1
Normal Pregnancy
Lecture 2
I.
Physiological Changes during Pregnancy
A.
Reproductive system and breasts
1.
Uterus
a.
increased vascularity/dilation of blood vessels
-60 gm(2oz) to 1100 gm(2.2 lb)
b.
hyperplasia-new muscle fibers/tissue
c.
hypertrophy-enlargement of pre-existing fibers
d.
development of the decidua
e.
growth changes R/T stimulation from high levels
of estrogen/progesterone
f.
shape changes
-7 weeks-egg size
-10 weeks-orange size
-12 weeks-grapefruit size
-initially pear shaped
-2nd trimester-globular
-term-ovoid
g.
position
-12 weeks-at or above the symphysis pubis
-16 weeks-between SP and umbilicus
-20 weeks-at the umbilicus
-36 weeks-almost to the xiphoid process
h.
lightening
-nulliparas-2 weeks before term
-multiparas-when labor starts
i.
ballottement-palpate floating structure
j.
altered center of gravity as enlarging uterus tilts
against the anterior abdominal wall
k.
Braxton-Hicks contractions
-start around 4 months
-irregular
-painless
-help to facilitate blood flow
l.
uteroplacental blood flow
-uterine blood flow increases
-more oxygen is extracted from the blood in the
latter part of the pregnancy
-at end of pregnancy, 1/6 of total blood volume
within the vascular system of uterus
m.
Hegar’s sign-6 weeks-softening of lower uterine
Segment
2
B.
2.
Cervix
a.
Goodell’s sign-softening of cx-6 weeks
b.
Chadwick’s sign-bluish cast-8 weeks
c.
friability increases
d.
operculum-mucus plug-endocervical glands
3.
Vagina
a.
increased vascularity
b.
leukorrhea-thick white vaginal discharge
c.
change in pH leads to higher risk for yeast inf.
4.
Breasts
a.
start to change by week 6 R/T hormone surge
b.
increase in sensitivity, breast and nipple size
c.
increase in feeling firm, heaviness, nipple erect
d.
nipples and areola become more pigmented
e.
vessels beneath the skin dilate-more visible
f.
striae gravidarum (stretch marks) may appear
g.
may leak colostrum as early as 16 weeks
Cardiovascular system
1.
Heart
a.
slight hypertrophy R/T increase blood flow
b.
position change R/T diaphragm position
c.
transient murmurs may be auscultated
d.
cardiac output
-increased 30-50% by week 32
-only 20% increase by week 40
-R/T increased stroke volume and heart rate
e.
pulse rate increases 10-15 bt/min
2.
Blood
a.
increase in blood volume 40-50% (1500ml)
-plasma-1000 ml
-RBC’s-450 ml
b.
physiological anemia-hemodilution of cells
-anemic if Hgb under 10g/dl, Hct under 35%
c.
increase in WBC’s
d.
coag times
-circulation time decreases by week 32
near normal at term
-↑ in clotting factors leads to ↑ tendency for
blood to coagulate
-↑ risk for thrombosis-esp. with C/S
3.
Blood Pressure
a.
1st trimester-no change in BP
b.
2nd trimester-BP ↓ 5-10 mm Hg
3
c.
d.
C.
D.
3rd trimester-BP returns to 1st trimester values
supine hypotensive syndrome
-if they lie on their backs
-at 5 minutes, reflex bradycardia
-CO ↓ by half
-woman feels faint
Respiratory system
1.
flaring of the rib cage
2.
shift from abdominal to thoracic breathing
3.
elevated maternal oxygen requirements
a.
acceleration in metabolic rate
b.
the need to add to the tissue mass of uterus
c.
fetal needs
4.
↑ vascularity of the upper resp. tract
a.
nasal and sinus stuffiness-(estrogen-induced)
b.
epistaxis (nosebleeds)
c.
changes in the voice
5.
pulmonary function
a.
deep breathing-↓ airway resistance-Progesterone
b.
↑ tidal volume
c.
resp rate ↑ 2 breaths/min
d.
↑ awareness to breath
e.
sensitivity in medulla to CO2-↑ depth, rate
6.
basal metabolic rate
a.
