NUR 346 Notes PDF

Obstetrics OB Gynecology GYN Pregnancy Gestation Gestational Age GA/EGA 20-37 weeks Preterm/Premature 37-42 weeks Full term After 42 weeks Post term A pregnancy/gestating woman Gravida Never been pregnant Nulligravida First time pregnant Primigravida Second time or more pregnant...

Obstetrics OB Gynecology GYN Pregnancy Gestation Gestational Age GA/EGA 20-37 weeks Preterm/Premature 37-42 weeks Full term After 42 weeks Post term A pregnancy/gestating woman Gravida Never been pregnant Nulligravida First time pregnant Primigravida Second time or more pregnant Multigravida Birth after 20 weeks Para (parity) Never given birth to live baby Nullip First time giving birth to baby Primip Carrying more than 2 babies at one time Multip Miscarriage (before 20 weeks) Abortion (AB) Conception to onset of labor Antepartum (AP) Time between labor and birth of baby and placenta Intrapartum (IP) Infant born dead after 20 weeks Stillbirth "alive" Viability TPAL T-\# of full term delivery (37-42 wks) P- \# of preterm deliveries (after 20 wks before 37 wk A-\# of abortions (before 20 wks) L-\# number of living children (regardless of COD) G5T2P1A1L3 5 pregnancy, 2 deliveries, 1 preterm, 1 loss, 3 living kids 2-8 weeks Embryo 8 weeks- moment of birth Fetus Estimated date of confinement EDC Estimated date of delivery EDD Estimated date of birth EDB Ways to determine due date LMP, Naegle's rule, uterine size, quickening, ultrasound 0-14 weeks 1^st^ trimester 14-28 weeks 2^nd^ trimester 29-42 weeks 3^rd^ trimester Postpartum- after birth through 6 weeks 4^th^ trimester Artificial rupture of membranes AROM Cesarean section C/S Low transverse cesarean section LTCS Pre-eclampsia PE Spontaneous vaginal delivery SVD **[Introductory Concepts]** Goal for maternal newborn (MNB) nursing- *A safe and satisfying experience for the mother, her family and baby* Quality nursing care recognizes, focuses, and adapts to pregnant women's needs as well as her family and newborn (can be father, siblings, grandparents, and friends) - STEEEP- safe, timely, effective, equitable, patient centered - Foster family unity promotes/protects the physiological well-being of mom and newborn - Hospitals have both labor/delivery rooms and labor/delivery/postpartum suites Pregnancy and childbirth are usually normal healthy events within the family - Childbirth affects the whole family/marks the beginning of an important new relationship - Families can make informed decisions about care when given proper information - Maternal/newborn nurses serve as an advocate for the rights of all family including fetus - Personal/cultural/religious attitudes influence the meaning of pregnancy and birth in family - Health promotion through role modeling, teaching, and counseling is important for future - Culturally competent care includes- religious/social beliefs, presence of extended family, communication patterns, beliefs/understanding of concepts of health/illness/physical contact with strangers, education Legal and special considerations- Nurse Practice Act defines scope and limits of nursing practice, health maintenance, and disease prevention. - Expanded practice roles include planning care, diagnosis, prescription privileges, standards of care, informed consent, or privacy Nurse Practice Act/Standards of Nursing care- establish minimum criteria for competent, proficient delivery of nursing care. Designed to protect the public and used to judge quality of care - Legal interpretation of actions within standards is based on what a reasonably prudent nurse with similar education and experience would do in similar circumstances - ANA/AWHONN help define nursing's SOC - AMA/ACOG help define medicine's SOC - Nurses who fails to meet appropriate standards of care may be subject to allegations of negligence or malpractice AWHONN Standards of Care - Comprehensive nursing care of women and their infants focus on assisting individuals and families to achieve their optimal health - Health education is an integral aspect of comprehensive nursing care, health teaching focuses on health promotion, maintenance, and restoration - Qualifications of personnel authorized to provide care are delineated. Scope is clarified in written policies, procedures, and protocols - Clinically competent to provide comprehensive care for mother and newborn. The nurse is legally accountable for the care given. - Sufficient number of qualified nursing personnel to meet patient care needs - Ethical principles guide clinical judgment