Metro Community College
NURS 1400 Family Nursing I
Unit 1
CONCEPTION
• Fertilization
• Implantation
DEVELOPMENTAL CHARACTERISTICS &
FUNCTION
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Placenta
Umbilical cord
Fetus
Fetal circulation
Pregnancy
Psychosocial Effects of Pregnancy
Presumptive Signs of Pregnancy
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Amenorrhea
Nausea and vomiting
Fatigue
Urinary frequency
Breast enlargement and tenderness
Quickening
Probable Signs of Pregnancy
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Goodell’s sign (softening of the cervix)
Chadwick’s sign (bluish vaginal tissue)
Hegar’s sign (softening of the cervix)
Ballottement
Ballottement
Positive pregnancy test
Figure 14–4 Hegar’s sign, a softening of the isthmus of the uterus, can be determined by the examiner during a vaginal
examination.
Figure 14–5 Early uterine changes of pregnancy. A, Ladin’s sign, a soft spot anteriorly in the middle of the uterus near the junction
of the body of the uterus and the cervix. B, Braun von Fernwald’s sign, irregular softening and enlargement at the site of
implantation. C, Piskacek’s sign, a tumorlike, asymmetric enlargement.
Figure 14–5 (continued) Early uterine changes of pregnancy. A, Ladin’s sign, a soft spot anteriorly in the middle of the uterus near
the junction of the body of the uterus and the cervix. B, Braun von Fernwald’s sign, irregular softening and enlargement at the site
of implantation. C, Piskacek’s sign, a tumorlike, asymmetric enlargement.
Figure 14–5 (continued) Early uterine changes of pregnancy. A, Ladin’s sign, a soft spot anteriorly in the middle of the uterus near
the junction of the body of the uterus and the cervix. B, Braun von Fernwald’s sign, irregular softening and enlargement at the site
of implantation. C, Piskacek’s sign, a tumorlike, asymmetric enlargement.
Positive Signs of Pregnancy
• Fetal heart tones
• Fetal movement
• Ultrasound
Abdominal ultrasound
Transvaginal probe
Estimation of Due Date
• Naegele’s rule
• Uterine size
• Ultrasound
Näegle’s Rule
• First day of last menstrual period – 3 months +
7 days = EDB
Expected Date of Delivery
• Other indicators of gestational age
– FHT with doppler at 10–12 weeks
– Fetal movement felt at about 20 weeks
– Fundal height correlation with gestational age
• Ultrasound
Fundal Height related
to Gestational Age
Physiologic Adaptation to
Pregnancy
Reproductive System
• Uterus
– Enlarges to hold a
volume of 15–20 liters
– At 12 weeks rises
out of the pelvis
– Walls thin, but
strengthened
with fibrous tissue
Reproductive System (continued)
• Uterus (continued)
– 20–25% of cardiac output
goes to uterus
– Braxton Hicks contractions occur throughout
pregnancy
• Cervix
– Softens and becomes bluish in color
– Mucous plug forms to protect the fetus
Reproductive System (continued)
• Vagina, perineum, and vulva
– Increased vascularity
– Increased vaginal discharge
• Acidic environment prevents bacterial infection
• Yeast infection (candida) common during pregnancy
Reproductive System (continued)
• Ovaries
– Normal function ceases
– Corpus luteum secretes progesterone
– Placenta produces progesterone by six to seven
weeks and corpus luteum regresses
Reproductive System (continued)
• Breasts
– Enlarge and become tender
– Increased alveoli
– Areola darken
