Pregnancy

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Antepartal - pertaining to the period spanning conception and labor. Length of Pregnancy: A normal pregnancy lasts 280 days from your LMP which is about 266 days from conception to birth. The first two weeks of your pregnancy includes the time of your period, ovulation and fertilization. Conception occurs approximately 14 - 16 days after the first day of your period. The date of conception is not always known and can vary between women. The date of LMP is known by most women so doctors use this date as a starting point for pregnancy. From your LMP they will add 280 days and this will give your Estimated Due Date or EDD. In general, all doctors agree that pregnancies, when using the LMP dating technique, average approximately 280 days or 40 weeks.

Reproductive System Changes When you become pregnant, the part of your body affected first and the part that undergoes the most significant changes is the uterus. It increases to 20 times its original weight, and 1,000 times its initial capacity. The amount of its muscle, connective and elastic tissue, blood vessels, and nerves increases. Its shape changes from elongated to oval by the second month, to round by midgestation, then back through oval to elongated at term (the end of a normal nine-month pregnancy). The uterus softens beginning at the sixth week. It changes position as it increases in size, ascending into the abdomen by the fourth month and eventually reaching to the liver. It also becomes more contractile (the tendency to decrease in size), with irregular, painless Braxton Hicks contractions beginning in the first trimester. You may feel these contractions in the last weeks of pregnancy, when they are known as false labor. Other parts of the reproductive system change along with the uterus. The cervix and vagina have an increased blood supply, which causes a darkening in color apparent by the sixth week. The amount of elastic tissue increases to prepare the way for the stretching that will be required during delivery. Secretions increase, and a mucous plug develops in the cervix. The fallopian tubes, ovaries, and ligaments supporting the uterus all enlarge and elongate. The ovaries, of course, cease to ovulate. During the fourth month, the uterus grows into the abdomen, causing the abdominal wall to expand to accommodate it. The connective and elastic tissues stretch and straighten, creating thinned areas called striae (stretch marks). While the red of the striae may fade, silver remnants usually remain after delivery. In 50 percent of women, striae develop in the third trimester. Late in pregnancy, the internal pressure from the large uterus may even cause the muscles of the abdominal wall to separate (diastasis). Your breasts must undergo many changes during pregnancy to produce milk. In the first two months of pregnancy, your breasts may feel sore or full. They enlarge, and veins may become visible. Striae can develop. The nipples also increase in size and usually darken. By midpregnancy, colostrum (a thick, yellowish fluid) can be expressed, but milk is not produced until after delivery. Blood flow also changes during pregnancy, in order to satisfy your enlarged reproductive organs and feed your baby. Read about changes in the blood during pregnancy next.

CHANGES OF SELECTED GLANDS OF THE ENDOCRINE SYSTEM DURING PREGNANCY a. Parathyroid Gland. This gland increases in size slightly. It meets the increased requirements for calcium needed for fetal growth. b. Posterior Pituitary. Near the end of term, the posterior pituitary will begin to secrete oxytocin that was produced in the hypothalamus and stored there. It will serve to initiate labor. c. Anterior Pituitary. At birth, the anterior pituitary will begin to secrete prolactin. This stimulates the production of breast milk. d. Placenta. The placenta acts as a temporary endocrine gland during pregnancy. It produces large amounts of estrogen and progesterone by 10 to 12 weeks of pregnancy. It serves to maintain the growth of the uterus, helps to control uterine activity, and is responsible for many of the maternal changes in the body.

CHANGES OF THE GASTROINTESTINAL SYSTEM DURING PREGNANCY a. As mentioned in paragraph 5-1, as the pregnancy progresses, the uterus enlarges. It rises up and out of the pelvic cavity. This action displaces the stomach, intestines, and other adjacent organs. b. Peristalsis is slowed because of the production of the hormone progesterone, which decreases tone and mobility of smooth muscles. This slowing enhances the absorption of nutrients and slows the rate of secretion of hydrochloric acid and pepsin. Flare-up of peptic ulcers is uncommon in pregnancy. Slow emptying may increase nausea and heartburn (pyrosis). Relaxation of the cardiac sphincter may increase regurgitation and chance for heartburn. Movement through the large intestines is also slowed due to an increase in water consumption from this area. This increases the chance for constipation. c. Nursing implications. (1) If the mother has difficulty with nausea and/or heartburn, advise her to eat small, frequent meals. (2) The patient should eat a well- balanced diet high in protein, iron, and calcium for fetal growth; high fiber and fluids to prevent constipation. (3) The mother should not lie flat for 1 to 2 hours after eating because this may cause heartburn and/or regurgitation. CHANGES OF THE URINARY SYSTEM DURING PREGNANCY a. The kidneys must work extra hard excreting the mother's own waste products plus those of the fetus. There is an increase in urinary output and a decrease in the specific gravity. b. The patient may develop urine stasis and pyelonephritis in the right kidney. This is due to pressure on the right ureter resulting from displacement of the uterus slightly to the right by the sigmoid colon. c. Frequent urination is a complaint during the first through third trimester. As the uterus rises out of the pelvic cavity in early pregnancy, pressure on the bladder decreases and frequency diminishes. When lightening occurs during the final weeks of pregnancy, pressure on the bladder returns to cause frequency.

