Signs of Pregnancy

• Presumptive:

  • Breast tenderness/enlargement, amenorrhea, urinary frequency, hyperpigmentation (mask of pregnancy), uterine enlargement, fetal movement (quickening)

• Probable:

  • Braxton Hicks’s contractions, Goodell’s signs, positive pregnancy test, abdominal enlargement, Hegar sign, softening of the lower uterine segment

• Positive:

  • HCP can see the baby via US or another radiological means, HCP can hear the fetal heart sounds using a doppler, US or fetoscope, HCP can FEEL the fetal outline and fetal movements

Prenatal Visits:

• What are we looking for?

  • Medical overview: health history, immunizations, underlying cardiovascular, respiratory, endocrine conditions

  • Sexual Health: Use of contraceptives, STI/STD history, safe sex practice, body image concerns

  • Diet/Well-being: nutrition, lifestyle practices (work & recreational)

  • Mental & Emotional Health: psychosocial issues like stress, abuse/violence exposure

  • Substances/Meds: illicit drugs, alcohol, drugs, tobacco products, OTC meds, prescription meds

  • Social Surroundings: do they have a support system, family, friends, community

• Assessment & Guidance:

  • Prenatal classes, education and assessment

  • Diabetes screening and management: family history of diabetes, over 25 with PCOS history, overweight pts

  • Diabetes during pregnancy can cause: spontaneous abortion, neonatal hypoglycemia, macrosomia, preeclampsia, fetal demise, hyperbilirubinemia

  • Insulin can be given because it does not cross the placenta

• Frequency of prenatal visits:

  • Conception to 28 weeks: 

  • Visits every 4 weeks

  • Screening for neural tube defects at 16 weeks

  • Gestational diabetes at 24-28 weeks

  • RhoGAM shot for Rh-negative mothers (think of ninin): routine at 28 weeks but is given after any episode of bleeding or invasive procedure that risks maternal/fetal blood mixing

  • 29 to 36 weeks: Visit every 2 weeks

  • 37 weeks to birth: Visit every week

• Health Behaviors/Education for Moms:

  • Bathing, breast care, clothing, exercise, sleep and rest, sexual activity, nutrition, travel, exposure to teratogens, travel, immunizations, alternative therapies, tobacco, alcohol, street drugs, potential testing, kick counts (10 movements in 2 hours during 3rd trimester)

• Danger signs when pregnant:

  • Vaginal bleeding

  • Severe unilateral lower abdomen pain

  • Painful urination

  • Cramping with lower backache and bleeding

  • No fetal movement

  • Severe headache with vision change or dizziness

  • Rapid weight gain

  • Severe leg pain

First trimester

• Psychological responses:

  • Uncertainty

  • Ambivalence

  • Focus on self

  • Changes in sexuality

• Changes in body systems:

  • Amenorrhea (GU): the progesterone and estrogen maintain the uterine lining, considerations for diagnosis include age and exposure

  • Urinary frequency (GU): causes include hormonal shifts, fluid volume changes, uterine growth which causes pressure on the bladder due to limited space in the true pelvis. CHECK URINE AND ENSURE HYDRATION.

  • Nausea and vomiting (GI): triggered by increased hormones and decreased gastric motility. Can be managed by frequent dry meals, consuming crackers, avoiding strong odors, using ginger as a remedy, medication is last resort, and be cautious of teratogens (medications, drugs, chemicals, MMR, varicella and other live vaccines. ONLY acceptable are TDAP, flu and covid)

  • Breast and skin changes (MS): hormonal causes- elevated estrogen, melanocyte-stimulating hormone and progesterone. Use a supportive bra and apply lotion for itching.

  • Fatigue, headache (neuro): Hormonal shifts and body adjustments. Ensure rest and relaxation, engage in mild exercise, report any severe or unrelenting fatigue, avoid over-the-counter medications WITHOUT HCP approval.

  • Vaginal, vulvar and cervical color changes and discharge (GU): Increased vascularity of pelvic organs. Wear a pad and change it frequently, report any itching, odor or other concerns.

• Cervical changes are triggered by progesterone - it causes thick mucus plug to stop the invasion of bacteria.

