week 2 slides Flashcards
what is the goal of preconception care?
- improve the health status of women and men before conception
- reduce those behaviours, individual and environmental factors that could contribute to poor maternal and child health outcomes
what is preconception care?
Preconception care involves identifying and modifying risk factors in individuals considering pregnancy in order to improve their health. Risk factors may include medical, behavioural, and social factors, many of which may be modifiable
what are the recommendations of preconception?
- 150 minutes per week of moderate to vigorous physical activity for adults aged 64 and under
- no more than 2 drinks per day, with no more than 10 drinks per week for non- pregnant women to reduce long term health risks
- all women who could become pregnancy should take a daily multivitamin containing 400 mcg (0.4 mg) of folic acid.
preconception care and folic acid
reduces the risk of neural tube defects, including anencephaly and spina bifida and associated with lower risk for other birth defects including cleft palate anomalies, cardiovascular and urinary anomalies, and some pediatric cancers
preconception care and healthy body weight
Both low and high preconception Body Mass Index (BMI) can negatively affect pregnancy outcomes. The preconception period is the ideal time to achieve (or progress towards) an optimal weight
preconception care and mental health:
Maternal depression and anxiety has adverse effects on outcomes such as premature birth, birth- weight, breastfeeding initiation, and cognitive and emotional development of infants and young children.
*think postpartum depression
preconception care and physical activity:
exercise contributes to overall health, decreasing the risk of chronic conditions, important for weight reduction and maintenance, and has a positive effect on mental health and well-being.
preconception and environmental hazards:
A person’s environment includes their home, community, workplace, and other places where exposure to potential chemical and physical hazards may occur. The health impacts of preconception exposure to toxins are complex and difficult to verify
preconception and nutrition:
Healthy eating is a key component to overall health, and the preconception period is an ideal time for women to improve their diet. Nutritional needs change in pregnancy, and a pre- existing pattern of healthy eating helps to optimize maternal and fetal health
preconception and immunizations:
Immunization prior to pregnancy can prevent adverse pregnancy outcomes, prevent infections from being transmitted to the fetus and provide protection during early infancy
preconception and smoking:
Quitting smoking during the preconception period can eliminate most of the negative impacts on future pregnancies, in addition to providing health benefits for the woman.
what is antepartum?
Prenatal period; between conception & onset of labour (also called prenatal, antenatal)
what is intrapartum?
Period from onset of true labour to delivery of baby & placenta
what is postpartum?
6-week period between delivery of placenta & membranes and time body returns to nonpregnant state
fetal and placental development
Blastocyst contains two distinct differentiated embryonic cell types:
* the outer trophoblast cells and the inner cell mass. The trophoblast cells form the placenta
* The inner cell mass forms the foetus and foetal membranes.
* Trophoblast cells differentiate into:
* Outer multinucleated syncytiotrophoblast, which
erodes maternal tissues maternal tissues allowing blood from uterine spiral arteries to enter the lacunar network.
* responsible for producing hormones such as Human Chorionic Gonadotropin (hCG)
* Inner mononucleated cytotrophoblast, which is actively proliferating.
* Cytotrophoblast cells invade the maternal spiral arteries and replace maternal endothelium
what are the functions of placenta?
respiratory: exchange oxygen and carbon dioxide
excretory: excrete waste products
endocrine: functions as an endocrine gland that secretes four hormones necessary to maintain the pregnancy and support the embryo and fetus.
* human chorionic gonadotropin * Estrogen
* progesterone
* human placental lactogen (hPL)
nutrition: nutrients pass from the mother’s blood into the foetal blood
storage: Carbohydrates, proteins, calcium, and iron for ready access to meet fetal needs
barrier: functions as an efficient barrier harmful substances
gravida
a person who is pregnant
Gravidity
pregnancy
nulligravida
a person who has never been pregnant and is not currently pregnant
primigravida
a person who is pregnant for the first time
multigravida
a person who has had two or more pregnancies
parity
the number of pregnancies in which the fetus or fetuses have reached 20 weeks gestation, not the number of fetuses (e.g., twins) born
nullipara
a person who has not completed a pregnancy with a fetus or fetuses beyond 20 weeks gestation
primipara
a person who has completed one pregnancy with a fetus or fetuses who have reached 20 weeks of gestation
mulipara
a person who has completed two or more pregnancies to 20 weeks of gestation or more
viability
Capacity to live outside the uterus; there are no clear limits of gestational age or weight.
