Maternal Exam 1

Ectopic pregnancy

**An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop in this area. The most common site is within a fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the cervix. oClient may experience: Unilateral, cramp-like abdominal pain ECTOPIC PREGNANCY An ectopic pregnancy is one in which implantation occurred outside the uterine cavity. The most common site (in approximately 95% of such pregnancies) is in the fallopian tube (Fig. 21.2). Of these fallopian tube sites, approximately 80% occur in the ampullar portion, 12% occur in the isthmus, and 8% are interstitial or fimbrial. With most ectopic pregnancy, fertilization occurs as usual in the fallopian tube. Unfortunately, because an obstruction is present, such as an adhesion of the fallopian tube from a previous infection (chronic salpingitis or pelvic inflammatory disease), congenital malformations, scars from tubal surgery, or a uterine tumor pressing on the proximal end of the tube, the zygote cannot travel the length of the tube. It lodges at a strictured site along the tube and implants there instead of in the uterus. Approximately 2% of pregnancies are ectopic, and because at least minimal bleeding occurs, it is the second most frequent cause of bleeding early in pregnancy. The incidence of ectopic pregnancy appears to be increasing, possibly because of the increasing rate of pelvic inflammatory disease, which can lead to tubal scarring. The incidence is also increased following in vitro fertilization (a woman might be having the in vitro fertilization because she has tubal scarring) and also in women who smoke. Women who have one ectopic pregnancy have a higher chance of having a subsequent ectopic pregnancy. This is because salpingitis generally leaves scarring, which is bilateral. Congenital anomalies such as webbing (fibrous bands) that block a fallopian tube may also occur in both tubes. For unknown reasons, oral contraceptives used before pregnancy reduce the incidence of ectopic pregnancy Assessment With an ectopic pregnancy, there are no unusual symptoms at the time of implantation. The corpus luteum of the ovary continues to function as if the implantation were in the uterus, so, often, no menstrual flow occurs. A woman may begin to experience the usual nausea and vomiting of early pregnancy and a pregnancy test for hCG will be positive. Many ectopic pregnancies are diagnosed because a woman has an early pregnancy ultrasound to date the pregnancy. Magnetic resonance imaging (MRI) is also effective to use for this. If not revealed by an ultrasound, at weeks 6 to 12 of pregnancy (2 to 8 weeks after a missed menstrual period), the zygote grows large enough that it ruptures the slender fallopian tube. Tearing and destruction of blood vessels and bleeding result. If implantation was in the interstitial portion of the tube (where the tube joins the uterus), rupture can cause severe intraperitoneal bleeding because of the large blood vessels in that part of the tube. Fortunately, the incidence of tubal pregnancies is highest in the ampullar area (the distal third), where the blood vessels are smaller and profuse hemorrhage is less likely. Constant, continued bleeding from this area, however, may result in a large amount of blood loss over time. Therefore, a ruptured ectopic pregnancy is serious regardless of the site of implantation. A woman usually experiences a sharp, stabbing pain in one of her lower abdominal quadrants at the time of rupture, followed by scant vaginal spotting. The amount of bleeding evident with a ruptured ectopic pregnancy usually does not reveal the actual amount present, however, because the products of conception from the ruptured tube and the accompanying blood may be expelled into the pelvic cavity rather than into the uterus. Blood does not reach the vagina to become evident. At the point the placenta dislodges, progesterone secretion will stop and the uterine decidua will begin to slough, causing additional vaginal bleeding. As soon as the woman becomes hypotensive from blood loss, she will experience light-headedness and a rapid pulse, signs of hypovolemic shock. Because of these symptoms, any woman with sharp abdominal pain and vaginal spotting needs to be evaluated by her healthcare provider to rule out the possibility of ectopic pregnancy. When helping determine whether an ectopic pregnancy is present, ask a woman what she was doing when she felt the pain, if she had pain but no vaginal bleeding. Occasionally, a woman will move suddenly and pull one of her round ligaments, the anterior uterine supports, which causes a sharp but momentary lower quadrant pain, so this must be ruled out. Vaginal spotting or bleeding does rule out round ligament pain as it would be rare for this phenomenon to be reported in connection with vaginal spotting. By the time a woman arrives at the hospital or primary healthcare provider's office, she may already be in severe shock, as evidenced by a rapid, thready pulse; rapid respirations; and falling blood pressure. Leukocytosis may be present, not from infection but from the trauma. Temperature is usually normal. A transvaginal ultrasound will demonstrate the ruptured tube and blood collecting in the peritoneum. Either a falling hCG or serum progesterone level suggests the pregnancy has ended. If the diagnosis of ectopic pregnancy is in doubt, a primary healthcare provider may insert a needle through the posterior vaginal fornix into the cul-de-sac under sterile conditions to see whether blood can be aspirated. A laparoscopy or culdoscopy can also be used to visualize the fallopian tube if the symptoms alone do not reveal a clear picture of what has happened. However, ultrasonography alone usually reveals a clear-cut diagnostic picture. If a woman waits for a time before seeking help, her abdomen gradually becomes rigid from peritoneal irritation. Her umbilicus may develop a bluish-tinged hue (Cullen sign). She may have continuing extensive or dull vaginal and abdominal pain; movement of the cervix on pelvic examination can cause excruciating pain. She may feel pain in her shoulders as well from blood in the peritoneal cavity causing irritation to the phrenic nerve. A tender mass is usually palpable in Douglas cul-de-sac on vaginal examination. Therapeutic Management Some ectopic pregnancies spontaneously end before they rupture and are reabsorbed over the next few days, requiring no treatment. It is difficult to predict when or if this will happen, however, so when an ectopic pregnancy is revealed by an early ultrasound, the woman is shown the sonogram, and after her agreement that therapy could be lifesaving, she is usually medically treated by the intramuscular or less often, oral, administration of methotrexate (see Chapter 53 for a general discussion of chemotherapy agents of this type). The advantage of this therapy is that the tube is left intact, with no surgical scarring that could cause a second ectopic implantation. Women are treated until a negative hCG titer is achieved. A hysterosalpingogram or ultrasound is usually performed after this to assess that the pregnancy is no longer present and also whether the tube appears fully patent. If an ectopic pregnancy is not discovered early, but rather, only when it ruptures, it creates an emergency situation. Keep in mind the amount of blood evident with a ruptured ectopic pregnancy is a poor estimate of the actual blood loss. A blood sample needs to be drawn immediately for hemoglobin level, typing and cross-matching, and possibly the hCG level for immediate pregnancy testing, if pregnancy has not yet been confirmed. Intravenous fluid using a large-gauge catheter to restore intravascular volume will be prescribed. Blood then can be administered through this same line as soon as it is matched. The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. A rough suture line on a fallopian tube may lead to another tubal pregnancy, so either the tube will be removed or suturing on the tube will be done with microsurgical technique. If a tube is removed, a woman may lose about 5% of her fertility. When she ovulates from either ovary, the egg can be moved into the remaining open tube with the peristaltic motion of that fallopian tube. As with miscarriage, women with Rh-negative blood should receive RhIG/RhoGAM after an ectopic pregnancy for isoimmunization protection in future childbearing.

Hyperemesis Gravidarum

**History of migraines is a risk factor for hyperemesis gravidarum, which typically occurs during the first 20 weeks of pregnancy. Hyperemesis gravidarum is more common in nulliparous women, beginning in the first trimester. Clinical manifestations can continue throughout the pregnancy in some women. Twin gestations are a risk factor for hyperemesis gravidarum and might be related to increasing hormone levels of estrogen, progesterone, and human chorionic gonadotropin (hCG). **Suggest: Eat crackers or plain toast before getting out of bed The Woman With Hyperemesis Gravidarum Hyperemesis gravidarum (sometimes called pernicious or persistent vomiting) is nausea and vomiting of pregnancy prolonged past week 16 of pregnancy or that is so severe that dehydration, ketonuria, and significant weight loss occur within the first 12 weeks of pregnancy. It occurs at an incidence of 2% in pregnant women. The cause is unknown, but women with the disorder may have increased thyroid function because of the thyroid-stimulating properties of human chorionic gonadotropin. Some studies reveal it is associated with Helicobacter pylori, the same bacteria that cause peptic ulcers. With hyperemesis gravidarum, weight loss can be severe because, with so much nausea and vomiting, a woman cannot maintain her usual nutrition. Urine may test positive for ketones, evidence the woman's body is breaking down stored fat and protein for cell growth. An elevated hematocrit concentration may be detected at a monthly prenatal visit because the inability to retain fluid has resulted in hemoconcentration (which is dangerous because it can lead to thromboembolism). In contrast, concentrations of sodium, potassium, and chloride may be reduced because of a woman's low intake; hypokalemic alkalosis may develop from loss of hydrochloric acid from the stomach. In some women, ataxia and confusion, caused by deficiency of vitamin B1 (thiamine), develops. If left untreated, a woman with hyperemesis may become so dehydrated she can no longer provide a fetus with essential nutrients for growth, and intrauterine growth restriction or preterm birth can result. Assessment Always try to determine exactly how much nausea and vomiting women are having during pregnancy. Ask the patient to describe the events of the day before: • How late into the day did the nausea last? • How many times did she vomit and how much? • What was the total amount of food she was able to eat? Therapeutic Management Women with hyperemesis gravidarum may need to be hospitalized for about 24 hours to document and monitor their intake, output, and blood chemistries and to restore hydration. All oral food and fluids are usually withheld for the first 24 hours. Intravenous fluid (e.g., 3,000 ml Ringer's lactate with added vitamin B1) may be administered to increase hydration. An antiemetic, such as metoclopramide (Reglan, pregnancy class B), may be prescribed to control vomiting. Throughout this period, carefully measure intake and output, including the amount of vomitus, so the degree of hydration can best be evaluated. If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid can be started and the woman discharged home, usually with a referral for home care. If she can continue to take clear fluid without vomiting, small quantities of dry toast, crackers, or cereal can be added every 2 or 3 hours, after which the woman may be gradually advanced to a soft diet and then to a regular diet. If vomiting returns at any point, enteral or total parenteral nutrition may be prescribed to ensure she receives adequate nutrition

Gestational Hypertension

**begins after the 20th week of pregnancy, describes hypertensive disorders of pregnancy whereby the woman has an elevated blood pressure at 140/90 mm Hg or greater recorded at least twice, 4 to 6 hours apart, within a 1 week period. There is no proteinuria. The presence of edema is no longer considered in the definition of hypertensive disease of pregnancy. A triad for gestational hypertension is: hypertension, edema, proteinuria to be considered hypertensive. Gestational hypertension. Gestational hypertension refers to a potentially severe and even fatal elevation of blood pressure that occurs during pregnancy usually after 20 weeks of pregnancy. A number of symptoms signal that gestational hypertension is developing: • Rapid weight gain (over 2 lb/week in the second trimester, over 1 lb/week in the third trimester) • Swelling of the face or fingers • Flashes of light or dots before the eyes • Dimness or blurring of vision • Severe, continuous headache • Decreased urine output • Right upper quadrant pain unrelated to fetal position • Blood pressure increased above 140/90 mmHg GESTATIONAL HYPERTENSION A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mmHg) but has no proteinuria or edema. Perinatal mortality is not increased with simple gestational hypertension, so careful observation but no drug therapy is necessary. **Know that to be diagnosed with Preeclampsia, You have to have two BP readings that are 140/90 or greater PREECLAMPSIA WITHOUT SEVERE FEATURES If a seizure from preeclampsia occurs, a woman now has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to be preeclamptic without severe features when she has proteinuria (1+ on a urine dip or 300 mg in a 24-hour urine protein collection or 0.3 or higher on a urine protein-creatinine ratio) and a blood pressure rise to 140/90 mmHg, taken on two occasions at least 6 hours apart. The diastolic value of blood pressure is extremely important to document because it is this pressure that best indicates the degree of peripheral arterial spasm present. A second criterion for evaluating blood pressure is a systolic blood pressure greater than 30 mmHg and a diastolic pressure greater than 15 mmHg above prepregnancy values. This rule is helpful for a woman with preexisting hypertension, but the value of 140/90 mmHg is a more useful cutoff point when there are no baseline data available, such as when a woman seeks prenatal care late in pregnancy. Average blood pressures in American women are available at http://thePoint.lww.com/Flagg8e. According to these averages, a woman younger than 20 years could have a blood pressure of 98/61 mmHg and still be within normal limits. If her blood pressure was elevated 30 mmHg systolic and 15 mmHg diastolic, it would be only 128/76 mmHg. This is well beneath the traditional warning point of 140/90 mmHg but would represent hypertension for her. Many women show a trace of protein during pregnancy. Actual proteinuria is said to exist when it registers as 1+ or more (this represents a loss of 1 g/L). A woman with preeclampsia will begin to show proteinuria of 1+ or 2+ on a reagent test strip on a random sample. Occasionally, women have orthostatic proteinuria (i.e., on long periods of standing, they excrete protein; on bed rest, they do not). If proteinuria is present without other signs of gestational hypertension (no hypertension and no edema), check to see when the specimen was obtained. Ask her to bring in a first morning urine sample next time as that may reveal that orthostatic proteinuria, not preeclampsia, is the cause of protein in her urine. Edema develops, as mentioned, because of the protein loss, sodium retention, and lowered glomerular filtration rate. The edema can be separated from the typical ankle edema of pregnancy because it begins to accumulate in the upper part of the body as well. A weight gain of more than 2 lb/week in the second trimester or 1 lb/week in the third trimester usually indicates abnormal tissue fluid retention is occurring. No noticeable edema may be present when this sudden increase in weight first occurs or it will be the first symptom a woman notices. PREECLAMPSIA WITH SEVERE FEATURES A woman has passed to preeclampsia with severe features when her blood pressure rises to 160 mmHg systolic and 110 mmHg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mmHg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample. With preeclampsia with severe features, extreme edema is most readily palpated over bony surfaces, such as over the tibia on the anterior leg, the ulnar surface of the forearm, and the cheekbones, where the sponginess of fluid-filled tissue can be palpated against bone. If there is swelling or puffiness at these points to a palpating finger but the swelling cannot be indented with finger pressure, the edema is described as nonpitting. If the tissue can be indented slightly, this is 1+ pitting edema; moderate indentation is 2+; deep indentation is 3+; and indentation so deep it remains after removal of the finger is 4+ pitting edema. This accumulating edema will reduce a woman's urine output to approximately 400 to 600 ml per 24 hours. It's helpful to further assess edema by asking a woman if she has noticed any swelling anywhere in her body. Women commonly report upper extremity edema as "My rings are so tight I can't get them off" and facial edema as "When I wake in the morning, my eyes are swollen shut" or "My tongue is so swollen I can't talk until I walk around awhile." Some women report severe epigastric pain and nausea or vomiting, possibly because abdominal edema or ischemia to the pancreas and liver has occurred. If pulmonary edema has developed, a woman may report feeling short of breath. If cerebral edema has occurred, reports of visual disturbances such as blurred vision or seeing spots before the eyes may be reported. Cerebral edema also produces symptoms of severe headache and marked hyperreflexia and perhaps ankle clonus (i.e., a pulsed motion of the foot after flexion)

