Uncomplicated/Healthy Pregnancy

Smooth Muscle of Uterine Wall

• experiences hypertrophic and hyperplastic changes to allow the uterus to increase in size as the fetus grows

• hypertrophic→Growth of organ by thickened fibers of the muscle.

• hyperplastic→Unexpected increase in cells composing a tissue.

Hormonal Changes

• Estrogen levels increase in pregnancy are thought to play a role in the uterine spiral artery changes, or remodeling

  • With the increase in maternal blood flow to the uterus to supply necessary nutrients and oxygen to the growing fetus throughout the pregnancy

• Increase in estrogen and progesterone levels cause breast tissue to differentiate and create additional milk ducts to prepare for milk production

Breast and Mammary Glands

• Breasts will increase in size as vascular remodeling occurs throughout the body

• Breasts may feel heavy or tender, and leaking colostrum that appears as a thick, yellow/white colored fluid begins and is a normal variation once production has begun

• colostrum→Fluid excreted from a breast at the onset of milk production.

Human chorionic gonadotropin (hCG):

• Basis for pregnancy testing and is produced by the corpus luteum.

• Rises quickly very early in pregnancy until placenta function takes over.

• Rises early in pregnancy, maintains corpus luteum until placenta takes over pregnancy hormone production, basis for pregnancy testing

Progesterone

• Establishes placenta, maintains health of uterine wall, supports blood vessel growth, prevents uterine contractions.

• Glucose homeostasis, insulin regulation, structure/function changes of maternal organ systems, maternal cardiovascular changes, mammary gland development, and water and sodium retention

• If not enough = preterm labor

Estrogen

• Promotes blood vessel growth, maintains uterine lining, and aids in fetal organ development

• Glucose homeostasis, insulin regulation, structure/function changes of maternal organ systems, maternal cardiovascular changes, mammary gland development, and water and sodium retention

• Strengthen spinal arteries

Prolactin

• Stimulates breast growth and breastmilk production

• Mammary gland development and milk production

Relaxin

• Promotes uterine relaxation, cervical softening, and maternal vasodilation.

• Maternal vasodilation of blood vessels, decreases uterine contractility, promotes growth of uterus and placenta, cervical softening

Oxytocin

• Stimulates uterine contractions and the release of prostaglandin.

• Promotes nursing behavior, maternal/newborn bonding, uterine smooth muscle contraction

Aldosterone and Cortisol:

Causes fluid accumulation in the body, resulting in hypervolemia and edema

Placental Growth Hormone

Secreted by the placenta, functions as an insulin antagonist, stimulates growth of maternal tissues

Human Placental Lactogens: ​​​​​​​

Growth hormone in pregnancy and contributes to insulin resistance

The maternal circulatory system must meet the oxygen demands of the growing fetus; thus

• Increased Maternal Blood Volume begins to increase early in pregnancy and reaches a volume of 30% to 50% greater than the prepregnant state, for a single pregnancy, by the middle of the third trimester

• Increased Maternal Heart Rate by 20% above the client’s expected heart rate in the prepregnant state

• Increased Clotting Factor which increases the risk for blood clots by nearly five times above that of the prepregnant state

• Increased Venous Pressure in Lower Extremities The gravid uterus and the pressure exerted on the pelvic and femoral vessels cause an increase in venous pressure of the lower extremities, which can cause varicosities- varicose veins in the lower extremities.

• Decreased Peripheral Vascular Resistance leading to a decrease in maternal blood pressure due to elevated estrogen levels.

• Resulting in Decreased Blood Pressure from baseline prepregnant values through the middle of the third trimester. Maternal blood pressure values return to the prepregnant state in the last trimester

• Decreased Hematocrit Values results in decrease the blood viscosity and lower resistance for blood to reach the uteroplacental circulation to provide oxygen and nutrients to the growing fetus. This adds to the increased risk for blood clots.

diastasis recti

Separation of the abdominal wall muscles at the linea nigra, resulting in a bulging area in the abdomen.

linea alba

A tendon in the abdomen between the rectus abdominis muscles, extending from the xiphoid process to the symphysis pubis.

