What are the goals of prenatal care?
- Maintenance of maternal fetal health
- Accurate determination of gestational age
- Ongoing assessments of risk status & implementation of risk appropriate intervention
- Build rapport with the childbearing family
- Referrals to appropriate resources
What are the goals of preconception care?
- Promote health and disease prevention for both men & women
- Identifies risk factors that may be changed before conception to reduce the negative impact on the outcome of pregnancy
- Ensures goos nutritional state and immunizations
- Encourage 0.4mg of folic acid daily for 6mo prior to conception to prevent neural tube defects
Define gravida, nulligravida, primigravida, & multigravida
- Gravida: woman who is pregnant
- Nulligravidia: woman who has never been pregnant
- Primigravida: woman who is pregnant for the first time
- Multigravida: two or more pregnancies
Define para, nullipara, primipara, multipara
- Para: number of living children
- Nullipara: woman has not completed a pregnancy past 20wks
- Primipara: woman has completed one pregnancy past 20 weeks
- Multipara: woman has completed 2 or more births more than 20 weeks gestation
What are the antepartum, intrapartum, postpartum periods and what is the gestational period?
- Antepartum (prenatal): conception until onset of labor
- Intrapartum: onset of labor until the birth of the infant and the placenta
- Postpartum: birth until the woman's body returns to pre-pregnant state (6wks)
- Gestation: number os weeks since the first day of the LNMP
Define abortion, preterm, term, postterm, and stillbirth
- Abortion: birth prior to 20 wks or birth of a fetus <50grams
- Preterm: 20-37 6/7 weeks gestation
- Term: 38-41 6/7 weeks gestation
- Postterm: 42+ wks gestation
- Stillbirth: fetus born dead after 20 wks gestation (aka fetal demise)
What are the presumptive (subjective) signs of pregnancy?
- Nausea & vomiting
- Urinary Frequency
- Breast Changes
- Skin Changes
What are the Probable (objective) signs of pregnancy?
- Changes in the pelvis organs
- -Hegars sign- elongation and softening of the uterine isthmus r/t incr blood flow
- -Goodell's sign- softening of the cervix
- -Chadwick's sign- bluish discoloration of mucosa of vagina
- -Uterine enlargement
- Abdominal enlargement
- Pigmentation of skin/abdominal straie
- Ballottment (baby bounces in amniotic fluid if the cervix is tapped)
- Pregnancy test
What are the Positive (diagnostic) signs of pregnancy?
- Hear: the fetal heart
- See: the fetus on ultrasound (abdom US can confirm preg 2-3 wks after conception, vag US can detect gestational sac 10 days after implantation)
- Feel: fetal movement by the health care provider
Using Nagele's rule, how would you calculate the estimated date of delivery (EDD)?
- Using the first day of the Last Normal Menstrual Period (LNMP), subtract 3 months and add 7 days
- (this is based on a normal, 28 day cycle with conception on the 14th day)
How would you calculate GP (TPALM)?
- G (gravida): Total of pregnancies
- P: broken into TPALM
- T: # of full term deliveries (38wks+)
- P: # of preterm deliveries
- A: # of pregnancies terminated prior to 20 wks
- L: # of living children
- M: # of multiple births
How does the reproductive system adapt to pregnancy?
- Uterus increases 8x in size. Growth occurs in a pattern. Centimeters in height from pubis correlates with weeks in gestation until the 36th week when lightening can occur
- Mucus plug in cervix prevents ascending infection
- Secretions in the vagina increase in both amount and acidity,leading to a decrease in pH. This decrease prevents infection, but makes the woman more susceptible to yeast infections
- Breasts increase in size and sensitivity
How does the cardiovascular system adapt to pregnancy?
- Progesterone causes a relaxing of smooth muscles, leading to potential hypotension
- Blood volume increases by 40-50%, with an increase in HR by 10-15 bpm and CO increase of 30-50%
- RBC production increases by 30% and plasma increase by 50%, with a decrease in hematocrit (physiologic anemia)
- Fibrinogen levels increase by 50%, putting the woman at risk of DVT
- Increased blood flow to uterus, placenta & breast
Describe the changes of bp in pregnancy?
- Decreases slightly and is lowest in the second trimester
- Near pre-pregnant levels by 40 wks
- Vena Cava compression r/t maternal position can cause supine hypotension
- Femoral venous pressure increases r/t weight of the fetus, causing dependent edema and varicose veins
- Orthostatic hypotension r/t relaxation of smooth muscle, decreases bp
What happens to WBCs during pregnancy? Platelets?
- WBCs increase to 5600-12,200
- May reach 20,000-30,000 during labor & early PP period
- Platelet count remains stable
How does the respiratory system adapt to pregnancy?
