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NCM NCM Presentation Transcript

  • NURSING CARE MANAGEMENT 101
    CARE OF MOTHER, CHILD AND FAMILY
    FLAS JULIUS A. FLORESTA RN,RM
  • 2
    Conception & Fetal Development?
    Physical &
    Psychologic
    Changes of
    pregnancy?
    Antepartal Nursing Assessment?
    Reproductive Anatomy &
    Physiology?
  • Maternal & Child Nursing Care
    Reproductive Anatomy andPhysiology
    CRISTINA MARIE M. MANZANO RN, RM, MAN
  • Learning Objectives
    Identify the structures and functions of the female and male reproductive systems.
    Summarize the actions of the hormones that affect reproductive functioning.
    Identify the two phases of the ovarian cycle and the changes that occur in each phase.
  • Describe the phases of the menstrual cycle, their dominant hormones, and the changes that occur in each phase.
    Discuss the significance of specific female reproductive structures during childbirth.
    Identify the functions of specific male reproductive structures for reproduction.
  • FIGURE 3–1 Sexual differentiation. A, At 7 weeks’ gestation, male and female genitalia are identical(undifferentiated). B and C, By 12 weeks’ gestation, noticeable differentiation begins to occur.D and E, Differentiation continues until birth but is almost complete at term.
  • FIGURE 3–2 Physiologic changes leading to onset of puberty. A, In females, and B, in males. Solid lines illustrate stimulation of hormone production, and broken lines illustrate inhibition. Through a neurotransmitter the central nervous system stimulates the hypothalamus, which in turn produces a gonadotropin-releasing factor that causes the anterior pituitary to produce gonadotropins (FSH or LH). These hormones stimulate specific structures in the gonads to secrete steroid hormones (estrogen, progesterone, or testosterone). The rise in pituitary hormone increases hypothalamus activity. Elevated steroid hormone levels stimulate the central nervous system and pituitary gland to inhibit hormone production.
  • Female Reproductive System
    External genitalia/vulva
    Mons pubis
    Labia majora
    Labia minora
    Clitoris
    Urethral meatus and opening of the paraurethral glands
    Vaginal vestibule
    Breasts: Accessories of the reproductive system
  • Female external genitals, longitudinal view.
  • FIGURE 3–14 Anatomy of the breast: sagittal view of left breast.
  • Female Reproductive System
    Internal genitalia
    Ovaries and fallopian tubes
    Cervix and uterus
    Vagina
  • FIGURE 3–4 Female internal reproductive organs
  • FIGURE 3–5 Structures of the uterus.
  • FIGURE 3–8 Uterine ligaments.
  • FIGURE 3–9 Fallopian tubes and ovaries.
  • Male Reproductive System
    Testes
    Epididymis, vas deferens and ejaculatory duct
    Accessory glands
    Penis
  • Male reproductive system, sagittal view.
  • Schematic representation of a mature spermatozoon
  • Hormones
    Female Hormones
    Estrogen
    Progesterone
    Prostaglandin
    Male Hormones
    Testosterone is the most important sex hormone
  • Estrogen
    Controls development of female secondary sex characteristics
    Assists in the maturation of the ovarian follicles
    Causes endometrial mucosa to proliferate following menstruation
    Causes uterus to increase in size and weight
  • Female reproductive cycle: interrelationships of hormones with the four phases of the uterine cycle and the two phases of the ovarian cycle in an ideal 28-day cycle
  • Estrogen
    Increases myometrial contractility in both the uterus and fallopian tubes
    Increases uterine sensitivity to oxytocin
    Inhibits FSH production
    Stimulates LH production
  • Progesterone
    Decreases uterine motility and contractility
    Facilitates vaginal epithelium proliferation
    Secretion of thick viscous cervical mucus
    Increases breast glandular tissue in preparation for breast feeding
  • Prostaglandin
    Prostaglandin: Increases during follicular maturation
    Causes extrusion of the ovum
  • FIGURE 3–16 Various stages of development of the ovarian follicles.
  • Follicular Phase
    Hypothalamus secretes gonadotropin-releasing hormone (GnRH)
    GnRH stimulates the anterior pituitary gland to secrete the gonadotropic hormones, follicle-stimulating hormone (FSH), and luteinizing hormone (LH)
    FSH is primarily responsible for the maturation of the ovarian follicle
  • Follicular Phase (cont’d)
    As the follicle matures, it secretes increasing amounts of estrogen
    Final maturation facilitated by LH
    The follicular phase ends with ovulation
  • Luteal Phase
    Release of ovum
    LH: Corpus luteum develops from ruptured follicle
    Secretion of progesterone increases
    Fertilized ovum able to implant into endometrium
    Secretion of human chorionic gonadotropin (hCG)
    Absence of fertilization
    Corpus luteum degenerates
    Decrease in estrogen and progesterone
    Increase in LH and FSH
  • Menstrual Phase
    Shedding of the endometrial lining
    Low estrogen levels
  • Proliferative Phase
    Enlargement of the endometrial glands
    Changes in cervical mucus
    Increasing estrogen levels
  • Secretory Phase
    Follows ovulation
    Influenced primarily by progesterone
    Increase in vascularity of the uterus
    Increase in myometrial glandular secretions
  • Ischemic Phase
    If fertilization does not occur, the ischemic phase begins
    The corpus luteum begins to degenerate
    Both estrogen and progesterone levels fall
    Escape of blood into the stromal cells of the endometrium
  • A
    FIGURE 3–12 Female pelvis. A, The false pelvis is a shallow cavity above the inlet; the true pelvis is adeeper portion of the cavity below the inlet.
