syndrome (Trisomy 21) in fetus Abnormal levels will necessitate further testing. Amniotic fluid will be assessed; more accurate In what situation would elevated AFP levels be considered normal? Domestic Violence Pregnant women more abused than general population Most likely related to the partner feeling a sense of lack of control/power Essential to screen throughout the entire pregnancy Important to ASK the questions: 1) “In your current relationship, do you feel safe?” 2) “Within the last 6 months have you been hit, slapped, kicked, or punched?” 3) “Do you fear for your own safety or the safety of your children?” Substance Abuse Alcohol Tobacco Marijuana Cocaine Amphetamines Heroin Other prescribed or ilicit drugs Substance Abuse If the nurse suspects the patient is a drug user, her urine is sent for a drug screen After delivery, infant’s first meconium is sent to the lab for a meconium drug screen Notify Social Services if infant drug screen is positive. CPS involvement is mandatory Narcan SHOULD NOT be given to mother on methadone or heroin as it may precipitate drug withdrawal Clinical Manifestations of Newborn Narcotic Withdrawal Hyperactivity Disorganized, Persistent shrill cry vigorous suck Poor feeding Vomiting Drooling Diarrhea Flushing, sweating Tachypnea (>60 bpm) Tremors Increased muscle tone Sneezing, hiccups, yawning Short, unquiet sleep Fever Fetal Alcohol Syndrome Fetal Alcohol Syndrome Symptoms: Microcephally Growth retardation Short palpebral fissures Maxillary hypoplasia Smooth philtrum Nursing Interventions: Decrease environmental stimuli Provide gavage feedings if neonate has uncoordinated sucking and swallowing Long Term Implications of FAS Mental retardation Poor coordination Facial abnormalities Behavioral deviations (irritability) Cardiac and joint abnormalities Routine Prenatal Care Prenatal Visits Blood pressure CBC (as needed) Weight Abdominal exam Assess fetal heart rate (FHR) Assess fetal position Measuring Fundal Height Measuring Fundal Height to Determine Gestational Age Various Prenatal Tests Non-stress test (NST) Contraction stress test (CST) Ultrasound (US) Biophysical profile (BPP) Alpha-fetoprotein (AFP) Amniocentesis Amniotic fluid index (AFI) Chorionic villi sampling (CVS) Non-Stress Test (NST) NST used to evaluated fetal status without uterine contractions Monitors FHR with fetal movement, which should accelerate 15 beats per minute for 15 seconds. Then would be considered “reassuring” Contraction Stress Test (CST) With CST, the uterus is made to contract artificially with the use of pitocin or nipple stimulation Fetal heart monitoring evaluates the respiratory function (oxygen/ carbon dioxide exchange) of the placenta This test is no longer commonly used but you should be aware of it Amniocentesis: Amniotic Fluid Removed From Amniotic Sac Genetic information Sex of fetus Chromosomal abnormalities Determine health or maturity of fetus Lecithin/sphingomyelin ratio (L/S ratio) to determine lung maturity. Ratio of 2:1 confirms fetal lung maturity *Ultrasound used with this procedure to help prevent injury to the fetus *Bladder should be full when done at <20 weeks gestation; bladder should be empty when done at >20 weeks gestation Chorionic Villi Sampling Sample of tissue (chorionic villi) from the edge of the placenta Detects genetic disorders; done at 8-12 wks Aspiration catheter or biopsy forcep is introduced through cervix Guided/monitored by ultrasound Biophysical Profile (BPP) (Confirms Fetal Well-Being and Placental Functioning) Variable Normal (Score=2) Abnormal (Score=0) Fetal Breathing Movements Gross Body Movements Fetal Tone Reactive FHR Qualitative Amniotic Fluid Volume (AFV) Score of 8-10 is optimal Score of 0-6 is ominous Note: Some BPPs will have a total grading score of 8 rather than 10. That is because the “Reactive FHR” is done separately Physiological Changes of Pregnancy Pregnancy affects all the major systems: Reproductive Musculoskeletal Cardiovascular Respiratory Gastrointestinal Urinary Endocrine Metabolic Reproductive System Uterus: enlarges (X 20); irregular, painless contractions occur Ovaries: ovulation stops due to high levels of placental estrogen and progesterone Vagina: becomes softer, mucosa thickens, vascularity increases, vaginal discharge increases and becomes more acidic Breasts: increases in size and become full and tender, areola darken; colostrum is excreted Cervix: softens (Goodell’s Sign), becomes congested with blood (Chadwick’s Sign), mucus plug forms Musculoskeletal System Relaxation of joints due to relaxin hormone Widening of symphysis pubis Waddling gait (pride of pregnancy walk) Lordosis Increased back strain Cardiovascular System Blood volume increases by 30-50% Pulse rate increases by 10-15 beats/minute Clotting factors increase which helps prevent hemorrhage however increases risk of DVT RBC mass increases (plasma portion faster…therefore causing physiological anemia) BP basically remains essentially unchanged due to peripheral vasodilation related to progesterone 500-1,000 mLs of blood to the uterus per