OB exam 1 Flashcards
Breasts
- Don’t finish developing until after first baby
- Growth caused by increase in progesterone at puberty
- Function: lactation, organs for sexual arousal
- Physiologic alterations in size and activity at minimum 5-7 days post menstruation (do BSE at this time)
Endometrial cycle phases
- Menstrual: shedding of top 2 layers of endometrium
- Proliferative: rapid growth lasting from day 5-14 (building up)
- Secretory: ovulation until 3 days before next period. After ovulation, increase in progesterone and endometrium is filled with blood and glandular secretions (lush and ready to fertilize) Implantation generally 7-10 days after ovulation.
- Ischemic: blood supply to endometrium is blocked and necrosis develops leading into menstruation
Hypothalamic-pituitary cycle
Regulates FSH and LH.
1. FSH: anterior pituitary
-Follicular phase: egg develops in ovary; causes the variation in period length
- LH: posterior pituitary
-Luteal phase: after ovulation, progesterone is released to prepare for fertilization
Ovarian cycle
- Estrogen: “fertilizer”
- Progesterone: “lawn mower”
- 14 days after ovulation, another cycle occurs
Prostaglandins
-Oxygenated fatty acids classified in hormones
-Effects on: ovulation (slough); fertility (move sperm along); changes in cervix and cervical mucus; tubal and uterine motility; sloughing of endometrium (menstruation); onset of abortion (spontaneous and induced); onset of labor (term and preterm)
-Semen has prostaglandins
Climacteric and menopause
- Climacteric: pre to post menopause
-ovarian fxn and hormone fxn decline
-onset of premenopausal ovarian decline to postmenopause - Menopause: no period after a year
-last period dated with certainty after 1 year
-ovaries shrink
-35-60 yrs old - Perimenopause: decreased estrogen= irregular bleeding
-pregnancies can still occur
Sexual response
- Physical maturity at age 17 both sexes
- Sexual stimulation results in circulation to blood vessels (venous congestion)
- Arousal (orgasm): myotonia (muscle contraction)
- Four phases: Excitement, plateau, orgasmic, resolution
Health promotion adolescents
- First to enter healthcare system as young women
- Teenage pregnancies: sexually active without contraception have 90% chance of conceiving
-declined in last 10 yrs r/t more education and contraceptive use - Pap smear at 21
Health promotion adults
- Young and middle:
-Contraception
-Pelvic and breast screenings - Late reproductive:
-Chronic diseases emerge
-Increased risks with pregnancy
Prenatal care
- Important to seek early!! Abnormalities of fetus already present after 56 days of fertilization
Risk factors of fetal abnormalities
- Substance use and abuse: prescription, illicit, alcohol use, cigarette smoking, caffeine (linked to miscarriage)
- Nutritional problems: deficiencies (more common in women), obesity (an American problem), eating disorders (anorexia, bulimia), lack of exercise (150 min/week)
- Other: stress, mental health disorders, sleep (6-8 hrs good), environmental and work hazards, female genital mutilation (tribal practice to remove clit), human trafficking (prevalent in kc, sold into sex slaves, more in women and children)
Intimate partner violence
- Physical or emotional abuse (pregnancy increases the risk)
- Sexual assault
- Isolation
- Controlling all aspects of the woman’s life: money, shelter, time, food, reproductive coercion (destroys birth control)
Can be scars, bruises, broken bones or all mental
Assessment of the woman
- Physical exam and hx: done in a private relaxed enviornment
- Pelvic exam
-external inspection
-bimanual palpation: outside and inside
-rectovaginal palpation: hand outside and 1 finger in rectum and 1 in vagina
-vulvar self-exam: done easily with mirror to look for any abnormalities
-papanicalaou test: no douche, sex or vaginal meds 24-48 hrs prior - Adolescents (13-19 yrs): asked the same questions, pay attention to hints about risky behaviors, eating disorders and depression
Health screening for women
- Fasting BG (45+)
