Maternity Antepartum Exam 1 Flashcards
(88 cards)
1
Q
Sentinel Event
A
unexpected occurrence involving death or serious physical or psychological injury or risk thereof.
2
Q
Types of Sentinel Events in Maternal Child
A
- leaving a foreign body in client (sponge, 4x4, Forceps)
- Falls
- Maternal death r/t the birth process
- wrong milk to wrong baby
- birth injury
3
Q
Gravidity and Parity using 6 digit system
A
Gestation is how long a woman is pregnant-ex. 40 weeks
Weeks are broken down into term and preterm
-Term 37-42 weeks
-Preterm 20-36.6 weeks
-Abortion less than 20 weeks
Gravida-number of times a woman is pregnant
Para-number of times she has emptied uterus
GT-Gravida and Para
GTPAL-Gravida, Term deliveries, Preterm deliveries, Abortions, and living
GTPALM-Gravida, Term, Preterm, Abortions, Living and multiples
4
Q
Gonadtropin-releasing hormone
A
Low blood levels of ovarian hormones stimulate the hypothalmas to secrete GnRH. GnRH stimulates anterior pituitary secretions of follical-stimulation hormone (FSH)
5
Q
Chlamydia CM's Chlamydia Trachomatis (Bacteria) most common STD in U.S; most prevalent in adolescents
A
Inflammation of cervix with mucopurulent discharge (dc).
May be asymptomatic
Untreated may lead to urethritis, tubal occlusion, pelvic inflammatory disease (PID) and infertility
6
Q
Chlamydia
Screening/Diagnosis
A
- Screen 1st trimester or when enter healthcare
- By culture or DNA probe, or enzyme immunoassay.
- CDC recommends nucleic acid amplification test (NAAT) or urinary vaginal or endocervical areas.
- Retest 3rd trimester/if multiple sex partners or younger than 25
- Test for gonorrhea.
7
Q
Chlamydia
Treatment/Management
A
-Azithromycin 1 g oral single dose, or
-Doxycycline 100 mg BID for 7 days (not for pregnant women)
-Erythromycin ophthalmic ointment NBs (Newborn) conjunctival sac 1 hr of birth.
Pregnant women cannot take Doxycycline because it crosses the placenta and will make the baby’s teeth turn yellow when they are developed.
8
Q
Chlamydia
Pregnancy/Fetal/Neonatal Effects
A
- Pregnancy: increased incidence of PROM (Premature rupture of membranes), PTL (preterm labor), PID (pelvic inflammatory disease), ectopic pregnancy
- Newborn may be asymptomatic
- Conjunctivitis scarring, blindness
- Respiratory problems may result in pneumonia
9
Q
Pelvic Inflammatory Disease (PID)
A
An infectious process that most commonly involves the uterine (fallopian) tubes (salpingitis), uterus (endometritis) and more rarely, the ovaries and peritoneal surfaces.
Puts woman at risk for ectopic pregnancy
Most cases are associated with gonorrhea, chlamydia, trachomatous
10
Q
Gonorrhea CM
Neisseria gonorrhea-an aerobic gram-negative diplococcus
A
- often asymptomatic
- Complaint of mucoid or mucopurulent vagina/endocervical discharge, dysuria, and swollen, reddened labia.
- Pelvic, lower abdominal or rectal pain
- Vulvovaginal inflammation progresses to yellow-green vaginal discharge
- May ascend to involve pelvic structures
11
Q
Gonorrhea
Screening/Diagnosis
A
- gram stain culture of endocervical, vaginal, rectum and possibly pharynx
- Also chlamydia culture and serologic test for syphilis
- screened at 1st prenatal visit. At risk clients screened again in 3rd trimester (36 weeks)
12
Q
Gonorrhea
Treatment/Management
A
-Ceftriaxone (Rocephin)
125 mg IM single dose
Baby-erythromycin ophthalmic ointment within 1 hour of birth
13
Q
Gonorrhea
Pregnancy/Fetal/Neonatal Effects
A
Pregnancy: amnionitis, PTL, and postpartum salpingitis (inflammation of fallopian tubes)
Newborn: ophthalmia neonatroum (gonococcal conjunctivitis) if untreated, blindness
*Because of the prevalence of Chlamydia and Gonorrhea all states have a law requiring preventive treatment to newborns at birth.
14
Q
Syphilis CM Treponema pallidum (spirochete)
A
-Primary stage-Ulcer-(chancre)
condyloma-warts maybe present on vulva, perineum or anus (flatter than HPV genital warts)
-Secondary-maculopapular rash can be on hands and soles of feet
This disease progresses to secondary and tertiary stages with varying characteristics.
