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Maternity

Antepartum

Objectives
Understand embryonic development

Identify physical and psychological


responses to pregnancy

Nursing care of the pregnant patient

Stages of
Development
Pre-embryonic:
1st 14 days after ovum fertilized

Embryonic:
Day 15 end of 8th week

Fetal stage:
End of 8th week until birth

Pre-embryonic Development
Fertilization takes place in fallopian tube
Union of sperm and ovum forms a zygote
Cleavage cell division continues to form a morula (mass of 16
cells)
Inner cell mass are blastocysts, which form amnion and chorion
Outer cell mass are trophoblasts, which form placenta and
chorion
Implantation occurs 7-10 days post-conception into endometrium

Embryonic Stage
Starts day 15 (3rd week after conception)
Tissues differentiate into essential organs
Main external embryonic features develop
Embryo most vulnerable to teratogens during this
period
Teratogen: substance that adversely affects fetus
Ends at completion of week 8
At this point embryo clearly resembles a human
being

Embryonic Layers of Cells


Ectoderm: forms CNS, skin and glands
Mesoderm: forms skeletal, urinary, circulatory and
reproductive organs
Endoderm: forms respiratory system, liver,
pancreas, and digestive system

Key points of
development
4 weeks: fetal heart activity noted
8 weeks: all organs formed
16 weeks: can see gender
20 weeks: mother feels fetal movement
24 weeks: fetus weighs 500 grams
Fetal respiratory movement noted

28 weeks: eyes open/close


38-40 weeks: baby gets antibodies from mother

Role of Amniotic Fluid


Helps maintain constant body temperature for
fetus
Permits symmetric growth and development
Cushions fetus from trauma
Allows umbilical cord to be relatively free from
compression
Promotes fetal movement to enhance
musculoskeletal development

Embryonic development

Role of the Placenta

Trophoblasts make hCG


hCG preserves the corpus luteum and its progesterone
production to maintain the endometrium
Removes waste products and deoxygenated blood from
the fetus via umbilical arteries
Brings oxygen and nutrients to fetus via umbilical veins

Signs of Pregnancy
Subjective signs (aka Presumptive signs)
Signs a woman experiences but can be due
to other causes

Objective signs (aka Probable signs)


Can be observed on physical examination by
an experienced health care practitioner

Subjective Signs of
Pregnancy
Amenorrhea
Nausea and vomiting
Excessive fatigue
Urinary frequency
Breast changes (tender, pigment changes)
Quickening

Objective Signs of
Pregnancy
Softening of cervix- Goodells sign
Bluish color of cervix- Chadwicks sign
Softening of uterine isthmus- Hegars sign
Ease of flexing body of uterus against cervixMcDonalds sign
General uterine enlargement and softening:
10-12 wks fundus palpable above symphasiS
20-22 weeks at umbilicus

Hegars Sign

Objective (probable) signs


Braxton Hicks contractions (16-28 weeks)
Positive pregnanacy test (4-12 weeks)
Abdominal enlargement
12 weeks fundus palpable just above symphasis
20 weeks fundus at umbilicus (20cm)
Ballottement (16-28 wks)

Positive Signs of
Pregnancy
Fetal heartbeat audible: 10 wks with a
doppler

Fetal movement actively palpated by trained


examiner (approximately at 20 wks)

Visualization of fetus by ultrasound (USG)

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Nongenetic Factors
Influencing Development
Teratogens

Drugs
Chemicals
Infection
Exposure to radiation
Maternal conditions

Maternal nutrition
Malnutrition
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Genetics
Provides the tools to determine the hereditary
component of many diseases
Improves our ability to predict susceptibility, onset,
progression, and response to treatment
A gradual shift from genetics to genomics

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Genetic Counseling
Standard practice in obstetrics
Goal is to identify risk
Genetic history should be obtained using a
questionnaire or checklist
Genetic counseling
Information
Education
Support
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Physical Changes of the


Uterus
Size increase to 20 times nonpregnant size
Weight increases from 2 ounces to 2 pound
Walls thin to 1.5 cm from a solid globe to hollow vessel
Volume capacity increase from 2 tsp to 1 gallon
1/6 of maternal blood volume is contained within the
vascular system of the uterus by term
The endocervical glands secrete a thick mucus

Fundal Height
Indicates uterine size by measuring from top
of symphysis pubis to top of fundus

Correlates with weeks of gestation between


20-30 weeks
20 weeks = 20 cm
24 weeks = 24 cm
30 weeks = 30 cm

Physical Changes of the


Cervix
Chadwicks sign: estrogen causes the cervix to
become hyperemic, resulting in a bluish color
Goodells sign: increased vascularity causes the
cervix to soften
Mucus plug: increased mucus forms to seal off
the cervix from outside bacteria

Physical Changes of the


Ovaries
Stop producing ova during pregnancy
Corpus luteum continues to produce hormones for
6 to 8 weeks
Progesterone secreted by corpus luteum
maintains the endometrium

Physical Changes of the


Vagina
Estrogen causes thickening of the vaginal
mucosa
Also causes loosening of connective tissue
Increase in acidic secretions and decreased
pH which help prevent bacteria
Increased blood flow to vagina

Physical changes of the


Breasts
Estrogen and progesterone cause change
Breasts enlarge as there is increased
nodularity to prepare for lactation
Nipples more erectile and pigmented, as
does areola

