maternity midterm

gravida

woman who is pregnant

gravidity

pregnancy

multigravida

woman with 2+ pregnancies

multipara

women who has completed two or more pregnancies to 20 weeks of gestation or more

nulligravida

woman who has never been pregnant and is not currently pregnant

primipara

woman who has completed one pregnancy with fetus/fetuses who have reached 20 weeks of gestation

viability

capacity to live outside the uterus, occurs 22-25 weeks ogf gestation

term

pregnancy from beginning of week 37 to week 40 plus 6 days

preterm

between 20 weeksa nd 36 weeks

early term

between 37 weeks and 38 weeks and 6 days

full term

39 weeks and 40 weeks 6 days

late term

pregnancy in the 41st week

post term

pregnancy after 42 weeks

hCG

human chorionic gonadotropin - earliest biological marker for pregnancy

hCG rise and fall

• detected 8-10 days after fertilization

• rises and peaks at 9-10 weeks

• falls a little then remains steady

higher than normal levels of hCG can indicate:

1. ectopic pregnancy

2. abnormal gestation (ex. fetus with down syndrome)

3. multiple gestation

4. molar pregnancy

abnormally slow increase or decrease in hCG may indicate:

impending miscarriage, fetus with some sort of chromosomal abnormality

how can hCG be measured?

in blood or urine

home pregnancy tests and hCG

very sensitive, early morning samples have the most hCG,

trophoblastic gestational disease aka molar pregnancy

• tumor develops after conception

• size of uterus large for gestation age

• considered malignant

what are some reasons you could get a false negative for a urine test?

1. doing test too early before significant rise in hCG

2. mistake interpreting type of test

3. medications - can cause either false positives or false negatives

4. improper collection of specimen

5. hormone-producing tumors

ELISA testing

uses specific monoclonal antibody with enzymes that bond with hCG

3 types of signs of pregnancy

1. presumptive - subjective changes felt by woman

2. probable - objective changes observed by examiner

3. postiive - signs attributed only to presence of the fetus

examples of presumptive signs

1. breast changes - 3-4

   1. premenstrual changes or oral contraceptives

2. amenorrhea - 4 weeks

   1. stress, malnutrition, etc

3. nausea and vomiting - 4-14 weeks

   1. gi virus, gi diseases

4. urinary frequency - 6-12 weeks

   1. infection, pelvic tumors

5. fatigue - 12 weeks

   1. stress, illness

6. quickening - 16-20 weeks

   1. gas, peristalsis

examples of probable signs

1. goodell sign - 5-6 weeks

   1. could also be pelvic congestion

2. chadwick sign - 6-8 weeks

   1. pelvic congestion

3. hegar sign - 6-12 weeks

   1. pelvic congestion

4. positive pregnancy test (serum) - 4-12 weeks

   1. choriocarcinoma

5. positive pregnancy test (urine) - 6-12 weeks

   1. flase positive

6. braxton hicks or prelabor

   1. tumors

7. ballottment - 16-28 weeks

   1. tumor or cervical polyps

positive signs examples

1. ultrasound fetal visualization- 5-6 weeks

2. fetal heart tones through ultrasound - 6 weeks

3. visualization by radiographic study - 16 weeks

4. doppler ultrasound fetal heart tones - 8-17 weeks

5. fetal stethoscope fetal heart tones - 17-19 weeks

6. fetal movements palpated - 19-22 weeks

7. fetal movements visible - late pregnancy

goodell sign

vagina portion of cervix is softening

chadwick sign

change in color of vulva - purply blue or deep red

hegar sign

softening of lower segment, narrowing of uterus, can bend when you do an exam

braxton hicks

will start stretching your uterus, will cause false labor contractions, painless contractions, can feel belly getting tight - but won’t dilate cervix like real contractions will

ballottment

when examiner does internal exam and can palpate something - whether its tumor or presenting part of fetus - you push up and presenting part will float back down and touch your fingers

uterus changes in shape

at conception: shaped like an upside-down pear

during second trimester: becomes spherical or globular as muscular walls strengthen and become more elastic

uterus becomes larger and more ovoid and rises out of pelvis into abdominal cavity as fetus lengthens

measuring fundal height:

used to determine uterine enlargement and to estimate duration of pregnancy

variation in position of fundus or fetus, amt of amniotic fluid present, presence of more than one fetus, maternal obesity, and examiner technique can reduce accuracy of this estimation

what happens at approximately 6 weeks of gestation?

