Healthy Pregnancy + Reproductive Promotion

Uterus and Mammary changes during prengnancy:

Uterus:

• Early:

  • Amenorrhea → ^ estrogen → hypertrophy + hyperplasia

• ^ blood flow to uterus

• Sprial arteries thicken and uterus prepares for deep pplacental implantation

Mammry:

• ^ Estrogen + Progesterone → breast tissue differentiation → milk duct additions → colostrum

• ALso ^ tenderness, heaviness, and leaking of colostrum

CV & Hematologic changes during pregnancy:

Blood volume ^ to supply own tissue + placenta + fetus

• third trimester = ^ 30-50% → ^ volume → ^ CO → ^ SV → ^ HR

  • Peaks around 20-24 weeks

• V Peripheral vascular resistance due to: → v BP around middle of 3rd trimester

  • ^ progesterone, vasodilation

Gravid uterus → ^ psi on femoral vessels → Varicose veins (normal finding)

Labs:

• V HcT → low viscosity → lower resitance of b.f. → ^ delivery to utero+placenta

• ^ clotting factors → 5x higher risk to have blood clots

Immune, Resp, GI, GU, Endocrine changes during pregnancy:

Immune: slightly compromised

REsp:

• ^ o2 demand = ^ RR

• as uterus grows → diaphragm pushes upwards → harder to breath → ^ RR

  • ^ Chest diameter to compensate

• Lightening: fetus stays deeper in pevlic nearing end of pregnancy → easier to breath

GI:

• Growing uterus pushes stomach and GI → earlier fullness and reflux/heartburn

• Progesterone relaxes smooth muscles → delayed emptying, tone, and absorption → ^ constipation risk and higher likely hood for reflux

GU:

• ^ kidney size due to higher CO →^ GFR to filter more blood

• Early:

  • ^ blood flow → ^ GFR → ^ urine → frequency

  • Nocturia

  • Possible slight glycosuria + proteinuria (MILD)

• Later:

  • Bladder compression → urge to void + frequency

Endocrine:

• ^ BMR

• 1st & 2nd → ^ fat storage → 3rd → use fat resovoir for fetus

Pregnancy hormones;

hCG:

• rises during early pregnancy; main for testing

• Maintains corpus luteum at the start

Progesterons: Protects the pregnancy

• Establishes placents, maintains walls

• Supports blood vessel growth

• Prevents contractions, SMC relaxation, slower GI

Estrogen: Growth + blood supply

• Promotes b.v. growth, maintains lining

• Aids organ dev. and mother’s mammary glands

Prolactin:

• Milk production

Relaxin:

• Uterine relaxation, softens serivx

• Helps joints be more flexible

Oxytocin:

• Contraction, ^ prostaglandin release

Cortisol + Alosterone → hypervolemia + edema

Placental growth hormone:

• For growth, and cretes insulin resistance to allow more glucose to go to baby

Center of gravity during pregnancy & expected painful changes

Shifts foward → Lumbar lordosis + Anterior pelvic tilt

• Lower back pain

• Gait change + hip pain

• Diastiss rect: abd muscles separate which can create a bulging area that makes urinary incontinence & back pain

Carpal tunnel syndrome:

• Due to hormones, fluids

• Numbeness, tingling, weak

Pregnancy change for Integumentary:

Stria Gradidarum: stretch msarks

• Increased uterine size and striae develop

• Purpe and pink

Linea Nigra: darkened linea alba

• Midline connective abd tissue

• Prominent in umbilicus → symphysis

Hyperpigmentation:

Melasma: facial hyperpigmentation

• In bridge of nose, cheeks, forehead, skin

Why does prenatal care matter?

I/x maternal health problems, screen for anomalies, i/x r/x, monitor progression, promote positive behaviours, reduces morbidity

• WHO recommends >8 contacts total

Signs of Pregnancy:

Presumptive: subjective experienced by pt

• Amenorrhea, breast changes, enlargement, N/V, fatigue, urinary frequency, Melasma, fetal movement, larger uterine

Probable signs

• Home pregnancy test/HcG test

• Goodell’s sign: cervix becomes soft 8wks

• Hegar’s sign: soft lower uterine segment 6wks

• Chadwick’s sign: bluish/purpule color of cervix/vagIna

• Ballottement: gently taps through vagina → fetus moves upward and returns downward 16-28wks

• Braxton Hicks (16-28)

Positive signs:

• Ultra sound (4-6), fetal heart activity (10-12), fetal movement (20)

Prenatal visits:

H-H-P-L-D-E

• History

• Health a/x

• Pregnancy dating

• Labs

• Diagnostics

• Education & health promotion

History for prenatal visits

• Previous illness/surgeries

• Menstrual h/x

• Family h/x

• ETOH, drugs, smoking

• STI’s, partner violence, mental health, pets

• Obsterical h/x:

  • Date of LMP, previous pregnancies/births, any issues, cramps, fetal movement, genetic conditions

GTPAL:

• Gravida: # of pregnancies

• Term: births at 37 weeks or later

• Preterm: Before 37 weeks

• Abortion: losses before 20 weeks

• Living: number of living children

Gravida vs Para:

(twins/triplets count as one for birth events)

Gravida: # of times pt has been pregnant

• Nulligravida: never been

• Primigravia: first time

• Multigravida: multiple

Para: how many births occured AFTER 20 weeks

• Nulli

• Primi

• Multi

Before 20 wks = abortion

FUll term: 39-40.6 weks

<37 weeks = preterm

Post term > 4 weeks

Important tests during pregnancy:

Naegele’s Rule: estimates date of birth (EDB)

• First day of LMP - 3 months + 7 days + 1 year

• May not be guarantted due to different variety of pts

US:

• Helps a/x EDB when LMP is unknown

• Transvaginal US: early in pregnancy used

  • Full bladder is NOT required

Crown-Rump Length:

• 8 6/7→ 13 6/7 weeks

• Measure gestational age

Later dating measurements:

• Biparietal diameter

Fundal height:

• Measures from pubic symphysis to top of fundus

• for 20-36 weeks

• measures via cm

  • If 28 weeks = 28 cm (26-30cm)

  • 2cm of variation btw

    • Anatmoy, previous ones, fetal growth, uterine position

Other important screenings/assessments (a/x):

Substance use

Tobacco use:

• leads to preterm birth, v growth, miscarriage

Alcohol and Teratogenic drugs

STI a/x: 5 P’s

• Partners: # and gender

• Practices:

  • Genital/Anal/Oral s3x

  • How they met, drugs used during intercourse?

  • S3x tradiing for money

• Protection:

  • Condoms, meds, vaccines, HIV prevention

• Past h/x:

  • Previous STIs

• Pregnancy intention

  • Intended?

Partner violence and depression

• Possible preterm birht, and lower birth weight

Physical examination and Lab testing for prenatal visits:

Physical:

• Height, Weight, BMI, VS Breast and Pelvic exams

• Fetal HR via Doppler OR fetoscope

  • 110-160/min

  • If hard to assess → use UltraSound (US)

Labs:

• CBC:

  • Hgb, HcT

    • If low → Iron and vitamin C supplements

• Urinalysis + culture

  • Proteinuria → Kidney disease, infection, stress

    • Possible sign of preeclampsia later in pregnancy

  • Glucose → gestational diabetes

  • Culture → possible infection

• HBsAg: to prevent fatal hepatitis transmission

  • If mother positive → Hepatitis B vaccine + Hepatitis B immuneglobulin in FIRST 12 HOURS OF LIFE

• Rh Factor: presence of Rho D protein on RBCs

  • + = present D antige; - = absent D antigen

  • If mother and fetus have opposites → mother produces antibodies → attacks fetal RBCs

    • Often occurs w/previous births or invasive procedures

  • RhoD immune globulin: prevents Rh sensitization

    • Routinely given around 28 weeks of gestation or fter potential exposure (bleeding, trauma, invasive procedures)

    • also give 72 hrs after birth

    • Possible anapylaxis or hemolytic reactions

    • dont give if pt is Rh-positive

    • Reduces MMR and Variclla vaccines effectiveness

Rubella immunity

Titers done during pregnancy to see if bebe is immune

Infections may lead to:

• deaf, cataracts, cardiac defects

• low birth weight, liver + spleen dmg

Give MMR vaccine postpartum

Prenatal screenings:

HIV:

• Should be done at initial visit to prevent transmission → repeat test after or for those w/high risk exposure

STI screening:

• If positive → Treat → retest 4 weeks later

Shyphillis screening:

• Uses Rapid plasma reagin → if positive → Penicillin t/x

• Nontreponemal + treponemal testing

  • should also be done in reverse to see possible current infections or t/x effectiveness

CDC Prenatal Infection Screening — Timing

First prenatal visit:

Infection	Who?
Syphilis	All pregnant clients
HIV	All pregnant clients
HBV	All pregnant clients
HCV	All pregnant clients
Chlamydia	<25 years OR older + increased risk
Gonorrhea	<25 years OR older + increased risk

Third TRIMESTER:

Infection	Who?
Syphilis	All pregnant clients
HIV	All pregnant clients
HBV	All pregnant clients
HCV	All pregnant clients
Chlamydia	<25 years OR older + increased risk
Gonorrhea	<25 years OR older + increased risk

Prenatal UltraSound and CVS

Ultrasound: may help look for viability, dating, anomalies, twins/triplets/etc.

