pregnant female exam 3 Flashcards
define 1st, 2nd, 3rd trimesters of pregnancy
1st trimester= 0-13 weeks 6 dats
2nd trimester= 14-27 weeks and 6 days
3rd trimester= 28-40 weeks and 6 days
Chadwick sign
bluish discoloration of vagina and cervix
Leukorrhea of pregnancy
white, milky, vaginal discharge that is normal during pregnancy
Naegele’s Rule
-used to calculate estimated date of confinement aka due date
-first day of pt’s last menstrual period + 7 days - 3 months +1 year
gestational age
time of pregnancy counting from the first day of the last menstrual period
developmental age
time of pregnancy counting from fertilization
embryo
fertilization - 8 weeks
fetus
8 weeks - birth
previable
before 24 weeks
preterm
24-36 weeks
term
37-42 weeks
increased estrogen
-promotes endometrial growth
-stimulates increased prolactin output
-contributes to hypercoagulable state of pregnancy
increased progesterone
-1st produced by corpus luteum but then by placenta after implantation
-causes increased tidal volume and alveolar ventilation
-relaxes tone of esophageal sphincter, ureters, and bladder
HCG (human chorionic gonadotropin)
-produced by placenta and support progesterone synthesis
-prevents loss of early embryo to menstruation
-stimulate tsh receptors
when do increased erythrocyte mass, increased blood volume, and increased cardiac output begin in pregnancy?
4 weeks
physiologic anemia
plasma volume expansion exceeds increase in red cell volume
**helps protect against blood loss during birth
increased basic metabolic rate
increases 15-20% which increases caloric needs
hegars sign
softening of the cervical isthmus *above cervix
symptoms of pregnancy
-breast enlargement/tenderness- 6weeks
-areolar enlargment and increased pigmentation- 6weeks
-cololstrum secretion- 16 weeks
-nausea w o vomiting
-urinary frequency
vaginal changes during pregnancy
-chadwicks sign
-vaginal walls become thicker and more rugated due to increase thickness of the mucosa, loosening of connective tissue, and hypertrophy of smooth muscle cells
-vaginal secretions are thick, white, and more profuse
-vaginal pH is more acidic from lactobacillus acidophilus
cervix and ovarian changes during pregnancy
-cervix looks and feels different
-chadwicks sign
-cervical canal fills w tenacious mucus plug
-red velvety mucosa
-corpus luteum may be felt on affected ovary as a small nodule
uterine changes during pregnancy
-uterus loses its firmness and resistance
-hegars sign
-volume expands 5 to 20 liters
-weight increases from 50-70 grams to 800-1200 grams
-muscle cell hypertrophy
-increase in blood vessels, size, lymphatics
uterus as fetus grows
-uterus pushed into anteverted position into the space occupied by blader
-uterus rotates to the right to accomodate the rectosigmoid structures on the left side of the pelvis
abdominal enlargement
12th week-uterus rises out of pelvis into abdomen
15th week- apparent increase in abdominal girth
linea nigra
diastasis recti
breast changes
6th week- increase in vascularity associated with a sensation of heaviness, tenderness
8th week- nipple and areola become more pigmented, and montgomery tubercle become more prominent
16th week- colostrum
20th week- further pigmentation and mottling of the areola
relaxin
One of the effects of relaxin is the loosening of ligaments throughout the body, making pregnant women less stable and more prone to injury, especially in their backs
sensation of fetal movement
usually begins at 20 weeks in the primagavida or 17/18 weeks in the multipara
lightening
“dropping” late in pregnancy when fetus descends into lower pelvis
when should healthy pregnant pts come in for first apt?
8-10 weeks
urine hcg (when positive, what can cause false negatives)
- positive ~4 weeks
- false negatives can be from being done too early or dilute urine
ultrasound time line (transvag, abd)
transvaginal
4-5 weeks gestation- sac
8-10 weeks- dating
abdominal- after 1st trimester
what is increased if the yolk sac is larger than 7 mm without signs of a developing fetal pole?
