Week 9: Pregnancy and Prenatal Care

Gravidity

The total number of times a patient has been pregnant, including the current pregnancy.

Types of Gravidity

• Nulligravida: A patient who has never been pregnant.

• Primigravida: A patient who is pregnant for the first time.

• Multigravida: A patient who is in their second or any subsequent pregnancy.

Parity

The number of pregnancies carried to the 20th week of gestation or the delivery of an infant weighing more than 500 g, regardless of the outcome.

Types of Parity

• Nullipara: A patient who has not given birth at more than 20 weeks of gestation.

• Primipara: A patient who has had 1 birth at more than 20 weeks of gestation, regardless of whether the baby is born dead or alive.

• Multipara: A patient who has had 2 or more births at more than 20 weeks of gestation.

• Grand Multipara: A patient who has given birth 5 or more times.

Gravidity and Parity Status (OB Story)

1. G: Total number of pregnancies (including present).

2. T: Number of term births (also noted as "F" for Full-term, 37 weeks or later).

3. P: Number of pre-term births (20-37 weeks).

4. A: Number of abortions (spontaneous abortions (SABs) or therapeutic abortions (TABs)).

5. L: Number of currently living children.

Presumptive Signs of Pregnancy (Subjective)

• Breast tenderness/changes.

• Amenorrhea (absence of menstruation).

• Nausea/Vomiting.

• Urinary frequency.

• Fatigue.

• Quickening (fetal movement felt by the mother).

• Hyperpigmentation of skin.

• Uterine/Breast enlargement.

Probable Signs of Pregnancy (Objective)

• Goodell’s Sign: Softening of the cervix.

• Chadwick's Sign: Bluish-purple discoloration of the cervix.

  • Chadwick = Original Chapstick (blue label)

• Hegar's Sign: Softening of the lower uterine segment.

• Positive pregnancy test.

  • Could be indicative of high HCG based on meds, tumor, or post-abortion.

• Braxton Hicks contractions.

Positive Diagnostic Signs of Pregnancy

• Visualization of the fetus by ultrasound.

• Presence of fetal heart tones (FHT).

• Fetal movements palpated.

Human Chorionic Gondaotropin (hCG)

• Biologic marker for pregnancy; production begins with implantation.

• Detected in serum approximately 6 days post-conception or 20 days since last menstrual period (LMP).

• Detected in urine 1-2 days after missed period; first morning urine (FMU) is ideal for the test

• hCG levels peak at 60-70 days of gestation.

• Test First Morning Urine (FMU).

Estimating the Date of Birth (Negele’s Rule)

• The Estimated Date of Confinement (EDC) or the Estimated Date of Birth (EDB) can be calculated using Nagele’s Rule:

  1. Add 7 days to the first day of LMP.

  2. Subtract 3 months.

  3. Add 1 year.

• Remember how many days are in each month:

  • 30 days hath September, April, June, and November.

  • All the rest have 31 days, except for February alone, with 28 days clear and 29 days in each leap year.

Uterine Changes During Pregnancy

• Growth in the first trimester is stimulated by estrogen and progesterone.

• Uterine size:

  • 7 weeks: Size of a hen’s egg.

  • 9 weeks: Size of a tennis ball.

  • 10 weeks: Size of an orange.

  • 12 weeks: Size of a grapefruit.

• Uteroplacental blood flow increases as the uterus increases in size.

• Fundal height is assessed; it typically reaches the level of the umbilicus by 20 weeks.

Reproductive System Changes

• Quickening: First felt at 17-18 weeks for multiparous; nulliparous may feel it later (20 weeks or greater).

• Braxton Hicks Contractions: Irregular, painless contractions that start after 16+ weeks.

• Fetal Drop: Descent of fetus into the pelvis in the third trimester; occurs 2 weeks before labor for nulliparous, at the start of labor for multiparous.

  • Seen when near due date. Aiding in easier breathing for the mom.

Vaginal, Cervical, and Ovarian Changes

• Vaginal and vulvar changes include Chadwick’s Sign (bluish color of mucosa).

  • Leukorrhea: white/gray mucoid discharge due to increased estrogen production.

• Cervical Changes (Goodell’s Sign): Softening of the cervix occurs by 6 weeks; a mucus plug forms to block the ascent of bacteria.

• Ovarian Changes: Ovum production ceases during pregnancy (no ovulation).