* Infants born at 22 to 25 weeks of gestation are considered to be on the threshold of viability.
preterm
A pregnancy between 20 weeks and 36 weeks 6 days of gestation
late preterm
A pregnancy that has reached between 34 weeks 0 days and 36 weeks 6 days of gestation
term
A pregnancy from the beginning of week 37 of gestation to the end of week 40 plus 6 days of gestation
early term
A pregnancy between 37 weeks and 38 weeks 6 days
full term
A pregnancy between 39 weeks and 40 weeks 6 days
late term
A pregnancy in the 41st week
post term
A pregnancy after 42 weeks
GTPAL stands for
g: gravidity
t: term
p: preterm
a: abortions
l: living children
Human chorionic gonadotropin (hCG)
is the easiest biochemical marker of pregnancy
what is the most popular method of testing for pregnancy?
Enzyme-linked immunosorbent assay (ELISA) testing is the most popular method of testing for pregnancy.
* ELISA technology is the basis for most over-the-counter home pregnancy tests.
what are the presumptive signs of pregnancy?
-cessation of menses
-nausea and vomiting
-frequent urination
-breast/chest tenderness
-skin changes
-quickening
-fatigue
“considered presumptive because there can be other causes”
what are the probable signs of pregnancy?
-enlargement of abdomen
-Braxton Hicks (end of 1st trimester)
-skin changes- striae, increased pigment
-positive pregnancy test
-Hegar’s sign
-Goodell’s sign
-Chadwick’s sign
what is hegar’s sign?
At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment (uterine isthmus) occurs
-softening of the lower uterine segment
what is Goodell sign?
is brought about by increased vascularity, slight hypertrophy, and hyperplasia (increase in number of cells). The glands near the external os proliferate beneath the stratified squamous epithelium, giving the cervix the velvety appearance characteristic of pregnancy.
-softening of the cervix at 8 weeks
what is Chadwick’s sign?
Blue-violet hue from congestion on vulva, vagina, cervix (esp. vaginal opening) – 6-8 weeks
what are the positive signs of pregnancy?
ULTRASOUND-fetal heart motion 4-8 weeks after conception; with doppler – 10-12 weeks
fetal heart is heard
-fetal movement felt by examiner -between 18-20 weeks
Visualization of fetus through ultrasound – around 5-6 weeks
what is Leukorrhea? adaptions to pregnancy
is a white or slightly grey mucoid discharge with a faint musty odour. This copious mucoid fluid occurs in response to cervical stimulation by estrogen and progesterone. The fluid is whitish because of the presence of many exfoliated vaginal epithelial cells caused by the hyperplasia of normal pregnancy. This vaginal discharge is never pruritic or blood stained.
when does colostrum begin to start being produced?
during the third trimester
what is Quickening
Quickening is the first recognition of fetal movements, or “feeling life.”
breast changes in pregnancy
Fullness,heaviness
* Heightenedsensitivityfrom tingling to sharp pain
* Areolae become more pigmented
* Montgomery’s tubercles- small spacious gland around the areola they secrete fatty substances to lubricate the nipple.
adaptions to uterus in pregnancy
Changes in size, shape, and position
* Softening of lower uterine segment (Hegar’s sign)
* Changes in contractility
* Uteroplacental blood flow- placenta perfusion depends on the blood flow to the uterus. blood flow increases rapidly as the uterus increases in size
* Cervical changes
* Goodell sign
* Changes related to fetal presence
* Ballottement
what is ballottement? “internal ballottement”
Around the 16th to 18th week of gestation, the fetus can be palpated by pressing a finger into the vagina and tapping gently. This action causes the fetus to move upward and then move back downwards to tap on the finger.
cardiac output in pregnancy
Slight or no change in diastolic pressure
∙ Slight decrease to mid-pregnancy (24–32 wk) and return to pre-pregnancy levels by end of pregnancy
∙ Blood volume Increases by 1 200–1 500 mL or 40–50% above pre-pregnancy level
∙ Hemoglobin level decreases -psychological anemia d/t increase in volume
∙ Haematocrit level decreases
∙ Red blood cell mass increases by 17%
∙ Cardiac output increases from 30 to 50% during pregnancy and half of this increase occurs by 8 weeks of gestation. A small decline occurs by term.
