Signs and Symptoms of Pregnancy
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Questions and Answers

Which of the following is classified as a presumptive sign of pregnancy?

  • Positive pregnancy test
  • Goodell sign
  • Nausea (correct)
  • Ultrasound

    • What is the earliest probable sign of pregnancy that can be detected by a healthcare provider?

  • Positive pregnancy test
  • Hegar Sign
  • Chadwick Sign
  • Goodell Sign (correct)

    • At what gestational age does fetal movement typically become detectable by a provider?

  • 24 weeks
  • 16 weeks
  • 12 weeks
  • 20 weeks (correct)

    • Which physiological adaptation happens to the uterus during pregnancy?

    <p>Increase in capacity and blood flow</p> Signup and view all the answers

    What symptoms are associated with supine hypotensive syndrome during pregnancy?

    <p>Dizziness and faintness</p> Signup and view all the answers

    Which sign indicates the softening of the lower portion of the uterus and can be identified by a healthcare provider?

    <p>Hegar Sign</p> Signup and view all the answers

    What term describes the practice contractions that occur during pregnancy?

    <p>Braxton Hicks contractions</p> Signup and view all the answers

    When does positive auscultation of fetal heart tones typically occur in pregnancy?

    <p>10-12 weeks</p> Signup and view all the answers

    Which of the following is NOT a symptom experienced during the early weeks of pregnancy?

    <p>Vaginal bleeding</p> Signup and view all the answers

    Which statement about the lower portion of the uterus during pregnancy is correct?

    <p>It gradually gets thinner.</p> Signup and view all the answers

    What is the expected position of the uterus at week 20 of pregnancy?

    <p>At the level of the umbilicus</p> Signup and view all the answers

    Which of the following signs indicates softening of the cervix during pregnancy?

    <p>Goodells Sign</p> Signup and view all the answers

    What is a common gastrointestinal symptom experienced during pregnancy?

    <p>Acid reflux</p> Signup and view all the answers

    What is the recommended weight gain for an underweight woman during pregnancy?

    <p>28-40 lbs</p> Signup and view all the answers

    Which of the following is NOT a danger sign during the second trimester of pregnancy?

    <p>Increased fetal movement</p> Signup and view all the answers

    Which method is used to estimate the due date based on the first day of the last menstrual period?

    <p>Nagele Rule</p> Signup and view all the answers

    Which of the following is an indication of preeclampsia during pregnancy?

    <p>Protein in urine</p> Signup and view all the answers

    What is the primary focus of prenatal care during follow-up visits at 29-36 weeks of pregnancy?

    <p>Monitor fetal growth and maternal health</p> Signup and view all the answers

    Which of the following indicates the need for further testing after a glucose screening for gestational diabetes?

    <blockquote> <p>140 mg/dl plasma glucose level</p> </blockquote> Signup and view all the answers

    During pregnancy, the increased levels of which hormone are linked to the development of insulin resistance?

    <p>Progesterone</p> Signup and view all the answers

    Which pelvic shape is most favorable for vaginal birth?

    <p>Gynecoid</p> Signup and view all the answers

    What effect does walking have on false labor contractions?

    <p>Contractions stop or slow down</p> Signup and view all the answers

    Which term describes the relationship of the fetal body parts during labor?

    <p>Fetal attitude</p> Signup and view all the answers

    In what stage of labor does complete dilation occur?

    <p>Second stage</p> Signup and view all the answers

    What is the term for the level of the presenting part in relation to the maternal ischial spines?

    <p>Fetal station</p> Signup and view all the answers

    Which of the following is an incorrect factor in affecting the labor process?

    <p>Fetal age</p> Signup and view all the answers

    During which phase of the first stage of labor does cervical dilation range from 0 to 6 centimeters?

    <p>Latent phase</p> Signup and view all the answers

    What should be done for pain management during labor according to the additional considerations?

    <p>Utilize a multi-faceted approach including medications and support</p> Signup and view all the answers

    What is an abnormal fetal presentation that is considered dangerous during labor?

    <p>Shoulder presentation</p> Signup and view all the answers

    What is the term for the period of active pushing during labor?

    <p>Pelvic phase</p> Signup and view all the answers

    What indicates that a baby is tolerating labor well during fetal heart rate assessment?

    <p>Moderate variability</p> Signup and view all the answers

    Which condition is indicated by a late deceleration in fetal heart rate?

    <p>Uteroplacental insufficiency</p> Signup and view all the answers

    Which of the following fetal heart rate changes is considered a very bad sign?

    <p>Variable decelerations</p> Signup and view all the answers

    In what manner should the mother's position be changed if variable decelerations are observed?

