Antepartum
Conception
● Ovulation - day 14 of menstrual cycle
● Ova fertile for 24 hours
● Sperm viable for 48-72 hours
Ethical Issues for Genetic Testing
● Counseling regarding termination of the pregnancy
○ Genetic testing offered to everyone
○ Many OB offices are not equipped to do Dad’s genetic testing
■ Have to go to own PCP, lab, etc.
○ Provide information in a factual, unbiased way
● Fetal rights
○ There aren’t any
○ What mom decides to do is what mom decides to do
Pregnancy Testing
● Detects the presence of HCG
● Produced by corpus luteum until placenta develops
● Usually detectable within 7-10 days
● Blood or urine
○ Blood is quantitative or qualitative
○ HCG should double every 24 hours
○ Urine is qualitative
● Peaks around 60-70 days gestation
○ Starts to taper off after peak
Signs of Pregnancy
Table 7-2 p. 152
● Presumptive
○ Amenorrhea
○ Fatigue
○ N/V
○ Breast tenderness
○ Urinary frequency
○ Quickening
● Probable
○ Hegar’s sign
○ Goodell’s sign
■ Cervical softening
○ Chadwick’s sign
○ + Pregnancy test
○ Braxton hicks
○ Ballotment
■ Push up on a baby during vaginal exam and it’ll ‘bounce
back and hit you’
● Positive
○ Hearting fetal heart tones
○ Visualization of the fetus
○ Palpation of fetal movements by examiner
**Pregnancy Terms
● Gravida
○ Total number of pregnancies (including current)
● Para
○ # of deliveries 20 weeks or >
○ Term 37 weeks+
● Term
● Abortion
● Living
● GTPAL
○ Gravida, Term, Preterm, Abortion, Living
Naegle’s Rule
● Method for calculating EDD
● First day of LMP
● Subtract 3 from the month
● Add 7 to the day
● Adjust year if needed
Prenatal Care: Initial Visit
● Medical history
○ Mom and her immediate family
● Gynecological history
○ When was LMP
● Past pregnancies and outcomes
○ Pregnancies
○ Deliveries
○ Gestational age
● Medications
○ Class A, B, C, D and X
○ X is a known teratogenic
○ Seizure medications, antihypertensives, antidepressants need
to be reviewed immediately
○ Tylenol is the only over the counter medication safe for
headache in pregnancy
○ Ibuprofen can prevent the ductus from closing during the third
trimester
○ Baby ASA is commonly started in the beginning of pregnancy
by many providers
● Substance abuse
○ Has mom drank during pregnancy?
■ How much?
○ Smoking
○ Illegal substances current or history of (marijuana, crack
cocaine, meth, etc.)
● Physical abuse
○ Ask every single patient
■ Have you ever been or currently in an abusive
relationship?
■ Is there anything going on in your relationship that would
make you afraid to take your baby home with you?
Genetic Screening
● Goal
○ To detect or define a risk for a genetic disease in low risk
populations and those for whom diagnostic testing may be
appropriate
○ Used to determine if an inheritable disorder exists
○ Risk factors
■ Age
● Advanced maternal age starts at age 35
■ Family history
■ Ethnicity
● Analysis of human DNA, RNA, chromosomes, or protein
● Prenatal Screening
Physical Exam
● Baseline: VS, weight
● PAP smear
● Palpation of uterus
○ Depending on where fundus is, determines how far along mom
is
● Pelvic exam
Schedule
● Monthly first 28 weeks
● Every 2 weeks until 35 weeks
● Weekly until delivery
Uterine Growth
● Early growth related to the effects of estrogen and progesterone
● After 12th week primarily related to the growth of fetus
● Blood flow 20x pre-pregnant state
Muscles and Ligaments
● Round ligaments
● Uterosacral ligaments
○ Don’t usually stretch as much as round ligaments
● Ligaments stretch to accommodate pregnancy
Fundal Height
● Top of uterus is called fundus
