NLOA LT3
B.5 Care of the Pregnant woman going through the various stages of pregnancy
Ch.9: Nursing Care During Normal Pregnancy & Care of Developing Fetus
Stages of development
 In just 38 weeks, fertilized egg (ovum) matures from a single-cell to a
fetus ready to born
 Fetal growth and development divided in 3 stages:
I. Pre-embyonic ( 1st 2 weeks, beginning w/ fertilization
a. Fertilization – (also referred to conception and
impregnation) is the union of the ovum and
spermatozoon
 Women’s ovum capable fertilization for only
24 hrs (48 hrs @ most) while a man’s
spermatozoon is about 48 hrs as well
 Total critical time during which sexual
relations must occur fertilization = 72 hours
(48 hrs before ovulation plus 24 hrs
afterward)
 Union of ovum and spermatozoon fuse to
form zygote
o The fertilized ovum has 46
chromosomes
(22
autosomes
autosomes & 1 sex chromosome from
both the sperm & ovum)
 Fertilization is never certain → depends on
3 factors…
o Equal maturation of ovum & sperm
o Ability of sperm to reach ovum
o Ability of sperm to penetrate the zona
pellucida & cell membrane of the
ovum
b. Implantation—contact between the growing structure
& uterine endometrium (approximately 8-10 days
after fertilization)
 Once implanted zygote is called an embryo
 Embryonic (weeks 3-8)
 Fetal (from week 8-birth)
Terms Used to Describe Fetal Growth
 Ovum—from ovulation -> fertilization
 Zygote—from fertilization -> implantation
 Embryo—from implantation -> 5-8 weeks
 Fetus—from 5-8 weeks until term
 Conceptus—developing embryo & placental structures throughout
pregnancy
 Age of viability—the earliest at which fetuses survive if they are born
in generally accepted at 24 weeks, or at the point a fetus weighs more
than 500-600g
Origin of Body Tissue
1. Ectoderm
 CNS
 Sense organs
 PNS
 Mucous membranes of anus,
mouth, nose, mammary glands
 Skin, hair, nails, & tooth enamel
2. Mesoderm
 Connective
tissue,
bones,  Reproductive system
cartilage, muscle, ligaments, &  Heart,
lymph,
circulatory
tendons
systems, & blood cells
 Kidneys, ureters
3. Endoderm
 Lining
of
pericardial  Lower urinary system (urethra
pleura/peritoneal cavities
& bladder)
 Lining of gastrointestinal tract, *All organ systems “complete” at
resp. tract, tonsils, parathyroid, 8 weeks gestation
thyroid, thymus gland
Amniotic Fluid
 Is constantly moving as fetus swallows it absorbing into the fetal
intestine to be transferred in fetal bloodstream → then it goes to the
umbilical arteries to the placenta & is exchanged across the placenta
to mom’s blood stream
 At term, fluid = about 800-2000 mL
o Hydramnios - more than 2000 mL in total or pockets of fluid
>8cm on ultrasound
o Oligohydramnios - reduction in the amount amniotic fluid
 Amniotic fluid index = @ least 5 cm while vertical pocket of amniotic
fluid = >2cm
 Purpose
o Shield fetus against pressure/blow to mom’s abdomen
o Protects fetus from changes in temp
o Aids in muscular movement → allow fetus freedom to move
o Protects umbilical cord from pressure → protecting fetal
oxygen supply
Fetal Developmental Milestones
 End of 4th Gestational Week
o Embryo length=0.75cm; Wt=400mg
o Spinal cord is formed & fused at midpoint
o Head is large in proportion & represents about 1/3 of entire
structure
o The rudimentary heart appears as prominent bulge on the
anterior surface
o Arms & legs are bud-like structures; rudimentary eyes, ears, &
nose are discernable
 End of 8th Gestational Week
o Fetus length=2.5cm; Wt=20g
o Organogenesis (--organ formation) complete
o Heart w/ septum (foramen ovale) & valves, beats rhythmically
SLM
o Facial features discernable; arms & legs developed
o External genitalia forming, but sex can’t be distinguished
o Abd bulges forward because fetus intestine is growing so
rapidly
o A sonogram shows a gestational sac, which is diagnostic of
