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CHAPTER Prenatal Care and Adaptations to Pregnancy
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Prenatal Care and Adaptations to Pregnancy CHAPTER 4 45. team to create an environment that allows for cultural The woman has a complete physical examination on. and individual differences while also being supportive her first visit to evaluate her general health determine. of the entire family her baseline weight and vital signs evaluate her nutri. tional status and identify current physical or social. Nursing Tip problems A pelvic examination is performed to evalu. ate the size adequacy and condition of the pelvis and. The major roles of the nurse during prenatal care include reproductive organs and to assess for signs of preg. data collection from the pregnant woman identifying and nancy see Box 4 3 Her estimated date of delivery. reevaluating risk factors educating in self care providing. EDD is calculated based on the LNMP An ultrasound, nutrition counseling and promoting the family s adaptation. to pregnancy, examination may be done at this visit or at a later visit. to confirm the EDD An assessment for risk factors that. may affect the pregnancy is performed during the first. PRENATAL VISITS visit and updated at subsequent visits. Ideally health care for childbearing begins before Several routine laboratory tests are performed on the. conception Preconception care identifies risk fac first or second prenatal visit Others are done at spe. tors that may be changed before conception to reduce cific times during pregnancy and may be repeated at. their negative impact on the outcome of pregnancy certain intervals Several tests are done for all pregnant. For example the woman may be counseled about women others are based on the presence of various. how to improve her nutritional state before preg risk factors The U S Preventive Services Task Force. nancy or may receive immunizations to prevent infec USPSTF has updated its recommendations concern. tions that would be harmful to the developing fetus ing obtaining urine cultures at 12 to 16 weeks of ges. An adequate folic acid intake before conception can tation to screen for asymptomatic bacteriuria Early. reduce the incidence of congenital anomalies see p treatment of this condition can prevent preterm births. Some risk factors cannot be eliminated such as Table 4 1 lists prenatal laboratory tests. preexisting diabetes but preconception care helps the The development of human genome mapping has. woman to begin pregnancy in the best possible state expanded the prenatal detection of genetic disorders. of health and provides the basis for future therapeutic interven. Prenatal care should begin as soon as a woman tions The future direction of prenatal testing is to pro. suspects that she is pregnant A complete history and vide early accurate noninvasive screening tests. physical examination identifies problems that may The recommended schedule for prenatal visits in an. affect the woman or her fetus The history should uncomplicated pregnancy is as follows. include the following,Conception to 28 weeks every 4 weeks. Obstetric history Number and outcomes of past,29 to 36 weeks every 2 to 3 weeks. pregnancies problems in the mother or infant,37 weeks to birth weekly.
Menstrual history Usual frequency of menstrual,The pregnant woman is seen more often if complica. cycles and duration of flow first day of the last tions arise Routine assessments made at each prenatal. normal menstrual period LNMP any spot visit include the following. ting since the LNMP,Review of known risk factors and assessment for. Contraceptive history Type used whether an,oral contraceptive was taken before the woman. Vital signs The woman s blood pressure should, realized she might be pregnant whether an be taken in the same arm and in the same posi. intrauterine device is still in place tion each time for accurate comparison with her. Medical and surgical history Infections such,baseline value.
as hepatitis or pyelonephritis past surgical,Weight to determine if the pattern of gain is. procedures trauma that involved the pelvis or normal Low prepregnancy weight or inad. reproductive organs equate gain are risk factors for preterm birth a. Family history of the woman and her partner to,low birthweight infant and other problems A. identify genetic or other factors that may pose a sudden rapid weight gain is often associated. risk for the pregnancy with gestational hypertension. Woman s and partner s health history to identify,Urinalysis for protein glucose and ketone levels. risk factors e g genetic defects or the use of,Blood glucose screening between 24 and 28. alcohol drugs or tobacco and possible blood weeks of gestation Additional testing is done if. incompatibility between the mother and fetus the result of this screening test is 135 mg dl or. Psychosocial history to identify stability of, lifestyle and ability to parent a child significant.
Fundal height to determine if the fetus is grow, cultural practices or health beliefs that affect the ing as expected and the volume of amniotic fluid. pregnancy is appropriate,Chapter 4 indd 45 6 7 06 11 34 49 AM. 46 U N I T TWO MATERNAL NEWBORN NURSING AND WOMEN S HEALTH. Table 4 1 Prenatal Laboratory Tests,TEST PURPOSE,FIRST TRIMESTER ROUTINE. Blood type and Rh factor and antibody screen Determines risk for maternal fetal blood incompatibility. Complete blood count CBC Detects anemia infection or cell abnormalities. Hemoglobin or hematocrit Detects anemia, VDRL or rapid plasma reagin RPR Syphilis screen mandated by law. Rubella titer Determines immunity to rubella, Tuberculin skin test Screening test for exposure to tuberculosis.
Hepatitis B screen Identifies carriers of hepatitis B recommended by American College of. Obstetricians and Gynecologists, Human immunodeficiency virus HIV screen Detects HIV infection required by some states Counseling concern. ing prevention and risks should be provided to all prenatal patients. Urinalysis and culture Detects infection renal disease or diabetes. Recommended by USPSTF to screen for asymptomatic bacteriuria. Papanicolaou Pap test Screens for cervical cancer if not done within 6 months before con. Cervical culture Detects group B streptococci or sexually transmitted diseases STDs. such as gonorrhea chlamydia,FIRST TRIMESTER IF INDICATED. Hemoglobin electrophoresis Identifies presence of sickle cell trait or disease in women of African. or Mediterranean descent, Endovaginal ultrasound Performed when high risk of fetal loss is suspected. SECOND TRIMESTER ROUTINE, Blood glucose screen 1 hour after ingesting Routine test done at 24 28 weeks of gestation to identify gestational. 50 g of liquid glucose diabetes results above 135 mg dl require medical follow up. Serum alpha fetoprotein Optional routine test to identify neural tube or chromosomal defect in. Ultrasonography Optional noninvasive routine test to identify some anomalies and. confirm EDD,SECOND TRIMESTER IF INDICATED, Amniocentesis Performed at 16 20 weeks of gestation when high risk for problem is.