Musculoskeletal changes occur during pregnancy due to the increased hormonal levels, including progesterone and relaxin

Relaxin - causes joints to become more flexible to accommodate for pregnancy changes, such as the pliability of the pelvis to promote fetal passage during the labor and birth process

As the gravid uterus increases in size the center of gravity shifts forward which causes the body to compensate with lumbar lordosis and anterior pelvic tilt

• Resulting in Postural and bodily changes

  • Exaggerated lordosis, many pregnant clients experience low back pain, which is the most frequently identified musculoskeletal manifestation in pregnancy

  • Gait changes affecting hips, knees, ankles and feet

  • Pain and edema in lower extremities

  • Diastasis recti where the abdominal muscles become separated due to abdominal wall weakness, resulting in widening and thinning of the linea alba, and a bulging area in the abdomen

Anatomy & Physiology Changes in Pregnancy: Integumentary System

• Hormonal changes and increased blood volume during pregnancy contribute to integumentary changes during pregnancy.

• Striae gravidarum (stretch marks) is one of the most common integumentary changes in pregnancy, as the skin stretches to accommodate the growing uterus.

  • Striae are visible as purple or pink bands in the areas of the skin displaying tension.

  • May also be seen on hips, buttocks, legs, or breasts.

  • Will be present throughout the pregnancy, occasionally lightening and becoming less visibly prominent over time

• Hyperpigmentation Changes

  • May also occur over typically darker areas of skin such as the areola, genitalia, or axillae/armpit.

  • Linea nigra (A darkened line running vertically down the midline of the abdomen is an expected finding.)

    • running vertically down the midline of the abdomen is an expected finding. Often the darkened area of the linea nigra will be most prominent between the umbilicus and the pubic symphysis

  • Melasma (Brownish colored patches on a pregnant client’s face; also known as the mask of pregnancy.)

    • appears on the face and can span across the bridge of the nose to the cheeks or onto the forehead and chin

• pubic symphysis→The joint between left and right side of the pelvic bone.

Respiratory System

• lightening→Decreasing pressure on the diaphragm as the fetus moves deeper into the pelvis, resulting in the ease of maternal respiratory effort.

• Increased maternal and fetal oxygen demand results in increased maternal respiratory rate

• Total volume expansion of lungs is decreased due to upward pressure from the uterus on the diaphragm (respirations difficult)

• Pt will often hyperventilate

Gastrointestinal System

• Displacement and upward pressure from the growth of the uterus may cause a more rapid feeling of fullness and susceptibility to gastric content reflux

• Hormonal changes, including the action of progesterone on smooth muscle

  • Delayed gastric emptying

  • Decreased gastroesophageal sphincter tone, causing clients to experience heartburn, which may lead to nausea and vomiting

  • Progesterone slows down motility = constipation

Genitourinary System

• Increased Cardiac output and blood volume leads to increase kidney size by approximately 30%.

  • Increase urine excretion

• Increases in glomerular filtration rate (GFR) at approximately 50% above baseline prepregnancy values

• Urinary frequency & nocturia are common

• Glycosuria and proteinuria are expected variations in pregnancy; however, significant increases in glycosuria or proteinuria should be monitored closely by a health care provider and could be indicators of pregnancy complications

• glomerular filtration rate (GFR)→Rate of blood filtration per minute.

• nocturia→interruption of sleep for the need to void

• glycosuria→abnormal amount of glucose in the urine

• proteinuria→protein present in the urine in unexpected amounts

Focus of Prenatal Care

• Is essential in promoting positive health outcomes and decreasing the risk of maternal and neonatal morbidity and mortality

• Prenatal Focus

  • Screening for fetal anomalies

  • Individualized education

  • Guidance on items such as weight gain, health behaviors and nutrition

• World Health Organization (WHO) recommend clients with uncomplicated pregnancies attend at least one visit in the first trimester, two visits in the second trimester, and five visits during the third trimester

Presumptive Signs

• Felt or experiences by client

  • Examples include amenorrhea, breast tenderness, nausea, fatigue

  • Positive home pregnancy test

Probable Signs

• Detected by provider

  • Lab results, such as a positive serum hCG pregnancy test.

  • The provider will also assess for

    • Ballottement:

      • The gloved finger of the provider pushes upward on the cervix, pushing the fetus upward in the uterus, then the fetus returns back down to the cervix and the provider feels the movement of the fetus.

