MATERNAL

• Maternal Care


  Physical and psychologic changes of pregnancy
• Reproductive System


  • External Structures: enlarged due to increased vascularity
  • Fallopian Tubes: elongate as uterus rises in pelvic and abdominal cavities
  • Ovaries: no ovulation during pregnancy, corpus luteum persists in early pregnancy until development of placenta is complete
  • Vagina: Increased vascularity (Chadwick's sign), Estrogen-induced leukorrhea, Change in pH (less acidic) may favor overgrowth of yeast like organisms, Connective tissue loosens in preparation for distention of labor and delivery
  • Cervix: Softens and loosens in preparation for labor and delivery (Goodell's Sign), Mucous production Increases and plug (Operculum) is formed as bacterial barricade
  • Uterus: Hypertrophy and hyperplasia of muscle cells, Development of fibroelastic tissue that increases ability to contract, Shape changes from pearlike to avoid, Rises out of pelvic cavity by 16th week of pregnancy, Increased vascularity and softening of isthmus (Hegar's sign) Mild contractions (Braxton Hicks sign) beginning in the fourth month through end pregnancy
  • Breasts: Increased vascularity; sensitivity and fullness, Nipples and areola darkens, Nipples becomes more erectile, Proliferation of ducts and alveolar tissue evidenced by increased breast size, Production of colostrums in the second trimester
• Cardiovascular System


  • Blood volume expands as much as 50% to meet demands of new tissue and increased needs of all systems
  • Progesterone relaxes smooth muscle, resulting in vasodilation and accommodation of increased volume
  • RBC volume increases as much as 30%; there may be slight decline in hematocrit as pregnancy progresses because of this relative imbalance (physiologic anemia)
  • Stroke volume and cardiac output increase
  • WBC's increased
  • Greater tendency to coagulation
  • Blood pressure may drop in early pregnancy, should not rise during the last half of pregnancy
  • Heart rate increases; palpitation possible
  • Blood flow to the uterus and placenta is maximized by side-lying position
  • Varicosities may occur in vulva and rectum as well as lower extremities
• Respiratory System


  • Increased vascularity of mucous membranes of this system gives rise to symptoms of nasal and pharyngeal congestion and fullness in the ears
  • Shape of thorax shortens and widens to accommodate the growing fetus
  • Sight increase in respiratory rate
  • Dyspnea may occur at end of third trimester before engagement or "lightening"
  • Increased respiratory volume by 40 to 50%
  • Oxygen consumption increases by 15%
• Renal System


  • Kidney filtration rate increases as much as 50%
  • Glucose threshold drops; sodium threshold rises
  • Water retention increases as pregnancy progresses
  • Enlarging uterus causes pressure on the bladder resulting in frequency of urination, especially during the first trimester; later in pregnancy relaxed ureters are displaced laterally, increasing the possibility of stasis and infection
  • Presence of protein (not an expected component of maternal urine) indicates possible renal disease or PIH
• Integumentary System


  • Increased pigmentation of nipples and areolas
  • Possible appearance of chloasma (mask of pregnancy); darkening of the areas on forehead and cheekbones
  • Greater sweat and sebaceous gland activity
  • Striae (stretch marks): separation of underlying connective tissue in breasts, abdomen, thighs and buttocks; fade after delivery
  • Appearance of linea nigra, darkened fine bisecting abdomen from symphysis pubis to top of fundus
• Musculoskeletal System


  • Alterations in posture and walking gait caused by change in center of gravity as pregnancy progresses
  • Increased joint mobility as a result of action of ovarian hormone (relaxin) on connective tissue
  • Possible headache
  • Occasional cramps in the calf may occur with hypocalcemia
• Neurologic System


  • Few changes with a typical pregnancy
  • Pressure on the sciatic nerve may occur later in pregnancy due to fetal position
• Gastrointestinal System


  • Bleeding gums and hypersalivation may occur
  • Tooth loss due to demineralization should not occur
  • Nausea and vomiting in 1st trimester due to rising levels of HCG
  • Appetites usually improves
  • Cravings/desires for strange food combinations may occur
  • Progesterone-induced relaxation of muscle tones leads to slow movement of food through GI tract; may result in heartburn
  • Constipation may occur as water is reabsorbed in the large intestine
  • Emptying time for gallbladder may be prolonged; increased incidence of gallstones
• Endocrine System