- Total blood cholesterol
- Lipid profile
- Urinalysis
- STI (<25 and as needed if sexually active)
- Mammogram (40)
- Clinical breast exam (20+)
- TB skin test
- Pap test (21-65; q3y until 30)
- Pelvic exam (until 70)
- Colon cancer screening (45)
- Bone mineral density (DEXA scan; 65)
Amenorrhea
Absence of a period
1. Primary causes:
-never started
-red flag by end of HS
-Autonomic: formed incorrectly at birth (pelvic exam, US)
-Endocrine
-Chronic disease
-Eating disorders
-Medications
- Secondary causes:
-result of pregnancy (most common cause)
-sign of variety of disorders
Hypogonadatropic amenorrhea
- Problem in central hypothalamic-pituitary axis
- Results from hypothalamic suppression
-Either a lesion or genetic inability to produce FSH and LH
-Ex: extreme activity can cause (usually secondary amenorrhea) - Management: counseling and education regarding stress, exercise, and weight loss; calcium and vitamin D
Dysmenorrhea
Dys= pain
-Pain during or shortly before menstruation (only a couple days; increased contraction of uterus)
- Primary: biochemical (arises from the release of prostaglandins) or abnormally increased uterine activity;
-Alleviating discomfort (medications, heat, alternatives: sex on first day of period will shorten and decrease severity of cramps) - Secondary: acquired menstrual pain (ex causes: STI, endometriosis: solved by surgery)
-Diagnosis and treat: pelvic exam, US, dilation and curettage, endometrial biopsy, laparoscopy
-Treatment directed to remove underlying pathology
-Menopause or suppression is a cure
Premenstrual syndrome (PMS)
Cyclic symptoms occuring in luteal phase of cycle (right before next cycle)
- Physical, psychologic and behavioral sxs
-30-80% of women experience
Premenstrual dysphoric disorder (PMDD)
Cyclic symptoms in the last 7-10 days of cycle (week to week and a half before period; right after ovulation)
-recognized in the DSM-5
-Severe variant of PMS
-3-8% of women
-Mood disorder (self destructive and homocidal; repetitive visions)
-May need counseling, hypnosis, acupuncture, SSRI’s used during the time (doesn’t take 4 weeks to get results in this case)
Endometriosis
Presence of growth outside of uterus (lesions)
-Sxs: dysmenorrhea, deep pelvic dyspareunia (painful sex)
-Treatment: Lupron drug therapy to supress ovulation; laparoscopy to get rid of lesions if trying to conceive
-Resolves at menopause (avg age 51)
Oligomenorrhea/hypomenorrhea
- Oligo: Infrequent
- Hypo: scant
Menorrhagia
Excessive mensturation
Metrorrhagia
bleeding between periods
Causes of abnormal uterine bleeding
- Pregnancy related conditions (miscarriage, abortion, ectopic)
- Lower reproductive tract infections (cervicitis, endometritis)
- Benign anatomic abnormalities
- Neoplasms
- Malignant lesions
- Trauma
- Systemic conditions (cushings, severe organ disease, thyroid disease)
- Iatrogenic (anticoagulants, medications, hormone use, tamoxifen)
STI’s and prevention
- more than 25 organisms spread
-19 million people affected annually in U.S.
-can scar fallopian tubes=infertility
-Prevention: safer sex practices! (knowledge of partner and reducing partners; low-risk sex: monogamous relationship; condom use; HPV vaccination)
Chlamydia
“clap”
-Most frequently reported STI (sexually active women under 25; older women with no barrier contraceptives; new or multiple partners)
-Often silent and highly destructive
-Difficult to diagnose
-Screening: asymptomatic and pregnant women; seen with a pap (white milky substance on cervix but doesn’t ever leave vagina)
-Treat with antibiotics
Gonorrhea
-Neisseria gonorrhoeae
-Oldest communicable disease
-Drug resistant strains on the rise because it has been around for so long (people struggle to tell their partners after its found)
-Women are often asymptomatic (greenish-yellow discharge is sxs)
-Management: antibiotic therapy
Syphilis
-treponema pallidum
-transmission into SQ tissue by abrasions and rashes
-transplacental transmission may occur during pregnancy
-stages: primary (5 to 90 days); secondary (6 weeks to 60 mo.)
