PRENATAL PERIOD
FIRST, SECOND AND THIRD TRIMESTERS OF PREGNANCY
FIRST TRIMESTER OF PREGNANCY
 The first trimester (from 0-12 Weeks) allows the pregnant woman’s body to undergo many changes as it adjusts to the growing
baby.
 It is important to understand that these are all normal events and that most of these discomforts will go way as the pregnancy
progresses.
 So included here are some of the symptoms experienced during pregnancy and how best to deal with them:
– Breast changes
– Tiredness
– Mood Changes
– Nausea and Vomiting
– Frequency of Urination
– Gastrointestinal Symptoms
– Dizziness
– Varicose Veins and Hemorrhoids
– Leg Cramps
– Increased heart rate
SECOND TRIMESTER OF PREGNANCY
 The second trimester (13-28 Weeks) is the most physically enjoyable for most women.
 While some symptoms such as a morning sickness and nausea can abate, new ones can begin.
 What follows is a list of changes that could be seen in a pregnant woman’s body during this trimester.
– Appetite Increase
– Increase belly size, stretch marks and skin changes
– Abdominal and low back pain
– Return to normal urination frequency
– Nosebleeds and gum bleeds
– Vaginal Discharge
– Tingling and Itching
– Continuation of other symptoms
THIRD TRIMESTER OF PREGNANCY
 As your fetus continues to grow, preparation for the delivery of the baby should be at hand. An uncomfortable feeling would
arise as weight gain continues and your false labor contractions continue.
 Childbirth classes and breastfeeding classes around this time are started.
 Included below is a list of some of the changes and symptoms this final trimester:
– Increased temperature
– The increased frequency of the bladder
– Swelling
– Hair
– Breast tenderness and colostrum
– Braxton Hicks contractions (false labor)
PRESUMPTIVE SIGNS OF PREGNANCY
 First Trimester
B-reast changes
U-rinary frequency
F-atigue
A-menorrhea
( after 10 days)
M-orning Sickness
E- nlarged Uterus
 Second Trimester
C -hloasma
L-inea Nigra
I -ncreased skin pigmentation
Q –uickening
S -triae gravidarum
PRESUMPTIVE SYMPTOMS
 Subjective:
– Client Need: Health promotion and maintenance
– Nursing Intervention:
 Instruct patient to eat dry crackers before arising
 Recommend frequent rest if possible
– Patient Teaching: Teach patient the differences and meaning of presumptive, probable and positive signs.
PROBABLE SIGNS OF PREGNANCY
 First Trimester
Chadwick’s sign (vagina)
• Goodell’s sign
( cervix )
• Hegar’s sign ( uterus )
• Elevated BBT
• Positive HCG
Second Trimester
Ballottement
Enlarged abdomen
Braxton-Hicks contractions
PROBABLE SYMPTOMS
OBSERVABLE SYMPTOMS
 Nursing Intervention:
– Use first voided morning urine to identify HCG
 Patient Teaching:
– Linea nigra will disappear when pregnancy ends
– Striae may not disappear; use cream or Vitamin A daily
– Chloasma is related to hormonal changes
– HCG in the urine is not diagnostic
EASY ASSOCIATION
 UTERUS
- Hegar’s Sign
 CERVIX
- Goodel’s Sign
 VAGINA
- Chadwick’s Sign
POSITIVE SIGNS OF PREGNANCY
 Demonstration of fetal heart rate separate from the mother
 Fetal movement felt by the examiner
( 20TH – 24TH WKS AOG )
 Visualization of the fetus by ultrasound
– Transabdominal
– Transvaginal Undeniable signs
Nursing Interventions:
– Calculate EDC/ EDD
– Calculate gestational age
Patient Teaching:
– Avoid x – ray during pregnancy, or protect abdomen as necessary.
DISCOMFORTS OF PREGNANCY
( 1 ) ANKLE EDEMA
 Elevate feet when sitting or resting
 Practice frequent dorsiflexion of feet
 Avoid standing for a long period of time.
