Chapter 12: Nursing Management During Pregnancy

Pregnancy Lightening

"Lightening" b/c baby is dropping down Multigravida babies take longer to drop down into the pelvis

When are CSTs done?

At viability so greater than or equal to 24 weeks

Nonstress Test (Non-Reactive)

Baby is kicking but no accelerations in HR - Further testing needed Ex: A baby at 22 weeks will have a strip like this, but their nervous system is not well developed so we don't do these tests until later

Assessment of Fetal Well-Being: Transcervical Chorionic Villus Sampling

Chorionic villus sampling (CVS) is an invasive procedure involving an 18-gauge needlestick through the abdomen or passage of a suction catheter through the cervix under ultrasound guidance. This test is used to obtain a sample of the chorionic villi from the placenta for prenatal evaluation of chromosomal disorders such as Down syndrome or cystic fibrosis, enzyme deficiencies, and fetal gender determination and to identify sex-linked disorders such as hemophilia, sickle cell anemia, and Tay-Sachs disease (Levy, 2019). Chorionic villi are fingerlike projections that cover the embryo and anchor it to the uterine lining before the placenta is developed. Because they are of embryonic origin, sampling provides information about the developing fetus. CVS can be used to detect numerous genetic disorders with the exception of neural tube defects (Leung & Qiao, 2019). There has been an impetus to develop earlier prenatal diagnostic procedures so that couples can make an early decision to terminate the pregnancy if an anomaly is confirmed. Early prenatal diagnosis by CVS has been proposed as an alternative to routine amniocentesis, which carries fewer risks if done later in the pregnancy. In addition, results of CVS testing are available sooner than those of amniocentesis, usually within 48 hours. Procedure CVS is generally performed 10 to 13 weeks after the LMP. Earlier, chorionic villi may not be sufficiently developed for adequate tissue sampling and the risk of limb defects is increased (Ng, 2019). First, an ultrasound is done to confirm gestational age and viability. Then, under continuous ultrasound guidance, CVS is performed using either a transcervical or transabdominal approach. With the transcervical approach, the woman is placed in the lithotomy position and a sterile catheter is introduced through the cervix and inserted in the placenta, where a sample of chorionic villi is aspirated. This approach requires the client to have a full bladder to push the uterus and placenta into a position that is more accessible to the catheter. A full bladder also helps in better visualization of the structures. With the transabdominal approach, an 18-gauge spinal needle is inserted through the abdominal wall into the placental tissue and a sample of chorionic villi is aspirated. Regardless of the approach used, the sample is sent to the cytogenetics laboratory for analysis. Potential complications of CVS include postprocedure vaginal bleeding and cramping (most common), hematomas, spontaneous abortion, limb abnormalities, rupture of membranes, infection, chorioamnionitis, and fetal-maternal hemorrhage (March of Dimes, 2020d). The pregnancy loss rate or procedure-related miscarriage rate is approximately 0.5% to 1.0%, which is the same rate for amniocentesis. In addition, women who are Rh-negative should receive immune globulin (RhoGAM) to avoid isoimmunization (Jordan et al., 2019). Nursing Management Explain to the woman that the procedure will last about 15 minutes. An ultrasound will be done first to locate the embryo, and a baseline set of vital signs will be taken before starting. Make sure she is informed of the risks related to the procedure, including their incidence. If a transabdominal CVS procedure is planned, advise her to fill her bladder by drinking increased amounts of water. Inform her that a needle will be inserted through her abdominal wall and samples will be collected. Once the samples are collected, the needle will be withdrawn and the samples will be sent to the genetics laboratory for evaluation. For transcervical CVS, inform the women that a speculum will be placed into the vagina under ultrasound guidance. Then the vagina is cleaned and a small catheter is inserted through the cervix. The samples obtained through the catheter are then sent to a laboratory. After either procedure, assist the woman into a position of comfort and clean any excess lubricant or secretions from the area. Instruct her about signs to watch for and report, such as fever, cramping, and vaginal bleeding. Urge her not to engage in any strenuous activity for the next 48 hours. Assess the fetal heart rate for changes and administer RhoGAM to an unsensitized Rh-negative woman after the procedure. ***tiny amount of fluid because the baby is so small

Really low levels of Maternal Serum Alpha-fetoprotein usually indicates what?

Down syndrome

True or False: A contraction stress test is commonly performed in place of a biophysical profile.

False

True or False: At 12 weeks gestation, the uterine fundus can be palpated at the umbilicus.

False

Fundal Height Measurement

Fundal height is the distance (in centimeters) measured with a tape measure from the top of the pubic bone to the top of the uterus (fundus) with the client lying on her back with her knees slightly flexed (Fig. 12.5). Measurement in this way is termed the McDonald method. Fundal height typically increases as the pregnancy progresses; it reflects fetal growth and provides a gross estimate of the duration of the pregnancy.Between 12 and 14 weeks' gestation, the fundus can be palpated above the symphysis pubis. The fundus reaches the level of the umbilicus at approximately 20 weeks and measures 20 cm. Fundal measurement should approximately equal the number of weeks of gestation until week 36. For example, a fundal height of 24 cm suggests a fetus at 24 weeks' gestation. After 36 weeks, the fundal height then drops due to lightening and may no longer correspond with the week of gestation. It is expected that the fundal height will increase progressively throughout the pregnancy, reflecting fetal growth. However, if the growth curve flattens or stays stable, it may indicate the presence of FGR. If the fundal height measurement is greater than 4 cm from the estimated gestational age, further evaluation is warranted if a multifetal gestation has not been diagnosed or hydramnios has not been ruled out (Jarvis, 2020).

Really high levels of Maternal Serum Alpha-fetoprotein usually indicates what?

Neural Tube Defects

Cat stretch

Pelvic tilt exercises to relieve back aches; some women may deliver babies like this if baby is osiputposterior instead of ostioanterior

Comprehensive Health History

Reason for seeking care Suspicion of pregnancy Date of last menstrual period Signs and symptoms of pregnancy Urine or blood test for hCG Past medical, surgical, and personal history Woman's reproductive history: menstrual, obstetric, and gynecologic history

What can smoking while pregnant lead to?

Smoking is linked to preterm birth and low birth weights and babies can be addicted to nicotine

Assessment of Fetal Well-Being: Positive Contraction Stress Test (CST)

abnormal and indicates late decelerations on more than half of the contractions Baby decompensated; deceleration which indicated lack of oxygen to the baby; Baby is hypoxic-can be born with things like ceberal pasly or they can be fine later May result in C-section/vaginal labor BAD

Preparation for Bottle Feeding

Once the placenta no longer provides nutrition, a newborn's survival depends on the ability to consume nutrients. Recent research indicates that infants who are fed formula within the first 6 months do have an increased incidence of otitis media, diabetes, asthma, atopic dermatitis, reflux, diarrhea, colic, constipation, and lower respiratory infections (Wells, 2019). It is important to inform mothers and their partners of this. Bottle feeding an infant is not just a matter of "open, pour, and feed." Parents need information on types of formulas, preparation and storage of formula, equipment, and feeding positions. It is recommended that normal full-term infants receive conventional cow's milk-based formulas; the physician should direct this choice. If the infant has a reaction (diarrhea, vomiting, abdominal pain, excessive gas) to the first formula, another formula should be tried. Sometimes a soy-based formula is substituted. In terms of preparation of formula and its use, the following guidelines should be stressed: Obtain adequate equipment (six 4-oz bottles, eight 8-oz bottles, and nipples). Consistency is important. Stay with a nipple that is comfortable to the infant. Frequently assess nipples for any loose pieces of rubber at the opening. Correct formula preparation is critical to the health and development of the infant. Formula is available in three forms: ready-to-feed, concentrate, and powder. Read the formula label thoroughly before mixing. Correct formula dilution is important to avoid fluid imbalances. For ready-to-use formula, use as is without dilution. For concentrated formulas, dilute with equal parts of water. For powdered formulas, mix one scoop of powder with 2 oz of water. If the water supply is safe, sterilization is not necessary. If the water supply is questionable, water should be boiled for 5 minutes before use. Bottles and nipples should be washed in hot, sudsy water using a bottle brush. Formula should be served at room temperature. Formula should not be heated in a microwave oven, because it is heated unevenly. Formula can be prepared 24 hours ahead of time and stored in the refrigerator. Teach the woman and other caregivers to feed the infant in a semi-upright position using the cradle hold in the arms. This position allows for face-to-face contact between the infant and caregiver. Advise the caregiver to hold the bottle so that the nipple is kept full of formula to prevent excessive air swallowing. Instruct the caregiver to feed the infant every 3 to 4 hours and adapt the feeding times to the infant's needs. Frequent burping of the infant (every ounce) helps prevent gas from building up in the stomach. Caution the caregiver not to prop the bottle; doing so can cause choking. Bottle feeding should mirror breast-feeding as closely as possible. While nutrition is important, so are the emotional and interactive components of feeding. Encourage the caregiver to cuddle the infant closely and position the infant so that their head is in a comfortable position. Also encourage communication with the infant during feedings. Nurses should know the different types of formulas available to provide advice to mothers who have made the informed choice not to breast-feed or to stop breast-feeding.

True or False: Between 17 and 56 days of development is when drugs and alcohol can do some MAJOR damage to the fetus.

True

True or False: Increased vaginal discharge during the first trimester is a normal finding.

True

True or False: Nagele's rule to determine the expected date of birth is inaccurate for women with irregular menstrual cycles.

True

True or False: The optimal time for alpha-fetoprotein screening is 16 to 18 weeks of gestation.

True

True or False: Twins are counted as one pregnancy.

True

True or False: At 24-28 weeks it is common and normal to hear a systolic murmur because of the blood increase by 50%.

True Ex: If we heard it at 6 weeks then it would a problem because blood volume has not increased drastically yet

Urinary frequency is a common complaint during the __________ and and third trimesters.

first

What vaccines are safe for pregnant women?

flu, covid

Varicosities of the rectum, or ________, result from progesterone-induced vasodilation and the pressure of the enlarging uterus.

hemorrhoids

Assessment of Fetal Well-Being: PUBS (percutaneous umbilical blood sampling)

invasive in 3rd trimester where get blood sample from umbilical cord, needle into cord, can confirm chromosomal abnormalities

The _______method of preparing for labor involves the use of specific breathing and relaxation techniques.

lamaze

Food allergies are _______ likely to develop in a breast fed baby.

less

If an infant contracts an STI, what negative effects can occur?

mostly intellectual problems; some cause blindness, etc.

