Slide 1 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 16 Nursing Care During Pregnancy

Slide 2 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction Prenatal period Period of physical and psychologic preparation for birth and parenthood that offers opportunities Health of the expectant mother and infant Diagnosis and treatment of maternal disorders Education and support for self-care and parenting

Slide 3 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction Pregnancy Spans 9 months Trimesters: First: weeks 1-13 Second: weeks 14-26 Third: weeks 27-40

Slide 4 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnosis of Pregnancy Signs and symptoms Presumptive indicators Reported by woman Amenorrhea, nausea and vomiting, breast tenderness, urinary frequency, fatigue Quickening

Slide 5 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnosis of Pregnancy Signs and symptoms―continued Probable indicators Detected by examiner Uterine enlargement Braxton Hicks contractions Uterine souffle Ballotement Positive pregnancy test

Slide 6 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnosis of Pregnancy Signs and symptoms―continued Positive indicators Attributed to the fetus Fetal heartbeat distinct from mother Fetal movement felt by someone other than mother Visualization of the fetus Estimating date of birth Nägele’s rule

Slide 7 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Adaptation to Pregnancy Maternal adaptation Accepting the pregnancy Identifying with the mother role Reordering personal relationships Establishing relationship with fetus Emotional attachment Preparing for childbirth

Slide 8 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Adaptation to Pregnancy Paternal adaptation Accepting the pregnancy Identifying with the father role Reordering personal relationships Establishing relationship with fetus Preparing for childbirth Sibling adaptation Grandparent adaptation

Slide 9 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care Management Initial visit Interview Reason for seeking care Current pregnancy Obstetric and gynecologic history

Slide 10 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care Management Prenatal interview Medical history Nutritional history History of drug/herbal preparation use Family history Social, experiential, occupational history

Slide 11 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care Management Prenatal interview—continued History of physical abuse Review of systems Physical examination Laboratory tests

Slide 12 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care Management Follow-up visits Interview Physical examination Fetal assessment Fundal height Gestational age Health status Laboratory/other tests

Slide 13 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Education for Self-Care Nutrition Personal hygiene Prevention of urinary tract infections Kegel exercises Preparation for breastfeeding Dental care Physical activity

Slide 14 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Education for Self-Care Posture and body mechanics Rest and relaxation Employment Clothing Travel Medication/herbal preparations Immunizations

Slide 15 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Education for Self-Care Alcohol, cigarette smoke, caffeine, drugs Normal discomforts Recognizing potential complications Recognizing preterm labor

Slide 16 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Variations in Prenatal Care Cultural influences Emotional response Clothing Physical activity and rest Sexual activity Diet

Slide 17 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Variations in Prenatal Care Age differences Adolescents Much less likely than older women to receive adequate prenatal care Women older than 35 years Multiparous women Primiparous women

Slide 18 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Variations in Prenatal Care Multifetal pregnancy Twin pregnancies often end in prematurity Spontaneous rupture of membranes before term is common Congenital malformations are twice as common in monozygotic twins as in singletons

Slide 19 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Variations in Prenatal Care Multifetal pregnancy―continued Shunting of blood between placentas serious problem Congenital heart failure may develop in the larger twin during first 24 hours after birth

Slide 20 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Variations in Prenatal Care Multifetal pregnancy―continued Likelihood of a multifetal pregnancy is increased if 1 or more is noted History of dizygous twins in the female lineage Use of fertility drugs More rapid uterine growth for number of weeks of gestation

Slide 21 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Variations in Prenatal Care Multifetal pregnancy―continued Hydramnios Palpation of more than the expected number of small or large parts Asynchronous fetal heartbeats or more than one fetal ECG tracing Ultrasonographic evidence of more than one fetus

Slide 22 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Variations in Prenatal Care Multifetal pregnancy―continued Counseling needs to be provided for Modification of weight gain and nutritional intake Selective reproduction Lifestyle changes

Slide 23 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Prenatal period: significant psychosocial adaptation for all members of expectant family as they anticipate changes in roles and responsibilities Prenatal care common among women of middle and high socioeconomic status Women living in poverty or lacking health insurance may not have access to care

