1
Q
Presumptive Signs of Pregnancy
Woman notices/experiences, indicates to her that she’s pregnant
Maternal physiologic changes
A
Missed menses
N/V
Breast tenderness
Fatigue
Ptyalism ( excessive secrition of saliva)
Skin pigmentation changes
2
Q
Probable Signs of Pregnancy
Maternal anatomic & physiologic changes, detected and documented by examiner
A
Enlargement of uterus ( pregnant vs fibroid tumor)
Chadwick’s sign - blue cervix, vagina and labia ( pregnant vs cancer)
? Fetal movement
3
Q
Positive Signs of Pregnancy
Detected & documented by an examiner, but can only be attributed to fetus
A
- Ultrasound
- X-ray
- Fetal heart tones
- ? Fetal movement
4
Q
Pregnancy Tests
Always used with Hx & PE
A
BhCG (Beta sub-unit of Human Chorionic Gonadotropin)
Blood or urine
Reliable
Low cost
Readily available
BhCG only during pregnancy
Low levels after fertilization; increase with implantation
Predictable rise, peaking at 60-70 days
5
Q
Qualitative BhCG
A
“quality” of being pregnant
Urine test
Non-invasive
Accurate
Cheap
Readily available
Serum test
Rarely needed
6
Q
Quantitative BhCG
A
Amount or “quantity”
Serum tests
Generally, high-risk only
Predictable rise of hCG
7
Q
Pregnancy Tests = Probable Signs
False positives
A
- Cross-reaction with LH
- Misread
- Protein or blood in urine (UTI)
- Marijuana use
- Aldomet use ( antihypertensive)
- Antidepressant use
- Tumors (ovary, breast, melanoma)
8
Q
Pregnancy Tests = Probable Signs
False negatives
A
- Impending abortion
- Misread
- Medications
- Ectopic pregnancy
- Too early/late in pregnancy
- Urine stored improperly
- Urine too dilute
9
Q
Antepartal Care ( 14 prenatal visits )
A
Every 4 weeks until 28 weeks
Every 2 weeks until 36 weeks
Weekly until delivery
Modify prn
10
Q
Trisomy
A
type of polysomy in which there are three instances of a particular chromosome, instead of the normal two.
E: trisomy 21 - Down syndrome
11
Q
History-Taking & Assessment
A
All pertinent areas: past, present, potential
Consider physical appearance; verbal & non-verbal communication
_“Why are you here today?” _
(abortion ?)
12
Q
History: Personal Characteristics
A
- Name, address, phone number - track down and find out why she never came back ;
- D.O.B. - Risk factors !!!
Adolescents
~ PIH ( pregnncy induced hypertension) , C/S, STDs, preemies, LBW ( starve themselves - hiding pregnancy) , anemia (unhealthy diet) , domestic violence
**Mature gravidas (35+) * turns 35 on the date of delivery **
~ PIH, C/S, trisomies ( Offer genetic caunseling !!! lawsuit for Wrongful Life), chronic health conditions
3.Marital status
family support, sexual practices, stress factors - Race/ethnicity/religion - African-American; Mediterranean sea countries - cickle cell anemia testing
- Education
- Occupation
13
Q
History: FOB (Father of Baby)
A
- Age
- Height/weight
- Race/ethnicity/religion
- Education
- Occupation
- Current health status
- Significant medical history - Self & family - as far as grandparents
- Use of licit or illicit substances
- Blood type & Rh ( M -) + (D+) = (B +)
- Response to pregnancy
14
Q
History: Current Pregnancy
A
- LMP
Any bleeding since? - Presumptive signs?
- Pregnancy test done?
