Module two Flashcards
1
Q
Why do you need to have good nutrition when pregnant?
A
Associated with good perinatal outcomes and decreased the incidence of
1. Low birth weight (LBW)
2. Preterm delivery (PTD)
3. Congenital anomalies (think NTD/folic acid)
2
Q
What do LBW, PTD, and congenital abnormalities all have in common?
A
All are leading causes of perinatal morbidity & mortality
3
Q
How many calories should a pregnant women have per day?
A
2000 calories or extra 300/day
4
Q
How many grams of protein should a pregnant women have per day?
A
60 grams
5
Q
How much fat should a pregnant women have per day?
A
unchanged
6
Q
How much iron should a pregnant women have per day? Ca and PO4? Vitamin C? Folic acid? B6? Vit D?
A
Iron: 27mg
Ca and PO4: 1,000-1,200mg
Vitamin C: 80-85mg
Folic acid: min 400 mcg
B6: 1.9mg
Vitamin D: 5 mcg
7
Q
What should be included in a nutritional assessment?
A
3-Day Dietary Recall including food, drink, non-food
Nutritional Questionnaire
8
Q
What foods should be avoided during pregnancy
A
Non-nutritive foods (Diet Coke and Skittles, etc.)
Alcohol
Illegal substances: Cocaine, Meth, etc.
Many prescription or over the counter drugs, herbs, supplements
Pica (craving and consuming of non-food substances)
Food made with unsafe preparation techniques
9
Q
What would cause pica cravings? What contains pica?
A
Clay, Dust, Ice, Starch, Laundry soap, etc
May be caused by iron deficiency anemia
10
Q
What would be considered unsafe preparation techniques?
A
Raw or undercooked meats and fish, unpasteurized dairy, excessive large mercury containing fish, etc.
11
Q
What could cause too little weight gain in pregnancy? (5)
A
Anorexia/body image disorders
Nausea, “morning sickness”
Substance abuse, smoking
Insufficient means: poverty, homelessness, etc.
Pica (filling up on non-nutritive foods)
12
Q
What could cause too much weight gain in pregnancy?
A
hidden calories
“stress” eating, depression
Poor dietary knowledge
13
Q
What are the consequences of inadequate weight gain during pregnancy? What does this put the infant at risk for?
A
More likely to have low birth weight babies
Respiratory Distress Syndrome, Intraventricular Hemmorrhage, Patent Ductus Arteriosis, Necrotizing Eneterocolitis, and Retinopathy of Prematurity as newborns and at increased lifelong risk for hypertension, diabetes mellitus and heart disease.
14
Q
What are the complications of obesity during pregnancy?
A
Birth Defects (Neural Tube Defects)
Chronic Hypertension
Pre-gestational diabetes
Gestational diabetes
Sleep disordered breathing
15
Q
What are the complications of obesity during labor and birth?
A
Primary and repeat cesarean section
Medical induction/augmentation
Prolonged first stage
Excessive blood loss and longer operative time
16
Q
What are the complications of obesity postpartum?
A
Wound infection
Urinary incontinence
Postpartum hemorrhage (70% higher in obese women)
Retained weight
Failure to successfully initiate breastfeeding
17
Q
Due to maternal obesity, newborn is at increased risk for
A
Large infants-macrosomia
Intrauterine growth restriction (IUGR)
Stillbirth
Preterm birth
18
Q
What is recommended weight gain during pregnancy based on? If patient has normal BMI what is the recommendation?
A
Based on BMI
Total gain : 25-35 puunds
1st Trimester: .5-3 pounds total
2nd/3rd Trimester: 1 pound/week
OR
5-10 pounds by 20 weeks, then 1 pound/week
19
Q
What are nursing intervention surrounding nutrition/weight gain?
A
Thorough assessment of what she is taking in (food, beverages, non-food)
Find out what her expectations are and address any misconceptions/myths
Make individualized plans, including her and anyone else that is feeding her/supplying groceries/providing support in the formation of the plans
Make specific, manageable recommendations
Give patients the tools to allow them to participate in their own care (food diaries, referral to WIC, etc.)
20
Q
Are antenatal testing required?
A
No the are all optional
21
Q
What birth defects can antenatal testing detect?
A
Heart defects, abdominal wall, or neural tube defects
22
Q
What chromosomal problems can antenatal testing detect?
