N106
Nursing Care of the
Expanding Family
Outline
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Issues & Trends
Menstrual Cycle
Conception
Fetal Development
Issues and Trends
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Family Centered
Role of Nurse
Legal and Ethical
Cultural Influence
Client Teaching
Ovarian and Endometrial Cycles
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Menstrual Cycle
Conception
Sperm penetration of an ovum
the fertilized ovum from conception to implantation
Fetal Development
• Ovum (pre-embryonic stage) – first 2 weeks
zygote
morula
blastocyst
• Embryonic stage – weeks 3 to 8
• Fetal stage – 8 weeks to birth
Figure 3–12 The actual size of a human conceptus from fertilization to the early fetal stage. The embryonic stage begins in the third
week after fertilization; the fetal stage begins in the ninth week. Source: Adapted from Marieb, E. N. (1998).
Foramen ovale
Ductus arteriosus
Ductus Venosus
Figure 3–11 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilical vein. After circulating through the
fetus, the blood returns to the placenta through the umbilical arteries. The ductus venosus, the foramen ovale, and the ductus
arteriosus allow the blood to bypass the fetal liver and lungs.
Outline
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Terminology
Pregnancy dating
Signs of Pregnancy
Normal Physical Changes of Pregnancy
Psychological Changes
Nutrition
Medication Admin
Terminology
• Gravida - # of times a uterus has held a
pregnancy
– Primigravida and Multigravida
• Para - # of times a uterus held a pregnancy past
20 wks – Primiparity and Multiparity
• Abortion – less than 20 weeks – miscarriage
• Viability – past 24 weeks – Federal /State
• Preterm – 20-37 weeks
• Term – 38-42 weeks
• Post term – after 42 wks
• BOW – bag of waters
• Bloody show – when cervix starts to dilate
Pregnancy dating
• Nagele’s rule – add 7 days to first day of
LMP and count back 3 months
• McDonald’s rule – fundal height = week of
gestation +/- 2-4 weeks
• Sonogram – early US at 7-13 weeks after
LMP most accurate for dating pregnancy
McDonald’s method is used to assess fundal height.
The TPAL approach
Signs and symptoms of pregnancy
• Presumptive
• Probable
• Positive
auscultation of FHT
fetal movement felt by examiner
fetus visualized by US
Physiologic changes
with Common Discomforts
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Reproductive
Cardiac
Respiratory
Gastrointestinal
Renal
Integumentary
Endocrine
Musculoskeletal
Neurological
Reproductive and Cardiac
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uterus
cervix
vagina
ovaries
breast
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heart
heart sound
pulse
blood volume
cardiac output
peripheral
vasodilatation
• B/P
• blood components
Vena caval syndrome.
Respiratory and Gastrointestinal
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Thoracic circumference
Diaphragm
Oxygen consumption
Tidal volume
• Gingivitis and
bleeding gums
• Heartburn
• Nausea
• Constipation
• Gallstones
Endocrine/ hormones
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Human Chorionic Gonatropin (HCG)
Human Placenta Lactogen (HPL)
Relaxin
Estrogen
Progesterone
Oxytocin
Prolactin
Physiologic changes
• Renal
• Integumentary
chloasma
linea nigra
striae gravidarum
• Musculoskeletal
lordosis
diastasis recti
• Neurological
Psychological changes
• First trimester – disbelief & ambivalence
focus: self-centered R/T physiologic
changes
• Second trimester – introspective
focus: baby; fetus becomes real
• Third trimester - pride and anxiety
focus: labor / delivery & baby’s well-being
Nutrition
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Affects size of baby
Wt gain 3.5 lbs during 1st trimester than 1 lb/wk
Total 25-35 lbs
Folic acid – prevent neural tube defects
Iron supplements – 30 mg daily
Additional 300 cal/day
Lactating requires 2700-2800 cal/day and 3000cc of
fluids /day
• Post partum 2200 to 2300 well balanced
Healthful eating
