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Presumptive signs of pregnancy
- Fatigue
- Breast tenderness
- Nausea and vomiting
- Amenorrhea
- Urinary frequency
- Hyperpigmentation of skin
- Fetal movement
- Uterine enlargement
- Breast enlargement
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Probable signs of pregnancy
Goodell's sign
Chadwick's sign
Hegar's sign
- Goodell's sign: softening of cervix
- Chadwick's sign: Purple coloration of cervix
- Hegar's sign: softening of lower uterine segment.
- Braxton Hicks contractions (false labor, practice contractions)
- Positive pregnancy test (urine test)
- Abdominal enlargement
- Ballottement (return impact of displaced fetus)
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Positive signs of pregnancy
- Ultrasound verification of fetus
- Fetal movement felt by clinician
- Auscultation of fetal heart tones
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Human Chorionic gonadotropin (HCG)
- Maintains corpus luteum, which secretes progesterone and estrogen
- Produces fetal trophoblast cells
- Earliest hormone for pregnancy test (urine test)
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Human chorionic somatomammotropin (HPL)
aka Human placental lactogen
- Prepares mammary glands for lactation
- Insulin antagonist (alters ability to use insulin)
- Increase free fatty acids for maternal needs
- Decrease maternal metabolism of glucose for fetal growth
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Relaxin
- Act synergistically with progesterone to maintain pregnancy
- Increase flexibility of pubic symphysis
- Dilation of cervix
- Suppress release of oxytocin
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Progesterone
- The "hormone of pregnancy"
- Supports the endometrium of uterus for fetal survival
- Causes thickening of uterine lining for implantation
- Inhibits uterine contractility
- Development of breast for lactation
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Estrogen
- Promotes enlargement of genitals, uterus and breast
- Increases vascularity
- Relaxation of pelvic ligaments and joints
- hyperpigmentation
- Aids in development of ductal system of breasts
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Gastrointestinal Adaptations
- Nausea and vomiting (HCG)
- Peristalsis: hemrrhoids, heartburn, constipation (Progesterone)
- Prolonged emptying of gallbladder
- Bleeding gums (estrogen)
- Ptyalism: excessive salivation
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Cardiovascular adaptation
- Blood volume increases by 1500 or 50% above non pregnant levels
- CO increases to 50%
- HR increases 10 - 15 BPM
- BP declines (limit 140/80)
- Physiologic anemia of pregnancy (diluted by extra volume)
- Vena caval syndrome (while laying on back, uterus presses on vena cava causing hypotension)
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Respiratory Adaptations
- Uterus pushes up on diaphragm, decreasing lung space (difficulty breathing)
- RR increases (increased due to greater O2 requirements to grow baby)
- Thoracic breathing (chest breathing)
- Congestion r/t increased vascularity
- Epitaxis (nosebleed) and rhinitis (stuffy nose)
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Renal/Urinary adaptation
- GFR increases due to more blood volume
- Urinary frequency
- 1st trimester uterus is a pelvic organ
- 2nd trimester uterus moves up and becomes abdominal organ (urinary frequency decreases)
- 3rd trimester frequency returns
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Musculoskeletal adaptation
- Lordosis: increase in curvature of spine
- Waddle gait- relaxin hormone
- Diastasis recti (seperation of abdominal muscles)
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Integumentary adaptation
- Hyperpigmentation
- Chloasma: "mask of pregnancy"
- Linea nigra (black line down the abdomen)
- Breast (darker nipples)
- Striae gravidarum (stretch marks)
- Altered hair growth (thick beautiful/thin hair)
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Endocrine adaptation
- Thyroid: promote fetal neurologic development
- Pituitary: promote breast development and lactation
- Oxytocin: contractions
- ADH: water balance
- Pancrease: insulin production
- Adrenal: cortisol increased
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Nutritional needs of pregnancy
- Prenatal vitamin
- Folic acid: prevent neural tube defects
- Ferrous sulfate (Iron)
- Calorie needs (300 extra)
- -Each woman has a different calorie need based on height and weight before pregnancy
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Weight gain during pregnancy
- weight gain: based on pre-pregnant weight
- average weight gain should be 25-35 lbs
- underweight
- (BMI <18.5) should gain 28-40 lbs
- overweight
- (BMI= 25-29.9) should gain 15-25 lbs
- Obese
- (BMI=/>30) should gain 11-20 lbs
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Maternal nutrition: nursing interventions
- Assessment:
- Physical health
- Knowledge
- Type of diet
- Cultural variations
- Psychosocial influence:
- socioeconomic
- Level of education
- Coping mechanisms
- Adolescent pregnancy
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PICA
PICA: Compulsive ingestion of non food substances (ice, clay, cornstarch) usually associated with iron deficiency anemia
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Psychosocial adaptation
- Ambivalence: conflicting emotions regarding pregnancy
- Introversion: focusing on oneself
- Acceptance: reality and validity of pregnancy
- Mood swings
- Changes in body image
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Psychosocial adaptation of family
- Couvade syndrome: partner undergoes a sympathetic response to pregnancy
- weight gain
- food aversions
- Sibilings reactio to pregnancy is age dependent
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First prenatal visit
- Complete health history