• Tranvaginal

• Transabdominal

  • Full bladder may help visualise uterus better

Chorionic Villus Sampling:

• 10-13 weeks

• Takes villi from placenta → looks for genetic abnormalities

• Done to higher risk patients w/abnromal results

• Avoid doing procedure if they have Gonorrhea/Herpes → ^ r/x of infection transmission to fetus

Weight gain and Nutrition during Pregnancy:

Prepregnancy BMI	Recommended total gain
<18.5	28–40 lb
18.5–24.9	25–35 lb
25–29.9	15–25 lb
≥30	11–20 lb

Nutrition:

• Fruits, Veggies, Whole grains, Legumes, Nuts, protein

• Omega-3 fatty acids: improves brain development

  • Fish, shellfish, walnuts, spinach

Vitamins:

• Folic acid: improves brain and spinal dev.

  • Dark leafy greens, beans, fortified cereal, orange juice

• Iron: ^ blood volume of momma

  • Prevents iron deficiency anemia

  • Vitamins, meat, lentils, beans

• Calcium and Vitamin D : supports bone development

  • Dairy products, fortified cereal, fish

Foods to avoid during pregnancy:

Listeria: can survive and grow in fridge

• Keep fridge <40F and freezer 0F

• Heat deli meat till steaming hot

High mercury fish

• Big ahh fish

UNdercooked food

Unpastureized milk

Caesar dressing

Diet during pregnancy:

Dry crackers, small frequent meals

Ginger

B banana

R rice

A applesauce

T toast

T tea

Feeding complications during pregancy

Hyperemesis Gravidarum:

• Severe N/V → dehydration, v weight, E+ imbalances → dark urine, tachycardia, fainting

• Mild N/V is normal btw and DOES NOT indicate this!

Heartburn:

• Spicy, greasy, large foods

• GERD interventions basically

  • HOB >30

  • Avoid late night meals or lying flat

  • small, frequent meals

  • Antacids

Sleeping during pregnancy:

Early: any position

Later: lying supin → v venous return in inferior vena cava → supine hypotension

• Left lateral position (CNA exam position) → ^ b.f. to uterus and kidneys

• Pillows between knees and back

Intercourse during pregnancy:

Good if not having large leakage of fluid, heavy bleeding, or severe cramping

Bad and Good vaccines to give during pregnancy:

Avoid Live vaccines like MMR and Varicella → give them after birth

Good: ↓

Influenza vaccine: give them by end of october

COVID

Tdap: for patient every pregnancy around 27-28 weeks

RSV (Abrysvo): given 32-36 weeks

• Around sep → Jan

• only give it once, do not repeat for every pregnancy

Second simester prenatal visits:

14 weeks → 27 weeks + 6 days

• Visit q4-6 weeks

2nd semester lab testing:

Maternal serum screening:

• 15-20 wks

• Quat/Triple screen: analyzes proteins to check for fetal abnormalities

• Possible down syndrome

Repeat Hgb/Hct

• Reassess anemia after 24 wks

Rh Negative:

• antibody screen at 24 weeks

• RhOIG given 26-28 wks for prophylaxis (IM/IV)

Gestational diabetes screening:

• 24-28 wks

• 1hr glucose challenge: 50 g of glucose → NPO → draw bloods 1 hr later → should be <140 mg/dL

  • Still after, do a oral glucose tolerance test to confirm

• Lifestyle changes → insulin with Contiunous glucose monitoring

2nd US:

18-20 wks

Full bladder → semi recumbent

• Checks for Head & nervous system, face & neck, chest, abdomen, spine, extremities, and genitalia

• 
  

2nd semester measurements:

Biparietal diameter: measures skull diameter

Head circumference: distance around the fetal head

Abd circumference: distance around the fetal abdomen

Femur length

all → estimated gestational age

Also shorter cervix = preterm birth risk

Amniotic fluid role in 2nd trimester:

Oligohydramine → v fluid

Polyhydramines → ^ fluid

Amniocentesis:

• Checks for chromosomal + genetic issues

• AFP: ^ = neural tube defect

• Clean area→ numbe it → US guidance → long needle into sac → withdraw fluid

• Possible cramping sensation; AVOID EXERCISE FOR 24 hours

Body changes during 2nd trimester:

N/V decreases → appetite ^ → weight gain

Heatburn, constipation, edema

Back pain: worse at end of day

• Maintain good posture, supportive shoes & clothing

• Ice, heat, pillows

• worse back pain may signify UTI OR Preterm labor

Round ligament pain: sharp pain in 1/both sides of lower abdomen/groin due to stritching of ligaments