Physical Examination: Vital Signs

need a baseline

Really high levels of Maternal Serum Alpha-fetoprotein usually indicates what?

neural tube defects

The heat associated with saunas and hot tubs may cause fetal ____________.

tachycardia

Nursing Management to Promote Self-Care (cont.)

•Sleep and rest •Sexual activity and sexuality •Employment (see Teaching Guidelines 12.3) •Travel (see Teaching Guidelines 12.4) •Immunizations and medications (see Box 12.5) Okay to travel, but don't do it too close to their due dates. May have to modify medications or make them come off completely and then reinstitute them in the 3rd trimester where the risk is much less

What is done on each visit to the OB?

urinalysis--not necessarily looking at the pregnancy but more at the lab values

Doppler Flow Study

uses ultrasound waves to determine the velocity of flow of blood within vessels Looks like shark fins Usually done in the 2nd and 3rd trimesters

What other vaccines are NOT administered during pregnancy?

varicella and DTaP

Assessment of Fetal Well-Being: Alpha-Fetoprotein

•Alpha-fetoprotein analysis (Screens for: down syndrome, other congenital problems, neural tube defects; a screener so ALWAYS do follow up; some babies will come back completely fine!) Alpha-fetoprotein (AFP) is a glycoprotein produced initially by the yolk sac and fetal gut, and later predominantly by the fetal liver. In a fetus, the serum AFP level increases until approximately 14 to 15 weeks and then falls progressively. In normal pregnancies, AFP from fetal serum enters the amniotic fluid (in microgram quantities) through fetal urination, fetal gastrointestinal secretions, and transudation across fetal membranes (amnion and placenta). About 30 years ago, elevated levels of maternal serum AFP or amniotic fluid AFP were first linked to the occurrence of fetal neural tube defects. This biomarker screening test is now recommended for all pregnant women along with other prenatal screening tests depending on risk profile AFP is present in amniotic fluid in low concentrations between 10 and 14 weeks' gestation and can be detected in maternal serum beginning at approximately 12 to 14 weeks' gestation (Jordan et al., 2019). If a developmental defect is present, such as failure of the neural tube to close, more AFP escapes into amniotic fluid from the fetus. AFP then enters the maternal circulation by crossing the placenta, and the level in maternal serum can be measured. The optimal time for AFP screening is 16 to 18 weeks' gestation. Currently, ACOG recommends offering screening and diagnostic tests to all pregnant women, regardless of age or risk factors present (2019b). Correct information about gestational dating, maternal weight, race, number of fetuses, and insulin dependency is necessary to ensure the accuracy of this screening test. If incorrect maternal information is submitted or the blood specimen is not drawn during the appropriate time frame, false-positive results may occur, increasing the woman's anxiety. Subsequently, further testing might be ordered based on an inaccurate interpretation, resulting in additional financial and emotional costs to the woman. A variety of situations can lead to elevation of maternal serum AFP, including open neural tube defects, underestimation of gestational age, the presence of multiple fetuses, gastrointestinal defects, low birth weight, oligohydramnios, maternal age, diabetes, and decreased maternal weight (King et al., 2019). Lower-than-expected maternal serum AFP levels are seen when fetal gestational age is overestimated or in cases of fetal death, hydatidiform mole, increased maternal weight, maternal type 1 diabetes, and fetal trisomy 21 (Down syndrome) or trisomy 18 (Edward syndrome) (Adigun & Bhimji, 2019). Measurement of maternal serum AFP is minimally invasive, requiring only a venipuncture for a blood sample. AFP has now been combined with other biomarker screening tests (triple, quad, or penta screens) to determine the risk of neural tube defects and Down syndrome. Nursing management for AFP testing consists of preparing the woman for this screening test by gathering accurate information about the date of her LMP, weight, race, and gestational dating. Accurately determining the window of 16 to 18 weeks' gestation will help ensure that the test results are correct. Also explain that the test involves obtaining a blood specimen.

Normal -up Visits

•Visit schedule: -Every 4 weeks up to 28 weeks -Every 2 weeks from 29 to 36 weeks -Every week from 37 weeks to birth Visit schedule doubles for high risk pregnancies •Assessments -Weight and BP compared to baseline values -Urine testing for protein, glucose, ketones, and nitrites -Fundal height (see Figure 12.5) -Quickening (occurs b/w 16 to 20 weeks)/fetal movement (see Box 12.4) -Fetal heart rate (see Nursing Procedure 12.1) •Teaching: danger signs

When do we test pregnant women's blood sugar?

24-28 weeks gestation is when we test blood sugar; if they have insulin resistance, DM, PCOS, etc. then we will test the day of first appointment

Assessment of Fetal Well-Being: Biophysical Profile

A biophysical profile (BPP) uses a real-time ultrasound and NST to allow assessment of various parameters of fetal well-being that are sensitive to hypoxia. A BPP includes ultrasound monitoring of fetal movements, fetal tone, and fetal breathing as well as ultrasound assessment of amniotic fluid volume with or without assessment of the fetal heart rate. A BPP is performed in an effort to identify infants who may be at risk of poor pregnancy outcome, so that additional assessments of well-being may be performed or labor may be induced or a cesarean section performed to expedite birth. The primary objectives of the BPP are to reduce stillbirth and to detect hypoxia early enough to allow delivery in time to avoid permanent fetal damage resulting from fetal asphyxia. These parameters, together with the NST, constitute the BPP. Each parameter is controlled by a different structure in the fetal brain: fetal tone by the cortex; fetal movements by the cortex and motor nuclei; fetal breathing movements by the centers close to the fourth ventricle; and the NST by the posterior hypothalamus and medulla. The amniotic fluid is the result of fetal urine volume. Some facilities do not perform an NST unless other parameters of the profile are abnormal (King et al., 2019). The BPP is based on the concept that a fetus that experiences hypoxia loses certain behavioral parameters in the reverse order in which they were acquired during fetal development (normal order of development: tone at 8 weeks; movement at 9 weeks; breathing at 20 weeks; and fetal heart rate reactivity at 24 weeks).

Laboratory Tests

A series of tests is generally ordered during the initial visit so that baseline data can be obtained, allowing for early detection and prompt intervention if any problems occur. Tests that are generally conducted for all pregnant women include urinalysis and blood studies. The urine is analyzed for albumin, glucose, ketones, and bacteria casts. Blood studies usually include a complete blood count (CBC) (hemoglobin, hematocrit, red and white blood cell counts, and platelets), blood typing and Rh factor, glucose screening for high-risk women, a rubella titer, hepatitis B surface antibody antigen, HIV, venereal disease research laboratory (VDRL) or rapid plasma reagin (RPR) tests, and cervical smears to detect STIs (Common Laboratory and Diagnostic Tests 12.1). In addition, most offices and clinics have ultrasound equipment available to validate an intrauterine pregnancy and assess early fetal growth. The need for additional laboratory studies is determined by a woman's history, physical examination findings, current health status, and risk factors identified in the initial interview. Additional tests can be offered (e.g., screening for genetic diseases, blood lead screening, rubeola, and so on), but ultimately the woman and her partner make the decision about undergoing them. Educate the client and her partner about the tests, including the rationale. In addition, support the client and her partner in their decision-making process, regardless of whether you agree with the couple's decisions. The couple's decisions about their health care are based on the ethical principle of autonomy, which allows an individual the right to make decisions about their own body. •Urinalysis (Ketones, drinking 8 glasses of water a day? UTI/STI?, proteinuria can be indicative of problem with BP; glucosuria?) •Complete blood count (Hemoglobin and Hematocrit, RBC/WBC/Platelet Count; less than 12 we are concerned about iron deficiency anemia (Ex: If 6 weeks pregnant we would give iron, but if a woman is at the end of her pregnancy then we won't mess with her) +Evaluates hemoglobin (12-14 g) and hematocrit (42% ± 5%) levels and red blood cell count (4.2-5.4 million/mm3) to detect the presence of anemia; identifies white blood cell level (5,000-10,000 mm−3), which if elevated, may indicate an infection; determines platelet count (150,000-450,000 mL3) to assess clotting ability •Blood typing •Rh factor (If mother is Rh- and father is Rh+ it does not matter the first pregnancy, but all the others will be an issue.; we give Rogam at 28 weeks and when else? to block antibodies that fight against Rh+ blood. (Ex: + and + no issues; - and - no issues) +Determines woman's blood type and Rh status to rule out any blood incompatibility issues early; Rh-negative mother would likely receive RhoGAM (at 28 weeks' gestation) and again within 72 hours after childbirth if she is Rh-sensitive •Rubella titer +Detects antibodies for the virus that causes German measles; if titer is 1:8 or less, the woman is not immune; requires immunization after birth, and the woman is advised to avoid people with undiagnosed rashes •Hepatitis B surface antigen +Determines if the mother has hepatitis B by detecting presence of hepatitis antibody surface antigen (HbsAg) in her blood •HIV, VDRL, and RPR testing +Detects HIV antibodies and if positive, requires more specific testing, counseling, and treatment during pregnancy with antiretroviral medications to prevent transmission to fetus •Cervical smears +Detects abnormalities such as cervical cancer (Pap test) or infections such as gonorrhea, chlamydia, or group B streptococcus so that treatment can be initiated if positive •Ultrasound