Breast Changes

• Progressive enlargement, increased sensitivity, tingling, and heaviness.

  • Due to the breast milk developing, referred to as colostrum.

• Increased pigmentation of nipple and areolae; nipples become more erect.

• Development of the mammary gland is functionally complete by mid-pregnancy; colostrum might be expressed by 16 weeks (LIQUID GOLD).

Venacaval Compression

• Compression of the vena cava when lying flat on the back.

• Can decrease CO and cause supine hypotension.

• Labor nurses love left lateral positioning as it assists in relieving pressure on the vena cava, enhancing blood flow, and improving both maternal and fetal heart rates.

Cardiovascular Changes

• Blood volume increases by 50% by the end of pregnancy; plasma volume increases 50-70% (1000 ml), while RBC mass increases by 20-35% (450 ml).

• Physiologic anemia of pregnancy due to disproportionate increase in plasma volume over RBC volume, leading to lower hemoglobin (Hgb) and hematocrit (Hct).

  • BP will slightly decrease due to the release of hormones.

  • Preclampsia will occur if the client is hypertensive.

• Total WBC increases, peaking in the third trimester; cardiac output increases by week 5.

• The heart muscle enlarges by 10%-15% during the first trimester.

• Hypercoagulable state: increased risk of clot formation.

• Compression of the iliac veins and inferior vena cava can cause increased venous pressure and low blood flow to the legs.

Respiratory Changes

• Increased maternal oxygen requirements; displacement of the diaphragm.

• Estrogen causes the upper respiratory tract to become more vascular, leading to nasal congestion and potential edema of surrounding tissues.

Renal Changes

• Renal changes during pregnancy include early, frequent urination due to uterine growth.

  • Hormonal changes lead to ureteral dilation, increasing urine volume and causing urinary stasis, which elevates the risk of UTIs and can result in bladder irritability and nocturia.

• Urine output increases by 25%, as maternal kidneys manage increased metabolic and circulatory demands along with fetal waste excretion.

• Monitoring urine for glucose (diabetes) and protein (preeclampsia) is essential.

Intugumentary Changes

• Integumentary changes during pregnancy include hyperpigmentation (facial chloasma, mask of pregnancy; linea nigra), striae gravidarum (stretch marks), palmar erythema, and pruritus.

• Other common changes involve gum hypertrophy, accelerated nail growth, oily skin and acne, hirsutism, and increased perspiration.

Endocrine Changes

• Thyroid gland: slight enlargement, increased activity, increase in BMR (basal metabolic rate)

• Pituitary gland: decrease in TSH, GH, inhibition of FSH and LH *GRADUAL INCREASE OF OXYTOCIN with fetal maturation in the posterior pituitary gland

• Pancreas- Insulin resistance ( We will discuss later)

• Adrenal glands- Increase in cortisol and aldosterone secretion

• Placental secretion: hCG, relaxin, progesterone, estrogen

Musculoskeletal Changes

• Musculoskeletal changes during pregnancy include a forward pelvic tilt, decreased abdominal tone, an altered center of gravity leading to an increased lumbosacral curve and a waddling gait, increased mobility and relaxation of the pelvic joints, potential separation of the rectus abdominis muscles, and progressive lordosis, which can cause backache.

GI Changes

• GI changes in pregnancy involve morning sickness, altered appetite and taste, and swollen gums.

  • Decreased smooth muscle tone and motility cause heartburn, regurgitation, slow emptying, and constipation.

  • Gallbladder changes can lead to itching due to bile salt retention, which may occur as a result of altered hormone levels and the pressure of the growing uterus.

• Abdominal discomfort, gas, distension, and round ligament tension are also common.

Prenatal Care

• Goal: Assist the client in self-care of the discomforts of pregnancy

• Promote a safe outcome of pregnancy

• Help foster positive feelings in the pregnant client and their families regarding their childbearing experience.

• PNC begins ideally within the first 12 weeks

• “Uneventful Pregnancy”- Visits are monthly for weeks 16-28, Q2 weeks from 29-36, Q week until delivery

• * High-risk patients may be seen more frequently!

• Need for a vitamin and mineral supplement daily

  • Prenatal vitamins must be stressed!