- EDC (Nagele's rule)
- Gynecological health history
- Medication history (Ibiprofen D/C)
- Life style history (alcohol, smoking, work intensity)
- Psychosocial history
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Pregnancy risk categories of medications
- Category A: No increased risk of fetal abnormalities
- Category B: Animal studies revelead no evidence of harm to fetus
- Category C: Animal studies have shown an adverse effect
- Category D: Demonstrated a risk to the fetus (adequate studies)
- Category X: Positive evidence of fetal abnormalities or risk (adequate studies)
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Reproductive History
Total number of pregnancies regardless of the duration; includes current pregnancy
Gravida: Total number of pregnancies regardless of the duration; includes current pregnancy
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Total births beyond the period of viability; 20 weeks or 500 gms
Para: total births beyond the period of viability; 20 weeks or 500 gms
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TPAL
- T- term >38 weeks to 42 weeks
- P- preterm (20 - 37 weeks at birth)
- A- abortions (termination of pregnancy before viability; spontaneous or elective, 20 weeks)
- L- living children
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Nagele's rule
- Nagele's rule
- Subtract 3 months of LMP
- Add 7 days to first day of LMP
- Correct year by adding 1 to it where necessary
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First prenatal visit
Physician exam for pap smear and probable signs of pregnancy
Fundal height
Lab tests
CBC, T&S, Rubella, Hepatitis B surface antigen, HIV, VDRL, STI cervical smear
- Physician look at probable signs of pregnancy
- Fundal height: used to monitor fetal growth (umbilicus at 20 weeks)
- Not accurate after 36 weeks because baby drops
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Follow up visits
Every __ weeks up to 28 weeks gestation
Every __ weeks from 29 - 36 weeks
Every week from 37 weeks to birth
- Every 4 weeks up to 28 weeks gestation
- Every 2 weeks from 29 - 36 weeks
- Every week from 37 weeks to birth
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Follow up assessments
- Blood pressure
- weight
- Urine test for protein and glucose
- Fundal height
- Fetal movement assessment (mother monitors)
- Fetal heart rate assessment
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Fetal movement
- patient performs daily self assessment of fetal movement
- Self assessment useful tool to determine fetal well being
- Decreased fetal movement associated with fetal hypoxia
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Factors affecting fetal movement
- Fetal sleep cycle (1.5 hours)
- Maternal blood glucose levels
- Gestational age
- Maternal smoking
- Maternal medications (CNS depressants)
- Maternal exercise
- Bilateral hip dislocation
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Fetal heart rate assessment
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Non stress test
- Indirect measurement of uteroplacental function
- Heart rate accelerations with fetal movement (good sign of health)
- Reactive VS non reactive
- 15 BPM x 15 seconds (20 minute NST strip)
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Contraction stress test
Diagnostic procedure to determine fetal heart rate response under stress
- Deceleration= HR decreases under stress
- Late fetal heart rate decelerations occurring with contractions associated with poorer fetal outcomes.
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Biophysical profile
- Real time ultrasound which applies score to following assessments:
- Body movement (2 points)
- Fetal tone (2 points)
- Fetal breathing (2 points)
- Amniotic fluid index (2 points)
- NST (2 points)
- *Diabetic mothers have a lot of amniotic fluid
- *Bad tone = sign of hypoxia, accidosis
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Gestational diabetes screen and Ultrasound
- Gestational diabetes screen
- Tested between 24 - 28 weeks
- Normal is <130
- Ultrasound
- Performed in each trimester to assess size, fluid, placental location and fetal well being
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Alpha fetoprotein
- Alpha fetoprotein: glycoprotein associated with neural tube defects with increased levels. Decreased levels may be down syndrome.
- Performed at 16 -18 weeks
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Amniocentesis
Amniocentesis: transabdominal puncture of amniotic sac to obtain a sample of amniotic fluid. Used to detect chromosomal abnormalities, neural tube defects and lung maturity.
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Amniocentesis procedure
- Performed with ultrasound
- Physician inserts long needle in amniotic cavity to aspirate fluid
- Pt must empty bladder prior
- Administer Rhogam if pt Rh negative
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Chorionic villus
- Chorionic villus sampling (CVS)
- Chromosomal disorders, enzyme deficiency, sex link disorders
- Performed at 10 - 13 weeks
- Complications: abortion, vaginal bleeding, limb abnormalities, fetal maternal hemorrhage
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Interventions to alleviate common discomforts
- Nausea/vomiting (crackers)
- Urinary frequency (no fluids after 7 pm)
- Fatigue (nap)
- Breast tenderness (good bras)
- Heartburn (smaller meals)
- Edema (elevate legs)
- Hemorrhoids (colace, water)
- Constipation
- Backache (exercise)
- Dyspnea
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Client education for self care
- Avoid hot tubs and saunas
- Dental care
- Breast care
- Sexual activity
- Travel
- Rest
- Exercise (contraindication for high risk pregnancies)
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Birthing methods
- Lamaze (breathing)
- Bradley (coach method)
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