UNIT 4 EXAM

Presumptive Signs of Pregnancy

• Experienced by the pregnant person
• Fatigue
• Nausea
• Breast tenderness (3-4 weeks)
• Urinary frequency (6-12 weeks)

Probable Signs of Pregnancy

• Detectable by a healthcare provider
• Goodell sign (softening of the cervix) - 5 weeks
• Chadwick Sign (bluish-purple discoloration of cervix) - 6-8 weeks
• Hegar Sign (softening of the lower portion of uterus) 6-12 weeks
• Positive pregnancy test (4-12 weeks)
• Braxton hicks contractions

Positive Signs of Pregnancy

• Ultrasound (4-6 weeks)
• Fetal movement felt by provider (20 weeks)
• Auscultation of fetal heart tones (10-12 weeks)

Physiological Adaptations During Pregnancy

• Uterus:
  • Increased blood flow and capacity
  • Grows past the pelvis after 12 weeks
  • Lower Uterine Segment:
    • Supine Hypotensive syndrome (pressure on vena cava and aorta when mother lays on back)
  • Fundal Height Measurement: Week 20 = 20 centimeters, should be level of the umbilicus by week 20
  • Braxton Hicks contractions (practice contractions)
  • Upper portion of the uterus has changes in circulation/blood flow
  • Lower portion of uterus gradually gets thinner
• Cervix:
  • Goodells Sign - softening of cervix
  • Chadwicks Sign - bluish-purple color
• Vagina:
  • Vaginal mucosa thickens, connective tissue loosens, vaginal vault lengthens
  • Increased/thickening of secretions (whitish vaginal discharge)
  • Vascularity increases
• Breasts:
  • Fullness
  • Tenderness
  • Nipple changes- enlarge and get darker in color
  • Colostrum- yellowish discharge (liquid gold)

Gastrointestinal System

• GERD
• Bleeding gums
• Increased Dental plaque and Debris, leading to Gingivitis
• Delayed Gastric Emptying
• Constipation
• Heartburn

Cardiovascular System

• Blood Volume (around 1500 ml increase) - results in anemia due to increased plasma
• Heart rate and blood pressure increase
• Hypercoagulable State: fibrin and fibrinogen levels increase, and see an increase in venous stasis

Respiratory System

• Increased oxygen requirements
• Faster and deeper breathing

Renal/Urinary System

• Dramatic changes related to increased blood volume

Musculoskeletal System:

• Changes in posture and gait
• Stretching joints
• Lordosis (bulging of spine inward)
• Waddle Gait (change of elasticity of joints)

Integumentary System

• Hyperpigmentation (nipples expand and darken)
• Striae Gravidarum (stretch marks)
• Linea Nigra (dark line of pigmentation down the midline of the abdomen)
• Varicosities

Endocrine System

• Growing fetus increased glucose demands
• Insulin does not cross the placenta; fetus supplies its own
• Glucose Intolerance (resistance developed by other hormones later on during pregnancy): prolactin, progesterone and estrogen are thought to oppose insulin (Gestational Diabetes)

Changing Nutritional Needs of Pregnancy

• Consider pre-pregnancy weight
• Food Concerns:
  • Mercury
  • Listeriosis
• Maternal Weight Gain:
  • Underweight- 28-40lbs
  • Normal weight- 25-35lbs
  • Overweight- 15-25lbs
  • Obese- 11-20 lbs
• Special Nutritional Considerations:
  • Cultural variations
  • Vegetarians
  • Pica

Dietary Advice:

• Avoid processed foods
• Limit caffeine
• Avoid diuretics
• DO NOT SKIP MEALS: eat 3 meals a day with 1-2 snacks daily

Psychosocial Adaptations

• Maternal Emotional Responses:
  • Ambivalence
  • Acceptance
• Partner:
  • Involve partner in support systems
• Siblings:
  • Prepare siblings for new baby

Preconception and Interconception Care

• Key areas for focus:
  • Immunization status
  • Underlying medical status
  • Reproductive health data
  • Sexuality and sexual practices
  • Support systems
  • Medications/drug use
  • Psychosocial status
  • Lifestyle practices
  • Nutritional history

