9/20/22

Developing cultural competence

• Definition: acknowledging, respecting, and appreciating diversity.
• Act in ways that meet the needs of the patient and are respectful of ways and traditions
that may be different from their own.
Key components to cultural competency
• 1. Disparity between one’s own culture and that of the patient
• 2. Educating and promoting health behaviors in a cultural context that has meaning for
the patient.
• 3. Applying knowledge from other cultures
• 4. Communicating respect
• 5. Preserving and promoting human dignity
VULNERABLE POPULATIONS in Reproductive Health
• Vulnerability in terms of health status contribute to disparities in health
• [Link]
• 2. Homeless
• 3. Adolescent pregnancy
• 4. Racial/ethnic minorities
• 5. Incarcerated
• 6. HIV positive
Prenatal care is the 1st and best way to prevent maternal mortality and morbidity
Nursing care for the transgender pt
Issues
• The New York Times reported that the number of people who identify as transgender
has doubled since 2011.
• Those numbers are already showing up in healthcare facilities nationwide.
• So don’t be surprised if a transgender male seeks an appointment for his annual pap
smear.
• As healthcare providers, a recent challenge is providing equal and unbiased care to
transgender patients
The transgender dilemma
• Transgender patients often avoid care.
• The fear of discrimination, lower quality of care, and lack of insurance access can be
paralyzing.
• Just entering your doors takes courage.
• Ask yourself how you could reward that courage with an open and nonjudgmental
attitude.
• Act like you’ve been here before, even if you haven’t. Make the patient believe this is
an everyday occurrence for you and nothing to be ashamed of.
Nursing must
• 1. A transgender patient is a person with a health concern.
• 2. Our job as nursing professionals is to provide equitable care
• Nurses who are firmly grounded in these two tenets are on their way to providing
quality care for these patients.
[Link] a Supportive Environment
• To a transgender patient, how they identify is more important than their sexual
equipment
• Use the pronoun the person prefers. He or she knows which one s/he prefers before
using one.
• If all else fails, “you” and “your” work great.
• On that subject, ask the patient the name s/he prefers. A patient’s legal name may be
Michael, but she prefers Debra.
• But verbal language is not the only kind of communication.
• Does the healthcare space offer symbols of inclusivity? A rainbow flag or poster about
World AIDS Day can go a long way.
• Ensure that forms cater to transgender individuals. There should be a section for
preferred name, sexual orientation, gender identity, and “partner” information.
• Rework assessment questions with hetero-preferential word choices. Even LGBTQ
members on your team can set the stage for open interaction.
2. Setting the Pace for Self-Disclosure: Let the Transgender Patient Lead
• The transgender patient may be slow to reveal much about themselves. Negative
experiences can do that to a person.
• Cultivate patience. Over time, the individual will feel assured that the environment is
safe for self-disclosure.
3. Gender Transitions Happen Slowly
• Transgender identity is a process. Individuals may fall at different points along the
transition spectrum.
• A transgender man is a person assigned female at birth but who identifies as male. A
transgender male patient may have taken hormones and/or had breast reduction
surgery, but may or may not have female genitalia.
• A transgender woman is a person assigned male at birth but who identifies as female. A
transgender woman may have a female voice and breasts, and also the male genitalia
that genetics gave her.
• Don’t assume she will use a bedpan. Instead, ask “Is there anything else you need for
your physical comfort?”
Put Yourself In His High Heels
• Transgender individuals often avoid or postpone preventive screenings.
• Get familiar with recommended screenings for transgender men and women. Be ready
with the correct information and protocol.
• A transgender male may be stressed by having to sit in a mammography waiting room
with women.
• He has a right to be there, though. His residual female breast tissue warrants a
mammogram.
o Likewise, a transgender woman still has a prostate needing an annual check.
Lastly, don’t be afraid to ask the tough, awkward questions in a non-judgmental fashion.
• Can you give information about your sexual preferences?
• With whom are a few of your supportive relationships?
• Are you engaged in high-risk behaviors?
 • Anything else I should know that could impact your health?
Menstrual Cycle/Reproduction / Health Promotion

Puberty
• Definition: time when the reproductive organs become fully functional and secondary
sex characteristics develop:
• Breast changes/ voice changes (male)
• Body contour changes
• Body hair / Skeletal growth
• Secondary sex characteristics: those changes NOT related to reproduction ( i.e.
breast development, pubic hair, axillary hair)
• Begins six months to one year earlier in girls
• Girls have earlier growth spurt then boys completed more quickly than boys
• Boys begin growth spurt later in puberty and lasts longer
• It IS possible for girls to ovulate before their first menstrual cycle, therefore pregnancy
CAN occur before the first menstrual cycle
• Girls are born with all the ova she will ever have
1. Girls age 8
2. D
3. Breast buds
4.
You have to have
1. Breast buds
2. Vulva hair
3. Axillary hair
To get period (usually within 6 months)
Male puberty
• Nocturnal emissions normal
• For normal sperm to form, a man’s testes must be cooler than core body temperature
• Seminal fluid is secreted by seminal vesicles, prostate, and bulbourethral glands nourish
and protect sperm, enhance motility, and ensure that most sperm is deposited in the
vagina during intercourse
1. Scrotum gets bigger
2. Voice changes
3. Wet dreams (nocturnal emissions)
Tanner Sexual Maturity Ratings
a. 1:Nopubic hair/penis and scrotum child size
b. 2: a few hairs/ testes scrotum begin enlargement
c. 3. sparse hair growth/penis enlarges
d. 4. thick hair growth/penis grows in length
e. 5. adult hair/penis shape and size
Between vagina and anus = perineum (gets really adversely affected by childbirth)
Female Reproductive System
• Internal structures
• Uterine wall (only organ that can stretch and fit stuff and go back to pre-
pregnancy size) involution = uterus stretching and then going back to normal size
• Endometrium
• Inner layer
• Cells that drop every month if a egg does not come there
• Myometrium
• Muscle cell
• These cells are the reason the uterus can stretch
• The reason for cramps
• Peritoneum (partial)
• Viable pregnancy must be in uterus
• Uterine tubes (fallopian tubes)
• Attach to uterine fundus
• Divided into 4 sections
• Guide sperm to egg or guide egg to uterus
• Ampula is where sperm and egg come together
• Tubes are like the driveway from ovary to uterus
• Ovaries (most women born with 2, in normal healthy they are not palpable or
visible; house of all womens eggs, women are born with all the eggs they’ll ever
have; by a time women reaches menarche she has about 400 eggs; 35 is
advanced maternal age)
• Ovulation
• Hormone production
• Estrogen and progesterone
 Round ligament holds uterus in place form
front to back
Pain that a pt feels is the ligament stretching
and growing