Placenta Previa

**occurs when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. The abnormal implantation results in bleeding during the third trimester as the cervix begins to dilate and efface. Hemorrhage is a major complication. PLACENTA PREVIA Placenta previa, a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus, is the most common cause of painless bleeding in the third trimester of pregnancy (Fig. 21.6). It occurs in four degrees: implantation in the lower rather than in the upper portion of the uterus (low-lying placenta), marginal implantation (the placenta edge approaches that of the cervical os), implantation that occludes a portion of the cervical os (partial placenta previa), and implantation that totally obstructs the cervical os (total placenta previa). The degree to which the placenta covers the internal cervical os is generally estimated in percentages: 100%, 75%, 30%, and so forth. Increased parity, advanced maternal age, past cesarean births, past uterine curettage, multiple gestation, and perhaps a male fetus are all associated with placenta previa. The incidence is approximately 5 per 1,000 pregnancies; it is thought to occur whenever the placenta is forced to spread to find an adequate exchange surface. There is a possibility an increase in congenital fetal anomalies or fetal restricted growth could occur if the low implantation does not allow optimal fetal nutrition or oxygenation, but in actual practice, this rarely happens Assessment Placenta previa is often detected during pregnancy through a routine sonogram done to date the pregnancy. Although many low-lying placentas detected on early ultrasounds migrate upward to a noncervical position, the condition is explained to the woman and she is cautioned to call her healthcare provider at any sign of vaginal bleeding. Therapeutic Management The bleeding of placenta previa, like that of ectopic pregnancy, creates an emergency situation as the open vessels of the uterine decidua (maternal blood) place the mother at risk for hemorrhage. Because the placenta is loosened, the fetal oxygen and nutrient supply may also be compromised, placing the fetus at risk as well. With the placental loosening, preterm labor (labor that occurs before the end of week 37 of gestation) may begin, posing the additional threat of preterm birth to the fetus. Immediate Care Measures To ensure an adequate blood supply to a woman and fetus, place the woman immediately on bed rest in a side-lying position. Be certain to assess: • Duration of the pregnancy • Time the bleeding began • Woman's estimation of the amount of blood—ask her to estimate in terms of cups or tablespoons (a cup is 240 ml; a tablespoon is 15 ml) • Whether there was accompanying pain • Color of the blood (red blood indicates bleeding is fresh or is continuing) • What she has done, if anything, for the bleeding (if she inserted a tampon to halt the bleeding, there may be hidden bleeding) • Whether there were prior episodes of bleeding during the pregnancy • Whether she had prior cervical surgery for premature cervical dilatation Inspect the perineum for bleeding and estimate the present rate of blood loss. Weighing perineal pads before and after use and calculating the difference by subtraction is a good method to determine vaginal blood loss. An Apt or Kleihauer-Betke test (test strip procedures) can be used to detect whether the blood is of fetal or maternal origin. Obtain baseline vital signs to determine whether symptoms of hypovolemic shock are present. Continue to assess blood pressure every 5 to 15 minutes or continuously with an electronic cuff. Never attempt a pelvic or rectal examination with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, possibly fatal to both mother and child. Attach external monitoring equipment to record fetal heart sounds and uterine contractions (an internal monitor for either fetal or uterine assessment is contraindicated). Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time, fibrinogen, platelet count, type and cross-match, and antibody screen will be assessed to establish baselines, detect a possible clotting disorder, and ready blood for replacement if necessary. Monitor urine output frequently, as often as every hour, as an indicator her blood volume is remaining adequate to perfuse her kidneys. Administer intravenous fluid as prescribed, preferably with a large-gauge catheter to allow for blood replacement through the same line. A vaginal birth is always safest for an infant. It is essential, therefore, to determine the placenta's location as accurately as possible in the hope that its position will make vaginal birth feasible. If the previa is under 30% by abdominal or intravaginal ultrasound, it may be possible for the fetus to be born past it. If over 30%, and the fetus is mature, the safest birth method for both mother and baby is often a cesarean birth. If only a minimum previa is detected by sonogram, the primary healthcare provider may attempt a careful speculum examination of the vagina and cervix to establish the degree of fetal engagement and to rule out another cause for bleeding, such as ruptured varices or cervical trauma. This should be done in an operating room or a fully equipped birthing room so that if hemorrhage does occur with cervical manipulation, an immediate cesarean birth can be carried out to remove the child and the bleeding placenta and contract the uterus. Have oxygen equipment available in case the fetal heart sounds indicate fetal distress, such as bradycardia or tachycardia, late deceleration, or variable decelerations during the exam. Continuing Care Measures The point at which a diagnosis of placenta previa is made and the age of the gestation dictate the final management. If labor has begun, bleeding is continuing, or the fetus is being compromised (measured by the response of the FHR to contractions), birth must be accomplished regardless of gestational age. If the bleeding has stopped, the fetal heart sounds are of good quality, maternal vital signs are good, and the fetus is not yet 36 weeks of age, a woman is usually managed by expectant watching. Typically, a woman remains in the hospital on bed rest for close observation for 24 to 48 hours. If the bleeding stops, she can be sent home with a referral for bed rest and home care. Assessments of fetal heart sounds and laboratory tests, such as hemoglobin or hematocrit, are obtained frequently. Betamethasone, a steroid that hastens fetal lung maturity, may be prescribed for the mother to encourage the maturity of fetal lungs if the fetus is less than 34 weeks gestation

Magnesium Sulfate

*Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy. MAGNESIUM SULFATE Action: Magnesium sulfate is a central nervous system depressant that acts to block neuromuscular transmission of acetylcholine to halt convulsions. It prevents seizures and relaxes muscles. Pregnancy Risk Category: A Dosage: Initially, 2-6 g IV administered in a 250-ml solution over a 20-30 minute period, followed by individually calculated IV infusion at a rate to maintain designated serum levels • Therapeutic range: 5-8 mg/100 ml • Patellar reflex disappears: 8-10 mg/100 ml • Respiratory depression occurs: 15-20 mg/100 ml • Cardiac conduction defects occur: more than 20 mg/100 ml Possible Adverse Effects: Flushing, thirst; with toxicity, absence of deep tendon reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, and decreased urine output Nursing Implications • Administer continuous infusion piggybacked into a main IV line so it can be discontinued immediately without interfering with fluid administration. • Always use an infusion control device to maintain a regular flow rate. • Assess maternal blood pressure and fetal heart rate continuously with bolus IV administration. • Assess deep tendon reflexes every 1-4 hours during continuous infusion. Use the patellar reflex. If patient has received epidural anesthesia, use the biceps reflex. • Monitor intake and output every hour during continuous infusion. Urine output should be 30 ml/hr or greater. • Assess patient's level of consciousness, including ability to respond to questions, every hour. • Obtain serum magnesium levels as indicated, usually every 6-8 hours. • Keep calcium gluconate, the antidote for toxicity, readily available at the bedside. • Maintain serum blood levels (for anticonvulsant use) at 5-8 mg/100 ml. If blood serum levels rise above this, respiratory depression, cardiac arrhythmias, and cardiac arrest can occur. • Do not administer additional doses and stop infusion if deep tendon reflexes are absent or if respiratory rate is less than 12-14 breaths/min or urine output is less than 30 ml/hr. • This drug may cause respiratory depression in the newborn if administered close to birth. Alert neonatal care personnel about this possibility. • Magnesium sulfate may cause osteoporosis in the mother if given over a long time.

Terbutaline

*Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy. Terbutaline is a drug approved to prevent and treat bronchospasm (i.e., narrowing of airways) but may be used, off-label, as a tocolytic agent (i.e., an agent to halt labor). Terbutaline carries a "black box" warning, however, that it should not be used for over 48 to 72 hours of therapy because of a potential for serious maternal heart problems and death. It should not be used in an outpatient or home setting because its administration requires constant professional assessment. Magnesium sulfate, given intravenously, is used primarily to treat preeclampsia and prevent eclamptic seizures. It was traditionally given to prevent preterm labor as well. However, recent research does not support the use of magnesium as a tocolytic. There are no differences seen between those women receiving magnesium and those receiving no treatment in preterm birth outcomes. Magnesium sulfate for fetal neuroprotection is used prior to 32 weeks to help prevent cerebral palsy in premature infants. For reasons not clearly understood, if, in the time between when preterm contractions begin and preterm birth occurs, a woman is administered a corticosteroid such as betamethasone the formation of lung surfactant appears to accelerate, thus reducing the possibility of respiratory distress syndrome or bronchopulmonary dysplasia. During the time labor is being chemically halted, therefore, if the pregnancy is under 34 weeks, a woman may be given two doses of 12 mg betamethasone intramuscularly 24 hours apart or four doses of 6 mg dexamethasone intramuscularly 12 hours apart. Although the effect of betamethasone lasts for about 7 days, it takes about 24 hours for the drug to begin its effect, so it is important labor be halted for at least 24 hours. If the fetus is not born within the 7-day time span, the dose of betamethasone may be repeated, but this is controversial because any corticosteroid can interfere with glucose regulation in the woman and potentially in the fetus. FETAL ASSESSMENT In addition to supervising tocolytic therapy, be certain to assess overall fetal welfare in the woman who is trying to delay or prevent preterm labor by assessing the FHR and activity Following this initial therapy and if contractions have ceased and there is evidence of fetal well-being, women with arrested preterm labor can be safely cared for at home as long as they can dependably drink enough fluid to remain well hydrated and, although there is little evidence that strict bed rest prevents preterm labor, a woman limits strenuous activities. It is also important for women to maintain adequate nutrition and to not smoke cigarettes as both poor nutrition and smoking are risks for preterm birth. To help with fetal assessment, a woman may be asked to record a daily fetal "kick" count or "count to 10" test.

Chadwick's sign

A bluish color to the vaginal mucosa and cervix due to increased vascularity

Depo- Provera - Why would this a good choice for women

A single intramuscular injection of depot medroxyprogesterone acetate or DMPA (Depo-Provera), a progesterone given every 12 weeks, inhibits ovulation, alters the endometrium, and thickens the cervical mucus so sperm progress is difficult (Box 6.8). The effectiveness rate of this method is almost 100%, making it an increasingly popular contraceptive method (CDC, 2014). The injection is made deep into a major muscle (buttocks, deltoid, or thigh) before the fifth day after the beginning of a menstrual flow. Be sure the woman does not massage the injection site after administration so the drug can absorb slowly from the muscle.

Miscarriage

A viable fetus is usually defined as a fetus of more than 20 to 24 weeks of gestation or one that weighs at least 500 g. A fetus born before this point is considered a miscarriage or is termed a premature or immature birth

Nulligravida

A woman who has never been and is not currently pregnant

Calcium Gluconate

Antidote for Magnesium Sulfate toxicity. Have prepared at bedside as the antidote when administering magnesium sulfate.

