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Chapter 4

Chapter 4. Prenatal Care and Adaptations to Pregnancy. Phases of Pregnancy. Antepartum Before birth (Prenatal) Intrapartum During birth Postpartum After birth. Prenatal Care Providers. Obstetricians Family practice physicians Certified nurse-midwives (CNMs) Nurse practitioners.

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Chapter 4

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  1. Chapter 4 Prenatal Care and Adaptations to Pregnancy

  2. Phases of Pregnancy • Antepartum • Before birth (Prenatal) • Intrapartum • During birth • Postpartum • After birth

  3. Prenatal Care Providers • Obstetricians • Family practice physicians • Certified nurse-midwives (CNMs) • Nurse practitioners

  4. Major Goals of Prenatal Care • Ensure a safe birth for mother and child by promoting good health habits and reducing risk factors • Teach health habits that may be continued after pregnancy • Educate in self-care for pregnancy • Provide physical care • Prepare parents for the responsibilities of parenthood

  5. Prenatal Visits

  6. Preconception Care • Identifies risk factors that may be changed before conception • Reduces their negative impact on outcome of pregnancy • Ensures good nutritional state and immunizations • Ensures adequate intake of folic acid • Prevents neural tube defects in developing fetus

  7. Prenatal Care • Complete History and Physical • To identify problems that may affect the woman and her developing fetus • To ensure healthy pregnancy and delivery of healthy infant

  8. Obstetric Menstrual Contraceptive Medical and surgical Woman’s family Partner’s family Woman’s and partner’s to identify risk factors Psychosocial Components of Prenatal Health History

  9. Physical Examinations • Evaluate the woman’s general health • Determine baseline weight and vital signs • Evaluate nutritional status • Identify current physical/social problems • Determine the estimated date of delivery (EDD)

  10. Pelvic Examinations • Evaluate the size, adequacy, and condition of the pelvis and reproductive organs • Assess for signs of pregnancy

  11. Recommended Schedule for Prenatal Visits—Uncomplicated Pregnancy • Conception to 28 weeks—every 4 weeks • 29 to 36 weeks—every 2 to 3 weeks • 37 weeks to birth—weekly • Certain laboratory and/or diagnostic tests are performed at various times throughout the pregnancy

  12. (see Table 4-1, page 46 for listing)

  13. Routine Assessments at Each Prenatal Visit • Risk factors: Review known and assess for new ones • Vital signs • Weight to determine if gain is normal • Urinalysis for protein, glucose, and ketone levels • Blood glucose screening • Fundal height to assess fetal growth and amniotic fluid volume • Leopold’s Maneuvers to assess presentation and position • Fetal heart rate • Review nutritional intake of woman • Discuss any discomforts or problems since last visit

  14. Vaginal Discharge During Pregnancy • Bacterial vaginosis is most common • Caused from: • Decrease in lactobacilli • Increase in bacteroids and other anaerobic microorganisms • May be milky-white discharge • No other clinical symptoms may be present • Has been associated with preterm labor

  15. Nursing Tip • Early and regular prenatal care is important for reducing the number of low birth weight infants born and for reducing morbidity and mortality for mothers and newborns

  16. Gravida Nulligravida Primigravida Multigravida Para Primipara Multipara Nullipara Abortion Gestational age Age of viability Terms Related to Pregnancy

  17. Determining the Estimated Date of Delivery • Average pregnancy is 40 weeks (280 days) after first day of last normal menstrual period (LNMP), plus or minus 2 weeks • Nägele’s rule • Identify first day of LNMP • Count backward 3 months • Add 7 days • Update year, if applicable

  18. Trimesters • Pregnancy divided into 3 parts, with 13 weeks each • It is important to know what occurs during each trimester to both the woman and the fetus

  19. Diagnosis of Pregnancy

  20. Signs of Pregnancy • Presumptive • Amenorrhea • Nausea • Breast tenderness • Deepening pigmentation • Urinary frequency • Quickening

  21. Signs of Pregnancy (continued) • Probable • Goodell’s sign • Chadwick’s sign • Hegar’s sign • McDonald’s sign • Abdominal enlargement • Braxton-Hicks contractions • Ballottement • Striae • Positive pregnancy test

  22. Signs of Pregnancy (continued) • Positive • Audible fetal heartbeat • Fetal movement felt by examiner • Ultrasound visualization of fetus

  23. Normal Physiological Changes in Pregnancy

  24. Height of Fundus During Gestation

  25. Effects of Pregnancy on the Reproductive System • Uterus • Becomes temporary abdominal organ • Capacity is 5000 ml (fetus, placenta, and amniotic fluid) • Cervix • Changes in color and consistency, glands in cervical mucosa increase • Mucous plug formed to prevent ascent of organisms into uterus

  26. Effects of Pregnancy on the Reproductive System (continued) • Ovaries • Produce progesterone to maintain decidua (uterine lining) during 1st 6 to 7 weeks of gestation until placenta can take over task • Vagina • Increased blood supply causes it to have a bluish color • Vaginal secretions increase, pH more acidic • Higher glycogen level, which promotes Candida albicans (yeast) growth

  27. Effects of Pregnancy on the Reproductive System (continued) • Breasts • High levels of estrogen and progesterone prepare breasts for lactation • Montgomery’s tubercles secrete substance to lubricate nipples • “Premilk” is expressed and is high in protein, fat-soluble vitamins, and minerals • Low calories, fats, and sugar

  28. Effects of Pregnancy on the Respiratory System • Oxygen consumption increases by 15% • Diaphragm rises ~4 cm (1.6 inches) • Causes ribs to flare • Dyspnea can occur until fetus descends into pelvis • Increased estrogen causes edema or swelling of mucous membranes of nose, pharynx, mouth, and trachea • Woman may complain of nasal stuffiness, epistaxis, and vocal changes