-looks akmost rash-like
-Screening: pregnant women, serologic tests; can have false positives
-Management: penicillin in glute; sexual abstinence during treatment
Pelvic inflammatory disease (PID)
-Ascending spread or microorganisms from vagina to upper genital tract (mostly involves: uterine tubes (salpingitis) or uterus (endometriosis))
-usually caused by chlamydia or gonorrhea
- Increased risk for: ectopic pregnancy, infertility, chronic pelvic pain (hard to treat and hysterectomy may be needed)
-Management: prevention, oral or parenteral therapy, bedrest, education
Human Papilloma Virus (HPV)
-reoccurring virus of genital warts
-causes changes in cytology
-4 to 6 high risk strains
-Guardisil to prevent
-Only therapy is freezing them or cream (not shown to remove completely)
-Can still give vaginal birth, but the tissue down there bleeds and tears terribly
-Sxs: itching and vaginal discharge, smelly, dysparenuria, post coital bleeding (post sex)
Herpes simplex virus (HSV)
-type 1: nonsexual
-type 2: sexual
-no antibiotics and painful w no cure
-Suppression therapy to keep outbreaks at bay, antivirals used, less easily passed if “dormant”
-CANNOT give vaginal birth (will kill a baby if there are lesions)
Hepatitis
- Hepatitis B virus (HBV): most threatening to fetus and neonate (silent killer)-Easily transmitted during birth, so baby will recieve shots to help prevent against it
- HCV: most common blood borne infection
Human immunodeficiency virus (HIV)
-Heterosexual transmission is most common transmission
-23% of new infections are in women
-Severe immune depression characterizes AIDS
-Sxs: fever, headache, night sweats, malaise, generalized lymphadenopathy, myalgias, N/D, weight loss, sore throat, rash
-No cure, but we are better at imaging it
-Can give vaginal birth without passing it on (higher risk fro infection with c-section; vaginal birth preferred)
Bacterial vaginosis
pH imbalance
-Most common symptomatic vaginosis
-“fishy odor” and thin discharge
-preterm birth
-usually gets rid of itself
-too much sex or soap can get rid of good bacteria and cause
Candidiasis - candida albicans
-Itchy (pruritus) and miserable
- Cheese-curd discharge
-vaginal pH imbalance
-Can be inside or outside
-Treated with OTC agents
Trichomoniasis - trichomonas vaginalis
-STI’s
-Common cause of vaginal infection
-Screening: pap smear/specular exam
-Management: communicated w/ partner and antibiotics
-Sxs: “frothy” malodorous vaginal discharge (thick and frothy)
Infertility
25% of reproductive age couples
-diagnosed after 1 year of unprotected sex when the woman is <35 or 6 month when 35+
-Goals: provide accurate info, assist w identifying causes, provide emotional support, guide and educate ab treatment
Female infertility
40% of cases
-85-90% dont need IVF only meds
-Causes: ovarian, tubal and peitoneal. uterine, vaginal-cervical factors
-Assessment: anatomy eval, ovulation detection, hormone analysis (FSH on 3rd day of period), US, endometrial biopsy, hysterosalpingography (dye injected into fallopian tubes); laparoscopy (into abd. cavity to look at structures for endometriosis)
Male infertility
40% of cases
-Non-invasive assessment always first
-Hormonal factors (semen analysis: basic test)
-Testicular factors (done w US)
-Sperm transport factors
-Idiopathic male infertility (no pathologic reason; can be psychological)
-Scrotal ultrasound: evaluates ejaculatory ducts, vans deferens, seminal vesicles
Infertility care management
-Psychological considerations (major life stressors-becomes a chore to try and get pregnant; exhibit grieving behaviors)
-Non-medical treatments (herbal alternatives, no caffiene, excercise, no nicotine, drugs or alcohol, lifestyle modifications, try to decrease stress, good nutrition)
-Medical therapy (80-90%, costly and have many AE)
-Surgical therapies (more to diagnose than treat)