THIRD TRIMESTER IF INDICATED, Real time ultrasonography Performed when problem is suspected. Identifies reduced amniotic fluid which can result in fetal problem. Identifies excess amniotic fluid which would indicate fetal anomaly or. maternal problem, Confirms gestational age or cephalopelvic disproportion. Determines fetal lung maturity lecithin and sphingomyelin ratio with. amniocentesis, Confirms presence of anomaly that may require fetal or neonatal. Cervical fibronectin assay Determines risk of preterm labor when problem is suspected. Additional prenatal diagnostic tests can be found in Table 5 1. Leopold s maneuvers to assess the presentation, and position of the fetus by abdominal palpa Nursing Tip. tion The nurse listens to concerns and answers questions from. Fetal heart rate During very early pregnancy the expectant family during each prenatal visit This is a. the fetal heart rate is measured with a Doppler prime time for teaching good health habits because most. transducer in later pregnancy it may also be women are highly motivated to improve their health. heard with a fetoscope Beating of the fetal heart, can be seen on ultrasound examination as early The most common cause of vaginal discharge is.
as 8 weeks after the LNMP bacterial vaginosis BV in which there is a decrease. Review of nutrition for adequacy of calorie in normal lactobacilli and an increase in bacteroids. intake and specific nutrients and other anaerobic microorganisms There may be a. Discomforts or problems that have arisen since milky white vaginal discharge but often there are no. the last visit other clinical symptoms Bacterial vaginosis has been. Chapter 4 indd 46 6 7 06 11 34 49 AM, Prenatal Care and Adaptations to Pregnancy CHAPTER 4 47. associated with preterm labor and many obstetri living The term is also used informally to. cians routinely screen pregnant women for BV early in describe a woman before the birth of her first. pregnancy Treatment with metronidazole Flagyl or child. clindamycin between 12 and 20 weeks of gestation is. Multipara A woman who has given birth to two, common The American College of Obstetricians and or more children past the point of viability. Gynecologists ACOG and the Agency for Healthcare regardless of whether the children were alive at. Research and Quality AHRQ recommend screening birth or are presently alive The term is also used. in high risk women with a history of preterm labor informally to describe a woman before the birth. Owen 2004 of her second child,The nurse establishes rapport with the expectant. Nullipara A woman who has not given birth to, family by conveying interest in their needs listening a child who reached the point of viability. to their concerns and directing them to appropriate. Abortion Termination of pregnancy before, resources The health care team must show sensitivity viability 20 weeks of gestation either sponta.
to the family s cultural and health beliefs and incorpo neously or induced. rate as many as possible into care For example Mus. Gestational age Prenatal age of the developing, lim laws of modesty dictate that a woman be covered fetus calculated from the first day of the wom. hair body arms and legs when in the presence of an an s LNMP. unrelated male and therefore a female health care pro. Fertilization age Prenatal age of the developing, vider is often preferred Latino families expect a brief fetus calculated from the date of conception. period of conversation during which pleasantries are approximately 2 weeks shorter than the. exchanged before getting to the point of the visit gestational age. An Asian woman may nod her head when the nurse,Age of viability A fetus that has reached the. teaches her leading the nurse to believe that she under stage usually 20 weeks where it is capable of. stands and will use the teaching However the woman living outside of the uterus. may be showing respect to the nurse rather than agree The gravida number increases by 1 each time. ment with what is taught Eye contact which is valued a woman is pregnant whereas the para number. by many Americans is seen as confrontational in some increases only when a woman delivers a fetus of at. cultures least 20 weeks of gestation For example a woman. who has had two spontaneous abortions miscar, Nursing Tip riages at 12 weeks of gestation has a 3 year old son. and is now 32 weeks pregnant would be described, Early and regular prenatal care is important for reducing the as gravida 4 para 1 abortions 2 The TPALM system.
number of low birthweight infants born and for reducing. see Box 4 1 is a standardized way to describe the,morbibity and mortality for mothers and newborns. outcomes of a woman s pregnancies on her prenatal,DEFINITION OF TERMS. The following terms are used to describe the obstetric DETERMINING THE ESTIMATED. history of a woman DATE OF DELIVERY,Gravida Any pregnancy regardless of duration. The average duration of a term pregnancy is 40 weeks. also the number of pregnancies including the 280 days after the first day of the LNMP plus or. one in progress if applicable minus 2 weeks N gele s rule is used to determine. Nulligravida A woman who has never been, the EDD To calculate the EDD one identifies the first. pregnant day of the LNMP counts backward 3 months and. Primigravida A woman who is pregnant for the,then adds 7 days see Box 4 2 The year is updated.
first time if applicable The EDD is an estimated date many. Multigravida A woman who has been pregnant, normal births occur before and after this date The. before regardless of the duration of the preg EDD may also be determined with a gestation wheel. nancy an electronic calculator designed for this purpose a. Para A woman who has given birth to one or,physical examination an ultrasound or a combina. more children who reached the age of viability tion of these methods. 20 weeks of gestation regardless of the number Pregnancy is divided into three 13 week parts. of fetuses delivered and regardless of whether called trimesters Predictable changes occur in the. those children are now living woman and the fetus in each trimester Understand. Primipara A woman who has given birth to her, ing these developments helps to better provide antic. first child past the point of viability regardless ipatory guidance and identify deviations from the. of whether the child was alive at birth or is now expected pattern of development. Chapter 4 indd 47 6 7 06 11 34 50 AM, 48 U N I T TWO MATERNAL NEWBORN NURSING AND WOMEN S HEALTH. Box 4 1 TPALM System to Describe Parity, T number of term infants born infants born after at least 37 weeks of gestation.