CHANGES OF THE RESPIRATORY SYSTEM DURING PREGNANCY a. The respiratory rate rises to 18 to 20 to compensate for increased maternal oxygen consumption, which is needed for demands of the uterus, the placenta, and the fetus. b. Women may feel out of breath and may need to sit a moment to catch their breath.

CHANGES OF THE SKELETAL SYSTEM DURING PREGNANCY a. There is a realignment of the spinal curvatures during pregnancy to maintain balance (see figure 5-3). It is due to the increase in size of the uterus and pressure on the abdominal wall. The patient walks with head and shoulders thrust backward and chest protruding outward to compensate. This gives the patient a "waddling" gait. b. There is a slight relaxation and increased mobility of the pelvic joints, which allows stretching at the time of delivery of the infant.

Figure 5-3. Postural changes during pregnancy.

TOP TEN SIGNS OF PREGNANCY If you have any of these signs, be sure to take an at home test. If it is positive, it is important that a mother-to-be receive prenatal care early in pregnancy. Your doctor will tell you to take prenatal vitamins with folic acid in them to prevent birth defects in your baby as soon as you know for sure that you're pregnant. Please note that pregnancy symptoms differ from woman to woman. while some have few, others have more. MISSED MENSTRUAL PERIOD A missed cycle can be a sign of pregnancy. It is usually the first indicator that conception has occurred, although some women claim to know they are pregnant before they miss a period.

MORNING SICKNESS Nausea can be a sign that a woman is pregnant. Many women say that they've had nausea up to two weeks before an expected monthly cycle and before any other symptom. Eating crackers before getting out of the bed in the morning can help and eating several smaller meals instead of larger ones can help with nausea. TENDER BREASTS Tender swollen breasts are another early symptom. While tender breasts are a symptom of an impending cycle, enlarged breasts are not. Sore and swollen breasts with a tingling sensation can be an early indicator of pregnancy. FATIGUE Extreme fatigue can be another indicator of pregnancy, especially if other symptoms are present. A nap a day can help a pregnant woman maintain normal daily activities. FREQUENT URINATION An increased urge to urinate can be an indicator and usually occurs between 6 to 8 weeks out. As difficult as headaches in pregnancy can be to tolerate, remember that this is a temporary condition and they diminish considerably by the end of the third or fourth month. Most women don't experience headaches past that point, unless other medical conditions are triggering them. PREGNANCY HEADACHES Headaches in early pregnancy are a common symptom and begin at about the 6th week. A quick nap can help diminish headaches in pregnancy. Preeclampsia or toxemia can begin with headache and can be dangerous to a pregnant woman. If you are pregnant and have this symptom, be sure to call your health care provider immediately. SPOTTING Spotting is a common symptom in pregnancy. Some women report what seems to be a short light period before the onset of other symptoms. This may be implantation bleeding and not a monthly period at all (when the egg implants itself into the lining of the uterus). If you are pregnant and you experience spotting check in with your doctor as spotting is also an indicator of miscarriage in early pregnancy. LIGHT HEADEDNESS Some pregnant women experience actual fainting and light headedness. Again, this is usually not an issue past the fourth month of pregnancy. CONSTIPATION Hormonal changes can affect the digestive system and cause constipation. Drinking plenty of water and exercising can help. A pregnant woman should ask her doctor for recommended exercises while pregnant.

