Pregnancy
Content
NORMAL PREGNANCY Pregnancy - a time of enormous change in a woman’s body and mind - the changes affect the physical well-being, self-esteem, interactions with other, daily activities and future plans R.N.’s role: form a professional bond with the pregnant client and offer impartial and accurate information that will guide her 9-month journey : Nurse-Client Relationship: “ safe haven” for pregnant women : how pregnancy and birth of newborn will affect her ADLs (activities of daily living), her relationship with other and her interaction with her HC providers Signs of Pregnancy: > Now, women prefer to use an over-the-counter pregnancy test at the 1st hint of pregnancy and later ask final confirmation from their HC provider 1. Presumptive Signs (Subjective signs) > are suggestive of pregnancy > signs that are caused by other conditions > do not establish a diagnosis of pregnancy > 1st few weeks of pregnancy, the pressure exerted on the bladder by the enlarging of the uterus causes urinary frequency > 2nd trimester, uterus grows into the abdomen, somewhat relieving the pressure > late in pregnancy, as the fetus grows and descends into the pelvis, urinary frequency returns > urinary frequency is not always caused by the changes of pregnancy (assess also for signs of infection) • Amenorrhea - absence of menses for 3 or more months - first sign to alert a woman to a possible pregnancy - affected by the following factors: (stop regular periods) * excessive exercise * emotional stress * chronic disease states * onset of menopause * use of oral contraceptives - its cause should be assessed and validated • Nausea and Vomiting - can appear after the 1st missed period and continue into the 4th month of pregnancy - “morning sickness” - can occur at any time of the day - causes: (not clear) * levels of hormones * emotional factors * noxious smells * irregular eating schedules * fatigue • Fatigue of Pregnancy - need for rest and sleep - very distressing
- causing client to be tired or drowsy after a normal day during pregnancy than she was after a normal day before she became pregnant • Changes in breasts - breasts swell and become tender - caused by: * amounts of estrogen and progesterone - initial changes in breasts is similar to changes in menstrual cycle - as the pregnancy progresses, the tenderness subsides, but growth of breast tissue continues Quickening - woman’s first awareness of fetal movement - movement: is described as a fluttery feeling (excited or having butterflies) - initially felt between 18 & 20 weeks of gestation, but may be felt by the multigravida as early as 16 weeks - documented date of 1st fetal movement can be used in conjunction with other data in determining the expected date of pregnancy 2. Probable Signs (Objective Signs) > can be documented by physical examination and there are signs that are most often only the seen during pregnancy > findings could also be caused by other conditions > do not establish a diagnosis of pregnancy > 8 to 10 weeks’ gestation, the bimanual pelvic examination will document an enlarged and softened uterine body > uterine enlargement is more definitive if the growth is progressive > 10 to 12 weeks, fundus is above the symphysis pubis > by 20th week, fundus is at the umbilicus >abdominal enlargement mirrors uterine growth and is evident earlier in the pregnancy of multigravida Nurse’s Role: alleviates her concerns by telling the client about the individuality of each pregnancy • Goodell’s sign - softening of the cervix (normally, cervix is firm) • Chadwick’s sign - color change from pink to bluish-purplish in the mucous membranes of the cervix, vagina and vulva - vascularization causes the color change and is attributed to the in estrogen • Hegar’s sgin - evident at 6 to 8 weeks’ gestation - softening of the isthmus of the uterus (lower uterine segment) • Ballotement - 4th or 5th month, if fetus is pushed upward through the vagina or abdomen the floating fetus rebounds against the examiner’s fingers - occurs while the fetus is small in comparison to the amount of amniotic fluid Pregnancy test - identify human chorionic gonadotropin (hCG) hormone, or a subunit, by detecting an anti-body to the hCG molecule in urine or serum - hCG hormone can be detected in maternal blodd at 7 days after conception with sensitive assays - exact hCG level can assist in dating the pregnancy - hCG is found in urine 3. Positive Signs > three physical findings that can establish a diagnosis of pregnancy > noted by the examiner