Gradual lordosis

As pregnancy advances, a lumbar lordosis develops and postural changes necessary to maintain balance lead to backache (see Box 12.3). Wearing shoes with low-to-moderate heels reduces the amount of spinal curvature necessary to maintain an upright posture. Encouraging a woman to walk with her pelvis tilted forward (i.e., putting pelvic support under the weight of the fetus) is also helpful. In addition, applying local heat from a heating pad may aid in relieving backache. To avoid back strain and worsen the condition, advise women to squat rather than bend over to pick up objects. Also encourage women to always lift objects by holding them close to the body. For some women, a firmer mattress during this time may be required. Sliding a board under the mattress is a cost-effective alternative for achieving a firmer sleeping surface rather than buying a new mattress. Pelvic rocking or tilting, an exercise described in Chapter 14, also helps to prevent and relieve backache. Obtaining a detailed account of a woman's back symptoms is crucial because back pain can be an initial sign of a bladder or kidney infection. Too often, women are observed at a prenatal visit only lying in a lithotomy position on an examining table. Always assess the manner in which a woman walks and what type of shoes she wears as she moves from a waiting room to an examining room to evaluate whether her posture or shoes could be a cause of backache. Generally, acetaminophen (Tylenol) is considered to be safe and effective for relieving this type of pain during pregnancy. Acupuncture can also be effective. Caution women not to take herbal remedies, muscle relaxants, or other analgesics (or any other medication) for back pain without first consulting their obstetric provider. A second skeletal problem that occurs at a greater incidence during pregnancy than at any other time is carpel tunnel syndrome or pain at the wrist from compression of the median nerve. Therapy for this is discussed in Chapter 49.

Betamethasone

BETAMETHASONE (CELESTONE) Action: Betamethasone is a corticosteroid that acts as an anti-inflammatory and immunosuppressive agent. It is given to pregnant women 12 to 24 hours before birth to hasten fetal lung maturity if a fetus is less than 34 weeks gestation and help prevent respiratory distress syndrome in the newborn (Karch, 2015). Pregnancy Risk Category: C Dosage: 12 to 12.5 mg intramuscularly (IM) initially; may be repeated in 24 hours and again in 1 to 2 weeks Possible Adverse Effects: Burning, itching, and irritation at the injection site; swelling, tachycardia, headache, dizziness, weight gain, sodium, and fluid retention; and increased risk of infection if used long term. Nursing Implications • Explain the purpose of the drug to the patient. • Administer the initial dose IM. Anticipate the need for repeat dosing within 24 hours and again in 1 to 2 weeks. • Assist with measures to halt preterm labor if indicated. • Continue to monitor patient's vital signs and fetal heart rate for changes. • If patient is also receiving a tocolytic agent, be alert for possible cardiac decompensation as a result of a drug-drug interaction. Observe for signs such as increased pulse, decreased blood pressure, and presence of edema. • Assess for signs and symptoms of possible infection with long-term use. • Instruct patient about the possibility that a repeat dose may be necessary. *Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy.

Sexually Transmitted Infections: - Chlamydia treatment

CHLAMYDIA TRACHOMATIS INFECTION Chlamydia trachomatis infections have become the most commonly reported bacterial cause of STIs in the United States. The incubation period is 1 to 5 weeks; symptoms include a heavy, grayish-white discharge and vulvar itching. Diagnosis is made by identification of the organism, which can be done at the point of care with a urethra or cervix swab. A urine specimen can be used as an alternative screening method. Therapy is oral doxycycline for 7 days or azithromycin as a single dose. Because the infection has become so common, most public health departments require that the infection be reported to the health department the same as other STIs such as gonorrhea. Because there is a strong association between gonorrhea and Chlamydia, if a chlamydial infection is documented, women are usually tested for gonorrhea as well. Long-term effects of chlamydial infections are PID, possibly leading to subfertility. Pregnancy and Chlamydia Screening for Chlamydia via a vaginal culture is usually done during a woman's first prenatal visit. If a woman has multiple sexual partners, screening may be repeated again in the third trimester. Doxycycline (Vibramycin), the therapy for nonpregnant women, is contraindicated during pregnancy because of possible fetal long-bone deformities; azithromycin (Zithromax) or amoxicillin (Amoxil) are used instead. A woman's partner also should be treated to prevent her from becoming reinfected. It's important that chlamydial infections be treated during pregnancy because they are associated with premature rupture of the membranes, preterm labor, and endometritis in the postpartum period. An infant who is born while a chlamydial infection is present can develop conjunctivitis or pneumonia after birth.

Rubella: - When should this be given and why

CONTRAINDICATED DURING PREGNANCY because it is a live vaccine. Rubella (German Measles) The rubella virus usually causes only a mild rash and mild systemic illness in a woman, but the teratogenic effects on a fetus can be devastating, such as hearing impairment, cognitive and motor challenges, cataracts, cardiac defects (most commonly patent ductus arteriosus and pulmonary stenosis), restricted intrauterine growth (i.e., small for gestational age), thrombocytopenic purpura, and dental and facial clefts, such as cleft lip and palate (Grant, Reef, Dabbagh, et al., 2015). Typically, a rubella titer from a pregnant woman to estimate whether a woman is susceptible to rubella is obtained on the first prenatal visit. A titer greater than 1:8 suggests immunity to the disease. A titer of less than 1:8 suggests a woman is susceptible to viral invasion. A titer that is greatly increased over a previous reading or is initially extremely high suggests a recent infection has occurred. A woman who is not immunized before pregnancy cannot be immunized during pregnancy because the vaccine contains a live virus that would have effects similar to those occurring with a subclinical case of rubella. After rubella immunization, a woman is advised not to become pregnant for about 3 months, until the rubella virus is no longer active. Immediately after a pregnancy, assess whether a woman who has a low rubella titer would like to be immunized to provide protection against rubella in future pregnancies. An increasing concern is women who demonstrate antibodies against rubella yet still become reinfected during pregnancy. Because of this, all pregnant women should avoid contact with children with rashes. Infants who are born to mothers who had rubella during pregnancy may be capable of transmitting the disease for a time after birth. Because of this, such an infant is isolated from other newborns during the newborn period. Be certain a woman is aware her infant might infect others, including pregnant women. Nurses who care for pregnant women or newborns should receive immunization against rubella to ensure they neither spread nor contract the disease ***The rubella immunization should be offered to the client shortly after or following the birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome.

Cullen's Sign

Cullen's sign is a blue discoloration similar to ecchymosis around the umbilicus. It indicates hematoperitoneum, a common clinical manifestation of a ruptured ectopic pregnancy.

Genitourinary tract infections: - Primarily dangerous because they are often asymptomatic until extensive damage is done.

During pregnancy, many changes occur in your body that increase your risk of developing a UTI, including changes to the make-up of your urine and immune system. As your baby grows, there is also an increase in the pressure on your bladder, which can reduce the flow of your urine and lead to an infection. UTIs can affect women whether they are pregnant or not. However, pregnant women are more likely to develop repeated or more severe infections. Up to 1 in 10 pregnant women will have a UTI but not have any symptoms at all. Having a UTI during pregnancy can increase your risk of developing high blood pressure, and your baby may be born early and smaller than usual. For this reason, even if you don't have any symptoms, it is important to treat a UTI as soon as possible. When you have a UTI, it is important to drink plenty of water to flush out the urinary tract. UTIs are treated with antibiotics that are safe in pregnancy. All pregnant women are offered a urine test, usually at their first antenatal visit or soon after. You may need to repeat the urine test if you have a history of UTIs; have symptoms of a UTI; have a contaminated sample or if your doctor thinks you are at high risk of developing a UTI. If you have frequent UTIs, you may also need additional tests such as an ultrasound of your kidneys. A systemic infection almost automatically increases body temperature, forcing a woman to expend more energy and increase her cardiac output as her metabolism increases, an effect that could be too extreme for a woman with heart disease to withstand. Caution women with heart disease, therefore, to avoid visiting or being visited by people with infections and to alert healthcare personnel at the first indication of an upper respiratory tract infection or urinary tract infection (UTI) so that, if warranted, antibiotic therapy can begin early in the course of the infection. Monthly screening for bacteriuria with a clean-catch urine test at prenatal visits should help detect UTIs. A WOMAN WITH A URINARY TRACT INFECTION As many as 4% to 10% of nonpregnant women have asymptomatic bacteriuria (i.e., organisms are present in the urine without symptoms of infection). In a pregnant woman, because the ureters dilate from the effect of progesterone, stasis of urine can occur. The minimal presence of abnormal amounts of glucose (glycosuria) that also occurs with pregnancy provides an ideal medium for growth for any organisms present. Combined, these factors cause asymptomatic UTIs in as many as 10% to 15% of pregnant women (Widmer, Lopez, Gülmezoglu, et al., 2015). Asymptomatic infections are potentially dangerous because they can progress to pyelonephritis (i.e., infection of the pelvis of the kidney) and are associated with preterm labor and premature rupture of membranes. Women with known vesicoureteral reflux (i.e., backflow of urine into the ureters) tend to develop UTIs or pyelonephritis more often than others. The organism most commonly responsible for UTI is Escherichia coli from an ascending infection. A UTI can also occur as a descending infection or can begin in the kidneys from the filtration of organisms present from other body infections. If the infectious organism is determined to be Streptococcus B, vaginal cultures should be obtained because streptococcal B infection of the genital tract is associated with pneumonia in newborns. Assessment A UTI typically manifests as frequency and pain on urination. With pyelonephritis, a woman develops pain in the lumbar region (usually on the right side) that radiates downward. The area feels tender to palpation. She may have accompanying nausea and vomiting, malaise, pain, and frequency of urination. Her temperature may be elevated only slightly or may be as high as 103° to 104°F (39° to 40°C). The infection usually occurs on the right side because there is greater compression and urinary stasis on the right ureter from the uterus being pushed that way by the large bulk of the intestine on the left side. A urine culture will reveal over 100,000 organisms per milliliter of urine, a level diagnostic of infection. Therapeutic Management Obtain a clean-catch urine sample for culture and sensitivity to assess for asymptomatic bacteriuria or symptoms of UTI (see Chapter 11). A sensitivity test will then determine which antibiotic will best combat the infection. Amoxicillin, ampicillin, and cephalosporins are effective against most organisms causing UTIs and are safe antibiotics during pregnancy. The sulfonamides can be used early in pregnancy but not near term because they can interfere with protein binding of bilirubin, which then leads to hyperbilirubinemia in the newborn. Tetracyclines are contraindicated during pregnancy as they cause retardation of bone growth and staining of the deciduous teeth. Nursing Diagnosis: Risk for infection related to stasis of urine with pregnancy Outcome Evaluation: Oral temperature is below 100.4°F (38°C), and a clean-catch urine specimen has a bacteria count below 100,000 colonies per milliliter. As part of prenatal education, remind all women during pregnancy of common measures to prevent UTIs, such as: Voiding frequently (at least every 2 hours) Developing a habit of urinating as soon as the need is felt and emptying the bladder completely when urinating Wiping front to back after voiding and bowel movements Wearing cotton, not synthetic fiber, underwear Voiding immediately after sexual intercourse Drinking a glass of cranberry juice daily The pregnant woman with a UTI needs to take the additional measure of drinking an increased amount of fluid to flush out the infection from the urinary tract. To be most effective, do not simply tell her to "push fluids" or "drink lots of water." Give her a specific amount to drink every day (up to 3 to 4 L per 24 hours) to make certain she increases her fluid intake sufficiently. A woman can promote urine drainage by assuming a knee-chest position for 15 minutes morning and evening. In this position, the weight of the uterus is shifted forward, releasing the pressure on the ureters and allowing urine to drain more freely. If a woman has one UTI during pregnancy, the chances are high she will develop another late in pregnancy, when urinary stasis tends to grow even greater. She may, therefore, be kept on prophylactic antibiotics throughout the remainder of the pregnancy. Ask at prenatal visits whether she is continuing to take this type of prophylactic medicine. When women have pain and symptoms of urinary frequency, they usually take medication consistently. When they no longer have any clinical evidence they are ill, their compliance rate may begin to fall dramatically. Urge a woman to post a chart on her refrigerator door or in her bathroom as a reminder to take the medication. Encourage her not to leave the medication on the counter as a reminder because she needs to begin to childproof her home. Pyelonephritis occurs as an extension of a UTI or infection that originated in or spread to the kidney (Suskind, Saigal, Hanley, et al., 2016). If this develops, a woman may be hospitalized for 24 to 48 hours while she is treated with intravenous antibiotics. After this acute episode, she will be maintained on a drug such as oral nitrofurantoin (Macrodantin) for the remainder of the pregnancy. Acidifying urine by the use of ascorbic acid (vitamin C), which is often recommended in nonpregnant women, is not usually recommended during pregnancy because a newborn can develop scurvy in the immediate neonatal period from vitamin C withdrawal. After birth, a woman who developed more than one UTI may have an ultrasound scheduled to detect any urinary tract abnormality that might be present, such as vesicoureteral reflux, to help prevent future infections.

Hydramnios

Excessive amniotic fluid. Associated with GI tract anomalies and Esophageal atresia At term, the amount of amniotic fluid has grown so much it ranges from 800 to 1,200 ml. If for any reason the fetus is unable to swallow (esophageal atresia or anencephaly are the two most common reasons), excessive amniotic fluid or hydramnios (more than 2,000 ml in total or pockets of fluid larger than 8 cm on ultrasound) will result. Hydramnios may also occur in women with diabetes because hyperglycemia causes excessive fluid shifts into the amniotic space

GTPAL:

Gravidity: number of times the woman has been pregnant (THIS INCLUDES CURRENT PREGNANCY, MISCARRIAGES, ABORTIONS and *twins/triplets count as one). Term Births: number born (alive or stillborn) at 37 weeks gestation onward (*twins/triplets count as one) Preterm births: number born 20-37 weeks (alive or stillborn) (*twins/triplets counts as one) Abortion: pregnancy losses before 20 weeks (counts as a pregnancy...so would put in gravidity as well)** if baby died after 20 weeks it is added under preterm or term not abortion. Living children: number of children living (NOTE: twin/triplets counts individually)

Miscarriages

Incomplete miscarriage With an incomplete miscarriage, the client has expelled some, but not all, of the products of conception. Missed miscarriage oWith a missed miscarriage, the fetus has died but the client retains the products of conception for several weeks. The client might have spotting or no bleeding at all. Inevitable miscarriage oWith an inevitable miscarriage, the client has moderate to heavy bleeding, cervical dilation, and often, ruptured membranes. Complete miscarriage oWith a complete miscarriage, the client has expelled all the products of conception.

