The physiological changes of pregnancy promoting maternal health

The physiological changes of pregnancy promoting maternal health

• 1.
  Misamis University Ozamiz City Graduate School THE PHYSIOLOGICAL CHANGES OF PREGNANCY: PROMOTING MATERNAL HEALTH In partial fulfillment of the requirements in MCN 312 Submitted to: Ginalyn Elmedulan, RN, MN-MAN Faculty, Graduate School Submitted by: Aries Glenn B. Galao, RN Jurmaida H. Pagayao, RN Marnelle Joy S. Pulmano, RN Master in Nursing Students May 21, 2011
• 2.
  MANIFESTATIONS OF PREGNANCY Pregnancymay be determined by cessation of menses, enlargement of the uterus, and a positive result on a pregnancy test. These and the many other manifestations of pregnancy are classified into three groups: presumptive, probable, and positive. Presumptive Signs and Symptoms Physical signs and symptoms that suggest, but do not prove, pregnancy.  Abrupt cessation of menses - pregnancy is suspected if more than 10 days have elapsed since the time of the expected onset in a healthy woman who previously had predictable menstrual periods.  Breast changes: o Breasts enlarge and become tender. Veins in breasts become increasingly visible. o Nipples become larger and more pigmented. Nipple tingling may also be present. o Colostrum, a thin, milky fluid, may be expressed in the second half of pregnancy. o Montgomery's glands, small elevations on the areolae, may appear.  Skin pigmentation changes: o Chloasma/melasma gravidarum (the mask of pregnancy) - brownish pigmentation appearing on the face in a butterfly pattern in 50% to 70% of women. It is usually symmetric and is distributed on the forehead, cheeks, and nose. The mask of pregnancy is more common in dark-haired, brown-eyed women and is progressive throughout the pregnancy. o Linea nigra - dark vertical line on the abdomen between the sternum and the symphysis pubis. o Abdominal striae (striae gravidarum) - reddish or purplish linear marks sometimes appearing on the breasts, abdomen, buttocks, and thighs because of the stretching, rupture, and atrophy of the deep connective tissue of the skin.  Nausea and vomiting (morning sickness) - occurs mainly in the morning but may occur at any time of the day, lasting a few hours. Begins between 2 and 6 weeks after conception and usually disappears spontaneously near the end of the first trimester (12 weeks).  Frequency of urination: o Caused by pressure of the expanding uterus on the bladder o Decreases when the uterus rises out of the pelvis (around 12 weeks) o Reappears when the fetal head engages in the pelvis at the end of pregnancy  Fatigue - characteristic of early pregnancy in response to increased hormonal levels. Probable Signs and Symptoms Objective findings detected by 12 to 16 weeks of gestation.  Enlargement of abdomen - at about 12 weeks' gestation, the uterus can be felt through the abdominal wall, just above the symphysis pubis.  Changes in shape, size, and consistency of the uterus: o Uterus enlarges, elongates, and decreases in thickness as pregnancy progresses. The uterus changes from a pear shape to a globe shape. 2|Page
• 3.
  o Hegar's sign - lower uterine segment softens 6 to 8 weeks after the onset of the last menstrual period.  Changes in cervix: o Chadwick's sign - bluish or purplish discoloration of cervix and vaginal wall. o Goodell's sign - softening of the cervix; may occur as early as 4 weeks. o With inflammation and carcinoma during pregnancy, the cervix may remain firm.  Intermittent contractions of the uterus (Braxton Hicks contractions) - painless, palpable contractions occurring at irregular intervals, more frequently felt after 28 weeks. They usually disappear with walking or exercise.  Ballottement - sinking and rebounding of the fetus in its surrounding amniotic fluid in response to a sudden tap on the uterus (occurs near midpregnancy).  Changes in levels of human chorionic gonadotropin (hCG) in maternal plasma and urine.  Leukorrhea - increase in vaginal discharge.  Quickening (sensations of fetal movement in the abdomen) - occurs between the 16th and 20th week after the onset of the last menses.  Positive hCG - laboratory (urine or serum) test for pregnancy. Positive Signs and Symptoms Diagnostic of pregnancy.  Fetal heart tones (FHTs) - usually heard between 16th and 20th week of gestation with a fetoscope or the 10th and 12th week of gestation with a Doppler stethoscope.  Fetal movements felt by the examiner (after about 20 weeks' gestation).  Outlining of the fetal body through the maternal abdomen in the second half of pregnancy.  Sonographic evidence (after 4 weeks' gestation) using vaginal ultrasound. Fetal cardiac motion can be detected by 6 weeks' gestation. MATERNAL PHYSIOLOGY DURING PREGNANCY Duration of Pregnancy  Averages 280 days or 40 weeks (10 lunar months; 9 calendar months) from the 1st day of the last normal menstrual period.  Duration may also be divided into three equal parts, or trimesters, of slightly more than 13 weeks or 3 calendar months each.  Estimated date of confinement is calculated by adding 7 days to the date of the 1st day of the last menstrual period and counting back 3 months (Nägele's rule). o For example, if a woman's last menstrual period (LMP) began on September 10, 1999, her estimated date of confinement (EDC) would be September 10, 1999, plus 7 days = September 17, 1999, minus 3 months = June 17, 1999. If the date of the woman's LMP begins after March 31, an additional year must be added to give a correct EDC. Thus, an additional year would be added to the above date making the correct EDC = June 17, 2000. o Another method of calculating the EDC is McDonald's rule: after 24 weeks' gestation, the fundal height measurement will correspond to the week of gestation plus 2 to 4 weeks. Changes in the Reproductive Tract 3|Page
• 4.
