REIMBURSEMENT ISSUES

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Chapter 25 Health Promotion and Pregnancy
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Physiology of Pregnancy

• Fertilization
• During sexual intercourse, the sperm carried in
  the ejaculatory semen of the male enters the
  vagina of the female.
• Through flagellation, the sperm travel through
  the mucus of the cervical canal, enter the
  uterine chamber, and move into the ampulla, the
  outer third of the fallopian tube.
• If the timing is such that an ovum has been
  produced and is also within the ampulla of the
  tube, fertilization may occur.

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Physiology of Pregnancy

• Fertilization (continued)
• Fertilization takes place when the sperm joins or
  fuses with the ovum this is called conception.
• Once fertilization has occurred, the new cell is
  referred to as a zygote or fertilized ovum.
• At the moment of fertilization, the sex of the
  zygote and all other genetic characteristics are
  determined and they do not change.

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Physiology of Pregnancy

• Implantation
• The zygote moves through the uterine tube through
  ciliary action and some irregular peristaltic
  activity.
• It requires about 3 or 4 days to enter the
  uterine cavity.
• During this time, the zygote is in a phase of
  rapid cell division called mitosis further
  changes result in formation of a structure called
  the morula.
• The morula develops into a blastocyst.

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Physiology of Pregnancy

• Implantation (continued)
• After the blastocyst is free in the uterine
  cavity for 1 or 2 days, the exposed cell walls of
  the blastocyst (called the trophoblast) secrete
  enzymes that are able to break down protein and
  penetrate cell membranes.
• These enzymes allow the blastocyst to enter the
  endometrium and implant.
• The action of the enzymes normally stops short of
  the myometrium but may cause slight bleeding
  this is called implantation bleeding.
• The bleeding may confuse some women who think
  they had a very light and short menstrual cycle.

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Physiology of Pregnancy

• Implantation (continued)
• The condition of the uterine lining is critical
  if implantation of the zygote is to occur.
• Implantation usually occurs in the fundus of the
  uterus on either the anterior or posterior
  surface.
• If uterine conditions are not suitable, it is
  unlikely that implantation will occur.
• If the intrauterine vascular or hormonal
  conditions cannot sustain the implanted embryo, a
  spontaneous abortion will occur usually during
  the first 8 weeks of pregnancy.

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Physiology of Pregnancy

• Implantation (continued)
• Ectopic pregnancy, in which implantation occurs
  outside of the uterine cavity, also poses serious
  problems.
• During the first few weeks after implantation,
  primary villi appear these villi are able to use
  maternal blood vessels as a source of nourishment
  and oxygen for the developing embryo.

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Physiology of Pregnancy

• Implantation (continued)
• It is also during these first few weeks that the
  first stages of the chorionic villi occur.
• Chorionic villi secrete human chorionic
  gonadotropin (hCG), a hormone that stimulates the
  continued production of progesterone and estrogen
  by the corpus luteum this is the reason that
  ovulation and menstruation cease during
  pregnancy.
• The chorionic villi become the fetal portion of
  the placenta.

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Physiology of Pregnancy

• Embryonic/Fetal Development
• During this period, the fertilized ovum develops
  from the two original cells into a many-celled
  organism.
• The zygote develops two distinct cavities.
• Amniotic cavity filled with amniotic fluid
• Yolk sac supplies nourishment until implantation
• The mesoderm is located between the two cavities
  it gives rise to all types of muscle, connective
  tissue, bone marrow, blood, lymphoid tissue, and
  all epithelial tissue.

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Physiology of Pregnancy

• Embryonic/Fetal Development (continued)
• During the embryonic stage, the three primary
  cell layers differentiate into tissue and layers
  that form the placenta, embryonic membranes, and
  the embryo itself.
• A simple heart begins beating, and rudimentary
  forms of all of the major organs and systems
  develop.
• By the end of this stage, the embryo has acquired
  a human appearance.
• Starting with the ninth week, the embryo is
  referred to as the fetus, and the fetal stage
  begins.

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Physiology of Pregnancy

• Embryonic/Fetal Physiology
• Placenta
• This disklike organ made up of about 20 sections
  called cotyledons and is present only during
  pregnancy.
• At full term, the placenta looks like a large red
  disk with a diameter of 6 to 10 inches and a
  thickness of 1 inch it weighs between 400 and
  600 g (1 lb. to 1 lb. 5 oz).
• Uterine side dark red with a rough surface
• Fetal side smooth and shiny

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Physiology of Pregnancy

• Embryonic/Fetal Physiology (continued)
• Placenta
• It functions as an endocrine gland secreting hCG
  and the steroidal hormones estrogen and
  progesterone, which maintain pregnancy.
• It is the site of exchange of nutrients, oxygen,
  and waste products between the fetus and the
  maternal circulation.
• Placental barrier refers to the ability of the
  placenta to block the transfer of certain
  substances.
• After delivery, the placenta is of no further use
  and is expelled.