2 ) BACK ACHE
 Practice good body mechanics
 Practice pelvic tilt exercise
 Avoid long standing, high heels, heavy lifting, over fatigue and excessive bending or reaching
( 3 ) BREAST TENDERNESS
 Wear a well – fitting supporting bra
 Decrease the amount of caffeine and carbonated beverages ingested.
( 4 ) CONSTIPATION
 Increase fiber in the diet
 Drink additional fluids
 Have a regular time for bowel movement
 Exercise
 Use stool softeners as needed
( 5 ) FATIGUE
 Plan a rest period regularly
 Have a regular bedtime routine and use extra pillow for comfort
6 ) FAINTNESS
 Arise and move slowly
 Avoid prolonged standing
 Remain in a cool environment; avoid crowded places
 Lie on left side when lying down.
( ( 7 ) HEADACHE
 Avoid eye strain
 Rest with a cool cloth on the forehead
 Report frequent and peristent headache to the doctor
( 8 ) HEARTBURN (PYROSIS)
 Eat small, frequent meals
 Avoid spicy, greasy foods
 Refrain from lying down immediately after eating
 Use low – sodium antacids
( 9 ) HEMORRHOIDS
 Avoid constipation and straining with BM
 Take hot sitz bath, apply topical anesthetics, ointments, ice packs
10 ) LEG CRAMPS
 Dorsiflex feet; Apply heat to affected muscle
 Evaluate calcium to phosphorous ratio in diet.
( 11 ) NAUSEA
 Avoid strong odors; drink carbonated beverages
 Avoid drinking while eating
 Eat crackers, avoid spicy and greasy food, eat small frequent meals
( 12 ) NASAL STUFFINESS
 Use cool air vaporizer
 Increase fluid intake, place moist towel on the sinuses; massage the sinuses
( 13 ) PTYALISM
 Use mouthwash as needed
 Chew gum or suck on hard candy.
( 14 ) ROUND LIGAMENT PAIN
 Avoid twisting motions,
 rise up slowly,
 and bend forward to relieve pain
( 15 ) SHORTNESS OF BREATH
 Proper posture; Use pillows under head & shoulders at night
(16) URINARY FREQUENCY
 Void at least q 2 hrs; Avoid caffeine; Practice Kegel exercise
(17) LEUKORRHEA
 Wear cotton underwear; bath daily; avoid tight panty hose
(18) VARICOSE VEINS
 Walk regularly; rest with feet elevated; avoid long standing; don’t cross legs; avoid knee high stocking; wear support hosiery
DANGER SIGNS OF PREGNANCY
 Chills and fever
 Cerebral disorders (dizziness )
 Abdominal pain
 Boardlike Abdomen
 Blood pressure elevation
 Blurred Vision
 Bleeding
 Swelling
 Scotoma ( blind spot on the retina )
 Sudden gush of fluid
Psychological
RISK CONDITIONS IN PREGNANCY
FACTORS THAT CATEGORIZE HIGH RISK PREGNANCIES
FACTORS THAT CATEGORIZE A PREGNANCY AS HIGH RISK
Social
Physical
Prepregnancy
- Occupation involving handling of toxic - Visual or hearing impaired
- History of drug dependence substances (including raidation and anesthesia
- Pelvic inadequacy or malshape
(including alcohol)
gases)
- Uterine incompetency, position or structure
- History of abusive behavior
Environmental contaminants at home
- Secondary major illness (heart disease,
- Survivor of battering
Isolated
hypertension,
tuberculosis,
blood
- History of mental illness
Lower economic level
disorder, malignancy)
- History of poor coping
Poor access to transportation for care
- Poor gynecologic or obstetric history
mechanisms
High altitude
- History of previous poor pregnancy
- Cognitive impairment
Highly mobile lifestyle
outcome
- Survivor of childhood sexual
Poor Housing
- History of child with congenital anomalies
abuse
Lack of support people
- Obesity
- Pelvic inflammatory disease (PID)
- History of inherited disorder
- Small stature
- Potential of blood incompatibility
- Younger than age 18 or older than 35
- Cigarette smoker
- Substance abuser
Pregnancy Period
- Loss of support person
Illness of a family
member
Decrease in self-esteem
Drug abuse (including
alcohol
and
cigarette
smoking)
Poor
acceptance
of
pregnancy
Labor and Delivery Period
- Severely frightened by
labor
and
delivery
experience
- Lack of participation due to