  • B
    FIGURE 3–12 (continued) Female pelvis. A, The false pelvis is a shallow cavity above the inlet; the true pelvis is adeeper portion of the cavity below the inlet. B, The true pelvis consists of the inlet, cavity(midpelvis), and outlet.
  • Division of the Pelvis
    False pelvis
    Part above the pelvic brim
    Serves to support the weight of the enlarged pregnant uterus
    Directs the presenting fetal part into the true pelvis
    Inlet: upper border of pelvis
    Pelvic cavity: Curved canal with a longer posterior than anterior wall
    Outlet: Pelvic outlet is at the lower border of the true pelvis
  • FIGURE 3–13 Pelvic planes: coronal section and diameters of the bony pelvis.
  • Basic Pelvic Types
    Gynecoid
    Android
    Anthropoid
    Platypelloid
  • Male Reproductive Structures
    Penis
    Scrotum
    Testes; seminal fluid
  • Male Reproductive Structures
    Epididymis
    Vas deferens
    Urethra
  • Functions of Male Reproductive Structures
    Penis: Deposits sperm in the vagina for fertilization of the ovum
    Scrotum: Protects testes and sperm by maintaining a temperature lower than the body
    Testes
    Serve as a site for spermatogenesis
    Produce testosterone
    Seminal fluid: Transports viable and mobile sperm to female reproductive tract
  • Functions of Male Reproductive Structures
    Epididymis: Reservoir for maturing spermatozoa
    Vas deferens: Rapidly squeeze sperm from their storage sites into urethra
    Urethra: Passageway for both urine and semen
  • Assignment
    Complete the activities: “Female Reproductive System”and “Male Reproductive System” on the accompanying Student CD-ROM.
    View the animations on the CD-ROM on the female and male pelvis.
  • Conception and Fetal Development
  • Learning Objectives
    Compare the difference between meiotic cellular division and mitotic cellular division.
    Compare the processes by which ova and sperm are produced.
    Describe the components of the process of fertilization.
  • Describe in order of increasing complexity the structures that form during the cellular multiplication anddifferentiation stages of intrauterine development.Describe the development, structure, and functions of the placenta and umbilical cord during intrauterine life
    Identify the differing processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed
    Summarize the significant changes in growth and development of the fetus in utero at 4, 6, 12, 16, 20, 24, 28, 36, and 40 weeks’ gestation.
  • Mitosis
    Process of cellular division
    Results in daughter cells that are exact copies of the original cell
    Identical to parent cell and to each other
    Contain a full set of chromosomes or genetic material
    Refered to as diploid cells
    Somatic cells continue to reproduce and replace each other
  • Mitosis
    The cell undergoes several changes ending in cell division
    At the last phase of cell division, a furrow develops in the cell cytoplasm
    The parent cell divides into two daughter cells
    Each daughter cell has its own nucleus
    They are identical to the parent cell
    They have the same diploid number of chromosomes (46) and same genetic makeup as the cell from which they came
  • Meiosis
    Type of cell division that produces reproductive cells called gametes (sperm and ova) - each cell contains half genetic material of parent cell (haploid)
  • Meiosis (cont’d)
    Meiosis consists of two successive cell divisions
    First division: Chromosomes replicate
    Second division: Chromatids of each chromosome separate and move to opposite poles of each of the daughter cells
    Cellular division results in formation of four cells
    Each cell contains haploid number of chromosomes
    Daughter cells contain only half the DNA of normal somatic cell
  • Comparison of Meiosis and Mitosis
  • FIGURE 7–1 Gametogenesis involves meiosis within the ovary and testis. A, During meiosis, eachoogonium produces a single haploid ovum once some cytoplasm moves into the polar bodies.B, Each spermatogonium produces four haploid spermatozoa.