First Prenatal Visit

• Anticipatory Guidance:
  • Informing the patient on upcoming visits and tests
• Comprehensive Health History:
  • Age
  • Menstrual history
  • Prior obstetric history
  • Past medical/surgical hx
  • Psych/genetic screening
  • Nutritional habits
  • STD exposure
  • Reproductive history (Menstrual History)
• Nagele Rule:
  • First day of last menstrual period, subtract 3 months, add 7 to number of days, adjust year by adding 1 year to determine EDD (Estimated Delivery Date)
• Reproductive History:
  • Obstetric History: Gravida (pregnancy)/para(delivery)
• Physical Examination:
  • Pelvic exam
• Laboratory Tests: - CBC, blood type, rubella titer, Hep B, HIV testing, pap smears, UTI screening, RPR, cultures

OB History:

• G (preganancies)
• P(any delivery over 20 weeks)
• T (Full term deliveries)
• P (preterm deliveries)
• A (abortion- loss of baby under 20 weeks)
• L (living children)

Follow Up Visits

• Every 4 weeks up to 28 weeks
• Every 2 weeks from 29-36 weeks
• Every week from 37 weeks to birth
• March of Dimes: Prenatal Care Checkups
  • Assessments:
    • Weight
    • BP
    • Urinalysis
    • Fetal Growth
    • Fetal movement
    • Apical HR
• Testing for Gestational Diabetes
  • Between 24-28 weeks
  • Oral 50g glucose load => 1 hr plasma glucose - >140mg/dl means further testing
• Testing for Group B Strep
  • Between 37-40 weeks

Protein in urine or excessive weight gain towards the end of pregnancy can indicate preeclampsia (affects the kidneys and can cause fluid retention)

Determining Fetal Well Being

• Fundal Height Measurement
  • McDonald Method (20 weeks old= 20 centimeters, week 21= 21 centimeters, ect.)
  • Until week 36, typically the largest height of the fundus, baby will drop afterward into the pelvic cavern
• Fetal Movement Determination - Count to 10 Method: Track fetal movements; every time you feel movement, keep track - DANGER SIGN: Absence of fetal movement for >12 hours.

DANGER SIGNS DURING PREGNANCY

• First Trimester (conception to 12 weeks)
  • Spotting or bleeding (miscarriage)
  • Painful urination (infection)
  • Severe persistent vomiting (hyperemesis gravidarum)
  • Fever over 100º (infection)
  • Lower abdominal pain with dizziness/Shoulder pain (Ruptured Ectopic Pregnancy)
• Second Trimester (13 to 28 weeks)
  • Regular uterine contractions (preterm labor)
  • Pain in calf (DVT)
  • Sudden Gush/leakage of fluid from vagina (prelabor ROM- rupture of membranes)
  • Absence of fetal movement for >12hrs (fetal distress/demise)
• Third Trimester (29 to 40 weeks)
  • Sudden weight gain
  • Periorbital or facial edema
  • Severe upper abdominal pain
  • Headache with visual changes (gestational HTN, preeclampsia)
  • Decrease in fetal movement (fetal destress/demise)

Assessment of Fetal Well being

• Ultrasonography
  • Non-invasive, Non-radiating
  • Transabdominal
  • Transvaginal
• Doppler Flow Studies
  • Non-invasive
  • Examine blood flow in vessels
  • Monitor fetal growth, placental function, central venous pressure, cardiac function
• Marker Screening Tests
  • Alpha-fetoprotein Analysis
  • Triple Marker Screen
  • Quad Screen
  • Cell Free DNA
• Amniocentesis
  • Obtain amniotic fluid
  • Determine fetal abnormalities
  • Examine fetal lung maturity
  • Complications possible, informed consent required
• Chorionic Villus Sampling (CVS)
  • Obtain small sample of chorionic villi from developing placenta
    • Transabdominal
    • Transcervical
• Nonstress tests (NST) - FHR accelerations: Reactive or non-reactive (Want to see reactive)
• Biophysical profile (BPP) - Five components: Ultrasound and NST - 10 points possible

Childbirth Preparation

• Perinatal education
  • Childbirth education
    • Lamaze
    • Bradely
    • Dick-read
• Review options:
  • Birth setting
  • Care provider
  • Finding choices
• Final preparation for labor and birth