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Physiology of Pregnancy

• Embryonic/Fetal Physiology (continued)
• Fetal Membranes
• The amniotic sac is composed of two layers, both
  originating in the zygote.
• The outer layer, the chorion, attaches to the
  fetal portion of the placenta.
• The inner layer, the amnion, blends with the
  fetal umbilical cord.
• These membranes appear to be very fragile, but in
  fact they are strong enough to contain the fetus
  and amniotic fluid even at full term.

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Physiology of Pregnancy

• Embryonic/Fetal Physiology (continued)
• Umbilical Cord
• The cord joins the embryo to the placenta it
  originates in the fetal portion of the placenta
  and is normally attached near the center.
• The cord is usually 20 to 22 inches long and less
  than 1 inch in diameter at the time of delivery.
• The major part of the cord is a pale white,
  gelatinous-mucoid substance called Whartons
  jelly it prevents compression of the blood
  vessels.
• There are two arteries (carry deoxygenated blood)
  and one vein (carries oxygenated blood).

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Physiology of Pregnancy

• Embryonic/Fetal Physiology (continued)
• Amniotic Fluid
• Acts as a cushion against mechanical injury
• Helps regulate fetal temperature
• Allows the developing embryo/fetus room for
  growth.
• Amount is about 30 ml at 10 weeks to 1 L at
  delivery

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Figure 25-3
(Courtesy of Marjorie Pyle, RNC, LifeCircle,
Costa Mesa, California.)
Transabdominal amniocentesis.
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Physiology of Pregnancy

• Fetal Well-being
• A variety of technologic and assessment tools can
  be used to evaluate fetal well-being.
• These tools are used to evaluate maternal and
  fetal health problems, fetal congenital
  anomalies, and fetal growth and maturity.
• Ultrasonography
• Maternal serum alpha-fetoprotein screening
• Chorionic villus sampling
• Nonstress test
• Contraction stress test
• Magnetic resonance imaging
• Biophysical profile

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Maternal Physiology

• Hormonal Changes
• Estrogen and progesterone levels remain elevated
  for the first 8 weeks of pregnancy as a result of
  hCG.
• After this time, the placenta takes over
  production and maintains necessary levels.
• As long as these levels are high,
  follicle-stimulating hormone (FSH), luteinizing
  hormone (LH), and ovulation are suppressed, as is
  menstruation.

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Maternal Physiology

• Uterus
• The uterus enlarges during pregnancy as a result
  of hormonal stimulus, increased vascularity,
  hyperplasia, and hypertrophy.
• The nonpregnant uterus is pear-shaped and weighs
  about 50 g by the third trimester, it is
  egg-shaped and has increased weight to 1000 g.
• In a nonpregnant state, it is a pelvic organ
  when the pregnancy reaches completion, the
  superior aspect of the uterus will be located at
  the level of the xiphoid process.

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Maternal Physiology

• Breasts
• There is hypertrophy of the mammary glandular
  tissue and increased vascularization,
  pigmentation, size, and prominence of nipples and
  areola.
• Changes are caused by hormonal stimulation.

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Maternal Physiology

• Maternity Cycle
• Antepartal or Prenatal Period
• Begins with conception and ends with the onset of
  labor
• Intrapartal or Perinatal Period
• Begins with the onset of labor and ends with
  delivery of the placenta
• Postpartal Period
• Starts after the delivery of the placenta and
  lasts for approximately 6 weeks or until the
  reproductive organs return to the prepregnancy
  state

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Maternal Physiology

• Maternity Cycle (continued)
• Pregnancy spans 9 months, approximately 40 weeks
• Divided into 3-month periods or trimesters.
• First trimester weeks 1 through 13
• Second trimester weeks 14 through 26
• Third trimester weeks 27 through term gestation
  (38 to 40 weeks)

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Antepartal Assessment

• General Physical Assessment
• Ideally, the woman has been receiving regular
  medical attention and is already known by the
  health care provider.
• Unfortunately, many people do not receive
  regular, routine health care.
• On the first visit, demographic data, such as
  age, occupation, marital status, and insurance
  information, are obtained this helps the primary
  care practitioner identify potential areas of
  concern.
• A basic family and personal medical history is
  obtained it should include genetic diseases.

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Antepartal Assessment

• Genetic Counseling
• The most useful means of reducing the incidence
  of genetic disorders is by preventing their
  transmission.
• With the accumulation of information about
  genetic disorders, the probability of recurrence
  in any given situation can be predicted with
  increased accuracy.
• A personal medical history is taken and a review
  of systems is done.
• Lifestyle patterns are assessed.
• A basic physical examination is completed.

