Signs of Pregnancy

Presumptive Signs of Pregnancy

1. Amenorrhea or the absence of menstruation.
2. Nausea and vomiting
3. Increased breast sensitivity and breast changes
4. Increased pigmentation in localized areas
5. Constipation
6. Frequent urination
7. Quickening or an initial motion
8. Abdominal enlargement

Probable Signs of Pregnancy

1. Uterine enlargement
2. Hegar’s sign or the softening of the lower uterine segment
3. Goodel’s sign or the softening of the cervix
4. Chadwick’s sign or the purplish discoloration of the vaginal mucosa
5. Ballotment or rebounding upon palpation
6. Braxton-Hicks Contraction
7. Positive pregnancy test

Positive Signs of Pregnancy

1. Fetal heart tone can be auscultated
2. Ultrasound of the fetus
3. Palpable fetal movements

Physiological Changes During Pregnancy

Reproductive System Changes

1. The uterus enlarges and painless contractions occur.
2. Ovulation stops due to high levels of placental estrogen and progesterone.
3. The vagina becomes softer, vaginal mucosa thickens, vascularity increases, and vaginal discharge increases and becomes more acidic.
4. The breast increase in size, become full and tender, and the areola darkens. Sometimes colostrum may be excreted.
5. The cervix softens (Goodel’s sign) and becomes congested with blood (Chadwick’s sign) proliferating glands form mucous plug.

Musculo-Skeletal System Changes

Gradual softening of pelvic ligaments and joints to facilitate passage of the fetus.

1. Relaxation of joints
2. Widening of symphysis pubis
3. Waddling gait
4. Lordosis or is known as the Pride of Pregnancy
5. Increased back strain
6. Leg cramps may occur from an imbalance of calcium phosphorus ratio in the body and from pressure of the uterus

Cardiovascular System Changes

1. The mother’s heart muscle enlarges.
2. The heart rotates upward and to the left.
3. Stroke volume increases.
4. Cardiac output increases as a result of the expanded vascular volume.
5. The pulse rate increases by about 10-15 beats per minute.
6. Peripheral vascular resistance falls under the influence of progesterone and prostaglandins.
7. Femoral venous pressure increases.
8. Blood pressure remains essentially the same, despite increase in the blood volume.
9. Blood volume increases to 1200-1500 mL above pre-pregnancy values.
10. Total red cell mass increases, however, the increase in plasma volume is even more pronounced.
11. White blood cell count increases to to an average of 10,000 per millimeter cube.
12. Clotting factors increase, offering protection against invading microorganisms but also increases the chance of thrombophlebitis.

Respiratory System Changes

1. Oxygen consumption increases by about 20 percent.
2. Dyspnea is a common occurrence.
3. Nosebleeds and nasal stuffiness are common.
4. The mother’s rib cage widen.
5. Respiratory depth increases.

Gatrointestinal System Changes

Changes in the Gastrointestinal system are significant because it creates some of the discomforts of pregnancy. Most of the changes are produced by progesterone, which relaxes the muscles of the stomach and intestine.

1. The gums appear red and swollen and bleed easier, this is caused by elevated levels of estrogen.
2. There is reduced tone of esophageal sphincter that allows reflux of acidic stomach contents, producing heart burns.
3. Decreased motility in the large intestine allows more water to be absorbed and may cause constipation and hemorrhoids.
4. Increased thirst and appetite.

Urinary System Changes

1. Increased urinary frequency on the first and third trimester because of pressure on the bladder.
2. The Glomerular filtration rate increases by 50%.
3. Glycosuria occurs because of the increased secretion of sugar by lowered renal threshold.
4. Lower specific gravity as a result of increase urinary output.

Endocrine System Changes

1. Thyroid activity is increased.
2. HCG reaches a peak in the third month.
3. There is secretion of oxytocin which stimulates uterine contractions coupled with the drop of progesterone that brings about labor.
4. Uterine contractions increase in frequency and intensity culminating in fetal expulsion.