  Uterus  Enlargement during pregnancy involves stretching and marked hypertrophy of existing muscle cells secondary to increased estrogen and progesterone levels.  In addition to an increase in the size of the uterine muscle cells, there is an increase in fibrous tissue and elastic tissue. The size and number of blood vessels and lymphatics increase.  Enlargement and thickening of the uterine wall are most marked in the fundus.  By the end of the third month (12 weeks), the uterus is too large to be contained wholly within the pelvic cavity - it can now be palpated suprapubically.  As the uterus rises out of the pelvis, it rotates somewhat to the right because of the presence of the rectosigmoid colon on the left side of the pelvis.  By 20 weeks' gestation, the fundus has reached the level of the umbilicus.  By 36 weeks, the fundus has reached the xiphoid process.  By the end of the fifth month, the myometrium hypertrophy ends and the walls of uterus become thinner, allowing palpation of the fetus.  During the last 3 weeks, the uterus descends slightly because of fetal descent into the pelvis.  Changes in contractility occur - from the first trimester, irregular painless contractions occur (Braxton Hicks contractions). In latter weeks of pregnancy, these contractions become stronger and more regular.  There is a progressive increase in uteroplacental blood flow during pregnancy. Cervix  Pronounced softening and cyanosis - due to increased vascularity, edema, hypertrophy, and hyperplasia of the cervical glands.  Endocervical glands secrete thick mucus that forms a cervical plug and obstructs the cervical canal. This plug prevents bacteria and other substances from entering and ascending into the uterus.  Erosions of cervix, common during pregnancy, represent an extension of proliferating endocervical glands and columnar endocervical epithelium.  Evidence of Chadwick's sign, the bluish, purplish coloring of the cervix. This sign is due to the increased vascularity and hyperemia caused by increased estrogen levels. Ovaries  Ovulation ceases during pregnancy; maturation of new follicles is suspended.  One corpus luteum functions during early pregnancy (first 10 to 12 weeks), producing mainly progesterone. However, small levels of estrogen and relaxin are also produced by the corpus luteum.  After 8 weeks' gestation, the corpus luteum remains the source for the hormone relaxin. However, relaxin is not required for a successful pregnancy outcome and normal delivery. Vagina and Outlet  Increased vascularity, hyperemia, and softening of connective tissue in skin and muscles of the perineum and vulva.  Vaginal walls prepare for labor: mucosa increases in thickness, connective tissue loosens, and small-muscle cells hypertrophy. Secretions are thick, white, and acidic in nature and play a major role in the prevention of infections.  Vaginal secretions increase; pH is 3.5 to 6 - because of increased production of lactic acid from glycogen in the vaginal epithelium by Lactobacillus acidophilus. (Acid pH probably aids in keeping vagina relatively free of pathogenic bacteria.) 4|Page
• 5.
   Hypertrophy of the structures, along with fat deposits, causes the labia majora to close and cover the vaginal introitus (vaginal opening). Changes in the Abdominal Wall  Striae gravidarum (stretch marks) may develop - reddish, slightly depressed streaks in the skin of abdomen, breast, and thighs (become glistening silvery lines after pregnancy).  Linea nigra may form - line of dark pigment extending from the umbilicus down the midline to the symphysis. Commonly during the first pregnancy, the linea nigra occurs at the height of the uterus. During subsequent pregnancies, the entire line may be present early in gestation.  Diastasis recti may occur as muscles (rectus) separate. If severe, a part of the anterior uterine wall may be covered by only a layer of skin, fascia, and peritoneum. Breast Changes  Tenderness and tingling occur in early weeks of pregnancy.  Increase in size by second month - hypertrophy of mammary alveoli. Veins become more prominent, and striae may develop as the breasts enlarge.  Nipples become larger, more deeply pigmented, and more erectile early in pregnancy.  Colostrum, a yellow secretion rich in antibodies, may be expressed by second trimester.  Areolae become broader and more deeply pigmented. The depth of pigmentation varies with the person's complexion.  Scattered through the areola are a number of small elevations (glands of Montgomery), which are hypertrophic sebaceous glands. Metabolic Changes Numerous and intensive changes occur in response to rapidly growing fetus and placenta. Weight gain average 25 to 35 lb (11.5 to 16 kg) Components of Weight Gain AREA kg lb Fetus 3.2-3.4 7-7.5 Placenta 0.5-0.7 1-1.5 Amniotic fluid 0.9 2 Uterus 1.1 2.5 Breast tissue 0.7-1.4 1.5-3 Blood volume 1.6-2.3 3.5-5 Maternal stores 1.8-4.3 4-9.5 Water metabolism  The average woman retains 6 to 8 L of extra water during the pregnancy due to hormonal influence.  Approximately 4 to 6 L of fluid cross into the extracellular spaces. This creates a physiologic increase in blood volume (hypervolemia).  Many pregnant women experience a normal accumulation of fluid in their legs and ankles at the end of the day. This is most common in the third trimester and is referred to as physiologic edema.  Sodium excretion in the normal pregnant woman is similar to the nonpregnant woman.  Sodium retention is usually directly proportional to the amount of water accumulated during the pregnancy. 5|Page
• 6.
  However, pregnancy lendsitself toward sodium depletion, making sodium regulation more difficult.  Additional sodium is required during pregnancy to meet the need for increased intravascular and extracellular fluid volumes and to maintain a normal isotonic state. NURSING ALERT The limitation of sodium is discouraged in pregnancy because it can result in decreased kidney function, resulting in decreased urine output. As a result, the pregnancy outcome could also be adversely affected. Protein Metabolism  The fetus, uterus, and maternal blood are rich in protein rather than in fat or carbohydrates.  At term, fetus and placenta contain 500 g of protein or approximately half of the total protein increase of pregnancy.  Approximately 500 g more of protein is added to the uterus, breasts, and maternal blood in the form of hemoglobin and plasma proteins. Carbohydrate Metabolism  Carbohydrate metabolism during pregnancy is controlled by glucose levels in the plasma and the metabolism of glucose in the cells.  The liver controls the plasma glucose level. Not only does it store glucose as glycogen, but it also converts it into glucose when the woman's blood glucose levels are low.  Early in pregnancy, the effects of estrogen and progesterone can induce a state of hyperinsulinemia. As pregnancy advances, there is increased tissue resistance coupled with increased hyperinsulinemia.  Approximately 2% to 3% of all women will develop gestational diabetes mellitus during pregnancy regardless if they have a history of carbohydrate intolerance.  Pregnant women with preexisting diabetes mellitus (type 1 or 2) may experience a worsening of the disease attributed to hormonal changes occurring with pregnancy.  During pregnancy, there is a “sparing” of glucose used by maternal tissues and a shunting of glucose to the placenta for use by the fetus.  Human placental lactogen (placental hormone) promotes lipolysis, increases plasma free fatty acids, and thereby provides alternative fuel sources for the mother.  Human placental lactogen, estrogen, progesterone, and cortisol oppose the action of insulin during pregnancy and promote maternal lipolysis as well. Fat Metabolism  Lipid metabolism during pregnancy causes an accumulation of fat stores, mostly cholesterol, phospholipids, and triglycerides.  This accumulation of fat stores has no negligible effect on the fetus. 6|Page
• 7.
