THE PHYSIOLOGICAL CHANGES OFPREGNANCY: PROMOTING MATERNAL HEALTHAries Glenn B. Galao, RNJurmaida H. Pagayao, RNMarnelle Joy S. Pulmano, RN
Presumptive Signs and Symptoms• Abrupt cessation of menses - more than 10 days• Breast changes• Skin pigmentation changes: – Chloasma/melasma gravidarum – Linea nigra – Abdominal striae• Nausea and vomiting (morning sickness)• Frequency of urination• Fatigue
Probable Signs and Symptoms• Objective findings detected by 12 to 16 weeks of gestation• Enlargement of abdomen• Hegars sign• Chadwicks sign• Goodells sign• Braxton Hicks contractions• Ballottement• Leukorrhea• Quickening• Positive hCG - test for pregnancy
Positive Signs and Symptoms• Fetal heart tones (FHTs) - usually heard between 16th and 20th week of gestation with a fetoscope or the 10th and 12th week of gestation with a Doppler stethoscope• Fetal movements felt by the examiner (after about 20 weeks gestation)• Outlining of the fetal body through the maternal abdomen in the second half of pregnancy• Sonographic evidence (after 4 weeks gestation) using vaginal ultrasound. Fetal cardiac motion can be detected by 6 weeks gestation
Duration of Pregnancy• Averages 280 days/40 weeks (10 lunar months; 9 calendar months) from the 1st day of LMP• Divided into 3 trimesters of slightly more than 13 weeks or 3 calendar months each• EDC is calculated by Nägeles rule +7 days, -3 months to LMP• McDonalds rule: after 24 weeks gestation, the fundal height measurement will correspond to the week of gestation plus 2-4 weeks
CHANGES IN THEREPRODUCTIVE TRACT
Uterus• Enlargement, stretching and marked hypertrophy of existing muscle cells 2° to increased estrogen and progesterone levels• Increase in fibrous tissue and elastic tissue; increase in size and number of blood vessels and lymphatics• Enlargement and thickening of the uterine wall are most marked in the fundus• By the end of 12 weeks, the uterus can be palpated suprapubically• The uterus rotates somewhat to the right because of the rectosigmoid colon on the left side of the pelvis
• 20 weeks: fundus has reached the level of the umbilicus• 36 weeks: fundus has reached the xiphoid process• End of 5th month, the myometrium hypertrophy ends and the walls of uterus become thinner, allowing palpation of the fetus• During the last 3 weeks, the uterus descends slightly because of fetal descent into the pelvis• Changes in contractility occur - from the first trimester, Braxton Hicks contractions; in latter weeks of pregnancy, contractions become stronger and more regular• Progressive increase in uteroplacental blood flow during pregnancy
Cervix• Pronounced softening and cyanosis - due to increased vascularity, edema, hypertrophy, and hyperplasia of the cervical glands• Operculum - prevents bacteria and other substances from entering and ascending into the uterus• Erosions of cervix, common during pregnancy, represent an extension of proliferating endocervical glands and columnar endocervical epithelium• Evidence of Chadwicks sign due to the increased vascularity and hyperemia caused by increased estrogen levels
Ovaries• Ovulation ceases during pregnancy; maturation of new follicles is suspended• One corpus luteum functions during early pregnancy (first 10 to 12 weeks), producing progesterone and small levels of estrogen and relaxin• After 8 weeks gestation, the corpus luteum remains the source for the hormone relaxin
Vagina and Outlet• Increased vascularity, hyperemia, and softening of connective tissue in skin and muscles of the perineum and vulva• Vaginal walls prepare for labor: mucosa increases in thickness, connective tissue loosens, and small-muscle cells hypertrophy• Vaginal secretions: thick, white, and acidic; pH=3.5 to 6 because of increased production of lactic acid from glycogen in the vaginal epithelium by Lactobacillus acidophilus; prevention of infections• Hypertrophy of the structures, along with fat deposits, causes the labia majora to close and cover the vaginal introitus (vaginal opening)
Changes in the Abdominal Wall• Striae gravidarum (stretch marks) - reddish, slightly depressed streaks in the skin of abdomen, breast, and thighs (become glistening silvery lines after pregnancy)• Linea nigra - line of dark pigment extending from the umbilicus down the midline to the symphysis. Commonly during the first pregnancy, the linea nigra occurs at the height of the uterus. During subsequent pregnancies, the entire line may be present early in gestation.• Diastasis recti may occur as muscles (rectus) separate. If severe, a part of the anterior uterine wall may be covered by only a layer of skin, fascia, and peritoneum.
