CRISTIN GABINI-UNGAB,RN

OBJECTIVE


1.

2.

3.

CAUSES result of hormonal influence, growth of the fetus inside the uterus, and result of the patient's physical adaptation to the change


1.

2.

CATEGORIES Local(confined to the reproductive organs) Systemic (affecting the entire body)

a. Ovaries increased levels of estrogen and progesterone secreted by the ovaries (corpus luteum) Corpus luteum functions until 16th week of pregnancy and becomes CORPUS ALBICANS

BEFORE PREGNANCY SIZE: small, semisolid, pear-shaped organ WEIGHT: 50 to 70 grams globular

DURING PREGNANCY

1000 grams

LENGTH: 6.5 CM DEPTH: 2.5 cm

WIDTH: 4 cm UTERINE BLOOD FLOW: 15 to 20 ml/min

32 cm 22 cm
24 cm 500 to 750 ml/min

RATIONALE: - due to formation of a few new muscle fibers in the uterine myometrium and stretching of existing muscle fibers

size of the uterus usually reaches its peak at 38 weeks gestation Growth of the uterus occurs at a steady, predictable pace

Uterine blood flow increases lower uterine segment just above the cervix becomes so soft; the wall cannot be felt or feels as thin as tissue paper HEGARS SIGN

CERVIX becomes more vascular and edematous GOODELLS SIGN marked softening of the cervix in which consistency closely resembles that of an earlobe

"operculum"
A mucus plug is formed in the cervical canal RATIONALE: result of the thick, tenacious secretions produced by the endocervical glands which occupy one half of the mass of the cervix at term

(LEUKORRHEA) - a white vaginal discharge throughout pregnancy - RATIONALE: increase in the activity of the epithelial cells under the influence of estrogen

"Chadwick's sign color changes from normal light pink to a purple hue RATIONALE: Increased circulation to the vagina early in pregnancy

breast may feel full, become tender, and grow larger ; increases in size and nodularity to prepare for lactation.

RATIONALE: - due to the influence of progesterone and estrogen

Nipples become easily erectile, and veins are more prominent RATIONALE: due to increased circulation and turn to a bluish tint to the breasts

Areola of the nipples darkens and the diameter increases.

Sebaceous glands become prominent; keeps the nipples lubricated for breastfeeding.

16th week (second trimester) the breasts begin to produce colostrum- is the precursor of breast milk. It is a thin, watery, yellowish secretion that thickens as pregnancy progresses. It is extremely high in protein.

a. Mask of Pregnancy (Facial Melasma ) - brownish hyperpigmentation of the skin over the face and forehead. RATIONALE: due to melanocyte- stimulating hormone secreted by the pituitary gland. - begins about the 16th week of pregnancy

b. Linea Nigra - a dark line that runs from the umbilicus to the symphysis pubis and may extend as high as the sternum. RATIONALE: primarily as a result of estrogen, progesterone and melanocyte-stimulating hormone levels.

c. Striae Gravidarum (Stretch Marks) pink or reddish streaks appearing on the sides of the abdominal wall and sometimes on the thighs. RATIONALE: due to the action of the adrenocorticosteroids. occurs over areas of maximal stretch--the abdomen, thighs, and breasts.

D. Diastasis Recti - bluish groove at the site of separation of the rectus muscles - RATIONALE: abdominal wall has difficulty stretching enough to accommodate the growing fetus, causing the rectus muscles to actually separate

E. Vascular spider nevi or telangiectases - (small, fiery-red branching spots) - sometimes seen on the skin of pregnant women, particularly on the face, neck, chest, arms, and thighs. RATIONALE- result from the increased level of estrogen in the body as well as increased subcutaneous blood flow

f. Sweat Glands increased activity of the sweat glands and sebaceous glands throughout the body. PROFUSE PERSPIRATION AND ACNE

RATIONALE Blood flow to the maternal skin increases to accommodate the additional heat loss requirements created by the active metabolism of the fetus

g. Palmar Erythema (redness and itching) may occur on the hands of a pregnant woman.
RATIONALE: the increased estrogen level but it has also been associated with liver and collagen vascular diseases.

h. Variations in Hair and Nail Growth the number of hair in the growth phase remains stable. In the later stages of pregnancy, increase number of hairs in the growing phase and decreases the number of hair in the resting phase.

