PREGNANCY

estimated birth of date

NAGELES RULE
Get the first day of the last menstrual period, subtract 3 months, add 7 days, and add 1 year.

the psychologic tasks of pregnancy

FIRST TRIMESTER

- accepting the pregnancy

SECOND TRIMESTER

- accepting the baby

THIRD TRIMESTER

- preparing for parenthood

1. reproductive tract changes

2. integumentary changes 3. systemic changes

a. uterine changes b. amenorrhea c. cervical changes d. vaginal changes e. ovarian changes

- increase in length, depth, width, and weight - length from 6.5 to 32 cm - depth from 2.5 to 22 cm - width from 4 to 24 cm - weight from 50 to 1000 g - this growth is due to muscle fibers which aids in the stretching

Lightening is the settling of the fetal head to prepare for birth.

Fundus of the uterus usually remains midline during pregnancy, but may be pushed slightly to the right due to larger bulk of sigmoid colon on the left.

Bimanual examination by week 6 of pregnancy would reveal an extreme softening of the lower uterine segment called hegars sign.

During week 16 to 20 of pregnancy, ballottement (from the french word balloter, meaning to toss about) may be demonstrated.

BRAXTON HICKS CONTRACTIONS

- uterine contractions which begin as early as week 12, and is present throughout the rest of the pregnancy - may be mistaken for true labor contractions and is often called false labor

DURING PREGNANCY - due to suppression of FSH - impregnation has occurred WITHOUT PREGNANCY - heralds onset of menopause - uterine infection, climate change, chronic illness, or stress

In pregnancy, cervix becomes more vascular and edematous. A tenacious coating of mucus called operculum fills the cervical canal which seal out bacteria during pregnancy and help prevent infection in the fetus and membrane.

Softening of the cervix during pregnacy is called goodells sign.

Vagina during pregnancy become hypertrophic and is enriched with glycogen, which results in white discharges. Vaginal secretions during pregnancy fall from a pH of over 7 to 4 or 5, which, unfortunately, favors the growth of candida albicans. Vaginal walls during pregnancy changes from light pink to deep blue, called chadwicks sign.

Ovulation stops due to active feedback mechanism of estrogen and progesterone. 1. corpus luteum early in pregnancy 2. placenta later in pregnancy

a. striae gravidarum b. diastasis c. umbilicus d. extra pigmentation e. vascular spiders f. activity of sweat glands g. changes in breasts

Pink or reddish streaks appearing on the sides of abdominal wall or thighs. Due to rupture and atrophy of small segments of connective layer of skin as the abdominal wall stretches. Lightens to a silvery-white color weeks after birth.

Separation of the rectus muscle due to difficulty of the abdominal walls to stretch.

Appears as a bluish groove after pregnancy.

May appear to be protruding as a round bump at the center due to stretching of the abdomen.

Linea nigra is a brown line from the umbilicus to the symphysis pubis.

Melasma are darkened areas on face, particularly cheeks and nose.

Small and fiery-red branching spots particularly on thighs. Result from increased estrogen in the body. May fade but not completely disappear after birth.

Increased perspiration. Palmar erythema on hands. Increased hair growth.

May experience feeling of fullness, tingling, or tenderness due to increased stimulation of breast tissue by high estrogen level in the body. Breast size increases, due to hyperplasia of mammary alveoli and fat deposits. Areola darkens in color, and diameter increases from 3.5 to 5 or 7.5 cm. Blue veins may become prominent over the surface of the breasts. Sebaceous glands of areola enlarge and become protuberant. Colostrum can be expelled from the nipples as early as 16th week.

a. respiratory system b. temperature c. circulatory system d. gastrointestinal system e. urinary system f. skeletal system g. endocrine system h. carbohydrate metabolism i. adrenal glands J. immune system

Feelings of shortness of breath due to enlargement of the uterus. This causes a great deal of pressure on the diaphragm and lungs.

early in pregnancy: - body temperature slightly increases - due to progesterone from the CL from 16 weeks onward: - temperature decreases to normal - due to placental take-over

1. BLOOD VOLUME 2. PALPITATIONS 3. BLOOD PRESSURE 4. SUPINE HYPOTENSION SYNDROME 5. BLOOD CONSTITUTION

1. BLOOD VOLUME
- increases from 30% to 50% - after birth, blood loss is about 300 to 1000 ml - woman may have pseudoanemia - all pregnant women need iron supplements

2. PALPITATIONS - common during pregnancy - due to increased SNS stimulation and increased thoracic pressure

3. BLOOD PRESSURE

Despite hypervolemia, BP does not normally rise due to increased action of the heart.

4. SUPINE HYPOTENSION SYNDROME

Causes lightheadedness, faintness, and palpitations. Weight of the growing uterus presses the vena cava against the vertebrae, obstructing blood flow from the lower extremities Suggest left side-lying position.