Breast Changes• Tenderness and tingling occur in early weeks of pregnancy• Increase in size by 2nd month - hypertrophy of mammary alveoli. Veins more prominent, and striae may develop• Nipples become larger, more deeply pigmented, and more erectile early in pregnancy• Colostrum may be expressed by 2nd trimester• Areolae become broader and more deeply pigmented.• Scattered through the areola are glands of Montgomery, which are hypertrophic sebaceous glands.
Weight gain average• 25 to 35 lb (11.5 to 16 kg)
Water metabolism• Retains 6-8 L of extra water during the pregnancy• Approximately 4-6 L of fluid cross into the extracellular spaces (hypervolemia)• Normal accumulation of fluid in their legs and ankles at the end of the day - 3rd trimester (physiologic edema)• Sodium retention is usually directly proportional to the amount of water accumulated during the pregnancy• Additional sodium is required during pregnancy to meet the need for increased intravascular and extracellular fluid volumes and to maintain a normal isotonic state
Protein Metabolism• The fetus, uterus, and maternal blood are rich in protein• At term, fetus and placenta contain 500 g of protein or approximately half of the total protein increase of pregnancy• Approximately 500 g more of protein is added to the uterus, breasts, and maternal blood in the form of hemoglobin and plasma proteins
Carbohydrate Metabolism• Early in pregnancy, the effects of estrogen and progesterone can induce a state of hyperinsulinemia. As pregnancy advances, there is increased tissue resistance coupled with increased hyperinsulinemia• Approximately 2% to 3% of all women will develop gestational DM during pregnancy• Pregnant women with preexisting DM may experience a worsening of the disease attributed to hormonal changes• “sparing” of glucose used by maternal tissues and shunting of glucose to the placenta for use by the fetus• HPL, estrogen, progesterone, and cortisol oppose the action of insulin during pregnancy and promote maternal lipolysis
Fat Metabolism• Lipid metabolism during pregnancy causes an accumulation of fat stores, mostly cholesterol, phospholipids, and triglycerides• Fat storage occurs before the 30th week of gestation• After 30 weeks gestation, there is no further fat storage, only fat mobilization that correlates with the increased utilization of glucose and amino acids by the fetus.• The ratio of low-density proteins to high-density proteins is increased during pregnancy
Caloric Requirements• An additional 300 kcal/dL are required during the 2nd and 3rd trimester• Caloric expenditure varies throughout pregnancy. There is a slight increase in early pregnancy and a sharp increase near the end of the 1st trimester, continuing throughout pregnancy.Protein Requirements• An additional requirement of 10 g of protein per day is recommended over the nonpregnant intake.
Carbohydrate and Fat Requirements• Carbohydrates should supply 55% to 60% of calories in the diet and should be in the form of complex carbohydrates, such as whole-grain cereal products, starchy vegetables, and legumes• Fat intake should not exceed 30% of the diet. Saturated fats should not exceed 10% of the total calories.Iron Requirements• Iron requirements are increased to 20 to 40 mg daily• Supplemental iron is valuable and necessary during pregnancy and postpartum• During the last half of pregnancy, iron is transferred to the fetus and stored in the fetal liver. This store lasts 3 to 6 months.