Vagina does not have a lot of nerve

endings

The cervix is the bottom of the uterus

and its almost closed

Mucus plug clogs it up in pregnancy

Fundus is the top of the uterus

• Bony pelvis: primary purposes

• Protects the pelvic structures
• Accommodates the growing fetus during pregnancy
• Anchors the pelvic support structures
• Bony pelvis: two parts
• False pelvis (TOP PART WHERE ILLIAC CREST IS)
• True pelvis
• WHEN SOMEONE IS TRULY IN LABOR THAT BABY IS IN THE TRUE PELVIS
• Feel where head is in relation to the ischial spine (station)
THE BONES DO NOT GROW OR STRETCH IN PREGNANCY BUT IT MAY BE MORE RELAXED
Pelvis should be ooblong which is called gynecoid
Menstrual Cycle
— Menarche – girl’s first menses
— On average 12 – 13 years old
— May be anywhere from 8 to 18 years
— It is earlier bc women are fatter than they were back in the day and something
about adipose tissue and exogenous estrogen
— Ppl who don’t get their periods are malnourished and extreme athletes;
osteoporosis with lack of estrogen is hella bad
 — Very complex / ovarian and endometrial
— Ovarian Cycle/ hormonal changes and changes in ovaries
— Endometrial Cycle/ changes in endometrial lining of uterus to prepare for
fertilized ovum
— Cervical mucous changes to encourage fertilization
— All happens at the same time : They BOTH make up the menstrual cycle
— 3 organs essential for menstural cycle
— Brain (mostly pituitary)
— Ovary
— Uterus
— On average most women have a 28 day cycle
— They bleed on day 1 and if they do not get pregnant within that time day 29
starts a new cycle
— What starts a first cycle is hypothalamus pushing out GNRH
— Cycles less than 21 days or more than 35 days means they are not producing
eggs
Overview of the 2 Cycles
ž Ovarian cycle
• Prepares the body for ovulation
• 3 Phases of the ovarian cycle
Ovulation: mid-cycle * ALWAYS 14 days before bleeding of menses
• Ovum is released from the follicle
• Enters the fallopian tube
• Journeys toward the uterus
• Egg is only good fo 12-24 hrs
• Sperm is good for about 3 days
Endometrial cycle
• Menstruation/ changes in endometrial lining
• Follicular Phase (phase 1 ) [follicle = dominant egg]
• Follicles grow and form a mature egg
• Inconsistent length of time b/c of follicular development
• Initiated by the hypothalamus ( GnRH stimulates anterior pituitary):
• Follicle-stimulating hormone (FSH) (anterior pituitary)
• Stimulates the ovary to produce 5-20 immature follicles
• Helps this egg grow
• Lutenizing hormone (LH) (anterior pituitary)
• Targets the follicle which will go through final development &
rupture
• WHAT HORMONE CAUSES OVULATION? LH
• Follicles release estrogen which stimulates growth of the endometrial lining
— Ovulation ( phase 2 )
Surge of LH releases the mature ovum day 14 of a 28 day cycle
Ø With ovulation estrogen drops
÷ Ovum only lives for 24 hours
 ÷ Spinnbarkeit: Cervical mucus – thin, clear, stretchy, slippery, abundant
÷ Mittelschmerz “middle pain”
Ø Ovulation is usually 14 days before menstruation on a 28 day cycle
— Luteal Phase (phase 3 )
Ø Begins with ovulation
Ø Progesterone levels are higher than estrogen
— Progesterone maintains the pregnancy
Ø Follicle ruptures, releases the egg & closes to form corpus luteum
FSH + estrogen (one really reacts to the estrogen and becomes dominant egg) -> LH and
progesterone
Corpus luteum is producing progesterone to keep the egg alive until sperm gets there but if
sperm doesn’t come for 12-24 hours then the egg goes back down and all the hormone
decrease and that’s when the period happens

