N106

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N106

• Nursing Care of the
• Expanding Family

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Outline

• Issues Trends
• Menstrual Cycle
• Conception
• Fetal Development

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Issues and Trends

• Family Centered
• Role of Nurse
• Legal and Ethical
• Cultural Influence
• Client Teaching

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Ovarian and Endometrial Cycles
.
Menstrual Cycle
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Conception
Sperm penetration of an ovum
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the fertilized ovum from conception to
implantation
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Fetal Development

• Ovum (pre-embryonic stage) first 2
  weekszygotemorulablastocyst
• Embryonic stage weeks 3 to 8
• Fetal stage 8 weeks to birth

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Figure 312 The actual size of a human
conceptus from fertilization to the early fetal
stage. The embryonic stage begins in the third
week after fertilization the fetal stage begins
in the ninth week. Source Adapted from Marieb,
E. N. (1998).
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Foramen ovale
Ductus arteriosus
Ductus Venosus
Figure 311 Fetal circulation. Blood leaves the
placenta and enters the fetus through the
umbilical vein. After circulating through the
fetus, the blood returns to the placenta through
the umbilical arteries. The ductus venosus, the
foramen ovale, and the ductus arteriosus allow
the blood to bypass the fetal liver and lungs.
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Outline

• Terminology
• Pregnancy dating
• Signs of Pregnancy
• Normal Physical Changes of Pregnancy
• Psychological Changes
• Nutrition
• Medication Admin

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Terminology

• Gravida - of times a uterus has held a
  pregnancy
• Primigravida and Multigravida
• Para - of times a uterus held a pregnancy past
  20 wks Primiparity and Multiparity
• Abortion less than 20 weeks miscarriage
• Viability past 24 weeks Federal /State
• Preterm 20-37 weeks
• Term 38-42 weeks
• Post term after 42 wks
• BOW bag of waters
• Bloody show when cervix starts to dilate

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Pregnancy dating

• Nageles rule add 7 days to first day of LMP
  and count back 3 months
• McDonalds rule fundal height week of
  gestation /- 2-4 weeks
• Sonogram early US at 7-13 weeks after LMP most
  accurate for dating pregnancy

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McDonalds method is used to assess fundal height.
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The TPAL approach
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Signs and symptoms of pregnancy

• Presumptive
• Probable
• Positive auscultation of FHTfetal movement felt
  by examinerfetus visualized by US

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Physiologic changes with Common Discomforts

• Reproductive
• Cardiac
• Respiratory
• Gastrointestinal
• Renal
• Integumentary
• Endocrine
• Musculoskeletal
• Neurological

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Reproductive and Cardiac

• uterus
• cervix
• vagina
• ovaries
• breast

• heart
• heart sound
• pulse
• blood volume
• cardiac output
• peripheral vasodilatation
• B/P
• blood components

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Vena caval syndrome.
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Respiratory and Gastrointestinal

• Thoracic circumference
• Diaphragm
• Oxygen consumption
• Tidal volume

• Gingivitis and bleeding gums
• Heartburn
• Nausea
• Constipation
• Gallstones

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Endocrine/ hormones

• Human Chorionic Gonatropin (HCG)
• Human Placenta Lactogen (HPL)
• Relaxin
• Estrogen
• Progesterone
• Oxytocin
• Prolactin

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Physiologic changes

• Renal
• Integumentary chloasmalinea nigrastriae
  gravidarum
• Musculoskeletallordosisdiastasis recti
• Neurological

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Psychological changes

• First trimester disbelief ambivalence
• focus self-centered R/T physiologic changes
• Second trimester introspective focus
  baby fetus becomes real
• Third trimester - pride and anxiety focus
  labor / delivery babys well-being

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Nutrition

• Affects size of baby
• Wt gain 3.5 lbs during 1st trimester than 1 lb/wk
• Total 25-35 lbs
• Folic acid prevent neural tube defects
• Iron supplements 30 mg daily
• Additional 300 cal/day
• Lactating requires 2700-2800 cal/day and 3000cc
  of fluids /day
• Post partum 2200 to 2300 well balanced

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Healthful eating Largest portion - grains, rice,
bread, and pastaSmallest portion - fats, oils,
and sweets,
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Medication Administration