CHANGES IN THECARDIOVASCULARSYSTEM
Heart• Diaphragm is progressively elevated during pregnancy; heart is displaced to the left and upward, with the apex moved laterally• Heart sounds - exaggerated splitting of the first heart sound; a loud, easily heard third sound• Heart murmurs - systolic murmurs are common and usually disappear after delivery
Blood Volume Changes• Cardiac volume increases by 40% to 50% (1,450 to 1,750 mL) by 32 weeks gestation• Cardiac output increases by 30% to 50% above normal within the first 13 weeks of pregnancy and reaches a volume of 6 to 7 L/minute by term• Femoral venous pressure increases• Increased cutaneous blood flow dissipates excess heat• Physiologic anemia of pregnancy or physiologic dilutional anemia
• Supine hypotensive syndrome
Blood Pressure Changes• During the first half of pregnancy, there is a slight (5 to 10 mm Hg) decrease in systolic and diastolic BP• By the third trimester, the BP gradually returns to prepregnancy levels• Maternal position influences blood pressure: the highest reading is obtained in the sitting position, the lowest reading is obtained in the left lateral position, and an intermediate reading is obtained in the supine position• Maternal blood pressure will also rise with uterine contractions and returns to the baseline level after the uterine contraction is over
Hematologic Changes• Total volume of circulating RBCs increases 18% to 30%; hemoglobin concentration at term averages 12 to 16 g/dL; hematocrit concentration at term averages 37% to 47%.• WBC count in the 3rd trimester is 5 to 12,000/ml• Pregnancy is a hypercoagulable state due to the increased levels of a number of essential coagulation factors.• Average platelet count is 140,000 to 400,000/mm3, which increases the risk to the pregnant woman for venous thrombosis.
CHANGES IN THERESPIRATORY TRACT
• Diaphragm is elevated during pregnancy• Thoracic cage expands its anteroposterior diameter causing flaring of the ribs• Breathing is more diaphragmatic than costal• Hyperventilation occurs - increase in respiratory rate, tidal volume increases 30% to 40%, and minute ventilation increases 40%• Increased total volume lowers blood partial pressure of carbon dioxide (Pco2), causing mild respiratory alkalosis that is compensated for by lowering of the bicarbonate concentration
• Increased respiratory rate and reduced Pco2 are probably induced by progesterone and estrogen• Oxygen consumption increases 15% to 20% and as much as 300% in labor• This increase leads to increased maternal alveolar and arterial oxygen partial pressure levels.• Approximately 60% to 70% of pregnant women experience shortness of breath; unknown cause• Nasal stuffiness and epistaxis secondary to vascular congestion caused from the increased estrogen levels
• Ureters become dilated and elongated during pregnancy because of mechanical pressure• When the uterus rises out of the uterine cavity, it rests on the ureters, compressing them at the pelvic brim• Glomerular filtration rate (GFR) increases 50% by the 2nd trimester, and the increase persists almost to term• Glucosuria may be evident because of the increase in glomerular filtration without an increase in tubular resorptive capacity for filtered glucose
• Excreted protein may be increased due to the increased GFR, but is not considered abnormal until the level exceeds 250 mg/dL• Toward the end of pregnancy, pressure of the presenting part impedes drainage of blood and lymph from the bladder base, typically leaving the area edematous, easily traumatized, and more susceptible to infection.
