Week 3-Maternal adaptation during pregnancy.pptx

Nursing materials

1. Essentials of Maternity, Newborn, and Women’s Health Nursing Week 3-Chapter 11 Maternal Adaptation During Pregnancy Dr Mona Almalik 2022/2023

2. Introduction Pregnancy is a normal life event that involves considerable physical and psychological adjustments for the mother. A pregnancy is divided into three trimesters of 13 weeks each. Pregnant women undergo physical and psychological changes as they prepare for parenthood.

3. Presumptive Signs (subjective) Probable (objective) signs Positive signs Signs and Symptoms of Pregnancy

4. 1-Presumptive Signs (subjective) The least reliable indicators of pregnancy because any one of them can be caused by conditions other than pregnancy Fatigue (12 weeks) Breast tenderness (3–4 weeks) Nausea and vomiting (4–14 weeks) Amenorrhea (4 weeks) Urinary frequency (6–12 weeks)

5. Presumptive signs (cont’d.) Hyperpigmentation of skin (16 weeks) Fetal movements (quickening) (16–20 weeks) Uterine enlargement (7–12 weeks) Breast enlargement (6 weeks)

6. 2-Probable (objective) signs can be detected on physical examination by a health care professional. Braxton Hicks contractions (16–28 weeks) Positive pregnancy test (4–12 weeks) Abdominal enlargement (14 weeks) Ballottement (16–28 weeks) the examiner pushes against the woman’s cervix during a pelvic examination and feels a rebound from the floating fetus

7. Goodell’s sign (5 weeks) Softening of the cervix Chadwick’s sign (6–8 weeks) Bluish-purple coloration of the vaginal mucosa and cervix Hegar’s sign (6–12 weeks) Softening of the lower uterine segment or isthmus

8. Human Chorionic Gonadotropin ( hCG ) is a glycoprotein and the earliest biochemical marker for pregnancy. hCG levels in normal pregnancy usually double every 48 to 72 hours until they peak approximately 60 to 70 days after fertilization. Low levels are associated with an ectopic pregnancy Higher-than-normal levels may indicate a molar pregnancy or multiple- gestational pregnancies

9. Although probable signs suggest pregnancy and are more reliable than presumptive signs, they still are not 100% reliable in confirming a pregnancy. E.g. uterine tumors , polyps, infection, and pelvic congestion can cause changes to uterine shape, size, and consistency. E.g. Ovarian cancer, choriocarcinoma , hydatidiform mole--- can also elevate hCG levels.

10. 3-Positive signs Ultrasound verification of embryo or fetus (4–6 weeks) Fetal movement felt by experienced clinician (20 weeks) Auscultation of fetal heart tones via Doppler (10–12 weeks)

11. Reproductive System Adaptations Uterus Before pregnancy, it is a small, semisolid, pear-shaped organ, wgt =70g. At the end of pregnancy, it is a thin-walled, muscular container housing the fetus , placenta, and amniotic fluid, wgt =1100-1200g. Ascent into abdomen after first 3 months Fundal height by 20 weeks’ gestation at level of umbilicus; 20 cm; reliable determination of gestational age until 36 weeks’ gestation

12. This enlargement is due to: Hypertrophy: increase in size of preexisting cells. Hyperplasia: formation of new cells. Braxton Hicks contractions : spontaneous, irregular, painless contractions ___help to move the blood through the placenta to the fetus . From beginning of pregnancy-----become more noticeable during the last month, when they function to thin out or efface the cervix before birth. Hegar’s sign -at 6-8 weeks gest .

13. Supine hypotensive . Frequent urination- first and last three months. Lightening.

14. Reproductive System Adaptations (cont’d.) Cervix Softening ( Goodell’s sign) Mucous plug formation Increased vascularization (Chadwick’s sign) Ripening about 4 weeks before birth Vagina Increased vascularity with thickening Lengthening of vaginal vault Secretions more acidic, white, and thick; leukorrhea

15. Reproductive System Adaptations (cont’d.) Ovaries Enlargement until 12 th to 14 th week of gestation Cessation of ovulation Produce hormones until 6-8 WG. Breasts Increase in size and nodularity to prepare for lactation; increase in nipple size, becoming more erect and pigmented Production of colostrum : antibody-rich, yellow fluid that can be expressed after the 12 th week; conversion to mature milk after delivery

16. Breasts (Cont.) The pigmentation of the areola and nipple darkens. Montgomery’s glands become more prominent and protect the nipple for breastfeeding.