   Fat storage occurs before the 30th week of gestation. After 30 weeks' gestation, there is no further fat storage, only fat mobilization that correlates with the increased utilization of glucose and amino acids by the fetus.  The ratio of low-density proteins to high-density proteins is increased during pregnancy. Nutrient Requirements Caloric Requirements  Additional calories are usually not required during the first trimester due to the limited metabolic demands.  An additional 300 kcal/dL are required during the second and third trimester over the nonpregnant woman. However, due to the variety of women and their individualized needs, the exact caloric requirements need to be established on an individual basis.  Caloric expenditure varies throughout pregnancy. There is a slight increase in early pregnancy and a sharp increase near the end of the first trimester, continuing throughout pregnancy. Protein Requirements  Protein is required for adequate amino acids to accommodate the normal development of the fetus, blood volume expansion, and growth of maternal breast and uterine tissue.  An additional requirement of 10 g of protein per day is recommended over the nonpregnant intake. Carbohydrate and Fat Requirements  As in the nonpregnant woman, carbohydrates should supply 55% to 60% of calories in the diet and should be in the form of complex carbohydrates, such as whole-grain cereal products, starchy vegetables, and legumes.  Fat intake should not exceed 30% of the diet. Saturated fats should not exceed 10% of the total calories. Iron Requirements  Total circulating red blood cells (RBCs) increase about 40% to 50% during pregnancy; therefore, iron requirements are increased to 20 to 40 mg daily. This usually exceeds dietary intake.  Supplemental iron is valuable and necessary during pregnancy and for several weeks after pregnancy or lactation.  During the last half of pregnancy, iron is transferred to the fetus and stored in the fetal liver. This store lasts 3 to 6 months. Changes in the Cardiovascular System Heart  Diaphragm is progressively elevated during pregnancy; heart is displaced to the left and upward, with the apex moved laterally.  Heart sounds - exaggerated splitting of the first heart sound; a loud, easily heard third sound.  Heart murmurs - systolic murmurs are common and usually disappear after delivery. 7|Page
• 8.
  Blood Volume Changes  Cardiac volume increases by 40% to 50% (1,450 to 1,750 mL) by 32 weeks' gestation, causing slight hypertrophy of the heart and increased cardiac output.  Cardiac output increases by 30% to 50% above normal within the first 13 weeks of pregnancy and reaches a volume of 6 to 7 L/minute by term.  In the supine position, the large uterus compresses the venous return from the lower half of the body to the heart. This may cause arterial hypotension, referred to as the supine hypotensive syndrome. Cardiac output increases by 25% to 30% with an increase in uterine and renal blood flow when the woman turns from her back to lateral position (either left or right side).  Femoral venous pressure increases - because of slowing of blood flow from lower extremities as a result of pressure of enlarged uterus on pelvic veins and inferior vena cava.  Increased cutaneous blood flow dissipates excess heat caused by increased metabolism of pregnancy.  Plasma volume increases 20% to 30% (250 to 450 mL), resulting in hemodilution, more commonly referred to as physiologic anemia of pregnancy or physiologic dilutional anemia. This “anemic” state is not a true pathologic state and does decrease the risk of thrombosis. Blood Pressure Changes  Blood pressure - during the first half of pregnancy, there is a slight (5 to 10 mm Hg) decrease in systolic and diastolic blood pressure, with the lowest point occurring in the second trimester. By the third trimester, the blood pressure gradually returns to prepregnancy levels.  Maternal position influences blood pressure: the highest reading is obtained in the sitting position, the lowest reading is obtained in the left lateral position, and an intermediate reading is obtained in the supine position.  Maternal blood pressure will also rise with uterine contractions and returns to the baseline level after the uterine contraction is over. NURSING ALERT Ensure that the maternal blood pressure is not taken during uterine contractions because it may give you a false elevated blood pressure. Should the woman have a history of elevated blood pressure before or during her pregnancy, it is best to take blood pressure while the woman is on her left side. The blood pressure should be taken in the arm that the woman is not lying on. Hematologic Changes  Total volume of circulating RBCs increases 18% to 30%; hemoglobin concentration at term averages 12 to 16 g/dL; hematocrit concentration at term averages 37% to 47%. 8|Page
• 9.
   Average leukocyte (WBC) count in the third trimester is 5 to 12,000/ml. WBC count can be elevated as high as 25,000 or more during labor - cause unknown; probably represents the reappearance in the circulation of leukocytes previously shunted out of active circulation.  Pregnancy is a hypercoagulable state due to the increased levels of a number of essential coagulation factors. These factors include factor I (fibrinogen by 50%), factor V (proaccelerin or labile factor), factor VII (proconvertin or serum prothrombin conversion accelerator), factor VIII (antihemophilic factor or antihemophilic globulin), factor IX (plasma thromboplastin component or Christmas factor), factor X (Stuart or Prower factor), and factor XII (Hageman or glass or contact factor). Factor II (prothrombin) increases slightly, whereas factors XI (plasma thromboplastin antecedent) and XIII (fibrin-stabilizing factor) decrease during pregnancy.  There is no significant change in the number, appearance, or function of platelets. Average platelet count is 140,000 to 400,000/mm3, which increases the risk to the pregnant woman for venous thrombosis. Changes in the Respiratory Tract  Diaphragm is elevated during pregnancy - chiefly by the enlarging uterus that decreases the length of the lungs.  Thoracic cage expands its anteroposterior diameter causing flaring of the ribs - result of increased mobility of rib attachments.  Breathing is more diaphragmatic than costal.  Hyperventilation occurs - increase in respiratory rate, tidal volume (amount of air inspired and expired with normal breath) increases 30% to 40%, and minute ventilation (amount of air inspired in 1 minute) increases 40%.  Increased total volume lowers blood partial pressure of carbon dioxide (Pco2), causing mild respiratory alkalosis that is compensated for by lowering of the bicarbonate concentration.  Increased respiratory rate and reduced Pco2 are probably induced by progesterone and estrogen to a lesser degree on the respiratory center.  Oxygen consumption increases 15% to 20% and as much as 300% in labor. This increase leads to increased maternal alveolar and arterial oxygen partial pressure levels. 9|Page
• 10.