- Response/adaptation to pregnancy
15
Q
Establish EDC by LMP
A
- EDC wheel ( first day of your last menstrual period)
- Nagele’s Rule:
LMP -3 months + 7 days
Example: April 20
Minus 3 mo. = January
Add 7 days = 27
EDC January 27
16
Q
Establish EDC by Ultrasound (US)
A
- CR length (crown-rump)
- *Most accurate method**
- 7 – 13 weeks’ only*
17
Q
Establish EDC by US
A
BPD (biparietal diameter)
After 13 weeks’ gestation
Earlier is better
16-18 weeks’: +/- 7 days
End of preg.: +/- 4 weeks
Femur length comparison
18
Q
History: Past Obstetric Data
A
Year of each previous pregnancy
Gestational age at outcome
Abortion, preterm, term, stillborn
Length of labor
Type of delivery
Gender, weight
Neonate’s health status
AP, IP, PP complications?
19
Q
Parity: TPAL
A
- Term: 38 weeks’ gestation +
- Preterm: 20-37 completed weeks’
- Abortion: any pregnancy that ended prior to 20 weeks’ gestation
- Living: alive today (not just born alive)
20
Q
History: Current Medical Data
A
Perception of current health status
Height, weight, vital signs
Blood type & Rh?
Current acute or chronic conditions
Allergies ( anesthetic agents)
Exposure to communicable disease or colds/flu since pregnant
Exposure to teratogens - N1: Alcohol since pregnant
Eating patterns ( Anorexia nervosa & Bulimia nervosa)
Exercise routines
Use of licit or illicit substances
21
Q
History: Past Medical Data
A
Childhood diseases
Immunizations
Hospitalizations
Surgeries
Blood transfusions
Onset/treatment: anemia, asthma, blood dyscrasias, Ca, CVD, DM, endocrine disorders,
HPN, psychiatric disorders ( take meds) , renal or UT diseases ( UTI - pyelonephritis - preterm delivery) , TB ( cannot take TB drugs)
22
Q
History: Family Medical Data
A
Both sides; back to grandparents
If deceased, note cause of death
Ca, cardiopulmonary diseases, pregnancy complications, congenital anomalies, DM, HPN,
psychiatric disorders, renal disease, TB, vascular disease
Operative deliveries - forceps delivery
23
Q
History: Gynecologic Data
A
- Menstrual history
- Menarche ( first time period)
- Typical cycle
- Dysmenorrhea: Primary ( cramps, headache) - gets better after pregnancy; Secondary - severe pain endometriosis (scaring, stenosis) - doesnt get better after pregnancy - Sexual history & practices
- Contraceptive history & practices - IUD + pregnant - remove!!! sepsis
- Injuries to pelvic structures/organs
24
Q
Physical Assessment
A
- Empty bladder - pelvic exam; urinalysis; urine per culture and sensitivity !!! asymptomatic UTI - pyelonephritis - preterm delivery
- Private, comfortable room; respect modesty
- Weight & VS, then PE
- Review changes/danger signs every visit
_Vaginal bleeding, loss of fluid, pelvic pain, back pain, abdominal pain, edema, HA, blurred
vision, contractions, no fetal movement ( fetus stops moving 8-12 hours before heart stops beating) _
25
Cardiovascular System
1. Heart rate increases 10-15 BPM
2. Blood volume increases 30-50% ( when give birth bleed - 500 vaginal; 1000 C-section)
* *_Estrogen (placenta) - STIMULATION _**
3. Cardiac stroke volume increases ( more blood with each systole ) - cardiac output increases 40 % !!! to supply uterus and placenta to get that blood to fetus
4. Cardiac output increases - healthy women can handle ; pre existing cardiac disease - HF during pregnancy
6. Slight decrease arterial BP ( 12-14 weeks gestation)
**_Progesterone (placenta) - RELAXATION_**
7.Systolic heart murmurs common - heart shifts position - Grade 2 murmur ( stethoscope) - common, innocent
26
Cardiovascular System
1. **_Vena cava syndrome AKA supine hypotensive syndrome ( 3 trimester)_**
- Position of woman
Compression of inferior vena cava or pelvic veins
Low BP, sweaty, dizzy
TX: get them off their back; turn to the side; sits or stands all day - walk around - skeletal muscles bring blood back up to the heart
27
Cardiovascular System
