Normal Antepartum

Uterus anatomic/physiologic changes

Increased amounts of estrogen and growing fetus, enlargement in size, increases in weight, strength, elasticity, and vascularity

Uterus signs/symptoms

Rotund, protruding abdomen, uterus is able to contract, fetus expelled during labor

Cervix anatomic/physiologic changes

Hyperplasia (enlargement of tissues), formation of mucous plug

Cervix signs/symptoms

Increased vascularity may cause bleeding after cervical exams, Goodell sign, Chadwick sign, Hegar’s sign

Goodell sign

Softening of cervical tissue

Chadwick sign

Bluish discoloration of cervical mucosa

Hegar’s sign

Softening of the lower uterine segment

Vagina anatomic/physiologic changes

Increased estrogen levels, increased thickness of mucosa, increased vaginal secretions to prevent bacterial infections, connective tissue relaxes

Vagina signs/symptoms

Acid pH increases chance of vaginal yeast infections, increased vaginal discharge

Breasts anatomical/physiologic changes

Increased estrogen and progesterone levels, increase in size and number of mammary glands

Breast signs/symptoms

Increased size causes soreness, nipples more erectile and areolas darker, striae may appear, colostrum produced in third trimester

Respiratory anatomic/physiologic changes

Increased levels of progesterone and volume of air, decreased airway resistance, increased anteroposterior diameter, thoracic breathing occurs as uterus enlarges

Respiratory system signs/symptoms

Increased size of uterus may cause SOB, increased vascularity may cause nasal stuffiness and nosebleeds (epistaxis)

Cardiovascular anatomic/physiologic changes

Increased levels of estrogen and progesterone, increased cardiac output and blood volume, increased blood volume = pseudoanemia, increased size of uterus interferes with blood flow return from LEs, increased level of RBC to increase O2 delivery to cells, increased clotting factors

Cardiovascular signs/symptoms

Varicose veins, hemorrhoids, ankle edema, increased risk for venous thrombosis, pressure on vena cava by enlarged uterus (Vena Cava Syndrome/Supine Hypotension Syndrome)

Vena Cava Syndrome/Supine Hypotension Syndrome

Pseudoanemia

Gastrointestinal anatomic/physiologic changes

Increased levels of progesterone (slows), delayed gastric emptying, decreased peristalsis, cardiac sphincter relaxation

Gastrointestinal signs/symptoms

N/V, bloating, flatulence, constipation, heartburn

Genitourinary system anatomic/physiologic changes

Increased blood volume, glomerular filtration rate increases, renal tubular reabsorption increases

Genitourinary system signs/symptoms

Increasing size of uterus and pressure on bladder, increased urination, glycosuria d/t kidneys inability to reabsorb all glucose

Skin and hair anatomic/physiologic changes

Increased progesterone, estrogen, and melanocytic stimulating hormone, increased pigmentation

Skin and hair signs/symptoms

Linea nigra, chloasma, hyperpigmented areolas, nipples, and vulva, striae, hair growth decreases, shedding during postpartum

Linea nigra

A dark, vertical line that appears on the abdomen during pregnancy, extending from the pubis to the umbilicus

Cholasma

Brown or gray-brown patches on the face, particularly on the cheeks, forehead, nose, and chin, resulting from increased melanin production

Musculoskeletal anatomic/physiologic changes

Increased estrogen and progesterone, relaxation of joints

Musculoskeletal signs/symptoms

Lordosis of lumbosacral spine, “waddling”, low backache, diastasis recti

Presumptive

Not proof, subjective

Probably

Not proof, objective

Positive

Proof, diagnostic

Presumptive signs

Amenorrhea, N/V, fatigue, urinary frequency, breast changes, quickening

Probable signs

Cervical changes (Goodall’s, Chadwick’s, Hegar’s signs), enlargement of abdomen, Braxton hicks contractions, uterine souffle, skin pigmentation changes, fetal outline palpated, pregnancy tests