of nurses caring for mother and infant - Research and findings are used to improve client outcomes - Systematic evaluations using specific clinical indicators is done to ensure quality of care **Informed consent= shared decision making-** Protects a patient's right to autonomy and self-determination. No action can be taken without that person's consent - Consent is obtained by physician or midwife; **RN witness client's signature** given consent - If RN determines that patient does not understand procedure or risk, RN notify MD - Pregnant teens are considered emancipated and may give consent for themselves - Refusal of treatment, medication, and procedures require signed form release providers and hospital from liability - Jehovah's Witness patient may refuse blood transfusions or Rhogam Pelvic Exam Consent- REQUIRE WRITTEN CONSENT FOR ANY PELVIC EXAM Right to Privacy (HIPPA)- avoid discussing care with people not involved in her care. Respect patient's right to person to keep person and property free from public scrutiny and avoid unnecessary exposure of women's body History of childbirth- the process of labor and birth has remained unchanged over thousands of years - Births have been the domain of women; family members, birth attendants, midwives - During Middle ages and Renaissance, physicians claimed responsibility for childbirth and moved births to asylums and hospitals; forceps developed - Poor sanitation and poor hand washing led to an increase in childbed fever - Hospitals became used because the use of chloroform,twilight sleep, poor sucking, feeding of infants from drugs, sleepy, drugged mothers made breastfeeding hard Family types- nuclear, dual career, childless, extended, extended kin network, single parent, stepfamily, binuclear (post-divorce family), nonmarital, gay, lesbian Nurses Roles in Women's Health - RN- labor nurses, mother-baby nurse, lactation consultants, clinic nurse, newborn nursery nurse, home health, NICU, gynecology nurse - RNC- RNs who have demonstrated clinical expertise in a field and are certified by national organization - NP- Master's prepared nurse who functions as advanced practice nurse. Focus on ambulatory nurse, neonatal NP's work in newborn nurseries and NICUs. NPs perform H&P, order diagnostic tests and procedures - Certified Nurse Midwife- similar to NP but also perform deliveries and care for newborns - Clinical Nurse Specialist- Master's degree and specialized knowledge and competence in specific Statistics in MNB nursing- identify types of clients who access services, determine populations at risk/risk factors, assess relationship between factors/interventions/outcomes, determine caseloads or staffing/equipment needs - **Birth rate**- number of live births per 1000 people - The birth rate declined across 15-39 age groups, sharpest decline in 15-19 group (down 55% since 2007) with slight increase seen in 40-44 group (overall increasing since 1982) - Birth rate has declined among white, non-Hispanic white, and Asian women; relatively unchanged in black women - **Infant morality**- number of deaths of infants under 1 year of age per 1000 live births - **Neonatal mortality**-number of deaths infants less than 28 days of age per 1000 live births - **Fetal death**- death of fetus while in utero at 20 weeks or more gestation - **Perinatal mortality**-both neonatal deaths/fetal deaths per 1000 live births(20 wks-28 days) Trends in Infant Mortality Rate- leading cause include birth defects, preterm delivery/LBW, and maternal complications - US rate higher than many other countries (ranks well below most industrialized nations) - Alarming racial/ethnic disparities (about 6%)- Non-Hispanic black (11.4), American Indian/Alaska Native (9.4), Native Hawaiian/other Pacific Islander (7.4), Hispanic (5.0), Non-Hispanic white (4.9), Asian (3.6) **Maternal Mortality**- number of deaths from nay cause during pregnancy cycle (include 42-day postpartum period) per 100,000 live births **Pregnancy- related death**- death of a women while pregnant or within one year of pregnancy ending for any cause related to or aggravated by pregnancy - US maternal mortality rate in 2017-26.4/100000;700-900 pregnancy related deaths per year - Worldwide developed countries- 12/100,000 - Racial disparity- 4x higher in blacks than whites - Increased CV, HTN, DM, C/sections rates in US than WW Other mortality factors- intermittent insurance coverage of some mothers with underlying medical conditions, Partisan politics, older mothers, increase