Common Complaints of Pregnancy

round ligament pain when most likely to occur

16 weeks, may be experienced on and off throughout

dizziness, fainting when most likely to occur

1st trimester and throughout pregnancy

fatigue and sleepiness when most likely to occur

1st trimester fatigue, can also be present in third trimester. Sleep efficiency increases as pregnancy progresses.

urinary frequency when most likely to occur

1st trimester, 3rd trimester

Vaginal discharge (physiologic leukorrhea) danger signs and symptoms

Should r/o vaginitis and SROM (spontaneous rupture of membranes ) No reason for consultation for physiologic discharge Vaginitis can be independently managed by midwife/NP

edema relief and comfort measures

Don't wear tight or restrictive clothing Elevation of legs periodically throughout the day Position on side when laying down Maternity abdominal support or girdle, which may take the pressure off the pelvic veins

fatigue and sleepiness physiological basis

Due to sleep-inducing effect of progesterone and altered sleep (REM sleep is decreased and non-REM sleep prolonged). Both can be exacerbated by nausea and vomiting.

heartburn relief and comfort measures

Eat small, frequent meals, slowly. Avoid large meals before bed. Maintain good posture, to give your stomach more room to function. Avoid drinking liquids with meals. Stretch your arms over your head to increase room for stomach, and decrease pressure. Sleep with your head elevated on pillows. Use antacids w/ aluminum hydroxide, magnesium hydroxide, or magnesium trisilicate. More teaching: Avoid spicy foods, high fat foods, and cold foods (or whatever you notice aggravates it). Drink peppermint tea with raspberry leaf, and nettles. This will aid in digestion, tone your uterus and assist with circulation and prevent varicosities! Some women find acupuncture, reflexology, homeopathy, and Chinese medicine to be very helpful.

Vaginal discharge (physiologic leukorrhea) relief and comfort measures

Ed. re normalcy of discharge Advise re good hygiene and cotton underwear to absorb secretions Remind that normal incr. in secretions may influence sex, as partners may note changes in smell and taste of vaginal area

edema danger signs and symptoms

Edema caused by preeclampsia/eclampsia (generalized edema, not localized to ankles and feet), (in a woman with BP> 140/90 and >or = than 1+ protein in urine)

insomnia physiological basis

Emotional concerns, anxiety, fetal movement, discomfort from the enlarged uterus and subsequent pressure, urinary frequency, nocturia, low back pain, round ligament pain, heartburn, etc, etc, etc.

varicose veins & hemorrhoids relief and comfort measures

Enlarged vessels can lead to pain, achiness (in the legs, feet, vulva and anal area) and prutitis and/or bleeding if hemorrhoids For varicose veins: rest & elevation. Advice supportive elastic stockings, use of nonrestrictive clothing. Avoid prolonged standing and a For hemorrhoid: Most important is prevention of constipation. Hydration and fiber. Reassurance VV are benign, can be removed after childbearing. Hemorrhoids: improve with preventative measures and with time. Prevention is better than treatment! Conservative medical management using local application of anti-inflammatory, anti-pruritic, and local anesthetic preparations.

flatulence relief and comfort measures

Establish consistent bowel habits: regular timing for bm, responding to "urge". Identify any foods that may be aggravating GI and causing gas production. Consider a 24 hour diet recall with patient. Avoid eating onion, beans, collard greens, cauliflower, brussel sprouts, cabbage, and turnips. Eat yogurt or take acidophilus to maintain normal gut flora. Knee-chest position helps expel gas.

insomnia danger signs and symptoms

Evaluate for anxiety/depression if pertinent

ptyalism when most likely to occur

Excessive saliva may happen sporadically during periods of rapid hormonal fluctuation like during the first and third trimesters. Other women will notice they have more saliva in general throughout their pregnancy.