      • Displacing the fetus by sharp upward pressure on the uterine wall and palpating the fetal return to original position

    • Chadwick’s sign

      • A blue discoloration of the cervix, vagina, and vulva due to increased vascularity.

    • Goodell’s sign

      • Cervical softening that occurs in pregnancy.

    • Hegar’s sign

      • Softening of the lower portion of the uterus.

Ballottement:

• The gloved finger of the provider pushes upward on the cervix, pushing the fetus upward in the uterus, then the fetus returns back down to the cervix and the provider feels the movement of the fetus.

• Displacing the fetus by sharp upward pressure on the uterine wall and palpating the fetal return to original position.

Chadwick’s sign

A blue discoloration of the cervix, vagina, and vulva due to increased vascularity.

Goodell’s sign

Cervical softening that occurs in pregnancy.

Hegar’s sign

Softening of the lower portion of the uterus.

Positive Signs

• Associated with the Fetus

• Confirmation of the presence of a pregnancy through visualization of the fetus and fetal heart activity on an ultrasound

CLIENT HISTORY

• Medical/surgical history

• Pregnancy/menstrual history

• Family history

• Alcohol/tobacco/drug use

• Sexually transmitted infections (STls)

• Partner violence

• Mental health history

• Pets

Obstetrical History

Encompass date of last menstrual period, information specific to previous pregnancies, including experience of infertility, spontaneous abortions, or previous birth of a neonate who had a genetic condition may warrant additional genetic screening

GTPAL System

• total number of pregnancies, identify how many of those resulted in term or preterm births, medically induced or spont abortions, number of living children

• G = Gravida, the number of pregnancies total, including current pregnancy

• T = Term, the number of births at 37 weeks or after

• P = Preterm births, the number of births born before 37 weeks

• A = Abortion, the number of medical, procedural and/or spontaneous abortions/miscarriages

• L = Living, the number of living children

Parity

used in conjunction with gravidity when describing pregnancy history, encompassing the number of births a client has after the 20th week of pregnancy

Primigravida

Client pregnant for the first time

Multigravida

Client who has had multiple previous pregnancies

Nulligravida

Client who has never been pregnant

Primipara

Client who has given birth for the first time after 20 weeks of gestation

Multipara

Client who has had multiple births after 20 weeks of gestation

Nullipara

Client who has never given birth after 20 weeks of gestation

Naegele’s rule

• helps guide practitioners in estimating date of birth. The calculation is based on the idea that the client has a 28-day cycle with ovulation on day 14. To obtain the EDD, the provider will take the first day of the last menstrual period (LMP), subtract three months and add seven days

• Calculation to estimate date of birth, using the first day of the last menstrual period, subtracting 3 months and adding 7 days.

The fundal height

is usually measured several times between 20 and 36 weeks gestation. While the height in centimeters should be approximately the number of weeks gestation, it can be off plus or minus 2 cm (weeks)

Substance Use

• Ask direct questions about the use of substances in a nonjudgmental approach using therapeutic communication

• Provide follow-up education on the risks of continuing use during the pregnancy

• fetal growth restriction→Fetal weight less than the 10th percentile as estimated via ultrasound.

• preterm birthing→Birth occurring at less than 37 weeks of gestation.

• teratogenic →Agents in environments that can cause birth defects.

• Substance Use Screening

  • "During this pregnancy have you used alcohol or other drugs?"

  • "Prior to pregnancy, did you use alcohol or other drugs?"

  • "Does your partner or support person use alcohol or other drugs?"

  • "Would you consider your parents to be addicted to alcohol or other drugs?"

Sexually Transmitted Infection (STI)

• Gather accurate and thorough sexual history including sexual practices and any risky sexual behaviors

• Awareness of the impact of sexual practices and assessing changes in sexual behaviors or partners during the pregnancy may result in additional screening for STIs

• Sexually Transmitted Infections: The Five Ps

  • Partners: Number and gender

  • Practices: Sexual practices (genital sex, anal sex, oral sex); how client has met sexual partners (online, through friends); use of drugs during sexual activities; exchanging sex for money, drugs, or housing

  • Protection from STIs: Use of male or female condoms; use of preventative medications, such as vaccinations against hepatitis A or B or medication to prevent HIV

  • Past history of STls

  • Pregnancy intention: Desire to be pregnant

Mental Health History

• Clients who are of childbearing age are more likely than other age groups to experience depressive manifestations.