15
Q
Syphilis
Screening/diagnosis
A
Screened at first prenatal visit VDRL or RPR serology and again in 3rd trimester and at time of birth if they are high risk.
(if HIV or other STI always check to see that a RPR or VDRL was done too)
16
Q
Syphilis
Treatment/Management
A
Penicillin G 2.4 million units single dose. If allergic doxycycline or tetracycline-not to be used in pregnancy
Treatment by 18th gestational week prevents congenital syphilis in neonate. However, treat at time of diagnosis.
17
Q
Syphilis
Pregnancy/Fetal/Neonatal
A
Pregnancy: May result in spontaneous abortion or PTL
Transmitted across placenta after approximately 18 weeks gestation
Newborn: Congenital anomalies and/or congenital syphilis
Congenital syphilis (test on cord blood)
18
Q
Spermatogenesis
A
the meiotic process by which male gametes are produced
19
Q
Oogenesis
A
process by which female gametes are produced
Oocytes form by 12 weeks of gestation
At birth a female has a lifetime supply of oocytes
Hypothalamus exerts control through release and inhibiting factors–Hypothalamic-Pituitary-Ovarian axis
Maturation and ovulation of primary ova follicle is cyclic-(ovarian cycle)
20
Q
Mitosis
A
the 23 chromosomes of the Ovum unite with the 23 chromosomes of the Sperm making 46 chromosomes and is called a germ cell
21
Q
Meiosis
A
occurs when the germ cell divides and decreases their chromosomal numbers by 1/2 and are called gametes or zygote.
22
Q
Process of Fertilization
A
- Takes place in the ampulla (outer third) of the uterine (fallopian) tube.
- when sperm successfully penetrates the membrane surrounding the ovum, both sperm and ovum are enclosed within the membrane
- the membrane becomes impenetrable to other sperm (zonal reaction)
- the second meiotic division of the secondary oocyte is then completed
- the nucleus of the ovum becomes the female pronucleus
- the head sperm enlarges to become the male pronucleus, and the tail degenerates
- the two nuclei fuse and the chromosomes combine, restoring the diploid number (46).
- Conception, the formation of the zygote (the first cell of the new unique individual) has been achieved.
23
Q
Seminal Fluid
A
Sperm are transported in fluid from the seminal vesicles and prostate gland.
Ph of seminal is alkaline-helps to neutralize the normally acidic female vagina
Seminal fluid is nutritive to sperm. Helps keep sperm viable
24
Q
Numbers and Lifespan of Sperm
A
Lifespan is 48-72 hours after ejaculation
200-500 million sperm per normal ejaculation
Flagellated, whip-like motion of sperm helps transports sperm
25
Ovarian cycle
Ovulation occurs 14 plus or minus 2 days
Before the next menstrual period
1 ovum matures each month with supportive cells.
Increase in Estrogen increases motility of the fallopian tubes and fimbriae (cilia). Captures the ovum and propels it to the uterine cavity. An ovum cannot move by itself.
26
Prep for conception
Hyaluronidase (path through cells for sperm to reach ovum)
One sperm penetrates the ovum
Membrane of the ovum changes--prevents entry of other sperms
27
Conception
- Capacitation: removes the protective coating from the heads of the sperm
- One sperm penetrates the ovum
- Occurs in outer 1/3 of FT (fallopian tube)
defined as the union of a single egg and sperm, marks the beginning of a pregnancy.
Conception occurs not as an isolated event but as part of a sequential process, which includes gamete (egg and sperm) formation, ovulation (release of egg), fertilization (union of gametes), and implantation in the uterus.
28
Inhibition of Implantation
- IUD initiates foreign body response
- Interferes with both fertilization and implantation
*Progesterone changes cervical mucus and endometrium to mature the uterine lining for implantation
Progestin prevents pregnancy
IUD may cause substances to accumulate in uterus and interfere with implantation
29
Development and Growth of Baby
Ovum-conception to day 14
Embryo-Day 15 to eight weeks (organs are forming greatest vulnerability)
Fetus-eight weeks to birth
30
Implantation
-Blastocyst (egg and sperm) implanted 6-8 days after fertilization
-site of implantation upper portion of uterus (anterior or posterior fundal region)
-trophoblast (outer layer) develops projections (chorionic villi)
-Chorionic villi extend into endometrium and tap into maternal blood supply for O2 and nutrients
-Endometrium is now called the decidua
Decidua basalis (beneath the blastocyst)
31
Development and Growth of Baby #2
Period of ovum (conception to day 14):
-encompasses cellular replication-zygote to blastocyst formation and differentiation into three PRIMARY GERM LAYERS of CELLS-