Assessment of Fetal Well-Being: Amniocentesis

A technique of prenatal diagnosis in which amniotic fluid, obtained by aspiration from a needle inserted into the uterus, is analyzed to detect certain genetic and congenital defects in the fetus. VERY INVASIVE Sterile procedure; awake with a little bit of lidocaine; we may give sedation to the mother but we do not want too much to the point that it makes the baby move too much and they hit the needle. DIAGNOSITIC RESULTS, NOT SCREENING SO A 100% WE WILL KNOW WHAT IS GOING ON Sometimes in the 3rd trimester we can do this to see if baby needs to be delivered sooner; for example a pregnant woman who has a 10 pound baby and still has a month to go; if the fluid says the lungs are good then we would go ahead and deliver the baby! Amniocentesis involves a transabdominal puncture of the amniotic sac to obtain a sample of amniotic fluid for analysis. The fluid contains fetal cells that are examined to detect chromosomal abnormalities and several hereditary metabolic defects in the fetus before birth. In addition, amniocentesis is used to confirm a fetal abnormality when other screening tests detect a possible problem. Amniocentesis is performed in the second trimester, usually between 15 and 20 weeks' gestation. At this age, the amount of fluid is adequate (approximately 150 mL), and the ratio of viable to nonviable cells is the greatest. About 20 mL is removed for a sample to be tested (March of Dimes, 2020c). More than 40 different chromosomal abnormalities, inborn errors of metabolism, and neural tube defects can be diagnosed with amniocentesis. It can replace a genetic probability with a diagnostic certainty, allowing the woman and her partner to make an informed decision about the option of therapeutic abortion. Amniocentesis can be performed in any of the three trimesters of pregnancy. An early amniocentesis (performed between weeks 11 and 14) is done to detect genetic anomalies. However, early amniocentesis has been associated with a high risk of spontaneous miscarriage and postprocedural amniotic fluid leakage compared with transabdominal chorionic villus screening (King et al., 2019). In the second trimester, the procedure is performed between 15 and 20 weeks to detect chromosomal abnormalities, evaluate the fetal condition when the woman is sensitized to the Rh-positive blood, diagnose intrauterine infections, and investigate amniotic fluid AFP when the MSAFP level is elevated (March of Dimes, 2020c). In the third trimester, amniocentesis is most commonly indicated to determine fetal lung maturity after the 35th week of gestation via analysis of lecithin-to-sphingomyelin ratios and to evaluate the fetal condition with Rh isoimmunization. Table 12.2 lists amniotic fluid analysis findings and their implications. Procedure Amniocentesis is performed after an ultrasound examination identifies an adequate pocket of amniotic fluid free of fetal parts, the umbilical cord, or the placenta (Fig. 12.7). The health care provider inserts a long pudendal or spinal needle, a 22-gauge, 5-in needle, into the amniotic cavity and aspirates amniotic fluid, which is placed in an amber or foil-covered test tube to protect it from light. When the desired amount of fluid has been withdrawn (about 20 mL), the needle is removed and slight pressure is applied to the site. If there is no evidence of bleeding, a sterile bandage is applied to the needle site. The specimens are then sent to the laboratory immediately for the cytologist to evaluate. Examining a sample of fetal cells directly produces a definitive diagnosis rather than a "best guess" diagnosis based on indirect screening tests. It is an invaluable diagnostic tool, but the risks include lower abdominal discomfort and cramping that may last up to 48 hours after the procedure, spontaneous abortion (one in 300 to 500), maternal or fetal infection, postamniocentesis chorioamnionitis that has an insidious onset, fetal-maternal hemorrhage, leakage of amniotic fluid in 2% to 3% of women after the procedure, and higher rates of fetal loss in earlier amniocentesis procedures (earlier than 15 weeks' gestation) versus later ones (Ghidini, 2019). Obtaining the test results may take up to 3 weeks. Women today are choosing noninvasive prenatal testing rather than undergoing invasive testing such as amniocentesis despite those tests not being 100% correct. Women with reassuring noninvasive results and normal ultrasound findings seem satisfied over the risk of procedure-related pregnancy loss (Norwitz et al., 2019). The number of invasive procedures has declined since the availability of noninvasive prenatal testing, and it is predicted that they will replace the more invasive procedures in the future. Nursing Management When preparing the woman for an amniocentesis, explain the procedure and its potential complications, and encourage her to empty her bladder just before the procedure to avoid the risk of bladder puncture. Inform her that a 20-minute electronic fetal monitoring strip is usually obtained to evaluate fetal well-being and obtain a baseline to compare after the procedure is completed. Obtain and record maternal vital signs.After the procedure, assist the woman into a position of comfort and administer RhoGAM intramuscularly if the woman is Rh-negative to prevent potential sensitization to fetal blood. Assess maternal vital signs and fetal heart rate every 15 minutes for an hour after the procedure. Observe the puncture site for bleeding or drainage. Instruct the client to rest after returning home and remind her to report fever, leaking amniotic fluid, vaginal bleeding, or uterine contractions or any changes in fetal activity (increased or decreased) to the health care provider. When the test results come back, be available to offer support, especially if a fetal abnormality is found. Also prepare the woman and her partner for the need for genetic counseling. Trained genetic counselors can provide accurate medical information and help couples interpret the results of the amniocentesis so they can make the decisions that are right for them as a family.

Danger Signs of Pregnancy: First Semester

-Bleeding -Painful urination -Severe/persistent vomiting -Lower abdominal pain -High Fever *No tubs, because we do not want to elevate temperature *Atopic pregnancies are EMERGENCIES, b/c of all the blood loss It is important to educate the client about danger signs during pregnancy that require further evaluation. Explain that she should contact her health care provider immediately if she experiences any of the following: + During the first trimester: spotting or bleeding (miscarriage), painful urination (infection), severe persistent vomiting (hyperemesis gravidarum), fever higher than 100°F (37.7°C; indicative of infection), and lower abdominal pain with dizziness and accompanied by shoulder pain (indicative of ruptured ectopic pregnancy).

Obstetric History: Terminology

-G (gravida): the current pregnancy + twins count as 1 pregnancy -T (term births): the number of pregnancies ending >37 weeks' gestation, at term -P (preterm births): the number of preterm pregnancies ending >20 weeks or viability but before completion of 37 weeks -A (abortions): the number of pregnancies ending before 20 weeks or viability -L (living children): number of children currently living

Ex: •M.A. is a 20 YO G2P0 at 36 weeks' gestation. She presents to you during her prenatal visit with c/o of decreased fetal movement. Her OB history is significant for gestational diabetes. You obtain the following VS: BP-130/88, P-84, R-14, T-97 and place M.A. on the fetal monitor for a non stress test (NST). •After 30 minutes of monitoring, you observe a fetal heart rate baseline of 160-165 bpm, no decelerations, and no accelerations. No contractions noted. -How can M.A.'s NST be interpreted? -What further testing can you expect for M.A.?

-Non reactive NST -Biophysical Profile

Danger Signs of Pregnancy: Second Semester

-S/S of preterm labor (PTL) -Gush or leaking of fluid -Absence of fetal movement -Sudden weight gain; facial weight gain from fluid due to increased BP *S/S of Preterm Labor: Low back ache, pelvic pressure, diarrhea, general stomach upset + During the second trimester: regular uterine contractions (preterm labor); pain in calf, often increased with foot flexion (indicative of DVT); sudden gush or leakage of fluid from vagina (prelabor rupture of membranes); and absence of fetal movement for more than 12 hours (indicative of possible fetal distress or demise).

Danger Signs of Pregnancy: Third Semester

-S/S preeclampsia (Headache with vision issues) -Decreased or absent fetal movement Bleeding + During the third trimester: sudden weight gain (usually a BP issue); periorbital or facial edema, severe upper abdominal pain (can be a liver rupture), or headache with visual changes (indicative of gestational hypertension and/or preeclampsia); and a decrease in fetal daily movement for more than 24 hours (indicative of possible demise).

Fundal Height Measurement

-after the uterus reaches a position that is palpable above the umbilicus -tape measure is placed with zero mark on the anterior aspect of the symphysis pubis -the measurement is taken at the palpable fundus (top) of the uterus -measurement in centimeters should = approx weeks of pregnancy (plus of minus 2-3 cm)

Normal Fetal Heart Rate

110-160 beats per minute

Nagele's Rule

1st day of LMP - 3 months + 7 days + 1 yr EX: 11/21/19 8/21/19 8/28/19 8/28/20 = EDB

Non Stress Test (Reactive)

2 accelerations in the HR within 20 mins --15 beats above baseline (resting HR) x 15 seconds duration means that the baby is well oxygenated

Assessment of Fetal Well-Being: Doppler Flow Studies

Doppler ultrasonography is the use of sound waves to examine the flow of blood in blood vessels. Comprehensive assessment of fetal well-being involves monitoring of fetal growth, placental function, central venous pressure, and cardiac function. Ultrasound evaluation of the fetus using 2D, color Doppler, and pulse-wave Doppler techniques forms the foundation of prenatal diagnosis of structural anomalies, rhythm abnormalities, and altered fetal circulation (Cunningham et al., 2018). Doppler flow studies can be used to measure the velocity of blood flow via ultrasound. Doppler flow studies can detect fetal compromise in high-risk pregnancies. The test is noninvasive and has no contraindications. The color images produced help to identify abnormalities in diastolic flow within the umbilical vessels. The velocity of the fetal red blood cells can be determined by measuring the change in the frequency of the sound wave reflected off the cells. Thus, Doppler flow studies can detect the movement of red blood cells in vessels to investigate fetal hemodynamics to use these findings for fetal surveillance (Maulik, 2020). In pregnancies complicated by hypertension or FGR, diastolic blood flow may be absent or even reversed (King et al., 2019). Doppler flow studies can also be used to evaluate the blood flow through other fetal blood vessels, such as the aorta and those in the brain. Research continues to determine the indications for Doppler flow studies to improve pregnancy outcomes. Nursing management of the woman undergoing Doppler flow studies is similar to that described for an ultrasound.

Ex: Miss Ann is 6 months pregnant. She had one miscarriage in the first trimester previously. Has one daughter that is 2 years old--born at 32 weeks gestation. Her other daughter is 6--born at 38 weeks.