CHANGES INGI TRACT
• Gums may become hyperemic and softened and may bleed easily• A localized vascular swelling of the gums may appear (epulis of pregnancy)• Stomach and intestines are displaced upward and laterally by the enlarging uterus. Heartburn (pyrosis) is common.• Decreased motility, mechanical obstruction by the fetus, and decreased water absorption from the colon leads to constipation• Hemorrhoids are common because of elevated pressure in veins below the level of the large uterus and constipation
• Distention and hypotonia of the gallbladder are common, which can cause stasis of bile• Decrease in emptying time and thickening of bile, resulting in hypercholesterolemia and gallstone formation• Prothrombin time may show a slight increase or be unchanged• Peptic ulcer formation or exacerbation is uncommon during pregnancy due to decreased hydrochloric acid (caused by increased estrogen levels• The appendix is pushed superiorly
CHANGES IN THEENDOCRINESYSTEM
• APG enlarges slightly; PPG remains unchanged• Thyroid is moderately enlarged because of hyperplasia of glandular tissue and increased vascularity – BMR increases progressively during normal pregnancy (25%) because of metabolic activity of fetus – Level of protein-bound iodine and thyroxine rises sharply and is maintained until after delivery because of increased estrogen and hCG• Parathyroid gland size and concentration of parathyroid hormone increase and peak between 15 and 35 weeks
• Adrenal secretions considerably increased - amounts of aldosterone increase as early as the 15th week• Pancreas – Estrogen, progesterone, cortisol, and hPL decrease the maternal utilization of glucose – Cortisol also increases maternal insulin production – Insulinase, an enzyme produced by the placenta, deactivates maternal insulin – These changes result in an increased need for insulin, and the islets of Langerhans increase their production of insulin
• Pigment changes because of MSH; elevated from the 2nd month of pregnancy until term• Striae gravidarum - slightly depressed streaks in the skin of the abdomen, breasts and thighs• Linea nigra - brownish-black line of pigment in the midline of the abdominal skin• Chloasma/melasma or “mask of pregnancy” - brownish patches of pigment on the face• Angiomas (vascular spider nevis), minute red elevations on the skin of the face, neck, upper chest, legs, and arms• Reddening of the palms (palmar erythema)• Increased warmth to the skin and increased nail growth
CHANGES IN THEMUSCULOSKELETALSYSTEM
• Relaxin - increases mobility of sacroiliac, sacrococcygeal, and pelvic joints• The center of gravity shifts secondary to increased weight gain, fluid retention, lordosis, and mobile ligaments. This contribute to alteration of maternal posture and back pain• Late in pregnancy, aching, numbness, and weakness in the upper extremities may occur because of lordosis and paresthesia, which ultimately produces traction on the ulnar and median nerves• Separation of the rectus muscles due to pressure of the growing uterus creates a diastasis recti
CHANGES IN THENEUROLOGICSYSTEM
• Mild frontal headaches are common in the 1st and 2nd trimester; related to tension or hormonal changes• Dizziness is common and is related to vasomotor instability, postural hypotension, or hypoglycemia following long periods of standing or sitting• Tingling sensations in the hands are common and are due to excessive hyperventilation, which decreases maternal Pco2 levels• Severe headaches that occur after 20 weeks gestation and are accompanied by visual changes, elevated blood pressure, proteinuria, and facial edema should be evaluated immediately.
CHANGES IN HORMONALRESPONSES
Steroid Hormones• Estrogen: – secreted by the ovaries in early pregnancy, but by 7 weeks gestation over half of the estrogen is secreted by the placenta – ensure uterine growth and development, maintenance of uterine elasticity and contractility, maintenance of breast growth and its ductal structures, and enlargement of the external genitalia• Progesterone: – initially secreted by corpus luteum; later by placenta – suppresses the maternal immunologic response to the fetus and rejection of the trophoblasts – helps to maintain the endometrium, inhibits uterine contractility, helps in the development of breast lobules for lactation, stimulates the maternal respiratory center, and relaxes smooth muscle
Placental Protein Hormones• hCG: – Secreted by the syncytiotrophoblasts; stimulates the production by the corpus luteum of progesterone and estrogen – 2x as high in multiple gestation than in single pregnancy – hlevels peak around 10 weeks gestation (50,000 to 100,000 mIU/mL) then decrease to 10,000 to 20,000 mIU/mL by 20 weeks gestation• hPL: – human chorionic somatomammotropin – Produced by the syncytiotrophoblasts of the placenta – increases the amount of free fatty acids available to the fetus and decreases the maternal metabolism of glucose allowing for protein synthesis. This allows the fetus to have the needed nutrients when the woman has not or is not eating