1ST HALF OF CYCLE

• FSH
• ESTROGEN
ND
2 HALF OF CYCLE
• LH
• PROGESTERONE
DOESN’T TAKE MUCH TO THROW OFF
CYCLE
OVULATION CAN CHANGE EACH
MONTH
The Endometrial Cycle 4 phases
#1 Menstrual phase ( bleeding)
#2 Proliferation (follicular) phase
• DIFFERENT AMOUNT OF DAYS FOR ALL WOMEN
#3 Secretory (luteal) phase
• Want it to stick like Velcro
• ALWAYS ALWAYS ALWAYSSSSS 14 DAYS
#4 Ischemic phase
• Pre menstral cramps
Endometrial Cycle
— Proliferative phase
Ø estrogen
Ø day 5 of the menstrual cycle until ovulation (surge in LH)
— Secretory phase
Ø Follows ovulation lasts until 3 days before the next menses
÷ Progesterone thickens the endometrium
÷ Estrogen drops & progesterone dominates
— Ischemic/ Menstrual phase : if fertilization does not occur, estrogen AND progesterone
fall --- ischemia occurs
Basal Body Temp
• Fertility awareness method
• Temp taken with special basal body thermometer
• Woman takes her temp each morning at the same time BEFORE arising from bed
• Temp will dip 0.4 degrees F and spike 0.5 to 1.0 F until menses
• Dip in temp signifies ovulation (LH surge) will occur within next 24 hrs
Fertility
• Sperm live approx 3 days but may live up to 5 days
• Ova live 24 hrs after rupture from graafian follicle (sac which holds maturing ova in
ovary)
• Partners should avoid unprotected intercourse for several days before anticipated
ovulation and for 3 days after ovulation if pregnancy is NOT desired
Sexual Response
• Females and males achieve physical maturity at approximately age 17 years.
• Individual development varies greatly.
• Women and men are more alike than different in their physiologic responses to sexual
excitement and orgasm.
• Glans clitoris and glans penis are embryonic homologs.
• Little difference exists between female and male sexual responses.
Reasons for Entering the Health Care System
• Preconception counseling and care
• Pregnancy
• Well-woman care
• Fertility control and infertility
• Menstrual problems
• Perimenopause
Barriers to Seeking Health Care
• Financial issues
• Cultural issues
• Gender issues
• Gender of health care provider
• Sexual orientation may also be a barrier
• Providers need to develop an approach that does not assume that all clients are
heterosexual
Nursing Management
What is your role as a professional nurse?
• Genetic history
• Family history
• Genetic counseling
• Make appropriate referrals
• Explain probabilities to patient
• Protect the patients’ privacy
• Provide informed consent about further testing
• Maintain professional demeanor!
Conception and Prenatal Development
Conception
• Gametogenesis
o Spermatogenesis
o Oogenesis
• Zygote (when sperm and egg come together)
• Ovum
o Produced by meiosis
• Sperm
o Capacitation
o Acrosome
• Fertilization (entrance of sperm into egg, should occur in distal portion of the fallopian
tube; takes 7-10 days before implantation)
o Morula
• 16 cell body that swims (for 7 days) down fallopian tube and lands in the
uterus
o Blastocyst
• Something happens and placenta starts to form
 • Implantation (where morula implants into the wall)
o Chorionic villi
o Decidua basalis

Fertilization
• Fertilization usually takes place in the distal third of the fallopian tube (
AMPULLA )
• Fertilized zygote travels through fallopian tubes to uterus ( 2-3 d )
• Takes 7 – 10 days for IMPLANTATION (nidation)
Mitosis: Once Fertilization Occurs
• Fertilization: union of one egg and one sperm (produced through meiotic division)
• 200-300 million sperm/2mL – only one fertilizes
• Zygote – fertilized egg contains 46 chromosomes (22 pairs autosomes/ 1 pair sex
chromosomes)
• XX or XY
• Fertilization requires sperm motility, open cervical os, patent fallopian tubes
• hCG= human chorionic gonadotropin (hormone which sustains/nourishes zygote)
• this is the first hormone of pregnancy and essential for maintaining pregnancy
• this is what pregnancy test looks for
• it should go up 1.5 each day
Fetal Development
Measured in weeks following fertilization
• Preembryonic stage: ( termed zygote) fertilization through week 2
• Embryonic stage: ( termed embryo) weeks 3 through week 8
o Major systems being laid down
o Baby is very susceptible to teratogens
o VERY susceptible to teratogens
o End of week 2 ( day 15 )through week 8
o Major organs & body structure completed
o Week 6: heart beats regularly & lungs are forming
 o Week 8: development of facial features
o Week 20 : vernix and lanugo present
o Week 38 : L/S ratio 2:1
o Know the basics embryologic development : TABLE 12-1 pp 278-280
• Fetal stage: ( termed fetus) week 9 until birth <- safest stage when its fully developed
• Growth & refinement of systems

TERATOGENS
• Definition: an agent that can cause defects in the developing baby during pregnancy.
o ETOH, smoking (constricts vessels so it causes low birth weight babies and
preterm labor), cocaine, marijuana (similar to alcohol effects, can cause
stillborn), infections
o TORCH viruses: cytomegalovirus, herpes, HIV, rubella, syphilis, toxoplasmosis
(bacteria in cat feces and raw food like eggs and meat; can cause severe
neurological problems in babies), varicella
o Medications: class of drugs
• A and B = safe C = OK D= unsafe
 Individual basis on what
that pregnant person needs

Fetal alcohol syndrome

2 components
1. Mild to severe neurological problems
2. Changes facial features of the baby
a. Flat faces
b. “Frankenstein”
c. Big forehead
d. Small nose
It is not fixable!
IN THIS COUNTRY, NO ALC IS SAFE

Embryo and Fetus (cont.)