Possible intercourse if there is not much vaginal bleeding, leakage, or complication

• Possible increased libido during this phase

Quickening & Braxton

first perception of fetal movement in lower abdomen near pubic bone

• 16-22 weeks

• Fluttering, Tapping, Pulsations, Flickering, Small spasms

Braxton Hicks:

• Uterus contracts and relaxes quickly, mimicking labor

• True labor has:

  • Higher frequency, duration, and intensity

  • Cervical dilation also occurs in true labor

Warning Manifestations in the Second Trimester

Preterm labor warning:

• Regular abd or back tightening > 4 times/hour

• Vaginal bleeding, leakage, cramping, SOB

Vaginal fluid leakage:

• Indicates membrane ruptures

Preeclampsia signs:

• Headaches, Blurry vision

• RUQ abd pain, edema of hands/face, SOB

• ^ BP

Expected vs Unexpected Findings 2nd semester

✅ Expected

• Mild back pain

• Mild heartburn

• Constipation

• Some ankle/foot edema

• Stretch marks

• Round ligament discomfort

• Quickening

• Braxton Hicks contractions

• Increased appetite

• Decreased nausea/vomiting

• Fetal movement beginning around 16–22 weeks

🚨 Unexpected / Requires Evaluation

• Regular contractions/tightening >4 times/hour

• Vaginal bleeding

• Fluid leakage

• Severe cramping

• New/worsening abdominal pain

• Persistent/worsening back pain

• Severe shortness of breath

• Severe headache

• Vision changes

• Right-sided abdominal pain

• Sudden facial/hand edema

MASTER SECOND-TRIMESTER TIMELINE

Gestation	What to remember
14 weeks	Second trimester begins
14–28 weeks	Ideal travel period
15–20 weeks	Maternal serum/quad screening
16–22 weeks	Quickening
18–20 weeks	Fetal anatomy ultrasound
~24 weeks	Repeat antibody screen for eligible unsensitized Rh-negative clients
24–28 weeks	Gestational diabetes screening
26–28 weeks	RhIG
27–36 weeks	Tdap
27 wk + 6 days	Second trimester ends

MASTER LAB & DIAGNOSTIC TABLE

Test	Timing	Purpose / Key Point
Maternal serum screen	15–20 wk	Screens for increased risk of fetal abnormalities
Repeat Hgb/Hct	After 24 wk if initially low	Reassess anemia
Antibody screen	~24 wk	Rh-negative, unsensitized clients
RhIG	26–28 wk	Prevent Rh sensitization
Glucose challenge	24–28 wk	Screen for gestational diabetes
Anatomy ultrasound	18–20 wk	Assess fetal anatomy/growth
Amniocentesis	When indicated	Genetic/chromosomal evaluation

Prenatal visits 3rd semester:

Beginning of 3rd semester → 36 weeks: go every 2-4 weeks

36 weeks → birth: weekly

• Check everything + BP, urine testing

• Fundal height, fetal HR

• Headaches, bleeding, leakage, hemorrhoids, abnormal weight gain, edema

Leopold Maneuvers

34 weeks; determines fetal presentation/position

• Palpates abd to know where fetus is

• Could also do US

Third-Trimester Laboratory Testing

Group B Streptococcus

• Done 36 → 37 weeks

• Cultural swab in rectum + vagina (where it lives)

• No problems for mom, but possible problems for baby complications

• If + → IV antibiotics during labor (Penicillin/Ampiccilin)

Rh-Negative Patients:

• If did not do repeat antibody screening before → perform it + give RhIG → prevents sensitization

Gestational diabetes screening if not done

STI screening done 32-36 weeks

Postterm Pregnancy

normal occurs 37-42 weeks; posterm > 42 weeks

Risks for mom:

• Long labor → vaginal injury → infection

• Possible C-section

Risks for bebe:

• Placental insufficiency → oligohydramnios

• Birth injury or still birth

Additional surveillances required:

• fetal movement counts

• Nonstress test

• Biophysical profile

• US

Third-Trimester Physical Changes & Discomforts

Hemorrhoids: swollen viens around anus

• due to growing fetus → ^ psi

• Also pregancy hormones contribute

• S/s:

  • Pain, swelling, itching, bleeding when straining or going to toilet

• Management:

  • ^ fiber, fluids

  • Avoid sitting too long

  • Ice packs, warm tub/sitz soaking, witch hazel pads

SOB:

• Normal but if sudden, then its not

Edema:

• Normal in feet + ankles + legs

• Abnormal could signify:

  • DVT, preeclampsia

  • Peripartum cardiomyopathy

  • Cellulitis

When should mom start counting kicks?