• Depression in pregnancy increases the risk of preterm birthing, low birth weight, and increased hospitalization duration.

• The client must weigh risks and benefits of pharmacologic interventions in the treatment of depression

Partner Violence

• Economic, physical, social, and emotional changes during pregnancy place the client at increased risk for partner violence

• Referrals to social work, adult/child protective services, or other community resources may be necessary based on the responses to partner violence questions

• Partner Violence Screening

  • "Do you feel you are mistreated in your home?"

  • "Have you ever been physically injured by a partner, family member, or anyone in your home, including being hit, punched, slapped, or pushed?"

  • "Have you ever been sexually mistreated or forced to do sexual activities by a partner, family member, or anyone in your home?"

  • "Do you feel safe in your home?"

Physical Examination

• Weight, Nutritional counseling based on weight gain/loss

• Blood pressure

• Urine sample

• Fundal height in centimeter – assess fetal growth

• Fetal heart rate using doppler 110-160 beats/min

• If fetal heart rate is not obtained by 12 weeks of gestation, an ultrasound examination should be performed for a more accurate assessment

Laboratory Tests

between 15 & 20 weeks

preeclampsia

• A serious complication of pregnancy occurring after 20 weeks of gestation in which a client’s blood pressure value is above 140/90 mm Hg.

• It can be accompanied by proteinuria, edema, headache, and vision changes.

  • SOB, epigastric pain

• Can become severe resulting in seizures.

Prenatal Panel

A complete blood count (CBC), blood type, Rh factor screening, rubella, hepatitis B surface antigen (HBsAg), human immunodeficiency virus (HIV), STI screening

Urine Culture

WBC, specific gravity, protein

Rh Factor Screening

• Rh negative blood will need laboratory assessment to determine if their blood has been sensitized to the protein, resulting in Rh isoimmunization, also referred to as Rh incompatibility.

• Rh incompatibility, the client’s body produces antibodies against and begins attacking Rh positive fetal blood, treating it as an invader similar to a viral or bacterial infection

• Review treatment * for negative Rh factor

• 300 mcg RhoGam shot

Glucose Challenge

• first one is one hour (screen)

• then three hours

If initial prenatal panel/ laboratory results result in:

• Low hemoglobin/hematocrit reported in screening it will be repeated after 24 weeks of pregnancy

• Clients who are at risk for HIV will be retested

• *treatment for negative Rh factor (positive Rh blood test require no further action) and who have not been Rh-sensitized will have an additional antibody screen performed a/round 24 weeks and between 24 and 29 weeks, Rho(D) immune globulin (RhIG) (Rhogam) will be administered

• external cephalic version→The manual process of repositioning a breech fetus into a cephalic position.

Diagnostic Screening

• Ultrasound

  • assesses fetal viability and dating of pregnancy, evaluates for anomalies, and assesses for multiple gestation

• Chorionic villus sampling (CVS)

  • is typically done between 10 and 13 weeks for clients who have an unexpected result in another genetic screening or who have a higher risk

  • Removal of a small section of the placenta for genetic testing.

Chorionic villus sampling (CVS)

• is typically done between 10 and 13 weeks for clients who have an unexpected result in another genetic screening or who have a higher risk

• Removal of a small section of the placenta for genetic testing.

Prenatal Panel Laboratory Testing

• Complete blood count

• Blood type

• Rh factor screening

• Hepatitis B status

• Rubella status

• HIV status

• Rapid plasma reagin

• Urinalysis

Weight Gain & Nutrition

• Remain nonjudgmental and use unbiased language to encourage a positive nurse-client relationship

• Provide a clear explanation regarding expected weight gain in pregnancy

• A balanced diet

• Prenatal vitamins contain folic acid, iron, iodine, calcium, and vitamins A, C, D, B6, and B12.