Largest portion - grains, rice, bread, and pasta
Smallest portion - fats, oils, and sweets,
Medication Administration
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Most medications cross placenta to fetus
Medications during PG can harm fetus
Pain meds in labor cross placenta
Newborn meds are Vitamin K & Erythromycin
PostPartum meds are oxytocics & analgesics
Prenatal Education
• Early pregnancy classes
• Childbirth Preparation classes
• Methods of childbirth
Bradley
Lamaze
Assessment during Pregnancy
• Prenatal appointments
monthly first 6 months
q 2 weeks in 7 & 8 month
weekly last month
• Vag exam initial visit and 2-3 wks a EDC
• Assessment each visit
wt, B/P, P, R, fundal ht, FHT
Danger Signs of Pregnancy
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Vaginal Bleeding
Rupture of membranes
Swelling of the fingers, face, eyes
Headache
Visual disturbances
Persistent abdominal pain
Chills and fever
Painful urination
Persistent vomiting
Change in fetal movements
Fetal Assessment
Ante-partal Fetal Assessment
• Labs
Alpha-fetoprotein
screening (MSAFP)
• Ultrasound
• glucose tol test (GTT)
• Amniocentesis
L/S ratio and PG
• Nonstress test (NST)
• Contraction stress
test (CST)
Amniocentesis
Reactive NST
Figure 14–5 Example of a reactive nonstress test (NST). Accelerations of 15 bpm lasting 15 seconds with each fetal movement (FM). Top of strip shows FHR;
bottom of strip shows uterine activity tracing. Note that FHR increases (above the baseline) at least 15 beats and remains at that rate for at least 15 seconds
before returning to the former baseline.
Nonreactive NST
Figure 14–6 Example of a nonreactive NST. There are no accelerations of FHR with FM. Baseline FHR is 130 bpm. The tracing of
uterine activity is on the bottom of the strip.
CST
Figure 14–8 Example of a positive contraction stress test (CST). Repetitive late decelerations occur with each contraction. Note that there are no accelerations
of FHR with three fetal movements (FM). The baseline FHR is 120 bpm. Uterine contractions (bottom half of strip) occurred four times in 12 minutes.
Complications Antepartal
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Gestational Diabetes
Hemorrhage - abortion
Hyperemesis Gravidarum
PROM – premature rupture of
membranes
Preterm labor
Pregnancy Induced Hypertension PIH
Substance abuse
Infections – TORCH
Gestational Diabetes
• Develops during pregnancy
• Risk factors: obesity, <25 yrs, family
history, chronic hypertension, large birth
wt, previous gestational diabetes
• Screening: between 24-28 weeks a 50 g,
1 hour glucose challenge test (GCT) if 140
or above recommend 3 hour oral glucose
tolerance test (OGTT)
• Increased for PIH and fetal macrosomia
Therapeutic Management
• Diet – 2200 -2400 calories per day
• Exercise – Moderate exercise for active
women, regular activity for sedentary
women
• Blood glucose monitoring – if FBG >95 or
PPBG >120 start on insulin
• Fetal surveillance – 28 weeks ultrasound,
amniocentesis, NST, CST, BPP
Insulin Therapy
• First trimester – insulin needs lower
• Second and Third trimester – increased
insulin due to placental hormones
• During labor – based on blood glucose
levels
• Post Partum – insulin not needed due to
abrupt cessation of placental hormones
Teaching Self-Care – S&S
• Hyperglycemia
fatigue
flushed hot skin
dry mouth, excessive
thirst
frequent urination
rapid resp
headache
depressed reflexes
• Hypoglycemia
shakiness
sweating
cold, clammy skin
pallor
disorientation
irritability
headache
hunger
blurred vision
Spontaneous Abortion
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Incidence
Threatened
Inevitable/imminent
Complete
Incomplete
Missed
Recurrent
Threatened
The cervix is not dilated, and the placenta is still attached
to the uterine wall, but some bleeding occurs.
Imminent
The placenta has separated from the uterine wall, the cervix
has dilated, and the amount of bleeding has increased.
Incomplete
. The embryo or fetus has passed out of the uterus, but
the placenta remains.