1. Ectoderm: trophoblast (outer layer) develops into the placenta, integument, neural tissue and glands
2. Mesoderm: forms muscles, bones, connective tissue, circulatory system, and genitourinary system.
3. Endoderm: digestive, respiratory and parts of the GU system.
EMBRYONIC STAGE IS THE MOST CRITICAL TIME IN THE DEVELOPMENT OF THE ORGAN SYSTEMS AND THE EXTERNAL FEATURES.
Developing areas with rapid cell division are the most vulnerable to malformation by environmental teratogens.
Teratogen: environmental substances or exposures that result in functional or structural disability. Time exposure occurs is an important factor.
32
Accessory Structures
Amniotic sac: inner membranes that surround the baby
Amniotic fluid-within the sac and around the baby:
-source of oral fluid for fetus
-repository for wastes (urine and meconium)
-assists in lung development
-volume 800-1200 mL; fetal urine contributes to volume
-Transparent yellow liquid
-characteristic odor but should not be mal-odorous
33
Accessory Structures #2
- Meconium released into AF (amniotic fluid) when baby is stressed or distressed. Source of concern at delivery if AF is meconium stained (meconium aspiration)
- 200-300 mL of AF at 16 weeks gestation, an amount that is sufficient for amniocentesis at this time. 1000-1200mL at delivery
- Ballottement-baby bounces against examiner's hand
- Oligohydramnios: <300 mL. Associated with fetal kidney obstruction or renal agenesis (failure of all or part of an organ to develop during embryonic growth).
- Polyhydramnios: >2000 mL. Associated with esophageal atresia (birth defect in which part of a baby's esophagus does not develop properly) and with severe CNS anomalies.
34
Functions of Amniotic Fluid (AF)
-protects fetus from mechanical injury and infection
-maintains stable thermal environment
-helps in fluid and electrolyte homeostasis
-allows freedom of movement for baby
-terms associated with AF:
Ballottement
Oligohydramnios
Polyhyhydramnios
35
Properties of Amniotic Fluid
-slightly alkaline
-Contains: albumin, urea, uric acid, creatinine, lecithin, sphingomyelin, bilirubin, fructose, fat, leukocytes, proteins, epithelia cells, enzymes and lanugo hair.
-contains lecithin and sphingomyelin
L/S a major component of Surfactant
L:S ration 2:1 indicaties fetal lung maturity
Amniotic fluid turns nitrazine paper blue. In contrast, in case of confusion, urine is acidic and turns paper red/yellow.
*Baby's head can get caught in the maternal pelvis and cause decels. Cord also, can get caught causing deoxygenated baby.**
36
Amniotic Fluid
Initially fluid comes from the maternal blood by diffusion
Fluid is also secreted by the respiratory and GI tracts of the fetus
Amount of fluid increases weekly
700mL-800mL is normal at birth
<300 mL (oligohydramnios)-renal abnormalities
>2000 mL (polyhydramnios)-GI and other malformations.
The baby swallows and inhales the amniotic fluid while in the utero and replaces the volume in the amniotic sac by urinating and exhaling the liquid
Amniotic fluid completely replaces itself every three hours, even after rupture of membranes (water breaks) occurs.
37
Amniotic fluid:
| Structure, Function, and Composition
Structure:
- Derives from maternal fluids by diffusion
- Volume serves as indicator of fetal well-being (700-1000mL (term)
Function:
-Maintains body temperature
-Barriers to infection
-Allows fetal lung development
-Provides freedom of movement=musculoskeletal development
-Cushions=blunting and dispersing outside forces
-Prevents tangling with membranes=facilitates symmetrical growth
-Source of oral fluids and repository for waste=balancing electrolytes
Fetus swallows fluid
Fluid travels into and out of fetal lungs
Fetus urinates (11 weeks)
38
Ruptures of Membranes
SROM-spontaneous rupture of membranes
| AROM-artificial rupture of membranes AKA amniotomy
39
Placental read page 237-239
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Provides nutrients (O2) and removes wastes (CO2)
Metabolizes drug...other substances
Produces hormones estrogen/progesterone for maintenance of pregnancy
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Flat, disc shaped...
When human chorionic gonadotrophin is released it produces as the placenta and begins to grow. An increase in HCG levels =indication of pregnancy.
