Normal Antepartum Flashcards
1
Q
The length of a pregnancy is divided into what?
A
Trimesters
1st - the first 13 weeks
2nd - through 26 weeks
3rd - 27 weeks until term
2
Q
How many weeks is early term?
A
37 0/7 weeks to 38 6/7 weeks
3
Q
How many weeks is full term?
A
39 0/7 weeks to 40 6/7 weeks
4
Q
How many weeks is late term?
A
41 0/7 weeks to 41 6/7 weeks
5
Q
How many weeks is post term?
A
42 0/7 weeks or above
6
Q
In GTPAL, what does G stand for?
A
(Gravida)
Total number of pregnancies past and present
7
Q
In GTPAL, what does T stand for?
A
(Term)
Number of deliveries after 37 completed weeks
8
Q
In GTPAL, what does P stand for?
A
(Preterm)
Number of deliveries after 20 weeks but before 37 completed weeks
9
Q
In GTPAL, what does A stand for?
A
(Abortions)
Number of pregnancies ending after 20 weeks
10
Q
In GTPAL, what does L stand for?
A
(Living)
Number of currently living children
11
Q
Types of symptoms
A
- Presumptive (subjective)
- Probable (objective)
- Diagnostic
12
Q
Characteristics of presumptive symptoms
A
These are symptoms the woman experiences and reports
13
Q
Characteristics of probable symptoms
A
- Signs perceived by the examiner
2. May be caused by conditions other than pregnancy
14
Q
Characteristics of diagnostic symptoms
A
- Signs perceived by the examiner
2. Can be caused only by pregnancy
15
Q
Examples of diagnostic signs of pregnancy
A
- Fetal heart rate can be detected with a doppler as early as 10 weeks
- Fetal movement palpable by HCP after about 20 weeks
- Visualization of fetus by USG
- Gestational sac visible 4-5 weeks gestation
- Heart beat visualized at 6-7 weeks
16
Q
Hormones that are initially produced by the corpus luteum and then produced by the placenta
A
- Human chorionic gonadotropin (hCG)
- Human placental lactogen (hPL)
- Estrogen
- Progesterone
- Relaxin
- Prostaglandins
17
Q
hCG
A
Human Chorionic Gonadotropin
- Stimulates estrogen and progesterone production by corpus luteum until placenta develops
- Basis for urine pregnancy tests
- Peaks at week 8 and then gradually decreases
- Responsible for a lot of pregnancy nausea
18
Q
hPL
A
Human Placental Lactogen
Acts as insulin antagonist by increasing the amount of free fatty acids and decreasing maternal metabolism of glucose (when this spikes, it is because the fetus is growing a lot)
19
Q
Estrogen
A
- First produced by the corpus luteum
- Placenta takes over production by 7th week
- Stimulates uterine development
- Prepares ducts in breasts for lactation
20
Q
Progesterone
A
- Produced by corpus luteum, then by the placenta at week 7
- Most important hormone for maintaining pregnancy by inhibiting uterine contractility and preventing early miscarriage
- Prepares breasts for lactation
- Slows down peristalsis
- Calms smooth muscles (uterus, intestines)
21
Q
Relaxin
A
- Inhibits uterine activity
- Diminishes strength of uterine contractions
- Aids in softening cervix
- Makes pelvis cartilage flexible
22
Q
Prostaglandins
A
- Function is uncertain; thought to be responsible for placental vascular resistance
- Decreased levels associated with HTN in pregnancy
- Thought to play a role in initiation of labor
* Sperm has prostaglandins which can soften the cervix
23
Q
Presumptive Signs of Pregnancy (Uterus)
A
- Amenorrhea
- Enlargement of abdomen
- Quickening
24
Q
Probable Signs of Pregnancy (Uterus)
A
- Braxton-Hicks contractions
- Uterine souffle
- Fetal outline can be palpated in the abdomen
25
Amenorrhea
The absence of menses
| - One of the earliest symptoms in a woman whose cycles are regular
26
Describe how the abdomen enlarges during pregancy
1. Uterus rises above the symphysis after 12 weeks, level of umbilicus at 20 weeks
2. Enlarges and thickens primarily due to hypertrophy not hyperplasia
3. Capacity - increases from 10 mL to 5000 mL
4. By end of pregnancy - 1/6 of maternal blood flow goes to the uterus
27
Quickening
Fetal movement felt by mom (fluttering sensation)
| * 18-22 weeks in 1st pregnancies, 16 weeks for experienced moms
28
Braxton-Hicks contractions
16-28 weeks
| Irregular, often painless, later may be confused with labor
29
Uterine Souffle
1. Soft blowing sound auscultated over maternal abdomen occurring at same rate as maternal pulse
2. Caused by uterine blood pulsating through placenta
30
How do hormones affect the cervix?