  • Oogenesis
    Process that produces the female gamete, called an ovum (egg), that begins to develop early in the fetal life of the female
    Ovaries begin to develop early in the fetal life of the female
    All ova that female will produce in her lifetime are present at birth - ovary gives rise to oogonial cells, which develop into oocytes
    During puberty: Mature primary oocyte continues through first meiotic division in ovary
    Haploid cells released at ovulalion
  • Oogenesis
    The first meiotic division
    Two cells of unequal size produced with same number of chromosomes
    One cell is secondary oocyte, other is minute polar body
    Secondary oocyte and polar body each contain 22 double-structured autosomal chromosomes and one double-structured sex chromosome (X)
    During puberty: Mature primary oocyte continues through first meiotic division in ovary
  • Spermatogenesis
    Production of the male gamete, or sperm, during puberty
    The spermatogonium (primordial germ cell)
    Begins with complete set of genetic material - diploid number of chromosomes
    Cell replicates before it enters first meiotic division
    Cell is now primary spermatocyte
    During second meiotic division, divide to form four spemiatids, each with haploid number of chromosomes
  • Spermatogenesis (cont’d)
    During the first meiotic division
    Spermatogonium forms two cells called secondary spermatocytes
    Each contains 22 double-structured autosomal chromosomes and either double-structured X sex chromosome or double-structured Y sex chromosome
  • Preparation for Fertilization
    Preparation is the first component of fertilization
    Ovum released into fallopian tube - viable for 24 hours
    Sperm deposited into vagina - viable for 48 to 72 hours (highly fertile for 24 hours)
    Sperm must undergo capacitation and acrosomal reaction
    Sperm penetration causes a chemical reaction that blocks more sperm penetration
  • Moment of Fertilization
    Sperm penetration causes chemical reaction that blocks more sperm penetration
    Sperm enters ovum, chemical signal prompts secondary oocyte to complete second meiotic division
    True moment of fertilization occurs as nuclei unite
    Chromosomes pair up to produce diploid zygote
    Each nucleus contains haploid number of chromosomes (23)
  • Moment of Fertilization (cont’d)
    Union restores diploid number (46)
    Zygote contains new combination of genetic material
    Sex of zygote determined at moment of fertilization
    Two chromosomes of twenty-third pair (sex chromosomes) - either XX or XY - determine sex of individual
    Females have two X chromosomes, males have an X and a Y chromosome
  • A
    FIGURE 7–2 Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a spermare depicted moving from top to bottom. B, Scanning electron micrograph of a human sperm surrounding a human ovum (750). The smaller spherical cells are granulosa cells of the corona radiata. Scanning electron micrograph used with permission from Nisson, L. (1990). A child is born. New York: Dell publishing.
  • B
    FIGURE 7–2(continued) Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a sperm are depicted moving from top to bottom. B, Scanning electron micrograph of a human spermsurrounding a human ovum (750). The smaller spherical cells are granulosa cells of the corona radiata. Scanning electron micrograph used with permission from Nisson, L. (1990). A child is born. New York: Dell publishing.(Photo Lennart Nilsson/Albert Bönniers Folag AB)
  • FIGURE 7–3 During ovulation the ovum leaves the ovary and enters the fallopian tube. Fertilizationgenerally occurs in the outer third of the fallopian tube. Subsequent changes in the fertilizedovum from conception to implantation are depicted.
  • Cell Multiplication
    Rapid mitotic division - cleavage
    Blastomeres grow to morula (solid ball of 12 to 16 cells) - solid ball of 12 to 16 cells
    Morula divides into solid mass (blastocyst); surrounded by outer layer of cells (trophoblast)
    Implantation; occurs in 7 to 10 days
  • Cell Differentiation
    10 to 14 days (ectoderm, mesoderm, and endoderm) from which all tissues, organs, and organ systems develop
    Blastocyst differentiates into three primary germ layers (ectoderm, mesoderm, and endoderm)
    All tissues, organs, and organ systems develop from these primary germ cell layers
    Embryonic membranes form at implantation
    The chorion and the amnion
  • Derivation of Body Structures from Primary Cell Layers
  • Cell Differentiation
    Amniotic Fluid: Created when amnion and chorion grow and connect andform amniotic sac to produce fluid
    Yolk sac
    DeveIops as part of the blastocyst
    Produces primitive red blood cells
    Soon incorporated into the umbilical cord
  • FIGURE 7–4 Formation of primary germ layers. A, Implantation of a 7 1/2-day blastocyst in which thecells of the embryonic disc are separated from the amnion by a fluid-filled space. The erosion of the endometrium by the syncytiotrophoblast is ongoing. B, Implantation is completed by day 9, and extraembryonic mesoderm is beginning to from a discrete layer beneath the cytotrophoblast. C, By day 16 the embryo shows all three germ layers, a yolk sac, and an allantois (an out pouching of the yolk sac that forms the structural basis of the body stalk, or umbilical cord). The cytotrophoblast and associated mesoderm have become the chorion, and chorionic villi are developing.
  • Cell Differentiation
    Ectoderm
    Mesoderm
    Endoderm - differentiation of endoderm results in formation of epithelium lining respiratory and digestive tracts
  • FIGURE 7–5 Endoderm differentiates to form the epithelial lining of the digestive and respiratory tractsand associated glands.
  • FIGURE 7–6 Early development of primary embryonic membranes. At 4 1/2 weeks, the decidua capsularis (placental portion enclosing the embryo on the uterine surface) and decidua basalis (placental portion encompassing the elaborate chorionic villi and maternal endometrium) are well formed. The chorionic villi lie in blood-filled intervillous spaces within the endometrium. The amnion and yolk sac are well developed.