-Fertility treatments more successful in a live birth in women <35
Reproductive alternatives
-Surrogacy
-Adoption
-Cryopreservation of human embryos
-Preimplantation genetic diagnosis: picking out “best” eggs for no chromosomal abnormalities; considered a moral and ethical issue
Contraception
Intentional prevention of pregnancy
-50% of pregnancies are unplanned
-Still risk for pregnancy
-Method should be safe, readily available, economical, acceptable and simple to use
Coitus interruptus
“Pull out”
-27% failure rate
Spermicides
Reduce sperm mobility
-Barrier method (N-9)
-29% failure rate (depends on consistency)
Male condoms
Non-spermicidal latex condoms provide barrier against STI’s and HIV too
-Polyurethane: thinner and stronger
-N-9 (spermicidal) condoms don’t protect against STI’s and HIV
-Latex prevent pregnancy better
Vaginal sheath
STI protection (barrier)
-Can be noisy
-Cannot use in combination with male condoms
- Failure rate 21%
Diaphragm- barrier method
Not very common
-Chemical barrier- holds spermicide against cervix
-Poor choice for people with poor vaginal muscle tone
Cervical cap
TSS can occur
-Less effective than diaphragm
-CI for those with abnormal pap
Contraceptive sponge
Barrier
-left in fro up to 24 hours and 6 hours after sex
-Less effective than diaphragm
-Sponge soaked with n-9
Combined estrogen-progestin contraceptives (COCs)
-Ovulation is inhibited: ovaries “turned off”
-99-100% effective
-CI: clotting disorders, liver disease, breast CA, pregnancy, smoking, <35, hypertension, diabetes, migraines with aura (sensory distrurbances)
-Transdermal (patch)
-Vaginal ring (NuvaRing): in for 3 weeks, out for 1 to initiate bleeding
Progestin-only contraceptives
Inhibit ovulation, thicken cervical mucus, alter tubal cilia, thin endometrium
-Can be used when breastfeeding
-Less CI bc of the lack of estrogen
-Oral progestins (minipill): no longer effective after 3 hours if missed, taken every day at the same time
-Injectable: 4x a year
-Implantable (norplant)
Emergency contaception (EC)
Used within 72 hours of unprotected sex
-Given before ovulation inhibits follicular development
-Counseling should be provided
Intrauterine devices (IUD’s)
- Copper IUD: small, t shaped, approved for 10 years, non-hormonal, copper created a volatile intrauterine environment (a spermacide)
- Levonorgestal-releasing: loaded with a pro gestational agent, approved for 5-7 years, non-estrogen, FDA approved for menorrhagia and contraception
IUD offers no protection against STI’s or HIV
Sterilization
Laparoscopic approach
-Strict regulation, pt must be 21+ for Medicaid
-Female: tubal occlusion (clamps); ligation (tubes cut and tied)
-Male: vasectomy (cutting vans deferens): complications rare and doesn’t reduce sex drive
Reversal: costly
-Female is easier done w occlusion (increased risk for ectopic pregnancy)
-Male tubal reconstruction (reanastomosis)
Abortion
Purposeful before 20 weeks (elective=requested; therapeutic=fetal or maternal health reasons)
-1/2 of pregnancies unintended and 40% result in abortion
-Factors: mothers health, fetus genetic disorders, rape or incest, requested
-AWHONN supports a nurses right to not participate in abortion procedures in keeping beliefs
First vs second trimester abortion and complications
- First:
-Surgical: aspiration (8-12 weeks from last period)- speculum and local anesthetic
-Medical: methotrexate (PO or IM) and misoprostol follows 3-7 days after (used in induction in way smaller dose); mifepristone 7 weeks after mensturation and misoprostal follows 48 hours later - Second:
-Dilation and evacuation (13-16 weeks)
-Cervical prep and prostoglandins
PROVIDE SUPPORT
-Pt needs to report fever >100.4, chills, bleeding heavy 3+ days, foul-smelling discharge, severe pain, tenderness w pressure
-Infection and retained products common
Chromosomal abnormalities
60% in spontaneous abortion