>28 weeks till birth

Helps detect any deviation fom normal patterns → risk for fetal compromise

Steps:

• Choose same time each day → monitor movements → count for 2 hrs → if less than 10 movements occurs CALL PROVIDER

Possible education during third trimester

Travling should choose a aisle seat to ahve more leg movement, stretching, and walking

Immuniations:

• take HepB, Influenza, and Tdap vaccines if still hasnt

S3xual activity:

• Good if there is no complication, leakage,or bleeding

How to recognize labor:

True contraction become: stronger + more regular + more frequent

• May also dilate cervix

• With amniotic fluid leakage

  • A/x color and amount

• Vaginal bleeding

True Labor vs Braxton Hicks

Feature	True Labor	Braxton Hicks
Strength	Increasing	Usually does not progressively intensify like true labor
Frequency	Becomes more frequent	May vary
Cervix	Dilates	Does NOT dilate
Activity/rest	Continues despite resting	May decrease with activity changes
Sleep	May prevent sleep	Client may sleep through them
Location	Back → wraps toward abdomen	Anterior/front abdomen
Purpose	Produces cervical change	Does not produce cervical dilation

Birth Plan topics:

Labor preferences

• Pain management

• IV fluids

• Support people

• Labor positions/devices

  • Birthing ball, stool, chair, squat chair, shower

• Episiotomy preferences

Environment

• Dimmed lights

• Noise control

Birth

• Who cuts umbilical cord

• Photos/videos

• Skin-to-skin

• Breastfeeding

Cesarean birth

• Support person

• Seeing newborn immediately after birth

Newborn care

• Feeding method

• Pacifier

• Rooming-in vs nursery

• Circumcision

Menstrual Cycle Hormone Pattern

Phase	Estrogen	Progesterone
Follicular phase	⬆ Increases	Low
Luteal phase	Relatively stable	⬆ Increases

hCG — Human Chorionic Gonadotropin

Unlike estrogen and progesterone, hCG is produced by the developing trophoblast/placental tissue after implantation.

Main roles:

• Signals the body that pregnancy has occurred

• Supports continued progesterone production early in pregnancy

• Helps prevent menstruation by maintaining the uterine lining

• hCG rises rapidly early in pregnancy and reaches high levels around the end of the first trimester

Fertilization → Implantation → Pregnancy

Step 1 — Ovulation

The ovary releases an oocyte.

⬇

Step 2 — Fertilization

Usually occurs in the fallopian tube.

Sperm + oocyte → zygote

⬇

Step 3 — Transport

The developing zygote travels through the fallopian tube toward the uterus.

⬇

Step 4 — Implantation

The developing conceptus implants into the endometrium of the uterus.

⬇

Step 5 — Trophoblast develops

The trophoblast contributes to the developing placenta and produces hCG.

The trophoblast is an early embryonic tissue that contributes to formation of the placenta.

It produces hCG after implantation.

Why is hCG important?

Early in pregnancy:

Trophoblast → hCG → maintains corpus luteum → progesterone remains elevated → endometrium maintained

⬇

Step 6 — hCG supports pregnancy

hCG signals continued hormonal support, including continued progesterone production early in pregnancy.

⬇

Step 7 — Progesterone maintains the uterine environment

Progesterone helps maintain the uterine lining so the pregnancy can continue.

Prevention in Reproductive Health

Level	Goal	Examples
🟢 Primary	Prevent disease before it occurs	HPV vaccination, lifestyle changes
🟡 Secondary	Detect disease early	Pap smear, prostate cancer screening
🔴 Tertiary	Manage an existing condition	Managing menstrual pain or sexual dysfunction

Preconception Care:

Preparing body for health pregnancy before conception

• 3 months before

Folic Acid: 400-800 mcg/day

Stop smoking, vaping, ETOH use

Toxic chemicals, avoid:

• Weed sprays, bug killers, household cleaners, ammonia fertilizers

1st, 2nd, 3rd trimester:

1st:

• Fatigue, Nausea, Breast tenderness, frequent urination

• Most spontanious abortions + congenital anomalies occur

2nd:

• Fatigue, Nausea → Fetal movement around 16-20wks → 20 weeks → fundal height + US checking

3rd:

• Check:

  • Fetal growth, movement, mom symptoms, and birth prep

• Measure fundal height again in cm

• Tdap (27-36wks), RSV

• GBS screening via vaginal + rectal swab (36-38 weeks)

Fertility

Infertility:

• <35 → 12 months

• >35 → 6 months

Perimenopause:

3 Years before final menstrual period

• v estrogen

• S/s:

  • Irregular menstrual periods

  • Hot flashes, sleep issues

  • Mood changes, dry

  • Night sweats, fatigue,

  • Lipid ^ while Bone mass v

Anti-Müllerian Hormone

The number of eggs in the ovaries

It can also correlate strongly with the time to menopause.