backache - upper back relief and comfort and measures

Exercise, joint manipulation w/ chiropractic/acupuncture, ice/heat

Striae gravidarum relief and comfort measures

Explanation of the hormonal changes to skin pigmentation should be given and the woman should be counseled that all skin changes could become darker in sunlight. Women should be encouraged to stay out of bright sun and counseled to wear sunscreen. Keeping the abdomen lubricated with an aloe or vitamin E based lotion may reduce the itching associated with the stretching of the skin. Women should be advised that there is nothing that can prevent stretch marks.

constipation relief and comfort measures

Fluid intake: 8 glasses/day Prunes or prune juice. Drink warm liquids in a.m. Eat high fiber foods, bulking laxatives. Establish consistent bowel habits: regular timing for bm, responding to "urge" Exercise e.g. walking Clockwise abdominal massage Fiber products Mild laxatives, stool softeners (Colace 100mg BID), glycerin suppositories. For short term use only.

varicose veins & hemorrhoids when most likely to occur

Frequent in the last trimester of pregnancy and immediately postpartum. Most Both VV and H common cardiovasc. condition in pregnancy

edema physiological basis

Impaired venous circulation and increased venous pressure in lower extremities b/c of pressure of the enlarging uterus on the pelvic veins when the woman is sitting or standing and on the inferior vena cava when she is supine

flatulence physiological basis

Relaxation of smooth muscles in the GI system by progesterone decreases gut motility and creates pockets of gas. Uterine displacement of intestines and pressure contributes to gas production.

round ligament pain physiological basis

Round "ligaments" are actually smooth muscle continuous with uterus. Muscle tissue hypertrophies in order to stretch and lengthen w/ pregnancy. Stretching combined with pressure from weight of uterus causes pain.

erythema of the palms physiological basis

Secondary to capillary engorgement Secondary to increase in hormones such as estrogen and progesterone

headaches danger signs and symptoms

Severe HA that doesn't respond to comfort measures and analgesia If accompanied by incr. BP, proteinuria, immediate eval. for preeclampsia If migraine headache, consult and collaborate w/MD

heartburn danger signs and symptoms

Severe vomiting. Heartburn that is not relieved by usual treatments Blood in vomit

dyspnea (SOB) when most likely to occur

"This symptom commonly starts during the first or second trimester. The frequency rises during the second trimester, and then is reasonably stable during the third trimester."

backache - upper back danger signs and symptoms

(Little danger signs identified- unless heart related) Accompanying symptoms of Heart disease- with abdominal pain, radiating pain to shoulder/tingling

breast enlargement/tenderness/leaking when most likely to occur

1st trimester: Hypertrophy of mammary alveoli. Biltat increase in size, often accompanied by tingling, tenseness, and tenderness. Hypertrophied sebaceous glands in the areola. Dilation of the subcutaneous veins under the skin, 2nd trimester and 3rd trimesters Vascular spiders on the upper chest Striae of the breast

leg cramps physiological basis

1. Possibly inadequate/impaired Ca uptake or an imbalance in the Ca-P ratio in the body 2. Possibly enlarged uterus exerts pressure on pelvis blood vessels impairing circulation, or on the nerves as they course through the obturator foramen on their way to the lower extremities Caused by a buildup of lactic and pyruvic acids leading to involuntary contraction of the affected muscles, usually in the legs

dyspnea (SOB) relief and comfort measures

"Dyspnea of pregnancy is usually worse when the pregnant woman is in the sitting/lying position, and is not associated with exercise." Reassurance that this is normal and education on danger signs. Instruct woman stand up, stretch arms above her head, to breathe slowly while maintaining good posture, which allows the lungs to fully expand. Elevate the head of bed, avoid lying flat. Get on to hands and knees to decrease pressure of uterus on other organs.

dyspnea (SOB) physiological basis

"The mechanism of dyspnea during normal pregnancy is not entirely clear. It occurs while the uterus is still relatively small, thus it cannot be attributed solely to an increase in abdominal girth. Progesterone and to a lesser degree estrogen-induced hyperventilation is partially responsible, perhaps due to the increased respiratory effort, and in turn the reduction in PCO2, during pregnancy.

urinary frequency physiological basis

1st trimester: enlarging fundus plus softening of uterine isthmus causes anteflexion of uterus - pressing on bladder. 3rd trimester: especially after "lightening" - when presenting part descends further into pelvis, pressing on bladder. Also: nocturia due to dependent pedal edema returning into circulation, and increasing glomerular filtration; this is excreted during the night.