1. Blood flow increased: some skin, GI, breasts, uterus
2. Blood flow unchanged: liver, brain
3. WBC rises: up to 12,000/ml normal
4. Blood hypercoagulable: fibrin, fibrinogen, clotting factors rise ( walk around)
5. Increased cholesterol, triglycerides, lipoproteins, fatty acids ( intact nervous system)
28
Pseudoanemia (Physiologic Anemia of Pregnancy)
Blood volume rises - Plasma rises faster than RBC - hematocrit drops 7 %
29
Respiratory System
1. **_Progesterone_** causes respiratory center in brain to become **more sensitive to CO2**
2. Need more O2 for fetus, placenta, cardiac & respiratory effort, maternal tissues (uterus,
breasts)
3. Kidney compensates; no changes in acid-base balance
4. Respiratory rate unchanged
- Amount of air breathed/minute increases 40%
- Breathing more efficient; less air in lungs after expiration
5. Mechanical changes
- Progressive flaring rib margins
- Breathing more diaphragmatic than costal
30
Gastrointestinal System
**_N/V common 1st TM_**
hCG & carbohydrate metabolism
“morning sickness”
Remedies: avoiding overly warm places, avoiding smell triggers, moving slowly in the
morning, dry crackers, avoiding greasy or spicy foods, eating small amounts frequently,
high protein foods, salty foods before meals, avoiding fluids with meals, peppermint tea
Take prenatal vitamins later in day, B6 50 mg/day, ginger capsules 250 mg 3x/day
Sea bands, acupressure, Reliefband
Need to differentiate normal “morning sickness” from **_hyperemesis gravidarum ( persistent; dehydration) _**
31
Gastrointestinal System
1. Hyperplasia (overgrow) of gums due to **estrogen**
- Soften, bleed
2. Ptyalism ( excessive salivation)
3. Decreased gastric activity
- Less gastric acid & pepsin
4. Stomach has less peristalsis & tone
- Due to elevated **progesterone**
32
Gastrointestinal System
1. Decreased cardiac sphincter tone = reflux of stomach acid = heartburn
2. Remedies: avoid lying down too soon after meals, small meals frequently, avoid greasy &
spicy foods, milk/yogurt/dairy products, Tums, papaya (fresh, tablets)
spicy foods, milk/yogurt/dairy products, Tums, papaya (fresh, tablets)
3. Late pregnancy, enlarged uterus displaces stomach & intestines upward, causing more
feelings of fullness & heartburn
33
Gastrointestinal System
1. Intestines hypotonic, with less peristalsis
**Due to progesterone**
- Constipation + hemorrhoids
2. Increase in gallbladder disease
- Due to low peristalsis (progesterone) & higher cholesterol levels
3. Liver produces less albumin
Less osmotic activity of blood
Edema occurs - massive ( preeclampsia - high BP ) ; small - normal
34
Urinary System
1. Changes begin early on
2. **Progesterone** dilates renal pelves & ureters + causes slowed peristalsis - hold more urine - UTI
3. After 3rd month, enlarging uterus may compress ureter; dilation above site
4. Increased susceptibility to UTIs
5. Rise in GFR (glomerular filtration rate)
Blood flow to kidneys increased
Kidneys filter more plasma
Increased clearance of urea & creatinine fall
Low renal threshold for glucose - glucosuria
35
Integumentary System
1, Increased blood flow to skin
- Accounts for increased cardiac output
- Aids in thermoregulation of heat from fetus & placenta
2. “**spider angiomas**”: dilated skin arterioles
Due to **elevated estrogen**
Darkening of nevi
Palmar erythema
Boggy mucosa
- Stuffy nose
- Swollen labia
36
Integumentary System
1. **Melanin** activity increases (due to **estrogen & progesterone**)
- Areolas darken
- Linea alba becomes linea nigra
- Chloasma (“mask of pregnancy”) **Avoid sun !!!**
2. Hair growth
- **testosterone & other masculinizing hormones** (estrogen & progesterone by-products)
- Hair follicles live longer - blood flow to skin
3. Striae (stretch marks)
- **Estrogen** causes softening of fibrous tissues
- Obesity & genetic tendency favor development
37
Musculoskeletal System