A
Down Syndrome (Trisomy 21)
Edwards Syndrome (Trisomy 18)
Patau Syndrome (Trisomy 13)
Turner’s Syndrome (X)
23
Q
What genetic diseases can antenatal testing detect?
A
Cystic fibrosis
Sickle Cell Disease
Fragile X Syndrome
Tay Sachs Disease
24
Q
What is a screening test for antenatal testing? (5)
A
only determines RISK
Maternal serum Quad Screen
Sequential Screen/First Trimester Screen
Cell-Free DNA
Carrier Screening (CF, Ashkenazi Jewish Panel, Fragile X, etc.)
Review of systems sonogram
25
What do maternal carrier screening tests test for?
Screens for recessive linked disorders where the parents are carriers and NOT disease affected
26
What does maternal quad serum test for? When should It be collected?
Screens for trisomy 18 and 21
Collected between 15 and 23 weeks from maternal serum but ideal timing between 16-18 weeks
27
What can maternal quad serum test be influenced by?
Influenced by maternal weight, gestational age, and ethnicity
Alpha-fetoprotein
hCG
Estriol
Inhibin-A
28
What does sequential screen/First trimester screen screen for?
Screens for trisomy 13, 18, 21, cardiac and neural tube defects
29
What does the sequential screen/First trimester screen look for at 11-13 weeks? 15-21 weeks?
11-13 weeks-- nuchal translucency (by ultrasound) and maternal serum
15-21 weeks-- 2nd draw of maternal serum alpha-fetoprotein to screen for neural tube and abdominal wall defects such as spinal bifida and gastroschisis
30
What is the most accurate screening option?
Free Fetal DNA (ffDNA)
31
What does an ffDNA screen for? When should it be preformed? When are the results less accurate? Most accurate?
Screens for trisomy 13, 18, 16, 20, 21, as well as sex chromosome aneuploidies and micro-deletions
After 10 weeks
Results not as accurate in low-risk women
Most accurate in high-risk women and women of advanced maternal age (35 years or older)
32
What can a standard ultrasound in 2nd or 3rd trimester be used to identify? (7)
Fetal presentation and number
Amniotic fluid index (how much fluid is around the fetus)
Placental location
Presence of cardiac activity
Fetal biometry (to confirm dating or measure interval growth)
Anatomy
Uterine/Pelvic anatomy including cervical length, ovaries, etc.
33
What anatomy can be seen on an ultrasound in 2nd or 3rd trimester?
Major organs (brain, heart, stomach, kidneys, etc.)
Spine
Extremities
34
What are the two types of ultrasounds and when are they used?
Transvaginally - used in early pregnancy
Transabdominal - Usually used after 12-week gestational age depending on maternal body habitus
35
When using an ultrasound, what defects can it help detect?
Crania-spinal defects
Gastrointestinal malformations
Cardiac defects
Renal malformations
Skeletal malformations
36
What is the standard US used? When is a 3D/4D US used?
Standard: 2D
3D/4D is used commercially and not usually used to evaluate a fetus
37
What is diagnostic testing used for?
Diagnostic tests are used to definitively confirm a chromosomal abnormality or inherited disorder
38
What are the 3 types of diagnostic testing?
Chorionic villus sampling (CVS)
Amniocentesis
Percutaneous umbilical cord blood sampling
39
When is a CVS used? What does it detect? What does it not detect?
at 10-12 weeks
Detects genetic, metabolic, and DNA abnormalities
Does not detect neural tube defects
40
What tests for neural tube defects?
Alpha fetoprotein (AFP) which is drawn between 15-20 weeks
41
How is a CVS done? What are two ways?
Catheter biopsy of chorionic villi obtained from edge of developing placenta
Transabdominal or transcervical
42
What is done earlier, amniocentesis or CVS?
CVS is done earlier which allows for termination before fetal movement is felt
43
How is a percutaneous umbilical blood sampling (PUBS) preformed? What does it test for?
Procedure performed to obtain fetal blood from the base of the umbilical cord
Used to aid in diagnosis of hemophilia, hemolytic disorders, fetal infections, chromosomal abnormalities, fetal hydrops, and assessment of fetal H&H
44
What are the risks of CVS?
Increased risk of spontaneous abortion (twice the chance of loss when compared with amniocentesis)
Risk of fetal limb defects (finger or toe missing)
Bleeding
Infection
Failure to obtain tissue
Leaking of amniotic fluid
45
When is an amniocentesis done? What does it detect? How is it preformed?