   Approximately 60% to 70% of pregnant women experience shortness of breath; the cause is unknown.  Nasal stuffiness and epistaxis (nosebleeds) are also common during pregnancy, secondary to vascular congestion caused from the increased estrogen levels. Changes in Renal System  Ureters become dilated and elongated during pregnancy because of mechanical pressure and perhaps due to the effects of progesterone. When the uterus rises out of the uterine cavity, it rests on the ureters, compressing them at the pelvic brim. Dilation is greater on the right side - the left side is cushioned by the sigmoid colon.  Glomerular filtration rate (GFR) increases 50% by the second trimester, and the increase persists almost to term. Renal plasma flow increases early in pregnancy and decreases to nonpregnant levels in the third trimester. These changes may be due to placental lactogen.  Glucosuria may be evident because of the increase in glomerular filtration without an increase in tubular resorptive capacity for filtered glucose.  Excreted protein may be increased due to the increased GFR, but is not considered abnormal until the level exceeds 250 mg/dL. Slight amounts of protein may be excreted during or just after vigorous labor.  Toward the end of pregnancy, pressure of the presenting part impedes drainage of blood and lymph from the bladder base, typically leaving the area edematous, easily traumatized, and more susceptible to infection. Changes in GI Tract  Gums may become hyperemic and softened and may bleed easily.  A localized vascular swelling of the gums may appear - called epulis of pregnancy.  Stomach and intestines are displaced upward and laterally by the enlarging uterus. Heartburn (pyrosis) is common, caused by reflux of acid secretions in the lower esophagus.  Tone and motility of GI tract decrease, leading to prolongation of gastric emptying due to the large amount of progesterone produced by the placenta. Decreased motility, mechanical obstruction by the fetus, and decreased water absorption from the colon leads to constipation. 10 | P a g e
• 11.
   Hemorrhoids are common because of elevated pressure in veins below the level of the large uterus and constipation.  Distention and hypotonia of the gallbladder are common, which can cause stasis of bile. Additionally, there is a decrease in emptying time and thickening of bile, resulting in hypercholesterolemia and gallstone formation.  Liver function tests are altered. With pregnancy, bilirubin, aspartate aminotransferase, and alanine aminotransferase values are unchanged; prothrombin time may show a slight increase or be unchanged. Liver size and morphology are unchanged.  Peptic ulcer formation or exacerbation is uncommon during pregnancy due to decreased hydrochloric acid (caused by increased estrogen levels).  The appendix is pushed superiorly. Changes in the Endocrine System  Anterior pituitary gland enlarges slightly; posterior pituitary gland remains unchanged.  Thyroid is moderately enlarged because of hyperplasia of glandular tissue and increased vascularity. o Basal metabolic rate increases progressively during normal pregnancy (as much as 25%) because of metabolic activity of fetus. o Level of protein-bound iodine and thyroxine rises sharply and is maintained until after delivery because of increased circulatory estrogen and hCG. o Hyperthyroidism during pregnancy is rare.  Parathyroid gland size and concentration of parathyroid hormone increase and peak between 15 and 35 weeks' gestation.  Adrenal secretions considerably increased - amounts of aldosterone increase as early as the 15th week to accommodate for the increased sodium excretion.  Pancreas - because of the fetal glucose needs for growth, there are alterations in maternal insulin production and usage. o Estrogen, progesterone, cortisol, and human placental lactogen (hPL) decrease the maternal utilization of glucose. o Cortisol also increases maternal insulin production. o Insulinase, an enzyme produced by the placenta, deactivates maternal insulin. o These changes result in an increased need for insulin, and the islets of Langerhans increase their production of insulin. Changes in Integumentary System  Pigment changes occur because of melanocyte-stimulating hormone, the level of which is elevated from the 2nd month of pregnancy until term.  Striae gravidarum appear in later months of pregnancy as reddish, slightly depressed streaks in the skin of the abdomen and occasionally over the breasts and thighs.  A brownish-black line of pigment is usually formed in the midline of the abdominal skin - known as linea nigra.  Brownish patches of pigment may form on the face - known as chloasma/melasma or “mask of pregnancy”.  Angiomas (vascular spider nevis), minute red elevations commonly on the skin of the face, neck, upper chest, legs, and arms, may develop.  Reddening of the palms (palmar erythema) may also occur.  There is also an increased warmth to the skin and increased nail growth. 11 | P a g e
• 12.