pregnancy
 End of 12th Gestational Week (1st Trimester)
o Fetus=7-8cm; Wt=45g
o Nail beds are forming on fingers & toes
o Spontaneous movements possible but usually too faint to be
felt by the mother
o Some reflexes, Babinski reflex, are present
o Bone ossification centers begin to form
o Tooth buds are present
o Sex is distinguishable on outward appearance
o Urine secretion begins but may not yet be evident in amniotic
fluid
o The heartbeat is audible through Doppler technology
 End of 16th Gestational Week
o Fetus length=10-17cm; Wt=55-120g
o Fetal heart sounds are audible by an ordinary stethoscope
o Lanugo is well formed
o Both the liver & pancreas are functioning
o The fetus actively swallows amniotic fluid, demonstrating an
intact but uncoordinated swallowing reflex; urine is present
in amniotic fluid
o Sex determined by ultrasonography
 End of 20th Gestational Weeks
o Fetus length=25 cm; Wt=223g
o Spontaneous fetal movements can be sensed by the mother
o Antibody production is possible
o Hair, including eyebrow, forms on head; vernix caseosa begins
to cover the skin
o Meconium is present in the upper intestine
o Brown fat (--special kind of fat that aids in temp regulation,
begins to form behind the kidneys, sternum, & posterior neck)
o Passive antibody transfer from mother to fetus begins
o Definite sleeping & activity patterns are distinguishable as the
fetus develops biorhythms that will guide sleep/wake
patterns throughout life
 End of 24th Gestational Week (2nd Trimester)
o Fetus length=28-36cm; Wt=550g
o Meconium present as far as the rectum
o Active production of lung surfactant begins
o Eyelids open; pupils react to light
o Hearing demonstrated by response to sudden sound
o When fetuses reach 24 weeks, or 500-600g, they have
achieved a practical low-end age of viability if they are cared
for after birth in a modern intensive care nursery
 End of 28th Gestational Week
o Fetus length=35-38cm; Wt=1200g
o Lung alveoli almost mature, surfactant can be demonstrated
in amniotic fluid
o Testes begin to descend into scrotal sac from lower
abdominal cavity
o Blood vessels of retina formed but thin & extremely
susceptible to damage from high oxygen concentrations (an
important consideration when caring for preterm infants who
need oxygen)
 End of 32nd Gestational Week
o Fetus length=38-43cm; Wt=1600g
o Subcutaneous fat begins to be deposited
o Responds to movement to sounds outside mom’s body
o Active Moro reflex present
o Iron stores beginning to be built
o Fingernails reach end of fingertips
SLM
 End of 36th Gestational Week
o Fetus length=42-48cm; Wt=1800-2700g (5-6lbs)
o Body stores of glycogen, iron, carbohydrate, & calcium
deposited
o Additional amounts of subcutaneous fat deposited
o Sole of foot only has 1 or 2 crisscross creases
o Amount of lanugo begins to diminish
o Most fetuses turn into vertex (--head down) presentation
 End of 40th Gestational Week
o Fetus length=48-52cm (crown 2 rump, 35-37cm); Wt=3000g
(7-7.5lb)
o Fetus kicks actively, sometimes hard enough to cause mother
considerable discomfort
o Fetal hemoglobin begins its conversion to adult hemoglobin
o Vernix caseosa starts to decrease after the infant reaches 37
weeks gestation & may be more apparent increase than the
covering of the body as the infant approaches 40 weeks/more
gestational age
o Fingernails extend over fingertips
o Creases on soles of feet cover at least 2/3s of surface
Naegele’s Rule
 Calculating Date of Birth (DOB) by this rule → count backward 3
calendar months from the 1st day of mom’s last menstrual period &
add 7 days
 A pregnancy ending 2 weeks before/2 weeks after calculated DOB is
considered w/in normal limits (38-42 weeks)
Assessment of Fetal Growth & Development
I. Nursing Responsibilities for assessment
