Prenatal Care and Pregnancy Physiology

Uncomplicated Healthy Pregnancy

• Focuses on the changes in the female reproductive system, cardiovascular and hematologic system, respiratory system, gastrointestinal system, genitourinary system, and skin during pregnancy
• Six essential hormones are also assessed

Female Reproductive System Changes

• Early pregnancy sign is the uterus adapting to support the growing fetus
• Amenorrhea (absence of menstruation) is an early sign

Uterine Growth

• Hypertrophy leads to the thickening of muscle fibers in the uterus
• Hyperplasia leads to an increase in the number of cells

Hormonal Influence

• Estrogen promotes blood flow, thickens the uterine wall, and aids fetal development
• Progesterone maintains the uterine lining and prevents contractions

Breast Changes

• Remodeling of the vascular system increases for milk production
• Production of colostrum is early milk that is thick, yellow/white fluid and contains antibiotic protein for the first life of the baby

Cardiovascular and Hematologic System

• Blood volume increases 30-50% to meet fetal oxygen demands
• Cardiac output and heart rate increase, cardiac output is ~20% higher than pre-pregnancy
• The heart enlarges due to increased workload, specifically the left ventricle thickens
• Blood pressure decreases due to reduced vascular resistance, but returns to normal before birth
• Clotting factor increase by 5x, leading to increased risk of blood clots
• Gravid uterus (pregnant uterus) presses on pelvic/femoral veins, leading to varicose veins

Respiratory System

• Respiratory rate increases due to increased oxygen demand
• Lung expansion decreases because of pressure on the diaphragm
• Hyperventilation helps remove CO2
• Lightening occurs when the baby drops lower in late pregnancy, easing breathing

Gastrointestinal System

• Stomach and intestinal displacement causes early fullness and reflux
• Progesterone effects delays gastric emptying, leading to heartburn, nausea, and vomiting
• Progesterone effects reduces intestinal motility leading to constipation

Genitourinary System

• Kidney size increases by 30% and GFR increases by 50%
• Early pregnancy urinary frequency is due to hCG and progesterone
• Later in pregnancy, urinary frequency is due to the uterus pressing on the bladder
• Glycosuria (glucose in urine) and proteinuria (protein in urine) are expected but should be monitored

Endocrine System (Pregnancy Hormones)

• Six essential hormones are assessed for pregnancy
• hCG (human chorionic gonadotropin) is the basis for pregnancy tests and maintains the corpus luteum
• Progesterone maintains the uterine lining and prevents contractions
• Estrogen promotes blood vessel growth and supports fetal development
• Prolactin prepares the breasts for milk production
• Relaxin softens the cervix, relaxes the uterus, and expands blood vessels
• Oxytocin triggers contractions and bonding between mother and baby

Other Key Hormones During Pregnancy

• Placental Growth Hormone increases maternal tissue growth and causes insulin resistance
• Aldosterone and Cortisol cause fluid retention, leading to hypervolemia and edema

Musculoskeletal System

• Flexibility of joints are increased through relaxin and progesterone to loosen joints for childbirth
• Postural changes include exaggerated curve, causing back pain, and pelvic tilt, leading to hip pain

Integumentary System (Skin Changes)

• Stretch marks (Striae Gravidarum) are common on the abdomen, breasts, hips, and thighs
• Hyperpigmentation leads to the linea nigra (dark line on the belly) and melasma (mask of pregnancy - brown patches on the face)

Diastasis Recti

• Separation of abdominal muscles can cause bulging

Key Medical Terms to Remember

• Ballottement: Pushing the uterus to feel fetal movement.
• Braxton Hicks Contractions: False labor contractions.
• Chadwick's Sign: Blue discoloration of cervix/vagina (early pregnancy sign).
• Goodell's Sign: Softening of the cervix.
• Hegar's Sign: Softening of the uterus.
• Quickening: Feeling first fetal movements (16-20 weeks).
• Supine Hypotension: Low blood pressure when lying on the back due to baby pressing on veins.
• Preeclampsia: High blood pressure after 20 weeks, may include proteinuria, swelling, headaches.
• Gestational Diabetes: Diabetes during pregnancy due to insulin resistance.