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Antepartal Assessment

• Obstetric Assessment
• Information about the womans gynecological,
  menstrual, and obstetric history is obtained.
• The number of pregnancies and their outcomes are
  discussed.
• Gynecological Examination
• The gynecological examination is also performed
  at this time.
• The nurse is often called on to prepare the
  necessary equipment and assist with this
  examination.

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Determination of Pregnancy

• Presumptive Signs
• Amenorrhea
• Nausea and vomiting
• Frequent urination
• Breast changes
• Changes in shape of the abdomen
• Quickening
• Skin changes
• Chadwicks sign

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Determination of Pregnancy

• Probable Signs
• Changes in the Reproductive Organs
• Hegars sign
• Goodells sign
• Ballottement
• Positive Pregnancy Test

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Figure 25-4
(From Wong, D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
Hegars sign.
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Figure 25-5
(From Wong, D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
Internal ballottement (18 weeks).
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Determination of Pregnancy

• Positive Signs
• Visualization
• Fetal movement
• Auscultation of fetal heartbeat

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Determination of Pregnancy

• Determination of the Estimated Date of Birth
• Normal human pregnancy, counting from the first
  day of the last menstrual period, is about 280
  days, 40 weeks, or 10 lunar months (slightly more
  than 9 calendar months).
• Nägeles rule
• Start with the first day of the womans last
  menstrual period and count back 3 months then
  add 7 days.

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Determination of Pregnancy

• Determination of the Estimated Date of Birth
  (continued)
• If the woman does not keep a menstrual record,
  the primary care provider must then rely on
  observations such as quickening, estimation of
  fetal size by palpation, or ultrasonic tests, all
  of which can be unreliable.

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Determination of Pregnancy

• Obstetric Terminology
• Terms used to describe the number of times a
  woman has been pregnant and given birth
• Gravida indicates a pregnant women
• Primigravida one pregnancy
• Nulligravida no pregnancies
• Multigravida multiple pregnancies
• Primipara one birth
• Nullipara no births
• Multipara multiple births
• Abortion indicating loss of a fetus before the
  age of viability

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Antepartal Care

• Health Promotion
• Pregnancy is a time in life when most women see
  the importance of regular medical supervision and
  are more willing to make changes in their habits
  than any other time.
• Once pregnancy is diagnosed, prenatal care is
  instituted.
• Early in pregnancy, the woman often begins to
  seek information and make choices regarding how
  and where she wishes to give birth.

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Antepartal Care

• Health Promotion (continued)
• Routine care during pregnancy begins with the
  initial examination and history.
• Appointments are recommended once a month through
  the seventh month, once every 2 weeks for the
  next month, and then once every week until
  delivery.
• Smoking and drinking alcoholic beverages during
  pregnancy are contraindicated.
• Taking any medications or drugs during pregnancy,
  including over-the-counter drugs, should be
  avoided.

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Antepartal Care

• Danger Signs During Pregnancy
• Visual disturbances
• Headaches
• Edema
• Rapid weight gain
• Pain
• Signs of infection
• Vaginal bleeding or drainage
• Persistent vomiting
• Muscular irritability or convulsions
• Absence or decrease in fetal movement once felt

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Antepartal Care

• Nutritional/Metabolic Health Pattern
• Pica
• This is the craving and eating of substances that
  are not normally considered edible.
• Substances such as clay or laundry starch are
  commonly ingested.
• They are not toxic but may interfere with iron
  absorption, resulting in anemia.
• Large amounts of clay may cause constipation.

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Antepartal Care

• Common Discomforts
• Excessive salivation
• Nausea
• Hyperemesis gravidarum
• Pyrosis (heartburn)

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Antepartal Care

• Skin Changes
• Linea nigra dark line midline of abdomen
• Chloasma the mask of pregnancy
• Striae gravidarum stretch marks
• Spider nevi dilated capillaries on the skin
• Palmar erythema reddened palms
• Hirsutism excessive body hair

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Antepartal Care

• Hygiene Practices
• Bathing and showering during pregnancy should
  continue as part of routine hygiene.
• Increased perspiration is common, and good
  personal hygiene is important to prevent body
  odor.
• Some primary care practitioners restrict tub
  baths in the last month, because the cervix may
  have dilated.
• Most primary care practitioners recommend that
  women avoid using hot tubs, sauna baths, and spas
  during pregnancy.

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Antepartal Care

• Elimination
• Gastrointestinal System
• Slowing of intestinal peristalsis can result in
  abdominal distention, flatulence, and
  constipation.
• Hemorrhoids can result from straining and because
  the enlarged uterus puts pressure on the pelvic
  blood vessels.
• Women with cholelithiasis may have problems as a
  result of increased cholesterol level.
• Adequate fluid intake, dietary roughage, and
  exercise may help reduce problems with
  constipation.