Breast Changes in
Pregnancy

Respiratory System
Changes
Progesterone decreases airway resistance which
results in greater oxygen consumption
Volume of air breathed each minute increases
(tidal volume)
these changes occur to meet the increased
oxygen demands of the pregnant woman/fetus
Enlarging uterus pushes diaphragm up

Respiratory system
changes, cont.
Breathing changes from abdominal to thoracic as
enlarging uterus pushes diaphragm up and changes
shape of thoracic cavity (chest circ increases)
Hyperventilation and dyspnea commom
Nasal stuffiness and epistaxis (nose bleed) occur due to
estrogen induced edema and increased vascularity

Cardiovascular System
Changes
Blood Volume
Blood volume increases 50% (1500 ml)
Mostly plasma (1000ml)
Begins 10-12 weeks, peaks at 32 weeks
Needed to provide nutrition and hydration to
fetus; perfuse uterus and other organs, esp
kidneys (due to increased waste excretion)
Provides reserve for birth and postpartum

Cardiovascular System
Changes
Cardiac Output and Heart Rate
Increases from 30-50% over non pregnant by
32 weeks
Heart rate increases 10-15 bpm in 2nd
trimester and remains until delivery
Slight hypertrophy to accommodate increase
in blood volume and cardiac output
This is to meet increased oxygen demands of
mother and fetus

Cardiovascular system
Changes
Blood Pressure
Decreases due to progesterone induced
vasodilation
Decreases in 2nd trimester and returns to near
normal by 3rd trimester
Supine hypotension syndrome (aka vena caval
syndrome)
In supine position, large uterus puts pressure on
vena cava, decreasing blood flow to heart
Woman becomes dizzy, diaphoretic

Cardiovascular system
Changes
Blood Components
Number of RBCs increase, to deliver more
oxygen
But there is a larger increase in plasma
volume (due to sodium and water retention)
This hemodilution causes physiologic
anemia of pregnancy

Cardiovascular system
changes
Iron (Fe) requirements increase due to fetal
demand and increase in maternal blood vol
Fe necessary for hemoglobin formation
Fibrin and fibrinogen increase (as well as other
clotting factors)
This makes pregnancy a hypercoaguable state
This factor and others increase risk of
thromboembolic events

Cardiovascular
system (cont)
Leukocyte production increases slightl
Clotting factors increase (VII, VIII, IX & X); pregnancy
is a hypercoagulable state

Increased peripheral circulation


Causes flushed face, reddened palms,
diaphoresis

Physical Changes of GI
Tract
Reflux of gastric contents common due to relaxation of
smooth muscles by progesterone
Ptyalism (excess salivation) is a common condition of
pregnant women
Decrease in intestinal motility due to progesterone
causes constipation
Nausea and vomiting due to high hCG levels from weeks
6-12

Gastrointestinal System
Changes
Gums become hyperemic, swollen, friable
Hygiene impt; dental referral

Ptyalism (excessive salivation) r/t nausea


Hyperemesis gravidarum (morning
sickness)
Usually 6-12 weeks
Due to elevated hCG levels

GI System, cont
Smooth muscle relaxation and decreased
peristalsis due to progesterone
This causes delay in gastric emptying (heartburn)
due to relaxation of cardiac sphincter, and
constipation
Emptying time of gallbladder prolonged (due to
progesterone) which increases risk of gallstone
formation

Urinary System Changes

1st trimester bladder still in pelvisuterus


presses against it, causing frequency
2nd trimester, bladder moves up..relief
Ureters dilate and elongate

Renal/Urinary System
Changes
Changes in renal function to accommodate
larger workload
More blood flows to kidneys, increases
glomerular filtration rate (GFR)
Causing increase in urine flow and volume
Increases substances delivered to kidneys
Increases filtration of water and solutes

Renal/Urinary, cont
Kidneys enlarge during pregnancy
Ureters elongate and dilate (progesterone)
Kidney activity increased with supine
position (even nonpregnant) but this is
increased in pregnancy
Increase in nighttime urination
Even more increase with left lateral position
Due to increase in venous return to heart

Urinary system, cont.


GFR increases 50%; this causes
increases in urine flow and volume.
to compensate for this renal tubular
absorption increases
This may cause a need to adjust
medication dosages

Skin and hair


changes
Stimulated by estrogen and progesterone
Increase in pigmentation in already
pigmented areas, such as the areola & vulva
Chloasma: mask of pregnancy
Linea nigra

Skin and hair


changes, cont.
Increase in activity of sweat and sebaceous
glands
some women notice decrease in hair growth
Followed by PP hair loss then regrowth

Spider veins
Above waist (arms, face, thorax), disappear
Striae gravidarum (stretch marks)

Musculoskeletal System
Changes
Joints of pelvis relaxresults in waddling gait
typical of pregnancy, due to progesterone and
relaxin
Center of gravity shifts due to increased
curvature of spinelow backache
Diastasis recti caused by pressure of enlarging
uterus on abdominal muscles

Psychosocial Response to
Pregnancy
Ambivalence: initial response; no visible body changes
yet
Acceptance: triggered by quickening in 2nd trimester
Introversion: turning in on oneself
Mood swings: from joy to despair
Body image changes

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