Flashcards in Promotion of women's health during pregnancy: Ch 19 Deck (43)
What vaccinations are important concerning pregnancy?
Hep B- should be vaccinated during pregnancy if not immune.
inluenza- should be vaccined with inactive form- NOT the live one
HPV- vaccination should ideally be given prior to coitarche; contraindicated during pregnancy
rubella- if not immune, mom should be cautioned to avoid anyone with a rash or viral illness and should be vaccinated after giving birth
What are presumptive signs/ symptoms of pregnancy?
Signs or symptoms frequently reported with pregnancy, although not conclusive for pregnancy. Include amenorrhea, breast tenderness and enlargement, Chadwick's sign, fatigue, hyperpigmentation, chloasma, linea nigra, fetal movements (quickening), urinary frequency, nausea, vomiting.
What are probable signs/ symptoms of pregnancy?
Signs or symptoms that are more reliable indicators of pregnancy, often noted on the physical examination or with laboratory testing. Include abdominal enlargement, ballottment, Braxton- hicks contractions, Goodell's sign, Hegar's sign, palpitation of fetal contours, positive pregnancy test, uterine enlargment
What are positive signs/ symptoms of pregnancy?
Signs or symptoms that provide absolute confirmation of pregnancy, when noted. Include auscultation of fetal heart rate, palpitation of fetal movements, radiologic and/ or ultrasonic verification of gestation
What hormone is detected in pregnancy tests? How does the level of this hormone fluctuate throughout pregnancy?
Human chorionic gonadotropin (hCG) is detected in pregnancy at about the time of implantation. Levels in normal pregnancy usually double every 1.4 to 2.0 days. Levels peak at approximately 60 to 90 days postfertilization, and then decrease to plateau at 16 weeks of pregnancy.
What can help determine the viability of a pregnancy?
Quantitative, serial measurements of serum beta-subunit hCG (β-hCG); Serum and urine tests specific for β-hCG have accuracy rates of 99 percent, with few false positives.
What does the initial prenatal visit include?
Confirmation of pregnancy with a β-hCG urine test, auscultate fetal heart tones (FHTs), or perform ultrasound; if all three are negative but pregnancy is still suspected, retest using a radioimmunoassay β-hCG serum test.
Thorough history and physical, determine expected date of delivery, routine labs, risk assessment, give prenatal educational materials/ anticipatory guidance and teaching
What is included in routine blood work to be done on all prenatal patients? (19.3)
ABO blood group/Rh factor identification/antibody screen
Complete blood cell count with indices (Hb, Hct, MCV, MCH, MCHC)
Syphilis screening/VDRL, RPR
Hepatitis B surface antigen
Urinalysis and urine culture
Cervical cytology (if indicated by routine screening guidelines)
HIV antibody screening
HIV—human immunodeficiency virus
MCHC—mean corpuscular hemoglobin concentration
MCH—mean corpuscular hemoglobin
MCV—mean corpuscular volume
RPR—rapid plasma reagin
VDRL—Venereal Disease Research Laboratories test
When is the risk of miscarriage highest?
When should patients schedule the first visit?
It is common to have women schedule a first OB visit between 8 and 10 weeks, and sometimes earlier if they are planning genetic testing (i.e., chorionic villus sampling [CVS])
What should be done at the visits during weeks 12- 16?
Review lab findings. Offer and order appropriate genetic testing as indicated. Follow-up on and address any medical or pregnancy risk factors. Provide anticipatory guidance related to fetal development and changes to expect as the pregnancy progresses. Counsel the client on lifestyle factors such as healthy nutrition, weight gain, and exercise.
What should be done at visits during weeks 16- 20?
Assess for fetal movements (quickening), which typically occur between 16 and 20 weeks of gestation. Offer and order appropriate genetic screening tests. US evaluation can be done to confirm gestational age and assess fetal anatomy. Encourage the woman and her partner or support person(s) to enroll in prenatal childbirth education classes. Continue to provide anticipatory guidance and screen for risk factors.
What should be done at visits during weeks 24- 28?
If Rh negative, reevaluate the antibody screen titer. Perform glucose screening for gestational diabetes. Administer RhoGAM (Rh immune globulin) as indicated. Retest H & H. Evaluate the client for risk of preterm labor and consider a cervical assessment including cervical position, consistency, length, and dilation, if indicated.
When should you instruct the patient to start performing fetal movement counts (FMCs) daily?
around 28 weeks' gestation
How should we instruct patients to perform daily FMCs?
Note the start time, the client may lie in the left lateral position; however, a seated or standing position may also be used.
Place a hand over the abdomen to palpate movement.
Remain in this position until you have counted 10 fetal movements.
Record the end time.
How long should it take for 10 fetal movements?
2 hours; if it is less then biophysical fetal assessment is indicated
What should be done at visits during weeks 28- 35?
Encourage the client to begin the process of finding a health care provider for the infant. Assess the client's breasts and discuss preparation for breastfeeding. Discuss the importance of daily fetal movement as an indicator of fetal well-being. Reassess the client for risk of preterm labor; assess the cervix as indicated. May begin assessing fetal presentation and position with Leopold's maneuvers.
What should be done at visits during weeks 35- 37?
Review with the client the signs and symptoms of labor; provide a handout listing them. Obtain a vaginal/anorectal culture for group B streptococcus. Assess for active herpes simplex virus outbreak, in those with positive history. For women at or beyond 36 weeks who are at risk for recurrent genital herpes infection, suppressive antiviral therapy may be considered. (acyclovir 400 mg twice a day or valacyclovir 500 mg twice daily until delivery). Retest for chlamydia, gonorrhea, syphilis, and/or HIV in those with infections earlier in pregnancy or those at high risk for STIs.