increased chance of abnormal pregnancy
goals of prenatal visit
-increase probability of a healthy baby without maternal compromise
-determine health of fetus and mother
-determine gestational age of fetus
-initiate a plan of continuing care
-focus on risk assessment
prenatal visits: when and how often
-ideally initail visit before conception
-less than 28 weeks=every month
-28-36 weeks= every 2-3 weeks
-36 weeks= once per week until delivery if pregnancy is uncomplicated
prenatal care timeline for labs and diagnostics
first visit:
-pap smear, Rh screen, std screen, other labs
weeks 8-12
-1st sonogram, amniocentesis, noninvasive prenatal testing
weeks 24-28
-diabetes screen**, cbc
week 36
-group B strep culture
gravidity
total number of pregnancies (if twins G=1)
parity
outcome of pregnancies
determining gestational age
count the number of weeks and days from last menstrual period
~40 weeks
positioning of pt during ob exam
-gown opening in front
-semi sitting position with knees bent for pelvic exam **dont lay all the way flat as can compress descending aorta and inferior vena cava
-all other exams procedures should be done in sitting or left side lying positions
cervical brush (cytobrush)
DO NOT USE ON PREGNANT PATIENTS
may cause bleeding
gestational HTN
systolic- over 140
diastolic- over 90
occuring after wk 20 without proteinuria that resolves by 12 weeks post partum
chronic HTN
systolic = over 140
diastolic= over 90
before pregnancy, before wk 20, and after 12 wks postpartum
preeclampsia
systolic= over 140
diastolic= over 90
after wk 20 WITH PROTEINURIA
first trimester weight loss
shouldnt exceed 5% of prepartum weight
thyroid gland and pregnancy
inspect and palpate as modest symmetric enlargement is suspected
what does facial edema after 24wks GA indicate?
gestational HTN
mammary souffle
the mammary souffle is commonly heard during late pregnancy or lactation, is strongest in the second or third intercostal space at the sternal border bilaterally, and is typically both systolic and diastolic, though only the systolic component may be audible.
diastolic murmur in pregnancy
A diastolic murmur in pregnancy is never normal and should be investigated further.
what to listen for when auscultating heart during pregnancy
Listen for a venous hum or a continuous mammary souffle that are common in pregnancy due to circulation
when is the uterus at the level of the umbilicus?
20 weeks
uterine contractility before 37 weeks
before 37 weeks regular contractions with or without bleeding is abnormal = preterm labor
fundal height greater than 4 cm
consider large fetus, extra amniotic fluid, or uterin leiomyoma
fundal height less than 4 cm
consider missed abortion, transverse lie, growth retardation or false pregnancy
what to check with the cervix during bimanual exam
-effacement= degree to which cervix has thinned (4cm is unchanged or unaffected)
-dilation
where is FHR best heard when head down and when breech
head down= best heard in LLQ
breech=best heard in RUQ
normal doppler FHR
120-160 bpm
fetoscope
a special stethoscope used to hear FHR after 20 weeks
4 parts of leopolds maneuvers
1= determine what fetal part occupies the fundus
2= determines what side is the fetal back
3= identify descent of the presenting part
4=identify the cephalic prominence
*from 28th week on these provide useful info to assess the lie and presentation of the fetus
fetal lie
relationship of the long axis of the fetus to the mother
-longitudinal lie vertex presentation
-longitudinal lie breech presentation
-transverse lie shoulder presentation
fetal presentation
vertex presentation, breech presentation, shoulder presentation
*normal presentation= vertex
leopolds 1st maneuver
-used to determine the fetal part that is in the uterine fundus
-buttocks feels firm but irregular
-the head feels hard and may be movable
leopolds 2nd maneuver
-locate the position of the fetal back
-on one side the back will be rounded and firm
-on the other side the limbs will be irregular, lumpy, and mvmt may be felt
leopolds 3rd maneuver
-palpate the lower pole of the fetus
-if lower pole is not engaged moveable part will be felt
leopolds 4th maneuver
-performed to confirm the presenting portion and to located the side of cephalic prominence
pregnancy nutritonal rules
-3 meals a day
-add extra 300 cals beginning 2nd trimester
-rx multivitamin with atleast 400 mcg of folic acid per day
CAUTION AGAINST
-soft cheese
-deli meats/cold cuts
-excessive amounts of vitamin A
-seafood
pregnancy weight gain
low bmi=28-40 lbs
normal bmi= 25-25 lbs
high bmi=15-25 lbs
obese=15 lbs
women carrying twins= 35-45 lbs
young adolescents=upper end of range
short women= lower end of range
exercise after 1st trimester
NO exercise in supine position
what vax should all pregnant women be up to date on?
tdap and flu vaccines
if indicated pregnant women may have what vax
-pneumococcal
-meningococcal
-hep B
concluding prenatal visits
-discuss next steps and sequence of future events
-discuss plans for breast feeding
-review need for contraception post partum
otc meds ok for pregnant women
benadryl, tylenol, robitussin, vicks, metamucil, imodium, neosporin, maalox, tums, mylanta