  • Progesterone secreted by corpus luteum until formation of placenta
  • Principal source of estrogen is placenta synthesized from fetal precursor
  • Pituitary: FSH and LH greatly decreased
  • Oxytocin secreted during labor and after delivery
  • Prolactin responsible for initiation and continuation of lactation
  • HPL produced by placenta; similar to growth hormone, it prepares breasts for lactation: also affects insulin/ glucose metabolism, may overstress maternal pancreas
  • Ovaries secrete Relaxin during pregnancy
  • Slight increase in thyroid activity and basal metabolic rate (BMR)
  • Pancreas may be stressed due to complete interaction of glucose metabolism, HPL and cortisol, resulting in diminished effectiveness of insulin and demand for increased production
• Psychological System


  • First trimester: Mother needs accurate diagnosis of pregnancy, Works through characteristic ambivalence of early pregnancy, Mother is self-centered, baby is part of her, Grandparents are usually the first relatives to tell of the pregnancy
  • Second trimester: Mother demonstrates growing realization of baby as separate and needing person, Fantasizes about unborn child
  • Third trimester: "Nesting" activity appears as due date approaches, Desire to be finished with pregnancy, Anxiety over "safe passage" for self and baby through labor and delivery, Reactions of father-to-be may parallel those of mother (e.g. ambivalence, anxiety), "COUVADE SYNDROME", Preparation of siblings varies according to their age and experience
• Classification of Pregnancy


  • Gravida - number of time pregnant, regardless of duration, including the present pregnancy
  • Para - number of pregnancies that lasted more than 20 weeks, regardless of outcome
  • TPAL M - para subdivided: Term, Premature births, Abortions, Living children, Multiple birth

  
• Determination of Pregnancy


  • Presumptive - subjective - sign that suggest that do not confirm pregnancy and could be due to other condition
  • Probable - objective - strong indication of pregnancy not likely but still possibly due to other condition
  • Positive - signs definitively confirming pregnancy
• Signs and Symptoms of Pregnancy


  • Presumptive: Amenorrhea, Morning sickness, Breast changes, Fatigue, Urinary frequency
  • Probable: Enlarging uterus, Quickening, Leucorrhea, Weight changes, Skin changes (Chloasma, Linea nigra, Striae gravidarum), Chadwick's, Goodell's, Hegar's, Ballottement, Braxton Hicks contraction
  • Positive: Positive HCG, Fetal outline palpation, Fetal heart tones, Fetal movements, Fetal outline on X-ray or ultrasound

  
• The Antenatal Period: Assessment


  • Time frame: First visit, Subsequent visit
  • Conduct of initial visit: Extensive collection of data, Complete physical examination, Laboratory work
  • Conduct of subsequent visit: Continue collection of data, Prepare for necessary testing
• Weight Gain


  • Variable, but 25 lb usually appropriate for average woman with single pregnancy
  • Woman should have consistent, with only 2-3 lb in first trimester, then average 12 oz gain every week in second and third trimesters
  • Normal weight gain: 25 to 35 lb
  • Pattern of weight gain: First trimester - 3 to 4 lb, Second trimester - 12 to 14 lb, Third trimester - 8 to 10 lb
• Specific Nutrient Needs


  • Calories: + 300 kcal/day. Never <1800 kcal/day
  • Protein: +30g/day to ensure intake of 74-76 g/day
  • Carbohydrates
  • Fats
  • Iron
  • Calcium: 1200mg/day
  • Sodium
  • Vitamins
• Dietary Supplements


  Many health care providers supplement the pregnant woman's diet with an iron-fortified multivitamins to ensure essential levels
• Special concerns: religious, ethics, and cultural
• oid (clean catch)


  1. Collect baseline data on vital signs

  2. Collect specimen

  3. Monitor client and fetus after procedure

  4. Provide support to client

  5. Document as needed
• THE ANTENATAL PERIOD: INTERVENTIONS (NUTRITION DURING PREGNANCY)


  • WEIGHT GAIN
  • SPECIFIC NUTRIENT NEEDS
  • DIETARY SUPPLEMENTS
  • SPECIAL CONCERNS
• Reproductive System

  • Ovaries stop ovulation due to active feedback mechanism of estrogen and progesterone
  • Corpus luteum regresses in size and appears white and fibrous on the surface of the ovary
  • Vaginal epithelium and underlying tissue become hypertrophic and enriched with glycogen
  • Vaginal secretions fall from pH of >7 to 4-5 due to Lactobacillus acidophilus
  • Cervix becomes more vascular and edematous
  • Uterus increases in size to accommodate growing fetus
• Weight gain


