مواقع اعضاء هيئة التدريس | KSU Faculty



UNIT II: PREGNANCYDefinitions:Braxton hicks contraction---irregular, mild uterine contractions that occur throughout pregnancy; they become stronger in the last trimester.Chadwick’s sign---bluish discoloration of the cervix, vagina and labia during pregnancy as a result of increased vascular congestion.Choasma---brownish pigmentation of the face during pregnancy; also called “mask of pregnancy”Decidua---endometrium.Erythema ---is reddening of the palms.Goodell`s sign---softening of the cervix, uterus, and vagina during pregnancy.Hagar’s sign---is a bimanual examination for assessing the softening and compressibility of the isthmus between the 6th and 12th weeks of pregnancy.Hyperplasia---increase number of cells due to division.Hypertrophy---increase in size of cells.Lordosis---increase the curvature of the back.Osiander`s sign---is an increased pulsation of blood in the uterine arteries, felt with the fingers in the lateral vaginal fornices.Ptyalism---increase of saliva.Vascular spiders--- is minute red elevations on the skin of the face, neck, arms and chest.Quickening---the first fluttering movements of the fetus felt by the mother. A primigravida woman feels it at 18-20weeks, and a multigravida woman at 16-18weeks.Steria gravidarum---irregular pinkish streaks resulting from tears in connective tissue; during pregnancy these streaks generally appear on the woman’s abdomen, breasts, or thighs.Uterine souffle---Gush of blood in the uterine arteries. Heard by fetal stethoscope.Umbilical souffle------Gush of blood in the umbilical cord. Heard by fetal stethoscope.Introduction: Physiological adaptation to pregnancy is dramatic and often underestimated. The timing and intensity of the changes vary between systems, but all are designed to enable the woman to nurture the fetus and prepare her body for labor and lactation. The appreciation of the normal physiological changes of pregnancy will enable to identify pregnancy induced alterations, detect abnormalities, especially when affected by preexisting illnesses, and provide appropriate care to all women.DIAGNOSIS OF PREGNANCYThe diagnostic confirmation of pregnancy is based on a combinationof the presumptive, probable, and positive changes/signs of pregnancy.This information is obtained through history, physical and pelvicexaminations, and laboratory and diagnostic studies.Presumptive Signs of PregnancyThe presumptive signs of pregnancy include all subjective signs ofpregnancy (i.e., physiological changes perceived by the woman herself ):and these signs lead a woman to believe that she is pregnant.■ Amenorrhea: Absence of menstruation■ Nausea and vomiting: Common from week 2 to 12■ Breast changes: Changes begin to appear at 2 to 3 weeks■ Enlargement, tenderness, and tingling of breast■ Increased vascularity of breast■ Fatigue: Common during the first trimester■ Urination frequency: Related to pressure of enlarging uterus onbladder; decreases as uterus moves upward and out of pelvis■ Quickening: A woman’s first awareness of fetal movement;occurs around 16 to 20 weeks’ gestationAll of these changes could have causes outside of pregnancy and arenot considered diagnostic.Probable Signs of Pregnancy:The probable signs of pregnancy are objective signs of pregnancyand include all physiological and anatomical changes that can beperceived by the health care provider.■ Chadwick’s sign: Bluish-purple coloration of the vaginalmucosa, cervix, and vulva seen at 6 to 8 weeks■ Goodell’s sign: Softening of the cervix and vagina withincreased leukorrheal discharge; palpated at 8 weeks■ Hegar’s sign: Softening of the lower uterine segment; palpatedat 6 to 8 weeks ■ Uterine growth and abdominal growth ■ Skin hyperpigmentation_ Melasma (chloasma), also referred to as the mask of pregnancy:Brownish pigmentation over the forehead, temples, cheek, and/orupper lip _ Linea nigra: Dark line that runs from the umbilicus to the pubes _ Nipples and areola: Become darker; more evident in primigravidas and dark-haired women■ Ballottement: A light tap of the examining finger on the cervixcauses fetus to rise in the amniotic fluid and then rebound to itsoriginal position; occurs at 16 to 18 weeks. Usually it is disappear with walking or exercise.■ Positive pregnancy test results_ Laboratory tests are based on detection of the presence of humanchorionic gonadotropin (hCG) in maternal urine or blood._ The tests are extremely accurate, but not 100%. There can be bothfalse-positive and false-negative results. Because of this, a positivepregnancy test is considered a probable rather than a positivesign of pregnancy._ A urine pregnancy test is best performed using a first morningurine specimen, which has the highest concentration of hCG, andbecomes positive about 4 weeks after conception.■ A maternal blood pregnancy test can detect hCG levels before amissed period. Home pregnancy tests are also accurate (but not 100%) andare simple to perform. These urine tests use enzymes and rely ona color change when agglutination occurs, indicating a pregnancy. The home tests can be performed at the time of a missed menstrualperiod. If a negative result occurs, the instructions suggestthat the test be repeated in one week if a menstrual period hasnot begun.All of these changes could also have causes other than pregnancy andare not considered diagnostic. The presumptive and probable signs ofpregnancy are important components of assessment in confirming apregnancy. Early in gestation, before any positive signs of pregnancy,a combination of presumptive and probable signs is used to make apractical diagnosis of pregnancy.Positive Signs of PregnancyThe positive signs of pregnancy are the objective signs of pregnancythat can only be attributed to the fetus:■ Auscultation of the fetal heart, by 10 to 12 weeks ■ Observation and palpation of fetal movement by the examiner after about 20 weeks' gestation■ Sonographic visualization of the fetus: Cardiac movement noted at 4 to 8 weeks.Physiological Changes during PregnancyPHYSIOLOGICAL CHANGESCLINICAL SIGNS AND SYMPTOMSRespiratory system -Hormones of pregnancy stimulate the respiratory center and act on lung tissue to increase and enhance respiratoryfunction-Increase of oxygen consumption by 15%–20%-Estrogen, progesterone, and prostaglandins cause vascular engorgement and smooth muscle relaxation-Upward displacement of diaphragm by enlarging uterus439420716280-Estrogen causes a relaxation of the ligaments and joints of rib -Increase in tidal volume by 30%–40%, Due to Expansion of the rib cage -Slight increase in respiratory rate by 2b\min-Increase in inspiratory capacity due to Increase in tidal volume-Decrease in expiratory or residual volume-up to 70% of pregnant women experience Slight hyperventilation, can be uncomfortable and may lead to dyspnoea and dizziness.