Striae gravidarum when most likely to occur

1st, 2nd or 3rd Trimester or in the postpartum period

back pain - lower back when most likely to occur

2nd half of pregnancy- pain aggravated w/activity, relieved by rest. Pain often worse at night- may interfere w/sleep

nausea & vomiting when most likely to occur

5 to 16 weeks gestational age, peak at 11. It is usually gone by 22 weeks GA for 90% of women, worse with multiple pregnancy or molar pregnancy- due to higher levels of hCG and estradiol.

erythema of the palms when most likely to occur

5th or 6th "lunar month"

heartburn physiological basis

A burning sensation in the esophagus caused by regurgitation or reflux of acidic gastric contents into the lower esophagus, which may be caused by the relaxing effect of progesterone on the cardiac sphincter of the stomach, decreased GI motility (relaxing of smooth muscle r/t high amounts of progesterone), displacement of the stomach up and to the right, decreased esophageal peristalsis, increased intragastric pressure or decreased intraesophageal pressure.

Vaginal discharge (physiologic leukorrhea) physiological basis

A result of hormonal stimulation, there is increased cervical mucus and transudate and incr. vascularity of the cervix and vagina. Normally clear to whitish clear, may be moderately thick, w/no associated symptoms of foul odor, itching or burning

breast enlargement/tenderness/leaking danger signs and symptoms

Any mass Coursed granular nodularity in a localized, unilateral area. Cracked or ulcerated nipples. Loss of elasticity of the nipples, increased firmness or thickening of skin texture (Varney, 2004, pg 1142)

backache - upper back when most likely to occur

Any time in the pregnancy. With any muscle irritation- e.g. after lifting, poor posture, large breasts

insomnia when most likely to occur

Anytime, but 1st and 3rd trimesters are most common.

Vaginal discharge (physiologic leukorrhea) when most likely to occur

Anytime. Varies form woman to woman and from pregnancy to pregnancy

dizziness, fainting relief and comfort measures

Avoid dehydration and hunger. Carry snacks and eat small frequent meals. Avoid excessive heat

lower back pain - radiating to the leg relief and comfort measures

Be pt., wait until PP( exp. compl. relief by 4 mos. PP)., change pos. and act. level freq., take breaks and rest periods, use chairs w/back supp., stools when standing (to shift wt.) or sitting, avoid aggrav. activities (stair climbing), good posture, exercise (lo impact), use pillows for support of top leg,abd., relaxation, massage, etc.

round ligament pain relief and comfort measures

Bend toward pain. Flex knees toward abdomen. Support uterus and upper knee with pillow while side-lying. Practice pelvic tilt from all-fours: on exhale, pull abd in, rotate hips forward, flatten lower back. Wear abdominal support or girdle. Heating pad/ Warm bath. Acupuncture

ptyalism danger signs and symptoms

Can accompany hyperemesis gravidarum. Can accelerate tooth decay. Some associated risk with PTL.

lower back pain - radiating to the leg when most likely to occur

Can occur as early as 12 wks, but peak occ. 5th-7th mo. Increases over the day, dec.w/ rest. Plateaus or dec. toward end of preg.

flatulence when most likely to occur

Can occur at anytime during pregnancy.

back pain - lower back physiological basis

Combination of wt gain and hormonal changes affect musculoskeletal changes. 1. Force on joints increases, exaggerated lordosis of lower back, forward flexion of neck, downward mvmt. of shoulders r/t enlarged uterus/change of center of gravity & stretching, weakness and separation of abd. muscles strain muscles. 2. Joint laxity in anterior & posterior longitudinal ligaments of lumbar spine; 3. Widening & increased mobility of sacroiliac joints and pubic symphysis to facilitate delivery; 4. Stance is widened to maintain trunk mvmt with increased anterior pelvic tilt, hip extensor, abductor and ankle plantar flexor muscles.

diarrhea relief and comfort measures

Comfort measures: Rest and oral hydration. Avoid the use of over-the-counter medications.

