Prenatal Care and Maternal Health

Herpes and Pregnancy

• Nonprimary herpes infection during pregnancy increases risks.

• Transfer of oral herpes to the genital area during pregnancy is dangerous.

• Hand washing is crucial to prevent virus transfer.

• 85-90% of herpes infections occur during delivery, often from asymptomatic genital herpes.

Psychosocial Screening in Pregnancy

• Pregnant individuals are at higher risk of intimate partner violence.

• Assess cultural sensitivities and respect diverse backgrounds.

• Address marginalization experienced by some community members in healthcare settings.

• Black women are statistically more likely to experience adverse pregnancy outcomes.

• LGBT couples may face judgment or discomfort; openness and acceptance is key.

• Use inclusive language (e.g., "pregnant people" instead of "pregnant women") to acknowledge transgender individuals who can become pregnant.

• Assess feelings about the pregnancy, and be mindful of potential PTSD triggers related to sexual abuse during medical assessments.

Maternal and Infant Mortality Statistics

• General maternal mortality rate: $14$ deaths per $100,000$ people.

• Black mothers die at triple the rate compared to other groups.

Addressing Patient Concerns

• Strive to make patients feel supported and cared for, regardless of their background.

• Use the STOP acronym to acknowledge and manage personal feelings to provide excellent care.

Intimate Partner Violence Screening

• Pregnant patients have a higher incidence of domestic violence, regardless of relationship type.

• Screen for intimate partner violence at every visit, looking for red flags:

  • Avoiding eye contact

  • Anxiety or depression

  • Substance use

  • Unexplained injuries

  • Partner refusing to leave the patient alone

• Create opportunities for patients to speak privately without their partner present.

• Validate reports of abuse, affirm it is not the patient's fault, and help identify resources for safety.

Prenatal Visit Schedule

• Every month until 28 weeks.

• Every other week from 28 to 36 weeks.

• Every week from 36 weeks until delivery.

• Full term is considered at 37 weeks.

• If labor starts before 37 weeks, try to stop it.

Assessments at Every Prenatal Visit

• Every visit entails checking weight, urine (for protein and sugar), blood pressure, fundal height, fetal heart rate, and fetal movement.

• Pelvic exams are typically done only at the first visit to assess pelvic type.

• Cervical checks begin at term, assessing readiness for labor.

Optional Screening: Maternal Serum Alpha-Fetoprotein (MSAFP)

• MSAFP is part of the quad test, screening for genetic abnormalities.

• Elevated MSAFP may indicate neural tube defects like spina bifida or anencephaly.

• Decreased MSAFP may indicate Down syndrome.

• High false-positive rate due to overlap between normal and abnormal ranges.

• Counseling: If results are abnormal, emphasize it is a screening test only.

• Follow up with more precise diagnostic tools, such as testing fetal alpha-fetoprotein via cord blood sample.

• Approximately $1$ out of $32$ positive results indicate an actual problem.

• Recommended for those with elevated risk factors like age, diabetes, teratogen exposure, or family history of neural tube defects.

Other Screening Tests

• Screen for gestational diabetes at $24-28$ weeks gestation.

• Recheck blood type at $24-28$ weeks to confirm accurate information for Rh-negative patients.

• Check for Group B Strep in the vagina around 37 weeks, treating with antibiotics during labor to prevent transmission to the baby.

Clinical Practice Example

• Ellie is at her first prenatal visit, last menstrual period was 08/03/2024

• Calculate the due date by adding $7$ days and subtracting $3$ months, making the due date May 10, 2025.

• Her G number is 4 (two full-term deliveries, one miscarriage)

• The T PAL is 2012 (2 term, 0 preterm, 1 abortion, 2 living)

• Assessments at every prenatal visit would include checking her weight, urine, blood pressure, fundal height, fetal heart rate, and fetal movement.

• Watch for signs and symptoms of intimate partner violence (eye contact, anxiety, depression, substance use, partner not leaving her alone).

Physiological Changes During Pregnancy

Reproductive Tract

• Uterus expands due to muscle fiber stretching and elongation.

• Round ligament pain: sharp, twinge-like pain in the lower abdomen, often on one side.