> 4 weeks’ gestation, normal pregnancy can be detected, using the last menstrual period (LMP) for dating > fetal brain and heartbeat can be visualized by 8 weeks’ gestation > use of trans-vaginal transducer - placed into the vagina is helpful when using ultrasound to confirm a pregnancy or seek pathology in obese women or to detect pregnancy in a complicated case - produces better visualization than abdominal ultrasound - can detect both early pregnancy and extra uterine structures (ectopic pregnancy or ovarian mass) > fetal heart rate can be detected via trans-vaginal ultrasound as early as 4 weeks’ gestation after conception • Fetal heart sound/heartbeat - can be auscultated with a fetoscope at 18 to 20 weeks - can be detected at 10 to 12 weeks with an electronic doppler - normal fetal HR is 120-160 beats/min - the earlier the fetal heartbeat is detected, the more likely is may be confused with other sounds that can be detected in pregnancy Uterine soufflé - sound made by the increased amount of the blood perfusion the uterus and mimics the maternal pulse Funic soufflé - sound heard as the blood flows through the umbilical cord • Fetal movement - detected by a qualified examiner and is a diagnostic of pregnancy - at 18 to 20 weeks’ gestation, movement is felt as a faint fluttering and progresses to rolling and kicking in the later 2nd and 3rd trimester - later gestation, movement can be seen on visual inspection of the abdomen • Visualization of the fetus during/use of ultrasound Ultrasound examination - accomplished by placing a transducer on the abdomen above the symphysis pubis Age of viability - 7 months To describe the parity: T - Term or # of full term (37 or up weeks, 9 months) P - Pre-term or pre-mature (not reaching full term) A - Abortion L - Living (# of children alive) M - Multiple pregnancy (kambal) e.g. Mrs. Dela Cruz pregnant for 36 weeks and this is her 6 th pregnancy. Had marriage of 2x, no premature delivery and 3 living == G6 P4 T3 - infants born after 37 weeks or at least 37 weeks P0 - infants born before 37 weeks’ gestation A2 L3 M0 *viability of 7 months means that the fetus reaches its full-term
To determine the Expected Date of Delivery/Confinement (EDD/EDC):: > trace the last menstrual period (LMP) or the 1st day of the last menstrual period > use the Naegel’s Rule to determine the expected date of delivery (EDD) or expected date of confinement (EDC) a.) LMP - 3 months + 7 days + 1 year (for April to December) EDD or EDC or b.) LMP + 9 months + 7 days for + 1 year (January to March) EDD or EDC To determine the Age of Gestation (AOG): # of days of the month - LMP + # of days of the succeeding months until the 1st day of the last pre-natal check-up Age of Gestation (AOG) e.g. LMP is April 05, 2004, Last pre-natal check-up is July 01, 2004. Determine EDD and AOG: > 04/05/2004 - 03/07/0001 01/12/2005 or January 12, 2005 (EDD) > April 30 days - LMP of 5 days 25 days May 31 June 30 July 31 days - 30 days not used 1 AOG 87 days SIGNS OF PREGNANCY Presumptive Signs > subjective in nature > definite diagnosis of pregnancy cannot be made because the signs and symptoms (S&S) are caused by other conditions > subjective > S&S cannot be determined by the examiner & document it > not sure that 100% mother is pregnant a. Amenorrhea - absence of menstruation & is caused by: > hormonal imbalance > stress Probable Signs > provide stronger evidence of pregnancy > can be documented by the examiner > objective Positive Signs
a. Abdominal enlargement a. Fetal heart - can be caused by other tone/sound/heart beat conditions > fluids in stomach > stretch marks (striae gravidarum) > hepatomegaly
