Care of the Client During Pregnancy

Lecture Three: Care of the Client During Pregnancy

NURS 2208
T. Dennis RNC, MSN

Objectives

• Examine various prenatal education programs, alternative birthing options, and nursing implications.
• Describe the different signs of pregnancy.
• Explain normal physical, physiologic, and psychological changes occurring in a woman throughout pregnancy.

Preparation for Parenthood

• Begins in the family setting
• Attitudes, feelings, ideas, fears
• Knowledge-accurate or inaccurate
• Comfort zone - no comfort zone

“The nurse fosters involvement by the family to help them cope with feelings of anxiety”

• Childbearing family-a variety of combinations
• Helps in decision making by informing the client of choices available-informed choices
• Reaffirms the clients ability to make decisions

Pre-Conception Counseling

• Teaching- No smoking, no caffeine, no OTCs
• Physical Exam- Both partners (optimal health)
• Nutrition
• Exercise
• Conception (RELAX)

Childbearing Decisions….Who will take care of    me?

• Types of providers available
• Interview the provider
• Ask questions now…not when pushing
• Visit different providers

The Birth Plan

• Assists clients /couples in making choices
• Encourages research into available options
• Tool for communication- “Are we all on the same page?”
• Helps client/couples set priorities
• Adds realization of limitations to the experience that may occur

“It is important for the nurse to be nonjudgmental and yet helpful to the client/couple in keeping their expectations realistic”

The Labor Support Person

• The Coach Role
• The Teammate Role
• The Witness Role
• The Doula
• The Monitrice

Siblings at the Birth

• Preparation is key (AV, classes, books)
• Child has “own” support person
• Allowed to participate (as long as not disruptive)
• Generally a “good” experience
• Fosters acceptance of the new infant

Classes for Family Members

• Early Prenatal classes
• Later Prenatal classes
• Adolescent parenting classes
• Breastfeeding programs
• Sibling preparation
• Classes for grandparents

Education for Cesarean Birth

• Preparation for cesarean birth
• Preparation for repeat cesarean birth
• Preparation for Vaginal Birth After Cesarean Section (VBAC)

Methods of Childbirth Education

• LAMAZE (psychoprophylactic)
• KITZINGER (sensory memory)
• BRADLEY (partner coached)

Lamaze

• “Mind prevention”
• Major components are education and training
• Body conditioning exercises (pelvic tilt, pelvic rock, Kegels)
• Relaxation exercises (Progressive, touch, disassociated)
• Breathing techniques

Advantages to Childbirth Education Classes

• Reduced need for analgesics and/or anesthetics
• Parental satisfaction (a shared journey, a sense of control over the process)
• Each method has been shown to shorten the labor process (relax, relax, relax)

INDIVIDUALITY”

• Vocalization or “sounding”
• Massage (increases relaxation)
• Breathing (any manner/technique)
• Warm water (compresses, bath, shower)
• Visualization
• Relaxing music - subdued lighting
• Aromatherapy
• The Birthing ball or Birthing bar

Changes occurring in pregnancy

• Uterus: circulatory requirements increase, walls thicken until late pregnancy when they become thinner, Braxton Hicks contractions occur intermittently.
• Cervix: Goodell’s sign (softening of the cervix), Chadwick’s sign (blue-purple discoloration
• Ovaries: cease ovum production during pregnancy.

Changes occurring in pregnancy

• Vagina: may show same bluish color as Chadwick’s sign
• Breasts: size and nodularity increase, striae (stretch marks) may appear, colostrum (an antibody rich, yellow secretion, may be expressed manually by 12th week and will eventually convert to milk.
• Respiratory system: diaphragm elevated and rib cage flares during latter part of pregnancy.

Changes occurring in pregnancy

• Cardiovascular system: hear pushed upward, blood volume increases, supine hypotensive syndrome or vena caval syndrome or aortocaval compression may occur producing a drop in blood pressure with dizziness,pallor and clamminess (may be relieved by turning to left side).
• Clotting changes place the pregnant woman at risk for developing venous thrombosis.
• Physiologic anemia of pregnancy: anemia that results during pregnancy due to the plasma volume increasing more than the erythrocytes.

Changes occurring in pregnancy

• strointestinal system: nausea & vomiting of pregnancy, peculiarities of taste and smell, gums may bleed.Heartburn occurs due to relaxation of the cardiac sphincter. Bloating and constipation may occur.
• Urinary tract: Frequency occurs due to pressure of growing uterus on bladder, more prone to infections.