in obesity/very obese mothers, marginalization of population sectors, increase in cesarean birth requests, infections, lack of emphasis/awareness of complications, relationship factors - Between 250,000-343,000 women are estimated to die each year from complications - The three leading causes are avoidable when resulting in death **(preeclampsia, pulmonary embolism, post-partum hemorrhage)**. Though not preventable with appropriate assessment, diagnosis, and treatment outcomes may improve Cesarean rates are on the rise worldwide, in the US the rates are hovering around 32-33% which is a 50% increase in rate in the past 10 years. - Historically in 1965 (4.5%), 1989 (23%), 2017 (31.9%) Preterm deliveries in 2017 were estimated to be 9.9% (20-27 weeks) **[Reproductive Anatomy and Physiology]** Internal reproductive organs- vaginas, uterus, fallopian tubes, ovaries - The **vagina** is a muscular and membranous tube that connects the external genitalia to the uterus. It is the passage for sperm, fetus, and menstrual products. It is used for protection - The **uterus** is a hollow, muscular organ - The **fallopian tubes** are on each side of the uterus and turn towards the ovaries, transport for the ovum and the ovary to the uterus (3-4 days) - Site for fertilization and is a nourishing environment for ovum or zygote - The **ovaries** are almond-shaped structures on each side of the pelvic cavity, and is the primary source of estrogen and progesterone The female reproductive cycle has 2 cycles that occur simultaneously the **ovarian**- ovulation occurs (follicular-immature follicles mature-FSH-anterior pituitary and the luteal-ovum leaves the follicle). **Uterine-menstruation** occurs (menstrual, proliferative, secretory, ischemic. Many resources now combine for ischemic phase with the secretory phase) - Female reproductive cells- interrelationships of hormones with he four phases of the uterine cycle and the two phases of the ovarian cycle in an ideal 28-day cycle - Many resources now combine with ischemic phase with the secretory phase **Gonadotropin-releasing hormone (GnRH)**- stored in brain (hypothalamus) and begins release by simulating the anterior pituitary gland Ovarian cycle- anterior pituitary releases follicle stimulating hormone (FSH) and luteinizing hormone (LH). - **FSH** causes maturation of ovarian follicles; maturing follicle secretes estrogen - **LH** production peaks at follicle maturity, triggering ovulation Menstrual cycle- **Estrogen** contributes to develop breasts, body hair, fat deposits. This leads to maturation of ovarian follicles and maturation of endometrium. Highest amount of estrogen during proliferative phase of menstrual cycle; increases uterine contractility. This inhibits FSH and LH production. **Progesterone** is secreted by corpus luteum, higher amounts of secretory phase of cycle; decreases uterine contractility caused by estrogen and contributes to endometrium stimulation. Causes rise in temperature at ovulation; increases breast tissue, cervical mucous with conception. **Ovulation**- LH production peaks at follicle maturity triggering ovulation. Ruptured follicle becomes corpus luteum (CL) which secretes large amounts of progesterone and small amounts of estrogen. - If no fertilization, CL begins to disintegrate, E&P production decreases, endometrium shed, anterior pituitary released FSH, LH again **Menstrual cycle**- menstruation is normal cyclic bleeding in response to hormonal changes. Usually 28 day cycle but can vary from 21-42 days (duration 3-8 days). - 4 phases- **menstrual phase** (shedding of endometrial lining), **proliferative** (endometrial development in response of estrogen), **secretory** (occurs after ovulation), **ischemic** (occurs once CL begins disintegration, may be combined with secretory phase) **[Conception and Fetal Development]** **Meiosis**- a type of cell division in which diploid cells in testes and ovaries give rise to gametes (sperm and ova). Each has haploid number of chromosomes (23) **Gametogenesis**- process by which germ cells or gametes (sperm & ovum) are produced. **Oogenesis**- female and **Spermatogenesis**- male **Mitosis-** cell division that produces diploid daughter cells (46 chromosomes) Fertilization- process by which a sperm fuses with an ovum to form a diploid cell (**zygote-fertilized ovum**). Ovum viable for 12-24 hours after ovulation, sperm viable for 24-72 hours. Fertilization occurs in ampulla (outer 1/3 of fallopian tube). Only one sperm can penetrate