Question

discuss the anticipatory guidance about managing the physiologic changes the nurse would expect to educate the couple on during each trimester of the prenancy

Answer 1

ANTICIPATORY GUIDANCE ABOUT MANAGING THE PHYSIOLOGIC CHANGES

DURING PREGNANCY

INTRODUCTION

Pregnancy has three trimesters, each of which is marked by specific fetal developments. A pregnancy is considered full-term at 40 weeks; infants delivered before the end of week 37 are considered premature. Premature infants may have problems with their growth and development, as well as difficulties in breathing and digesting.

First Trimester (0 to 13 Weeks)

The first trimester is the most crucial to baby's development. During this period, baby’s body structure and organ systems develop. Most miscarriages and birth defects occur during this period. Body also undergoes major changes during the first trimester. These changes often cause a variety of symptoms, including nausea, fatigue, breast tenderness and frequent urination. Although these are common pregnancy symptoms, every woman has a different experience. For example, while some may experience an increased energy level during this period, others may feel very tired and emotional.

Second Trimester (14 to 26 Weeks)

The second trimester of pregnancy is often called the "golden period" because many of the unpleasant effects of early pregnancy disappear. During the second trimester, woman likely to experience decreased nausea, better sleep patterns and an increased energy level. However, woman may experience a whole new set of symptoms, such as back pain, abdominal pain, leg cramps, constipation and heartburn. Somewhere between 16 weeks and 20 weeks, woman may feel baby's first fluttering movements.

Third Trimester (27 to 40 Weeks)

Pregnant woman have now reached final stretch of pregnancy and are probably very excited and anxious for the birth of baby. Some of the physical symptoms she may experience during this period include shortness of breath, haemorrhoids, urinary incontinence, varicose veins and sleeping problems. Many of these symptoms arise from the increase in the size of uterus, which expands from approximately 2 ounces before pregnancy to 2.5 pounds at the time of birth.

THE CONTENT OF CHILDBIRTH GUIDANCE

Women who are prepared for childbirth tend to require less medication, report less pain during labour and birth, have shorter labors, and have a more positive attitude about the childbirth experience. Stress interferes with the process of parturition. The educational requirements for individual women clearly vary with their educational level and motivation for self-study.

Factors should be considered when discussing topics related to pregnancy and birth:

· Marital status: presence of a support individual;

· Income/economic status: ability to afford adequate nutrition, formal childbirth education classes, continued prenatal care, provisions for an infant;

· Culture/religion/ethnicity: nutritional variations/restrictions, modesty, pain management philosophy, refusal of blood products, attitudes about childbirth;

· Parity: previous experiences, previous problems during pregnancy; and

· Educational level: knowledge about reproduction and family planning.

Preconception

· Reproductive anatomy and physiology

· Nutritional evaluation and information

· Genetic risk evaluation and counselling

· Medical conditions: immunity status, medications, acute and chronic illness

· Risk factors associated with pregnancy risk: smoking, alcohol, recreational and over-the-counter drugs

· Environmental/work hazards

· Counseling regarding safe sex, pregnancy planning, spacing of children, and contraception

First Trimester

· Reproductive anatomy and physiology, calculation of estimated date of confinement

· Nutritional needs of pregnant women, vitamins, iron supplements

· Genetic counseling/referral

· Physiologic and psychological changes of pregnancy

· Body changes: breast growth, acne

· Common discomforts: nausea/vomiting, fatigue, constipation, headache, indigestion, faintness

· Self-help remedies for discomforts

· Fetal growth and development

· Laboratory tests

· Pregnancy risks

· Avoidance of teratogens

· Smoking, drugs, alcohol, caffeine, Nutra-Sweet and other food additives

· Exposure to infectious diseases

· General instructions

· Weight gain

· Travel

· Health habits: hygiene, exercise, dental care, rest and sleep

· Sexual relations, safe sex

· Seat belt use

· Warning signs of the first trimester: bleeding, cramping, fever, severe vomiting

· Prenatal care

· Content and timing of prenatal visits

· Individual risk factors and management

Second Trimester

· Physiologic and psychological changes

· Body changes: abdominal growth, striae gravidarum, chloasma

· Common discomforts: backache, constipation, hemorrhoids, indigestion, ligament pain, vaginal discharge

· Mood swings

· Self-help remedies for discomforts

· Fetal growth and development, quickening

· Laboratory tests

· General instructions

· Weight gain

· Travel restrictions (if any)