1. Estrogen causes an increase of cells and hyperactivity
| 2. Hormone stimulated changes lead to a mucus plug
31
What is the purpose of a mucus plug?
1. Seals endocervical canal
2. Protects pregnancy form ascending microorganisms (infection)
* Will lose 2 weeks before delivery
32
Probable Signs of Pregnancy (Cervix)
1. Goodell's sign
2. Chadwick's sign
3. Ballottement
33
Goodell's Sign
Softening of the cervix; usually caused by estrogen or vasocongestion (blood pooling)
34
Chadwick's Sign
Bluish discoloration from increased vascularity; can be caused by vasocongestion
35
Ballottement
Passive fetal movement, rebound, when examiner pushes against the cervix
- Baby is still free floating (not in labor)
36
Hegar's Sign
A probable sign of pregnancy
| - Softening of the isthmus
37
McDonald's Sign
A probable sign of pregnancy
| - An ease in flexing the body of the uterus against the cervix
38
Normal Antepartum (ovaries)
They continue to produce hormones
| * The placenta takes over around 6-7 weeks
39
Changes to the vaginal epithelium during pregnancy
1. Increased secretions (means more flushing which means its cleaner)
2. Thickening of mucosa
3. Increased risk of yeast infections (because of increased BG and pH imbalances)
40
Changes to the connective tissue of the vagina during pregnancy
1. Loosens throughout pregnancy
| 2. Later allows for expansion needed for delivery
41
Presumptive Signs of Pregnancy (Breasts)
1. Montgomery's tubercles (bumps of the breast tissue); helps with lubrication later on in pregnancy
2. Hypertrophy and hyperplasia
- Become more nodular
- More and larger glands
42
Changes to the breasts during pregnancy
1. Areola darken; nipples erectile
2. Veins become more prominent
3. Colostrum production
- Occurs in last trimester
- Antibody rich yellow secretion
43
Changes to the respiratory system during pregnancy
1. Increased O2 needs (20-40% increase)
2. Structural changes
3. Growing uterus will elevate the diaphragm until lightening (when the baby drops 36-40 weeks)
4. Increased subcostal angle
5. Increased chest diameter
6. Increased air volume exchange
7. Nasal stuffiness and epistaxis (nose bleed); more susceptible to allergies
8. Respiratory rate increases as pregnancy progresses
44
Changes to the cardiovascular system during pregnancy (heart)
1. Increased workload due to increased volume
2. More flow to uterus and kidney's, increased potential for dependent edema in lower extremities and variscosities in legs, vulva, rectum
3. Systolic flow murmur due to resistance of increased blood volume
4. Sinus arrhythmia
5. 50% increase in blood volume
6. Pulse increases
7. BP decreases during 2nd trimester, then increases to pre-pregnancy levels by end of 3rd trimester
45
Changes to the cardiovascular system during pregnancy (blood volume)
Physiologic Anemia
- Plasma volume greater than erythrocyte volume (can cause a lower H/H lab result
- Increased production of leukocytes (5000-15,0000)
- Fibrin and fibrinogen levels (increased risk thrombosis)
46
What is supine hypotensive syndrome?
1. Occurs during 2nd and 3rd trimesters when the weight of the uterus presses on the vena cava when the patient is supine
2. Decreased blood flow return to the right atrium (decreased BP) which leads to dizziness, pallor, and clamminess
47
How do you correct supine hypotensive syndrome?
Left side-lying position (which increases cardiac output)
48
Presumptive Signs of Pregnancy (Gastrointestinal System)
1. Nausea and vomiting
- Common in 1st trimester due to increased hCG levels
- May be accompanied by ptyalism (salty taste before vomiting)
49
Changes to the gastrointestinal system during pregnancy
1. Pyrosis (heartburn)
2. Bloating and constipation
3. Hemorrhoids
50
Why is pyrosis typical during pregnancy?
