Normal Pregnancy

Professor Burke

Terminology Used to Document an Obstetric History

Gravida: a pregnant woman
Gravida I (primigravida): first pregnancy Gravida II (secundigravida): second pregnancy, etc. Para: a woman who has produced one or more viable offspring carrying a pregnancy 20 weeks or more Primapara: one birth after a pregnancy of at least 20 weeks (primip) Multipara: two or more pregnancies resulting in viable offspring (multip) Nullipara: no viable offspring; para 0

Obstetric History Terms

G (gravida) the current pregnancy

T (term births) the number of pregnancies ending > 37 weeks gestation, at term
P (preterm births) the number of preterm pregnancies ending > 20 weeks or viability but before completion of 37 weeks A (abortions) the number of pregnancies ending before 20 weeks or viability L (living children) number of children currently living

Calculating the Estimated Date of Birth (EDB) Using Nageles Rule

Use the first day of LNMP 11/21/99 Subtract 3 months 8/21/99 Add 7 days 8/28/99 Add 1 year 8/28/2000 = EDB

Signs and Symptoms of Pregnancy

Presumptive (time of occurrence)
Fatigue (12 weeks) Breast tenderness (3-4 weeks) Nausea and vomiting (4-14 weeks) Amenorrhea (4 weeks) Urinary frequency (6-12 weeks) Hyperpigmentation of the skin (16 weeks) Fetal movements (quickening) (16-20 weeks)

Signs and Symptoms of Pregnancy

Uterine enlargement (7-12 weeks) Breast enlargement (6 weeks)

Probable (time of occurrence)

Braxton-Hicks contractions (16 - 28 weeks) Positive pregnancy test (4-12 weeks) Abdominal enlargement (14 weeks) Ballottement (16-28 weeks) Goodells sign (5 weeks) Chadwicks sign (6-8 weeks) Hegars sign (6-12 weeks)

Physical Changes of the Cervix During Pregnancy

Chadwicks sign: Estrogen causes the cervix to become congested with blood (hyperemic), resulting in a bluish color that extends to include the vagina Goodells sign: Increased vascularity causes the cervix to soften Mucus plug: Increased mucus forms to seal off the cervix from outside bacteria

Signs and Symptoms of Pregnancy (cont.)

Positive (time of occurrence)
Ultrasound verification of embryo or fetus (4-6 weeks) Fetal movement felt by experienced clinician (20 weeks) Auscultation of fetal heart tones via Doppler (10-12 weeks)

Physical Changes of the Uterus During Pregnancy

Size increases to 20 times that of nonpregnant size
Weight increases from 2 ounces to approximately 2 pounds at term Walls thin to 1.5 cm or less from a solid globe to a hollow vessel Volume capacity increases from 2 teaspoons to 1 gallon 1/6 of total maternal blood volume is contained within the vascular system of the uterus by term

Hormones of Pregnancy
HCG
HPL Progesterone Estrogen

Relaxin

Physical Changes of the Breasts During Pregnancy

Breasts increase in size and nodularity to prepare for lactation Nipples increase in size, become more erect, and more pigmented Colostrum is produced
an antibody-rich, yellow fluid that can be expressed after the 12th week converts to mature milk after delivery

Cardiovascular Changes
Cardiac output increases Increase in plasma volume & RBC Increase in fibrin & plasma fibrinogen Decrease in Hb & HCT Increase in WBC

Physical Changes of the GI Tract During Pregnancy

Reflux of gastric contents common due to relaxation of smooth muscles by progesterone Ptyalism (excessive salivation) is a common condition of pregnant women Decrease in intestinal motility causes constipation Nausea and vomiting (morning sickness) is due to high hCG levels from 6 to 12 weeks

Psychological Response to Pregnancy

Ambivalence: initial response; no visible body change yet Acceptance: triggered by quickening in 2nd trimester Introversion: turning in on oneself Mood swings: from great joy to despair Body image change: the picture you have of your body and of yourself

Maternal Roles
Ensuring safe passage throughout pregnancy and birth Seeking acceptance of infant by others Seeking acceptance of self in maternal role to infant Learning to give of oneself 1st trimester: identifying what must be given up to assume new role 2nd trimester: identifying with infant, learning how to delay own desires 3rd trimester: questioning ability to become a good mother to infant (Rubin, 1984)

Focus of Preconception Care

Immunization status Underlying medical conditions Reproductive healthcare practices Sexuality and sexual practices Nutrition Lifestyle practices Psychosocial issues Medication and drug use Support system

Characteristics of the Initial Health History

Includes questions about three major areas: reason for seeking care past medical, surgical, and personal history patients reproductive history Establishes a trusting relationship Focuses on education for overall wellness Attempts to detect and prevent potential problems

Components of a Physical Examination of a Pregnant Woman

Head-to-toe assessment
head and neck chest abdomen Extremities

Pelvic examination
examination of external and internal genitalia
bimanual examination

pelvic shape pelvic measurements

Pelvic Shapes

Assessments Taken at Subsequent Prenatal Visits

Weight and blood pressure measurements; compared to the baseline values Urine testing for presence of protein, glucose, ketones, and nitrites Fundal height measurement to assess fetal growth Assessment for quickening/fetal movement to determine well-being Assessment of fetal heart rate; should range between 120160 bp

Fundal Height
Indicates uterine size by measuring from the top of the symphysis pubis to the top of the fundus

Correlates with weeks of gestation between 2030 weeks

20 weeks = 20 cm 24 weeks = 24 cm 30 weeks = 30 cm

Measuring fundal height

Nursing Management to Promote SelfCare of the Pregnant Woman

Personal hygiene Clothing Exercise Sleep and rest

Sexual activity and sexuality Employment Travel Immunizations and medications

First Trimester
Urinary frequency or incontinence Fatigue Nausea and vomiting Breast tenderness

Constipation Nasal stuffiness, bleeding gums and epistaxis Cravings Leukorrhea

Second Trimester
Blood volume continues to increase B/P drops slightly Oxygen consumption up 15-20% Pelvic ligaments relax May have gall bladder & urinary problems GFR increases up 50% Chloasma, striae gravidarum, linea nigra.

Postural Changes

Third Trimester
Change in balance Backache B/P drops slightly Slowing of peristalsis Fundus = Xiphoid = SOB Edema of LE Hemorrhoids & varicosities

Natural Childbirth Education Classes

Lamaze (psychoprophylactic) method
promotes the use of specific breathing and relaxation techniques

Bradley (partner-coached) method

uses various exercises and slow, controlled abdominal breathing to accomplish relaxation

Dick-Read method
is based on relaxation and breathing techniques

Sibling Class