HEARTBURN Heartburn can be a symptom in months 1-9. In months 1-4, heartburn is caused by hormonal changes. In months 5-9, the baby can cause pressure on a pregnant woman's organs. Eating frequent smaller meals and remaining in an upright position at least an hour after eating can help. In pregnancy, with some fathers-to-be, it is difficult for them to understand the life that is within their mate. It is beneficial for the mother and father to be at the first ultrasound together as it seems to help fathers-to-be form a mental picture when they see movement of their baby on the ultrasound screen. Anticipation soon grows! IN CONCLUSION By the end of the fourth month of pregnancy, most of these pregnancy symptoms subside and the elation and joy overcome most any mother to be. Energy levels return to normal as does the desire for food. Common discomfort of pregnancy and relief measures Pregnancy can be a time of great joy and happiness for any couple after all, watching your baby grow and develop is one of the most exciting things in the world! Plus, you get to participate in lots of fun things, like choosing your baby's name and decorating his nursery. Unfortunately, pregnancy isn't all fun and games. During these nine months you may experience a number of pregnancy discomforts that can sometimes make life a little tough. From backaches to morning sickness, the discomforts of pregnancy can really put a damper on things. By knowing what to expect and how to go about getting some relief, you can help to put that spring back into your step. Swelling Now that you are pregnant, you may have noticed that your ankles and feet have begun to swell up a little. You may find that it isn't so easy to get into those dainty shoes that you once sported with confidence, and you may wonder why your feet are looking more and more like they belong on an elephant. Well don't worry though this swelling may not look pleasant, it is completely normal during pregnancy. Also known as edema, pregnancy swelling typically hits during the third trimester. It usually affects the ankles and feet, though it can also cause your hands to swell up slightly. This swelling is the result of the hormonal shifts that are occurring in your body. Because of these hormonal changes, your body will retain more fluid than usual, which will shift more easily to your soft tissues. This swelling can be relieved by making sure that you rest your lower extremities. Prop your feet up from time to time during the day and stretch frequently. Drink lots of water to maintain proper circulation and think about wearing support stockings to keep the swelling down. It is important to watch for signs of severe swelling during your pregnancy, as this could signal a pregnancy complication. Swelling of the face and eyes could indicate that you are suffering from preeclampsia, a serious condition during pregnancy.

Backache Are you constantly clutching your lower back now that your nearing your due date? Well, then you are just one of the 50% of pregnant women who experience back pain during pregnancy. Generally, pregnancy back pain attacks the hollow in the your lower back, and tends to get worse as your pregnancy progresses. Thanks to your increased body weight and the size of baby, your back is taking a lot more stress than usual. This can cause the muscles in

your back to scream out in pain. These backaches are also caused by pregnancy hormones particularly, a hormone called Relaxin. Relaxin helps to soften your muscles and ligaments for labor. While this is good for labor, it's murder on your back as it no longer has the support that it is used to. If you are suffering from persistent backaches there are some measures that you can take. Wearing a support belt around your belly can help to improve your posture and relieve added stress on your back. Sleeping with a pillow under your knees can also work wonders for a sore back. Taking a swim will help to ease your pain, as the water will cushion all the curves on your body. If you are experiencing any pins and needles or leg weakness with your back pain, though, it's a good idea to contact your health care professional. This may indicate that a nerve in your back is being pinched, and requires treatment. Hemorrhoids Unfortunately, hemorrhoids do not just attack later in life as many of us think. In fact, up to 30% of pregnant women suffer from hemorrhoids at some point during their pregnancy or labor. Hemorrhoids are actually a type of varicose vein. They appear on and around the rectum and are caused by poor circulation in the lower extremities. The added weight of your uterus sometimes interferes with the function of your pelvic blood vessels, causing blood to pool and form hemorrhoids. Typically occurring in the third trimester or during labor, hemorrhoids usually itch but they can also cause pain and bleeding. If you are suffering from hemorrhoids, then it is a good idea to try to relieve the pain and swelling that they cause. Baking soda is a great hemorrhoid treatment try taking a warm baking soda bath, or apply a baking soda paste directly to the hemorrhoids. If you are constipated, try to eat more fiber and drink lots of water, as constipation can make hemorrhoids worse. Your hemorrhoids should go away after you give birth. However, if they linger for more than a few months, contact your health care provider. Constipation Constipation is the bane of every pregnant woman. Affecting more than 50% of all pregnant women, constipation is a very common pregnancy discomfort. Unfortunately, it can be very unpleasant, causing abdominal pain and bloating and even hemorrhoids. Constipation in pregnancy can usually be attributed to a slow-moving digestive system. The pregnancy hormones, progesterone and estrogen, work to slow down the gastrointestinal tract. This means that food stays inside your stomach and intestines longer than usual. As a result, waste products aren't flushed out of your system as frequently, which can cause your stools to become quite hard. In severe cases, constipation can cause terrible abdominal pain and even interfere with labor. To deal with constipation, try to add lots of whole grain products and fresh fruits and vegetables to your diet. These foods contain fiber, which can help to soften your stools. Try to drink at least six glasses of water a day, and supplement your fluid intake with prune juice. Exercise can also help to stimulate bowel contractions, which will help you to pass compacted stools. If you are experiencing severe abdominal pains or if you are noticing any rectal bleeding, consult with your health care provider. She may be able to provide you with a laxative that is safe to take during pregnancy. Indigestion and Heartburn Many pregnant women complain of indigestion and heartburn, particularly during the later stages of pregnancy. If you feel bloated or if you have a burning sensation in your upper chest, then you may also be suffering from this

