Health Promotion and Pregnancy: Antepartum

Christensen Foundations of Nursing Chapter 25

Fetal Development
Gestation begins with conception (fertilization with union of sperm and egg) and continues throughout birth and pregnancy Lasts 40 weeks 3 trimesters of 3 months each Fertilization the union of the egg and the sperm to form a zygote 2 weeks after the last normal menstrual period (LMP or LMNP) Sex is determined at fertilization Occurs in outer 1/3 of fallopian tube

Fetal Development
Implantation occurs when the zygote (blastocyst) enters the endometrium of the uterine fundus between 6-10 days after conception
Decidua endometrium after implantation

Chorionic villi fingerlike projections that develop out of the trophoblast (developing placenta) and extend into the maternal blood vessels of the decidua

Fetal Intrauterine Development

Ovum stage conception to day 14 Morula blastocyte germ layers Embryo stage day 15 to 8 weeks Greatest risk from teratogens Most organ systems and external structures develop Fetal stage 9 weeks until completion of pregnancy Recognizable as a human

Fetal Development
4 weeks fetal heart begins to beat, body flexed, C-shaped with arms and leg buds present 8 weeks all organs formed, first indication of musculoskeletal ossification (first 8 weeks are the most critical) 8-12 weeks fetal heart rate can be heard using a doppler 12 weeks sex can be determined, blood forming in marrow, kidneys secrete urine

Fetal Development
16 weeks face looks human, meconium in bowel, heart muscle well developed, sensory organs differentiated 20 weeks primitive respiratory movements, heartbeat heard with fetoscope, quickening (fetal movement), brain grossly formed, vernix caseosa (protective, cheese like coating) on the skin, and lanugo (fine, downy hair), viable outside of the uterus (has some chance of life outside of the uterus)

Vernix Caseosa and Lanugo

Fetal Development
24 weeks body lean, well proportioned, lecithin (respiratory marker) begins to appear in amniotic fluids, able to hear 28 weeks brown fat present, eyes open and close, weak suck reflex 32 weeks subcutaneous fat collecting, has fingernails/toenails, sense of taste, aware of sounds outside mothers body 34+ weeks skin pink, body rounded, scant vernix caseosa, lanugo on shoulders and upper body only, fetus receives antibodies from mother

Fetal Development
Growth and development, before and after birth, follows the cephalocaudal (head to toe) principle Fetus has 4 specialized circulatory pathways: Ductus arteriosus connects pulmonary artery to the aorta bypassing lungs Foramen ovale opening between atria shunting blood from right to left atria Ductus venosus shunts blood from umbilical vein to the IVC bypassing liver Placenta

Ductus Arteriosus and Foramen Ovale

The Placenta
Produces hormones needed to maintain pregnancy Performs the metabolic functions of respiration, nutrition, excretion, and storage Maternal oxygen diffuses across the placenta into the fetal blood Carbon dioxide diffuses from the fetal blood across the placenta into the maternal blood

The Placenta

The Amniotic Fluid

Suspends the embryo/fetus Maintains constant fetal body temperature Source of oral fluid and repository for fetal waste Cushions fetus to prevent injury Allows fetal movement for musculoskeletal development Prevents the amnion (inner placental membrane) from fetal adherement Prevents umbilical cord compression

The Umbilical Cord

Connects fetal blood vessels contained in the placental villi with those within the fetal body Consists of 2 arteries that carry deoxygenated blood from the fetus to the placenta Consists of 1 vein that supplies the embryo with oxygen and nutrients from the placenta Whartons jelly thick substance that surrounds the umbilical cord acting as a physical buffer to prevent pressure on the vessels

Presumptive Signs of Pregnancy

Amenorrhea, nausea, vomiting, fatigue, urinary frequency, breast changes, uterine enlargement Quickening fetal movement felt at 16-20 weeks gestation Linea nigra Chloasma (melasma) mask of pregnancy Striae gravidarum stretch marks Darkened areola

Linea Nigra Striae Gravidarum

Chloasma

Probable Signs of Pregnancy

Abdominal enlargement, cervical changes Hegars sign softening and compressibility of lower uterus at 6-8 weeks pregnancy Chadwicks sign violet-blue color of vaginal mucosa Goodells sign cervical tip softening Ballottement rebound of unengaged fetus felt in the 4th or 5th month of pregnancy Braxton Hicks contractions Positive pregnancy test, palpable fetal outline