↑ 15-20% by term
b.
reflects ↑ in oxygen demand
c.
may experience heat intolerance R/T excess
heat from ↑ BMR
7.
acid-base balance
a.
pregnancy is a state of resp. alkalosis
compensated by mild metabolic acidosis
b.
facilitates maternal-fetal O2-CO2 transfer
Renal system
1.
anatomic changes
a.
↑ estrogen and progesterone = ↑ uterus size and
blood volume
b.
dilations of ureters, pelvis, renal calyces→ large
amt. of urine
c.
urine flow rate slowed→stasis/stagnation→
medium for bacteria
4
d.
e.
f.
g.
E.
tubular reabsorption impaired→glucose ↑ in urine
→more alkaline urine
urinary frequency from ↑ in bladder sensitivity
and compression from uterus
2nd trimester, bladder pulled up into the
abdomen
urethra lengthens-possible problem with cath
2.
functional changes
a.
↑ in GFR
b.
most efficient in L lateral-↑ perfusion to kidneys
3.
fluid and electrolyte balance
a.
↑ tubular reabsorption to maintain needed Na
level
b.
may be overstressed by excessive Na intake
c.
pooling of fluids in legs = less blood flow to kidneysbetter to elevate legs than diuretics
d.
slight protein leakage +1 ok
Integumentary
1.
hyperpigmentation
a.
caused by stimulation of anterior pituitary
hormone melanotropin
b.
chloasma=brownish facial pigmentation-intensified
by sun
-usually fades after pregnancy
c.
darkening of nipple, areola, vulva, thighs
d.
linea nigra=dark vertical line from symphysis
pubis to fundus
-starts as linea alba-before pigmentation
-not present in all pregnant women
e.
striae gravidarum-stretch marks
-on abdomen, breasts, thighs
-separation of collagen
-50-90% of women will have this
2.
other changes
a.
angiomas-vascular spiders
b.
palmar erythema-blotches on hands
c.
pruritus
d.
gum hypertrophy-bleeding gums
e.
accelerated nail growth
f.
hirsutism-excessive hair growth
g.
↑ blood supply = ↑ perspiration
5
F.
G.
H.
Musculoskeletal
1.
↑ lordosis-center of gravity is more forward
2.
relaxin, an ovarian hormone, helps with relaxation and
increased mobility of pelvic joints
-waddling gait
3.
diastasis recti abdominis-persistent separation of
muscles of the abdominal wall
Neurologic system
1.
compression of pelvic nerves may cause sensory
changes in legs
-sciatica
2.
edema on peripheral nerves-carpal tunnel syndrome
a.
burning, paresthesia
b.
pain in the hand, radiating to the elbow
3.
↑ tension headaches
4.
syncope common in early pregnancy
Gastrointestinal
1.
↓ peristalsis→constipation, N & V
2.
bleeding of gums/problems of the mouth
a.
caused by rising level of estrogen
b.
ptyalism-excessive salivation
3.
15-20% will have problem with hiatal hernia
4.
↑ estrogen = ↓ secretion of HCl acid
5.
6.
↑ progesterone = ↓ stomach emptying time=heartburn
↑ gallbladder distention→prolonged emptying time and
thickening of bile→development of gall stones
7.
pruritus gravidarum-may be R/T accumulation of bile
8.
change in appetite/food consumption
a.
change in CHO, protein, fat metabolism
b.
pica-craving for non-food material
c.
morning sickness-usually ends by 2nd trimester
6
I.
II.
Endocrine system
1.
↑ secretions of pituitary hormones:
a.
thyrotropin
b.
FSH/LH
c.
prolactin
d.
vasopressin (antidiurectic hormone)
e.
oxytocin
2.
↑ secretions of thyroid hormones:
a.
thyroxine
b.
triiodothyronine
3.
↑ secretion of parathyroid hormones
4.
↑ secretion of the adrenal hormones:
a.
cortisol-r/t ↑ estrogen-regulates CHO/prot meta.
b.
Aldosterone-protective response to Na excretion
5.
↑ secretion of insulin from the pancreas
Diagnosis of Pregnancy
A.
