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Lecture Three: Care of the Client During Pregnancy

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Title: Lecture Three: Care of the Client During Pregnancy


1
Lecture Three Care of the Client During Pregnancy
  • NURS 2208
  • T. Dennis RNC, MSN

2
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.

3
Preparation for Parenthood
  • Begins in the family setting
  • Attitudes, feelings, ideas, fears
  • Knowledge-accurate or inaccurate
  • Comfort zone - no comfort zone

4
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

5
Pre-Conception Counseling
  • Teaching- No smoking, no caffeine, no OTCs
  • Physical Exam- Both partners (optimal health)
  • Nutrition
  • Exercise
  • Conception (RELAX)

6
Childbearing Decisions.Who will take care of me?
  • Types of providers available
  • Interview the provider
  • Ask questions nownot when pushing
  • Visit different providers

7
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

8
It is important for the nurse to be
nonjudgmental and yet helpful to the
client/couple in keeping their expectations
realistic
9
The Labor Support Person
  • The Coach Role
  • The Teammate Role
  • The Witness Role
  • The Doula
  • The Monitrice

10
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

11
Classes for Family Members
  • Early Prenatal classes
  • Later Prenatal classes
  • Adolescent parenting classes
  • Breastfeeding programs
  • Sibling preparation
  • Classes for grandparents

12
Education for Cesarean Birth
  • Preparation for cesarean birth
  • Preparation for repeat cesarean birth
  • Preparation for Vaginal Birth After Cesarean
    Section (VBAC)

13
Methods of Childbirth Education
  • LAMAZE (psychoprophylactic)
  • KITZINGER (sensory memory)
  • BRADLEY (partner coached)

14
Lamaze
  • Mind prevention
  • Major components are education and training
  • Body conditioning exercises (pelvic tilt, pelvic
    rock, Kegels)
  • Relaxation exercises (Progressive, touch,
    disassociated)
  • Breathing techniques

15
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)

16
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

17
Changes occurring in pregnancy
  • Uterus circulatory requirements increase, walls
    thicken until late pregnancy when they become
    thinner, Braxton Hicks contractions occur
    intermittently.
  • Cervix Goodells sign (softening of the cervix),
    Chadwicks sign (blue-purple discoloration
  • Ovaries cease ovum production during pregnancy.

18
Changes occurring in pregnancy
  • Vagina may show same bluish color as Chadwicks
    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.

19
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.

20
Changes occurring in pregnancy
  • Gastrointestinal 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.

21
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.

22
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.

23
Changes occurring in pregnancy
  • Metabolism 25 - 35 lb weight gain is
    recommended. 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.

24
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.

25
Presumptive Signs of Pregnancy(Subjective)
  • Amenorrhea
  • Nausea and vomiting of pregnancy (NVP or morning
    sickness)
  • Excessive fatigue
  • Urinary frequency
  • Breast changes
  • Quickening

26
Probable Signs of Pregnancy(Objective)
  • An observer can perceive the objective signs that
    occur in pregnancy.
  • Changes in the pelvic organs (Chadwicks sign,
    Goodells sign, Hegars sign , McDonalds sign)
  • Enlargement of the abdomen (during childbearing
    years)
  • Uterine souffle

27
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

28
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)

29
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?
  • Human chorionic gonadotrophin (hCG) in the urine
  • Breast tenderness
  • Morning sickness
  • Fetal heart tones

30
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31
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.

32
  • 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.
  • Mother
  • Ambivalence
  • Acceptance
  • Introversion
  • Mood swings
  • Changes in body image

Siblings
Sibling rivalry Regression
GRANDPARENTS
Unsure of their role Support resource
33
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.

34
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

35
Initial Client History (pg. 252)
  • 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.

36
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 Madelines gravity and parity using the
    TPAL system.
  • 3-1-1-1-1
  • 3-0-1-1-1
  • 4-0-1-2-1
  • 4-1-1-1-1

37
Determination of Due Date (pg. 268)
  • EDC Estimated date of confinement
  • EDD Estimated date of delivery
  • EDB Estimated date of birth
  • Nägeles 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)

38
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 preparation.

39
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40
Danger Signs in Pregnancy
  • Persistent vomiting
  • Severe headache
  • Edema of hands, feet, face and legs
  • Muscular irritability, convulsions
  • Epigastric pain
  • Oliguria, Dysuria
  • Absence of fetal movement
  • Sudden gush of fluid from vagina
  • Vaginal bleeding
  • Abdominal pain
  • Temperature gt 101 and chills
  • Dizziness, blurring of vision, spots before eyes

41
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 clients individual
    needs and assessment of her risks.

42
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)

43
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 crampsflex 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

44
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.

45
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.

46
Questions?
47
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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