Signs of Pregnancy

• Essential for positive maternal and fetal health outcomes
• Aids in early detection of fetal anomalies and maternal conditions
• Provides education on nutrition, weight gain, vitamin supplements, and healthy behaviors
• WHO recommends at least 8 visits (1 in the first trimester, 2 in the second, and 5 in the third)

Presumptive Signs (Felt by the Client)

• Amenorrhea (missed period)
• Breast tenderness/enlargement
• Nausea, vomiting, fatigue
• Urinary frequency
• Melasma (skin changes)

Probable Signs (Detected by Provider)

• Positive pregnancy test (hCG in urine/blood)
• Goodell's sign - softening of the cervix
• Hegar's sign - softening of the lower uterus
• Chadwick's sign - bluish discoloration of the cervix
• Ballottement - fetal movement when tapped during an exam

Positive Signs (Fetal Confirmation)

• Ultrasound visualization of fetus
• Fetal heart activity detected

First Prenatal Visit

• Establishes provider-client relationship
• Involves history taking, physical exam, lab tests, and education Client history includes: Medical/Surgical, pregnancy/menstrual, Family history, STI, substance use

Obstetrical History (Using GTPAL System)

• Total pregnancies= Gravida
• Term births (37+ weeks)
• Preterm births (<37 weeks)
• Abortions (spontaneous or elective)
• Living children

Estimating Due Date (Naegele's Rule)

• Formula: LMP (first day) - 3 months + 7 days
• Example: LMP = Feb 1 → EDB = Nov 8
• Ultrasound can estimate gestational age, when LMP is unknown

Fundal Height Measurement

• Measured from pubic symphysis to fundus (top of the uterus)
• Correlates to gestational age in weeks (±2 cm variation)
• Used between 20-36 weeks

Substance Use in Pregnancy

• Smoking causes fetal growth restriction, preterm birth, & miscarriage
• Alcohol/Drugs can be teratogenic (birth defects)
• Nicotine replacement (patches, gum) may help in quitting

Substance Use Screening Questions

• "During this pregnancy, have you used alcohol or drugs?"

Sexually Transmitted Infections (STIs)

• Take a nonjudgmental approach
• High-risk behaviors may continue during pregnancy

The 5 Ps of STI Screening

• Partners (Number & gender)
• Practices (Sexual activities & behaviors)
• Protection (Condom use, vaccinations, HIV prevention)
• Past STI history
• Pregnancy intention (Desire to conceive)

Depression in Pregnancy

• Pregnancy in childbearing age can increase pre term birth, Low birth weight, longer hospitalization
• Screening helps in early intervention (counseling, medications)

Key Terms to Remember

• Morbidity: Illness or disease occurrence.
• Mortality: Death rate.
• Neonate: Is a newborn baby, usually in the first 28 days
• Teratogenic: Causes birth defects.
• Ballottement: Floating fetus felt when topped during an exam

Initial Steps of Physical Examination

• Client's height, weight, and vital signs are obtained
• BMI is calculated
• Providers can also perform breast and pelvic exams
• Fetal heart rate is checked using Doppler or fetoscope
• Should be between 110-160 bpm
• If no heart rate is heard by 12 weeks, an ultrasound should be done for further assessment

Laboratory testing

• Prenatal panel includes a variety of tests

• Complete blood count ( CBC)

• Blood type & Rh factor

• Rubella immunity

• Hepatitis B screening

• Urine culture is done for infection and to monitor for gestational diabetes or preeclampsia

• Monitoring the hematocrit or hemoglobin levels.

• Assess to detect anemia where iron supplementation is recommended.

• Hepatitis B positive clients may need immunization for their newborn within 12 hours after birth.

Rh Factor & Isoimmunization

• Factor testing assessing whether the blood carries the Rh protein
• Rh-negative mothers develop antibodies against Rh-positive fetal blood
• Rh incompatibility leads to hemolytic disease in the newborn
• RhoGAM (Rh immune globulin) is given to prevent sensitization
• At 28 weeks after delivery, after trauma, invasive procedure, or delivery of an Rh-positive infant

Rubella and HIV Testing

• Rubella testing is done to check immunity
• MMR vaccine is given postpartum if not immune
• HIV screening is recommended for all pregnant clients
• Repeat test later in pregnancy for high risk HIV
• Syphilis screening is also completed, penicillin treatment is given if positive

Diagnostic testing

• An ultrasound can be used to assess for: pregnancy viability dating, anomaly,multiple gestation
• Chorionic villus sampling (CVS)' done between 10 to 13 weeks if there is abnormal screening high risk