P number of preterm infants born infants born before 37 weeks of gestation. A number of pregnancies aborted spontaneously or induced. L number of children now living,M multiple birth optional. Name Gravida Term Preterm Abortions Living Multiple. Katie Field 3 1 0 1 1 0,Anna Luz 4 1 1 1 2 0,Katie Field Gravida 3 para 10110. Anna Luz Gravida 4 para 11120, Box 4 2 N gele s Rule to Determine the Estimated Date DIAGNOSIS OF PREGNANCY. of Delivery EDD, The signs of pregnancy are divided into three general. Determine first day of the last normal menstrual groups presumptive probable and positive depend. period LNMP ing on how likely they are to be caused by factors other. Count backward 3 months than pregnancy see Box 4 3. Add 7 days,Correct the year if needed PRESUMPTIVE SIGNS.
OF PREGNANCY, The presumptive indications of pregnancy are those. First day of LNMP January 27, from which a definite diagnosis of pregnancy cannot be. Count backward 3 months October 27,made These signs and symptoms are common during. Add 7 days November 3 is EDD, pregnancy but often can be caused by other conditions. The presumptive indications are discussed here, Amenorrhea the cessation of menses in a healthy and.
sexually active woman is often the first sign of preg. Box 4 3 Signs of Pregnancy nancy However strenuous exercise changes in metab. olism and endocrine dysfunction chronic disease cer. PRESUMPTIVE tain medications anorexia nervosa early menopause. Amenorrhea or serious psychological disturbances may also be the. Nausea cause, Breast tenderness Nausea and sometimes vomiting occur in at least half. Deepening pigmentation of all pregnancies Morning sickness describes the. Urinary frequency symptoms but they may occur at any time of day A. Quickening, distaste for certain foods or even their odors may be. PROBABLE the main complaint The nausea begins about 6 weeks. Goodell s sign after the LNMP and usually improves by the end of the. Chadwick s sign first trimester Emotional problems or gastrointestinal. Hegar s sign upsets may also cause nausea and vomiting. McDonald s sign Breast changes include tenderness and tingling as. Abdominal enlargement hormones from the placenta stimulate growth of the. Braxton Hicks contractions ductal system in preparation for breastfeeding Simi. Ballottement lar breast changes also occur premenstrually in many. Striae women Striae are pink to brown lines that may develop. Positive pregnancy test as the breasts enlarge see Figure 4 1. POSITIVE Pigmentation changes occur primarily in dark. Audible fetal heartbeat,skinned women They include increased pigmentation. Fetal movement felt by examiner of the face chloasma or mask of pregnancy breasts. Ultrasound visualization of fetus darkening of the areolae and abdomen linea nigra. a line extending in the midline of the abdomen from. Chapter 4 indd 48 6 7 06 11 34 50 AM, Prenatal Care and Adaptations to Pregnancy CHAPTER 4 49. just above the umbilicus to the symphysis pubis See. Figure 4 2 for common skin changes of pregnancy,Frequency and urgency of urination are common in.
the early months of pregnancy The enlarging uterus. along with the increased blood supply to the pelvic. area exerts pressure on the bladder Urinary frequency. occurs in the first trimester until the uterus expands. and becomes an abdominal organ in the second trimes. ter The pregnant woman experiences frequency of uri. nation again in the third trimester when the present. ing part descends in the pelvis in preparation for birth. Causes of urinary disturbances other than pregnancy. are urinary tract infections and pelvic masses, Fatigue and drowsiness are early symptoms of preg FIGURE 4 1 Striae and pigmentation of breasts Note the. nancy Fatigue is believed to be caused by increased darkened pigmentation of areolae and the pink white lines. metabolic needs of the woman and fetus In an other at the base of the breasts that are caused by stretching of. wise healthy young woman it is a significant sign of the elastic tissue as the breasts enlarge Pigmentation will. pregnancy However illness stress or sudden changes disappear after pregnancy and striae will fade into silvery. in lifestyle may also cause fatigue,Quickening fetal movement felt by the mother is. first perceived at 16 to 20 weeks of gestation as a faint. fluttering in the lower abdomen Women who have pre. viously given birth often report quickening at an ear. lier stage than women who have not This is an impor. tant event to record because it marks the approximate. midpoint of the pregnancy and is another reference. point to verify gestational age Abdominal gas normal. bowel activity or false pregnancy pseudocyesis are. other possible causes,PROBABLE SIGNS OF PREGNANCY, The probable indications of pregnancy provide stron. ger evidence of pregnancy However these also may be. caused by other conditions,Goodell s sign is the softening of the cervix and. the vagina caused by increased vascular congestion. Chadwick s sign is the purplish or bluish discoloration. of the cervix vagina and vulva caused by increased. vascular congestion Hormonal imbalance or infection. may also cause both Goodell s and Chadwick s signs. Hegar s sign is a softening of the lower uterine seg. FIGURE 4 2 Abdominal striae are pinkish white or purple gray. ment Because of the softening it is easy to flex the body lines that may occur in pregnancy They may be found on the. of the uterus against the cervix McDonald s sign breasts abdomen and thighs The dark line at the midline. Abdominal and uterine enlargement occurs rather is the linea nigra an area of increased pigmentation most. irregularly at the onset of pregnancy By the end of the noticeable in dark skinned women. twelfth week the uterine fundus may be felt just above. the symphysis pubis and it extends to the umbilicus Ballottement is a maneuver by which the fetal part is. between the twentieth and twenty second weeks see displaced by a light tap of the examining finger on the. Figure 4 3 Uterine or abdominal tumors may also cervix and then rebounds quickly Uterine or cervical. cause enlargement polyps small tumors may cause the sensation of bal. Braxton Hicks contractions are irregular painless lottement on the examiner s finger. uterine contractions that begin in the second trimester Fetal outline may be identified by palpation after the. They become progressively more noticeable as term twenty fourth week It is possible to mistake a tumor. approaches and are more pronounced in multiparas for a fetus. They may become strong enough to be mistaken for Abdominal striae stretch marks are fine pinkish. true labor Uterine fibroids benign tumors may also white or purplish gray lines that some women develop. cause these contractions when the elastic tissue of the skin has been stretched. Chapter 4 indd 49 6 7 06 11 34 50 AM, 50 U N I T TWO MATERNAL NEWBORN NURSING AND WOMEN S HEALTH.