6% in still birth
-Major cause of reproductive loss, congenital problems, gynecologic disorders
-An error at the genetic code level during cell division at conception
-Ex: down syndrome
Multifactorial: most common genetic malfunction
-Combination of environmental and genetic factors (nutrition, drinking/smoking, chemical exposure)
-Ex: cleft lip, congenital heart disease, pyloric stenosis
Genetic counseling
Goal is to identify the risk
-Education
-Information
-Support
Conception steps
-Ovum released
-Sperm takes 4-6 hrs to reach egg
-1 sperm to the egg and it doesn’t allow others to enter
-Cilia capture the egg and move it along the fallopian tubes
-Cleavage in 1 day (cells separate into 2)
-Morula in 3 days (solid ball of cells)
-Blastocyst in 4 days and implants into endometrium in 6 days
Intrauterine development
- Ovum or pre-embryonic: conception to 14 days
- Embryonic stage: 15 days-8 weeks
-most critical time
-greatest risk to teratogens - Fetal stage: 9 weeks to birth
-becomes recognizable as a human being
-susceptible to CNS teratogens entire pregnancy
-less drastic changes
Placenta
Main fxn is the hormone control
-hCG: detected 8-10 days after conception
-human placental lactogen: stimulates maternal metabolism for growth
-estrogen: uterine growth (steroid hormone), placental blood flow
-progesterone: maintains endometrium and decreases contractility of uterus, develop breasts
Fetal waste crosses placental membrane and is excreted by mom
Fetal maturation circulatory system
-cephalocaudal formation: oxygen rich blood in head, neck and arms
-high Hgb concentration
-heart starts beating <3 weeks after conception
Fetal maturation liver and blood
liver enlarges tremendously in 6th week for blood production
Fetal maturation renal and GI
- Renal: urine is a major constituent of amniotic fluid. developed fully at birth, but low GFR and low ability to concentrate (easy to dehydrate or overhydrate)
- GI: swallows amniotic fluid in 5th month, waste accumulates before birth and is black/tarry
Fetal maturation respiratory
begins 4th week. fluid in lungs after birth is reabsorbed into blood. surfactants to prevent lung collapse
Fetal maturation nuerologic
brain is 1/4 adult brain at birth, susceptible to damage
Fetal maturation endocrine and reproductive
- Endocrine: thyroid develops as head does (3-4 week), maternal thyroxine doesn’t cross placenta can be born with hypothyroidism, pancreas forms mid first trimester
- Reproductive: differentiation at 7 weeks
Fetal maturation musculoskeletal and integumentary
- MS: bones and muscles develop by 4th week and ossification occurs throughout childhood
- Integumentary: vernix caseosa is a cream cheese substance that protects the skin during birth
Maternal nutrition and development
-Malnutrition links to brain development
-Folic acid needs to increase in diet: #1 way to prevent neural tube defects
Teratogens
exposure in the first 15-60 days can cause death
-drugs
-chemicals
-infection
-radiation exposure
-maternal conditions
Vaginal adaptations pregnancy
- Leukorrhea: thick white acidic discharge that prevents pathogenic infections; more prone to yeast infections however (glycogen stores increase)
- Estrogen helps to become more vascular- good blood supply
- Increased vascularity (stretching) to promote healing
- Loosening of connective tissue
Breast adaptations pregnancy
- Increase in fullness and size
- Areola darkens so baby can see it
- Montgomery’s tubercles keep nipples lubricated (little bumps)
- Striae gravidarum (stretch marks)
- Colostrum: thick yellow fluid starting at the 2nd trimester. “first milk”
CV adaptations pregnancy
- Slight hypertrophy: muscle enlarges bc its working harder
- Apical pulse shifts: enlarged stomach shifts heart
- HR increases between 1-15 bpm between 14 and 20 weeks
- Murmurs may be present and undiscovered abnormalities appear