RATIONALE: increased metabolism

nail growth may be affected, and nail changes include transverse grooving, softening, and increased brittleness

RATIONALE significant to the health of the fetus because they are important for adequate placental and fetal circulation.

a. Blood Volume total circulatory blood volume of a womans body increases gradually by 30 to 50% (1500 ml or 3 units DECREASE concentration of red blood cells and hemoglobin

RATIONALE To provide for an adequate exchange of nutrients in the placenta and to provide adequate blood to compensate for blood loss at birth

Anemia (second trimester ) hemoglobin (<10.5 grams per 100 ml )and hematocrit drops (<30%)

ANEMIA (first and third trimester) hemoglobin (<11 g/100ml )or hematocrit (<33%)

b. Cardiac Output increases about 30% during the first and second trimester RATIONALE: to accommodate for hypervolemia (increased blood volume in the circulatory system)

HEART RATE increases by 10 beats per minute. RATIONALE: Reflection for the change in cardiac output

heart is shifted to a more transverse position in the chest cavity, a position that appear enlarged on Xray examination audible functional (innocent) heart murmurs during pregnancy

RATIONALE Because the diaphragm is pushed upward by the growing uterus late in pregnancy

Palpitations in the early months of pregnancy

Palpitations in the later months of pregnancy

RATIONALE - caused by sympathetic nervous system stimulation

RATIONALE - result from increased thoracic pressure caused by the pressure of the uterus against the diaphragm

c. Blood Pressure will not rise

RATIONALE: because the increased heart action takes care of the greater amount of circulating blood

decreases slightly during the second trimester (dizzinesor lightheaded) RATIONALE: Because the peripheral resistance to circulation is lowered as the placenta expands rapidly

Progesterone and prostaglandin relax smooth muscle and produce vasodilation

d. Venous Return swelling of the feet and legs as well as varicosities of the vulva, rectum and legs RATIONALE: lower extremities are often hampered in the last months of pregnancy due to the pressure of the expanding uterus on veins and arteries restricting physical movement and interfering with the return of blood flow

Vena Cava Syndrome or Supine Hypotension patient may complain of feeling dizzy, nauseated, or weak and palpitations RATIONALE: lie in a supine position since this inhibits the return of blood flow as the heavy uterus presses on the vena cava against the vertebrae

e. Blood Constitution Fibrinogen increases as much as 50% RATIONALE: - D/T increased level of estrogen

clotting factors such as factors VII, VIII, XI, and X as well as the platelet count also increased RATIONALE: safeguarding against major bleeding should the placenta be dislodged and the uterine arteries or veins be opened

Total white blood cell count rises slightly (up to 20,000 cells/ mm3) RATIONALE: Both as protective mechanism and as a reflection of a womans total blood volume

total protein level decreases

RATIONALE: indicates that it is being used by the fetus

ankle and foot edema

RATIONALE Since the circulating system has a lower total protein load and hypervolemia, fluid readily leaves the blood for interstitial tissue vessels to equalize osmotic and hydrostatic pressure

Blood lipids increase by one third, cholesterol serum level increases by 90% to 100%

RATIONALE: provide a ready supply of available energy for the fetus.

respiratory rate rises to 18 to 20 breaths per minute RATIONALE: to compensate for increased maternal oxygen consumption, which is needed for demands of the uterus, the placenta, and the fetus

shortness of breath late in pregnancy RATIONALE: crowding of the chest cavity causes an acute sensation of, until lightening relieves the pressure

marked congestion, or stuffiness, of the nasopharynx RATIONALE: results from increased estrogen levels

body temperature increases slightly

RATIONALE: secretion of progesterone from the corpus luteum

Displacement of the stomach, intestines, and other adjacent organs RATIONALE: Enlargement of the uterus

