Week 3: Antenatal Care (Chapter 14)

What is TPAL?

It's an additional obstetrical history assessment that describes: number of Term Births (alive or not), Preterm Births (alive or not), Abortions, and currently Living children TPAL: · Term · Preterm · Abortions · Living children

Gravida

A woman who is pregnant

Pregnant woman at 25 weeks gestation with a set of 3-year-old twins born at 36 weeks and a history of one stillbirth at 27 weeks What's the G and P?

Gravidity: 3 Parity: 2 (We do not count the current pregnancy for parity number. Even though she is passed 20 weeks with her current pregnancy, parity only counts completed/ended pregnancies)

Gravidity vs Parity

Gravidity: The number of pregnancies conceived (including the current one) Gravidity includes miscarriages. It's ANY pregnancy that has been conceived including abortions; Does not matter the outcome or the week the pregnancy ended/delivered. It counts all conceptions before 20 weeks, after 20 weeks (to term pregnancies and birthed children.) -- Gravidity includes it all. Parity: Is the number of pregnancies completed after 20 weeks, it DOES NOT include any current pregnancies, only those that have ended (even if it results in stillbirth, if it's after 20 weeks, its counted towards parity.) The number of fetuses does not matter (if there's twins, it's still one parity.) If a miscarriage/abortion happens before 20 weeks, it is not counted towards parity (but is counted towards gravidity.) If the baby is a still born at 21 weeks, it's counted towards both G and P. Parity: -Is she past 20 weeks? -Is the pregnancy complete (over, gave birth, terminated) -- Cannot include current pregnancies with parity. The Para number can NEVER exceed the gravidity number; It is not possible

Fetal assessment How is fetal gestational age determined? Fetal health is depended on what?

In an uncomplicated pregnancy, fetal gestational age is estimated after the duration of pregnancy and EDB has been determined. Fetal gestational age is determined from the menstrual history, contraceptive history, pregnancy test result, first fetal heart sound heart, date of first fetal movements, LMP, ultrasound date and more. Assessment of the fetal health status is dependent on fetal movement; an absence of movement is correlated with fetal death. A decrease in movement is related to adverse outcomes.

What do subsequent visits to the HCP's include? (After the first prenatal visit)

Included review and Monitor maternal health status, risk areas (physical and psychosocial), and changes to the baseline labs -Screenings and diagnostics -Physical examinations -Symptom management -Education (trimester specific) -Needs assessments and referrals o Monitor fetal growth and well-being (FHT's, fundal height, Leopold's maneuvers) o Symptom management o Trimester-specific teaching o Childbirth preparation - birth planning After the initial visits; it's about comparing new assessments to the baseline assessment. -(H&H goes down after the first visit this is expected.) -We identify risk factors during this time (cardiac issue, etc.) -Auscultating fetal heart tones -Fundal height = way of measuring fetal growth Leopold = palpating the abdomen to locate where the baby is in the abdomen.

What is Leopolds maneuver?

It is used to determine the baby's position and know where to place the stethescope.

-Early term -Full term -Late term -Later preterm -Extremely preterm Dates for each?

(Early term, full term, late term all refer to at TERM pregnancies (at least 37 weeks gestation) but are subcategories of TERM pregnancy. -Early term: 37-39 weeks -Full term: 39-41 weeks -Late term: 41-42 weeks -Later preterm: 34-37 weeks -Extremely preterm: < 28 weeks

What are some pregnancy symptoms to be aware of?

-Nausea -Mood swings -Lack of energy -Sore breasts and/or sensitive nipples -Spotting -Frequent urination -Increased cervical mucous -Cramps -Feeling tearful -Heartburn, back pain, feeling dizzy, fainting, bloating, indigestion, fatigue, cravings, weight gain, increased sensitivity to smells

What are some things that need to be done during a woman's First prenatal visit? What are things we need to take into consideration and be aware of?