Numbness, tingling of fingers & toes, Carpel Tunnel Syndrome physiological basis

Compression (as a result of changing postures, edema, tissue inflammation, or repetitive motion) of the median and ulnar nerves.

constipation danger signs and symptoms

Constipation not relieved by dietary changes and/or laxatives Rectal bleeding Severe Abdominal pain

leg cramps danger signs and symptoms

Cramping causes no lasting damage to muscle, but it can be very painful. Interventions for leg cramps in pregnancy.

diarrhea danger signs

Danger signs: long lasting (for milder loose stools, longer than 2 weeks; for severe diarrhea, longer than a few days). Bloody stools. Dehydration.

constipation when most likely to occur

Develops during second or third trimester if there has been no previous problem with constipation.

Numbness, tingling of fingers & toes, Carpel Tunnel Syndrome relief and comfort measures

Discontinue repetitive motions, maintain good posture / body mechanics, wear supportive bra. Relaxation exercises focused on muscles surrounding joints where nerves enter spine (upper back, chest, shoulder). Use of splint (particularly at night or during the day if severe). Complimentary tx include: osteopathic and chiropractic for increasing wrist mobility or acupressure/acupunture. Nutrition recs include increasing B6 and magnesium.

breast enlargement/tenderness/leaking physiological basis

Increased generalized coarse nodular and lobular feel of the breast as a result of hypertrophy of the mammary alveoli, breast vasculature and fatty tissue. Lactation (colostrum) may began during pregnancy d/t increased circulating hormones

food cravings (pica) relief and comfort measures

Indulge in limited quantities if safety is not an issue. Maintain adequate nutrition.

back pain - lower back danger signs and symptoms

LB pain w/ UTI symptoms LB pain that is not relieved by rest and is accompanied by tightening of the uterus (contraction) or is experienced in a rhythmic pattern and is menstrual-like(R/O SAB or PTL)

dizziness, fainting danger signs and symptoms

LOC associated with fainting. Visual disturbances(R/O Preeclampsia)

headaches when most likely to occur

May have incr. in 3rd trimester Women w/hx of migraines tend to experience remission or decreased freq./severity during pregnancy May be related to caffeine withdrawal

leg cramps when most likely to occur

More common in second half of pregnancy and are especially troublesome at night Interventions for leg cramps in pregnancy.

edema when most likely to occur

Most likely 3rd trimester. When a woman is sitting with pressure of the enlarging uterus on the pelvic veins or standing on the inferior vena cava when she is supine

heartburn when most likely to occur

Most likely towards the end of the 2nd trimester through the third trimester.

backache - upper back physiological basis

Muscle irritation- R/T poor posture

headaches physiological basis

Muscle tension (most common cause) Stress, postural changes, eye strain, nasal or sinus congestion, fatigue, mild respiratory alkalosis, altered cerebral fluid dynamics

Striae gravidarum danger signs and symptoms

N/A

erythema of the palms danger signs and symptoms

N/A

round ligament pain danger signs and symptoms

Nausea/ Vomiting Fever Localized to right side Sudden onset Jaundice Dizziness/ Syncope Vaginal bleeding/ Spotting R/O PTL if pertinent

lower back pain - radiating to the leg danger signs and symptoms

No change w/ movement, rest, &/or convent. Rx., perist./disablg. pain not responsive to Rx, neurological involvement (weakness, loss of sensation or function, part. in pelvis, urinary, GI, perineum, loss of reflexes lower limbs R/O sciatica nerve impingement/herniation

flatulence danger signs and symptoms

None; referral is rarely necessary

diarrhea when most likely to occur

Normal loose stools: The very end of the 3rd trimester.

nausea & vomiting danger signs and symptoms

Persistent N/V after first trimester or weight loss of >5% of pre-pregnancy weight (or >4 lbs). Sings of dyhadration, + Ketonuria Hyperemesis gravidarum defined as severe intractable N/V, which results in dyhadration, electrolyte imbalance and weight loss. Incidence .5 to 2%. Nausea and vomiting that presents initially after the first trimester consider liver DZ, occult infection and preeclampsia.