  • Folic acid is an important factor in promoting fetal brain and spine development. Encourage folic acid consumption in dark green leafy vegetables, beans, fortified cereals, and orange juice

• Avoid consuming raw or under cooked foods which can cause foodborne illnesses, such as E. coli, listeria, salmonella, campylobacter, toxoplasma gondii

Foods to Avoid During Pregnancy

• Fish with high levels of mercury (bigeye tuna, king mackerel, marlin, orange roughy, shark, swordfish, or tilefish)

• White tuna, limit to 6 oz/week

• Raw or undercooked seafood, meat, or poultry

• Unpasteurized juice or cider

• Raw milk

• Soft cheeses: brie, feta, queso fresco, camembert

• Raw eggs

• Unheated deli meat

• Premade meat salads (tuna salad or seafood salad)

• Meat spreads or pates

• Raw cookie dough

• Raw sprouts (alfalfa or bean sprouts)

Nausea, Vomiting & Heartburn

• Common term used to describe manifestations is “morning sickness."

  • Manifestations usually begin early in pregnancy and subside at around 14 weeks of gestation.

• Eating dry crackers and small meals and following the BRATT (bananas, rice, applesauce, toast, tea) diet helps decrease nausea and vomiting manifestations. Ginger supplements in the forms of capsules, candies, ginger ale, or ginger tea can ease manifestations

Mental Health

• Some clients experiences increased stress, anxiety or depression

• Changes in hormones, previous pregnancy outcomes, mood changes, relationship changes, birth anticipation, and financial changes can cause a client to feel additional stress

• Encouraging the client to discuss feelings. Work with provider to determine treatment plan which may include pharmacologic or nonpharmacologic interventions.

Exercise

• Exercise is both beneficial and safe in uncomplicated pregnancies.

• Mild to moderate exercise three times per week is recommended and customizable based on the regular exercise performed by the client prior to pregnancy

Sleep

• Recommended sleeping positions vary based on pregnancy gestation.

• Supine positioning for sleep is not recommended because of the pressure on the inferior vena cava, which could compromise blood flow to the uterus, also known as supine hypotension

• Supine Hypotension→Typically occurring after 20 weeks of gestation, it is pressure on the inferior vena cava due to the growing fetus causing decreased blood flow back to the maternal heart and resulting in hypotension.

Pets

• Cats can be a source of toxoplasmosis is a serious infection that, if contracted by a client who is pregnant, can be passed on to the fetus, leading to complications later in life, such as cognitive disabilities or blindness.

• Example: avoid changing litter boxes

Sexual Intercourse

Sexual intercourse is not contraindicated. Clients may experience some cramping or spotting after sexual intercourse. However, leakage of fluid, heavy bleeding, or severe cramping is unexpected and should be reported to a health care provider

Travel & Vaccinations

• Travel in the first trimester is acceptable in uncomplicated pregnancies.

• Vaccinations protect both the client and fetus from infection. Initially, the neonate is protected from placental transfer of immunoglobulin G (IgG). Live vaccinations are contraindicated in pregnancy due to the risk of congenital infections and miscarriage

Prenatal Visits 2nd

• Every 4 to 5 weeks throughout (from 14 to 27 weeks)

• Ensure pregnancy is progressing

• Identify any possible complication

Physical Examination 2nd

• Client weight nutritional counseling if there is weight loss or unexpected weight gain

• Client blood pressure & Urine sample - each visit to screen for early manifestations of hypertension and preeclampsia

• Fundal height measurement in centimeters assesses fetal growth.

• Fetal heart rate assessments using a doppler will assess fetal well-being and ensure expected FHR of 110 to 160 beats/min

Laboratory Testing 2nd

• Maternal serum screening (between 15 and 20 weeks)

  • identifies clients whose fetuses have an increased risk for birth defects and is also known as the quad screen or the triple screen, assesses proteins in the client’s blood, identifying clients who are at risk for carrying a fetus with chromosomal disorders such as Down syndrome

• Glucose Challenge

  • (between 24 and 28 weeks gestation -either late second trimester or early third trimester), a glucose challenge test will be ordered to screen for gestational diabetes

• Clients who have a negative Rh factor and who have not been Rh-sensitized

  • will have an additional antibody screen performed around 24 weeks. Or between 24 and 29 weeks, Rho(D) immune globulin (RhIG) (Rhogam) will be administered