What should be done at visits during weeks 37- 40?
Assess fetal position and presentation. Review and negotiate the client's birth expectations. Forward a copy of the client's prenatal records to the hospital labor area, as indicated. Document the client's choice of a pediatrician. Initiate fetal surveillance as indicated. A cervical examination may be performed per the protocol of the institution. Review client plans for postpartum contraception, and reinforce preparation for breastfeeding. Ensure that client has made plans for infant car seat. Review signs of postpartum depression and discuss available resources should client need them.
What should be done at visits during weeks 40 and beyond?
Prepare the client for postdate pregnancy protocol. Perform a cervical assessment and consider membrane sweeping if no contraindications exist, such as cervicitis, low-lying placenta or placenta previa, unknown fetal lie, and vaginal bleeding. Institute fetal surveillance, such as ultrasound, to evaluate amniotic fluid volume; nonstress testing; and semiweekly office visits, according to practice protocol.
What are major milestones during first trimester and when do they occur?
fetal heart movements- 6 weeks' gestation
closure of the neural tube- 7 weeks' gestation
rapid head and brain growth beginning in the 7th week.
Common physical changes during pregnancy- skin
Increased vascularity; increased pigmentation of face (chloasma), areola, abdomen (linea nigra), and genitalia; striae of breasts and abdomen.
Common physical changes during pregnancy- head
Mild changes in scalp; excessive oiliness or dryness.
Common physical changes during pregnancy- eyes
Mild corneal edema and thickening.
Common physical changes during pregnancy- mouth
Edematous gums; increased gingivitis.
Common physical changes during pregnancy- Respiration/cardiovascular
Physiologic dyspnea of pregnancy; progressive elevation of the diaphragm; hand/pedal edema; leg and vulvar varicosities and hemorrhoids. Exaggerated heart sounds, particularly functional systolic murmurs.
Common physical changes during pregnancy- breasts
Increased fullness, tenderness, enlargement, and excretion of colostrum are common by the third trimester.
Common physical changes during pregnancy- abdomen
Distention secondary to flatus and increased uterine size; diminished bowel sounds as peristaltic movements are slowed; enlarging uterus, which displaces abdominal organs.
Common physical changes during pregnancy- Genitalia/reproduction: external
Increased pigmentation; pubic hair may lengthen. Near term, pelvic congestion and overall swelling of labia majora are common; vulvar varicosities may be noted.
Common physical changes during pregnancy- Genitalia/reproduction: vagina
Rugation of vaginal mucosa is prominent.
Common physical changes during pregnancy- Genitalia/reproduction: cervix
Chadwick's and Goodell's signs are noted. May soften, dilate, and efface close to term.
What is Chadwick's sign?
bluish/purple color of cervix
What is Goodell's sign?
softening with growth of cervical glands
Common physical changes during pregnancy- Genitalia/reproduction: uterus
6 weeks' gestation- Hegar's sign
12 weeks- fundus is noted at the symphysis pubis
16 weeks- the fundus is midway between the symphysis and the umbilicus.
20 weeks- uterine fundus can be palpated at the umbilicus and measures 20 cm (Uterine enlargement occurs in linear fashion- 1 cm per week).
36 weeks- fundus is just below the xiphoid process and measures approximately 36 cm; the fundal height may decrease slightly or plateau near term (lightening). Measurement may then no longer correspond with week of gestation. The uterus maintains a globular/ovoid shape throughout pregnancy.
What is Hegar's sign?
softening of the lower uterine segment
Common physical changes during pregnancy- Genitalia/reproduction: adnexa
Discomfort may be noted with exam due to stretching of the round ligaments throughout pregnancy. The ovaries are not palpable once the uterus fills the pelvic cavity at 12 to 14 weeks' gestation.
Common physical changes during pregnancy- Genitalia/reproduction: urinary
The bladder may be palpable; frequency and incontinence are common, particularly with multiparity.
Common physical changes during pregnancy- Genitalia/reproduction: rectal
Increased vascular congestion with resulting hemorrhoids is often noted.
Common physical changes during pregnancy- Genitalia/reproduction: musculoskeletal
Increased relaxation of pelvic structures, lordosis, sciatica, and discomfort at the symphysis pubis are common. Pain from round ligament syndrome often noted.
Common physical changes during pregnancy- Genitalia/reproduction: endocrine
May have mildly enlarged thyroid; however, diffusely enlarged thyroid nodularity or increased firmness is abnormal.
What are the recommendations for total weight gain during pregnancy for underweight, normal, overweight, and obese women?
underweight (BMI < 18.5)- 28-40lbs
normal weight (BMI 18.5- 24.9)- 25- 35lbs
overweight- (BMI 25- 25.9)- 15- 25lbs
obese (BMI 30+)- 11- 20lbs
What are the danger signs/ symptoms of the first trimester?
spotting or bleeding; cramping; painful urination; severe vomiting and/or diarrhea; fever higher than 100.4°F; symptoms of vaginal infection or STIs; persistent or severe low abdominal pain (unilateral, bilateral, or midline); and lightheadedness or dizziness (particularly if accompanied by shoulder pain). If a woman experiences any abdominal trauma, this should be reported to her health care provider. Additionally, women and their partners should be counseled to report any new onset or exacerbations of depression and/or anxiety symptoms.