Antepartal Nursing

Ana H. Corona, MSN, FNP-C

Nursing Instructor

July 2008

Antepartal Nursing• Period of pregnancy between conception

and onset of labor, used in reference to the mother.

Pre-embryonic development

• Two week period that includes: – Fertilization (conception) – Implantation

• Miscarriage is a problem at this stage.

Embryonic Development• 3-8 weeks • major functions of this period:

– Cell multiples and grow – Cells differentiate and grow – By the end of week 8, all organ systems and

external structures are present.

• Primary germ layers develop – Ectoderm (brain, nervous system) – Medoderm (heart, bones) – Endoderm (lungs, intestinal organs)

Embryonic Development• Fetal membrane develops

– Amnion inner lining produces amniotic fluid

– Chorion outmost lining chorionic villi develop into placenta

• Amniotic fluid – Function: shock absorber – Amount: 1500ml or more

The Placenta– Provides “food” and secretes hormones that

continue the pregnancy – Circulation: Mom and baby’s circulation is

completely separate! – Metabolic function

• Respiration • Nutrition • Excretion

• Storage

Umbilical Cord• Lifeline to mom

– 2 arteries • unoxygenated blood

– 1 vein • oxygenated

– Wharton’s jelly • Outer covering of umbilical cord (protects

cord)

Hormones• Human chorionic gonadatropin (hCG) • Supplied by corpus luteum • Detected in mom’s blood 8-10 days after

conception • Keeps corpus luteum active which

supplies: – Estrogen – Progesterone

• The placenta takes the place of the corpus luteum around the 16th week of pregnancy

Hormones continue• Human placental lactogen (hPL) • Acts as a growth hormone • Stimulates mom’s metabolism (mom needs extra

energy) • Increases mom’s resistance to insulin (sends

more sugar to baby) • Facilitates glucose transport across placental

membrane • Stimulates breast development to prepare for

lactation.

Hormones • Progesterone • Maintains endometrium • Decreases contractibility of uterus • Breast development • Estrogen (by 7 weeks) • Stimulates uterine growth and blood flow

between uterus and placenta (uteroplacental)

• Breast development

An Important Point• Placental function depends on maternal

blood pressure

• If there is interference with circulation with the placenta, the following develops: – Vasoconstriction (blood flow to baby is

decreased) • Maternal hypertension • Maternal smoker • Cocaine abuse

Fetal Development• Fetal period is 9 week to birth

• Rapid growth and organ development

• Some dates/terms related to fetal growth:

• Integumentary – Lanugo:

• Downy hair covering the body • Appears at 13 weeks, disappears at 36 weeks

– Vernix caseosa • Protects skin; most abundant in the creases (neck)

and flexor surfaces.

Fetal Development• Cardiovascular

– Heart beat heard at 10 weeks by Doppler – Heard at 16 weeks via fetoscope

• Respiratory – Surfactant matures by 36th week

• Surfactant permits expansion of the lungs

• GI system – Meconium (tarry stool)

• Urinary system – By 5th month, fetus urinates into amniotic fluid – 2nd half of pregnancy: urine makes up major part of amniotic

fluid

• Sexual – Can identify male/female by 16th week

Emotional Responses to Pregnancy• Emotional responses to pregnancy • Ambivalence (contradictory feelings) • Grief • Self-centered; feels need to protect her body • Introversion or extroversion • Body image changes • Stress • Mood changes • Sexual desire changes • Couvade syndrome

– The father experiences the physical symptoms; morning sickness or backache; the “empathy” belly.

Three Psychological tasks of pregnancy

• 1st trimester: accepting the pregnancy

• 2nd trimester: accepting the baby

• 3rd trimester: preparing for parenthood; nesting

Terms related to pregnancy

• Para: number of babies born after 22 weeks • Gravida: A woman who is or has been pregnant • Primigravida: a woman who is pregnant for the

1st time • Primipara: A woman who has delivered one child

after 22 weeks • Multigravida: A woman who has been pregnant

previously • Multipara: A woman who has carried 2 or more

pregnancies after 22 weeks • Nulligravida: A woman who is not pregnant and

is not currently pregnant.

Pregnancy Tests

• Measure hCG (human chorionic gonadatropin)

– 95-98% accuracy

– blood and urine tests

Estimated Date of Delivery• Nagele’s rule

• Begins with 1st day of last menstrual period, subtract 3 months, and add 7 days

McDonald’s Method

• Measure from top of symphysis pubis over curve of abdomen to top of uterine fundus in cm. – Helps determine gestation week – Gives indication of IUGR, twins, hydramnios

(excess amniotic fluid) – 12-16 weeks, just above the symphysis pubis – 20-22 weeks, at umbilicus

Danger signs of pregnancy—call M.D. • Sudden gush of fluid from vagina • Vaginal bleeding (however, a little spotting can be normal

due to fluctuating hormones) • Abdominal pain • Apigastric pain (placenta may be tearing away from

uterine wall) • Signs of toxemia/pre-eclampsia

– Dizziness, blurred vision, diplopia (double vision), see spots – Severe headache – Edema of the hands, face, legs, and feet – Muscular irritability, seizures