Changes occurring in pregnancy

• Skin and hair: Pigmentation of skin may increase, linea nigra (linea alba, midline from pubic area to umbilicus) darkens, chloasma (mask of pregnancy) appears. Striae may appear. Vascular spider nevi, small, bright red elevations of the skin radiating from a central body. Rate of hair growth slows and hair loss may occur.

Changes occurring in pregnancy

• Musculoskeletal system: Lordosis (spinal curvature) may occur in late pregnancy. Waddling gate may occur in late pregnancy.
• Eyes: Intra-ocular pressure decreases. A slight thickening of the cornea occurs (makes contact lens slightly uncomfortable). These changes usually resolve by 6 weeks post partum.

Changes occurring in pregnancy

• Metabolism: 25 - 35 lb weight gain isrecommended. An increase in water retention occurs. Demand for iron is accelerated. The demand for carbohydrates increases.
• Endocrine system: Thyroid usually slightly enlarged due to increased vascularity and hyperplasia of glandular tissue.

Signs of Pregnancy

• Subjective: Presumptive changes that are the symptoms the client experiences and reports.
• Objective: Probable changes that occur in pregnancy that are more diagnostic than subjective symptoms.
• Diagnostic: Positive signs that are completely objective and offer conclusive proof of pregnancy.

Presumptive Signs of Pregnancy (Subjective)

• Amenorrhea
• Nausea and vomiting of pregnancy (NVP or morning sickness)
• Excessive fatigue
• Urinary frequency
• Breast changes
• Quickening

Probable Signs of Pregnancy (Objective)

• An observer can perceive the objective signs that occur in pregnancy.
• Changes in the pelvic organs (Chadwick’s sign, Goodell’s sign, Hegar’s sign , McDonald’s sign)
• Enlargement of the abdomen (during childbearing years)
• Uterine souffle

Probable Signs of Pregnancy (Objective)

• An observer can perceive the objective signs that occur in pregnancy.
• Changes in the pelvic organs (Chadwick’s sign, Goodell’s sign, Hegar’s sign , McDonald’s sign)
• Enlargement of the abdomen (during childbearing years)
• Uterine souffle

Probable Signs of Pregnancy(Objective)

• Changes in pigmentation of the skin and the appearance of abdominal striae
• The fetal outline may be identified by palpation after 24 weeks gestation
• Ballottement may be felt on vaginal exam
• Pregnancy tests based on hCG
• Over-the-counter pregnancy tests

Diagnostic (positive) Signs of Pregnancy

• Completely objective, conclusive proof of pregnancy , not confused with other pathological states
• Fetal heart rate
• Fetal movement palpated by an examiner after 20 weeks gestation
• Visualization of the fetus by ultrasound (fetal parts and heart rate visible at 8 wks)

Question

Suzanne Martin comes to her prenatal check up. She tells the nurse that she thinks she is 10 weeks pregnant. Which one of the following would be a probable (objective) sign of pregnancy?

1. Human chorionic gonadotrophin (hCG) in the urine
2. Breast tenderness
3. Morning sickness
4. Fetal heart tones

 Psychological Response in Pregnancy

• Anxiety: pregnancy is a developmental turning point as childless couples become parents.
• Lifestyle changes occur.
• The reality of labor and birth. How will my life change after I have a baby?
• Social support is important.
• Affects both mother, father, siblings and grandparents.

 

Mother

• Ambivalence
• Acceptance
• Introversion
• Mood swings
• Changes in body image

Father

• Ambivalence about being a parent.
• Concern of moving into a parenting role.
• Stress due to financial issues, changing relationship with partner, his role in the pregnancy.
• Concern about their ability to parent.
• May exhibit signs or symptoms related to the pregnancy.

Siblings
Image
Sibling rivalry
GRANDPARENTS
Unsure of their role
Support resource

Cultural Diversity and Pregnancy

• Health values: ritualistic since ancient man, normal occurrence, sign of virility, generalizations are inappropriate.
• Health beliefs: time of vulnerability,equilibrium model (hot/cold)
• Health practices: home remedies, healthcare professionals, importance of indigenous healers.

Cultural factors and Nursing care

• Become aware of cultural differences
• Identify personal biases
• Learn rituals and customs of other cultures
• Include cultural assessment
• Foster an attitude of respect
• Provide for interpreters
• Learn the language or key phrases
• Incorporate practices into care

Initial Client History

• Gravida and para refer to pregnancies not to the fetus.
• TPAL is a useful acronym helpful in remembering term used to identify the number of infants born: (T) number of term infants born, (P) number of preterm infants born, (A) number of abortions, (L) number of children currently living.