G-4 T-1 P-1 A-1 L-2

Assessment of Fetal Well-Being: Negative Contraction Stress Test (CST)

GOAL: 3 contractions in 10 mins that last at least 40 seconds Negative b/c nothing bad happened AND WE SEE ACCELERATIONS; trying to figure out how well the fetus is handling the contractions Done when they reach viability so over 24 weeks Only done in L+D, not clinic because we can do something about in the hospital GOOD

Physical Examination: Head to Toe Assessment

HEAD AND NECK Assess the head and neck area for any previous injuries and sequelae. Evaluate for any limitations in range of motion. Palpate for any enlarged lymph nodes or swelling. Note any edema of the nasal mucosa or hypertrophy of gingival tissue in the mouth; these are typical responses to increased estrogen levels in pregnancy. Palpate the thyroid gland for enlargement. Slight enlargement is normal, but marked enlargement may indicate hyperthyroidism, requiring further investigation. CHEST Auscultate heart sounds, noting any abnormalities. A soft systolic murmur caused by the increase in blood volume may be noted. Anticipate an increase in heart rate by 10 to 15 beats per minute (bpm) (starting between 14 and 20 weeks of pregnancy) secondary to increases in cardiac output and blood volume. The body adapts to the increase in blood volume with peripheral dilation to maintain blood pressure. Progesterone causes peripheral dilation. Auscultate the chest for breath sounds, which should be clear. Also note symmetry of chest movement and thoracic breathing patterns. Estrogen promotes relaxation of the ligaments and joints of the ribs with a resulting increase in the anteroposterior chest diameter. Expect a slight increase in respiratory rate to accommodate the increase in tidal volume and oxygen consumption. Inspect and palpate the breasts and nipples for symmetry and color. Increases in estrogen and progesterone and blood supply make the breasts feel full and more nodular with increased sensitivity to touch. Blood vessels become more visible and there is an increase in breast size. Striae gravidarum (stretch marks) may be visible in women with large breasts. Darker pigmentation of the nipple and areola is present, along with enlargement of Montgomery glands. Colostrum (yellowish secretion that precedes mature breast milk) is excreted typically in the third trimester, but it can be seen as early as the second trimester. ABDOMEN The appearance of the abdomen depends on the number of weeks of gestation. The abdomen enlarges progressively as the fetus grows. Inspect the abdomen for striae, scars, shape, and size. Inspection may reveal striae gravidarum and the linea nigra, a thin brownish black pigmented line running from the umbilicus to the symphysis pubis, depending on the duration of the pregnancy. Palpate the abdomen, which should be rounded and nontender. A decrease in muscle tone may be noted due to the influence of progesterone. Typically, the height of the fundus is measured when the uterus arises out of the pelvis to evaluate fetal growth. At 12 weeks' gestation, the fundus can be palpated at the symphysis pubis. At 16 weeks' gestation, the fundus is midway between the symphysis and the umbilicus. At 20 weeks, the fundus can be palpated at the umbilicus and measures approximately 20 cm from the symphysis pubis. By 36 weeks, the fundus is just below the xiphoid process and measures approximately 36 cm. The uterus maintains a globular/ovoid shape throughout pregnancy (Jarvis, 2020). EXTREMTIES Inspect and palpate both legs for dependent edema, pulses, and varicose veins. If edema is present in early pregnancy, further evaluation may be needed to rule out gestational hypertension. During the third trimester, dependent edema is a normal finding. Ask the woman if she has any pain in her calf that increases when she ambulates. This might indicate a deep vein thrombosis (DVT). High levels of estrogen during pregnancy place women at higher risk for DVT. PELVIC EXAM -Pelvic Exam; collect gonorrhea/chlamydia/syphyllis cultures; biannual exam to palpate the sex organs The pelvic examination provides information about the internal and external reproductive organs. In addition, it aids in assessing some of the presumptive and probable signs of pregnancy and allows for determination of pelvic adequacy. During the pelvic examination, remain in the examining room to assist the health care provider with any specimen collection, fixation, and labeling. Also provide comfort and emotional support for the woman, who might be anxious. Throughout the examination, explain what is happening and why, and answer any questions as necessary. EXTERNAL GENITALIA After the client is placed in the lithotomy position and draped appropriately, the external genitalia are inspected visually. They should be free from lesions, discharge, hematomas, varicosities, and inflammation upon inspection. A culture for STIs may be collected at this time. INTERNAL GENITALIA Next, the internal genitalia are examined via a speculum. The cervix should be smooth, long, thick, and closed. Because of increased pelvic congestion, the cervix will be softened (Goodell sign), the uterine isthmus will be softened (Hegar sign), and there will be a bluish coloration of the cervix and vaginal mucosa (Chadwick sign). The uterus is typically pear shaped and mobile with a smooth surface. It will undergo cell hypertrophy and hyperplasia so that it enlarges throughout the pregnancy to accommodate the growing fetus. During the pelvic examination, a Papanicolaou (Pap) smear may be obtained. Additional cultures, such as for gonorrhea and chlamydia screening, may also be obtained. Ensure that all specimens obtained are labeled correctly and sent to the laboratory for evaluation. A rectal examination is done last to assess for lesions, masses, prolapse, or hemorrhoids. Once the examination of the internal genitalia is completed and the speculum is removed, a bimanual examination is performed to estimate the size of the uterus to confirm dates and to palpate the ovaries. The ovaries should be small and nontender without masses. At the conclusion of the bimanual examination, the health care provider reinserts the index finger into the vagina and the middle finger into the rectum to assess the strength and regularity of the posterior vaginal wall.

Everyone who is pregnant is tested for what? Why?

HIV; prophylaxis

Rubella vaccines have to be given after pregnancy? Why?

Live virus vaccine Does leave the baby open to deafness, blindness, and miscarriage

Fasting Blood Glucose for Pregnant Women

Preconception and interconception counseling should address the importance of glycemic control, ideally an A1c level lower than 6.5% to reduce the risk of congenital anomalies, preeclampsia, macrosomia, and other complications. A1c is a blood test that measures the average blood glucose level over the previous 3 months to determine glucose control and management. Fasting and postprandial self-monitoring of blood glucose are recommended to achieve glycemic control. Due to increased red blood cell turnover, A1c is slightly lower during pregnancy. The target A1c should be lower than 6% to 7% to prevent hypoglycemia. The ADA recommends targets for women with type 1 or type 2 diabetes as follows: Fasting: lower than 95 mg/dL 1-hour postprandial: lower than 140 mg/dL 2-hour postprandial: lower than 120 mg/dL Insulin is the preferred medication for treating hyperglycemia in gestational diabetes as it doesn't cross the placenta to a measurable extent. If oral hypoglycemic agents are used, they shouldn't be the first-line therapy since there are no safety data from long-term studies yet.

Preparation for Breast Feeding

Substantial scientific evidence documents the health benefits of breast-feeding for newborns. Current evidence cited by the AAP showed improved outcomes for breast-fed infants with regard to otitis media, lower respiratory infections, gastroenteritis, atopic dermatitis, childhood asthma, childhood obesity, type 1 and type 2 diabetes, childhood leukemia, sudden infant death syndrome, and cognitive development, and for their mothers with regard to breast cancer, ovarian cancer, and type 2 diabetes. The AAP recommends that infants be breast-fed exclusively until the age of 6 months and continue to be breast-fed for a year and/or for as long as it is mutually desired (2019). In addition, a lack of breast-feeding contributes to a negative impact on the health care system by increasing the number of client visits, hospital admissions, rate of obesity, and health care costs. Most researchers agree that the duration of breast-feeding is inversely associated with overweight risk. Breast-feeding is a cost-effective, natural, and effective prevention strategy for reducing childhood obesity. Human milk provides an ideal balance of nutrients for newborns (ACOG, 2019e). Breast-feeding is advantageous for the following reasons: Human milk is digestible and economical and requires no preparation. Bonding between mother and child is promoted. Cost is less than purchasing formula. Ovulation is suppressed (however, this is not a reliable birth control method). The risk of ovarian cancer and the incidence of premenopausal breast cancer are reduced for the woman. Extra calories are used, which promotes weight loss gradually without dieting. Oxytocin is released to promote more rapid uterine involution with less bleeding. Sucking helps to develop the muscles in the infant's jaw. Absorption of lactose and minerals in the newborn is improved. The immunologic properties of breast milk help prevent infections in the baby. The composition of breast milk adapts to meet the infant's changing needs as they grow. Constipation in the baby is not a problem with adequate intake. Food allergies are less likely to develop in the breast-fed baby. The incidence of otitis media and upper respiratory infections in the infant is reduced. Breast-fed babies are less likely to be overfed, thus reducing the risk of adult obesity. Breast-fed newborns are less prone to vomiting (AAP, 2019; ACOG, 2019e; American Academy of Family Physicians, 2019; U.S. Preventive Services Task Force [USPSTF], 2019). One could say that lactation and breast-feeding are so natural that they should just happen on their own accord, but this is not always the case. Learning to breast-feed takes practice, requires support from the partner, and requires dedication and patience on the part of the mother; it may be necessary to work closely with a lactation consultant to be successful and comfortable when breast-feeding. Figure 12.14 shows the different positions that may be used for breast-feeding. Nurses can encourage breast-feeding for all mothers except those who are HIV-positive and are untreated, have active tuberculosis, use illicit drugs, or take prescribed cancer chemotherapeutic agents. Nurses can also advise new mothers who breast-feed their infants that the use of pacifiers does not interfere with breast-feeding success (La Leche League International, 2020a). However, breast-feeding has some uncomfortable side effects for the mother. These include breast discomfort, sore nipples, mastitis, engorgement, breast abscess, milk stasis, flat or inverted nipples, vaginal dryness, and decreased libido (Jordan et al., 2019). The most common cause of nipple pain is an improper latch, and such discomfort is usually piercing, immediate, and short-lived, typically occurring as soon as the baby starts nursing and gradually subsiding during the feeding. Some mothers feel it is inconvenient or embarrassing, limits other activities, limits partner involvement, increases their dependency by being tied to the infant all the time, and restricts their use of alcohol or drugs. Nurses can help mothers cope with their fear of dependency and feelings of obligation by emphasizing the positive aspects of breast-feeding and encouraging bonding experiences. Nurses can be instrumental in helping mothers prepare and continue to breast-feed after they return to work. PREPARATION FOR BREAST-FEEDING Nipple preparation is not necessary during the prenatal period unless the nipples are inverted and do not become erect when stimulated. Assess for this by placing the forefinger and thumb above and below the areola and compressing behind the nipple. If it flattens or inverts, advise the client to wear breast shields during the last 2 months of pregnancy. Breast shields exert a continuous pressure around the areola, pushing the nipple through a central opening in the inner shield (La Leche League International, 2020b). The shields are worn inside the bra. Initially the shields are worn for 1 hour, and then the woman progressively increases the wearing time up to 8 hours daily. The client maintains this schedule until after childbirth, and then she wears the shield 24 hours a day until the infant latches on easily (La Leche League International, 2020b). In addition, suggest that the woman wear a supportive nursing bra 24 hours a day. Encourage the woman to request a certified lactation specialist (CLS) at the hospital, if giving birth there. Lactation specialists are health care providers who specialize in the clinical management of breast-feeding. Some run their own breast-feeding support groups as well. In addition, suggest that the woman attends a breast-feeding support group (e.g., La Leche League), provide her with sources of information about infant feeding, and suggest she reads a good reference book about lactation. All of these activities will help in her decision-making process and will be invaluable to her should she choose to breast-feed her newborn. Women returning to work can pump their breasts and store the milk in the freezer for future use.