Gravidity and Parity
1.
gravida-woman who is pregnant
a.
nulligravida-never been pregnant
b.
multigravida-2 or more pregnancies
c.
primigravidas-first pregnancy
2.
parity-number of births after 20 weeks gestation
a.
doesn’t matter if born alive or stillborn
b.
nullipara-never completed a pregnancy
c.
multipara-completed 2 or more births at
more than 20 weeks gestation
d.
primipara-completed one birth > 20 weeks
e.
not the number of fetuses born
3.
preterm-before 37 weeks gestation
4.
postdates-after 42 week of gestation
5.
viability-capacity to live outside the uterus
a.
somewhere between week 22-24
b.
fetus greater than 500 gms
6.
5-digit system
a.
gravida
b.
term-para
c.
preterm
d.
abortions-spontaneous or therapeutic
7
e.
B.
living children
Pregnancy tests
1.
hCG-human chorionic gonadotropin
a.
production starts with implantation
b.
found in blood 6 days after conception
c.
in urine by day 26
d.
level rises until peak at day 60-70 in pregnancy
then falls-lowest level at 100-130 days
2.
ELISA-enzyme linked immunosorbent assays
a.
color change with hCG bonding
b.
result as fast as 5 minutes
c.
detect hCG in 7-9 after conception
C.
Nagele’s Rule
1.
First day of LMP→subtract 3 months→add 1 week
D.
Classic indicators
1.
presumptive
a.
amenorrhea-week 4
b.
quickening-weeks 16-20
c.
breast changes-weeks 3-4
d.
N & V-weeks 4-14
e.
urinary frequency-weeks 6-12
f.
fatigue-week 12
2.
probable
a.
Goodwell’s sign-week 5
b.
Chadwick’s sign-weeks 6-8
c.
Hegar’s sign-weeks 6-12
d.
+ pregnancy test (serum)-weeks 4-12
e.
+ pregnancy test (urine)-weeks 6-12
f.
Braxton-Hicks contractions-week 16
g.
abdominal enlargement
h.
ballottement-weeks 16-28
i.
palpable fetal outline
3.
positive
a.
visualization of fetus on U/S-weeks 5-6
b.
fetal heart tones by U/S-week 6
c.
fetal heart tones by Doppler-weeks 10-17
d.
FHT by stethoscope-weeks 17-19
e.
fetal movements palpated-weeks 19-22
f.
visibility-late pregnancy
8
III.
First Trimester
A.
History taking
1.
reasons for seeking care
a.
may have other concerns besides the preg.
b.
use open ended questions
B.
2.
current pregnancy
a.
review signs and symptoms
b.
evaluate how pt is coping
3.
OB/Gyn history
a.
menstrual history
b.
contraceptive history
c.
any infertility concerns
d.
any Gyn concerns
e.
ck last Pap and cultures for STI’s
4.
medical history
a.
pre-existing medical conditions/concerns
b.
history of surgical procedures
5.
nutritional history
a.
assess for food allergies
b.
any special dietary concerns
6.
history of drug use
a.
past and present use of legal medications
b.
h/o illegal drug use
7.
family history
8.
psychosocial history
a.
situational factors
b.
any previous care of infants
c.
coping mechanisms
9.
history of physical/verbal abuse
a.
abuse may increase during pregnancy
b.
need immediate clinical intervention
Physical examination
1.
vital signs
2.
head to toe assessment
3.
pelvic exam with vaginal/abdominal U/S
4.
review of systems
9
a.
b.
C.
D.
assess each sign/symptom for onset, character,
and course
assess for aggravating/alleviating factors
Laboratory tests
1.
blood work up
a.
CBC
b.
blood type and Rh factor
c.
rubella titer
d.
HIV screen
e.
HbsAG screen
f.
RPR/VDRL
g.
Tay-Sachs
h.
Sickle-cell
i.
glucose tolerance test
2.
urine screen
a.
urinalysis with culture
b.
UDAP
3.
pelvic
a.
Pap smear
b.
cultures for STI’s
4.
TB skin test
5.
screening for fetal chromosome anomalies
a.
NT-nuchal translucency (fetal nuchal fold)
b.
serum testing for free beta hCG and PAPP-A
c.