  Changes in theMusculoskeletal System  The increasing mobility of sacroiliac, sacrococcygeal, and pelvic joints during pregnancy is a result of hormonal changes, specifically the hormone relaxin.  The center of gravity shifts secondary to increased weight gain, fluid retention, lordosis, and mobile ligaments. This mobility and the change in the center of gravity contribute to alteration of maternal posture and to back pain.  Late in pregnancy, aching, numbness, and weakness in the upper extremities may occur because of lordosis and paresthesia, which ultimately produces traction on the ulnar and median nerves.  Separation of the rectus muscles due to pressure of the growing uterus creates a diastasis recti. If this is severe, a portion of the anterior uterine wall is covered by only a layer of skin, fascia, and peritoneum. Changes in the Neurologic System  Usually no system changes.  Mild frontal headaches are common in the first and second trimester and are usually related to tension or hormonal changes.  Dizziness is common and is related to vasomotor instability, postural hypotension, or hypoglycemia following long periods of standing or sitting.  Tingling sensations in the hands are common and are due to excessive hyperventilation, which decreases maternal Pco2 levels.  Severe headaches that occur after 20 weeks' gestation and are accompanied by visual changes, elevated blood pressure, proteinuria, and facial edema should be evaluated immediately. NURSING ALERT Hypertensive disease affects up to 22% of pregnancies and is associated with maternal and fetal death. Recently, it has been recommended that the term “gestational hypertension” replace the term “pregnancy-induced hypertension (PIH)” to describe cases in which elevated blood pressure without proteinuria occurs in a woman past 20 weeks of gestation who previously had a normal blood pressure. Changes in Hormonal Responses Steroid Hormones  Estrogen: o Is secreted by the ovaries in early pregnancy, but by 7 weeks' gestation over half of the estrogen is secreted by the placenta. o The three classic estrogens during pregnancy are estrone, estradiol, and estriol. More than 90% of the estrogen secreted during pregnancy is estriol. o Estrogens also ensure uterine growth and development, maintenance of uterine elasticity and contractility, maintenance of breast growth and its ductal structures, and enlargement of the external genitalia.  Progesterone: o Is initially secreted by the corpus luteum and later by the placenta. o Plays a critical role in the maintenance of the pregnancy by suppressing the maternal immunologic response to the fetus and the rejection of the trophoblasts. o Progesterone also helps to maintain the endometrium, inhibits uterine contractility, helps in the development of breast lobules for lactation, stimulates the maternal respiratory center, and relaxes smooth muscle. Placental Protein Hormones  hCG: o Secreted by the syncytiotrophoblasts and stimulates the production by the corpus luteum of progesterone and estrogen until the fully developed placenta takes over. o In multiple gestations, hCG can be twice as high as in a single pregnancy. 12 | P a g e
• 13.
  o hCG levels peak around 10 weeks' gestation (50,000 to 100,000 mIU/mL) then decrease to 10,000 to 20,000 mIU/mL by 20 weeks' gestation.  hPL: o Also referred to as human chorionic somatomammotropin. Produced by the syncytiotrophoblasts of the placenta; detected in maternal serum as early as 6 weeks' gestation. o Serum hPL levels rise concomitantly with placental growth. o hPL is an antagonist of insulin. It increases the amount of free fatty acids available to the fetus for metabolic needs and decreases the maternal metabolism of glucose allowing for protein synthesis. This action allows the fetus to have the needed nutrients when the woman has not or is not eating. Other Hormones  Prostaglandins: o Exact function is still unknown. o Affect smooth muscle contractility and some potent vasodilators. o Essential for the cardiovascular adaptation to pregnancy, cervical ripening, and initiation of labor. o Increased levels of prostaglandins may lead to vasodilatation.  Relaxin: o Secreted primarily by the corpus luteum. Can be secreted in small amounts by the decidua and the placenta. o Inhibits uterine activity, decreases the strength of uterine contractions, softens the cervix, and remodels collagen.  Prolactin: o Released from the anterior pituitary gland. o Responsible for sustaining milk protein, casein, fatty acids, lactose, and the volume of milk secretion during lactation. PRENATAL ASSESSMENT Health History Age  Adolescents (younger than age 19) have an increased incidence of anemia, gestational hypertension, preterm labor (PTL), small-for- gestational-age (SGA) infants, intrauterine- growth-restricted infants, cephalopelvic disproportion, and dystocia.  Women of advanced maternal age (over age 35) have an increased incidence of hypertension, pregnancies complicated by underlying medical problems such as diabetes, multiple gestation, and infants with genetic abnormalities. Family History 13 | P a g e
• 14.
   Includes maternal and paternal history  Congenital disorders, hereditary diseases, multiple pregnancies, diabetes, heart disease, hypertension, mental retardation, renal disease, use of diethylstilbestrol NURSING ALERT Daughters born to mothers who sustained their pregnancies with DES may have uterine anomalies that increase their risk of PTL or uterine hyperstimulation. Woman's Medical History  Childhood diseases, especially rubella. Others to consider are measles and chickenpox.  Major illnesses, surgery (especially of the reproductive tract, spinal surgery or appendectomy), blood transfusions.  Chronic medical conditions, such as epilepsy, diabetes mellitus.  Drug, food, and environmental sensitivities.  Urinary tract infections (UTIs), heart disease, hypertension, endocrine disorders, anemias.  Menstrual history (onset of menarche, length, amount, regularity, and pain [dysmenorrhea] of menstrual cycle). Also, assess bleeding between periods.  Gynecologic history (sexually transmitted diseases, contraceptive use, sexual history).  Use of medications (prescription and over-the-counter [OTC]), recreational drugs, alcohol, nicotine, tobacco, and caffeine.  History of tuberculosis, hepatitis, group B beta-hemolytic streptococcus, or human immunodeficiency virus (HIV). Woman's Nutritional History  Adherence to special dietary practices (religious, social or cultural preferences)  Eating disorders (obesity, bulimia, anorexia nervosa). Woman's Past Obstetric History  Problems of infertility, date of previous pregnancies, and deliveries - dates; infant weights; length of labors; types of deliveries; multiple births; abortions; and maternal, fetal, and neonatal complications.  Woman's perception of past pregnancy, labor, and delivery for herself and effect on her family. Woman's Present Obstetric History  Gravidity, parity.  Date of last menstrual period.  Estimated date of birth - expected date of confinement.  Signs and symptoms of pregnancy - amenorrhea, breast changes, nausea and vomiting, fetal movement, fatigue, urinary frequency, skin pigment changes. Expectations for her present pregnancy, labor, and delivery. Expectations for her health care providers and her perception of her relationship between herself and her nurse.  Rest and sleep patterns - length, quality, and regularity of rest and sleep.  Activity and employment - exercise patterns, type and hours of employment, exposure to hazardous material (occupational hazards), plans for continued employment.  Sexual activity - sexual satisfaction, frequency and positions during intercourse, alternative practices used to achieve sexual satisfaction.  Diet history - weight gain, eating patterns (times and frequency of eating daily), number of servings of food from the five food groups, calories, protein, vitamins, and minerals consumed daily  Psychosocial status - emotional changes she is experiencing, woman's and family's reactions to present pregnancy, support system - family's and friends' willingness to provide support, woman's present coping with lifestyle changes caused by the pregnancy. Physical Assessment General Examination 14 | P a g e
• 15.