Pregnancy Education

• Weight gain In pregnancy
• Based on BMI, range from 11-40 lbs on pregnancy
• Nutrition: Should encourage diet high in food, vegetables , and whole grains
• Prenatal vitamins are essential: vitamin D, folic acid, calcium, iron
• Folic acid prevent neural tube defects

Avoid

• Must avoid to eat raw and undercooked food
• Fish high in mercury

Discomforts & Relief in Pregnancy

• Nausea and Vomiting: Is very common in early pregnancy
• Ginger and small meals may help with symptoms
• Heartburn
• Elevate head and eat small frequent meals
• Should avoid eating late night and greasy food
• Antacids can help neutralize acid and alleviate symptoms

Exercise During Pregnancy

• Can be safe and beneficial for women with un complicated emergencies
• Walk, mild to modreate exercises three times a week recommended
• Reduce back pain, Regular exercise can strengthen back and leg muscles

Pets and Toxoplasmosis

• Cat litter carry toxoplasmosis and cause cognitive disabilities or blindless
• Avoid toxoplasmosis by ensure that they are closed, and cats are in a litter box
• Travel:
• Vaccination
• First trimester will be recommended if un complications present

Pregnant clients can keep their cats by

• Avoid changing cat litter
• Wash hand
• Keep Indoor
• Sandboxes covered

Sexual Intercourse:

• Allow for safe sexual intercourse
• Client made experience spotting, cramping, and pain
• *Risky behaviors: Addressed with education of the potential list of with in St is
• *Addtional List: Me included for clients high risk behaviors

Vaccinations

• Vaccinations are critical to the health of both mother and fetus
• Vaccinnation is highly recommenced reduce to severe disease
• The Tdap vaccine that will portend both pregnant clients and their newborn
• Vaccinations are contracted during pregnancy
• Due to risk of congenial infections and miscarragie

Second Trimester Follow-up Care

• Prenatal visits are recommended every 4-6 weeks
• The purpose is to ensure healthy progression and monitor for complications
• Weight is assessed at each visit to monitor for unexpected weight loss or gain

Blood pressure and urine tests

• These test check for hypertension and preeclampsia
• Ultrasound at 10–20 weeks can measure the height and assets of fetus and height
• Will be assisted with with dropper come from normal rate

Testing, Testing, Labratory

• Internal serum screening is for testing Down syndrome
• If negative of the Rh, and anti body will performed 24 weeks will reduce the hemolytic desiese fetus
• If the client has had a screening for gestational and results abnormal glucose test will be requested

Diagnostic Testing of the pregnancy

• Body changes in a weight gain accelerate in the set trimester with increase appetite
• Hear burn, constipation, and urinary frequency
• the uterus the back may experience more strain leading to back pain proper shoes can correct this

Common discomforts in the second trimester

• Can occur as an abdomen stretches

• Client will start to notice that she can move from 16 to 28 weeks

• Consider enrolling in birth education for better outcomes

• Complications for safe sexual intercourse are vaginal, aniotic fluid

• Some may increase sex drive or decrease in vomiting

• DVT for traveling

• Sock, take break

Warning Manifestations

• Tighting of the uterus normal,
• Contraction more than 1 hour
• Vaginal breeding or fluid leakage
• Severe abdominalpain or cramping Breathlessness, head ache, right side abdominal pain

Third Timester Notes for Prenatal Care

• Frequency: Every 2-4 weeks util 36 weeks then the visits are weekly

• Will be a fetal well being, including feetl heart rate

• fundal measured in centimeters to assess the fetus

• Screening , include GBS,RH ,and STI

Laboratory Testing

• Group B will swab from gina and rectum will gie 4 antiobiotics to protect the neonate
• Rh wil take negative RH negative who has the 2nd trimester
• Early ,screen may occur during 3rd trimester STI screening or if additonal is nessary
• Posttermp regnancy: beyond 42 week Definition: pregnancy extending beyond 42 weeks Risk: increased risk from vaginal to birth in injury
• Monitoring: additional tests that monitor client and feetl saftely

Body changes & Discomforts

O: Hemorroids,Swollen veins in the anal

• Area where they have pressure give fiber an teach the client.

• Monitor before signs like hrt and head

• Monitorfor the same is normal

• Fetal mvmts: Instruct clinicients to monitor Time ,less than 10 in 2-3 hours should prompt a healthcare provider

• Some some airline restrictions should be restricted

##Preparing Education

1. Is is best the client is educated ,to help the pain

• will explain that they will be there from the moment ti birsth and after