minute! Supine hypotension a major problem Hgb < 11g/dL Hct < 33% indicates anemia Normal Hematologic Values NORMAL HEMATOLOGIC VALUES Nonpregnant Pregnant Hemoglobin (HGB) 12–16 g/dL 11.5–15 g/dL Hematocrit (HCT) 36–48% 32–36.5% White blood cells (WBC) 4-10.6/mm3 6-20/mm3 Cardiovascular The pregnant uterus compressing the aorta and the inferior vena cava (aortocaval compression). Patient in supine position. Uterine displacement with wedge under hip to relieve aortocaval compression. Aortocaval Compression Respiratory System Oxygen consumption increases by about 20% Dyspnea is common Nosebleeds and nasal stuffiness are common and related to estrogen Rib cage widens Respiratory depth increases Gastrointestinal System Gums appear red and swollen and bleed easier, caused by elevated levels of estrogen Nausea and vomiting occurs in 50% of women and common in the first trimester Delayed gastric emptying and reduced tone of esophageal sphincter allows reflux, producing heartburn. Caused by progesterone Decreased motility in large intestine causes constipation and hemorrhoids Gallbladder emptying time prolonged—may lead to gall stone formation Increased thirst and appetite Urinary System Frequent urination is common, particularly in the first and third trimesters Urinary stasis predisposition to urinary tract infection (UTI) Increased renal plasma flow Glucosuria may occur; normal finding Bladder Changes Note: A full bladder will prevent the fetal head from descending Neurological System Loss of consciousness Headaches Reflexes (DTRs) Light-headedness/fainting may be due to: Hormones B/P Blood sugar Cardiac problems Anemia Endocrine System Placenta becomes an endocrine organ and produces large amounts of hormones Heat intolerance due to vasodilatation, fetal and maternal heat production Thyroid gland 25% larger during pregnancy; basic metabolic rate increase 25% Oxytocin and prolactin are secreted by the pituitary gland Endocrine System: Placental Hormones 1) Estrogen: increases vascularity. Level remains high during pregnancy 2) Progesterone: Relaxes all smooth muscle. Maintains the endometrium and prevents abortion by relaxing uterine muscles 3) Human Chorionic Gonadotropin (hCG): Hormone measured in pregnancy tests. Stimulates the corpus luteum to produce estrogen and progesterone until the placenta can assume that function 4) Human Placental Lactogen: Acts as a insulin antagonist; increases availability of glucose for fetal growth and development 5) Relaxin: Softens connective tissue and relaxes pelvic joints Metabolic Changes Protein demands increase Carbohydrate demands increase Glycosuria may be present Iron needs increase Water requirements increase Metabolic Changes and Weight Gain Fluid retention common Dependent edema Lower extremities Weight gain should be approximately 25-35 pounds Clients should gain 1 pound per week in the 2nd and 3rd trimesters Nutritional Needs of Pregnancy Must eat nutritious, well-balanced meals Prenatal vitamins usually prescribed. Megadoses of Vitamin A and D found to be teratogenic to fetus Pica: Unexplained urge to eat non-nutritive substances such as dirt, starch, ice, clay, freezer frost. Thought to be related to an iron deficiency Nausea and vomiting are also common. Related to hCG and estrogen. Ginger has been found to be a safe anti-emetic for pregnant women Specific Nutritional Needs Protein 60-65 grams/day Calcium 1,200 mg/day Average of 2,500 calories/day; only 300 additional daily calories required during pregnancy. (A breastfeeding mother requires 500 extra calories daily) Before conception: Folic acid 400 mcg/day which helps prevent neural tube defects such as spina bifida. During pregnancy 600 mcg per day is recommended Dietary Sources of Folic Acid Liver (chicken, turkey, goose, lamb, beef) Fortified cereals and breads Spinach Broccoli Peas Beans Nutritional Concerns Should not consume soft cheeses as they harbor listeria monocytogenes, the organism that causes listeriosis Maternal effects of listeriosis includes meningitis, pneumonia and sepsis Increased risk of delivering stillborn babies Another concern? Fish…mercury poisoning Danger Signs in Pregnancy Danger Sign Possible Cause Gush of fluid from vagina Rupture of membranes Vaginal bleeding Placenta abruption, previa, bloody show Abdominal pain Premature labor, placenta abruption Temperature > 101.0 F Infection Persistent vomiting Hyperemesis gravidarum Visual disturbances Hypertension, preeclampsia Generalized edema Hypertension, preeclampsia Severe headache Hypertension, preeclampsia Epigastric pain Preeclampsia, HELLP Dysuria Urinary tract infection Decreased fetal movement Compromised fetal well-being Mother’s Psychological Response to Pregnancy Ambivalence Acceptance Introversion Mood swings Changes in body image Rubin’s (1984) Developmental Tasks of Pregnancy Ensuring safe passage through pregnancy, labor and birth Seeking acceptance of this child by others Seeking commitment and acceptance of self as mother to the infant (binding in) Learning to give of oneself on behalf of one’s child