-Slight respiratory alkalosis-Dyspnea-Nasal and sinus congestion& Epistaxis,because edema and vascular congested which cause by increase estrogen level. -Shift from abdominal to thoracic breathing-Chest and thorax expand to accommodate thoracic breathing and upward displacement of diaphragm- Lung capacity slight decrease or may remain unchanged .-Shortness of breath because enlarge uterus cause elevated the diaphragm on the lungHyperventilation of pregnancy causes a 15-20% decrease in maternal arterial CO2. Hyperventilation facilitates the transfer of CO2 from fetus to the mother and to be washed out of the lungs.INTEGUMENTARY SYSTEM-Estrogen and progesterone levels stimulate increased melanin deposition, causing light brown to dark brown pigmentation.-Increased blood flow, increased basal metabolic rate, progesterone-induced increase in body temperature, andvasomotor instability-Increased action of adrenocorticosteroids leads to cutaneous elastic tissues becoming fragile-Increased estrogen levels lead to color and vascular changes.568325530860-Increased androgens lead to increase in sebaceous gland secretions-Linea nigra-Melasma (chloasma)-Darken of nipples, areola, vulva, scars, and moles-Hot flashes, facial flushing, alternating sensation of hot and cold-Striae gravidarum (stretch marks) on abdomen, thighs, breast, and buttocks-Angiomas (spider nevi)-Palmar erythema: Pinkish-red mottling over palms of hands-Increased oiliness of skin and increase of acne-Mild hirsutism is common during pregnancy, particularly on the face -Itching of the skin in pregnancy (not common), can be distressing. The evidence suggests that, in the absence of a rash, aspirin is effective but if there is a rash, chlorphenamine may be more effectiveChanges in the urinary system-Increased progesterone levels, which cause a relaxation of smooth muscles-Pressure of enlarging uterus on renal structures-Alterations in cardiovascular system (increased cardiac output and increased blood and plasma volume) lead to increasedrenal blood flow of 50%–80% in first trimester and then decreases-Decreased renal flow in third trimesterIncreased vascularity311150320675-urinary frequency occur during in the first and third trimester due to pressure of the large uterus on the bladder. -Dilatation of the kidney, ureter and urethra .- Urinary stasis and urinary tract infection due pressure of the uterus on ureter and urethra .-Glycosuria due to re-absorption of glucose by renal tubules may be evident because of the increase in glomerular filtration,. - Increase renal clearness of urea and creatinine.-. Kidneys increase in weight and lengthen by 1cm -Bladder pressure increases and may result in reduced bladder capacity. The muscles of the internal urethral sphincter relax, with pressure from the pregnant uterus on the bladder, causes some women experience some degree of stress incontinenceGASTROINTESTINAL SYSTEM-Increase levels of hCG and altered carbohydrate metabolism-Increased progesterone levels lead to decreased muscle tone and slowing of digestive processes-Increased progesterone levels lead to decreased muscle tone ofgallbladder, resulting in prolonged emptying time.-Changes in senses of taste and smell-Displacement of intestines by uterus-Increased levels of estrogen lead to increased vascular congestionof mucosa.-Nausea and vomiting during early pregnancy-Constipation-Delayed stomach emptying leads to heartburnIncreased risk of gallstone formation and cholestasis-Increase or decrease in appetiteNausea-Pica: Abnormal; craving for and ingestion of nonfood substances such as clay or starch-Flatulence, abdominal distension, abdominal cramping, and pelvic heaviness-Gingivitis, bleeding gums, increase risk of periodontal disease-Secreation of saliva may increase.-Heartburn (pyrosis) is common caused by reflux of acid secretions in the lower esophagus, and relaxation of the stomach muscle ( delay stomach emptying time).-Hemorrhoids are common because of elevated pressure in veins below the level of the large uterus and constipationMUSCULOSKELETAL SYSTEM-Increased progesterone and relaxin levels lead to softening of joints and increased joint mobility, resulting in widening andincreased mobility of the sacroiliac and symphysis pubis.-Distension of abdomen related to expanding uterus, reducedabdominal tone, and increased breast size-Increased estrogen and relaxin levels lead to increased elasticity and relaxation of ligaments -Abdominal muscles stretch due to enlarging uterus-Altered gait: “Waddle” gait-Facilitates birthing process Pelvic tilts forward, leading to shifting of center of gravity that results in change in posture and walking style, increasing lordosis-Increased risk of falls due to shift in center of gravity and change in gait and posture-Round ligament spasm-Increase risk of joint pain and injuryDiastasis recti-Late in pregnancy aching, numbness, and weakness in the upper extremities may occur because of lordosis, and pressure on the unlar nerve.ENDOCRINE SYSTEMDecreased follicle-stimulating hormoneIncreased progesteroneIncreased estrogenIncreased prolactinIncreased oxytocinIncreased human chorionic gonadotropin (hCG)Human placental lactogen/human chorionic somatomammotropinHyperplasia and increased vascularity of thyroidIncreased BMR related to fetal metabolic activityIncreased need for glucose due to developing fetusIncrease in cortisolAmenorrheaMaintains pregnancy by relaxation of smooth muscles, leadingto decreased uterine activity, which results in decreasedrisk of spontaneous abortionsDecreases gastrointestinal motilityFacilitates uterine and breast developmentFacilitates increases in vascularityFacilitates hyperpigmentationAlters metabolic processes and fluid and electrolyte balanceFacilitates lactationStimulates uterine contractionsStimulates the milk let-down or ejection reflex in responseto breastfeedingMaintenance of corpus luteum until placenta becomes fullyfunctionalFacilitates breast developmentAlters carbohydrate, protein, and fat metabolismFacilitates fetal growth by altering maternal metabolism;acts as an insulin antagonistEnlargement of thyroidHeat intolerance and fatigueDepletion of maternal glucose stores leads to increased riskof maternal hypoglycemia.Increased production of insulinIncrease in maternal resistance to insulin leads to increasedrisk of hyperglycemia.H. Metabolic ChangesAverage weight gain during pregnancy is 11.5 to 16 kg.I. Neurological System changes: - Usually no system changes - Mild frontal headaches are common in the first and second trimester- Dizziness due to postural hypotension- Tingling sensations in the hands4538345110490Cardiovascular system changes. 1.the heart is displaced upward, to the left, and forward. 