• Oliguria (decreased urine output) • Dysuria (Painful or difficult urination) • Temp above 101 and chills (could mean sepsis) • Persistent vomiting • Absence of fetal movement (12 hours)

Prenatal Health Assessment• hCG confirms pregnancy • Complete health history

– genetic disorders – chronic illnesses – meds – obstetrical history – personal habits

• Complete physical exam – VS – Weight/height – Pelvic exam – Assess size/shape of boney pelvis

Lab Tests– Serology – Hematocrit and hemoglobin

• N: 38-47% and 12-16 g/dl – Sickle cell trait – WBC

• N: 4,500-11,000 – ABO and Rh typing (indirect coombs)

• N: Rh neg • Rationale: check for presence of Rh antibodies

– Rubella, Hep B, and Varicella titers • N: Increased titer indicates immunity

– Urinalysis • Abnormal color • Protein, RBC’s, WBC’s • Glucose: small vs. large amount

Subsequent Prenatal Visits• Subsequent visits

– Physical assessment – Measure fundal height

• Fetal heart tones – Fetoscope

• 16 weeks, and almost always by 19 or 20 weeks

– Doppler • 10-12 weeks

• Prenatal visits – Q 4 weeks for 1st 28 weeks – Q 2 weeks until 36 weeks, then – Q 1 week until childbirth

Nutrition During Pregnancy– Vitamin D and Folacin (folic acid) is increased

100% – Iron is HUGE, need 433% due to that

pseudoanemia • Pseudoanemia is a drop in hematocrit during

pregnancy. The increase in circulating blood volume reflects an altered ratio of serum to RBC’s; plasma volume increases by 50%, whereas the RBC count increases by 30%.

• 2nd and 3rd trimesters need to increase 300 kcals/day

Fluids and Fiber

• Drink 8 glasses of fluid daily (water is best fluid)

• No alcohol, limit caffeine

• Limit artificial sweeteners

• Fiber is good! – Fights constipation – Lowers cholesterol

Weight

• Recommended weight gain during pregnancy: – 25-40 lb

• 1st trimester – gain 1 pound per month

• 2nd and 3rd trimesters – gain 1 pound per week

• Watch for sudden large gains- could be fluid

Physiological changes and discomforts in pregnancy

• Uterus • Hegar’s sign

– Softening of the lower uterine segment, a probable sign of pregnancy that may be present during the 2nd and 3rd month of pregnancy.

– The lower part of the uterus is easily compressed between the fingers placed in the vagina and those of the other hand over the pelvic area.

– Due to the softening of the uterus related to increasing vascularity and edema and because the fetus does not completely fill the uterine cavity at this point, so the space is empty and compressible.

The Uterus • Braxton Hick’s

– Changes in contractibility – “False labor”; does not cause dilation and effacement of the

cervix. • Effleurage (massage) and rest

• Ballottement – A diagnostic maneuver in pregnancy. The fetus rebounds when

displaced by a light tap of the examining finger through the vagina.

• Quickening – Initial awareness of the movement of the fetus within womb – Felt 16th-18th week

• Lightening – The descent of the presenting part of the fetus into the pelvis.

Feels as if the baby is “dropping”. – Happens around the 36th week

The Cervix• Goodell’s sign

– Softening of the cervix (due to increasing vascularity and edema)

• Chadwick’s sign – Deep blue-violet color of the cervix and

vagina

• Mucus Plug “Operculum” – The plug of mucus that fills the opening of the

cervix on impregnation – Prevents bacteria from getting into uterus

The Ovaries

• No ovulation

• Corpus luteum increases until week 16; then replaced by placenta

• Increased estrogen and progesterone inhibit the release of LH and FSH.

The Vagina• Chadwick’s sign • Preparing for stretching during labor and birth:

– Connective tissue loosens – Hypertrophy – Lengthens – Luekorrhea

• White, thick secretions

• pH in vagina becomes more acidic – fights off bacteria, but, – promotes fungus/yeast infections

• bathe daily, wear absorbent cotton panties • no crossing legs or douching

The Breasts• Increase in fullness, heaviness, tenderness • Nipples darken • Thin and watery secretions • Montgomery’s tubercles

– Sebaceous glands in the areola surrounding the nipple of the female breast

– Prevention of nipple cracking

• Blood vessels more visible • Estrogen and progesterone cause these changes • During 2nd and 3rd trimesters, most growth due to

mammary glands – Wear a well fitting bra for breast tenderness

Cardiovascular • Blood volume in mom increases by

1500ml or 40-50% above pre-pregnancy levels. – Changes due to hormones, meet woman’s

and growing fetus’ needs – Cardiac output increases 30-50% – Heart rate increases 10-15 BPM – RBC’s increase, but cannot keep up with the

pace of the plasma volume; decreased hemoglobin and hematocrit occur. This is called pseudoanemia. Know it and love it.