· Health habits: exercise, body mechanics, rest and sleep

· Sexual relations, safe sex

· Promotion of breast-feeding

· Warning signs of the second trimester: premature labor, vaginal bleeding, or fluid loss

· Introduction to outside resources

· Childbirth education classes

· Social services: Women, Infants and Children (WIC) Supplemental Food Program, housing support, financial support

· Substance abuse referral to treatment center

· Mental health treatment referral

Third Trimester

· Physiologic and psychological changes

· Body changes: see second trimester changes, engagement

· Common discomforts: constipation, shortness of breath, edema, heartburn, backache

· Fetal growth and development, tests for fetal wellness

· Ultrasonography

· Nonstress testing, contraction stress tests

· Fetal movement counts

· Laboratory tests

· General instructions

· Signs of labor: contractions, rupture of membranes, bloody show

· Analgesia and anesthesia for labor and birth

· Discussion of birth plan: routine procedures for labor and birth: intravenous lines, fetal monitoring, vaginal examination, episiotomy

· Contacting the physician or midwife for labor, where to go

· Family roles and adjustment

· Warning signs of the third trimester: severe edema, headache, visual disturbances, abdominal pain, vaginal bleeding, premature labor, premature rupture of membranes

Postpartum

· Warning signs for immediate postpartum period

· Physiologic and psychological changes

· Body changes: weight loss, return of menses, resumption of intercourse

· Psychosocial adaptation to parenthood

· Family planning

· Child spacing

· Contraception

· General instructions

· Nutrition, weight lossHealth habits: hygiene, rest, exercise

· Health maintenance: breast self-examination, annual gynecologic examination, immunizations

· Resources

· Return to work

PHYSIOLOGICAL CHANGES

1. Pregnancy-related changes in posture and joints

A pregnant woman’s entire posture changes as the baby gets bigger. Her abdomen transforms from flat or concave (dished) to very convex (bulging outwards), increasing the curvature of her back. The weight of the fetus, the enlarged uterus, the placenta and the amniotic fluid (the bag of waters surrounding the baby), together with the increasing curvature of her back, puts a large strain on the woman’s bones and muscles. As a result, many pregnant women get back pain. Too much standing in one place or leaning forward can cause back pain, and so can hard physical work. Most kinds of back pain are normal in pregnancy, but it can also be a warning sign of a kidney infection.

2. Changes in body weight during pregnancy

Continuing weight increase in pregnancy is considered to be one favourable indication of maternal adaptation and fetal growth. However, routine weighing of the mother during pregnancy is not now thought to be necessary, because it does not correlate well with pregnancy outcomes. For example, there can be a slight loss of weight during early pregnancy if the woman experiences much nausea and vomiting (often called ‘morning sickness’). The expected increase in weight of a healthy woman in an average pregnancy, where there is a single baby, is as follows:

· About 2.0 kg in total in the first 20 weeks

· Then approximately 0.5 kg per week until full term at 40 weeks

· A total of 9 -12 kg during the pregnancy.

A woman who is pregnant with more than one baby will have a higher weight gain than a woman with only one fetus. She will also require a higher calorie diet. A lack of significant weight gain may not be a cause for concern in some women, but it could be an indication that the fetus is not growing properly.

3. Changes in the cardiovascular system

During the second trimester of pregnancy, the mother’s heart at rest is working 40% harder than in her non-pregnant state. Most of this increase results from a more efficiently performing heart, which ejects more blood at each beat. Blood volume (the total volume of blood in the circulation, measured in litres) increases gradually by 30-50 % in the pregnant woman. The total volume of red cells in the circulation increases by about 18% during pregnancy, in response to the extra oxygen requirements made by the maternal, placental and fetal tissues. Taking iron supplements during pregnancy can result in a much greater increase in red blood cells, up to 30% more than non-pregnant levels. Although there is a constant increase in the number of red blood cells in the circulation during pregnancy, the increase in the volume of blood plasma is much larger. So even though the pregnant woman has more red blood cells than before she was pregnant, they are diluted in the much larger volume of blood plasma. This effect is referred to as physiological anaemia. It explains why iron in the diet, or from iron tablets, is so important during pregnancy.