    <p>To a left lateral position</p> Signup and view all the answers

    Which of the following is NOT classified under pharmacologic interventions for labor?

    <p>Acupuncture</p> Signup and view all the answers

    Which maternal assessment is crucial during the admission and first stage of labor?

    <p>Cervical dilation and effacement</p> Signup and view all the answers

    What is the ideal response in fetal heart rate when tactile stimulation is applied?

    <p>It should increase by at least 15 bpm for 15 seconds</p> Signup and view all the answers

    In the context of assisting with delivery, what is the indication for performing an episiotomy?

    <p>To prevent laceration of the perineum</p> Signup and view all the answers

    What does the presence of tachycardia in the fetus typically indicate?

    <p>Fetal infection</p> Signup and view all the answers

    Which factor is associated with first-degree laceration during delivery?

    <p>Involvement of the vaginal mucosa only</p> Signup and view all the answers

    Which of the following is a probable sign that can be detected by a healthcare provider during pregnancy?

    <p>Goodell sign</p> Signup and view all the answers

    What physiological change occurs in the lower portion of the uterus during pregnancy?

    <p>Gradual thinning</p> Signup and view all the answers

    At what point can fetal movement be felt by a healthcare provider?

    <p>20 weeks</p> Signup and view all the answers

    What symptoms occur when a pregnant woman lies supine, potentially leading to dizziness or fainting?

    <p>Supine hypotensive syndrome</p> Signup and view all the answers

    Which sign indicates the earliest detectable change in the cervix during pregnancy?

    <p>Goodell sign</p> Signup and view all the answers

    What is the typical timeframe for the onset of Braxton Hicks contractions during pregnancy?

    <p>Around 20 weeks</p> Signup and view all the answers

    Which of the following best describes the relationship of the uterus with the surrounding organs as it grows during pregnancy?

    <p>It compresses the diaphragm and stomach.</p> Signup and view all the answers

    What is the primary reason for increased glucose demands during pregnancy?

    <p>Growing fetus's needs</p> Signup and view all the answers

    What vascular change occurs in the cardiovascular system during pregnancy?

    <p>Increase in venous stasis</p> Signup and view all the answers

    Which of the following is an appropriate weight gain recommendation for a normal weight woman during pregnancy?

    <p>25-35 lbs</p> Signup and view all the answers

    Which sign during the third trimester is an indication of potential gestational hypertension?

    <p>Severe upper abdominal pain</p> Signup and view all the answers

    What change in the respiratory system is expected as a physiological adaptation during pregnancy?

    <p>Increased oxygen requirements</p> Signup and view all the answers

    Which of the following factors does NOT influence the onset of labor?

    <p>Maternal weight gain patterns</p> Signup and view all the answers

    In the context of maternal nutrition during pregnancy, which of the following is considered a potential concern?

    <p>Consumption of processed foods</p> Signup and view all the answers

    Which of the following procedures is NOT typically performed to assess fetal well-being during pregnancy?

    <p>Routine blood pressure measurement</p> Signup and view all the answers

    Which change is a common adaptation of the musculoskeletal system during pregnancy?

    <p>Lordosis development</p> Signup and view all the answers

    What characterizes the contractions experienced during false labor?

    <p>Irregular and frequently weak in strength</p> Signup and view all the answers

    Which pelvic shape is considered not favorable for vaginal birth?

    <p>Android</p> Signup and view all the answers

    What is the term for the relationship of the fetal body parts during labor?

    <p>Fetal attitude</p> Signup and view all the answers

    In which stage of labor does the expulsion of the placenta occur?

    <p>Third stage</p> Signup and view all the answers

    What is the primary force responsible for cervical dilation during labor?

    <p>Contractions of the uterus</p> Signup and view all the answers

    Which of the following factors is NOT commonly considered part of the '5P's' affecting the labor process?

    <p>Pain management</p> Signup and view all the answers

    What does the term 'engaged' refer to regarding fetal descent during labor?

    <p>Fetus begins to descend through the birth canal</p> Signup and view all the answers

    Which fetal presentation is considered optimal for vaginal delivery?

    <p>Cephalic</p> Signup and view all the answers

    What is the expected fetal position reference when assessing during labor?