• Most medications cross placenta to fetus
• Medications during PG can harm fetus
• Pain meds in labor cross placenta
• Newborn meds are Vitamin K Erythromycin
• PostPartum meds are oxytocics analgesics

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Prenatal Education

• Early pregnancy classes
• Childbirth Preparation classes
• Methods of childbirth
• BradleyLamaze

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Assessment during Pregnancy

• Prenatal appointmentsmonthly first 6 monthsq 2
  weeks in 7 8 monthweekly last month
• Vag exam initial visit and 2-3 wks a EDC
• Assessment each visitwt, B/P, P, R, fundal ht,
  FHT

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Danger Signs of Pregnancy

• Vaginal Bleeding
• Rupture of membranes
• Swelling of the fingers, face, eyes
• Headache
• Visual disturbances
• Persistent abdominal pain
• Chills and fever
• Painful urination
• Persistent vomiting
• Change in fetal movements

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Fetal Assessment
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Ante-partal Fetal Assessment

• LabsAlpha-fetoprotein screening (MSAFP)
• Ultrasound
• glucose tol test (GTT)

• AmniocentesisL/S ratio and PG
• Nonstress test (NST)
• Contraction stress test (CST)

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Amniocentesis
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Reactive NST
Figure 145 Example of a reactive nonstress
test (NST). Accelerations of 15 bpm lasting 15
seconds with each fetal movement (FM). Top of
strip shows FHR bottom of strip shows uterine
activity tracing. Note that FHR increases (above
the baseline) at least 15 beats and remains at
that rate for at least 15 seconds before
returning to the former baseline.
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Nonreactive NST
Figure 146 Example of a nonreactive NST. There
are no accelerations of FHR with FM. Baseline FHR
is 130 bpm. The tracing of uterine activity is on
the bottom of the strip.
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CST
Figure 148 Example of a positive contraction
stress test (CST). Repetitive late decelerations
occur with each contraction. Note that there are
no accelerations of FHR with three fetal
movements (FM). The baseline FHR is 120 bpm.
Uterine contractions (bottom half of strip)
occurred four times in 12 minutes.
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Complications Antepartal

• Gestational Diabetes
• Hemorrhage - abortion
• Hyperemesis Gravidarum
• PROM premature rupture of membranes
• Preterm labor
• Pregnancy Induced Hypertension PIH
• Substance abuse
• Infections TORCH

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Gestational Diabetes

• Develops during pregnancy
• Risk factors obesity, lt25 yrs, family history,
  chronic hypertension, large birth wt, previous
  gestational diabetes
• Screening between 24-28 weeks a 50 g, 1 hour
  glucose challenge test (GCT) if 140 or above
  recommend 3 hour oral glucose tolerance test
  (OGTT)
• Increased for PIH and fetal macrosomia

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Therapeutic Management

• Diet 2200 -2400 calories per day
• Exercise Moderate exercise for active women,
  regular activity for sedentary women
• Blood glucose monitoring if FBG gt95 or PPBG
  gt120 start on insulin
• Fetal surveillance 28 weeks ultrasound,
  amniocentesis, NST, CST, BPP

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Insulin Therapy

• First trimester insulin needs lower
• Second and Third trimester increased insulin
  due to placental hormones
• During labor based on blood glucose levels
• Post Partum insulin not needed due to abrupt
  cessation of placental hormones

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Teaching Self-Care SS

• Hyperglycemia fatigueflushed hot skindry
  mouth, excessive thirstfrequent urinationrapid
  respheadachedepressed reflexes

• Hypoglycemiashakinesssweatingcold, clammy
  skinpallordisorientationirritabilityheadacheh
  ungerblurred vision

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Spontaneous Abortion

• Incidence
• Threatened
• Inevitable/imminent
• Complete
• Incomplete
• Missed
• Recurrent

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Threatened
The cervix is not dilated, and the placenta is
still attached to the uterine wall, but some
bleeding occurs.
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Imminent
The placenta has separated from the uterine wall,
the cervix has dilated, and the amount of
bleeding has increased.
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Incomplete
. The embryo or fetus has passed out of the
uterus, but the placenta remains.
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Ectopic Pregnancy