-We need to allow extra time for this first prenatal visit (It's when we collect all of our baseline information) We gather information including: -History/physical -Baseline lab tests -Discussion about pregnancy and education of first trimester symptoms/management, early fetal development, nutrition, lifestyle issues, psychological considerations -Resource referral if needed -Consider the literacy of the patient, access to healthcare and $$

How many fetal movements a day is normal?

10

When is quickening felt?

16-20 weeks gestation

What is a post mature pregnancy?

A post-term pregnancy with additional signs of placental aging and fetal compromise > 42 weeks During post mature stage, Co2 and oxygen exchange decrease, the baby uses their own fat stores for energy, the placenta ages and the body does not hold pregnancy well.

What is considered a preterm pregnancy? Late preterm? Extremely preterm?

A pregnancy that has reached 20 weeks of gestation but ends before completion of 37 weeks of gestation *late preterm 34-37 weeks *extremely preterm <28 weeks (if the baby is lost before 20 weeks, it is considered gravidity and not counted towards parity)

What is considered a to term pregnancy? Early, full and late term pregnancies?

A pregnancy that has reached between 37 weeks 0 days and 41 weeks 6 days of gestation (37-42 weeks) *early term 37-39 *full term 39-41 *late term 41-42) - all of these are considered to term pregnancies

What is considered a post term pregnancy?

A pregnancy that has reached between 42 weeks 0 days and beyond of gestation (Past 42 weeks gestation) > 42 weeks gestation

What is education we need to provide women about multifetal pregnancy?

ART and more women over the age of 35 giving birth has increased multifetal pregnancies. These place both the mother and fetus at increased risk for adverse outcomes. Hormone levels, hCG, and more are increased significantly compared to a single fetus pregnancy. Maternal blood flow is increased way beyond what it is with a singleton pregnancy resulting in an increased strain on the maternal cardiovascular system. Anemia often develops because there's a greater demand for iron by the fetuses. Increased risk of miscarriage, diabetes, postpartum hemorrhage, and other pregnancy complications. Risks rise with the more fetuses. If more than three fetuses is diagnosed, parents may receive counseling regarding selective reduction to reduce complications and give the other fetuses the chance to thrive and grow.

What is Abortion? What does it include?

Abortion includes spontaneous miscarriages but overall is the induced termination of a pregnancy prior to 20 weeks/500 grams

Airline travel recommendations for pregnant women?

Airline travel poses little risk to a healthy pregnant woman. Most HCP's allow travel up to 36 weeks of gestation for domestic travel and 32-35 weeks for international. There's lower O2 concentration in planes which shouldn't be a big deal for someone healthy but might be for someone with anemia, sickle cell disease or cardiovascular conditions.

What are the settings in which a woman can give birth? (3)

Birth settings (3): Hospital, free-standing birth centers, and home. (Most births occur in the hospital) Birth centers: free standing birth centers are separate from the hospital often nearby in case the woman needs to be transferred there. Only women with low-risk pregnancies do these. They are more home like, comfortable and people discharge within 6 hours of birth. (very boujie) -Attending birth and parenting classes is mandatory for these centers, so is making a birth plan -More resources for patients (libraries, and more childbirth educators.) -Ambulance rides must be readily available -Fees are often less than or equal to the hospital Home birth: these numbers are increasing in the U.S. Not as safe; Safest setting is in the hospital or accredited birth center -Home birth is associated with fewer interventions but has an increased risk for perinatal death. -Advantages are that the mother is more comfortable and relaxed, it's less expensive and serious infection is less likely assuming strict aseptic principles are followed and because people are generally relatively immune to their own home bacteria.

What is the duration of pregnancy in days, weeks and lunar months? How are trimesters broken up?