Lower blood pressure is particularly common in early pregnancy. Many women report occasionally feeling dizzy in the first trimester, because less blood and less oxygen is being pumped to the brain. Progesterone can also cause a sudden larger relaxation in the blood vessels, resulting in an acute feeling of dizziness, or even a brief loss of consciousness.

Another cause of dizziness can result from lying flat on the back. This is more common after 24 weeks of pregnancy, but it can happen earlier during twin pregnancies, or conditions that increase the volume of amniotic fluid (waters surrounding the fetus). When a pregnant woman is lying flat on her back, the weight of her uterus and its contents compresses the large blood vessel (vena cava) leading from her lower body to the heart. When this blood vessel is squashed, the blood flow back to the heart is reduced, which in turn leads to a reduction in the blood flow out of the heart to the rest of the body.

4. Exercise and blood flow in pregnancy

The weight gain in pregnant women increases the workload on the body from any physical activity. Steady, non-violent exercise is good for the mother because it prepares her body for labour but sudden strong exercise, or working for too many hours without a break, may make her feel dizzy. This is because the reduced blood pressure and slight physiological anaemia cannot keep pace with the demand of her body for more oxygen.

A pregnant woman should not do exercises where she is lying on her back, due to the compression of the major blood vessels returning blood to her heart. Strong exercise may lead to decreased blood flow to the uterus because blood is diverted to the muscles, but this has not been shown to have any long-term effects on the baby. Pregnant women should not exercise vigorously in hot weather, or if it makes them breathless or if there are known risk factors such as a history of miscarriage.

5. Oedema in pregnancy

It is a common condition in pregnant women, particularly if they stand for a long time during the day. Oedema of the hands may also occur. Advise the woman to rest frequently and to elevate (raise) her feet and legs while sitting. This will improve the return of blood to her heart and decrease swelling of the legs.

6. Respiratory changes

During pregnancy, the amount of air moved in and out of the lungs increases by nearly 50% due to two factors:

· Each breath contains a larger volume of air

· The rate of breathing (breaths per minute) increases slightly.

During pregnancy, many women find they get short of breath (cannot breathe as deeply as usual). This is because the growing baby crowds the mother’s lungs and she has less room to breathe. But if a woman is also weak and tired, or if she is short of breathe all of the time, she should be checked for signs of sickness, heart problems, anaemia or poor diet. Get medical advice if she may have any of these problems.

7. Changes in the gastrointestinal system in pregnancy

During pregnancy, the muscles in the walls of the gastrointestinal system relax slightly, and the rate at which food is squeezed out of the stomach and along the intestines is slowed down.

Many women also have nausea in the first months of pregnancy. A burning feeling, or pain in the stomach or between the breasts, is called indigestion (or ‘heartburn’, although the heart is not involved). It happens because as the pregnancy progresses, the growing baby crowds the mother’s stomach and pushes it higher than usual . The acids in the mother’s stomach that help digest food are pushed up into her chest, where they cause a burning feeling. This is not dangerous and usually goes away after the birth.

If the mother has difficulty with nausea or indigestion, advise her to eat small, frequent meals. The mother should not lie down flat for 1 to 2 hours after eating, because this may cause these symptoms.

8. Changes in the urinary system during pregnancy

Urinary system must work extra hard to filter the mother’s own waste products from her blood, plus those of the fetus, and get rid of them in her urine. Therefore, there is also an increase in the amount of urine produced during pregnancy.

Needing to urinate (pee) often is normal, especially in the first and last months of pregnancy. This happens because the growing uterus presses against the bladder. In late pregnancy, a woman often has to get up during the night to urinate, because fluid retained in the legs and feet during the day (oedema) is absorbed into the blood circulation when her legs are raised in bed. The kidneys extract the excess fluid and turn it into urine, so the bladder fills more quickly at night.

9. Skin changes

Changes in the woman’s hormones, and mechanical stretching of her growing abdomen and breasts, are responsible for several changes in the skin during pregnancy.

1  Linea nigra:This dark line may appear between the umbilicus (belly-button) and the symphysis pubis (pubic bone); in some pregnant women it may extend as high as the sternum (the bone between the breasts). It is a hormone-induced excess production of brown material (pigment) in the skin cells in this area. After delivery, the line begins to fade, though it may never completely disappear.

2  Mask of pregnancy (chloasma):Some women produce a brownish pigmentation of the skin over the face and forehead, known as the ‘mask of pregnancy’ (or chloasma). It gives a bronze look. It begins about the 16th week of pregnancy and gradually increases, but it usually fades after delivery.