lightening,16 Umbilicus,8 Symphysis, FIGURE 4 3 Height of fundus during gestation A The numbers represent the weeks of. gestation and the circles represent the height of the fundus expected at that stage of gestation. Note The fortieth week is represented by a dotted line to indicate lightening has occurred. B A health care provider measures the height of the fundus during a clinic visit B courtesy of. Pat Spier RN C, to its capacity see Figure 4 2 Increased amounts of. estrogen cause a rise in adrenal gland activity This POSITIVE SIGNS OF PREGNANCY. change in addition to the stretching is believed to cause Positive signs of pregnancy are caused only by a devel. breakdown and atrophy of the underlying connective oping fetus They include demonstration of fetal heart. tissue in the skin Striae are seen on the breasts thighs activity fetal movements felt by an examiner and visu. abdomen and buttocks After pregnancy the striae alization of the fetus with ultrasound. lose their bright color and become thin silvery lines Fetal heartbeat may be detected as early as 10 weeks. Striae may occur with skin stretching from any cause of pregnancy by using a Doppler device The examiner. such as weight gain can detect the fetal heartbeat using a fetoscope between. Pregnancy tests use maternal urine or blood to deter the eighteenth and twentieth weeks of pregnancy. mine the presence of human chorionic gonadotropin When the fetal heartbeat is heard with a fetoscope it. hCG a hormone produced by the chorionic villi of is important because it provides another marker of the. the placenta Home pregnancy tests based on the pres approximate midpoint of gestation When assessing. ence of hCG in the urine are capable of greater than the fetal heartbeat with a Doppler device or fetoscope. 97 accuracy but the instructions must be followed the woman s pulse rate must be assessed at the same. precisely to obtain this accuracy Professional pregnancy time to be certain that the fetal heart is what is actually. tests are based on urine or blood serum levels of hCG heard The fetal heart rate at term ranges between a. and are more accurate A highly reliable pregnancy low of 110 to 120 beats min and a high of 150 to 160. test is the radioimmunoassay RIA The RIA accurately beats min The rate is higher in early gestation and. identifies pregnancy as early as 1 week after ovulation slows as term approaches. Pregnancy tests of all types are probable indicators Additional sounds that may be heard while assess. because several factors may interfere with their accu ing the fetal heartbeat are the uterine and funic souf. racy medications such as antianxiety or anticonvul fles Uterine souffle is a soft blowing sound heard over. sant drugs blood in the urine malignant tumors or the uterus during auscultation The sound is synchro. premature menopause nous with the mother s pulse and is caused by blood. Chapter 4 indd 50 6 7 06 11 34 51 AM, Prenatal Care and Adaptations to Pregnancy CHAPTER 4 51. 5000 ml 5 quarts enough to house the term fetus,placenta and amniotic fluid. Soon after conception the cervix changes in color and. consistency Chadwick s and Goodell s signs appear, The glands of the cervical mucosa increase in number.
