Reproductive Organ Changes
 Uterus
 enlargement -- 2 ounces to 2 pounds
 rises out of pelvic area and displaces the
intestines
 changes in tissue
 increase in vascularity
 hypertrophy
 isthmus of uterus softens - Hegars
Sign
 uterine soufflé
 Patient teaching

Braxton-Hicks contractions

Cervix
 softens - Goodell’s sign
 fills with a mucus plug
 increase in discharge, leukorrhea
 Vagina
 increase in vascularity - Chadwick's sign
 increase in discharge, leukorrhea
 pH rises and become more susceptible to
yeast infections
Mrs. Andrews complains of a whitish
discharge. What is the teaching
regarding vaginal discharges?

Perineum
 increased vascularity and pressure causes
vulvar varicosities
 What should the nurse teach regarding
decreasing the pressure in the perineal
area?

Ovaries
 corpus luteum remains functioning and
there is NO ovulation or menstruation.
Mrs. Andrews asks why she stops having
menstrual periods while pregnant. What is
the nurses response ?

Breasts
 Growth of alveolar tissue
 Nipples become more pigmented
 Mrs.
Andrews states that her breasts
are more full and have become very
heavy.
What teaching should the nurse
include?
Cardiovascular Changes

cardiac enlargement

Vasodilation

increase blood volume,
hemodilution

increase cardiac output – 30-50%
Cardiovascular Changes

Blood Components and Variations in
common laboratory tests
– RBC – erythrocytes increase by 25% to 33% from
acceleration in production ~5.7million
– WBC – leukocytes increase (5,000-15,000)
– Hgb – 12 – 16 g/dl – stays about the same
– Hct -- 37% decreases RT hemodilution. There is
an increase of about 1500 ml. Over 1000 ml. of that
is plasma.
Cardiovascular Care
Nursing Care
–Avoid supine hypotension by side
lying
–Arise slowly from a lying position
–Wear support hose and avoid
constipation to decrease formation
of varicose veins
–Instruct that palpitations may be felt
and are normal
Respiratory Changes
– The body adjusts to meet the oxygenation
needs by:
» Thoracic rib cage is pushed upward and
the diaphragm is elevated as uterus
enlarges
» Lower thoracic cage widens to increase
tidal volume
» Oxygen consumption is increased to
support fetus
– Vasodilation of vessels in nose causing
epistaxis and nasal stuffiness

Respiratory Changes

Nursing Care
– Instruct that because of shortness of
breath and dyspnea may need to:
» sleep in an upright position
» avoid overloading the stomach
» stop smoking!
– Nasal stuffiness is normal because of
increase in hormones
Gastrointestinal Changes

Nausea and Vomiting
– Related to:
» increased levels of HCG
» changes in CHO metabolism
» fatigue
– Nursing Care
» Avoid offending odors
» eat dry CHO (crackers) upon wakening
» Eat 5-6 small meals per day
» Avoid spicy, gas forming foods
» Drink carbonated beverages
Gastrointestinal Changes
Heartburn
and Indigestion
–Related to:
»slowing of motility and digestion because
of progesterone
»relaxation of cardiac sphincter, regurgitation
occurs
»stomach displaced upward and compressed by
enlarged uterus
– Nursing Care
» avoid large meals
» use good posture
» Take low Sodium antacids --
Gastrointestinal Changes

Constipation
– Related to:
» slowing of motility
» intestinal compression
» oral iron supplement
– Nursing Care
» Increase water and fiber in diet
» moderate exercise
» **Don’t take laxatives or enema without
a doctor’s permission
Gastrointestinal Changes

Hemorrhoids
– Related to :
» pelvic congestion
» straining with stool
– Nursing Care
» avoid constipation
» Apply topical agents to area
Review
 Mrs.
Andrews says that she just
mixes up some baking soda and
that takes care of her indigestion.
 Is
there any teaching that needs to
be done in this situation?
Urinary Changes

Renal Changes
– Related to:
» Kidneys increase in size and weight to
enable greater filtration
» Enlarged uterus presses on kidneys and
ureters reducing effective flow.
» ureters dilate
» Urinary stasis
Urinary Changes

Urinary frequency and urgency
– Related to:
» pressure of uterus on bladder
When is this more common?
Nursing care
Kegels exercises
Limit fluid intake before bedtime
Report dysuria or burning
Skin and Hair Changes