ovum due to reaction of outer layer of ovum - Sperm enters ovum, nuclei unite, sperm/ovum unite to form zygote,chromosomes pair up to restore diploid number.Zygote beings as single cell with complete set of genetic material(23 chromosomes from mother,23 chromosomes from father,total of 46 chromosomes) - Sex chromosomes in chromosome number 23 XX female XY male. Females have only X sex chromosome possible in ovum, males may contribute either X or Y sperm - Sex is determined at moment of fertilization **Pre-embryotic development**-first 14 days fertilization ovum called zygote(cells rapidly multiply differentiate) - Moves through fallopian tube by weak fluid current and beating action of ciliated epithelium that lines tube. Tubal peristalsis occurs in response to estrogen. Journey to uterine cavity takes about 3 days. Once zygote has divided into 16 cells it is called a morula which is divided into blastocyst and trophoblast. - Blastocysts develop into embryo; trophoblast into chorion - Nidation (implantation)- endometrium prepares for implantation (between days 6-10 or 3-5 days after fertilization). Cells of trophoblast grow into thickened endometrium and form chorionic villi - Trophoblast also secrets human chorionic gonadotropin (hCG) which singles corpus luteum to continue secreting E&P. CL continue to produce E&P until placenta fully develop and take over function at 3-4 weeks. - hCH is marker for serum and urine pregnancy tests. - Fertilized ovum is called a zygote until implantation then an embryo **Cellular differentiation-** between 10-14 days blastocyst differentiates into primary germ layer from which all tissues and organs develop. - Primary germ layer is divided into endoderm, mesoderm, and ectoderm. Embryonic membrane develops and form the amnion and chorion - Amniotic fluid forms in this area- act as a cushion for the embryo, controls temperature, permits symmetrical growth, allows freedom of movement so fetus doesn't attach itself to amnion, prevents umbilical cord compression - Yolk sac develops day 8-9 after conception. Forms RBCs in early development until the embryonic liver takes over process and is incorporated in umbilical cord. - Umbilical cord develops from amnion. 3 blood vessels (2 arteries /1 vein) which are surrounded by Wharton's jelly (cushions vessels, prevents compression by uterus) **Placental development/function-** placenta provides metabolic and nutrient exchange between embryonic and maternal circulation. - Doesn't develop until 3^rd^ week but grows until 20 weeks (becomes thicker after 20 but doesn't get any larger). At term placenta weighs 400-600 grams - Placenta- maternal side red, flesh like. The fetal side is covered by amnion and is shinny. Placenta consists of 20 cotyledons. Each cotyledon has a complete vascular system that allows for the exchange of gas/nutrients. **Placental circulation**-maternal fetal placenta circulation exchange occurs by 17 days(fetal heart begins function) - Umbilical cord consists of two arteries and one vein (AVA).Arteries carry deoxygenated blood to placenta where oxygen/nutrient exchange occurs. Veins carry oxygenated blood back to fetus. - Placenta function- fetal respirations, nutrition, and excretion **Fetal circulation-** most of blood supply in fetal circulation bypasses fetal lungs and liver (lungs do not perform respiratory gas exchange, placenta provides oxygen and excrete carbon dioxide). - Blood from the placenta flows through umbilical veins, entering at abdominal wall. - Blood bypasses liver and enters ductus venosus and directly enters fetal inferior vena cava - Blood from inferior vena cava enters right atrium, passes through foramen ovale into left atrium, pours into left ventricle and to aorta to perfuse body - Small amounts of blood flow from right artium to right ventricle and up to pulmonary artery and to lungs to provide nourishment - Most of this blood passes from pulmonary artery through ductus arteriosus into descending aorta, bypassing lungs - Fetal circulation delivers highest oxygen concentration to head, neck, brain and heart and less to abdominal organs and lower body. Leads to cephalocaudal development Embryonic and fetal development- pregnancy last 40 weeks, 280 days, 10 lunar phases. Onset calculated from LMP to time of birth. Most infants are born with 10-14 days of EBD using LMP. - Fetal development is based on time from fertilization which occurs two weeks after LMP - Zygote phase (preembrycotic stage 0-14 days, embryotic stage day 15- 