Slide 24 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Prenatal care: multidisciplinary activity that fosters safe birth and promotes satisfaction with the pregnancy and birth experience Initial prenatal visit includes in-depth interview to determine presence of potential complications, comprehensive physical exam, and selected lab tests

Slide 25 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Follow-up visits important for monitoring the health of mother and fetus and providing anticipatory guidance Individualized care implemented through assessment, formulation of nursing diagnoses, and planning outcomes; evaluation of care is ongoing process

Slide 26 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Nurse plays important role in teaching about physical changes and discomforts of pregnancy and self-care measures Each woman needs to know how to recognize and report preterm labor and other warning signs and symptoms

Slide 27 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Culture, age, parity, and multiple pregnancy may have significant impact on the course and outcome of pregnancy

Slide 28 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 17 Childbirth and Perinatal Education

Slide 29 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. The Need for Childbirth Education Empowering women and their partners Prenatal support and partner relationships

Slide 30 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Childbirth Education History Early methods of childbirth education Grantly Dick-Read method Lamaze method Bradley method Current practices Selecting a certified childbirth educator Coalition to Improve Maternity Services (CIMS)

Slide 31 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Options for Care Perinatal provider and care choices Physicians Nurse-midwives Direct-entry midwives Doulas Birth plans

Slide 32 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Birth Setting Choices Labor, delivery, recovery, and postpartum rooms Birth centers Home birth Advantages Disadvantages Factors increasing safety of home birth

Slide 33 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Components of Perinatal Education Programs Pain management Childbirth preparation Relaxation Imagery and visualization Conscious breathing Biofeedback Energy work, massage, music, acupressure Cesarean birth

Slide 34 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Components of Perinatal Programs Sibling classes Grandparent classes Parenting Breastfeeding Infant massage Couple sexuality Family adjustments to parenthood

Slide 35 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Improved confidence, birth satisfaction, and better family relationships are positive outcomes of childbirth education Childbirth education should be available to all pregnant women in a culturally sensitive format Preconception care stresses behavior that promotes the health of woman and fetus

Slide 36 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Childbirth education teaches tuning in to the body’s inner wisdom and strategies that enhance coping during labor and birth Stress and pain management strategies are valuable tools throughout life Childbirth education strives to promote healthier pregnancies and family lifestyles

Slide 37 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Active support during labor and birth promotes personal satisfaction and adaptation to the maternal role

Slide 38 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 18 Labor and Birth Processes

Slide 39 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Factors Affecting Labor 5 factors affecting process of labor and birth Passenger: fetus Size of fetal head Fetal presentation Fetal lie Fetal attitude Fetal position

Slide 40 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Factors Affecting Labor 5 factors affecting process of labor and birth—continued Passageway: birth canal Bony pelvis Soft tissues Powers Primary powers: contractions Secondary powers: bearing down efforts

Slide 41 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Factors Affecting Labor 5 factors affecting process of labor and birth—continued Position of laboring woman Upright position “All fours” position Lithotomy position Semirecumbent position Lateral position

Slide 42 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Process of Labor Labor: process of moving fetus, placenta, and membranes out of the uterus and through the birth canal Signs preceding labor Lightening Bloody show Onset of labor Cannot be ascribed to a single cause

Slide 43 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Process of Labor Stages of labor First stage Second stage Third stage Fourth stage

Slide 44 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Process of Labor Mechanism of labor Turns and adjustments necessary in human birth process 7 cardinal movements of mechanism of labor Engagement Descent Flexion

Slide 45 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Process of Labor Mechanism of labor 7 cardinal movements of mechanism of labor―continued Internal rotation Extension Restitution and external rotation Expulsion

Slide 46 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Physiologic Adaptation to Labor Fetal adaptation Fetal heart rate (FHR) Fetal circulation Fetal respiration

Slide 47 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Physiologic Adaptation to Labor Maternal adaptation Woman exhibits both objective and subjective symptoms Cardiovascular changes Respiratory changes Renal changes Integumentary changes Musculoskeletal changes Neurologic changes Gastrointestinal changes Endocrine changes