Slow peristalsis (heartburn (pyrosis) and nausea) RATIONALE: Due to production of the hormone progesterone, which decreases tone and mobility of smooth muscles

Constipation RATIONALE: Movement through the large intestines is also slowed due to an increase in water consumption from this area

generalized itching (subclinical jaundice) RATIONALE: gradual slowing of the gastrointestinal tract may result to decreased emptying of bile from the gallbladder. This can lead to reabsorption of bilirubin into the maternal bloodstream

gradual softening of a womans pelvic ligaments and joints RATIONALE: to create pliability and to facilitate passage of the baby through the pelvis at birth caused by the influence of both the ovarian hormone relaxin and placental progesterone

the pride pregnancy /WADDLING GAIT - woman tends to stand straighter and taller than usual - shoulders back and the abdomen forward, creates a lordosis (forward curve of the lumbar spine RATIONALE: To change her center of gravity and make ambulation easier

increase in urinary output decrease specific gravity RATIONALE: kidneys excreting the mother's own waste products plus those of the fetus

urine stasis and pyelonephritis in the right kidney RATIONALE: due to pressure on the right ureter resulting from displacement of the uterus slightly to the right by the sigmoid colon

Frequent urination (first &third trimester) RATIONALE: pressure on the bladder

lengthen the kidneys by 1 to 1.5 cm RATIONALE: Increased renal vascular and interstitial volumes and hormonal influences

an increased risk for urinary tract infection RATIONALE: muscular relaxation coupled with increased urine volume and stasis

dilation of the renal calyces, pelves, and ureters RATIONALE: relaxing effects of progesterone on smooth muscle

GLUCOSURIA RATIONALE: Renal tubules are unable to reabsorb the dramatic increase in glucose load PROTENURIA RATIONALE: because of the increased glomerular filtration when protein- filtered load exceeds the tubular reabsorptive capacity

Parathyroid Gland
increases in size slightly. RATIONALE: It meets the increased requirements for calcium needed for fetal growth.

Posterior Pituitary
begin to secrete oxytocin that was produced in the hypothalamus and stored there. RATIONALE: It will serve to initiate labor.

Anterior Pituitary
At birth, secrete prolactin. RATIONALE: This stimulates the production of breast milk.

Placenta
acts as a temporary endocrine gland during pregnancy produces large amounts of estrogen and progesterone, HCG, human placental lactogen (hPL), relaxin, and prostaglandins.

Thyroid Gland
basal body metabolic rate increases by about 20 percent Levels of protein-bound iodine, butanolextractable iodine, and thyroxine are all elevated in blood serum.

Pancreas
increases production of insulin RATIONALE: response to the higher levels of glucocorticoid produced by the adrenal glands

Insulin is less effective than normal during pregnancy RATIONALE: d/t estrogen, progesterone, and human placental lactogen which are all antagonists to insulin

Normal weight gain = (25 to 35 pounds) during pregnancy gains 2 to 4 pounds (end of the first trimester) gain of a pound per week is expected during the second and third trimesters

 28 to 40 pounds (underweight

women) 15 to 25 pounds (overweight women)

First Trimester: Accepting the Pregnancy

WOMAN Task of a woman: to accept the reality of pregnancy Ambivalence (woman) women are able to change their attitude toward pregnancy by the time they feel the child move inside them

First Trimester: Accepting the Pregnancy

PARTNER TASK accepting the certainty of pregnancy Accepting the reality of the child to come accepting the woman in her changed state

 Second

Trimester: Accepting the Baby

WOMAN psychological task of a woman: accept that she is having a baby change usually happens at quickening, or when the woman feels the fetal movement begins to imagine herself as a mother anticipatory roleplaying

 Second Trimester:

Accepting the Baby

PARTNER may feel as if he is left standing in the wings as the woman begins to prepare for the coming of the baby