8 weeks, fetal stage 9 weeks until delivery) - Tissue differentiates into essential organs and main external features develop. Embryo most vulnerable to teratogens (insults) during embryotic stage **[Physical and Psychological Changes of Pregnancy]** Uterus capacity grows from 10 mL to 5000mL and same number of cells in myometrium but enlarge **Cervix**- endocervical cells produce a thick mucus plug - Goodell's sign- softening of cervix due to increased vascularity - Chadwick's sign- bluish discoloration due also to vascularity - Gegar's sign- softening of uterine isthmus (area between cervix and body of uterus) **Vagina-** estrogen causes increased vaginal discharge **Breasts**- enlarged and become more glandular. - Areola- darken, nipple become more erect - Striae develop - Colostrum- produced/excreted in last trimester **Respiratory system**- as uterus enlarged, more pressure on diaphragm, chest circumference expands, and nasal stuffiness/epistaxis is common **Cardiovascular system**-increased CO, increased pulse, BP decreases slightly in 2^nd^ trimester, then returns to prepregnant levels in 3^rd^ trimester. Enlarging uterus puts pressure on pelvic/femoral vessel - Dependent edema, varicosities, hemorrhoids, postural hypotension - Blood volume increases, this includes both plasma and erythrocytes which are necessary for O2 transport. Because plasma volume is greater than erythrocyte volume, anemia occurs (physiological anemia of pregnancy) - Increased Fe needs to make hemoglobin, leukocyte production increased up to 12,000. Clotting factors increase slightly making pregnancy a hypercoagulable state **Gastrointestinal system**- nausea/vomiting common first trimester due to HCG level, gums bleed easily, ptyalism, delayed gastric emptying, decreased peristalsis resulting in bloating, constipation **Urinary tract-** uterus remains a pelvic flood organ first trimester (places mechanical compression on bladder), in 3^rd^ trimester presenting part compresses on bladder. - Glycosuria common, often warrants further testing **Skin and Hair-** skin pigmentation is common especially at areola, nipples, vulva perineal areas - Linea nigra extends from umbilicus to pubic area, chloasma (melasma gravidarum) is darkening of skin over cheeks/nose/forehead (most common in dark haired women) - Striae appears on abdomen/thighs/buttocks/breast, spider nevi, hair growth rate decreases; postpartum women may note increase shedding of hair for 1-4 months **Musculoskeletal system-** joints of pelvis relax resulting in waddle (hormone "relaxin" implicated), increased lumbar curve to compensate for growing uterus (resulting in backache, round ligament, broad ligament, pain, discomfort) - Diastasis reci is separation of abdominal muscle due to pressure of enlarging uterus **Metabolism-weight gain(underweight- 28-40 lbs,normal 25-35 lbs,overweight 15-25 lbs,obese 10-20 lbs)** one lb per week in second and third trimester - Water/nutrient-increased water retention,mother's protein and carbs need to increase,fats absorbed **Endocrine**- thyroid enlarges basal metabolic rate increases 20-25% - Pituitary- anterior (FSH, LH, prolactin), posterior (vasopressin, oxytocin) - Adrenals- cortisol - Pancreas- increased insulin needs **Signs of pregnancy**- subjective (presumptive)- symptoms women experiences and reports but may be due to other causes, objective (probable)- perceived by examiner but may be due to other causes, diagnostic (positive)- perceived by examiner but can be due only by pregnancy - Presumptive- amenorrhea (absence of menses), nausea/vomiting, excessive fatigue, urinary frequency, breast changes, quickening (mothers perception of fetal movement usually occurs between 16-20 weeks) - Probable- changes in pelvic organs- enlargement and softening of uterus, Goodell's- softening of cervix, Chadwick's- bluish, Hegar's-softening of the isthmus, McDonald's- ease in flexing the uterus against the cervix. Enlargement of abdomen, Braxton-Hicks, urerine souffle- soft blowing sound, skin pigmentation changes, pregnancy tests (otc detect hCH, usually positive 7-10 days after conception - Positive signs-fetal heartbeat, fetal movement noted by examiner, visualization of fetus by ultrasound **Developmental tasks**- both parents must deal with major psychosocial adjustment, altered body image, recording of social relationships, change in family roles, ambivalence, acceptance, introversion, mood swings, changes in body image, renewed interest in own mother - First