2. edema and varicosities of the legs because pressure of the uterus on the blood vessels and blood stasis .3. supine position during the 2nd trimester, due to pressure of the uterus on the inferior vena cava so decrease blood return to the heart then circulation.4.By mid-pregnancy more than 90% of women develop an systolic murmur, which lasts until the first week postpartum. 20% develop a transient diastolic murmur and 10% develop continous murmurs, heard over the base of the heart, owing to increased mammary blood flow.5. heart rate increase by 10 to 15 beats\mint6. blood volume increase 30% to 50%7.cardiac output increase by 25% to 50%.-The increased cardiac output allows blood flow to the kidneys, brain and coronary arteries to remain unchanged, while the distribution to other organs varies as pregnancy advances *The increased cardiac output is due to increases in both stroke volume and heart rate. 8.Blood pressure: decrease blood pressure beginning in the first trimester and becoming maximal in the second trimester . then returns to pre-pregnancy levels in the third trimester.the systolic blood pressure falls an average of 5-10 mmhg below baseline levels and the diastolic pressure falls 10-15 mmhg by 24 weeks` gestation. 131889528575The expansion in plasma volume is greater than the expansion of red cell mass, causing the physiological anemia .-The increase in plasma volume reduces the viscosity of the blood and improves capillary flow. Red cell mass, increases during pregnancy in response to the extra oxygen requirements of maternal and placental tissue. The total white cells count rises in pregnancy and reaches a peak at 30 weeks.. increase in the fibrinogen level, and decrease hematocrit ( MCV)Immunity---HCG and prolactin are known to suppress the immune response of pregnant women. Lymphocyte function is depressedChanges in the Reproductive Tract:A. Uterus: - Enlargement and thickening of the uterine wall are most marked in the fundus.- Braxton Hicks contractions irregular painless contractions can be felt by women by fourth months .- uterian circulation increase so increase the Size and number of the blood vessel and lymphaticAs the uterus rises out of the pelvis, it rotates somewhat to the right because of the presence of the recto sigmoid colon on the left side of the pelvis.. Cervix:softening(goodle sign) and cyanosis` ”due to increased vascularity, edema, hypertrophy, and hyperplasia of the cervical glands.Endocervical glands secrete thick mucus that forms a cervical plug and obstructs cervical canal. This plug prevents bacteria and other substances from entering and ascending into uterus.Chadwick's sign, bluish, purplish coloring of cervix due to increased vascularity caused by increased estrogen levels. c. ovaries: - amenorrhea ( absent of the menses ) -corpus luteum functions during early pregnancy (first 10 to 12 weeks), producing mainly progesterone.Antenatal CareIntroductionEvery year there are an estimated 200 million pregnancies in the world. 50 million each year, experience pregnancy-related health problems during or after childbirth. Fifteen percent of these women suffer serious or long-term complications (WHO, 1999; SMH, 2002). a pregnant woman’s risk for optimal health of the mother and her fetus. In Egypt, according to the last statistics from Ministry of Health and Population, maternal mortality rate is about 84/100000/year women die from complications of pregnancy and childbirth (Ministry of Health and Population, 2000). While risks in pregnancy cannot be totally eliminated, they can be reduced through effective, affordable, accessible and acceptable maternity care. Therefore, it is recommended that all mothers see a trained provider at least four times during pregnancy. The EIDHS-98 found that during the five-year period before the survey, only 33 % of women reported that they had received four or more antenatal visits. So The nurse plays an important role to improve the quality of antenatal care,Definitions? It is a planed examination and observation for the woman from conception till the birth .Or? Antenatal care refers to the care that is given to an expected mother from time of conception is confirmed until the beginning of laborGoals and Objectives of Antenatal CareGoals* To reduce maternal mortality and morbidity rates.* To improve the physical and mental health of women and children.* antenatal care aims to prevent, identify, and ameliorate maternal and fetal abnormality that can adversely affect pregnancy outcome.*to decrease financial recourses for care of mothers.Objectives? Antenatal care support and encourage a family’s healthy psychological adjustment to childbearing FACTORS AFFECTING MOTHERS UTILIZATION OF ANTENATAL CAREDemographic and Biological FactorsSocioeconomic FactorsPsychosocial FactorsHealth Services FactorsEnvironmental FactorsPreparation of Antenatal Rooms? Furniture: Ensure that the furniture is arrangedconveniently for the work of all staff and comfortable for the clients.? Stationery: Ensure that the desk is supplied with cards, pencils, etc.? Trays: check the preparation of the following trays : * Medication tray. * Immunization kit . * Temperature tray. * Treatment and dressing tray.? Visual displays : Ensure that the visual displays and posters are arranged.? Waiting area : Ensure that the waiting area is comfortable for the clients and educational materials are available.? Examination instruments and equipment: * Make sure that all instruments and equipment are available and in working order. * Check and balance the scales at the beginning of the clinic, then repeat as needed during the ponent of antenatal care:Assessment:The assessment process begins at the initial prenatal visit and is continued throughout pregnancy. The initial assessment interview can establish the trusting relationship between the nurse and the pregnant woman. It is a planned purposeful communication that focuses on specific content. The purposes of the initial interview include establishing rapport, getting information about the woman’s physical and psychological health, and obtaining a basis for anticipatory guidance for pregnancy .1- Physical Examinations and Assessments6235700Initial Visit and Examination- Welcome the woman .- Greet her to establish a good relationship .? keep Privacy or Discuss in suitable place .- Discuss any problems.- follow the principals of good communication .Component of antenatal care .1-History taking: The nurse begins to take complete history from the pregnant woman, which includes personal, obstetric, medical, surgical, family, and psychological elements. ? Personal and social history- The woman's name and address should be filled out clearly, so that the individual woman can be traced by a home visit if she fails to keep her next appointment.