Natural vs. Induced Menopause

Natural menopause

Occurs as part of the normal aging process.

Induced menopause

May occur because of:

• Surgery

• Medical conditions

• Hormonal birth control

• Radiation therapy

Types of abortion:

Medical abortion → medications

Prcedural: medical prcedure

all based on gestational age

Prenatal Care & Appointment Schedule

Pregnancy stage	Visit frequency
First prenatal visit	Ideally by 10 weeks gestation; may occur as early as 4 weeks
Until ~28 weeks	Every 4 weeks (monthly)
28–36 weeks	Every 2 weeks
After 36 weeks	Weekly until birth

Medication Risks during pregnancy

• Prescription medications

• OTC medications

• Supplements

Some medications can negatively affect:

• Pregnancy

• Fetal growth

• Fetal development

Prenatal Infections

Rubella

Can cause serious fetal complications.

Cytomegalovirus (CMV)

A viral infection that can affect the developing fetus.

Toxoplasmosis

Associated with exposure to contaminated substances, particularly cat feces.

Increased Calorie Needs + Hydration

+300–500 calories/day

• Prepregnancy weight

• Physical activity

• Individual needs

1,600–2,400 calories/day

fiber:

Age	Fiber
19–30	28 g/day
31–50	25 g/day
51+	22 g/day

Calcium:

Age	Calcium
9–18	1,300 mg/day
19–50	1,000 mg/day
51+	1,200 mg/day

Vitamin D

600 IU/day

Iron

Age	Iron
14–18	15 mg/day
19–50	18 mg/day
51+	8 mg/day

8–12 glasses/day

Equivalent to approximately:

64–96 oz/day

<200 mg/day for caffeine

All maternal risk factors:

Risk factor	Potential concern
Age >35	Gestational diabetes, hypertension, chromosomal abnormalities
Hypertension	Pregnancy complications
Diabetes	Pregnancy/fetal complications
Thyroid disease	Pregnancy complications
Obesity	Pregnancy complications
Autoimmune disease	Pregnancy complications
Smoking	Preterm birth, low birth weight, developmental problems
Alcohol	Developmental problems
Illicit drugs	Preterm birth, low birth weight, developmental problems
Certain medications	Potential fetal/pregnancy effects
Rubella	Fetal harm
CMV	Fetal harm
Toxoplasmosis exposure	Fetal harm
Unsafe sex/STIs	Maternal/fetal complications
Heavy lifting	Injury, preterm birth, spontaneous abortion
Prolonged standing	Pregnancy complications
Limited transportation	Reduced access to prenatal care
Food insecurity	Poor nutrition
Low health literacy	Difficulty participating in care
Stress/depression/anxiety	Hypertension, preterm labor

HPV Vaccine

Age	Recommendation
11–12 years	Routine HPV vaccination
As early as 9 years	May be administered
Adults ≤26	May be recommended if not previously vaccinated
27–45	Shared clinical decision-making

Breast Cancer Screening

Biennial mammography beginning at age 40

• Biennial = every 2 years

Ages 75+

• Evidence is limited, so mammography decisions should be individualized.

Under 40

• Routine mammography generally does not benefit average-risk clients, but clients with increased risk factors may need earlier screening.

Pap Test

Abnormal cervical cell growth → cervical cancer risk

Age	Recommendation
21–29	Pap every 3 years if prior results are normal
30–65	Pap every 5 years when combined with HPV testing
30–65	Pap alone every 3 years
>65	Generally unnecessary

Reproductive Care for Trans Men

Puberty Suppression

• Reduce breast development

• Reduce body-hair development

• Delay menstruation

Testosterone Therapy

• Facial hair

• Deeper voice

• Increased muscle mass

• Typical male fat distribution

It may cause:

• Reduced ovarian function → possible egg freeing to “maintain” fertility

• Uterine atrophy

For safe s3x:

Possible pregnancy-prevention methods can include:

• Pills

• IUDs

• Other appropriate contraceptive methods

Natural Family Planning

Natural family planning is also called:

Fertility awareness

The client identifies fertile days by tracking:

• Menstrual cycle

• Basal body temperature

• Cervical mucus

Why might clients choose it?