Blood Pressure

– First trimester: no change – Second trimester: systolic and diastolic decrease 5-10

mm Hg – 3rd trimester: Returns to first trimester levels. – Supine hypotension syndrome can occur in the 2nd half

of pregnancy (vertigo, decreased BP). • Palpitations and murmurs can cause an issue for these issues.

Encourage mom to take naps, have partner assist with housework, get to bed early, and good nutrition. Teach mom that that these symptoms are normal. If mom feels faint, tell her to lower head between legs, lie down, rise slowly, avoid standing long periods. Avoid lying on back, instruct to lie on side (due to compressed inferior vena cava).

• WBC are elevated in the 2nd and 3rd trimester of pregnancy – Could mask infection.

• Varicose veins – Due to the compression of the iliac veins and

inferior vena cava by uterus; increases venous pressure and decreases blood flow to the legs.

• Interventions: Exercise, don’t cross legs; wear support hose; keep legs and hips up; exercise feet.

Respiratory • Increased tidal volume • Increased oxygen consumption • Slight elevation in respiratory rate (18-20 in

pregnancy; 12-20 is normal) • Nasal stuffiness (1st trimester) • SOB (not hubby, breath) 2nd trimester • Dyspnea

– Estrogen causes upper respiratory tract to become more vascular. As capillaries fill, edema develops in the nose.

• Interventions: Use cool air vaporizer • NO SPRAYS • Proper position; semi-Fowlers when sleeping.

Gastrointestinal • Nausea and vomiting (1st trimester) • Gingivitis • Increased saliva • Increased gastric acid (heartburn/pyrosis)

– Causes are due to the cardiac sphincter relaxes; increased progesterone; gastric displacement; hCG levels

• Interventions: Avoid greasy, highly seasoned food, eat small meals frequently, eat dry toast or crackers before arising. Warm sprite and ginger ale can be helpful.

• Sit upright 1 hour after eating • Sodium bicarb after eating • 6-8 glasses of water every day

GI continue• Decreased motility constipation (2nd half)

– Causes are due to the iron supplement most women are on; displacement of the intestines.

• Interventions: Exercise qid, increase fluids/bulk, be regular

• Hemorrhoids (2nd half of pregnancy) – Productions of relaxin

• Avoid constipation, prolonged standing, constricting clothing • Use topical meds, warm soaks, anesthetic agents

• Flatulence (2nd half – I don’t know why?

• Avoid gaseous foods, chew thoroughly, exercise.

Integumentary

• Increased skin pigmentation – Melanocyte-stimulating hormone – Facial mask (melasma) – Linea ligra (dark line from pubis to umbillica) – Vascular spider nevi – Stretch marks on abdomen (striae gravidarum)

• Stretching ruptures small segments of connective tissue

– Rectus diastasis: Blue groove after pregnancy • Abdominal wall separates

– Increased sweat glands (problems with perspirations • Increased estrogen levels

– Palmar erythema • Increased estrogen

– Use lotions

Renal • Fluid retention: Aids with increased blood volume • Increased water absorption • Increased aldosterone • Increased diameter of uterers • Increased bladder capacity (urinary frequency and

urgency (symptoms disappear at 12 weeks, then reappear 3rd trimester) – Estrogen and progesterone cause this – Mom gets rid of own waste and fetus’; compression of the bladder

and uterers – Ankle edema

• Decrease fluid intake in the evening, limit caffeine; empty bladder Q2h to prevent distention and stasis; kegal exercises

• Avoid tight garments; elevate legs; do dorsiflexion of the feet while standing or sitting for prolonged time

• May be slight (trace) spilling of glucose (glucouria)

Musculoskeletal • Changes in gravity • Calcium and phosphorus needs increase • Later in pregnancy, gradual softening of pelvic

ligaments and joints • Lordosis

– Caused by relaxin and progesterone – Leg cramps (late pregnancy) – Backache (late pregnancy)

• Good nutrition, rest with legs elevated, wear warm clothing. • During leg cramp, pull toes up toward the leg while pressing

down on the ankle • Use proper body mechanics; avoid high heels

Endocrine • Placental hormones

– Estrogen: breast/uterine enlargement – Progesterone: maintains endometrium; inhibits uterine

contractibility; lactation – hCG: stimulates corpus luteum to produce estrogen

and progesterone until placenta takes over. – hPL (Human placental Lactogen): antagonist to

insulin (frees fatty acids for energy so glucose is available)

– Relaxin: Inhibits uterine activity; softens cervix and collagen in joints.

– Prostaglandins: May trigger labor

Endocrine continues

• Pituitary gland – Oxytocin – Prolactin: lactation

• Thyroid increases in size – Increased BMR – Better use of calcium and vitamin D

• Adrenal glands – Aldosterone

• Pancreas: – Insulin; additional glucose available for fetus

Immune System

• Resistance to infection during each trimester

• 1st trimester: 3-5 pounds

• 2nd trimester: 12-15 pounds

• 3rd trimester: 12-15 pounds