Term 3 Quiz #1

Term 3 | Quiz 1 | 09/12/24 Maternity & Pediatric | Chapter 3: Fetal Development Introduction ASHLEY A. ●​ How life begins: sperm + ovum = single cell ●​ Deoxyribonucleic acid(DNA) programs genetic code to nucleus(control development & fx of cell) ○​ Defects in DNA code = inherited disorders ●​ Genes & chromosomes: Located in DNA; determine uniqueness of traits & features. ●​ Normal chromosomes start in pairs(1 from mother, 1 from father) ○​ 46 chromosomes total (23 pairs). ○​ Autosomes: 22 pairs (body chromosomes). ○​ Sex chromosomes: 1 pair (determines sex of fetus). ●​ Each chromosomes has genes(involve heredity) ●​ Cell division: Basis of human growth and regeneration. ●​ Biological development is not isolated ●​ Influence by: ○​ External environment: ■​ Maternal drug use(teratogens: damage growing cells) ■​ Maternal undernutrition ■​ Maternal smoking ○​ Sound: heard by fetus & recognize by newborn ●​ This influences healthy outcomes and disease susceptibility in adulthood. Cell Division And Gametogenesis ●​ Cell division: Begins in the nucleus, containing gene-bearing chromosomes. ●​ Types of Cell Division: ○​ Mitosis ■​ Continuous process where the body grows, develops, and replaces dead cells. ■​ Each daughter cell has the same number of chromosomes as the parent cell (46 chromosomes or diploid number). ■​ Spermatogenesis: process in sperm. ■​ Oogenesis: process in ovum. ○​ Meiosis ■​ Involves two sequential divisions of reproductive cells. ■​ Chromosome number is reduced by half, resulting in 23 chromosomes per cell with 1 sex chromosome (haploid number). ■​ Completed in sperm before it reaches the fallopian tube and in the ovum if fertilized after ovulation. ■​ During fertilization (union of sperm and ovum), the new cell has 23 chromosomes from sperm and 23 chromosomes from ovum, restoring the diploid number (46). ●​ Traits are inherited from both mother and father. ■​ The formation of gametes through this division process is called gametogenesis. Fertilization Nurse should emphasize survival time of sperm ejaculated to area of the cervix may be up to 5 days and pregnancy can occur w/ intercourse 5 days before ovulation ●​ Occurs when a sperm penetrates the ovum and unites with it, restoring the total chromosome number to 46 ●​ Takes place in the outer third of the fallopian tube, near ovary ●​ Sperm Journey ○​ Sperm → cervix(uterus) → fallopian tube ○​ Movement is aided by flagellar (whip-like) activity of sperm tails. ○​ Sperm can reach the fallopian tube within 5 minutes after coitus. ●​ Post-Fertilization → A chemical change occurs in the membrane around the fertilized ovum, preventing penetration by additional sperm. ●​ Fertilization occur in a brief moment because of short life span of mature gametes ○​ Ovum: survive up to 24 hours after ovulation Both mother and father influence sex of their offspring, although father contributes actual sex chromosomes. Fact may reduce blame in some culture when child sex is not desired.​ Knowledge of inheritance allows nurse to offer decision making and suggest referral. ○​ Sperm: can fertilize ovum up to 5 days after ejaculated into the cervix SEX DETERMINATION ●​ Sex determined at fertilization ○​ Ovum: contributes X chromosome(gamete) ○​ Sperm: carry X or Y chromosome(gamete) ●​ Outcome: ○​ XX (female): Result when an X-bearing sperm fertilizes an X-bearing ovum. ○​ XY (male): Result when a Y-bearing sperm fertilizes an X-bearing ovum. ●​ Factors: ○​ Male partner determines sex of the child as only sperm can carry a Y chromosome. ○​ Female reproductive tract factors: ■​ pH and estrogen levels affect the survival and speed of X- and Y-bearing sperm. ■​ This influences which sperm fertilizes the ovum. ●​ Embryonic Development ○​ Male Embryo: Differentiates by 6-7 weeks' gestation under the influence of the Y chromosome. ■​ Testosterone secretion begins by 8 weeks' gestation. ○​ Female Embryo: Gonadal development occurs in the presence of estrogen and absence of testosterone. ■​ By 6-8 weeks' gestation, two female gonads develop into ovaries, which will produce ova only during fetal life. INHERITANCE ●​ Genes: Segments of DNA responsible for inheritance and individual traits like hair color, facial features, and body shape. ●​ Dominant vs Recessive ○​ Dominant traits ■​ Overpower recessive traits and are passed to offspring ■​ If one parent carries a dominant trait: 50% chance offspring will inherit it. ■​ If both parents carry the dominant trait: Higher chance ○​ Recessive disorder: Caused by an alteration or defect in one gene. ○​ Dominant disorder: Caused by defects in both genes. ●​ Genetic Testing: Diagnoses disorders, predicts future risk of disorders, and assists in reproductive decision-making. TUBAL TRANSPORT OF THE ZYGOTE ●​ Zygote: cell formed by union of sperm and ovum ●​ Moves through the fallopian tube into the uterus. ○​ During transport, the zygote undergoes rapid mitotic division or cleavage: ■​ Cleavage sequence: 2 cells → 4 cells → 8 cells → blastomere. ■​ Zygote size remains the same as individual cells divide and become smaller, forming a morula (solid ball of cells). ○​ Morula enters uterus on 3rd day and floats for another 2-4 days ○​ Cells form a cavity with two distinct layers: ■​ Blastocyst (inner layer): Solid mass that develops into the embryo and embryonic membranes. ■​ Trophoblast (outer layer): Develops into an embryonic membrane (chorion). ●​ Tubal Ectopic Pregnancy: Occurs if the zygote implants in the fallopian tube lining instead of the uterus. IMPLANTATION OF THE ZYGOTE ●​ Zygote usually implants in upper section of posterior uterine wall ●​ Cells burrow to prepared lining of uterus(endometrium) ○​ After implantation: Endometrium → decidua ■​ Decidua basalis: area under blastocyst and give rise to maternal part of placenta Development ECTODERM Outer layer of skin Oil glands & hair follicles of skin Nails & hair External sense organs Mucous membrane of mouth & anus MESODERM True skin Skeleton Bone & cartilage Connective tissue Muscles Blood & blood vessels Kidneys and gonads ENDODERM Lining of trachea, pharynx, and bronchi Lining of digestive tract Lining of bladder and urethra Nutrition Considerations: Folic Acid and Neural Tube Defects Folic acid supplements can prevent most neural tube defects such as spina bifida. However, in an unplanned pregnancy, it is possible for a neural tube defect to occur before a woman knows she is pregnant. Early prenatal care w/ good nutrition and folic acid supplements are desirable so the embryo is protected in the very first days and weeks of development CELL DIFFERENTIATION ●​ Week between fertilization and implantation, all cells w/in zygote are identical ●​ After implantation, cells begin to differentiate and develop specialized fx. ●​ Chorion, amnion, yolk sac, and primary germ layers appear Chorion ●​ Develops from trophoblast and surrounds amnion, embryo, and yolk sac. ●​ Thick membrane w/ finger-like projections(villi) on outermost surface ●​ Villi extend to decidua basalis on uterine wall and form embryonic/fetal portion of placenta Amnion ●​ 2nd membrane; thin structure that envelops and protects embryo ●​ Forms boundaries of amniotic cavity, and outer aspect meets inner aspects of chorion ●​ Chorion + amnion = amniotic sac(filled w/ fluid/water that allows embryos to float freely) ○​ Amniotic fluid: clear, mild odor, and often contains bits of vernix(fetal skin covering) or lanugo(fetal hair on skin) ○​ Amniotic fluid volume steadily increases: 30 mL(10 weeks’ gestation) to 350 mL(20 weeks); 1000 mL(37 weeks) ■​ Latter part of pregnancy, fetus swallow 400 mL of the fluid per day and excrete urine to fluid ○​ Fx of amniotic fluid: ■​ Maintain even temp ■​ Prevents amniotic sac from adhering to fetal skin ■​ Allows symmetrical growth ■​ Allows buoyancy and fetal movement ■​ Acts as a cushion to protect fetus and umbilical cord from injury Yolk Sac ●​ 9th day after fertilization, cavity(yolk sac) forms in blastocyst. ●​ Fx is only during embryonic life and initiate production of RBC ○​ Continues for 6 weeks until embryonic liver takes over ○​ Umbilical cord surround yolk sac and yolk sac degenerates Germ Layers ●​ After implantation, zygote in blastocyst stage transforms its embryonic disc to 3 primary germ: ectoderm, mesoderm, and endoderm ○​ Each develops into different part of growing embryo PRENATAL DEVELOPMENTAL MILESTONES ●​ 3 Basic stages characterize prenatal development: Zygote, embryo, and fetus ●​ Zygote: continues to grow and develop as it passes through fallopian tube and implants into wall of uterus ●​ Embryo: development period from 2-8 weeks ●​ Fetus: 9th week of development until birth ●​ 2nd week after fertilization ○​ Ectoderm, endoderm, and amnion start to develop ●​ 3rd week ○​ Mesoderm and neural tube form; primitive heart begins to pump ○​ Some women first realize they have missed their menstrual period and suspect they are pregnant ●​ 8th week ○​ Ovaries or testes are present, all systems are beginning to develop, extremities exhibit movement. ●​ Fetal period: Begins at 9 weeks. ●​ 10 weeks: External genitalia visible via ultrasound. ●​ 12 weeks (end of 1st trimester): ○​ Maternal-fetal circulation is established. ○​ Placenta attaches to the uterine wall; failure = miscarriage. ○​ Complications: Abnormal attachment = placenta accreta or placenta previa. ○​ Respiratory movements: Promote chest muscle and lung growth. 14 weeks: Fetus moves in response to external stimuli. 20 weeks: Age of viability—lungs mature enough for survival with NICU care. 28 weeks: Eyes open, fetal position becomes stable in the uterus. 39-40 weeks: Fetus is considered full term. Late gestation: Millions of alveoli form, emphasizing the importance of the last weeks of pregnancy for lung development. ●​ Survival and development depend on both biological development of the infant and the parental response. ○​ Fetal development is linked to the psychological and physical changes experienced by the mother prenatally. ●​ ●​ ●​ ●​ ●​ Accessory Structures Of Pregnancy PLACENTA ●​ Placenta(afterbirth): Temporary organ for fetal respiration, nutrition, excretion, and functions as an endocrine gland. ●​ Forms when chorionic villi from the embryo extend into maternal decidua basalis. ●​ Maternal side: Arises from decidua basalis, has a beefy, red appearance. ●​ Fetal side: Develops from chorionic villi and blood vessels, covered by amnion—gives a grayish, shiny appearance. ●​ Maternal circulation to placenta is fully established by the end of the 1st trimester. ●​ Enlarged placenta: May indicate maternal diabetes, signaling potential increased neonatal morbidity. ●​ Small placenta: Can result from stress, undernutrition, steroid exposure, or chronic hypoxia. Placental Transfer ●​ Maternal and fetal blood are separated by a thin membrane; they do not normally mix. ○​ Mixing may occur at birth due to placental separation, potentially causing issues in later pregnancies if blood types are incompatible. ●​ Fetal Circulation: ○​ Deoxygenated blood and waste leave the fetus via two umbilical arteries and enter the placenta through villus branches. ○​ Oxygenated blood from the mother enters the intervillous space(lacuna) through spiral arteries in the decidua. ○​ Fetal blood exchanges carbon dioxide and waste for oxygen and nutrients in the placenta and returns via the umbilical vein. ●​ Placental membrane: ○​ Provides limited protection but is not a full barrier. ○​ Harmful substances (e.g., drugs, nicotine, viral agents) can transfer to the fetus, leading to drug addiction, congenital anomalies, or fetal infection. Placental Hormones ●​ Placenta produces four key hormones: progesterone, estrogen, human chorionic gonadotropin (hCG), and human placental lactogen (hPL). Progesterone: ●​ Initially produced by corpus luteum, later by placenta. ●​ Fx: ○​ Maintains uterine lining for implantation. ○​ Reduces uterine contractions to prevent miscarriage. ○​ Prepares breast glands for lactation. ○​ Stimulates testes to produce testosterone for male reproductive development Estrogen: ●​ Functions during pregnancy: 1.​ Stimulates uterine growth. 2.​ Increases blood flow to uterine vessels. 3.​ Stimulates breast duct development for lactation. ●​ Non-pregnancy-related effects: ○​ Increased skin pigmentation (e.g., "mask of pregnancy"). ○​ Vascular changes in skin, nose, and mouth. ○​ Increased salivation. Human Chorionic Gonadotropin (hCG): ●​ Signal hormone indicating conception has occurred. ●​ Causes the corpus luteum to persist and continue producing estrogen and progesterone to sustain pregnancy. ●​ Detectable in maternal blood 7-9 days after fertilization. ●​ Basis for most pregnancy tests. Human Placental Lactogen (hPL): ●​ Also known as human chorionic somatomammotropin. ●​ Decreases insulin sensitivity and glucose utilization in the mother. ●​ Increases glucose availability for fetal growth. UMBILICAL CORD ●​ Develops w/ placenta & fetal blood vessels(lifeline between mother & fetus) ●​ Two arteries carry blood away from the fetus, one vein returns blood to the fetus. ●​ Covered by Wharton jelly to cushion vessels and allow movement without restricting circulation. ●​ Normal length: ~55 cm (22 inches). ●​ Typically protrudes from the center of the placenta. Fetal Circulation Fetal Programming Of Adult Health ●​ After 4th week of gestation, fetal circulation w/ placenta is well established. ●​ Since fetus doesn't breathe/process waste via liver, 3 fetal circulatory shunts are present: 1.​ Ductus venosus: Diverts blood away from liver, sending it to IVC. 2.​ Foramen ovale: Shunts blood from RA to the LA, bypassing lungs. 3.​ Ductus arteriosus: Directs blood from pulmonary artery to aorta, bypassing lungs. CIRCULATION BEFORE BIRTH ●​ Oxygenated blood enters through umbilical vein. ○​ Half goes to liver via portal sinus. ○​ The rest enters the inferior vena cava via the ductus venosus. ●​ Blood in the inferior vena cava flows into the right atrium, and most is shunted to the left atrium through the foramen ovale. ●​ A small amount is pumped to the lungs by the right ventricle. ●​ Remaining blood in right ventricle is diverted to the aorta via the ductus arteriosus. ●​ Blood w/ waste products returns to placenta via umbilical arteries. CIRCULATION AFTER BIRTH ●​ Fetal shunts no longer needed once infant breathes and blood circulates to lungs. ●​ Foramen ovale: Closes as right-sided heart pressure ↓ when lungs inflate, reducing blood flow resistance. ●​ Ductus arteriosus: Constricts as blood O2 levels rise. ●​ Ductus venosus: Closes when umbilical cord flow stops. ●​ ●​ As the fetus develops in the uterus of the mother, it interacts with the microbiomes that are present in her body and influenced by her diet and health practices ○​ Exchange of microbes between the mother and fetus before and after birth is related to the health of the infant in later life ●​ Undernutrition in utero can result in permanent changes in fetal structure, physiology, and metabolism and can influence the development of conditions such as heart disease and stroke in adult life ●​ Toxins in utero or factors that occur in the first 3 years of growth and development can influence health ●​ The environment provided by the other controls alterations in organ structure, cell responses, and gene expression that impacts the metabolism and physiology of the newborn infant ●​ Nutritional supplements before and during pregnancy may reduce the risk of some birth defects (cretinism and spina bifida) ●​ Bisphenol-A (BPA) plastics used by pregnant women can expose the fetus and result in newborn developing obesity or altered emotional development as an older