SG #2: ANTEPARTUM Prof. Unn Hidle Updated Spring 2010

1. SG #2: ANTEPARTUMProf. Unn HidleUpdated Spring 2010

2. Review of Nagele’s Rule • EDD, EDC, EDB • ADD 7 days (to the date of 1st day of LMP) • SUBTRACT 3 months • ADD 1 year

3. PREGNANCY TESTS • URINE vs. SERUM • WHICH ONE WOULD YOU DO?

4. PREGNANCY TESTS cont. • URINE • Detection of hCG (human chorionic gonadotrophin) released by the placenta early in pregnancy • Always have a follow-up serum pregnancy test to confirm results • OTC (over-the-counter) pregnancy tests are 95-99% accurate if done according to instructions • Much more sensitive today. May detect pregnancy 1-2 days after first missed period (some newer versions even sooner) • Some test results within 1 minute • SERUM • More accurate than urine • May be as sensitive as detecting pregnancy (positive) as early as 1-2 days after implantation

5. EXAMPLES

7. SIGNS OF PREGNANCY PRESUMPTIVE SIGNS PROBABLE SIGNSPOSITIVE SIGNS

8. PRESUMPTIVE SIGNS • SUBJECTIVE = Key! • S/S the woman experiences • May have other causes than pregnancy • Amenorrhea • N/V • Weight gain • Fatigue • Breast fullness, tenderness; pronounced nipples with increased pigmentation of areola • Urinary frequency • “Quickening” (16-18 weeks) • Chadwick’s sign and thickening of vaginal mucosa • Chadwick’s sign also considered probable

9. PROBABLE SIGNS • OBJECTIVE = Key! • Objective changes perceived by examiner • May be causes other than pregnancy: • Abdominal/uterine enlargement • Hegar’s sign (softening of uterine wall – 6th week) • Goodell’s sign (softening of cervix – 8th week) • Chadwick’s sign (discoloration) • Ballottement • Fetal outline by palpation (NOT ultrasound) • Braxton Hicks contractions • Positive pregnancy test (hCG)

10. Assessing for Hegar sign

11. Ballottement

12. POSITIVE SIGNS • CONCLUSIVE of pregnancy: • FHR by Doppler/US at 8-12 weeks • FHR by Fetoscope at 18-20 weeks • Active fetal movement palpable by examiner AFTER 18 weeks • Outline of fetal skeleton via X-ray or US transvaginally as early as 10 days after implantation

13. Physiologic Changes of Pregnancy by systems

14. UTERUS • Weight • Increases from 70 grams to 900-1200 grams • Volume • Increases from 10ml to 2-10 liters • Position • Dextro rotates = moves to the right • Pressure on ureter and on vena cava and aorta in 3rd trimester = hypotensive or inferior vena cava syndrome (hypotension, lower extremity edema) • Location of uerus • 12 weeks: “Lifts” into the pelvis = palpable • 3 months: At symphysis pubis • 5 months: At umbilicus • 9 months: At xyphoid

15. UTERUS cont. • Endometrium • Proliferates – estrogen necessary to prepare for implantation • Insufficient progesterone – prevents successful implantation • Storage of glycogen – nourishment • Cervix • Chadwick’s sign = Increased vascularity • Goodell’s sign = edematous and muscles soften • “Mucus plug” forms from endocervical gland secretions • Glandular hyperactivity = significant increase in discharge • Braxton Hicks Contractions • Irregular, sporadic non-rhythmic contractions throughout pregnancy (stretching of uterus and estrogen) • “False labor” – in 3rd trimester

16. OVARIES • After ovulation, ovaries stop producing ova • Corpus luteum is formed – produces progesterone: • Secures implantation • Development of placenta • Corpus luteum supplies nutrition + hormones • It regresses and is almost gone by mid-pregnancy • 10-12 weeks of pregnancy, placenta takes over • hCG is released and remains in circulation until 3 day in PP period

17. VAGINA • Vascular and congested (Chadwick’s sign) • Walls thicken • Leukorrhea: • Caused by increased circulation & hormones • Thick & white • Acidic: pH 3.5-6.0 • Lactic acid produced by lactobacilli • Controls growth of pathogenic bacteria (tends to grow in moist environment) • Favors yeast organisms such as Candidiasis-monilia

18. BREASTS • Increased size – glands - (preparation for lactation) • Nodularity • Sensitivity • Superficial veins more prominent due to increased circulation and hormones (estrogen and progesteron), however, no major discoloration • Nipples erect & areolas darken • Montgomery’s follicles: enlarged sebacious glands • Stria • Secretory stage: mid-pregnancy • Colostrum expressed • Stimulation of breasts in last trimester may induce contractions (oxytocin release)

19. Breast Changes

20. CARDIOVASCULAR • Cardiac output: • INCREASES 30-50% first trimester • INCREASES 10% last two trimesters • Change in blood distribution • Increased heart size; displaced up and to the left • Pulse rate increase 10-15 beats/min • Kidney filtration and O2 transport increase • Uterine blood flow: • Factors decreasing uterine blood flow • Contractions, hypertonus, hypertension or hypotension, streneous exercise, smoking, pathologic conditions (anemia, placental abnormalities, etc) • Factors increasing uterine blood flow • Bedrest • (Left) lateral recumbent position

21. CARDIOVASCULAR cont. • Plasma volume • INCREASES by 50% and at a quicker rate than RBC volume • Result: hemodilution = “physiologic anemia” or “pseudoanemia” • Decreased Hgb and Hct due to increased but diluted blood volume • Abnormal value: Hct <29% in 2nd trimester • Volume expansion does not maintain iron stores = increase iron supplementation • Vessel walls increase in permeability • Approx. 500ml of blood is lost in vaginal delivery (1000ml is acceptable in C-section)

22. CARDIOVASCULAR cont. • Peripheral circulatory changes • Peripheral vascular resistance DECREASES due to: • Progesterone causing smooth muscle relaxation in vessel walls • Increased circulation due to addition of uteroplacental unit • Fetal heat production causing vasodilation • Increased synthesis of prostaglandins which causes resistance to circulating vasoconstrictors (angiotensin II and norepinephrine) • This will cause INCREASED venous return to the heart and MAINTAIN STABLE BP • However, factors such as prolonged standing, crossing legs, excessive weight gain may cause decrease venous return due to “pooling”/”stagnation” of blood.