  • Umbilical Cord
    Develops from amnion
    Body stalk attaches embryo to yolk sac, fuses with embryonic portion of placenta
    Provides pathway from chorionic villi to embryo
    Contains two arteries and one vein; surrounded by Wharton’s jelly to protect vessels
    Wharton’s jelly: Specialized connective tissue
    Protects blood vessels
    Function of umbilical cord: Provides circulatory pathway to embryo
  • Placenta
    Placental development
    Begins at third week of embryonic development
    Develops at site where embryo attaches to uterine wall
    Function: Metabolic and nutrient exchange between embryonic and maternal circulations
    Placenta has two parts
    Maternal
    Fetal
  • Placenta
    Maternal portion
    Consists of deciduas basalis and its circulation
    Surface appears red and flesh-like
    Fetal portion
    Consists of the chorionic villi and their circulation
    The fetal surface of the placenta is covered by the amnion
    Appears shiny and gray
  • FIGURE 7–8 Maternal side of placenta (Dirty Duncan).
  • FIGURE 7–9 Fetal side of placenta (Shiny Shultz).
  • FIGURE 7–10 Vascular arrangement of the placenta. Arrows indicate the direction of blood flow. Maternal blood flows through the uterine arteries to the intervillous spaces of the placenta and returnsthrough the uterine veins to maternal circulation. Fetal blood flows through the umbilical arteries into the villous capillaries of the placenta and returns through the umbilical vein to the fetal circulation.
  • FIGURE 7–11 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilicalvein. After circulating through the fetus, the blood returns to the placenta through the umbilical arteries. The ductus venosus, the foramen ovale, and the ductus arteriosus allow the blood to bypass the fetal liver and lungs.
  • Figure 7–7 A, Formation of fraternal twins. (Note separate placentas.) B, Formation of identical twins.
  • Figure 7–7 (continued) A, Formation of fraternal twins. (Note separate placentas.) B, Formation of identical twins.
  • Identical Twins
    Develop from single fertilized ovum
    Of same sex and have same genotype
    Identical twins usually have common placenta; monozygosity is not affected by environment, race, physical characteristics, or fertility
    Both fetus are same sex with same characteristics
    Single placenta
  • Identical Twins
    Number of amnions and chorions present - depends on timing of division
    Division within 3 days of fertilization; two embryos, two amnions, and two chorions will develop
    Division about 5 days after fertilization
    Two embryos develop with separate amniotic sacs
    Sacs will eventually be covered by a common chorion
    Monochorionic-diamniotic placenta
  • Identical Twins (cont’d)
    If amnion already developed, division approximately 7 to 13 days after fertilization
    Two embryos with common amniotic sac and common chorion
    Monochorionic-monoamniotic placenta
    Occurs about 1% of the time
  • Fraternal Twins
    Also referred to as dizygotic
    Arise from two separate ova fertilized by two separate spermatozoa
    Two placentas, two chorions, and two amnions
    Sometimes placentas fuse and appear to be one
    Fraternal twins
    No more similar to each other than singly bom siblings
    May be of same or different sex
  • FIGURE 7–12 The actual size of a human conceptus from fertilization to the early fetal stage. The embryonic stage begins in the third week after fertilization; the fetal stage begins in the ninthweek.
  • Fetus Growth and Development
    4 weeks: 4–6 mm, brain formed from anterior neural tube, limb buds seen, heart beats, GI system begins
    6 weeks: 12 mm, primitive skeletal shape, chambers in heart, respiratory system begins, ear formation begins
  • Fetus Growth and Development
    12 weeks: 8 cm, ossification of skeleton begins, liver produces red cells, palate complete in mouth, skin pink, thyroid hormone present, insulin present in pancreas
    16 weeks: 13.5 cm, teeth begin to form, meconium begins to collect in intestines, kidneys assume shape, hair present on scalp
  • FIGURE 7–13 The embryo at 5 weeks. The embryo has a marked C-shaped body and a rudimentary tail. Use with permission from Petit/Nestle/Science Source/Photo Researchers, Inc.
  • FIGURE 7–14 The embryo at 7 weeks. The head is rounded and nearly erect. The eyes have shifted forward and closer together, and the eyelids begin to form. Use with permission from Petit/Nestle/Science Source/Photo Researchers, Inc.
  • FIGURE 7–15 The fetus at 9 weeks. Every organ system and external structure is present. Use with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.(Photo Lennart Nilsson/Albert Bönniers Folag AB)
  • FIGURE 7–16 The fetus at 14 weeks. During this period of rapid growth, the skin is so transparent that blood vessels are visible beneath it. More muscle tissue and body skeleton have developed,and they hold the fetus more erect. Use with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.(Photo Lennart Nilsson/Albert Bönniers Folag AB)
  • FIGURE 7–17 The fetus at 20 weeks weighs 435 to 465 g and measures about 19 cm. Subcutaneousdeposits of brown fat make the skin a little less transparent. “Woolly” hair covers the head,and nails have developed on the fingers and toes. Use with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.(Photo Lennart Nilsson/Albert Bönniers Folag AB)
  • Fetus Growth and Development
    20 weeks: 19 cm, myelination of spinal cord begins, suck and swallow begins, lanugo covers body, vernix begins to protect the body
    24 weeks: 23 cm, respiration and surfactant production begins, brain appears mature
    28 weeks: 27 cm, nervous system begins regulation of some functions, adipose tissue accumulates; nails, eyebrows, and eyelids are present; eyes are open
    36 weeks: 35 cm, earlobes soft with little cartilage, few sole creases
  • Fetus Growth and Development
    40 weeks : 40 cm, adequate surfactant, vernix in skin folds and lanugo on shoulders, earlobes firm, sex apparent
    Weight about 3,000 to 3,600 g (6 lb., 10 oz. to 7 lb., 15 oz.)