Vulnerable Populations

• Pregnant adolescents
• Women of advanced maternal age

Presumptive Signs of Pregnancy

• Experienced by the patient
• Fatigue
• Nausea
• Breast Tenderness (3-4 weeks)
• Urinary Frequency (6-12 weeks)

Probable Signs of Pregnancy

• Detectable by the provider
• Goodell's sign (softening of the cervix) 5 weeks
• Chadwick's Sign (bluish-purple discoloration of the cervix) 6-8 weeks
• Hegar's Sign (softening of the lower portion of the uterus) 6-12 weeks
• Positive pregnancy test 4-12 weeks
• Braxton Hicks contractions

Positive Signs of Pregnancy

• Ultrasounds (4-6 weeks)
• Fetal movement felt by the provider 20 weeks
• Auscultation of fetal heart tones (10-12 weeks)

Uterine Adaptations During Pregnancy

• Increase in blood flow and capacity
• After 12 weeks, uterus starts growing past the pelvis
• Lower uterine segment gradually gets thinner
• Fundal Height:
  • Week 20, uterus should be at the level of the umbilicus (20 centimeters)
• Braxton Hicks contractions
• Supine Hypotensive Syndrome:
  • Mother is laying on her back, increases pressure on the vena cava and aorta-
  • Can cause dizziness, faintness, etc.
• Uterus puts pressure on the diaphragm, bladder and stomach as baby grows

Cervix Adaptations During Pregnancy

• Goodells Sign - softening of cervix
• Chadwicks Sign - bluish-purple color

Vagina Adaptations During Pregnancy

• Vaginal mucosa thickens, connective tissue loosens, vaginal vault lengthens
• Increased/thickening of secretions (whitish vaginal discharge)
• Vascularity increases

Breast Adaptations During Pregnancy

• Fullness
• Tenderness
• Nipple changes- enlarge and get darker in color
• Colostrum- yellowish discharge (liquid gold)

Gastrointestinal System Adaptations During Pregnancy

• GERD
• Bleeding gums
• Increased dental plaque, debris, and gingivitis
• Delayed Gastric Emptying
• Constipation
• Heartburn

Cardiovascular System Adaptations During Pregnancy

• Blood Volume increases around 1500 ml (expect to see a level of anemia because of the increase in plasma)
• Heart rate and blood pressure increase
• Blood components: (hypercoagulable state) - fibrin and fibrinogen levels increase, and see an increase in venous stasis

Respiratory System Adaptations During Pregnancy

• Increased oxygen requirements
• Individual breathes faster and deeper

Renal/Urinary Adaptations During Pregnancy

• Dramatic changes due to increased blood volume

Musculoskeletal System Adaptations During Pregnancy

• Changes in posture and gait
• Stretching joints
• Lordosis (bulging of spine inward)
• Waddle Gait (change of elasticity of joints)

Integumentary System Adaptations During Pregnancy

• Hyperpigmentation (nipples expand and darken)
• Striae Gravidarum (stretch marks)
• Linea Nigra (dark line of pigmentation down the midline of the abdomen)
• Varicosities

Endocrine System Adaptations During Pregnancy

• Pancreas:
  • Growing fetus has growing glucose demands
  • Insulin does not cross the placenta; fetus supplies its own
  • Glucose intolerance (resistance developed by other hormones later on during pregnancy) prolactin, progesterone and estrogen are thought to oppose insulin (Gestational Diabetes)

Changing Nutritional Needs of Pregnancy

• Consider pre-pregnancy weight
• Food concerns:
  • Mercury
  • Listeriosis

Maternal Weight Gain

• Steady weight gain week by week
• Underweight- 28-40 lbs
• Normal weight- 25-35 lbs
• Overweight- 15-25 lbs
• Obese- 11-20 lbs

Special Nutritional Considerations

• Cultural variations
• Vegetarians
• Pica

Nutritional Recommendations

• Avoid processed foods
• Limit caffeine
• Avoid diuretics
• DO NOT SKIP MEALS, eat 3 meals a day with 1-2 snacks daily

Psychosocial Adaptations

• Maternal Emotional Responses
  • Ambivalence
  • Acceptance
• Partner
• Siblings

Preconception and Interconception Care

• Key areas for focus:
  • Immunization status
  • Underlying medical status
  • Reproductive health data
  • Sexuality and sexual practices
  • Support systems
  • Medications/drug use
  • Psychosocial status
  • Lifestyle practices
  • Nutritional history