Skin
– Increase pigmentation RT increase in
production of melanotropin
» face = chloasma
» breasts = areola darkens
» abdomen = linea nigra
– Spider nevi on face and upper trunk
– Striae gravidarum
 Hair
– Increase in hair growth
Musculoskeletal Changes

Joints, bones, and teeth
– Softening of pelvic cartilage and exaggerated
elasticity of connective tissue can lead to unstable
gait
– Posture changes
– Leg cramps
– Carpal tunnel syndrome
– Teeth--there is no demineralization
– Nursing Care
Wear low heel shoes for support
Exercises
Walk leading with the heel of the foot
Wrist supports until after delivery assist with
pain related to carpal tunnel syndrome. Goes
away after delivery.
Hormones

Endocrine
– The placenta produces new hormones:
»
»
»
»
»
Human chorionic gonadotropin – maintain pregnancy
Human placental lactogen – antagonist of insulin
Estrogen – stimulates development of uterine lining
Progesterone – maintains pregnancy
Relaxin – aids in softening the cervix
Confirmation
of the
Pregnancy
Situation
Mr. and Mrs. Andrews visit the
clinic and tell the nurse that Mrs. A
has “missed two menstrual
periods, has urinary frequency, and
is tired all of the time”.
First Prenatal Visit
 What
is the most important thing
that the nurse can do at this first
prenatal visit?
FIRST PRENATAL VISIT
 Most
important intervention for
the nurse is to:
MAKE THE PATIENT WELCOME !
Why?
(so the couple will continue with
prenatal care)
 The
nurse will gather data
regarding presumptive,
probable, and positive signs
of pregnancy.
Presumptive Signs of
Pregnancy








Cessation of Menstruation
Breast changes -- tenderness
Nausea and Vomiting
Frequent Urination
Quickening
Chadwick's sign
Increased pigmentation of the Skin
Fatigue
Probable Signs of Pregnancy


Enlargement of the Abdomen
Hegar’s Sign -- softening of the isthmus of the
uterus





Goodell’s Sign --softening of the cervix
Braxton-Hicks contractions
Ballotment
Outline of the fetus by abdominal palpation
Positive Pregnancy Test
Positive Signs of Pregnancy

Auscultation of fetal heart tones

Active fetal movement felt by Trained person

Ultrasound showing fetal outline
Confirm the Pregnancy
All tests rely on detection of HCG
Enzyme
Radioreceptor
Assay
Pregnancy
Tests
Radioimmune assay
Urine
Hemaagglutination
Inhibition
 Mrs.
A says that she used a
home pregnancy test and the
results were positive.
 What
are some of the
advantages and
disadvantages of using home
pregnancy testing?
Health History Assessment

Collect information about:
– Obstetric History -- Current and past pregnancies
– Menstrual History
– Family history--genetic and environmental factors that
affect health
– Medical history-- diabetes, heart

Perform Physical Examination including a
Pelvic Examination (Pap test, measurements,
cervical culture)

Perform Laboratory Studies
– Hgb., Hct, Type, Rh, CBC, Rubella, Hepatitis, HIV
 Now
that the couple has
been welcomed to the clinic
and the history is complete,
it is time to confirm that
Mrs. A is pregnant.
It is confirmed that Mrs.
Andrews is pregnant.
The nurse will continue with the
assessment of physiological
and psychological needs of the
family.
Assessment begins at the initial
visit and continues throughout
pregnancy.
Calculation of Gravida and
Parity

Obstetrical Status
–Gravida = number of times pregnant
regardless of duration or outcome
–Parity = number of deliveries after
the age of viability (20 weeks).
** It is not the number of babies that
come out, but the number of
deliveries of a pregnancy
Calculation of Gravida and
Parity

Further Breakdown into TPAL
–T = Term
–P = Preterm
–A = Abortions
–L = Live births
Check Yourself !
 The nurse obtained the following data from
Mrs. Andrews. She has five year old twins
that delivered at 35 weeks, a three year old
son that delivered at 39 weeks, had a
miscarriage last year at 12 weeks gestation.
 What is her gravida and parity?
 What is her gravida and parity using the TPAL
system?

Mr. and Mrs. Andrews are both excited about
the pregnancy. It is her first so she is
considered a Gravida 1, Para 0.

They ask the nurse “When is the baby due”?