    Varies in different ethnic groups
    Skin has a smooth, polished look
    Hair on head is coarse and about 1 inch long
    Body and extremities are plump
  • Fetal Development: What Parents Want to Know
  • Fetal Development: What Parents Want to Know (cont’d)
  • Assignment
    Access the CD-ROM to view the cell division animation.
    Review the following animations:oogenesis, spermatogenesis, oogenesis and spermato-genesis compared, matching oogenesis and spermatogenesis.
    View and review all animations.
  • Physical and Psychologic Changes of Pregnancy
  • Learning Objectives
    • Identify the anatomic and physiologic changes that occur during pregnancy.
    • Relate these anatomic and physiologic changes to the signs and symptoms that develop in the woman.
    • Compare subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy.
    • Contrast the various types of pregnancy tests.
    • Discuss the emotional and psychological changes that commonly occur in a woman, her partner, and her familyduring pregnancy.
    • Summarize cultural factors that may influence a family’s response to pregnancy.
  • Anatomic and Physiologic Changes
    Uterus: Increased amounts of estrogen and growing fetus
    Enlargement in size
    Increase in weight, strength, elasticity, and vascularity
    Cervix: Increase estrogen levels
    Hyperplasia
    Formation of mucous plug
    Mucous plug prevents organisms entering uterus
  • Anatomic and Physiologic Changes
    • Vagina: Increased estrogen levels
    • Increased thickness of mucosa
    • Increased vaginal secretions to prevent bacterial infections
    • Connective tissue relaxes
    • Breasts: Increased estrogen and progesterone levels
    • Increase in size and number of mammary glands
    • Nipples more erectile and areolas darken
    • Colostrum produced during third trimester
  • Anatomic and Physiologic Changes
    Respiratory system: Increasing levels of progesterone causes:
    Increased volume of air
    Decreased airway resistance
    Increased anteroposterior diameter
    Thoracic breathing occurs as uterus enlarges
  • Anatomic and Physiologic Changes
    Cardiovascular system: Increased levels of estrogen and progesterone
    Cardiac output and blood volume increases
    Increased size of uterus interferes with blood return from lower extremities
    Increased level of red cells to increase oxygen delivery to cells
    Clotting factors increase
  • Anatomic and Physiologic Changes
    GI system: Action of increasing levels of progesterone
    Delayed gastric emptying
    Decreased peristalsis
    GU system: Increased blood volume
    Glomerular filtration rate increases
    Renal tubular reabsorption increases
  • Anatomic and Physiologic Changes
    Skin and Hair: Increased skin pigmentation caused by increased estrogen and progesterone
    Musculoskeletal: Relaxation of joints caused by increased estrogen and progesterone
    Metabolism: Increased during pregnancy
    Demands of the growing fetus and its support system
    Weight Gain: Recommended 25 to 35 lb
    Overweight, recommended gain is 15 to 25lb.
    Underweight: Gain weight needed to reach ideal weight plus 25 to 35 lb
  • Anatomic and Physiologic Changes
    Endocrine System
    Thyroid
    Pituitary
    Adrenals
    Pancreas
  • Signs and Symptoms
    Uterus: Enlargement of abdomen
    Increased strength and elasticity: Allows uterus to contract
    Fetus expelled during labor
    Cervix: Mucous plug expelled as labor begins
    Increased vascularity may cause bleeding after vaginal exams
    Vagina: Acid pH increases chance of vaginal yeast infections
    Breasts: Increase in size causes soreness
    Colostrum may be present during the third trimester
  • Signs and Symptoms
    Respiratory system
    Increased size of uterus may cause shortness of breath
    Increased vascularity may cause nasal stuffiness and nosebleeds
    Cardiovascular system: Decreased blood return from lower extremities
    Varicose veins
    Hemorrhoids
  • Signs and Symptoms (cont’d)
    Pressure on vena cava by the enlarged uterus
    Dizziness
    Decreased blood pressure
    Skin and Hair: Increased skin pigmentation
    Causes linea nigra and chloasma
  • Signs and Symptoms (cont’d)
    GI system: Increased levels of estrogen cause:
    Nausea and vomiting
    Constipation
    Slow peristalsis and motility
    GU system: Increased urination caused by:
    Increasing size of uterus
    Pressure on bladder
    Increased blood volume and glomerular filtration
  • Signs and Symptoms (cont’d)
    Musculoskeletal: Action of estrogen and progesterone
    Relaxation of joints: Lordosis of lumbosacral spine
  • FIGURE 9–5 Approximate height of the fundus at various weeks of pregnancy.