Third Trimester: Preparing for Parenthood

WOMAN couples usually begin nest-building activities such as planning the infants sleeping arrangements, buying clothes, choosing a name for the infant, and ensuring a safe passage by learning about birth

a. Ambivalence refers to the patient's simultaneous attraction for and against the pregnancy

woman may have doubts as to whether she will be a good parent, wonders if she is ready for a baby, how a new baby will affect her family and her lifestyle, and so forth she may be experiencing joy and excitement as well as happiness and anticipation

b. Introversion versus Extroversion

introversion or turning inward to concentrate on oneself and ones body, is a common finding during pregnancy extrovert: become more active, appear healthier than ever before and are more outgoing

c. Narcissism
Self-centeredness (narcissism): generally an early reaction to pregnancy begins to concentrate on her body, and weight

d. Couvade Syndrome

refers to the men who experience physical symptoms such as nausea, vomiting, and backache to some degree or even more intensely than their partners do

RATIONALE: often the result of stress, anxiety, and empathy for the pregnant woman. The more the partner is involved in or attuned to the changes of the pregnancy, the more symptoms he may experience

e. Emotional Lability

Mood changes occur frequently in a pregnant woman

RATIONALE: partly as a manifestation of narcissism (her feelings are easily hurt by remarks that would have been laughed off before) and partly because of hormonal changes, particularly the sustained increase in estrogen and progesterone

g. Changes in Sexual Desire

first trimester: most women report a decrease in libido RATIONALE: D/T nausea, fatigue, and breast tenderness that accompany early pregnancy

g. Changes in Sexual Desire

second trimester: libido and sexual enjoyment rise markedly RATIONALE: as blood flow to the pelvic area increases to supply the placenta

g. Changes in Sexual Desire

third trimester, it may remain high or decreases RATIONALE: D/T difficulty finding a comfortable position and increasing abdominal size

PERIODS
Emotional Response

First Trimester Second Trimester

Uncertainty, ambivalence, focus on self, emotional lability Increased focus on fetus, narcissistic, introverted, concerned about changes in her body and sexuality Seeks acceptance of the fetus and her role as mother from family and significant others

Third Trimester
Vulnerability, increased dependence; acceptance that fetus is separate but totally dependent Prepares for birth; internalizes a view of how a good mother behaves and sets up expectations for self

Role

Seeks safe passage for self and fetus by prenatal care, cultural expectations I am pregnant.

Self Statement

I am going have a baby.

to I am going to be a mother.

By REVA RUBIN pregnant woman prepares for her new role through accomplishment of the developmental tasks during this time PURPOSE: to successfully incorporate the maternal identity in her personality

Safe Passage pregnant woman is seeking safe passage for herself and her child through pregnancy, labor, and delivery - MAJOR TASK: to achieve a healthy pregnancy and an intact newborn with no detrimental effects to the mother
1.

1ST TRIMESTER TASK pregnant woman concentrates on her own well being and her pregnancy; she is concerned with what she eats and drinks

2nd Trimester

fears about the baby and how delivery appears; very aware of her responsibilities to protect the fetus and does this by adhering to different aspects of her prenatal care

thoughts shift to mother

3rd Trimester

and baby as a couple; becomes increasingly uncomfortable and looks forward to delivery for relief; seek out role models and expert advice on the best way to proceed through the pregnancy and delivery and on parenting

2. Acceptance by Others

TASKS

pregnant woman is ensuring the acceptance by significant persons in her family and secondary groups of the child she bears

Relationships have to be adjusted and redefined in the family Mother has to create a new identity for herself and build this identity into her life assist other children in adapting to the growing family

3. Binding in to the Child

Binding in to her unknown baby refers to the establishment of a bond between mother and baby

IST TRIMESTER TASK woman focuses on herself and maintaining the pregnancy 2ND TRIMESTER TASK once fetal movement is felt, fetus becomes real and she begins to feel theres a significance in working to meet the challenges of becoming a mother.

