L3 CH12

when is preconception/inter conception care recommended? what are the goals?

• recommended for all people who are planning a pregnancy or the potential to be pregnant, pre-existing conditions should initiate care before becoming pregnant

• goals

  • promote optimal health & well being of person planning pregnancy

  • create individualized plan based on personal circumstances & risk factors

when is the first prenatal care visit? what is the healthy people 2030?

• first visit by 12 wks, typically between 8-10 wks

• 2030: increase the proportion of pregnant women who receive early & adequate prenatal care

what are components of the preconception/prenatal assessment & why assessed?

• health, lifestyle

  • ask about habits → can help improve reproductive & pregnancy outcomes

• immunization status

  • prevents infections, viruses

  • if not updated → see if you can or can’t give birth

  • assess for tetanus toxoid, reduced diphtheria toxoid, acellular pertussis (Tdap), MMR, hep B, varciella

  • recommend annual influenza vaccine

• underlying medical conditions

  • ensure chronic conditions are medically managed (ex. HTN, DM)

• reproductive health care practices

  • STD testing or any that needs to be tx

• sexuality & sexual practices

  • are they sexually active

• nutrition

  • screen diet & vitamin supplements & ensure they are meeting recommended daily allowances for calcium, iron, vitamin A, vitamin B, vitamin D, vitamin B12

  • encourage folic acid supplementation

• lifestyle practices

• psychosocial issues

  • screen intimate partner violence, mental health

• medication & drug use

  • review medications including supplements & herbal products, opioids, alcohol, nicotine,

• support system

  • what is there support system

• travel

  • exposure to infectious diseases & travel restrictions

what is prenatal care? what is the purpose? what are the components? what are some barriers to prenatal care?

• the care you receive throughout pregnancy

• purpose: reduce risk to pregnant person & fetus

• components:

  • routine assessments & screenings increasing in frequency

  • individualized counseling related to diagnoses & prenatal testing

  • pt education

    • what to expect throughout pregnancy

  • can be individualized or group settings

• barrier:

  • pregnancy is an access point to healthcare for many populations

  • financial limitation

  • lack of adequate healthcare resources

  • geographic

  • personal/social barriers

  • perception of lack of services/coverage

  • inadequate childcare

what are the 5 social determinants of health & what is this? how does this connect to prenatal care?

• education access & quality

  • educational barriers

• health care access & quality

  • health care deserts

• economic stability

  • poverty

• social & community context

  • structural racism, social/physical structures/institutions impact health outcomes

• neighborhood & built environment

• impacts people’s health, wellbeing, quality of life

what is health equity initiatives? what is the role of healthcare professionals?

• health equity initiatives

  • govt & grassroots that seek to minimize increased morbidity/mortality

• role is to address implicit biases & raising awareness

what are the risk factors for adverse pregnancy outcomes? (or adds risk to pregnancy)

• cardiac dx/htn (extra stress on the heart)

• substance use disorder

• obesity (incr. risks of htn, diabetes, etc)

• diabetes (preconception)

• folic acid deficiency (risk of neural tube defects)

• HIV/AIDS (can be transmitted to baby)

• hypothyroidism

• metabolic disorders

• rubella seronegativity (not immune to rubella → infection during pregnancy causes harms)

• oral anticoagulant

• medications incompatible w/ pregnancy (can cause fetal harm)

• STI

• smoking

• alcohol

• Isotretinoin (acutane)

• diabetes

who runs birth centers?

nurse midwives

medical model vs centering pregnancy

1. medical model

• meet 1:1 with provider in office

• set schedule of visits

• physician or CNM

2. centering pregnancy

• evidence based model

• group visits w/ pregnant people w/ similar estimated due date

• improves health outcomes/reduces disparities

• greatest impact for black childbearing people

• often CNM lead

• counseling, able to actively participate in care (take weight, BP, etc), develop friendships

define gravida/gravidity, nulligravida, nullipara, primagravida, primapara, multigravida, multipara

• gravida/gravidity

  • number of pregnancies (no matter how it ended)

• nulligravida

  • never been pregnant

• nullipara

  • never had a birth

• primagravida

  • first time being pregnant

• primapara

  • first time giving birth

• multigravida

  • pregnant many times

• multipara

  • given birth many times

explain GTPAL.