child or adult ●​ Post Traumatic stress disorder (PTSD) during pregnancy can alter cortisol levels and result in a newborn who may develop behavioral distress or asthma during later childhood ●​ Intake of licorice (contains glycyrrhiza) can predispose the newborn to develop verbal or visual problems or aggression in later life ●​ Infants born before 37 weeks gestation are at risk of developing gestational hypertension in their own pregnancies ●​ Impaired fetal liver growth in late gestation can permanently impair lipid metabolism and predispose to increased cholesterol levels in adult life ●​ Reduce liver size can be identified by measuring abdominal circumference at birth Multifetal Pregnancy ●​ Hormones given to assist with ovulation, twinning and other multifetal births (triplets, quadruplets and quintuplets) are more likely to occur ●​ Monozygotic (MZ) twins are called identical twins ○​ Genetically identical, Same sex and look alike b/c they developed in a single fertilized ovum ○​ Physical differences are due to prenatal environmental factors involving variations in the blood supply from the placenta ○​ Begin to develop at the end of the first week after fertilization ○​ Result is two identical embryos, each with its own amnion but with a common chorion and placenta and some common placental vessels ○​ If the embryonic disc does not divide then various types of conjoined (siamese) twins may form. YThey are named by the location they are joined at ●​ Dizygotic (DZ) twines are called fraternal twins ○​ May or may not be of the same sex, and they develop from two separate ova fertilized by two separate sperm ○​ Always have two amnions, two chorions and two placenta ■​ Chorions and placenta may be fused ○​ Tend to repeat in families and increases with maternal age ●​ Twins are born prematurely because the uterus becomes overly distended ●​ Placenta may not be able to supply sufficient nutrients to both fetuses, with the result that one or both twins is smaller than average Maternity & Pediatric | Chapter 4: Prenatal Care And Adaptations To Pregnancy Introduction Pregnancy is a temporary, physiological process affecting a woman physically & emotionally 3 phases of pregnancy: ●​ Antepartum – prenatal, which is before birth ●​ Intrapartum – during birth ●​ Postpartum – after birth Goals Of Prenatal Care Prenatal care providers ●​ Obstetricians | Family practice physicians | Certified nurse-midwives | Nurse Practitioners Major goals of prenatal care ●​ Promote health of the mother, fetus, newborn & family ●​ Ensure a safe birth for mother & child by promoting good health habits & ⬇ risk factors ●​ Teach health habits that can be continued after pregnancy ●​ Educate in self-care for pregnancy ●​ Develop a partnership with parents & family for continuous & coordinated health care ●​ Provide physical care ●​ Prepare parents for parenthood responsibilities Preconception Care And Interconceptual Care Maternal diet, exercise, smoking, stress, drugs & environmental pollutants can affect the adult health of the developing fetus, so the current goal of prenatal care is expanded to the prevention of adult disease in the newborn infant Smoking during pregnancy ●​ A study from the 2017 International Meeting for Autism Research examined how smoking can affect the developing eggs of a female fetus, which can affect the grandchildren of the smoker, which can be r/t autism spectrum disorder Preconception ●​ Pregnancy wellness begins before conception occurs ●​ Preconception care involves: ○​ A discussion of pregnancy intention | Access to care | Use of multivitamins & folic acid | Smoking | Sexually transmitted infections | Illicit drug use | Mental health issues ○​ Education r/t healthy weight & glycemic control | Use of teratogenic medications | Discussion of family hx & chronic illness Optimal obstetric care involves: ●​ Preconception care – preparation for the impact the newborn will have on family dynamics & preparation, including follow-up of the preconception interview ●​ Prenatal care – monitoring, care & management of issues arising during pregnancy ●​ Intrapartum care – continuous presence & support of the parents by a L&D nurse or doula during the birth process ●​ Postpartum care – supporting the adjustment after birth, which includes encouraging breastfeeding, skin-to-skin contact, and bonding while reducing separations & interruptions ●​ Interconceptual care – care between the end of a pregnancy & the beginning of the next Prenatal Visits -​ Preconception Care: Ideally, healthcare for childbearing starts before conception. This care identifies risk factors that can be modified to improve pregnancy outcomes. For example, improving a woman's nutritional state and immunizing against infections that may harm the fetus. -​ Folic Acid: Adequate folic acid intake before conception is highlighted as a measure to reduce the incidence of congenital anomalies. History and Examination -​ Obstetric History: Includes details about past pregnancies, outcomes, and any complications in the mother or infant. -​ Menstrual History: Covers the usual frequency and duration of menstrual cycles, the first day of the last normal menstrual period (LNMP), and any spotting since then. Contraceptive History: Details the type of contraceptive used, any use of oral contraceptives before pregnancy recognition, and whether an intrauterine device is still in place. -​ Medical and Surgical History: Includes infections (like hepatitis or pyelonephritis), surgical procedures, and any trauma involving the pelvis or reproductive organs. This information is used to assess and manage potential risks that could affect the pregnancy or the health of the developing fetus. -​ Family, Health, and Psychosocial Histories -​ Family History: Assess both the woman's and her partner's family history to identify genetic or other risk factors for pregnancy. -​ Health History: Review both partners' health histories to identify potential risk factors (e.g., genetic defects, alcohol, drugs, tobacco use, blood incompatibility). -​ Psychosocial History: Evaluate stability of lifestyle, parenting ability, and significant cultural practices or health beliefs that might impact pregnancy. Physical Examination -​ First Visit Examination: Includes a complete physical examination to assess general health, vital signs, nutritional status, and identify any physical or social problems. -​ Pelvic Examination: Performed to evaluate the reproductive organs' size, adequacy, and condition. Health Promotion -​ Prenatal Care: Emphasizes a "teachable moment" for promoting lifelong self-care and wellness skills, including continuous screening, immunizations, and regular follow-up of risk factors. Estimated Date of Delivery (EDD) -​ Calculation: Based on the Last Normal Menstrual Period (LNMP). An ultrasound may confirm EDD. -​ Risk Assessment: Conducted at the first visit and updated in subsequent visits. Routine Laboratory Tests -​ Types of Tests: Include urine cultures, tests for group B streptococcus, sexually transmitted infections, and others based on risk factors. -​ Purpose: Most tests establish a baseline for comparison throughout pregnancy. Prenatal Visit Schedule -​ Recommended Schedule: Conception to 28 weeks: Every 4 weeks. -​ 29 to 36 weeks: Every 2 weeks. -​ 37 weeks to birth: Weekly. -​ Importance of Regular Care: Helps reduce low-birth-weight infants and mortality. Routine Prenatal Visit Assessments -​ Risk Review: Ongoing assessment of risk factors. -​ Vital Signs: Regular blood pressure monitoring. -​ Weight Monitoring: To identify patterns that could indicate risks (e.g., preterm birth, pre-eclampsia). Screenings: -​ Urinalysis for protein, glucose, ketones. -​ Blood glucose screening at 24-28 weeks. -​ Hematocrit, group B streptococcus, and STI testing at 36 weeks. -​ Fetal Monitoring: Fundal height measurement, Leopold's maneuvers, fetal heart rate, and fetal activity ("kick count"). . Establishing Rapport in Prenatal Care -​ Building Rapport: Nurses should establish rapport with expectant families by showing genuine interest in their needs, listening actively to their concerns, and directing them to appropriate resources. -​ Cultural Sensitivity: It's crucial for healthcare providers to demonstrate sensitivity to the cultural and health beliefs of the family and integrate these into care plans as much as possible. Examples of Cultural Practices: -​ Muslim Women: Prefer female healthcare providers due to modesty laws requiring them to be covered in the presence of unrelated men. -​ Latino Families: Expect some informal conversation before discussing serious topics. -​ Asian Women: May nod out of respect, which might not indicate agreement with what is taught. Eye contact, valued by Americans, might be perceived as confrontational in some cultures. Virtual Prenatal Care: Telehealth -​ Introduction to Telehealth: Telehealth and virtual prenatal visits have been developed to reduce healthcare costs and improve access. These can substitute some in-person visits. Benefits of Virtual Visits: -​ Increases patient satisfaction. -​ Lowers costs. -​ Suitable for low-risk and moderate- to high-risk patients. -​ Expanded significantly during the COVID-19 pandemic. Guidelines for Virtual Visits: -​ Ensure consent forms are completed, signed, and dated. -​ Conduct visits in private settings to ensure open communication. -​ Start with a warm greeting, maintain eye contact, be an active listener, and use a warm tone. -​ Plan for follow-up care at the end of the virtual visit. Definitions Of Terms ●​ Gravida: Any pregnancy, regardless of duration (include current one) ○​ Nulligravida: women who has never been pregnant ●​ Primigravida: pregnant for the first time ○​ Multigravida: pregnant before, regardless of the duration of the pregnancy ●​ Para: given birth to one or more children who reached the age of viability (20 weeks gestation), regardless of the number of fetuses delivered and regardless of whether they are living now ●​ Primipara: given birth to her first child (past the point of viability), regardless of whether the child was alive at birth or is now living. Used informally to describe a woman before the birth of their first child ●​ Multipara: given birth to two or more children (past the point of viability), regardless of whether the children were alive at birth or alive now. Used informally to describe a women before the birth of her second child ○​ Nullipara: a women who has never given birth to a child who reached the point of viability ●​ Abortion: termination of pregnancy before viability (20 weeks gestation) either spontaneous or induced ●​ Gestational age: Prenatal age of the developing fetus calculated from the first day of the woman's LNMP ○​ Fertilization age: prenatal age of the developing fetus as calculated from the date of conception; ~ 2 weeks less than the gestational age ○​ Age of viability: fetus that has reached the stage (usually 24 weeks) where it is capable of living outside the uterus ●​ Gravida: number of pregnancies ○​ Increases with each pregnancy ●​ Para: indicated the outcome of the pregnancies ○​ Increases only when fetus is delivered at 20 weeks gestation ●​ TPALM is a standardized way to describe the detailed outcome of a woman's pregnancies on her prenatal record ○​ T: number if term births (after 37 weeks gestation) ○​ P: number of premature births (after 20 weeks and before 37 weeks gestation) ○​ A: number of pregnancies aborted before 20 weeks (spontaneously or induced) ○​ L: number of living children ○​ M: multiple birth number of multiple gestation (optional) Determining The Estimated Date Of Delivery Average duration of a term pregnancy is 40 weeks (280 days) after the first day of the LNMP ●​ Nageles rule is used to determine EDD (estimated date of delivery) ○​ Calculate EDD: identify the LMNP, count backward 3 months, and then add 7 days ■​ Ex. First day of LNMP: January 27 ■​ Count backwards 3 months: October 27 ■​ Add 7 days: Nov 3 is the estimated date of delivery ○​ Estimated date, birth may occur before or after ●​ EDD can also be determine by gestational wheel, electronic calculator, physical examination, ultrasound or combo of these methods ●​ If the LMNP is unknown, or the abdominal ultrasound in the first trimester differs from the Nagele’s calculation by more than 5 days, a crown-rump length on ultrasound can be used ●​ An abdominal ultrasound after 14 weeks gestation can use the biparietal diameter, head circumference, abdominal circumference and femur length to confirm EDD ●​ Pregnancy divided into three 13-week parts called trimesters Diagnosis Of Pregnancy Signs of pregnancy are divided into three groups 1.​ Presumptive ●​ Definitive diagnosis of the pregnancy can not be made ●​ S/S ○​ Amenorrhea is the first sign of pregnancy ■​ Can be caused by other factors other than pregnancy such as stress, medication, endocrine dysfunction, etc. ○​ Nauseous as a result of increased human chorionic gonadotropin (hCG) levels ■​ “Morning sickness” can occur at anytime of the day ■​ Begins at about 4 weeks after LNMP and improves by the end of the 20th week ■​ Diclegis (doxylamine and pyridoxine) is prescribed to relieve nausea ●​ extended -release tablet given at bedtime ●​ Drowsy side effect ●​ Not recommended for breastfeeding mothers ○​ Breast changes (tingling and tenderness) caused by the placenta hormones stimulating growth of the ductal system to prepare for breastfeeding ○​ Pigmentation changes commonly occur in dark-skinned women ■​ Common areas include the face, breast (areolae), and abdomen (linea nigra, line extending in the midline of the abdomen to the symphysis pubis) ●​ Chloasma (mask of pregnancy): pigmentation of the face ○​ Frequency and urgency of urination are common in the early months of pregnancy due to the enlarged uterus and increased blood supply to the pelvic area exerting pressure to the bladder ■​ Urinary frequency occurs in the first trimester until the uterus expands and moves into the abdominal area in the second trimester ■​ Frequent urination occurs in the third trimester due to the presenting part descending into the pelvis in preparation for birth ○​ Fatigue and drowsiness are an early symptom of pregnancy due to the increased metabolic needs of the woman and fetus ○​ Quickening, fetal movement felt by the mother ■​ Perceived at 16 to 20 weeks of gestation as a fain flutter in the lower abdomen ■​ Important event to record because it marks the approx. midpoint of pregnancy and is a reference point to verify gestational age ■​ Women who previously given birth van report it at an earlier stage b/c Pseudocyesis: false pregnancy Hormonal imbalance or infection can cause Goodell’s and Chadwick’s signs Uterine fibroids (benign tumors) can cause Braxton Hicks contractions they know how to identify it 2.​ Probable ●​ Goodell’s sign ○​ Softening of the cervix and vagina caused by increased vascular congestion ●​ Chadwick’s sign ○​ Purplish or bluish discoloration of the cervix, vagina, and vulva caused by increased vascular congestion ●​ Hegar’s sign ○​ Softening of the lower uterine segment ■​ Mcdonalds sign - easy to flex the body of the uterus against the cervix ●​ By the end of the 12th week, the uterine fundus may be felt above the symphysis pubis and extends to the umbilicus between 20 - 22 weeks ●​ Braxton Hicks contractions ○​ Irregular, painless uterine contractions ■​ May be mistaken for true labor ○​ Begin in the second trimester ○​ Abdomen hard and tense ●​ Ballottement ○​ Maneuver which the fetal part is displaced by a light tap of the examining finger on the cervix, and then the part rebounds quickly ■​ Uterine or cervical polyps (small tumors) mat cause the sensation of ballottement ●​ Abdominal striae (stretch marks) are fine, pinkish white or purplish gray lines that women develop when the elastic tissue has been stretched to capacity ○​ Increased amounts of estrogen cause and adrenal increase is believed to be the reason for the atrophy of the connective tissue ○​ After pregnancy the lines turn thin and silvery ●​ Pregnancy test ○​ Use urine or blood to detect the presence of hCG ■​ hCG is produced by the chorionic villi of the placenta ■​ Radioimmunoassay ●​ Most reputable blood pregnancy test ●​ Detects pregnancy 1 week after ovulation ○​ Factors that can affect pregnancy test results ■​ Meds: antianxiety or anticonvulsants ■​ Blood in urine ■​ Malignant tumors ■​ Premature menopause 3.