Reproductive Organ Changes Uterus

enlargement -- 2 ounces to 2 pounds rises out of pelvic area and displaces the

intestines changes in tissue

increase in vascularity hypertrophy

isthmus of uterus softens - uterine soufflé

Patient teaching Braxton-Hicks contractions

Hegars Sign

Cervix softens - Goodell’s sign fills with a mucus plug increase in discharge, leukorrhea

Vagina increase in vascularity - Chadwick's sign increase in discharge, leukorrhea pH rises and become more susceptible to

yeast infections

Mrs. Andrews complains of a whitish discharge. What is the teaching regarding vaginal discharges?

Perineum increased vascularity and pressure causes

vulvar varicosities What should the nurse teach regarding

decreasing the pressure in the perineal area?

Ovaries corpus luteum remains functioning and

there is NO ovulation or menstruation.

Mrs. Andrews asks why she stops having menstrual periods while pregnant. What is the nurses response ?

Breasts Growth of alveolar tissue Nipples become more pigmented

Mrs. Andrews states that her breasts are more full and have become very heavy.

What teaching should the nurse include?

Cardiovascular Changes• cardiac enlargement

• Vasodilation

• increase blood volume, hemodilution

• increase cardiac output – 30-50%

Cardiovascular Changes

• Blood Components and Variations in common laboratory tests– RBC – erythrocytes increase by 25% to 33% from

acceleration in production ~5.7million

– WBC – leukocytes increase (5,000-15,000)

– Hgb – 12 – 16 g/dl – stays about the same

– Hct -- 37% decreases RT hemodilution. There is an increase of about 1500 ml. Over 1000 ml. of that is plasma.

Cardiovascular Care Nursing Care– Avoid supine hypotension by side lying – Arise slowly from a lying position– Wear support hose and avoid constipation

to decrease formation of varicose veins– Instruct that palpitations may be felt and

are normal

Respiratory Changes

– The body adjusts to meet the oxygenation needs by: • Thoracic rib cage is pushed upward and the diaphragm

is elevated as uterus enlarges• Lower thoracic cage widens to increase tidal volume• Oxygen consumption is increased to support fetus

– Vasodilation of vessels in nose causing epistaxis and nasal stuffiness

•

Respiratory Changes

• Nursing Care– Instruct that because of shortness of

breath and dyspnea may need to:• sleep in an upright position• avoid overloading the stomach• stop smoking!

– Nasal stuffiness is normal because of increase in hormones

Gastrointestinal Changes• Nausea and Vomiting – Related to:• increased levels of HCG• changes in CHO metabolism• fatigue

– Nursing Care• Avoid offending odors• eat dry CHO (crackers) upon wakening• Eat 5-6 small meals per day• Avoid spicy, gas forming foods• Drink carbonated beverages

Gastrointestinal Changes

– Nursing Care• avoid large meals• use good posture• Take low Sodium antacids --

Heartburn and Indigestion–Related to:

»slowing of motility and digestion because of progesterone»relaxation of cardiac sphincter, regurgitation occurs»stomach displaced upward and compressed by enlarged uterus

Gastrointestinal Changes• Constipation– Related to:

• slowing of motility• intestinal compression• oral iron supplement

– Nursing Care• Increase water and fiber in diet• moderate exercise• **Don’t take laxatives or enema without a doctor’s

permission

Gastrointestinal Changes

• Hemorrhoids– Related to :• pelvic congestion• straining with stool

– Nursing Care• avoid constipation• Apply topical agents to area

Review

• Mrs. Andrews says that she just mixes up some baking soda and that takes care of her indigestion.

• Is there any teaching that needs to be done in this situation?

Urinary Changes• Renal Changes– Related to:• Kidneys increase in size and weight to enable

greater filtration• Enlarged uterus presses on kidneys and ureters

reducing effective flow.• ureters dilate• Urinary stasis

Urinary Changes

• Urinary frequency and urgency– Related to:• pressure of uterus on bladder

When is this more common? Nursing care

Kegels exercises Limit fluid intake before bedtime Report dysuria or burning

Skin and Hair Changes• Skin– Increase pigmentation RT increase in production

of melanotropin• face = chloasma• breasts = areola darkens• abdomen = linea nigra

– Spider nevi on face and upper trunk– Striae gravidarum

• Hair – Increase in hair growth

Musculoskeletal Changes• Joints, bones, and teeth

– Softening of pelvic cartilage and exaggerated elasticity of connective tissue can lead to unstable gait

– Posture changes– Leg cramps– Carpal tunnel syndrome– Teeth--there is no demineralization

– Nursing Care Wear low heel shoes for support Exercises Walk leading with the heel of the foot Wrist supports until after delivery assist with pain related to

carpal tunnel syndrome. Goes away after delivery.

Hormones

• Endocrine– The placenta produces new hormones:

• Human chorionic gonadotropin – maintain pregnancy• Human placental lactogen – antagonist of insulin• Estrogen – stimulates development of uterine lining• Progesterone – maintains pregnancy• Relaxin – aids in softening the cervix

Confirmation of the Pregnancy

Confirmation of the Pregnancy

Situation

Mr. and Mrs. Andrews visit the clinic and tell the nurse that Mrs. A has “missed two menstrual periods, has urinary frequency, and is

tired all of the time”.

First Prenatal Visit

• What is the most important thing that the nurse can do at this first prenatal

visit?

• Most important intervention for the nurse is to:

MAKE THE PATIENT WELCOME !

Why? (so the couple will continue with

prenatal care)

FIRST PRENATAL VISIT

• The nurse will gather data

regarding presumptive, probable, and positive signs of pregnancy.

Presumptive Signs of Pregnancy

• Cessation of Menstruation• Breast changes -- tenderness• Nausea and Vomiting• Frequent Urination• Quickening• Chadwick's sign• Increased pigmentation of the Skin• Fatigue

Probable Signs of Pregnancy

• Enlargement of the Abdomen• Hegar’s Sign -- softening of the isthmus of the uterus

• Goodell’s Sign --softening of the cervix

• Braxton-Hicks contractions• Ballotment• Outline of the fetus by abdominal

palpation• Positive Pregnancy Test

Positive Signs of Pregnancy• Auscultation of fetal heart tones

• Active fetal movement felt by Trained person

• Ultrasound showing fetal outline

Confirm the Pregnancy

Pregnancy Tests

All tests rely on detection of HCG

Urine Hema-agglutination Inhibition

Radioimmune assay

EnzymeRadioreceptor Assay

• Mrs. A says that she used a home pregnancy test and the results

were positive.

• What are some of the advantages and disadvantages of using home

pregnancy testing?

Health History Assessment• Collect information about:– Obstetric History -- Current and past pregnancies– Menstrual History– Family history--genetic and environmental factors

that affect health– Medical history-- diabetes, heart

• Perform Physical Examination including a Pelvic Examination (Pap test, measurements, cervical culture)

• Perform Laboratory Studies– Hgb., Hct, Type, Rh, CBC, Rubella, Hepatitis, HIV

• Now that the couple has been welcomed to the clinic and the history is complete, it is time to confirm that Mrs. A is pregnant.

It is confirmed that Mrs. Andrews is pregnant.

The nurse will continue with the assessment of physiological and psychological needs of

the family. Assessment begins at the initial visit and

continues throughout pregnancy.

Calculation of Gravida and Parity• Obstetrical Status– Gravida = number of times pregnant

regardless of duration or outcome

– Parity = number of deliveries after the age of viability (20 weeks).

** It is not the number of babies that come out, but the number of deliveries of a pregnancy

Calculation of Gravida and Parity• Further Breakdown into TPAL– T = Term–P = Preterm–A = Abortions– L = Live births

Check Yourself ! The nurse obtained the following data

from Mrs. Andrews. She has five year old twins that delivered at 35 weeks, a three year old son that delivered at 39 weeks, had a miscarriage last year at 12 weeks gestation.

What is her gravida and parity? What is her gravida and parity using the

TPAL system?

• Mr. and Mrs. Andrews are both excited about the pregnancy. It is her first so she is considered a Gravida 1, Para 0.

• They ask the nurse “When is the baby due”?

• How will you calculate this?

Calculation of E. D. C. Nagele’s Rule

First day of last Menstrual Go back 3 months Add 7 days

Mrs. Andrews tells you her last menstrual period began on July 18.

Her baby is due on ____________.

TEST YOURSELFMrs. B. began her menses onJanuary 21. What is her E.D.C.using Nagele’s Rule?

Mrs. C. started her menses onJune 27. What is her E.D.C. using Nagele’s Rule?

Problem Solving• If Mrs. Andrews did not know the first

day of her last menstrual period, what method of calculation would you use?

McDonald’s Rule Use Fundal height measurement, measure

from the symphysis to the top of the fundus.

Months = measure cm. X 2/7 Weeks = measure cm. X 8/7

Mrs. Andrew’s fundal height is 7 cm. How far along is she?

Assessment of Pelvic Adequacy• Clinical Pelvimetry via ultrasound can

be performed to determine if the pelvis is of adequate size to allow for a normal vaginal delivery.

• Manual measurement via examiner

Conclusion of Visit

• You are completed with Mr. and Mrs. Andrews first prenatal visit.

• Before they leave, it is important to discuss the following topics:

Conclusion of Visit

• Danger Signals

• Patient Teaching

• Diet Counseling

• Referrals

• Date of next visit

Danger Signals• Vaginal Bleeding• Fluid from the Vagina• Abdominal Pain• Increased Temperature• Dizziness, Blurred vision or Double Vision• Persistent Vomiting• Edema• Headache• Dysuria• Absence of Movement of the Baby

Patient Teaching

Review interventions on how to

overcome the Common Discomforts of

pregnancy and Health Behaviors with

each subsequent visit .

Teaching Health Behaviors

• Employment– Criteria for work:• is work environment safe for the fetus• can woman carry out work commitments

without undue stress

• What other teaching is necessary regarding work and breaks.

Teaching Health Behaviors

• Mrs. Andrews says that she is employed as a bank teller on a full time basis.

• She asks whether she can continue to work throughout her pregnancy

• Exercise, Leisure, Travel– May attend regular prenatal exercise classes– Don’t take up a new sport– Travel--wear seat belt

Wear shoulder belt Wear shoulder belt over top of abdomenover top of abdomen

Wear lap belt lowWear lap belt lowover the hipsover the hips

Teaching Health Behaviors• Avoid exposure to teratogens– Alcohol– Smoking– Drugs

Immunizations - avoid live vaccines

Advise about use of prescription and over-the-counter drugs

First Trimester• Uncertainty

– Incorporation and integration of the fetus as an integral part of the woman.

• Ambivalence

• Self as primary focus– Baby not perceived as a reality.– Fetus is not perceived as a separate object– Interest and concern about their bodily and emotional changes.

Psychological Task - Needs to be able to say “I am Pregnant”

Second Trimester• Fetus as primary focus

– Sees fetus as a separate object and not an extension of self.– Picture the fetus as a newborn infant.– Assign sex and describe with specific characteristics.

• Narcissism and Introversion– Wants to do the right things to protect herself and her baby

• Body Image

Psychological Task - Needs to be able to say “I am going to have a baby”

Changes in Sexuality

• First Trimester – nausea, fatigue, fear of miscarriage interfere with

sexual feelings• Second trimester – freedom from worry of getting pregnant so enjoy

sex– Increase in sexual responsiveness

• Third Trimester– Suggest alternate positions for sex– Sexual response varies widely

Third Trimester• Vulnerability

– Worry that baby may be lost or harmed

• Increasing dependence

• Preparation for birth – Planning baby’s arrival at home.– Decide on method of feeding.– Acceptance of demands baby will make on parents.– More confident in knowledge about labor and delivery.– Interest in child care and planning for the future.

Psychological Task - Needs to be able to say “I am going to be a parent.”

Paternal Responses• Readiness for fatherhood is more likely if

there is a stable relationship between partners

• May be more difficulty for males to adapt to role as father because they are often neglected when the focus is on the woman

• Need the same support as the woman

Cultural Influences

In working with clients of other cultures, health In working with clients of other cultures, health professionals should be open to and respectful professionals should be open to and respectful

of other beliefsof other beliefs

Nutrition in Pregnancy

• Increase in calories• Increase in protein• Adequate intake of minerals and

vitamins

• May have food cravings or Pica

Nursing care:– Teach to take prenatal vitamins and iron

– Teach about normal weight gain ~ 25 lbs.