Cardiac output in late pregnancy is appreciably higher when the patient is in the lateral recumbent position than when they are supine. In the supine position, the large, heavy uterus often impedes venous return to the heart and affects blood pressure. Cardiac
output increases with any exertion such as labour and birth.
blood pressure in pregnancy
-Blood pressure is influenced by two major factors: cardiac output (CO) and systemic vascular resistance (SVR). Although CO increases significantly during pregnancy, blood pressure remains the same or decreases slightly. This is due to reduced SVR caused primarily by the vasodilatory effects of progesterone, prostaglandins, and relaxin.
-During the first trimester, systolic blood pressure usually remains the same as the prepregnancy level but can decrease slightly as pregnancy advances. Diastolic blood pressure begins to decrease in the first trimester, continues to drop until 28 weeks, and gradually increases, returning to prepregnancy levels by term
respiratory system and pregnancy
-oxygen consumption increases during pregnancy by 20 to 40% above nonpregnant levels.
∙ Change from abdominal to thoracic breathing as pregnancy progresses
∙ Increased vascularization in upper respiratory tract due to increased estrogen
∙ Nasal and sinus stuffiness, nosebleeds, voice changes
Maternal oxygen consumption increases during pregnancy by 20 to 40% above nonpregnant levels. This increase is necessary to support the needs of the fetus, placenta, and changes in maternal organs
renal system in pregnancy
- Increased glomerular filtration rate
- Increase frequency and Nocturia
- Dilation of ureters & renal pelvis increase of
pyelonephritis
endocrine system in pregnancy
-Thyroid – may enlarge; total thyroxine (TT4) may increase
* Adrenal – Cortisol & aldosterone increase
* Pituitary – Gland enlarges; Prolactin levels
increase.
* Pancreas – fetus needs glucose ++ for growth and
development
* hyperglycemia & hyperinsulinemia occur after
eating
* Potential for gestational diabetes
GI system in pregnancy
-Morning sickness due to hCG hormone
* Constipation
* Gas, general discomfort
* Risk of gallstones
* Heartburn
* Hiatus hernia
* Mouth, gum soreness and bleeding
* Haemorrhoids
musculoskeletal system in pregnancy
- Lumbar lordosis as uterus enlarges and moves
upwards and outwands - Relaxation of motility of pelvic joints – creates
“waddle” - Rectis abdominous muscle may separate –
diastasis recti - Umbilicus protrudes
neurological system in pregnancy
▪ Light headedness; fainting
▪ Carpaltunnel
▪ Sensory changes in legs
▪ Headaches
▪ Some women complain of decrease in attention, concentration and memory; resolves after pregnancy
integumentary system in pregnancy
-Chloasma (mask of pregnancy) -Facial melasma (also called chloasma or mask of pregnancy) is a blotchy, brownish hyperpigmentation of the skin over the cheeks, nose, and forehead, especially in pregnant patients with dark complexions
-Linea negra
-Striae gradarium (stretch marks)
-Reduced connective tissue strength
b/c elevated adrenal steroid levels
-Thicker hair
what is Nägele’s rule?
-Determine first day of last menstrual period (don’t care when you complete your cycle)
(LMP), subtract 3 months, and add 7 days
plus 1 year
* Alternatively, add 7 days to LMP and count
forward
9 months
Uterine sizing – and fruit
-Non-pregnant or 5 weeks uterus – size of a
small pear
* 6 weeks – size of a small egg
* 8 weeks – size of a large orange; 12 weeks –
size of a large grapefruit
what is the fundal height?
measures size of uterus from pubic symphysis to fundas (top of uterus). Between 22-34 weeks gestational age correlates well with measurements in cm., + or - 3 cm.