Discomforts of Pregnancy

• Ankle Edema
• Backache
• Breast Tenderness
• Constipation
• Fatigue
• Headache
• Hemorrhoids
• Leg Cramps
• Urinary Frequency
• Vaginal Discharge
• Varicosities

Danger Signs of Pregnancy

• Vaginal bleeding
• Persistent vomiting
• Chills and Fever
• Sudden escape of fluid from the vagina
• Abdominal or chest pain
• Danger signs of Pregnancy Induced Hypertension
  1. Swelling of the face and fingers
  2. Flashes of lights or dots before the eyes
  3. Dimness or blurring of vision
  4. Severe or continuous headache

Prenatal Care

The objective of prenatal care is to reach all pregnant women, to give sufficient care, and to ensure a healthy pregnancy and a birth of a full term healthy baby.

Schedule of first visit is as soon as the woman missed her menstrual period and pregnancy is suspected .

Follow-up visit of a mother should be once a month from 1st week to the 32nd week, twice a month for the 32nd week until the 36th week, and every week from the 36th week to the 40th week.

Common Laboratory Procedures during Pregnancy

Complete Blood Count (CBC), Hemoglobin (Hgb), Urinalysis, Urine test for Protein, Random blood sugar, and Blood typing are some of the common laboratory procedures done on a pregnant client. All pregnant women shall be given tetanus toxoid immunization.

Common Prescriptions during Pregnancy

Iron supplements shall be given from the 5th month of pregnancy up to 2 month post-partum. (100-200 mg orally per day daily for 210 days).

Low–dose Vit.A supplements (10,000 IU in 2 weeks).

In areas with Malaria, 2 tablets of Chloroquine (150 mg/2 tablets every week for the duration of pregnancy).

First Stage of Labor

The first stage of labor usually have 20 t0 40 contractions.

Three Phases of the First Stage of Labor

1. Latent Phase. The mother is excited. This lasts from the beginning of labor until 3 cm of cervical dilatation.
2. Active Phase. The mother is anxious. The cervix dilates from 4-7 cm and dilates in a more rapid rate.
3. Transition Phase. The mother is irritable. The cervix dilates from 8-10 cm and the fetus descends further into the pelvis.

Second Stage of Labor

This is where the vulva is stretching. Contractions are at 40-60. This begins with complete dilatation and full effacement of the cervix and end with the birth of the baby.

Third Stage of Labor

This begins with the birth of the baby and ends with the expulsion of the placenta. The placenta is formed by the union of the chorionic villi and decidua basalis.

Types of Placental Separation

• Schultz. The presenting part is the fetal side which is shiny.
• Duncan. The presenting part is the maternal side which is called “dirty” because it is raw and red.

Nursing Care During the Third Stage of Labor

• Do not hurry the expulsion of the placenta. This usually takes around 20 minutes.
• Tract cord slowly.
• Inspect for missing cotyledons. There should be 30.
• Palpate the uterus.
• Inject oxytocin.
• Inspect the perineum.
• Put down the legs of the mother together to prevent injury.
• The mother should be flat on bed without pillows for 6 hours.
• If the client is experiencing chills, provide her with a blanket and NOT soup.
• Provide additional nourishment.
• Allow the mother to sleep to regain her strength.

Fourth Stage of Labor

The fourth stage of labor is the most critical stage. This lasts from the delivery of the placenta through the first 1-4 hours after birth. The nurse should assess the fundus, blood pressure and pulse rate, the lochia which should be moderate in flow, and the perineum. If the flow of the lochia is heavy the mother should be checked for lacerations and rechecked for retained placental fragments.

Nursing Care During Labor

• Monitoring the fetus.
• Monitoring the laboring woman.
• Helping the woman cope with labor.

Condition Assessment with Fetal Compromise

1. Fetal Heart Rate. Lower limit is 110-120 bpm and the upper limit is 150-160 bpm.
2. No variability in the electronic monitoring.
3. Slowing of the fetal heart rate. This persists or preceeds after contraction.
4. Meconium stained. The amniotic fluid is green..
5. If the amniotic fluid is yellow, cloudy, or has a foul odor, it may indcate infection.
6. Contractions that last for 90 secs.
7. Incomplete uterine relaxation.
8. Maternal hypotension.
9. Maternal hypertension.
10. Maternal fever.