   The woman is asked to empty her bladder before the examination to enhance her comfort and to facilitate palpation of her uterus and pelvic organs during the vaginal examination.  Evaluation of the woman's weight and blood pressure.  Examination of the eyes, ears, and nose - nasal congestion during pregnancy may occur as a result of peripheral vasodilatation.  Examination of the mouth, teeth, throat, and thyroid - the gums may be hyperemic and softened because of increased progesterone.  Inspection of breasts and nipples - the breasts may be enlarged and tender; nipple and areolar pigment may be darkened.  Auscultation of the heart.  Auscultation and percussion of the lungs. Abdominal Examination  Examination for scars or striations, diastasis (separation of the rectus muscle), or umbilical hernia.  Palpation of the abdomen for height of the fundus (palpable after 13 weeks of pregnancy); measurement recorded and used as guideline for subsequent calculations.  Palpation of the abdomen for fetal outline and position (Leopold's maneuvers) - third trimester.  Check of FHT - FHTs are audible with a Doppler after 10 to 12 weeks and at 18 to 20 weeks with a fetoscope.  Record fetal position, presentation, and FHTs. Pelvic Examination  The woman is placed in lithotomy position.  Inspection of external genitalia.  Vaginal examination - done to rule out abnormalities of the birth canal and to obtain cytologic smear (Pap and, if indicated, smears for gonorrhea, vaginal trichomoniasis, candidiasis, herpes, group B beta streptococcus, and chlamydia).  Examination of the cervix for position, size, mobility, and consistency. Cervix is softened and bluish (increased vascularity) during pregnancy.  Identification of the ovaries (size, shape, and position).  Rectovaginal exploration to identify hemorrhoids, fissures, herniation, or masses.  Evaluation of pelvic inlet - anteroposterior diameter by measuring the diagonal conjugate.  Evaluation of midpelvis - prominence of the ischial spines.  Evaluation of pelvic outlet - distance between ischial tuberosities and mobility of coccyx. Subsequent Prenatal Assessments  Uterine growth and estimated fetal growth. o Fundus at symphysis pubis indicates 12 weeks' gestation. o Fundus at umbilicus indicates 20 weeks' gestation. o Fundal height corresponds with gestational age between 22 and 34 weeks. o Fundus at lower border of rib cage indicates 36 weeks' gestation. o Uterus becomes globular, and drop indicates 40 weeks' gestation.  A greater fundal height suggests: o Multiple pregnancy. o Miscalculated due date. o Polyhydramnios (excessive amniotic fluid). o Hydatidiform mole (degeneration of villi into grapelike clusters; fetus does not usually develop). o Uterine fibroids.  A lesser fundal height suggests: o Intrauterine fetal growth restriction. o Error in estimating gestation. o Fetal or amniotic fluid abnormalities. o Intrauterine fetal death. o SGA.  FHTs - palpate abdomen for fetal position. 15 | P a g e
• 16.
  o Normal -110 to 160 beats per minute (bpm).  Weight - major increase in weight occurs during second half of pregnancy; usually between 0.5 lb (0.2 kg)/week and 1 lb (0.5 kg)/week. Greater weight gain may indicate fluid retention and hypertensive disorder.  Blood pressure - should remain near woman's prepregnant baseline.  Complete blood count at 28 and 32 weeks' gestation; VDRL - rechecked at 36 to 40 weeks' gestation.  Antibody serology screen if Rh negative at 36 weeks' gestation.  Culture smears for gonorrhea, chlamydia, group B beta-hemolytic streptococcus, and herpes, as indicated; usually at 36 and 40 weeks' gestation.  Urinalysis - for protein, glucose, blood, and nitrates.  AFP - done at 15 to 20 weeks.  Diabetic screening - done as indicated at 24 to 28 weeks.  Administer RhoGAM as indicated at 28 weeks.  Edema - check the lower legs, face, and hands.  Evaluate discomforts of pregnancy - fatigue, heartburn, hemorrhoids, constipation, and backache.  Evaluate eating and sleeping patterns, general adjustment and coping with the pregnancy.  Evaluate concerns of the woman and her family.  Evaluate preparation for labor, delivery, and parenting. HEALTH EDUCATION AND INTERVENTION Nursing Diagnoses  Acute Pain (backache, leg cramps, breast tenderness) related to physiologic changes of pregnancy  Imbalanced Nutrition: Less Than Body Requirements related to morning sickness and heartburn and lack of knowledge of requirements in pregnancy  Impaired Urinary Elimination (frequency) related to increased pressure from the uterus  Constipation related to physiologic changes of pregnancy and pressure from the uterus  Impaired Tissue Integrity related to pressure from the uterus and increased blood volume  Anxiety or Fear related to the birth process and infant care  Ineffective Role Performance related to the demands of pregnancy  Activity Intolerance related to physiologic changes of pregnancy and enlarging uterus PATIENT EDUCATION GUIDELINES Prenatal Care  It is important to keep scheduled prenatal care appointments: o Weeks 1-28: Every month o Weeks 28-36: Every 2 weeks o Weeks 36-delivery: Every week  Expect the following discomforts of pregnancy, and speak with your nurse or health care provider about strategies for relief: o Back pain, leg cramps, breast tenderness 16 | P a g e
• 17.