Medication Overview

Insulin o Insulin is the first line of treatment for clients who are pregnant and are unable to maintain blood glucose levels within the recommended range. Unlike oral hyperglycemics, insulin does not cross the placenta and affect the fetus. Magnesium Sulfate: oMagnesium sulfate IV is given as a tocolytic medication for preterm labor to relax smooth muscle of the uterus and as a treatment for preeclampsia. The underlying pathophysiology of preeclampsia is vasospasm. The nurse should closely monitor the client for signs of magnesium toxicity, such as loss of patellar reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, urinary retention, and serum magnesium levels higher than 8 mEq/L. oIf a client is preeclamptic and has manifestations of CNS irritability including 3+ deep tendon reflexes, headache, and blurred vision. These manifestations place the client at a greater risk for seizure activity; therefore, the provider should prescribe a magnesium sulfate 4 g IV bolus, followed by a 2 g/hr maintenance dose. oTo evaluate the effectiveness of therapy the nurse should anticipate the provider to prescribe monitoring the client's blood pressure every 15 to 30 min. oDiminished or absent deep-tendon reflexes is a manifestation of magnesium toxicity. The nurse should stop the infusion immediately if present. oA dark, quiet environment helps to decrease CNS stimulation, which minimizes the risk of seizures. oThe client's respiratory rate should be at least 12/min to maintain adequate respiratory function. Magnesium toxicity causes bradypnea. The nurse should stop the infusion immediately if present. oThe client's urine output should be at least 25 to 30 mL/hr to promote adequate excretion of magnesium. The nurse should stop the infusion immediately if present. oBradycardia is a manifestation of magnesium toxicity. The nurse should stop the infusion immediately if present. Calcium Gluconate: oCalcium gluconate is the antidote for magnesium sulfate and should be readily available when administering magnesium sulfate. The nurse should be prepared to administer the medication in response to manifestations of magnesium toxicity, such as depressed respirations, oliguria, sudden drop in BP, loss of deep-tendon reflexes, and fetal distress Betamethasone: oBetamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of certain enzymes that help produce surfactant. oBetamethasone is classified as a corticosteroid medication. Corticosteroids are often administered to the mother to assist in fetal lung maturity. These are usually administered by IM injection of 12 mg for the first two doses. The subsequent dosing should be 6 mg by IM every 12 hr x 4 doses. Terbutaline: oTerbutaline is a beta2-adrenergic agonist that acts to relax uterine smooth muscles. Terbutaline is used to stop contractions in a client who is experiencing preterm labor. oAdverse effect: Dyspnea: The presence of dyspnea is a manifestation of pulmonary edema, which is a potentially life-threatening complication of terbutaline. This finding should be reported to the provider immediately. Acyclovir: oAcyclovir is an antiviral medication used to treat certain viral infections, such as genital herpes. If a client is exhibiting manifestations of genital herpes, which include open vesicles and pustules on the labia majora, labia minora, and perineum, draining pus with an erythematous base, not feeling well, and thick mucus vaginal discharge. The nurse should anticipate a provider prescription for acyclovir to help decrease the manifestations associated with genital herpes. Azithromycin. oA single dose of azithromycin is an appropriate treatment for a chlamydial infection. An acceptable alternative is doxycycline twice a day for 7 days.

Amenorrhea

No menses. The absence of periods can have causes that aren't due to underlying disease. Examples include menopause, pregnancy, use of birth control, medication side effects, delayed puberty, and stress. Occurs with pregnancy because of the suppression of follicle-stimulating hormone (FSH) by rising estrogen levels.

Preterm Birth & Post-term birth

Pre: Refers to a birth between 20 weeks and completion of 36 weeks Post: Refers to anytime after completion of 41 weeks gestation

Signs of Pregnancy

Presumptive (signs felt by woman) oAmenorrhea, tender breasts, quickening, nausea, etc. Probable (signs observed or interpreted by provider) oChadwick's, Goodell's, Hegar's, etc. opregnancy test (HCG... first morning void ) Positive (signs present due to actual fetus) oFHR, Ultrasound of fetal outline, fetal parts felt by examiner

Multigravida

Refers to a woman who has had 2 or more pregnancies

Primigravida

Refers to a woman who has had one birth at more than 20 weeks gestation regardless of whether the infant was born alive.

Goodell's Sign

The Goodell sign refers to a probable sign of pregnancy, characterized by softening of the cervical tip. A positive Goodell sign occurs due to increased blood flow noticed in the cervix during the first 4 to 8 weeks of pregnancy, which can also give the vaginal part of the cervix a bluish appearance (Chadwick sign).

Amniotic Fluid

THE AMNIOTIC FLUID Amniotic fluid never becomes stagnant because it is constantly being newly formed and absorbed by direct contact with the fetal surface of the placenta. The major method of absorption, however, happens within the fetus. Because the fetus continually swallows the fluid, it is absorbed from the fetal intestine into the fetal bloodstream. From there, it goes to the umbilical arteries and to the placenta and is exchanged across the placenta to the mother's bloodstream. At term, the amount of amniotic fluid has grown so much it ranges from 800 to 1,200 ml. If for any reason the fetus is unable to swallow (esophageal atresia or anencephaly are the two most common reasons), excessive amniotic fluid or hydramnios (more than 2,000 ml in total or pockets of fluid larger than 8 cm on ultrasound) will result. Hydramnios may also occur in women with diabetes because hyperglycemia causes excessive fluid shifts into the amniotic space. Early in fetal life, as soon as the fetal kidneys become active, fetal urine adds to the quantity of the amniotic fluid. A disturbance of kidney function, therefore, may cause oligohydramnios or a reduction in the amount of amniotic fluid. Oligohydramnios can be detected by ultrasound. The amniotic fluid index is measured, and it should be at least 5 cm. The vertical pocket of amniotic fluid should be greater than 2 cm. The appropriate amount of amniotic fluid ensures adequate kidney function. The most important purpose of amniotic fluid is to shield the fetus against pressure or a blow to the mother's abdomen. Because liquid changes temperature more slowly than air, it also protects the fetus from changes in temperature. Another function is that it aids in muscular development, as amniotic fluid allows the fetus freedom to move. Finally, it protects the umbilical cord from pressure, thus protecting the fetal oxygen supply. Even if the amniotic membranes rupture before birth and the bulk of amniotic fluid is lost, some will always surround the fetus in utero because new fluid is constantly being formed. Amniotic fluid is slightly alkaline, with a pH of about 7.2. Checking the pH of the fluid at the time membranes rupture and amniotic fluid is released helps to differentiate amniotic fluid from urine because urine is acidic (pH 5.0 to 5.5).

Lightening

The movement of the fetus down into the pelvis late in pregnancy. About 2 weeks before term (the 38th week) for a primigravida, a woman in her first pregnancy, the fetal head settles into the pelvis and the uterus returns to the height it was at 36 weeks. This settling of the fetus into the midpelvis is termed lightening because a woman's breathing is so much easier that she feels as if her load is lightened. The point at which lightening will occur is not predictable in a multipara (a woman who has had one or more children). In such women, it may not occur until labor begins.

Placental abruption

Unlike placenta previa, in premature separation of the placenta (also called abruptio placentae; Fig. 21.7), the placenta appears to have been implanted correctly. Suddenly, however, it begins to separate and bleeding results. This occurs in about 10 out of 1,000 pregnancies and, because it can lead to extensive bleeding, is the most frequent cause of perinatal death. The separation generally occurs late in pregnancy; even as late as during the first or second stage of labor. Because premature separation of the placenta may occur during an otherwise normal labor, it is important to always be alert to both the amount and kind of pain and vaginal bleeding a woman is having in labor. The primary cause of premature separation is unknown, but certain predisposing factors are high parity, advanced maternal age, a short umbilical cord, chronic hypertensive disease, hypertension of pregnancy, direct trauma (as from an automobile accident or intimate partner violence), vasoconstriction from cocaine or cigarette use, and thrombophilic conditions that lead to thrombosis formation. It also may be caused by chorioamnionitis or infection of the fetal membranes and fluid. Yet another possible cause is a rapid decrease in uterine volume, such as occurs with sudden release of amniotic fluid as can happen with poly-hydramnios. Usually, the fetal head is low enough in the pelvis that when membranes rupture, this prevents loss of the total volume of the amniotic fluid at one time, so normally a rapid reduction in amniotic fluid does not occur. Assessment A woman experiences a sharp, stabbing pain high in the uterine fundus as the initial separation occurs. If labor begins with the separation, each contraction will be accompanied by pain over and above the pain of the contraction. Tenderness can be felt on uterine palpation. Heavy bleeding usually accompanies premature separation of the placenta, although it may not be readily apparent. External bleeding will only be evident if the placenta separates first at the edges, so blood escapes freely into the uterus and then the cervix. In contrast, if the center of the placenta separates first, blood can pool under the placenta, and although bleeding is just as intense, it will be hidden from view. Whether blood is evident or not, signs of hypovolemic shock usually follow quickly. The uterus becomes tense and feels rigid to the touch. If blood infiltrates the uterine musculature, Couvelaire uterus or uteroplacental apoplexy, forming a hard, boardlike uterus occurs. As bleeding progresses, a woman's reserve of blood fibrinogen becomes diminished as her body attempts to accomplish effective clot formation, and DIC syndrome can occur (see later). If a woman is being admitted to the hospital after experiencing symptoms at home, assess when the time the bleeding began, whether pain accompanied it, the amount and kind of bleeding, and her actions to detect if trauma could have led to the placental separation. Initial blood work should include hemoglobin level, typing and cross-matching, and a fibrinogen level and fibrin breakdown products to detect DIC. Therapeutic Management Because of the threat to both the woman and the fetus, separation of the placenta is immediately an emergency situation. A woman needs a large-gauge intravenous catheter inserted for fluid replacement and oxygen by mask to limit fetal anoxia. Monitor fetal heart sounds externally and record maternal vital signs every 5 to 15 minutes to establish baselines and observe progress. The baseline fibrinogen determination will be followed by additional determinations up to the time of birth. Keep a woman in a lateral, not supine, position to prevent pressure on the vena cava and additional interference with fetal circulation. It is important not to disturb the injured placenta any further. Therefore, do not perform any abdominal, vaginal, or pelvic examination on a woman with a diagnosed or suspected placental separation. For better prediction of fetal and maternal outcomes, the degrees of placental separation can be graded (Table 21.5). Unless the separation is minimal (grades 0 and 1), the pregnancy must be ended because the fetus cannot obtain adequate oxygen and nutrients. If vaginal birth does not seem imminent, cesarean birth is the birth method of choice. If DIC has developed, cesarean birth may pose a grave risk because of the possibility of hemorrhage during the surgery and later from the surgical incision. Intravenous administration of fibrinogen or cryoprecipitate (which contains fibrinogen) can be used to elevate a woman's fibrinogen level prior to and concurrently with surgery. With the worst outcome, a hysterectomy might be necessary to prevent exsanguination.

Linea Nigra

a dark line appearing on the abdomen and extending from the pubis toward the umbilicus The umbilicus is stretched by pregnancy to such an extent that by the 28th week, its depression becomes obliterated and it is pushed so far outward in some women, it appears as if it has turned inside out, protruding as a round bump at the center of the abdominal wall. Extra pigmentation generally appears on the abdominal wall because of melanocyte-stimulating hormone from the pituitary. A narrow, brown line (linea nigra) may form, running from the umbilicus to the symphysis pubis and separating the abdomen into right and left halves

Hegar's sign

softening of the lower uterine segment

Biophysical Profile

**A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. A biophysical profile combines five parameters (i.e., fetal reactivity, fetal breathing movements, fetal body movement, fetal tone, and amniotic fluid volume) into one assessment. The fetal heart and breathing record measures short-term central nervous system function; the amniotic fluid volume helps measure long-term adequacy of placental function. The scoring for a complete profile is shown in Table 9.3. By this system, each item has the potential for scoring a 2, so 10 would be the highest score possible. A biophysical profile is more accurate in predicting fetal well-being than any single assessment. Because the scoring system is similar to an Apgar score determined at birth on infants, it is often referred to as a fetal Apgar score. Biophysical profiles may be done as often as daily during a high-risk pregnancy. The fetal scores are as follows: • A score of 8 to 10 means the fetus is considered to be doing well. • A score of 6 is considered suspicious. • A score of 4 denotes a fetus potentially in jeopardy. For simplicity, some centers use only two assessments (amniotic fluid index [AFI] and a nonstress test) for the analysis. Referred to as a modified biophysical profile, this predicts short-term viability by the nonstress test and long-term viability by the AFI. A healthy fetus should show a reactive nonstress test and an AFI range between 5 and 25 cm. Nurses play a large role in obtaining the information for both a modified and a full biophysical profile by obtaining either the nonstress test or the sonogram reading.