– Tubercles of Montgomery enlarge and secrete a
substance to maintain areolar suppleness
– Colostrum may leak from the breast
Hematologic System
• Blood volume
– Increases by 40–50%
– Plasma volume increases by 1,200–1,600 ml
– Red blood cells increase by 450 ml
– Physiologic anemia results
• Hemoglobin drops up to 2 mg/dl
• Iron deficiency anemia considered when hemoglobin
drops to 10.5 mg/dl or less
Hematologic System (continued)
• Blood coagulation
– Increase in clotting factors and risk of thrombus
Cardiovascular System
• Heart
– Displaced up and to the left
– Heart enlarges
– Systolic murmurs common
Cardiovascular System (continued)
• Cardiac output
– Increases by 10 weeks, peaks at 24 weeks
– Heart rate increases by 20 beats/minute
• Blood pressure
– Decreases in first trimester
– Returns to normal reading by term
• Systemic vascular resistance
– Decreases during pregnancy
Cardiovascular System (continued)
• Effect of positioning
during pregnancy
– Supine hypotension
A. Supine position
B. Right lateral position
Descending
aorta
Inferior
vena cava
Respiratory System
• Changes in mechanical function
– Diaphragm rises 4 cm
– Chest circumference increases 5 to 7 cm
• Progesterone
– Causes increase in tidal volume (30–40%) and
decrease in Pco2 (compensated respiratory
alkalosis)
• Rate does not change
• Changes facilitate removal of carbon dioxide
from fetus
Gastrointestinal System
• Mouth
– Gums become soft and edematous
– Ptyalism may develop
– Benign tumors may appear
• Esophagus
– Progesterone relaxes cardiac sphincter
– Pyrosis or heartburn develops from acid reflux
Gastrointestinal System (continued)
• Stomach and intestine
– Delayed stomach emptying
– Constipation common
• Gallbladder
– Predisposed to stone formation
Gastrointestinal System (continued)
• Liver
– Spider angioma
– Palmar erythema
– Albumin decreased, alkaline
phosphatase increased, Liver
pushed up
cholesterol increased
Stomach
compressed
Bladder largely in pelvis
therefore frequent urination
Endocrine System
• Thyroid
– Enlarges, euthyroid state maintained
– Increase in BMR by 25%
• Parathyroid
– Increased secretion of parathyroid hormone to
meet calcium needs of the fetus
• Pituitary
– FSH, LH suppressed
– Prolactin increased
– Oxytocin for contractions and lactation
Endocrine System (continued)
• Adrenal glands
– Cortisol
• Activates gluconeogenesis
• Increases blood glucose levels
– Aldosterone
• Increases
• Protects the woman from sodium loss
• Pancreas
– Beta cells increase in number and size
Endocrine System (continued)
• Placenta
– hCG
• Confirms pregnancy
• Maintains corpus luteum
– Human placental lactogen (HPL)
• Produces insulin resistance
• Makes adequate glucose available to fetus
Endocrine System (continued)
• Placenta (continued)
– Estrogen
• Vasodilation, softens cervix, breast development
– Progesterone
• Relaxes smooth muscle of uterus, GI tract, GU tract,
and aids breast development
Endocrine System (continued)
• Changes in metabolism
– Fetus has constant need for glucose
– In fasting state ketosis develops rapidly
– Maternal insulin resistance develops
– Diabetogenic effect of pregnancy
– Increased need for iron
– Water retention
– Dependent edema common in late pregnancy
Weight Gain in Pregnancy
• Individualized by pre-pregnancy weight
• Average weight gain is 27.5 lbs.