and activity Secretion of thick mucus forms a mucous. plug that seals the cervical canal The mucous plug pre. vents the ascent of vaginal organisms into the uterus. With the beginning of cervical thinning effacement. and opening dilation near the onset of labor the plug. is loosened and expelled, FIGURE 4 4 The pregnant woman s family may be present Ovaries. during an ultrasound,The ovaries do not produce ova eggs during preg. nancy The corpus luteum empty graafian follicle see. entering the dilated arteries of the uterus The funic p remains on the ovary and produces progesterone. souffle is a soft swishing sound heard as the blood to maintain the decidua uterine lining during the first. passes through the umbilical cord vessels 6 to 7 weeks of the pregnancy until the placenta can. Fetal movements can be felt by a trained examiner in perform this function. the second trimester Fetal activity must be distinguished. by the examiner because to a prospective mother Vagina. normal intestinal movements can appear similar to the The vaginal blood supply increases causing the blu. faint fetal movements typical of early pregnancy Fetal ish color of Chadwick s sign The vaginal mucosa. movements can be seen with ultrasonography thickens and rugae ridges become prominent The. Identification of the embryo or fetus by means connective tissue softens to prepare for distention as. of ultrasound photography of the gestational sac is the child is born Secretions of the vagina increase In. possible as early as 4 to 5 weeks of gestation with 100 addition the vaginal pH becomes more acidic to pro. reliability This noninvasive method is the earliest tect the vagina and uterus from pathogenic microor. positive sign of a pregnancy An ultrasound is often ganisms However the vaginal secretions also have. routinely done around the twentieth week of gestation higher levels of glycogen a substance that promotes. see Figure 4 4 the growth of Candida albicans the organism that. causes yeast infections,NORMAL PHYSIOLOGICAL CHANGES Breasts. IN PREGNANCY Hormone induced breast changes occur early in. pregnancy High levels of estrogen and progesterone. The woman s body undergoes dramatic changes as she prepare the breasts for lactation The areolae of the. houses and nourishes her growing child Most of these breasts usually become deeply pigmented and seba. changes reverse shortly after birth ceous glands in the nipple tubercles of Montgomery. become prominent The tubercles secrete a substance. REPRODUCTIVE SYSTEM that lubricates the nipples, Uterus In the last few months of pregnancy thin yellow. The uterus undergoes the most obvious changes in fluid called colostrum can be expressed from the. pregnancy Before pregnancy it is a small muscu breasts This premilk is high in protein fat soluble. lar pear shaped pelvic organ that weighs about 60 g vitamins and minerals but is low in calories fat and. 2 oz measures 7 5 cm 3 inches 5 cm 2 inches sugar Colostrum contains the mother s antibodies to. 2 5 cm 1 inch and has a capacity of about 10 ml diseases and is secreted for the first 2 to 3 days after. of an ounce The uterus expands gradually during birth in the breastfeeding woman. pregnancy by increasing both the number of myome, trial muscle cells during the first trimester and the RESPIRATORY SYSTEM.
size of individual cells during the second and third The pregnant woman breathes more deeply but her. trimesters The uterus becomes a temporary abdomi respiratory rate increases only slightly if at all These. nal organ at the end of the first trimester At term changes increase oxygen and carbon dioxide exchange. the uterus reaches the woman s xiphoid process and because she moves more air in and out with each. weighs about 1000 g 2 2 pounds Its capacity is about breath Oxygen consumption increases by 15 during. Chapter 4 indd 51 6 7 06 11 34 52 AM, 52 U N I T TWO MATERNAL NEWBORN NURSING AND WOMEN S HEALTH. pregnancy The expanding uterus exerts upward pres woman s aorta resulting in fetal hypoxia Symptoms. sure on her diaphragm causing it to rise about 4 cm 1 6 of supine hypotension syndrome include faintness. inches To compensate her rib cage flares increasing lightheadedness dizziness and agitation Displacing. the circumference of the chest about 6 cm 2 4 inches the uterus to one side by turning the patient is all. Dyspnea may occur until the fetus descends into the that is needed to relieve the pressure If the woman. pelvis lightening relieving upward pressure on the must remain flat for any reason a small towel roll. diaphragm placed under one hip will also help to prevent supine. Increased estrogen levels during pregnancy cause hypotension syndrome. edema or swelling of the mucous membranes of the Orthostatic hypotension may occur whenever a. nose pharynx mouth and trachea The woman may woman rises from a recumbent position resulting in. have nasal stuffiness epistaxis nosebleeds and faintness or lightheadedness Cardiac output decreases. changes in her voice A similar process occurs in the because venous return from the lower body suddenly. ears causing a sense of fullness or earaches drops Palpitations sudden increase in heart rate may. occur from increases in thoracic pressure particularly. CARDIOVASCULAR SYSTEM if the woman moves suddenly, The growing uterus displaces the heart upward and to Although both plasma fluid and red blood cells. the left The blood volume gradually increases hyper erythrocytes increase during pregnancy they do not. volemia to about 45 greater than that of the prepreg increase by the same amount The fluid part of the. nant state by 32 to 34 weeks of gestation at which time blood increases more than the erythrocyte compo. it levels off or declines slightly This increase provides nent This leads to a dilutional anemia or pseudoane. added blood for the following mia false anemia As a result the normal prepreg. Exchange of nutrients oxygen and waste prod nant hematocrit level of 36 to 48 may fall to 33. ucts within the placenta to 46 Although this is not true anemia the hema. Needs of expanded maternal tissue tocrit count is reevaluated to determine patient status. Reserve for blood loss at birth and needs The white blood cell leukocyte count also. Cardiac output increases because more blood is increases about 8 mostly neutrophils and returns. pumped from the heart with each contraction the to prepregnant levels by the sixth day postpartum see. pulse rate increases by 10 to 15 beats min and the Table 4 2. basal metabolic rate BMR may increase 20 during There are increased levels of clotting factors VII. pregnancy VIII and X and plasma fibrinogen during the second. Blood pressure does not increase with the higher and third trimesters of pregnancy This hypercoagu. blood volume because resistance to blood flow lability state helps prevent excessive bleeding after. through the vessels decreases A blood pressure of delivery when the placenta separates from the uterine. 140 90 mm Hg or a significant elevation above the wall However these changes increase the possibil. woman s baseline measurement requires attention ity of thrombophlebitis during pregnancy and are the. Supine hypotension syndrome also called aortocaval reason the pregnant patient requires careful assess. compression or vena cava syndrome may occur ment for this risk and specific teaching to prevent. if the woman lies on her back see Figure 4 5 The the venous stasis that can lead to thrombophlebitis. supine position allows the heavy uterus to compress The current increased interest in physical fitness has. her inferior vena cava reducing the amount of blood resulted in many pregnant women continuing to exer. returned to her heart Circulation to the placenta cise during pregnancy Consideration of the effects of. may also be reduced by increased pressure on the exercise on the cardiovascular system that already has. Uterus during contractions,Uterus between contractions. Inferior vena cava, FIGURE 4 5 Supine hypotension syndrome When a pregnant woman lies on her back. supine the weight of the uterus with its fetal contents presses on the vena cava and. abdominal aorta Placing a wedge pillow under the woman s right hip helps to relieve. compression of these vessels,Chapter 4 indd 52 6 7 06 11 34 52 AM.