• Multifetal pregnancy
o Twins
• Dizygotic
• They each have their own sac and placenta
• Least risky and best outcomes
 • Monozygotic
• In one sac and share a placenta
• High risk bc one can get more blood flow than the other or one
can move and cut off support or one getting more nutrients
• Conjoined
o Other multifetal pregnancies
• Nongenetic factors influencing development
o Congenital: condition present at birth
• Environmental factors and maternal nutrition may also influence
development
Biggest risk of twins is premature delivery

Placenta
• Placental function:
o metabolic ( provides some nutrients for fetus)
o transfer of substances between mother and fetus
• GAS exchange, nutrient and antibody transfer, and waste removal***
o Endocrine
• human chorionic somatomammotropin( HcS) , and
progesterone/estrogen
• HCS is the growth hormone of pregnancy
• Estrogen and progesterone help maintain pregnancy
• Maternal side: lobular/ decidua
• Fetal side: smooth / chorion & amnion
• Exchange of oxygen & waste products within the intervillous space/ chorionic villi
• MOST IMPORTANT ORGAN OF PREGNANCY
• STARTS TO FROM DAY 17
• Umbilical cord has 3 vessels
o 1 big meaty vein and 2 arteries
o Umbilical vein provides oxygenated blood to the baby
o Babies don’t eat in utero, they grow through blood flow
• After baby is born, nurse has to make sure entire placenta has come out bc if it doesn’t,
the uterus will not go back to small size and woman could bleed to death
 Maternal and fetal blood flow should never
mix

Placental circulation
• Blood leaves maternal circulation
• Goes into the intervillous space via the spiral arteries
• Oxygenated maternal blood washes over the chorionic villi which contain fetal
capillaries
• Returns to maternal circulation via endometrial veins
• NO mixture of the blood – exchange across the membrane of the villi
Amniotic Fluid
• Amniotic fluid
o Protects the growing fetus and promotes normal prenatal development
• Cushions against impact
• Provide stable temperature
• Allow symmetric development of fetus & room for fetal movement
• Provides sterile environment/protect from bacteria of vagina
o Derived from two sources : fetal urine and fluid from maternal blood across
amnion
 • If theres not enough, wonder why the baby is not peeing
• Babies with small amount of amniotic fluid (oligohydramnios) are at risk
for death
• Too much amniotic fluid (polyhydramnios) its dangerous bc the uterus is
stretching more than it should
• Maybe the mom has diabetes
o Volume of fluid increases during pregnancy until 500 to 1000 ML at term
Fetal Circulation The 3 Doors
How does the baby breathe?
1. Placenta – umbilical vein – lungs are developing
2. Inferior vena cava thru the ductus venosus
o Bypasses liver
3. Left atrium thru the foramen ovale
o Right atrium to left atrium
4. Right ventricle to pulm. art joins oxygenated blood in the aorta through the ductus
arteriosus
o DA connects aorta and pulmonary arteries
Head and upper body
receive most oxygenated blood
umbilicus -> ductus venosus (bypasses liver)-> sends blood to heart -> hole from R atrium to L
atrium (foramen ovale) bypasses blood going to lungs (bc fetus lungs do not do gas exchange) -
> ductus arteriosis

• Umbilical Cord:
o 2 arteries
o 1 vein
 o Arteries carry waste products and UNOXYGENATED ( high CO2) blood AWAY
from fetus to placenta
o Vein carries nutrients and OXYGENATED ( high O2) blood TO fetus
o Wharton’s Jelly: protective cushioning substance
o FETAL Hgb has a 20-50% higher O2 carrying-capacity than adult Hgb
• Delay cord cutting (1-2 min) so the baby can get ready for outside life and
get this nice blood all in them

What happens with birth?