- O2 demand of heart, kidneys, & uterus by 15-20%
- Increase of blood supply to the lungs lead to increase in secretions in nose and mouth
- Dyspnea related to increased abdominal volume and elevation of diaphram
- Rib cage flares due to Relaxin and chest circ increases about 6cm
- Estrogen causes edema & vascular congestion
What adaptations does the renal system make during pregnancy?
- Renal blood flow increases by 50%
- Kidneys increase in size
- Glomerular filtration rate increases, causing an increased reabsorption of salt, calcium & water
- Glycosuria & proteinuria in small amount not uncommon, but assessments for GDM and preeclampsia should be done
- Urinary frequency is common (should not have symptoms of UTI)
How does the gastrointestinal system adapt to pregnancy?
- Progesterone causes the relaxation of smooth muscle, leading to constipation
- Decreased gastric motility and sphincter control leads to acid reflux & heartburn
- Increased secretion of saliva
- Nausea & vomiting common, watch for dehydration
- Prolonged emptying time of gallbladder may predispose women to formation of gallstones and puritis
What adaptations does the musculoskeletal system make during pregnancy?
- Lordosis r/t the shift in the center of gravity
- Relaxin hormone causes loosening of cartilage
- Leg cramps r/t decreased calcium levels (may take calcium supplements)
- Diastasis Rectus results from the enlarging uterus
How does the integumentary system adapt to pregnancy?
- Hyperpigmentation of the nipples, areolae, & umbilicus r/ increased melanin (straie, linea nigra, melasma)
- Hot flashes
- Oily skin/acne
How does the endocrine system adapt to pregnancy?
- Thyroid increases in size and T3, T4 production increases while TSH decreases. BMR increases by 20-25% due to fetal metabolism
- Parathyroid increases to meet calcium demands of the fetus
- Insulin producing cells in the pancreas increase in size and number. Fetal blood sugar levels decrease by 15-20mg/dL r/t accelerated starvation effect of HPL
How does the pituitary adjust to pregnancy?
- Prolongs the corpus luteal phase with hCG to maintain the endometrium
- Alters maternal metabolism to support pregnancy
- Prolactin supports initial lactation while oxytocin promotes the let down reflex
- Oxytocin also promotes uterine contractions for delivery
- hCG, hPL, estrogen, progesterone, and Relaxin are utilized
For a low risk pregnancy, how are prenatal visits scheduled?
- First 28 weeks: every 4 weeks making 5-6 visits, depending on when first visit occurred
- 28-36 weeks: visit every two weeks, resulting in 5 visits
- 36 + wks: visit every week (4 visits)
- Total of 14-16 prenatal visits for the healthy, low risk mother
What is done at the initial prenatal care visit?
- Comprehensive health and risk assessment
- Current pregnancy history
- Completed physical and pelvic exam
- Determination of EDD
- Nutritional assessment
- Psychosocial assessment
- Assessment for intimate partner violence
What screening tests are done at the initial prenatal visit?
- Pap test
- Hiv Screen
- Type and RH*
- Hepatitis B antigen
- Urine Culture*
- STD screening
During each follow up prenatal visit, what is assessed?
- Vital signs
- Uterine size
- Fetal Heart Beat
- Urinary Analysis to check for glucose, protein & WBC
- Risk factor assessments
- Questions/concerns for women and family
- Education and anticipatory guidance appropriate for gestational week
What tests are done during the second and third trimesters?
- Glucose screen at 28 weeks for GDM
- Hemoglobin & GBS @ 35-37 weeks (if she is positive, she will be treated in labor. If status unknown at labor, baby will be kept for 48 to watch for signs of infection and treated if necessary)
When are ultrasounds done during prenatal care?
- Ultrasound is done at initial assessment for dating of pregnancy
- 20 week ultrasound to determine anatomy and gender of baby
- Done during the third trimester to measure fetal growth
What is RhoGam, when is it given, and what special considerations need to be made?
- RhoGam is a blood product which prevents the formation of antibodies in Rh- mothers with Rh+ babies
- May be given to Rh- mothers prophylactically at 28 wks and again within 72 after birth
- Will also give if mother is has chance of being exposed to fetal blood due to amniocentesis, abdominal trauma, or pregnancy loss
- Because it is a blood product, keep in mind that special consent and procedures may be necessary
What prenatal teaching should be done for nutrition?
- Nutritional reviews should be done during all prenatal visits
- 8-10 glasses of water/fluid a day
- Limit caffeine to 200mg per day
- Avoid fish higher in mercury such as King Mackerel, swordfish, & tilefish
- Prevent foodborne illnesses
- Excessive or inadequate weight gain is associated with poor perinatal outcomes
What prenatal vitamins should be taken?
- Folic Acid & Iron
- All others should be achieved through a healthy, balanced diet
- Other vitamins may be prescribed for a deficiency
What is the normal pattern of weight gain during pregnancy?