Done at 15-18 weeks
Detects genetic, metabolic, and DNA abnormalities
Needle guided aspiration of amniotic fluid
46
What are the risks/side effects for amniocentesis?
Spontaneous abortion (0.5%)
Infection
Vaginal spotting
Cramping
Damage to fetus
47
What would an amniocentesis be used for later in pregnancy?
assess for infection, determine extent of fetal anemia, or assess fetal lung maturity
48
What are the ethical, legal, and social benefits for antenatal testing?
More customized treatment (such as birth location and special Dr.)
Earlier diagnosis with potential for higher survival rates
Increased social support - more time to plan
Preparation for grieving/palliative care after birth if anomaly is incompatible with life
Option to terminate affected pregnancy
49
What are the ethical, legal, and social risks for antenatal testing?
Increased anxiety for pregnant women with both true and false positive results.
Increased exposure to maternal levels of stress for fetus
Delayed bonding with the pregnancy
Family stress if opinions on testing/interventions differs between partners
Elective termination
50
What is the difference between positive, probable and presumptive s/s of pregnacy?
Positive: Can’t be anything else
Probable: Objective and things the provider can observe/measure
Presumptive: Subjective and things the woman experiences and reports
51
What are positive signs of pregnancy?
Fetal heartbeat per Doppler or fetoscope
Fetal movement with palpated (per trained provider) or visualized (per trained provider)
Visualization of fetus on ultrasound
Delivery
52
What are presumptive s/s of pregnancy? (8)
Amenorrhea
N/V
Urinary frequency
Breast tenderness
Darkened areola
Quickening
Weight gain
Fatigue
53
What are probable s/s of pregnancy? (10)
Goodell’s, Hegar’s sign
Chadwick’s sign
Braxton Hicks
Uterine souffle
Linea nigra
Abdominal striae
Ballottement
Palpation of fetal outline
Abdominal enlargement
Positive pregnancy test
54
What is partner couvade? How does this resent?
Unintentional taking on the physical symptoms of the pregnant partner
Low back pain
Nausea
Weight gain
55
What are hormonal causes for common pregnancy discomforts?
Estrogen
Progesterone
Relaxin
Human placental lactogen
Prolactin
Oxytocin
Human chorionic gonadotropin
56
What are mechanical issues r/t common pregnancy discomforts?
Enlarging uterus
Weight gain
Postural changes
Emotional stress (nausea, HA, difficulty sleeping, etc.)
57
What are the vaginal changes in pregnancy?
Estrogen influence
Hypertrophy
Hyperplasia of lining
Increased thick white secretions
58
What are the nutritional changes in pregnancy?
Normal weight gain fo 20-30 pounds
Balanced diet and increased folic acid and caloric intake
Increased need for water
59
What are the uterus changes in pregnancy?
Increase in size and weight
Increase fibrous CT
Braxton hicks
Cervical softening
Mucus plug
60
What are 3 signs caused by estrogen and progesterone?
Chadwick’s sign (blue tinge to cervix/vagina)
Goodell’s sign (cervical softening)
Hegar’s sign (softening lower segment)
61
What causes the uterus to enlarge?
estrogen and progesterone
62
What is leukorrhea? What is the cause?
White discharge form the vagina
Estrogen
63
What is the cause of a mucus plug?
Estrogen
64
What are the causes of Braxton hicks?
estrogen and oxytocin
65
When the uterus enlargers, what should you pay special attention to d/t the effects it causes?
Lungs/diaphragm
Intestines
Bladder
Spine curvature
66
What occurs with the organs from 0-12 weeks?
Pelvis pushes down on bladder and against the intestines
67
How does pregnancy change the sense?
heightened taste, smell – may lead to food aversions
68
How does pregnancy affect HEENT?