Fundal Height: - Checked at prenatal visits to determine a steady and predictable increase in size - Where should the fundus be at different weeks?

**Checked at prenatal visits to determine a steady and predictable increase in size **At 22 weeks of gestation, the fundal height should be just above the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a gross estimate of the weeks of gestation. Measuring fundal height at prenatal visits is an indirect way to assess if a woman's nutrition intake is adequate. The easiest method for determining if a woman's caloric intake is adequate is assessing if she is gaining weight. Keep in mind a woman's weight gain pattern is as important as the total weight gain. Even if a woman has surpassed her target weight before the end of the third trimester, encourage her not to restrict her caloric intake. She should continue to gain weight because a fetus grows rapidly during these final weeks. At about 12 to 14 weeks of pregnancy, the uterus becomes palpable as a firm globular sphere showing over the symphysis pubis. It grows to reach the umbilicus at 20 to 22 weeks and the xiphoid process of the sternum at 36 weeks. In primiparas, it then often returns to about 4 cm below the xiphoid process because of "lightening" for the rest of pregnancy. If a woman is past 12 weeks of a pregnancy, assess whether the fundus of the uterus is palpable, measure the fundal height (from the top notch of the symphysis pubis to the superior aspect of the fundus), and plot the height on a graph such as the one shown in Figure 11.3; plotting uterine growth at each visit this way can help detect any unusual variation in uterine or fetal growth. If an abnormality is detected, further investigation with ultrasound can be scheduled to determine the cause of the unusual increase or lack of growth. Fetal Growth As a fetus grows, the uterus expands to accommodate its size. Although not evidence grounded, typical fundal (top of the uterus) measurements are: • Over the symphysis pubis at 12 weeks • At the umbilicus at 20 weeks • At the xiphoid process at 36 weeks McDonald's rule, another symphysis-fundal height measurement (although, again, not documented to be thoroughly reliable), is an easy method of determining midpregnancy growth. Typically, tape measurement from the notch of the symphysis pubis to over the top of the uterine fundus as a woman lies supine is equal to the week of gestation in centimeters between the 20th and 31st weeks of pregnancy (e.g., in a pregnancy of 24 weeks, the fundal height should be 24 cm). A fundal height much greater than this standard suggests a multiple pregnancy, a miscalculated due date, a large-for-gestational-age (LGA) infant, hydramnios (increased amniotic fluid volume), or possibly even gestational trophoblastic disease (see Chapter 21). A fundal measurement much less than this suggests the fetus is failing to thrive (e.g., intrauterine growth restriction), the pregnancy length was miscalculated, or an anomaly interfering with growth has developed. McDonald's rule becomes inaccurate during the third trimester of pregnancy because the fetus is growing more in weight than in height during this time.

Natural Family Planning: - Billings method - Basil body temp

**If using the Billings method, the client should avoid sexual intercourse when her cervical mucus becomes thin and flexible. Cervical Mucus Method (Billing's Method) Yet another method to predict ovulation is to use the changes in cervical mucus that occur naturally with ovulation (Fig. 6.1B). Before ovulation each month, the cervical mucus is thick and does not stretch when pulled between the thumb and finger. Just before ovulation, mucus secretion increases. On the day of ovulation (the peak day), it becomes copious, thin, watery, and transparent. It feels slippery (like egg white) and stretches at least 1 inch before the strand breaks, a property known as spinnbarkeit (see Chapter 5, Fig. 5.14). In addition, breast tenderness and an anterior tilt to the cervix occur. All the days on which cervical mucus is copious, and for at least 3 to 4 days afterward, are considered to be fertile days, or days on which the woman should abstain from coitus to avoid conception. A woman using this method must be conscientious about assessing her vaginal secretions every day, or she will miss the change in texture and amount. The feel of vaginal secretions after sexual relations is unreliable because seminal fluid (the fluid containing sperm from the male) has a watery, postovulatory consistency and can be confused with ovulatory mucus. Figure 6.1B shows a hypothetical month using this method. This method has a potentially high failure rate because of difficulty in interpreting mucus status. Because sperm have a life span from 3 to more than 5 days, a woman needs to abstain for at least 4 days prior to the appearance of estrogen-influenced mucus; therefore, this method should be combined with a calendar method for best results. Basal Body Temperature Method: Just before the day of ovulation, a woman's basal body temperature (BBT), or the temperature of her body at rest, falls about 0.5°F. At the time of ovulation, her BBT rises a full Fahrenheit degree (0.2°C) because of the rise in progesterone with ovulation. This pattern serves as the basis for the BBT method of contraception.To use this method, the woman takes her temperature, either orally or with a tympanic thermometer, each morning immediately after waking before she rises from bed or undertakes any activity; this is her BBT. A woman who works nights should take her temperature after awakening from her longest sleep period, no matter what the time of day. As soon as a woman notices a slight dip in temperature followed by an increase, she knows she has ovulated. She refrains from having coitus (sexual relations) for the next 3 days (the possible life of the discharged ovum). Because sperm can survive from 3 to 5 days and rarely as many as 7 days in the female reproductive tract, it is usually recommended that the couple combine this method with a calendar method, so they abstain for a few days before ovulation as well. The BBT method has an ideal failure rate as low as 3% but a failure rate of 25% (see Table 6.1). For more information on BBT and how it also can be used to aid conception, see Chapter 7 and Figure 7.2. A problem with assessing BBT for fertility awareness is that many factors can affect BBT. For example, a temperature rise caused by illness could be mistaken as the signal of ovulation. If this happens, a woman could mistake a fertile day for a safe one. Changes in the woman's daily schedule, such as starting an aerobic program or getting up earlier than usual, could also affect BBT.

Alpha-fetoprotein Test

**It is a screening test for spinal defects in the fetus. **The maternal serum alpha-fetoprotein (MSAFP) screening test is used to identify suspected neural tube defects (NTDs) and abdominal wall defects. These include spina bifida, microcephaly, and anencephaly. This tool is the basis for further testing, such as amniocentesis and specialized ultrasounds. Alpha-fetoprotein tests are blood tests to check AFP between 16 and 22 weeks of pregnancy. Irregular AFP levels may point to the presence of a genetic disorder or neural tube defect in the fetus. It's important to understand that AFP tests are screening tools, not diagnostic ones.

NST: - Purpose of an NST o When the fetus moves, the fetal heart rate should increase about 15 beats per minute and remain elevated for 15 seconds. A non-stress test usually is done for 20 minutes. o What could the nurse do if there is limited or no fetal movement while conducting the NST

**Measures the response of the fetal heart rate to fetal movement. When the fetus moves, the fetal heart rate should increase about 15 beats per minute and remain elevated for 15 seconds. A non-stress test usually is done for 20 minutes. **A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations. Purpose of an NST: A nonstress test measures the response of the fetal heart rate to fetal movement. Position the woman and attach both a fetal heart rate and a uterine contraction monitor. Instruct the woman to push the button attached to the monitor (similar to a call bell) whenever she feels the fetus move. This will create a dark mark on the paper tracing at these times. When the fetus moves, the fetal heart rate should increase approximately 15 beats/min and remain elevated for 15 seconds. It should decrease to its average rate again as the fetus quiets. If no increase in beats per minute is noticeable on fetal movement, further testing may be necessary to rule out poor oxygen perfusion of the fetus. A nonstress test usually is done for 20 minutes. The test is said to be reactive (healthy) if two accelerations of fetal heart rate (by 15 beats or more) lasting for 15 seconds occur after movement within the time period. The test is nonreactive (fetal health may be affected) if no accelerations occur with the fetal movements. The results also can be interpreted as nonreactive if no fetal movement occurs or if there is low short-term fetal heart rate variability (less than 6 beats/min) throughout the testing period. If a 20-minute period passes without any fetal movement, it may only mean that the fetus is sleeping, although other reasons for lessened variability are maternal smoking, drug use, or hypoglycemia. Although not evidence based, if you give the woman an oral carbohydrate snack, such as orange juice, it can cause her blood glucose level to increase enough to cause fetal movement. The fetus also may be stimulated by a loud sound (discussed later) to cause movement. Because both rhythm strip and nonstress testing are noninvasive procedures and cause no risk to either the pregnant woman or fetus, they can be used as screening procedures in all pregnancies. They can be conducted at home daily as part of a home monitoring program for the woman who is having a complication of pregnancy. If a nonstress test is nonreactive, an additional fetal assessment, such as a biophysical profile test, will be scheduled. When the fetus moves, the fetal heart rate should increase about 15 beats per minute and remain elevated for 15 seconds. A non-stress test usually is done for 20 minutes. What could the nurse do if there is limited or no fetal movement while conducting the NST: or acoustic (sound) stimulation, a specially designed acoustic stimulator is applied to the mother's abdomen to produce a sharp sound of approximately 80 dB at a frequency of 80 Hz, thus startling and waking the fetus. During a standard nonstress test, if a spontaneous acceleration has not occurred within 5 minutes, apply a single 1- to 2-second sound stimulation to the lower abdomen. This can be repeated again at the end of 10 minutes if no further spontaneous movement occurs, so two movements within the 20-minute window can be evaluated.

NST (nonstress test)

**Measures the response of the fetal heart rate to fetal movement. When the fetus moves, the fetal heart rate should increase about 15 beats per minute and remain elevated for 15 seconds. A non-stress test usually is done for 20 minutes. oA contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations. Nonstress Testing A nonstress test measures the response of the fetal heart rate to fetal movement. Position the woman and attach both a fetal heart rate and a uterine contraction monitor. Instruct the woman to push the button attached to the monitor (similar to a call bell) whenever she feels the fetus move. This will create a dark mark on the paper tracing at these times. When the fetus moves, the fetal heart rate should increase approximately 15 beats/min and remain elevated for 15 seconds. It should decrease to its average rate again as the fetus quiets (Fig. 9.10C). If no increase in beats per minute is noticeable on fetal movement, further testing may be necessary to rule out poor oxygen perfusion of the fetus. A nonstress test usually is done for 20 minutes. The test is said to be reactive (healthy) if two accelerations of fetal heart rate (by 15 beats or more) lasting for 15 seconds occur after movement within the time period. The test is nonreactive (fetal health may be affected) if no accelerations occur with the fetal movements. The results also can be interpreted as nonreactive if no fetal movement occurs or if there is low short-term fetal heart rate variability (less than 6 beats/min) throughout the testing period. If a 20-minute period passes without any fetal movement, it may only mean that the fetus is sleeping, although other reasons for lessened variability are maternal smoking, drug use, or hypoglycemia. Although not evidence based, if you give the woman an oral carbohydrate snack, such as orange juice, it can cause her blood glucose level to increase enough to cause fetal movement. The fetus also may be stimulated by a loud sound (discussed later) to cause movement. Because both rhythm strip and nonstress testing are noninvasive procedures and cause no risk to either the pregnant woman or fetus, they can be used as screening procedures in all pregnancies. They can be conducted at home daily as part of a home monitoring program for the woman who is having a complication of pregnancy. If a nonstress test is nonreactive, an additional fetal assessment, such as a biophysical profile test, will be scheduled. **NST measures the response of the fetal heart rate to fetal movement. When the fetus moves, the fetal heart rate should increase about 15 beats per minute and remain elevated for 15 seconds. A non-stress test usually is done for 20 minutes. oNST = performed during 3rd trimester, non invasive, monitor response reactivity of FHR to fetal movement (may not be reactive if fetus is in sleep cycle, fetal immaturity, maternal medications or nicotine use) **What could the nurse do if there is limited or no fetal movement while conducting the NST Offer the client a snack of orange juice and crackers. oA nonstress test depends upon fetal movement if there is limited or no movement the fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement.

Leopold Maneuver: - What does this determine - Know where a nurse would auscultate fetal heart tones in relation to what is felt with a Leopold maneuver

**These maneuvers are a systemic method of observation and palpation to determine fetal presentation and position and are done as part of a physical examination. oKnow where a nurse would auscultate fetal heart tones in relation to what is felt with a Leopold maneuver oEx: nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. **Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant. What does this determine: leopold maneuvers are a systematic method of observation and palpation to determine fetal presentation and position and are done as part of a physical examination. Know where a nurse would auscultate fetal heart tones in relation to what is felt with a Leopold maneuver: With a breech presentation, fetal heart sounds usually are heard high in the abdomen. Leopold maneuvers and a vaginal examination usually reveal the presentation. If fetus is head down (cephalic presentation) you can hear fetal heart tones halfway between the symphysis pubis and the umbilicus. If you palpate baby's back, that is where you will hear FHT.