Uterine souffle

Caused by increased blood flow to the uterine arteries

Pregnancy tests

Performed on urine, sensitive, detects Beta HCG, can detect pregnancy as early as first day of missed period, if negative result, test may be repeated in one week if period has not occurred

Positive sign

Fetal heartbeat (detected by Doppler ~10-12 weeks), fetal movement (palpated by examiner ~ week 20), visualization of the fetus by ultrasound (4-5 weeks gestational sac seen, 6-8 weeks fetal parts and cardiac movement)

Initial maternal health assessment

OB/GYN history (prior and present), medical/surgical history, family history, social history, baseline physical assessment, medication review, psychosocial assessment, cultural assessment

Major risk factors

<16yo or >35yo, low socioeconomic status, nonwhite race, multiparity (increases with # of pregnancies), low prepregnancy weight or obesity, height <5ft, smoking, alcohol or illicit drug use, previous macrosomic infant, prior neonatal or fetal death, Rh sensitization, previous preterm birth, diabetes, hypo/hyperthyroidis, cardiac or renal disease, lupus (SLE), psychological conditions

Naegele’s rule

First date of last menstrural cycle, -3 months, +7 days

Obstetric history

Gravida, para

Gravida

Total number of pregnancies, same for G/P and GTPAL system

Para

Number of births after 20 weeks, if using G/P, para categories if GTPAL, term (>37w), preterm (20w-36w6d), abortion (<20w), living (number of children currently living)

Metabolism

Increased during pregnancy due to demands of growing fetus and its support system, normal to gain up to 1 lb/month for first 3 months, normal to gain 1-2 lb/week in second and third trimester

Normal BMI weight gain

25-35 lbs

Overweight BMI weight gain

15-25 lbs

Underweight BMI weight gain

28-40 lbs

Prenatal nutrition

Needs do not change much in first trimester, prenatal vitamin recommended, careful consideration if mother is vegetarian or vegan to maintain nutritional intake, artificial sweeteners safe in moderation, beware of foodborne illness, be mindful of the amount of fish eaten for mercury content, avoid unpasteurized foods, appetite, cravings, and food aversions, encourage fresh fruits and vegetables, high fiber, high protein, and unprocessed foods as main categories

Second/third trimester calorie intake

300-400 calories per day

Water intake

8-10 8oz glasses of fluids per day – 4-6 of which should be water

Caffeine limit

<200 mg

Foods at risk for listeria

Deli/lunch meat, hotdogs, soft cheese

Vitamins to take

Folic acid (prevents neural tube deficits), iron (replenish RBC and transfer to fetus)

Tasks of pregnancy

Choosing a provider (OBGYN, midwife, doula), choosing a birth place (hospital, birthing center, home birth), childbirth education (birthing support methods, infant care, birth plan creation)

Maternal adaptation to pregnancy

Acceptance of pregnancy, identification with maternal role, examining own mother’s role, preparation for labor, anxiety and/or fear regarding labor/birth

Partner adaptation to pregnancy

Participation/inclusion, examine their role, comparison with role models

Factors that may influence maternal adaptation

Multiparity, maternal age, family support/lack of, multifetal pregnancy, current/past abuse/IPV/trauma, SDOH

Adolescent maternal age

<20, higher likelihood of abandonment by partners, social and economic impacts, education impacts, impacts developing sense of self, increased potential for harm and risky behavior related to development and maturation

Advanced maternal age

>35, increased adverse perinatal outcomes, increased congenital/chromosomal abnormality risk, chronic disease more common, more likely to have complications and/or fetal loss, often more financially stable, sometimes have stronger support system

Maternal norms

BP 90/50 to <140/90, tends to decrease slightly in 2nd trimester then come back up to normal, respirations and pulse may increase from baseline but normal ranges, increased renal output, normal to run trace albumin and trace glucose

Initial visit testing/labs

Pap smear, GC/chlamydia, blood type, Rh factor, VDRL/RPR (syphilis), hepatitis B surface antigen, HIV, rubella, CBC, US (may not be at initial visit, timing, dates), genetic testing