- no back sleeping after 20 weeks, puts pressure on inferior vena cava causing hypotension; BP decrease in 2nd trimester and are normal in 1st and 3rd
- LE edema present in late pregnancy r/t leakage of fluid from capillaries
Blood adaptions pregnancy
- Increases by 1-2 L (mostly plasma volume): makes up for blood loss during birth and blood supply to baby circulatory system
- Cardiac output increases 30-50% above baseline: heart is working harder and increases BP
- Greater risk for blood clots, more vulnerable to DVT, decreased vascular resistance
- Increase in WBCs 2nd and 3rd tri
- Physiologic anemia: hemodilutional effect of increased plasma
Respiratory adaptations pregnancy
- Increase in O2 requirements; constant dyspnea (10- 20% more)
- Diaphragm rises 4 cm or so
- Estrogen stimulation leads to nasal and sinus stuffiness and nose bleeds
- Increased RR (2 breaths per min)
Renal adaptations pregnancy
- Functional: Increased GFR, urinary stasis, increased susceptibility to UTI’s
- Bladder irritability, nocturia, frequency and urgency occurs in early pregnancy and returns near term
- Bladder walls thicken (hypertrophy), has increased capacity and is more susceptible to injury during birth because it is right above the uterus
Integumentary adaptions pregnancy
- Melanocyte stimulating hormone (MSH): leads to hyperpigmentation during pregnancy
- Linea nigra (line down stomach)
- Darker underarms; palmar erythema
- Accelerated nail growth
- Chloasma: hyperpigmentation patches on face
- 50-80% have stretch marks
Musculoskeletal adaptations pregnancy
- Lordosis (altered posture): center of gravity changed
- Discomforts: stretching ligaments and legs cramping
- Gait changes: wider stance, waddle, leaning back
- Diastalis recti abdominus: separation of stomach muscle
- Progesterone leads to clumsiness
GI adaptions pregnancy
- Appetite and food intake fluctuate
-Morning sickness, N/V, altered sense in taste and smell - Mouth: epulis (gum overgrowth); pytalism (excessive salvation)
- Esophagus, stomach, intestine
-Increased progesterone slows everything down
-slow digestion and heartburn
-displaced appendix - Abd. discomfort: pelvic heaviness and pressure, round ligament tension, flatulence, distention, bowel cramping, uterine contractions
Endocrine adaptations pregnancy
- Estrogen
-Enlargement of genitals, breast
-Relaxation of pelvic ligaments/joints
-Water retention (dependent edema)
-Increased vascularity and vasodilation
-Decreased ability to use insulin - Progesterone
-Increases significantly and is essential in maintaining pregnancy
-Relaxes smooth muscle
-Decreased ability to use insulin - Relaxin
-Placental hormone, affects tone - Prolactin
-Anterior pituitary releases
-Responsible for initial lactation - Oxytocin
-Posterior pituitary produces
-Stimulates uterine contractions during pregnancy
-Stimulated milk ejection reflex after birth
Gravida
a woman who is pregnant
-primagravida: first pregnancy
-multigravida: 2+
-nulligravida: never
Viability
capacity to live outside uterus
-20 weeks is cut off bc of respiratory system development
-typically 22-24 weeks
Parity
number of pregnancies where the fetuses reached viability
-multipara: completed 2+ pregnancies
-nullipara: not completed a pregnancy
-primipara: 1 completed pregnancy
Preterm, term and post-term
- Preterm: week 20-37
- Term: week 38-42
- Post-term: pregnancy goes beyond 42 weeks
GTPAL
- gravidity: # of pregnancies not babies
- term births
- preterm births
- abortions
- living children
Possible pregnancy signs
Felt by woman
-amenorrhea
-N/V
-fatigue
-breast changes (tingling, tender, painful, increased vascularization)
-urinary urgency and frequency
-weight gain
-fetal movement 16-20 weeks
Probable pregnancy signs
Observed by provider
-Hegars sign: softening of lower uterine segment
-Goodells sign: cervix softening
-Chadwicks sign: purple/blueish color of cervix, vagina and vulva