3  Stretch marks:As the woman’s weight increases, stretching of the skin occurs over areas of maximal growth — the abdomen, thighs and breasts. Pink or brownish stretch marks may appear in some women, which can be quite dramatic. They usually fade after delivery, although they never completely disappear.

4  Sweat glands:Activity of the sweat glands throughout the body usually increases during pregnancy, which causes the woman to perspire (sweat) more profusely than usual, particularly in hot weather or during physical work.

10. Changes in the breasts

In early pregnancy, the breasts may feel full or tingle, and they increase in size as pregnancy progresses. The areola around the nipples (the circle of pigmented skin) darkens and the diameter increases. The Montgomery’s glands (the tiny bumps in the areola) enlarge and tend to protrude (stick out more). The surface blood vessels of the breast may become visible due to increased circulation, and this may give a bluish tint to the breasts.

By the 16th week (during the second trimester), the breasts begin to produce colostrum. This is the precursor of breast milk. It is a yellowish secretion from the nipples, which thickens as pregnancy progresses. It is extremely high in protein and contains antibodies (special proteins produced by the mother’s immune system) that help to protect the newborn baby from infection. Near the end of pregnancy, the nipples may produce enough colostrum to make wet patches on the woman’s clothes. Reassure her that this is normal and a good sign. After the baby is born, colostrum is produced for about the first three days, before the proper milk begins to flow. Make sure that the mother breastfeeds the colostrum to her baby, so he or she gets all the nutrients and antibodies it contains.

11. Grief

Grief may arise from the realization that one’s roles would be changed permanently. A pregnant woman would be weaned off her role as a dependent daughter, or as a happy-go-lucky girl, or a friend who is always available. Even the partner would have to leave the roles or the life he has been accustomed to as a man without a child to support.

12. Mood Swings

Also known as emotional lability, this psychological reaction can be caused by two factors: hormonal changes or narcissism. The comments that she had brushed off in her nonpregnant state can now touch a nerve or hurt her. Crying is a common manifestation of mood swings, during and even after the pregnancy.

13. Changes in Sexual Desire

Women on the first trimester of pregnancy experience a decrease in libido mainly because of breast tenderness, nausea, and fatigue. On the second trimester, sexual libido may rise because of increased blood flow to the pelvic area that supplies the placenta. The third trimester might bring an increase or decrease in sexual libido due to an increase in the abdominal size or difficulty in finding a comfortable position.Estrogen increase may also affect sexual libido as it may bring a loss of desire. The couple must be informed that these changes are normal to avoid misunderstanding the woman’s attitude.

14. Stress

Pregnancy is a major change in roles that could cause stress. The stress that a pregnant woman feels might affect her ability to decide. The discomforts that she may feel could also add up to the stress she is experiencing. Assess whether the woman is in an abusive relationship as it may contribute further to the stress.

15. Introversion/Extroversion

Introversion refers to someone who focuses entirely on her own body and a common manifestation during pregnancy. Some pregnant women also manifest extroversion, or acting more active, healthier and more outgoing than before their pregnancy. Extroversion commonly happens to women who had a hard time conceiving and finally hit jackpot.

16. Social Changes

In the past, a pregnant woman is isolated from her family starting from visiting for prenatal consultation until the day of birth. She is isolated from her family and the baby a week after birth. Today, having a support system for pregnant women is highly encouraged, like bringing along someone to accompany her during prenatal visits and allowing the husband to be with the wife during birth if he chooses to. Opinions on teenage pregnancy, late pregnancies, and having the same sex parents are now widely accepted compared to being taboos in the past.

17. Cultural Changes

A pregnant woman’s culture and beliefs may also greatly affect the course of her pregnancy. Assess if the woman and her partner have particular beliefs that might affect the way the take care of the pregnancy so you can integrate them in your plan of care. Despite the modern ages, there are still groups who firmly believe in their culture’s explanations about birth complications and the health care providers must respect this. Myths that surround the pregnancy should always be respected, but the couple should be educated properly regarding what could be dangerous for the fetus’ health.

18.Family Changes

The environment where the woman grew influences the way she would perceive her pregnancy. Family culture and beliefs also affect a woman’s perception of pregnancy. If she is loved as a child, she would have an easy time accepting her pregnancy compared to women who were neglected by her family during childhood. A woman who has been told of disturbing stories about giving birth and pregnancy would view her own in a negative light, while those who grew with beautiful birth stories would more likely be excited for their pregnancy. A positive attitude would only result from a positive outcome and influence from the woman’s own family.

