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ANTEPARTUM Signs of Pregnancy Presumptive Signs Probable Signs Positive Signs Presumptive SIGNS Breast changes feeling of tenderness, fullness, or tingling; enlargement and darkening of areola. Nausea and Vomiting Amenorrhea Frequent urination Fatigue Uterine enlargement uterus can be palpated over symphysis pubis Quickening Linea nigra line of dark pigment on the abdomen. Melasma dark pigment on face Striae gravidarum red streaks on abdomen. Probable Signs Chadwicks sign discoloration of the vagina. Goodells sign softening of the cervix. Hegars sign softening of the isthmus of the uterus. Ballottement passive fetal movement elicited by pushing up against the cervix with 2 finger. Braxton Hicks contractions periodic uterine tightening. Positive SIGNS Fetal heart beat ( 17-20 wks). Fetal heart rate is between 120 -160 bpm. Fetal movement actively palpable by a trained examiner after about 20 weeks gestation (19-22 weeks). Visualization of the fetus by ultrasound (5-6 weeks). Psychological Tasks of Pregnancy 1st Trimester: Pregnancy Validation - ambivalence, or feeling both pleased and not pleased about the pregnancy. Fetal Embodiment the mother feels that the fetus is a part of her. 2nd Trimester: Fetal Distinction she daydreams about what the baby will be like and think about the kind of mother she wants to be. Role Transition exploring the meaning of mothering and parenting skills. 3rd Trimester: Nesting 0r energy surge as due date approaches. Desire to get to the end of the pregnancy. Focus on the baby, delivery. Factors Affecting Psychological Response Body image some women feel fat and ugly, and others feel so good and beautiful when they are pregnant. Financial Situation a poor financial situation may be the cause of anxiety about infant care. Cultural Expectations conflicts may occur if the cultural expectations of the mother are different form that of the father or partner. Emotional Security a planned or long anticipated pregnancy will be received with joy and excitement, an unexpected or unwanted pregnancy may be met with fear, dread, or uncertainty. Support from Significant Others father/partner may feel left out, siblings see the new baby as a threat to their relationship with the parents, grandparents feel they are too young to become grandparents. Couvade is the development of physical symptoms by the expectant father such as fatigue, depression, headache, and nausea. Physiological Changes of Pregnancy Reproductive System Cardiovascular System Respiratory System Musculoskeletal System Gastrointestinal System Urinary System Integumentary System Endocrine System Reproductive System Uterus enlarges by hypertrophy of the muscle cells stimulated by estrogen and the growing fetus expanding evenly in all directions during pregnancy. Cervix - secretes a thick, sticky mucus that forms a plug in the cervix which prevents microorganisms from entering through the vagina. Ovaries follicles do not mature and ovulation does not occur during pregnancy. Vagina the acidic secretions prevent bacterial infections. Breast the nipples become more erect, the areolas darken, and the breast enlarge from hormonal influence. Cardiovascular System Dependent edema and varicose veins - Stasis of the blood in the lower extremities, caused by the enlarged uterus interfering with return blood flow. Supine hypotensive (vena caval)syndrome occurs when the mothers lies supine. Physiologic anemia of pregnancy - in plasma causing hemodilution as manifested by a lower hematocrit. Musculoskeletal System Gastrointestinal System Nausea and vomiting. Constipation this is caused by delayed gastric emptying, decreased peristalsis, and enlarging uterus that displaces the stomach and intestines. Heartburn - results from relaxation of cardiac sphincter allowing acidic gastric contents reflux. Urinary System Integumentary System Linea nigra pigmented line on the abdomen from umbilicus to symphysis pubis. Chloasma mask of pregnancy it is the darkening of the skin of the forehead and around the eyes. Striae gravidarum stretch marks are reddish streaks found in the abdomen, thighs, buttocks, and breasts. Endocrine System Thyroid disorders which occur during pregnancy are autoimmune in nature. Body develops antibodies against thyroid cells, which affect thyroid gland functions. Antibodies damage the thyroid cells result in lymphocytic thyroiditis (inflammation of the thyroid), known as Hashimoto's disease. Metabolism The metabolic rate of the mother increases during pregnancy as the demands of the growing fetus increase. The mother must meet her own and the fetuss nutritional needs. Metabolically speaking, pregnant women live in a state of "accelerated starvation."