  o Morning sickness, heartburn o Frequent urination o Constipation o Swelling of legs, varicose veins o Fatigue  Follow a healthy, balanced diet with three meals per day, and take prenatal vitamin as directed by your health care provider.  Get regular exercise, and use proper body mechanics to avoid injury.  Be aware of danger symptoms of pregnancy; these must be reported to your health care provider promptly: o Vision disturbances - blurring, spots, or double vision o Vaginal bleeding, new or old blood o Edema of the face, fingers, and sacrum o Headaches - frequent, severe, or continuous o Fluid discharge from vagina; unusual or severe abdominal pain o Chills, fever, or burning on urination o Epigastric pain (severe stomachache) o Muscular irritability or convulsions o Inability to tolerate food or liquids, leading to severe nausea and hyperemesis Nursing Interventions Minimizing Pain  Teach the woman to use good body mechanics - wear comfortable, low-heeled shoes with good arch support; try the use of a maternity girdle.  Instruct the woman in the technique for pelvic rocking exercises.  Encourage the woman to take rest periods with her legs elevated.  Inform the woman that adequate calcium intake may decrease leg cramps.  Instruct the woman to dorsiflex the foot while applying pressure to the knee to straighten the leg for immediate relief of leg cramps.  Instruct the woman to wear a fitted, supportive brassiere.  Instruct the woman to wash her breasts and nipples with water only.  Instruct the woman to apply vitamin E or lanolin cream to the breast and nipple area. Lanolin is contraindicated for women with allergies to lamb's wool. Minimizing Morning Sickness and Heartburn and Maintaining Adequate Nutrition  Encourage the woman to eat low-fat protein foods and dry carbohydrates, such as toast and crackers.  Encourage the woman to eat small, frequent meals.  Advise the woman to eat slowly.  Instruct the woman to avoid brushing her teeth soon after eating.  Instruct the woman to get out of bed slowly.  Encourage the woman to drink soups and liquids between meals to avoid stomach distention and dehydration.  Instruct the woman in the use of antacids; caution against the use of sodium bicarbonate because it results in the absorption of excess sodium and fluid retention.  Instruct the woman to avoid offensive foods or cooking odors that may trigger nausea.  Encourage the woman to eat a few bites of soda cracker or dry toast before getting out of bed in the morning.  Teach the woman the importance of good nutrition for herself and her fetus. Review the basic food groups with appropriate daily servings. o Seven servings of protein-rich foods, including one serving of a vegetable protein o Three servings of dairy products or other calcium-rich foods o Seven servings of grain products o Two or more servings of vitamin C-rich vegetable or fruit 17 | P a g e
• 18.
  o Three servings of other fruits and vegetables o Three servings of unsaturated fats o Two or more servings of other fruits and vegetables  If the woman is a vegetarian, inform her of appropriate intake. Assess type of vegetarian and food intake. o Two broad groups of vegetarians:  Traditional - cultural or religious affiliation prescribes their diet.  New - adopted vegetarian dietary patterns as a personal or philosophical choice. o Subgroups exist within the above two groups.  Vegan - eat no animal foods.  Lacto - eat milk/dairy products, but eat no meat, poultry, fish, seafood, or eggs.  Lacto-ovo - eat milk/dairy products and eggs, but eat no meat, poultry, fish, or seafood. o Partial vegetarians may exclude a specific type of animal food, usually meat, but may consume fish and poultry. o Recommend iron and folic acid supplements.  Inform the woman that average weight gain in pregnancy is 25 to 35 lb (11 to 16 kg). About 2 to 5 lb (0.9 to 2.3 kg) are gained in the first trimester and about 1 lb (0.5 kg) per week for the remainder of the gestation. o Average weight gain for obese women is 15 lb (6.8 kg). o Adolescent weight gain should be about 5 lb more than for adult women if within 2 years of starting menses. o Women with a multiple pregnancy should gain between 35 and 45 lb (15.9 and 20.5 kg). o Average weight gain for underweight women is 28 to 40 lb (12.7 to 18.1 kg).  Advise the woman to limit the use of caffeine.  Inform the woman that alcohol should be limited or eliminated during pregnancy; no safe level of intake has been established.  Inform the woman that smoking should be eliminated or severely reduced during pregnancy; risk of spontaneous abortion, fetal death, low birth weight, and neonatal death increases with increased levels of maternal smoking.  Inform the woman that ingesting any drug during pregnancy may affect fetal growth and should be discussed with her health care provider. Minimizing Urinary Frequency and Promoting Elimination  Instruct the woman to limit fluid intake in the evening.  Instruct the woman to void before going to bed.  Encourage the woman to void after meals.  Encourage the woman to void when she feels the urge and after sexual intercourse.  Encourage the woman to wear loose-fitting cotton underwear.  Cranberry or blueberry juice may be recommended to help prevent UTIs. Caffeine should be avoided. Avoiding Constipation  Instruct the woman to increase fluid intake to at least eight glasses of water per day. One to two quarts of fluid per day is desirable.  Teach the woman that foods high in fiber should be eaten daily.  Encourage the woman to establish regular patterns of elimination.  Encourage daily exercise such as walking.  Inform the woman that OTC laxatives should be avoided and that bulk-forming agents may be prescribed if indicated. Maintaining Tissue Integrity  Encourage the woman to take frequent rest periods with her legs elevated.  Instruct the woman to wear support stockings and wear loose-fitting clothing for leg varicosities.  Instruct the woman to rest periodically with a small pillow under the buttocks to elevate the pelvis for vulvar varicosities.  Instruct the woman to avoid constipation, apply cold compresses, take sitz baths, and use topical anesthetics, such as Tucks, for the relief of anal varicosities (hemorrhoids). 18 | P a g e
• 19.