Hegars Sign

Positive Signs of Pregnancy

Fetal heart sounds Fetoscope Doppler Fetal movement palpated by an experienced examiner Visualization of fetus by ultrasound or through x-ray examination

Physiologic Changes in Pregnancy

Reproductive uterus increases in size and changes shape and position, ovulation and menses stop Cardiovascular increase in cardiac output, blood volume, and heart rate Respiratory maternal oxygen needs increase, size of chest may enlarge during last trimester (rib cage flaring) Musculoskeletal weight increases, pelvic joints relax, lordosis of the lower back occurs

Physiologic Changes in Pregnancy

Gastrointestinal nausea and vomiting may occur, stomach and intestines are displaced Renal increased GFR, urinary frequency Endocrine levels of estrogen and progesterone rise till close of pregnancy, human chorionic gonadotropin (HCG) rises in early pregnancy then drops second trimester, and human placental lactogen (HPL) rises

Maternal Changes Trimester

st 1

1st month implantation spotting, fatigue, headache, mood swings 2nd month amenorrhea, positive pregnancy test, morning sickness, urinary frequency, tenderness or tingling of the breasts, fatigue, facial outbreaks, weight gain, may have heartburn 3rd month fetal heartbeat by doppler above the symphisis pubis, fatigue, weight gain, less nausea, palpable uterus, linea nigra/chloasma

Maternal Changes Trimester

nd 2

4th month less urination, increased energy, abdominal pulling, quickening (1620 weeks) 5th month uterus easily felt below umbilicus, quickening, increased , energy, constipation, darker areola, leukorrhea 6th month back pain, leg and foot cramps, mild swelling in the ankles and feet, striae gravidarum, weight gain, fast growing hair and nails

Maternal Changes Trimester

rd 3

7th month cramps in feet/legs, swelling in hands or feet, Braxton-Hicks contractions, stress incontinence 8th month heartburn, indigestion, shortness of breath, varicose veins, hemorrhoids, BraxtonHicks contractions, orthostatic hypotension 9th month surge of energy, lightening, urinary frequency, improved breathing, loss of cervical mucus plug, rupture of membranes

Laboratory Tests
HCG (human chorionic gonadotropin) biochemical markers for pregnancy that can be detected in serum and urine Blood type, Rh factor, and presence of irregular antibodies determines risk of maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia CBC with differential, Hgb, and Hct detects anemia and infection Serum alpha-fetoprotein detects neural tube defects such as spina bifida

Laboratory Tests
Hemoglobin electrophoresis detects hemoglobinopathies (sickle cell anemia and thalessemia) Urinalysis identifies DM, gestational HTN, renal disease, infection, and hematuria One hour glucose tolerance identifies gestational diabetes; done at initial visit for high risk clients, and at 24-28 weeks for all pregnant women (blood sugar > 135 mg/dL requires follow-up)

Laboratory Tests
Three hour glucose tolerance screens for diabetes in clients with elevated 1 hour glucose test, requires 2 elevated readings to confirm diagnosis Papanicolaou (PAP) test screens for cervical cancer, herpes simplex type 2, and/or HPV Vaginal/cervical culture detects group B streptococci (routinely obtained at 35-37 weeks), bacterial vaginosis, or STIs (gonorrhea and chlamydia)

Laboratory Tests
Rubella titer determines immunity to rubella (teratogen) PPD, chest screening after 20 week gestation with positive PPD identifies exposure to tuberculosis Hepatitis B screen identifies carriers Venereal disease research laboratory (VDRL) syphyllis screening mandated by law HIV detects HIV infection (requires consent)

Laboratory Tests
TORCH acronym for a group of infections that can negatively affect a woman who is pregnant, and cross the placenta and have teratogenic affects on the fetus Toxoplasmosis Other infections Rubella Cytomegalovirus Herpes virus

Toxoplasmosis
Caused by protozoan Toxoplasma gondii Domestic cats are the definative hosts with infections via: ingestion of contaminated raw or undercooked meats and garden products and contact with cat feces Infection more prevalent in Europe Maternal infection usually asymptomatic or has influenza symptoms or lymphadenopathy 33% risk of fetal infection if mother is infected during pregnancy