    <p>R or L side and Anterior or Posterior</p> Signup and view all the answers

    Study Notes

    Presumptive Signs of Pregnancy

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

    Probable Signs of Pregnancy

    • Detected by the 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 thins
      • Fundal height measurement
        • At 20 weeks, the fundus should be at the level of the umbilicus (~20 cm)
      • Supine hypotensive syndrome (pressure on vena cava and aorta) can cause dizziness, fainting, etc.
      • Braxton Hicks contractions (practice contractions)
    • Cervix:
      • Goodell’s Sign - softening of cervix
      • Chadwick’s Sign - bluish-purple discoloration
    • Vagina:
      • Thickening of vaginal mucosa
      • Loosening of connective tissue
      • Lengthening of vaginal vault
      • Increased/thickening of secretions (whitish vaginal discharge)
      • Increased vascularity
    • Breasts:
      • Fullness
      • Tenderness
      • Nipple changes- enlargement and darkening
      • Colostrum- yellowish discharge (liquid gold)
    • Gastrointestinal System:
      • GERD
      • Bleeding gums
      • Increased dental plaque, debris and Gingivitis
      • Delayed gastric emptying
      • Constipation
      • Heartburn
    • Cardiovascular System:
      • Increase in blood volume (~1500 mL)
      • Expect to see a level of anemia due to increase in plasma
      • Increase in heart rate and blood pressure
      • Hypercoagulable state (increased fibrin and fibrinogen levels, increased venous stasis)
    • Respiratory System:
      • Increased oxygen requirements
      • Faster and deeper breathing
    • Renal/Urinary:
      • Dramatic changes related to increased blood volume
    • Musculoskeletal System:
      • Changes in posture and gait
      • Joint stretching
      • Lordosis (bulging of spine inward)
      • Waddle Gait
    • Integumentary System:
      • Hyperpigmentation
      • Striae Gravidarum (stretch marks)
      • Linea Nigra (dark line of pigmentation down the midline of the abdomen)
      • Varicosities
    • Endocrine System:
      • Pancreas:
        • Growing fetus increases glucose demand
        • Insulin does not cross the placenta (fetus supplies its own)
        • Glucose Intolerance can develop due to other hormones (prolactin, progesterone, and estrogen) opposing insulin (Gestational Diabetes)

    Changing Nutritional Needs During Pregnancy

    • Consider pre-pregnancy weight
    • Food concerns:
      • Mercury
      • Listeriosis
    • Maternal weight gain:
      • Should be steady 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
    • General Dietary Advice:
      • Avoid processed foods
      • Limit caffeine
      • Avoid diuretics
      • Do NOT skip meals - eat 3 meals a day with 1-2 snacks daily

    Preconception and Interconception Care

    • Key areas of 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 including:
        • Age
        • Menstrual history
        • Prior obstetric history
        • Past medical/surgical history
        • Psych/genetic screening
        • Nutritional habits
        • STD exposure
        • Reproductive history (Menstrual History)
      • Nagele Rule - to determine Estimated Delivery Date (EDD):
        • First day of first menstrual period, subtract 3 months, add 7 to number of days, adjust year by adding 1 year
      • 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)

    Obstetric History:

    • G - Gravida (pregnancies)
    • P - Para (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 preclampsia (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, the baby will drop afterward into the pelvic cavern
    • Fetal Movement Determination
      • Count to 10 method - every time you feel baby movement track the movements

    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
      • Check for fetal abnormalities
      • Check for fetal lung maturity
      • Ultrasound used
      • Complications possible
    • Chorionic Villus Sampling
      • Obtain small sample of chorionic villi from developing placenta
      • Transabdominal
      • Transcervical
      • Significant risks => informed consent
    • Nonstress tests (NST)
      • 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
      • Women of advanced maternal age

    Factors Influencing the Onset of Labor

    • Uterine stretching
      • Elongates
      • Cervical effacement
      • Cervical Dilation
    • Progesterone withdrawal
    • Increased oxytocin sensitivity
    • Increased release of prostaglandins
    • Contractions happen from fundus down

    Premonitary Signs of Labor

    • Lightning Bolt (Belly Drop): Baby descends into the pelvis
    • Braxton-Hicks Contractions: Body getting ready for labor
    • Cervical Changes:
      • Softening of the cervix (Stretching and thinning)
      • Effacement of uterine walls
    • Bloody Show:
      • Dislodgment of the mucus plug, may cause some bleeding (sign of cervical change)
    • Rupture of Membranes (Water Breaking):
      • Fluid should be clear
      • Any odor or green color indicates meconium
      • If water breaks, ensure the umbilical cord isn't outside the vagina (EMERGENCY)
    • Sudden burst of energy: "Nesting," preparing for baby, increased focus

    True vs. False Labor

    • True Labor:
      • Contraction timing: Regular
      • Contraction strength: Stronger with time
      • Contraction discomfort: Starts in the back and radiates to the front of the abdomen
      • Change in activity: Contractions continue regardless of position changes
    • False Labor:
      • Contraction timing: Irregular
      • Contraction strength: Frequently weak
      • Contraction discomfort: Usually felt in the front of the abdomen
      • Change in activity: Contractions may stop or slow down with walking/positioning