Due to relaxation of cardiac sphincter with resultant reflux of stomach acid into lower esophagus
51
Why is bloating and constipation typical during pregnancy?
1. Increased progesterone relaxes smooth muscle which leads to delayed gastric emptying time and slowed peristalsis
2. Uterus adds pressure in abdominal cavity
52
Why are hemorrhoids typical during pregnancy?
They are the result of increased blood volume, decreased venous return, and slowed peristalsis
53
Changes to the liver during pregnancy
Decreased plasma albumin and serum cholinesterase
54
Changes to the gall bladder during pregnancy
Decreased emptying time may predispose to gallstone formation
55
Presumptive Sign of Pregnancy (Urinary Tract)
Urinary Frequency
- Experienced in 1st trimester when uterus still in true pelvis
- In 3rd trimester the weight of the uterus presses on the bladder
56
Changes to the urinary tract during pregnancy
1. Increased urine output
2. Increased volume
3. Bladder capacity doubles
4. Glomerular filtration rate increased by 50% by 2nd trimester and remains elevated until delivery
5. Renal tubular absorption increases during 2nd and 3rd trimesters
6. Renal threshold for glucose decreases (unable to reabsorb all the glucose filtered by the glomeruli which leads to glucosuria which may indicate development of gestational DM) (trace is okay)
7. Renal pelvis and ureters dilate and relax
57
Why are UTI's typical during pregnancy?
The renal pelvis and ureters dilate and relax which leads to urinary stasis which leads to UTI
58
Probable Signs of Pregnancy (Integumentary System)
1. Linea nigra
2. Chloasma
3. Striae
59
Linea nigra
Pigmented line (vertical midline abdomen)
60
Chloasma
"Mask of pregnancy" over cheeks, nose, forehead
- Seen more in dark haired women
- Fades after pregnancy when hormones decrease
61
Striae
"Stretch marks"
- Wavy lines that may appear on abdomen, thighs, buttocks, breasts due to changes in connective tissue
- May fade after pregnancy but will not go away completely
62
Changes in the integumentary system during pregnancy
1. Darkening of nipples, areola, vulva, and perianal area
2. Telangiectasis
3. Sebaceous glands are often hyperactive
63
Telangiectasis
Spider nevi
- Small, bright red elevations appearing on the chest, neck, face, arms, and/or legs
- Due to estrogen related increase in subcutaneous blood flow
64
Changes in the musculoskeletal system during pregnancy
1. Gums are likely to bleed
2. Pelvic joints relax - waddling gait secondary to relaxin
3. Increased lordosis due to size of the uterus, center of gravity changing (may result in backache)
4. Diastasis recti
65
What is diastasis recti?
Separation of abdominal muscles giving appearance of hernia
66
Presumptive Sign of Pregnancy (Metabolism)
Fatigue
67
Changes in metabolism during pregnancy
1. Pregnancy is a hypermetabolic state
2. BMR increases 25%
3. Mother must meet her own needs and needs of growing fetus
4. Weight gain rules
68
Weight gain rules during pregnancy
1. 25-30 lbs for normal weight woman
2. Underweight (BMI < 18) advised to reach ideal weight plus 25-30 lbs
3. Overweight (BMI < 25-29.9) advised to gain 15-25 lbs
4. Obese (BMI > 30) advised to gain 11-20 lbs
5. First trimester 3.5-5 lbs gain expected
6. 2nd and 3rd trimester 12-15 lb gain expected
69
Changes to the thyroid during pregnancy
1. Thyroid gland enlarges
2. Increased serum protein-bound iodine
3. BMR increases 25% due to fetal metabolic activity
* Women with low thyroid have problems with miscarriages and neurological development of the fetus and should be tested throughout pregnancy
70
Changes to the pituitary during pregnancy
Prolactin from anterior pituitary responsible for initial lactation
71
Changes to the adrenals during pregnancy
1. Cortisol levels increase in response to estrogen levels
2. Increased aldosterone levels by 2nd trimester
3. Thought to help in sodium regulation
72
Changes to the pancreas during pregnancy
1. Increased insulin needs during pregnancy
