Physiological Changes in the Reproductive OrgansUterus
enlargement -- 2 ounces to 2 pounds rises out of pelvic area and displaces the
intestineschanges in tissue
increase in vascularityhypertrophy
isthmus of uterus softens-- Hegar’s signuterine souffle
Patient teaching Braxton-Hicks contractions
Cervixsoftens - Goodell’s signfills with a mucus plugincrease in discharge, leukorrhea
Vaginaincrease in vascularity - Chadwick’s signincrease in discharge, leukorrheapH rises and become more susceptible to
yeast infections
Perineumincreased vascularity and pressure causes
vulvar varicositiesWhat should the nurse teach regarding
decreasing the pressure in the perineal area?
Ovariescorpus luteum remains functioning and there
is NO ovulation or menstruation.
BreastsGrowth of alveolar tissue Nipples become more pigmented
Your patient states that her breasts are more full and have become very heavy. What teaching should the nurse include?
Cardiovascular System• Circulatory System
▫ Related to: cardiac enlargement vasodilation increase blood volume, hemodilution increase cardiac output – 30-50%
•Variations in common laboratory tests▫ Hgb – 12 – 16 g/dl – stays about the same▫ Hct -- 37% decreases RT hemodilution. There is an
increase of about 1500 cc . Over 1000 cc of that is plasma.
▫ RBC -- ~5.7million which is about a 17% increase
Nursing Care▫Avoid supine hypotension▫Arise slowly from a lying position▫Wear support hose to avoid varicose veins▫Avoid constipation to decrease formation of
hemorrhoids▫Instruct that palpitations may be felt and
are normal
Respiratory Changes▫ Related to:
Thoracic cage is pushed upward and the diaphragm is elevated as uterus enlarges
Oxygen consumption is increased to support fetus Lower thoracic cage widens to increase tidal volume
Nursing Care◦ Instruct due to shortness of breath and dyspnea may need to:
sleep in an upright position avoid eating large meals stop smoking! Nasal stuffiness is normal due to increase in hormones
Elimination:Gastrointestinal Changes•Nausea and Vomiting
▫Related to: increased levels of HCG changes in CHO metabolism fatigue
▫Nursing Care Avoid offending odors eat dry CHO (crackers) upon wakening Eat 5-6 small meals per day Avoid spicy, gas forming foods Drink carbonated beverages
Heartburn and Indigestion– Related to:
»slowing of motility and digestion due to progesterone
»relaxation of cardiac sphincter, regurgitation occurs
»stomach displaced upward and compressed by enlarged uterus
Nursing Care avoid large meals use good posture take low Sodium antacids
Constipation◦ Related to:
slowing of motility intestinal compression oral iron supplement
◦ Nursing Care Increase water and fiber in diet moderate exercise No laxatives or enema without a doctor’s permission
Hemorrhoids◦ Related to :
pelvic congestion straining with stool
◦ Nursing Care avoid constipation Apply topical agents to area
Elimination:Urinary SystemRenal Changes
◦ Related to: Kidneys increase in size and weight to due to increased
filtration needs Enlarged uterus presses on kidneys and ureters reducing
effective flow ureters dilate Urinary stasis occurs
Urinary frequency and urgency◦ Related to:
pressure of uterus on bladder first and last trimester Nursing care
Kegel’s exercises Limit fluid intake before bedtime Report dysuria or burning
IntegumentarySkin changes
◦ Increase pigmentation R/T increase in production of melanotropin face = chloasma breasts = areola darkens abdomen = linea nigra
◦ Spider nevi on face and upper trunk◦ Striae gravidarum
Regulatory Changes
• Joints, bones, and teeth▫ Softening of pelvic cartilage and exaggerated elasticity of
connective tissue▫ Posture changes▫ Leg cramps▫ Carpal tunnel syndrome▫ Teeth--there is no demineralization
• Endocrine▫ The placenta produces new hormones
• Exercise, Leisure▫ May attend regular prenatal exercise classes▫ Don’t take up a new sport▫ Travel--wear seat belt
Safety with Seat BeltsSafety with Seat Belts
Wear shoulder Wear shoulder belt belt over top of over top of abdomenabdomen
Wear lap belt lowWear lap belt lowover the hipsover the hips
Regulatory
•Employment▫Criteria for work:
safe environment for the fetus can woman carry out work commitments
without undue stress
•What other teaching is necessary regarding work and breaks?