Assessment of Fetal Well-Being: Biophysical Profile (Scoring and Interpretation)

The BPP is a scored test with five components, each worth two points if present. A total score of 10 is possible if the NST is used. Thirty minutes are allotted for testing, though less than 10 minutes are usually needed. The following criteria must be met to obtain a score of 2; anything less is scored as 0 (Blackburn, 2018): Body movements: three or more discrete limb or trunk movements Fetal tone: one or more instances of full extension and flexion of a limb or trunk Fetal breathing: one or more fetal breathing movements of more than 30 seconds Amniotic fluid volume: one or more pockets of fluid measuring 2 cm NST: normal NST = 2 points; abnormal NST = 0 points Interpretation of the BPP score can be complicated, depending on several fetal and maternal variables. Because it is indicated as a result of a nonreassuring finding from previous fetal surveillance tests, this test can be used to quantify the interpretation, and intervention can be initiated if appropriate. A maximum score of 10 can be achieved and the test is complete once all of the variables have been observed. For the test to be judged abnormal and a score of zero awarded for the absence of fetal movement, fetal tone, or fetal breathing movements, a period of not less than 30 minutes must have elapsed. Because of the excellent sensitivity of fetal NST for fetal acidemia, it has been proposed that this acute marker alone may be used for fetal assessment in combination with the amniotic fluid volume assessment, a chronic marker. This combination, also known as the modified BPP, has been shown to have excellent false-negative rates that compare with those of the complete BPP. In addition, a recent study reported that BPP scores correlates fairly closely with the Apgar scores obtained after birth (Manning, 2019). One of the important factors is the amniotic fluid volume, taken in conjunction with the results of the NST. Amniotic fluid is largely composed of fetal urine. As placental function decreases, perfusion of fetal organs, such as kidneys, decreases, and this can lead to a reduction of amniotic fluid. If oligohydramnios or decreased amniotic fluid is present, the potential exists for antepartum or intrapartum fetal compromise (Crum et al., 2019). Overall, a score of 8 to 10 is considered normal if the amniotic fluid volume is adequate. A score of 6 or below is suspicious, possibly indicating a compromised fetus; further investigation of fetal well-being is needed. Because the BPP is an ultrasonographic assessment of fetal behavior, it requires more extensive equipment and more highly trained personnel than other testing modalities. The cost is much greater than those of less sophisticated tests. It permits conservative therapy and prevents premature or unnecessary intervention. There are fewer false-positive results than with the NST alone (Norwitz et al., 2019).

Follow-Up Visit Intervals and Assessments

Up to 28 weeks' gestation, follow-up visits involve assessment of the client's blood pressure and weight. The urine is tested for protein and glucose. Fundal height and fetal heart rate are assessed at every office visit. The best procedure for screening and diagnosing gestational diabetes remains controversial. All strategies involve an oral glucose test, but there remains disagreement about how many grams of glucose (50, 75, or 100) the woman ingests and how long afterward her blood sample is drawn. A recent release of Standards of Medical Care in Diabetes - 2020 by the ADA (2020) concluded that there was insufficient evidence to determine which assessment test is the best method to use to identify women who have gestational diabetes. Screening for gestational diabetes is best done between 24 and 28 weeks' gestation, unless screening is warranted in the first trimester for high-risk reasons (obesity, older age, family history of diabetes, history of gestational diabetes, or woman is of Hispanic, Native Americans, Asian, or African American descent) (ADA, 2020). Between weeks 24 and 28, a blood glucose level is obtained using an oral 50-g glucose load followed by a 1-hour plasma glucose determination. If the result is more than to 140 mg/dL, further testing, such as a 3-hour 100-g glucose tolerance test, is warranted to determine whether gestational diabetes is present (ADA, 2020). Because insulin resistance increases as pregnancy advances, testing at this gestational point yields a higher rate of abnormal test results. During this time, review the common discomforts of pregnancy, evaluate any client complaints, and answer questions. Reinforce the importance of good nutrition and use of prenatal vitamins, along with daily exercise. Between 29 and 36 weeks' gestation, all the assessments of previous visits are completed, along with assessment for edema. Special attention is focused on the presence and location of edema during the last trimester. Pregnant women commonly experience dependent edema of the lower extremities from constriction of blood vessels secondary to the heavy gravid uterus. Periorbital edema around the eyes, edema of the hands, and pretibial edema (edema on the front, or shin part of the leg) are abnormal and could be signs of gestational hypertension. Inspecting and palpating both extremities, listening for complaints about rings becoming too tight on the fingers, and observing for swelling around the eyes are important assessments. Abnormal findings in any of these areas need to be reported. If the mother is Rh-negative, her antibody titer is evaluated. RhoGAM is given if indicated. RhoGAM is used to prevent development of antibodies to Rh-positive red cells whenever fetal cells are known or suspected of entering the maternal circulation such as after a spontaneous abortion or amniocentesis. It is also recommended for prophylaxis at 28 weeks' gestation and following birth if the infant is Rh-positive (King et al., 2019). The client is also evaluated for risk of preterm labor. At each visit, ask if she is experiencing any common signs or symptoms of preterm labor (e.g., uterine contractions, dull backache, feeling of pressure in the pelvic area or thighs, increased vaginal discharge, menstrual-like cramps, vaginal bleeding). If the woman has had a previous preterm birth, she is at risk for another, and close monitoring is warranted. An initial preterm labor evaluation if the woman reports signs and symptoms of preterm labor includes: review of prenatal record for risk factors; evaluation of reported symptoms (uterine contractions, vital signs, fetal heart rate, pelvic exam for cervical dilation and effacement assessment, and status of fetal membranes); and a urine culture to diagnose asymptomatic bacteriuria (Jordan et al., 2019). If positive for preterm labor, the woman may be requested to rest, and medications to stop contractions may be in order. Counsel the woman about choosing a health care provider for the newborn if she has not selected one yet. Along with completion of a breast assessment, the nurse should discuss and educate the client about the choice of breast-feeding versus bottle feeding. The American Academy of Pediatrics (AAP) does encourage all mothers to breast-feed their offspring, but the decision to do so is ultimately the woman's. The nurse can refer the client to the Nursing Mothers and La Leche League websites for further information to assist her in making that decision. Reinforce the importance of daily fetal movement monitoring as an indicator of fetal well-being. Reevaluate hemoglobin and hematocrit levels to assess for anemia. Between 37 and 40 weeks' gestation, the same assessments are done as for the previous weeks. In addition, screening for group B streptococcus, gonorrhea, and chlamydia is done. Fetal presentation and position (via Leopold maneuvers) are assessed. Review the signs and symptoms of labor, and forward a copy of the prenatal record to the hospital labor department for future reference. Review the client's desire for family planning after birth as well as her decision to breast-feed or bottle feed. Remind the client that an infant car seat is required by law and must be used to drive the newborn home from the hospital or birthing center.

Gestational Wheel

Used by RN or OB/Gyn or midwife to determine EDC

Assessment of Fetal Well-Being: Nuchal Translucency

the amount of fluid behind the neck of the fetus; also known as the nuchal fold. fetuses at risk for down syndrome tend to have a higher amount of fluid Linked with chromosomal abnormalities •At 11 to 14 weeks, this con be seen in babies with Down Syndrome Nuchal translucency screening (ultrasound) is also done in the first trimester between 11 and 14 weeks. This allows for early detection and diagnosis of some fetal chromosomal and structural abnormalities. Over the years, it has become clear that increased nuchal translucency is a marker for chromosomal abnormalities and is also associated with a wide spectrum of structural anomalies, genetic syndromes, and high risk of abortion and fetal death (Levy, 2019). Ultrasound is used to identify an increase in nuchal translucency, which is due to the subcutaneous accumulation of fluid behind the fetal neck. Increased nuchal translucency is associated with chromosomal abnormalities such as trisomies 21, 18, and 13. Infants with trisomies tend to have more collagen and elastic connective tissue, allowing for accumulation. In addition, diaphragmatic hernias, cardiac defects, and fetal skeletal and neurologic abnormalities have been associated with increased nuchal translucency measurements (Leung & Qiao, 2019). See Chapter 10 for more information.

Vena Cava Syndrome (Supine Hypotensive Syndrome)

uterus compresses the aorta and vena cava when mother is supine decreasing fetoplacental blood flow. Tx is changing position of mother, elevating one hip in a side-lying position When woman lay all the way back BP will go down fast!: Supine hypotensive syndrome Wedge or lying to the side is meant to push the uterus to one side to or the other! Never lay a women flat on their back in the 2nd-3rd trimester; they need a wedge