- Other personal data such as age, education, marital status, duration of marriage, and occupation of both partners.- Housing and finance should be considered as evidence that prenatal mortality and morbidity are higher in families who live in poor conditions.- Religion may give an indication of particular attitudes, beliefs or practices associated with childbirth and lifestyle such as dietary taboos.- Nationality and language should also be recorded.? Medical and surgical history: as evidence studies showed that Certain diseases may have an adverse effect on pregnancy, so a note is made about details regarding:- Childhood illnesses and any serious, chronic, or infectious diseases such as: diabetes mellitus, hypertension, urinary tract troubles, heart diseases, and viral infections.- Allergies, radiation exposure, blood transfusions, and current medications.- Previous operations such as cesarean section, genital repair, and cervical cerclagc.- Recent surgery, particularly on the genital tract.- Accidents involving injury of the bony pelvis.? Obstetrical history:Details of previous pregnancies such as:? Length, outcome, and problems of each pregnancy.? Date of last abortion. Details of previous labors such as:? Sex and weight of each infant.? Whether live or stillborn.? Whether breast or artificially fed.? Prematurity and neonatal death,? Complications of previous labors.? Date of last delivery. Details of previous postpartum such as:? Contraceptive history.? Complications such as postpartum hemorrhage.Menstrual history: * Age of menarche.* Regularity and frequency of menstrual cycle. * Duration and nature of menstrual flow.* Any previous treatment of menstrual! problems or infertility.* Date and character of last menstrual period (LMP).* Expected date of delivery (EDD) is calculated as follows:? 1st day of LMP + 7 days - 3 months + 1 year.? 1st day of LMP + 7 days + 9 months. Family history:Family history: * Some families have genetic pre-dispositions to certain diseases especially if the parents are close relatives. * Prevalence of any of the following within the families of both parents should be noted; diabetes mellitus, essential hypertension, cardiac disease, mental illness, multiple pregnancy, congenital abnormalities, and allergic conditions such as asthma, eczema and high fever.* Sickle cell anemia and thalassemia are common in particular races.* Poor living conditions may increase the chance of tuberculosis and/or vitamin deficiency that may cause spina bifida.? History of present pregnancy:* Symptoms of pregnancy. * Minor complaints of pregnancy.* Symptoms of complications as pre-eclampsia. * Fetal movement.2-Physical ExaminationsGeneral Examination? It should be started from the moment the pregnant woman walks into the examination room. A general examination should be done systematically. Start by looking at the woman's face, then progress downwards to finish with an inspection of her legs and feet,? Examine general appearance:Observe the woman for stature or body build and gait.Check the hair of woman to assess her health. The hair of a healthy woman is shim and glossy.? Look at the woman's face to assess her health. The face is observed for skin color as pallor and pigmentation as chloasma.* Observe the eyes for edema of the eyelids and color of conjunctiva. Healthy eyes are bright and clear.* Observe the mouth for:? Dryness or cyanosis of the lips.? Gingivitis of the gums.? Septic focus or caries of the teeth.* Observe the neck for enlarged thyroid gland and scars of previous operations.* Observe complexion for presence of blotches.* Ensure that the general manner of the woman indicates vigor and vitality.* An anemic, depressed, tired or ill woman is lethargic, not interested in her appearance, and unenthusiastic about the interview.* Lack of energy is a temporary state in early pregnancy, a woman often feels exhausted and debilitated.* Discuss the woman's sleeping patterns and minor disorders and give advice as necessary.* Report any signs of ill health.? Examine height :* Height of over 150 cm and shoe size above 3 give an indication of an average-sized pelvis.?Weight :* The approximate weight gain during pregnancy is 12 kg-i 2kg in the first 20 weeks and 10 kg in the remaining 20 weeks (1.5 kg per week until term) as evidance.* Little or no maternal weight gain leads to fetal jeopardy.* Obesity (more than 20 kg above the weight-height formula) leads to an increased risk of gestational, diabetes pregnancy-induced hypertension and thrombo embolic disorders.* Underweight (less than 20 kg below the weight-height formula) also puts the pregnant woman at great risk.? Blood pressure:* It is taken to ascertain normality and provide a baseline reading for a comparison throughout the pregnancy.* If the blood pressure is elevated because the woman is nervous and anxious, take it again when the woman is more relaxed.* In late pregnancy, raised systolic pressure of 30 mm Hg or raised diastolic pressure of 15 mm Hg above the baseline values on at least two occasions of 6 or more hours apart indicates toxemia.? Breast examination:* The breast should be gently palpated to feel any lump.* The nipple should be drawn forward to see if it is protractile.* The breast should be observed for pregnancy changes.? Medical examination:* The doctor should examine the heart and lungs to exclude diseases.? Elimination:* Ask the woman about her bowel habits. * Carry out routine urine analysis.* Check the presence of dysuria and frequency of micturition.? Vaginal discharge:* Ask the woman about any increase or change of vaginal discharge.* Report to the obstetrician any mucoid loss before the 37th week of pregnancy.? Vaginal bleeding:* Vaginal bleeding at any time during pregnancy should be reported to the obstetrician to investigate its origin.? Legs:* Legs should be noted for edema.* They should be observed for varicose veins which predispose to deep vein thrombosis.* The calf must be observed for reddened areas which may be caused by phlebitis and white areas which could be caused by deep vein thrombosis.* Ask the woman to report tenderness during examination.* The legs should be observed for unequal length or muscle wasting which may be an indication of pelvic abnormalities.? Local Abdominal Examination1-InspectionThe nurse should look at the following:? Skin changes such as linea nigra, striae gravidarum and scars of previous operations.? The size of the abdomen is inspected for:* Height of the fundus, which determines the period of gestation.* Multiple pregnancy and polyhydramnios will enlarge both the length and breadth of the uterus.* A large fetus increases only the length of the uterus.? The shape of the abdomen is inspected for:* Fetal lie and position.