1. **Estrogen** causes softening of joint capsules, connective tissue & ligaments
2. Pelvic joints become more mobile
- Waddling gait
3. Interosseous ligaments soften
- Flat feet & back pain result
- Bigger shoe size
4. Rectus abdominus separates
- **Diastasis rectus** occurs ( do stomach crunch - feel )
5. Ligaments supporting reproductive organs under tension & stretched
6. Postural changes -Growing uterus- Increased breast size- Change in center of gravity
38
Endocrine System
Pregnancy impossible without ES
1. **Anterior pituitary: FSH & LH (****Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) **
- Pituitary prolongs **corpus luteal phase** of ovary ( after the egg is released) - Maintains endometrium
**2. Posterior pituitary secretes oxytocin**
Promotes uterine contractility
39
Endocrine System
1. **Thyroid gland** enlarges & capacity to bind thyroxine is greater
**Estrogen responsible**
**BMR increased by 25%** by late pregnancy
2. **Adrenal gland** cortex enlarges
**Estrogen responsible**
**Cortisol levels rise**; regulate carbohydrate & protein metabolism
3. **Aldosterone increases** by 2nd TM
Protective response to higher Na+ excretion?
4. **Pancreas** secretes **more insulin**
- To meet maternal needs
-Islets of Langerhans are stressed - **Gestational diabetes **
40
Placental Hormones
1. **hCG**: secreted by trophoblast; Basis of pregnancy tests
- Stimulates **corpus luteum** to produce estrogen & progesterone until placenta developed
enough
2. **Estrogen**: uterine development & ductal system of breasts
3. **Progesterone:** glandular tissue in breasts
**_Progesterone plays greatest role in maintaining pregnancy_**
- Maintains endometrium
- Stops uterine contractility
2/4/11, FDA approved **_Makena_** (hydroxyprogesterone caproate) to ↓ preterm birth
41
Placental Hormones
1. **HPL, human placental lactogen**
- _Insulin antagonist_
- Increases amount of free fatty acids
- Maternal metabolic needs
- Decreases maternal metabolism of glucose
- Favors fetal growth
2. **Relaxin**
- Inhibits uterine contractility, decreases strength of contractions, softens cervix, remodels
collagen
42
Reproductive System
1. Uterine myometrial cells enlarge
- Estrogen + distention from growing fetus
2. Uterus strong & elastic
- Fibrous tissue between muscle bands increases
3. 1/6 of maternal blood volume within uterine vascular system by EDC
4. **Braxton-Hicks contractions**
- Irregular, painless (help cervix get ready for labor)
- Occur throughout pregnancy; more aware of in 4th month
5. **Hegar’s sign:** softening of uterine isthmus
6. **McDonald’s sign**: ease of flexion of uterine body against cervix
43
Reproductive System
1. Glandular tissue of cervix stimulated by estrogen
cell # increases (hyperactive)
2. Endocervical glands secrete thick, sticky mucus plug
Seals off endocervical canal
Protects against bacterial infections
3. **Goodell’s sign:** cervix soft
- Feels like lower lip (usually feels like tip of your nose)
4. **Chadwick’s sign**: cervix cyanotic
Due to increased blood flow
44
Reproductive System
1. Ovaries do not produce ova during pregnancy
- Corpus luteum produces hormones
- Placenta takes over by **_10-12 weeks_**
2. Vagina: affected by estrogen
- Thickening of mucosa
- Loosening of connective tissue
- Increased vaginal secretions
Thick, white, acidic
- **Yeast infections rise
- Bacterial infections decrease**
45
Uterine Size
Bimanual Exam before 12 weeks
46
Fundal Height: # of Weeks
After 12 weeks
1. Palpable above pubic symphysis: 12
2. Midway between pubic bone & umbilicus: 16
3. **_At umbilicus: 20_**
- Quickening ( baby is moving on the daily basis)
- Fetoscope ( hear heart beat)
Decreases at end of pregnancy ( baby dropping to pelvis)
47
McDonald Method
From top of the symphysis pubis to the top of the fundus - roughly equal to the week of pregnancy ( +/- 2 sm )
Consistent Measurements Needed!