 Verifying signed consent forms for any invasive diagnostic
procedures
 Being certain the woman & her support person are aware of
what procedures will entail & any potential risks
 Preparing woman physically & psychologically
 Providing support during procedure
 Assessing both mom & fetal responses during & after
procedure
 Necessary follow-up care
 Managing equipment & specimens
II. Health history
 Pregnancy illness (gestational diabetes/heart disease)
 Drugs
 Nutritional intake
 Cigarette smoking
 Alcohol
 Exercise
III. Physical examination
 Maternal Wt & general appearance
 Bruises? → domestic abuse
 Elevated BP? → hypertension
IV. Estimating fetal health
 Fetal growth
a. Typical Fundal (--top of uterus) Measurements
o Just over symphysis pubis @ 12 weeks
o In-between symphysis pubis & umbilicus @
16 weeks
o @ umbilicus @ 20 weeks
o @ xiphoid process @ 36 weeks
b. McDonald’s Rule—tape measurement from top
notch of symphysis pubis to over the top of the
uterine fundus as a woman lies supine is equal to
the weeks of gestation in
centimeters (cm)
between the 20th & 31st weeks of pregnancy
SLM
 Fetal Well-being
a. Fetal heart rate → heard & counted as early as 10th
-11th week of pregnancy using ultrasound
Doppler technique
o Done routinely @ every prenatal visit past 10
weeks
 Daily fetal movement count (kick counts)
a. Quickening—fetal movement felt by mom
o Can be felt 18-20 weeks of pregnancy & peaks
in intensity 28-38 weeks
o Healthy fetus moves about 10 movements
per hour (mph)
 Decreased movement seen in fetuses
not receiving enough nutrients
because
of
poor
maternal
nutrition/placental insufficiency
b. Kick Counting Test
o Mom lies in left recumbent position after a
meal
o Observe & record # of fetal movement (kicks)
fetus makes until mom has counted 10
movements
o Record time (typically, occurs under an hour)
o If hour passes w/out movement → mom
should walk around a little & then try again
o If 10 movements can’t be felt in 2nd 1-hour
period → telephone primary healthcare
provider (fetal movements vary especially in
relation 2 sleep cycles, mom’s activity, & time
since mom last ate)
 Rhythm Strip Testing → assesses fetal heart rate 4 normal
baseline rate
a. Procedure…
o Place mom in semi-fowlers
o Attach external fetal heart rate monitor
abdominally
o Record fetal heart rate 4 20 minutes
b. What you want…
o Baseline reading → average rate of the fetal
heartbeat (ex: fetal heartbeat is
130
beats/min)
o Variability → small changes in heart rate the
occur from second 2 second if the fetal
parasympathetic nervous system is receiving
adequate oxygen & nutrients
o Want to see 2/more instances of fetal heart
rate acceleration on a 20 - minute rhythm
strip
o Results:
 Absent: No peak-2-trough range is
detectable
 Minimal: An amplitude range is
detectable, but the rate is 5
beats/min or fewer
 Moderate/normal: An amplitude
range is detectable; rate is 6- 25
beats/min
 Marked: An amplitude range is
detectable; rate is >25 beats/min
 Nonstress Testing - measures the response of fetal heart rate
to fetal movements
SLM
a. Attach both a fetal heart rate & uterine contraction
monitor
b. Instruct mom to press the button attached to the
monitor whenever she feels the fetus move
o → creates dark mark on paper tracing those
times mom feels movement
c. Results…
o Is reactive (normal) if fetal heart rate should
increase (called accelerations) approximately
15 beats/min & remain elevated for 15
seconds twice. It should decrease to its
average rate again as fetus stops moving
o Is nonreactive (abnormal) if no accelerations
occur or if there is low short- term fetal heart
rate variability (<6 beats/min) throughout the
testing period
 If fetal movement does NOT occur
after 20 minutesfetus may just be
sleeping → give carbohydrate snack
(popsicle)
to
increase
fetal
movement or….