19. Individual Changes

Becoming a new mother is never an easy transition. The woman must first be able to cope with stress effectively, as this is a major concern during pregnancy. She needs to have the ability to adapt effectively to any situation, especially if the pregnancy is her first because there might be a lot of new situations that would arise. Her ability to cope with a major change and manage her temper would be put to a test during motherhood. The woman’s relationship with her partner also affects her ability to accept her pregnancy easily.If she feels secure with her relationship with the father of her child, she would have an easier time accepting her pregnancy as opposed to an unstable relationship where she feels insecure and may doubt the decision of keeping the pregnancy. A woman who feels that the pregnancy may rob her of her looks, her freedom, a promotion, or her youth would need to have a strong support system so she could express her feelings and unburden her chest. The father’s acceptance of the pregnancy also influences the woman’s ability to accept the marriage. Utmost support from her husband would be very meaningful for the woman especially during birth.

20. The Psychological Tasks of Pregnancy

Both the woman and her husband walk through a tangle of emotions during pregnancy. Accepting that a new life would be born out of your blood is not as easy as others may think. There are several stages that both should undergo, the psychological way.

First Trimester: Accepting the Pregnancy

The shock of learning about a new pregnancy is sometimes too heavy for a couple, so it is just proper for the both of them to spend some time recovering from this major life-altering situation and avoid overwhelming themselves at first.One of the most common reactions of a couple who would be having a baby for the first time is ambivalence, or feeling both pleased and unhappy about the pregnancy.

Second Trimester: Accepting the Baby

The woman and her partner will start to merge into the role of novice parents as second trimester closes in.Emotions such as narcissism and introversion are commonly present at this stage.Role playing and increased dreaming are activities that help the couple embrace their roles as parents.At this stage, the woman and her partner must start to concentrate on what it will feel like to be parents.

Third Trimester: Preparing for the Baby

The couple starts to grow impatient as birth nears. Preparations for the baby, both small and big, takes place during this stage. The baby’s clothing and sleeping arrangements are set and the couple is excited for his arrival.

Guidance should focus mainly on following points.

• Oestrogen and progesterone are the chief pregnancy hormones.
• High levels of progesterone cause some internal structures to increase in size, including the uterus which changes from the size of a small pear in its non-pregnant state to five times its normal size at full term.
• The expected increase in weight of the mother in an average pregnancy is 9-12 kg.
• A higher circulating blood volume is required to provide extra blood flow through the placenta to the fetus, and the mother also produces more red blood cells.
• The increase in blood volume exceeds the increase in red blood cells, so they are diluted in the much larger volume of blood plasma, causing physiological anaemia. This is one reason why iron supplementation is so important in pregnancy.
• Lower blood pressure is particularly common in early pregnancy because progesterone causes a slight relaxation in the blood vessels. This can cause dizziness and perhaps even a brief loss of consciousness.
• A reduction in blood flow back to the heart may lead to oedema — swelling due to fluid collecting in the legs and feet.
• During pregnancy, many women get short of breath because the growing baby crowds the mother’s lungs and she has less room to breathe. She may also experience indigestion as her stomach is pushed higher.
• During pregnancy, the muscles in the walls of the gastrointestinal system relax slightly, and the rate at which food moves along the gut is slowed down. This maximises the absorption of nutrients into the mother’s blood, which is good for the foetus, but the mother may also experience nausea or constipation.
• Needing to urinate often is normal, especially in the first and last months of pregnancy, because the growing uterus presses against the bladder. At night, the bladder fills more quickly as fluid (oedema) that collected in the legs during the day is re-absorbed.
• Changes in the woman’s hormones, and mechanical stretching of her growing abdomen and breasts, can cause stretch marks in the skin of these areas during pregnancy. Other skin changes may include brown pigmentation and increased sweating.
• In the second trimester, the breasts begin to produce colostrums — a yellowish secretion that thickens as pregnancy progresses. It is rich in proteins and maternal antibodies, and should always be fed to newborn babies.

CONCLUSION

The transition of a woman from the start until the end of the pregnancy is a big turning point for her and the people who surround her. Every single one of them must be prepared physically, mentally and emotionally.