Safety / SensorySafety
◦Clothing◦Bathing◦Immunizations - avoid live vaccines
EyeEar
◦ Clothing◦ Bathing◦ Immunizations - avoid live vaccines
Nutrition
Increase in caloriesIncrease in protein
May have food cravings or Pica
Nursing care:◦ Teach to take prenatal vitamins and iron
◦ Teach about normal weight gain ~ 25 lbs.
Situation
•Mr. and Mrs. Andrews visit the clinic and tell the nurse that Mrs. A has “missed two menstrual periods, has urinary frequency,
and is tired all of the time”.
First Prenatal Visit
•What is the most important thing that the nurse can do at this first prenatal visit?
FIRST PRENATAL VISIT
•Most important intervention for the nurse is to:
MAKE THE PATIENT WELCOME !
Why? (so the couple will continue with prenatal
care)
Now that the couple has been welcomed to the clinic, one of the first things that must be done is to confirm
that Mrs. A is pregnant.
•Mrs. A says that she used a home pregnancy test and the results were positive.
•What are some of the advantages and disadvantages of using home pregnancy testing?
Home Pregnancy Testing• Advantages
▫ Easily available▫ Uncomplicated ▫ Convenient▫ Have a greater than 97%
accuracy▫ Minimal time
• Disadvantages▫ Must be able to follow
the directions as described or can lead to improper collection and errors in performing or reading the test
▫ False-positive results – anticonvulsants, aspirin,
tranquilizers, marijuana▫ False-negative results –
diuretics, promethazine▫ Laboratory errors
Confirm the PregnancyAll tests rely on detection of HCG
EnzymeImmunoassay Tests
Radioimmune assay Tests
UrineHema-agglutinationInhibitionTests
Presumptive Signs
•Cessation of Menstruation•Breast changes -- tenderness•Nausea and Vomiting•Frequent Urination•Quickening•Chadwicks sign•Increased pigmentation of the Skin•Fatigue
Probable Signs
•Enlargement of the Abdomen•Hegar’s Sign -- softening of the isthmus
of the uterus•Goodell’s Sign --softening of the cervix•Braxton-Hicks contractions•Ballotment•Outline of the fetus by abdominal
palpation•Positive Pregnancy Test
Positive Signs
•Ausculation of fetal heart tones
•Active fetal movement felt by a trained provider
•Ultrasound showing fetal outline
•It is confirmed that Mrs. Andrews is pregnant.
•The nurse will continue with the assessment of physiological and psychological needs of the family.
•Assessment begins at the initial visit and continues throughout pregnancy.
Legal Implication•Nurses must exercise caution when
discussing obstetric history with the expectant mother in the presence of her family or significant other. Although the antepartum record may indicate a previous pregnancy or childbirth, she may not have shared this Information with her family, and probing questions could jeopardize her right to privacy.
• The confidentiality of the pregnant woman must always be protected.
Health History Assessment• Collect information about:
▫ Obstetric History -- Current and past pregnancies▫ Menstrual History▫ Family history--genetic and environmental factors
that affect health▫ Medical history-- diabetes, heart
• Perform Physical Examination including a Pelvic Examination (Pap test, measurements, cervical culture)
• Perform Laboratory Studies▫ CBC, Type & Cross, RPR, Rubella, Hepatitis, HIV
Calculation of Gravida and Parity•Obstetrical Status
▫Gravida = number of times pregnant regardless of duration or outcome
▫Parity = number of deliveries after the age of viability (20 weeks).
** It is not the number of babies that come out, but the number of deliveries of a pregnancy
Calculation of Gravida and Parity•Further Breakdown into TPAL
▫T = Term▫P = Preterm▫A = Abortions▫L = Living children
Check Yourself !The nurse obtained the following data
from Mrs. Andrews. She has five year old twins that delivered at 35 weeks, a three year old son that delivered at 39 weeks, had a miscarriage last year at 12 weeks gestation.