-Urine pregnancy test: detects HCG (in some carcinomas as well)
-Abd changes: show after 14 weeks, braxton hicks 16 weeks
-Balltoment: 16-28 weeks, passive movement of fetus when tapped on cervix
Positive pregnancy signs
-Heart tones (fast)
-Visualizing of fetus via ultrasound (8-10 weeks first able to see)
-Palpating fetal movements
Pregnancy time span
9 months
-First trimester: weeks 1-13
-Second trimester: weeks 14-26
-Third trimester: weeks 27-40
Estimating DOB (EDB)
First day of LMP (last menstural period), count forward 9 months and add 7 days
Couvade syndrome
A psychological syndrome where the partner starts having same symptoms and weird cravings as pregnant woman
Barriers to obtaining prenatal care
-Lack of motivation: in denial, multiple children before
-Inadequate finances
-Lack of transportation
-Unpleasant clinical personnel
-Unpleasant facilities or procedures: dirty of sexual trauma/PTSD
-Inconvenient clinical hours: 13 appts or so during pregnancy, no sick time to make it to those
-Problems with child care
-Personal or cultural attitudes
Initial interview and physical exams
- Interview: detailed health hx, family hx, drugs and herbals use, past or current
- Physical: VS and weight, doppler heart tones after 1st trimester, MMR and varicella titer to see if immune (live vaccines so cant get booster while pregnant and the risk of contracting one is higher), syphillis and HIV testing, fundal height (same for everyone), pap smear, blood tests, ultrasound, amniocentesis (needle into stomach for amniotic fluid collection)
Care management education
-Nutrition: no raw fish or meats, no deli meat, or certain teas
-Personal hygiene: a little sweatier, more susceptible to yeast infections
-Prevention of UTI
-Kegel exercises: quicker deliver, strengthens pelvic floor muscles
-Dental health: bacteria can build up and has easy access to blood stream (can be hard when nauseous all the time)
-No high risk physical activity
-Rise slowly and have good posture
-Rest when tired
-Be cautious of enviornemntal risks at work
-Don’t wear tight clothing as it compresses sciatic nerve and can cause infections as well
-No travel restrictions
-Sexual counseling (baby cant feel anything, alternative positions, incompetent cervix=no contraction at all!)
Cultural and age influences in prenatal care
- Cultural: dont seek care until ill (normal life process so not needed)
- Age: adolescents are lost and dont know what to do once the signs are very apparent. less access to care; older than 35 has genetic risks and worry about pre-exisitng conditions
Twin pregnancies
- Often end preterm, 38-39 weeks
- Congenital malformations (organs dont develop properly) 2x as common in monozygotic twins (1 egg, 1 sperm)
- No increased incidence of abnormalities in dizygotic twins (2 eggs, 2 sperm)
- Probability increased by…
-hx of dizygous twins in female line
-use of fertility drugs (ovulation inducers)
-rapid uterine growth in early weeks
-polyhydramnios: lots of amniotic fluid
-asyncronous heartbeats and many limbs felt when palpated
-ultrasound evidenc - Severe backache common, more weight will be gained, increased nutritional demand especially iron
Nutrition before conception
- First trimester is crucial!
- Spinal column develops early on
- Folate or folic acid intake important to prevent neural tube defects
- Suggest to increase in diet in conception age wether planning to conceive or not
Factors that contribute to pregnancy increased nutritional need
- Uterine-placental-fetal unit: rapid growth in 3rd trimester
- Maternal blood volume and constituents: peak 28-34 wks
- Maternal mammary development
- Metabolic needs increase by 20%
BMI
- Weight gain should only be 25-35 lbs through pregnancy
-Underweight: <18.5
-Goal: 18.5-24.9
-Overweight: 25-29.9
-Obese: >30
-Morbidly obese: >40
-Excessive weight gain is a problem!