• Don't want hormones

• Don't want devices

• Personal preference

• Cultural/religious beliefs

Calendar Method

• Takes cycles for 8-12 months:

• Day 1= first day of bleeding

Cervical Mucus Method

• Around ovulation, Mucus:

→ increases
→ becomes more noticeable
→ reaches its greatest amount

Cycle period	Mucus
Before/early cycle	Less mucus
Approaching ovulation	Increasing mucus
Ovulation	Greatest amount / most fertile
After ovulation	Less mucus again; thicker/stickier

Basal Body Temperature (BBT)

The client takes their temperature:

• Immediately after waking, before getting out of bed.

Before ovulation

• 96–98°F (35.5–36.7°C)

After ovulation

• 97–99°F (36.1–37.2°C)

What Can Interfere With Cervical Mucus Tracking?

• Breastfeeding

• Hormonal birth control

• Douching/feminine hygiene products

• Vaginitis

• STIs

• Cervical surgery

Menstrual Cycle

Days 1–4

The uterine lining is shed.

Around day 5

The lining is at its thinnest.

Days 5–28

The uterine lining gradually thickens.

Around day 14

Ovulation

• A follicle develops.

• The follicle matures.

• Ovulation occurs.

• Egg leaves the follicle.

• Remaining follicle becomes the corpus luteum.

• Corpus luteum eventually degenerates.

Coitus Interruptus

The penis is withdrawn from the vagina before ejaculation.

Advantages

• No prescription

• No device

• No medication

• less reliable

External Condom

Advantages

• STI protection

• Inexpensive

• No hormones

• Can be used while breastfeeding

• No waiting period after childbirth according to the notes

Disadvantages

• Requires planning

• Must be used correctly

• Latex/polyurethane allergies possible

Internal Condom

Advantages

• STI protection

• No hormones

• Can be used while breastfeeding

• Can be inserted up to 8 hours before sex

Disadvantages

• Requires planning

• Must be inserted correctly

• Possible polyurethane allergy

Diaphragm + Spermicide

Important facts

• Requires fitting by a healthcare provider

• Used with spermicide

• Failure rate in notes: 6–12%

• No hormonal effects

• Can be used while breastfeeding

⚠ Risks

• Vaginal irritation/burning

• UTI risk

• TSS

• Spermicide reactions

🚨 TSS prevention

• Do not leave the diaphragm in longer than 24 hours.

No STI prevention

Cervical Cap + Spermicide

Key facts

• Must be used with spermicide

• May be inserted 6 hours before intercourse

• No hormonal effect

• Can be used while breastfeeding

Failure rate

13–32%

⚠ Problems

• Vaginal odor

• Irritation

• Refitting may be needed after weight changes

• TSS risk

❌ STI protection?

No.

Sponge

Placed inside the vagina.

Contains/works with spermicide.

Key facts

• Used as needed

• Can remain for up to 30 hours

• Failure rate: 12–24%

• Can be used while breastfeeding

⚠ Cannot use:

• During menstruation

• Until at least 6 weeks postpartum

❌ STI protection?

No.

🚨 TSS

Rare but possible.

Spermicide

Spermicide is:

• A liquid, foam, or gel placed inside the vagina before intercourse.

Failure rate

18–20%

Can be combined with:

• Condoms

• Diaphragms

Advantages

• Inexpensive

• Available without prescription

• No hormones

• Doesn't affect milk supply

Disadvantages

• Vaginal burning/irritation

• Requires correct timing/application

• No STI protection

Hormonal Contraception

• Oral contraceptive pills

• Patch

• Vaginal ring

• Injection

• Implant

Combined Oral Contraceptive (COC)

Contains:

Estrogen + progesterone Main mechanisms

↓ FSH/LH → suppress ovulation

AND

Thicker cervical mucus → harder for sperm to reach egg

The endometrial/cervical environment is also altered.

Taken everyday:

• On the first day of menstrual bleeding, or

• With backup contraception for the initial period as instructed

• 21 active pills → placebo week

  The placebo week allows withdrawal bleeding

COC Side Effects

• Nausea

• Headache

• Breast tenderness

• Breakthrough bleeding

• Amenorrhea

• Abdominal cramps

• Bloating

• Depression

• Hypertension

• Edema

• Melasma

Serious complications

Most important:

• Thromboembolism / blood clots

• Leg pain/swelling

• Chest pain

• Severe headache

• Visual changes

COC Contraindications / Major Cautions

• Smoking

• Age >35

• History of blood clots

• Thromboembolic disease

• Stroke/cerebrovascular disease

• Coronary artery disease

• Migraine with aura

• Uncontrolled hypertension

• Certain vascular complications of diabetes

• Breast cancer

• Significant liver disease/tumors

• Major surgery with prolonged immobility

ACHES — COC Warning Signs for Complications

A — Abdominal pain

Possible liver/gallbladder/pancreatic problem

C — Chest pain

Possible pulmonary embolism

H — Headache

Especially severe/unusual headache

E — Eye problems

Blurred vision/visual changes

S — Severe leg pain

Possible DVT

COC Teaching

• Take the pill at the same time every day

• Don't skip pills

• Follow the pack sequence

• Take with food if nausea occurs

• Use backup contraception when instructed

• Report concerning symptoms

• Avoid smoking

• Understand that the pill does not protect against STIs

Progestin-Only Pill / Mini-Pill

• Altering cervical mucus

• Altering endometrial environment

• Sometimes suppressing ovulation

May cause irregular bleeding

Transdermal Patch

The patch releases:

Estrogen + progesterone

into the bloodstream.

Schedule

Patch → weekly × 3 weeks

Then:

1 week without patch

Menstrual bleeding may occur during the patch-free week.

Placement

Can be placed on:

• Buttocks

• Upper arm

• Abdomen

❌ Do NOT place on:

Breasts

Also avoid irritated areas or places where clothing may rub it off.

Source-specific point

The notes identify the patch as contraindicated with:

BMI >30

Vaginal Ring

A flexible ring is inserted into the vagina.

It releases:

Estrogen + progesterone

The hormones are absorbed through vaginal tissue.

Key concept

Ring = monthly vaginal hormonal method

Depot Medroxyprogesterone Acetate (DMPA)

Progestin-only injection

• Q3months

• Suppresses ovulation, mucus, and endometrium

• Possible bone loss and bleeding

  • ^ VD and Ca supplementation

Implant — Nexplanon

Long-acting reversible contraceptive (LARC)

• Uses etonogestrel for 3 yars to suppress ovulation

IUDs

Hormonal IUD

Contains:

• Levonorgestrel

Mechanisms includes:

• Thickening cervical mucus

• Reducing sperm movement

• Sometimes suppressing ovulation

Copper IUD

Contains:

• Copper, no hormones

Can remain effective for:

Up to 10 years

Copper:

→ impairs sperm motility
→ reduces sperm viability

Edu:

• Professional inserts it → follow up around 4-6 weeks after

Emergency Contraception

Used after:

• Unprotected intercourse

• Condom breakage

• Contraceptive failure

Mostly delays or X ovulation

Can be used up 5 days after unprotected intercourse

• The sooner, the more effective

Options:

• Ulipristal acetate

• Levonorgestrel

• Certain high-dose combined oral contraceptive regimens

• Copper IUD

Edu:

• Take exactly as directed

• Do not use it as routine contraception

• It does not protect against STIs

• Report vomiting soon after taking it

• Follow up if pregnancy is suspected

Possible reaction w/Rifamipin

Screening Before Hormonal Contraception

urrent contraception?

“Are you currently using hormonal birth control?”

2. Allergies?

“Have you had an allergic reaction to hormonal contraceptives?”

3. Blood clots?

“History of blood clots or stroke?”

4. Smoking?

“Do you smoke or have a history of smoking?”

5. Cancer?

“History of breast cancer or another cancer?”

6. Hypertension/diabetes?

“Do you have high blood pressure or diabetes?”

7. Medications?

“Are you taking medications that interact with hormonal contraception?”

8. Pregnancy?

“Are you pregnant or could you be pregnant?”

9. Other medical conditions?

“Do you have a condition that could affect your ability to use hormonal contraception?”

Hormonal Contraception: Red Flags

❤ Chest pain 🦵 Leg pain/swelling 🧠 Severe headache 👁 Visual changes 🩸 History of blood clots 🚬 Smoking + older age 🩺 Uncontrolled hypertension

→ Further evaluation is needed before selecting an appropriate hormonal method.

Sterilization:

Female:

• Permanent

• A/x risks, benefits, complications, h/x, alternatives, questions

• Tubal ligation:

  • Cutting, sealing, or blocking fallopian tube

• Hysteroscopic sterilization : Fallopian tubes are blocked using inserts/coils.

• Bilateral salpingectomy : Both fallopian tubes are surgically removed.

• Hysterectomy: The uterus is removed.

Male:

• Vasectomy:

  • May still not be sterile right after

Contraceptive Effectiveness Tiers

🥇 Tier 1 — More effective

• Implant

• Vasectomy

• Tubal occlusion

• IUD

🥈 Tier 2

• Injection

• Pill

• Patch

• Ring

🥉 Tier 3 — Less effective

• External condom

• Fertility awareness

• Diaphragm

• Sponge

• Withdrawal

• Internal condom

• Spermicide