• Treatment: Lie on the opposite side of the pain and support with a pillow, apply a heating pad with caution.

• Seat belt positioning: Advise pregnant patients to position the seat belt under the abdomen, over the pelvis, not over the gravid abdomen.

• Cervix increases cervical mucus output, forming a mucus plug from denser mucus that stays in place during the pregnancy.

• If increased vaginal discharge is bothersome, teach the pregnant patient to wear sanitary pads.

• Teach the pregnant patient to not douche.

Breasts

• Mammary glands grow, causing nodularity or lumpiness.

• Increased breast tenderness; wear supportive bra.

• Nipples get darker and larger.

• Montgomery tubercles (small bumps around the nipple) become more prominent.

• Possible stretch marks (striae) may appear.

• Colostrum production may start as early as 16 weeks, especially in multiparous patients.

Cardiovascular Changes

• Pregnancy puts strain on the heart, well-tolerated by healthy hearts.

• Significant increase in cardiac output and blood volume.

• Decreased vascular resistance causes blood vessels to dilate.

• This dilation, combined with increased clotting factors, increases the risk of venous stasis and DVT (deep vein thrombosis).

• Teach patients to avoid sitting for long periods, to get up and move around, and to notify the doctor if they have warmth, redness, or swelling of their calves.

• Pitting edema is not normal.

• Comfort Measures:

  • Elevate feet, lay on the left side to improve placental circulation and venous return.

  • Patients should stay off their back: supine hypotension syndrome (vena cava syndrome) can occur.

• Supine hypotension syndrome (vena cava syndrome): patient's uterus compress vessels, reducing blood flow and causing lightheadedness, dizziness and coldness.

• If feeling these symptoms of Supine hypotension syndrome (vena cava syndrome), patients should be moved to their side, preferably the left.

• CPR during pregnancy: Chest compressions mid-sternum with a left lateral tilt.

Respiratory Changes

• Thoracic cavity expands, increasing tidal volume; patients may still feel short of breath.

• Estrogen gives pregnant patients an "air hunger."

• Elevate the head of the bed to alleviate shortness of breath.

Musculoskeletal Changes

• Relaxin hormone loosens joints, increasing the risk of joint damage.

• Increased risk for carpal tunnel syndrome, leg cramps, and back pain.

• Encourage good body mechanics and pelvic support.

• Leg cramps: stay hydrated, dorsiflex the foot (pull the toe towards the knee), and ensure adequate calcium and phosphorus intake.

• Back pain: pelvic support belt, good posture, avoid high heels, physical therapy, and massage.

• Pelvic tilt exercise can strengthen lower back muscles.

Gastrointestinal Changes

• Constipation: progesterone slows bowels, iron supplements worsen it, and intestinal compression contributes.

• Treatment: increase fluids, activity, and fiber.
  Stimulant bowel are not safe during pregnancy.

• Heartburn: gastric reflux.

• Avoid eating close to bedtime, because laying down worsens it.

• Increased risk for gallstones: be aware if pregnant or postpartum patients experience nausea, vomiting, and right upper quadrant pain, fever or high fever.

Genitourinary Changes

• Increased urinary frequency:

  • First trimester: increased glomerular filtration rate.

  • Third trimester: compression on the bladder.

• Maintain hydration: drink plenty of fluids.

• Trace amounts of protein in the urine are normal towards the end of the pregnancy.

• High risk for UTIs and pyelonephritis due to progesterone dilating the ureters.

• Glucose urea is possible due to decreased reabsorption of glucose in the kidneys.

• Monitor for signs and symptoms of a UTI: dysuria (painful urination), urgency, frequency, blood or mucus in the urine, and cramping.

Integumentary Changes

• Hyperpigmentation: chloasma or melasma (mask of pregnancy) on the face.

  • Wearing sunscreen can help make sure it doesn't get worsened by the sun.

• Linea nigra is a dark line down the center of the abdomen.

• Stretch marks (striae gravidarum): initially reddish, fade to silver over time.

• Ointments or creams for itching may provide some relief.

Hair Changes

• Hair gets thicker during pregnancy due to hair follicles not going dormant.

• Postpartum hair loss occurs as hair follicles that would have gone dormant start shedding.