• Baby takes a breath
• Blood flows to the lungs ->decreased resistance in pulmonary arteries
• Pressure in the right side of the heart falls
• Foramen ovale closes right to left shunt CEASES
• Pressure in the aorta rises  blood flows from aorta to pulmonary arteries goes to
lungs.
• Ductus arteriousis closes ( may take 12-24 hrs )
• Ductus venosus closes when the umbilical cord is clamped/ blood supply from placenta
ceases
• Obvious when these things don’t close is extra heart sounds during cardiac assessment
not cyanosis
Pregnancy Dating
• EDC – expected date of confinement (most important info w will give to pt when they
come in)
• What is the first day of their last menstrual period?
• Then ultrasound
• EDD – expected date of delivery
• EDB – expected date of birth
• All of the above are used interchangeably to note the date a baby is due
• Part of the antepartum assessment and intake interview
• Gestation = chronological age of a pregnancy
• Pregnancy length is counted from the LMP (First day of last menstrual period = LMP)
a) 280 days
b) 40 weeks
c) 10 lunar months (perfect 28 day months)
d) Nine calendar months consisting of three trimesters of three months each
  Trimester: a division of pregnancy; one of three equal parts of 13 weeks each
 LMP begins week one
 First trimester =week 1 through 13
 Second trimester = week 14 through 26
 Third trimester = week 27 through 40
 FULL-TERM = 38 to 40 weeks of gestation
 Last organ to full develop is lungs
 Have to have a medial reason before 38 weeks
 Should not go past 42 weeks bc placenta could die
 Post-term birth: a birth that occurs after 41-42 weeks gestation
 Preterm birth: a birth that occurs after the 20th week and before the 38th week of
gestation
o Highest risk thing you see in OB
 Full-term birth: a birth occurs between 38 and 40 weeks gestation
 Nagele’s Rule : method used to establish an EDD
 Menstrual history is part of and antepartum assessment
 Nagele’s rule: take first day of LMP, subtract three months, add seven days = EDD
o Don’t forget to correct for year i.e. 2015 will deliver in 2016
• The client states her LMP is January 30, 2016
o Remember this must be the first day of her last NORMAL menses.
o Begin subtracting three months = October 30, 2015
o Add seven days and correct for the year (March has 31 days)
EDD = Novemeber 7, 2016 using Nagele’s Rule
• Gestation calculation wheels are used frequently to date pregnancies
• Ultrasound measurement of fetus gives accurate EDD (the earlier the better for accuracy
in ultrasound dating)
• Because some women experience implantation bleeding or spotting, they do not know
they are pregnant
Viability = baby able to live outside the womb, for legal reasons 20 wks, but really before 23
wks they will have a lot of deficiencies
Physiologic and Psychological Changes of Pregnancy and Nursing Care
• Prenatal period
o Period of physical and psychological preparation for birth and parenthood that
offers opportunities for:
• Health of the expectant mother and infant
• Diagnosis and treatment of maternal disorders
• Education and support for self-care and parenting
Pregnancy Tests
• Human chorionic gonadotropin (hCG) is earliest biochemical marker for pregnancy
o Production begins as early as day of implantation
o Can be dated 7 to 10 days after conception
o HcG continues to keep the corpus luteum viable
o 2.5x every 48hr
Gravida and Para
• Gravida : refers to the number of times a woman has been pregnant, regardless of the
outcome
• Para : refers to the number of deliveries (not children) that have occurred after 20
weeks of gestation.
o When calculating parity, multiple births count as only one
o A fetus born dead after 20 weeks is added to the parity count
o TPAL (term births (birth over 38wks), preterm births (any birth under 38wks),
abortions (miscarriages and abortions before 20 wks), and living children) may
be calculated
• Pre term birth may die or may have huge life issues
• Pre term birth may repeat itself
Gravidity and Parity
• Primipara: woman who has completed
1 pregnancy with a fetus or fetuses who have reached stage of fetal viability
• Term: pregnancy from the beginning of week 38 to end of week 42 of gestation
• Viability: capacity to live outside the uterus
• Mutiparous : woman who has completed multiple ( more than 1 ) pregnancy
Para
• TPAL
 T is TERM BIRTHS
• P PRETERM Births
• A Abortions (Spontaneous or Elective)
• L Living Children
Physiological changes
• Reproductive system
o Uterus
o Cervix
o Vagina
o Ovaries
o Breasts
• General body system
o Gastrointestinal
o Cardiovascular
o Respiratory
o Renal / urinary
o Musculoskeletal
o Integumentary
o Endocrine
• Thyroid, pituitary, etc
Reproductive System
• Uterus: tremendous growth
o Non pregnant vs size @ 36 wks
 • Size of a pear to able to hold 5000 mL
o Muscle fibers increase in length & width
o Measure from public bone to top of uterus (fundus)
o Can be off by +/- 2cm
o Uterine Size:
• 12 weeks @ symphsis
• 16 wks ½ way to umbilicus
• 20 wks at umbilicus
• 36 wks at xyphoid process (when it measures the highest because after
that the baby should drop into the pelvis)
o Lightening / engagement (2 wks before labor)
Cervix (door to the uterus)
• Cervix: soften, increased cx mucous ( leukorrhea )
o Chadwick’s sign: bluish color of vagina
o Goodell’s sign: softening of the cervix
o Mucous plug: thick mucous covers canal to protect fetus from infection
• Vagina:
o increased vascularity
o Increased secretions (caused by estrogen and progesterone)
• Its called leukoria when there is excessive discharge in pregnancy but its
normal and a protective factor
• Can lead to more yeast growth
• Ovaries: enlarge until 12 – 14 wks
o Secrete hormones (progesterone) until wk 6-7 when placenta takes over
Reproductive system
• Breasts
o Become more full
o More tender/ “tingling” sensation
o Increased vascularization
o Nipples larger & more erectile
o Colostrum expressed beginning week 12 in 3rd trimester (yellow in color and
normal)
o Striae (stretch marks)
o Can get breastmilk by 13-14wks
Cardiovascular changes
• Changes in Blood Volume (to get more volume to the fetus)
• Plasma volume
o Increases 40-60%
• RBC volume
o Increases 20-30%
o Total volume: increases 30-50% because
 Physiological anemia of pregnancy: due to hemodilution
o Hgb 10.5g/dl to 11g/
o Anemia causes exhaustion, pregnancy causes exhaustion
o Give them iron supplements and prenatal vitamins
• Drink plenty of fluids and activity and increase fiber
• It can cause tarry stool
• Take at bedtime, not on empty stomach and vitamin C
• Cardiac output
o Stroke volume + heart rate = cardiac output
o Increases 50% by wk 20
• Heart rate
o Increases 10-20 bpm
o Slight cardiac enlargement during pregnancy
o Heart works harder to provide oxygen for mom
o BP should go down at 1st visit bc estrogen and progesterone relax vessels
o Day of delivery BP should be back to baseline normal
• Blood components
o Hypercoagulable
• Fibrin & fibrinogen increase by 50%
• Protective mechanism to prevent postpartum hemorrhage
o Venous stasis / long periods of standing or sitting
o Increased risk of DVT (what assessment postpartum?)
• S/S: unilateral edema that may be red and tender, warmth, pulse below
the clot is gone
Vena Caval Syndrome
(Supine Hypotensive Syndrome)
 Pt becomes really dizzy
 Pregnancy has cut off its own blood flow
 Turn them to their left side
 Teaching: after around 20 wks you cant
 o Cause: Weight of uterus on Vena Cava
o Presentation: Pt feels faint, dizzy, fetal bradycardia
o Treatment: Left lateral or right lateral( side lying)
Respiratory System
• Oxygen consumption increases 20%
- Respiratory rate remains unchanged
• Physical space
- Baby takes up more space & presses against diaphragm
- Common for them to say they feel SOB
• Hormonal changes
o Progesterone relaxes smooth muscle
o Estrogen leads to increased vascularity & congestion
– Nasal & sinus stuffiness
• Use a humidifier
• Saline nasal spray (GENTLY)
– Epistaxis (nosebleeds)
Gastrointestinal System
• GI system
o Ptyalism / increased salivation
o Smooth muscle relaxation (progesterone)
• Constipation
• Slower emptying / reflux / pyrosis (heartburn)
• Increased risk of gallstones
o Nausea & Vomiting (50 – 80% pregnant women)
• Prevention: dry crackers, small frequent meals, ginger ale, salty or tart
foods i.e. lemonade and pretzels
• Eat whatever you can eat as long as its not contraindiciated
• Eat before you get out of bed
• The theory is that abrupt rising out of bed is increasing HcG
• NOT just morning sickness however its most common in the morning
• Hyperemesis is usually correlated with weight loss and not compatible
with life
• Zofran if its significant and they cant keep food or fluid down
• Most times it corrects itself after 20wks
o Only need 200-300 more calories when pregnant
 o Breastfeeding you need like 500
Urinary frequency
 Common discomfort of pregnancy
 Also a sign of UTI (which can cause pre term birth)
 Usually Normal for them to pee all the time 1st and 3rd trimester
 If they are peeing all the time in 2nd trimester, send to lab
Renal / Urinary System
• Increased workload (increased blood volume)
o 30 – 60 % increase blood flow
• Increased GFR :
• Pressure of the baby on the bladder = urinary frequency
• More prone to UTI ( progesterone=smooth muscle relaxer and increased GFR =
increased “spilling” of glucose in urine )
o S/S: dysuria, urinary frequency, hematuria, cloudy urine, smelly urine, dribbling
Integumentary System
• Hyperpigmentation
• estrogen, progesterone & melanocyte – stimulating hormone
• Especially around breasts (areola) and face
• Brownish patches: melasma, chloasma, mask of pregnancy
• Linea nigra
• Changes to connective tissue
• Striae gravidarum
Linea nigra
• Cutaneous vascular changes chloasma striae
• Spider veins
• Sometimes palmar erythema