Too big - gestational diabetes; dates off; caring more than one baby
Too small - dates off; mom is starving herself; not groving properly
48
Fetoscope
Don’t Date Pregnancy by First FHT by Ultrasound Doppler!
_18-20 Weeks_ - hear heart beat !!!
49
Tests Done by MD/CNM/NP
1. UA/UC (dipstick, too)
- Dipstick for glucose, protein (preeclampsia), ketones (not eaten recently)
2. R/O UTI - asymptomatic
3. Pap Smear
- R/O cervical cancer
4. Gonorrhea culture/Chlamydia culture/genital culture
- R/O STDs
5. Bacterial vaginosis AKA “BV” (nonspecific vaginitis)
(strong odor after intercoarse; frothy gray discharge; weaken bag of water - break too soon )
6. Non-lab test: clinical pelvimetry - feel bones in vagina to see if she can deliver vaginaly)
50
Routine Maternal Laboratory Tests
1. Complete Blood Count (CBC)
- Anemia
- Infection
- Abnormal platelet count - **less than 100000 - Danger !!!**
2. Blood type, Rh, abnormal antibodies
- **Erythroblastosis fetalis - Rh disease - M (-) and B (+) - M destroys Bs RBC - B anemic **
- Hyperbilirubinemia
- Some antibodies carry risks to fetus
3. **_Serology_** (VDRL/RPR)
- Syphilis ( after 16 weeks can cross placenta - congenital syphilis)
4. HbSAg (Hepatitis B Surface Antigen)
Risk of hepatitis B transmission ( tells if someone has been exposed to Hepatitis B)
51
Routine Lab Tests
1. Rubella titer
- Immunity to **“German measles” ( Positive is immune; negative - need immunization after baby is born)**
2. **Sickle cell screening** (prn) - positive
-Diagnostic test = Hgb Electrophoresis ( disease or trait) - African american, Mediterian sea, India)
3. **HIV testing**
4. **MSAFP (maternal serum alpha fetoprotein)**
-15-20 weeks, _optional screening_ test
- AKA “quad screen” or “quad check”
↑ suggests neural tube defects - spina bifida
↓ suggests Down Syndrome - amniocentesis
52
Routine Lab Tests
1. Down Syndrome Screening
- Bloodwork at 9-13 weeks (1st trimester)
- Ultrasound 11-14 weeks: **_nuchal translucency_** ( 2nd ) - collection of fluid on the back of babies neck - suggestive - more testing
2. Serum glucose (GCT) - glucose challenge testing
24-28 weeks’ gestation
3. GBS: group B strep - baby risk - meningitis, pneumonia
35-37 weeks’ gestation
Vaginal/rectal/UC culture
Treat in labor if positive - antibiotic ( Ampicillin) 2 doses 4 hours prior to delivery. Baby - 48 hours, vitals Q4
53
Chorionic Villus Sampling (CVS)
**10-13 weeks**, removal of **chorionic villi**
Transcervical or transabdominal route
Chromosomes, paternity
Results in **1-2 weeks**
98-99% accurate
1% risk of miscarriage
54
Amniocentesis
**14-20 weeks (11) - enough amniotic fluid **
Chromosomes, paternity, lung status (late preg.)
Results **days-4 weeks**
98-99% accurate
1/400 miscarriage risk
55
Nursing - obstetric component
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