    Factors Affecting Labor Process (5 P’s)

    • 1. Passageway
      • Birth canal: pelvis and soft tissue
      • Mother’s pelvic size:
        • True pelvis (inlet baby has to pass through)
        • False pelvis (Bony flares at the hip)
      • Birth passage: Pelvic Shape
        • Gynecoid (Most common and most favorable)
        • Android (Not favorable for vaginal birth)
        • Anthropoid (More narrow, may still work for birthing)
        • Platypelloid (Not favorable for vaginal birth)
      • Cervix: Dilation & Effacement
      • Pelvic floor muscles: Provide resistance for baby’s rotation
    • 2. Passenger
      • Fetal Head:
        • Reference Pont (make sure head is down, biggest part of baby coming out first)
        • Nurses feel for the occipital bone and both fontanels
      • Fetal attitude: relationship of body parts (flexion of neck, arms, legs)
      • Fetal Lie: Axis of mom-baby
        • Longitudinal (Parallel)
        • Transverse (Sideways)
        • Oblique (Diagonal)
      • Fetal presentation: Presenting part entering first
        • Cephalic (optimal)
        • Breech
        • Shoulder
        • NC: vaginal exam, Leopold’s maneuver
      • Types of Fetal Presentations:
        • Vertex presentation (smallest diameter coming through)
        • Military presentation (A bit larger than vertex)
        • Brow presentation (Even larger)
        • Face presentation (Very large diameter)
        • Shoulder presentation (Not safe for baby, to the OR)
        • Hip or bottom presentation (Frank Breech, won’t do delivery vagianlly, legs stay flexed)
        • Complete breech (legs stay open)
        • Footling breech (feet first, to the OR)
      • Fetal Position:
        • R or L: side of pelvis
        • Presenting part: Occiput, Mentum, Sacrum
        • Part-Pelvis: Antierior, Posterior, Transversal
      • Fetal Station: Level of presenting part in relation to the maternal ischial spines (usually the narrowest diameter through which the fetus must pass)
      • Engagement
        • Floating: Level of spine is 0
        • Dipping: Fetal head dips into inlet, ballotable
        • Engaged: Presenting part is at level of ischial spines
    • 3. Powers:
      • Forces of Labor
        • Primary: Contractions => Dilation/effacement, thin and dilate the cervix
          • Contractions/Waves:
            • Frequency: Onset-onset
            • Duration: Length beginning-end
            • Intensity: At peak (mild, moderate, strong by palpation)
        • Secondary: Abdominals => Pushing
    • 4. Position:
      • Standing and walking promote cervical changes
      • Squatting opens pelvis to help progress labor
      • Kneeling brings baby forward and takes pressure off the back
      • Side recline opens the pelvis
      • Peanut ball opens the pelvis in different ways
    • 5. Psychological Response:
      • Positive attitude
      • Willingness to birth
      • Sociocultural
      • Socioeconomic (access to prenatal care)
      • Coping with physical demands of labor
      • Maintaining physiological/emotional balance

    Other P’s to Consider (Not in the “Five P’s”)

    • Philosophy
    • Partners
    • Patience
    • Patient preparations
    • Pain management

    Systematic Response to Labor

    • Maternal
      • Cardiovascular:
        • Blood volume increase
        • Increased cardiac output
        • Increased BP
      • Respiratory:
        • Hyperventilation => respiratory alkalosis
        • Pushing => respiratory acidosis
        • Acid base levels WNL within 24 hours
      • GI: Emptying is slowed => N/V
      • Lab values: Increased WBC
      • Pain receptors
    • Fetal
      • Heart rate changes:
        • Accelerations & decelerations
        • Fetal movement
        • Fetal scalp stimulation

    Stages of Labor

    • First Stage (Longest):
      • Latent phase (0-6 cm)
      • Active phase (6-10 cm)
    • Second Stage:
      • Complete dilation to birth of newborn
      • Pelvic phase: Period of fetal descent
      • Perineal phase: Period of active pushing
    • Third Stage:
      • Placental separation and delivery
        • Placental separation: Detaching from uterine wall
        • Placental expulsion: Coming outside the vaginal opening
          • Does it come out Fetal or maternal first? If retained then subinvolution can happen
    • Fourth Stage:
      • 1-4 hours after birth of newborn
      • Hypotonic bladder R/T trauma

    Cardinal Movements of Labor

    • Engagement
    • Descent
    • Flexion
    • Internal rotation
    • Extension
    • External rotation
    • Expulsion