Musculoskeletal System
• Changes are progressive
• Joint softening beginning weeks 10 – 12
• Swayback posture as center of gravity shifts forward
o Lordosis ( cat arch and pelvic tilt to relieve pain)
• Hormone “relaxin”: relaxation of pelvic joints
o Pregnancy waddle
Endocrine system
• Changes throughout the endocrine system
o Estrogen / progesterone
• Pancreas: insulin fluctuations
o Glucose levels in pregnancy fluctuate
 o Insulin resistance at the beginning of pregnancy due to HcS and it lead to fetal
growth
• Placental hormones:
o HcG, Estrogen, Progesterone, hCS(HPL), Relaxin
Pancreas
o Maternal glucose crosses the placenta
o Insulin does not cross the placenta
 Baby produces her own (14 weeks)
 Early pregnancy increased glucose diverted to growing baby
 hPL (from the placenta) & cortisol (adrenal cortex) decrease maternal sensitivity to
insulin
 Increased circulating glucose
Placental Hormones
• hCG :Human chorionic gonadotropin (hCG) is earliest biochemical marker for pregnancy
o Production begins as early as day of implantation
o Can be dated 7 to 10 days after conception
o PREGNANCY TEST hormone
• hPL : human placental lactogen. Responsible for insulin resistance in second trimester
now called hCS.
Other changes
• Changes in metabolism
o Water metabolism: requirements increase
– Dependent edema
o Carbohydrate metabolism
– More insulin is required b/c maternal “insulin resistance” later in
pregnancy ( 24-26 weeks)
– Sometimes have periodic hyperglycemia
– Pregnancy-induced glucose intolerance: gestational diabetes
• Immune system
o Decreased resistance to disease
o Pregnancy is a lower immunity state

Common Discomforts: know these!

• Nausea & vomiting: crackers/ginger/tart foods
• Heartburn: small, freq meals/ TUMS
• Food sticks in the stomach longer bc of progesterone and estrogen so they
should sit up after eating
• Backache: posture/excercise (cat arch/ swim) rest
• Round ligament pain:
• BILATERAL PAIN IN THE ABDOMEN USUALLY SEEN AROUND 16-18 WK
• Cant take meds for it
• Urinary frequency: kegel excercises/ decrease intake at night/
• 2nd trimester = UTI
 • Varicosities: limit standing periods/feet up/don’t cross legs/ rest/ TEDs
• Hemorrhoids: hi fiber diet/fruit/prune jc/ No straining/ witch hazel pads/topical
anesthetic
• Movement, hydration, fiber, stool softener (colace)
• Constipation: hi fiber diet/drink H2O/ fruit/stool softener
• Leg cramps: elevate often/dorsiflex the foot/
• Nasal stuffiness : cool air vaporizer/ saline nasal drops
• Estrogen and progesterone dilate the nasal mucosa
Confirmation of Pregnancy
• Trimester ( 13 weeks); 3 trimesters
• Signs of pregnancy
o Presumptive: changes the woman experiences
o Probable: objective findings that can be documented
o Positive: only caused by the pregnancy
Presumptive signs
• Experienced by the woman
o Amenorrhea ( most common cause of secondary amenorrhea= pregnancy)
• No period
o Fatigue
o Nausea & vomiting
o Urinary frequency
o Breast & skin changes
o Quickening/ Fetal movement ( feels like little gas bubbles). Usually around 20
wks
Probable signs
• Objective assessment findings
o Abdominal enlargement
o Chadwick’s sign : bluish color of vagina (or necrosis)
o Goodell’s sign: softening of the cervix (Could also be that you just had a baby)
o Ballottement
• Fluid in the abdomen that you can see moving or can push and it moves
in a distinct pattern
o Hegar’s sign
o Braxton Hicks contractions
• Practice contractions; they stop
o Palpation of the baby
o Pregnancy tests
 Hegar’s Sign