Toxoplasmosis
Most infants (70-90%) asymptomatic at birth but are high risk for developing abnormalities Classic fetal triad of symptoms: chorioretinitis, hydrocephalus, and intracranial calcifications Other symptoms include: fever, rash, microcephaly, seizures, jaundice, thrombocytopenia, lymphadenopathy

Rubella
Single stranded RNA viral disease that is vaccine preventable and not endemic in the U.S. Mild, self limiting disease in adults with rash, muscle ache, joint pain, and lymphedema Infection early in pregnancy has a higher probability of affecting the fetus (teratogenic) In infants may cause sensorineural hearing loss, cataracts, glaucoma, cardiac malformations, neurologic problems, growth retardation, bone disease, thrombocytopenia, blue berry muffin lesions, and death

Blueberry muffin spots

Cytomegalovirus (CMV)
Most common congenital viral infection affecting approximately 40,000 infants annually in the U.S. Mild, self-limiting disease in adults that is usually asymptomatic or has mononucleosis-like symptoms Transmission can occur with primary infection or reactivation of the virus with 40% risk of transmission to the infant in primary infection Studies suggest increased risk to the fetus if acquired late in the pregnancy

Herpes Simplex Virus

HSV 1 and HSV 2 that is primarily transmitted through infected maternal genital tract lesions Requires C-section prior to rupture of membranes Primary maternal infection has greater risk for transmission than reactivation infection Initial manifestations in infants very nonspecific Infants may present with infection of the skin, mouth, eyes, CNS disease, or disseminated disease

Diagnostic Tests
Ultrasound (18-40 weeks) high frequency sound waves are used to visualize internal organs and tissues by producing a 3 dimensional image of the fetus and maternal structure allowing for pregnancy confirmation, determining gestational age, identifying multifetal pregnancy, identifying site of implantation (uterine or ectopic), fetal viability, placental attachment site, and volume of amniotic fluid External abdominal ultrasound Internal transvaginal ultrasound

Transvaginal Ultrasound

Diagnostic Tests
Doppler ultrasound blood flow analysis external ultrasound method of studying the maternal-fetal blood flow by measuring the velocity at which the RBCs are traveling n the uterine and fetal vessels Useful for identifying fetal intrauterine growth problems, poor placental perfusion, and as an adjunct in high risk pregnancies

Diagnostic Tests
Nonstress test (NST) doppler transducer and tocotransducer are attached externally producing paper tracing strips during the third trimester to evaluate fetal heart rate (FHR), fetal movement, and the fetal nervous system during the third trimester Reactive NST FHR accelerates 15 beats/min for at least 15 seconds and occurs 2-3 times/20 minute period (normal) Nonreactive NST FHR does not accelerate with fetal movement or no fetal movement occurs in 40 minutes (abnormal)

Nonstress Test (NST)

The detection of fetal movement is important Instruct the mother to drink a fluid, have a snack, or to touch or rock the abdomen to move the fetus

Diagnostic Tests
Contraction stress test (CST) an assessment performed to stimulate contractions (which decrease placental blood flow) and analyze the FHR in conjunction with the contraction to determine how the fetus will tolerate labor Negative CST (normal) - there are no late decelerations of the FHR in a 10 minute period with 3 contractions Positive CST (abnormal) persistent and consistent late decelerations on more than of the contractions

Diagnostic Tests
Biophysical profile (BPP) uses a ultrasound to visualize physical and physiological characteristics of the fetus in response to stimuli 2 = normal, 0 = abnormal, total 8-10 = normal Fetal heart rate (cardiotocogram) Fetal breathing movements Gross body movements (body or limb) Fetal muscle tone and posture Amniotic fluid volume and evaluation

Diagnostic Tests
Amniocentesis (3rd trimester) aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into the uterus and amniotic sac when mother is > 35 years, has history of previous fetal or parental chromosomal anomaly, fetal hemolytic disease, and meconium in the fluid to test for: Alpha-fetoprotein (AFP) high levels associated with neural tube defects Fetal lung maturity low levels associated with Downs syndrome and hydatidiform mole

Amniocentesis

Neural Tube Defect: Spina Bifida

Hydatidiform Mole
Benign abnormal uterine mass derived from chorionic villi that appears as a bunch of grapes Very large cystic vesicles U.S. incidence is 1 out of every 2000 pregnancies Early in the pregnancy maternal blood will present with high levels of hCG Associated with fertilization of the ovum by 2 or more sperm