• Chorionic Villus Sampling (10-13 weeks)

  • Detects down syndrome, cystic fibrosis and fetal gender. THIS CAN BE THROUGH THE ABDOMEN - placental tissue is removed 

• Amniocentesis (15-20 weeks)

  • Through the amniotic sac - amniotic fluid is drawn

• Surveillance and Interventions

  • Prenatal visits: Assess history, medications, lifestyle, risk factors, age

  • Doppler: Detect fetal heart rate at 10-12 weeks

  • Growth pattern: Regular measurements to track progress

  • Ultrasound: visual imaging of fetus and uterus

  • Laboratory Work: blood typing, CBC, HIV, Hep B, Rubella titer, Diabetes screening for high risk

  • Cervical examination: pap smear, STI screening

  • Nutritional Adjustments: dietary recommendations or corrections based on individual needs

  • Testing options: chorionic villus sampling, amniocentesis, genetic screenings

• Embryo (week 3-week 8)

  • HIGH risk for teratogenic damage

  • High mortality rate

  • BY week 4: all organs are present in some form, heart starts beating at days 18-21, neural tube is closed by the end of week 4, heartbeat can be viewed by week 5.

  • By week 8, embryo becomes a fetus, all organ systems are present, some movement is observable

Second Trimester

• Psychological responses

  • Physical evidence of pregnancy

  • Fetus is the primary focus

  • Narcissism and introversion: “the world revolves around me”

  • Body image concerns: “Do I look fat in these jeans?”

  • Changes in sexuality- increased interest.

• Surveillance and Testing

  • Monthly visits include: weight gain check, BP monitoring, Urine tests for protein, BS and bacteria, bloodwork for Hgb, Hct and CBC, uterine growth measurements

• Fetal Heart monitoring:

  • US detection by 5 weeks

  • Doppler deception by 9-12 weeks

• Alpha-fetoprotein (12-14 weeks)

  • Blood draw for neural tube defects

  • Optimal time: 16-18 weeks

  • THIS IS SCREENING ONLY

• Ultrasound

  • Monitors growth and progression

  • Identifies potential abnormalities

• BPP (Biophysical profile)

  • Desired score 8/10

• Diabetic Screening:

  • Recommended between 24-28 weeks

• Additional tests if indicated:

  • Amniocentesis

  • Percutaneous umbilical cord sampling

  • Non-stress test (NST)

  • Administered 2x weekly after 28 weeks of gestation

  • Seeks an increase of 15 bpm for 15 seconds over a 20-minute period

• Biophysical profile

  • Ultrasound checks for: fetal muscle tone, breathing movements, HR, amniotic fluid pockets, NST

• Discomforts:

  • Backache: caused by uterus pulling forward the abdomen

  • Varicosities of the vulva and legs: results from growing uterus exerting pressure, slowing down venous return. This is more problematic for women who stand all day. 

  • Hemorrhoids: due to uterine growth pressure combined with constipation

  • Flatulence with bloating: slowing the GI tract because of progesterone

• Straie: stretch marks

• Linea Nigra: dark line down the middle of the stomach

• Fetal development: (weeks 14-28)

  • 16 weeks: fetus is more active, measures 6 inches, external genitalia is more discernible, meconium is produced

  • 18 weeks: mother can feel the fetus move (16-18 weeks), appearance of lanugo (soft hair that covers the fetus)

  • 24 weeks: fetus measures about 12 inches, protective vernix forms on the skin, the fetus accumulates fat. The possibility of survival outside the uterus is more possible because the alveoli and capillaries support gas exchange

  • 28 weeks: fetus is 15 inches, approx. 90% chance of survival if born, skin becomes thicker

• Mom needs to lay on her side to prevent supine hypotension syndrome

Third Trimester

• Psychological Responses

  • Vulnerability: feeling limited due to increased size and decreased mobility

  • Increasing dependence: Physical and Mental concerns: concerns about receiving adequate care during childbirth and in the immediate postpartum period, experiencing unusual or vivid dreams

  • Preparation for Birth: attending childbirth classes, engaging in nesting behaviors to ready the home for the baby

  • Changes in Sexuality: Intimacy may become uncomfortable, sex is still generally safe but is essential to discuss safe and suitable positions, partners may also have concerns and anxieties

• Changes in Body systems:

  • Uterine changes: uterus becomes larger and its walls get thinner, changes in the cervix

  • GI (gastrointestinal