Striae Gravidarum pinkish white or purplish lines that some women develop due to stretching of elastic tissues to its capacity b. Nausea & vomiting - b. Goodel’s sign - b. Fetal movement morning sickness and is softening of the cervix caused by: > gastritis, ulcer > indigestion c. Urinary frequency - c. Chadwick’s sign - color c. Visualization of fetus because of pressure to change from purplish to through ultrasound the bladder as the uterus bluish discoloration of the increase vagina d. Fatigue - because of d. Hegar’s sign - softening metabolic needs of of the lower uterine woman and fetus segments (LUS) of the uterus (-) not pregnant - tip of the nose (+) pregnant - earlobes then lips > to give way for the enlarging of fetus inside the uterus e. Breast changes - e. Ballotement firmness & tingling of breasts in preparation to lactation f. Quickening - fetal f. Mask of pregnancy movement felt by the “chloasma” or skin mother pigmentation in the neck, axilla, etc. g. Braxton Hick’s contractions - painless irregular uterine contractions h. (+) pregnancy test because in urine it will appear (+) for hCG, but still hCG may not indicate fetus…instead H-mole is present
- causing client to be tired or drowsy after a normal day during pregnancy than she was after a normal day before she became pregnant • Changes in breasts - breasts swell and become tender - caused by: * amounts of estrogen and progesterone - initial changes in breasts is similar to changes in menstrual cycle - as the pregnancy progresses, the tenderness subsides, but growth of breast tissue continues Quickening - woman’s first awareness of fetal movement - movement: is described as a fluttery feeling (excited or having butterflies) - initially felt between 18 & 20 weeks of gestation, but may be felt by the multigravida as early as 16 weeks - documented date of 1st fetal movement can be used in conjunction with other data in determining the expected date of pregnancy 2. Probable Signs (Objective Signs) > can be documented by physical examination and there are signs that are most often only the seen during pregnancy > findings could also be caused by other conditions > do not establish a diagnosis of pregnancy > 8 to 10 weeks’ gestation, the bimanual pelvic examination will document an enlarged and softened uterine body > uterine enlargement is more definitive if the growth is progressive > 10 to 12 weeks, fundus is above the symphysis pubis > by 20th week, fundus is at the umbilicus >abdominal enlargement mirrors uterine growth and is evident earlier in the pregnancy of multigravida Nurse’s Role: alleviates her concerns by telling the client about the individuality of each pregnancy • Goodell’s sign - softening of the cervix (normally, cervix is firm) • Chadwick’s sign - color change from pink to bluish-purplish in the mucous membranes of the cervix, vagina and vulva - vascularization causes the color change and is attributed to the in estrogen • Hegar’s sgin - evident at 6 to 8 weeks’ gestation - softening of the isthmus of the uterus (lower uterine segment) • Ballotement - 4th or 5th month, if fetus is pushed upward through the vagina or abdomen the floating fetus rebounds against the examiner’s fingers - occurs while the fetus is small in comparison to the amount of amniotic fluid Pregnancy test - identify human chorionic gonadotropin (hCG) hormone, or a subunit, by detecting an anti-body to the hCG molecule in urine or serum - hCG hormone can be detected in maternal blodd at 7 days after conception with sensitive assays - exact hCG level can assist in dating the pregnancy - hCG is found in urine 3. Positive Signs > three physical findings that can establish a diagnosis of pregnancy > noted by the examiner
> 4 weeks’ gestation, normal pregnancy can be detected, using the last menstrual period (LMP) for dating > fetal brain and heartbeat can be visualized by 8 weeks’ gestation > use of trans-vaginal transducer - placed into the vagina is helpful when using ultrasound to confirm a pregnancy or seek pathology in obese women or to detect pregnancy in a complicated case - produces better visualization than abdominal ultrasound - can detect both early pregnancy and extra uterine structures (ectopic pregnancy or ovarian mass) > fetal heart rate can be detected via trans-vaginal ultrasound as early as 4 weeks’ gestation after conception • Fetal heart