Evaluate Fetal Heart Rate

1. Baseline Rate. The range of contractions and its changes and fluctuations. This should be constant.
2. Variability. The decreases and fluctuations.
3. Periodic changes. The changes in baseline rate. Classified as acceleration and deceleration. Types:
   • Early decelerations. The rate of decrease during contraction but return to baseline by end of contraction.
   • Variable decelerations. 70 bpm or less for longer than 60 seconds. This may suggest fetal cord compression around the neck or inadequate amniotic fluid.
   • Late deceleration. This is similar to early deceleration except it does not return to baseline until contractions end.

Inspection of Amniotic Fluid

• Normal color is clear with flecks of vernix caseosa.
• Green stained fluid indicates the amniotic fluid is meconium stained.
• Cloudy or yellow amniotic fluid is infected.

E = Engagement

It is the mechanism wherein the fetus ‘engages’ to the pelvis. It is also called lightening or dropping.

D = Descent

Descent is the mechanism where the fetal head begins its journey through the pelvis. Assessment measurement is termed as station.

F = Flexion

Is the mechanism where the fetal head is nodding or flexing forward toward its chest.

IR = Internal Rotation

This occurs from the occiput transverse position to the occiput anterior position while descending.

E = Extension

This enables the head to emerge when the fetus is in cephalic position. This begins when the head is crowning.

R = Restitution

It is the realignment of the head of the fetus with the body as the fetus’ head emerges.

ER = External Rotation

This mechanism is where the shoulders rotate externally once the head emerges and restitution occurs so that the shoulders would be in the anteroposterior diameter of the mother’s pelvis.

E = Expulsion

It is the birth of the entire body of the fetus.

Other Terminologies and Procedures

Crowning. The fetal head distends the labial and perineal tissue and the anus is stretched wide.

Ritgen Maneuver. Pressure is applied to the fetal chin through the perineum at the same time pressure is applied to the occiput. This aids the mechanism of extension as the fetal head comes under the symphysis.

Preparation for Leopold’s Maneuver

Ask the mother to empty the bladder. The nurse should then warm the hands and apply it to the abdomen of the mother by using firm and gentle pressure.

Maneuvers

First Maneuver

This determines what part of the fetus is in the fundus.

1. Place palms on each side of the upper abdomen and palpate around the fundus.
2. If the head is at the fundus, you would feel a hard, round, and movable object. If the buttocks is at the fundus, you will feel a soft and irregular shaped mass that is difficult to move.

Second Maneuver

1. Move your hands downward, still on both sides of the abdomen, while applying firm and even pressure.
2. If you palpate a smooth hard surface on one side then it would be the fetal back. If you palpate irregular lumps it would be the hands, feet, elbows, and knees and should be on the opposite side of the abdomen.

Third Maneuver

This maneuver confirms the fetal position.

1. Place your hands above the symphysis pubis.
2. Bring the thumb and fingers together and grasp the part of the fetus between them. Findings could be the head or the buttocks.

Fourth Maneuver

This is used in the late stage of pregnancy to determine how far the fetus has descended into the pelvic inlet.

1. Place your hands on both sides of the lower abdomen close to the midline.
2. Slide your hands downward, then press inward.
3. If you palpated the buttocks in the fundus, then you shoul feel for the head. If one cannot feel the head, then it probably has descended.

Different Fetal Positions

Vertex

• LOA – Left Occipito Anterior
• LOP – Left Occipito Posterior
• LOT – Left Occipito Transverse
• ROA – Right Occipito Anterior
• ROP – Right Occipito Posterior
• ROT – Right Occipito Transverse

Breech

• LSA – Left Sacro Anterior
• LSP – Left Sacro Posterior
• LST – Left Sacro Transverse
• RSA – Right Sacro Anterior
• RSP – Right Sacro Posterior
• RST – Right Sacro Transverse

Face

• LMA – Left Mento Anterior
• LMP – Left Mento Posterior
• LMT – Left Mento Transverse
• RMA – Right Mento Anterior
• RMP – Right Mento Posterior
• RMT – Right Mento Transverse

Shoulder

• LADA – Left Acromion Dorsal Anterior
• LADP – Left Acromion Dorsal Posterior
• RADA – Right Acromion Dorsal Anterior
• RADP – Right Acromion Dorsal Posterior

Longitudinal Lie

The fetal spine is parallel with the mother’s spine. Usually the fetus is in cephalic or breech presentation.