– 27.5–39.6 lb for underweight women
– 25.3–35.2 lb for normal weight women
– 15.4–25 lb for overweight women
Urinary System
• Anatomic changes
– Kidneys and ureters enlarge
– Ureters compressed at pelvic brim
– Increased incidence of pyelonephritis
– Urinary frequency and incontinence common
– Bladder tone relaxed and capacity and pressure
increase
– UTIs common in pregnancy
Urinary System (continued)
• Physiologic changes
– Increased blood flow by 35–60%
– Increase in GFR
• Increased urine flow and volume
• Decreased BUN, creatinine, uric acid
• Increased filtration of solutes
– Glucose
– Protein
• Altered excretion of drugs (increased)
Integumentary System
• Spider angiomas and
palmar erythema
• Hyperpigmentation
– Linea nigra
– Chloasma
• Striae gravidarum
Musculoskeletal System
• Lordosis develops
– Back pain common during pregnancy
• Ligaments soften due to relaxin
– Pelvic discomfort
– Unsteady gait
Eye, Cognitive, and
Metabolic Changes
• Decreased intraocular pressure
• Thickening of cornea
• Reports of decreased attention,
concentration, and memory
• Extra stored water, fat, and protein are stored
• Fats more completely absorbed
Nausea and Vomiting
• Probably caused by hormones
• Client education
– Plenty of fluids, avoid caffeine and carbonation
– Frequent, small meals, high protein, and
carbohydrates
– Eat crackers to avoid an empty stomach
– Avoid noxious odors
– Limit stress
Nausea and Vomiting (continued)
• Hyperemesis gravidarum–severe vomiting
requiring medical intervention
Heartburn
• Caused by reflux
• Client education
– Monitor for foods that cause symptoms
– Spread liquids throughout the day
– Stay upright after meals
– Don’t eat close to bedtime, extra pillows
– Bend at waist
– OTC calcium containing antacids
Heartburn (continued)
• Epigastric pain can also be associated with
hypertension in pregnancy
Constipation
• Caused by progesterone’s effect on GI tract
• Aggravated by iron supplementation
• Client education
– Increase fiber
– Increase fluids
– Regular exercise
– Regular time for bowel movements
Fatigue
• More common early in pregnancy
• Client education
– Meditation may be helpful
– Rest when tired
– Alleviate stress
– Reassurance that the fatigue lessens after the first
trimester
Frequent Urination
• Most common early in pregnancy
• Client education
– Notify HCP if pain or burning occur
– Kegel exercises
Varicosities
• Can occur in the legs,
vulva, and rectum
• Client education
– Support hose
– Avoid long standing,
sitting, leg crossing
– Elevate legs when sitting
– Loose clothing and avoid
knee-high hose
Other Discomforts in Pregnancy
• Hemorrhoids
– Client education
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Maintain healthy and regular bowel habits
Sitz bath
Compresses soaked with witch hazel
Reduce external hemorroids if possible
• Back pain
– Good body mechanics
Figure 14–1 Vena caval syndrome. The gravid uterus compresses the vena cava when the woman is supine. This reduces the blood
flow returning to the heart and may cause maternal hypotension.
Other Discomforts in Pregnancy
(continued)
• Leg cramps
– Adequate calcium
– Stretching exercises
Signs of Potential Problems
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Persistent vomiting
Vaginal bleeding
Edema of face/hands
Temperature >101°F
Persistent abdominal pain, epigastric pain
Dysuria
Health Promotion
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Employment
Travel
Smoking
Alcohol use
Drug use
Medication use
Psychological Response to
Pregnancy
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Acceptance of pregnancy
Time for reflection
Body image changes
Becoming a mother
Development of the maternal role
– Mimicry, role play, fantasy, role fit
Maternal Tasks
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Safe passage
Acceptance by others
Binding in to the child
Giving of oneself
Conflicting developmental tasks
Paternal Tasks
• Transition to fatherhood
• Stress of the paternal role
• Bonding between father and infant
Family Response
to Pregnancy
• Siblings:
– Rivalry
– Fear of changing parent relationships
• Grandparents:
– Closer relationship with expectant couple
– Increasing support of couple
Nursing Process
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Assessment
Nursing diagnosis
Planning
Intervention
Evaluation
Nursing Care of
the Pregnant Woman
The Initial Prenatal Visit
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Medical history
Physical exam
Diagnostic tests
Assess risk factors
Education
Nutrition
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Avoidance of potential teratogens
Folic acid supplementation
Prenatal vitamin and mineral supplements
Weight gain
– Individualized according to pre-pregnancy weight
– Weight assessed at every visit
– Weight loss is never normal
– Excessive weight gain requires evaluation
Harmful Substances in Pregnancy
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Alcohol
Caffeine
Artificial sweeteners
Herbal supplements
Medications
Pica
Gravidity and Parity
• Gravida–number of pregnancies
• Para–number of births after 20 weeks
• Five-digit system
– G–total number of pregnancies
– T–full-term pregnancies (37–40 weeks)
– P–preterm deliveries (20–36 weeks)
– A–abortions and miscarriages (before 20 weeks)
– L–living children
Figure 15–1 The TPAL approach provides more detailed information about the woman’s pregnancy history.