17. Table 11.2 Summary Of Reproductive System Adaptations

18. GI System Adaptations Gums: hyperemic, swollen, and friable—estrogen effect Ptyalism -more acidic saliva Dental problems; gingivitis—preterm and LBW Decreased peristalsis and smooth muscle relaxation Constipation + increased venous pressure + pressure from uterus = hemorrhoids Slowed gastric emptying; heartburn Prolonged gallbladder emptying--gallstone Nausea and vomiting (morning sickness).

19. Causes of morning sickness: high levels of hCG , high levels of circulating estrogens, prostaglandins, reduced stomach acidity, advancing maternal age, and the lowered tone and motility of the digestive tract.

20. Cardiovascular System Adaptations Increase in blood volume (50% above pre-pregnant levels)—1.5 L Increase in cardiac output; increased venous return; increased heart rate Slight decline in blood pressure until mid pregnancy, then returning to prepregnancy levels Increase in number of RBCs; plasma volume > RBC leading to hemodilution (physiologic anemia) Increase in iron demands, fibrin & plasma fibrinogen levels, and some clotting factors, leading to hypercoagulable state

21. Respiratory System Adaptations Breathing more diaphragmatic than abdominal due to increase in diaphragmatic excursion, chest circumference, and tidal volume Increase in oxygen consumption Congestion secondary to increased vascularity . Epistaxis and rhinitis. Nasal and sinus stuffiness. Changes in the tone and quality of the woman’s voice.

22. Renal/Urinary System Adaptations Dilation of renal pelvis; elongation, widening, and increase in curve of ureters Increase in length and weight of kidneys Increase in GFR; increased urine flow and volume Increase in kidney activity with woman lying down; greater increase in later pregnancy with woman lying on side changes in the anatomy take up to 3 months postpartum to subside

23. Musculoskeletal System Adaptations Softening and stretching of ligaments holding sacroiliac joints and pubis symphysis Postural changes: increased swayback and upper spine extension Forward shifting of center of gravity Increase in lumbosacral curve (lordosis); compensatory curve in cervicodorsal area Waddle gait

24. Integumentary System Adaptations Increase in estrogen, progesterone, and melanocyte -stimulating hormone levels Hyperpigmentation ; mask of pregnancy (facial melasma / chloasma ). Linea nigra Striae gravidarum (stretch mark) Varicosities Vascular spiders Palmar erythema Decline in hair growth; increase in nail growth

25. Palmar erythema Spider nevi

26. Endocrine System Adaptations Thyroid gland: slight enlargement; increased activity; increase in BMR Pituitary gland: enlargement; decrease in TSH, GH; inhibition of FSH & LH; increase in prolactin , MSH; gradual increase in oxytocin with fetal maturation Pancreas; insulin resistance due to hPL and other hormones in 2 nd half of pregnancy Adrenal glands: increase in cortisol and aldosterone secretion Prostaglandin (chemical mediators) secretion-- softening the cervix and initiating and/or maintaining labor Placental secretion: hCG , hPL , relaxin , progesterone, estrogen ( see Table 11.3 )

27. TABLE 11.3 Placental Hormones

28. TABLE 11.3 Placental Hormones cont …

29. Nutritional Needs Direct effect of nutritional intake on fetal well-being and birth outcome Need for vitamins and minerals supplement daily Dietary recommendations Increase in protein, iron, folate, and calories ( see Table 11.5- Dietary recommendations for the pregnant and lactating woman ) Avoidance of some fish due to mercury content

30. Average weight gain during pregnancy: 11.4-15.9 kg. During first trimester: 1.3-1.8 kg. During 2 nd and 3 rd trimesters: 0.5 kg/week. The weight gain during: 1 st tri. RT maternal tissue growth. 2 nd tri. RT growth of maternal tissue and some fetal tissue. 3 rd tri. RT fetal growth. Obese women should not limit their diet during pregnancy, but they can control the quality of food intake.