• Continuing prenatal vitamins after delivery may help.

Hormonal Changes

• hCG (Human Chorionic Gonadotropin):

  • Produced initially by the chorionic villi, then the placenta.

  • Responsible for nausea and vomiting (morning sickness), peaking in the first trimester.

  • If people are unable to hold down food for more than 24 hours, contact a doctor.

• Progesterone:

  • Maintains pregnancy.

  • Relaxes uterine muscle, preventing preterm labor.

  • Dilates ureters, slows GI motility, and relaxes blood vessels.

• Estrogen:

  • Facilitates fetal cell growth and provides a rich blood supply.

  • Promotes circulation and oxygenation of the placenta.

  • May contribute to "momnesia" (forgetfulness).

• Pituitary Gland:

  • Prolactin stimulates breast milk production.

  • Oxytocin allows for milk letdown and causes uterine contractions.

Metabolic Changes

• Increased metabolic rate and appetite during pregnancy.

• Maternal tissue becomes more resistant to insulin to free up glucose for the fetus.

• Pregnant patients are check to see if they trigger gestational diabetes at 24 to 28 weeks of pregnancy due to insulin resistance.

• Pregant body needs a lot more protein to grow the fetus.

• Pregnant bodies are also efficient at protein storage.

Psychosocial Changes During Pregnancy

• First Trimester: Goal is to accept the pregnacy. Feeling ambivalent (mixed emotion) is valid.
  *Rapid mood changes from hormones.

• Second Trimester: The pregnancy individual starts to accept the baby as uniqe. Patients still have rapid mood changes due hormones.

• Third Trimester: Start thinking about life after getting the baby, ready the nursery and to figure out childcare. Might also still have feelings ambivalent.

• Childbirth education helps relieve fears for everybody involved.

• The Partner of the pregnant patient will also experience stress around the pregnancy.

• Sympathetic pregnancy: When symptoms can start happening to the partner as well.

• We want to just encourage people just to kind of be give each other grace and to be kind and thoughtful and try to understand things from different perspectives from the other partner's perspective.

Diagnostic Studies During Pregnancy

• Fetal Kick Counts: Start at 28 weeks gestation, count 10 fetal movements. Contact the doctor if its less than 10 fetal movements within two hours.

• Ultrasound: determine gestational age and due date, sex, and abnormalities. There are two types: transabdominal and transvaginal. Patients can come with a full bladder for better viewing.

• Amniocentesis: Done with an ultrasound to find fluid, withdrawl is used for genetic screening.

• Percutaneous Umbilical Blood Sampling (Cordocentesis): Aims towards umbilical cord, withdrawl the blood so you can tell if there's a genetic problem.
  *Chorionic Villus Sampling: Done at 8 weeks into the fetal stage and with a needle they can withdraw blood from the placenta with blood.

Nonstress Test: It's not an invasive process. Monitoring for how many contractions for fetal heart rate.
Reactive is always reassuring.
We want a nonreactive nonstress test because its shows that the fetus is healthy.
Tells us there is a problem.
Contraction test: A diagnostic test that has the fetal stress during contractions
Negative=Fetus is healthy overall
With contraindications, it means positive C section
Positive decelerations. With light deceleration
BPP: BioPhyiscal profile; combined stress test with ultrasound
Non Stress Test: (practice, breathing movements, body movements, fetal tone, amniotic movement

How much do we weigh pregnant women
Most important aspect is Nutrition. during prengancy
Increase protein and calories. During pregnancy
Proteing is needed to the fetus.
How to prevent pregnancy (iron, red means, fruits, orange juice)
Most important is Iodine. Pregnant
Folic is important to eat when their pregnant.
Vitamin and minerals are also importhat
Personalize
Pica Eating non-food substances. In low economic areas. Where the pregnant females can't afford the things that actually help them.
They're usually looking to get sources of iron and not just, you know, eating dirt. It's the body craving for the resources (of iron).
Vitamin and minerals.
Can have exercises
Decrease Risk for gestational diabetes
Well most of them already in shape so we want to encourage them to begin moderate activity.
What's dangerous for the baby
What's safe? (keep up exercises they were doing before. Avoid high impacts)