* The abdomen is longer if the fetal lie is longitudinal as occurs in 99.5% of cases.* The abdomen is lower and broad if the lie is transverse.* Contour of the abdominal wall is observed for pendulous abdomen, lightening protrusion of umbilicus and full bladder.* Fetal movements are inspected as evidence of fetal life and position.* The abdomen is also inspected for edema and varicose veins.2-Palpation? The uterus will be palpable per abdomen after the 12th week of gestation? Abdominal palpation includes:* Estimation of the period of gestation. This is done by determination of fundal height.-The uterus may be higher than expected due to large fetus, multiple pregnancy, polyhydrammnios or mistaken date of last menstrual period.-The uterus may be lower than expected due to small fetus, intrauterine growth retardation, oligohydramnios or mistaken date of last menstrual period.? Fundal palpation is performed to determine whether it contains the breech or the head. This will help to diagnose the fetal lie and presentation.61595-876300 Pelvic examination is done to determine: * Fetal position and presentation. * Engagement of fetal head.* Disproportion between head and pelvis.? Pawlik's maneuver is sometimes used to: * Locate the round, hard head.* Judge the size flexion and mobility of the head.3-Auscultation? Fetal heart sound is heard by sonicaid as early as 10 th week of pregnancy.? Fetal heart sound is heard by Pinard's fetal stethoscope after the 20 th week of pregnancy.? The normal fetal heart rate is 120-160 beats/minute.? Fetal heart sound has been described as the ticking of a watch under a pillow.-3492536195Investigations:? Urine is tested for protein, glucose, and ketones. Traces of protein and sugar, and low specific gravity of urine(less than 1.102) may be found due to physiological changes of pregnancy.? Stool analysis for ova and parasites.? Complete blood picture:* Hemodilution of blood during pregnancy results in lowered hemoglobin level (11-12 g/dl), hematocrit, and red blood cell count (normal range is 3.600.000-4.700.000/mm3).* White blood cells are increased especially neutrophils (more than 70%), which enhances the blood phagocytotic and bactericidal properties.* Coagulation time changes from 12 to 8 minutes. This increased capacity for clotting results in higher risk of thrombosis and embolism.* Screening for sickle cell anemia, thalassemia and hepatitis may be necessary for some women.* Testing for rubella antibodies if the pregnant woman comes in contact with the disease is required.* ABO blood group and Rhesus factor (Rh).* Random blood glucose (80-120 mg/looml).* Venereal disease tests should be performed (VDRL). Toxoplasmosis.* Ultrasound scanning is used to assess the fetal * Urine should be tested for sugar, ketones, and protein.* Hemoglobin will be repeated:- At 36 weeks of gestation.- Every 4 weeks if Hb is<9g/dl.- If there is any other clinical reason.? Fetal kick count:* The pregnant woman reports at least 10 movements in 12 hours.* Absence of fetal movements precedes intrauterine fetal death by 48 hours.Schedual of antenatal care: the nurse provides the pregnant women information about the recommended schedule for antenatal care visits during normal pregnancy. It entails that she should have a medical check up every four weeks up to 28 weeks gestation, then every 2 weeks until 36 weeks of gestation followed by a visit each week until delivery (Littleton and Engebreston,2002).More frequent visits may be required if there are abnormalities or complications or if danger signs arise during pregnanc the WHO technical working group has recommended a minimum of 4 antenatal visits for a woman with normal pregnancy. However, some women will require more than 4 visits especially those who develop complications (WHO, 2002). Services at subsequent visits:-There is continuity & follow up of the all types of services provide at first visit.-At the subsequent prenatal visits, the nurse inquires about physical changes that are related directly to the pregnancy, such as the woman’s perception of fetal movement, any exposure to contagious illness, medical treatment and therapy prescribed for non-pregnancy problems since the last visit, and any prescribed medications that were not prescribed as a part of the women’s prenatal care. By evaluation, the woman is able to verbalize her knowledge, fells comfortable in her ability to care with her situation, and has resources to call on. The woman will accept minor discomfort of her pregnancy (Lond, 2000). Items of health education: Follow up:Advice the mother to follow up according to the schedule of antenatal care that mentioned before, advise the mother to follow up immediately if any danger sings appears, describe the important of follow up to the mother. Danger signs of pregnancy:Every pregnant woman should be thought as a part of her antenatal care about the following warning sings:Vaginal bleeding including spotting.Persistent abdominal pain.Sever & persistent vomiting.Sudden gush of fluid from vagina. Absence or decrease fetal movement.Sever headache.Edema of hands, face, legs & feet.Fever above 100 F( greater than 37.7C).Dizziness, blurred vision, double vision & spots before eyes.Painful urination.Any woman developing any of the following warning sings should report the nearest clinic with out delay. Hygiene:-the pregnant woman should bath daily to remove increased perspiration and become comfort.- Avoid hot bath because of fainting.- avoid vaginal douche because of changing the vaginal PH & cause infection.- Daily complete bath is very necessary.- pregnant woman can have a routine dental care. - It is advisable to have cavities filled and infected teeth treated. -The nurse can encourage the woman to use a soft toothbrush to lessen bleeding from the gums, which increases due to the increased vascularity during pregnancy (Pillitteri, 2003).. Breast examination & care:-Careful examination of the nipples to be sure that it is not retracted or inverted,- advise the mother to be mentally prepared for breast feeding,- the breast should be supported with a well fitting brassiere for prevent or alleviating upper back ache & gives comfortable, -advise the pregnant woman to expresses colostrums during the last trimester of pregnancy to prevent congestion.-She should put emphasis on the importance of cleanliness especially as the client begins produce colostrum (Wheat, 2001). Diet:-Daily requirement in pregnancy about 2500 calories.- Women should be advised to eat more vegetables, fruits, proteins, and vitamins and to minimize their intake of fats.Purpose:*Growing fetus.*Maintain mother health.*Physical strength & vitality in labor.