● From symphysis pubis to fundus
● Measured in centimeters
● Indicative of fetal growth
● Measurement of + or - 2 cm compared to gestational age
Breast changes
● Tenderness
● Fullness
● Areolar changes
● Colostrum
Cardiac Changes
● Blood volume increases 40%-50%
● Cardiac output increases 30%-40%
● Increased risk for blood clotting due to poor venous return d/t weight
of the uterus and increase in clotting factors
Respiratory Changes
● Increased O2 requirements to meet pregnancy needs
● Ligaments of rib cage relax
● Diaphragm is displaced due to growing enlarging uterus; chest
breathing vs abdominal breathing
● Upper respiratory more vascular; congestion, epistaxis, changes in
voice
Gastrointestinal Changes
● N/V d/t increase in HCG
○ Anything that extends beyond 1st trimester is concern for
hyperemesis gravidarum
● Changes in taste or smell
● Pytalism
● Pica
● Low tone and motility in GI tract (reflux, constipation)
Hyperemesis vs Morning Sickness
● Morning Sickness
○ Nausea sometimes accompanied by vomiting
○ Nausea that subsides at 12 weeks or soon after
○ Vomiting that does not cause severe dehydration
○ Vomiting that allows you to keep some food down
● Hyperemesis
○ Nausea accompanied by severe vomiting
○ Nausea that does not subside
○ Vomiting that causes severe dehydration
○ Vomiting that does not allow you to keep food down
○ Weight loss
Urinary System
● Urinary frequency and urgency (early and late pregnancy)
● Decreased bladder tone
● Higher risk for UTI
○ Educate on s/s
○ Many moms are asymptomatic
Skin Changes
● Melasma or Cholasma (mask of pregnancy)
● Linea nigra
○ Darkening of vertical line on abdomen
● Striae gravidarum
● Palmar erythmea
○ Reddening of palms w/o itching
● Increase in nail and hair growth
● Increase in perspiration due to increased BMR
Initial Visit
● Medical and pregnancy history
● Physical exam
● Baseline v/s and weight
● Lab work (page 176)
○ Hgb and Hct
○ Platelets (10,000)
○ Blood type and Rh
○ Antibody screen
○ Rubella titer
■ Rubella can cause congenital defects in pregnancy
■ MMR cannot be given during pregnancy
■ Mom will get booster shot before she goes home after
delivery if non-immune or equivocal
■ Varicella vax is not given during pregnancy either
○ UA
○ Pap smear
○ Screening for HIV and Hep B
○ VDRL or RPR - Syphillis
○ Gonorrhea and Chlamydia
○ May screen for sickle cell
○ May screen for Cystic Fibrosis
Chorionic Villus Sampling
● 10-12 weeks
● Small tissue specimen from fetal side of placenta
● Transcervically or transabdominally
● Risks:
○ Vaginal spotting or bleeding
○ Miscarriage
○ Breaking of water
○ Chorioamniotis
○ Limb anomalies
Optional Screening Test
● Screening to detect fetal chromosome abnormalities
● Measures two maternal biochemical markers
● Available from 11-14 weeks
● Does not screen for neural tube defects
Signs of Complications - 1st Trimester
● S/S
○ Severe vomiting
○ Chills, fever
○ Burning on urination
○ Diarrhea
○ Abdominal cramping
○ Vaginal Bleeding
● Possible Causes
○ HG
○ Infection
○ Ectopic Pregnancy
Common Discomforts - First Trimester
● Breast enlargement, pain, tingling, tenderness
● Urgency and frequency or urination
● Fatigue
● N/V
● Ptyalism (excessive salivation)
● Gingivitis
● Nasal Stuffiness
● Leukorrhea
Fetal Assessment
● Listen to fetal heart tones (10-12 weeks)
○ Normal FHR 110-160
● Assess fundal height
● Ask about fetal movement
Psychosocial Assessment - First Trimester
● Determine support system
○ Is the father of the baby involved?
○ If not, who is the support person going to be during
pregnancy/delivery?