• GTPAL a more accurate obstetrical hx

• Gravidity: total number of pregnancies

• Term: term births

• Preterm: preterm births (>20 wks, <37 wks)

• Abortions (<20 wks)

  • spontaneous (miscarriage) & therapeutic

• Living Children (how many)

explain G/P. what is the G/P if pt was pregnant once & has twins?

• Gravidity: total number of pregnancies

• Parity (number of birth events including term & preterm)

• G1/P1 because it is one birth event aka a single delivery

what is the prenatal visit schedule? (when is the 1st visit, subsequent visits, more visits for those…)

• 1st visit: 8-10 wks

• subsequent

  • every 4 wks up to 28 wks

  • every 2 wks up to 29 to 36 wks

  • every wk from 37 wk to birth

• more frequent visits may be schedule for higher risk pts

what are we doing on the first prenatal visit? (what info do we gather, what screenings to do, what to confirm)

• confirm pregnancy w/ blood or urine pregnancy test, ultrasound

• gather health baseline

  • vital signs

  • weight (BMI) → are we gaining or losing weight

  • reproductive hx (how was their last pregnancy, were they preggo before)

  • medications (is it compatible)

  • substance use

  • nutritional status

  • comorbidities (age, HTN, diabetes, cardiac)

• comprehensive hx:

  • family structure, psychosocial risk factors

• determine estimated due date

• screening exams:

  • blood tests

  • U/A (infection), urine dip (albumin, protein, ketones)

  • STI tests: gonorrhea, chlamydia

  • full physical assessment

  • pelvic assessment (maybe pap smear): size, shape, measurements

what does EDD, EDC, EDB mean?

• EDD- estimated due date

• EDC- estimate date of confinement

• EDB-estimated date of birth

what is Naegele’s Rule? what if last period is 1/1/2026, what is EDD?

• pregnancy dating

• take

  • last menstrual period (LMP)

  • plus 7 days

  • minus 3 months

  • = EDD

• ex. answer: 10/8/2026

what is another way to do pregnancy dating?

gestation wheel

why are these initial lab screening tests obtained: CBC, blood type, serology, A1C <6.5%, renal function tests, cervical cultures, pap test, urinalysis, urine culture ?

1. CBC

• checks for anemia, infection, platelet problems

2. blood type

• for blood transfusion

3. serology (rubella, rapid plasma regimen, varicella, HIV, HEPB)

• screen for viruses

4. A1C <6.5%

• detects diabetes

5. renal function tests

• assess kidney function can be d/t diabetes or growing uterus compressing on bladder

5. cervical cultures for STIs

• screens for infections such as chlamydia & gonorrhea → can cause newborn complications

6. pap test (cervix test)

• screens for abnormal cervical cells/cancer

7. U/A

• checks for protein, glucose, ketones, leykocytes

  • PROTEIN TO SEE IF IT IS PREECLAMPSIA , KIDNEYS/UTI

  • KETONES (burning fat instead of carbs for energy)

    • can mean malnourished or not eating enough

    • dehydration or fasting triggered by morning sickness, skipped meals or low fluid intake

    • metabolic stress (reflects poor blood suagr control or stress)

8. urine culture

• checks for infection

what to do at follow up visits w/ pregnant person (the mom)?

• weight tracking (see sudden weight gain or gaining too little → something could be wrong)

• assess physical & emotional wellbeing

• VS/BP

• check urine (ketones, glucose, protein, leukocytes)

• additional PRN blood tests (based on pt’s results)

• additional tests 2nd/3rd tri:

  • group beta strep (GBS): lives in the vagina & doesn’t cause harm

    • if passes onto baby (GBS+) → deadly

    • test done at 36 wks

  • gestational diabetes mellitus (GDM)

    • a glucose challenge test → work up if abnormal

• planning birth

• education

• genetic testing

• rhogram PRN

  • if mom is Rh- & potential Rh+ baby → given to prevent mom’s antibodies from attacking the baby

who gets rhogam & why?