* McDonald method – uses tape measure – cm from top of symphysis pubis to top of uterine fundus
what is quickening?
awareness of fetal movements by the pregnant person- usually between 16-22 weeks gestation
Oxytocin hormone
Produced by hypothalamus and secreted by posterior pituitary
* Induces uterine contractions in labour
* Responsible for “letdown” reflex during lactation
-also given sometimes when we need the placenta to come out- a shot to the thigh or through IV fluids
prolactin
Produced by anterior pituitary
* By term: levels increase up to 10x greater than pre-
pregnancy levels
* Essential for milk production
relaxin
-Produced 1st by corpus luteum then placenta after 6-8
weeks
* Relaxes pelvic muscles & joints to prepare for birth
inadequate nutrition can lead to an increase in
Low-birth-weight (LBW) infants (2500 g or less) * Preterminfants
BMI less than 18.5
underweight/ low
BMI 18.5 -24.9
considered normal
BMI 25 to 29.9
considered overweight and high
BMI of 30 and above
obese
Recommended extra energy intake during pregnancy:
-1st trimester: same as nonpregnant
-2nd trimester: additional 340 kcal
-3rd trimester: additional 452 kcal
how much should someone with a BMI of 18.5 gain weight during pregnancy?
0.5 kg/1pound a week
12.5-18/ 28-40 lb total weight gain
how much should someone with a BMI of 18.5-24.9 gain weight during pregnancy?
0.4kg/1.0lbs
11.5-16kg/25-35 lbs total weight gain
how much should someone with a BMI of 25.0-29.9 gain weight during pregnancy?
0.3kg/0.6lbs
7-11.5/15-25 lbs total weight gain
how much should someone with a BMI of 30 or over gain weight during pregnancy?
0.2kg/0.5lb
5-9kg/ 11-20 lb total weight gain
the first trimester is the most important for?
embryonic and fetal organ development
folic acid (folate) intake
important for the periconceptual period.
- Neural tube defects (NTDs) are more common in infants of patients with poor folic acid intake.
- Low-risk clients: 0.4 mg daily for at least 2-3 months before **pregnancy, during pregnancy and postpartum if breastfeeding
- Moderate or high-risk clients (diabetes, epilepsy, obesity, history of NTDs) – increase amount of folic acid (can be up to 1-4 mg/day)
Nutrient Needs During Pregnancy
-Energy needs – vary during trimesters
* Protein- for fetal growth
* Fluids
* Omega 3 fatty acids
* Fat-soluble vitamins
* VitaminsA,D,E,andK
what water-soluble vitamins are needed in pregnancy?
- Folate or folic acid
- Vitamin B6 (Pyridoxine)
- Vitamin C (Ascorbic acid)
- Vitamin B12 (Cobalamin)
Minerals, vitamins, and electrolytes needed for pregnancy
-Iron: ↑ requirement
* Calcium
* Vitamin D
* Magnesium
* Sodium
* Potassium
* Zinc
* Fluoride
* Vitamin B12 (for vegan diets)
what are common discomforts during pregnancy?
- Nausea and vomiting
- Heartburn
- Breast tenderness
- Vaginal discharge/bleeding
- Headaches
- Nosebleeds
- Gingivitis- swelling and inflammation of the gums
- Abdominal pain/cramping
- Fatigue
- Constipation
- Urinary frequency
- Back pain
- Skin changes (linea negra, chloasma, etc.)
- Ptyalism- excessive saliva
- Quickening
*Pica- eating disorder of nonfood substances
what is Pica?
Pica is an eating disorder characterized by the consumption of nonfood substances (e.g., clay, dirt, chalk, soap, and laundry starch) or excessive amounts of foodstuffs low in nutritional value (e.g., cornstarch, ice or freezer frost, baking powder, and baking soda).
Pica has been associated with mineral deficiencies (e.g., iron deficiency).
prenatal visits
-1 visit per month until 28 weeks
-every 2 weeks: in weeks 28-36
-every week: in weeks 37-40
*** a high-risk pregnancy will require more frequent visits
what are your assessments during the first initial visit with the pregnant person?