​ Positive ●​ Positive signs of pregnancy include fetal heart activity, fetal movements felt by examiner and visualization of the fetus with ultrasound ●​ Fetal heartbeat ○​ Normal fetal heart rate ■​ Low 110 - 120 beats/min and high 150 - 160 beats/min ■​ Rate is higher in early gestation and slows as term approaches ○​ may be detected by 10 weeks gestation using a doppler device ○​ Fetoscope is used to detect the heartbeat at 18 weeks and 20 weeks ■​ Provides another marker of approximate midpoint of gestation when it can be heard through this device ○​ Assess the mother HR at the same time as the fetus to be certain that the fetal heart rate is truly being heard ○​ The uterine and funic souffles may be heard as well ■​ Uterine souffle is a soft blowing sound heard over the uterus ●​ Synchronous with the mother pulse ●​ Caused by the blood entering the dilated arteries of the uterus ■​ Funic souffle ●​ Soft swishing sound ●​ Heard as the blood passes through the umbilical cord vessels ●​ Fetal movement can be felt in the second trimester and visible in an ultrasound ○​ May feel like normal intestinal movement to mother ●​ Identification of fetus or embryo is possible at 4 - 5 weeks gestation through an ultrasound ○​ Earliest positive sign of pregnancy ○​ Routinely performed at 20 weeks gestation Physiological Changes in Pregnancy Roles of Microbiomes in Pregnancy ●​ Microbiome plays a role in maintaining pregnancy, preparing for labor and establishing a microbiome to pass onto the newborn ○​ Contributes to development of the pacific vaginal changes that occur during pregnancy that protect the women from vaginal infections and play a role in preventing preterm births ○​ Microbes in the mothers oral cavity can spread by blood in the placenta ■​ Explains relationship between periodontal (dental disease and preterm birth ●​ Breastmilk can contribute to the establishment of the gut microbiome in the newborn infant after birth Endocrine System Uterus ●​ Before pregnancy: small, muscular, pear-shaped that weighs 60 g (2 oz), measures 7.5 cm (3 inch) long x 5cm (2 in) wide x 1 2.5 cm (0.4 - 1 in) deep ○​ Capacity of 10 mL (⅓ oz) ●​ Increases in size during pregnancy by increasing myometrial (muscle) cells in the first triments and individual cells in the second and third trimester ●​ At term the uterus reaches the women's xiphoid process and weights 1000g (2.2lb) ●​ Capacity of 5000 mL (5 quarts) ○​ Houses fetus, placenta and amniotic fluid Cervix ●​ After conception the cervix changes color and consistency ○​ Chadwicks and Goodell’s signs appear ●​ Mucous plug appears that seals the cervical canal ○​ Prevents the ascent of vaginal organisms into the uterus ○​ Cervical thinning (effacement) and opening (dilation) near the onset of labor, the plug loosens and is expelled Ovaries ●​ Corpus luteum (empty graafian follicle) remains on the ovary and produces progesterone to maintain the decidua (uterine lining) during the first 6 - 7 weeks of pregnancy until the placenta can perform this fx Vagina ●​ Vaginal blood supply increases ○​ Causes bluish color of Chadwick’s sign ●​ Vaginal mucosa thickens and rugae (ridges) become prominent ●​ Connective tissue softens for birth ●​ pH is more acidic to protect vagina and uterus from pathogenic microbes ○​ Higher levels of glycogen in vaginal secretions which promotes growth of Candida albican (yeast infection microbe) ●​ Most common cause of vaginal discharge is bacterial vaginosis ○​ Decrease in normal lactobacilli and increase in bacteroids and other anaerobic microbes ○​ Milky white vaginal discharge but often no other symptoms ○​ Associated with preterm labor ○​ Tx with antimicrobial between 12 - 20 weeks gestation is common Breast ●​ High levels of estrogen and progesterone prepare the breast for lactation ●​ Areolae becomes deeply pigmented and sebaceous glands of the nipple (tubercles of Montgomery) become prominent ○​ Tubercles lubricate nipples ●​ Colostrum is expressed from breast in the last few months of pregnancy ○​ Thin yellow fluid ○​ high in protein, fat-soluble vitamins and mineral ○​ Low in calories, fat and sugar ○​ Contains antibodies and is secreted for the first 2 - 3 days after birth Respiratory System ●​ Oxygen consumption increases by 15% during pregnancy ●​ Expanding uterus presses against the diaphragm, causing it to rise about 4 cm (1.6 inch) ○​ Rib flare is compensated by increasing the circumference of the chest about 6 cm (2.4 in) ●​ Dyspnea may occur until the fetus descends into the pelvis (lightening), relieving upward pressure on the diaphragm ●​ Increased estrogen causes edema or swelling of the mucous membranes oof the nose, pharynx, mouth and trachea ○​ Can experience nasal stuffiness, epistaxis (nose bleeding), changes in voice, and ear aches/fullness Cardiovascular system ●​ The growing uterus displaces the heart upward and to the left ○​ Blood volume increases (hypervolemia) about 45% greater by 32 to 34 weeks gestations ○​ Purpose ■​ Exchange nutrients, oxygen, and waste products within the placenta ■​ Needs of expanding maternal tissue ■​ Reserve for blood loss at birth ●​ Cardiac output increases b/c more blood is pumped from the heart with each contraction ○​ Pulse rate increases by 10 - 15 bmp and basal metabolic rate increases 20% ●​ BP does not increase with hypervolemia b/c resistance to blood flow through the vessels decreases ○​ BP of 140/90 mmHg or higher than the baseline calls for attention ○​ Supine hypotension syndrome (aortocaval compression or vena cava syndrome) ■​ Occurs when the woman lies on her back. In supine the heavy uterus compresses the inferior vena cava, reducing the amount of blood returned to her heart ●​ Symptoms: faintness, lightheadedness, dizziness, and agitation ●​ To relieve pressure, preferably displace the uterus to the left side by turning the pt ●​ Use a rolled towel under the hip if the pt must remain in the supine position ■​ Circulation to the placenta may also be reduced by increasing pressure on the woman's aorta, resulting in fetal hypoxia ●​ Orthostatic hypotension occurs when cardiac output decreases b/c venous return from the lower body suddenly dropped ○​ Palpitations (sudden increase in HR) may occur from increases in thoracic pressure, particularly if they move suddenly ●​ Plasma (fluid) and RBCs do not increase by the same amount during pregnancy ○​ Fluid of the blood increases more than the erythrocyte component which leads too delusional anemia or pseudoanemia (false anemia) ○​ Normal pregnancy hematocrit level is 36% - 48% may fall to 33% - 46% ●​ WBC count increases about 8% (mostly neutrophils) and returns to normal levels by the 6th day postpartum ●​ Increase in clotting factors VII, VIII, X, and plasma fibrinogen during the second and third trimester ○​ Helps prevent excessive bleeding after delivery when the placenta separates from the uterine wall ○​ Can increase possibility of thrombophlebitis during pregnancy ■​ Prevention of venous stasis that can lead to thrombophlebitis ●​ Venous pressure may increase in