Diagnostic Tests
Chorionic villus sampling (CVS) (8-12 weeks) assesses a portion of the developing placenta (chorionic villi) through aspiration using a thin sterile catheter or syringe passed through the abdomen or intravaginally to detect genetic chromosomal abnormality
First trimester alternative to amniocentesis Does not detect spina bifida or anencephaly

Anencephaly

Danger Signs During Pregnancy

First trimester vaginal bleeding or spotting, pelvic/abdominal cramping, no longer feeling pregnant, excessive vomiting Second and third trimesters vaginal bleeding with or without cramping, pressure, or pain, bleeding with severe abdominal pain, vaginal or lower abdominal pressure, preterm labor (PTL), premature rupture of membranes (PROM), decreased fetal movement, pregnancy induced hypertension (PIH)

Complications of Pregnancy
Spontaneous abortion
When a pregnancy is terminated before 20 weeks gestation or a fetal weight of < 500 g S/S - vaginal bleeding, uterine cramping, backache, rupture of membranes, dilation of the cervix, partial or complete expulsion of products of conception, and signs and symptoms of hemorrhage

Spontaneous Abortion

Spontaneous Abortion
Threatened may or may not have cramping, spotting to moderate bleeding, cervix is closed Inevitable cramping, bleeding, dilated cervix Incomplete cramping, bleeding, partial fetal tissue passed, dilated cervix Complete bleeding, complete expulsion of uterine contents, closed cervix Missed brownish discharge, retained tissue, closed cervix Septic malodorous discharge, dilated cervix Recurrent fetal tissue passed, dilated cervix

Spontaneous Abortion
Perform pregnancy test Use term miscarriage Place client on bedrest and administer sedation as ordered Advise client to avoid coitus Avoid vaginal exam Assist with ultrasound Administer IV pitocin, analgesics, blood products as ordered Save all passed tissue Assist with D&C Administer antibiotics and RhoGam as ordered

Complications of Pregnancy
Ectopic pregnancy
Abnormal implantation outside the uterus Implantation in the fallopian tube tubal rupture fatal hemorrhage Risk factors include any factor that compromises tubal patency (PID, IUD > 2 yrs) Transvaginal US shows empty uterus S/S unilateral stabbing pain, vaginal spotting, referred shoulder pain, nausea, vomiting, and shock

Ectopic Pregnancy
Assess for unilateral pain and vaginal bleeding Assess vital signs Asses skin color and urine output Provide replacement fluid and maintenance of electrolyte balance Provide education and psychological support Prepare client for surgery: linear salpingostomy (helps to salvage fallopian tube if not ruptured) and laparoscopic salpingostomy (tube removal)

Complications of Pregnancy
Gestational trophoblastic disease
Proliferation and degeneration of trophoblastic villi in the placenta which becomes swollen, fluid filled, and grape like Complete mole all genetic material is paternally (father) derived and contains no fetus, placenta, amniotic membranes, or fluid Partial mole genetic material is derived both maternally (mother) and paternally and contains abnormal embryonic or fetal parts, an amniotic sac, and fetal blood

Molar Pregnancy

Gestational Trophoblastic Disease

Risk factors include: low protein intake, < 18 years of age, > 35 years of age Ultrasound will reveal dense growth with characteristic vesicles, but no fetus in utero S/S rapid uterine growth, vaginal bleeding, discharge, excessive vomiting, PIH, elevated hCG Measure fundal height, assess bleeding, assess GI status and appetite, check VS, assess edema May have suction curettage for mole evacuation

Complications of Pregnancy
Incompetent cervix
Painless, passive dilation of the cervix in the absence of uterine contraction Usually occurs around 20 weeks of gestation Cervix cannot support the weight and pressure of the fetus and results in expulsion Risk factors include cervical trauma, in utero exposure to DES, congenital structural defects, and increased maternal age

Incompetent Cervix
Ultrasound will show short cervix, < 20 mm in length, which indicates cervical incompetence S/S bleeding pelvic pressure, rupture of membranes, uterine contractions, uterine pressure May have cervical cerclage, a surgical procedure that uses heavy ligature to strengthen the cervix Place client on bedrest; tocolytic medications Client must avoid intercourse, prolonged standing, and heavy lifting