5. BLOOD CONSTITUTION
- fibrinogen, factor 7, 8, 9, and 10, and platelet increases - WBC increases - lipids and cholesterol increases - protein decreases

Slow intestinal peristalsis and emptying time leads to heartburn, constipation, and flatulence. Decrease gastric motility due to presence of the relaxin hormone during pregnancy. Morning sickness due to increasing levels of HCG and progesterone. Subclinical jaundice or symptom of generalized itching due to reabsorption of biliburin into the maternal bloodstream. May have hypertrophy of gums, bleeding of gingival tissue when brushing, and hyperptyalism.

Urine output increases from about 60% to 80% during pregnancy, while total body water increases.

Calcium and phosphorus needs are increased. Gradual softening of pelvic ligaments due to relaxin and progesterone. Has the pride of pregnancy stance and lordotic gait

The most striking change is the addition of the placenta.

Maternal glucose level should be maintained high to prevent fetal hypoglycemia. Though the fetal pancreas secretes increased insulin, it appears to be not as effective, that is why fat stores and glucose of the woman are utilized.

Activity of the adrenal glands during pregnancy increases. Believed to suppress an inflammatory reaction against the foreign protein of the fetus.

Immunologic competency decreases to prevent rejecting the fetus as foreign.

The IgG decreases, but WBC increases.

WEEKS AOG

PRESUMPTIVE SIGNS

PROBABLE SIGNS
~ serum laboratory tests

POSITIVE SIGNS

1
2 3 6
~ breast changes ~ amenorrhea ~ frequent micturition

~ chadwicks sign ~ goodells sign ~ hegars sign ~ sonographic evidence of gestational sac ~ sonographic evidence of fetal outline ~ fetal heart audible ~ fatigue ~ uterine enlargement ~ ballottement ~ fetal outline ~ quickening ~ braxton hicks sign ~ fetal outline felt by examiner ~ linea nigra ~ melasma ~ straie gravidarum ~ fetal movement felt by examiner

8 10 12 16 18 20 24

THE GROWING FETUS

1.FERTILIZATION 2.IMPLANTATION 3.FETAL DEVELOPMENT

MESODERM

~ ~ ~ ~ ~ ~

supporting structures of the body upper portion of the urinary system reproductive system heart circulatory system blood cell

ENTODERM

~ lining of the GIT, respiratory tract, tonsils, parathyroid, thyroid, thymus glands ~ lower urinary system ~ ~ ~ ~ nervous system skin, hair, nails sense organs mucous membranes of the anus and mouth

ECTODERM

- rapidly growing embryo - spinal cord has formed and fused at the midpoint - head becomes prominent - back is bent - the rudimentary heart (fetal circulation and fetal hemoglobin) appears as a prominent bulge on the anterior surface - rudimentary eyes, ears, and nose are discernible - length is 0.75 to 1 cm and weight is 400 mg

- length is about 1 inch and weighs 20 g - organogenesis is complete - the heart beats rhythmically - genitalia is present, though not discernible - primitive tail is undergoing retrogression - abdomen appears large - a sonogram would demonstrate a gestational sac and is diagnostic of pregnancy

- length is 7 to 9 cm and weighs 45 g - capable of spontaneous movements though not felt by the mother - some reflexes such as babinski is present - ossification of bones and tooth buds are formed - kidney secretion has begun - heart beat is audible by a doppler

- length is 10 to 17 cm and weighs 55 to 120 g - fetal heart tones can be heard through a stethoscope - formation of lanugo - liver and pancreas are functioning - starts the swallowing reflex

- length is 25 cm and weighs 223 g - mother feels the movement - capable of antibody production - meconium is present - definite sleep and activity pattern

- length is 28 to 36 cm and weighs 550 g - vernix caseosa is produced - active production of lung surfactant begins - the eyes can open

- length is 35-38 cm and weighs 1200 g - lung alveoli begin to mature - in the male, testes begin to descend in the scrotal sac - blood vessels of retina are extremely susceptible to damage from high oxygen concentrations

- length is 38-42 cm and weighs 1600 g - subcutaneous fats begins to be deposited - fetus is aware of the sounds outside - has an active moro reflex

- length is 42 to 49 cm and weighs 1900 to 2700 g - amount of lanugo begins to diminish - most babies turn into a vertex or head-down presentation

- length, crown to heel, 48 to 52 cm and weighs 3000 g - fetus kicks actively - fetal hemoglobin begins to transform into adult hemoglobin - vernix caseosa is fully formed - the sole creases covers 2/3 of the foots surface - lightening is felt

MATERNAL AND FETAL HEALTH

1. pre-natal check up

2. proper maternal nutrition

3. assessing fetal well-being