    Maternal Assessment During Labor and Birth

    • Vaginal Examination:
      • Use sterile gloves
      • Cervical dilation and effacement
        • Baby should be head down
      • Fetal descent
      • ROM
    • Uterine Contractions:
      • Intensity: Palpate at the fundus during a contraction
      • Frequency
    • Leopold Maneuvers:
        1. Feel the top of fundus to determine if baby is upside down
        1. Feel the sides to determine which way the baby is facing
        1. Feel the base of the fundus to determine if face or butt is pointing towards the cervix
        1. Palpate while at the mother’s head to determine where the baby is facing

    Fetal Assessment During Labor and Birth

    • Analysis of amniotic fluid

      • Determine if it’s fluid or urine based on color

    • External Fetal Monitoring

      • Two devices belted to mother
        • Top one determines contractions
        • Bottom one (transducer) monitors fetal heart rate (placed over back of fetus)

    • Internal Fetal Monitoring

      • Fetal scalp electrode (internal fetal heart monitor)
      • Intrauterine pressure catheter (gives specific pressure reading for the timing and intensity of contractions)

    • Analysis of Fetal Heart Rate (tells how baby is tolerating labor)

      • Variability:

        • Absent: Range indetectable
        • Minimal: Range is less than 5 bpm
        • Moderate: Range from 6-25 bpm (Sweet spot, this is what we are looking for)
        • Marked: Range is over 25 bpm

      • Periodic Changes:

        • Accelerations: Should accelerate the baby’s heart rate when there are movements or tactile stimulation (touching the fetal scalp during cervical exams)
        • Decelerations:
          • Early: Will happen at the same time of the peak of the contraction (Usually caused by the fetal head getting compressed) Typically don’t drop too low and bounce back after the contraction ends. THIS IS GOOD, WHAT WE ARE LOOKING FOR.
          • Late: Drops after the contraction has peaked (NOT OKAY, Usually indicates uteroplacental problems, baby does not have sufficient oxygen to deal with contractions)
          • Variable: Sharp, unpredictable drops. VERY BAD SIGN, Can mean cord compression

      • Baby tachycardia: Can indicate infection in mother

      • Baby bradycardia: Can indicate nervous system issues, lack of oxygen (bad sign)

    Fetal Heart Monitor Tracing

    • Strip has two components:
      • Upper Graph: FHR data
        • Small squares represent 10 bpm increases as well as 10-second duration
      • Lower Graph: Contraction data
        • Small squares represent 10-second duration or 10 mmHg intensity (if IUPC used)
    • Dark line to dark line represents one minute of time
    • When stimulated HR must go up by 15 beats and be there for at least 15 seconds
    • Early deceleration is good, shows that baby is working through the birth canal
    • Variable will look like a V, U, or W (NOT GOOD, Usually caused by cord compression)
    • Late decelerations, utero-placental deficiency, baby is compromised, will dip after contractions

    Interventions for Decelerations

    • Cord compression: Change mother’s position to her side
    • Late decelerations:
      • Change mother’s position to left lateral
      • Increase fluids
      • Give O2
      • If signs of 2 or 3 late decelerations, stop oxytocin
      • If first nursing interventions don’t work, may need to internal monitoring
      • Could result in a vacuum delivery, forceps, or even C-section

    Deceleration Mnemonic

    • Compression = Decel
    • Variable
    • Cord clamping
    • Early
    • Head compression
    • Acceleration
    • Okay
    • Late
    • Placental insufficiency

    Non-pharmacological Measures for Labor Pain

    • Continuous labor support
    • Hydrotherapy
    • Ambulatory and position changes
    • Acupuncture and acupressure
    • Attention focusing and imagery
    • Therapeutic touch and massage; effleurage
    • Breathing techniques

    Pharmacologic Interventions for Labor Pain

    • Adequate comfort and analgesia safely for mom and baby
    • Neuraxial analgesia/anesthesia:
      • Systemic analgesia
      • Inhaled analgesia - Nitrous Oxide
    • Regional analgesia/anesthesia:
      • Local anesthetics
      • Epidural
      • Combined spinal epidural
      • Pudendal block
    • General anesthesia - EMERGENCY ONLY

    Nursing Assessments During Labor

    • Admission and First Stage:
      • Prenatal record - maternal history, intrapartum high risk screen
      • Physical Assessment - VS, Fundus and contractions (palpation, external fetal monitoring, intrauterine pressure catheter), cervical dilation and effacement, amniotic fluid, presenting part and descent
      • Cultural assessment
      • Laboratory tests
      • Psychosocial concerns