anesthesia
- Separation of infant at
birth
- Lack of preparation for
labor
- Delivery of infant who is
disappointing in some way
- Illness in newborn
-
-
Refusal of or neglected prenatal care
Exposure to environmental teratogens
Disruptive family incident
Decreased economic support
Conception under 1 year from last
pregnancy and pregnancy within 12
months of the first pregnancy
Lack of support person
Inadequate home for infant care
Unplanned cesarean birth
Lack of access to continued health care
Lack of access to emergency personnel or
equipment
-
- Subject to trauma
- Fluid or electrolyte imbalance
- Intake of teratogen such as a drug
- Multiple gestation
- A bleeding disruption
- Poor placental formation or position
- Gestational diabetes
- Nutritional deficiency of iron, folic acid, or
protein
- Poor weight gain
- Pregnancy-induced hypertension
- Infection
- Amniotic fluid abnormality
- Postmaturity
- Hemorrhage
- Infection
- Fluid and electrolyte imbalance
- Dystocia
- Precipitous delivery
- Lacerations of cervix or vagina
- Cephalopelvic disproportion
- Internal fetal monitoring
- Retained placenta
-
LABOR AND DELIVERY
INTRAPARTAL NURSING CARE MANAGEMENT
THEORIES OF THE ONSET OF LABOR





UTERINE STRETCH - any hollow object when stretch to maximum will contract and
empties.
OXYTOCIN - labor stimulates PPG to produce oxytocin that causes uterine contraction.
PROSTAGLANDIN - labor causes release of arachidonic acid which in turn increases the production of prostaglandin -> uterine
contraction
AGING PLACENTA - decrease blood supply causes uterine contraction
PROGESTERONE DEPRIVATION – decrease causes uterine contraction
PRELIMINARY SIGNS OF LABOR
1. LIGHTENING
 Descent of fetal presenting part; 10 – 14 days before labor onset
2. INCREASE IN LEVEL OF ACTIVITY
 Due to increase epinephrine as a result of decrease progesterone
3. BRAXTON HICK’S CONTRACTION
 Painless uterine contraction; few days or weeks before labor onset
4. RIPENING OF THE CERVIX
 Internal sign seen in pelvic examination; buttersoft ( softer than Goodell’s Sign )
SIGNS OF TRUE LABOR
1.
2.
3.
PRODUCTIVE UTERINE CONTRACTION
 longer duration, greater intensity, regular
BLOODY SHOW ( PINKISH )
 Due to expulsion of the mucus plug(operculum)mixed with ruptured capillaries as cervix softens
RUPTURE OF THE MEMBRANE
 Gush or seeping
 Risk for intrauterine infection and cord prolapse
CHARACTERISTICS OF TRUE LABOR
 Contractions occur at regular intervals
 Contractions start in the back and sweep around to the abdomen, increase in intensity and duration, and gradually have
shortened intervals
 Walking intensifies contractions
 “Bloody Show”
 Cervix becomes effaced and dilated
 Sedation does not stop contractions
CHARACTERISTICS OF FALSE LABOR
 Contractions occur at irregular intervals
 Contractions are located chiefly in the abdomen, the intensity remains the same or is variable, and the intervals remain long
 Walking does not intensify contractions and often gives relief
 “Bloody Show” usually is not present; if present, usually brownish rather than bright red
 There are no cervical changes
 Sedation tends to decrease the number of contractions
COMPONENTS OF LABOR
4 P’s OF LABOR:
1. PASSAGEWAY – adequacy of the woman’s pelvis and birth canal in allowing fetal decent
2. PASSENGER – ability of the fetus to move through the passageway
3. POWERS - frequency, duration, and strength of uterine contractions to cause complete cervical effacement and
dilation
4. PSYCHE – psychological state, available support systems, preparation for childbirth, experiences, and coping strategies
THE POWERS
Uterine Contractions
 Phases:
a. Increment or Crescendo
b. Acme or Apex
c. Decrement or Decrescendo
Important Aspects:
– Duration = beginning to end of same
 Early labor = 20 – 30 secs; late: 60 – 70 secs.