  • FIGURE 9–2 Linea nigra.
  • FIGURE 9–1 Vena caval syndrome. The gravid uterus compresses the vena cava when the woman issupine. This reduces the blood flow returning to the heart and may cause maternal hypotension.
  • FIGURE 9–3 Postural changes during pregnancy. Note the increasing lordosis of the lumbosacral spine and the increasing curvature of the thoracic area.
  • Changes of Pregnancy
    Subjective (presumptive) changes
    Amenorrhea
    Nausea and vomiting
    Fatigue
    Urinary frequency
    Breast changes
    Quickening
  • Differential Diagnosis of Pregnancy - Subjective Changes
  • Differential Diagnosis of Pregnancy - Subjective Changes
  • Changes of Pregnancy
    Objective (probable) changes
    Goodell’s and Chadwick’s sign
    Hegar’s and McDonald’s sign
    Enlargement of the abdomen
    Braxton Hicks contractions
    Uterine soufflé
    Skin pigmentation changes
    Pregnancy tests
  • FIGURE 9–4 Hegar’s sign, a softening of the isthmus of the uterus, can be determined by the examinerduring a vaginal examination.
  • Differential Diagnosis of Pregnancy - Objective Changes
  • Differential Diagnosis of Pregnancy - Objective Changes
  • Changes of Pregnancy
    Diagnostic (positive) changes
    Fetal heartbeat
    Fetal movement
    Visualization of the fetus
  • Pregnancy Tests
    Urine tests
    Hemagglutination-inhibition test (Pregnosticon R test)
    Latex agglutination test (Gravindex and Pregnosticon Slide tests)
    The first two are done on first early morning urine specimen
    Positive within 10 to 14 days after the first missed period
    Detect hCG during early pregnancy
  • Pregnancy Tests
    Serum tests
    -subunit radioimmunoassay: Positive a few days after presumed implantation
    Immunoradiometric assay (IRMA) (Neocept, Pregnosis); requires only about 30 minutes to perform
    Enzyme-linked immunosorbent assay (ELISA) (Model Sensichrome, Quest Confidot): Detects hCG levels as early as 7 to 9 days after ovulation and conception, 5 days before the first missed period
    Fluoroimmunoassay (FIA) (Opus hCG, Stratus hCG); takes about 2 to 3 hours to perform; used primarily to identify and follow hCG concentrations
  • Pregnancy Tests
    Over-the-Counter pregnancy tests
    Enzyme immunoassay tests
    Performed on urine
    Sensitive
    Detect even low levels of hCG
    Can detect a pregnancy as early as first day of missed period
    Negative result, test may be repeated 1 week if period has not occurred
  • Mother’s Emotional and Psychological Changes
    First trimester: Disbelief and ambivalence
    Second trimester: Quickening; helps mother to view fetus as separate from herself
    Third trimester: Anxiety about labor and birth; nesting (bursts of energy) occurs
  • Mother’s Emotional and Psychological Changes (cont’d)
    Rubin’s four tasks: Ensuring safe passage through pregnancy, labor, and birth
    Seeking acceptance of this child by others
    Seeking commitment and acceptance of herself as mother to infant
    Learning to give of oneself on behalf of one’s child
  • Father/Partner’s Emotional and Psychologic Changes
    First trimester
    May feel left out
    Disbelief
    May be confused by his partner’s mood changes
    Might resent the attention she receives
    Second trimester: Begins to decide which behaviors of own father he wants to imitate or discard
    Third trimester: Anxiety about labor and birth
  • Family’s Emotional and Psychologic Changes
    Siblings
    May view baby as threat to security of their relationships with parents
    Reaction depends on age of siblings
    Preparation for birth is essential
    Grandparents
    Usually supportive
    Excited about the birth
    May be unsure about how deeply to become involved
  • Cultural Assessment
    Determines
    Main beliefs
    Wishes
    Traditions of the family
    Values
    Behaviors about pregnancy and childbearing
    Helps to explore woman’s (or family’s) expectations of healthcare system
    Allows nurse to provide care that is appropriate and responsive to family needs
  • Cultural Factors
    Factors that will impact the family’s plans for the pregnancy
    Religious preferences
    Language
    Communication style
    Common etiquette practices
    Ethnic background
    Amount of affiliation with the ethnic group
    Patterns of decision making>
  • Assignment
    Draw the female internal reproductive anatomy. Label each organ, and list the changes that occur in each organ system(note book).
  • Antepartal Nursing Assessment
  • Learning Objectives
    Summarize the essential components of a prenatal history.
    Define common obstetric terminology found in the history of maternity clients.
    Identify factors related to the father’s health that are generally recorded on the prenatal record.
    Describe areas that should be evaluated as part of the initial assessment of psychosocial and cultural factors relatedto a woman’s pregnancy.
    Describe the normal physiologic changes one would expect to find when performing a physical assessment of apregnant woman.
