week 2 maternity: phys aspects of pregnancy

pt teaching of folic acid

• it decreases neural tube defects

• folic acid supplementation of 400 mcg of folic acid/day for childbearing aged women reduced the incidence of NTDs such as spina bifida

• beneficial impact of folic acid supplementation is greatest between 1 month before pregnancy and through the first trimester, the period of neural tube development

sources of folic acid

• dark green leafy vegetables

• legumes (beans, peanuts)

• orange juice

• asparagus

• spinach

• fortified cereal and pasta

may be lost in cooking

what can iron supplementation aid in during pregnancy?

• can reduce preeclampsia, PICA, premature rupture of membrane, higher risk of low birth weight

• multigravida pts or short interconeption periods may lead to low FE in beginning of pregancy

sources of iron rich foods

• shrimp

• oysters

• cream of wheat

• peas

• eggs

• prunes

• broccoli

• beef and chicken

what should pregnant pts avoid doing exercise wise?

• yoga poses on back for long periods

• hot yoga or pilates causing overheating

• contact sports, scuba diving, skydiving, anything risking injury or fall

pt should stop exercising and call her HCP if she experiences?

• abd pain w or w/o nausea

• calf pain or swelling

• chest pain

• dizziness, syncopre

• headache

• muscle weakness affecting balance

• new dyspnea before exercising

• regular, painful uteine contactions

• vagginal bleeding or leaking fluid from the vagina

what is the length of gestation/human pregnancy

• average 280 days or 40 wks

• typically between 37 wks and 42 wks

what is trimester 1 week/month wise?

• month 1: 1-4 wks

• month 2: wks 5-8

• month 3: wks 9-13

what is tri 3 week/month wise?

• month 4: week 14-17

• month 5: week 18-22

• month 6: week 23-27

what is tri 3 month/week wise?

• month 7: week 28-21

• month 8: week 32-35

• month 9: 36-40

what are preSUmptive indicators during pregnancy

• subjective changes experienced and reported by the patient

  • amenorrhea

  • N/V

  • breast changes - end of first tri into third

  • fatigure

  • urinary frequency

  • vagianl and cervical color changes

  • quickening: first time mother feels fetal movement

what are probably indicators of pregnancy

• objective findings that can be documented by an examiner

  • uterine growth and abdominal growth

what is chadwicks sign

• increased congestion to the cervix because of increased estrogen

• bluish purple coloration of the vaginal ucosa, cervix, and vulva seena t 6-8 weeks

what is goodells sign

• softening of the servix and vagina with increased leukorrheal discharge; palpated at 8 wks

what is hegar’s sign

• about 6 to 8 wks after the last menses, the lower uterine segment is so soft it can be compressed to the thinness of paper

what is melasma

• mask of pregnancy

• mask of darker skin tone

what is linea nigra

• dark line in between belly button

what do pregnancy tests detect?

• hCG (human chorionic gonadotropin) or the beta subunit of hCG, in which is secreted by the placenta and present in maternal blood nd urine shortly after conception

what are some positive indicators of pregnancy

• auscultation of fetal heart sounds

  • btwn 10-12 wks

  • normal FHR is 110-160 BPM

• Observation and palpation of fetal movements by examiner

  • felt or visualized by examiner

  • observed after about 20 wks

• visualization of embry or fetus

  • imagine such as ultrasonography

  • as early as 3-4 wks of gestation

what is quickening

• first time that mother feels fetal movement usually around 18 wks-20 wks gestation

  • sometimes as early as 14 to 16 wks of gestation in multigravida

  • occasionally as late as 22 wks of gestation in some primigravidas

what is gravidity/gravida

• refers to totqal numbers/times a woman has been pregnant without reference to how many fetuses there were with each pregnancy or when the pregnancy ended

  • simply how many times a woman has been pregnant, including the current pregnancy

what is parity or para

• refers to the number of births after 20 wks gestation whether live births or still births

what is GTPAL?

G = # of pregnancies

T = # of term pregnancies (>= 37 wks and 0 days & beyond)

P = # of preterm pregnancies (>= 20 wks to 36 wks & 6 days0

A = # of abortions before 20 wks gestation

L = living children

what is nulligravida

• a woman who has never been pregnant or given birth

what is primigravida

• a woman who is pregnant for the first time

what is multigravida

• more than 1 pregnancy

what are the goals for prenatal care?