Prenatal Care and Adaptations to Pregnancy CHAPTER 4 53. Table 4 2 Normal Blood Values in Nonpregnant and Pregnant Women. VALUE NONPREGNANT PREGNANT,Hemoglobin g dl 12 16 11 12. Hematocrit 36 48 33 46,Red blood cells 3 8 5 1 4 5 6 5. million mm3, White blood cells 5000 10 000 mm3 5000 12 000 mm3 increases during labor and postpartum. up to 25 000 mm3,Fibrinogen mg dl 200 400 300 600, an increased blood volume increased cardiac output Glucose metabolism is altered because of increased. and increased coagulability during pregnancy must be insulin resistance during pregnancy This allows. reviewed before an exercise plan is carried out Venous more glucose utilization by the fetus but also places. pressure may increase in the femoral veins as the size the woman at risk for the development of gestational. and weight of the uterus increase resulting in varicose diabetes mellitus Progesterone and estrogen relax the. veins in the legs of some women muscle tone of the gallbladder resulting in the reten. tion of bile salts and this can lead to pruritus itching. GASTROINTESTINAL SYSTEM of the skin during pregnancy. The growing uterus displaces the stomach and intes. tines toward the back and sides of the abdomen see URINARY SYSTEM. Figure 4 6 Increased salivary secretions ptyalism The urinary system excretes waste products for both. sometimes affect taste and smell The mouth tissues the mother and the fetus during pregnancy The glo. may become tender and bleed more easily because of merular filtration rate of the kidneys increases The. increased blood vessel development caused by high renal tubules increase the reabsorption of substances. estrogen levels Contrary to popular belief teeth are that the body needs to conserve but may not be able to. not affected by pregnancy keep up with the high load of some substances filtered. The demands of the growing fetus increase the by the glomeruli e g glucose Therefore glycosuria. woman s appetite and thirst The acidity of gastric and proteinuria are more common during pregnancy. secretions is decreased emptying of the stomach Water is retained because it is needed for increased. and motility movement of the intestines are slower blood volume and for dissolving nutrients that are. Women often feel bloated and may experience consti provided for the fetus. pation and hemorrhoids Pyrosis heartburn is caused The relaxing effects of progesterone cause the renal. by the relaxation of the cardiac sphincter of the stom pelvis and ureters to lose tone resulting in decreased. ach which permits reflux backward flow of the acid peristalsis to the bladder The diameter of the ureters. secretions into the lower esophagus and the bladder capacity increase because of the. note compression,Large intestine,Urinary bladder,Pubic bone.
FIGURE 4 6 Compression of abdominal contents as uterus enlarges The nonpregnant state. A shows the relationship of the uterus to the abdominal contents As the uterus enlarges at. 20 weeks of gestation B and 30 weeks of gestation C the abdominal contents are displaced. and compressed,Chapter 4 indd 53 6 7 06 11 34 52 AM. 54 U N I T TWO MATERNAL NEWBORN NURSING AND WOMEN S HEALTH. relaxing effects of progesterone causing urine stasis The pelvic joints relax with hormonal changes dur. The combination of urine stasis and nutrient rich ing late pregnancy and entry of the fetal presenting. urine makes the pregnant woman more susceptible part into the pelvic brim in the last trimester A woman. to urinary tract infection Consuming at least eight often has a waddling gait in the last few weeks of. glasses of water each day reduces the risk for urinary pregnancy because of a slight separation of the sym. tract infection Although the bladder can hold up to physis pubis. 1500 ml of urine the pressure of the enlarging uterus A change in the center of gravity and joint instabil. causes frequency of urination especially in the first ity because of the softening of the ligaments predispose. and third trimesters Changes in the renal system the pregnant woman to problems with balance Inter. may take 6 to 12 weeks after delivery to return to the ventions concerning safety should be part of prenatal. prepregnant state education,Fluid and Electrolyte Balance. The increased glomerular filtration rate in the kidneys NUTRITION FOR PREGNANCY AND LACTATION. increases sodium filtration by 50 but the increase in. the tubular resorption rate results in 99 reabsorption Good nutrition is essential to establish and maintain a. of the sodium Sodium retention is influenced by many healthy pregnancy and to give birth to a healthy child. factors including elevated levels of the hormones of Good nutritional habits begun before conception and. pregnancy Although much of the sodium is used by the continued during pregnancy promote adaptation to. fetus the remainder is in the maternal circulation and the maternal and fetal needs The Food Guide Pyra. can cause a maternal accumulation of water edema mid should be used as a guide for healthy daily food. This fluid retention may cause a problem if the woman choices The U S Department of Agriculture in a joint. in labor is given intravenous fluids containing oxytocin effort with the U S Department of Health and Human. Pitocin which has an antidiuretic effect and can result Services offers dietary guidelines for Americans these. in water intoxication Agitation and delirium possible guidelines were updated in 2005 see Figure 4 7 A. signs of water intoxication should be recorded and Good nutrition is vital to good health and essential for. reported and an accurate intake and output record normal growth and development A healthy balanced. should be kept during labor and the immediate post nutrient