    • Compare the methods most commonly used to determine the estimated date of birth.
    • Develop an outline of the essential measurements that can be determined by clinical pelvimetry.
    • Delineate the possible causes of the danger signs of pregnancy.
    • Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy.
  • Prenatal History
    Details of current pregnancy
    First day of last normal menstrual period (LMP)
    Presence of complications
    Attitude toward pregnancy
    Results of pregnancy tests, if completed
    Presence of discomforts since LMP
    Number of pregnancies and number of living children
    Number of abortions, spontaneous or induced
  • Prenatal History
    History of previous pregnancies
    Length of pregnancy
    Length of labor and birth
    Type of birth
    Type of anesthesia used (if any)
    Woman’s perception of the experience
    Complications associated with childbirth
    Neonatal complications
  • Prenatal History
    Gynecologic history
    Date of last Pap smear - any history of abnormal Pap smear
    Previous infections: Vaginal, cervical, tubal, or sexually transmitted
    Previous surgery
    Age at menarche and sexual history
    Regularity, frequency, and duration of menstrual flow
    History of dysmenorrhea and contraceptive history
  • Prenatal History
    Current medical history
    General health: Weight, nutrition, and regular exercise program
    Blood type and Rh factor, if known
    General health: Nutrition and regular exercise program
    Medications and use of herbal medication use during pregnancy
    Previous or present use of alcohol, tobacco, or caffeine
    Illicit drug use and drug allergies and other allergies
  • Prenatal History
    Current medical history
    Potential teratogenic insults to this pregnancy
    Presence of disease conditions such as diabetes
    Immunizations (especially rubella)
    Presence of any abnormal symptoms
  • Prenatal History
    Past medical history
    Childhood diseases
    Past treatment for any disease condition
    Surgical procedures
    Presence of bleeding disorders or tendencies (Has she received blood transfusions?)
  • Prenatal History
    Family medical history
    Presence of chronic or acute systemic diseases
    Complications associated with childbirth: Preeclampsia
    Occurrence of multiple births
    History of congenital diseases or deformities
    Occurrence of cesarean births and cause, if known
  • Prenatal History
    Religious preference and religious beliefs related to health care and birth:
    Prohibition against receiving blood products
    Dietary considerations or circumcision rites
    Practices that are important to maintain her spiritual well-being
    Practices in her culture or that of her partner that will influence care
  • Prenatal History
    Occupational history: Physical demands of present job
    Partner’s history: Genetic conditions and blood type
    Woman’s demographic information
    Age, educational level
    Ethnic background
    Socioeconomic status
  • Common Obstetric Terminology
    Gravida: Any pregnancy, regardless of duration, includes the current pregnancy
    Parity: Birth after 20 weeks’ gestation; infant may be born alive or dead
  • Common Obstetric Terminology (cont’d)
    TPAL
    T: Number of term infants born
    P: Number of preterm infants
    A: Number of pregnancies ending in either spontaneous or therapeutic abortion
    L: Number of currently living children
  • FIGURE 10–1 The TPAL approach provides detailed information about the woman’s pregnancy history.
  • Common Obstetric Terminology (cont’d)
    Gestation: Number of weeks since the first day of the last menstrual period
    Abortion: Birth occurring before the end of 20 weeks’ gestation
    Term: Normal duration of pregnancy (38 to 42 weeks’ gestation)
    Antepartum: Time between conception and the onset of labor
    Intrapartum: Period from the onset of true labor until the birth of the infant and placenta
  • Common Obstetric Terminology (cont’d)
    Postpartum: Time from birth until the woman’s body returns to prepregnant condition
    Preterm or premature labor: Labor that occurs after 20 weeks’ but before completion of 37 weeks’ gestation
    Nulligravida: Woman who has never been pregnant
    Primigravida: Woman pregnant for the first time
  • Common Obstetric Terminology (cont’d)
    Nullipara: Woman who has had no births at more than 20 weeks’ gestation
    Primipara: Woman who has had one birth at more than 20 weeks’ gestation
    Multipara: Woman who has had two or more births at more than 20 weeks’ gestation
    Stillbirth: Infant born dead after 20 weeks’ gestation
    Multigravida: Woman in second or any subsequent pregnancy
  • Father’s Information
    Existing medical conditions
    History of chronic illness - father or immediate family member
    Blood type and Rh factor
    Age
    Occupation
    Current use of recreational drugs
  • Father’s Information (cont’d)
    Present use of tobacco and alcohol
    Genetic disorders
    Educational level
    Methods by which he learns best
    Attitude toward the pregnancy
  • Cultural and Psychosocial Factors
    Language preference
    Religious preference
    Socioeconomic status
    Psychological status
    Educational needs
    Support system
  • Cultural and Psychosocial Factors (cont’d)
    Determine food preferences
    Determine significant people to client - assess degree of involvement of those people