31. Maternal Weight Gain Healthy weight BMI = 18.5–24.9 1 st trimester: 1.5 to 2.5 kg 2 nd & 3 rd trimesters: 0.5 kg/week BMI < 18.5 1 st trimester: 2.5 kg 2 nd & 3 rd trimesters: 0.5 + kg/week BMI 25–29.9: 1 st trimester: 1 kg 2 nd & 3 rd trimesters: 1-1.4 kg/week

32. Vegetarianism It is a dietary choice of persons for religious, health and personal reasons. Types of vegetarians: Lactoovovegetarians : dairy products and eggs. Sometimes fish and poultry. Lactovegetarians : dairy products and no eggs. Vegans: pure vegetarian, no food from animal sources. Special Nutritional Considerations

33. Protein can be obtained from dairy products and eggs, or from grains, legumes, nuts, & seeds. Daily supplement of vitamin B12 is necessary. If no soy milk is used: daily supplements of 1200 mg Ca and 10 ug of vitamin D are needed. Special Nutritional Considerations cont...

34. Lactose intolerance People who have difficulty digesting milk products. Inadequate amount of lactase enzyme that break milk sugar lactose into digestible products. Taking Lactose may cause: nausea, vomiting, abdominal distension, diarrhea , and abdominal cramps. Special Nutritional Considerations cont...

35. Pica is a term used to describe the intense craving for and eating of non-food items. Many women experience unusual food cravings during their pregnancy. Pica is the compulsive ingestion of nonfood substances. The exact cause of pica is not known. Common substances ingested include clay, laundry starch, stones, charcoal, ice, cornstarch, toothpaste, soap, sand, plaster, coffee grounds, paint, chips, coffee grounds, baking soda, and cigarette ashes, etc …. Special Nutritional Considerations cont...

36. Special Nutritional Considerations cont... Pica cont …. Soil, Ice and Laundry starch can cause Iron deficiency anemia. Clinical manifestations of anemia often precede the identification of pica because the health care provider rarely addresses the behavior and the woman does not usually volunteer such information

37. Maternal Emotional Responses Ambivalence: having conflicting feelings ( the woman may feel proud and excited by the news, while at the same time fearful and anxious of the implications ) at the same time- 1 st & 2 nd trimesters. Introversion: focusing on oneself-1 st trimester. (The woman may withdraw and become increasingly preoccupied with herself and her fetus) She may participate less with the outside world, and she may appear passive to her family and friends.

38. Maternal Emotional Responses cont … Acceptance:2 nd trimester T he physical changes of the growing fetus, including an enlarging abdomen and fetal movement, bring reality and validity to the pregnancy. Mood swings Changes in body image

39. Pregnancy and Sexuality Numerous changes, possibly stressing sexual relationship Changes in sexual desire with each trimester Sexual health and link to self-image

40. Potential complications of sex during pregnancy: preterm labor , pelvic inflammatory disease, antepartum hemorrhage in placenta previa , venous air embolism.

41. Pregnancy and Partner Family-centered emphasis Partner’s reaction to pregnancy and changes Couvade syndrome: sympathetic response to their partner’s pregnancy , gain weight around the middle, nausea and other GI disturbances Ambivalence- 1 st trimester Acceptance of roles (2 nd trimester) Preparation for reality of new role (3 rd trimester)

42. Pregnancy and Siblings Age-dependent reaction Sibling jealousy with introduction of new infant into family Sibling preparation imperative

43. References Ricci, S. S. (2017). Essentials of Maternity, Newborn, and Women’s Health Nursing , 4 th ed. Wolters Kluwer Health, Lippincott Williams & Wilkins.

44. Any question??