Slide 48 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Labor and birth are affected by the five Ps: passenger, passageway, powers, position of woman, and psychologic responses Because of its size and relative rigidity, the fetal head is a major factor in determining the course of birth

Slide 49 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Diameters at plane of pelvic inlet, midpelvis, and outlet, plus axis of birth canal, determine possibility of vaginal birth and manner in which fetus passes down birth canal Involuntary uterine contractions act to expel fetus and placenta during 1st stage of labor Augmented by voluntary bearing-down efforts during 2nd stage

Slide 50 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points First stage of labor lasts from time dilation begins to time when the cervix is fully dilated Second stage of labor lasts from time of full dilation to birth of the infant Third stage of labor lasts from infant’s birth to expulsion of the placenta Fourth stage is the first 2 hours after birth

Slide 51 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Cardinal movements of the mechanism of labor: engagement, descent, flexion, internal rotation, extension, restitution and external rotation, and expulsion of the infant Although events precipitating onset of labor are unknown, many factors involved: changes in maternal uterus, cervix, and pituitary gland

Slide 52 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Healthy fetus with adequate uterofetoplacental circulation is able to compensate for the stress of uterine contractions As woman progresses through labor, various body systems adapt to the birth process

Slide 53 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 19 Management of Discomfort

Slide 54 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Discomfort During Labor and Birth Neurologic origins Perception of pain Expression of pain

Slide 55 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Discomfort During Labor and Birth Factors influencing pain response Physiologic factors Culture Anxiety Previous experience Gate-control theory of pain Comfort Support Environment

Slide 56 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nonpharmacologic Management of Discomfort Childbirth preparation methods Relaxing and breathing techniques Focusing and relaxation Breathing techniques Effleurage and counterpressure Music Water therapy (hydrotherapy)

Slide 57 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nonpharmacologic Management of Discomfort Transcutaneous electrical nerve stimulation Acupressure and acupuncture Application of heat and cold Touch and massage Hypnosis

Slide 58 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Nonpharmacologic Management of Discomfort Biofeedback Aromatherapy Intradermal water block

Slide 59 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Pharmacologic Management of Discomfort Sedatives Analgesia and anesthesia Systemic analgesia Opioid agonist analgesics Opioid agonist-antagonist analgesics Opioid antagonists

Slide 60 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Pharmacologic Management of Discomfort Nerve block analgesia and anesthesia Local perineal infiltration anesthesia Pudendal nerve block Spinal anesthesia (block)

Slide 61 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Pharmacologic Management of Discomfort Nerve block analgesia and anesthesia—continued Epidural anesthesia/analgesia Lumbar epidural anesthesia/analgesia Combined spinal-epidural analgesia Epidural and intrathecal opioids

Slide 62 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care Management Informed consent Timing of administration Preparation for procedures Administration of medication Intravenous route Intramuscular route Spinal nerve blocks

Slide 63 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Expected outcome of preparation for childbirth and parenting: “education for choice” Nonpharmacologic pain and stress management strategies alone or in combination with pharmacologic methods manage discomfort

Slide 64 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Gate-control theory of pain and the stress response are basis for many nonpharmacologic methods of pain relief Type of analgesic or anesthetic is determined in part by the stage of labor and method of birth Sedatives may be appropriate for women in prolonged early labor to decrease anxiety or promote sleep or therapeutic rest

Slide 65 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Phenothiazines and benzodiazepines can be used in labor to decrease anxiety and apprehension, increase sedation, potentiate opioid analgesic effects, and reduce nausea and vomiting Naloxone (Narcan) is an opioid antagonist that can reverse opioid effects Pharmacologic control of discomfort requires collaboration among health care providers and the laboring woman

Slide 66 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Nurse must understand medications, expected effects, potential adverse reactions, and methods of administration Maintenance of maternal fluid balance is essential during spinal and epidural nerve blocks

Slide 67 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points Maternal analgesia or anesthesia potentially affects neonatal neurobehavioral response Opioid agonist-antagonist analgesics with preexisting opioid dependence may cause symptoms of abstinence syndrome

Slide 68 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Key Points General anesthesia is rarely used for vaginal birth but may be used for cesarean birth or when rapid anesthesia is needed in an emergency situation