sound/heartbeat - can be auscultated with a fetoscope at 18 to 20 weeks - can be detected at 10 to 12 weeks with an electronic doppler - normal fetal HR is 120-160 beats/min - the earlier the fetal heartbeat is detected, the more likely is may be confused with other sounds that can be detected in pregnancy Uterine soufflé - sound made by the increased amount of the blood perfusion the uterus and mimics the maternal pulse Funic soufflé - sound heard as the blood flows through the umbilical cord • Fetal movement - detected by a qualified examiner and is a diagnostic of pregnancy - at 18 to 20 weeks’ gestation, movement is felt as a faint fluttering and progresses to rolling and kicking in the later 2nd and 3rd trimester - later gestation, movement can be seen on visual inspection of the abdomen • Visualization of the fetus during/use of ultrasound Ultrasound examination - accomplished by placing a transducer on the abdomen above the symphysis pubis Age of viability - 7 months To describe the parity: T - Term or # of full term (37 or up weeks, 9 months) P - Pre-term or pre-mature (not reaching full term) A - Abortion L - Living (# of children alive) M - Multiple pregnancy (kambal) e.g. Mrs. Dela Cruz pregnant for 36 weeks and this is her 6 th pregnancy. Had marriage of 2x, no premature delivery and 3 living == G6 P4 T3 - infants born after 37 weeks or at least 37 weeks P0 - infants born before 37 weeks’ gestation A2 L3 M0 *viability of 7 months means that the fetus reaches its full-term
To determine the Expected Date of Delivery/Confinement (EDD/EDC):: > trace the last menstrual period (LMP) or the 1st day of the last menstrual period > use the Naegel’s Rule to determine the expected date of delivery (EDD) or expected date of confinement (EDC) a.) LMP - 3 months + 7 days + 1 year (for April to December) EDD or EDC or b.) LMP + 9 months + 7 days for + 1 year (January to March) EDD or EDC To determine the Age of Gestation (AOG): # of days of the month - LMP + # of days of the succeeding months until the 1st day of the last pre-natal check-up Age of Gestation (AOG) e.g. LMP is April 05, 2004, Last pre-natal check-up is July 01, 2004. Determine EDD and AOG: > 04/05/2004 - 03/07/0001 01/12/2005 or January 12, 2005 (EDD) > April 30 days - LMP of 5 days 25 days May 31 June 30 July 31 days - 30 days not used 1 AOG 87 days SIGNS OF PREGNANCY Presumptive Signs > subjective in nature > definite diagnosis of pregnancy cannot be made because the signs and symptoms (S&S) are caused by other conditions > subjective > S&S cannot be determined by the examiner & document it > not sure that 100% mother is pregnant a. Amenorrhea - absence of menstruation & is caused by: > hormonal imbalance > stress Probable Signs > provide stronger evidence of pregnancy > can be documented by the examiner > objective Positive Signs
a. Abdominal enlargement a. Fetal heart - can be caused by other tone/sound/heart beat conditions > fluids in stomach > stretch marks (striae gravidarum) > hepatomegaly
Striae Gravidarum pinkish white or purplish lines that some women develop due to stretching of elastic tissues to its capacity b. Nausea & vomiting - b. Goodel’s sign - b. Fetal movement morning sickness and is softening of the cervix caused by: > gastritis, ulcer > indigestion c. Urinary frequency - c. Chadwick’s sign - color c. Visualization of fetus because of pressure to change from purplish to through ultrasound the bladder as the uterus bluish discoloration of the increase vagina d. Fatigue - because of d. Hegar’s sign - softening metabolic needs of of the lower uterine woman and fetus segments (LUS) of the uterus (-) not pregnant - tip of the nose (+) pregnant - earlobes then lips > to give way for the enlarging of fetus inside the uterus e. Breast changes - e. Ballotement firmness & tingling of breasts in preparation to lactation f. Quickening - fetal f. Mask of pregnancy movement felt by the “chloasma” or skin mother pigmentation in the neck, axilla, etc. g. Braxton Hick’s contractions - painless irregular uterine contractions h. (+) pregnancy test because in urine it will appear (+) for hCG, but still hCG may not indicate fetus…instead H-mole is present