 Vibroacoustic stimulation - acoustic
stimulation w/ a stimulator is applied
to mom’s abdomen 2 produce a sharp
sound to wake fetus & get him/her
moving
o Testing is done for 20 minutes
o RESTING BETWEEN (110-160BPM)
 Ultrasonography - measures response of sound waves against
solid objects
a. Is used 4…
o Diagnose pregnancy as early as 6 weeks
gestation
o Confirm presence, size, & location of placenta
& amniotic fluid
o Establish fetus is growing & has no gross
anomalies
o Establish sex
o Establish presentation & position of fetus
o Predict gestational age by measurement of
biparietal diameter of head/crown 2 rump
measurement
o Discover complications of pregnancy, genetic
disorders, & fetal anomalies
o After birth, used 2 detect retained placenta or
poor uterine involution in new mom
b. Better results if mom has full bladder → ask her to
drink full glass of water every 15 minutes beginning
90 minutes before procedure & don’t void till after
c. Procedure…
o Expose mom’s abdomen
o Gel is applied to abdomen
o Transducer applied to abdomen & moved
horizontally & vertically until uterus &
contents are fully visualized
Types
of ultrasonography
d.
o Biparietal Diameter—ultrasonography used to
predict fetal maturity by
measuring
biparental
diameter
(side-2-side
measurement) of fetal head
o Doppler Umbilical Velocimetry—measures
velocity RBCs in uterine & fetal vessels travel
o Placenta Grading for Maturity
 0: 12-24 weeks
 1: 30-32 weeks
 2: 36 weeks
SLM
 3: 38 weeks → Grade 3 placenta
suggest fetus is mature
o Amniotic Fluid Volume
 Between 28 & 40 weeks total pockets
of amniotic fluid revealed by
sonogram average 12-15 cm
 Amount
>20-24cm
indicates
hydramnios (--excessive fluid)
 Amount
<5-6cm
indicates
oligohydramnios
(--decreased
amniotic fluid)
 Biophysical Profile—focuses on 5 different areas (fetal
reactivity, fetal breathing movement,
fetal body
movement, fetal tone, & amniotic fluid volume
a. Score of 8-10 → fetus considered 2 be doing well
b. Score of 6 → suspicious
c. Score of 4 → fetus potentially in jeopardy
 Magnetic Resonance Imaging → can identify structural
anomalies/soft tissue disorders (good especially ectopic
pregnancy/trophoblastic disease)
 Maternal Serum Analysis
a. Maternal Serum α-fetoprotein
o Level abnormally high if fetus has open
spinal/abdominal wall defect because more
AFP to enter mother’s circulation than usual
o Level is low if fetus has chromosomal defect
like Down syndrome
b. Maternal Serum 4 Pregnancy-Associated Plasma
Protein A--protein secreted by placenta
o Low levels associated w/ fetal chromosomal
anomalies
c. Quadruple Screening—analyzes for indicators of
fetal health: AFP, unconjugated estriol (UE), hCG, &
inhibin A
d. Fetal Gender can be determined @ about 7 weeks
w/ maternal serum
 Invasive Fetal Testing
a. Chorionic villi sampling
b. Amniocentesis—pocket of amniotic fluid is located
by sonogram & small amount of fluid is removed by
needle aspiration
o Needed empty bladder to perform &
ultrasound guiding for needle placements
c. Percutaneous Umbilical blood sampling—aspiration
of blood from umbilical vein for analysis
o Fetal heart rate & uterine contractions need
to be monitored before & after
the
procedure to certain uterine contractions are
not beginning
d. Fetoscopy - fetus is visualized by inspection through
a fetoscope allowing direct visualization of amniotic
fluid & fetus
o Earliest time in pregnancy a fetoscopy can be
performed 16th or 17th weeks.
o Procedure…
 Mother is draped for amniocenteses
 Local anesthetic is injected into
abdominal skin
 Fetoscopy inserted through a minor
abdominal incision
 If fetus very active, meperidine
(Demerol) may be administered to
the woman to help sedate fetus to
SLM
avoid fetal injury by scope & allow for
better observation
o Small risk of premature labor or amnionitis
(infection of the amniotic fluid)
2020 Health Goals
 Reduce the fetal death rate (death between 20 and 40 weeks of
gestation) to no more than 5.6 per 1,000 live births from a baseline of
6.2 per 1,000.