- Current pregnancy
- Obstetric hx
- Gynecological hx
- Current & past Medical hx
- Including RH incompatibility- bc we need to know if they need blood transfusion or if they will have a reaction
- Family medical hx * Genetic hx
- Surgical hx
- Occupational hx
- Medications * Allergies
what are the assessments you will do every visit with a pregnant person?
- Weight
- Vital signs
- Fetal heart
▪ 160-170 beats/minute in early pregnancy ▪ 110-160 beats/minute in late pregnancy - Fundal size
- Urine (protein, keytones, glucose, nitrates)–> this checks for Pre-eclampsia
- Potential complications (bleeding, vomiting, headache, visual disturbances, epigastric pain)
- Coping/adjustment; support; SDH
- Domestic violence
what are we screening during the 1st Trimester?
- Pap if needed * CBC
- HIV
- Urine culture * Rubella titre
- ABO & RH typing
- STI testing
- Other relevant tests
- E.g. sickle cell, thalasemia, tay sachs, TB if high risk
- Ultrasound – for nuchal translucency (NT) (example Down syndrome) (11-14 weeks gestation) combined with serum screening for free B-hCG and for pregnancy associated plasma protein A (PAPP-A)
- Increased NT, Elevated free B-hCG and reduced PAPP-A suggest aneuploidy
- Women with these findings are offered genetic counseling and chorionic villus sampling, or 2nd trimester amniocentesis
- If negative- no further testing
what are we screening during the 2nd trimester?
- Quadruple screen: blood test – between 15-20 weeks
- Levels of Alpha fetal proteins (AFP), human chorionic gonadotropin (hCG),
unconjugated estriol (UE), inhibin-A (placental hormone) - Maternal serum alphaproteins (MSAFP) for neural tube defects and open abdominal wall defects
- Ultrasound- assess gestational age, growth; abnormalities; heart activity
- Abdominal or transvagina
fetal assessments
Ultrasound
* First trimester – assess gestational age;
number of fetuses, etc.)
* Assess for problems (bleeding; ectopic)
* Second/thirdtrimester
* Confirm gestational age
* Assess level amniotic fluid
* Assess location of placenta
* Identify presentation
* Assess cause of bleeding; fetal death
* Amniocentesis ( prenatal dx of genetic disorders or congenital anomalies)
what is Amniocentesis?
Amniocentesis is performed to obtain amniotic fluid, which contains fetal cells. Under direct ultrasound visualization, a needle is inserted transabdominally into the uterus, amniotic fluid is withdrawn into a syringe, and various assessments are performed on the fluid sample
Amniocentesis is possible after week 14 of pregnancy, when the uterus becomes an abdominal organ and sufficient amniotic fluid is available for testing
what are we screening for during the 3rd trimester?
- Gestational diabetes – (24-28 weeks)
- Group B streptococcus – Rectal and vaginal swabs – 35-37 weeks)
- Tests as needed re fetal health * Fetal movement counts
- Non-stress tests
- Contraction stress test
- Ultrasound
what are the six practices for supporting culturally safe, humble, trauma-informed perinatal care?
-cultural safety and cultural humility
-self-determination
-trust through relationship
-respect
-anti-indigenous racism
-strength an resilience- based practice
perinatal education includes
-physical and emotional changes during pregnancy
-breastfeeding/infant feeding
-nutrition during pregnancy
-working during pregnancy
-safety- Zika virus, toxoplasmosis
-pain management strategies during labour- pharmacological and non pharmacological
-labour and birth process
-becoming a parent
-transition to parenting
-newborn care
perinatal education includes
-physical and emotional changes during pregnancy
-breastfeeding/infant feeding
-nutrition during pregnancy
-working during pregnancy
-safety- Zika virus, toxoplasmosis
-pain management strategies during labour- pharmacological and non pharmacological
-labour and birth process
what is the goal to perinatal education?
Goal is to assist individual and family to make informed, safe decisions about pregnancy, birth, and early parenthood
-well supported childbirth experience
-health-promoting education
-methods of childbirth education
-birth plans -where they want to give birth, who will be at the birth, what forms of pain relief the person wishes, what type of medical interventions and practices they want/don’t want, and what the person would like to happen immediately after the birth with the baby