Embryonic Stage 4th week - The embryo produces hormones which stop the mother's menstrual cycle. 5th Week Embryo is the size of a raisin. By day twenty-one, the embryo's tiny heart has begun beating. Blood is now pumping and all four heart chambers are now functioning. The neural tube enlarges into three parts, soon to become a very complex brain. Umbilical cord develops. The spine and spinal cord grows faster than the rest of the body at this stage and give the appearance of a tail. Lungs start to appear, along with brain. Arm and leg buds appear. The placenta begins functioning. 6th Week The arms and legs continue to develop - These limbs are stretching out more and more. Brain is growing well. Lenses of the eyes appear. Nostrils are formed. Intestines grow - Initially these are actually located outside the baby's body within the umbilical cord. Pancreas the fetus is now equipped to deal with digestive enzymes and take on processing the insulin and glucagons the body needs to function. 7th Week Facial features are visible, including a mouth and tongue. The major muscle system is developed. The child has its own blood type, distinct from the mother's. These blood cells are produced by the liver now instead of the yolk sac. Intestines start to form in the umbilical cord. Teeth begin to develop under the gums. Elbows form. The eyes have a retina and lens. 8th Week The embryo is about half an inch long protected by the amniotic sac, filled with fluid. The arms and legs have lengthened, and fingers can be seen. The toes will develop in the next few days. Brain waves can be measured. Cartilage and bones begin to form. The basic structure of the eye is well underway. The tongue begins to develop Intestines move out of the umbilical cord into the abdomen. Body grows and makes room. The fingers and toes have appeared but are webbed and short. Baby's length (crown to rump) is 0.61 inch (1.6cm) and weight is 0.04 ounce (1gm). 9th Week
Bleeding Complications Abortion loss of pregnancy before fetus is viable (>20 wks). a. Threatened vaginal bleeding, cervix closed, fetus not expelled. b. Inevitable vaginal bleeding heavy, + contractions, cervix dilated. c. d. e. Interventions: Peripad count Save all tissue passed Prepare patient for D&C. Provide emotional support. Incomplete fetus expelled, placenta retained. Complete all products of conception expelled. Missed fetus dies in utero and is retained.
Ectopic Pregnancy The fertilized ovum is implanted outside the uterine cavity. In 95% of all ectopic pregnancies, the egg is implanted in one of the fallopian tubes so rupture of the site usually occurs. Alternative names are abdominal, cervical, or tubal pregnancy. If left untreated, an ectopic pregnancy can lead to severe internal bleeding, which is life-threatening. Prevalent in blocked fallopian tubes or damaged due to endometriosis, scarring after tubal surgery, pelvic inflammatory disease (PID), or a previous ectopic pregnancy. Risk factors include infertility, exposure to several STDs, smoking, and having an IUD in place during conception.
Symptoms: Significant cramping or tenderness, usually on one side of the lower abdomen. If a tubal rupture occurs, the pain becomes very sharp and steady before spreading throughout the entire pelvic region. Brown vaginal spotting or light bleeding. Heavy bleeding if the tube ruptures. Nausea and vomiting (might be difficult to distinguish from morning sickness). Dizziness or weakness. (If the tube ruptures, a weak pulse, clammy skin, and fainting are common.)
Assessment: Symptoms of early pregnancy. Abdominal pain, localized on one side. Rigid, tender abdomen; abnormal pelvic mass. Bleeding; if severe may lead to shock. Positive Cullens sign (bluish discoloration around the umbilicus). Diagnostic Exams: Ultrasound exams are used to determine whether pregnancy is developing in the right place. Culdocentesis a needle is inserted into the space at the top of the vagina, behind the uterus. A sample of fluid is extracted. If the sample contains blood, bleeding from a ruptured fallopian tube has occurred. Laparoscopic surgery - the surgeon inserts a small camera beneath the umbilicus and looks at the tubes and ovaries to see if there is an ectopic pregnancy. Interventions: Prepare client for surgery. Institute measures to control/treat shock. If hemorrhage severe continue to monitor postoperatively. Allow client to express feelings about loss of pregnancy and concerns about future pregnancies. Disseminated Intravascular Coagulation Pathological clotting disorder that is diffuse and causes injury rather than protecting sites of coagulation. The consumption of clotting factors such as platelets and fibrinogen resulting in widespread external or internal bleeding. Uncontrolled uterine hemorrhage, bleeding from laceration sites, placental abruption, abortion, or shock. Prothrombin and platelets Widespread formation of intravascular clots Clotting factor expended Severe generalized hemorrhaging Life threatening! Etiologies Septic shock Placental/uterine hemmorhage IUFD Amniotic fluid embolism Thrombi secondary to preeclampsia Thrombi secondary to thrombophlebitis Early signs of DIC Protime Fibrinogen Thrombocytopenia Bleeding from gums Bleeding from puncture sites Ecchymosis Treatment complex, packed cells, fibrinogen, whole blood, plasma Assessment Spontaneous or uncontrolled bleeding Monitor labs for decreasing platelets, fibrinogen, and increasing prothrombin time. Observe for signs of shock (tachycardia, anxiety, restlessness).