dense diet combined with adequate physical. partum phase activity is the core of the revised dietary guidelines. In pregnancy blood is slightly more alkaline than The 2005 Dietary Guidelines can be designed to meet. in the nonpregnant state and this mild alkalemia is the individual needs of the consumer On the inter. enhanced by hyperventilation that often occurs dur net site www MyPyramid gov a personalized portion. ing pregnancy This status does not impact a normal sized diet plan that includes individualized activity. pregnancy level advice can be accessed by the general public. Additional recommendations for specific populations. INTEGUMENTARY AND can be found at www healthierus gov dietaryguide. SKELETAL SYSTEMS lines Women who follow this guide before pregnancy. The high levels of hormones produced during preg will be well nourished at the time of conception Nurs. nancy cause a variety of temporary changes in the ing Care Plan 4 1 lists common nursing diagnoses and. integument skin of the pregnant woman In addition interventions for nutrition during pregnancy and lac. to the pigmentary changes discussed under the pre tation. sumptive signs of pregnancy the sweat and sebaceous The woman should be educated to read food labels. glands of the skin become more active to dissipate heat carefully to promote the intake of calories that are nutri. from the woman and fetus Small red elevations of skin ent dense rather than empty The U S Food and Drug. with lines radiating from the center called spider nevi Administration FDA along with the U S Department. may occur The palms of the hands may become deeper of Agriculture USDA has developed uniform food. red Most skin changes are reversed shortly after giv labels that inform consumers of the contents of pack. ing birth ages and canned goods An example of how a food. The woman s posture changes as her child grows pyramid can be modified to fit Latin American dietary. within the uterus The anterior part of her body preferences is shown in Figure 4 7 B. becomes heavier with the expanding uterus and the During pregnancy and lactation an adequate. lordotic curve in her lumbar spine becomes more pro dietary intake of docosahexaenoic acid omega 3 fatty. nounced The woman often experiences low backaches acid DHA is essential for optimal brain development. and in the last few months of pregnancy rounding of of the fetus and infant The World Health Organization. the shoulders may occur along with aching in the cer WHO recommends that a full term infant receive 20. vical spine and upper extremities mg of DHA per kilogram per day Maternal dietary. Chapter 4 indd 54 6 7 06 11 34 53 AM, Prenatal Care and Adaptations to Pregnancy CHAPTER 4 55. FIGURE 4 7 A The 2005 Food Guide Pyramid is a guide to healthful eating for all people The. colors represent the basic food groups in the diet with approximate recommended amounts to. consume in relation to the total diet plan Portion size can be individualized to the consumer by. accessing the internet site www MyPyramid gov and entering the individual s weight gender. and activity level The orange color represents whole grains green represents vegetables red. represents fruit the tiny white section represents healthy oils such as those from fish nuts. and vegetable oil blue represents a calcium source such as milk and purple represents meat. poultry eggs and beans Continued,Chapter 4 indd 55 6 7 06 11 34 53 AM. 56 U N I T TWO MATERNAL NEWBORN NURSING AND WOMEN S HEALTH. FIGURE 4 7 cont d B The Traditional Healthy Latin American Diet Pyramid This diet. pyramid is a modification of the North American diet and has daily physical activity as its base. It contains foods common to the Latin American diet. sources of DHA include fish such as mackerel Atlantic Nursing Tip. and sockeye salmon halibut tuna flounder egg yolk, red meat poultry canola oil and soybean oil at two to There is a high correlation between maternal diet and fetal.
health To ensure that deficiencies do not occur during. three servings per week Frying these foods negatively. the critical first weeks of pregnancy the nurse explains. alters DHA content Brooks Mitchell Steffanson to women of childbearing age the value of eating well. 2000 Refer to Table 15 6 p for culturally diverse balanced meals so they may start pregnancy in a good. food patterns nutritional state,Chapter 4 indd 56 6 7 06 11 34 54 AM. Prenatal Care and Adaptations to Pregnancy CHAPTER 4 57. NURSING CARE PLAN 4 1,Nutrition During Pregnancy and Lactation. PATIENT DATA Mrs S is seen in the clinic She is 35 years old in the first trimester of her first pregnancy and appears. interested in starting a health diet in order to have a healthy pregnancy outcome. NURSING DIAGNOSIS Knowledge deficient related to importance of nutrition in pregnancy and lactation. Goals Outcomes Nursing Interventions Rationales, Patient will verbalize 1 Determine age parity present weight 1 Many factors influence nutritional. the need for good nutri prepregnant nutritional status food status of patient during pregnancy. tion in pregnancy and preferences and dislikes food intoler and lactation nutrition teaching must. lactation ances and general health of pregnant be individualized to best meet her. patient pregnancy nutritional needs, 2 Determine socioeconomic and cul 2 Socioeconomic and cultural factors. tural factors that may influence food affect the patient s food choices. choices Make recommendations to fit These factors must be considered. specific needs Consult with a dietitian to increase the chance that a patient. if the patient s nutritional needs are will adhere to dietary recommenda. complex tions The assessment may identify,the need for referral to programs.
