[0:09]Hello everyone, welcome to module one. Just wanted to let you know, I will have to keep the camera off for during the recording, just to ensure that the recording will be smooth and not interrupted. So welcome back to Nursing 2500 Child and Family Health. This week, we are going to start module one, which uh focuses on the profound life transitions that occur throughout pregnancy. And this isn't just about a biological changes. Now, it is about an individual, the mother, as well as the family unit of the individual. Pregnancy is a state where it involves constant changes. So as nurses, we must understand that every physiological change comes with a corresponding psychological and social impact to it. So, we are going to take a look at the three stages of the trimester through the lens of the maternal adaptations and also fetal development for gaining better understanding. Now, by definition, let's start with the basics. Pregnancy is defined as the period from conception to birth after the egg is fertilized by a sperm and then implanted in the lining of the uterus. It develops into the placenta and embryo and later into a fetus. Now using more of a visual tool here to understand the uh pregnancy stages, is important that the nine months of pregnancies are divided into three stages or trimesters, as we call it. Each with distinct characteristics in term of the mother's experience and fetals development. Now, for in the first trimester, the focus here is on organogenesis where the mother will often feel the worst here unfortunately. Um, the amount of fatigue as well as nausea are one of the most paramount symptoms here during this trimester at the first trimester. Advancing into the second trimester is where we refer to us the honeymoon um period where the mother's energy uh returns, there's more energy, uh improved energy level, um increased appetite, and the fetus begins to move also as well to during here, this trimester. And well into the third trimester, we refer uh the focus here is on fetal weight gain. Now, though the mother can experience shortness of breath because as the uh increasing in size of the fetus, um and also as we know it, is the maternal discomfort is really tying in high correlation with the fetal development. So as nurses, it's important for us to become more aware about sort of these corresponding physiological changes of the fetus in response to the mother's um comfort level. Um, for example, like common uh complaints like leg cramps or heartburn during this trimester can be very classics and common symptoms uh being reported by the mother. Now, moving into more of a uh another visual, not more, but another visual here, um which tells us a little bit more of um maternal symptoms with fetal milestones. So as you can see here, during the first trimester, uh by month three, the heart is beating. So sort of um we're able to then uh sort of being able to capture the uh heartbeat as well already. And by month five, which is the midway of the second trimester, the parent can often find out the biological sex of the baby already. And into the third trimester, the focus shifts to lightning when the body drops uh the baby drops into the pelvis. Now also um it's all about the fetal growth here because during this trimester, all organs will finish maturing. The baby will continue to um grow and beginning from sort of that 8.8 ounce to an average birth weight of 6 to 8 or even up to 10 pounds um by birth rate, uh birth weight. So this growth um during this pregnancy is what drives the maternal physiological changes and also often symptoms um that the mother will experience during this trimester. Now, signs of pregnancy are three different uh types. There's the presumptive sign, probable, as well as positive. In a very simplistic way to talk about presumptive is much more of a subjective um, uh experience where the mother will be able to share how they feel um sort of other different changes. Moving into the probable signs are more objective data that can be observed or obtained through assessment. And positive are those definitive signs and um assessment data. So before we look into it a little bit closer, let's take a look at a very quick video, which is very helpful for us to um uh distinguish the different the different signs of pregnancy, the goodles to Chatwix and Hager sign.
[6:16]Okay, so moving into a little bit more detail of these signs. So let's look closer. The presumptive signs can really be starting to uh be observed, um and be reported by, um the mother, uh, which is sort of the at the fourth week mark where the amenorrhea. And also at the sort of 18 to 20 week signs, there could be sort of the quickening that first feeling of fetal movement. Uh, before that, it could be a company of morning sickness, um the nausea vomiting, uh unexplained fatigue throughout the day, frequent urination as early as six week. And also feeling of breast tenderness and changes or even excessive saliva. Now, some of those probable signs that have just been captured in the video very quickly are more objective. So, as mentioned, these are more objective assessment data that can be obtained. Um a positive HCG test that can be detected through blood or urine test, uh again, can be a positive um signs of probable pregnancy. Umment is also when the medical examiner pushes the cervix and feels the rebound from the fetus. These are signs of physical manifestations of the uterus, um changes and adaptation of the maternal mother's body due to pregnancy. So the good old signs, the Chadwick signs, as well as the uh Heger signs are all probable signs of pregnancy. And of course, with more of a devinitive way to be able to confirm a pregnancy beyond any doubt, we needs positive signs. They are the fetal heart rate, for example, that can be obtained via Doppler, uh that can be heard as early as 10 to 12 weeks. And also seeing the fetus of on an ultrasound, it's a gold