↑ NT, ↑ free beta hCG, and ↓ PAPP-A can
suggest aneuploidy
Priority patient education topics
1.
schedule of visits
2.
rationale for labs
3.
Kegel exercises for pelvic floor
4.
review nutritional needs
5.
ok to travel and continue exercise as comfortable
6.
ck all use of medications with your provider-even OTC
a.
will start on PN vitamins with folic acid
b.
iron tabs prn anemia
7.
immunizations
10
a.
b.
IV.
ok if killed-flu, DT, Hep B, rabies (Tdap-after 26 wks)
no ok if live-measles, MMR, C Pox, mumps, polio
8.
alcohol, tobacco usage→ PROM, PTL, abruption
9.
tips to help with fatigue, N & V
Second trimester
A.
Ongoing care
1.
physical examination
a.
weight-approx. 1 lb per week past 1st trimester
b.
BP-watch for ↑ 140/90 or ↑ systolic 30>baseline
↑ diastolic 15>baseline
c.
dip urine for protein, glucose
d.
auscultate FHT
e.
assess breasts/nipples
f.
review birth plan
g.
ask about quickening-approx 20 weeks
2.
pertinent laboratory tests
a.
Quad Screen-done between 15-20 weeks:
1. MSAFP
2. hCG
3. UE-unconjugated estriol
4. inhibin-A
5. Assessing for possible spina bidifa, Down
syndrome, or other chromosomal defects
b.
follow-up on any prior test results
c.
amniocentesis
3.
potential complications
a.
bleeding
b.
decreased fetal activity
c.
PIH/GHTN
-headache
-swelling of face/fingers
-epigastric pain
-muscular irritability
-visual disturbance
d.
PROM
-amniotic fluid discharge
e.
infections
-chills
-fever
-burning with urination
11
V.
4.
fundal height
a.
fundal height (from symphysis pubis to top of
uterus) # in cm = weeks of gestation
(weeks 18-36)
b.
stable or decreased fundal height-? IUGR
c.
excessive increase-multifetal gestation,
hydramnios
5.
gestational age
a.
determined from LMP, contraceptive history, and
pregnancy test results
b.
usually confirmed with U/S
6.
interventions for discomforts
a.
assess skin changes
b.
headaches-rest, hydration, acetaminophen
c.
constipation-hydration, exercise, prune juice
d.
varicose veins-elevate legs, support stockings
e.
food cravings-6 small meals-keep BS level even
f.
heartburn-small meals, sit up after eating, ↓ spicy
foods, antacids
g.
joint/ligament pain-support garments
7.
education topics
a.
warning signs
b.
assess nutrition status
c.
hygiene-R/T increase perspiration
d.
UTI prevention-hydration, freq. Voids
e.
breast shields for inverted nipples
-too much stimulation can lead to PTL
f.
dental care
g.
R&R
h.
risk factors at work-i.e. caustic agents
i.
travel-if not high risk, ok
j.
avoid alcohol, cigarettes
k.
need for support garments
Third Trimester
A.
History and physical
1.
vaginal exams may begin in the last month
2.
B.
assess for S & S of PTL, PIH, GDM
Laboratory tests
1.
Group Beta strep culture-35-37 weeks
2.
rhogam injection-26-28 weeks for Rh - moms
12
3.
glucose tolerance test
4.
may retest for STI’s
C.
Interventions for discomforts (same as 2nd trimester)
D.
Family adjustments
1.
maternal tasks
a.
accept the concept of being pregnant
b.
may dislike pregnancy but love child
c.
if happy about pregnancy-usually have
higher self-esteem, confidence
d.
dealing with rapid mood changes
e.
may have feelings of ambivalence
f.
prepare for childbirth
g.
practice of mothering role
h.
may need to work on communication with
family members
i.
work on relationship with her mother
j.
trust and share with the partner
k.
work on sexual relationship with spouse
l.