Acyclovir

*Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy. Acyclovir (Zovirax) or valacyclovir (Valtrex) can both be safely administered to women who develop lesions during pregnancy as well as to their newborns at birth (Groves, 2016). Either drug is recommended daily as prophylaxis at 36 weeks of pregnancy to prevent a lesion at the time of birth. The primary mechanism for protecting a fetus, however, is disease prevention. Urging women to practice safer sex is important to lessen their exposure to this and other sexually transmitted infections. An antiviral drug such as acyclovir (Zovirax), a drug that inhibits viral DNA synthesis, is effective in combating this overwhelming infection. Prevention, however, is the newborn's best protection. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at birth and reduces the need for cesarean birth (Pinninti & Kimberlin, 2014). Women with active herpetic vulvar lesions are advised to have cesarean birth rather than vaginal birth to minimize the newborn's exposure. Infants with an infection should be separated from other infants in a nursery. Although transmission from this source is rare, women with herpes lesions on their face (herpes simplex I, or cold sores) need to be assessed before they hold their newborns to be sure lesions are crusted and, therefore, are no longer contagious. Healthcare personnel who have herpes simplex infections should not care for newborns until the lesions are crusted. Although facial herpes simplex lesions are probably caused by herpesvirus type 1, limiting contact does not seem excessive in light of the severity of HSV-2 disease. Urge a woman who is separated from her newborn at birth to view her infant from the nursery window and participate in planning care to aid bonding.

FACTS ABOUT CONTRACEPTION

-Pelvic relaxation and large cystocele are contraindications for diaphragm use. -What contributes to success and failure rates (depends on Method, and compliance/consistency of use) -Benefits and Risks of different methods (i.e Stroke associated with hormone contraception, Thromboembolism increased risk for smokers, Benefit of fertility awareness method... no chemical or hormones, Injectable progestins good choice for women who can't remember to take daily -Surgical methods... important things to educated patients regarding (i.e Vasectomy... may take several months to clear ducts of sperm, Tubal ligation fallopian tubes are blocked, chances for success of reversals)

Amniotomy (artificial rupture of membranes (AROM))

AMNIOTOMY Amniotomy is the artificial rupturing of membranes during labor if they do not rupture spontaneously to allow the fetal head to contact the cervix more directly, which possibly increases the efficiency of contractions and therefore increases the speed of labor. There is still conflicting evidence about the risks and benefits of amniotomy with regard to shortening labor duration and risks for cesarean section after amniotomy; therefore, practices may vary widely in how often this technique is used. If the procedure is scheduled, a woman is asked to assume a dorsal recumbent position; an amniohook (a long, thin crochet-like instrument) or a hemostat is passed vaginally. The membranes are torn, and amniotic fluid is allowed to escape. A disadvantage of amniotomy is that it puts a fetus momentarily at risk for cord prolapse if a loop of cord escapes into the vagina with the fluid. It is important to only perform an amniotomy if the fetal head is well applied to the cervix. Always measure the FHR immediately after the rupture of membranes to determine this did not happen.

Amniotic Fluid

Amniotic fluid volume Increases weekly and 800 to 1000 mL is present at term Oligohydramnios = Less than 300 mL. Associated with fetal renal abnormalities because fetal urination adds to volume, also IUGR Complications: cord compression, musculoskeletal abnormalities, facial distortion Hydramnios or polyhydramnios = more than 2000 mL. Associated with fetal gastrointestinal abnormalities because fetus swallows amniotic fluid and multiple fetuses. Also this condition can increase risk for preterm labor and premature rupture of membranes. Concerns: umbilical cord prolapse, breech presentation Amniocentesis.... when and why is it done? (i.e. Checking lung maturity) Empty bladder to reduce risk of puncture Don't hold breath, this can depress diaphragm, which shifts the contour of the uterus and can shift the location of the placenta to insertion site for amnio Risks include; Cramping Bleeding Leaking amniotic fluid Infection Rh sensitization Preterm labor

Contraception: - Most reliable form of contraception - How do you help clients decide? - Fertility awareness contraception requires no chemicals or hormones

An intrauterine device (IUD) is the most reliable form of contraception. Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most reliable methods of contraception. How do you help clients decide: the nurse will need to know more about the individual's sexual activity." This is an example of providing a general lead when using therapeutic communication. It allows the client to provide information that will enhance effective consultation about the best form of contraception for her. Important things to consider when helping a couple choose a method that will be right for them include: • Personal values • Ability to use a method correctly • If the method will affect sexual enjoyment • Financial factors • If a couple's relationship is short term or long term • Prior experiences with contraception • Future plans For counseling to be successful, it is necessary to understand how various methods of contraception work and how they compare in terms of benefits and disadvantages (Box 6.2). In addition to assessing to determine the best contraceptive option, be certain to emphasize safer sex practices. Although there are many contraceptive options for reliable pregnancy prevention, only condoms (both male and female) provide protection against sexually transmitted infections (STIs) or HIV—an important concern if a relationship is not a monogamous one. Consider each person's lifestyle and overall health, as these influence what type of conception a woman will choose (Box 6.3). Morbidly obese women, for example, may need to choose different types than women with an average body mass index (Mody & Han, 2014). Women in a male-dominant family may have little choice as to what reproductive life planning method they can choose. If their partner does not wish to participate in contraception planning, it would be unhelpful to suggest a type where male cooperation is needed, such as the use of a male condom or natural family planning. Fertility awareness contraception (natural family planning) requires no chemicals or hormones: abstinence, lactation amenorrhea, calendar, standard day method, basal body temperature, ovulation method, symptothermal, two day method, withdrawal.

Prenatal Care

Benefits (Education, maternal and fetal wellbeing, identify risks, treat conditions, birth plan) When to notify doctor/dangers or concerns (vaginal bleeding, increased weight gain) Behaviors to avoid (alcohol, smoking etc.) Test to assess fetal well being (FHR / Non=stress test / Alfa fetoprotein what do abnormal levels indicate i.e. neural-tube defects) Folic Acid.... It is the most important supplement or nutrient to help prevent birth defects PKU phenylketonuria: inherited disorder that causes an amino acid called phenylalanine to build up in the body. If client has PKU, they need to eliminate protein-rich foods that contain phenylalanine from diet ex: meats, eggs, milk, nuts, and wheat products. Conditions associated with increased estrogen levels during pregnancy (itching palms, stuffy nose, spider veins, swelling, tender breasts, melasma, acne and blotchy skin, growth of breast tissue etc) Methods to relieve discomfort during examinations (warm/cover speculum, relax and breath slowly, position stirrups so they are comfortable for her)

STI's

Challenges for asymptomatic (prevention=vaccine detection=screenings and cultures education=safe sex *** Infections of reproductive tract asymptomatic and damage is done) Actions to reduce the risk of STI's to fetus (medications, Delivering c section vs vaginal with STI's, eye prophylaxis) Chlamydia is treated with one dose of azithromycin." A single dose of azithromycin is an appropriate treatment for a chlamydial infection. An acceptable alternative is doxycycline twice a day for 7 days.

Conception: - Sequential process:

Fetal Development: Conception Process = Sequential process (Gamete formation, ovulation, fertilization in the fallopian tube near the ovary, implantation) Gamete (reproductive cells = ovum or egg 40,000 born with, sperm trillions made regularly over lifetime) Ovulation Fertilization = outer third of fallopian tube after fertilization called ZYGOTE Implantation into uterine wall = takes 8 to 10 days to travel down fallopian tube and implant. After implantation called EMBRYO Once the heartbeat can be detected somewhere around 5 - 8 weeks gestation it is called a FETUS In-utero growth and development = Zygote / embryo / fetus (what develops in each stage) Zygotic period = genetic information is exchanged and chromosomes are paired. Rapid cell division occurs and the cells begin to differentiate and develop specific forms and functions Embryonic period = the development of organ systems as well as external features. Hcg levels rise Fetal = further development and refinement of organ and systems function, growth of fetus Ways to evaluate fetal growth (Fundal height, weight gain, FHR ultrasound etc.) Fundal height (McDonalds rule) = rough determination of fetal gestation compared to measurement from pubic bone to fundus (in centimeters) Over the symphysis pubis at 12 weeks Over symphysis pubis at 12 weeks At the umbilicus at 20 weeks 1 cm per week gestation 20 weeks to 31st week Reaches ziphoid process at 36 weeks The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of gestation. The embryonic stage of development is considered a critical time for development of organ systems and main external features.

Fetal Development: - The fetal heartbeat is audible by Doppler stethoscope when - The embryonic stage of development is considered a critical time for development for what

Fetal Development: In just 38 weeks, a fertilized egg (ovum) matures from a single cell to a fully developed fetus ready to be born. Although different cultures or religions debate the point at which life begins, for ease of discussion, all agree fetal growth and development can be divided into three time periods:Pre-embryonic (first 2 weeks, beginning with fertilization), Embryonic (weeks 3 through 8), Fetal (from week 8 through birth). The fetal heartbeat is audible by Doppler stethoscope when: The heartbeat may be heard with a Doppler instrument as early as the 10th to 12th week of pregnancy. Normal fetal heart rate is 110-160 BPM. The embryonic stage of development is considered a critical time for development for what: All organ systems are complete, at least in a rudimentary form, at 8 weeks gestation (the end of the embryonic period). During this early time of organogenesis (organ formation), the growing structure is most vulnerable to invasion by teratogens (i.e., any factor that affects the fertilized ovum, embryo, or fetus adversely, such as a teratogenic medicine; an infection such as toxoplasmosis; cigarette smoking; or alcohol ingestion). he neurologic system seems particularly prone to insult during the early weeks of the embryonic period and can result in neural tube disorders. The embryo grows rapidly, and the baby's external features begin to form. Your baby's brain, spinal cord, and heart begin to develop. Baby's gastrointestinal tract starts to form. It is during this time in the first trimester that the baby is most at risk for damage from things that may cause birth defects.

Pregnancy Changes: - Physiological changes (1- 3rd trimesters)

First Trimester: Cardiovascular: blood volume increases, pseudo-anemia may occur, clotting factors increase. Ovarian: corpus luteum active. Uterus: steady increased growth. Cervix: softening begins. Vagina: white discharge present. Kidney: maternal glomerular filtration rate increases, glycosuria begins and increases, aldosterone increases, aiding retention of sodium and fluid. Thyroid: increased metabolic rate. Second Timester: Cardiovascular: BP slightly decreases. Ovarian: corpus luteum fading. Uterus placenta producing estrogen and progesterone, steady increased growth. Cervix: softening increases. Musculoskeletal: progressive cartilage softening, lordosis increasing. Pigmentation: progressively increasing. GI: slowed peristalsis. Third Trimester: Cardiovascular: BP returns to pre-pregnancy levels. Uterus: steady increased growth. Vagina: increased white discharge. Cervix: ripe. Musculoskeletal: possible back or pelvis girdle pain.

Nutrition: - Folic Acid (why is it important, when is the most critical time to take it) - Iron intake: - Smoking: - PKU

Folic Acid is important to take during preconception and the first trimester- Increased consumption of folic acid in the 3 months prior to conception, as well as throughout the pregnancy, reduces the incidence of neural tube defects in the developing fetus. Iron intake: During pregnancy, the need for iron increases to allow transfer of the appropriate amounts to the fetus and to support expansion of the client's red blood cell volume. Smoking: Clients who smoke place their newborns and themselves at risk for diverse complications, including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death. PKU The nurse should instruct the client to eliminate protein-rich foods that contain phenylalanine from the diet. These include meats, eggs, milk, nuts, and wheat products.

Gestational Hypertension: - Hypertension types and indications for each - Medications - Why could this individual be at higher risk for hemorrhage?