2. If insulin needs are not met, gestational diabetes develops in response to increased stress on islets of Langerhans
* hPL works against your body's insulin, which is why your body needs to produce more insulin
73
Common discomforts during 1st trimester
1. Nausea, vomiting, and ptyalism
2. Urinary frequency
3. Fatigue
4. Breast tenderness
5. Increased vaginal discharge
6. Nasal stuffiness and epistaxis
74
Interventions to help with nausea, vomiting, and ptyalism during 1st trimester
1. Getting out of bed in the morning (early) slowly
2. Avoid sudden movements
3. High protein snack at night to avoid empty stomach
4. Ginger (up to 1 gram) increases tone and peristalsis in GI tract
5. Cracker before getting out of bed
6. Ginger ale
7. Drink fluids between meals
75
Interventions for urinary frequency and incontinence
Kegels
| - Worse in 1st and 3rd trimester
76
Interventions for fatigue
1. Rest
2. Sleep side-lying
3. Relaxation techniques
4. Increase exercise
77
Interventions for breast tenderness
Supportive bra, adjust to larger size
78
Interventions for increased vaginal discharge
Cotton underwear to allow air flow; mild soap
79
Interventions for nasal stuffiness and epistaxis
Cool mist
80
Common discomforts during 2nd trimester
1. Backache
2. Leg cramps
3. Varicosities of vulva and legs
4. Constipation and hemorrhoids
5. Gas and bloating
81
Interventions for backache
1. Heat and ice
2. Support shoes
3. One foot on stool while standing
82
Interventions for leg cramps
1. Flex towards body
| 2. Increase calcium
83
Interventions for varicosities of vulva and legs
1. Avoid long periods of sitting/standing
2. Do not cross legs
3. Elevate legs above the heart
84
Interventions for constipation and hemorrhoids
1. 2 liters of fluid daily
2. High fiber
3. Sitz bath
4. Cold/witch hazel compresses
85
Interventions for gas and bloating
1. Increase water
2. Reduce gum chewing
3. Reduce gas forming foods
86
Common discomforts during 3rd trimester
1. SOB and dyspnea
2. Pyrosis
3. Ankle edema
4. Braxton-Hicks
87
Interventions for SOB and dyspnea
Will increase until lightening
1. Raise HOB
2. Side-lying
88
Interventions for pyrosis during 3rd trimester
1. Small frequent meals
2. Limit gas forming foods
3. Up for 1 hour after food
89
Interventions for ankle edema
1. Change positions frequently
2. Elevate legs
3. Avoid high sodium
90
Interventions for Braxton-Hicks
1. Rest
2. Differentiate between labor contractions
3. Usually lessen with walking
91
Danger Signs in Pregnancy
1. Sudden gush of fluid from vagina
2. Vaginal bleeding
3. Abdominal pain
4. T > 101 degree F (38.3 degree C) and chills
5. Dizziness, blurred vision, double vision, scotoma
6. Persistent vomiting
7. Severe headache
8. Edema of hands, face, legs, and feet
9. Muscular irritability, convulsants
10. Epigastric pain
11. Oliguria
12. Dysuria
13. Absence of fetal movement
92
Maternal psychological responses during 1st trimester
1. Ambivalence
2. Disbelief, seems unreal
3. Mood swings due to hormone changes
93
Maternal psychological responses during 2nd trimester
1. Quickening makes it seem real
2. Excited
3. Partner may withdraw
4. Body image changes
5. Concern about partner support
94
Maternal psychological responses during 3rd trimester
1. Pride in pregnancy
2. Anxiety about delivery
3. Concern about health of baby
4. Surge of energy near end prior to labor when woman prepares home for baby
95
Rubin's psychological tasks of mother
1. Ensuring safe passage through pregnancy, labor, and birth (for self and fetus)
2. Seeking acceptance of this child by others
3. Seeking commitment and acceptance of herself as mother to the infant (binding in)
4. Learning to give of oneself on behalf of one's child
96
Father's psychological responses to pregnancy
1. Pride in pregnancy
2. Ambivalence - readiness for responsibilities of parenthood
3. Stress - financial concerns
4. Concerns and fears - change in relationship, health of baby or partner
5. Couvades
97
What is Couvades?