trimester- ambivalence, feeling poorly, introspective - Second trimester- quickening makes pregnancy become more real; emotional liability, changes in body image - Third trimester- physical discomfort, anxiety about L&D **Psychological task of mother**- ensure safe passage through pregnancy, labor, birth. Seeking acceptance of child by others, commitment and acceptance of herself as mother to infants (binding in), learning to give of oneself on behalf of one's child **Psychological task of father/primary partner**- may experience initial excitement but rule undefined, may become more real once fetal movement palpated. Couvade: unintentional development of physical symptoms of partner. Pica: weird cravings (nonfood items) **[Common Discomforts of Pregnancy]** Discomfort is the result from physiological/anatomic changes of pregnancy; can be generalized by trimester 1^st^ trimester- mostly due to hormonal influence and resolves by weeks 12-14 (N/V, urinary frequency, fatigue, breast tenderness, increase vaginal discharge, nasal stuffiness/epistaxis, ptyalism) - N/V "morning sickness"- occurs in 70-85% pregnancies, can be toward specific foods, and specific time of day or throughout the day. Could be due to elevated hCG levels; evaluate skin turgor, mucous membranes, ketonuria, weight loss. - Small, frequent meals, eat before rising out of bed, avoid rich/spicy/greasy foods, drink carbonated beverages - CAM: ginger, vitamin B6 and Unisom, acupressure: sea bands/relief bands, RX: Phenergan, Zofran, Compazine - Urinary frequency- due to pressure of growing uterus on bladder; occurs in 1^st^ and 3^rd^ trimester; differentiate between frequency/urgency with dysuria/hematuria. - Encourage 8-10 glasses of water daily but avoid drinking much after nightfall: frequent void - Evaluate for suprapubic pain, CVA tenderness to R/O pyelonephritis - Fatigue- due to hormonal changes and adaptation to pregnancy - Rest when possible, regular exercise helps, family support to help with responsibilities - If severe, evaluate thyroid, CBC - Breast tenderness- related to hormonal changes particularly estrogen - Appropriately fitted bra; wider straps - Evaluation by bra specialist - Increased vaginal discharge "Leukorrhea"- caused by hyperplasia of vaginal mucosa and increased mucus production, increased acidity encourages growth of candida albicans - Bathe daily, avoid douching, cotton underpants - Note complaints of vaginal purities, odor - Nasal stuffiness/epistaxis-estrogen may produce edema of nasal mucosa leading to stuffiness/discharge - Vaporizers may help but many resort to OTC nasal sprays that increase symptoms over time - Limited OTC meds can be used in pregnancy (sprays cause CTX; antihistamines accelerate FHR) - Ptyalism- excessive, bitter salivation; unknown cause (chew gum, suck hard candies) 2^nd^ and 3^rd^ trimester- second is when a women feels best (heartburn, edema, varicosities, flatulence, hemorrhoids, constipation, backache, leg cramps, faintness, dyspnea, difficulty sleeping, round ligament pain, carpal tunnel syndrome) - Heartburn "pyrosis"- regurgitation of acidic gastric contents into esophagus, creating burning sensation. Due to displacement of stomach by growing uterus, effects of progesterone, decreased gastric motility and relaxation of cardiac sphincter. - Eat small. Frequent meals, avoiding greasy/fried/spicy foods, avoid lying down or sitting after eating - OTC antacids- Maalox, H2 prohibitors (Zantac, Tagamet) - Headache- due to hormonal fatigue, fluid changes, caffeine withdrawal. Evaluate timing, duration of headache; what provides relief - Treat with Tylenol products, increase fluid consumption, rest, avoid stimuli. Migraine headache difficult to treat in pregnancy. - Concern if associated with visual disturbances, scotomata, elevated BP - Edema- due to poor venous return and more common in hot months/with prolonged sitting/standing - Elevate legs, frequent dorsiflexion of feet, if sedentary move around frequently, avoid restriction around legs - Limit sodium consumption, avoid high heels - Varicosities- weakening of walls of veins or faulty function of valves. Due to poor circulation, prolonged standing, pressure of gravid uterus on pelvic vessels inhibiting venous return. - Vulvar varicosities cause aching and sense of heaviness - Treat by elevation of legs,support hose,avoid crossing legs,prolonged standing,perineal sling - Hemorrhoids- varicosities of veins in lower rectum and anus. Due to gravid uterus causes pressure on veins and impending