Other Hormones• Prostaglandins: – Affect smooth muscle contractility and some potent vasodilators – Essential for the cardiovascular adaptation to pregnancy, cervical ripening, and initiation of labor.• Relaxin: – Secreted by the corpus luteum, decidua and placenta – Inhibits uterine activity, decreases the strength of uterine contractions, softens the cervix, and remodels collagen• Prolactin: – Released from the APG – Responsible for sustaining milk protein, casein, fatty acids, lactose, and the volume of milk secretion during lactation
Age• Adolescents (younger than age 19) have an increased incidence of anemia, gestational hypertension, preterm labor (PTL), small-for-gestational-age (SGA) infants, intrauterine-growth-restricted infants, cephalopelvic disproportion, dystocia• Women of advanced maternal age (over age 35) have an increased incidence of hypertension, pregnancies complicated by diabetes, multiple gestation, and infants with genetic abnormalitiesFamily History• Includes maternal and paternal history• Congenital disorders, hereditary diseases, multiple pregnancies, diabetes, heart disease, hypertension, mental retardation, renal disease, use of diethylstilbestrol
Womans Medical History• Childhood diseases (rubella, measles, chickenpox)• Major illnesses, surgery (reproductive tract, spinal surgery or appendectomy), blood transfusions• Chronic medical conditions (epilepsy, diabetes mellitus)• Drug, food, and environmental sensitivities• UTI, heart disease, HTN, endocrine disorders, anemia• Menstrual history (menarche, length, amount, regularity, dysmenorrhea, menstrual cycle, bleeding between periods• Gynecologic history (STD, contraceptive use, sexual hx)• Use of medications (prescription and OTC), recreational drugs, alcohol, nicotine, tobacco, caffeine• History of TB, hepatitis, group B beta-hemolytic streptococcus, HIV
Womans Nutritional History• Adherence to special dietary practices (religious, social or cultural preferences)• Eating disorders (obesity, bulimia, anorexia nervosa).Womans Past Obstetric History• Problems of infertility, date of previous pregnancies, and deliveries - dates; infant weights; length of labors; types of deliveries; multiple births; abortions; and maternal, fetal, and neonatal complications.• Womans perception of past pregnancy, labor, and delivery for herself and effect on her family.
Womans Present Obstetric History• Gravida, Para / GTPALM, LMP, EDC• Signs and symptoms of pregnancy; Expectations for her present pregnancy, labor, and delivery• Rest and sleep patterns• Activity and employment• Sexual activity• Diet history• Psychosocial status
General Examination• Empty her bladder before the examination to enhance her comfort and to facilitate palpation of uterus and pelvic organs• Evaluation of the wt and BP• Examination of the eyes, ears, and nose• Examination of the mouth, teeth, throat, and thyroid• Inspection of breasts and nipples• Auscultation of the heart• Auscultation and percussion of the lungs.
Abdominal Examination• Examination for scars or striations, diastasis (separation of the rectus muscle), or umbilical hernia• Palpation of the abdomen for height of the fundus (palpable after 13 weeks of pregnancy)• Palpation of the abdomen for fetal outline and position (Leopolds maneuvers) - third trimester• Check of FHT; audible with a Doppler after 10 to 12 weeks and at 18 to 20 weeks with a fetoscope• Record fetal position, presentation, and FHTs
Pelvic Examination• lithotomy position• Inspection of external genitalia• Vaginal examination• Examination of the cervix for position, size, mobility, and consistency• Identification of the ovaries (size, shape, and position)• Rectovaginal exploration to identify hemorrhoids, fissures, herniation, or masses• Evaluation of pelvic inlet, midpelvis, pelvic outlet
Vaginal Speculum Examination
Subsequent Prenatal Assessments• Uterine growth and estimated fetal growth. – Fundus at symphysis pubis indicates 12 weeks – Fundus at umbilicus indicates 20 weeks – Fundal height corresponds with gestational age between 22 and 34 weeks. – Fundus at lower border of rib cage indicates 36 weeks – Uterus becomes globular, and drop indicates 40 weeks• A greater fundal height suggests: – Multiple pregnancy. – Miscalculated due date. – Polyhydramnios (excessive amniotic fluid). – Hydatidiform mole (degeneration of villi into grapelike clusters; fetus does not usually develop). – Uterine fibroids
Height of Fundus
• A lesser fundal height suggests: – Intrauterine fetal growth restriction. – Error in estimating gestation. – Fetal or amniotic fluid abnormalities. – Intrauterine fetal death. – SGA• FHTs - palpate abdomen for fetal position. – Normal - 110 to 160 beats per minute (bpm)• Weight - major increase in weight occurs during second half of pregnancy; usually between 0.5 lb (0.2 kg)/week and 1 lb (0.5 kg)/week• BP- should remain near womans prepregnant baseline• Complete blood count at 28 and 32 weeks gestation; VDRL - rechecked at 36 to 40 weeks gestation.