Duration of pregnancy = 280 days, 40 weeks, or 10 lunar months 1st trimester 0 - 12 6/7 weeks 2nd trimester 13 0/7 - 26 6/7 weeks 3rd trimester 27 0/7 - 40 weeks -Trimesters are about 3 months each. -Pregnancy goes off of menstrual dating* · 1st = most sensitive to teratogens (symptoms from hCG levels being high) · 2nd = gaining weight, symptoms gone (from hCG levels going down), libido up · 3rd= Baby gaining weight, laying down white fat.

How to take the Blood pressure of a pregnant woman during each visit?

Each visit, BP should be measured in the same arm with the woman in a seated position with her back and arm supported. Use the right arm. The upper arm should be at the level of the right atrium.

Which bacteria is the most common cause of UTIs s/s of UTI and some education tips to provide pregnant women?

Escherichia coli Signs and symptoms are frequency, urgency, dysuria, dribbling and hesitance. Wipe from front to back Pregnant women should drink at LEAST 2.5L of water a day. Urinate as soon as you feel it otherwise bacteria will stay in bladder and multiply Kegel exercises to strengthen pelvic muscles and improve muscle tone help with urinary incontinence

Physical discomforts related to pregnancy: -First trimester -Second trimester -Third trimester

First trimester: Breast changes, urinary frequency increases, nausea and vomiting begins (in 70% of women.) Starts in weeks 4-6, peaks by week 9 and stops by week 12. Ptyalism (excessive salivation starting after week 2-3.) Nasal stuffiness (epistaxis- Nosebleed from increased estrogen levels.) Mood swings from hormones. Second trimester: Pigmentation deepens (nipples and vagina,) mask of pregnancy occurs (all from melanocyte stimulating hormone from anterior pituitary.) Spider nevi (angiomas) (redness) over neck, face, arms in 2nd or 3rd trimester from increased dilated arterioles from increased estrogen. Pruritus (noninflammatory) (itching.) Palpations, supine hypotension, faintness, food cravings, heartburn (from progesterone slowing GI tract motility and digestion,) constipation, flatulence/bloating/belching (all from progesterone slowing the GI tract, reversing peristalsis, relaxing cardiac sphincter, and delaying emptying time of the stomach.) Headaches, carpal tunnel, numbness and tingling of fingers (compression of median nerve) Third trimester: SOB and dyspnea occur in 60% of women from expansion of the diaphragm, insomnia from fetal movements, mood swings, emotions and increasing anxiety, urinary frequency returns, perineal discomfort and pressure from vascular engorgement, Braxton hicks contractions and ankle edema.

Signs/Symptoms of potential complications during pregnancy: -First trimester -Second trimester -Third trimester

First trimester: Severe vomiting, chills, fever, burning on urination, diarrhea, abdominal cramping, and vaginal bleeding Second/third trimesters: Persistent severe vomiting, sudden discharge of fluid from vagina before 37 weeks, vaginal bleeding, severe abdominal pain, severe back pain, or flank, change in fetal movements, cramping before 37 weeks, visual disturbances (blurring, double vision, seeing spots,) and more on page 288.

Medication recommendations/teaching for pregnant women? Vaccine education? Tdap education?

Most medications and their teratogenicity is unknown. The greatest danger of these is the time from fertilization through first trimester. Immunizations with LIVE or attenuated live viruses is contraindicated. Live virus vaccines like measles (rubella,) mumps, varicella (chicken pox,) and more should not be given. Vaccines that CAN be given during pregnancy include Tdap, hep B, and influenza (inactivated.) Tdap should be given between 27 and 36 weeks' gestation. Pregnant women should get another dose of Tdap with each pregnancy no matter if they have gotten it before since these antibodies are short lived and drop significantly during the first year after vaccination. If not, it should be given immediately after pregnancy. Influenza (flu) vaccines are safe throughout pregnancy.