circulation as well as straining that accompanies constipation - Itching, burning, pain, bleeding, may be thrombosed. May reduce hemorrhoid manuallu, use OTC products (witch hazel, preparation H), Sitz bath - Avoid constipation and straining with BM - Constipation/Flatulence- due to increased bowel sluggishness from progesterone, intestinal displacement, oral iron supplements. High fiber diet, adequate fluids, exercise - May use stool softeners, suppositories, avoid laxatives for concerns re uterine contraction - Flatulence often associated with constipation and die to decreased GI motility (OTC Mylicon, Gas X) - Backache- exaggeration of lumbosacral curve due to enlarging, heavier uterus; relaxation of pelvic joint from hormone relaxin's effect on cartilage. Avoid bendig over at waist, heavy lifting, high heel shoes, use good body mechanics (bend at knees, wide stance when standing) - Treat with pelvic rock exercise, back rubs, massages - Backaches usually present as consent pain in lower back. Must distinguish from premature uterine contractions that are usually of shorter duration and come and go - Leg cramps- painful muscle spasms of gastrocnemius muscles. Occur most frequently at night or with extension of foot. Due to pressure of enlarged uterus on pelvic nerves/blood vessels/poor circulation, calcium-phosphorus ration imbalance - Relieve by dorsiextenxion foot towards leg, massage, warm compresses - Eat high calcium food, avoid phosphate foods, potassium supplements - Faintness- due to changes in blood volume, postural hypotension caused by pooling of blood in dependent veins; may also be due to anemia, low blood glucose levels. May occur with sudden change of position, prolonged standing especially in warm, crowded areas - Sit/lie down with head lower, fresh air, hard candy, orange juice. Avoid long periods without eating, prolonged standing - Evaluate CBC and B/P - Shortness of breath (dyspnea)- due to rise of uterus into abdomen and pressure on diaphragm - Proper posture, sleep propped up on pillows at night - Round ligament pain- enlarging uterus stretches round ligament. May present as intense grabbing sensation in lower abdomen and inguinal area - Heating pad, changing position. Distinguish between UTI, fetal movement, appendicitis - Carpel Tunnel Syndrome- characterized by numbness, tingling of hand near thumb. Due to compression of median nerve in carpal tunnel of wrist from edema of hand, shoulder; ill fitted bra may also contribute - Aggravated by repeated hand movement, treat by splintering of wrist, elevate arm - Skin changes- not usually physically uncomfortable but may be emotionally alarming. - Changes- chloasma, acne of pregnancy, and "glow" Guidelines - Exercise- pre-pregnancy regime;avoid horseback riding,skiing,bike rides after 1^st^ trimester - Sex- is ok; cessation not contraindicated unless pregnancy complication - Dental care- may go for routine cleanings, treatment, lead apron for x-rays - Work- can work while pregnant; should be aware of fetotoxic hazards related to occupation - Travel- usually no restrictions but prolonged trips after 26 weeks not advised - Automobile- stop q2 to ambulate, always wear seat belt/harness - Plane/train is best for long distance but hydrate, ambulate frequently to avoid phlebitis - If she develops complications/deliver far from home, infants will not travel home with her Medications- all medications carry a risk potential during pregnancy and lactation. Former FDA A, B, C, D, X classification system phasing out - Pregnancy and lactation labeling rule now in effect. Designed to decrease confusion, increase safety - New labeling began June 2015 transitioning ends June, 2020. - Attention given to safety risks, clinical considerations/available research data for medications used during pregnancy and lactation or with potential reproduction impact Caffeine- moderate intake shows no teratogenic effect nor linkage to LBW, preterm birth - 600 mg daily associated with decreased birth weight (one cup of coffee- 100 mg, 12 can soda- 50 mg, cup of tea- 50 mg) advised to limit to 300 mg daily Alcohol- safe thresholds unknown. Fetal alcohol syndrome (growth retardation, facial anomalies, CNS dysfunction) Tobacco- associated with SIDS, preterm labor and delivery, low birth weight infants, stillbirths Carbon monoxide and nicotine are toxic to fetus and decrease availability of oxygen to tissue, cause premature aging of placenta. - Most women aware of harm but addiction too great. Encourage to smoke \