Ectopic Pregnancy
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Pregnancy outside the uterine cavity
S & S of PG
Rupture at 6-12 weeks
Severe pain
Vaginal tenderness and shock
Treatment – salpingectomy if ruptured
linear salpingostomy if tube is intact
• Care – assess for bleeding and pain, prepare for
surgery, emotional support
Various implantation sites in ectopic pregnancy. The
most common site is within the fallopian tube, hence the
name “tubal pregnancy.”
Complications of pregnancy
Hyperemesis gravidarum
Hyperemesis Gravidarum
• Persistent, uncontrolled vomiting
• Cause unknown may be high hCG or
psychological problem – hydatidiform mole
• S&S: Nausea and vomiting, weight loss,
fatigue, signs of dehydration, signs of
starvation
• TX: antiemetics, IV fluids, quiet
environment ,sedation, counseling
• Care: Allow to verbalize
Reducing nausea and vomiting
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1) small portions q 2-3 hours
2) attractively presented
3) eliminate strong odors
4) low-fat foods,
5) easily digested carbohydrates, such as
fruit, breads, cereal, rice and pasta
• 6) soups and liquids taken between meals
• 7) sitting upright to reduce gastric reflex
Complications of Pregnancy
Premature Rupture of Membranes
Premature rupture of membranes
(PROM)
• Diagnose – Nitrazine or fern test
• Gestational age - more than 36 wks deliver
if – ripe cervix, abnormal FHT, meconium
stained fluid, possible infection, abnormal
presentation Tx – walking, Prostaglandin
• Gestational age between 32-35 weeks
deliver if – mature fetal pulmonary status,
abnormal FHT, possible infection
• Strategies – tocolytics, steroids, antibiotics
Nursing Care for PROM
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Stay hospitalized until birth
Frequent VS & FHT q 4 hours
Frequent CBCs , mtr records “kick counts”
Check vaginal bleeding
No vag exams, restrict activity
A & Z for 7 days
Complications of Pregnancy
Preterm Labor
Premature rupture of membranes
(PROM)
• Diagnose – cramping and vag discharge
prior to 20 and 37 weeks gestation
• Tocolytics act by depressing smooth
muscle, glucocorticoids accelerate fetal
lung maturity
• Nursing Care – monitor FHT & contractions,
provide emotional support, manage side
effects of tocolytics, teach what to do if
occur at home
Complications of Pregnancy
Hypertensive Disorders
Pregnancy Induced Hypertension
• Incidence – 8% of all pregnant woman
• Risk factors
• Etiology - Preeclampsia is due to
generalized vasospasm
• Cause remains unknown
• Cardinal signs
1) hypertension
2) proteinuria
3) weight gain of 2 lbs in one week
Classification of hypertensive
disorders of pregnancy
• Pregnancy-induced
hypertension (PIH)
• Preeclampsia
• Eclampsia
• HELLP
PIH - HELLP syndrome – reflects
severity of disease
• Signs and Symptoms
headaches
visual changes
oliguria
hyperreflexia
epigastric pain
flu like symptoms
generalized edema
nausea and vomiting
severe elevated BP
proteinuria
• Criteria of diagnosis
hemolysis
elevated liver enzymes
AST(SGOT)>72U/L
ALT(SGPT)>50U/L
serum LDH>600IU/L
low platelet
<100,000/mm
PIH - management
• Dependent on severity of disease &
gestational age of fetus
Activity restriction / quiet environment
Pharmacologic therapy
anticonvulsive therapy
antihypertensive therapy
stimulant for fetal surfactant
• Only cure – delivery of the fetus
• Goal – prevent eclampsia & other severe
complications while allowing fetus to mature
PIH – eclampsia nursing
interventions
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Reduce risk of aspiration
Prevent maternal injury
Ensure maternal oxygenation after seizure
Ensure fetal oxygenation after seizure
Establish seizure control with MgSO4
Treat severe hypertension
Correct maternal acidemia
Initiate process of delivery
Complications of pregnancy
Substance Abuse
Types of substance
Risk Factors
Signs and Symptoms
Nursing Management
Complications of Pregnancy
• Gestational Diabetes
Complications of Pregnancy
Infections during Pregnancy
TORCH
Infections
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T – toxoplasmosis
O - other
R – rubella
C – cytomegalovirus
H – herpes simplex virus