Striae gravidarum physiological basis

Pigmentation changes can occur because increased estrogen levels stimulate melanin. Stretch marks can occur anywhere on the body but are most often found on the abdomen, thighs and breasts. They may become deep pink in color but usually fade to pale pink or silver following delivery.

food cravings (pica) danger symptoms/signs

Poor weight gain or refractory anemia (check for this with hx of pica). No concerns as long as diet is otherwise adequate.

varicose veins & hemorrhoids physiological basis

Pregnancy increases risk due to relaxation of venous walls caused by progesterone and relaxin, increased blood volume; uterine growth slowing venous return; and in hemorrhoids tendency towards constipation.

back pain - lower back relief and comfort measures

Prevented by avoiding excessive wt gain, regular exercise before pregnancy. Exercises to strengthen back muscles. Upright posture, comfortable low shoes, resting, elevating feed to flex hips- non elastic maternity support binders, acupuncture, aquatic exercise and Rx (acetaminophen; narcotics, prednisone if severe with MD consultation)- help lifting heavy objects, sleep on side w/pillows between knees for support; heat/cold/massage to painful area

dizziness, fainting physiological basis

Progesterone Induced systemic venous relaxation Decreased venous return Decreased cardiac output

Numbness, tingling of fingers & toes, Carpel Tunnel Syndrome danger signs and symptoms

Progressive tingling or worsening of symptoms as this may be concerning for more generalized nerve involvement, damage, or illness.

headaches relief and comfort measures

Reassure that most headaches during preg. are benign (if no associated w/hypertension or other med. disorder) To decrease tension: massage, warm compress, warm bath/shower Rest in dark room, glass of juice Acetaminophen (600-1000mg PO q6hrs), although some do not recommend use in 1st trimester unless absolutely necessary -ibuprofen should not be used in pregnancy. -Acupuncture - if caffeine withdrawal, may need to wean from caffeine

urinary frequency relief and comfort measures

Reassure that this is normal, explain why it is happening. Suggest increased fluids during the day and decrease in fluid intake before bed, to reduce nighttime trips to bathroom. Limit caffeine. Shiatsu of kidney meridian.

fatigue and sleepiness relief and comfort measures

Reassure that this is normal. May improve (fatigue) by second trimester. Have frequent naps or rests during the day. Mild exercise and good nutrition may also be helpful.

constipation physiological basis

Relaxation of smooth muscles in the GI system by progesterone decreases gut motility and contribute to constipation. Pressure on and displacement of the intestines by the uterus contributes to constipation. Side effect of Iron supplementation.

nausea & vomiting relief and comfort measures

Small frequent meals; dry crackers or toast before arising; don't brush teeth immediately after eating (to avoid gag reflex); drink carbonated beverages, especially ginger ale; avoid food with strong or offensive odors; reduce fats; acupressure wristbands; rest; remember nausea will most likely end during 2nd trimester; medications if necessary (pyridoxine[B6] OTC and doxylamine [Unisom]), some women require phenothiazine or H1-receptor blocker antiemetics. Teach family/FOB to provide her with considerate understanding, loving treatment with special attention to the little things important to her.

diarrhea physiological basis

Some women experience diarrhea as part of or just before onset of labor

ptyalism relief and comfort measures

Spit frequently. Suck on hard candy to aid swallowing. Brush teeth and use mouthwash several times a day, eat frequent, small, well balanced meals and avoid excessive amounts of starchy food, and drink plenty of water, taking frequent, small sips. Most women who have this condition also have excessive gastric secretion. In this case medications that treat ulcers and gastritis can be helpful.