Question

• Madeline is 8 weeks pregnant. She has a baby girl born at 35 weeks that is living and well, a pregnancy that ended in a stillbirth at 41 weeks, and a spontaneous abortion at 12 weeks gestation. Determine Madeline’s gravity and parity using the TPAL system.

1. 3-1-1-1-1
2. 3-0-1-1-1
3. 4-0-1-2-1
4. 4-1-1-1-1

Determination of Due Date (pg268)

• EDC: Estimated date of confinement
• EDD: Estimated date of delivery
• EDB: Estimated date of birth
• Nägele’s Rule: Begin with the first day of the last menstrual period, subtract three months, and add seven days (most common method of determining the EDB)

Antepartum Assessment

• Uterine Assessment: Uterine size may be one of the single most important clinical method for dating pregnancy ( in the first 10-12 weeks, dates accurate).
• Fundal height: A centimeter tape is used to measure the distance from the top of the symphysis pubis over the curve of the abdomen to the top of the uterine fundus.
• Pelvic adequacy: Clinical pelvimetry is performed by a nurse with special 

 

Danger Signs in Pregnancy

• Sudden gush of fluid from vagina
• Vaginal bleeding
• Abdominal pain
• Temperature > 101 and chills
• Dizziness, blurring of vision, spots before eyes
• Persistent vomiting
• Severe headache
• Edema of hands, feet, face and legs
• Muscular irritability, convulsions
• Epigastric pain
• Oliguria, Dysuria
• Absence of fetal movement

Subsequent Prenatal Visits

• Every four weeks for the first 28 weeks
• Every 2 weeks until 36 weeks gestation
• After 36 weeks, every week until childbirth
• These are general guidelines. The frequency of visits should be based on the client’s individual needs and assessment of her risks.

Common Discomforts of Pregnancy - First Trimester

• Nausea and vomiting: Dry carbohydrate snack before getting OOB, small frequent meals , acupressure.
• Urinary frequency/stress incontinence: empty bladder frequently, good hygiene, Kegel exercises
• Fatique: frequent rest periods
• Breast-tenderness: wear good support bra
• Increased vaginal discharge: good hygiene
• Nasal stuffiness and nosebleed (epistaxis): humidify air, vitamin C, lubricate nostrils
• Ptyalism (excessive, often bitter salivation)

Common Discomforts of Pregnancy - 2nd & 3rd Trimesters

• Heartburn (pyrosis): small frequent meals, avoid fried, greasy or spicy foods
• Ankle edema: elevate feet, wear support hose, decrease sodium in diet
• Varicose veins: support hose
• Hemorrhoids, flatus and constipation: increase exercise, increase fluids and roughage in diet
• Backache: pelvic tilt exercises, good posture
• Difficulty sleeping/pelvic heaviness: side lying position, knee to chest
• Leg cramps:flex toes toward face and hyper extend foot, increase calcium/phosphorous levels
• Faintness: avoid sudden position change or supine position
• Dyspnea: arms over head, slow breathing stretch to elongate trunk
• Round ligament pain: no sudden turns, support abdomen
• Carpal tunnel syndrome

Dietary Teaching

• Achieve a protein intake of 60 gms per day
• Maintain a calcium intake of 1200 mg per day.
• Folic acid intake of 400mcg per day is desired.
• An appropriate weight gain of 3.5 to 5 lb per week during the first trimester and 1 lb per week thereafter.
• Avoid fried foods to relieve heartburn.
• No caloric increase during the first trimester
• Increase caloric intake by 300 kcal during the second and third trimester.

Nutrition

• Folic acid sources: fresh green leafy vegetables, liver, peanuts, and whole grain breads and cereals.
• Iron: lean meats, dark green leafy vegetables, eggs, and whole-grain and enriched breads, dried fruits, legumes, shellfish, and molasses. (Iron absorption is improved when taken in conjunction with a food rich in vitamin C.)
• Vitamin C: citrus fruit, tomatoes, cantaloupe, strawberries, broccoli, and leafy green vegetables.

Questions?

Medical Blooper
A young female patient had come into our office for a diaphragm fitting. The doctor explained that for easier insertion the diaphragm should be lubricated with jelly. Upon her return to the office, the doctor noted that the cervix was remarkably discolored. When the doctor asked her what kind of jelly she used, she replied, “Grape.”
A chuckle a day…® from the medical community.
 
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