*Successful lactation. Activity:Avoid heavy work, house work continued but with exercises & rest.Rest and Sleep:the nurse informs the pregnant women about adequate rest during pregnancy. At least sleep for 8 hours per day and 1-2 hours during afternoon are important for both physical and emotional health. Sleeping becomes more difficult during the third trimester because of the enlarged abdomen so the nurse should encourage the client to try a left lateral position, which reduces uterine pressure on the other organs. Also the nurse should teach the client the appropriate relaxation technique to prepare her for sleep (Lees et al, 2000). Exercises:Prenatal exercises are very important in pregnancy:Purpose:1. To develop a good posture.2. To reduce constipation & insomnia.3. To alleviate discomvortable, postural back ache& fatigue.4. To ensure good muscles tone& strength pelvic supports.5 To develop good breathing habits, ensure good oxygen supply to the fetus. 6- to prevent circulatory stasis in lower extremities, promote circulation, lessen the possibility of venous thrombosisGuide lines for exercises during pregnancy:-Maintain adequate fluid intake.-Warm up slowly, use stretching exercises but avoid over stretching to prevent injury to ligaments.-Avoid jerking or bouncing exercises.Be careful of loose throw rugs that could slip& cause injury.Exercises on regular basis (three times per week).After first trimester, avoid exercises that require supine position. Contraindications:-Vaginal bleeding.-Sever anemia.-History of preterm labor,-Extreme over or under weight.-Hypertension, heart, lung, thyroid diseases. Coitus:Sexual relations continue throughout normal pregnancy. Contraindications:Rupture of membranes.Preterm labor. Incompetent cervix. Spotting or bleeding. Clothes:-It must be comfortable, washable, loose, mood fitting,-avoid restrictive clothing because they can impede venous circulation -adjustable & comfortable shoes -Shoes should fit properly, feel comfortable, and have a flat or low wedge heel. - The nurse should instruct the pregnant woman to avoid high-heeled shoes because they increase spinal curvature and aggravate backache (Pillitteri, 2003). Employment: unless jobs involve exposure to toxic substances, lifting heavy objects or other kinds of excessive physical strain, long period of standing, or having to maintain body balance, employment is not forbidden during pregnancy (Frazier et al, 2001). Traveling:It must be comfortable, train is safer than traveling by car for car traveling long journey break must taken every two hours air traveling is contraindication after 34 weeks of gestation. Hazards: Occupational hazards: lead, mercury, X ray s& ethylene oxide.Infection: rubella, toxoplasmosis, syphilis.......................Smoking & alcohol: increase risk for pregnancy, prematurity, fetal death, mental retardation & congenital anomalies.Drugs: as sedative & analysis, anticoagulant, antithyrodism, hormones& antibiotics.Immunization: the nurse instructs the woman to receive immunization against -tetanus to prevent the risk for her and her fetus. Also, it is important that every pregnant mother should receive a tetanus vaccination card with her first tetanus dose and keep it to record subsequent doses (WHO, 1999). Preparation for labor:Many women expecting a child have a profound desire to learn about pregnancy & birth & want to be as well prepared as possible for this events, many prenatal & child birth program are offer to meet this need in a variety of setting prenatal clinic & hospital. While program length& organization may differ among the various classes offered, all have certain content in common:Pain management & relaxation& breathing techniques that can be used during labor& delivery.Role of support person during labor& delivery.Possibility of high risk birth including CS.Preparation for parenting.Family planning: the role of the nurse involves counseling about family planning methods and modern contraceptive or emergency type of contraceptives. The nurse should use a wide variety of audio-visual methods or teaching strategies as overhead transparencies, posters, films, and lectures with group discussion (Leonard and Perry, 2004). Mental preparation: Fear from unknown acts through the cortex& hypothalamus on sympathetic system, tension is produced neither mother nor her uterus can property relax & exhaustion fallows. Fear of labor is universal the most effective antidote is a doctor -client relationship which allows the mother to repose an absolute trust & confidence in her attendants, close personal involvement of the doctor is not always possible in the circumstance of present day obstetric practice, but antenatal instruction has been systematized.Minor Disorders of Pregnancy "First Trimester". Digestive System Morning sickness:Nausea and vomiting occur between 4-6 weeks gestation in about 50-70 percent of expectant mothers. It is not confined to early morning but can occur at any time during the day.Causes:The most likely cause is hormonal influences such as human chorionic gondotrophin, estrogen and progesterone.Emotional factors such as tension Management:Understanding the cause helps in coping.Adequate rest and relaxation will often help to reduce tension and prevent nausea.Eating six small meals a day rather than three large ones is advisable in an attempt to keep some food in the stomach at all times.Solid food may be tolerated better than liquid food, e.g. eating two or three crackers or a piece of dry toast with nothing to drink, immediately on awakening, then lying quietly in bed for 20-30 minutes and thereafter arising and eating a light breakfast.Carbohydrate snacks at bedtime and before rising can prevent hypoglycemia, which cause nausea and vomiting.Food should not have a strong odor, should not be either very hot or very cold, and fried or greasy foods should be avoided. Excessive salivation (ptyalism) It occurs from 8 weeks gestation and may accompany heartburn.Causes: is a pregnancy hormone.Management: Explanation and attentive listening are helpful. Heart burn:It is a burning sensation in the stomach that rises into the throat.Causes:?Progesterone hormone relaxes the cardiac sphincter of the stomach and allows reflux or bubbling back of gastric contents into the esophagus.Management ?Avoiding bending over and lying flat can prevent the reflux.?Sleeping with more pillows and lying on the right side can sometimes help.?Small frequent meals take up less room in the reduced stomach space and are digested more easily.?Resting in a semi-reclining position for about half an hour after meals is helpful.?For persistent heartburn, the doctor may prescribe antacids.Taking baking soda in a glass of water is contraindicated because of the possibility of retention of sodium and subsequent edema. Distress:A