 Reduce low birth weight to an incidence of 7.8% of live births and very
low birth weight to 1.4% of live births from baselines of 8.2% and
1.5%.
 Increase the proportion of women of childbearing potential with an
intake of at least 400 mg of folic acid from fortified foods or dietary
supplements from a baseline of 23.8% to 26.2%
NLOA LT3
B.5 Care of the Pregnant woman going through the various stages of pregnancy
CH.10: Nursing Care Related to Psychological & Physiological Changes of
Pregnancy
Psychological Tasks
I. 1st trimester tasks: Accepting the Pregnancy
 The woman & her partner both spend time recovering from
the surprise of learning they are pregnant & concentrate on
what it feels like 2 be pregnant. Common reaction is
ambivalence— feeling both pleased & not pleased about
pregnancy
II.
2nd trimester task: Accepting the fetus
 Woman & her partner move through emotions such as
narcissism & introversion as they concentrate on what it will
feel like to be a parent. Role-playing & increased dreaming are
common
III.
3rd trimester task: Preparing for the baby & end of pregnancy
 Woman & her partner prepare clothing & sleeping
arrangement for baby but also grow impatient as they ready
themselves for birth
Assessing Events Contributing to Difficulty Accepting a Pregnancy
 Pregnancy is unintended
 Learning the pregnancy is multiple, not single
 Learning fetus has developmental abnormality
 Pregnancy is <1 year after previous pregnancy
 Family has to relocate during pregnancy → need new support people
 Woman has role reversal (support person becomes dependent/vice
versa
 Main family support person suffers job loss
 Woman’s relationship ends because of partner infidelity
 Major illness in self, partner, or relative
 Loss of significant other
 Complication of pregnancy occur (like severe hypertension)
 Woman has series of devaluing experiences (like failure @
work/school)