• given to pregnant individuals with Rh- blood type to prevent their immune system from attacking an Rh+ baby’s blood cells

what additional tests is done in the 2nd/3rd trimester?

• Gram beta strep (GBS): lives in the vagina & doesn’t cause harm

  • if passes onto baby (GBS+) → deadly can cause sepsis, pneumonia, meningitis

  • test done at 36 wks

• gestational diabetes mellitus (GDM)

  • a glucose challenge test → work up if abnormal

why do we check for protein & ketones every visit?

• protein in urine → think preeclampsia

  • proteinuria (urine in protein)

• ketones → think not enough glucose/energy available

  • ketones are produced when body starts breaking down fat (body uses fat for fuel)

  • someone may be dehydrated, not eating enough, vomiting

what to do at follow up visits w/ fetus?

• assess fetal wellbeing

• review genetic testing

• fetal growth/position

  • fundal height

    • measured from pubis to top of uterus

  • leopold’s maneuvers

    • 4 abd palpation steps using during 3rd trimester to determine fetal position, presentation, engagment

what are non-invasive ways to assess fetal wellbeing?

• doppler auscultation

  • handheld device to listen to fetal HR

• ultrasonography doppler flow studies

• subjective assessments: kick counts

how do we assess fetal heart rate? when do we hear it? what is the bpm?

• use doppler

• 10 weeks+ (hard to hear before 10 wks)

• 110-160 bpm

what is the standard procedure/most accurate for determining gestational age in 1st trimester? why is this procedure usually used?

• ultrasound (high frequency sound waves create image)

  • considered low risk

  • use in all trimesters

  • the earlier it is done, the more accurate

• used to see…

  • fetal wellbeing, fetal growth, gestational age, disorders/physical anomalies, placental position, fetal anatomy, fetal genetic, fetal heart activity

what does the ultrasound tell us in the 1st, 2nd, 3rd trimester?

• 1st: confirm pregnancy, presence or absence of fetal cardiac & body movements, gestational age

• 2nd: use for visualization during amniocentesis (remove fluid for genetic testing)

• 3rd: detect fetal position, amniotic fluid volume levels

is fetal movement assessed with each visit? is it considered a vital sign along pain?

YES

what are kick counts? when can we feel it?

• a vital sign along with pain to see how well baby is moving

• will not have fetal movements until 20 wks

• should feel 10 counts in 2 hours

• something the client can do themselves & can feel differences or changes

how to measure fundal height (fetal assessment)? what is the fundal height if someone is at 26 wks gestation?

• measured from the pubis to the top of uterus

• should correspond (plus or minus 2 cm) w/ gestational age of the fetus

• fundal height should be 24 cm or 28 cm & ANYTHING LESS would be growth restriction

what is a non-stress test & when is it done? what do we want to see? how is it used to assess fetal well being?

• NST: 20 min fetal monitoring tracing done before labor to assess fetal well being or if pregnancy is high risk

• see if fetal HR changes w/ movement → yes/no does not mean something is wrong

• want to see 2 accelerations within 20 mins on strip

  • acceleration is a FHR equal or greater than 15 BPM over baseline lasting 15 seconds or more

• evaluate FHR during movement

• either reactive or nonreactive

what is a contraction stress test & when is it done? how is it used to assess fetal well being? what is positive vs negative?

• induces contractions to check fetal response either with oxytocin or nipple stimulation

• checks for signs of fetal distress during stimulated uterine contractions → sees how fetal heart rate reacts when uterus contracts

• given to see if fetus will tolerate labor

• results

  • positive: decelerations with 50% or more of contractions (decrease in blood flow w/ contractions → concerning)

  • negative: no decelerations w/ 3 contractions lasting 40-60 seconds in 10 mins (tolerates contractions well → GOOD)

what are the contraindications to contraction test & why?