standard. And a nurse or doctor can uh either perhaps feel the fetal movement upon examination is also a positive sign. The mother feeling it is also uh though it can be only presumptive, but in conjunction with the observation by medical um provider, can be a what we refer to as positive signs to confirm the pregnancy. Now, pregnancy affects every single body system. It's a state of physiological stress for the mother. So uh we're going to approach it in more of a systematic way. We're going to take a look at it um at it via different systems such as the GI, MSK, cardiovascular, respiratory, urinary, and tegmentary system. And understanding the why behind these changes will help us be able to better understand the physiological changes that the mother goes through during pregnancy as a um as a corresponding response to the development of the fetus and baby, um the fetus. Now, taking a look at just very briefly, the impact of pregnancy can be for example, increase of heart rate, um increase respiratory, um uh stress as well, too because of that anatomical changes and pressure. There can be also um uh dilation of the urinary collecting system, due to as well anatomical changes, hormonal changes. Uh GI can be experienced with delayed gastric emptying and prolonged small bowel transit. Again, that anatomic uh anatomical um pressure and changes, all of which can be an impact as a result of pregnancy to the mother physiologically. Now, in specific here in the GI system, we need to really keep in mind the anatomy. Anatomy is the key here because think about that enlarging uterus which pushes the bowel up and out of the way. Um this is clinically significant. Now, if a pregnant patient has appendicitis, for example, the pain may not be at McBurney's point because now anatomically they are now out from where they are supposed to be. It might be much higher than it um than where we typically would think they, um they would be. Also, the lower esophageal, uh esophageal sphincter may relax due to that increasing push pressure, leading to that um reflex sensation. Some functional changes can also be um leading to like nausea and vomiting as a result, reduced mobility of the gut. Again, that expanded, um continuing dilation, increasing of pressure, and also by the increase of HCG in circulation. Uh, it's also, uh, the reason why there's a lot of these functional changes of the digestive system, which is characterized with nausea, vomiting, constipation, uh acidity and heartburn that reflex to abdominal discomfort and Pika. Now, this visual here shows, as you can see here, the crowding of the abdominal um cavity. When the patient's ask, uh, why why am I feeling so constipated? You can really kind of then pinpoint some of these mechanical anatomy of the increasing pressure, um in the abdominal cavity to help explain some of the symptoms that may have been experienced, um very wide range of intensity, um in the, um maternal mother. Now, taking a look at nausea, typically peaks at the 10 weeks mark when the HCG is at his highest level. So as nurses, it's important for us to also taking a look at, uh, monitoring of, uh, that vomiting, uh, episode and and frequencies as well. Because if the vomiting is so severe, it can lead to dehydration and weight loss, so it's not something to underestimate. It is, uh, it can be leading to um complications, so it's definitely something that we wanted to monitor, be able to manage and be able to prevent complications. So some of the nursing interventions, uh, related to GI changes as a result can be dietary changes. So um engaging in more small frequent meals, rather than big meals altogether, um, maybe uh taking a look at what are, uh, more tolerable diet. Uh, because it can vary from person to person, um, maybe on also avoid spicy or oily foods. And also, uh, if at the by the point when these interventions are rendered not helpful, uh, medication can be considered to help manage that nausea and vomiting. Now, always use our critical thinking and clinical judgment because, uh, is nausea just because of pregnancy or is it uh, a result of other, uh, conditions and underlying symptoms? Uh could it be because of UTI or could it be because of bowel obstruction? So it's very important for us to really look into um the symptoms, beyond just the symptoms itself, but also really trying to figure out what is the the root causes of it. Is it the from the pregnancy or there's also other factors that may be involved. Now, constipation is another very frequently reported uh symptom, and why would it, why does this happen? Well, one of that is due to the effect of progesterone. It slows everything down, and so then it diminish and also diminished physical activity and pressure of the gravid uterus on the pelvic colon. Uh utilizing iron supplements can also contribute to constipation. So it's very important that not only it's not only is it the hormonal changes, but it's also due to the supplemental needs. Um in iron supplementation that may contribute uh as a result of the patient feeling constipation. So the management of that can be increasing of fiber, right? Uh exercise regularly to facilitate uh peristalsis and bowel movements. Uh also drink at least six glasses of water a day to stay hydrated, right? And to also, what the key thing here is we really try to avoid laxative unless is absolutely necessary. So we always sort of consider that least invasive interventions first before we consider more in um uh other could be potentially much more invasive um interventions. Now, hemorrhoids is another uh very common symptoms that gets reported from the, um mother. Now, hemorrhoids are essentially uh varicose veins, uh, of the rectum. They can result from constipation and the pressure of the uterus slowing the Venus return. So some of these nursing care could be, uh, soaking in a warm sit bath, sitting on a soft pillow, uh encouraged patient to engage in a high fight uh fiber