3 phases of developmental pattern
-accept biological fact-“I am pregnant”
-accepts need to nurture fetus-“I am going to
have a baby”
-prepares for role of parent-“I am going to be a
mother”
2.
paternal tasks
a.
acceptance of pregnancy
-may express joy or dismay
-unwanted vs. unplanned
-affairs/battery of spouse
b.
couvades
-observance of rituals = transition to fatherhood
-may have psychosomatic symptoms of preg.
c.
participate in childbirth education
d.
identify with father role
-may be influenced by how their father was
e.
reordering personal relationships
-may see fetal as a rival
-may feel wife is too dependent on MD/CNM
f.
observer vs. expressive vs. instrumental
g.
establish relationship with fetus
-kiss or rub abdomen
-talk to fetus
-assist with preparing baby’s room
13
E.
3.
sibling adjustment
a.
first crisis for a child
b.
may feel replaced
c.
need to prepared to become the big sister or
brother
d.
sibling classes
4.
grandparent responses
a.
if only in 30’s or 40’s-may not be as interested
b.
may be non-supportive-try to decrease new
mother’s self esteem
c.
most see the pregnancy as a renewal of their
youth
d.
continuity of past and present
e.
may help bridge a previous estrangement
f.
now have classes on being a grandparent
5.
other psychosocial issues
a.
adolescent mothers
-most pregnancies unintended-80%
-40% will end in abortion-EABs & SABs
-higher rates for Hispanics, African-Americans
-most unmarried, low SES
-more likely not to receive PN care
-RN needs to encourage PN visits, nutritional
guidelines, and social service consult
b.
older mothers
-multips-pregnancy may be surprise-thought
to have started menopause
-may feel separated from younger moms
-nullips-pregnancy is a chosen event
-may feel isolated from older friends
-usually seek genetic counseling and PN care
-higher risk for adverse perinatal outcomes
Education topics
1.
preparation for childbirth classes
a.
prenatal yoga
b.
Lamaze
c.
prenatal breast feeding
d.
cesarean information
2.
review warning signs
3.
signs and symptoms of labor
14
4.
VI.
other potential complications
a.
PIH
b.
PTL/PROM
c.
bleeding
d.
↓ FM
Ongoing safety issues
A.
Travel/exercise
1.
use common sense
a.
no prolonged use of hot tubs
b.
high risk for clots in legs if not moving around
1.
walk around the plane during long trips
2.
stop the car every few hours for stretch
B.
C.
2.
should avoid air travel after the 7th month
3.
MVA-most common cause of fetal death-seatbelts
4.
continue with non-weight bearing exercises
Substance abuse
1.
no such thing as a safe level of drugs
2.
alcoholism-risk of fetal alcohol syndrome, abortion
-problem with using antabuse-suspected teratogenic
3.
smoking-retards fetal growth and development
a.
↑ risk for PTL, PROM, abruption
b.
second-hand smoke just as bad
4.
caffeine-since it’s a stimulant, best to limit-300 mg/day
a.
risk of SAB
b.
risk of growth restriction
Vaccinations-ok if not a live vaccine
1.
Flu vaccine-any time during pregnancy-no preservative
2.
Tdap
a.
administer with every pregnancy-regardless of
previous Tdap history
b.
optimal timing-27-36 weeks gestation
c.
timing allows for maximum maternal antibody
response and passive antibody transfer to infant
15
VII.
Multifetal pregnancies
A.
Maternal concerns
1.
blood volume ↑→↑ strain on CV system
B.
2.
↑ anemia
3.
↑ uterine distention→separation of abdominal muscles
4.
↑ risk for placenta previa
5.
↑ for separation of placenta
6.
lack of emotional preparement
a.
will need additional education and support
b.
possible need for selective reduction
7.
↑ strain on finances, space, workload, and relationships
Fetal concerns
1.
risk of prematurity
2.
PROM
3.
types of twins
a.
dizygotic-from 2 fertilized ova/2 spermatozoa
1.
2 placentas
2.
2 chorions
3.
2 amnions
4.
there will be 2 corpus luteum seen
b.
monozygotic-originating from one fertilized ovum
1.
dichorionic-diamniotic twins (20-30%)
-if division 3 days after fertilization
-may have separate or fused placentas
-# of chorions=# of placentas
(don’t know if identical or fraternal twins until
delivery)
2.
monochorionic-diamniotic
-if division 5 days after fertilization
3.
monochorionic-monoamniotic
-if division 7-13 days after fertilization
-rarest
c.