vague and ill-defined form of discomfort that occurs after eating. It resembles heartburn and makes the woman very uncomfortable. It is more likely to occur in a person who eats rapidly, or does not chew food thoroughly, or eats more at one time than the stomach can comfortably hold. Small amounts of food taken slowly and masticated thoroughly may prevent distress. Pica (Cravings): It is the term used when a mother craves certain foods or unnatural substances such as coal.Cause: is unknown, but may be due to pregnancy hormones and changes in metabolism.The nurse should be aware of this condition and seek medical advice if the substance craved is harmful to the fetus, e.g. lead. Flatulence:It may or may not be associated with heartburn; it is fairly common and rather uncomfortable.Causes:Bacterial action in the intestines, which result in the formation of gas.Hypochlorhydria during pregnancy and decreased motility of the entire gastrointestinal tract retard normal peristalsis and gas sometimes accumulates to a very uncomfortable extent.Management:?The diet should contain adequate amounts of fresh fruits, coarse vegetables, whole-grain breads and cereals and abundant fluids.?A regular time for defecation should be established and action upon the desire for defecation should be prompt.?When trying to have bowel movement, the woman should sit comfortably back on the commode seat with her feet flat on the floor or supported on a low step.?A glass of warm water in the morning before tea or breakfast may activate the gut and help regular bowel movement.?Exercise, especially walking, is also beneficial.?Laxatives and cathartics should be taken only if prescribed by the physician.Irritant cathartics and enemas are to be avoided during pregnancy unless all other treatment has been ineffective.Mineral oil is contraindicated as it is ineffective and inhibits the absorption offal-soluble vitamins. Musculoskeletal System?Many women experience marked fatigue and lassitude early in pregnancy. ? This feeling usually disappears by the end of the third month of pregnancy.? Women require many more hours of sleep during this time than they usually do. Genitourinary System? Changes in frequency of micturition.?In the early weeks of pregnancy, it occurs due to the pressure of the growing uterus on the bladder.?The pregnant woman should be reassured that the problem is resolved when the uterus rises into the abdomen after the 12th week. Circulatory System Fainting:In early pregnancy it may be due to the vasodilatation effect of progesterone.Management:The reason should be explained to the pregnant woman.The pregnant woman should avoid long periods of standing.Minor Discomforts of Pregnancy - Third Trimester Respiratory System Dyspnea:Causes:?Upward pressure of the uterus.?Increased sensitivity of the respiratory center to the carbon dioxide content of the blood.?It is aggravated by the mother lying down.Management:?Dyspnea is relieved by sitting up preferably in a straight chair, or being well propped up on pillows while lying down.?Lying on the back with the arms extended above the head and resting on the bed for a few minutes and before sleep at night.?Intercostal breathing may also give some relief. Digestive System Heart bum:Causes:The pressure of the growing uterus on the stomach from about 30-40 weeks gestation.Management: Same as first trimester. Distress: Same as first trimester. Flatulence: Same as first trimester. Constipation:Causes:?The gut is displaced by the growing fetus.?Constipation is sometimes associated with the taking of oral iron.Management: Same as first trimester Musculoskeletal System Backache:Causes:?Backache may be due to muscular fatigue and strain that accompany poor body balance.?It may be due to increased lordosis during pregnancy in an effort to balance the body.?The pregnancy hormones sometimes soften the ligaments to such a degree that some support is needed.Management:?The pregnant woman is reassured that once birth has occurred, the ligaments will return to their pre-pregnant strength.?Exercises: improvement of posture and abdominal support aid in the prevention of backache. Round ligament pain:As the uterus grows, the round ligaments are stretched and cause abdominal pain and tenderness.Management:?Other causes of abdominal pain should be ruled out.?Rest and change of position usually will provide relief.?Cramps in the leg, numbness or tingling may be the result of overstretching of muscles and fascia.?They may be caused by circulatory impairment in the muscles owing to pressure of the large, heavy uterus on the pelvic veins.?A muscular tetany, resulting in leg cramps is sometimes caused by depression of available serum calcium, due to excess phosphorus in the blood.Management to relieve sudden cramps in the calf muscle:?In the sitting position, the woman may be advised to hold the knee straight and stretch the calf muscle by pulling the foot upwards (dorsiflexion).?She stands firmly on the affected leg and strides forward with the other leg.?She raises the foot of the bed about 25 cm.?Application of a hot water bottle or gentle leg movement whilst in a warm bath enhances circulation and removes waste products from the muscle.The doctor may prescribe vitamin B complex and calcium. Fatigue:Tiredness is likely to reappear during the last trimester.Management is the same as first trimester. Genitourinary System Frequency of micturition:In the later weeks, it occurs because the fetal head usually enters the pelvis and reduces the space required by the bladder.The pregnant woman should be reassured that the problem is resolved after delivery.It is increased white, non-irritating vaginal discharge during the latter months of pregnancy.Management:?Douching should be avoided during pregnancy except when specifically ordered by the physician.?In addition to regular bathing, the vulva may be rinsed with warm water after each voiding.?Wearing cotton underwear and thin sanitary napkins usually gives a feeling of cleanliness and comfort.?If the discharge is abnormally profuse, irritating or foul smelling, and distressing by persistent itching and burning, medical investigation is needed for possible pathologic causes.Circulatory System Supine hypotensive syndrome:It may cause dizziness and a faint feeling during the latter part of pregnancy.The inferior vena cava may be compressed by pressure of the heavy pregnant uterus when the mother lies on her back causing decreased venous return to the hart.Management:?An immediate change of position to the left side is important for the mother's comfort.?A folded towel placed under the right hip will usually displace the uterus enough to prevent or relieve symptoms. Varicosities:Although varicose veins are confined to the