Second Trimester Discomforts Teachings

•Backache Musculoskeletal pain is a common occurrence during pregnancy and the postpartum period. Up to 75% of women report having back pain at some point during pregnancy. This can seriously impact the quality of life of women and have socioeconomic impacts from lost days at work. The pain can be lumbar or sacroiliac. The pain may also be present only at night. Back pain is thought to be due to multiple factors, which include shifting of the center of gravity caused by the enlarging uterus, increased joint laxity due to an increase in relaxin, stretching of the ligaments (which are pain-sensitive structures), and pregnancy-related circulatory changes. Treatment includes heat and ice, acetaminophen, massage, proper posturing, good support shoes, and a good exercise program for strength and conditioning. Pregnant women may also relieve back pain by placing one foot on a stool when standing for long periods of time and placing a pillow between the legs when lying down (Jordan et al., 2019). After ruling out other potential causes such as uterine contractions, urinary tract infection, ulcers, or musculoskeletal back disorders, the following instructions may be helpful: Maintain correct posture with head up and shoulders back. Wear low-heeled shoes with good arch support. Get daily exercise to strengthen back muscles. Swimming or aquatic therapy relieves joint and muscle pressure. Consider investing in a firm mattress for better back support. When standing for long periods, place one foot on a stool or box. Use good body mechanics when lifting objects. Sleep on one side with a pillow between the legs for support. When sitting, use foot supports and pillows behind the back. Try pelvic tilt or rocking exercises to strengthen the back (ACOG, 2019c). The pelvic tilt or pelvic rock is used to alleviate pressure on the lower back during pregnancy by stretching the core lower back muscles. It can be done sitting, standing, or on all fours. To do it on all fours, the hands are positioned directly under the shoulders and the knees under the hips. The back should be in a neutral position with the head and neck aligned with the straight back. The woman then presses up with the lower back and holds this position for a few seconds, then relaxes to a neutral position. This action of pressing upward is repeated frequently throughout the day to prevent a sore back (Kellerman & Rakel, 2019). Avoid standing or sitting in one position for long periods. Apply heating pad (low setting) to the small of your back. Support your lower back with pillows when sitting. Use proper body mechanics for lifting anything. Avoid excessive bending, lifting, or walking without rest periods. Wear supportive low-heeled shoes; avoid high heels. Stand with your shoulders back to maintain correct posture. •Varicosities of the vulva and legs Varicose veins are abnormally enlarged superficial veins due to vasodilation caused by progesterone's effects on the vessel walls and valves. Varicosities of the vulva and legs are associated with the increased venous stasis caused by the pressure of the gravid uterus on pelvic vessels. Progesterone relaxes the vein walls, making it difficult for blood to return to the heart from the extremities; pooling can result. Genetic predisposition, inactivity, obesity, and poor muscle tone are also contributing factors. Exercise may prevent varicose veins if started early in the pregnancy. Encourage the client to wear support hose that have gradient pressure in them, and teach her how to apply them properly. Advise her to elevate her legs above her heart while lying on her back for 10 minutes before she gets out of bed in the morning, thus promoting venous return before she applies the hose. Instruct the client to avoid crossing her legs and avoid wearing knee-high stockings. They cause constriction of leg vessels and muscles and contribute to venous stasis. Also encourage the client to elevate both legs above the level of the heart for 5 to 10 minutes at least twice a day (Fig. 12.9); to wear low-heeled shoes; and to avoid long periods of standing or sitting, frequently changing her position. If the client has vulvar varicosities, suggest she apply ice packs to the area when she is lying down. Walk daily to improve circulation to extremities. Elevate both legs above heart level while resting. Avoid standing in one position for long periods of time. Don't wear constrictive stockings and socks. Don't cross the legs when sitting for long periods. Wear support stockings to promote better circulation. •Hemorrhoids Hemorrhoids are varicosities of the rectum and may be external (outside the anal sphincter) or internal (above the sphincter) (Kellerman & Rakel, 2019). They occur as a result of progesterone-induced vasodilation and from pressure of the enlarged uterus on the lower intestine and rectum. Hemorrhoids are more common in women with constipation, a low-fiber diet, poor fluid intake or poor dietary habits, smokers, sedentary lifestyle or those with a previous history of hemorrhoids (Sandler & Peery, 2019).Instruct the client in measures to prevent constipation, including increasing fiber intake and drinking at least 2 L of fluid per day. Recommend the use of topical anesthetics (e.g., Preparation H, Anusol, witch hazel compresses such as Tucks) to reduce pain, itching, and swelling, if permitted by the health care provider. Teach the client about local comfort measures such as warm sitz baths, witch hazel compresses, or cold compresses. To minimize her risk of straining while defecating, suggest that she elevates her feet on a stool. Also encourage her to avoid prolonged sitting or standing (Yikar & Nazik, 2019). Establish a regular time for daily bowel elimination. Avoid constipation and straining during defecation. Prevent straining by drinking plenty of fluids and eating fiber-rich foods and exercising daily. Use warm sitz baths and cool witch hazel compresses for comfort. •Flatulence with bloating Flatulence and gas pain are another result of decreased gastrointestinal motility. The physiologic changes that result in constipation (reduced gastrointestinal motility and dilation secondary to progesterone's influence) may also result in increased flatulence. As the enlarging uterus compresses the bowel, it delays the passage of food through the intestines, thus allowing more time for gas to be formed by bacteria in the colon. The woman usually reports increased passage of rectal gas, abdominal bloating, or belching. Instruct the woman to avoid gas-forming foods, such as beans, cabbage, and onions, as well as foods that have a high content of white sugar. Adding more fiber to the diet, increasing fluid intake, and increasing physical exercise are also helpful in reducing flatus. In addition, reducing the amount of swallowed air, if chewing gum, will reduce gas buildup. The knee-chest position may also help with discomfort from unexpelled gas. Consuming six smaller meals a day will help avoid digestive system overload. Eating slowly can reduce air swallowing, and taking a brisk walk after meals will help mobilize gas for expulsion. Reducing the intake of carbonated beverages and cheese and eating mints can also help reduce flatulence during pregnancy. OTC mediations, such as Gas-X or Beano, may also help (Hubbard & Rizzolo, 2019).

Menstrual History

•Date of last menstrual period (LMP) •Calculation of estimated or expected date of birth (EDB) or delivery (EDD) -Nagele's rule -Gestational or birth calculator or wheel -Ultrasound is the best method of dating a pregnancy

First Prenatal Visit

•Establishment of trusting relationship •Focus on education for overall wellness •Detection and prevention of potential problems •Comprehensive health history, physical examination, and laboratory tests

Ex: A client is currently in her fourth pregnancy. Her previous pregnancy includes a delivery at 34 weeks' gestation (the child is currently living), a miscarriage at 10 weeks' gestation, and a twin delivery at 36 weeks' gestation (both children are currently living). Calculate her GTPAL and GP. •G •T •P •A •L •G •P

•G-4 •T-0 •P-2 •A-1 •L-3 •G-4 •P-2

The client has now given birth to a newborn at 38 weeks' gestation (the newborn survives). What is her current GTPAL and GP? •G •T •P •A •L •G •P

•G-4 •T-1 •P-2 •A-1 •L-4 •G-4 •P-3

Obstetric History: Gravida

•Gravida: a pregnant woman -Gravida I (primigravida): first pregnancy -Gravida II (secundigravida): second pregnancy, etc.

Assessment of Fetal Well-Being: Nonstress Test

•Non-invasive •Done after 28 weeks •Great to use with patients who are diabetic, have renal disease, post term pregnancies •Eat a meal before they come b/c glucose "wakes baby up" •Never supine; want mother in left lying position •When the baby moves; the HR should increase mother will mark with the button when she feels movement The nonstress test (NST) is the most common method of prenatal testing used in practice today. The NST provides an indirect measurement of uteroplacental function. Unlike the fetal movement counting done by the mother alone, this procedure requires specialized equipment and trained personnel. The basis for the NST is that the normal fetus produces characteristic fetal heart rate patterns in response to fetal movements. In the healthy fetus, there is an acceleration of the fetal heart rate with fetal movement. Currently, an NST is recommended twice weekly (after 28 weeks' gestation) for clients with diabetes and other high-risk conditions, such as intrauterine growth restriction (IUGR), preeclampsia, post-term pregnancy, renal disease, and multifetal pregnancies (Cunningham et al., 2018). NST is a noninvasive test that requires no initiation of contractions. It is quick to perform and there are no known side effects. Procedure Before the procedure, the client eats a meal to stimulate fetal activity. Then she is placed in the left lateral recumbent position to avoid supine hypotension syndrome. An external electronic fetal monitoring device is applied to her abdomen. The device consists of two belts, each with a sensor. One of the sensors records uterine activity, while the second sensor records fetal heart rate. The client is handed an "event marker" with a button that she pushes every time she perceives fetal movement. When the button is pushed, the fetal monitor strip is marked to identify that fetal movement has occurred. The procedure usually lasts 20 to 30 minutes. Nursing Management Prior to the NST, explain the testing procedure and have the woman empty her bladder. Position her in a semi-Fowler position and apply the two external monitor belts. Document the date and time the test is started, client information, the reason for the test, and the maternal vital signs. Obtain a baseline fetal monitor strip over 15 to 30 minutes. During the test, observe for signs of fetal activity with a concurrent acceleration of the fetal heart rate. Interpret the NST as reactive or nonreactive. A reactive NST includes at least two fetal heart rate accelerations from the baseline of at least 15 bpm for at least 15 seconds within the 20-minute recording period. If the test does not meet these criteria after 40 minutes, it is considered nonreactive. A nonreactive NST is characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion in a 20-minute time frame. A nonreactive test has been correlated with a higher incidence of fetal distress during labor, fetal mortality, and IUGR. Additional testing, such as a biophysical profile, should be considered (King et al., 2019). After the NST procedure, assist the woman off the table, provide her with fluids, and allow her to use the restroom. Typically, the health care provider discusses the results with the woman at this time. Provide teaching about signs and symptoms to report. If serial NSTs are being done, schedule the next testing session.

Obstetric History: Para

•Para: a woman who has produced one or more viable offspring carrying a pregnancy 20 weeks or more -Primipara: one birth after a pregnancy of at least 20 weeks ("primip") -Multipara: two or more pregnancies resulting in viable offspring ("multip") -Nullipara: no viable offspring; para 0 (non have lived)

Preparation for Labor, Birth, and Parenthood

•Perinatal education •Childbirth education -Lamaze (psychoprophylactic) method: focus on breathing and relaxation techniques -Bradley (partner-coached childbirth) method: focus on exercises and slow, controlled abdominal breathing -Dick-Read (natural childbirth) method: focus on fear reduction via knowledge and abdominal breathing techniques •Options for birth setting -Hospitals: delivery room, birthing suite -Birth centers -Home birth •Options for care providers -Obstetrician -Midwife (have training like an NP) -Lay Midwife (not common anymore; non clinical training) -Doula (do not deliver; more like a coach) •Feeding choices -Breast-feeding: advantages and disadvantages -Bottle-feeding: advantages and disadvantages -Teaching •Final preparation for labor and birth -Attend childbirth classes -Select pediatrician -If boy needs to be circumcised -Pack suitcase Car seat

Nursing Management to Promote Self-Care

•Personal hygiene •Avoidance of saunas and hot tubs •Perineal care •Dental care •Breast care •Clothing Exercise •Brush teeth, floss teeth; dental care •Wash hands •Shower everyday •Avoid perfume, spays, etc. to genitals •No tampons or douches •No harsh detergent to the skin •Avoid saunas and hot tubs; prefer not to be soaking in a tub •Avoid X-rays and no laughing gas (b/c systemic) •Sugar free gum after meals to lower acids •Breast pads to collect colostrum •Loose fitting; layered clothes—NO SHAPEWEAR •Continue with exercise (Ex: running 3 miles a day keep doing it; if they haven't done it before they do not need to do it during pregnancy) •150 minutes of exercise a week is the recommendation