  • Variable, but 25 lb usually appropriate for average woman with single pregnancy
  • Woman should have consistent, with only 2-3 lb in first trimester, then average 12 oz gain every week in second and third trimesters
  • Normal weight gain: 25 to 35 lb
  • Pattern of weight gain: First trimester - 3 to 4 lb, Second trimester - 12 to 14 lb, Third trimester - 8 to 10 lb
• Respiratory System


  • Marked congestion of nasopharynx
  • Diaphragm displaced upward causing shortness of breath
  • Vital capacity does not decrease
  • Residual volume decreased up to 20%
  • Tidal volume increased up to 40%
  • Total O2 consumption increases up to 20%
  • Breathing rate more rapid than usual (18-20 breaths per minute)
• SPECIFIC NUTRIENT NEEDS


  • Calories: + 300 kcal/day. Never <1800 kcal/day
  • Protein: +30g/day to ensure intake of 74-76 g/day
  • Carbohydrates
  • Fats
  • Iron
  • Calcium: 1200mg/day
  • Sodium
  • Vitamins
• Cardiovascular System


  • Cardiac output increases 25 to 50% over non-pregnant output
  • Pulmonary and peripheral vascular resistance decreases lowering blood pressure in first and second trimesters
  • Blood pressure rises again to first trimester levels in third trimester
  • Haemoglobin concentration and haematocrit values decrease in first or third trimester, then increase in second trimester
• SPECIAL CONCERNS


  • religious, ethics, and cultural practices that influence selection and preparation of foods
  • Pica (ingestion of non-edible or nonnutritive substances)
  • Vegan vegetarians - no meat products, may need B12 supplement
  • Adolescence
  • Economic deprivation
  • Heavy smoking, alcohol consumption, drugs
  • Previous reproductive problems
• Renal System


  • Urinary frequency in first and third trimesters due to gravid uterus pressing on bladder
  • Urine output gradually increases by about 60-80%
• Integumentary System


  • Striae gravidarum (stretch marks) appear on abdomen and thighs
  • Diastasis - abdominal wall has difficulty stretching enough causing rectus muscles to separate
  • Linea nigra - narrow brown line forms from umbilicus to pubic symphysis
  • Melasma (chloasma) - darkened areas appear on face
  • Vascular spiders or telangiectases - small, fiery-red branching spots on skin
• Women who need special attention


  • Pregnant teenagers
  • Extremes in weighing scale - low prepregnant weight and obese
  • Low income women
  • Successive pregnancies
  • Vegetarians
• Musculoskeletal System


  • Waddling gait
  • Lordosis may develop
• Neurologic System


  • Pressure on sciatic nerve may occur later in pregnancy due to fetal position
• Nutritional assessment


  Based on taking a diet history first: Food preferences/eating habits, Cultural/religious influences Educational/occupational level
• Gastrointestinal System


  • Morning sickness in first trimester due to increased hCG
  • Heartburn
• Computation of caloric equivalents

  Carbohydrates x 4, Proteins x 4, Fats x 9
• Instruct client to choose from 3 basic food groups
• Endocrine System


  • FSH and LH greatly decreased due to increased estrogen and progesterone
  • Increased production of growth hormone and melanocyte-stimulating hormone
  • Thyroid gland enlarges in early pregnancy
  • Pancreas increases insulin production in response to higher glucocorticoid levels
• Psychosocial Changes in Pregnancy


  • First Trimester: Accepting pregnancy, ambivalence common
  • Second Trimester: Accepting the baby, role playing and increased dreaming common
  • Third Trimester: Preparing for baby and end of pregnancy, nest-building activities, couvade syndrome
• Classification of Pregnancy


  • Gravida - Number of times pregnant
  • Para - Number of pregnancies lasting more than 20 weeks
  • AOG - Age of Gestation (Term, Post-term, Preterm, Abortion)

  
• Diagnosis of Pregnancy (3Ps S/S)


  • Presumptive (Subjective) - Experienced by the woman but cannot be documented
  • Probable (Objective) - Can be documented by an examiner but not positive diagnostic findings
  • Positive - Demonstration of fetal heart, fetal movements, visualization of fetus by ultrasound