How will you calculate this?
Calculation of E. D. C.
 Nagele’s Rule
 First day of last Menstrual
 Go back 3 months
 Add 7 days
 Mrs. Andrews tells you her last
menstrual period began on July 18.
 Her baby is due on ____________.
TEST YOURSELF
Mrs. B. began her menses on
January 21. What is her E.D.C.
using Nagele’s Rule?
Mrs. C. started her menses on
June 27. What is her E.D.C.
using Nagele’s Rule?
Problem Solving
 If
Mrs. Andrews did not know
the first day of her last
menstrual period, what
method of calculation would
you use?
 McDonald’s Rule
 Use Fundal height measurement,
measure from the symphysis to the
top of the fundus.
 Months = measure cm. X 2/7
 Weeks = measure cm. X 8/7
 Mrs. Andrew’s fundal height is
7 cm. How far along is she?
Assessment of Pelvic
Adequacy

Clinical Pelvimetry via ultrasound can be
performed to determine if the pelvis is of
adequate size to allow for a normal vaginal
delivery.

Manual measurement via examiner
Conclusion of Visit

You are completed with Mr. and Mrs. Andrews
first prenatal visit.

Before they leave, it is important to discuss
the following topics:
Conclusion of Visit

Danger Signals

Patient Teaching

Diet Counseling

Referrals

Date of next visit
Danger Signals










Vaginal Bleeding
Fluid from the Vagina
Abdominal Pain
Increased Temperature
Dizziness, Blurred vision or Double Vision
Persistent Vomiting
Edema
Headache
Dysuria
Absence of Movement of the Baby
Patient Teaching
Review interventions on how to
overcome the Common Discomforts of
pregnancy and Health Behaviors with
each subsequent visit .
Teaching Health Behaviors
Bathing
Breast Care
Clothing
Teaching Health Behaviors

Employment
– Criteria for work:
» is work environment safe for the fetus
» can woman carry out work
commitments without undue stress

What other teaching is necessary regarding
work and breaks.

Mrs. Andrews says that she is
employed as a bank teller on a full time
basis.

She asks whether she can continue to
work throughout her pregnancy
 Exercise,
Leisure, Travel
– May attend regular prenatal exercise classes
– Don’t take up a new sport
– Travel--wear seat belt
Wear shoulder belt
over top of abdomen
Wear lap belt low
over the hips
Teaching Health Behaviors

Avoid exposure to teratogens
– Alcohol
– Smoking
– Drugs

Immunizations - avoid live vaccines

Advise about use of prescription and
over-the-counter drugs
First Trimester

Uncertainty
– Incorporation and integration of the fetus as an
integral part of the woman.

Ambivalence

Self as primary focus
– Baby not perceived as a reality.
– Fetus is not perceived as a separate object
– Interest and concern about their bodily and
emotional changes.
Psychological Task - Needs to be able to say “I am Pregnant”
Second Trimester

Fetus as primary focus
– Sees fetus as a separate object and not an
extension of self.
– Picture the fetus as a newborn infant.
– Assign sex and describe with specific
characteristics.

Narcissism and Introversion
– Wants to do the right things to protect herself and
her baby

Body Image
Psychological Task - Needs to be able to say “I am going to have
a baby”
Changes in Sexuality



First Trimester
– nausea, fatigue, fear of miscarriage
interfere with sexual feelings
Second trimester
– freedom from worry of getting pregnant so
enjoy sex
– Increase in sexual responsiveness
Third Trimester
– Suggest alternate positions for sex
– Sexual response varies widely
Third Trimester

Vulnerability
– Worry that baby may be lost or harmed

Increasing dependence

Preparation for birth
–
–
–
–
–
Planning baby’s arrival at home.
Decide on method of feeding.
Acceptance of demands baby will make on parents.
More confident in knowledge about labor and delivery.
Interest in child care and planning for the future.
Psychological Task - Needs to be able to say “I am going to
be a parent.”
Paternal Responses

Readiness for fatherhood is more likely if there
is a stable relationship between partners

May be more difficulty for males to adapt to role
as father because they are often neglected when
the focus is on the woman

Need the same support as the woman
Cultural Influences
In working with clients of other cultures,
health professionals should be open to and
respectful of other beliefs
Nutrition in Pregnancy

Increase in calories
Increase in protein
Adequate intake of minerals and vitamins

May have food cravings or Pica


Nursing care:
– Teach to take prenatal vitamins and iron
– Teach about normal weight gain ~ 25 lbs.