    Assess family functioning
    Level of involvement
    Stability of living conditions
    Be aware of the practices of various cultural groups
  • Complementary Care (Yoga)
  • Normal Physiological Changes
    Pulse may increase by 10 beats per minute
    Respiration may be increased and thoracic breathing predominant
    Temperature and blood pressure within normal limits
    Weight varies: Should be proportional to the gestational age of the fetus
    Nose: Nasal stuffiness
    Chest and lungs: Transverse diameter greater than anterior-posterior diameter
  • Normal Physiological Changes (cont’d)
    Skin:
    Linea nigra
    Striae gravidarum
    Melasma
    Spider nevi
    Mouth: Gingival hypertrophy
    Neck: Slight hyperplasia of thyroid in the third trimester - small, nontender nodes
  • Normal Physiological Changes (cont’d)
    Breasts
    Increasing size
    Pigmentation of nipples and areola
    Tubercles of Montgomery enlarge
    Colostrum appears in third trimester
  • Normal Physiological Changes (cont’d)
    Abdomen
    Progressive enlargement
    Fetal heart rate heard at approximately 12 weeks’ gestation
    Extremities: Possible edema late in pregnancy
    Spine: Lumbar spinal curve may be accentuated
    Pelvic area: Vagina without significant discharge
  • Normal Physiological Changes (cont’d)
    Cervix closed
    Uterus shows progressive growth
    Laboratory tests
    Physiologic anemia may occur (decrease in hemoglobin and hematocrit)
    Small degree of glycosuria may occur
  • Commonly Used Methods
    Nägele’s rule
    Begin with the first day of the LMP
    Subtract 3 months, and add 7 days
    Physical Examination - fundal height: Measurement of uterine size
    Ultrasound: Method used to measure fetal parts
    Crown-to-rump measurements
    Biparietal diameter (BPD) measurements
  • FIGURE 10–2 The EDB wheel can be used to calculate the due date. To use it, place the “last mensesbegan” arrow on the date of the woman’s LMP. Then read the EDB at the arrow labeled 40. Inthis case the LMP is September 8, and the EDB is June 17.
  • FIGURE 10–3 A cross-sectional view of fetal position when McDonald’s method is used to assess fundalheight.
  • FIGURE 10–4 Listening to the fetal heartbeat with a Doppler device.
  • Pelvic Measurements
    Pelvic inlet
    Diagonal conjugate
    Measure at least 11.5 cm
    Obstetric conjugate - 10 cm or more
  • A
    FIGURE 10–5 Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, whichextends from the lower border of the symphysis pubis to the sacral promontory. B, Estimationof the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.
  • B
    FIGURE 10–5 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, whichextends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.
  • C
    D
    FIGURE 10–5 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, whichextends from the lower border of the symphysis pubis to the sacral promontory. B, Estimationof the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.
  • Pelvic Measurements
    Pelvic outlet
    Anteroposterior diameter
    Should be 9.5 to 11.3 cm
    Transverse diameter should be 8 to 10 cm
  • FIGURE 10–6 Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal knuckles. If they do not, they can use a measuring device.
  • Signs of Infection or Cancer
    Elevation in vital signs
    Urine with elevated white blood cells
    High white blood cell count in the blood
    Lesions in the genital area
    Excessive malodorous vaginal discharge
    Positive tests for sexually transmitted infections
  • Signs of Infection or Cancer
    Tender, hard fixed nodes in the neck
    Abnormal lung sounds
    Breast lumps
    Nipple discharge
    Redness and tenderness of breast tissue
  • Signs of Anemia or Cardiopulmonary Problems
    Pale mucous membranes
    Skin pallor
    Signs of nutrition deficiency
    Low hemoglobin and hematocrit levels
    Elevations in blood pressure
    Edema
    More than expected weight gain
  • Signs of Cardiopulmonary Problems
    Abnormal lung sounds
    Increased respiratory rate
    Abnormal heart rhythm
    Extra heart sounds
  • Other Danger Signs
    Less than expected weight gain
    Petechiae or bruises
    Inflamed gingival tissue
    Enlarged thyroid
    Abdominal tenderness or mass
    Lack of peripheral pulses
  • Other Danger Signs
    Failure to detect fetal heart rate
    Abnormal spinal curves
    Hyperactive reflexes
    Below normal pelvic measurements
    Hemorrhoids
  • Danger Signs in Pregnancy
  • Danger Signs in Pregnancy (cont’d)
  • Subsequent Prenatal Assessment
    Prenatal visits
    Every 4 weeks for the first 28 weeks’ gestation
    Every 2 weeks until 36 weeks’ gestation
    After week 36, every week until childbirth
  • Subsequent Prenatal Assessment
    Assessments during prenatal visits
    Vital signs and weight
    Edema
    Uterine size and fetal heartbeat
    Urinalysis
    Blood tests for AFP, glucose
    Vaginal swab for group B strep
    Expected psychological stage of pregnancy
  • Activity:
  • Documentation
    Document within context of nursing practice
    Example: Music therapy for the child having acute pain
    Cristina Marie M. Manzano RN, RM, MAN
  • Thank You…
    &
    See You Again Next Meeting!!!
    Don't forget your assignments & present your "Ticket to Class "
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