Cervical Cerclage

Complications of Pregnancy
Placenta previa
Occurs when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus Results in bleeding during the 3rd trimester as cervix dilates and effaces Major complications associated with placenta previa are: maternal hemorrhage, and fetal prematurity or death

Placenta Previa
3 types:
Complete or total when the cervical os is completely covered by the placental attachment Incomplete or partial when the cervical os is only partially covered by the placental attachment Marginal or low-lying when the placenta is attached in the lower uterine segment but does not reach the cervical os

Placenta Previa

Placenta Previa
Risk factors include: previous placenta previa, uterine scarring, maternal age > 35 years, multifetal gestation, multiple gestations, or closely spaced pregnancies Diagnosed with transabdominal or transvaginal ultrasound which shows placental placement S/S painless, bright red vaginal bleeding, relaxed, nontender uterus with normal tone, higher than expected fundal height, palpable placenta, fetus in breech, oblique, or transverse position

Placenta Previa
Assess bleeding, leaking, or contraction Count pads for bleeding amount Examine the abdomen, and assess fundal height Perform Leopolds maneuvers to determine fetal position and presentation Check VS and assess I&O Place client on bedrest, IV fluids as ordered, blood replacement as ordered Nothing inserted vaginally Corticosteroids given for fetal lung maturation

Complications of Pregnancy
Abruptio placenta
Premature separation of the placenta from the uterus Can be partial or complete detachment Occurs after 20 weeks gestation, usually in the 3rd trimester Leading cause of maternal death Moderate to severe abruption disseminated intravascular coagulopathy (DIC) Associated with maternal hypertension

Abruptio Placenta

Abruptio Placenta
Associated with abdominal trauma, cocaine abuse, prior history of abruption, smoking, premature rupture of membranes, short umbilical cord, and multifetal pregnancy Diagnosed with ultrasound to determine fetal well-being and placental placement S/S sudden onset of intense localized uterine pain, vaginal bleeding, board-like abdomen, firm rigid uterus with contractions, fetal distress, hypovolemic shock

Abruptio Placenta
Palpate the uterus for tenderness and tone Assess bleeding rate, amount, and color Assess fetal heart rate, maternal VS, maternal color and turgor, maternal capillary refill, urine output, and LOC Place client on bedrest, refrain from vaginal exams Administer blood products, fluid volume replacement, corticosteroids, and immune globulin as ordered Treatment: cesarean delivery

Complications of Pregnancy
Hyperemesis gravidarum
Excessive nausea and vomiting, related to elevated hCG levels, that is prolonged past 12 weeks gestation and results in 5% weight loss from nonpregnancy weight, dehydration, electrolyte imbalance, ketosis, and acetonuria May be accompanied by liver dysfunction Risk to fetus for intrauterine growth restriction or preterm birth

Hyperemesis Gravidarum
Risk factors include: mother < 20 years, obesity, 1st pregnancy, multifetal gestation, gestational trophoblastic disease, history of psychiatric disorders, transient hyperthyroidism, vitamin B deficiencies, high stress levels Diagnostics include: UA for ketones and acetones, elevated specific gravity, chemistry profile, elevated liver enzymes, thyroid test, and elevated Hct

Hyperemesis Gravidarum
S/S excessive vomiting, dehydration with possible electrolyte imbalance, weight loss, decreased B/P, increased P, poor turgor Monitor I&O, skin turgor, mucus membranes, VS, and weight NPO for 24-48 hours, advancing to clear liquids after 24 hours if no vomiting, advancing to diet as tolerated, TPN in severe cases IV fluids of lactated Ringers solution, vitamin B6 and other supplements, antiemetic and corticosteroids

Complications of Pregnancy
Gestational hypertension (GH)/Pregnancy induced hypertension (PIH)
Gestational hypertensive diseases are associated with placental abruption, ARF, hepatic rupture, preterm birth, and fetal and maternal death High risks include: mother < 19 years or > 40 years old, 1st pregnancy, morbid obesity, multifetal gestation, CRF, chronic HTN, diabetes, Rh incompatibility, molar pregnancy, previous GH

Gestational Hypertension/Pregnancy Induced Hypertension

Diagnostics include: dipstick urine testing for proteinuria, 24 hour urine collection for protein and creatinine clearance, liver enzymes, serum creatinine, BUN, uric acid, magnesium, CBC, clotting studies, chemistry profile, nonstress test, and doppler blood flow analysis Vasospasm poor tissue perfusion s/s of pregnancy hypertensive disorders S/S severe headache, visual changes, sudden edema or swelling, rapid weight gain, epigastric pain

