Prenatal Care – Module A NUR 106 Spring, 2005 Anatomical Landmarks Female Male External Structures Internal Structures Midsagital View Uterus Uterine Ligaments Pelvic Bones Female Pelvis Pelvic Types Muscles of the Pelvic Floor Male: External and Internal Structures Testis Testis Sperm Female Reproductive Cycle Ovulation Menstruation Menarche Climacteric Menopause Female Reproductive Cycle Conception and Fetal Development Nine Month Miracle Miracle of Life Internet sites Conception Fertility Sexual intercourse Pregnancy Genetics Chromosomes Autosomal Sex Chromosomal syndromes Modes of inheritance Patterns of Inheritance Dominant Recessive X-linked Nursing Responsibilities Identify families at risk Education Liaison Support / Crisis intervention Continuity of care Teratogens Tobacco Alcohol Marijuana Cocaine Heroin Anticonvulsants Anticoagulants Acne medications Reproductive Ethics Maternal-fetal conflict Abortion Intrauterine fetal surgery Reproductive assistance Embryonic stem cell research Human genome project Cord blood banking Fertilization One spermatozoon enters the ovum Two nuclei containing the parents’ chromosomes merge Occurs in the outer third of the fallopian tube Sex is determined Multifetal Pregnancy Dizygotic twinning -- fraternal Monozygotic twinning -- identical Implantation Nidation Gradual process Occurs between 6th / 7th and 10th days Upper part of posterior uterine wall Placenta develops Fertilization and Implantation Amniotic Membranes Amnion (inner) Chorion (outer) Enclose fetus in amniotic fluid Protects fetus from infectious organisms Amniotic Sac Amniotic Fluid Clear, slightly yellow, alkaline fluid Approximately 1 liter at term Derived from Maternal plasma Cells of the amnion Fetal fluids from lung, skin, fetal urine Functions of Amniotic Fluid Cushions fetus from trauma Facilitates fetal movement Facilitates symmetrical growth Regulates intrauterine temperature Provides source of oral fluid Cushions umbilical cord Receptacle for fetal substances Placenta / Function Fully functional by week 12 Respiration Nutrition Waste removal Protection Endocrine Placenta Placenta After Delivery Umbilical Cord One vein Two arteries Wharton’s jelly Amnion Placenta and Cord Umbilical Cord 12 weeks 18 Weeks 4 Months 5 Months 30 Weeks 40 Weeks Fetal Development Preembryonic or ovum Embryonic Fetal Fetal Circulation Ductus venosus Ductus arteriosus Foramen ovale Fetal Circulation Factors Affecting Fetal Development Exposure to teratogens Maternal health habits and lifestyle Paternal health habits and exposure to environmental influences Physiological Changes During Pregnancy Uterus Ligaments Cervix Chadwick’s Goodell’s Hegar’s Breast Montgomery tubercles Skin Circulatory System Increases up to 50% Pseudoanemia Iron requirements increased Increase in size Blood pressure changes Fibrinogen increases Mechanical circulatory effects Supine Hypotension Syndrome Respiratory System Thoracic cage Oxygen consumption increases Hyperventilation Respiratory alkalosis Mucosal edema Digestive System Nausea / vomiting Constipation Flatulence / heartburn Gallstones Urinary System Kidneys Function increases Renal threshold for sugar reduced Bladder and ureters Blood supply increased Pressure Atonia Joints, Bones, Teeth, and Gums Pelvic cartilages Gait Uterus Posture changes Teeth Gums Endocrine System Placenta HCG HPL Estrogen Progesterone Pituitary Adrenal Thyroid Signs of Pregnancy Presumptive – Subjective Probable – Objective Positive -- Diagnostic Signs of Pregnancy: S, O, or D Amenorrhea Goodell’s sign Fetal heart sounds Urinary frequency Positive pregnancy test Nausea and vomiting Enlargement of the abdomen Quickening Palpable fetal movements Braxton Hicks contractions How would you explain the differences between the subjective (presumptive), objective (probable), and diagnostic (positive) signs of pregnancy to an expectant mother? Maternal Psychosocial Changes First trimester Ambivalent Second trimester Baby becomes real Maternal introspection Third trimester Begins to think of baby as separate being Restless Self-centered Rubin’s Maternal Tasks Seeking safe passage Securing acceptance Learning to give of self Committing self to child Paternal Psychosocial Changes First trimester Excitement over virility Financial concerns Energetic Exhibit symptoms with wife Second trimester More confident Concerns about wife’s changes / introspection Third trimester Rivalry with fetus Interest in himself Fantasizes about child Factors Affecting Psychological Response Body image Personal characteristics Financial situation Cultural expectations Emotional security Support from significant others Changes in sexuality Role of the father and siblings Preparation for Parenthood Preconception Childbearing decisions Prenatal education Childbirth preparation Childbirth Education Provides information on pregnancy and childbirth to facilitate optimal decision making Classes for special groups Importance of exercise during pregnancy Selection of birthing process Infant care First Trimester Physical and psychosocial