Third Trimester Discomforts Teachings

•Return of first trimester discomforts •Shortness of breath and dyspnea Dyspnea is a common complaint in pregnant women during the first and third semesters. Physiologic and hemodynamic changes can result in significant dyspnea in such cases. In some women, dyspnea in normal daily activities can be a sign of heart and lung disease and may be associated with poor perinatal and cardiac outcomes in which early detection can prevent adverse events. The increasing growth of the uterus prevents complete lung expansion late in pregnancy. As the uterus enlarges upward in the second and third trimesters, the expansion of the diaphragm is limited. Dyspnea can occur when the woman lies on her back and the pressure of the gravid uterus against the vena cava reduces venous return to the heart (Jordan et al., 2019). Reassure the woman that dyspnea is normal and will improve when the fetus drops into the pelvis (lightening). Instruct her to adjust her body position to allow for maximum expansion of the chest and to avoid large meals, which increase abdominal pressure. Raising the head of the bed on blocks or placing pillows behind the back can be helpful too. Under normal circumstances, resting with the head elevated while taking slow, deep breaths reduces shortness of breath. In addition, emphasize that lying on the left side will displace the uterus off the vena cava and improve breathing. Having the woman periodically stand up and stretch her arms above her head and take a deep breath is helpful with relieving dyspnea. Also, advise the woman to avoid exercise that precipitates dyspnea, to rest after exercise, and to avoid overheating in warm climates. If she still smokes, encourage her to stop. •Heartburn and indigestion Heartburn, also termed gastroesophageal reflux, is common during pregnancy. Heartburn and indigestion result when high progesterone levels cause relaxation of the cardiac sphincter, allowing food and digestive juices to flow backward from the stomach into the esophagus. Irritation of the esophageal lining occurs, causing the burning sensation known as heartburn. It occurs in up to 80% of women at some point during pregnancy with an increased frequency seen in the third trimester (King et al., 2019). The pain may radiate to the neck and throat. It worsens when the woman lies down, bends over after eating, or wears tight clothes. Indigestion (vague abdominal discomfort after meals) results from eating too much or too fast; from eating when tense, tired, or emotionally upset; from eating food that is too fatty or spicy; and from eating heavy food or food that has been badly cooked or processed (Lee et al., 2019). In addition, the stomach is displaced upward and compressed by the large uterus in the third trimester, thus limiting the stomach's capacity to empty quickly. Food sits, causing heartburn and indigestion. Review the client's usual dietary intake and suggest that she limit or avoid gas-producing or fatty foods and large meals. Instruct the woman to pay attention to the timing of the discomfort. Usually it is heartburn when the pain occurs 30 to 45 minutes after a meal. Encourage the client to maintain proper posture and remain in the sitting position for 1 to 3 hours after eating to prevent reflux of gastric acids into the esophagus by gravity. Urge the client to consume small, frequent meals and eat slowly, chewing her food thoroughly to prevent excessive swallowing of air, which can lead to increased gastric pressure. Instruct the client to avoid foods that act as triggers such as caffeinated drinks; greasy, gas-forming foods; citrus; spiced foods; chocolate; coffee; alcohol; and spearmint or peppermint. These items stimulate the release of gastric digestive acids, which may cause reflux into the esophagus. She should avoid late-night or large meals and gum chewing and avoid lying down within 3 hours after eating. Finally, elevating the head of the bed by 10 to 30 degrees may help. Avoid spicy or greasy foods and eat small frequent meals. Sleep on several pillows so that your head is elevated 30 degrees. Stop smoking and avoid caffeinated drinks to reduce stimulation. Avoid lying down for at least 3 hours after meals. Try drinking sips of water to reduce burning sensation. Avoid foods that trigger symptoms—fried foods, citrus, soda, chocolate. Take antacids sparingly if burning sensation is severe. •Dependent edema Total body fluids increase by 6 to 8 L during pregnancy, most of which is extracellular. Swelling is the result of increased capillary permeability caused by elevated hormone levels and increased blood volume. Sodium and water are retained, and thirst increases. Edema occurs most often in dependent areas such as the legs and feet throughout the day due to gravity; it improves after a night's sleep. Warm weather or prolonged standing or sitting may increase edema. Generalized edema appearing in the face, hands, and feet can signal preeclampsia if accompanied by dizziness, blurred vision, headaches, upper quadrant pain, or nausea (Norwitz et al., 2019). This edema should be reported to the health care provider. Appropriate suggestions to minimize dependent edema include: Elevate your feet and legs above the level of the heart periodically throughout the day. Wear compression stockings when standing or sitting for long periods. Change position frequently throughout the day. Walk at a sensible pace to help contract leg muscles to promote venous return. When taking a long car ride, stop to walk around every 2 hours. When standing, rock from the ball of the foot to the toes to stimulate circulation. Lie on your left side to keep the gravid uterus off the vena cava to return blood to the heart. Avoid foods high in sodium, such as lunch meats, potato chips, and bacon. Avoid wearing knee-high stockings. Drink six to eight glasses of water daily to replace fluids lost through perspiration. Avoid high intake of sugar and fats because they cause water retention. •Braxton Hicks contractions Braxton Hicks contractions are irregular, painless contractions that occur without cervical dilation. Typically, they intensify in the third trimester in preparation for labor. In reality, they have been present since early in the pregnancy but may have gone unnoticed. They are thought to increase the tone of uterine muscles for labor purposes (Jordan et al., 2019). Keep in mind that these contractions are a normal sensation. Try changing your position or engaging in mild exercise to help reduce the sensation.Reassure the client that these contractions are normal. Instruct the client in how to differentiate between Braxton Hicks and labor contractions. Explain that true labor contractions usually grow longer, stronger, and closer together and occur at regular intervals. Walking usually strengthens true labor contractions, while Braxton Hicks contractions tend to decrease in intensity and taper off. Advise the client to keep herself well hydrated and to rest in a left-side-lying position to help relieve the discomfort. Suggest that she use breathing techniques to ease the discomfort.Drink more fluids if possible.

Risk Factors for Adverse Pregnancy Outcomes

•Substance abuse •Teratogens (can be any medication that cause abnormalities to a fetus) +Certain antiepileptic drugs are known teratogens (e.g., valproic acid). Recommendations suggest that before conception, women who are on a regimen of these drugs and who are contemplating pregnancy should be prescribed lower dosages of these drugs. •Diabetes (preconception); insulin issues w/ PCOS +(preconception): The threefold increase in the prevalence of birth defects among infants of women with type 1 and type 2 diabetes is substantially reduced through proper management of diabetes. •Folic acid deficiency +Daily use of vitamin supplements containing folic acid (400 mcg) has been demonstrated to reduce the occurrence of neural tube defects by two thirds. •STI's +Chlamydia trachomatis and Neisseria gonorrhoeae have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain. STIs during pregnancy might result in fetal death or substantial physical and developmental disabilities, including intellectual disability and blindness. Early screening and treatment prevent these adverse outcomes. •Smoking +Preterm birth, low birth weight, and other adverse perinatal outcomes associated with maternal smoking in pregnancy can be prevented if women stop smoking before or during early pregnancy. Because only 20% of women successfully control tobacco dependency during pregnancy, cessation of smoking is recommended before pregnancy; causes placental birth issues that are linked to pretermed birth and low birth weights •HIV/AIDS +If HIV infection is identified before conception, timely antiretroviral treatment can be administered, and women (or couples) can be given additional information that can help prevent mother-to-child transmission. •Poor weight gain •Domestic violence •Other infections -Rubella Titer for Immunity -GBS (not an STD; just bacteria that lives in the vaginal area and rectal area; CAN CAUSE SEPSIS which is why we treat them prophylactical at delivery) -Toxoplasmosis (seen in pork and cat feces--cook meat well; pass of litter duty to someone else or use gloves, same with gardening)

Assessment of Fetal Well-Being: Ultrasound

•Ultrasonography (Everyone gets an ultrasound b/w 18 to 20 weeks specifically for providers to try to identify any issues with the fetus; THEY CHECK EVERYTHING) Obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and establish an accurate gestational age in order to improve pregnancy outcomes. Because the ultrasound procedure is noninvasive, it is a safe practice for low-risk women and an accurate and cost-effective tool. It provides important information about fetal activity, growth, and gestational age; assesses fetal well-being; and determines the need for invasive intrauterine tests (WHO, 2019). There are no hard-and-fast rules as to the number of ultrasounds a woman should have during her pregnancy. A low-risk woman does not necessarily require any, but most practices do them as part of the prenatal care routine. A transvaginal ultrasound may be performed in the first trimester to confirm pregnancy, exclude ectopic (in which a fertilized egg implants somewhere other than the main cavity of the uterus) or molar (hydatidiform mole, a benign tumor that develops in the uterus) pregnancies, and confirm cardiac pulsation. ***A second abdominal scan may be performed at about 18 to 20 weeks to look for congenital malformations, exclude multifetal pregnancies, and verify dates and growth. A third abdominal scan may be done at around 34 weeks to evaluate fetal size, assess fetal growth, and verify placental position (Crum et al., 2019). An ultrasound is used to confirm placental location during amniocentesis and to provide visualization during chorionic villus sampling (CVS). An ultrasound is also ordered whenever an abnormality is suspected. During the past several years, ultrasound technology has advanced significantly. Now available for expecting parents is 3D/4D ultrasound imaging. Unlike traditional 2D imaging, which takes a look at the developing fetus from one angle (thus creating the "flat" image), 3D imaging takes a view of the fetus from three different angles. Software then takes these three images and merges them to produce a 3D image. Because the fourth dimension is time and movement, with 4D, parents are able to watch the live movements of their fetus in 3D. Nursing management during the ultrasound procedure focuses on educating the woman about the ultrasound test and reassuring her that she will not experience any sensation from the sound waves during the test. No special client preparation is needed before performing the ultrasound, although in early pregnancy, the woman may need to have a full bladder. Inform her that she may experience some discomfort from the pressure on the full bladder during the scan, but it will last only a short time. Tell the client that the conducting gel used on the abdomen during the scan may feel cold initially.