Gestational Hypertension/Pregnancy Induced Hypertension

Gestational hypertension
Begins after the 20th week of pregnancy Woman has B/P of 140/90 or >, or systolic increase of 30 mm Hg or a diastolic increase of 15 mm Hg from prepregnancy baseline No proteinuria or edema Returns to baseline by 6 weeks postpartum Associated with uteroplacental insufficiency due to vasospasm, rupture of the liver, and intrauterine growth restriction

Gestational Hypertension/Pregnancy Induced Hypertension

Mild preeclampsia
Begins after the 20th week of pregnancy Woman has B/P of 140/90 or >, or systolic increase of 30 mm Hg or a diastolic increase of 15 mm Hg from prepregnancy baseline 1+ to 2+ proteinuria Weight gain of > 2 kg (4.4 lb) per week in the second and third trimesters

Gestational Hypertension/Pregnancy Induced Hypertension

Severe preeclampsia
Begins after the 20th week of pregnancy Woman has B/P is 160/100 mm Hg or >, 3+ to 4+ proteinuria Oliguria, elevated serum creatinine > 1.2 mg/dL, headache, blurred vision, hyperreflexia with possible ankle clonus Pulmonary and cardiac involvement, peripheral edema, hepatic dysfunction, epigastric and RUQ pain, thrombocytopenia

Gestational Hypertension/Pregnancy Induced Hypertension

Eclampsia
Begins after the 20th week of pregnancy Woman has B/P is 160/100 mm Hg or >, 3+ to 4+ proteinuria Oliguria, elevated serum creatinine > 1.2 mg/dL, headache, blurred vision, hyperreflexia with possible ankle clonus Pulmonary and cardiac involvement, peripheral edema, hepatic dysfunction, epigastric and RUQ pain, thrombocytopenia, seizures or coma

Gestational Hypertension/Pregnancy Induced Hypertension

HELLP syndrome is a variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction
H hemolysis anemia and jaundice EL elevated liver enzymes (AST, ALT), epigastric pain, nausea and vomiting LP low platelets thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly DIC

Gestational Hypertension/Pregnancy Induced Hypertension

Monitor B/P, observe for edema, check DTRs, assess FHR for variability and decelerations Monitor respirations, LOC, pulse oximetry, urine output, daily weights, and VS Maintain bedrest in side-lying position Avoid foods high in sodium, alcohol, and limit caffeine Hyperreflexia and epigastric pain = seizures Encourage fluids; antihypertensive medications Seizure precautions, dark quiet environment

Gestational Hypertension/Pregnancy Induced Hypertension

Administer IV magnesium sulfate, the medication of choice as an anticonvulsant agent for prophylaxis or treatment Magnesium sulfate will lower blood pressure and depress the CNS Magnesium sulfate toxicity includes: absence of patellar DTRs, urine output < 30 mL/hr, respirations < 12/min, decreased LOC If magnesium toxicity is suspected: D/C medication, administer calcium gluconate (antidote), and prevent respiratory or cardiac arrest

Complications of Pregnancy
Gestational diabetes
An impaired tolerance to glucose with the first onset or recognition during pregnancy Ideal blood glucose 60-100 mm/dL Symptoms may disappear a few weeks following delivery Approximately 50% of women develop DM within 5 years Risk factors include: mother > 30 years, obesity, family history of diabetes, stillborn

Gestational Diabetes
Insulin acts like growth hormone on the fetus Increased fetal risks including: spontaneous abortion, infections, hydramnios (excess amniotic fluid), ketoacidosis, hypoglycemia, and hyperglycemia Maternal risk of: urinary tract infections due to glycosuria, and ketoacidosis Diagnostics include: urinalysis with glycosuria, 1 and 3 hour GTT, urine ketones, BPP, amniocentesis with AFP, nonstress test

Gestational Diabetes
S/S hunger and thirst, frequent urination, blurred vision, excess weight gain during pregnancy Monitor blood glucose; monitor fetus Teach s/s of hypoglycemia and hyperglycemia Educate about diet and exercise Administer insulin and teach self administration Oral hypoglycemic medications contraindicated Instruct client to perform daily kick counts