-1st and 2nd trimester weight gain r/t mother increase in tissue growth
-3rd trimester gain r/t baby rapid growth (more weight put on)
Nutrition during pregnancy
1.Protein: nitrogen is important (usually good at eating enough)
2. Fluids: water, milk, decaf tea
3. Iron: increases maternal RBC, anemia common
4. Magnesium: slight increase needed, not too much can cause HTN
5. Potassium: reduces risk for HTN
6. Sodium: peripheral edema common
7. Zinc: in prenatal vitamin (malformations of CNS linked to low zinc)
8. No need to increase fluoride or calcium
9. AVOID dehydration: can lead to pre-term labor
Minerals and vitamins during pregnancy
- Vitamin A: don’t supplement
- Vitmains D, E, K: not included in supplements
- Folate and folic acid
- Pyridoxine: vitamin B6- can decrease N/V
- Vitamin C: tissue formation and repair
- B12: formation RBC’s
Pica
Consuming non-food items or non-nutritional items in bulk (ex. ice).
-Can cause person to not feel need to eat nutritional items
Adolescent pregnancy nutrition
Help planning meals and focus on knowledge.
-Baby and mom growing, so fighting for the nutrients
-Increased risk for problems
Nutrition and lactation
- Adequate fluid intake necessary to produce milk
- Need for energy, increase 400-500 kcal for first 6 mo
- Gradual but steady weight loss during 1st month of lactation
High risk pregnancy factors
- Biophysical: genetic disorders, nutritional disorders, etc.
- Psychosocial: emotional distress, hx. mental illness, IPV, substance abuse, etc.
- Sociodemographic: low income, member of minority ethnic group
- Environmental: workplace hazards
Antepartum testing/ indications
- Identify fetuses at risk for injury r/t acute or chronic interruption of oxygen so permanent injury or death can be avoided
- Risks: DM, HTN, preeclampsia, lupus, renal disease, cyanotic heart disease, fetal growth restriction, oligohydramnios, late term gestation, previous stillbirth, low fetal movement
Ultrasound
- Transvaginal: probe into vagina allows greater detail
-no need to have a full bladder
-detect ectopic preg
-identify abnormalities
-cardiac activity seen at 6 wks - Abdominal
-Need full bladder
-fetal HR activity
-Gestational age
-Fetal growth and anatomy
-Genetic disorders
-Placental position and function
Biophysical profile
Done in the late 2nd and 3rd trimester
-Indicated fetus well-being
-8-10 is considered normal
Amniocentesis
Detects genetic disorders by drawing amniotic fluid from outside abdomen. This fluid contains fetal cells.
-Done after 14 wks.
-Genetic conerns: women 35+ or men 40-50, family hx of chromosomal abnormalities
-Measures fetal lung maturity
-Fetal hemolytic disease detected
-AE: bleeding, fetal death
Chorionic villus sampling (CVS)
Removal of small tissue specimen from fetal portion of placenta inserted in vagina.
-10 to 13 weeks gestation
-Earlier diagnosis and rapid results
-Tissue reflects genetic makeup of fetus
Alpha-fetoprotein (AFP)
Screening tool for neural tube defects, not to diagnose.
-15- 20 weeks
-80-85% of NTD can be detected early
-Recommended all women have this exam done
Multiple marker screens
Detects chromosomal abnormalities, specifically trisomy 21 (down syndrome)
-11- 14 weeks
Coombs’ test
Determines rH incompatibility with mother
-Fetal hemolytic anemia
->1.8 indicates need for amniocentesis
Cell free DNA in maternal blood
Non-invasive prenatal genetic diagnosis. Amplifies cell free DNA.
-Fetal Rh status
-Fetal gender
-Paternally transmitted single cell gene disorders
-women with positive CF DNA results are referred for an amniocentesis to confirm
Non-stress test
Fetal activity determination
-3rd trimester testing
-done if daily fetal kick count is less than 10 movements in 2 hours
-Reactive NST is favorable result
-Vibroacoustic stimulation: sound and vibration added to a non-reactive test to try and stimulate movement
Contraction stress test (CST)
Used as backup testing for NST.
-Nipple-stimulated: mother massages 1 nipple for 10 min to release oxytocin
-Oxytocin-stimulated: IV placed and oxytocin started
-Can be anywhere from 20-20 min to hours.
-Can’t be done if mother is not able to give vaginal birth
-CI: preterm labor, placental previa, vasoprevia, cervical insufficiency, multiple gestation, previous c-section incision
-Negative CST is the desired result