the femoral veins as the size and weight of the uterus increase, resulting in varicose veins in the legs of women GI System ●​ Growing uterus displaces the stomach and intestines toward the back and sides of the abdomen ●​ Increased salivary secretions (ptyalism) ●​ Mouth tissues become tender and bleed more easily b/c of increased blood vessel development caused by high estrogen levels ○​ Teeth are not affected by pregnancy ●​ Growing fetus increases the woman's appetite and thirst ●​ Acidity of the gastric secretions is decreased; emptying of the stomach and motility of the intestines are slower ○​ Women feel bloated and experience constipation and hemorrhoids ●​ Pyrosis (heartburn) is caused by the relaxation of the cardiac sphincter of the stomach and permits reflux ( backflow) of the acid secretions into the lower esophagus ●​ Altered glucose metabolism b/c of increased insulin resistance ○​ Allows more glucose use by the fetus but places the woman at risk for gestational diabetes ○​ Progesterone and estrogen relax muscle tome of the gallbladder, resulting in the retention of bile salts → leads to pruritus (itching) Urinary System ●​ Excretes waste product for the mother and fetus ●​ Glomerular filtration rate of the kidney increases ●​ Renal tubules increase the reabsorption of substances the body needs to conserve but they might not be able to keep up with the high load of substances filtered by the glomeruli (ex. glucose) ○​ Results in glycosuria and proteinuria ○​ Water retained for blood volume and dissolving nutrients for fetus ●​ Relaxing effects of progesterone cause the renal pelvis and ureters to lose tone, resulting in decreased peristalsis to the bladder ●​ Diameter of the ureters and bladder capacity increase b.c of the relaxing effects of progesterone, causing urine stasis ○​ Combo of urine stasis and nutrient-rich urine places them at risk for UTIs ○​ Consume at least 8-oz of water a day ●​ Changes in renal system may take 6 to 12 weeks after delivery to return to normal Fluid and electrolyte Balance ●​ Increased glomerular filtration rate in the kidneys increases sodium filtration by 50% but the increase in tubular resorption rate results in 99% reabsorption of the sodium ●​ Sodium retention is influenced by elevated hormones in pregnancy ●​ Fluid retention can cause a problem in the woman in labor is given IV containing oxytocin (Pitocin), which has an antidiuretic effect and can result in water intoxication ○​ Symptoms of water intoxication: agitation and delirium ○​ Record I&O during labor and postpartum phase ●​ Blood in pregnancy is more alkaline which enhances hyperventilation that often occurs during pregnancy Integumentary and Skeletal System ●​ Sweat and sebaceous glands of the skin become more active to dissipate heat from the woman and fetus ●​ Small red elevation of the skin with lines radiating from the center, called spider nevi may occur ●​ Palms of the hands may become deeper red ●​ Anterior part of the woman's body becomes heavier with the expanding uterus and the lordotic curve in her lumbar becomes more pronounced ○​ Lower back pain is experienced and rounding shoulders may occur along with aching in the cervical spine and upper extremities ●​ Pelvic joints relax with hormonal changes during late pregnancy and entry of the fetal presenting part into the pelvic brim in the last trimester ●​ Woman have a “waddling” gait in the last few weeks due to a slight separation of the symphysis pubis ●​ Change in center of gravity and joint stability b/c of the softening of the ligaments predispose them to problems with balance (fall risk) Nutrition For Pregnancy And Lactation - Good Nutrition: vital to good health & essential for normal growth and dev’t; essential for healthy pregnancy and infant. - Good nutritional habits begun before conception, continued during pregnancy; promote adaptation to maternal and fetal needs. - Healthy, balanced, nutrient-dense diet combined w/ adequate physical activity is the core of revised dietary guidelines; women who follow this guide b4 pregnancy=well nourished at conception. ●​ Read food labels - During pregnancy & lactation ●​ Adequate seafood w/ (DHA)-omega 3 fatty acid: essential 4 optimal brain dev’t -​ Crab, oysters, salmon, scallops, tilapia, & shrimp -​ Fish oil supplements in pregnancy= ↓ asthma & wheezing in offspring -​ WHO recommends 20 mg of DHA/kg for full term infant ●​ Mackerel, Atlantic sockeye salmon, halibut, tuna, flounder; egg yolk; red meat; poultry; canola oil; soybean oil ●​ 2- 3 servings recommended; frying= detracts DHA content RECOMMENDED DIETARY ALLOWANCES (RDA) & RECOMMENDED DIETARY INTAKES - RDAs : required to maintain optimal health ●​ Past: nutrients primarily supplied by foods, particularly non-fortified ones ●​ Research: ↑ use of dietary supplements & fortified foods = need to describe upper limit to prevent toxicity -​ Toxicity: combination intake of supplements & food exceeds present upper limit Weight Gain Recommended weight gains: ●​ Normal-weight women: 25 to 35 lb (11.4- 15.9 kg) ●​ Underweight women: 28 to 40 lb (12.7 - 18.2 kg) ●​ Overweight women: 15 to 25 lb (6.8 - 11.3 kg) ●​ Obese women: 11 - 20 ( 5 - 9.1 kg) Women carrying twins should gain more weight ●​ Normal wt: 37 to 50 lb ●​ Overweight women: 25 to 42 lb -Pregnant adolescents: should gain in upper part of range recommended -Recommended gain: 4.4 lb first trimester; 1 lb per week during rest of pregnancy Nutritional Requirements during pregnancy 2nd trimester: calorie increase of 340 cal/day 3rd trimester: calorie increase of 450 cal/day -​ Recommended to provide growth of fetus, placenta, amniotic fluid, and maternal tissues -​ Examples of food w/ 340 cal: a banana, a carrot, pc of whole wheat bread -​ Half roast beef sandwich on whole wheat & fresh green salad = healthy diet -​ Caloric Intake must be nutritious ●​ Important Nutrients: Protein, Calcium, Iron, Folic Acid ●​ Pregnant women should use MyPLate to choose her daily diet Protein -Needed for metabolism and support growth and repair of maternal and fetal tissues -Recommended during pregnancy ●​ 60g/day: an increase of 14g over non-pregnant diet ●​ Best sources: meat, fish, poultry, and dairy products ●​ Provide amino acids: beans, lentils, legumes; breads & cereals; seeds & nuts ●​ Complementary plant protein: corn & beans; lentils & rice; peanut butter & bread ●​ Animal proteins: grilled cheese sand, cereal w/ milk, chili made of meat and beans -Vegetarians should be provided w/ info on non meat sources of protein -Fish high in mercury level (albacore tuna, mackerel): eaten w/ caution -Raw meat and raw eggs should be avoided= can be contaminated -Pregnant: NOT eat swordfish, shark, king mackerel (high level of mercury) Calcium Pregnancy & lactation: ↑calcium nearly 50% ●​ 1000 mg DRI of calcium for pregnant ●​ Most source: dairy products ●​ Other sources: cereals, legumes, nuts, dried fruits, broccoli, green leafy vegetables, canned salmon, sardines that contain bones ●​ Calcium supplement for non milk drinkers & younger than 25( bone density not complete) ●​ Calcium: taken separately w/ iron= best absorption; Vit D = enhance absorption Iron Pregnancy: heavy demand for iron; DRI- 30 mg/day for pregnant, 15mg/day for non pregnant ●​ fetus store an adequate supply-meet the needs,3-6 mos ●​ Pregnancy increases supply production of erythrocytes -Difficult to obtain from diet alone ●​ HCP Rx iron supplements -​ 27mg/day, beginning 2nd trimester; after decrease of morning sickness -​ taking on empty stomach improves absorption; not taken w/ coffee or tea, or w/ high calcium foods -​ Vit C may enhance iron absorption - 2 forms: ●​ Heme: found in red meat; body absorbs best ●​ Nonheme: found in plant products; molasses, whole grains, iron-fortified cereals & breads, dried fruits, dark leafy veggies