Important Demographic Data
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Age
Occupation
Education
Residence
Ethnicity
Race
Religion
Pets
Medical and Family History
• Includes client and her partner
• Information to obtain
– Prior or current health issues
– Medications and allergies
– Possible inherited diseases in the families
– Significant health issues in family members
– Use of tobacco, alcohol, street drugs
Critical Pathway for Prenatal Care
• Physical exam
• Lab work and
testing
• Nutrition
• Elimination
• Rest/activity
• Comfort
Critical Pathway for Prenatal Care
(continued)
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Psychosocial/family
Developmental/pregnancy progress
Spiritual
Risk assessment
Medications
Assessment of
Pelvic Adequacy
• Pelvic inlet
• Midpelvis
• Pelvic outlet
Figure 15–6 Anteroposterior diameters of the pelvic inlet and their relationship to the pelvic planes.
Figure 15–7 Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower
border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends
from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual
estimation of anteroposterior measurements.
Figure 15–7 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from
the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet,
which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check
the manual estimation of anteroposterior measurements.
Figure 15–7 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from
the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet,
which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check
the manual estimation of anteroposterior measurements.
Figure 15–8 Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal
knuckles. If they do not, they can use a measuring device.
Figure 15–9 Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic ramus. C,
Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.
Figure 15–9 (continued) Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic
ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.
Figure 15–9 (continued) Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic
ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.
Figure 15–9 (continued) Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic
ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.
Laboratory Analysis and Testing
in Pregnancy
• Blood Work
– Blood type and Rh
status
– Antibody screen
(Coombs’ test)
– CBC
– Rubella titer
– HIV
– Hepatitis B
– Syphilis
– Sickle cell
– Glucose screen
– Triple screen
– Cystic fibrosis
– Varicella
Laboratory Analysis and Testing
in Pregnancy (continued)
• Other Testing
– Ultrasound
– Urinalysis
– Pap smear
– GC culture
– Chlamydia culture
– Group B streptococcus
– PPD
First Trimester Ultrasound
• Establish gestational age:
– Crown to rump length
– Most accurate between 6 and 10 weeks
• Nuchal translucency testing:
– Combined ultrasound and serum testing
– Risk for chromosomal disorder
– Screened between 11 weeks and 1 day and 16
weeks and 7 days
First Trimester Viability
Confirmation
• Serial quantitative serum beta hCG testing
• Progesterone
• Ultrasound
Second Trimester
Ultrasound
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Fetal life
Fetal number
Fetal presentation
Fetal anatomy
Gestational age
Amniotic fluid index
Second Trimester
Ultrasound (cont’d)
• Placental position
• Uterus
Fetal Movement
• Noninvasive
• Cost-effective
• Indirect measure of the fetal central nervous
system (CNS)
• Vigorous movement indicates fetal well-being
• Decreased movement is associated with
chronic oxygen compromise
Nonstress Test (NST)
• Accelerations imply an intact CNS.
• Acceleration patterns are affected by
gestational age
• Accelerations must be 15 beats/minute above
baseline, lasting 15 seconds
• Reactive—two or more accelerations within
20 minutes
• Nonreactive—insufficient accelerations over
40 minutes
Figure 21–11 Example of a reactive nonstress test (NST). Accelerations of 15 bpm lasting 15 seconds with each fetal movement
(FM). Top of strip shows fetal heart rate (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.
Figure 21–12 Example of a nonreactive NST. There are no accelerations of FHR with fetal movement (FM). Baseline FHR is 130
bpm. The tracing of uterine activity is on the bottom of the strip.
Vibroacoustic
Stimulation (VAS)
• Application of sound and vibration to
stimulate fetal movement
• Used to facilitate NST
Figure 21–13 Fetal acoustic stimulation testing. SOURCE: Photographer, Elena Dorfman.
Contraction Stress
Test (CST)
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Evaluates uteroplacental function
Identifies intrauterine hypoxia
Observes FHR response to contractions
If compromised, FHR will decrease
Interpretation of CST
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Negative
Positive
Equivocal-suspicious
Equivocal-hyperstimulatory
Unsatisfactory
Figure 21–14 Example of a negative CST (and reactive NST). The baseline FHR is 130 bpm with acceleration of FHR of at least 15
bpm lasting 15 seconds with each fetal movement (FM). Uterine contractions recorded on the bottom half of the strip indicate
three contractions in 8 minutes.