• maintenance of maternal fetal health

• accurate determination of gestational age

• ongoing assessment of risk status and implementation of risk-appropriate intervention

• rapport built with the childbearing family

• referrals to appropriate resources

frequency of prenatal care visits: conception to 28 wks

• every 4 weeks

frequency of prenatal care visits: 29 to 36 wks

• every 2 weeks

frequency of prenatal care visits: 37 weeks to birth

• weekly

what are the prenatal lab tests?

• ABO & Rh type with antibody screen to identify isoimmunization

• Hgb = anemia

• Rubella = MMR vaccine if not immune pp

• Varicella = if not immune, offer Varivax vaccine pp

• VDRL or RPR = treatment for positive syphilis

• Gonorrhea & chalmydia = treat

• urine culture = if bacteruria

• Hepatitis B surface antigen = immunoprophylaxis

• HIV = treat w antiretrovirals if +

• cervical screening = for HPV

• TB skin test = for @ risk pts

• prenatal screening = for abnormalities, diseases, defects

what is RhoGAM

• antibody tests may be repeated in 3rd trimester in pts who are Rh-negative if the father of the baby is Rh-positive

  • if unsensitized, the pt should recieve Rho (D) immune globulin aka RhoGAM, prophylactically at 28 wks of gestation, after any invasive procedure such as amniocentesis, abdominal trauma

  • need give RhoGAM again within 72 hrs after birth if infants blood type is Rh positive

total weight gain for underweight BMI (<18.5)

28-40 lbs

total weight gain for normal BMI (18.5-24.9)

• 25-35lbs

• 37-54lbs for twin pregnancies

total weight gain for overweight BMI (25-29.9)

• 15-25lbs

• 31-50lbs for twin pregnancies

total weight gains for obese BMI (>=30)

• 11-20lbs

• 25-42lbs for twin pregnancies

what fish to avoid during pregnancy and why

• bc of high levels of mercury

  • king mackerel

  • orange roughy

  • marlin

  • shark

  • swordfish

  • tilefish

• tuna is safe but limit white (albacore) tuna to 6oz per week

foods to avoid in pregnancy

• raw and unpasteurized - risk of listeria, parasites, bacteria

  • unpasterized juices or dairy products

  • raw sprouts of any kind

  • unpasteurized soft cheeses such as brie, camembert, or feta

  • refrigerated, smoked seafood

  • unheated deli meats or hot dogs

  • raw eggs

  • raw fish and shellfish

what teas promomte uterine contractions

• teas with chamomile, peppermint, licorice, raspeberry leaf

what is PICA?

• cravings for nonnutritive substances such as ice, clay, dirt, laundry starch

• cause is unknown

• iron deficiency is often associated with pica

• substances may be contaminated with toxins or parasites

• may cause dental problems

• may cause nutritional deficiencies

warning signs for 1st trimester

• abd cramping or pain indicates possible threatened abortion, UTI, appendicitis

• vaginal spotting or bleeding indicates possible threatened abortion

• absence of FH tone indicated missed abortion

• dysuria, freq., urgency indicate possible UTI

• fever or chills indicate infection

• prolonged N/V indicated hyperemesis gravidarum, increased risk of dehydration

warning signs for 2nd trimester

• abd. or pelvic pain indicates possible preterm labor, UTI, pyelonephritis, or appendicitis

• absence of fetal movement ones the woman has been feeling daily movement indicates possible fetal distress or death

• prolonged N/V indicates possible hyperemesis gravidarum, this woman is at risk for dehydration

• fever and chills indicate possible infection

• dysuria, freq., urgency indicate possible UTI

• vaginal bleeding indicates possible infection, friable cervix caused by pregnancy changes, placenta previa, abruptio placeta, or PTL

what is leopolds 1st maneuver

• abdomen

what is leopolds 2nd maneuver

• abdomen

leopolds 3rd manuever

• on fetal presenting part

leopolds 4th maneuver

• on fetal presenting part

what is the screening for group beta steptococcus for?

• it is a 3rd tri lab

• vaginal and rectal swab at around 35-37 wks gestation

• if present bacteria, anticipate intapartum antibiotic treatment PRN

• can be invasive and severe with potential longer term neurological sequelae

what is a 1hr glucose test for?