Treatment/ Management: Physical Examination: A woman with severe high-risk factors in pregnancy should be referred to a perinatal center to obtain the highest level of care for herself and her baby. Antepartum Testing Amniocentesis Fetal transfusions Fetal surgery Chorionic Villi Sampling Aging placenta post term pregnancy 3x more likely to cause death of the baby. The treatment is to induce labor before problems start to occur. Hemolytic disease of the newborn (destruction of the red blood cells) can occur when Rh incompatibility exists between child and mother. Rhogham [Rh0(D)immune globulin], which can be given to the mother in the first 72 hours after delivery and at the twenty-eighth week of pregnancy Blighted Ovum Known as anembryonic pregnancy happens when a fertilized egg attaches itself to the uterine wall, but the embryo does not develop. Cells develop to form the pregnancy sac, but not the embryo itself. A blighted ovum usually occurs within the first trimester before a woman knows she is pregnant. A high level of chromosome abnormalities usually causes a womans body to naturally miscarry. Teratology of Drugs and other Substances Artificial Sweetener - Aspartame Caffeine Aspirin Smoking Antihistamines Antibiotics Recreational Drugs (marijuana, cocaine) Antidepressant Drugs Antiepileptic Drugs Acne Drugs - accutane Cardiovascular Drugs TORCH: Teratogenic Maternal Infections Cytomegalovirus Member of herpes family MOT: transmitted by droplet infection, transplacental Mother: asymptomatic Fetus: Severe brain damage (hydrocephalus, microcephaly, spasticity), eye damage, deafness, or chronic liver disease The child may have Blueberry muffin lesions (large petechiaes) Rubella (German Measles) Caused by rubella virus usually causes only mild systemic illness in the mother Fetus: deafness, mental and motor retardation, PDA and Pulmonary artery stenosis, SGA, thrombocytopenic purpura, cleft lip and palate. Do not administer rubella vaccine during pregnancy or if the woman is planning to conceive Upon administration of rubella vaccine, woman is not advised to become pregnant for three months Herpes Simplex Virus (Genital Herpes Infection) If happens in the first trimester = Spontaneous abortion
Lyme Disease
Symptoms:a typical skin rash, erythema chronicum migrans (large, macular lesions with a clear center), joint pains, bells palsy. Fetus: spontaneous abortion. Prevention: Wear long sleeves when hiking. Use tick repellant. Remove the tick within 24 hours. Treatment: Administration of tetracycline and doxycycline. Hypertension During Pregnancy PIH A condition unique to pregnancy where HTN is accompanied by proteinuria, edema usually appears after the 20th week. Mild: a. Edema of hands & face b. HTN +30/+15mmHg over baseline. c. Proteinuria +1. Severe: Headache Epigastric pain (impending seizure) Visual disturbance Eclampsia (all of the above) plus: Tonic clonic seizure Altered mental status coma. Labor may begin. Eclampsia Fatal condition can develop in the 2nd half of pregnancy, no known etiology, believed it results from poor nutrition. Pre-eclampsia signs include high blood pressure, protein in the urine, and excessive edema. Stages of Eclamptic Seizure: 1. Premonitory stage 2. Tonic stage 3. Clonic stage 4. Comatose stage Premonitory stage Usually missed; the woman rolls her eyes, facial and hand muscles twitch slightly. Tonic stage - The twitching turns into clenching. The woman may bite her tongue as she clenches her teeth, while the arms and legs go rigid. The respiratory muscles spasm, causing the woman to stop breathing. This stage continues for around 30 seconds. Clonic stage Spasm stops but the muscles start to jerk violently. Frothy, slightly bloodied saliva appears on the lips and can sometimes be inhaled. The convulsions stop, leading into a temporary unconscious stage. Comatose stage