  29. Effects of Pregnancy on the Cardiovascular System • Blood volume increases by ~45% compared to prepregnant state • Increase provides for: • Exchange of nutrients, oxygen, and waste products within the placenta • Needs of expanded maternal tissue • Reserve for blood loss at birth • Pulse rate increases by 10 to 15 beats/min

  30. Also called aortocaval compression or vena cava syndrome Occurs if woman lies flat on her back Allows heavy uterus to compress inferior vena cava Reduces blood returned to her heart Can lead to fetal hypoxia Symptoms Faintness Lightheadedness Dizziness Agitation Turning to one side relieves pressure on inferior vena cava Supine Hypotension Syndrome

  31. Supine Hypotension Syndrome

  32. Cardiovascular System • Orthostatic hypotension • Palpitations • Dilutional anemia (pseudoanemia) • Increased clotting factors in 2nd and 3rd trimesters • Increased risk of thrombophlebitis

  33. Effects of Pregnancy on the Gastrointestinal System • Growing uterus displaces stomach and intestines • Increased salivary secretions • Oral mucosa may become tender and may bleed more easily • Increased appetite and thirst • Decreased gastric acid secretions • Delayed gastric emptying and intestinal movement • Progesterone and estrogen relax muscle tone of gallbladder • Leads to retained bile salts • Can cause pruritus during pregnancy

  34. Effects of Pregnancy on the Urinary System • Excretes waste products of woman and fetus • Glomerular filtration rate of kidneys increases • Glycosuria and proteinuria more common • Water retention due to increased blood volume and dissolving nutrients provided for fetus • Progesterone causes renal pelvis and ureters to lose tone, leads to urinary stasis • Woman more susceptible to UTIs • 99% of sodium is reabsorbed, leads to fluid retention

  35. Effects of Pregnancy on the Integumentary and Skeletal Systems • Striae • Spider nevi • Sweat and sebaceous glands become more active • To dissipate heat from woman and fetus • Posture changes • Low back aches • Relaxation of pelvic joints • Waddling gait • Change in center of gravity • Balance may become an issue

  36. Nutrition for Pregnancy and Lactation

  37. Nutritional Education • Read food labels • Eat foods that are nutrient dense rather than nutrient empty • Protein versus sugary foods

  38. Nursing Tip • High correlation between maternal diet and fetal health • Ensure that deficiencies do not occur during the critical first weeks of pregnancy • Explain the value of eating well-balanced meals

  39. Weight Gain • Women of normal weight: 25 to 35 pounds (11.5 to 16 kg) • Underweight women: 28 to 40 pounds (12.6 to 18 kg) • Overweight women: 15 to 25 pounds (7 to 11.5 kg) • If multifetal: twins; woman should gain 4 to 6 pounds in 1st trimester, 1.3 pounds per week in 2nd and 3rd trimester, for a total of 35 to 45 pounds.

  40. Nutritional Requirements for Pregnant Women • Increase intake by 300 kcal per day; should also include: • Protein—60 g/day • Calcium—1200 mg/day • Iron—30 mg/day • Folic acid—400 mcg (0.4 mg)/day

  41. RDA/RDI • No need to provide nutrients in excess of the upper limits of the Recommended Dietary Allowance (RDA) • The combination of supplements and food fortification must not exceed present upper limits of safety, or adverse responses, such as toxicity, can occur • Recommended Dietary Intake (RDI) is an umbrella term that includes the RDA and upper levels of intake

  42. Special Nutritional Considerations • Pregnant adolescent • Sodium intake • Vegetarian • Pica • Lactose intolerance • Gestational diabetes mellitus

  43. Nutrition During Lactation • Caloric intake during lactation should be about 500 calories more than the nonpregnant woman’s RDA • Protein intake should be 65 mg/day • Calcium and iron intake should be the same as during pregnancy • Vitamin supplements are often continued during lactation • Limit intake of caffeine and alcohol • Drugs should only be taken upon the advice of the health care provider

  44. Exercise During Pregnancy • Maternal cardiac status and fetoplacental reserve should be the basis for determining exercise levels during all trimesters of pregnancy • It is important to assess the exercise practices of the woman • Goal of exercise during pregnancy should be maintenance of fitness, not improvement of fitness or weight loss

  45. Basic Factors Related to Exercise and Pregnancy • Elevated temperature • Can impact fetal circulation and cardiac function • Hypotension • Can reduce blood flow to the fetus • Cardiac output • Peripheral pooling decreases cardiac reserves for exercise

  46. Basic Factors Related to Exercise and Pregnancy (continued) • Hormones • Changes in oxygen consumption and in levels of epinephrine, glucagon, cortisol, prolactin, and endorphin • Other factors • Moderate exercise has many benefits—a more positive self-image, a decrease in musculoskeletal discomforts during pregnancy, and a more rapid return to prepregnant weight after delivery

  47. Nursing Guidance for Exercise • Start with a warm-up, end with a cool-down • Do not exceed ACOG recommendations for moderate exercise • Exercise combined with a balanced diet is beneficial • Eating 2 to 3 hours before exercise, and immediately after, is recommended • Avoid marked changes in depth of water (such as scuba diving) and/or altitude • Avoid becoming overheated, increase fluid intake • Intensity of exercise should be modified based on the “talk test”

  48. Travel During Pregnancy • Air travel is generally safe • Avoid sitting for extended periods of time • Avoid locations that increase the risk of exposure to infectious diseases • Bring a copy of obstetric records • Obtain information about nearest health care facility • Encourage hand hygiene and dietary precautions • Provide the “recipe” for oral rehydration formula

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