    Nursing Management of the Second Stage of Labor

    • Breathing techniques
    • Pushing techniques
    • Contractions
    • Maternal VS
    • FHR (Fetal HR)
    • Amniotic fluid
    • Coping
    • Episiotomy: Surgical incision of the perineum to aid with delivery (midline or mediolateral)
      • Indications: LGA, vacuum/forceps delivery, maternal exhaustion
      • Assessment and Interventions - REEDA, comfort measures: ice, tucks, sitz bath
    • Lacerations:
      • First degree: Vaginal mucosa perineum
      • Second degree: + fascia (perineal muscles)
      • Third degree: + ext. anal sphincter
      • Fourth degree: + int and ext anal sphincters, anal mucosa
      • Prevention: Perineal massage, different pushing positions, warm soaks, counterpressure, and gradual pushing when crowning

    Assisted Delivery

    • Forceps

    Presumptive Signs of Pregnancy

    • Reported by the patient
    • Fatigue
    • Nausea
    • Breast tenderness (3-4 weeks)
    • Urinary frequency (6-12 weeks)

    Probable Signs of Pregnancy

    • Detectable by the 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

    • Increase in blood flow and capacity
    • After 12 weeks, grows past the pelvis
    • Lower Uterine Segment, gradually thins
    • Supine Hypotensive syndrome, uterus presses on vena cava and aorta
    • Fundal Height, should be at level of umbilicus at week 20 (20 centimeters)
    • Braxton Hicks contractions (practice contractions)

    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, debris and Gingivitis
    • Delayed Gastric Emptying
    • Constipation
    • Heartburn

    Cardiovascular System

    • Blood Volume (around 1500 ml increase)
    • Expect to see a level of anemia because of the increase of 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

    • Increased oxygen requirements
    • Breathes faster and deeper

    Renal/urinary

    • 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

    • Pancreas
    • Growing fetus: 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

    • Should be steady weight gain, week by week
    • Underweight- 28-40lbs
    • Normal weight- 25-35lbs
    • Overweight- 15-25lbs
    • Obese- 11-20 lbs

    Special Nutritional Considerations

    • Cultural variations
    • Vegetarians
    • Pica

    Dietary 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 hx
      • Psych/genetic screening
      • Nutritional habits
      • STD exposure
      • Reproductive history (Menstrual History)

    Nagele Rule

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

    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

    Proteinuria and Weight Gain

    • Protein in urine or excessive weight gain towards the end of pregnancy can indicate preclampsia (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 - every time you feel baby movement, keep tracking movements

    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
    • Fetal abnormalities
    • Fetal lung maturity
    • Ultrasound
    • Complications

    Chorionic Villus Sampling

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

    Nonstress tests (NST)

    • 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

    Factors influencing the onset of labor

    • Uterine stretching
      • Elongates
      • Cervical effacement
      • Cervical Dilation
    • Progesterone withdrawal
    • Increased oxytocin sensitivity
    • Increased release of prostaglandins
    • Contractions happen fundus down

    Premonitory Signs of Labor

    • Lightning - belly drop, baby in pelvis
    • Braxton-hicks Contractions - body getting ready for labor, not true labor contractions
    • Cervical Changes - Softening of cervix (Streching and thinning), ephasion of uterine walls
    • Bloody show - mucus plug (protective barrier for baby) stays in place for pregnancy, will dislodge and may pull capillaries and bleed some, sign that the cerxiv is changing, don’t immediately go to the hospital
    • Rupture of membranes - water breaking, color should be clear, any odor, baby had maconium if fluid was green, if water broke make sure imbilucal cord didn’t wash out THIS IS TRUE EMERGENCY, WILL PINCH OFF IMBILUCAL CORD
    • Sudden burst of energy - Nesting, preparing everything for baby, hyperfocused

    True VS.False Labor

    • Contraction timing - During labor will be regular, during false labor will be irregular
    • Contraction strength - Will become stronger with time, false frequently weak
    • Contraction discomfort - Starts in back and radiates around twords front of abdomen, false usually felt in front of abdomen
    • Any change in activity - Contractions continue no matter what postural change is made, contractions may stop or slow down with walking/positioning
    • Stay or go - Stay home if contractions are 5 minutes apart, last 45-60 seconds, and are strong enough so that conversation isn’t possible

    Factors Affecting Labor Process

    • 5P’s
      • Passage way
      • Passenger
      • Powers
      • Position
      • Psychological response

    Passage Way

    • Birth canal: pelvis and soft tissue
    • Mother’s pelvic size: diameters - True pelvis (inlet baby has to pass through); false pelvis (Bony flares at hip)
    • Birth passage: Pelvic Shape - Gynecoid (Most common and most favorable), android (Not favorable for vaginal birth), anthropoid (More narrow, may still work for birthing), platypelloid (Not favorable for vaginal birth)
    • Cervix: Dilation & Effacement
    • Pelic floor muscles - gives enough resistance, so baby trunks certain ways to get out