Vitamins and Minerals - Adequate intake= essential during pregnancy; excess = problems ●​ Vit A -​ Excess: fetal anomalies & cardiac defects; -​ Recommended: 3000 mcg/day ●​ Vit B6 (pyridoxine): reduced nausea -​ Excess: cause numbness & muscle weakness ●​ Zinc: required in vegetarian bec whole grains dec zinc absorption ●​ Copper & zinc: part of prenatal vit formula ●​ Folates: prevent neural tube defects; Rx separately from prenatal vit( not achieved) ●​ Iron: taken between meals w/ orange juice= enhance absorption ●​ Iron & calcium: not taken together at same time -​ Pregnant, lactating women older than 19: 1000mg of Calcium/day; 2000-4000 IU of Vit D ●​ Water Soluble Vit: not stored in body, daily intake is important -Women w/ multiple gestations, eating ds, vegan/vegetarian: referred to registered dietitian Vitamin D -A hormone synthesized from cholesterol in the body(research); - Fx: role in developing immunity; aids calcium metabolism; prevent inflammations (e.g.,airway ds, cancer) - Vit D deficiency: linked w/preterm birth, complications of pregnancy (preeclampsia, gestational diabetes) -NOT possible to obtain adequate Vit D from prenatal vitamins -Sources of Vit D: egg yolk, salmon, cod liver oil, fortified milk -Vit D need sunlight to metabolized properly in body; 10 mins of exposure to sun, 2-3x/week Folic Acid - also called “folacin/folate” ; water soluble B vit essential for formation & maturation of RBC and WBC in bone marrow -reduce neural tube defects (spina bifida & anencephaly), when taken b4 conception, as defects can form as early as 28 days of gestation -DRI for pregnant women: 400 mcg/day during 4-9 mos -Sources of folic acid: liver, lean beef, kidney and lima beans, dried beans, potatoes, strawberries, whole wheat bread, peanuts, fresh dark green leafy veggies -Folic acid supplements in non-pregnant: decrease cervical dysplasia & bacterial vaginosis -Used w/ caution to pt taking anticonvulsant drugs or oral contraceptives Fluids -Pregnant women: drink 8-10 glasses/day; most should be water; limit caffeinated & sugary -Caffeine: acts as diuretic, counteracts some benefit of fluid intake; limit 2 cups/day -Women at risk for insufficient amniotic fluid (oligohydramnios): increase daily fluid intake Sodium - essential for maintaining normal sodium levels in plasma, bone, brain, muscle (both tissue & fluid expand during prenatal) - should NOT be restricted during pregnancy; but AVOID lunch meat & chips -Diuretics: not recommended for healthy pregnant women (reduce fluids necessary 4 fetus) ●​ Added fluid during pregnancy supports mother’s increased blood volume Special Nutritional Considerations Pregnant Adolescents Gynecological Age: number of years between onset of menses & date of conception ●​ Adolescent who conceives soon after 1st period: greater nutritional needs ●​ Nurse Role: -​ assess adolescent’s characteristics like resistance, ambivalence, and inconsistency when planning nutritional interventions -​ Remember that girl’s peer group is importance to her; help find nutritious foods that allow her to fit in w/ friends Inadequate Weight Gain & Nutrient Deficits in pregnant adolescent ●​ Cont growth + growth of fetus: difficult for her to meet nutritional needs ●​ Body image: sees herself as “fat” is priority; peer pressure to eat junk foods=at risk Moderate Change in Diet helps ●​ Nurse should give positive reinforcement for her efforts -​ point out that fast foods offer salads, chicken, tacos, bake potatoes, & pizza ●​ Provide many important nutrients & still allow socialization Nutritional Intervention in prenatal : necessary for healthy mother and child ●​ Younger/ smaller adolescent needs additional 200kcal/day + 300kcal/day for normal ●​ Communities programs: provides social support, education about prenatal care, nutritional advice; adolescents respond well in peer groups -​ WIC (WOmen, Infants, Children) & food stamps, if needed Vegetarian or Vegan Diets - Should focus on protein rich foods ●​ soy milk, tofu, tmpeh, & beans ●​ Supplement diet w/ prenatal vitamins = meet dietary need of pregnancy ●​ May require supplements of Vit B12, Calcium, Vit D, Iron, Zinc ●​ Consult a registered dietitian Pica -Craving for and ingestion of nonfood substances: clay, starch, raw flour, cracked ice ●​ Ingestion maybe harmless; large amounts may cause significant health problems ●​ Starch can interfere w/ iron absorption ●​ Large amounts of clay may cause fecal impaction ●​ Any other maybe be harmful bec nutrients for healthy fetal development will not be available -Difficult habit to break ●​ Nurse role: be aware of the practice when discussing nutrition, food cravings & myth; educate in nonjudgmental way about importance of good nutrition, SO the pica should be eliminated/decreased Lactose Intolerance -Caused by a deficiency of lactase (enzyme, digests sugar in milk) ●​ Some women cannot digest milk/milk products=increase risk calcium deficiency ●​ Native Americans, Latinos, African, Middle Eastern & Asian descents: higher incidence than Causacians ●​ S/S: abdominal distention, flatulence, nausea, vomiting, loose stools after ingestion of dairy products Lactose-intolerant women may tolerate cultured/fermented milk products ●​ Aged cheese, buttermilk, yogurt ●​ Enzyme lactase (Lactaid) available in tablet or liquid to add to milk ●​ Lactose treated milk: available commercially ; used under HCP direction Cultural Preferences -Varied cultures believe foods include a dominant trait that affects “humoral balance” in body when ingested ●​ “Hot” or “ Cold”: nothing to do w/ temperature ●​ Ex of hot foods: Peanuts, mangoes, ice cream, tea, cereal grains, hard liquor ●​ Ex of Cold foods: milk, green leafy veggies, freshwater fish, chicken, bananas, citrus fruits ●​ Framework, several health problems: classified as hot or cold, requiring cold or hot for balance ●​ Pt teaching: cultural belief and practices must be included Gestational Diabetes Mellitus -diagnosed in pregnancy -Calories evenly distributed during the day ●​ 3 meals & 3 snacks = maintain adequate and stable BG levels ●​ Pregnant diabetic: susceptible to HYPOglycemia at night; fetus still use glucose while mom sleeps ●​ HS snack: protein and a complex carb = provide more BG stability -Registered dietitian: supervise dietary management -Glycemic control during 1st and 2nd trimesters: important in preventing complications ●​ Macrosomia: abnormally large newborn -Uncontrolled DM in last trimester: increased risk of stillbirth Nutritional Requirements During Lactation -Caloric intake during lactation: 500 calories more than nonpregnant -Maternal protein intake: 65 mg/day -Calcium & Iron: same as during pregnancy -Vit supplements, often continued -Fluids sufficient to relieve thirst and replace fluids lost via breastfeeding should be taken -Drink 8 to 10 glasses of liquids -Some foods should be omitted: ones that causes gastric upset in mom and child -Caffeine should be restricted: 2 cups/day -Caution on drugs ●​ can be secreted in amounts in the breast milk ●​ taken only w/ HCP advice Exercise During Pregnancy Overview ●​ Evidence suggest mild to moderate exercise is beneficial during normal pregnancy but vigorous exercise should be avoided ●​ Maternal cardiac status and fetoplacental reserve should be the basis for determining exercise levels during all trimesters of pregnancy ●​ Avoid skydiving, horseback riding, skiing, and scuba diving ●​ The goal of exercise during pregnancy should be maintenance of fitness, not improvement of fitness or weight loss ●​ Moderate activity during pregnancy can be determined by the “talk test” where the woman can maintain a conversation during activity without stopping to breathe ●​ Recommended exercises during pregnancy and postpartum: walking stationary cycling, dancing, stretching, and resistance exercises using