• Antibody serology screen if Rh negative at 36 weeks• Culture smears for gonorrhea, chlamydia, group B beta- hemolytic streptococcus, and herpes; usually at 36 and 40 weeks• Urinalysis - for protein, glucose, blood, and nitrates• AFP - done at 15 to 20 weeks• Diabetic screening - done as indicated at 24 to 28 weeks• Administer RhoGAM as indicated at 28 weeks• Edema - check the lower legs, face, and hands• Evaluate discomforts of pregnancy, eating and sleeping patterns, general adjustment and coping with the pregnancy
HEALTH EDUCATION ANDINTERVENTION
• Acute Pain (backache, leg cramps, breast tenderness) related to physiologic changes of pregnancy• Imbalanced Nutrition: Less Than Body Requirements related to morning sickness and heartburn and lack of knowledge of requirements in pregnancy• Impaired Urinary Elimination (frequency) related to increased pressure from the uterus• Constipation related to physiologic changes of pregnancy and pressure from the uterus
• Impaired Tissue Integrity related to pressure from the uterus and increased blood volume• Anxiety or Fear related to the birth process and infant care• Ineffective Role Performance related to the demands of pregnancy• Activity Intolerance related to physiologic changes of pregnancy and enlarging uterus
Prenatal Care• Prenatal care appointments: – Weeks 1-28: Every month – Weeks 28-36: Every 2 weeks – Weeks 36-delivery: Every week• Expect the discomforts of pregnancy: – Back pain, leg cramps, breast tenderness – Morning sickness, heartburn – Frequent urination – Constipation – Swelling of legs, varicose veins – Fatigue• Follow a healthy, balanced diet with 3 meals per day, and take prenatal vitamin as directed by health care provider
• Get regular exercise, and use proper body mechanics to avoid injury.• Be aware of danger symptoms of pregnancy; report to your health care provider promptly: – Vision disturbances - blurring, spots, or double vision – Vaginal bleeding, new or old blood – Edema of the face, fingers, and sacrum – Headaches - frequent, severe, or continuous – Fluid discharge from vagina; unusual or severe abdominal pain – Chills, fever, or burning on urination – Epigastric pain (severe stomachache) – Muscular irritability or convulsions – Inability to tolerate food or liquids, leading to severe nausea and hyperemesis
Minimizing Pain• Use good body mechanics - wear comfortable, low-heeled shoes with good arch support• Pelvic rocking exercises• Take rest periods with legs elevated• Adequate calcium intake may decrease leg cramps• Dorsiflex the foot while applying pressure to the knee to straighten the leg for immediate relief of leg cramps• Wear a fitted, supportive brassiere• Wash breasts and nipples with water only• Apply vitamin E or lanolin cream to the breast and nipple area
Minimizing Morning Sickness andHeartburn and MaintainingAdequate Nutrition• Eat low-fat protein foods and dry carbohydrates (toast, crackers); Eat small, frequent meals, Eat slowly• Avoid brushing teeth soon after eating• Get out of bed slowly• Drink soups and liquids between meals to avoid stomach distention and dehydration• Caution against the use of sodium bicarbonate because it results in the absorption of excess Na and fluid retention• Avoid offensive foods or cooking odors that may trigger nausea
• Basic food groups with appropriate daily servings. – 7 servings of protein-rich foods, including one serving of a vegetable protein – 3 servings of dairy products or other calcium-rich foods – 7 servings of grain products – 2 or more servings of vitamin C-rich vegetable or fruit – 3 servings of other fruits and vegetables – 3 servings of unsaturated fats – 2 or more servings of other fruits and vegetables• If the woman is a vegetarian, inform her of appropriate intake. Assess type of vegetarian and food intake – Recommend iron and folic acid supplements
• Average weight gain: 25-35 lb (11-16 kg). – 2-5 lb (0.9-2.3 kg) gained in the 1st trimester; – 1 lb (0.5 kg)/wk for the remainder of the gestation• Average weight gain – Obese: 15 lb (6.8 kg) – Adolescent: 5 lb more than for adult women if within 2 years of starting menses – Multiple pregnancy: 35-45 lb (15.9-20.5 kg) – Underweight: 28-40 lb (12.7-18.1 kg)• Limit the use of caffeine; Eliminate alcohol and smoking – Risk of spontaneous abortion, fetal death, low birth weight, and neonatal death• Ingesting any drug during pregnancy may affect fetal growth; discuss with health care provider