    Passenger

    • Fetal Head - reference pont - make sure head is down, biggest part of baby coming out first, Nurses feel for occipital bone, and both frontanels
    • Fetal attitude - relationship of body parts, flexion of neck, arms, legs
    • Fetal Lie - Axis of mom-baby - Longitudinal (Parallel), transverse (side ways), Oblique (Diagonal)
    • Fetal presentation - Presenting part entering first - Cephalic (optimal), breech (Many but EX feet first), shoulder, NC: vaginal exam, leopold’s maneuver
      • Vertex presentation (smallest diameter coming through), Military presentation (A bit larger than vertex), Brow presentation (Even larger), Face presentation (Very large diameter), Shoulder presentation (Not safe for baby, to the OR), Hip or bottom presentation (Frank Breech, won’t do delivery vagianlly, legs stay flexed), Complete breech (legs stay open), Footling breech (feet first, to the OR)
    • Fetal Position - R or L: side of pelvis, Presenting part: Occiput, Mentum, Sacrum, Part-Pelvis: Antierior, Posterior, Transversal
    • Fetal Station
      • Level of presenting part in relation to the maternal ischial spines
      • Usually narrowest diameter through which the fetus must pass
    • Engagement
      • Floating, level of spine is 0
      • Dipping, fetal head dips into inlet, ballotable
      • Engaged, presenting part is at level of ischial spines

    Powers

    • Forces of Labor
      • Primary : contractions => dialtion/effacement, thin and dilate the cervix
        • Contractions/Waves:
          • frequency: onset-onset
          • duration: length beginning-end
          • Intensity: at peak, mild moderate, strong by palpation
      • Secondary: Abdominals => Pushing

    Position

    • Standing and walking promotes cervical changes
    • Squating opens pelvis to help progress labor
    • Kneeling brings baby forward and takes pressure of back
    • Side recline opening pelvis
    • Peanut ball open pelvis up in different ways

    Psychological Response

    • Positive attitude
    • Willingness to birth
    • Sociocultrural
    • Socioeconomic - Did they have the money to receive prenatal care
    • Coping with physical demands of labor
    • Maintain physiological/emotional balance

    Other P’s to Consider

    • Philosophy
    • Partners
    • Patience
    • Patient preparations
    • Pain management

    Systematic Response to Labor

    Maternal

    • Cardiovascular: Blood volume increase, increase cardiac output, increased BP
    • Respiratory: Hyperventilation => respiratory alkalosis, pushing respiratory acidosis, acid base levels WNL within 24 hours
    • GI: emptying is slowed => N/V
    • Lab values: Increased WBC
    • Pain receptors

    Fetal

    • Heart rate changes: Accekerations and decelerations, fetal movement, fetal scalp stimulation

    Stages of Labor

    • First stage is longest: Latent phase (0-6cm) and Active phase (6-10cm)
    • Second Stage: complete dilation to birth of newborn, pelvic phase - period of fetal decent, Perineal phase - period of active pushing
    • Third stage: Placenta seperation and delivery, placental separation - detaching from uterine wall, Placental expulsion: coming outside the vaginal opening, Does it come out Fetal or maternal first, if retained then subinvolution can happen
    • Fourth stage: 1-4 hours after birth of newborn, hypotonic bladder R/T trauma

    Cardinal Movements of Labor

    • Engagement
    • Descent
    • Flexion
    • Internal rotation
    • Extension
    • External rotation
    • Expulsion

    Maternal Assessment During Labor and Birth

    • Vaginal Examination must use sterile gloves
      • Cervical Dilation and Effacement - Baby should be head down,
      • Fetal descent
      • ROM
    • Uterine Contractions
      • Intensity- palpate at the fundus during the contraction
      • Frequency
    • Leopold Maneuvers
      • 1.Feel the top of fundus to determine if baby is upside down
      • 2.Feel the sides to determine which way the baby is facing
      • 3.Feel the base of the fundus to determine is face or butt is pointing towards cervix
      • 4.Palpate while at the mothers head to determine where the baby is facing

    Fetal Assessment During Labor and Birth

    • Analysis of amniotic fluid
      • Determine if fluid or urine based on color
    • External Fetal Monitoring
      • Two devices belted to mother
      • Top one determines the contractions
      • The bottom one (transducer) is for monitoring fetal heart rate and should be placed over the back of fetus
    • Internal Fetal Monitoring
      • Fetal scalp electrode, an internal fetal heart monitor
      • Intrauterine pressure catheter (gives specific pressure reading for the timing and intensity of the contractions)