diet and avoid to to help avoid constipation, uh drinking sufficient fluids, increase exercise such as walking and applying ointment, drugs taken if needed. If the hemorrhoid is very uncomfortable, um ointment can help to reduce the inflammation as well, right? The anti-inflammatory ointments and also drugs can be considered, um to help be a part of that treatment. Now, acidity and heartburn is also another very common uh symptoms. Heartburn is caused by the relaxation of the cardiac sphincter as we mentioned the esophageal sphincter. The acid then gets moved up because the stomach is being pushed up by the uterus, and so that increasing pressure will therefore in fact lead to, um, that reflux, that gastric reflux. The management for that would be to eat slowly, eat small meals, okay? Um, though you can have frequent but small portion meals, drink milk between meals because it helps to form that lining to help reduces the chance of that reflux of acid. To avoid overeating and not to go to bed immediately after the meal, so sit upright after eating and avoid fatty and gas forming foods. Now, Pika is the craving for non food items. So, I'm sure you it's very common for you to hear where, um, patients will be experiencing the craving of ice or craving of certain, um, like, uh, craving for clay or or or or paint or something like that's non food related. So if a patient mentioned these cravings, we must check their hemoglobin levels, and also, um very important to classify that it is generally classified as an eating disorder if one eats non-food items for more than a month. So anywhere from 26 uh 27 to 68% of pregnant women can experience Pika, uh, with a large variation over different geographies. Now, some of the MSK changes by looking at this diagram here, the center of gravity can really shift as a result, and tends to compensate. The mother will lean back, creating what we refer to as a sway back. This can causes back pain, lower back pain, uh and hormones changes as well, too, can also soften the pelvic joints, leading to more of a waddling gate as a result to compensate for that increasing weight, um of the fetus. Management for that can be leading to, uh, where, um, possible encouraged rest where possible, avoid excessive weight gain, sleep on a firm mattress to helps with that supportive of the increase, uh, increasing weight of fetal development. Where appropriate, well fitted shoes, avoid high heel shoes, so flat shoes is much better. And apply local heat and light massages could be very helpful into accommodate for managing those symptoms. Now, other uh MSK related symptoms can be leg cramps, so often happens at night unfortunately and can be due to deficiencies of vitamin, um such as calcium, phosphorus, for example, or even just the pressure on the nerves as a result. Um so some of the treatments could be to, um stretch the calf muscles immediately, dorsiflex the foot, for example. And some of these management include like lying back on her back, getting regular exercises to help prevent and reduce the occurrences of it. Eat a diet with uh, uh, eat a diet adequate with calcium or even prescribed calcium, taking prescribed vitamin D and B per doctor's instructions can also be helpful strategies. Now, cardiovascular uh changes is that the heart is literally being pushed upward as a result of that expanding of um continual expansion of the fetal development. You might hear, uh, in during the pregnancy that these physiological changes can then lead to sort of, uh, more cardiovascular symptoms such as shortness, um such as uh increase heart rate, increase of cardiac output, for example. This all begins very early on during the pregnancy period, and typically the heart is working at almost 40% higher. Um of increased cardiac output to accommodate for this physiological changes. Um so it's very important that it to understand that there is significant amount of blood being circulated, um to be able to meet the demands of the physiological changes. And so then when car uh uh CO2 increases still more in labor, 15% of it could be happening during the first stage of labor and 50% in the second stage of labor. All of which are cardiovascular changes, including blood pressure changes. Now, when a pregnant woman lies on her back, it's important to understand that the heavy uterus can crush the inferior vena cava because of that heavy weight. So this can drop her blood pressure, making her feel faint and or nauseated and reduced oxygen to the baby. So the fix here is always positioned the patient on her side, uh being the left side is best for blood flow, or use a wedge under one hip to help alleviate some of those pressure off, um while sleeping on the side, and preferably best to prevent sleeping supine on their back.
[21:10]And some of the um other uh symptoms can be ankle edema, which are very common, uh due to that weight gain, and also um can be can be evidence of preeclampsia. Now, mild ankle edema is common, but when generalized edema occurs, that affect also the face and the hands can be red flags of preeclampsia. So always check the blood pressure when we see a sudden swelling and edema occurs, um in patients. Now, it's important to understand the management of that would be to, um that edema would subside on rest with slight elevations of the limb. Maintain good posture because then again, that increased anatomical pressure can be a contributing reason. Restrict excessive salt intake as well as avoiding prolonged standing or sitting. Now with varicose vein as an other type of symptoms that we will noticeably observe in the legs of, uh, patients, is also another very common symptoms. Uh generally speaking, the hormonal changes such as the progesterone uh level can relaxes the veins and then which makes it more difficult for blood to return back, um for leaving the legs to return back to the heart. So some of the interventions to consider can be using of uh