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Antepartal Care

• Elimination
• Urinary System
• Frequency of urination is a common complaint.
• The mother must excrete not only her own waste
  products but also those of the fetus.
• Early in pregnancy, the enlarging uterus
  irritates the bladder by putting pressure on it
  this continues until the uterus rises into the
  abdominal cavity.
• Later in pregnancy, when the presenting part
  descends into the pelvis, the pressure and
  symptoms return.

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Antepartal Care

• Activity/Exercise
• Normal activity should continue throughout an
  uncomplicated pregnancy.
• Fatigue is a common complaint during pregnancy.
• Changes in balance and posture occur as the fetus
  increases in size to compensate for the shifting
  center of gravity, the lumbodorsal curve
  increases (lordosis).
• Hormonal influence on the pelvic bones, resulting
  in joint relaxation, can lead to a waddling gait.
• Leg cramps are a common occurrence.

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Antepartal Care

• Rest/Sleep
• Early in pregnancy, few changes in sleep patterns
  are experienced.
• As the size of the abdomen increases, it may
  become increasingly difficult for the woman to
  find a position of comfort.
• The supine position is not recommended as a woman
  approaches her due date this may cause excessive
  pressure on the aorta and vena cava and may
  result in decreased circulation for the fetus.
• Rest periods during the day with the feet
  elevated should be encouraged.

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Figure 25-7
(From McKinney, E.S., James, S.R., Murray, S.S.,
Ashwill, J.W. 2005. Maternal-child nursing.
2nd ed.. Philadelphia Saunders.)
During third trimester, pillows supporting
abdomen and back provide a comfortable position
for rest.
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Antepartal Care

• Sexuality/Reproductive System
• Breast Changes
• Breast changes begin early in pregnancy there
  may be tingling and a feeling of fullness.
• Generally, the breasts increase in size in
  preparation for lactation.
• The nipples and areola darken.
• Colostrum may be secreted by the nipples in late
  pregnancy.

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Antepartal Care

• Sexuality/Reproductive System
• Sexual Activity
• Unless there are complications in the pregnancy
  or the bag of water has ruptured, there is no
  physiological reason to limit sexual activity
  during pregnancy.
• Many women experience a decrease in desire as a
  result of hormonal changes and the multiple
  discomforts that may be occurring.
• Discussion of various coital positions and sexual
  activity that does not include intercourse is
  appropriate.

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Antepartal Care

• Vaginal Bleeding
• Vaginal bleeding at any time during pregnancy
  should be reported to the physician at once.
• Sexual activity should cease until the cause of
  the bleeding is determined and should be resumed
  only when the physician determines that no danger
  exists.

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Antepartal Care

• Coping/Stress Tolerance
• All of the physical and hormonal changes of
  pregnancy place additional stress on the woman.
• Mood swings and ambivalence are common as the
  woman works through her fears and comes to grip
  with the reality of pregnancy and how the
  pregnancy will affect her life.
• Listening and allowing the woman adequate time to
  verbalize her fears can also help reduce
  anxieties.

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Antepartal Care

• Role/Relationship
• Pregnancy introduces a totally new role, that of
  a mother.
• Culture will have much to do with how the woman
  will define her role.
• Dynamics also change between the woman and the
  babys father, particularly with the first
  pregnancy. The woman is no longer just a wife or
  girlfriend she is also a mother.

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Antepartal Care

• Self-Perception/Self-Concept
• Rapid changes in body shape and size can lead to
  changes in self-image.
• Many women feel that they are not attractive when
  they are pregnant.
• They may also feel a loss of control related to
  the changes taking place.

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Antepartal Care

• Cognitive/Perceptual
• Although sensory changes are uncommon with
  pregnancy, blurring or diplopia may indicate
  problems with pregnancy-induced hypertension.
• Prenatal education is important.

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Preparation for Childbirth

• Childbirth Preparation Classes
• Some classes are general in nature, whereas
  others are targeted toward specific groups such
  as adolescents, those having cesarean or vaginal
  birth after cesarean delivery, siblings, or
  grandparents.
• Common methods of prepared childbirth include
• Dick-Read
• Bradley
• Leboyer
• Lamaze

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Figure 25-8
(From Lowdermilk, D.L., Perry, S.E. 2004.
Maternity womens health care. 8th ed.. St.
Louis Mosby.)
Entire family participating in a childbirth
preparation course.
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Preparation for Childbirth

• Cultural Variations in Prenatal Care
• It is imperative that the practitioner determine
  and explore cultural practices and beliefs with
  the patient.

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Nursing Process

• Nursing Diagnoses
• Body image, disturbed
• Nutrition less than body requirements
• Injury, risk for
• Activity intolerance
• Incontinence, stress urinary
• Constipation
• Sleep pattern, disturbed
• Fatigue

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Nursing Process

• Nursing Diagnoses (continued)
• Knowledge, deficient
• Family processes, interrupted
• Fear
• Parenting, risk for impaired