4. Giving of Oneself

woman is learning to give of herself

mother learns to put baby's needs above her own communication of appreciative approval from the partner, family and friends help the woman to endure the changes and discomforts of the pregnant body.

PRESUMPTIVE VERBALIZE BY THE WOMAN PROBABLE SEEN BY THE EXAMINER POSITIVE CONFIRMED THE PREGNANCY

Amenorrhea (Cessation of Menstruation) Nausea and Vomiting (Morning Sickness) Frequent Urination Breast Changes Leukorrhea Quickening (or fetal movement) Striae gravidarum (stretch marks) Linea nigra Melasma Fingernails Fatigue Positive Home Test

enlarging uterus Hegar's sign Ballottement mucus plug chadwicks sign Goodells sign Braxton-Hick's contractions increase basal body temperature pregnancy test by physician (urine and blood or serum)

Fetal Heart Sounds Ultrasound Scanning of the Fetus Palpation of the Entire Fetus Palpation of Fetal Movement

STAGE

PRESUMPTIVE

PROBABLE

POSITIVE

First Trimester

Amenorrhea Morning sickness Breast changes Fatigue Urinary frequency Enlarging uterus

Chadwicks Ultrasound signs Evidence Goodells sign Hegars sign Positive HCG (pregnancy test) Elevation of BBT Enlarged abdomen Fetal heart tone Braxton Hicks Fetal movement Contraction felt by the Ballotement examiner Fetal outline on Xray

Second Trimester

Quickening Increased skin pigmentation; (chloasma and linea nigra) Striae gravidarum

Maneuver

Purpose

Procedure

Findings

First Maneuver: Fundal Grip

To determine fetal part lying in the fundus. To determine presentation.

Second Maneuver: Umbilical Grip

To identify location of fetal back. To determine position.

Using both hands, feel Head is more firm, hard for the fetal part lying in and round that moves the fundus. independently of the body. Breech is less well defined that moves only in conjunction with the body. Using both hands, feel Fetal back is smooth, for the fetal part lying in hard, and resistant the fundus. surface. Knees and elbows of fetus feel with a number of angular nodulation. The presenting part is engaged if it is not movable. It is not yet engaged if it is still movable. The presenting part is not engaged if it is not movable. It is not yet engaged if it is still movable.

Third Maneuver: Pawliks Grip

Using thumb and finger, grasp the lower portion of the abdomen above symphysis pubis, press in slightly and make

Maneuver Fourth Maneuver: Pelvic Grip

Purpose To determine the degree of flexion of fetal head. To determine attitude or habitus.

Procedure Facing foot part of the woman, palpate fetal head pressing downward about 2 inches above the inguinal ligament. Use both hands.

Findings Good attitude if brow corresponds to the side (2nd maneuver) that contained the elbows and knees. Poor atitude if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head). Also palpate infants anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards womans back).

1. Urine Performed 42 days after LMP or 2 weeks after the first missed period Detects HCG First morning urine Urine tests can detect as little as 35 mIU/mL of HCG.

2. Blood

performed by radioimmunoassay (RIA), enzyme-linked immunosorbent assay (ELISA), or radioreceptor assay (RRA) techniques early as 24 to 48 hours or 2 days after implantation or 10 days after the first menstrual period is missed. reach a measurable level (about 50mIU/mL) or 7 to 9 days after conception. Levels peak : 100mIU/mL between 60th and 80th day of gestation.

3. Ultrasound

Done if LMP is unknown, to confirm the pregnancy length or document healthy fetal growth a technique that can be used for a positive diagnosis as early as 6th week of pregnancy (3-4 weeks after conception)

3. Ultrasound

gestational sac:observed by 5 to 6 weeks gestation (3 to 4 weeks after conception); fetal parts and fetal heart movement: be seen as early as 10 weeks TRANSVAGINAL SONOGRAPHY OR TVS ABDOMINAL USD