23. CARDIOVASCULAR cont. • Compression of pelvic - & femoral vessels: • Stagnation of blood, varicosites, dependent edema in pelvis and lower extremities • Pressure on vena cava in supine position • Supine hypotensive syndrome = vena cava syndrome • BP (systolic and diastolic) decreases in first 20 weeks by 5-10mmHg, then rise back to “normal” • Any rise of 30mmHg SBP or 15mmHg DBP is ABNORMAL (…… 140/90……..)

24. RESPIRATORY • Low CO2 levels in the mother • Due to sensitivity to progesterone • Fetal plasma CO2 is higher and therefore passes easily from fetal to maternal circulation (“getting rid of the waste”) • Increased progesterone • Increased in vocal cord size • Deeper voice

25. URINARY TRACT • Compression of bladder • Frequency of urination • Stagnation urine • Risk of reflux and infection • Increased renal blood flow • Glomerular filtration increases by 50% • Result: decrease threshold for glucose and spillage of glucose (glucosuria) • “Nutritious urine” • Excretion of folates, glucose, lactose, amino acids, vitamin B12 and ascorbic acid

26. HORMONES • Increased water retention (physiologic edema) due to: • Estrogen from placenta • Aldosterone secretion from the adrenals • Na and other electrolyte loss in urine • Progesterone increases kidney size

27. POSTURE • Key word: GRAVITY! • Pooling in pelvis and lower extremities (sitting and standing) = DEPENDENT EDEMA • Lateral recumbent position: • Increases kidney filtration • Redistribution of fluid to the body; may cause nocturia

28. Right Wrong

29. GASTROINTESTINAL • Displaced stomach and intestine • Constipation, pyrosis (heartburn), indigestion • Hemorrhoids & varicosites (vessel dilitation and “pooling”) • Hormonal changes • Decreases tone and motility of GI tract • Decreases emptying time causing • Constipation (also from decrease motility and more time for reabsorption of H2O from bowel content) • Reflux • nausea

30. GASTROINTESTINAL • Cholestasis • Supression of bile flow (due to progesterone causing gallbladder to hypotonic and have prolonged emptying time) • Retention of bile salt • SEVERE pruritis (itching) • Indigestion • DECREASED secretion of HCL acid and pepsin secondary to estrogen • PICA • Saliva production increases

31. MUSCULOSKELETAL • Postural changes • Shift in center of gravity • Backache • Lordosis • Diastasis recti • Herniation of the uterus • From pressure of enlarging uterus • Protein • Increased daily requirement due to fetal growth • Maternal muscle mass may decrease

32. SKIN • Increased pigmentation due to estrogen: • Chloasma • Linea negra • Striae • Spider angiomas • Palmar erythema

33. Pregnancy Changes: Skin

34. Spider Angioma

35. Palmar erythema

36. Chloasma

37. How would you feel during pregnancy????

39. Discomforts of Pregnancy in order of REASON

40. REST & ACTIVITY

41. FATIGUE • Increased hormonal production • Increased demands of cardiopulmonary system • Increased metabolic rate • Inadequate nutrition • Anemia • Lack of exercise or excessive! • Excessive weight gain; incorrect posture • Infection or other illness • Psychological factors (depression)

42. Fatigue: Nursing • ALWAYS rule out underlying physiologic causes & also psychological factors • Reassurance (“normal”) • Teaching

43. INSOMNIA • Anxiety • Comfort – position • Nocturia • Eating habits (large meals, spices = heart burn & ingestion) • Fetal activity • Leg cramps • Dyspnea

44. INSOMNIA: Nursing • Assessment: • Sleep patterns and habits • Nutritional status • Psychological state • Reassurance • Intervention • Based on assessment, i.e. correction of comfort issues, support, etc.

45. ELIMINATION

46. URINARY FREQUENCY • When? • Stretching of the base of the bladder by the enlarging uterus (1st trimester) = reduced bladder capacity. • Compression of bladder (3rd trimester)

47. URINARY FREQUENCY: Nursing • Rule out any physiologic cause (check s/s): • UTI • (Gestational) Diabetes • Advise woman to: • Decrease Caffeine • Hydration: adequate during the day, decrease towards the night • Voiding when having the urge • Kegal exercises • Teaching

48. FLATULENCE • Causes: • Ingestion of gas-forming foods • Aerophagia (air swallowing) • Ptylaism (increased saliva) • Nausea • Decreased GI motility • Decreased exercise • Uterine compression of GI tract • Constipation (fecal impaction

49. FLATULENCE: Nursing • Assessment • Reassurance • Teaching: • Avoid gas producing foods • Avoid large meals • Proper chewing • NO gum (?????) • No smoking • Regular bowel habits and exercise

50. CONSTIPATION • Progesterone causes: • Decreased peristalsis • Relaxation of muscle tone • Uterine pressure • Personal factors: • Alteration in nutritional habits • Decreased fiber • Iron intake • Decreased fluid intake • Decreased physical activity