Eyes may change shape – vision changes
Ptyalism (Hyper salivation)
Bleeding gums-estrogen and progesterone
Nose bleeds-estrogen and progesterone
Feeling of fullness/stuffiness in ears, nose and sinuses
69
What are changes to hair/skin (10)
Linea nigra
Melasma (aka Chloasma or Facial mask)
Darkening areolae, vulva, axilla
Acne vulgaris
Vascular spider nevi*- progesterone
Striae (abd stretch marks) -50-90%*
Increased hair and nail growth (prolonged growth phase, less in resting phase)-estrogen
Palmar erythema-estrogen
Increased skin pigmentation
Dermatitis
70
What causes the changes to the hair/skin?
estrogen and progesterone
71
What are the changes to the breasts? (10)
Enlargement - glandular hypertrophy (E &P)
Tenderness and sensitivity (E & P)
Nipple sensitivity (E & P)
Human Placental Lactogen - breast development
Vein prominence- progesterone
Nipples become more erect
Areolar changes – darkening, enlargement-estrogen
Montgomery’s tubercles
Heaviness and fullness
Thin watery secretions
72
When is colostrum? What causes it?
12 weeks
Prolactin
73
What are the changes in respiratory? (7)
Respiratory alkalosis- R/T increased RR, increased oxygen consumption
Capillary engorgement and swelling/stuffy nasal passages, epistaxis-estrogen
Upward displacement of diaphragm
Rib cage flare
Increased respiratory rate
20% increased oxygen consumption
Increased tidal volume
74
What are endocrine changes that occur in pregnancy?
Increased metabolic rate d/t thyroid increasing in size and activity
Increased body temperature
75
What does TSH do in the first trimester of pregnancy? What does this cause?
TSH decreases in first trimester
Thyroid increase in size and activity
76
What are the CV differences during pregnancy? (8)
Lateral displacement of heart
Increased stroke volume, heart rate, cardiac output
Vasodilation with subsequent drop in BP-progesterone
Increase in resting heart rate by 10-15 bpm
Systolic murmur up to 90% heard
Increase in blood volume, max at 32 weeks (50% increase in plasma volume)
Heart enlargement
Increased palpitation
77
What are the hematologic changes in pregnancy?
Increase in plasma
RBC production is not proportional to RBC usage --> physiologic anemia
Immunocompromised —> elevated WBC
Increase clotting factors
Pseudoanemia
78
What are the hbg levels in the 1st and 2nd and 3rd trimester that would indicate need for iron? When does iron begin to be stored?
1st and 3rd trimesters: < 11 g/dL treat
2nd trimester: < 10.5 g/dL treat
Fetus begins to store iron after 20 weeks
79
What are the changes in GI during pregnancy? (8)
Displaced stomach/intestines
Decreased GI motility and emptying (gas, constipation)-progesterone
Nausea and vomiting- HCG
Decreased gallbladder muscle tone leads to delayed emptying (risk for stones) - progesterone
Progesterone causes “valve” between stomach and esophagus to “soften” -heartburn
Dilated vessels – hemorrhoids; progesterone and mechanical
Elevated alkaline phosphatase – no clinical significance
Pregnancy gingivitis
80
What are the renal changes during pregnancy? (9)
Increased renal blood flow
Dilation and urinary stasis in renal pelvises (droopy ureters) --> risk for UTI/pyelonephritis- progesterone
Increased glomerular filtration rate (though “sloppy” so glucose and traces of protein may be spilled)
Increased frequency
Mechanical compression of bladder
Increased urine output of 200 ml more urine per day
Decreased bladder tone
Decreased renal threshold for sugar
Decreased BUN, creatinine and uric acid
81
What are the MSK changes in pregnancy? (8)
Loosening of joints- Relaxin, progesterone, estrogen
Widening /increased mobility of symphysis and sacroiliac joints, useful to fit out babies
Cause loosening of knees, ankles, wrists- other joints
Postural changes with associated lower back pain
Exaggerated lordosis
Altered center of gravity
Duck waddling gait
Increased lumbosacral care
82
What is a concern d/t MSK changes?
SAFETY - prone to slips, trips and falls
83
What does hormone levels cause in pregnant women?
hormone levels trigger fluid retention, which can cause swelling. This swelling can, in turn, push against the median nerve in the carpal tunnel – increasing pressure in the carpal tunnel and sometimes causing pain in your wrist and hand.
84
What is superior vena cava syndrome? What does it lead to?
Enlarged uterus compresses the inferior vena cava and the lower aorta when patient is supine
Reduced venous return to heart
85
What are the s/s of superior vena cava syndrome?
decreased BP, light headedness, syncope, racing heart, sweating, fetal heart rate changes
86
How do you differentiate between discomfort and a problem?