softening and compressibility of lower uterine segment - hegar sign - results in exaggerated uterine anteflexion, where uterine fundus presses on urinary bladder, causing woman to have urinary frequency

uterine changes in contractility

braxton hicks - facilitate uterine blood flow through placenta and promote oxygen delivery to fetus, not painful but can be annoying

after 28th week, these contractions can become more definite

uterine changes in blood flow

increases rapidly as uterus increases in size

estrogen stimulation can increase uterine blood flow

doppler ultrasound can be used to measure uterine blood flow velocity

cervical changes during pregnancy

goodell sign

after childbirth, cervix becomes more horizontal

leukorrhea

ehite or slightly grey mucoid discharge with a faint musty odour - occurs in response to cervical stimulation by estrogen and progesterone, never pruritic or blood stained

causes the formation of mucous plug (operculum) which acts as a barrier against bacterial invasion

what happens at 36 weeks?

baby starts dropping into pelvis, becoming engaged to get ready for birth

breast changes during pregnancy

• breasts will become full and tender

• areola become darker

• montgomerys tubercules - little cysts and sebaceous glands that secrete moisturizing fluid to prepare nipple and areola for breastfeeding

• colustrum - first milk excreted, full of vitamins and nutrients - can be expressed as early as 16 weeks

• stria gravidarum may appear at outer aspects

• during 2nd and 3rd trimesters, growth of mammary glands accounts for the progressive breast enlargement

• lactation inhibited until a decrease in estrogen level occurs after birth

cardiovascular changes in pregnancy

• increased blood volume and cardiac output

• cardiac output goes up by 30-50%

• by 32 weeks, decrease in CO to 20% higher than pre-pregnancy

• hr increases by 10-15 bpm

• systolic bp may slightly increase or decrease

• diastolic bp may slightly decrease until mid-pregnancy (24-32 weeks)

• increase of 1500 mL of blood volume

blood clotting and pregnancy

• increase of clotting factors

• extra clotting factors as protective measure will increase risk of develpping blood clot

• women with c-sections have even more risk developing clots - will receive heparin (an anticoagulant) to prevent clots from developing

• check for DVT during assessment

supine hypotensive syndrome

compression of vena cava when women lie on backs during second half of pregnancy - can cause fall of more than 30 mm in systolic bp

after 4-5 minutes - bradycardia, co reduced by half, and woman feels faint

physiological anemia

decrease in normal hemoglobin values bc plasma blood increases more than rbc production

respiratory system in pregnancy

• basal metabolic rate increases - reflects increased oxygen demands of uterus, placenta and fetus

• by 3rd trimester, bmr will increase by 10-20% over pre-pregnancy levels, will become normal 5-6 days after pregnancy

• increased perspiration , increased tolerance to heat

• respiration rate can increase

• tidal volume - increases by 30-40%

renal system changes in pregnancy

• urine flow rate slower - pressure from enlarging uterus, increased bv cause larger volume of urine to be held in pelvis

• increased risk for UTIs

• bladder more vascular and susceptible to bleeding

• pregnant urine can have a little bit of glucose and more nutrients - encourage drinking water

• increased frequency especially in first and third trimester

• renal function most efficient in lateral recumbent position and least efficient in a supine position

fluid and electrolyte balance in pregnancy

• earlier kidneys are able to excrete water more efficiently vs later in pregnancy

• early on, women may feel more thirsty

• can have pooling of fluids

physiological vs. pathological edema

physiological - swelling will go away

pathological - associated with hypertensive disorders - if feet are swollen and she sits down and puts legs up and fluid doesn’t go away

proteinuria occurence

can happen during labor or after birth, but be careful and keep monitoring if excreting protein in urine

warning signs for hypertensive disorder in pregnancy

blood pressure up and protein in urine

integumentary system in pregnancy

• increased secretion of melanotropin during pregnancy

• chloasma that can come back in later pregnancies or after starting birth control

• linea nigra, grows at same rate as fundus

• striae gravidarum

• angioma - vascular spider nevi

• palmar erythema - red blotches on palms of hands, due to increase in estrogen levels

• puppp/pep - very itchy

• epulis - red, raised nodule on gums that bleeds easily

musculoskeletal system in pregnancy

• relaxin secreted - helps joints esp pelvis to move very slightly to allow or accommodate for birth