High vascular and operates as lung metabolic functions are respirations, nutrition, excretion (especially drugs) and storage. Oxygen is diffused from the maternal blood into the fetal blood and CO2 is diffused in the opposite direction
Intervillous spaces...large spaces separating chorionic villi in the placenta
Blood enters the intervillous spaces from uterine arteries that penetrates the basal part of the placenta
Oxygenated blood transported to fetus through umbilical vein
Oxygen depleted blood leaves the fetus--chorionic villi by umbilical arteries.
Endometrial artery...CO2...deoxygenated blood
Endometrial vein..returns oxygenated blood to fetus
2 arteries and 1 vein
40
Umbilical Cord
Approximately 1% of umbilical cords have one artery and one vein (sometimes associated with congenital malformation)
true knots are rare but false knots occur as folds or kinks in the cord (jeopardizing circulation)
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cord vessels (2 arteries, 1 vein) supply nutrients and O2 from mom
arteries-carries blood (deoxygenated) from the embryo
Blood collected at delivery provides objective measures of respiratory status
vein-returns blood (oxygenated) to the embryo
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Cord is located centrally but if located toward the edge, its called battledore placenta.
2 sides-dirty Duncan net to uterine wall and Shiny Shultz-nearest to the baby that hold the amniotic fluid.
41
Placental takes charge
- Corpus luteum main source of estrogen and progesterone until 3rd month of pregnancy, By the end of 3rd month
- Placental produces most of the hormones
- Estrogen stimulates uterine development to provide environment for baby
- Progesterone relaxes uterine muscle...prevents spontaneous abortion.
42
Functions of Placenta
- transfer O2 and CO2 through intervillous spaces
- Conjugation of drugs and hormones
- produces hormones estrogen and progesterone for maintenance of pregnancy
43
Factors that Affect Placental Perfusion
- decreased blood flow r/t maternal position (vena cava syndrome put mother in recumbent position) cuts off O2 and nutrition to baby
- blood pressure changes-increased or decreased (HTN or blood loss); vasoconstriction-perfusion limited-blood supply to baby is decreased
- Vasoconstrictor drugs-includes nicotine
Heavy uterus presses on mom's aorta and vena cava-cuts off circulaton to brain and also the uterine arteries that perfuse the placenta. Often occurs during vaginal examination
Condition of shock does the same thing.
Vessel constrict so that blood supply goes to major organs of heart and lungs. Mom is dizzy and faint, Baby is suffocating
Treatment: turn slightly to one side wedge a small pillow under the hip.
44
Umbilical Cord
Connects fetus and placenta
Arises from center of fetal side of placenta
Contains 1 large vein and 2 arteries
Arteries carry deoxygenated blood and waste from fetus
-Vein carries oxygenated blood and provides O2 and nutrients to fetus
-Veins and arteries surrounded by Wharton's Jelly (connective tissue that cusions vessels from compression)
45
Function of Umbilical Cord
Transport O2 and nutrients from mom to baby and waste back to maternal blood
Permits free movement for baby within the membranes
Complication:
Knotted and cut off circulation to baby
may be caught between baby head and ischial spine during birth or ROM-fetal hypoxia.
46
Fetal Viability
-Viability: capability to survive outside uterus
-Major criteria--CNS function and O2 capability of lungs
-Viability defined for obstetrics as:
weight: 350g, 400g, or 500g (varies by state)
20 weeks past conception (22 weeks since LNMP)
TN: 20 weeks and 500 g
22-25 weeks still very concerning
47
More info on Conception
Blastocyst secretes HCG to make sure that the corpus luteum remains viable.
Corpus luteum secretes estrogen and progesterone first 2-3 months of pregnancy
First week of human development: transport of embryo down uterine tube and into uterus.
Mitotic cellular replication (cleavage) occurs as baby (zygote) is propelled toward uterus.
Morula-16 cells
Trophoblast-outer layer of cells
Blastocyst-inner layer of cell-baby
48
Fetal Circulatory System
The cardiovascular system is the first organ system to function in the developing human.
Blood vessels and blood cell formation begins in the 3rd week and supplies the embryo with oxygen and nutrients from the mother.
By the end of the 3rd week the tubular heart begins to beat, and the primitive cardiovascular system links the embryo, connecting stalk, chorion and yolk sac.
4th and 5th weeks the heart develops into a four chambered organ.
By the end of the embryonic stage, the heart is developmentally complete.
49
Fetal Circulation #2
The fetal lungs do not function for respiratory gas exchange, so a special circulatory pathway, the ductus arteriosus, bypasses the lungs.