Frequency of antenatal visits

Every 4 weeks until 28 weeks gestation, every 2 weeks 28-36 weeks gestation, every week 36 weeks gestation until delivery (normal pregnancy)

Ongoing antenatal care

Weight, blood pressures, urine dipped for protein/glucose, fundal height, fetal heart tones (doppler), questions regarding contractions, fluid loss, vaginal bleeding, fetal movement, anticipatory guidance, prenatal education

Ultrasound

Early dating and confirmation of pregnancy, viability of fetus, assesses placental location, abnormalities, assesses fetal structure, growth, and position, assess fluid volume, cervical structures, painless, non-invasive (transabdominal), slightly invasive (transvaginal)

Testing 18-22 weeks

Anatomy scan ultrasound; confirms viability, assesses fetal anatomy, umbilical cord vessels, insertion site, assess amniotic fluid volume

Antenatal testing 28 weeks

1 hour glucose tolerance test (gtt), 3 hour if pt fails (above 140), repeat CBC, rhogam given if needed

Antenatal testing 36 weeks

GBS testing, GC/Chlamydia as needed, growth scans considered, NSTs considered

Fetal movement counts (kick counts)

Decreased fetal movement is a very reliable indicator for increased risk of adverse outcomes/fetal demise, primary method of fetal surveillance for all pregnancies = kick counts, track fetal movement for 1-2 hours, decreased fetal movement warrants evaluation by HCP and possibly Non-stress test (NST) or biophysical profile (BPP)

Fetal movement normal range

4 movements in 1 hour, 10 movements in 2 hours

Non-stress test

Most widely accepted method of evaluating fetal status, particularly for high-risk pregnancies, external EFM for 20 minutes (up to 40 minutes)

Reactive non-stress test

Reassuring, normal baseline, moderate variability, 2 or more accelerations present (15x15 for >32w; 10x10 for 28-32w), no decelerations present

Non-reactive non-stress test

Insufficient accelerations (<2), repetitive variable decelerations or late decelerations

Vibroacoustic stimulation

Method using auditory stimulation to elicit change in fetal behavior, fetal startle movements, and increased FHR variability if NST is non-reactive/fetal sleep cycles, not appropriate if decelerations, fetal bradycardia, known fetal cardiac issues are present, or GA <28 weeks

Biophysical profile

Assesses movement, tone, breathing, AFI, NST via US and EFM, fetal activities that appear earliest in pregnancy, are last to cease (tone and movement)

Biophysical profile 8/10 score

Reassuring

Biophysical profile 6/10 score

Equivocal, may indicate fetal hypoxia, repeat in 12-24 hours depending on GA

Biophysical profile 4/10

Non-reassuring, probable fetal hypoxia, warrants further evaluation and consideration of delivery

Biophysical profile 2/10 or 0/10 score

Almost certain fetal hypoxia and immediate delivery

Amniotic fluid index

Assesses pockets of amniotic fluid in 4 quadrants via US

Amniotic fluid index 8-24 cm

Normal

Amniotic fluid index <5

Oligohydraminos, decreased uteroplacental perfusion -> decreased fetal renal blood flow -> decreased urine production -> oligohydramnios (in absence of PROM)

Amniotic fluid index >24

Polyhydraminos, may indicate fetal malformations, obstructions, hydrops, uncontrolled blood glucose levels

Contraction stress test

Screening tool to assess ability of fetus to tolerate contractions, 20 minutes of EFM and stimulating contractions, if equivocal/suspicious, further testing considered, not as commonly used; false high-positive rate, which leads to unnecessary intervention

Negative contractions stress test

Normal, no variable or late decelerations in 10 min strip with 3 ctx with moderate variability

Positive contraction stress test

Late decelerations with 50% or more of ctxs, associated with increased rate of fetal death, birth complications, and requires further testing (often BPP)