• abdominal muscles have to relax and allow for the uterus to grow

• diastis recti abdominus - separation of muscles in umbilicus

neurological system

• carpal tunnel - swelling or edema of peripheral nerves

• enlarging of uterus can compress some erves causing decreased sensation in legs

• tension headaches

• fainting or syncope

gi system in pregnancy

• nausea and vomiting, esp in first trimester

• hyperemsis - multiple gestation, thyroid problems, molar pregnancies - will need iv hydration, medications, vitamin b6, multivitamins

• antiemetics - have to be sure it’s okay to take in pregnancy

• morning sickness normal as long as she’s not losing weight and is able to keep some food down

• pica - non food cravings

• increase in progesterone causes decrease in luscle tone - slow musclemovement in gi tract

  • heart burn (pyrosis)

  • constipation

• gallballdder and liver - bile stored in gallbladder bc of slow emptying

hCG effect in pregnancy

maintains production of estrogen and progesterone until placenta takes over

progesterone

maintains pregnancy by relaxing smooth muscle and decreasing uterine contracility, decreases mother’s ability to use insulin

estrogen

promotes enlargement of the necessary stuff, promotes retention of sodium and water, decreaes mother’s ability to use insulin

oxytocin

stimulates uterine contractions

cortisol

stimulates production of insulin, increases peripheral resistance to insulin

nagele’s rule

determine first day of lmp and add 7 days and count forward 9 months

can vary plus or minus 7 days

normal stages for mother

1. honeymoon /acceptance stage - might be really excited about the pregnancy

2. ambivalence stage - starts to realize baby will change life, might not be as excited

3. emotional attachment - often after they feel baby move or see ultrasound

couvade syndrome

father takes on symptoms of pregnancy like nausea and weight gain

father stages of pregnancy

1. announcement phase - few hours to weeks - accepting biological fact of pregnancy

   1. ambivalence is normal

   2. might find it difficult to accept

   3. increased cheating and violence

2. moratorium - accepting the reality of pregnancy

3. focusing - father’s active involvement in pregnancy and his relationship with child

establishing a relationship with fetus stages

1. accepting biological fact of pregnancy

2. accepting the growing fetus as distinct from herself and a person to nurture

3. woman prepares herself realistically for the birth and parenting of the child

sibling adjustment pregnancy

• younger teenagers - lot to adapt to

• older teenagers - act more like an adult

• toddlers - want to be involved in the process

pregnancy care (appointments)

• end of first trimester to 28 weeks - see her every month

• 29-36 weeks - see her every 2 weeks

• 37-birth - weekly

interview

first prenatal visit, will be longer than other visits

initial assessment: woman’s subjective appraisal of her health and nurse’s objective observatoins

will take a comprehensive health history and nutritional history and history of drug use

risks with pregnancy and obesity:

• miscarriage

• gestational diabetes

• infertility

• increased bp

• gestational pre-eclampsia

• heavier bleeding post-partum

• risk of poor pregnancy outcomes

STI screening in pregnancy

• cervical cultures for chlamydia and gonorrhea should be obtained at first prenatal visit

• all women should have serum testing for hep b virus and syphilis at first prenatal visit

• if considered to be high risk, blood testing should be repeated later in pregnancy

• will test hep c for high risk women - multiple partners, known iv drug users

coombs test

rh incompatibility test

will give rhogam at 24-28 weeks, if baby born positive she will get another dose (will help future pregnancies)

bacterial STIs

• bacterial vaginosis

• trichomoniasis

• usually a foul smelling discharge with these two

HIV testing

• strongly recommended for all pregnant women

• must be voluntary and without coercion

• testing must be done with woman’s understanding of the test and potential result

• consent needs to be documented on antenatal records

how can HIV be passed from mother to fetus?

• through maternal circulation (as early as the first trimester of pregnancy)

• to the infant during labor and birth by ingesting maternal blood/other infected fluids

• to the infant through breast milk

HPV testing

• pap test

• tests for cervical dysplasia (changes in cervical cells that could be precancerous)

herpes in pregnancy

• ask if she has this

• if she has herpes there will be an outbreak like blisters (which could be painful)

• if she has an outbreak close to birth will do a c-section so she doesn’t pass it to the baby

what can bacteria STIs cause on the baby?