leg cramps relief and comfort measures

Straighten her affected leg and point her heel (dorsiflex foot). If on bed, woman needs strong, steady pressure against bottom of her foot, someone's hand/footboard of head to push against. If standing, the floor works. Encourage general exercise and a habit of good body mechanics to improve circulation. Leg elevation periodically throughout the day. Diet that includes Ca and P. Calcium or Mg Citrate supplementation Magnesium lactate or citrate taken as 5mmol in the morning and 10mmol in the evening Interventions for leg cramps in pregnancy.

dyspnea (SOB) danger symptoms/signs

The presence of other symptoms and signs of cardiac or pulmonary disease, i.e. sudden onset or presence of cough, wheezing, rales, chest pain, fever, or hemoptysis.

food cravings (pica) when most likely to occur

Transient

ptyalism physiological basis

Uncertain etiology. Can exacerbate pregnancy-related nausea. (ACOG relates it to a reluctance of a nauseated mother to swallow saliva.) It may be associated with stimulation of salivary glands by the ingestion of starch

nausea & vomiting physiological basis

Unknown. Theories are: Hormonal changes, low blood sugar, gastric overloading, slowed peristalsis, emotional factors.

food cravings (pica) physiological basis

Unknown. Theories are: sense of taste may be blunted, leading to an increased desire for spicy foods. Also, pica, a craving for clay, dirt, ice shavings or laundry starch, is considered to be sociocultural in origin.

erythema of the palms relief and comfort measures

Usually disappear postpartum No clinical significance

varicose veins & hemorrhoids danger signs and symptoms

VV: Orthostatic hypotension or faintness when raising (good hydration) Predisposition to superficial thrombophlebitis, edema, skin ulcers Hemorrhoids danger signs: Bleeding from hemorrhoids is scant, bright red, and appears at end of a bowel movement. Any woman with rectal bleeding should be offered a colonoscopy/sigmoidoscopy (safe during pregnancy). Recurrent and severe hemorrhoids may be reason for surgical removal, which may be done in pregnancy. (Up to Date)

insomnia relief and comfort measures

Warm baths before bed. Drink warm milk before bed. Side lying with a pillow between your knees is the most comfortable way to sleep, and promotes relaxation. Homeopathy. Herbal teas.

breast enlargement/tenderness/leaking relief and comfort measures

Wear a supportive bra to ease the strain on your breasts and on your back muscles as your breasts become heavy. You may be more comfortable sleeping in a bra. Wear disposable or washable breast pads if you are leaking colostrum. Avoid soap on your areola and nipple, as this tends to dry out the skin. Use warm water to keep the area clean. If you are leaking, allow your breasts to air dry a few times a day and after a shower. Cotton bras are preferable to those made of synthetic fabrics because cotton allows the skin to breathe. If you plan to nurse your baby, your nursing bras will probably be about one cup size larger than those you need in late pregnancy so purchase your nursing bras in your ninth month.

Numbness, tingling of fingers & toes, Carpel Tunnel Syndrome when most likely to occur

Women frequently experience worsening of sx at night and/or with use of affected hand(s).

lower back pain - radiating to the leg physiological basis

Wt. gain, shift in center of grav., poor posture, muscular fatig., Hormones-relaxin (dec. joint support by ligamentous laxity), prolonged sitting, standing, twisting, repetitive flexion, etc., stair climbing, turning in bed at night, not using enough LB support (cushions, rolled towels, belts, etc.)

urinary frequency danger symptoms/signs

dysuria, suprapubic pain, gross hematuria, malodorous or cloudy urine; severe flank pain, abdominal pain fever and chills, malaise

fatigue and sleepiness danger symptoms/signs

fever, sore throat, lymphadenopathy, myalgia, chills, muscle weakness, fatigue not alleviated by rest, postexertional malaise lasting >24 hrs. Enlarged tender cervical nodes. Consider anemia/dietary deficiencies.