Oxygen rich blood from the placenta flows rapidly through the umbilical vein into the fetal abdomen.
When the umbilical vein riches the liver, it divides into two branches; one branch circulates some oxygenated blood through the liver.
Most of the blood passes through the ductus venosus into the vena cava.
Most of this blood passes straight through the right atrium and through the foramen ovale, an opening into the left atrium.
There it mixes with the deoxygenated blood returning from the fetal lungs through the pulmonary veins.
50
Fetal Circulation #3
Shunts allow most oxygenated blood go to the brain
Maternal and fetal blood do NOT normally mix
1. ducts venosus-shunts around liver
Placenta does the work of liver for fetus
2. foramen ovale-right to left shunt...blood transfers from right atrium thru foramen ovale to left atria
3. ducts arteriosus-shunts around the lung...just enough to keep viable.
51
Hematopoietic
Hematopoiesis-the formation of blood
- starting in the yolk sac (3rd week)
- stemcells seed the liver function 5th week
- hematopoiesis begins the 6th week
- stem cells seed the fetal bone marrow, spleen, thymus and lymph nodes wk 8 & 11
- Antigenic factors determine blood type and are present in the erythrocytes around 5 weeks
**babies have their own blood type. Forms in yolk sac.**
52
Circulatory System
Blood cells and heart functioning at 3 weeks
Heart is fully developed at 8 weeks
Hgb in fetus is about 50% greater than mother
Normal fetal HR 110-160 bpm
=cardiac output per fetal body weight
higher than an adults
The antigenic factors that determine blood type are present in the erythrocytes after 6th week.
53
Oxygenation
- Pulmonary surfactant
- Lecithin: Sphingomyelin (LS) ratio 2:1 at maturity
- Lung movement can be seen by 11th week
- Lungs fully mature about 34 weeks gestation
*Just because they have lung maturity at 34 weeks does not mean they know how to use the lungs.
Breathing (swallowing of AF) can be seen on U/S
54
Multifetal Pregnancy
Twins
Dizygotic twins: two separate pregnancies occurring simultaneoulsy. 2 embryos, 2 placentas, 2 chorions and 2 amnions (fraternal)
each embryo has their own amniotic sac and their own placenta
Monozygotic twins: result from the division of a single fertilized ovum. same sex, same physical traits. Shared placenta 2 embryos, 2 amnions, 1 chorion and 1 placenta.
- Monochorionic/Diamniotic (mo/di) twins each embryo has their own amniotic sac (amnion) but share a placenta (chorion)
- Monochorionic/Monoamniotic (mo/mo) twins-2 embryos, 1 sac, 1 placenta (Always identical)
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Fetal Development: Major Milestones
- End of wk 1: Blastocyst is free floating. Implantation 6-8 days after fertilization
- End of wk 4 gestation: Weight 400 mg; Week 1-8 (organogenesis) Greatest vulnerability to teratogens. By 3rd wk blood cells and blood vessels beginning to form. Heart is beating; neural tube formed but open; Eye formation 4-5 weeks.
- End of 8 wk (end of embryonic period): Heart development complete FHR 110-160; head greatly enlarged; facial features distinct; iron/glycogen stored in large fetal liver (lasts up to 5 mo after birth)
- End of wk 12: weight 19 gm (1 oz); kidneys formed and secreting urine; fetal heartbeat heard by 10-12 weeks with US Doppler; center ossification appearing in most bones; spontaneous movements occur; sex is apparent.