Positive signs
• Visualization of the baby by ultrasound
• Auscultation of baby’s heart beat
• Health care provider palpates the baby
• THESE ARE THE ONLY ACCURATE WAYS TO DETERMINE PREGNANCY !!
• When a person has more than 2 miscarriages, we call them a frequent aborter,
pseudopregnancy before
Antepartum care
• Preconception care
• Initial Visit (ideally done in 1st trimester): determine EDC using Nagele’s rule
o Ask 1st day of last period and if they don’t know, ultrasound
• Ultrasound can be off by 1 wk in 1st trimester, 2 weeks in second and 3
week in third
o History intake: med/surg hx, OB hx, current pregnancy hx
o Determine Gravida and Para
o Perform physical exam
o Take VS; BP should remain NO MORE than 30 pts systolic and 15 pts diastolic
from prepregnancy baseline
o Test urine for protein/glucose EACH VISIT
• In preclampsia or kidney disease they will spill lots of protein in urine
o Check for FHT
• Starts at 8-10wks, fetal heart tone
o Obtain lab data– send client to lab with Rx and PNV prescription!!!
• Need to figure out if blood is positive or negative

• Prenatal care:
o Timing of visits:
• Conception until 28 wks: every month
 • 28 wks until 36 weeks: every 2 weeks
• 36 weeks until delivery : WEEKLY
• Nursing care for each visit INCLUDES:
o Gestational age
o Urine dipstick for glucose/protein
o Maternal BP and WEIGHT ( to assess for gain )
• Weight tells us nutrition
• Edema?
o Fundal height
o FHT
o Assess fetal movement
o Assess for any questions/concerns/ appropriate bonding and psychological
status for stage of pregnancy/ needs
Lab Data
• Hgb ( >11) & Hct ( >33)
• Anemic
• WBC with diff ( for baseline)
• Hgb electrophoresis ( for sickle cell patients)
• Sickle cell pt have high risk pregnancies
• PAP and cytology ( for gonorrhea and chlamydia)
• Antibody screens : HIV, Hep B, toxoplasmosis, rubella titer (> 1.10= immunity),
RPR/VDRL, cytomegalovirus ( CMV ), PPD ( Tb skin test)
• Rubella titer: super important, if a woman contracts it 1st trimester they will
likely have a miscarriage, one of the worst diseases for pregnancy
• MMR is not safe in pregnancy so if they don’t have immunity in pregnancy, they
need to be careful and get it in postpartum period
• Rh and blood type : IMPORTANT
• Also in case anything happens and need to transfuse blood
• Rh – mom will receive Rho-GAM at 28 weeks as precaution for possible Rh + fetus
Rho GAM
• Given at 26-28 weeks to ALL Rh – moms during their routine prenatal visit
• Also give it if mom is in an accident and after birth and the cord blood is checked
and if the baby is Rh+ the mom gets it again
• Inhibits “sensitization” against any fetal Rh+ antigen which may enter maternal
bloodstream
• Given after ANY invasive test where fetal cell may enter maternal bloodstream
• Given within 72 hrs after birth if infant is Rh+
• The next time the mom gets pregnant, the body says FOREIGN OBJECT FOREIGN OBJECT
and reject it with antibodies
• Rho GAM is an immunoglobulin made to protect an Rh – mom with an Rh + baby
 Assessing fundal height fundal
height correlates with gestational
age of pregnancy
i.e 28 wks = 28cm
(give or take 2)

Beginning at 20 weeks, uterus is

@ level of umbilicus.
The fundal height is measured in
cm, and correlates
With the gestational age of the
pregnancy i.e. weeks

