Chapter 5
Gravida: # of times a woman has been pregnant and is pregnant now.
Para: # of viable fetus’s the woman has delivered (born after 24 weeks).
Primagravida: pregnant for the first time. Primip.
Multigravida: has been pregnant more than once and is pregnant now. Also called Multip.
Changes during pregnancy:
Blood volume will increase up to 50%.
Most of this increase is plasma.
Hgb and Hct values will drop (Hct drops because of increase in plasma).
Will have a physiological anemia of pregnancy.
If Hgb levels drop, she will be given iron.
Usually given iron anyway because fetus will store it to make its own RBC.
Increase blood volume for proper functioning of placenta and for compensation of blood loss at delivery (which could be 300-400cc).
Hypervolemia à increase in blood volume. Will occur at about 28 week of pregnancy. This typically does not affect us. A woman with heart problems needs to be watched.
WBC increases à Normal is 5000-10000. May increase to 18000 or more. This protects the mom from invading organisms and helps get rid of dead cells after delivery.
BP typically stays the same à Will drop initially, then go to non-pregnant level before delivery.
Supine hypotension à in the 2nd trimester, if a woman lies on her back the growing pressure will put pressure on the IVC. It decreases venous return to the heart. BP drops, dizzy, fast pulse. Encourage to lie left lateral. Effects how much O2 the fetus gets. Also called vena caval syndrome.
Orthostatic hypotension à
decrease in venous return to the heart.
Teach not to change positions rapidly, dangle first.
Edema à seen typically in lower extremities. Called dependent edema. Growing fetus puts pressure on the vessels leading to the legs, decreasing venous return. Swollen feet is typical during pregnancy. Swollen face or unable to take rings off could be an indicator of PIH (toxemia).
Vericose veins à engorged vein. In legs because of increase in pressure. Valves may not function. Obesity. Standing in one position. Family tendency. Increase in clotting factors.
Mother is able to breathe easy because the placenta is secreting progesterone that causes relaxation of smooth muscle. Progesterone decreases pulmonary resistance by relaxing smooth muscle.
SOB gets worse when the growing fetus pushes against the diaphragm. At 36 weeks, it will be at the xyphoid process. Baby also begins to drop into the pelvic cavity (lightening). Will feel relief when this occurs. Until this happen the woman can rest better propped up.
Nasal congestion occurs because of increased estrogen. They think they have a cold. We should let them know it’s normal and not to take OTC’s. May use some humidifiers, warm towels or NS nose drops.
Increase in blood flow to kidneys (50%).
Output may go up or stay the same.
Typically output goes up.
Increase lowers specific gravity.
Trace of protein may occur.
Monitor closely for PIH.
May have glycosuria because of
HPL provides protein and sugar for the fetus’ metabolic needs. Has an anti-insulin affect. Needs to be watched closely because she can become a gestational diabetic. May take insulin if not controlled by exercise and diet.
Frequency of urination in relation to the trimesters:
Progesterone relaxes the ureters and causes urinary stasis and makes a good site for bacteria growth. Displacement of the uterus to the right also puts pressure on the ureters.
Typically there is an increase in saliva production (ptyalism). We don’t know why.
Gums bleed more easily.
Nausea and vomiting due to changes in hormones. Usually subsides by 3 months.
Constipation from relaxation of the bowels and iron intake. Teach to drink lots of fluid, eat fiber, and walk for exercise. Not heeding to the call of nature à constipation à straining à hemorrhoids.
Pica: craving for non-food substances. Laundry starch, clay, moth balls, ice, burnt match tips, ashes. Eating non-food substances and not getting the nutrients will cause anemia most of the time.
Striae gravidarum: stretch marks from secretions of the adrenocortical hormones. Shiney and do lighten up after birth.
Linea nigra: dark line from symphysis pubis to above the umbilicus.
Melasma: hyperpigmentation of the face.
Perspiration increases because of increase in sebacious glands.
Center of gravity shifts from behind the symphasis pubis. Walks with head and shoulders back, chest out, swayback (lordosis). This can cause a back ache because of strain on abdominal muscles and lower back.
Relaxin à secreted by corpus luteum and then the placenta. It loosens cartilage and connective tissue in the joints of the pelvis. Symphasis pubis, sacroiliac joints.
Rectus abdominus will sometimes separate during gestational period and will go back after delivery.
Increase in production of thyroid hormones in 1st trimester (T3 and T4). Necessary for metabolism and supporting gestational growth.
At the onset of labor estrogen and progesterone drop and so the pituitary gland will release oxytocin. Will cause stimulation of uterine muscle. Prolactin is released by the pituitary and stimulaties production of milk.
Uterusà
2 ½ ounces – 2 ½ pounds. Will rise out of the pelvis about the 12th week. At 20th week uterus is at level of umbilicus. At 36th week felt at level of xyphoid. 38th week lightening occurs. Whatever week you are, should be the same fundal height in cm. If more, than there is a possibility of multiple fetus’.