such as the Women Infants and,Children WIC nutrition program. 3 Review specific nutritional needs and 3 If patient understands specific nutri. food sources for optimal outcome of tional needs of pregnancy and food. pregnancy and successful lactation sources she is more likely to choose. foods that meet these needs, 4 Provide written information in the 4 Written information reinforces. patient s primary language regard verbal teaching and helps patient. ing nutrition and food preparation to recall forgotten information. Modify the information to incorporate Recommendations must fit within. cultural practices or food dislikes or a patient s individualized needs to. intolerances increase the chance that she will,adhere to them. 5 Encourage questions and provide ap 5 Encouraging the patient s questions. propriate answers allows the nurse to identify and cor. rect areas of inadequate knowledge,or misunderstanding. Patient will implement 1 Teach the patient the purpose of and 1 A 24 hour food diary helps the. good nutrition during how to maintain a 24 hour food diary nurse to evaluate a patient s usual. pregnancy and lactation Teach the patient to eat normally and diet and her likes and dislikes as. as evidenced by a 24 to write down everything she eats well as how to improve her diet It. hour diary and drinks including approximate may identify the need for a dietitian. amounts for 1 day referral, 2 Review the 24 hour intake from the 2 Analysis of usual meals and snacks.
diary and make appropriate recom enables the nurse to identify ad. mendations for improvement Refer equate and inadequate intake of. to a dietitian if nutritional assessment specific nutrients The 24 hour diary. reveals complex needs allows the nurse to reinforce areas of. adequate intake and concentrate on,areas of deficient nutrients. 3 Teach the patient about the Food 3 Choices on the Food Guide Pyra. Guide Pyramid and how to read food mid provide essential nutrients on. labels a daily basis Reading labels helps,the patient to select more nutritious. items from those available,Chapter 4 indd 57 6 7 06 11 34 55 AM. 58 U N I T TWO MATERNAL NEWBORN NURSING AND WOMEN S HEALTH. NURSING CARE PLAN 4 1 cont d,Goals Outcomes Nursing Interventions Rationales. Patient will demonstrate 1 Maintain a chart to show the patient s 1 Weight chart identifies both the. a gradual weight gain actual weight at each visit amount and the pattern of weight. appropriate for her preg gain to identify inadequate or exces. nancy 25 to 35 pounds sive gain,for most women, 2 Review progress of weight with pa 2 Reviewing the patient s weight.
tient at each visit and compare it with identifies whether the patient s. the recommended amount of gain for weight gain is normal and whether. that point in pregnancy additional teaching or exploration of. needs is required, WEIGHT GAIN pounds 1 6 kg during the first trimester and just. In the past a woman s weight gain was restricted dur under 1 pound per week 0 44 kg during the rest of. ing pregnancy Rickets caused by a deficiency of vita pregnancy Nausea and vomiting and some transient. min D resulted in deformity of women s pelves many food dislikes often limit weight gain or cause weight. years ago It was thought that minimal weight gain loss during the first trimester but the weight is usually. would keep the fetus small and therefore easier to regained when the gastrointestinal upsets subside. deliver More recently low weight gain was thought to Women often want to know why they should gain. reduce the risk for gestational hypertension a theory so much weight when their infant weighs only 7 or 8. that has been disproved Creasy Resnick 2004 pounds The nurse can use the distribution of weight. Low maternal weight gain is associated with com gain during pregnancy shown in Table 4 3 to teach. plications such as preterm labor and recommenda women about all the factors that contribute to weight. tions for weight gain during pregnancy have gradually gain. increased Current recommended weight gains during,pregnancy are as follows NUTRITIONAL REQUIREMENTS. Women of normal weight 25 to 35 pounds 11 5, A calorie increase of 300 kilocalories day is recom. to 16 kg mended to provide for the growth of the fetus pla. Underweight women 28 to 40 pounds 12 5 to, centa amniotic fluid and maternal tissues 300 kilocal. 18 kg ories kcal is not a large increase A banana a carrot a. Overweight women 15 to 25 pounds 7 to, piece of whole wheat bread and a glass of low fat milk.
11 5 kg total about 300 kilocalories A half of a roast beef sand. Women with multiple fetuses should gain more wich on whole wheat bread and a fresh green salad. weight Women with twins should gain 4 to 6 pounds added to a healthy diet would also meet the added. in the first trimester and 1 pounds per week in the caloric requirement Caloric intake must be nutritious. second and third trimesters for a total of 35 to 45 to have beneficial effects on pregnancy Four nutrients. pounds The adolescent should gain in the upper are especially important in pregnancy protein cal. part of the range currently recommended for adult cium iron and folic acid The amounts are specified. women in Table 4 4, The pattern of weight gain is also important The The pregnant woman should use the same Food. general recommendation is that a woman gain 3 Guide Pyramid to choose her daily diet Servings that. will supply enough of the additional nutrients needed. Table 4 3 Distribution of Weight Gain in Pregnancy are presented in Table 4 5 A sample menu for a preg. nant woman is shown in Box 4 4,SOURCE OF WEIGHT GAIN WEIGHT GAIN IN POUNDS kg. Uterus 2 5 1 1, Fetus 7 0 7 5 3 2 3 4 Added protein is needed for metabolism and to sup. Placenta 1 0 1 5 0 5 0 7 port the growth and repair of maternal and fetal tis. Amniotic fluid 2 0 0 9,Breasts 1 5 3 0 0 7 1 4,sues An intake of 60 g day is recommended during. Blood volume 3 5 4 0 1 6 1 8 pregnancy The best sources of protein are meat fish. Extravascular fluids 3 5 5 0 1 6 2 3 poultry and dairy products Beans lentils and other. Maternal reserves 4 0 9 5 1 8 4 3 legumes breads and cereals and seeds and nuts in. Total 25 0 35 0 11 4 15 9 combination with another plant or animal protein can. Modified from McKinney E S et al 2005 Maternal child nursing 2nd ed provide all the amino acids components of protein. Philadelphia W B Saunders needed,Chapter 4 indd 58 6 7 06 11 34 55 AM.


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