    Analysis of Fetal Heart Rate

    • Tell how baby is tolerating labor
    • Want to see variability in the heart rate
      • Absent: range indetectable
      • Minimal: Range is less than 5 bpm
      • Moderate: Range from 6-25 bpm (Sweet spot, this is what we are looking for)
      • Marked: Range is over 25 bpm
    • Periodic Changes
      • Accelerations: should accelerate the baby’s heart rate when there are movements or tactile stimulation (touching the fetal scalp when doing a cervical exam)
      • Decelerations: Early, Late, Variable
        • Early: will happen at the same time of the peak of the contraction (Usually caused by the fetal head getting compressed) typically do not drop to low and will bounce back after the contraction ends.THIS IS GOOD, WHAT WE ARE LOOKING FOR
        • Late: Drops after the contraction has peaked (NOT OKAY, usually indicated that there is uteroplacental problems, baby does not have sufficient oxygen to deal with contractions)
        • Variable: sharp, unpredictable drops.VERY BAD SIGN, can mean cord compression
    • Baby tachycardia- can indicate infection in mother
    • Baby bradycardia- can indicate nervous system issues, lack of oxygen, bad sign

    Fetal Heart Monitor Tracing

    • Strip has two components.
      • Upper Graph: FHR data
        • Small squares represent 10 bpm increases as well as 10 seconds duration
      • Lower Graph: Contraction data
        • Small squares represent 10-second duration or 10 mmHg intensity (if IUPC used)
    • Dark line to dark line represents one minute of time.When stimulated HR must go up by 15 beats and be there for atleast 15 seconds

    Fetal Heart Monitor Interpretation

    • Early deceleration is good too, shows that baby is working through birth canal

    • Variable will look like a V, U, or W, none of these are good, usually caused by cord compression

    • Late decels, utero-placental deficiency, baby is compromised, will dip after contractions

    • If cord compression is present change moms position to her side

    • Late decels, change moms position to left lateral, increase fluids, gove O2, is signs of 2 or 3 stop oxytocin, vitals, of all of those first Nursing interventions didn’t work may need to internal monitoring, could result in vacuum delivery, forceps or even C-section

    Compression = Decel

    • V ariable

    • C ord clamping

    • E early

    • H ead compression

    • A cceleration

    • O kay

    • L ate

    • P lacental inssufiency

    • On late will see peak of HR comes after peak of contraction

    • Early will be at the same time

    Non pharmocologic measure

    • Continuos labor support
    • Hydrotherapy
    • Ambulatory and position changes
    • Acupuncture and acupressure
    • Attention focusing and imagery
    • Therapeutic touch and massage; effleurage
    • Breathing techniques

    Pharmacologic Interventions

    • Adequate comfort and analgesia safely for mom and baby
    • Neuraxial analgesia/anesthesia
    • Systemic analgesia
    • Inhaled analgesia - Nitrous Oxide
    • Regiona; analgesia/anesthesia - local anesthetics, epidural, combined spinal epidural, pudendal block
    • General anesthesia - EMERGENCY ONLY
    • Epidual causes vasodilation lowering BP, will receive order for bolus, more fluid higher BP

    Maternal Nursing assessments: Admission & first stage

    • Prenatal record - maternal history, intrapartum high risk screen
    • Physical Assessment - VS, Fundus and contractions: palpation external fetal monitoring, intauterine pressure catheter, cervical dilation and effacement, amniotic fluid, presenting part and descent
    • Cultural assessment
    • Laboratory tests, psychosocial concerns

    Stage 2

    • Breathing techniques
    • Pushing techniques
    • Contractions
    • Maternal VS
    • FHR (Fetal HR)
    • Amniotic fluid
    • Coping

    Nursing Management of second stage

    • Episiotomy - surgical incision of periniem to aid with delivery, midline or mediolateral, indictions: LGA, vaccum/forcep delivery, maternal exhaustion, Assessment and interventions - REEDA, comfort measures: ice, tucks, sitz bath
    • Lacteration - first degree: Vaginal mucosa perineum, Second degree + fascia: perineal muscles, Third degree: + ext.Anal sphincter, fourth degree + int and ext anal sphincters, anal mucosa
    • Prevention: Perineal massage, different pushing positions, warm soaks, counterpressure, and gradual pushing when crowning

    Assisted Delivery

    • Foreceps

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    This quiz covers the presumptive, probable, and positive signs of pregnancy along with physiological adaptations during pregnancy. Test your knowledge on early pregnancy indicators and the changes a woman's body undergoes. Perfect for healthcare students and professionals.

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