Maternal serum screening (between 15 and 20 weeks)

identifies clients whose fetuses have an increased risk for birth defects and is also known as the quad screen or the triple screen, assesses proteins in the client’s blood, identifying clients who are at risk for carrying a fetus with chromosomal disorders such as Down syndrome

Glucose Challenge

(between 24 and 28 weeks gestation -either late second trimester or early third trimester), a glucose challenge test will be ordered to screen for gestational diabetes

Clients who have a negative Rh factor and who have not been Rh-sensitized

will have an additional antibody screen performed around 24 weeks. Or between 24 and 29 weeks, Rho(D) immune globulin (RhIG) (Rhogam) will be administered

Diagnostic Testing 2nd

• Ultrasound (between 18-20 weeks) to assess fetal anatomic structures

  • biparietal diameter, head circumference, abdominal circumference, femur length

• Fetal Anatomy Scan = assess head, skill brain, nuchal skin folds, face, neck, thorax, heart, abdomen, spine, extremities, genitalia, placental location, appearance, and proximity to the internal cervical opening (or cervical os) will be identified

• Amniocentesis (if risk is determined) screens amniotic fluid, assessing for proteins that could indicate chromosomal or genetic concerns, such as Down syndrome or cystic fibrosis

  • Avoid strenuous activities for 24 hr after procedure

• oligohydramnios→Less than typical amount of fluid surrounding the fetus in pregnancy.

• polyhydramnios→Large amount of fluid surrounding the fetus in pregnancy.

• acetylcholinesterase→Enzyme produced in fetal body that can be released into amniotic fluid in the presence of a neural tube defect.

Body Changes & Discomfort 2nd

• 2nd Trimester there is often reduced nausea vomiting -> increased appetite

• Increased weight gain – review health weight gain and eating

• Bodily changes may lead to increased heart burn (second and third trimester)

• Other Common:

  • difficulty sleeping, constipation, urinary frequency and edema, stretch marks forming on their abdomen, legs, or breasts

  • some edema may occur in the second trimester of the feet, hands, or ankles.

  • risk for urinary tract infection

Fetal Movement 2nd

• feeling of quickening can be compared to tapping, pulsations, fluttering, flickering, or small muscle spasms

• if not felt until closer to 20 weeks = the feeling may appear higher in the abdomen

Quickening

• (between 16 and 20 weeks gestation) the client begins feeling fetal movements, although some clients feel movement slightly earlier

• Early fetal movements, typically felt between 16 and 20 weeks of gestations, that are often described as fluttering, small muscle spasms, gas bubbles, flickering, tapping, or pulsations.

Birth & Newborn Care

• Begin Birth planning may include hospital or birthing center tour, choosing a newborn provider, birth experience.

• Classes topics may include birth, breastfeeding and newborn care

Sexual Intercourse

Safe in pregnancy as long as the client is not experiencing pregnancy complications or vaginal bleeding or leaking of amniotic fluid.

Travel and Vaccines 2nd

• May continue to travel as long as no pregnancy complications are present. The ideal time to travel is between 14 to 28 weeks gestation due to increased energy and decreased nausea and vomiting.

• Traveling longer than 4 hr. more than doubles the risk of DVTs, so full length or knee length compression socks may be worn. Plan for frequent extra stops and walking

Warning Manifestations 2nd

• Braxton Hicks contractions vs premature Labor

• Braxton Hicks Contractions

  • Tightening and relaxation of the uterus that does not dilate or efface the cervix, often referred to as “practice contractions.”

• True Labor Contractions

  • increase in duration, frequency, intensity & dilate the cervix

• Preterm Labor

  • regular tightening in the abdomen or back for more than four times per hour

• Vaginal leaking or bleeding

• Preeclampsia manifestation may include headaches, blurred vision or vision changes, right-sided abdominal pain, edema of hands or face, or shortness of breath, the client is encouraged to notify the provider

Braxton Hicks Contractions

Tightening and relaxation of the uterus that does not dilate or efface the cervix, often referred to as “practice contractions.”