Women older than 35 consist of two groups -Multiparous women -Primigravids

Multiparous women (given birth before or more than once): Who intentionally or unintentionally become pregnant in the perimenopausal period. Primigravids (first time giving birth): women who have deliberately delayed childbearing until their late 30s or early 40s or who were unable to conceive before but now able to due to reproductive technology. Pregnancy over the age of 35 is associated with increased risk for miscarriage, stillbirth, diabetes, hypertension, placental abruption, C section, and pregnancy related mortality, LBW infants, preterm birth and multiple gestation* (twins.) Women who used ART (assistive reproductive technology) are at an increased risk for preterm labor, preeclampsia and more.

What does nullipara mean?

Nulli = none Para = past 20 weeks So this would be a person who has never had a pregnancy past 20 weeks. If they are a nullipara with a history of 2 miscarriages, their gravidity would be 3, and there parity would be 0.

Nulli- Primi- Multi-

Nulli- = none Primi- = one Multi- = more than one

Determining EDB (estimated date of birth) using Nagele's rule Pregnancy wheel?

NÄGELE'S RULE = -SUBTRACT 3 MONTHS FROM LMP -ADD 7 DAYS -ADD A YEAR (if applicable) (Goes from an accurate recall of LMP) (Nagels rule can be inaccurate because it assumes that a woman has a 28 day cycle and that fertilization occurred on the 14th day.) Pregnancy wheel: (another term of preg dating) = based on nageles rule, but more precise... Months do not all have the same number of days so the wheel is more accurate. Can figure out how pregnant a woman is on an exact day. Only 3-5% deliver on their due date. (Moving away from due date and going towards due week because it can be so inaccurate from not having a normal cycle and not being able to determine LMP accurately.) Ultrasounds help with pregnancies dating because of fetal growth and amniotic size, sack size, etc to help date the pregnancies

Is the pregnant woman's relationship with her mother or partner more important?

Partner relationship and their acceptance of the pregnancy/baby is most important. Women's needs during pregnancy from her partner are to feel loved and valued and to have the child accepted by the partner. The partner needs to respond to the woman's feelings of vulnerability.

What is preeclampsia?

Pregnancy induced hypertension

PROM

Premature rupture of membranes

What is the most common complication of pregnancy?

Prenatal depression

Which hormone causes the woman to have fatigue, SOB, increased RR?

Progesterone

Max amount of recommended time for pregnant women to sit a day?

Prolonged sitting in cars or at work increases risk of venous stasis and blood clots. 6 hours per day of sitting is the maximum amount of time for driving. They should stop every 2 hours to rest. The seat belt should be worn low across the pelvic bones and as snuggly as possible. The shoulder harness should be worn above the gravid uterus and below the neck to prevent chaffing. The steering wheel should be tilted up and away from the abdomen, seat should be moved back

When should Rh testing be done? (which prenatal visit) What dose of Rh immune globulin is given?

Rh testing is done at the first prenatal visit. Women who are Rh- and carry an Rh + fetus can develop antibodies against the D antigen and cause lysis of the fetal red blood cells (the mothers body attacks the fetus Rh + D cells.) Prophylactic Rh immune globulin can be administered to the Rh - mother (D negative) to prevent the formation of antibodies (alloimmunization) by destroying any fetal red blood cells in the maternal circulation before her immune system recognizes the D antigen and begins to produce antibodies. A dose of 300 micrograms Rh immune globulin is given at 26-30 weeks to all Rh-negative women. If she gives

What does the term Viability refer to?

The capacity to live outside the uterus. Infants born at 22 to 25 weeks of gestation are considered to be on the threshold of viability and are especially vulnerable to brain injury if they survive. Viability is the ability for the fetus to survive outside the uterus In CA, the age for viability is 20 weeks. After 20 weeks, the baby gets a birth certificate and is considered a live birth even if they are stillborn. Born before 20 weeks = baby is not considered viable

What is the EDB determined from? What is the most accurate assessment of the EDB?

The estimated date of birth (EDB) is determined based on the date of the woman's last normal menstrual period (LMP) and the first accurate ultrasound examination. The most accurate assessment of the EDB is based on a ultrasound measurement of the embryo or fetus during the first trimester of pregnancy*

What is the goal of prenatal care? What are some issues as to why women do not seek prenatal care?