What is her gravida and parity?What is her gravida and parity using the
TPAL system?
•Mr. and Mrs. Andrews are both excited about the pregnancy. It is her first so she is considered a Gravida 1, Para 0.
•They ask the nurse “When is the baby due”?
•How will you calculate this?
Calculation of E. D. C. Nagele’s Rule
First day of last Menstrual Go back 3 months Add 7 days
Mrs. Andrews tells you her last menstrual period began on July 18.
Her baby is due on ____________.
TEST YOURSELF
•Mrs. B. began her menses onJanuary 21. What is her E.D.C.using Nagele’s Rule?
•Mrs. C. started her menses onJune 27. What is her E.D.C. using Nagele’s Rule?
Problem Solving
•If Mrs. Andrews did not know the first day of her last menstrual period, what method
of calculation would you use?
McDonald’s Rule Use Fundal height measurement, measure
from the symphysis to the top of the fundus.
Months = measure cm. X 2/7 Weeks = measure cm. X 8/7
Mrs. Andrew’s fundal height is 7 cm. How far along is she?
Assessment
•The nurse continues with assessment of Mrs. Andrews and gathers data regarding presumptive, probable, and positive signs of pregnancy
Conclusion of Visit
•You are completed with Mr. and Mrs. Andrews first prenatal visit.
•Before they leave, it is important to discuss the following topics:
Conclusion of Visit
•Patient Teaching
•Diet Counseling
•Referrals
•Danger Signals
•Date of next visit
Danger Signals• Vaginal Bleeding• Fluid from the Vagina• Abdominal Pain• Increased Temperature• Dizziness, Blurred vision or Double Vision• Persistent Vomiting• Edema• Headache• Dysuria• Absence of Movement of the Baby
Psychological Tasks of PregnancyMr. Andrews says they were excited about
having the baby but he had just taken a new job and was concerned.
Is this Normal?
The First Trimester
• Major Feelings are:
▫ Disbelief / Uncertainty Much time is devoted to the attempt to
determine for sure whether she is pregnant
▫ Ambivalence Feelings fluctuate between acceptance and
rejection of the pregnancy
The First Trimester
• How the Nurse Can Assist the Woman to Adjust:
▫ Assist her to confirm that she is Pregnant▫ Recognize that she is self-centered▫ Focus on Current Events▫ Provide opportunities for her to discuss
concerns▫ Guide her to appropriate community resources
The Second Trimester
•The Major Task is to:• Perceive the Fetus as • a Growing Infant• be able to say:
•“I am Going to have a Baby”
The Second Trimester
• Major Feelings are:▫ Woman feels well and good about herself▫ Concerned with producing a healthy baby▫ Self- Centered and Introverted▫ Visualizes the infant as a separate being▫ Views body image changes as positive sign
that the baby is doing O.K.
The Second TrimesterWays Health Care Worker can assist the
woman to adjust:◦ Take advantage of the Prime Time for Teaching Individual Care
Nutrition Clothing Exercise
Baby Care◦ Confirm that the baby is Growing and Doing Well◦ Praise her on following Prenatal
Recommendations
The Third Trimester
The Major Task is toPrepare for the end of Pregnancy and she need to be able to say
“I am Going to Be a Parent”
The Third Trimester• Major Feelings are:
▫ Vulnerable Fears loss of the baby Fantasies about harm coming to the baby
▫ Dependent Needs satisfaction that partner / support
person is there ▫ Concerned with how to cope with labor and
delivery▫ Need to Prepare for Parenthood
The Third Trimester
• Ways in which the Health Care Worker can assist the woman to adjust:▫ Assure her of the baby’s well- being▫ Be a Good Listener▫ Nurture her▫ Provide with information about childbirth
classes▫ Assist her with contacting appropriate
agencies that may assist in caring for the infant after birth
Sexual Changes
•First trimester – decrease in sex drive
•Second trimester – return of sex drive“Baby Moon”
•Third trimester – decrease in sex drive
•Exceptions – those women who are prone to preterm labor.
Factors that affect psycosocial adaptations
•Age•Multiparity•Social support•Absence of a partner•Socioeconomic status•Abnormal situations