Transverse Lie

The fetal spin is horizontal or is at a right angle with the mother’s spine. The presenting part of the fetus is the shoulder and delivery is usually caesarian.

Oblique Lie

The fetal spine is diagonal to the mother’s spine. Delivery is by caesarian section if uncorrected.

Three Categories of Fetal Presentation

1. Cephalic Presentation

   Cephalic Presentation is the most favorable among the three. The fetal head is the largest angle of the fetal part. It can gradually change shape to adapt to the size and shape of the maternal pelvis. The fetal head is smooth, round, and hard. There are three variations of cephalic presentation. These are:
   • Vertex. The brow is partly extended.
   • Military. The face is fully extended.
   • Suboccipito. Most favorable, is the neutral position.

2. Breech Presentation

   The disadvantages of Breech Presentation are that the buttocks are not smooth and firm like the head and is less effective at dilating. Variations of the breech presentation are frank breech, full breech, and footling.

3. Shoulder Presentation

   The fetus is in a transverse lie. The arm, back, abdomen, or side could present. If the fetus does not rotate spontaneously or if the fetus cannot be manually turned, caesarian section may be performed.

Powers

The Powers is the uterine contraction which is the primary force moving the fetus through the pelvis and the maternal pushing efforts during the second stage which add to the forces of the uterine contraction to propel the fetus.

Passageway

The Passage consists the maternal pelvis and the soft tissues of the pelvic floor, cervix, vagina, and introitus. The bony pelvis is divided by the Linea Terminalis (pelvic brim) into the false pelvis above and the true pelvis below. Softening of the cartilage linking the pelvic bones occurs at term because of the hormone Relaxin.

Subdivisions of the Pelvis

• Inlet or upper pelvic opening
• Midpelvic or pelvic cavity
• Outlet or lower pelvic opening

Four Basic Pelvic Shapes

• Gynecoid. This is the most common shape in females and is the most favorable for childbirth.
• Android. This is the most common shape in males and is not favorable for child birth.
• Anthropoid. Has an ape-like shape
• Platypelloid, Is broad and flat shaped.

Passenger

The Passenger is the fetus plus the membranes and placenta.

Psyche

Psyche is the most crucial part of childbirth. The mother may experience anxiety and fear.

A major focus of nursing is childbearing and the childbearing families because to have healthy individuals, one must have healthy children and to have healthy children health care practitioners should promote the health of the pregnant women and her family from conception, birth and the growth of her child.

Maternal care is the care of the mother before conception, during pregnancy, during labor and delivery, and after giving birth. Child care is concerned with the child after being conceived, all throughout pregnancy, and its growth and development. The primary goal of maternal and child health nursing is the promotion and maintenance of the health of the mother and child and their family. This includes the care of women before conception, during the trimesters of pregnancy, care of the children during the perinatal period, from birth through adolescence, and the care of the settings involve in the birthing and maintaining the health of the mother and child like the delivery room, pediatric care unit, and the home of the client.

Maternal and child care is family-centered with the family considered as the primary unit of care. Assessment data should include the family as well as the individual assessment. Promoting the health of the mother and child is an important nursing role, because it helps protect the health of the following generation.

Types of Abortion

• Induced. Has therapeutic or elective reason for terminating the pregnancy.
• Spontaneous. Pregnancy ends because of natural causes.
• Complete. Loss of all products of conception
• Incomplete. There is loss of some products of conception and retention of others.
• Inevitable. The loss cannot be prevented.
• Missed. Retention of products of conception in utero after fetal death
• Habitual. Spontaneous abortions in three or more successive pregnancies occur.

Assessment Findings for Abortion

• Passage of clots or tissue occurs.
• Spontaneous vaginal bleeding occurs.
• Hemorrhage and shock can happen.
• Low uterine cramping or contractions occur.

Nursing Interventions for Abortion

• Maintain bed rest of the client.
• Monitor vital signs.
• Monitor bleeding and cramping.
• Count perineal pads to evaluate blood loss and save expelled tissues and clots.
• Maintain intravenous fluids as prescribed, nurses should monitor for signs of shock.
• Prepare the client for dilatation and curettage as prescribed for incomplete abortion.
• Administer Rh immune globulin is given to Rho(D)-Negative woman as ordered.