Emotional Responses to Pregnancy
 Grief—mom has to give up irresponsible/carefree girl & sleeping
soundly for next couple years
 Narcissism—self-centeredness is early reaction pregnancy → stop
harmful activities to protect self
 Introversion vs extroversion
o Introversion—turning inward to concentrate on oneself &
one’s body
o Extroversion—becoming more active, healthier, and more
outgoing than before
 Body image & boundary
o Body image—way your body appears to yourself
o Body boundary—zone of separation you perceive between
yourself and objects or other peopl
 Ex: women walking farther away from table than
necessary to avoid it
 Stress
 Depression—feeling of sadness marked by loss of interest in usual
things, feelings of guilt or low self- worth, disturbed sleep, low energy,
& poor concentration
 Couvade syndrome—Partner experiencing same physical symptoms as
mom, like N/V & backache to same degree or more intensely
o Can result from stress, anxiety, or empathy for mom
 Changes in expectant family
o Older children need preparation about the baby
o Younger children may need to be assured that baby is
addition to the family & won’t replace them
Presumptive Indication of Pregnancy
 **Think Subjective!! → could be pregnancy but could be something
else
o Breast changes
o N/V
o Amenorrhea
o Frequent urination
o Fatigue
o Uterine enlargement
o Quickening
o Linea nigra—line of dark pigment forms on abdomen
o Melasma—dark pigmentation forms on face
o Striae gravidarum—stretchmarks
Probable Signs of Pregnancy
 **Think objective!! → you can see it & it can be verified
o Maternal serum test
o Chadwick’s sign—color change of the vagina from pink to
violet
o Goodell’s sign—softening of the cervix
o Hegar’s sign—softening of the lower uterine segment
o Sonographic evidence of gestational sac
o Ballottement—when lower uterine segment is tapped on
bimanual examination ( 2 finger examination), fetus can be
felt to rise against abdominal wall
o Braxton Hicks contractions—periodic uterine tightening
occurs
o Fetal outline felt by examiner
Positive Signs of Pregnancy
 ** Only 3; Finds that can be determined!!
o Sonographic evidence of fetal outline
SLM
o Fetal heart audible
o Fetal movement felt by examiner
Physiological Changes of Pregnancy
 Changes in Breasts
o Feeling of fullness, tingling, tenderness
o Breas size increase → d/t growth of mammary alveioli & in fat
deposits
o By 16th week → colostrum expelled from nips
o Montgomery’s tubercles (--sebaceous glands of areola)
enlarge → keeping nipples from cracking & drying
 Systemic Changes
a. Reproductive system (p.213; Table 10.3)
o Uterine changes → increase length, depth, width, Wt,
wall thickness, & volume
o Amenorrhea → absence of menstrual flow
o Cervical changes → operculum, Goodell’s sign, cervical
ripening
o Vaginal changes → vaginal walls & underlying tissues
increase in size, muscle fibers loosen, color change 2
violet, pH 4or 5
o Ovarian changes → ovulating stops d/t active feedback
loop of estrogen &
o progesterone → cause pituitary to halt production of FSH
& luteinizing hormone
b. Endocrine system (p.217; Table 10.4)
o Placenta → produces estrogen & progesterone &
hCG/other hormones impact growth of uterus & body &
timing/onset of labor
o Pituitary gland → produces prolactin & oxytocin late in
pregnancy
c.
d.
e.
f.
g.
SLM
o Thyroid & parathyroid glands → increase hormone levels
that increase basal metabolic rate by 20% → cause
emotional liability, preparation, tachycardia, palpitations
o Adrenal glands → increase corticosteroid levels &
aldosterone →inhibit immune response  prevents fetus
rejection
o Pancreas → increase insulin production but insulin less
effective → allows glucose (increase levels) in blood
(mom’s) 4 fetus
Immune systems
o Competency decreases → mom prone to infection
o IgG is decreased
o WBC increased → no cause; just rises
Integumentary system
o Striae gravidarum
o Diastasis possible
o Linea nigra
o Melasma
o Vascular spiders
o Palmar erythema
o Sweat glands increase
o Scalp hair growth increase
Respiratory system (p.218; Table 10.5)
o Marked congestion & SOB d/t increase in estrogen
o Pt with asthma might be more effected
Temperature
o Slight increase temp @ early pregnancy but decrease as
placenta takes over
Cardiovascular system (p. 219; Table 10.6)
o Cardiac output 25-50%
o Heart rate increased 80-90 beats/min
o Blood volume increases
o Leukocytes increases 2 25,000-30,000
o Blood pressures → decreases in 2nd trimester, rises 2
pre-pregnancy level in 3rd trimester
o Iron → need 800 µg daily
o Folic acid → need 400 µg daily
o Peripheral blood flow → impaired blood return from
lower extremities through the pelvis (d/t weight of the
baby)
o Supine hypotension syndrome—lying supine compresses
vena cava, blood return 2 heart → lie on left side or put a
pillow under mom’s hip
o Blood constitution → increased clotting factors,
platelets, WBCs, lipids & decreased protein levels
h. Gastrointestinal system
o N/V early pregnancy → subsides in 3 months
o Voracious appetite
o Heartburn
o Constipation, flatulence, hemorrhoids
o Subclinical jaundice
o Hypertrophy of gum lines & bleeding of gingival tissue, &
increased saliva formation
i. Urinary system
o Fluid retention d/t increased aldosterone production
o Renal function
o Bladder capacity increased by 1000 mL
o Frequency increases to 10-12x/day at end of pregnancy
o Ureter & bladder function → increased urinary output &
increased urinary stasis (bladder infections &
pyelonephritis more likely)
j. Musculoskeletal system
o Calcium & phosphorus needs increase because of fetal
skeleton development
o Progressive cartilage softening for passage of baby
through pubis d/t Relaxin
o Possible back/girdle pain
o Possible creation of lordosis (pride of pregnancy stance)
SLM