common pregnancy discomfort. Indigestion is normal during pregnancy because of the pressure that your growing uterus exerts on your stomach. The fact that pregnancy hormones slow down the rate at which your stomach processes food also tends to exacerbate indigestion. To fight the effects of heartburn and indigestion, try eating smaller meals more frequently throughout the day. This will help your stomach to process food more easily and will reduce bloating. Avoid spicy or fried foods, which can trigger heartburn, and instead focus on eating lots of fresh fruits and vegetables. To reduce heartburn in the evenings, avoid eating before you go to bed or sleep propped up on a lot of pillows. If your indigestion just won't go away, talk to your health care provider about an antacid that is safe to take during pregnancy, or for another type of indigestion remedy. Chat with other pregnant women about the many common discomforts in pregnancy, like pregnancy cramps, in our pregnancy forum Major Goals of Comprehensive Prenatal Assessment The major goal of prenatal care is to ensure the birth of a healthy baby with minimal risk for the mother. There are several components involved in achieving this objective: Early, accurate estimation of gestational age Identification of the patient at risk for complications Ongoing evaluation of the health status of both mother and fetus Anticipation of problems and intervention, if possible, to prevent or minimize morbidity Patient education and communication The percentage of pregnant women who initiate prenatal care in the first trimester is one of the standard clinical performance measures used to assess the quality of maternal health care. In the United States in 2006, 83 percent of pregnant women obtained prenatal care in the first trimester, but 3.6 percent received no care or initiated prenatal care in the third trimester [1]. The optimal components of prenatal care have not been rigorously examined in randomized trials [2-6]. A systematic review of observational studies and randomized trials concluded that there was no conclusive evidence that prenatal care improved birth outcomes [2,4]. Randomized trials have also shown that enhanced prenatal care (eg, extra office visits, health education, home visits, telephone contact, psychosocial support) did not result in improved outcomes compared to routine prenatal care [7,8]. Further, comparison of pregnancy outcomes in women who receive and do not receive prenatal care is consistently confounded by socioeconomic and other factors that influence access to prenatal care and maternal/perinatal outcome. In the developing world, if prenatal care is not readily available, then adequate delivery of other health care and social services often also are not readily available. This is important since complications resulting in serious morbidity or mortality are most likely to occur at delivery.

PRINCIPLES OF PRENATAL CARE a. Definition. Antepartal or prenatal care refers to the medical and nursing supervision and care given to the pregnant patient during the period between conception and the onset of labor. b. Objectives of Prenatal Care. During the initial visit, the objectives are directed toward confirming a diagnosis of pregnancy and beginning the process of data collection to act as a basis for ongoing prenatal care. These objectives include: (1) Prevention of complication. (2) Modification of those complications that may develop. (3) Support of the patient's goal to carry the infant to term and deliver a healthy baby. (4) Education of the mother-to-be and her family for the parenting role. (5) Inclusion of the family as a whole in the concept of "family-centered maternity care."

c. Health Care Professionals. Health care professionals involved in the administration of the prenatal care includes: (1) Physicians. They are primarily involved in diagnosing normal and abnormal conditions associated with the childbearing cycle. (2) Nursing personnel. Nursing personnel includes the nurse practitioners, clinical nurse specialists, registered nurses, and licensed practical nurses. Nursing personnel serves as teachers, counselors, and resource personnel. They have the responsibility to develop and implement nursing care plans. (3) Others. Other health care personnel that are involved in prenatal care are: (a) Dietitians. (b) Laboratory technicians. (c) Social services. (d) Occupational therapists. (e) Similar support personnel. d. Choice of Health Care Professionals. The pregnant patient is responsible to choose the type of individual she prefers to consult for prenatal supervision and care. She may choose a private obstetrician, family practice physician, clinic with no control over which physician provides the care, or a nurse midwife. The primary concern is whether the individual she chooses meets her goals, desires, and expectations. e. Early Care. Early, competent care is essential for the patient to avoid unnecessary risks to herself and her fetus.

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