- End of 16 wk: Amniotic fluid (AF) is adequate amount for amniocentesis (or as early as 14 weeks); face has human appearance; lanugo (hair begins) apparent
- End of 20 wk: weight 300-500 gm; quickening at 18-20 weeks (Multips may have at 14-16 wks); viable 20 weeks after conception or 500 g or more; swallows AF-gastric emptying and peristalsis present; meconium accumulates in colon-if stressed fetus passes meconium
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Fetal Development: Major Milestones #2
- end of 24 wks: weight 600g, C-R length 23 cm; body is lean, well proportioned, vernix and lanugo present; reflex hand grasp functions
- end of 28 wks: weight 1100 gm; C-R length 31 cm; weak suck reflex; brown fat being deposited for thermoregulation after birth; surfactant forming on alveolar surfaces. LS ration still inadequate; lungs developed-gas exchange (if born as this time can breathe)
- end of 32 wk: weight 1800-2100 gm (over 4lbs) C-R 31 cm; sense of taste, sound; male testes descend to scrotum; bones fully developed; LS ration 1.2:1 still not optimal for supporting breathing (ideal is 2:1)
- end of 36 wk: weight is 2500 g; skin pink, body rounded; less wrinkled; LS 2:1 at about 35 weeks; Lanugo shedding
- end of 40 wks: weight 3200 gm 3.3 kg=7lb C-R 40 cm; Lanugo present upper arms, shoulders, vernix decreased; fingernails beyond fingertips; sole (plantar) creases run down to heel; male testes in scrotum, female labia majors well developed
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B.R.A.I.D.E.D Contraception
| Inform consent regarding education the patient concerning contraception and sterilization
B.-Benefits: information about advantages and success rates
R.-Risks: information about disadvantages and failure rates
A.-Alternatives: Information about other available methods
I.-Inquiries: opportunities to ask questions
D.-Decisions: opportunity to decide or to change mid
E.-Explanations: information about method and how it is used
D.-Documentation: Information given and patient's understanding
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Non-pharmacological Methods Contraception
Fertility Awareness Methods
Barrier Methods
Diaphragm
Female and male sterilization by tubal ligation or vasectomy
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Barrier Methods
Male and female condoms:
- used in conjunction with spermicidal foam to increase effectiveness
- recommended to prevent sexually transmitted diseases for couples not in long-standing, mutually monogamous relationships.
- Spermicides alone are not effective when highly reliable contraceptive method is sought.
* Spermicides work by reducing the sperm's mobility*
Diaphragm:
- round flexible device that covers the cervix
- must be fitted for size by health care provider
- inserted into the vagina up to 6 hours before intercourse
- used with spermicidal jelly or cream
Teaching r/t diaphragm
- must remain in place for 6-8 hrs after intercourse
- increases risk of UTI
- return to health care provider for size refitting if weight fluctuates up or down
- Does not prevent STD
* Must be washed after each use with mild soap and water then dried and kept away from heat in order to keep the integrity of the device.
- cervical cap is like a diaphragm, but smaller and can at times shift from the cervical os
- contraceptive sponge, not used as much; sponge contains N9 spermicide that destroys the sperm cell membrane. The sponge is moistened before insertion. Good for 24 hours. Wearing greater than 24-30 hrs could cause Toxic Shock Syndrome TSS
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Hormonal Methods
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Oral contraceptive pills
Contraceptive Transdermal (skin) patch
Vaginal Ring
Single rod implant
Depo Provera
Intrauterine device (IUD)
Emergency Contraceptive (EC)
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61
Presumptive Signs of Pregnancy
3-4 wk Breast changes (Premenstrual changes, oral contraceptives)
4 wk Amenorrhea (Stress, vigorous exercise, early menopause, endocrine problems, malnutrition)
4-14 wk Nausea/Vomiting (GI virus, food poisoning)
6-12 wk Urinary Frequency (Infection, pelvic tumors)
12 wk Fatigue (Stress, illness)
16-20 wk Quickening (Gas, peristalsis)
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Probable Signs of Pregnancy
5 wk Goodell sign: velvety appearance of cervix due to increased vascularity and hypertrophy and hyperplasia of cervix (Pelvic congestion)
6-8 wk Chadwick sign: violent-blue vaginal mucosa and cervix (Pelvic congestion)
6-12 wk Hegar Sign: a softening consistency of the uterus and the uterus, and the uterus and cervix seem to be two separate regions (pelvic congestion)
4-12 wk: + result of pregnancy test serum (hydatidiform mole, chriocarcinoma)
6-12 wk: + result of pregnancy test urine (false-+ maybe pelvic infection, tumors)
16 wk: Braxton Hicks contractions (myomas, other tumors)
16-28 wk: Ballottement (tumors, cervical polyps)
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Positive Signs of Pregnancy
5-6 wk: visualization of fetus by real-time ultrasound
6 wk: FHT's detected by ultrasound
16 wk: Visualization of fetus by radiographic study
8-17 wk: FHT's detected by Doppler ultrasound stethoscope
17-19 wk: FHT detected by fetal stethoscope
19-22 wk: Fetal movements palpated
Late pregnancy: fetal movements visible
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Physical Changes Associated with Pregnancy
- early changes are related to increase in estrogen and progesterone levels
- Mid pregnancy changes anatomical-caused by pressure from expanding uterus
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Uterine changes
Fundus height an important measure of fetal well being
Fundal height measurement helps to estimate gestational age of fetus
During 2nd and 3rd trimester (18-30 weeks) fundal height in cm approximately equals fetal age in weeks plus/minus 2 cm
16 weeks halfway between symphysis pubis and umbilicus
20-22 weeks at approximately the umbilicus
66
Other Uterine changes during pregnancy
- uterine contractions (UC)-increase blood flow to uterus and strengthen muscle s for birth process-Braxton Hicks
- do not cause cervical dilation
- hegar's sign: softening and thinning of lower segment of uterus about the 6th week (Probable sign of pregnancy)
- Lightening-fundal height decreases as fetus descends into the pelvis in preparation for delivery (38-40 weeks)
Braxton hicks are often mistaken for early labor. Sometimes patients perceive as painful, but usually are not. May be felt as early as the 4th month, can cause urinary frequency
67
Other markers of Pregnancy
Ballottement=passive movement of fetus (techniques of palpating a floating structure by bouncing it gently and feeling it rebound.