changes of pregnancy Self-care in pregnancy Protecting and nurturing the fetus Choosing a care provider and birth setting Prenatal exercise Relief of common early pregnancy discomforts Second Trimester Planning for breast-feeding Sexuality in pregnancy Relief of common later-pregnancy discomforts Third Trimester Preparation for childbirth Development of a birth plan Relaxation techniques Postpartum self-care Infant stimulation Infant care and safety Goals of Prenatal Care Safe birth Health promotion Self-care Provide physical care Provide anticipatory guidance Risk Factors / Reproductive Outcomes Maternal age Parity Socioeconomic status Ethnicity Geographic factors Behavioral and Lifestyle risks Health risks Previous pregnancies Role of Nurse Physical assessment Identify and reevaluate risk factors Teach self-care Nutrition counseling Promote family’s adaptation to pregnancy Prenatal Visits Every 4 weeks for first 28 to 32 weeks Every 2 weeks from 32 to 36 weeks Every week from 36 to 40 weeks Terminology Gravida Multipara Nulligravida Nullipara Primigravida Abortion Multigravida Gestational age Para Fertilization age Primipara Nomenclature G T P A L M = = = = = = number of pregnancies number of term deliveries number of preterm deliveries number of abortions number of living children number of multiple births Nägele’s Rule First Day of Last Menstrual Period Minus 3 months Plus 7 days Identify the causes and interventions for each discomfort of pregnancy: Heartburn Hemorrhoids Urinary frequency Nausea / vomiting Leg cramps Vaginal discharge Fatigue Backache Constipation Varicose veins Edema Dyspnea Why is a positive pregnancy test not a positive sign of pregnancy? Routine Lab Tests Blood grouping Rh factor and antibody screen CBC H&H VDRL, RPR, or STS Rubella titer TB skin test Hg electrophoresis HIV screen Hepatitis B screen UA PAP test Cervical culture MSAFP Maternal blood glucose Prenatal Laboratory Tests: Normal or Abnormal ? Hemoglobin 13.6 g/dL Hematocrit 35% Rubella titer 1:6 WBC 6,200/ mm3 Sickle Cell screen negative Prenatal Self-Care Measures Breast tenderness Leg cramps Nausea Constipation Backache Risk Factors Definition Social / Personal Preexisting medical disorders Obstetric considerations Problems associated with current pregnancy Prenatal Diagnostic Studies Ultrasound Estriol: Increases with fetal growth Amniotic Fluid Amniocentesis Lecithin / sphingomyelin ratio Fern test Nitrazine test Kick test Chorionic villus sampling Alpha feto protein level Level I Ultrasound Basic Detect gestational sac (5 weeks after LMP) Identify number of fetuses Document fetal life Detect gross fetal structural anomalies Estimate gestational age Determine fetal position Locate the placenta Estimate amniotic fluid volume Evaluate maternal pelvic masses Level II Ultrasound Evaluate gestational age Measure fetal growth Perform specific examinations of the brain, heart, kidney, and cord insertion Quantify amniotic fluid volume Determine placental location Performed after 18 weeks List two advantages of prenatal ultrasound assessment for the mother and fetus. Tests of Fetal Well-Being Ultrasound Amniocentesis Nonstress Test (NST) Contraction Stress Test (CST) Breast Self-Stimulation Test (BSST) Danger Signs in Pregnancy C = Chills and fever Cerebral disturbances A = Abdominal pain B = Blurred vision Blood pressure Bleeding S = Swelling Sudden escape of fluid Nutrition During Pregnancy Choose foods from food guide pyramid Increase of 300 calories / day Calorie needs greater in last two trimesters Encourage diet high in folic acid with supplements Calcium needs increase nearly 50% Heavy demand for iron for fetal stores Drink 8 to 10 glasses of water / day Food Guide Pyramid Vegetarianism Need ample and complete proteins from dairy products and eggs Protein from brown rice and whole wheat, legumes, nuts, cooked and fresh vegetables and fruits Vitamin B12 supplement Lactose Intolerance Abdominal distention, discomfort, nausea, vomiting, loose stool, cramps May tolerate milk in cooked form Cheese and yogurt Lactase may be prescribed Lactase-treated milk Lactose-free products Pica Non-nutritive eating Associated with poverty and inadequate diets Iron deficiency anemia Weight Gain Normal: 25 -- 35 pounds Underweight: 28 -- 40 pounds Overweight: 15 -- 25 pounds Uterine Growth During Pregnancy F Uterine Growth During Pregnancy What is the average pattern of weight gain during each trimester of pregnancy? Maternal Weight Gain Distribution Fetus, placenta, amniotic fluid Uterus Increased blood volume Breast tissue Maternal stores Total 11 pounds 2 pounds 3 pounds 3 pounds 5-10 pounds 25-35 pounds Medications Prenatal vitamins Iron supplements Folic Acid Antacids Case Study A client, who is a primigravida in her second trimester, has come in for a scheduled prenatal visit. When the nurse asks how things are going, the client replies, “Not very well. It seems like I’m just falling apart. I have heartburn after I eat, my ankles swell, I’m constipated all the time, and I think I may be getting hemorrhoids.”