Healthcare During Pregnancy

Prenatal period is the period between conception and onset of labor Regular prenatal care is associated with lower infant mortality and better child outcomes Goals of good prenatal care: Promote physical and mental wellness of the mother during pregnancy and afterward Help the woman give birth safely and without complications Ensure a healthy baby

Healthcare During Pregnancy

Components of prenatal care: early and regular prenatal care, maintenance of maternal health; promotion of good habits, and recognition and treatment of physical, mental, social, and economic problems Risk assessment identifies women and fetuses who have a chance of having a complication during pregnancy, birth, or the neonatal period

Healthcare During Pregnancy

Prenatal visits:
Every 4 weeks for the 1st 28 weeks Then every 2 weeks until 36 weeks Then weekly until birth

The postpartum visit is usually scheduled at 4 to 6 weeks after birth Some providers like to see the woman at 2 weeks postpartum

Healthcare During Pregnancy

Initial prenatal visit
Establish schedule of prenatal visits Health history past illnesses, inherited diseases, multifetal pregnancy, previous difficulties during pregnancy, serious infections, STDs, or HIV Physical exam pelvic examination and measurements, head-to-toe assessment, height, weight, PAP test, and STD tests Laboratory tests blood type and Rh factor

Healthcare During Pregnancy

Initial prenatal visit
Other tests VDRL, CBC, antibody screen, and rubella titer HIV testing should be offered Pregnancy test and urine test for albumin, glucose, and bacteria PPD tuberculin skin test Genetic counseling and testing if indicated Determining the babys due date

Healthcare During Pregnancy

A full term pregnancy is approximately 280 days from the first day of the last menstrual period (LMP), or 266 days after fertilization Determining the estimated date of delivery (EDD); also called the estimated date of confinement (EDC), uses Nageles Rule
Determine the date of the 1st day of the womans LMP, add 7 days, subtract 3 months, the resulting date is the EDD

Healthcare During Pregnancy

Return prenatal visits
Following measures should be performed: weight, B/P, urine dipstick, measure of fundal height, fetal heart tones, checking for edema, and continuing risk assessments Ultrasound between 16-20 weeks to determine gestational age Maternal serum alphafetoprotein (MSAFP) test between 5-19 weeks to screen for fetal neural tube defects

Fundal Height

Fundal Height
The fundal height is measured in centimeters and equals the approximate gestational age in weeks, until week 32 Fundal height:
12 weeks 12 centimeters 16 weeks 16 centimeters 20 weeks 20 centimeters 24 weeks 24 centimeters

Healthcare During Pregnancy

Return prenatal visits
Triple marker screen the MSAFP may be combined with 2 other tests (HCG and estriol) which increases the number of neural tube defects that may be identified and also screens for Down syndrome Between 24-28 weeks all women should be screened for diabetes using a 1 hour random glucose tolerance test

Healthcare During Pregnancy

Return prenatal visits The Rh antibody test is repeated at 26 to 27 weeks, and RhoGam is given at 28 weeks if the antibody test remains negative Many providers repeat STD testing at 36 weeks, and may also do a vaginal culture for group B streptococcus

Healthcare During Pregnancy

Elimination and hygiene
Daily bowel movement is preferred More active oil and sweat glands so daily bath is important May experience ptyalism increase in saliva

Breast care
Supportive bra Elaborate breast care unnecessary, little or no soap on the nipples

Healthcare During Pregnancy

Rest
During the last months of pregnancy the woman should rest on her left side for at least 1 hour in the morning and afternoon to relieve fetal pressure Avoid sleeping or lying on the back due to supine hypotension syndrome due to fetal compression on the aorta and the vena cava If woman must remain on back, place small pillow or towel roll under one hip

Aortocaval Compression

Healthcare During Pregnancy

Exercise, posture, and activity
Exercise improves circulation, appetite, and digestion Exercise should be daily, rather than sporadic

Sexual relations
Sexual response cycle is affected by pregnancy Touch needs, comfort and reassurance needs continue

Sexual Safety
Women who experience bleeding should avoid vaginal penetration Sex with a partner who has STDs, or sex after rupture of membranes increase risk of infection Sexual arousal may initiate labor for a woman at risk for preterm labor Orgasm stimulates uterine contractions Blowing air into the vagina increases risk of air embolism