Braxton Hicks contractions: occur throughout pregnancy. Get more noticeable at the end (stronger) of pregnancy. They do not dilate cervix. They start out painless.
Cervix à
Operculum: cervix makes mucus that mixes with blood from capillaries and forms a plug that seals the opening of the cervix so bacteria does not get up into the cervix. Bloody show is a sign of true labor and this is when the mucus plug comes out.
Goodell’s sign: at 6 weeks softening of the cervix occurs. Feels like the tip of the nose and then the earlobe.
Hegars sign: softening of the lower uterine segment between the body of the uterus and the cervix. Examiner feels this during the bimanual exam and happens when the fetus has not yet filled the lower uterine segment.
Laden’s sign: soft spot felt also in a bimanual exam anteriorly in the uterus just above the utero cervical junction. Also an early sign.
Ballottement: Fetus can be felt rebounding against examiners finger or when the abdomen is tapped.
Vagina à
Chadwick’s sign: early sign at 8-10 weeks the vagina will turn a blue/purple color due to increased vascularization. The mucosa turns from light pink to a blue/purple color.
Leukorrhea: increased vaginal discharge. Will be white, thick and more acidic. Should not itch. Change in pH from 7 to 5. Helps to decrease bacterial infection. Will increase, however, the risk of yeast infections which do itch.
Amenorrhea: no menstrual period. Ovaries will stop ovulation.
Breasts à
(page 82 is a good picture)
Secondary sex cells. Known as mammary glands. Consists of 15-20 lobes of glandular tissue. Each of the lobes are drained by a duct called the lactiferous duct which opens on the tip of the nipple. Alveoli within the lobes will secrete milk after delivery. Milk will be stored in the lactiferous sinuses until infant nurses. Brown part of nipple is the areola. It contains tiny sebacceous glands (montgomery tubercules). These tubercules secrete a fatty substance that will lubricate and protect the nipple. When they feel soft, it is called supple.
Tenderness caused by estrogen and progesterone production. After delivery prolactin is released by the pituitary which is responsible for milk production. Oxytocin is responsible for the let down reflex – gets down into the sinuses.
The areola will get darker. Will also have superficial veins that are more prominent.
About the 16th week colostrum is formed. It is the precursor to milk. Baby will get it 2-3 days after delivery Thin watery fluid full of nutrients and antibodies. Also has a laxative effect.
Increases to meet needs. As a result heat, water and CO2 production increases. Will gain 25-35 pounds usually. Depends on what weight you were before.
1st = 2-4 pounds
2nd= 1 pound per week (about 12-14 pounds)
3rd= same as 2nd
Pattern of weight gain is what we are most concerned with. A lot over a long period is not as bad as over a short period. Most weight gain is from increase in blood volume and extracellular body fluid.
* breasts = 1 ½ - 3
Diet should not be less than 1500 calories.
Presumptive: by themselves would not indicate pregnancy.
Probable: strong indicators. Should have 2 or more. Detected about week 12.
Positive:
Note: when you are on postpartum, you may have a mom that has not had her baby yet, but is having complications. You will take vitals of mom and heart tones of baby.
Determining Date of Delivery:
Normal length of pregnancy is 9 calendar months, 10 lunar months, 40 weeks or 280 days.
EDDà estimated date of delivery. This is found by Nagele’s rule.
LMP + 7 days – 3 months = EDD.
Psychosocial Changes:
First trimester:
Task is acceptance of the pregnancy. Happy, excited and scared. Questions if she will be a good mother or if this is the right time. Will have feeling of ambivalence (mixed feelings). Also a change in body image. Experiences mimicry (starts looking at other pregnant women).
DAD: worrying about finances and whether they are going to be a good father. Couvadeà (to hatch) the term used when the man experiences the same symptoms as the woman. Has guilty feelings because their mate is sick.
Second trimester:
Task is role playing. Major goal is to develop a sense of physical and mental well being. Pregnancy begins to be more real. Offers to baby sit for other people. Get into some education classes. Acceptance of fetus as separate from herself is another task. Fantasizes about the sex and what it will look like.
DAD: May take an active role in helping with house work and diet or he may be just an observer. Still concerned about being the provider and whether he will be a good father.
Third trimester:
Task is separation from the fetus thru the birth process. Transition stage for the mother. Takes childbirth classes. Finalizes plans about where baby is to be born. Start getting the nursery ready. These activities are called nesting activities.
DAD: Takes part in the birth classes (not always). May be drawing closer to one another.
From the Book and Page 80:
1st:
2nd:
3rd:
The underlined are what she mentioned in class for us to underline.
Bonding:
Def à the attachment between fetus and mother. Can have pre-natal bonding especially when baby responds to what you do.
How do we encourage pre-natal bonding? Ask about names and encourage her to use it. Help her identify parts by palpation. Help listen to fetal heart tones. Sonogram photos and videos.
Times difficult to bond:
