Fo
su
(ID
:8
0
39
17
)
NurseAchieve
Li
ce
ns
ed
• Objectives
• Terminology
• Conception
• Fetal development
• Signs of pregnancy
• Pregnancy weight gain
• Prenatal period
to
Na
vis
1
• Physiological maternal changes
• Psychological maternal changes
• Discomforts and interventions
• Prenatal care
• Obstetrical assessment
• High-risk pregnancy
• Adolescent and geriatric
• Multifetal
• Complications of pregnancy
• Ectopic and molar pregnancy
• Preterm labor
• Eclampsia and pre-eclampsia
• Cultural considerations
• Summary
• References
2
1
•
•
•
•
•
•
•
•
Fo
su
(ID
:8
39
17
)
Understand common terminology associated with the ante-partum period
Calculate EDB using Naegele’s rule
Review conception and development of embryo and fetus
Identify abnormalities in conception
Distinguish between the signs of pregnancy
Demonstrate understanding of normal pregnancy weight gain
Review the psychological and physiological changes of pregnancy
Implement interventions to relieve common discomforts during the 3
trimesters
• Explain effective prenatal care
• Conduct maternal and fetal assessments
• Understand pregnancy complications and high-risk pregnancies
to
Na
vis
3
ns
ed
• Antepartum and prenatal period are used
interchangeably
Li
ce
• Time between conception and onset of labor
• Period where the women is pregnant
• Normal pregnancy lasts: 9 calendar months, 10
lunar months, 40 weeks, or 280 days
• Divided into 3-month trimesters
• First trimester: week 1 – week 13
• Second trimester: week 14 – week 26
• Third trimester: week 27 – term gestation
4
2
Gravida: A women who is pregnant
Gravidity: Number of pregnancies (including the current one)
Multigravida: A women who has had two or more pregnancies
39
17
)
Multipara: A women who has completed two or more pregnancies to 20 or more weeks of
gestation
:8
Nulligravida: A woman who has never been pregnant
Nullipara: A women who has not completed a pregnancy with a fetus(es) whom have reached
(ID
20 weeks of gestation
Fo
su
Parity: The number of pregnancies in which the fetus(es) have reached 20 weeks of gestation
when they were born. This is not affected by twins or stillborn pregnancies
to
Na
vis
5
Li
ce
ns
ed
Postdate or post term: a pregnancy that goes
beyond 42 weeks of gestation
Preterm: a pregnancy that is carried until 20-37
weeks gestation
Primigravida: a women pregnant for the first time
Primipara: a women who has completed one
pregnancy with a fetus(es) who reached 20 weeks of
gestation
Term: a pregnancy that is carried until 37-42 weeks
gestation
Viability: capacity for the baby to live outside the
uterus. No clear guidelines. Infants at 22-25 weeks
are considered borderline viable
Abortion: loss of pregnancy before the
fetus is viable outside the uterus
Miscarriage (spontaneous abortion):
Abortion that occurs, naturally
Induced abortion: purposeful
interruption of a pregnancy before 20
weeks of gestation
Elective abortion: performed at the
women's request
Therapeutic abortion: performed for
maternal or fetal health reasons
6
3
• Two common acronyms used during health assessments : GP and GTPAL
• GP: Gravidity and parity
39
17
)
• GTPAL: Gravidity, term, preterm, abortions, living children
(ID
Fo
su
GP = gravida 3 para 1
GTPAL = 3-0-1-1-2 (Note: Twins is considered 1 pregnancy)
:8
E.g. Shira is 37 weeks pregnant with a girl, she has 2year-old twin boys born at 35 weeks. At 16 years old,
she had an elective abortion when the fetus was 8
weeks gestation. Using GP and GTPAL, what should
the nurse document in the client’s chart?
to
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7
ed
• Most common method for
determining estimated date of
birth (EDB) using women's last
menstrual period (LMP)
• Not always accurate, as some
women do not have regular
menstrual cycles
• Formula:
1st day of LMP
– 3 months
+ 7 days
= EDB
Li
ce
ns
E.g. Susan’s LMP started on July 7th
2017. Using Nagele’s rule, what is her
EDB?
1
First day of LMP
Subtract 3 months
July 7
- 3 months
April 7th
2
Add 7 days
EDB
+ 7 days
April 14th 2018
*Add one year to determine correct EDB*
8
4
Meiosis produces gametes (ova and sperm)
during gametogenesis (oogenesis and
spermatogenesis)
Ovulation occurs release of the egg
Union of the gametes
(fertilization) in the fallopian tube
39
17
)
Sperm
Ovulation
Egg
Ovary
Implantation in the uterus
(ID
:8
Baby
Fallopian tube
Uterus
Sperm Travelling
Fo
su
Fetal
development
Image adapted from: BruceBlaus License
Ovum development
Embryo development
ed
Functions of amniotic fluid:
to
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9
Sperm enters the
vagina
• Acts as a wedge during labor
ns
• Protection
• Controls temperature
Li
ce
• Permits growth and
development
• Fetal extracellular space
• Tested to determine fetal
health and maturity
• Oral fluid for fetus
Floating embryo develops in
a fluid-filled amniotic sac.
Volume changes constantly
and increases weekly.
Fetus swallow's fluid, fluid
flows in and out of fetal
lungs, and fetus urinates
into the fluid (at 11 weeks
gestation).
• Repository for waste
• Provides room for movement • Maintains fluid and
to aid in musculoskeletal
electrolyte homeostasis
development
• Barrier to infection
• Allows umbilical cord to be
• Fetal lung development
free from compression
10
5
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)
:8
Fo
su
(ID
• Oligohydramnios – too little amniotic
fluid (less than 400 ml). Associated
with fetal renal abnormalities, PROM,
prolonged pregnancy, uteroplacental
insufficiency, IUGR, and maternal
hypertensive disorders.
• Polyhydramnios – too much amniotic
fluid (more than 2 L). Associated with
fetal malformations (e.g.
gastrointestinal obstruction), and
poorly controlled diabetes mellitus.
to
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11
Li
ce
ns
ed
The placenta begins to form at implantation and grows until 20
weeks when it covers half the inside of the uterus. The placenta is
the means of metabolic and nutrient exchange between the
embryo (via umbilical cord) and maternal circulations.
Endocrine
• Hormone secretion
(estrogens, progesterone,
hCG) to maintain pregnancy
and stimulate development
• Mediates hormone
transmission between
mother and fetus
Functions
Nutrition/Digestion
• Mediates the diffusion of
maternal nutrients
• Nutrient storage
• Excretion and filtration of
fetal nitrogenous wastes
into maternal blood
Respiration
• Maternal-fetal oxygen
transport
• Fetal-maternal oxygen
transport
Chart: Adapted from OpenStax College License
12
6
39
17
)
Definition: abnormal implantation of placenta during
development in which the placenta is implanted in the
lower uterine segment, completely or partially
covering the cervix.
• Abnormal placental positioning causes fetus to lie
high up, causing greater than expected fundal height
(ID
• Hemorrhage is the major complication
:8
• Classic symptoms: painless bright red vaginal
bleeding in the 2nd or 3rd trimester
Fo
su
• Most women require cesarean birth
Placenta
Cervix
Image adapted from: Sigrid derooij. “Liscence”
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13
Umbilical
Cord
ns
ed
Definition: premature separation of placenta (placental
abruption) occurring after 20 weeks gestation and before
birth
Li
ce
• Classification: partial separation (concealed hemorrhage),
partial separation (apparent hemorrhage), and complete
separation (concealed hemorrhage)
• Extensive myometrial bleeding can lead to maternal
hypovolemia and coagulopathy- significantly  risk of
maternal and fetal morbidity and mortality
• Classic symptoms: vaginal bleeding, abdominal pain, boardlike abdomen, uterine tenderness, and contractions
• Treatment: immediate vaginal birth if fetus is stable and at
term or cesarean section if there are signs of fetal distress
14
7
Onset
Bleeding
Color of blood
Anemia
Shock
Quiet and sneaky
External
Bright red
= Blood loss
= Blood loss
Sudden and stormy
External or concealed
Dark venous
> apparent blood loss
> apparent blood loss
Toxemia
Pain
Uterine tenderness
Uterine tone
Uterine contour
Fetal heart tones
Engagement
Presentation
Absent
None
Absent
Soft and relaxed
Normal
Usually present
Absent
May be abnormal
May be present
Severe and steady
Present
Firm to hard
May enlarge and change shape
Present or absent
May be present
No relationship
(ID
:8
39
17
)
Abruptio placentae
Fo
su
Differences
between
placenta
previa and
abruptio
placentae
Placenta previa
to
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15
Fetal stage:
8 weeks – birth
Li
ce
ns
ed
Embryonic stage:
Day 15 – 8 weeks
Image of Embryo: Ed Uthman License
Image of Fetus: Woodleywonderworks License
16
8
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)
:8
(ID
Fo
su
4 weeks
• 0.4-0.5 cm long and 0.4 g
• Neural tube forms
8 weeks
• 2.5-3 cm and 2 g
• Major organs nearly formed
• Starting to take shape
8-12 weeks
• 6-9 cm long, 19 g
• Fetal heart tones can be heard by Doppler
• Kidneys secrete urine
• Fingernails start to develop at 12 weeks
16 weeks
• 11.5-13.5 cm and 100 g
• Sex can be clearly identified
Li
ce
ns
ed
to
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vis
17
20 weeks
• 16-18.5 cm and 300 g
• Heartbeat heard by fetoscope
• Mother feels movement (quickening)
• Vernix (lanolin-like covering) protects the
body
• Lanugo (fine hair) keeps oil on skin
• Kidneys produce lots of urine
• Scalp hair present
18
9
24 weeks
• Weighs 780 g ( 1 lb 10 oz) & 23 cm
long
• Termed viable
39
17
)
32 weeks
• Forming muscle
• Subcutaneous fat is being laid
down
• Most lanugo sheds off
:8
28 weeks
• Baby is 2/3 birth size
• Final stage of fetal lung
development occurring
• Can blink
Fo
su
(ID
38+ weeks
• Baby fills total uterus
• Organs functional
• Reflexes active
to
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19
ed
• Presumptive
Li
ce
ns
• Subjective
• Felt by the woman
• Can be due to other possible causes
• Probable
• Objective
• Observed by an examiner
• Can be due to other possible causes
• Positive
• Diagnostic
• Attributed only to the presence of the fetus
20
10
• Amenorrhea at 4 weeks
39
17
)
• Nausea and vomiting
• Urinary frequency
• Breast tenderness
Fo
su
(ID
• Fatigue
:8
• Quickening
to
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vis
21
Li
ce
ns
ed
• Goodell’s sign (softening of the cervical tip) at 5 weeks
• Hegar’s sign (softening and compressibility of lower uterine
segment) at 6-12 weeks
• Chadwick’s sign (Purple vaginal mucosal) at 6-8 weeks
• Enlargement of the abdomen
• Braxton hicks
• Uterine souffle (sound made by uterine arterial blood
synchronous with maternal heart rate)
• Skin changes
• Ballottement at 16-28 weeks
• Clinical and OTC pregnancy tests
• Palpation of the fundus
22
11
• Fetal heartbeat
• Via Doppler at 8-17 weeks
• Via Fetoscope at 17-19 weeks
:8
Fo
su
(ID
• Visualization of fetus by ultrasound
• Gestational sac at 4-5 weeks
• Fetal parts and heart movement at 8 weeks
• Vaginal probe can detect gestational sac at 10 days
after implantation
39
17
)
• Fetal movement detected by a trained examiner after
20 weeks
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23
1st trimester
1-2 kg
2nd trimester
0.5 kg per week
3rd trimester
0.5 kg per week
( 1 – 1.3 lbs)
Total weight gain
12.5 – 18 kg
(28 – 40 lbs)
0.5-2 kg
(1.1 – 4.4 lbs)
0.4 kg per week
0.4 kg per week
(0.8 – 1 lbs)
11.5 – 16 kg
(25 – 35 lbs)
1-2 kg
0.3 kg per week
1-2 kg
0.2 kg per week
0.3 kg per week
(0.5 – 0.7 lbs)
0.2 kg per week
(0.4 – 0.6 lbs)
7 – 11.5 kg
(15 – 25 lbs)
5 – 9kg
(11 – 20 lbs)
Li
ce
Underweight
women
BMI <18.5
ns
ed
Women who are underweight have increased weight gain in the 2nd & 3rd trimesters. Women who
are overweight have decreased weekly weight gain in the 2nd & 3rd trimesters.
Normal weight
women
BMI: 18.5-24.9
Overweight women
BMI: 25-29.9
Obese women
BMI > 30
24
12
Fo
su
(ID
:8
39
17
)
On average, total
maternal weight
gain is
distributed to
the following
areas:
to
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25
Chart: Adapted from OpenStax College License
Download for free at http://cnx.org/content/col11496/latest/
Li
ce
ns
ed
Underweight pre-pregnancy
• Low birth weight infant
• Preterm labor
• Intrauterine growth restriction
Women with an eating disorder:
Women who are • Fetus lacks nutrients
underweight or
• Miscarriage
severely
• Low birth weight
overweight
before pregnancy • Premature birth
• Obstetric complications
have an
increased risk of • Perinatal mortality
developing
• Birth defects
complications
• Post partum depression
Pre-pregnancy
weight is an
important factor
for both mothers
and their babies.
Obese
pre-pregnancy
Obesity
• Gestational diabetes
• Gestational hypertension
• Preeclampsia
• Birth defects & birth trauma
• Emergency cesarean birth
• Fetal macrosomia
• Perinatal death
• Postpartum anemia & hemorrhage
• Child becoming obese when older
• Premature delivery
• Fetopelvic disproportion
• Wound, GI, & urinary tract
infections
26
13
• Potential causes:
inadequate dietary intake
& nausea
• Mothers who restrict their
diet during pregnancy are
limiting their intake of
important nutrients
leading to:
• Catabolism of fat stores
• Production of ketones,
leading to preterm
labor
• Potential causes: Multiple
gestation, excessive
dietary intake,
accumulation of fluids
(edema), gestational
hypertension,
preeclampsia, & pica
• Difficult to lose after
birth, leading to chronic
obesity and chronic
diseases
:8
39
17
)
Excessive weight gain
Fo
su
(ID
Inappropriate
weight gain during
pregnancy needs
to be evaluated
thoroughly
Inadequate weight gain
ed
to
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vis
27
Li
ce
ns
• Breasts increase in size over
the first 20 weeks
• Nodular
• Tingling sensations during 1st
and 3rd trimesters
• Darker pigmentation
• Prominent and dilated
superficial veins
• Multiparas display striae
• Montgomery’s tubercles
enlarge
• Colostrum may be present
after 12th week
• Secondary areola appear at 20
weeks
• Breasts become less firm
28
14
• Hypertrophy
39
17
)
• Increased estrogen and progesterone
• Thickening of uterine walls in early
pregnancy
• At end of pregnancy musculature thins
• At end of pregnancy
• Weighs ≈ 2.5lb
• Dimensions ≈ 28 x 24 x 21 cm
• Capacity of 5 L
Fo
su
(ID
:8
• In most cases, pregnancy will
“show” at 14 weeks
• Hegar’s sign: softening of the
isthmus of the uterus
to
Na
vis
29
ns
ed
• Ballottement: technique to identify passive
movements of the unengaged fetus. Examiner
feels the rebound movements of the fetus
Li
ce
• Quickening: fetal movements generally
described as a fluttering
• Uterine souffle: soft blowing sound made by
blood in the uterine arties. It is in synch with
the maternal pulse
• Funic souffle: soft blowing sound made by
blood rushing through the umbilical vessels. It
is in synch with the fetal heart rate
Braxton Hicks contractions
• Irregular uterus contractions
• Painless yet annoying
• Often stop with walking or exercise
• Help stimulate blood movement in
the placenta
• Occur throughout pregnancy,
increasing in late pregnancy
• Do not increase in intensity or
duration or cause cervical dilation
• Not to be confused as premature
labor
30
15
At 12 weeks, the uterus
is the size of a grapefruit
Fo
su
At 10 weeks, the uterus is
the size of an orange
(ID
:8
39
17
)
At 7 weeks gestation,
the uterus is the size
of a large hen’s egg
to
Na
vis
31
ed
• Chadwick’s sign
Li
ce
ns
• Blue-purple discoloration of vaginal mucosa and cervix due
to increased vascularization
• Goodell’s sign
• Softening of cervix due to increased vascularization
• Mucous plug
• Estrogen stimulates endocervical glands
• Seals endocervical canal, prevents bacteria from entering
• Expelled when cervical dilation begins
32
16
• pH becomes more acidic due to increased lactic acid
• Helps to prevent some infections
• More vulnerable to yeast infections
39
17
)
• Increased vascularity
• Increased sensitivity – increasing sexual arousal in 2nd trimester
• Leukorrhea
(ID
• White-gray mucoid discharge
:8
• Edema and varicosities of vulva
• Faint musty odor
Fo
su
• Due to estrogen and progesterone
• Never pruritic or blood stained
•
•
•
ed
ns
•
•
•
•
Uterus compresses pelvic blood vessels
slowing venous return
Varicose veins
Hemorrhoids
Increased blood volume ≈ 40-50%
To manage demands of fetal nourishment
and fetal waste removal
Increased cardiac output ≈ 30-50%
Systolic blood pressure: slight or no decrease
Diastolic blood pressure: slight decrease at
24-32 weeks, and returns gradually by
delivery
Li
ce
•
to
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vis
33
•
•
•
•
•
•
•
•
•
Between 14-20 weeks gestation to term
Pulse increases 10-15 beats/min
Significant increase with twin gestations
Red blood cell mass: increases
Hemoglobin: decreases
Hematocrit: decreases
Possible slight cardiac hypertrophy
Displaced diaphragm elevates heart and
rotated forward to the left
White blood cell count increases in 2-3rd
trimesters
34
17
• Respiratory rate: unchanged or slightly
increased
• Increased blood flow leads to swelling of
respiratory mucosa
• Nasal congestion
• Vital capacity: unchanged
• Nose bleeds
• Expiratory reserve volume: decreased
• Growing uterus exerts upward pressure on
diaphragm
• Shortness of breath or dyspnea
:8
• Inspiratory capacity: increased
39
17
)
• Tidal volume: increases 30-40%
• Total lung capacity: unchanged or slightly
decreased
(ID
• Once lightening occurs, dyspnea is
normally relieved
Fo
su
• Oxygen consumption increases 20-40%
to
Na
vis
35
• Urinary stasis
ns
ed
• Urinary changes are most problematic during first and third
trimester
Li
ce
• Urine flow rate slows due to anatomical changes of
pregnancy
• Increased risk of urinary tract infections
• Increased urine production
• Mother excretes both maternal and fetal wastes
• Frequent urination
• Downward pressure of uterus compresses bladder
• Nocturia & urgency
36
18
Related to increased hormone levels
Linea nigra: Pigmented line from symphysis pubis to the top of fundus
39
17
)
Chloasma : “mask of pregnancy” facial melasma. Blotchy, brownish
hyperpigmentation of the skin on face. More common in dark skinned
women
Palmar erythema: Pinkish mottling/blotches on palmar surfaces of hands
(ID
:8
Striae gravidarum: Stretch marks on lower abdomen. Fade after delivery
Fo
su
Spider angiomas: tiny star shaped dilated arterioles found on neck, thorax, face
and arms. Resulting from elevated circulating estrogen. Usually disappear after
birth
to
Na
vis
37
Image of Spider Angiomas: Herbert License
ed
• Postural changes
ns
• Changes center of gravity
Li
ce
• Accentuated lumbodorsal spinal curve (lordosis) &
compensatory curvature in the cervicodorsal region
• To compensate for weight of uterus
• Back pain
• Aching, numbness, & weakness of upper extremities
• Waddling gait
• Hormonal changes cause relaxation of sacroiliac,
sacrococcygeal, and pubic joints of pelvis
Image of Lordosis: OpenStax License
38
19
• Vasomotor instability, postural
hypotension or hypoglycemia can
lead to:
• Light-headedness
39
17
)
• Faintness
• Edema compressing median
nerve beneath the carpal
ligament of the wrist
• Carpal tunnel syndrome
• Paresthesia and pain
• Sleep disturbances
• Fatigue
• Sensory changes in legs
• Compression of pelvic
nerves
• Vascular stasis form
enlarged uterus
• Syncope
• Anxiety and uncertainty
• Traction of the brachial plexus
• Acroesthesia (numbness and
tingling of the hands)
Fo
su
• Stoop-shouldered stance
(ID
:8
• Tension headaches
to
Na
vis
39
•
• Pressure of growing uterus on the
stomach + smooth muscle relaxation
due to elevated progesterone
• Gastric reflux and heartburn
(pyrosis)
• Abdominal discomfort
Alterations in taste and
smell
• Impaired appetite
• Food cravings
•
Gum tissue becomes hyperemic,
softened, and bleeds with minor trauma
Increased secretion of saliva (ptyalism)
Progesterone levels decrease gallbladder
emptying time
• Bile salts retained
• Leading to pruritus
Li
ce
ns
ed
• Constipation & bloating
• Decreased intestinal peristalsis
• Morning sickness – nausea and
vomiting
• Pregnancy related hormones
• Decreased intestinal peristalsis
•
•
40
20
• ↑ Thyroid gland size and
activity
Hormonal activity:
• Several hormones are released and are required to
maintain pregnancy
• Fertilized ovum and chorionic villi produce human
chorionic gonadotropin
• Most hormones are initially produced by corpus
luteum until the placenta takes over
• ↑ Parathyroid gland size and
activity
39
17
)
• Adrenal glands
• Cortisol
• Aldosterone
Pancreatic and Pituitary Hormones
• FSH and LH
• Vasopressin
• Thyrotropin
• Estrogen
• Adrenotropin
• Progesterone
• Prolactin
• Human chorionic
• Oxytocin
somatomammotropin
:8
• Pancreas
(ID
• Increased insulin needs
Fo
su
• Islets of Langerhans
become stressed to meet
this increased demand
Na
vis
41
ed
to
First
Trimester
Breast tenderness
ns
• Well-fitted supportive bra
• Avoid odors, causative factors, greasy &
seasoned foods
Li
ce
• Wash with warm water and keep dry
Nausea and vomiting (morning sickness)
• Eat dry crackers or toast before getting
out of bed
• Increase fluids during day
• Acupressure, wristbands, ginger, vitamin
B6 (with doxylamine)
Urgency and frequency of urination
• Void when urge is felt
• Decrease fluids before bed
Languor, malaise, fatigue
• Small frequent meals
Ptyalism
• Plan rest or nap time
• Astringent mouthwash
• Seek support with ADL’s
• Chewing gum or hard candy
42
21
First
Trimester
:8
(ID
Fo
su
Leukorrhea
• Daily bathing and proper hygiene practices
• Avoid: douching, nylon underwear, pantyhose
• Wear cotton underpants
• Apply powder
39
17
)
Gingivitis and epulis
• Eat well balanced diet
• Brush teeth gently and follow good dental hygiene
Nasal stuffiness and epistaxis
• Cool-air vaporizer/humidifier
• Normal saline nose drops
• Avoid nasal sprays and decongestants
ed
to
Na
vis
43
Li
ce
ns
Pruritus
• Keep fingernails short
• Comfort measures:
baths, oils, & lotions
Palpitations
• Contact HCP if
accompanied with signs
of cardiac
decompensation
Supine hypotension and
bradycardia
• Side-lying/semi-sitting
posture with knees
flexed
Food cravings
• Satisfy (unless unsafe)
Faintness and syncope
• Moderate exercise
• Avoided sudden
changes and triggering
environments
• Deep breathing
Second
Trimester
Heartburn
• Limit gas
producing/aggravating
foods
• Sip milk
• Drink hot herbal tea
Constipation
• 8-10 glasses of water
per day
• Moderate exercise
• Bowel schedule
44
22
Second
Trimester
Fo
su
(ID
Round ligament pain
• Squatting or bringing
knees to chest
• Heat
Joint pain, backache, pelvic
pressure, hypermobility of
joints
• Good posture/body
mechanics
• Low-heeled shoes
• Conscious relaxation
and rest
• Firm mattress
• Heat or ice packs
• Pelvic rock exercises
39
17
)
Headaches
• Conscious relaxation,
rest, and massage
• OTC analgesics (check
with HCP)
Carpal tunnel syndrome
• Avoid aggravating hand
movements
• Use splint as prescribed
• Elevate affected arm
:8
Flatulence, bloating
• Chew slowly and thoroughly
Varicose veins
• Avoid lengthy standing,
or sitting, constipation
• Rest with legs and hips
elevated
• Wear compression hose
• Warm sitz baths for
hemorrhoids
Periodic numbness
• Maintain good posture
• Supportive bra
Urinary frequency and
urgency return
• Empty bladder
regularly
• Kegel exercisers
• Perineal pads
Perineal discomfort and
pressure
• Reassurance and rest
• Good posture
Li
ce
ns
ed
Shortness of breath and
dyspnea
• Sleep propped up on
pillows
• Proper sitting/standing
posture
Insomnia
• Conscious relaxation
• Back
massage/effleurage
• Supportive pillows
• Warm milk/warm
shower before bed
to
Na
vis
45
Braxton Hicks contractions
• Reassurance and rest
• Change position
• Breathing techniques
Third
Trimester
Leg cramps
• Check for signs of DVT,
if negative: apply heat
and massage muscle
• Dorsiflex foot to
relieve spasm
Ankle edema
• Foot dorsiflexion
exercises following
prolonged sitting or
standing
• Elevate legs
• Avoid restrictive bands
around legs
• Ample fluid intake
46
23
Third trimester
Period of radiant
health
Period of watchful
waiting
Baby becomes more
real to women as she
notices abdomen size
increasing and fetal
movements
Begins thinking of
baby as separate being
Grasping idea of
pregnancy
May be ambivalent or
anxious
Remains self centered
Fears well-being of
baby and herself
Fo
su
Becomes more
introspective
May be restless,
uneasy, and impatient
:8
Period of adjustment
(ID
First trimester
39
17
)
Second trimester
ed
to
Na
vis
47
ns
Warning signs of psychological problems during pregnancy
Li
ce
• Increasing anxiety
• Depression or increasing
sadness
• Inability to communicate
• Inappropriate responses or
actions
• Denial of pregnancy
• Inability to cope with stress
• Intense preoccupation with the
sex of the baby
• Failure to acknowledge
quickening
• Failure to plan and prepare for
baby
• Indications of substance abuse
Provide
support and
counselling
Refer to
appropriate
personal
48
24
• Libido often decreases in 1st
trimester and increases in 2nd
trimester
39
17
)
• No medical reason to limit sexual
activity, unless:
• Membranes are ruptured
:8
• Premature dilation of cervix
Fo
su
(ID
• Placenta previa diagnosed
• Uterine cramping or vaginal
bleeding occur
to
Na
vis
49
ed
Recommended frequency of prenatal visits
for an uncomplicated pregnancy:
Li
ce
ns
• Every 4 weeks for the first 28 weeks of
gestation
• Every 2 weeks from 28-36 weeks gestation
Supplementation
Nutrition
• After 36th week, every week until
childbirth
Medication
Vaccination
50
25
Folic acid supplement
• Prevent neural tube defects
39
17
)
• Should be taken prior to pregnancy
(ID
• To correct physiologic anemia of pregnancy (a
normal adaptation)
• 30mg of ferrous iron daily starting by 12 weeks
:8
Iron supplements
Fo
su
• Should still consume food sources in daily diet
to
Na
vis
51
ns
ed
• Besides folate and iron, nutrients
required for pregnancy can be met
through dietary sources
A pregnant woman’s diet must include:
• Calcium
• Magnesium
• During 2nd and 3rd trimester the mom
should consume an additional 300 kcal
calories per day
• Potassium
Li
ce
• Energy requirements during first
trimester are unchanged
• Sodium
• Zinc
• Vitamins A, D, E, K
• Pyridoxine (Vitamin b6)
• Vitamin C
• Vitamin B 12
52
26
Foods to Avoid:
39
17
)
• Herbs: blue cohosh, black cohosh, chamomile,
valeria, comfrey, dong quai, ephedra, goldenseal,
ginkgo biloba, ginseng, horehound, fresh
horseradish.
• High mercury levels can damage the nervous
system of fetus
Fo
su
(ID
:8
• Avoid fish high in mercury (shark, swordfish,
king mackerel, and tilefish)
ed
to
Na
vis
53
Li
ce
ns
Listeria bacteria can lead to listeriosis, increasing risk of miscarriage,
premature birth and stillbirth
• Avoid unpasteurized milk or products (e.g. brie, camembert, soft
Mexican cheeses & homemade ice cream )
• Hot dogs, luncheon meats, bologna, and deli meats can only be
eaten if reheated to steaming hot
• Avoid deli/store made salads with egg, chicken, ham, and seafood
Salmonella
• Avoid foods with raw or lightly cooked eggs
• Cake batter, cookie dough, homemade eggnog, Caesar salad
dressing & hollandaise sauce
54
27
• Pregnant women should avoid all
medications, if possible
• If medication is required, the
benefits must outweigh the risks
• Women must check with HCP
before taking any medication
• Many medications are associated
with teratogenic effects
• Worst effect on fetus during
the first trimester
Category A: no associated fetal risk
Category B: animal studies show no risk and no
studies done on women. Or animal studies show a
risk but human studies show no risk. E.g. penicillin's
39
17
)
Category C: no adequate studies, animal studies
show teratogenic effects but no controlled studies in
women have been done. Many drugs are in this
category
(ID
:8
Category D: human fetal risk exists. In some
situations, benefits outweigh the risks. E.g.
tetracycline, Vincristine, lithium, hydrochlorothiazide
Fo
su
Category X: fetal risks outweigh any possible benefit
E.g. Accutane
ed
to
Na
vis
55
• Alcohol
• Chemotherapy and radiation therapy
• Caffeine
Li
ce
ns
Adversely affects the growth and
development of fetus
• Cleaning agents, herbicides, and
pesticides
• Tobacco
• Low birth weight infants, preterm
labor, PROM, abruptio placentae,
placenta previa, and fetal death
• Cocaine and other illicit substances
• Fetal alcohol syndrome
• High intake linked to
spontaneous abortion and low
birth weight
• Limit caffeine intake to 300
mg/day
• Marijuana
• Low birth weight, developmental
defects
56
28
• Many immunizations can cause teratogenic effects
• Women of childbearing age should ideally receive vaccinations prior to
becoming pregnant
Fo
su
(ID
:8
39
17
)
• Immunizations with live/attenuated live viruses are contraindicated during
pregnancy
• Measles and rubella
• Chickenpox and mumps
• Varicella-zoster
• Smallpox
• Human papilloma virus
• Vaccinations that are safe during pregnancy are:
• Tetanus, diphtheria, recombinant hepatitis B, inactivated influenza
vaccines, and vaccination against COVID-19
to
Na
vis
57
Li
ce
ns
ed
Assessment of fetal development:
• Quickening
• Fetal heartbeat
• Ultrasound
Assessment of pelvic adequacy:
• Pelvic inlet
• Pelvic cavity (mid-pelvis)
• Pelvic outlet
Routine Laboratory tests:
• Clean catch urine test:
• Glucose, protein, nitrates,
leukocytes
• Bloodwork for chromosomal
abnormalities
• Blood glucose levels drawn
• GBS screening test
Image of Woman: Daniel Lobo License
58
29
1st
2nd
• Fundal height is measured routinely to determine uterine
enlargement
3rd
39
17
)
• By 12-14 weeks: palpated above symphysis pubis
• By 22-24 weeks: at the level of umbilicus
• From weeks 18-32 the height of the fundus in cm is approximately the same as the
number of weeks of gestation (give or take 2 weeks)
(ID
• At term fundal height reaches xiphoid process
:8
• E.g. A women who is 28 weeks gestation should have a fundal height of 26-30cm
• Lightening occurs, descent and engagement of fetus, which decreases fundal height
Fo
su
• 2 weeks before labor in nullipara and at the start of labor in multipara
to
Na
vis
59
Chart: Adapted from OpenStax College License
Download for free at http://cnx.org/content/col11496/latest/
• Height of uterus above the symphysis pubis
2nd trimester
• Establish or confirm
EDB & viability
• Detect
polyhydramnios or
oligohydramnios
• Detect congenital
anomalies
• Detect IUGR
• Assess placental
location
• Use for visualization
during
amniocentesis
Li
ce
ns
ed
1st trimester
• Confirm pregnancy &
viability
• Determine gestational age
• Rule out ectopic pregnancy
• Detect multiple gestation
• Determine cause of vaginal
bleeding
• Use for visualization during
chorionic villus sampling
• Detect maternal
abnormalities: bicornuate
uterus, ovarian cysts,
fibroids
3rd trimester
• Confirm gestational age & viability
• Detect macrosomia or congenital
anomalies
• Detect IUGR
• Determine fetal position
• Detect placenta previa or placental
abruption
• Use for visualization during
amniocentesis external version
• Biophysical profile
• Amniotic fluid volume
• Doppler flow studies
• Detect placental maturity
60
30
Percutaneous umbilical cord
sampling (PUBS)
39
17
)
Also called cordocentesis
Obtains pure fetal blood
from the umbilical cord of
the fetus while in utero
Used for blood sampling and
transfusion
Indicated for diagnosis of
fetal blood disorders
All 3 tests are invasive, with
associated fetal and
maternal complications.
Many parents will decide
on abortion following the
results of the test
(ID
:8
Chorionic villus sampling
Used for the same reasons
as amniocentesis
Sample of chorionic villi
from the edge of the
developing placenta
Performed at 10-12 weeks
gestation
Woman is placed in
lithotomy position for
transcervical procedure
Woman is placed in supine
position for transabdominal
procedure
Fo
su
Amniocentesis
Procedure for genetic testing
diagnosis
Needle is inserted through
maternal abdomen to maintain
amniotic fluid
Performed between 15-20 weeks
gestation
Indicated in women: older than
35, have a child with or family
history of certain birth defects, or
have other abnormal genetic
testing results
Place women on left side during
procedure
to
Na
vis
61
Li
ce
ns
ed
Severe vomiting: hyperemesis gravidarum, hypertension, pre-eclampsia
Chills, fever, diarrhea: infection
Dysuria: urinary tract infection
Vaginal bleeding: miscarriage, ectopic pregnancy, placenta previa, or abruptio placentae,
cervical or vaginal lesion, “bloody show”, cervical or vaginal infection
Sudden discharge of fluid from vagina (before 37 weeks): premature rupture of membranes
(PROM)
Abdominal pain: miscarriage, premature labor, abruptio placentae
Severe backache or flank pain: kidney infection/stones or preterm labor
Any unusual change in fetal movements: fetal jeopardy/distress, intrauterine fetal death,
maternal medication, or obesity
Glycosuria and positive glucose tolerance test reaction: gestational diabetes mellitus
62
31
Hypertensive conditions, preeclampsia:
Fo
su
(ID
:8
39
17
)
• Visual disturbances (blurring, double vision, spots)
• Swelling of face or fingers and over sacrum
• Headaches (severe, frequent, continuous)
• Muscular irritability or convulsions
• Epigastric or abdominal pain
to
Na
vis
63
ns
ed
Many pre-existing conditions place
mom at an increased risk for
complications:
Li
ce
• Diabetes mellitus
• Maternal phenylketonuria (PKU)
• Cardiovascular disorders
• Anemia
• Pulmonary disorders
• Neurologic disorders
• Autoimmune disorders
• Substance abuse
• Thyroid disorders
• Requires close monitoring
• Careful management from
multidisciplinary health team
• Explain risks and complications to
both mother and baby
• Goal is to achieve optimal outcomes
for both the pregnant woman and
the fetus
• Medications may need to be altered
64
32
• Requires increased weight gain
• 17-25 kg (37.4 – 55lb) total weight gain
for twin gestation
Fo
su
(ID
:8
Image of Twins: Christina T3 License
• Women carrying triplets+ may be placed on
bedrest beginning at 20 weeks
Increased risk of adverse outcomes
• Anemia
• Placenta previa
• PROM
• Premature delivery
• Cesarean delivery
• Abnormal presentations
• Miscarriage
• Neonatal morbidity and mortality
• Congenital malformations in
monozygotic twins
• Twin-to-twin transfusion
• Distress/asphyxia during birth
• Cerebral palsy
39
17
)
• Pregnancy with more than one fetus
to
Na
vis
65
ed
• The following factors increase likelihood of multifetal pregnancy
ns
• Fertility-enhancing medications and procedures
• Older age (35+ years)
Li
ce
• History of dizygotic twins in female lineage
• Rapid uterine growth
• Polyhydramnios
• Palpation of more than the expected number of parts
• Asynchronous/more than one fetal heartbeat detected
• Ultrasound detection
• With the presence of more than 3 fetuses, parents may seek selective reduction of one of
the fetuses to improve the odds of the remaining fetuses
Image of Twins: Kevin Dufendach License
66
33
• Fetal complications:
• Low birth weight
• Preterm birth
• Long-term serious disabilities
• Dying during first year of life
Many adolescents are not ready for the
emotional, psychosocial, and financial
responsibilities of pregnancy, and most do
not have adequate prenatal care
:8
• Additional risks associated with adolescent
pregnancy:
• Eating disorders
• Smoking during pregnancy
• Postpartum depression
• Sexually transmitted infections
• Alcohol and drug use during pregnancy
Fo
su
(ID
• Maternal complications:
• Inadequate weight gain during
pregnancy
• Preeclampsia-eclampsia
• Iron deficiency anemia
39
17
)
• Developmentally immature
• Pregnancy impedes on adolescents’
psychological development
• Mother and fetus compete for nutrients
• Pelvis is not fully developed
• Cephalopelvic disproportion
to
Na
vis
67
Li
ce
ns
ed
At risk for:
• Abruptio placentae
• Fetal malpresentation requiring C-section
• Multiple births
• Infertility
Infants at risk for:
• Low birth weight
• Premature birth
• Chromosomal abnormalities
• Down syndrome and trisomy 18
Increased maternal mortality due to:
• Hemorrhage
• Infection
• Embolism
• Hypertension
• Cardiomyopathy
• Stroke
Tend to be:
• Better educated
• Have a career and higher income
68
34
Definition:
• Fertilized ovum implanted outside
uterine cavity
• Sometimes in abdominal cavity,
ovary, or cervix
• Delayed menses
• Abnormal vaginal bleeding 6-8
weeks after LMP
to
Na
vis
69
Fo
su
• Abdominal pain
(ID
:8
3 classic symptoms:
Prognosis:
• Embryo does not survive in tubal
ectopic pregnancy
• 5% of fetus’s reach viability in
abdominal ectopic pregnancy
Treatment:
• Methotrexate is the medication of
choice used to dissolve the tubal
pregnancy
39
17
)
• Most cases are in the uterine tube
ed
Gestational trophoblastic disease:
Li
ce
ns
• Instead of embryo developing, cells form a benign proliferative growth
called a hydatidiform mole
• Grapelike cluster of fluid-filled vesicles
• Grow rapidly, causing the uterus to enlarge
• Women may believe they are pregnant as abdomen enlarges
Treatment:
• Most moles abort spontaneously
• May require suction curettage to remove growth
70
35
Preterm labor (before 37 weeks)
• Uterine contractions (every 10
minutes lasting 1 hour)
• Dull low backache
• Suprapubic pain or pressure
• Change in character or amount of
vaginal discharge
• Diarrhea
Fo
su
• Leaking of water from vagina
(ID
• Painful menstrual-like cramping
:8
39
17
)
• Pelvic pressure or heaviness
Interventions:
• Clients should be educated on the symptoms
of preterm labor and the need to seek
medical attention
• Women at risk for preterm birth may need to
restrict sexual activity and modify physical
activity levels
Pharmacological Interventions:
• Tocolytics used to arrest labor after uterine
contractions have occurred. Used to delay
birth so that interventions to reduce neonatal
morbidity may be administered (such as lung
surfactant)
ns
Proteinuria
Preeclampsia
Seizure
Eclampsia
Li
ce
BP increase
after 20
weeks
gestation
ed
to
Na
vis
71
Preeclampsia
72
36
Mild preeclampsia
Severe preeclampsia
Blood pressure ≥ 160/110 for
two readings, 6 hours apart,
while on bedrest
Proteinuria ≥ 300 mg in a 24hour specimen
Proteinuria ≥ 5 g in a 24-hour
specimen
Fo
su
(ID
HELLP syndrome
:8
39
17
)
Blood pressure ≥ 140/90
For two readings, 4-6 hours
apart, within a 1 week period
Eclampsia
Image of BP Cuff: Medisave UK License
to
Na
vis
73
Seizure or coma
that occurs
before or during
labor, or early in
postpartum
period
Li
ce
ns
ed
HELLP Syndrome: a condition of severe pre-eclampsia involving
hepatic dysfunction, and is defined by the following laboratory
diagnostics:
Hemolysis, Elevated Liver enzymes, Low Platelet count
The woman with HELLP syndrome does
not always display symptoms of
preeclampsia and is often misdiagnosed.
The only known cure for pre-eclampsia is
birth of the infant
74
37
Keep airway patent: turn head
to one side, place pillow under
shoulder/back if possible
Expedite ordered blood work, provide hygiene,
support, and a quiet environment
Insert indwelling urinary catheter and monitor blood pressure
Monitor fetal, uterine, and cervical status
Birth may be imminent
Raise bed side rails
Pad side rails if possible
Maintain IV access and start IV fluids
Administer ordered anticonvulsant drug (magnesium sulfate)
:8
Fo
su
Do not leave client after seizure
Asses postictal state & ABC’s
to
Na
vis
75
Suction secretions as needed
Insert oral airway if needed
Admin O2 by nonrebreather face
mask at 10 L/min
(ID
Observe and
record convulsion
activity
39
17
)
Call for help
Do not leave bedside
ns
ed
Assessment used to determine worsening preeclampsia or magnesium sulfate toxicity
Assessment
4+
Hyperactive, very brisk, jerky, clonus abnormal
3+
Brisker than average, may not be abnormal
2+
Average response, normal
1+
Diminished response, low normal
0
No response – abnormal
Li
ce
Rating
Hyperreflexia,
CNS irritation
Magnesium
toxicity
76
38
•
•
39
17
)
•
•
:8
•
(ID
•
Naegele’s rule is the most common method for determining estimated date of birth (EDB)
using women's last mental period (LMP)
Conception involves the development of the embryo and associated structures: amniotic
sac, placenta, and umbilical cord
Oligohydramnios, polyhydramnios, placenta previa, and abruptio placentae are
abnormalities in conception
Sex of the fetus can be identified around 16 weeks gestation
The signs of pregnancy are presumptive (subjective), probable (objective), and positive
(diagnostic)
Average total weight gain for a normal weight woman is 25-35 lbs
Pregnancy involves many normally occurring changes to woman’s breast, uterus, cervix,
vagina, vulva, skin, cardiovascular system, respiratory system, renal system, musculoskeletal
system, neurological system, gastrointestinal system and endocrine system
Fo
su
•
to
Na
vis
77
ed
• There are many nonpharmacological and pharmacological interventions that can be
suggested to women experiencing common discomforts during the 3 trimesters
Li
ce
ns
• There are normal expected changes to a women’s psychological well-being, and it is
important for the nurse to be aware of psychological warning signs
• Prenatal care is important to ensure a successful pregnancy
• There are many foods, medications, and vaccinations that must be avoided during pregnancy
• Fundal height is an important factor to assess during an obstetrical exam
• Many factors and conditions predispose women to having a high-risk pregnancy or
complications
• Adolescents and women over 35 years old are considered high risk pregnancies
• Preeclampsia involves blood pressure increases and proteinuria
• Eclampsia occurs when a seizure/coma happens in women with existing preeclampsia
78
39
1. Davidson MC, London M, Ladewig P. (2020). Old’s Maternal-Newborn &
Women’s Health Across the Lifespan (11th edition). Pearson.
39
17
)
2. Hockenberry MJ, Wilson D. (2019) Wong’s Nursing Care for Infants and
Children (11th edition). Mosby.
:8
3. Lowdermilk DL, Perry SE, Cashion MC, Alden KR, Olshansky E. (2020).
Maternity and Women’s Health Care. (12th edition). Mosby.
Fo
su
(ID
4. Perry SE, Hockenberry MJ, Lowdermilk DL, Wilson D, Alden KR, Cashion
MC. (2018). Maternal Child Nursing Care. (6th edition). Mosby.
Li
ce
ns
ed
to
Na
vis
79
40