Healthcare During Pregnancy

Clothing
Need for looser clothing, use of flat heels May have trouble typing laces or fastening buckles Wide strapped bra for support

Travel and employment

Use seat belts and shoulder straps Never fly in small non pressurized plane Avoid risky jobs: radiation, toxins, standing

Healthcare During Pregnancy

Teratogens are substances known to cause fetal defects
Diseases Rubella, herpes, toxoplasmosis, syphilis Medications phenytoin, lithium, valproic acid, isotretinoin, and warfarin Substances of abuse tobacco, alcohol, heroin, cocaine Ionizing medication

Fetal Alcohol Syndrome

Alcohol crosses the placental barrier and cause: growth deficiency, craniofacial deformity, behavioral and cognitive impairment, motor and sensory deficits, and seizures

Nutrition During Pregnancy

Adequate nutrition to support the mother and the growing fetus
Increase milk and milk products Increase calories by 300/day Increase iron, folic acid, and most vitamins Reduce empty calories Use iodized salt Avoid laxatives and enemas Increase fluid to 10 glasses/day

Nutrition During Pregnancy

Changes in the womans body during the early part of pregnancy may interfere with appetite Caffeine can be harmful to pregnant women contributing to mastitis, and cross the placenta causing irritability in the fetus Avoid coffee, some teas, most colas and other soft drinks, and chocolate Pica abnormal craving for nonfood items such as clay, dirt, or cornstarch

Weight Gain During Pregnancy

Recommended weight gain during pregnancy is usually 25-35 pounds General rule: weight gain of 3-4 pounds the first trimester, and 1 pound per week for the last 2 trimesters Excessive weight gain macrosomia (big baby) and labor complications Poor weight gain low birth weight

Adapting to Pregnancy
1st trimester: weeks 1-13 Acceptance of the pregnancy May exhibit ambivalence, shock, disbelief, self-focus, and fear 2nd trimester: weeks 14-27 Incorporate fetus into maternal body image May exhibit dependency, excitement, calmness, increased libido 3rd trimester: week 28-terms Sees the fetus as separate from self

Prenatal and Childbirth Education

1st trimester teaching:
Physical and psychosocial changes Discomforts of pregnancy and relief measures Lifestyle: exercise, stress, nutrition, sex, dental care, medication use, substance abuse, and STDs Complications, choosing an obstetrician Fetal growth and development Prenatal exercise, laboratory testing

Prenatal and Childbirth Education

2nd trimester teaching:
Planning to breast or bottle feed Common discomforts and relief measures Lifestyle: sex and pregnancy, rest and relaxation, posture, body mechanics, clothing, seat best safety, and travel Fetal movement (quickening) Complications Childbirth preparation

Prenatal and Childbirth Education

3rd trimester teaching:
Birth plan Breathing and relaxation techniques Decisions about pain management Signs and symptoms of labor Labor process Infant care Postpartum care Fetal movement/kick counts

Common Discomforts
Nausea and vomiting should eat crackers or dry toast to 1 hour before rising Breast tenderness bra that provides support Urinary frequency 1st and 3rd trimesters Urinary tract infections wipe front to back, unscented toilet tissue, cotton underpants, 8 glasses of water, eat yogurt and acidophilus milk, urinate after intercourse Fatigue frequent rest periods Heartburn small frequent meals Constipation increase fluids, fiber, exercise

Common Discomforts
Hemorrhoids warm sitz bath or witch hazel pads Backaches regular exercise, pelvic tilts, proper body mechanics Shortness of breath and dyspnea good posture, extra pillows, avoid overeating Leg cramps extend leg and dorsiflex foot Varicose veins and lower extremity edema elevate legs, support hose, avoid sitting or standing for prolonged periods

Common Discomforts
Gingivitis, nasal stuffiness, and epistaxis gently brush teeth, good dental hygiene, humidifer, and normal saline nose drops or spray Braxton-Hicks contractions change of position and walking Report increase in intensity and frequency Supine hypotension lay in side-lying or semisitting position with knees slightly flexed

Common Birthing Methods

Dick-Read method refers to childbirth without fear, uses controlled breathing, and relaxation Lamaze focuses on partner-coached breathing, relaxation with panting, and outside focal points Leboyer refers to birth without violence, dim lights, soft voices, warm room Bradley stresses partners involvement, natural childbirth, breathing techniques, relaxation