1. Traditionally, observance of certain rituals and taboos during transition to fatherhood
2. Now also refers to development of physical symptoms usually seen in women such as weight gain and nausea during pregnancy
98
Siblings response to pregnancy
1. "Sibling rivalry"
2. Siblings require assistance in dealing with the birth of a new baby in developmentally appropriate ways
3. Anticipate some regression in siblings
4. Siblings need "alone time" with parents after baby arrives
99
What is included in the initial OB visit?
1. OB history
2. GYN history
3. Current medical history
4. Past medical history
5. Family medical history
6. Religious, spiritual, cultural history
7. Occupational history
8. Partner's history
9. Personal information about patient
10. Violence screening
100
Questions to ask about current pregnancy during initial OB visit
1. LMP
2. Regular cycle?
3. Contraceptive use prior
4. Bleeding, cramping, spotting, vaginal discharge
5. N/V
6. Urinary symptoms
7. Fever
101
Questions to ask about past pregnancies during the initial OB visit
1. GTPAL
- Length of labor, type of delivery
- Abortions (elective or spontaneous); if ectopic, which tube removed
2. Infant weight, status
3. Given Rhogam if Rh negative
102
Questions to ask about GYN history during the initial OB visit
1. GYN surgeries or procedures
2. Abnormal paps
3. STI's
4. Menstrual history - menarche, dysmenorrhea, regular, flow, duration
103
Questions to ask about current medical history during the initial OB visit
1. VS
2. General: nutrition and exercise
3. Medications
4. Allergies
5. Alcohol, tobacco, caffeine, illicit drugs
6. Teratogenic exposure
7. Present disease conditions
8. Immunizations
9. Any abnormal symptoms
104
Questions to ask about past medical history during the initial OB visit
1. Surgeries
2. Past treated diseases (hepatitis, etc.)
3. History of blood transfusions
105
Questions to ask about family medical history during the initial OB visit
1. Genetic disorders
| 2. Congenital anomalies
106
EDD
Estimated date of delivery
107
EDC
Estimated date of confinement
108
EDB
Estimated date of birth
109
Nagele's rule
1st day of LMP, subtract 3 months, add 7 days
| *The wheel can help determine this without doing the math yourself
110
McDonald's Rule
The distance abdominally from the top of the symphysis pubis to the top of the uterine fundus measured in centimeters; correlates well with weeks of gestation between 22 and 34 weeks (26 weeks measures about 26 cm)
111
What is done to confirm gestational age/due dates?
Ultrasound - more accurate the earlier performed
112
What does the physical assessment during the initial prenatal visit include?
1. Physical examination of the new prenatal patient includes a complete head-to-toe assessment with notation of the size, shape, position of the uterus, fundal height, FHR, FM
2. With a Pap smear, a test for gonorrhea, Chlamydia, gardnerella, trich, yeast may be done
3. The pelvis is also assessed for adequacy for delivery
113
What is done during subsequent prenatal visits?
1. BP
2. Weight
3. Urine for protein and glucose
4. Fetal heart tones (FHT)
5. Fetal movement (FM)
6. Fundal height (FH)
114
How often to go to prenatal visits?
1. Visits every 4 weeks until 28 weeks
2. Visits every 2 weeks until 28-36 weeks
3. Visits weekly 36 weeks until delivery
- Vaginal exams done 37 + weeks
115
What kind of laboratory assessment is done during the initial prenatal visit?
1. Pap smear
2. CBC
3. Hemoglobin electrophoresis
4. Rubella immune status
5. ABO, Rh, antibody screen
6. STI screening
7. Pregnancy test
116
What is included in a STI screening?
1. Syphilis
2. Gonorrhea
3. Chlamydia
4. Hepatitis B surface antigen
5. HIV 1 and 2 antibody screen
117
Subsequent labs that are drawn during pregnancy
1. 1 hour glucose tolerance with 50 mg glucola (24-26 weeks)
- If elevated 3 hour OGTT with 100 mg glucola
2. Hct/Hgb (24-28 weeks)
3. Antibody screen prior to Rhogam at 28 weeks if Rh -
4. Group B strep screen (35-36 weeks)
5. Gonorrhea/Chlamydia (36 weeks if risk +)
118
Genetic Screening
MaternitT-21, Harmony (tests for trisomy 13, 18, 21)
1. Can be done as early as 10 weeks
2. Will map the DNA of the baby including sex XX or XY
119
Quad Marker Screening
1. Blood test best performed at 15-20 weeks gestation
| 2. Utilizes MSAFP, hCG, diametric inhibin-A, and unconjugated estriol to screen for NTD, trisomy 21, and trisomy 18
120
Amniocentesis
1. 15-20 mL amniotic fluid withdrawn with needle from uterine cavity through maternal abdomen