Quickening-maternal observation of fetal movement 18-20 weeks gestation (nulliparous) or 14-16 weeks (multiparous)
Examiner taps cervix gently and palpates fetal rebound in the amniotic fluid
Usually present about 16 weeks gestation
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Cervical Changes
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Chadwick's sign-bluish color of cervix (6-8 weeks)
Goodell's sign-softening of cervical tip in a normal unscarred cervix (around 6th week)
Mucus plug (operculum) seals endocervical canal-prevents ascent bacteria from vagina to the uterus.
Leukorrhea white or slightly gray mucoid vaginal discharge that occurs in response to cervical stimulation by estrogen and progesterone.
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69
Vaginal Changes
pH of vaginal vault 3.5-Acidic
vaginal secretions increased (leukorrhea)
screening-evaluate for pathology and presence of STD's
Gonorrhea
Chlamydia
Syphilis
Herpes
Gonorrhea and Chlamydia-risk of corneal scarring of infant during vaginal birth.
Herpes Simplex Virus (HSV)-organism may cross placenta and contaminate fetus OR in contact during vaginal delivery
Penicillin 2.4 million units IM once is used to treat primary, secondary, and early latent syphilis
Erythromycin 500 mg oral qid x7 days for pregnant women for Chlamydia or Amoxicillin 500 mg tid x 7 days
Chlamydia is the most common cause of ophthalmia neonatorum
70
Breast changes
- colostrum: may leak from nipple (precursor to milk-yellow in color) This usually happens after delivery but can start before delivery
- Breast size increases-nipples and areola darken
- May have striae gravidarum (stretch marks)
- Superficial veins become prominent
Breast-glands increase in both size and number
Colostrum-high in protein and immune properties "liquid gold"
Estrogen and Prolactin have an inverse relationship. When placental delivered then prolactin becomes dominant
Oxytocin responsible for milk letdown
Prolactin responsible for production
71
CV system changes Blood volume
-expansion of vascular volume up to 45%-50%
-Peaks 32-34th wk
-Increase in vascular volume 50%-increase in RBCs (30%)-hemodilution-pseudoanemia of pregnancy
Hemoglobin below 11g/dL usually caused by iron deficiency anemia
Folic acid and iron supplement to meet demands of increased blood supply and fetus
32-34th wk most vulnerable time for pregnant cardiac client
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Cardiac Output
CO increases 30-50% (peaking at 25-30 weeks)
Affected by maternal position-vena cava syndrome aka supine hypotensive syndrome
More than 95% of pregnant women develop systolic murmurs: check left sternal border (may hear splitting s1 and s2 then half-way through may hear s3 this is due to paid diastolic filling.