GESTATIONAL HYPERTENSION A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mmHg) but has no proteinuria or edema. Perinatal mortality is not increased with simple gestational hypertension, so careful observation but no drug therapy is necessary. PREECLAMPSIA WITHOUT SEVERE FEATURES If a seizure from preeclampsia occurs, a woman now has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to be preeclamptic without severe features when she has proteinuria (1+ on a urine dip or 300 mg in a 24-hour urine protein collection or 0.3 or higher on a urine protein-creatinine ratio) and a blood pressure rise to 140/90 mmHg, taken on two occasions at least 6 hours apart. The diastolic value of blood pressure is extremely important to document because it is this pressure that best indicates the degree of peripheral arterial spasm present. A second criterion for evaluating blood pressure is a systolic blood pressure greater than 30 mmHg and a diastolic pressure greater than 15 mmHg above prepregnancy values. This rule is helpful for a woman with preexisting hypertension, but the value of 140/90 mmHg is a more useful cutoff point when there are no baseline data available, such as when a woman seeks prenatal care late in pregnancy. Average blood pressures in American women are available at http://thePoint.lww.com/Flagg8e. According to these averages, a woman younger than 20 years could have a blood pressure of 98/61 mmHg and still be within normal limits. If her blood pressure was elevated 30 mmHg systolic and 15 mmHg diastolic, it would be only 128/76 mmHg. This is well beneath the traditional warning point of 140/90 mmHg but would represent hypertension for her. Many women show a trace of protein during pregnancy. Actual proteinuria is said to exist when it registers as 1+ or more (this represents a loss of 1 g/L). A woman with preeclampsia will begin to show proteinuria of 1+ or 2+ on a reagent test strip on a random sample. Occasionally, women have orthostatic proteinuria (i.e., on long periods of standing, they excrete protein; on bed rest, they do not). If proteinuria is present without other signs of gestational hypertension (no hypertension and no edema), check to see when the specimen was obtained. Ask her to bring in a first morning urine sample next time as that may reveal that orthostatic proteinuria, not preeclampsia, is the cause of protein in her urine. Edema develops, as mentioned, because of the protein loss, sodium retention, and lowered glomerular filtration rate. The edema can be separated from the typical ankle edema of pregnancy because it begins to accumulate in the upper part of the body as well. A weight gain of more than 2 lb/week in the second trimester or 1 lb/week in the third trimester usually indicates abnormal tissue fluid retention is occurring. No noticeable edema may be present when this sudden increase in weight first occurs or it will be the first symptom a woman notices. PREECLAMPSIA WITH SEVERE FEATURES A woman has passed to preeclampsia with severe features when her blood pressure rises to 160 mmHg systolic and 110 mmHg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mmHg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample. With preeclampsia with severe features, extreme edema is most readily palpated over bony surfaces, such as over the tibia on the anterior leg, the ulnar surface of the forearm, and the cheekbones, where the sponginess of fluid-filled tissue can be palpated against bone. If there is swelling or puffiness at these points to a palpating finger but the swelling cannot be indented with finger pressure, the edema is described as nonpitting. If the tissue can be indented slightly, this is 1+ pitting edema; moderate indentation is 2+; deep indentation is 3+; and indentation so deep it remains after removal of the finger is 4+ pitting edema. This accumulating edema will reduce a woman's urine output to approximately 400 to 600 ml per 24 hours. It's helpful to further assess edema by asking a woman if she has noticed any swelling anywhere in her body. Women commonly report upper extremity edema as "My rings are so tight I can't get them off" and facial edema as "When I wake in the morning, my eyes are swollen shut" or "My tongue is so swollen I can't talk until I walk around awhile." Some women report severe epigastric pain and nausea or vomiting, possibly because abdominal edema or ischemia to the pancreas and liver has occurred. If pulmonary edema has developed, a woman may report feeling short of breath. If cerebral edema has occurred, reports of visual disturbances such as blurred vision or seeing spots before the eyes may be reported. Cerebral edema also produces symptoms of severe headache and marked hyperreflexia and perhaps ankle clonus. ECLAMPSIA Eclampsia is the most severe classification of pregnancy-related hypertensive disorders. A woman has passed into this stage when cerebral edema is so acute a grand mal (tonic-clonic) seizure or coma has occurred. With eclampsia, the maternal mortality can be as high as 20% from causes such as cerebral hemorrhage, circulatory collapse, or renal failure (Gongora & Wenger, 2015). The fetal prognosis with eclampsia is also poor because of hypoxia, possibly caused by the seizure, with consequent fetal acidosis. If premature separation of the placenta from extreme vasospasm occurs, the fetal prognosis becomes even graver. If a fetus must be born before term, all the risks of immaturity will be faced. Medications: Magnesium sulfate to prevent seizures, reduce edema (calcium gluconate as antidote), hydralazine (antihypertensive) to reduce BP, diazepam to halt seizures, betamethasone if delivery needs to happen before 37 weeks. Why could this individual be at higher risk for hemorrhage: Take blood pressure frequently (at least every 4 hours) or with a continuous monitoring device to detect any increase, which is a warning that a woman's condition is worsening. Obtain blood studies such as a complete blood count, platelet count, liver function, blood urea nitrogen, and creatine and fibrin degradation products as ordered by the obstetric team to assess renal and liver function and the development of DIC, which often accompanies severe vasospasm, as well as plasma estriol levels (a test of placenta function), and electrolyte levels. Because a woman is at high risk for premature separation of the placenta and resulting hemorrhage, a blood sample for type and cross-match is usually also obtained.

Pregnancy Complications

Gestational Diabetes: -Increased exercise benefits the client and can result in improved management of gestational diabetes. -Insulin is the first line of treatment for clients who are pregnant and are unable to maintain blood glucose levels within the recommended range. Unlike oral hyperglycemics, insulin does not cross the placenta and affect the fetus. Gestational Hypertension: -Hypertension types oGestational hypertension - begins after 20 weeks. Symptoms affect all organs. ·Signs and symptoms - B/P 140/90. No proteinuria or edema. The client's blood pressure returns to normal 6 weeks postpartum. Preeclampsia: Hypertension during pregnancy 140/90 or greater - what else would indicate preeclampsia? -Elevated liver enzymes, proteinuria, rapid swelling especially in face and hands, epigastric pain and unresolved headache may indicate worsening of the preeclampsia oMild preeclampsia - B/P 140/90. Proteinuria is 1 to 2 +. Weight gain is over 2 lbs. a week in second trimester and 1 lb. a week in third semester. Mild edema in upper extremities. ·Signs and symptoms - same as above ·The client who has mild preeclampsia is encouraged to drink six to eight 8-ounce glasses of water (48 to 64 ounces) per day. She should avoid alcohol and limit intake of caffeinated beverages. · oSevere Preeclampsia - consists of blood pressure that is 160/90 mm Hg or greater, proteinuria greater than 3+, oliguria, elevated serum creatinine greater than 1.2 mg/dL. ·Signs and symptoms - headache and blurred vision, hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and upper quadrant pain, and thrombocytopenia. Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex. ·The disease causes changes in the cortex, which disrupt the equilibrium of impulses between the cerebral cortex and the spinal cord oEclampsia - is severe preeclampsia symptoms along with the onset of seizure activity or coma ·Signs and symptoms - eclampsia is usually preceded by headache, severe epigastric pain, hyperreflexia, and hemoconcentration's, which are warning signs of probable convulsion. oHELLP syndrome - is a variant of gestational hypertension in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory tests, not clinically. ·What to do: magnesium sulfate, decrease chance of seizures by.. dark quiet room... decrease CNS stimulation, which minimizes the risk of seizures., Possibility of calcium gluconate ·Therapeutic intent - cure is delivery ·Medications -Antihypertensive medications - Methyldopa (Aldomet), Nifedipine (Procardia), Hydralazine (Apresoline), Labetalol (Normodyne). -Anticonvulsant medications - Magnesium sulfate - PLEASE KNOW THAT POSTPARTUM HEMORRHAGE CAN OCCUR DUE TO MUSCLE OF UTERUS SO RELAXED. - Disseminated Intravascular coagulation -What would you see? Clinical manifestations of disseminated intravascular coagulation (DIC) include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria. Genitourinary tract infections: -Primarily dangerous because they are often asymptomatic until extensive damage is done. Placenta Previa -** Monitor FHTs** -Painless red vaginal bleeding supports the diagnosis Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester. Is it always an emergency? What would you want to know? How would you confirm Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is. What might you see in severe or a conserning situation? Pulse, blood pressure what would be an intervention you would want to initiate? IV- why... What else do you need to consider? Fetus... apply an external fetal monitor to evaluate heart sounds Possible C-Section ·"Pelvic rest" is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examinations, no douching, and no vaginal intercourse. ·Types - these are classified into three types of dependent on the degree to which the cervical os is covered by the placental attachment. -Complete or total - when the cervical os is completely covered by the placental attachment. -Incomplete or partial - when the cervical os is only partially covered by the placenta. -Marginal or low lying - when the placenta is attached in the lower uterine segment but does not reach the cervical os. ·Risk factors - previous placenta previa, uterine scar, over 35 to 40 year of age, multiple gestation, smoking, closely spaced pregnancies. ·Assessment -Subjective - PAINLESS, bright red bleeding during second and third trimester. -Objective - uterus is soft, relaxed, non-tender, reassuring FHR, vital signs WNL, usually baby is breech, oblique or transverse position, fundal height is high. ·Laboratory tests - CBC, blood type and Rh, coagulation profile, Kleihauer-Betke (used to detect fetal blood in maternal circulation). ·Diagnostics - ultrasound, external fetal monitoring ·Nursing actions - no vaginal exam, IVF's, assess bleeding, leakage and contractions. Assess fundal height, perform Leopolds (fetal position and presentation). Corticosteroids, such as Betamethasone to promote fetal lung maturation if delivery is anticipated (C/S). Placental Abruption: -Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption. -The classic signs of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions. -Preeclampsia: Hypertension during pregnancy 140/90 or greater - what else would indicate preeclampsia Elevated liver enzymes, proteinuria, rapid swelling especially in face and hands, epigastric pain and unresolved headache may indicate worsening of the preeclampsia ·severe 160/100 (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria 3+-4+. Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex. §May also have intense headaches, visual problems, nausea and vomiting §What to do: magnesium sulfate, decrease chance of seizures by.. dark quiet room... decrease CNS stimulation, which minimizes the risk of seizures., Possibility of calcium gluconate ·The client who has mild preeclampsia is encouraged to drink six to eight 8-ounce glasses of water (48 to 64 ounces) per day. She should avoid alcohol and limit intake of caffeinated beverages.

Gestational Diabetes: - How is it diagnosed - Exercise - Treatment

Gestational Diabetes: A condition of abnormal glucose metabolism that arises during pregnancy. Possible signal of an increased risk for type 2 diabetes later in life. Approximately 2% to 3% of all women who do not begin a pregnancy with diabetes develop the condition during pregnancy, usually at the midpoint of pregnancy when insulin resistance becomes most noticeable. This is termed gestational diabetes mellitus (Landon, Catalano, & Gabbe, 2012). The symptoms fade again at the completion of pregnancy, but the risk of developing type 2 diabetes later in life may be as high as 50% to 60%. It is unknown whether gestational diabetes results from inadequate insulin response to carbohydrate, from excessive resistance to insulin, or from a combination of both. Risk factors for developing gestational diabetes include: • Obesity • Age over 25 years • History of large babies (10 lb or more) • History of unexplained fetal or perinatal loss • History of congenital anomalies in previous pregnancies • History of polycystic ovary syndrome • Family history of diabetes (one close relative or two distant ones) • Member of a population with a high risk for diabetes (Native American, Hispanic, Asian) How is it diagnosed: Because diabetes is such a serious complication in pregnancy, all women should be screened during pregnancy for gestational diabetes. A fasting plasma glucose greater than or equal to 126 mg/dl or a nonfasting plasma glucose greater than or equal to 200 mg/dl meets the threshold for the diagnosis of diabetes and does not need confirmation. It is recommended that all pregnant women receive a 50-g glucose challenge test between 24 and 28 weeks gestation to determine if they are at risk for gestational diabetes. If the result of that test is 140 mg/dl (some providers use 130 mg/dl as the cutoff), then the woman will need to do a three hour glucose tolerance test. For this, after a fasting glucose sample is obtained, the woman drinks an oral 100-g glucose solution; a venous blood sample is then taken for glucose determination at 1, 2, and 3 hours later. If two of the four blood samples collected for this test are abnormal or the fasting value is above 95 mg/dl, a diagnosis of diabetes is made. The values that confirm diabetes are reviewed in Table 20.3. Exercise: Exercise is another mechanism that lowers serum glucose levels and, therefore, the need for insulin. If a woman begins an exercise program for the first time during pregnancy, she may notice excessive glucose fluctuations at first. Therefore, it's best if she begins her exercise program before pregnancy, when glucose fluctuation can be evaluated and food and snacks adjusted accordingly before a fetus is involved. With exercise, blood glucose levels decrease because the muscles increase their need for glucose, an effect which lasts for at least 12 hours after exercise. If the arm in which a woman injected insulin is actively exercised, the insulin is released so quickly that it can cause hypoglycemia. To avoid this phenomenon, a woman should eat a snack consisting of a protein or complex carbohydrate before exercise and should maintain a consistent exercise program—she should not do aerobic exercises one day and then none the next, but rather, do 30 minutes of walking every day. In a woman with poor blood glucose control, extreme exercise will cause hyperglycemia and ketoacidosis as the liver both releases glucose and breaks down fatty acids in an attempt to supply enough energy for the exercise, yet the body cannot use them because of inadequate insulin. Treatment: Because blood glucose levels near normal help minimize the risk of maternal and fetal complications, both women with gestational diabetes and those with overt diabetes need more frequent prenatal visits than usual to ensure close monitoring of their condition and that of the fetus. Insulin therapy is needed is it is not controlled. Short acting insuling may be used alone or with an intermediate type. 2/3 given before breakfast and 1/3 given before dinner. Blood Glucose monitoring four times a day. Her goals should be fasting numbers that are 90 and below and postprandial values that are less than 140. Insulin pump therapy can also be used during pregnancy.

Human Chorionic Gonadotropin (hCG)

Human chorionic gonadotropin is a hormone produced primarily by syncytiotrophoblastic cells of the placenta during pregnancy. The hormone stimulates the corpus luteum to produce progesterone to maintain the pregnancy. *Hormone responsible for the first trimester nausea *Secreted by the placenta which acts as an endocrine gland Human Chorionic Gonadotropin The first placental hormone produced, hCG, can be found in maternal blood and urine as early as the first missed menstrual period (shortly after implantation has occurred). Levels vary throughout pregnancy. The pregnant woman's blood serum will be completely negative for hCG within 1 to 2 weeks after birth. Finding no serum hCG after birth can be used as proof that placental tissue is no longer present. hCG's purpose is to act as a fail-safe measure to ensure the corpus luteum of the ovary continues to produce progesterone and estrogen so the endometrium of the uterus is maintained. hCG also may play a role in suppressing the maternal immunologic response so placental tissue is not detected and rejected as a foreign substance. Because the structure of hCG is similar to that of luteinizing hormone of the pituitary gland, if the fetus is male, it exerts an effect on the fetal testes to begin testosterone production and maturation of the male reproductive tract. At about the eighth week of pregnancy, the outer layer of cells of the developing placenta begins to produce progesterone, making the corpus luteum, which was producing progesterone, no longer necessary. In coordination with this, the production of hCG, which sustained the corpus luteum, begins to decrease at this point.