Minimizing Urinary Frequency andPromoting Elimination• Limit fluid intake in the evening• Void before going to bed• Void after meals• Void when feeling the urge and after sexual intercourse• Wear loose-fitting cotton underwear• Cranberry or blueberry juice to help prevent UTIs• Avoid caffeine
Avoiding Constipation• Increase fluid intake to at least 8 glasses of water/day; 1-2 quarts of fluid per day• Eat foods high in fiber daily• Establish regular patterns of elimination• Daily exercise (walking)• Avoid OTC laxatives; bulk-forming agents may be prescribed if indicated
Maintaining Tissue Integrity• Take frequent rest periods with legs elevated• Wear support stockings and loose-fitting clothing for leg varicosities• Rest periodically with a small pillow under the buttocks to elevate the pelvis for vulvar varicosities• Avoid constipation, apply cold compresses, take sitz baths, and use topical anesthetics, such as Tucks, for the relief of anal varicosities (hemorrhoids)• Varicosities will totally or greatly resolve after delivery
Reducing Anxiety and Fear andPromoting Preparation for Labor,Delivery, and Parenthood• Discuss knowledge, perceptions, cultural values, and expectations of the labor and delivery process• Provide information on childbirth education classes and sibling and grandparent preparation•• Tour of the birth facility• Coping and pain control techniques for labor and birth• Common procedures during labor and birth
• Guidelines for coming to the birth facility• Discuss perceptions and expectations of parenthood and their “idealized child”• Discuss the infants sleeping, eating, activity, and response patterns for the first month of life• Physical preparations for the infant, such as a sleeping space, clothing, feeding, changing, and bathing equipment• Plans for returning to work and childcare arrangements• Planning time for themselves and each other apart from the newborn• Attend baby care, breast-feeding, and parenting classes• Answer any questions the woman/couple may have
Enhancing Role Changes• Discussion of feelings and concerns regarding the new role of mother and father• Emotional support to the woman/couple regarding the altered family role• Physiologic causes for changes in sexual relationships (fatigue, loss of interest, discomfort from advancing pregnancy); Some women experience heightened sexual activity during the 2nd trimester• There are no contraindications to intercourse or masturbation to orgasm provided the womans membranes are intact, there is no vaginal bleeding, and she has no current problems or history of premature labor• Female superior or side-lying positions are usually more comfortable in the latter half of pregnancy
Minimizing Fatigue• Teach the reasons for fatigue, and plan a schedule for adequate rest – Fatigue in the 1st trimester is due to increased progesterone and its effects on the sleep center. – Fatigue in the 3rd trimester is due mainly to carrying increased weight of the pregnancy – About 8 hours of rest are needed at night – Inability to sleep may be due to excessive fatigue during the day – In the latter months of pregnancy, sleep on the side with a small pillow under the abdomen – Frequent 15-30 minute rest periods during the day – Work while sitting with legs elevated – Avoid standing for prolonged periods, especially during the 3rd trimester.
• To promote placental perfusion, the woman should lie on left lateral position; either side is acceptable• Plan for adequate exercise – Keep with the prepregnancy pattern and type of exercise – Avoid activities or sports that have a risk of bodily harm (skiing, snowmobiling, ice skating, inline skating, horseback riding) – Endurance during exercise may be decreased – Exercise classes for pregnant women that concentrate on toning and stretching have resulted in enhanced physical condition, increased self-esteem, and greater social support as a result of being in the exercise group.