Murmurs caused by the increases in blood volume and cardiac output
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Blood Pressure
BP DOES NOT increase during pregnancy: progesterone, prostaglandins and relaxin effect. May even decrease during second trimester
BP 140/90 is a danger signal of pregnancy
Absolute value determination of gestational hypertension
Watch the MAP (mean arterial pressure) when HTH
BP 140/90 OR systolic increased 30 mm Hg over baseline and Diastolic elevated 15 mm Hg over baseline is an absolute for preeclampsia
DANGER WHEN WAIT UNTIL 2ND TRIMESTER FOR PRENATAL CARE
MAP 86.4 plus/minus 7.5 mm Hg
74
Clotting Factors Increased
Fibrinogen
Clotting factors VII, VIII, IX, and X
Risk of blood clots
75
Respiratory SystemChanges
Oxygen consumption increases 20%-40%
Diaphragm elevated by enlarging uterus-thoracic cage widens to compensate so vital capacity same
Breathing changes from thoracic (abdominal) to diaphragmatic (chest)
Shortness of Breath may be experienced
Pregnancy is a state of Alkalosis -hyperventilation-decreased CO2 levels-alkalosis
76
Pulmonary Congestion
Epistaxis-nose bleeds is common
Increased vascularity of upper respiratory tract-engorgement and edema of mucosa (nose, oropharynx, larynx, and trachea)
Symptomatic nasal congestion
Pregnant woman's nose widens at base allows mother to have better O2 consumption and ventilation
77
Renal System Changes
Urinary frequency in 1st trimester...again in 3rd trimester r/t lightening
High risk for UTI (symptomatic or asymptomatic
UTI correlated to Premature labor
Symptoms of UTI (frequency, urgency, dysuria, hematuria)
Risk of UTI due to dilated ureters and renal pelvis
Relaxed tone-increased capacity-stasis of urine
Glycosuria (high sugar content) perfect place for infections to occur. Bacterial love sugar, warm dark wet places-vagina and ureter
Glycosuria occurs at <160 mg/dl in pregnant clients
This is lower levels than non -pregnant client
ALL PREGNANT CLIENTS ARE SCREENED FOR GESTATIONAL DIABETES AT 24-28 WEEKS GESTATION
High risk patients tested earlier
Suspine positon compromises renal flow, cardiac, and uterine flow
78
Basal Metabolism and Acid-Base Balance
- Basal metabolism rate increases 10-20% by term
- Increases in O2 demand of the uterine-placental-fetal unit
- Acid-base balance-respiratory alkalosis compensated by mild metabolic acidosis
Breathing pattern of hyperventilation blowing off CO2--alkalosis
79
Protein in Urine
```
Proteinuria-UA at each clinic visit
Cardinal signs of PRE-ECLAMPSIA:
-proteinuria
-edema
-elevated BP
-Headaches or dizziness
-blurred vision
```
If you see increase in BP start looking for protein in urine Pre-eclampsia is progressive disease of pregnancy... No one knows the exact cause..mild, moderate, and progressing to full-blown eclampsia with seizures.
80
Skin Changes
Chloasma r/t estrogen
Palmar erythema
Hypertrophy of gums
Chlosama- facial pigmentation
Linea nigra- a darkly pigmented line from umbilicus to pubic area
Striae gravidarum-stretch marks on trunk and thighs r/t stretching of connective tissue
Palmar erythema: darker red palms r/t hyperemia
Accutane for acne
81
Musculoskeletal System
Postural and gait changes
Lumbar lordosis as center of gravity shifted forward. Lumbar and dorsal curves accentuated-results in low back pain
Typical "waddling gait" as Relaxin hormone relaxes pelvic points.
82
Neurologic System
Changes in sensorium (light-headed or dizzy) r/t postural hypotension/hypoglycemia
Carpal tunnel syndrome, edema, and compression of median nerve in wrist
Lordosis (Back sway)
Hypocalcemia can cause cramp and tetany
83
GI System
Ptyalism (excessive salivation)
Check for starchy food consumption or nausea
Nausea and Vomiting
- early subjective sign of pregnancy
- may be related to hormonal changes
- subsides past 1st trimester
R/T hypermesis gravidarum if persists longer than 1st trimester
Pyrosis (heartburn) common -increased progesterone causes decreased tone and motility of smooth muscles resulting in reflux, have slower emptying time and reverse peristalsis (also can cause constipation)
Hemorrhoids r/t constipation and increased pressure on blood vessels in the rectum
Gallbladder sluggish-along with increased secretion of cholesterol may predispose to gallstones
Pica-craving non-nutritive substances
84
Pica substances in pregnancy
```
Baking powder
Cornstarch
Baking Soda
Laundry Starch
Ice
Nzu from Nigeria
Red clay from Georgia
```
85
Folate (Folic acid)
Needed to reduce the risk of NTDs in the fetus
86
EDD, EDB, EDC
Estimated Due Date
Estimated Date of Birth
Estimated Date of Confinement (in the 18th century the elite were confined to an area of the home to give birth)
87
Naegele's Rule
Take the 1st day of the last Menstrual period
Subtract 3 months
Add 7 days
```
Example:
LMP April 27, 2019
-3 months
+ 7 days
=34
-30 (April has 30 days)
Estimated due date is January 4, 2020
```
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Trimesters
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1st trimester
week 1-13
2nd trimester
week 14-26
3rd trimester
week 27-40
Term pregnancy is 37.0 to 40.0 weeks
```