↑ risk of congenital malformations-in monozygotic
twins, ie: 2-vessel cord
d.
twin to twin shunting
4.
delivery complications
16
VIII.
Cultural variations during the prenatal period
A.
Examples of cultural variations
1.
belief of whether pregnancy is state of illness/health
2.
behavioral expectations of mother/provider
3.
dietary prescriptions/restrictions
a.
warm vs. cold
b.
like to like
c.
pica
4.
activity restrictions
5.
availability of advice/if advice is sought at all
6.
consideration of modesty/religion
a.
clothing
b.
amulets, beads
7.
pain
a.
b.
c.
d.
inevitable, to be endured
can be avoided completely
punishment for sin
can be controlled
8.
no tying of knots-leads to knot in umbilical cord
9.
knife under bed to cut the pain
10.
specific groups
a.
Mexicans
-stoic until just before delivery
-avoid eclipse of moon-cleft palate
-everybody present at delivery
b.
Middle Eastern
-only female attendants
-FOB usually not at delivery
c.
Asian
-prefer warm fluid
-natural childbirth
-labor in silence
-may eat during labor
-FOB may or may not be present
17
B.
Nursing care
1.
support cultural belief-offer alternatives
2.
IX.
encourage patients to participate in medical
decisions
Maternal Nutrition
A.
Nutritional requirements
1.
energy needs-additional 300 kcal greater than
pre-pregnancy
2.
protein
a.
needed for growing fetus
b.
milk, meat, eggs, cheese-complete proteins
c.
only slightly higher need than non-pregnancy
3.
fluids
a.
b.
c.
d.
4.
recommend 8-10 glasses (2-3 liters)
caffeinated drinks don’t count-diuretic
may be good to avoid artificial sweeteners
proper hydrations helps prevent headaches,
constipation, and uterine cramping
minerals and vitamins
a.
iron
-needed for fetus and expansion of maternal
RBC mass
-poor iron intake/absorption = iron deficiency
-if diagnosed with anemia-extra iron supplements
and iron-rich diet
-iron deficiency can lead to:
-maternal: cardiac failure, PP infections,
poor wound healing, death
-fetal: PTL, low-birth weight infant
-deficiencies more common in teen moms and
African-Americans
b.
calcium
-no change in DRI for calcium
-1000 mg daily if 19 yrs or older
-1300 mg daily if under 19
-if lactose-intolerant, seeks non-dairy sources of
calcium
-may need dietary supplement containing
600 mg calcium
-helps prevent leg cramps from imbalance of
calcium/phosphorus ratio
c.
sodium
-slight increase in need
18
d.
e.
f.
B.
-essential for maintaining water balance
-restriction only needed in women with
HTN, renal or liver failure
zinc
-deficiency associated with CNS malformations
-needed for protein metabolism
-if pt on high-dose iron supplements, needs
additional zinc supplement
fat-soluble vitamins-A, D, E, K
-chronic overdoses can lead to toxic levels
-Accutane-if used for cystic acne, may cause
multiple birth defects
-neonatal hypocalcemia noted in areas where
mother’s skin lacked access to sunlight
-Vit. K.-for synthesis of prothrombin
water-soluble vitamins-B, C
-readily excreted in urine so needs frequent
intake
-Folic acid
-need 50% more folic acid than nonpregnancy
-400-800 mcg daily
-CDC-50-70% of NTD (neural tube defect) &
anaencephaly ↓ with adequate folate
Weight gain
1.
1st trimester-5 lbs (1-2 kg)
2nd-3rd trimester-1 lb/week (0.44 kg/week)
2.
normal BMI-11.5-16 kg (25-35 lbs)
underweight-12.5-18 kg (28-40 lbs)
overweight-7-11.5 kg (15-25 lbs)
obese-7 kg (≤ 15 lbs)
3.
1st trimester-development of fetal tissues
2nd and 3rd trimester-growth of fetal tissues
C.
Cultural differences
D.
Nutritional risk factors
1.
Vegetarian
2.
Pica
3.
Lactose Intolerant
4.
Anorexia/Bulimia
01/16