First Prenatal Visit

• Anticipatory guidance
• Comprehensive Health history
  • Age
  • Menstrual history
  • Prior obstetric history
  • Past medical/surgical history
  • Psych/genetic screening
  • Nutritional habits
  • STD exposure
  • Reproductive history (Menstrual History)

Nagele's Rule

• First day of first menstrual period, subtract 3 months, add 7 days, adjust year by adding 1 year to determine EDD (Estimate Delivery Date)

Reproductive History

• Gravida (pregnancy)/para(delivery)

Physical Examination

• Pelvic exam

Laboratory tests

• CBC
• Blood type
• Rubella titer
• Hep B
• HIV testing
• Pap smears
• UTI screening: RPR, cultures
• GTPAL
  • G (preganancies)
  • P(any delivery over 20 weeks)
  • T (Full term deliveries)
  • P (preterm deliveries)
  • A (abortion- loss of baby under 20 weeks)
  • L (living children)

Follow Up Visits

• Every 4 weeks up to 28 weeks
• Every 2 weeks from 29-36 weeks
• Every week from 37 weeks to birth

March of Dimes: Prenatal Care Checkups

• Assessments
  • Weight
  • BP
  • Urinalysis
  • Fetal Growth
  • Fetal movement
  • Apical HR

Testing for Gestational Diabetes

• Between 24-28 weeks
• Oral 50g glucose load => 1 hr plasma glucose

  • 140mg/dl means further testing

Testing for Group B Strep

• Between 37-40 weeks

Protein in urine or excessive weight gain towards the end of pregnancy

• Can indicate preeclampsia (affects the kidneys and can cause fluid retention)

Determining Fetal Well Being

• Fundal Height Measurement
  • McDonald Method (20 weeks old= 20 centimeters, week 21= 21 centimeters, etc.)
  • Until week 36, typically the largest height of the fundus, babys will drop afterward into the pelvic cavern

Fetal Movement Determination

• Count to 10 method - every time you feel the baby move, keep tracking movements

DANGER SIGNS DURING PREGNANCY

First Trimester (conception to 12 weeks)

• Spotting or bleeding (miscarriage)
• Painful urination (infection)
• Severe peristent vomiting (hyperemesis gravidarum)
• Fever over 100º (infection)
• Lower abdominal pain with dizziness/Shoulder pain (Ruptured Ectopic Pregnancy)

Second Trimester (13 to 28 weeks)

• Regular uterine contractions (preterm labor)
• Pain in calf (DVT)
• Sudden Gush/leakage of fluid from vagina (prelabor ROM- rupture of membranes)
• Absence of fetal movement for >12hrs (fetal distress/demise)

Third Trimester (29 to 40 weeks)

• Sudden weight gain
• Periorbital or facial edema
• Severe upper abdominal pain
• Headache with visual changes (gestational HTN, preeclampsia)
• Decrease in fetal movement (fetal distress/demise)

Assessment of Fetal Well Being

Ultrasonography

• Non invasive
• Non radiating
• Transabdominal
• Transvaginal

Doppler Flow Studies

• Non-invasive
• Examine blood flow in vessels
• Monitor fetal growth, placental function, central venous pressure, cardiac function

Marker Screening Tests

• Alpha-fetoprotein Analysis
• Triple Marker Screen
• Quad Screen
• Cell Free DNA

Amniocentesis

• Obtain amniotic fluid
• Fetal abnormalities
• Fetal lung maturity
• Ultrasound
• Complications

Chorionic Villus Sampling

• Obtain small sample of chorionic villi from the developing placenta
• Transabdominal
• Transcervical
• Significant risks => informed consent

Nonstress tests

• FHR accelerations
• Reactive or non reactive (Want to see reactive)

Biophysical profile (BPP)

• Five components
• Ultrasound
• NST
• 10 points possible

Childbirth Preparation

• Perinatal education
• Childbirth education
  • Lamaze
  • Bradely
  • Dick-read
• Review options
  • Birth setting
  • Care provider
  • Finding choices
• Final preparation for labor and birth

Vulnerable populations

• Pregnant adolescents
• Woman of advanced maternal age