• contraction tests causes contraction

• pre-term labor (contractions would worsen labor & lead to preterm birth)

• placenta previa (can cause bleeding)

• cervical insufficiency (causes it to dilate even earlier)

• multiple gestation (high risk pregnancy → increases complications)

• previous c-section (puts stress on uterine scar)

what is a biophysical profile (BPP) & how is it used to assess fetal well being? how long is this test? how is it scored?

• combines ultrasound and nonstress test data to assess fetal well being

• up to 30 mins allotted for test

• each category is 0 or 2 points

• min score= 0, max: 10

what are the 5 components of biophysical profile (BPP)?

• NST

  • normal (2 accelerations of HR within 20 mins)or abnormal movement of fetal HR

• body movements (is the fetus moving)

  • 3 or more discrete limb or trunk movements

• fetal tone (are they flexed or extended)

  • 1 or more instances of full extension & flexion of a limb or trunk

• fetal breathing (see them practicing taking breaths)

  • 1 or more fetal breathing movements of more than 30 sec

• amniotic fluid volume (amniotic fluid index) (AFI/AVI)

  • 1 or more pockets of fluid measuring > 2cm

  • 5-25 cm is normal (10-15)

    • 5-10 is low normal

    • >25 = polyhydroamnios

  • measures the vertical depths of the largest pocket of amniotic fluid in all 4 quadrants surrounding maternal umbilicus & totaled

what are the maternal adaptations of pregnancy that contribute to the discomforts of pregnancy?

• progesterone → smooth muscle relaxation → constipation & heart burn

• growing uterus → compression → urinary frequency & SOB

• venous compression → venous pooling → edema & varicosities

• relaxin → ligament relaxation → back/pelvic pain

when is 1st trimester? what are the discomforts?

• wk 1-13

• urinary frequency or incontinence

• fatigue

• N/V (morning sickness)

• breast tenderness

• constipation

• nasal stuffiness, bleeding gums, epistaxis

• cravings,

• leukorrhea

when is 2nd trimester? what are the discomforts?

• wk 14-27

• backache

• varicosities of the vulva & legs

• hemorrhoids

• flatulence w/ bloating

when is 3rd trimester? what are the discomforts?

• wk28-40 or till birth

• return of first trimester discomforts

• short of breath & dyspnea

• heartburn & indigestion

• dependent edema

• braxton hicks contractions

what are some warning signs to keep in mind for 1st, 2nd, 3rd trimester?

1. 1st tri

• spotting or bleeding (miscarriage)

• painful urination (infection)

• persistent vomiting & weight loss, loss of appetite (hyperemesis gravidarum)

• fever >100F (37.7C) → infection

• dizziness or fainting, worsening headache, and lower abdominal pain with dizziness and accompanied by shoulder pain and vaginal bleeding (indicative of ruptured ectopic pregnancy)

2. 2nd tri

• regular uterine contractions, back pain, increased vaginal discharge or gush of fluid (preterm labor)

• calf pain increased w/ foot flexion → DVT

• sudden gush or leakage of fluid from vagina (prelabor rupture of membranes)

• absence of fetal movement for more than 12 hours (indicative of possible fetal distress or demise)

3. 3rd tri

• sudden weight gain

• periorbital or facial edema, severe RUQ pain, or headache with visual changes and extreme swelling of face or hands (indicative of gestational hypertension and/or preeclampsia)

• a decrease in fetal daily movement for more than 24 hours (indicative of fetal hypoxia and possible demise 

• late pregnancy bleeding (indicative of placenta previa, abruptio placentae, or placenta accreta)

what are the potential complications of the warning signs above?

• Infections 

• Miscarriage 

• Hyperemesis gravidarum

• PPROM (premature rupture of membranes)

  • not in labor & not time to be but water breaks

• Pyelonephritis 

• IUFD (intrauterine fetal demise aka stillbirth)

• Kidney stones 

• Hypertensive disorders 

• GDM