COMMUNITY AND HOMECARE INSTRUCTIONS
• Prevention-oriented care• Case management coordinates health care management collaboratively• Register for prepared childbirth classes; Preferable to those associated with the familys intended delivery hospital• Prenatal education on nutrition, sexuality, stress reduction, lifestyle behaviors, and hazards at home or work• Cultural practices have important implications for the provision of nursing care
• Verbalizes understanding of proper body mechanics and wears low-heeled shoes• Identifies the basic food groups and describes meals to include needed servings for pregnancy• Reports limited fluid intake in the evening• Describes foods high in fiber• Wears support stockings and loose-fitting clothing• Discusses expectations for labor, delivery, and parenthood and attends educational classes• Verbalizes an understanding of the physiologic causes that may change the sexual relationship• Reports engaging in regular exercise
Oxytocin as a High-Alert Medication:Implications for Perinatal Patient SafetyKathleen Rice Simpson PhD, RNC, FAAN and G. Eric Knox, MDMCN, The American Journal of Maternal/Child Nursing, January/February 2009, Volume 34, Number 1, Pages 8 - 15• In 2007, the Institute for Safe Medication Practices added intravenous (IV) oxytocin to their list of high-alert medications.• Errors that involve IV oxytocin administration for labor induction or augmentation are most commonly dose related and often involve lack of timely recognition and appropriate treatment of excessive uterine activity (tachysystole).
• Other types of oxytocin errors involve mistaken administration of IV fluids with oxytocin for IV fluid resuscitation during nonreassuring (abnormal or indeterminate) fetal heart rate patterns and/or maternal hypotension and inappropriate elective administration of oxytocin to women who are less than 39 completed weeks gestation.• Oxytocin medication errors and subsequent patient harm are generally preventable.• The perinatal team can develop strategies to minimize risk of maternal-fetal injuries related to oxytocin administration consistent with safe care practices used with other high- alert medications.
Oral Intake During Labor: A Review of theEvidenceNancy C. Sharts-Hopko PhD, RN, FAANMCN, The American Journal of Maternal/Child Nursing, July/August 2010, Volume 35, Number 4, Pages 197 - 203• Fasting in labor became standard policy in the United States after findings of a 1946 study suggested that pulmonary aspiration during general anesthesia was an avoidable risk.• Today general anesthesia is rarely used in childbirth and its associated maternal mortality usually results from difficulty in intubation.•
• Research from the United States, Australia, and Europe suggests that oral intake may be beneficial, and adverse events associated with oral intake such as vomiting and prolongation of labor do not seem to be associated with alterations in maternal or infant outcomes.• The World Health Organization recommends that healthcare providers should not interfere in womens eating and drinking during labor when no risk factors are evident.• Nurses in intrapartum settings are encouraged to work in multidisciplinary teams to revise policies that are unnecessarily restrictive regarding oral intake during labor among low-risk women.
Overcoming the Challenges: MaternalMovement and Positioning to FacilitateLabor ProgressElaine Zwelling PHD, RN, LCCE, FACCEMCN, The American Journal of Maternal/Child Nursing, March/April 2010, Volume 35, Number 2, Pages 72 - 78• The benefits of maternal movement and position changes to facilitate labor progress have been discussed in the literature for decades.• Recent routine interventions such as amniotomy, induction, fetal monitoring, and epidural anesthesia, as well as an increase in maternal obesity, have made position changes during labor challenging.
• The lack of maternal changes in position throughout labor can contribute to dystocia and increase the risk of cesarean births for failure to progress or descend.• This article provides a historical review of the research findings related to the effects of maternal positioning on the labor process and uses six physiological principles as a framework to offer suggestions for maternal positioning both before and after epidural anesthesia.
A baby is somethingYou carry inside you for nine months, In your arms for three years,And in your heart till the day you die. -Anonymous (A Mother)