legs, they may occur in the vulva. Varicose veins in the vulva are very rare and painful.Aching of the legs is a common symptom, even when the veins are not visible.Causes:?Progesterone relaxes the smooth muscles of the veins and results in sluggish circulation. The valves of the dilated veins become inefficient and varicose veins result.?Varicose veins are most likely to develop in pregnant women with a family history or when they must stand for long periods of time or sit with legs dependent.Management:?One preventive measure is to sit down with the feet elevated.?If it is necessary to stand up, moving the legs about is better than standing still.Lying flat on the bed with the legs elevated 45 degrees, resting them on a footstool for 5-10 minutes three to four times a day will help reduce varicose veins and aching of the legs.Exercising the calf muscle by rising on to the toes or making circling movements with the ankles will help venous returnElastic stockings or spiral elastic bandages will give relief and help to prevent the veins from growing larger. They should be put on before getting up in the morning or after resting for few minutes with the leg elevated.Tight bands that interfere with return circulation should be avoided.Engorged veins in the vulva may be relieved by:1. Lying flat and elevating the hips, or by adopting the elevated Sim's position for a few moments several times a day2. Applying pressure to the vulva by means of a folded up hand towel, several sanitary pads or a panty girdle. Hemorrhoids:They are varicose veins that protrude from the rectum.They are extremely painful and may itch and bleed.Straining incident to constipation and pressure made by the enlarging uterus may cause them.Management:?Exacerbation of hemorrhoids will be reduced by avoidance of constipation.?Push them back gently into the rectum after lubricating the fingers with petroleum jelly or cold cream.Lying down with the hips elevated on a pillow and application of an ice bag or cold compresses to the anus usually give relief.The physician may prescribe medicated ointments, lotions or suppositories in case of sever condition.Operation is rarely resorted to during pregnancy because there is marked improvement after delivery. Edema:Swelling of the feet is very common during pregnancy and sometimes there is also swelling of the hands.Edema may be confined to the back of the ankles or may extend up to the legs and thighs and may even include the vulva.It is physiological and results from mechanical interference with venous return and other circulatory modifications of pregnancy.Management:Lying down in a lateral position favors venous return from the lower extremities and decreases fluid retention.Sitting with the feet resting on a chair or footstool also will give some relief.For employed woman, elevation of the feet for 10-15 minutes, several times a day may increase her comfort.Dietary salt restriction is not indicated since sodium retention is not an etiologic factor.Sodium intake is necessary to maintain normal maternal and fetal electrolyte balance.The nurse must be keenly aware of the fact that although edema may be of mechanical origin, it is also a sign of toxemia and any swelling should prompt further investigation. Nervous System Carpal tunnel syndrome:It is a feeling of numbness and pins and needles in the fingers and hands in the morning or at any time of the day.It is caused by fluid retention, which creates edema and pressure on the median nerve.Management:Explain to the pregnant woman that this syndrome usually resolves spontaneously following delivery.Wearing a splint at night with the hand resting high on two or three pillows sometimes gives relief.The doctor may prescribe diuretics. Insomnia:1. Physical reasons include:Difficulty in finding a comfortable position in bed because of a large and cumbersome body.Fetal activity is often vigorous and disturbing.Nocturnal frequency of micturation.2. Psychological reasons include:The excitement and anticipation of birth may make it hard to relax and "turn off the mind for sleeping.Dreams about labor and the infant may be more frequent and sometimes frightening.Management:A warm drink or warm bath at bedtime or reading some light material in bed.A back rub with a soothing lotion promotes relaxation.Relaxation techniques learned in parenting classes are beneficial now.Lying on the side and using small pillows or rolled towels to support the heavy abdomen and upper leg will usually permit greater muscle relaxation.It is helpful to concentrate on having every part of the body limp and then to make a conscious effort to have each inspiration and expiration exactly the same length and depth.Periods of rest and sleep during the day are important in order to compensate for loss of sleep during the night.Going to bed earlier may give the infant an active period and allow the pregnant woman to sleep at her usual time.Talking through common fears of pregnancy will relieve anxieties.Sensitive listening, explanation and reassurance can be helpful.A lie-in in the morning or a rest in the afternoon will help to prevent tiredness and depression that can occur in the last trimester of pregnancy.Sharing the pregnant woman's feeling can result in a sense of normality and lightness.Encouraging the pregnant woman to think about positive aspects of the infant and having a family may relieve depression due to hormonal changes towards the end of pregnancy. Skin: Itching:The breasts, abdomen and palms of the hands are commonly affected areas, although itching may be generalized to the entire body.Causes:The increased excretory function of the skin may result in the elimination of irritating substances by the skin glands.Stretching of the skin owing to weight gain, the growing uterus, and the fluid that is held in the skin.Generalized itching over the abdomen results from liver response to pregnancy hormones and raised bilurubin levelsManagement:Explain to the pregnant woman that itching will be reduced after childbirth.Bathing in tepid rather than hot, water and adding sodium bicarbonate (baking soda) to the bath water are soothing measures.Dabbing, rather than rubbing, to dry the skin with a towel will reduce stimulation of the skin and is less likely to produce itching.Lotions and oils are often helpful and rubbing them on the uncomfortable area is a constructive alternative to scratching.Sometimes, changing soaps or reducing the use of soap to a minimum will provide relief.Loose, nonrestrictive clothing is comfortable and not so apt to induce itching.Antihistamines that are prescribed by the doctor will provide limited comfort.Investigationhealth education first trimester (1-3 ................
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