• done at 24-28 wks gestation

• third trimester lab

• 3hr glucose tolerance test is ordered if 1hr screen is elevated

  • determines gestational diabetes

warning symptoms in 3rd trimester to contact their provider immediately

• abdominal or pelvic pain (PTL, UTI, pyelonephritis, appendicits)

• decreased or absent fetal movement (Fetal hypoxia or death)

• prolonged N/V (dehydration, hyperemesis, gravidarum)

• fever chills (infection)

• dysuria, frequency, urgency (UTI)

• vaginal bleeding (infection, friable cervix caused by pregnancy changes or pathology, placenta previa, placenta abruptio, PTL)

signs and symptoms of PTL in 3rd tri

• rhythmic lower abdominal cramping or pain

• low backache

• pelvic pressure

• leaking of amniotic fluid

• increased vaginal discharge

S/S of hypertensive disorders in third trimester

• severe headache that does not respond to usual relief measures

• visual changes

• RUQ pain

• facial or generalized edema

breast changes are normally caused by what hormone levels increasing?

• estrogen and progesterone

• produced by the corpus luteum and then by the placenta

how early is colostrum secreted?

• as early as 16 wks

• due to relwase of prolactin

what is lightening?

by 40 wks, fetal head descend into pelvic cavity

what is braxton hicks?

• first contractions

• uterus temporarily tightens and then returns to its original relaxed state

what is chadwicks sign?

• bluish coloration of cervix, vaginal mucosa, and vulva

• gives off blue hue

• this is due to increased estrogen

what is goodell’s sign?

• softening of the cervix

what is hegars sign?

• softening of the lower uterine segment

what is supine hypotension

• weight of gravid uterus partially occludes vena cava and the aorta and diminish blood return to lower extremities and reduces cardiac return

  • dizziness, lightheadeness, nausea, syncope

  • light on side instead

what are respirstory system changes during pregnancy?

• estrogen and progesterone causes vascular engorgement and smooth muscle relaxation leading to dyspnea, nasal and sinus congestion, epistaxis (nose bleeds)

  • this is due to estrogen and progesterone

• causing upward displacement of diaphragm by enlarging uterus

renal system in pregnancy

• increased GFR > increased urine output

• urinary frequency and incontinence and increased risk of UTI may be asymptomatic

• small proteinuria and glycosuria can be normal

  • increased progesterone levels = relaxation of smooth muscles

GI system in pregnancy

• gingivits/bleeding gums

• excessive salivation (ptyalsim)

  • increased progesterone levels relax smooth muscle, causing bloating, flatulence, and constipation

musculoskeletal system in pregnancy

• increased progesterone and relaxin levels lead to softening of ligaments and increased joint mobility, resulting in widening and increased mobility of the sacroiliac and symphysis pubis to help facilitate birthing

  • can also lead to low back pain or pelvic discomfort

  • pelvis tilts forwarf, changing posture (increasing lordosis) and making a “waddle” gait

  • increased risk of falls due to shift in cent of gravity and change in gait and posture

• distention of abdomen related to expanding uterus, reduced abdominal tone, and increased breast size leading to round ligament spasm

• abdominal muscles stretch due to enlarging uterus causing diastasis recti

what is diastasis recti

• seperation of the rectus abdominis muscles

integumentary system changes in pregnancy

• linea nigra

• melasma (chloasma)

• increased prigmentation of nipples, areola, vulva, scars, and moles

  • due to estrogen and progesterone levels stimulating increased melanin deposition, causing light brown to dark brown pigmentation

what is the human chorionic gonadotropin (hCG)

• primary function of hCG in early pregnancy is to prevent deterioration of the corpus luteum so it can continue producing estrogen and progesterone until the placenta is sufficiently developed

• hormone detected in pregnancy tests

how is the corpus luteum produced?

• early in pregnancy

• due to estrogen

what are the effects of estrogen during pregnancy regarindg the endocrine system?

• placenta continues to produce estrogen for the remainder of pregnancy

  • facilitates uterine and breast development

  • facilitates increases in vasculariy

  • facilitates hyperpigmentation

  • alters metabolic processes and fluid and electrolyte balance

how is progesterone produced?

• first produced by the corpus luterume and then by the fully developed placenta

what major fx does progesterone have?