supportive shoes, elevate the feet when sitting, lying with feet and hips elevated. Again, to relieve that pressure, uh get adequate rest, avoid leg crossing, because again, that you don't want to increase pressure to it. So long time standing or saying, again, that extended long time pressure, and or also to avoid any constructive clothing as well as to avoid obesity. Because if not, that that added weight gain could just contribute further to that increased abdominal cavity, um pressure, which then leads to much more pressure resistance against the, uh, Venus blood to be returned. So those are again in a cyclical uh effect to one another, which leads to the uh report of symptoms of varicose veins in, um pregnant patient. Now, in the renin angiotensin, uh, the ren the kidney, the renal system, the kidneys and placenta, they work together to increase the production of, um, renin angiotensin 2. Because it helps to manage the massive increase of blood volume that is required to perfuse throughout the placenta as a result of pregnancy. Um so again, as a result of all of these components, they will then increase during this pregnancy period. So it's very important to have a delicate balance between that and as well as hypertension. Now, in respiratory uh changes, again, thinking about it anatomically first. The lower ribs would get flare up because of that increasing push upward. Subcostal angle can increase significantly, transverse diameter of the chest can also increase by 2 centimeter even. The mother really transitions from abdominal breathing to more of a chest thoracic breathing as a result. So some of the functional changes is that the mother is required to breathe deeper, okay? Every single, um, breath to accommodate for that. So it it's to help off to help with that increased demand of respiratory demand. As well as making it easier for the baby CO2 to be released and cross the placenta to the mother. So this is what we refer to as again, a physiological dyspnea. Right. Now in the, uh, genital urinary system, urinary frequency is a very common symptom in the first and the third trimester. Especially when the head of the baby is already sitting on the bladder. And so that which increases the frequencies of urination, as well to during the um third pregnancy. Now some anatomical changes to that, oops, sorry, some of the anatomical changes to that could be a small enlargement in the size of the kidneys, as well as dilation of the renal pelvis, which all of those could lead to functional changes such as increasing renal blood flow, which can increase our GFR rate, the glomerular filtration rate. This means that pregnant women, um, uh, will spill glucose into their urine much more easier than normal. Um when it can, while it can be normal, we, it is important for us to screen for gestational diabetes as a result, as well. Um and so those are also very important observations that needs to be kept track with, um during the pregnancy period. Now, vaginal discharge, um what we refer to as Lauria is important to understand that they are a thin white vaginal discharge. Though is usually normal that because it's caused by the increased estrogen, is important for us to uh teach patients of, um, proper cleansing hygiene, wear cotton underwear to help prevent and reduces the chance of, um, infection, and to cleanse the vulva at least once a day with soap and water, and to dry it thoroughly to prevent infection of yeast, for example. Now, in the entegumentary system, skin, the mask of pregnancy refer to is the chloasma or the dark lines for or the stretch mark even. Are all due to hormonal changes, and most of these will fade after giving birth except for for for example, stretch marks, which may turn into different color pigmentation. Now, if the patient experiences vaginal bleeding, all right? Now or reduced fetal movement, or any frontal and recurring headache, or rupture of the membrane, or sudden nausea and sickness to a very severe level of intensity, and or feeling of epigastric pain, those are all conditions that will required immediate action. Because, for example, with vaginal bleeding, um, there we're concerned about being the risk of preeclampsia. These are again medical conditions that require immediate medical attention. And some other pregnancy complications are captured here in the video. All right. And last but not least, we are going to transition to the psychological side of things um of pregnancy. Now, during the first trimester, psychologically speaking, um, the focus is on the self, the mother. The mother is often ambivalent, um, there could be question about whether do, is she ready? Do I want this, for example? So focusing on her own physical changes and the reality of pregnancy. As time passes and progress into the second trimester, the psychological focus here is on the baby, so accepting the baby. So as the mother, um and the family unit, right? Um comes to accept the baby, feeling the movement of the fetus, um it will then, um increases that focus from the self towards the baby. And last but not least, is well into the third trimester, it's now moving into preparing for the arrival of the baby. So though it's tired, uh, the majority of the time, the mother could be they're tired of the physiological changes during pregnancy, um but then it will then translate into more of an anxiety, uh side of things about the labor, the birth, as well as sort of that newborn care, um as a result. So this concludes our module one, and remember, pregnancy is as much about the spirit and the family, um also the psychological and physiological changes of the body of the mother and also to the family. So it's important for us to understand the signs, the symptoms, as well as what are the red flags during, um pregnancy, all are all very important for us to be well aware and knowledgeable to be able to support our patient. Thank you, and I will see you all in the next lecture.