2. Usually done around 18 weeks (genetic)
3. Fetal lung studies around 30-35 weeks
4. Placement of placenta verified with US, empty bladder prior to procedure
121
Nursing Responsibilities for amniocentesis
1. After - monitor for contractions, cramping, bleeding, and check status of fetus
2. Give Rhogam for Rh negative mom
3. Instruct client to report ...
- Decreases fetal movement
- Vaginal discharge
- Uterine contractions ro abdominal pain
- Fever or chills
4. Instruct client to increase PO fluids and only light activities for 24 hours
122
Chorionic Villi Sampling (CVS)
1. Done at 10-12 weeks
2. Diagnostic for genetic, metabolic, and DNA abnormalities
3. Cannot detect NTDs (neural tube defects), MSAFP recommended
4. Full bladder for procedure
5. Rhogam if Rh negative mom
123
Ultrasound
1. Noninvasive
2. Diagnoses pregnancy
3. Calculates gestational age
4. Determines position
5. Monitors growth
6. Assess for genetic or congenital problem (best done around 18-20 wks)
7. Fetal nuchal translucency measurement at 10-13 wks can ID chromosome anomalies
124
Fetal kick counts
1. Daily kick counts encouraged to determine fetal movement changes
2. Same time each day
3. Further testing should be done within 12 hours of decreased fetal movement findings
125
Promotion of wellness/self-care (Clothing)
Avoid tight fitting clothes
126
Promotion of wellness/self-care (Bathing)
1. Showers are safer later in pregnancy (risk of falling in tub)
2. No douching
3. Cotton undies
127
Promotion of wellness/self-care (Sex)
Condoms decrease the risk of prostaglandin exposure from semen; no sex if bleeding
128
Pregnant Caloric Requirement
300 kcal above pre-pregnancy RDA
129
Lactating Caloric Requirement
500 kcal above pre-pregnancy RDA
130
Postpartum (not lactating) Caloric Requirement
RDA pre-pregnancy
131
Pregnant adolescent nutrition needs
1. Additional serving of dairy products per day
2. Inadequate iron also major concern
3. If < 4 years from menarche, high biologic risk due to own growing
4. Caloric needs vary
132
What is the primary source of energy from a pregnant woman's diet?
Carbohydrates
1. Promotes weight gain of fetus, placenta, and maternal tissues
2. Should be whole grain (oatmeal, brown rice)
133
Why is protein intake during pregnancy important?
1. Development of uterine, breast, and fetal tissue
2. Energy metabolism
3. Greatest demand during 2nd half of pregnancy
4. Need to increase from 60 to 80 grams a day (stored to maintain level needed for breast milk)
134
Why is iron intake important during pregnancy?
Because it is needed for development of blood cells so the mother should increase her iron consumption
135
Water requirements during pregnancy
1. 2 quarts per day
2. Increased water retention from increased estrogen and progesterone, and from decreased serum albumin
3. H2O needed for fetus, placenta, amniotic fluid, mother's increased blood volume and enlarged organs
136
Importance of folic acid
1. Deficits can lead to increased risk of NTD (neural tube defects)
2. 50-70% of NTD could be prevented with adequate intake
3. Recommendation is for all women of reproductive age to supplement with 400 mcg daily
4. 3 months prior to conception, 1 mg daily is recommended
5. 4 mg may be recommended if previous infant with NTD
137
Pica
Craving and eating of non-nutritive substances
1. Ice - causes iron deficiency anemia
2. Soil/Clay - can contain toxic substances/parasites
138
Methylmercury Risks
High levels of methylmercury found in ...
1. Swordfish
2. Shark
3. Tilefish
4. King mackerel
5. Ahi tuna
139
What kinds of seafood products are low in mercury?
1. Canned tuna
2. Salmon
3. Catfish
140
Listeria risks
1. No soft cheeses
2. No lunch meats/hotdogs unless reheated
3. No unpasteurized milk products
4. No ham/chicken salads from store