Figure 21–15 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.
Amniotic Fluid Index (AFI)
• Decreased uteroplacental perfusion results in
oligohydramnios
• AFI of five or less requires further evaluation
Biophysical Profile (BPP)
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Fetal heart rate acceleration
Fetal breathing
Fetal movements
Fetal tone
Amniotic fluid volume
Maternal Serum
Alpha-Fetoprotein
• Component of quadruple check
• Screening test for:
– Neural tube defects
– Trisomy 21 (Down syndrome)
– Trisomy 18
• Performed between 15 and 22 weeks of
gestation
Amniocentesis
• Used to detect genetic, metabolic, and DNA
abnormalities
• Can detect neural tube defects
• Amniotic fluid obtained through needle
aspiration
• Complications include:
– Vaginal spotting and cramping
– Mild fluid leaking
Figure 21–19 Amniocentesis. The woman is usually scanned by ultrasound to determine the placental site and to locate a pocket
of fluid. As the needle is inserted, three levels of resistance are felt when the needle penetrates the skin, fascia, and uterine wall.
When the needle is placed within the amniotic cavity, amniotic fluid is withdrawn.
Chorionic Villus
Sampling (CVS)
• Used to detect genetic, metabolic, and DNA
abnormalities
• Needle aspiration of chorionic villi from
placenta
• Earlier diagnosis than amniocentesis
• Cannot detect neural tube defects
• Pregnancy loss is twice as high as with
amniocentesis
• Potential for limb reduction
Predictors of Preterm Labor
• Fetal fibronectin (fFN):
– Presence between 20 and 34 weeks is predictor of
preterm delivery
• Cervical length and internal os:
– Measured by ultrasound
– Shortened cervix and dilated internal os can
predict preterm birth
– False-positive common
Fetal Lung Maturity
• Lecithin/sphingomyelin ratio:
– Ratio of 2 to 1 indicates fetal lung maturity
• Phosphatidylglycerol (PG):
– Presence indicates fetal lung maturity
Return Visits in Pregnancy
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Education
Blood pressure
Weight
Fundal height
Fetal heart tones
Presentation of the
fetus
Return Visits in Pregnancy
(continued)
• Urine test for protein, glucose
• Assessment for edema
• Evaluation for developing complications
Strategies for Labor Management
• Relaxation techniques
• Paced breathing
• Progressive muscle
relaxation
• Neuromuscular
dissociation
• Touch
• Imagery
Managing the Discomforts of
Pregnancy
Round Ligament Pain
• Felt on one or both
sides of the lower
abdomen
• Client teaching
– Calcium
supplementation
– Good body mechanics
– Reassurance
Urinary Frequency
• Etiology
– Mechanical pressure on the bladder by the
enlarging uterus
– Increased fluid volume
• Client teaching
– Maintain adequate fluid intake
– Report burning or pain with urination
Nausea and Vomiting
• Etiology
– Hormones of pregnancy
• Client teaching
– Dry diet
– Avoidance of offending smells and foods
– Ginger or peppermint tea
Indigestion
• Etiology
– Hormones cause relaxation of the cardiac
sphincter
• Client teaching
– Avoidance of offending foods
– Extra pillows at night
– Avoiding large meals close to bedtime
– Antacids may be used, but avoid those with high
sodium content
Constipation and Hemorrhoids
• Etiology
– Hormones of pregnancy slow GI motility
– Sluggish venous return predisposes to
hemorrhoids
• Client teaching
– Ample fluid intake
– Diet high in fiber
– Stool softeners
– Exercise
Edema
• Etiology
– Increased fluid volume
– Sluggish venous return
• Client teaching
– Avoid long periods of
standing
– Elevate feet
– Exercise
Danger Signs in Pregnancy
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Vaginal bleeding
Edema of the face and hands
Severe headache
Vision changes
Abdominal pain
Chills and fever
Persistent vomiting
Fluid from the vagina