weights and elastic bands ●​ Exercise helps manage glucose levels in type 2 diabetics ●​ 30 min a day x 5 days a week can improve ability to cope with labor, decrease the risk of postpartum depression, and prevent excess weight gain during pregnancy Elevated Temperature ●​ Exercise can elevate the maternal temp. And result in decreased fetal circulation and cardiac function ○​ Maternal body temp should NOT exceed 38℃ (100.4℉) ○​ Do not use hot tubs or saunas during pregnancy ●​ Maternal heat in the first trimester is associated with neural tube defects and miscarriages ●​ Increased body temp during exercise is more easily tolerated b/c normal physiology of pregnancy as it pertains to increased peripheral blood flow, thermal inertia from weight gain and peripheral venous pooling Hypotension ●​ Flat supine positions is assumed, the uterus presses on the vena cava and cause poor venous return resulting in supine hypotension syndrome ●​ Orthostatic hypotension can reduce blood flow to fetus Cardiac Output ●​ Increase in peripheral pooling during pregnancy results in a decrease in cardiac output reserves for exercise ○​ Blood may be diverted from the uterus, causing fetal hypoxia ○​ Exercise increases catecholamine levels, which the placenta may not be able to filter resulting in fetal bradycardia and hypoxia ○​ Strenuous and prolonged exercise causes blood flow to be distributed too the skeletal muscle and skin and away from the viscera, uterus, and placenta ○​ Serious adverse effects if the blood flow reduces 50% to the uterus ○​ Exercise increases maternal hematocrit levels and uterine oxygen uptake so moderate exercise will not cause decreased oxygen supplies to the fetus Hormones ●​ Exercise can cause changes in oxygen consumption and epinephrine, glucagon, cortisol, prolactin, and endorphin levels ●​ In early pregnancy these hormones can negatively affect implantation of the zygote and vascularization of the uterus ●​ In late pregnancy the increase in catecholamines during exercise can trigger labor ●​ Joint instability caused by hormonal changes can result in injury if the woman engages in deep flexion or extension of the joints ○​ DO NOT exceed prepregnancy ROM Other factors ●​ 30 min of fairly moderate exercise several times a week from the 8th week thorough delivery is advised ○​ Avoid vigorous activity and competitive sports ●​ Benefits include: positive self-image, decrease in musculoskeletal discomfort, more rapid return to prepregnancy weight after delivery ●​ Avoid exercise in hot humid weather ●​ Women with hypertension or multiple gestations should speak with their HCP before engaging in exercise programs ●​ Exercise should be no more than 1 hr 3-5x a week ●​ Eating 2 -3 hrs before exercise and immediately after exercise is recommended ●​ Avoid scuba diving below a depth of 30 feet or exercising in altitudes above 8000 ft Smoking During Pregnancy ●​ Smoking has a deleterious effect on the neural development of the fetus and may play a role in the sudden infant death syndrome (SIDs) ●​ Studies show a relation with maternal smoking and psychiatric disorders in the offspring, such as schizophrenia and attention-deficit/hyperactivity disorder ●​ Affects the developing eggs of the female fetus, which affect the grandchildren of the smoker ●​ Smoking marijuana is associated with preterm birth ●​ Nicotine replacement therapy can result in long-term lung problems in the offspring Travel During Pregnancy ●​ Air travel is safe for pregnant women up to 36 weeks gestation ●​ Due to the increased levels of clotting factors and plasma fibrinogen that normally occur during pregnancy, the woman should be counseled to avoid long periods of sitting b/c of increased risk of developing thromboembolism ●​ Max of 6 hrs per day driving with 2 hr breaks for walking and hydration ●​ Hand hygiene and dietary precautions to avoid diarrhea is essential ○​ Special prepackaged oral rehydration solution (ORSs) contain 3.5g sodium chloride, 1.5g potassium chloride, 2.9g trisodium citrate dihydrate, and 2.9g glucose anhydrous ○​ Dissolve in 1 L of water ○​ Emergency preparation of ORS contains 1 L of water, 6 tsp of sugar) and ½ tsp of salt ●​ Eat foods high in potassium Common Discomforts In Pregnancy ●​ Water aerobics in healthy women can relieve edema b/c the hydrostatic pressure forces fluid into the circulation, stimulating glomerular filtration and excretion of water ●​ Use saline nasal drops or room humidifiers to relieve nasal stuffiness caused by edema of nasal tissues as a result of the high level of estrogen Psychosocial Adaptation to Pregnancy Impact on the Mother 4 Maternal tasks that woman accomplishes during pregnancy 1.​ Seeking safe passage for herself & her fetus: obtaining care by HCP & adhering cultural practices 2.​ Securing acceptance of herself as a mother & for her fetus Prenatal Education Interactive process that requires input from the pt concerning individual needs and assessment of outcome; a healthy mother and child and an intact family unit Based on the desired outcome and includes the development of positive attitudes and perceptions, achievement of knowledge of facts and the learning skills to cope with pregnancy, labor and transition into parenthood ●​ Perception that pregnancy is a normal process that is enhanced by good nutrition and a healthy lifestyle ●​ Knowledge to select the proper diet ●​ Skills to perform exercises, breathing, and relaxation techniques to prepare for labor Birth plan is used to collect data to assess cultural needs Effects Of Pregnancy And Lactation On Medication Metabolism ●​ Subtherapeutic drug levels may occur b/c of the increased plasma volume, cardiac output, and glomerular filtration that occur during pregnancy ●​ Decrease gastric emptying time during pregnancy changes absorption of drugs and can delay onset of action ●​ Parenteral meds may be absorbed more rapidly b/c of increased blood flow and may have a faster onset action that in the nonpregnant state ●​ Increases levels of estrogen and progesterone may alter hepatic (liver) fx, resulting in drug accumulation in the body ●​ Drugs that can cross the placenta can have an impact on fetal development ○​ Dangers in the first trimester ○​ Increased absorption levels in the developing fetus in the third trimester ●​ Ibuprofen in the third trimester can cause early closure of the ductus arteriosus, resulting in delta distress ●​ If meds must be taking while the mother is breastfeeding, take the medications immediately after the infant breastfeeds to minimize passage to the infant ●​ ACOG recommends prescribing low-dose aspirin (81 mg per day) initiated between the 12th and 28th week of pregnancy to prevent preeclampsia and other complications Immunizations During Pregnancy Nursing Care During Pregnancy ●​ Live-virus vaccines: contraindicated —>possible AE on the fetus ●​ Screening questionnaire to determine if vaccine is contraindicated/ appropriate for pt ●​ Most single-dose vaccines = thimerosal-free & safe use for pregnant women ●​ Vaccines contraindicated for pregnant: bacille Calmette-Guerin; HPV, live attenuated vaccine nasal spray form, MMR -​ Woman advised to avoid pregnancy for at least 1 month after MMR ●​ Vaccine allowed when exposed to high risk infections: Hepa A & B, inactivated influenza, and inactivated polio vaccine. ●​ High risk pregnant women vaccine: Japanese encephalitis and anthrax vaccine ●​ Human Varicella Zoster immune globulin (VariZIG) given 4-10 days of exposure ●​ TDap vaccine: 29 days after gestation ●​ Flu vaccine protects pregnant women ●​ Vaccines in vials w/ natural rubber tops should not be administered to women allergic to latex Teaching for the prenatal pt should include the risks of smoking, alcohol use, and illicit drug use and the advantages of breastfeeding and good nutrition during pregnancy