Thorough history
OLD CART (Onset, location/radiation, duration, character, aggravating factors, relieving factors, timing , severity)
Thorough physical exam
87
What is gravidity?
the number of pregnancies the patient has had, including the current one
88
What is parity?
the number of births after 20 weeks
Does not include miscarriages or abortions before 20 weeks
89
Nulligravida
Never been pregnant
90
Nullipara/Nullip
Never given birth to a fetus > 20 weeks
91
Primigravida
Pregnant for the first time
92
Primipara/primip
Has given birth once to a fetus > 20 weeks
93
Multigravida
Pregnant more than once, irrespective of outcome
94
Multipara/Multip
Two or more births > 20 weeks gestation
95
Grand multipara
five or more births > 20 weeks gestation
96
What does term mean r/t GTPAL?
the number of births > 37 weeks, regardless of the outcome
97
What does pre term mean r/t GTPAL?
the number of births from 20 weeks to < 37 weeks
98
What does abortions mean r/t GTPAL?
loss of pregnancy less than 20 weeks; spontaneous (miscarriage) or therapeutic (termination abortion)
99
What odes living mean r/t GTPAL?
number of children currently living
100
What are preconception goals? (6)
Normal BMI (18.5-29.9)
30 minutes of regular daily exercise
Vaccines up to date
Dental work up to date
GYN care up to date
Begin tracking menses
101
What vaccines should you make sure are up to date before conception?
Rubella, varicella, covid, flu
102
What substance should you stop using in pre-conception?
caffeine, tobacco, ETOH, illegal drugs, some prescription meds
103
When are preconception goals usually addressed?
usually at the first prenatal appointment after patient already pregnant d/t lack of pre-conception care
104
What is address at the first prenatal appointment?
Establish and accurately date the pregnancy
Review all preconception/NOB goals
Health history
Evaluate for risk factors and try to prevent risk
Give support for common discomforts
Provide anticipatory guidance for birth, parenting, role change, breastfeeding, etc.
105
How do you establish a pregnancy?
Missed menses
Positive home pregnancy test
Positive lab hCG test
Positive lab blood hCG test
Fetus on ultrasound
106
What is term pregnancy considered? When is due date sate for?
37-42 weeks
Due date is 40 weeks after first day of LMP or 280 days from LMP
107
What id EDD? EDC? EDB?
EDD-Estimated Due Date
EDC-Estimated Date of Confinement
EDB-Estimated Date of Birth
108
When do first time moms typically go into labor?
75% of first time moms go 7-10 days after their due date
109
What is pre term?
Before 34 weeks
110
Late pre term?
34 weeks 0 days - 36 weeks 6 days
111
Early term?
37-38 weeks 6 days
112
What is regular full term?
39 - 40 weeks 6 days
113
Late term?
41 weeks 0 days - 41 weeks 6 days
114
What is post term?
42 weeks and beyond
115
What are methods of calculating due date?
Naegele's rule
Wheel
Online application
Ultrasound
116
What is Naegele's rule? Any problems with this method?
Need a known LMP for accuracy
LMP + 1 year - 3 months + 7 days = EDD
Does not account for cycle length (late ovulation)
Does not account for variation in length of months or leap years (not always exactly 280 days from LMP)
117
What is the wheel for EDD?
Quick
Can use conception date, adjust for cycle length
Can estimate current gestation within pregnancy
Some online versions
118
What are the initial labs that should be drawn? (12)
CBC (hgb/hct/plt)
Blood Type, Rh, ABS
Syphilis (RPR/VDRL, TPA)
Rubella status
Hepatitis
HIV
Hep C
Urine culture
Gonorrhea & Chlamydia
Pap smear
*TB testing (high risk pts)
*Varicella
119
What are the 28 week labs that should be drawn?
CBC
Glucose tolerance test
ABS (if Rh negative)
Syphilis (high risk)
120
What are the 36-37 week labs that should be drawn?
GBS testing
121
What are optional lab testing that could be done?
Antenatal screening
Carrier screening (CF, SMA, etc)
122
What occurs in pregnancy r/t Rh factor?
Rh negative women and Rh positive man make baby
Rh negative woman carrying Rh positive baby
Cells from Rh positive baby gets into moms blood
Mom becomes sensitized --> antibodies formed to fight Rh positive blood cells
In next Rh positive pregnancy, maternal antibodies attack fetal RBC
Hemolytic disease of newborn
123
What is the solution to the issue with Rh factor?