• Pregnancy outside the uterine cavity
• S S of PG
• Rupture at 6-12 weeks
• Severe pain
• Vaginal tenderness and shock
• Treatment salpingectomy if rupturedlinear
  salpingostomy if tube is intact
• Care assess for bleeding and pain, prepare for
  surgery, emotional support

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Various implantation sites in ectopic pregnancy.
The most common site is within the fallopian
tube, hence the name tubal pregnancy.
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Complications of pregnancy

• Hyperemesis gravidarum

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Hyperemesis Gravidarum

• Persistent, uncontrolled vomiting
• Cause unknown may be high hCG or psychological
  problem hydatidiform mole
• SS Nausea and vomiting, weight loss, fatigue,
  signs of dehydration, signs of starvation
• TX antiemetics, IV fluids, quiet environment
  ,sedation, counseling
• Care Allow to verbalize

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Reducing nausea and vomiting

• 1) small portions q 2-3 hours
• 2) attractively presented
• 3) eliminate strong odors
• 4) low-fat foods,
• 5) easily digested carbohydrates, such as fruit,
  breads, cereal, rice and pasta
• 6) soups and liquids taken between meals
• 7) sitting upright to reduce gastric reflex

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Complications of Pregnancy

• Premature Rupture of Membranes

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Premature rupture of membranes (PROM)

• Diagnose Nitrazine or fern test
• Gestational age - more than 36 wks deliver if
  ripe cervix, abnormal FHT, meconium stained
  fluid, possible infection, abnormal presentation
  Tx walking, Prostaglandin
• Gestational age between 32-35 weeksdeliver if
  mature fetal pulmonary status, abnormal FHT,
  possible infection
• Strategies tocolytics, steroids, antibiotics

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Nursing Care for PROM

• Stay hospitalized until birth
• Frequent VS FHT q 4 hours
• Frequent CBCs , mtr records kick counts
• Check vaginal bleeding
• No vag exams, restrict activity
• A Z for 7 days

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Complications of Pregnancy

• Preterm Labor

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Premature rupture of membranes (PROM)

• Diagnose cramping and vag discharge prior to 20
  and 37 weeks gestation
• Tocolytics act by depressing smooth muscle,
  glucocorticoids accelerate fetal lung maturity
• Nursing Care monitor FHT contractions,
  provide emotional support, manage side effects of
  tocolytics, teach what to do if occur at home

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Complications of Pregnancy

• Hypertensive Disorders

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Pregnancy Induced Hypertension

• Incidence 8 of all pregnant woman
• Risk factors
• Etiology - Preeclampsia is due to generalized
  vasospasm
• Cause remains unknown
• Cardinal signs1) hypertension2) proteinuria3)
  weight gain of 2 lbs in one week

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Classification of hypertensive disorders of
pregnancy

• Pregnancy-induced hypertension (PIH)
• Preeclampsia
• Eclampsia
• HELLP

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PIH - HELLP syndrome reflects severity of
disease

• Signs and Symptomsheadachesvisual
  changesoliguriahyperreflexiaepigastric pain
• flu like symptomsgeneralized edemanausea and
  vomitingsevere elevated BPproteinuria

• Criteria of diagnosishemolysiselevated liver
  enzymes AST(SGOT)gt72U/L ALT(SGPT)gt50U/L
  serum LDHgt600IU/Llow plateletlt100,000/mm

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PIH - management

• Dependent on severity of disease
  gestational age of fetusActivity restriction /
  quiet environmentPharmacologic therapy
• anticonvulsive therapy
  antihypertensive therapy stimulant for fetal
  surfactant
• Only cure delivery of the fetus
• Goal prevent eclampsia other severe
  complications while allowing fetus to mature

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PIH eclampsia nursing interventions

• Reduce risk of aspiration
• Prevent maternal injury
• Ensure maternal oxygenation after seizure
• Ensure fetal oxygenation after seizure
• Establish seizure control with MgSO4
• Treat severe hypertension
• Correct maternal acidemia
• Initiate process of delivery

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Complications of pregnancy

• Substance Abuse
• Types of substance
• Risk Factors
• Signs and Symptoms
• Nursing Management

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Complications of Pregnancy

• Gestational Diabetes

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Complications of Pregnancy

• Infections during Pregnancy
• TORCH

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Infections

• T toxoplasmosis
• O - other
• R rubella
• C cytomegalovirus
• H herpes simplex virus