Naegele's Rule

Naegele's Rule is named after Franz Karl Naegele (1778-1851), the German obstetrician who devised the rule. Accurate use requires that a woman have a regular 28 day menstrual cycle. -Subtract 3 months from the first day of the last menstrual period -Add 7 days to the first day of the last menstrual cycle -Add one year to the date (adjust if needed) Example: First day of last cycle October 8 2021 -3 +7 + 1 July 15 2022

Kegel Exercises

Kegel exercises are exercises designed to strengthen the pubococcygeal muscles. Each is a separate exercise and should be done about three times per day. Kegel exercises improve the strength of perineal muscles, facilitating stretching and contracting during childbirth. 1. Squeeze the muscles surrounding the vagina as if stopping the flow of urine. Hold for 3 seconds. Relax. Repeat this sequence 10 times. 2. Contract and relax the muscles surrounding the vagina as rapidly as possible 10 to 25 times. 3. Imagine you are sitting in a bathtub of water and squeeze muscles as if sucking water into the vagina. Hold for 3 seconds. Relax. Repeat this action 10 times. 4. Caution: Don't regularly start and stop the flow of urine during urination to try and strengthen muscles as this can lead to incomplete emptying of the bladder. It may take as long as 6 weeks of exercise before pubococcygeal muscles are strengthened. In addition to strengthening urinary control and preventing stress incontinence, Kegel exercises can lead to increased sexual enjoyment because of tightened vaginal muscles and can help avoid tearing of the perineum with childbirth.

Fetal Well-being

Kick-counts = fetal movement counting. 10 movements in 2 hours is reassuring. Do once daily, once feels 10 movements can stop timing, if over 2 hours let provider know. No caffeine within 12 hours of doing counts ·FHR = can be auscultated (may need a doppler) @ 10-12 weeks gestation rate = 110-160 ·A fetoscope is not able to detect FHT this early in the pregnancy. The nurse should use a Doppler or ultrasound stethoscope. Typically at 12 weeks, the heart tones will be heard midline just above the symphysis pubis with a Doppler or ultrasound device. A fetoscope can be used to assess FHT later in the pregnancy, around 16 to 20 weeks. Biophysical profile=score points for each category, 8-10 is normal: A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. Alfa fetoprotein what do abnormal levels indicate i.e. neural-tube defects) Maternal serum alpha-fetoprotien screening is done for who and why? MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman. Ultra sound Maternal lie; sims position- side lying, Semi Fowlers with one hip slightly elevated to promote uterine perfusion and prevent supine hypotension as a result of the uterus compressing the maternal vena cava.

Lactation Amenorrhea: LAM

LACTATION AMENORRHEA METHOD When a woman is breastfeeding, there is a natural suppression of both ovulation and menses. Lactation amenorrhea method (LAM) is a safe birth control method (a failure rate of about 1% to 5%) if: • An infant is: • Under 6 months of age • Being totally breastfed at least every 4 hours during the day and every 6 hours at night • Receives no supplementary feedings, and • Menses has not returned After 6 months, or if the infant begins to receive supplemental feedings or isn't sucking well, the use of LAM as an effective birth control method becomes questionable and the woman probably should be advised to choose another method of contraception. A woman should also consider a different method of contraception once her baby begins sleeping through the night, even if this occurs before the child reaches 6 months of age.

Pregnancy Changes: - Sequence of Maternal Changes

Maternal hypotension can be caused from the weight of the uterus on the vena cava, the client should not lie flat on her back. **Sequence of Maternal Changes: Amenorrhea Goodell's sign Quickening Lightening **Physiological changes 3rd trimester Gradual lordosis Clients who are pregnant can develop a gradual, forward curving of the spine as the growth of the fetus pulls the pelvis forward. This lordosis resolves after delivery. Emotional Grief / loss from freedom / independence, or adapting to more children Narcissism = form of denial, may hide pregnancy, criticize partner, self centered, oIntroversion vs extroversion = first part of pregnancy introversion, looking inward, wondering what is happening in her body, then later part of pregnancy extroversion she is looking outward, preparing for baby, talking with family, reaching out to others for advice Feelings of uncertainty related to the pregnancy can be common for women in early pregnancy be sure that you offer a therapeutic communication technique while providing information in addressing the client's concerns and feelings. Couvade syndrome = partner experiences pregnancy syndromes Nausea/vomiting Cravings Aches and pains Weight gain Water retention Weight Gain Expected 1 lb per week It would be a concern if She gains more than 3 pounds a week beginning at 20 weeks' gestation Clients who are obese, having a BMI greater than 30, should be advised that the recommended weight gain is 5 to 9 kg (11 to 20 lb). This client is not obese Clients who are overweight, having a BMI of 25 to 29.9, should be advised that the recommended weight gain is 7 to 11.5 kg (15 to 25 lb). The pattern of weight gain is also important, with minimal gain in the first trimester Clients who have a single fetus and a BMI of 18 to 24.9, the normal range, should gain 11.5 to 16 kg (25 to 35 lb) during pregnancy. This client's BMI indicates that she is overweight. Clients who are underweight, having a BMI less than 18.5, are advised that a weight gain of 0.5kg (1.1 lb) per week during the second and third trimesters is appropriate. This client's BMI indicates that she is overweight. Skin Changes: Second trimester Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to the top of the fundus and is an expected finding during pregnancy. Chloasma, or the mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over the forehead, nose, and cheeks and is an expected finding during pregnancy. Striae gravidarum, or stretch marks, occur because of the separation of underlying connective tissue on the breasts, thighs, and abdomen. Cardiovascular changes Increased blood volume: increases 50 percent during pregnancy (though red blood cell count increases, anemia can still be an issue, even with the increase in blood volume. White blood cell count also increases, especially during labor and the following few days). Iron and folic acid are important... baby needs them to make their own RBS and mother's blood volume increased as well. Vena cava syndrome = supine hypotension syndrome which occurs when lying flat on back and the weight of the pregnant uterus compresses the vena cava and inhibits blood flow. Morning sickness Nausea due to increased hormones especially HCG in first trimester, and increased pressure on abdomen History of migraines is a risk factor for hyperemesis gravidarum, which typically occurs during the first 20 weeks of pregnancy Hyperemesis gravidarum is more common in nulliparous women, beginning in the first trimester. Clinical manifestations can continue throughout the pregnancy in some women Things that help to relieve it, (toast and crackers in morning, ginger, Vit B6 and 12, Zofran) Twin gestations are a risk factor for hyperemesis gravidarum and might be related to increasing hormone levels of estrogen, progesterone, and human chorionic gonadotropin (hCG). oHyperemesis gravidarum is a much worse condition and will be discussed in a future lecture Gradual lordosis Clients who are pregnant can develop a gradual, forward curving of the spine as the growth of the fetus pulls the pelvis forward. This lordosis resolves after delivery.

Pregnancy Changes: - Maternal hypotension can be caused from what - Recommended position

Maternal hypotension can be caused from what: Uterine perfusion and placental circulation are most efficient when the mother lies on her left side, as this position lifts the uterus away from the inferior vena cava, preventing blood from becoming trapped in the woman's lower extremities. If the woman lies on her back and the weight of the uterus compresses on the vena cava, known as vena cava syndrome, placental circulation can be so sharply reduced that supine hypotension (i.e., very low maternal blood pressure and poor uterine circulation) can occur Recommended position: lying on her left side

Narcissism

Narcissism Self-centeredness (narcissism) may be an early reaction to pregnancy. A woman who previously perhaps was barely conscious of her body, who dressed in the morning with little thought about what to wear, suddenly begins to concentrate on these aspects of her life. She dresses so her pregnancy will or will not show. She may lose interest in her job or community events because the work seems alien to the more important event taking place inside her. It may be an early reaction to pregnancy. Dresses to show or hide the pregnancy. Criticizes her partner. She does these things to unconsciously protect her body and her baby. Narcissism may also be revealed by changes in activity. A woman may stop playing tennis, for example, even though her primary healthcare provider has assured her it will do no harm in moderation. She may criticize her partner's driving, although it never bothered her before. She does these things to unconsciously protect her body and her baby. Her partner may demonstrate the same behavior by reducing risky activities, such as mountain biking, trying to ensure he or she will be present to raise their child. This need of a woman to protect her body has implications for nursing care. It means a woman may regard unnecessary nudity as a threat to her body (e.g., be sure to drape properly for pelvic and abdominal examinations). She may resent casual remarks such as "Oh my, you've gained weight" (i.e., a threat to her appearance) or "You don't like milk?" (i.e., a threat to her judgment). There is a tendency to organize health instructions during pregnancy around the baby: "Be sure to keep this appointment. You want to have a healthy baby." "You really ought to eat more protein for the baby's sake." This approach may be particularly inappropriate early in pregnancy, before the fetus stirs and before a woman is convinced not only that she is pregnant but also that there is a baby inside her. At early stages, a woman may be much more interested in doing things for herself because it is her body, her tiredness, and her well-being that will be directly affected (e.g., "Eat protein because it keeps your fingernails from breaking" or "Protein will give you long-term energy").

Placenta Previa - Priority monitoring - What supports the diagnosis - Types - these are classified into three types of dependent on the degree to - which the cervical os is covered by the placental attachment.

Priority monitoring: sonogram/ultrasound detects placenta previa. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression. Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding. What supports the diagnosis: bright red vaginal bleeding, usually without pain, at least after 20 weeks of pregnancy. Sometimes spotting happens before an event with more blood loss. Types (these are classified into three types of dependent on the degree to which the cervical os is covered by the placental attachment): It occurs in four degrees: implantation in the lower rather than in the upper portion of the uterus (low-lying placenta), marginal implantation (the placenta edge approaches that of the cervical os), implantation that occludes a portion of the cervical os (partial placenta previa), and implantation that totally obstructs the cervical os (total placenta previa). The degree to which the placenta covers the internal cervical os is generally estimated in percentages: 100%, 75%, 30%, and so forth.

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Umbilical Cord

THE UMBILICAL CORD **The umbilical cord has one vein and two arteries The umbilical cord is formed from the fetal membranes, the amnion and chorion, and provides a circulatory pathway that connects the embryo to the chorionic villi of the placenta. Its function is to transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta. It is about 53 cm (21 in.) in length at term and about 2 cm (0.75 in.) thick. The bulk of the cord is a gelatinous mucopolysaccharide called Wharton jelly, which gives the cord body and prevents pressure on the vein and arteries that pass through it. An umbilical cord contains only one vein (carrying blood from the placental villi to the fetus) and two arteries (carrying blood from the fetus back to the placental villi). The number of veins and arteries in the cord is always assessed and recorded at birth because about 1% to 5% of infants are born with a cord that contains only a single vein and artery. Of these infants, 15% to 20% are found to have accompanying chromosomal disorders or congenital anomalies, particularly of the kidney and heart. The rate of blood flow through an umbilical cord is rapid (350 ml/min at term). The adequacy of blood flow (blood velocity) through the cord, as well as both systolic and diastolic cord pressure, can be determined by ultrasound examination. Counting the number of coils in the cord may be used as a prediction of healthy fetal growth, as hypocoiling is associated with maternal hypertension and hypercoiling is associated with respiratory distress in the newborn. Because the rate of blood flow through the cord is so rapid, it is unlikely a knot or twist in the cord will interfere with the fetal oxygen supply. In about 20% of all births, a loose loop of cord is found around the fetal neck (nuchal cord) at birth. If this loop of cord is removed before the newborn's shoulders are born (not usually hard to do) so there is no traction on it, the oxygen supply to the fetus remains unimpaired. The walls of the umbilical cord arteries are lined with smooth muscle. When these muscles contract after birth, the cord arteries and vein are compressed to prevent hemorrhage of the newborn through the cord. Because the umbilical cord contains no nerve supply, it can be clamped and cut at birth without discomfort to either the child or mother.

Paragravida

The number of pregnancies that have reached viability (20 weeks gestation) regardless of whether or not the infants were born alive

Pregnancy Changes: - Weight Gain (normal weight gain per week)

the average weight gain during pregnancy is 25-35 pounds. During the first trimester (0.8 kg) 1.5 lb. per month should be gained. During the last two trimesters (0.4kg) 1 lb. per week should be gained.

Quickening

the first movement of the fetus in the uterus that can be felt by the mother. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks. During the second trimester, the psychological task of a woman is to accept she is having a baby, a step up from accepting the pregnancy. This change usually happens at quickening, or the first moment a woman feels fetal movement. Until a woman experiences for herself this proof of the child's existence and although she ate to meet nutritional needs and took special vitamins to help the fetus grow, it seemed more like just another part of her body. With quickening, the fetus becomes a separate identity. She then may imagine herself as a mother, teaching her child the alphabet or how to ride a bicycle. This anticipatory role-playing is an important activity for midpregnancy as it leads her to a greater concept of her condition and helps her realize she is more than just pregnant—there is a separate human being inside her. Women often use the term "it" to refer to their fetus before quickening but begin to use he or she afterward. Some women continue to use it, however, so doing so is not a sign of poor attachment but an individual preference as some women believe referring to the child as "she" or "he" will bring bad luck or disappointment if the sonogram report was wrong. Most women can pinpoint a moment during each pregnancy when they knew definitely they wanted their child. The firmer this attachment, the less postpartum depression they are apt to experience