If a mom is obese or has multiples

this wont work for them, so they
need ultrasounds all the time

Before you do the doppler, have to

know the position baby is in

Best on the babies back near the heart

Fetal heart rate is btwn 110-160

If baby is head down, lower quadrants

Danger signs !
• Vaginal bleeding
• Rupture of membranes
• Swelling of hands or face
• Unrelenting headache
• Visual disturbances (blurred vision/ spots before eyes)
• Severe belly pain
• Chills / fever
 • Persistent vomiting
• Symptoms of a UTI
• Decreased fetal movement
• Preterm labor : uterine cx, cramps, constant or irregular low backache, pelvic pressure
• 2 things super important need to come in ASAP
• I could feel my baby before and now hes not moving
• Im bleeding (except if they are miscarrying and they know you are)
Teaching points
• Health Behaviors
o Bathing
o Hot tubs ( increase risk for NTD )
o Douching
o Breast care
o Clothing (should be loose fitting to allow uterus to grow)
o Exercise
o Sleep, Rest & Nutrition
o Safety
o Teratogens
o Travel
o Immunizations
• Lifestyle changes
o Medications
o CAM
o Toxic habits
Psychological Adaptation
• Emotional Responses
o Mom: varies by trimester
 Not adjusting lifestyles, missing appt, not touching abdomen, not talking
about pregnancy
 Do they have past trauma? Do they have a supportive person (husband,
bestie, mom)?
o Dad/partner: wide variations;
 Create role for involvement
 Couvade; pregnancy-related symptoms and behavior in expectant
partner
• Siblings:
o Toddlers < 2 unaware
o 3-12yrs: listen to heartbeat, questions on fetal development. Include school-
aged children in preparations for new baby
o Adolescents : embarrassed about sexuality
Maternal response by trimester
• 1st Trimester
o Uncertainty
 o Ambivalence
o Primary focus is on herself
nd
• 2 Trimester
o Pregnancy is REAL/ quickening occurs: Focus on the baby
o Introverted about ability to care for herself / her baby
o Body image & sexuality
rd
• 3 Trimester
o Vulnerable & Dependent
o Prepare for the birth ( CBE classes: encourage partner also )
• Throughout Pregnancy
o Mood swings ( joy/fear/anticipation)
o Pregnant woman is ULTRAsensitive
• Send for a psych consult when
o They say they want to kill themselves
o They aren’t keeping up with self care
o Cant get out of bed
SIGNS OF MATERNAL FETAL BONDING
• Nurse to look for these signs-
• Talking to fetus in utero
• Massaging abdomen
• Nicknaming fetus
• ALL healthy psychosocial activities
Factors that Influence Psychosocial Adaptations
• Age
• Multiparity
• Social support
• Absence of partner
• Socioeconomic status
• Cultural Beliefs: health beliefs/belief in fate/ illness prevention/ modesty
communication
Variations in Prenatal Care
• Age differences
o Adolescents
• Much less likely than older women to receive adequate prenatal care
o Women older than 35 years
• Multiparous women
• Primiparous women
• Multifetal pregnancy
o Twin pregnancies often end in prematurity
o Spontaneous rupture of membranes before term is common
o Congenital malformations twice as common in monozygotic twins as in
singletons
Childbirth and Perinatal Education
 • Goal is to assist individuals and family members to make informed and safe decisions
about pregnancy, birth, and early parenthood
• Childbirth education programs
o Current practices
o Pain management
Perinatal Care Choices
• Physicians
• Nurse-midwives (RN who goes back and gets masters and then can deliver in hospital)
• Direct entry midwives (take a class and can only deliver at home)
• Doulas (assist a person with pregnancy, delivery and after)
• Birth plans
Birth Setting Choices
• Labor, delivery, recovery, postpartum (birthing) rooms
o LDR
o LDRP
• Birth centers
• Home births
Nutrition in Pregnancy
Nutrition is one of the most modifiable factors we can help pt w with
Nutrient Needs Before Conception
• Healthy diet ensures adequate nutrients for developing fetus
• First trimester critical in terms of embryonic and fetal development
• Folic acid intake
o 0.4 mg in fortified foods recommended
o Neural tube defects can occur with poor intake
• Defects of the CNS, primarily the spine
o Folate is natural form and folic acid in vitamin form
o Pt can not get enough folate in their normal diet so need to supplement
• Desirable body weight reduces maternal and fetal risks
• Gold standard is that all women of child bearing age take folic acid
 Nutritional needs are based on
stage of pregnancy

Weight gain
• Normal weight/BMI: 25-35 lbs
o BMI = weight in lbs divided by height in meters squared
o Or look at on-line tables
• Underweight: 28-40 lbs
o Preterm births / LBW babies
• Overweight: 15-25 lbs
• Obese: 15 lbs
o Gestational Diabetes, Preeclampsia, Neural tube defects, macrosomia, c/s pp
complications
• Twin pregnancy: 35-45 lbs
• In the US, 60% of pregnant woman are overweight
• Obesity is a major risk factor for pregnant women (can lead to HTN, diabetes etc)
 Weight Gain
• Record weight every visit
• Total gain should average 25 to 35 LB
• First trimester weight gain recommended 2-4 pounds
• Advise client to maintain steady weight gain of ½ to 1 pound/week for the second and
third trimesters
• Prenatal vitamins are prescribed by healthcare provider
• Pt who gain a lot of weight at beginning of pregnancy, tend to gain a lot during the rest
of pregnancy
Nursing Implications
• Increase calories by 300 KCal per day (half a small sandwich, small candy bar)
• Increase protein daily (important building block in tissue growth)
• Increase intake of iron and folic acid through diet and supplements i.e. prenatal vitamins
o Vit C increases absorption of iron: Take PNV with OJ or prune juice
• Increase vitamin A, vitamin C and calcium through diet
o TUMS is a great source of calcium and is safe in pregnancy
• Increase fluid intake to 8 to 10 glasses per day
Dietary Sources
o Important to review the content in table 15-1: Pregnancy intake
recommendations
o Folic Acid: non-pregnant woman daily supplement, pregnant women need PNV
due to increase amount of Folic acid
o Calcium
o TUMS : give Ca+ supplement AND relieve heartburn
o Vitamin C
 o Vitamin D increases absorption of calcium
• Lactose intolerant and vegans need to supplement their diets
Caution!
ž Mercury in fish [damages the baby’s CNS]
o High mercury levels: Avoid !
– Large fish: shark, swordfish, albacore, white tuna
o Low mercury : 2 servings / wk
– Shrimp, canned light tuna, salmon, pollock, catfish
ž Listeria [miscarriages, stillbirth]
o Cold cuts, hot dogs, soft cheeses [brie, feta, blue cheese, camembert], pate,
meat spreads
ž Toxoplasmosis [may be asymptomatic / develop neuro sequelai later in life, CDC]
o Undercooked eggs & meat
o Cat Feces
o HAND WASHING
PICA : eating non-food items in place of food
• Ice, clay pots, laundry starch
Nutritional Assessment
• Interview
o Ask for the last 24 hr food intake
o Appetite
o Eating habits
o Food preferences
o Psychosocial influences
• Physical assessment
o Weight at initial visit
o Weight at subsequent visits
o Signs of nutrient deficiency
• Laboratory tests
o Hemoglobin (Hgb) and hematocrit (Hct) usually drawn at first prenatal visit to
assess for anemia