First Trimester Discomforts Teachings

•Urinary frequency or incontinence Urinary frequency or incontinence is common in the first trimester because the growing uterus compresses the bladder. This is also a common complaint during the third trimester, especially when the fetal head settles into the pelvis. However, the discomfort tends to improve in the second trimester, when the uterus becomes an abdominal organ and moves away from the bladder region. After infection and gestational diabetes have been ruled out as causative factors of increased urinary frequency, suggest that the woman decrease her fluid intake 2 to 3 hours before bedtime and limit her intake of caffeinated beverages. Increased voiding is normal, but encourage the client to report any pain or burning during urination. Also explain that increased urinary frequency may subside as she enters her second trimester, only to recur in the third trimester. Teach the client to perform pelvic floor muscle training exercises, also called Kegel exercises, to increase support of the uterus, bladder, small intestine, and rectum throughout the day to help strengthen perineal muscle tone, thereby enhancing urinary control and decreasing the possibility of incontinence. Try pelvic floor exercises to increase control over leakage. Empty your bladder when you first feel a full sensation. Avoid caffeinated drinks, which stimulate voiding. Reduce your fluid intake after dinner to reduce nighttime urination. •Fatigue Fatigue plagues all pregnant women, primarily in the first and third trimesters (the highest-energy levels typically occur during the second trimester), even if they get their normal amount of sleep at night. First-trimester fatigue is most often related to the many physical changes (e.g., increased oxygen consumption, increased levels of progesterone and relaxin, increased metabolic demands) and psychosocial changes (e.g., mood swings, multiple role demands) of pregnancy. Third-trimester fatigue can be caused by sleep disturbances from increased weight (many women cannot find comfortable sleeping positions due to the enlarging abdomen), physical discomforts such as heartburn, and insomnia due to mood swings, multiple role anxiety, and a decrease in exercise (Blackburn, 2018). Once anemia, infection, and blood dyscrasias have been ruled out as contributing to the client's fatigue, advise her to arrange work, child care, and other demands in her life to permit additional rest periods. Work with the client to devise a realistic schedule for rest. Using pillows for support in the left-side-lying position relieves pressure on major blood vessels that supply oxygen and nutrients to the fetus when resting (Fig. 12.8). Also recommend the use of relaxation techniques, providing instructions as necessary, and suggest she increase her daily exercise level. Attempt to get a full night's sleep without interruptions. Eat a healthy balanced diet. Schedule a nap in the early afternoon daily. When feeling tired, pause and rest. •Nausea and vomiting It is estimated that somewhere between 70% and 90% of pregnant women experience nausea and vomiting. In the United States, this translates to approximately 4 million women. It is found more often in Western countries and urban populations and is rare among Africans, Native Americans, Eskimos, and most Asian populations (Jordan et al., 2019). The problem is generally time-limited, with the onset about the 5th week after the last menstrual period, a peak at 8 to 12 weeks, and resolution by 16 to 18 weeks. Despite popular use of the term morning sickness, nausea and vomiting of pregnancy may persist throughout the day in the majority of affected women and has been found to be limited to the morning in less than 2% of women (Smith et al., 2020). The physiologic changes that cause nausea and vomiting are unknown, but research suggests that unusually high levels of estrogen, progesterone, and hCG, and a vitamin B6 deficiency may be contributing factors. Symptoms generally last until the second trimester and are generally associated with positive pregnancy outcomes, in terms of lower rates of miscarriages, congenital malformations, and preterm births (Cunningham et al., 2018). In summary, the etiology of nausea and vomiting in pregnancy is physiologic, thus assessment of the condition focuses on severity, and the management is largely supportive. Nausea and vomiting of pregnancy can take a physical and psychological toll on the pregnant woman, and may have an adverse effect on her partner, family members, and even coworkers. The burden it places on the woman is usually minimized, as it is considered a normal part of pregnancy, thus it may not be worthy of evaluation, diagnosis, management, and emotional support. As a result, it may not be taken seriously because it is so common and time-limited, leading some women to feel frustrated and feel guilty that they are even complaining about their symptoms. Nurses need to pick up on this, address it, and provide support for her. The goal of treatment is to improve symptoms while minimizing risks to mother and fetus. Treatment management ranges from simple dietary modifications to drug therapy. To help alleviate nausea and vomiting, advise the woman to eat small, frequent meals that are bland and low in fat (five or six times a day) to prevent her stomach from becoming completely empty. Other helpful suggestions include eating dry crackers, Cheerios, or cheese or drinking lemonade before getting out of bed in the morning and increasing her intake of foods high in vitamin B6, such as meat, poultry, bananas, fish, green leafy vegetables, peanuts, raisins, walnuts, and whole grains, or making sure she is receiving enough vitamin B6 by taking her prescribed prenatal vitamins. Pharmacologic treatment of nausea and vomiting in pregnancy is limited. The Food and Drug Administration (FDA) has approved vitamin B6 (pyridoxine) alone or in combination with doxylamine-pyridoxine (Diclegis) therapy for use during pregnancy, which seems to work fairly well based on the current reviews (ACOG, 2018). Other pharmacotherapies that might be considered may include diphenhydramine (e.g., Benadryl); dimenhydrinate (e.g., Dramamine); meclinine (e.g., Antivert); prochlorperazine (e.g., Compazine); promethazine (e.g., Phenergan); or ondansetron (e.g., Zofran). Other helpful tips to deal with nausea and vomiting include: Get out of bed in the morning slowly. Avoid sudden movements. Avoid triggers that stimulate or exacerbate nausea—strong food odors. Eat a high-protein snack before retiring at night to prevent an empty stomach. Take ginger (up to 1 g in divided doses daily; 250-mg capsules QID), which increases tone and peristalsis in the gastrointestinal tract. Open a window to remove odors of food being cooked. Eat more protein than carbohydrates and take in more liquids than solids. Limit intake of fluids or soups during meals (drink them between meals). Avoid fried foods and foods cooked with grease, oils, or fatty meats, because they tend to upset the stomach. Increase periods of rest. Suck on popsicles throughout the day. Avoid highly seasoned foods such as those cooked with garlic, onions, peppers, and chili. Drink a small amount of caffeine-free carbonated beverage (ginger ale) if nauseated. Trying acupressure using a wristband has been FDA-approved for nausea. Avoid wearing tight or restricting clothes, which might place increased pressure on the expanding abdomen. Avoid stress (Jordan et al., 2019; Kellerman & Rakel, 2019; King et al., 2019). Avoid an empty stomach at all times. Eat dry crackers/toast in bed before arising. Eat several small meals throughout the day. Avoid brushing teeth immediately after eating to avoid gag reflex. Acupressure wristbands can be worn daily. Drink fluids between meals rather than with meals. Avoid greasy, fried foods or ones with a strong odor, such as cabbage or Brussels sprouts. •Breast tenderness As a result of increased estrogen and progesterone levels, which cause the fat layer of breasts to thicken and the number of milk ducts and glands to increase during the first trimester, many women experience breast tenderness. Offering a thorough explanation to the woman about the reasons for the breast discomfort is important. Wearing a larger bra with good support can help alleviate this discomfort. Advise her to wear a supportive bra, even while sleeping. As her breasts increase in size, advise her to change her bra size to ensure adequate support. •Constipation Constipation affects up to 38% of pregnancies (Yikar & Nazik, 2019). Increasing levels of progesterone during pregnancy lead to decreased contractility of the gastrointestinal tract, slowed movement of substances through the colon, and a resulting increase in water absorption. All of these factors lead to constipation. Lack of exercise or too little fiber or fluids in the diet can also promote constipation. In addition, the large bowel is mechanically compressed by the enlarging uterus, adding to this discomfort. The iron and calcium in prenatal vitamins can also contribute to constipation during the first and third trimesters. Explain how pregnancy exacerbates the symptoms of constipation and offer the following suggestions: Eat fresh or dried fruit daily. Eat more raw fruits and vegetables, including their skins. Eat whole-grain cereals and breads such as raisin bran or bran flakes. Participate in physical activity every day. Engage in pelvic floor exercises, stretching exercises, and yoga daily. Eat meals at regular intervals. Establish a time of day to defecate, and elevate feet on a stool to avoid straining. Drink six to eight glasses of water daily. Decrease intake of refined carbohydrates. Drink warm fluids upon arising to stimulate bowel motility. Decrease consumption of sugary sodas. Avoid eating large amounts of cheese. If the suggestions above are ineffective, suggest that the woman use a bulk-forming laxative such as Metamucil. Increase your intake of foods high in fiber and drink at least eight 8-oz glasses of fluid daily. Ingest prunes or prune juice which are natural laxatives. Consume warm liquids (e.g., tea) upon rising to stimulate peristalsis. Exercise each day (brisk walking) to promote movement through the intestine. Reduce the amount of cheese consumed. •Nasal stuffiness, bleeding gums, epistaxis Increased levels of estrogen cause edema of the mucous membranes of the nasal and oral cavities. Advise the woman to drink extra water for hydration of the mucous membranes or to use a cool mist humidifier in her bedroom at night. If she needs to blow her nose to relieve nasal stuffiness, advise her to blow gently, one nostril at a time. Advise her to avoid the use of nasal decongestants and sprays. If a nosebleed occurs, advise the woman to loosen the clothing around her neck, sit with her head tilted forward, pinch her nostrils with her thumb and forefinger for 10 to 15 minutes, and apply an ice pack to the bridge of her nose. If the woman has bleeding gums, encourage her to practice good oral hygiene by using a soft toothbrush and flossing daily. Warm saline mouthwashes can relieve discomfort. If the gum problem persists, instruct her to see her dentist. •Cravings Food craving refers to an intense desire to consume a specific food. Desires for certain foods and beverages are likely to begin during the first trimester but do not appear to reflect any physiologic need. Foods with a high sodium or sugar content are often the ones craved. At times, some women crave nonfood substances such as clay, cornstarch, laundry detergent, baking soda, soap, paint chips, dirt, ice, or wax. As explained in Chapter 11, this craving for nonfood substances, termed "pica," may indicate a severe dietary deficiency of minerals or vitamins, or it may have cultural roots (Kane & Prelack, 2019). Leukorrhea Increased vaginal discharge begins during the first trimester and continues throughout pregnancy. The physiologic changes behind leukorrhea arise from the high levels of estrogen, which cause increased vascularity and hypertrophy of cervical glands as well as vaginal cells (Cunningham et al., 2018). The result is progressively increasing vaginal secretions throughout pregnancy. Advise the woman to keep the perineal area clean and dry, washing the area with mild soap and water during her daily shower. Also recommend that she avoid wearing pantyhose and other tight-fitting nylon clothes that prevent air from circulating to the genital area. Encourage the use of cotton underwear and suggest wearing a nightgown rather than pajamas to allow for increased airflow. Also instruct the woman to avoid douching and tampon use.