● Employment and work environment
● Feelings of ambivalence (happy one min, crying the next)
● Acceptance of pregnancy parallels growing reality of having a child
● Stage 1 (Rubin): Accepts biological fact she is going to have a child “I
am pregnant”
Planning and Interventions
● Decrease anxiety about health of herself and fetus by educating on
ways to alleviate common discomforts
● Include spouse/support person in prenatal care
● Provide referrals if needed
Nutritional Needs
● Iron - due to increased RBC mass and to meet fetal needs
● NA needs increased, however, average diet contains enough
● Folic acid - enriched grain products, added to prenatal vitamins,
reduces risk of neural tube defects
Weight Gain
● Average weight gain: 25-35 lbs
● Underweight - gain more
○ Most common reason for underweight mothers is body image
disturbance/eating disorder
○ “We want you eating adequately to help you grow the healthiest
baby”
● Overweight - gain less
● Increase calories by 300/day
Second Trimester (Weeks 14-26)
● Office visit every 4 weeks unless complications
● Weight (1lb week avg)
● V/S: Increase in pulse 10-15 bpm, decrease in diastolic BP by
10mmHg
● Urine dipstick - glucose and protein
Amniocentesis
● Week 14 or later
● Can only be completed after uterus moves into abdominal cavity,
adequate amniotic fluid
● Performed with guidance of US
● Used for diagnosis of genetic abnormalities, lung maturity
● Maternal complications: leakage of fluid. Infection, hemorrhage,
abruption, amniotic fluid embolism
● Fetal complications: death, hemorrhage, infection, injury from needle
Trisomy 21 (Down’s Syndrome)
● Flattened nose and face
● Upward slanting eyes
● Single palmar crease
● Short fifth finger that curves inward
● Widely separated first and second toes and increased skin creases
Turner’s Syndrome (X-)
● Missing an X chromosome on the 23rd pair
● Affects only females
Trisomy 18 (Edward’s Syndrome)
● Occurs when there is a 3rd copy on all or part of chromosome 18
Trisomy 13
● Incompatible with life
Oomphalocele
● Can be detected with early screening of the mother and fetus
● Intestines or other abdominal organs develop outside of the abdomen
through the umbilicus
● The survival rate is 90% if this is baby’s only issue
Signs of Complications
● Persistent severe vomiting
● Sudden discharge/fluid from vagina
● Vaginal bleeding/severe abd pain
● Chills, fever, burning on urination, diarrhea
● Severe backache or flank pain
● Change in absence of fetal movement
● Uterine contractions
● Symptoms of preeclampsia
○ Severe swelling
○ Severe/persistent headache
Common Discomforts (p.187 Table 8-3)
● Acne, pigmentation changes
● Palmar erythema
● Pruritus
● Palpitations
● Supine hypotension (vena cava syndrome)
● Faintness, syncope
● Heartburn
● Constipation, flatulence
● Headaches
● Carpal tunnel syndrome
● Periodic numbness, tingling of fingers
● Round ligament pain
● Joint pain, backache, pelvic pressure
Fetal Assessment
● Fetal heart tones (110-160)
● Quickening - first fetal movement felt
● Fundal height (+ or - 2 cms)
● May do growth ultrasound (18-20 weeks)
Psychosocial Assessment - Second Trimester
● Begins to accept fetus as distinct person from herself
● Stage 2 (Rubin): “ I am going to have a baby”
● Increased attachment to fetus d/t feeling movement and seeing
picture on US
● Good time to introduce topic of childbirth classes - usually eager to
learn
Third Trimester (Weeks 27-40)
● Every 2 weeks from week 28-35
● Weekly until delivery
● Assess for any signs of complications
● Assess weight (1lb/week)
● Assess VS
● 1 HR GTT (24-28 weeks) - if abnormal, 3 HR GTT
● Rhogam if Rh ● GBS vaginal or rectal smear at 35-37 weeks
Signs of Complications
● Same as second trimester
Common Discomforts
● SOB and dyspnea
● Insomnia and nightmares
● Mood swings, increased anxiety
● Urinary frequency and urgency return
● Perineal discomfort and pressure
● Leg cramps
● Ankle edema
Fetal Assessment
● Fetal heart tones
● Fetal movement (kick counts)
● Fundal height
● Lightening (drops into pelvis)
● Non-stress test
○ Hook baby up to monitor and watch HR
● Oxytocin Challenge Test (OCT)
○ Trial of labor - Causing contractions to determine how baby will
tolerate labor
○ 2 contractions per 10 min
Fetal Kick Counts
● Normal - 10 kicks per 2 HRS
● Eat meal or snack before counting
● Limit external stimuli to concentrate on kicks
Psychosocial Assessment
● Stage 3 (Rubin): “I am going to be a mother”
● See’s fetus as a distinct person from herself
● Speculates on what child will be like
● Attends prenatal classes
● Cannot get epidural if patient has thrombocytopenia (low platelets) or
certain other conditions
Planning and Interventions
● More focused on impending labor and birth
● Becoming increasingly more uncomfortable
● Educate on signs of complications
● Educate on signs of labor
● Education on common discomforts
Special Considerations: Adolescent Pregnancy
● Nutritional needs related to their growth, fear of gaining too much
weight, eating habits
● Lack of or late prenatal care d/t fear of telling someone about
pregnancy
● Increased use of alcohol and tobacco in this age group
● May feel isolated from peers, inaccurate information
● Need additional support with parenting skills
● Increased risk for anemia, preterm birth, preeclampsia/HEELP,
hemorrhage, chorioamnionitis
Special Considerations: Advanced Maternal Age >35 years
● Two groups:
○ Women who have many children or have a period during their
perimenopausal period
○ Those who delay pregnancy until their late 30’s or early 40’s
○ Higher risk for preterm birth, IUGR, low birth weight, placental
abruption, multiple births
Cultural Considerations
● Page 23-24, Table 2-2
● Beliefs and practices
● Nutritional needs
● Family roles