PREVENT antibody formation by giving Rho(D)Immune Globulin(Rhogam):
124
When should Rhogam be given?
when mixing is suspected (trauma, bleeding, etc.)
prophylactically at 28 weeks in each pregnancy she has
within 72 hours of delivery if baby is Rh + or status of fetus is unknown (miscarriage/abortion)
125
What does TORCH stand for?
Toxoplasmosis
Other: Varicella, Parvovirus, Syphilis, Listeria, & Coxsackie Virus, Zika
Rubella
Cytomegalovirus (CMV)
Herpes Simplex Virus (HSV)
126
Why are TORCH diseases so dangerous in pregnant women? What should be done?
All are associated with potential for significant negative fetal outcomes including fetal death if infection occurs during pregnancy
Often mild or even NO symptoms in mother
Often limited or no treatment available
**PREVENTION, PREVENTION, PREVENTION!!!!!!!
127
How do you prevent Toxoplasmosis?
Avoid eating raw or undercooked meat, avoid contact with feces of infected cats
128
How do you prevent Parvo (5th disease), coxsackie (hand foot mouth), CMV?
Check status of those with high exposure risks-day care workers, etc. Precautions if non-immune.
129
How do you prevent listeria?
Avoid eating unpasteurized cheeses
130
How do you prevent rubella and varicella?
Immunization available but not given during pregnancy – check status, precautions if non-immune, immunize postpartum.
131
How do you prevent syphillis or herpes?
Safe sex practices (condoms), suppressive therapy for HSV in the weeks before labor to prevent an active outbreak and transmission to baby.
132
What type of vaccines cannot be given during pregnancy? Why?
No live virus immunizations during pregnancy due to the theoretical risks of congenital infection
133
How do you prevent influenza? What cannot be given for influenza?
Given in pregnancy at any time during flu season
Cannot give nasal spray vaccine as live
134
What does Tdap protect against? Can it be given during pregnancy? Who else is it recommended for?
Prevention of Pertussis (whooping cough) infection, Tetanus, and Diphtheria
Booster recommended at 27-36 weeks to all pregnant patients in each pregnancy
Recommended for all people who will are around newborns who have not had Tdap booster in last 10 years
135
What does a booster Trap shot at 27-36 weeks pregnant do for the fetus?
Antibodies passed through placenta into fetus to help reduce risk within first 2 months of life until baby able to get vaccine (Dtap)
136
What are weight gain recommendations if underweight?
28-40 pounds
137
What are weight gain recommendations if normal weight?
25-35 pounds
138
What are weight gain recommendations if overweight?
15-25 pounds
139
What are weight gain recommendations if obese?
11-20 pounds
140
What are weight gain recommendations if morbid obese?
No weight gain
141
What are the complications if mom is underweight? Overweight?
Underweight- potential for increased risk of PTL, low birth weight infants
Obesity- increased risks of HTN, DM/GDM, macrosomia, injury, c/s, postpartum hemorrhage, stillbirth, miscarriage
142
What are the complications if there is not adequate weight gain?
potential for increased risk of fetal growth restriction
143
What should be done during physical exam of pregnant women?
*Vital signs
*Basic measurements-height, weight, BMI*
Head to toe exam (Quick mouth/dental check, Thyroid, Heart, Lungs, Abdomen, Lower extremity skin, edema, varicosities)
*OB/GYN specific assessment (Leopold’s (presentation/position), Fundal height, FHT’s)
Pelvic exam: Vulva, vagina, cervix (prn), Pap, GC/CT
144
What are leopolds?
145
What should the fondus height be at 12 weeks? 20 weeks? 36 weeks? 37-40 weeks? Postpartum?
12 weeks: pubic symphysis
20 weeks: umbilicus
36 weeks: Xiphoid process
37-40 weeks: regression of fundal height 36-32 cm
Postpartum: umbilicus
146
Where is the baby's HR the loudest?
On their back
147
When can fetal HR been seen on US?
after 6 weeks
148
When can fetal HR be heard via doppler?
10-12 weeks
149
When will the first fetal movement be felt?
18-22 weeks
150
When should the initial pregnancy visit occur? How often between inital-28 weeks? How ofter between 28-36 weeks? How often between 36-birth?
First visit between 8-12 weeks
Visits Q 4 weeks until 28 weeks
Visits Q 2 weeks until 36 weeks
Visits Q 1 week until birth