• suppresion of FSH and LH

• maintenance of the endometrial layer for implantation of the fetilized ovum and prevention of menstruation

• maintains pregnancy by relaxation of smooth muscles leading to decreased uterine activity which results in decreased risk of spontaneous abortions

• decreases GI motility and slows digestive processes

why is glucose needed in pregnancy? why is insulin needed?

• increased need for glucose due to developing fetus leading to increased production of insulin

• increase in circulating cortisol leading to increase in maternal rsistance to insulin leads to increased risk of hyperglycemia

pt teaching is experiencing N/V (nutrition/food wise)

• eat crackers, dry toast, or dry cereal before arising in the morning, then get out of bed slowly

• eat small amounts of high carbohydrate, low fat foods, q2 hrs and a total of 5-6 small meals per day to prevent an empty stomach

• eat a protein snack before bedtime

• suck on hard candy

what is hyperemesis gravidarum?

• a condition associated with severe vomiting leading to weight loss, dehydration, electrolyte imbalance, and ketosis

N/V pt teaching (nonpharm/ cannot PO wise)

• wear a P6 acupressure wrist band

• take vitamins at bedtime with snack (not in the morning)

  • suggest vitamin B6, 25 mg by mouth 3 times daily or ginger, 250 mg by mouth four times daily

• oral or rectal meds may be prescribed for management of troublesome symptoms

pt teaching for heartburn

• eat small meals q2/q3 and avoid fatty, acidic, or spicy foods

• eliminate or curtail smoking and drinking coffee and carbonated beverages, which stimulate acid formation in the stomach

• avoid citrus fruits and juices, tomato based products, chocolate, and peppermint if they increase symptoms

• try chewing gum

• remain upright for 30-45 mins after eating

• avoid bending over or lying flat

• refrain from eating atleast 3 hrs before bedtime

what may be causing backache in pregnancy

• increased joint mobility, lumbar lordosis, and relaxed ligaments contribute to the problem

pt teaching for backache

• teaching correct psture and body mechanics can help prevent back pain

• stooping or bending puts a great deal of strain on the muscles of the lower back

• instruction should include correct and incorrect methods of lifting

what exercises can you do to relieve backaches ?

• pelvic tilt/pelvic rocking (cow position)

• tailor sitting (almost like criss cross applesauce)

• shoulder circling

what is round ligament pain?

• sharp pain in the inguinal area or on the side, usually on the right

• results from softening and stretching of the ligament from hormones and uternie growth

• may be difficult for woman to distinguish from uterine contractions

• careful assessment to rule out contractions followed by reassurance are appropriate measures

pt teaching for round ligament pain

• lie on her side and flex the knees up to the abdomen

• bend toward pain

• do pelvic tilt and pelvic rock exercises

• use warm baths or compresses

• use side lying in exaggerated sim’s position with pillows for additional support of the abdomen and in btwn legs

• use maternity belt

when is urinary frequency and nocturia most common?

1st and 3rd trimester

pt teaching of urinary frequency and nocturia

• reassure the woman of the normalcy of response

• encourage the owman to empty her bladder frequenctly, front to back

• kegel exercises may help maintain bladder control

constipation in pregnancy

• can casue abd. fullness and flatulence and hemorrhoids

• hard, dry stools, decreased frew. of bowel movements

• iron supplementation can caus e

what happens to intestinal motility during pregnancy

• decreased during pregnancy as a result of progesterone, pressure from the enlarged uterus and decreased activity

‘pt teaching of constipation

• maintain adequate fluid intake

• engage in regular exercise such as walking

• increased fiber in diet through veggies, fruits, and whole grians

• maintain regular bowel habirs

• maintain good posture and body mechanics

pt teaching of hemmorhoids

• avoid bearing down with bowel movements

• comfort meassures (ice packs, warm baths or sitx baths, witch hazel compresses)

• elevate hips and lover extremeities during rest periods throughout day

• gently reinsert hemorrhoid into rectume while doing kegel exercises

pt teaching of leg cramps

• dorsiflex foot to stretch calf (towards body)

• apply warm compress to area

• change positions slowly

• massage

• engage in regular exercise and muscle conditioning

relaxin

one of the hormones that causes gradual softening of pelvic cartilage and connective tissues

after ovulation, this is the remaining cells of an old follicle thsy prrsists for ~12 days

corpus luteum

folic acid

supplementation decreases risk of neural tube defects