– Interval = end of one contraction to beginning of one
 Early labor: 40 – 45 mins.; late: 2 – 3 mins.
– Frequency = beginning to beginning
 Time 2 – 3 contractions to come up with clearer view
– Intensity = strength of contractions
STAGES OF LABOR
 FIRST STAGE
– Latent Phase: onset of contractions; effacement and dilation of cervix at 3 to 4 cms
– Active Phase: dilation continuous from 3 to 4 to 7 cms; contractions are stronger
– Transition Phase: cervix dilates from 8 to 10 cms; irresistible urge to push
 SECOND STAGE (EXPULSIVE STAGE)
– Cardinal Movements or Mechanisms
 Engagement
 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation (Restitution)
 Expulsion
 THIRD STAGE (PLACENTAL STAGE
 Placental Separation
 Signs of Placental Separation:
 Uterus becoming globular
 Fundus rising in the abdomen
 Lengthening of the cord
 Increased bleeding (trickle or gush)
 Placental Expulsion
FOURTH STAGE (RECOVERY AND BONDING)
– First 1 to 4 hours after birth
– Mother and newborn recover from physical process of birth
– Maternal organs undergo initial readjustment
– Newborn body systems begin to adjust to extrauterine life and stabilize
– Uterus contracts in the midline of the abdomen with the fundus midway between the umbilicus and symphysis pubis
FETAL PRESENTATION AND POSITION
 ATTITUDE
– degree of flexion of head, body, extremities; Complete Flexion
 ENGAGEMENT
– settling of the presenting part
– the presenting part ( widest diameter ) has pass through the pelvic inlet
 STATION
– relationship of fetal presenting part with the ischial spine of the mother
 FETAL LIE
– relationship of long axis of mother with long axis of fetus
FETAL STATION
 Relationship of the presenting part to ischial spine
 -1: 1 cm above ischial spine
 -3: needs therapeutic rest
 0: level of ischial spine, ENGAGEMENT
 +3, 4, 5: crowning (2nd stage of labor)
PRESENTATION/FETAL LIE
 Longitudinal
– Cephalic
 Vertex: face, brow, chin
– Breech
 Complete
 Incomplete: frank, footling, kneeling
– Shoulder
 Transverse
– Horizontal or perpendicular
Frank
Breech
Complete
Breech
ShoulderAcromium
Single
Footing
MECHANISM OF LABOR
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Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion
NURSING CONSIDERATIONS: FIRST STAGE OF LABOR
 Bath patient as necessary
 Monitor patient’s Vital Signs, especially Blood Pressure
– If patients has the same BP  rest
– If elevated BP  notify immediate attending physician
 Place patient on Nothing Per Orem (NPO)
 Encourage mother to void
 Do perineal preparation or cleansing
 Administer Enema (as per hospital policies)
– Cleanse bowel to prevent infection
– Place patient in Lateral Sidelying (Sims) Position, elevated enema can to about 12-18 inches, insert catheter
slowly and pull out slowly if with resistance to allow water flow to rectum
– Clamp rectal tube if (+) contraction
– Check FHT before and after (120-160, irregular)
SECOND STAGE OF LABOR
 Fetal stage or Expulsion Stage
 Primigravida: transfer at 10 cm dilatation
 Multigravida: transfer at 7 - 8 cm dilatation
 Lift legs simultaneously ( Lithotomy )
 Bulging of perineum – best sign of delivery initiation
 Pant and blow breathing, push with open glottis
DELIVERY
 Support head and remove secretions
 Check for cord coil
 Maintain temperature
 Put on abdomen of mother to facilitate contractions
 Clamp cord, don’t milk, wait for the pulsation to stop the cut cord
 Administration of vitamin K and tetracycline eye ointment
 Proper identification
THIRD STAGE: BIRTH TO EXPULSION OF PLACENTA (PLACENTAL STAGE)
 First sign: fundus rises  Calkin’s sign
 Signs of placental separation
– Fundus becomes globular and rises
– Gush of blood
– Cord descends several inches out of vagina