• opthalmeia

• neonatorum

• conjunctivitis

• test mother and then at 36 weeks - if mother is potsitive treaet the babies

• erythromyecin around the eyes of baby

group b stretococcus

• can grow normally in the vagina, but won’t normally overtake the rest of the flora

• when it does get out of control, causes grief for baby

• membranes can rupture in or out of labor

• risk that it will be shared with fetus

• can cause neonatal sepsis - get into blood and cause neonatal septicemia

• can also cause chorioamnionitis

chorioamnionitis

• infection through the uterus

• swab - if positive, treat as soon as membranes rupture or she goes into labor

• treat with IV antibiotics - penicillin g

• will get penicillin g every 4 hours until birth

• 5 million units as a loading dose, then 2/5 million units every four hours

• test for this at 35 weeks

amniotic fluid

• fluid that maintains fetus body, things like temperature

• continously produced

• cushions the fetus

• helps for musculoskeletal development and acts as a barrier to infections

oligohydramnious

• less than 300 mLs of amniotic fluid

• could be a problem with placenta not getting enough blood flow, could be renal, maybe there’s been a premature rupture so the membranes have been leaking

polyhydramnious

• too much amniotic fluid

• more than 2000 mLs

• could be bc multiple babies at the same time

• maybe fetus has swallowing issues and isn’t swallowing the fluid

• maybe mother has a condition like diabetes

risks for baby: obesity and pregnancy

• higher risk of stillbirth

• higher risk of neural tube defects (issue with spinal column fusing properly) - spinal bifida

• shoulder dystocia

• fetal macrosomia - baby’s head is too big for pelvis

gestational diabetes assessment

• 24-28 weeks - send her for glucose challenge test (goes to lab, no fasting, eats regularly, give a very sugary drink, wait an hour, then have blood taken)

rubella testing

• can’t take rubella vaccine when pregnant because it is a live vaccing

• our levels of antibodies can drop and become unreactive (why we need a booster)

• if rubella levels low, flag her and say she needs a booster postpartum

ultrasound

• will have one at 10 weeks, then another at 18 weeks

• look for:

  • fetus developing normally

  • assess amount of amniotic fluid

  • where is the placenta, where has it implanted, is it low in the uterus, etc

routine prenatal assessment

• check urine for glucose and protein

• check vitals (bp and pulse)

• fetal heart rate (around 17-19 weeks)

• once uterus starts to grow and we can palpate we will do leopold’s maneuvers

kegel exercises

• deliberate contraction and relaxation of the pubococcygeus muscle

• strengthens the muscles around the reproductive organs and improve muscle tone

dental health in pregnancy

• nausea can lead to poor oral hygeine and allow dental caries to develop

• brush at least twice daily and floss once in the evening

• some inflammation may occur

physical activity in pregnancy

moderate activity for 30 minutes a day at least 5 days per week

low folic acid intake

neural tube defects (failure in closure of neural tubes) common in women with low folic acid intake

physiological anemia of pregnancy

• reference values for hemoglobin and hematocrit must be adjusted during pregnancy

• lower limit is 110 during pregnancy compared to 120 normally

listeriorsis

• rare but serious infection by consuming listeria bacteria, found in food, water, and soil

• if pregnant woman develops listeriosis during first three months, may experience a miscarriage

• up to 2 weeks before a miscarriage: may experience mild flu-like illness with chills, fatigue, headache, muscular and joint pain

5 Ps

1. passenger (fetus and placenta)

2. passageway (birth canal)

3. powers (contractions)

4. position of the mother

5. psychological response

other factors that affect labor

• place of birth

• type of provider

• availability of labor support

• procedures

• physiology (internal force)

movement of passenger determined by what factors?

1. size of fetal head

2. fetal presentation

3. fetal lie

4. fetal attitude

5. fetal position

   placenta must also be considered as a passenger, but rarely impedes the process of labor in normal vaginal birth (exception: placenta previa)

fetal skull composition

1. two parietal bones, two temporal bones, the frontal bone, the occipital bone

2. membranous sutures

3. fontanels (anterior and posterior)

4. palpation of fontanels and sutures during vaginal examination reveals fetal presentation, position, and attitude

fetal presentation definition

refers to part of the fetus that will enter the pelvic inlet first and lead through the birth canal during labor at term

three main fetal presentations

1. cephalic presentation (head first) most common

2. breech presentation (buttocks, feet, or both first)

3. shoulder presentation (most rare)

what is defined as a presenting part?

the part of the fetus that lies closest to the internal os of the cervix, part of the fetal body first felt by examining finger during a vaginal examination

presenting part in cephalic presentation

occiput, called vertex position