What’s Included in a PNC Visit

• Determining EDD

• Medical/Surgical Hx

• Physical assessment (weight, VS, pelvic exam)

• Labs- HGB, WBC, Blood type and RH, Rubella titer, UA, Renal function test, HIV, HEP B, toxoplasmosis (found in cat feces/undercooked meat), Pap, RPR (Syphilis), glucose (24-28weeks)

• Updated Vaccinations!!!

• Ongoing PNC- FHR, FUNDAL HEIGHT

Rogan Injections

• Administered to Rh-negative women during pregnancy to prevent Rh alloimmunization, typically given at 28 weeks of gestation and within 72 hours postpartum.

  • Why?: To protect future pregnancies from hemolytic disease of the newborn, which can occur if an Rh-negative mother produces antibodies against Rh-positive fetal blood.

Fundal Height

• Measured in centimeters from the pubic symphysis to the top of the uterus, and is an important indicator of fetal growth and development during pregnancy.

  • Regular assessment helps to identify any potential issues, such as intrauterine growth restriction (IUGR) or multiple gestations.

McDonald’s Rule

• A method used to estimate the gestational age by measuring the fundal height in centimeters and correlating it with the number of weeks of pregnancy, typically used between 20 and 36 weeks.

TORCH Infections

• “TORCH” = microorganisms A/W known congenital disease

  • It can cause harm to the fetus.

• T: Toxoplasmosis gondii

• O: (Other Viruses): Listeria monocytogenes, Treponema pallidum, varicella zoster virus (VZV), human immunodeficiency virus (HIV), enteroviruses, and parvovirus B19

• R: Rubella

• C: Cytomegalovirus (CMV)

• H: Herpes simplex virus-1 (HSV-1) and HSV-2

Promoting Breastfeeding

• Feeding decisions are made before pregnancy/first trimester

• Early support from health care providers is key to initiation and continuation

• HCP education & collaboration are important.

Danger Signs During Pregnancy

• S/S UTI- 1^st trimester

  • Severe Vomiting/Diarrhea, Feverl Abdominal Pain.

• 2^nd/3^rd trimester

  • Gush of fluid, VB, Change in fetal activity, Severe H/A, Fever, Blurred vision, Edema in face & hands, E/P, S/S of UTI.

Nutritional Needs

• Increase in protein, iron, folate, and calories

• Use of the USDA’s Food Guide My Plate

• •Good Fish (low mercury): cod, flounder, salmon, tilapia, freshwater trout, haddock, anchovies

• Don’t forget cultural considerations, gluten-free diet, lactose intolerance & vegetarians

  • Lactovegetarians (eat vegetables, dairy, eggs): Need additional iron, vitamin B12

  • Lactovegetarians (eat vegetables & dairy only): Need additional iron, zinc, B12, iodine

  • Strict vegans (no animal products): Need ↑ protein, calcium, B12, riboflavin, iron, iodine, zinc

Foods to Avoid During Pregnancy

• Avoidance of some fish high in mercury: Shark, swordfish, king mackerel, bigeye tuna, tilefish, marlin, and tilefish

• Undercooked raw meat/lunch meats (Listeria), raw eggs (found Ceaser dressing), caffeine (limit to 200 milligrams per day- ACOG), unpasteurized dairy products, and alcohol

  • Listeriosis/Listeria: Bacterium found in soil and water that can cause miscarriage, stillbirth, PTL, and serious newborn illness and death

    • Deli/processed meats, unpasteurized cheeses (i.e, Brie, feta, queso fresco)

    • Substitute with roasted fresh meats, etc.

• PICA- CRAVING & CHEWING SUBSTANCES THAT HAVE NO NUTRITIONAL VALUE

Importance of Folic Acid

• Important during the first 28 days after conception to help prevent neural tube defects and support proper fetal development.

  • Can help prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida)

• Green leafy vegetables, dried peas, beans, seeds & OJ

  • March of Dimes recommends that clients who wish to become pregnant take 400 mcg daily & pregnant women should take 600 mcg of folic acid

• Note- Women who take anti-epileptic meds may need to take a higher dose of folic acid to prevent neural tube defects

Weight Gain

• Healthy Weight BMI- 25 to 35 lbs

  • First Trimester: 3.5-5 lb

  • Second and third trimester: 1lb/week

• BMI- <19.8: 28 to 40lb

  • First trimester: 5lb

  • Second and third: +1 lb week

• BMI- >25: 15 to 25 lb

  • First trimester: 2 lb

  • Second & third trimester:2/3 lb week