- First trimester: 1.1-4.4 lbs
- Second & Third trimester: 1lb per week
- Normal weight woman: 25-35 lbs
- Underweight woman:28-40 lbs
- Overweight woman: 15-25 lbs
- Obese woman: 11-20lbs
What are some warning/danger signs during the first trimester?
- Abdominal cramping
- Vaginal spotting or bleeding
- Dysuria, frequency, urgency (any changes from normal)
- Fever, chills
- Prolonged N/V (hyperemesis gravidarum can cause excessive dehydration)
- Absence of FHT
During the second trimester, what are some warning/danger signs?
- Abdominal or pelvic pain
- Absence of fetal movement
- Prolonged n/v
- Dysuria, frequency, urgency
- Fever, chills
- Vaginal Bleeding
What are some warning/danger signs during the third trimester?
- Abdominal or pelvic pain
- Absence of fetal movement
- Prolonged N/V
- Dysuria, frequency, urgency
- Fever, chills
- Vaginal Bleeding
- S/S preterm labor
- S/S hypertensive disorders
What are the warning signs for preterm labor?
- Rhythmic lower abdominal cramping or pain
- Low Backache
- Pelvic Pressure/heaviness
- Leaking of fluid
- Increased vaginal discharge
What are the warning signs for Hypertensive disorders?
- Severe onset headache that does not respond to treatment
- Visual changes
- Facial or generalized edema
What should your patient teaching focus on during pregnancy?
- Teaching should be appropriate to the stage of pregnancy
- General information about changes in pregnancy
- General information about fetal development
- General health maintenance
- Warning and danger signs
How do you determine if drug therapy is safe during pregnancy?
- Benefits of the therapy vs. the risk to mother or fetus
- Most drugs cross the placenta and dependence producing drugs can cause a dependent fetus
- Most drugs are not tested during pregnancy, but FDA class C, D or X should not be used
What are teratogens?
- Cause congenital anomolies
- Preembryonic stage (1-2 wks): minimal or no effect until ndation
- Embryonic stage (3-8wks): gross malformations as embryo structures are forming
- Fetal stage(9-40wks): disrupts the function of a structure
- Few drugs are proven teratogens, but not many effects are known during pregnancy
What is the biggest determinant of fetal health?
- MATERNAL HEALTH!!
- When possible, teratogenic drugs should be subsituted for other drugs to meet same effect
- If the drug is necessary for maternal health (such as chemo) the pregnancy may need to be terminated
What biophysical assessments are done during pregnancy?
- Doppler flow studies
- Biochemical assessments such as Chorionic villi sampling and fetal fibronectin
What do doppler flow studies assess?
- Assess the placental function
- Assess for flow through the umbilical artery
What does chorionic villus sampling achieve?
- Performed at 10-12 weeks gestation, it can detect genetic, metabolic, and DNA abnormalities as the chorionic villi contain the fetal DNA
- Cannot detect a neural tube defect
What is fetal fibronectin testing? Is it reliable?
- fFN produced by the trophoblast and is found in the attachment of the placental membranes
- Test done by vaginal swab
- If test is negative, no preterm labor
- Positive test is not very reliable, but a true positive indicates 99% chance of labor within 2wks
When is an amniocentesis done and what can it show?
- 14-20 weeks to test for chromosomal defects, elevated bilirubin, and culture for infection
- Third trimester to test for lung maturity
- -Lecithin/sphingomylein ratio are components of surfactant. 2:1 indicates a low risk of RDS in newborns
- -Phospatidylglycerol (PG) is another component of surfactant appearing around 36 weeks. Presence indicates low risk of RDS
What maternal assays are done?
- AFP (Alpha-fetoprotein):
- -Maternal blood test. High levels may indicate a neural defect, multiple pregnancy or older gestational age than anticipated and low levels may indicate down syndrome
- Maternal Marker Screen:
- -maternal blood test that measures the level of various chemical markers to detect trisomies and neural tube defects
- -AFP, hCG, Estriol Level, Inhibin-A
What tests are done to assess the fetal status and well-being?
- Fetal Movement: can be measured at about 28 wks. Decreased fetal movement should be reported immediately
- NST (non stress test): vibroacoustic stimulation, fetal movement, FHT acceleration
- Amniotic Fluid Index: Ultrasonic measurement of amniotic fluid volume. A strong indicator of fetal status and is accurate in detecting fetal hypoxia-decrease in O2 leads to decrease perfusion of kidneys, which leads to a decrease production of amniotic fluid
What assessments are done during the third trimester?
- CST (stress test): evaluates the fetal well-being and uteroplacental function
- Biophysical Profile: Identify compromised fetus or confirm a healthy fetus by NST, Ultrasound, AFP
- Modified biophysical profile: NST, AFI, reflect long term uteroplacental function
- Estimation of fetal weight