The goal of prenatal care is to promote the health and well-being of the pregnant woman, her fetus, the newborn, and the family. It included education about healthy lifestyle behaviors like nutrition and physical activity, self-care for the common pregnancy discomforts and more. Women's reasons for delaying prenatal care include cost, lack of insurance, lack of child care, transportation barriers, or inability to take time off work. Lack of culturally sensitive care providers, discrimination based on sexual orientation, and barriers to communication resulting from differences in language also affect care.

Standard test for GDM (gestational diabetes) is what?

The standard test for GDM is a 1 hour 50 g oral glucose tolerance test. If it's elevated, they do another 3 hour 100g GTT

If a mother has HIV, what is the chance of her passing it along to her baby?

There's a 25% chance of giving HIV to the baby if the mother does not get treated. If triple drug antiviral or HAART therapy is used, it decreases the chance of transmission to less than 1%

When are genetic screenings for NTD's and other fetal defects done? (Usually)

They are done in the second trimester by measuring the maternal serum AFP (MSAFP) level and by ultrasound.

What is a traditional prenatal visit? How long do we space appointments out after the first visit?

Traditional prenatal visit: First visit within the first trimester (12 weeks,) Monthly visits through 16-28 weeks, every 2 weeks from weeks 29-36, and weekly visits from 36 weeks to birth.

Benefits of umbilical cord blood banking?

Umbilical cord blood banking = it's believed that umbilical cord blood has hematopoietic stem cells that can treat inborn errors of metabolism, leukemia and disorders of the immune system and fight infectious diseases. Parents may ask about this.

Auscultation fetal heart rate How do we do it? (With what tools) At how many weeks can we do it?

We measure fetal heart rate with a doppler, electronic fetal monitor, or even with a stethoscope. We can listen to the FHB usually after about 12 weeks after the uterus becomes and abdominal organ *** Fetal heart tones: In the third trimester fetal heart tones can be heard with a doppler device that transmits FHTs.

Erythroblastosis fetalis

a disorder that results from the incompatibility of a fetus with Rh-positive blood (from father who is Rh +) and a mother with Rh-negative blood, causing red blood cell destruction in the fetus; Give Rhogam This is why we take maternal blood and test for Rh sensitivity during the first prenatal visit.

Measuring fundal height When does the uterus become an abdominal organ? -When does fundal height correlate to how far along the pregnancy is? -When does the fundal height stop correlating to how far along the mom is?

it's the measurement of the uterus above the symphysis pubis Fundus = top of uterine wall. Weeks 12-16 is when uterus becomes an abdominal organ. (second trimester is when we measure fundal height, not first) Weeks 14-36 = fundal cm correlates to how far along the mom is (+/- 2) Umbilicus (belly button)= reference point for mid pregnancy. (20 cm = 20 weeks at this point) **20 cm = about 20 weeks gestations** 40 weeks - the baby drops down and engages in the pelvis to get ready for childbirth After 36 weeks measuring the fundus is not as accurate because the baby drops down... ** When doing the pregnant woman abdominal assessment, watch for supine hypotension. (we measure the height of the fundus)

What are doulas and some of their benefits?

· Doulas: are trained to provide physical, emotional, and informational support to women and their partners during labor and birth. They assist the woman on achieving her pregnancy goals. o **The doula does not get involved with clinical tasks** o Evidence says that doulas that offer support during labor benefit births without the support of doulas. There's a decreased need for pain medication, decreased need for epidural, shorter labors, increase satisfaction with birthing, reduced C-sections, and more.

Primigravida Multiparous women Primiparous women

· Primigravida: Woman who is pregnant for the first time · Multiparous women: Women who have given birth at least 2 times before (past 20 week mark) · Primiparous women: Have had a pregnancy past 20 weeks in the past. Been pregnant once before