   Provide reassurance that varicosities will totally or greatly resolve after delivery. Reducing Anxiety and Fear and Promoting Preparation for Labor, Delivery, and Parenthood  Encourage the woman or couple to discuss their knowledge, perceptions, cultural values, and expectations of the labor and delivery process.  Provide information on childbirth education classes, and encourage them to attend.  Provide information on sibling and grandparent preparation as indicated.  Encourage a tour of the birth facility.  Discuss coping and pain control techniques for labor and birth.  Inform the woman or couple of common procedures during labor and birth.  Provide guidelines for coming to the birth facility.  Encourage the woman or couple to discuss their perceptions and expectations of parenthood and their “idealized child”.  Discuss the infant's sleeping, eating, activity, and response patterns for the first month of life.  Discuss physical preparations for the infant, such as a sleeping space, clothing, feeding, changing, and bathing equipment.  Discuss plans for returning to work and childcare arrangements.  Discuss the importance of planning time for themselves and each other apart from the newborn.  Provide information and encourage attendance at baby care, breast-feeding, and parenting classes.  Answer any questions the woman/couple may have. Enhancing Role Changes  Encourage discussion of feelings and concerns regarding the new role of mother and father.  Provide emotional support to the woman/couple regarding the altered family role.  Discuss physiologic causes for changes in sexual relationships, such as fatigue, loss of interest, and discomfort from advancing pregnancy. Some women experience heightened sexual activity during the second trimester.  Teach the woman or couple that there are no contraindications to intercourse or masturbation to orgasm provided the woman's membranes are intact, there is no vaginal bleeding, and she has no current problems or history of premature labor.  Teach the woman or couple that female superior or side-lying positions are usually more comfortable in the latter half of pregnancy. Minimizing Fatigue  Teach the woman reasons for fatigue, and have her plan a schedule for adequate rest. o Fatigue in the first trimester is due to increased progesterone and its effects on the sleep center. o Fatigue in the third trimester is due mainly to carrying increased weight of the pregnancy. o About 8 hours of rest are needed at night. o Inability to sleep may be due to excessive fatigue during the day. o In the latter months of pregnancy, sleeping on the side with a small pillow under the abdomen may enhance comfort. o Frequent 15- to 30-minute rest periods during the day are important to avoid overfatigue. o Whenever possible, the woman should work while sitting with her legs elevated. o The woman should avoid standing for prolonged periods, especially during the third trimester.  To promote placental perfusion, the woman should not lie flat on her back - left lateral position provides the best placental perfusion; however, either side is acceptable.  Help the woman plan for adequate exercise. o In general, exercise during pregnancy should be in keeping with the woman's prepregnancy pattern and type of exercise. o Activities or sports that have a risk of bodily harm (skiing, snowmobiling, ice skating, inline skating, horseback riding) should be avoided. 19 | P a g e
• 20.
  o During pregnancy, endurance during exercise may be decreased. o Exercise classes for pregnant women that concentrate on toning and stretching have resulted in enhanced physical condition, increased self- esteem, and greater social support as a result of being in the exercise group. Community and Home Care Instructions  Community and home care is prevention-oriented care.  Case management coordinates health care management collaboratively.  Search out and register for prepared childbirth classes. Preferable to attend those associated with the family's intended delivery hospital.  Prenatal education should focus on nutrition, sexuality, stress reduction, lifestyle behaviors, and hazards at home or work.  Consider cultural practices because they have important implications for the provision of nursing care. Evaluation: Expected Outcomes  Verbalizes understanding of proper body mechanics and wears low-heeled shoes  Identifies the basic food groups and describes meals to include needed servings for pregnancy  Reports limited fluid intake in the evening  Describes foods high in fiber  Wears support stockings and loose-fitting clothing  Discusses expectations for labor, delivery, and parenthood and attends educational classes  Verbalizes an understanding of the physiologic causes that may change the sexual relationship  Reports engaging in regular exercise UPDATES Oxytocin as a High-Alert Medication: Implications for Perinatal Patient Safety Kathleen Rice Simpson PhD, RNC, FAAN and G. Eric Knox, MD P atient injury from drug therapy is the single most common type of adverse event that occurs in the in-patient setting. When medication errors result in patient injury, there are significant costs to the patient, healthcare providers, and institution. Some medications that have a heightened risk of causing significant patient harm when they are used in error are called "high-alert medications."In 2007, the Institute for Safe Medication Practices added intravenous (IV) oxytocin to their list of high-alert medications. This is significant for perinatal care providers because oxytocin is a drug that they use quite freguently. Errors that involve IV oxytocin administration for labor induction or augmentation are most commonly dose related and often involve lack of timely recognition and appropriate treatment of excessive uterine activity (tachysystole). Other types of oxytocin errors involve mistaken administration of IV fluids with oxytocin for IV fluid resuscitation during nonreassuring (abnormal or indeterminate) fetal heart rate patterns and/or maternal hypotension and inappropriate elective administration of oxytocin to women who are less than 39 completed weeks' gestation. Oxytocin medication errors and subsequent patient harm are generally preventable. The perinatal team can develop strategies to minimize risk of maternal-fetal injuries related to oxytocin administration consistent with safe care practices used with other high-alert medications. MCN, The American Journal of Maternal/Child Nursing, January/February 2009, Volume 34, Number 1, Pages 8 - 15 20 | P a g e
• 21.
  Oral Intake DuringLabor: A Review of the Evidence Nancy C. Sharts-Hopko PhD, RN, FAAN T he purpose of this article is to review evidence and practices within and beyond the United States related to the practice of maternal fasting during labor. Fasting in labor became standard policy in the United States after findings of a 1946 study suggested that pulmonary aspiration during general anesthesia was an avoidable risk. Today general anesthesia is rarely used in childbirth and its associated maternal mortality usually results from difficulty in intubation. Healthcare professionals have debated the risks and benefits of restricting oral intake during labor for decades, and practice varies internationally. Research from the United States, Australia, and Europe suggests that oral intake may be beneficial, and adverse events associated with oral intake such as vomiting and prolongation of labor do not seem to be associated with alterations in maternal or infant outcomes. The World Health Organization recommends that healthcare providers should not interfere in women's eating and drinking during labor when no risk factors are evident. Nurses in intrapartum settings are encouraged to work in multidisciplinary teams to revise policies that are unnecessarily restrictive regarding oral intake during labor among low-risk women. MCN, The American Journal of Maternal/Child Nursing, July/August 2010, Volume 35, Number 4, Pages 197 - 203 Overcoming the Challenges: Maternal Movement and Positioning to Facilitate Labor Progress Elaine Zwelling PHD, RN, LCCE, FACCE T he benefits of maternal movement and position changes to facilitate labor progress have been discussed in the literature for decades. Recent routine interventions such as amniotomy, induction, fetal monitoring, and epidural anesthesia, as well as an increase in maternal obesity, have made position changes during labor challenging. The lack of maternal changes in position throughout labor can contribute to dystocia and increase the risk of cesarean births for failure to progress or descend. This article provides a historical review of the research findings related to the effects of maternal positioning on the labor process and uses six physiological principles as a framework to offer suggestions for maternal positioning both before and after epidural anesthesia. MCN, The American Journal of Maternal/Child Nursing, March/April 2010, Volume 35, Number 2, Pages 72 - 78 21 | P a g e