True Labor Contractions

increase in duration, frequency, intensity & dilate the cervix

Preterm Labor

regular tightening in the abdomen or back for more than four times per hour

Preeclampsia

manifestation may include headaches, blurred vision or vision changes, right-sided abdominal pain, edema of hands or face, or shortness of breath, the client is encouraged to notify the provider

Prenatal Care 3rd

• Prenatal appointments are approximately every 2 to 4 weeks until 36 weeks when appointments occur on a weekly basis

• Physical assessment and update the history at each appointment to ensure pregnancy is progressing appropriately and to identify complications

Physical Examination 3rd

• Leopold Maneuvers

  • Palpation method to determine fetal position, presentation, and engagement.

  • After 34 weeks

• Blood pressure & urine sample – monitor for manifestations of hypertension and preeclampsia

• Additional screening: headaches, edema, hemorrhoids, weight gain, vaginal bleeding, and amniotic fluid leaking

• Fundal Height

• Fetal heart rate

• May preform Leopold’s maneuvers or ultrasound to assess fetus presentation

Leopold Maneuvers

• Palpation method to determine fetal position, presentation, and engagement.

• After 34 weeks

Laboratory Testing 3rd

• Group B streptococcus (GBS) screening between 35 and 37 weeks gestation, all pregnant clients

• Any Rh-negative client who did not receive a repeat antibody screening during 2nd Trimester will be screened and receive Rh(D) immune globulin.

Postterm Pregnancy

• Most will deliver 37-42 weeks

• Any pregnancy extending beyond 42 weeks

• Higher risk for complications such as placental insufficiency, oligohydramnios, and birth injury.

• Require closure monitoring of client and fetus

Body Changes and Discomfort 3rd

• peripartum cardiomyopathy→Heart failure developing late in pregnancy or after birth.

• cellulitis→A bacterial infection affecting the skin, often causing pain and redness and most often impacting the legs.

• Hemorrhoids

• Physiological Edema

• Review of warning manifestation of preterm labor, preeclampsia, Deep Vein Thrombosis (DVT)

Fetal Movement
Kick Counts:

• Beyond 28 weeks of gestation until time of brith

• Clients encouraged to monitor fetal movement and patterns

• Done over 2 to 3 hr.

• If the client feels less than 10 movements during the time frame, they are instructed to notify their health care provider

Travel and Vaccines 3rd

• International travel may be restricted after 36 weeks

• Vaccines not previously given before or during earlier pregnancy such as hepatitis B, influenza, and Tdap vaccines should be given

Sexual Activity 3rd

• Sexual intercourse may continue

• Manifestations post sexual intercourse to report provider include, profuse vaginal bleeding, fluid leakage, or persistent cramping

Manifestations of Labor

• Example: increasingly strong, regular uterine contractions, which may be accompanied by amniotic fluid leaking from the vagina and vaginal bleeding.

• Report to provider, noting fluid leaking, the color and amount

• Differentiate between Labor and Braxton Hicks contractions

  • Unlike true labor in which contractions cause cervical dilation and increase in frequency or duration even while resting, Braxton Hicks contractions do not cause cervical dilation and may decrease with activity changes, and clients can sleep through them.

  • Often Braxton Hicks contractions tend to increase in duration and frequency toward the end of pregnancy. Braxton Hicks contractions are initiated from the anterior abdomen, and true labor contractions are initiated from the back and wrap around to the front of the abdomen.

episiotomy

Surgical incision of the perineum during labor to ease the birth of the infant.

Birth Plan

• Create & Share with Provider

  • Topics included in a birth plan include a preference for pain management, IV fluids, support people during the birth, umbilical cord blood storage, and episiotomy.

• Alternative for Safety of Client & Newborn

  • Ensure the client is aware that the birth plan may be altered based on the events during the labor and birth process to ensure the safety of both the client and the newborn. Cesarean Birth – may be planned

  • Neonatal care, including feeding method, use of a pacifier, rooming-in or nursery usage, and circumcision for male infants

• Neonate Care

During Labor Process

• Use and Choice of Labor Assistive Devices

  • such as a birthing ball, stool, chair, squat bar, and shower. For a vaginal birth, the client can use a mirror to visualize the birth

• Requests for Labor Environment

  • Requesting dimmed lights and noise level control.

• Cutting Umbilical Cord or Recording of Birth

  • Plan on who is to cut the umbilical cord, whether pictures or videos will be taken of the birth.

• Skin-to-Skin Contact

• Breastfeeding and Neonate Care