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Week6: Chp 16-Labor and Birth Processes, Chp 19., Chp.32 labor and birth complications(EXAM 3)
Terms in this set (54)
Chapter 32: Labor and Birth Complication
Proloasped umbilical cord
Meconium stained fluid:
-Meconium Aspiration Syndrome (MAS)
-Meconium Stained Amniotic fluid: Indicates that the fetus has passed meconium (first stool before birth).
3 possible reasons:
1. Normal physiologic that occurs with maturity or with breech presentation
2. Is the result of hypoxia induced peristalsis and sphincter relaxation
3. Umbilical cord compression
Immediate management of newborn with Mecoium stained amniotic fluid
-assess amniotic fluid for the presence of meconium after rupture of membranes
-If amniotic fluid is meconium stained, gather equipment and supplies that might be necessary for neonatal sesucitation
-Have at least one person capable of performing end tracheal intubation on the baby present at birth.
Immediately After birth:
-Assess babys respiratory efforts heart rate and muscle tone
-Suction only the baby mouth and nose, using either a bulb syringe or a large bore suction catheter if the baby has:
Strong respiratory efforts
Good muscle tone
Heart rate > 100 bpm
suction the TRACHEA using an endotracheal tube to remove any meconium present before many spontaneous respirations have occurred or assisted ventilation has been initiated if the baby has:
-Decreased muscle tone
Heart rate <100 bp
Is meconium-stained amniotic fluid associated with unfavorable fetal outcome? How did this happen?
No. The fetus has had an episode of loss of sphincter control, allowing meconium to pass into amniotic fluid.
What color may the amniotic fluid be? Consistency?
black to greenish, yellow, or brown. Consistency may be thin or heavy.
What are the criteria for evaluation/assessment of meconium-stained amniotic fluid?
•Often present in breech presentation, and may not indicate fetal hypoxia.
•Present with no changes in FHR
•Stained fluid accompanied by variable or late decelerations in FHR (ominous sign)
What interventions would the nurse implement upon finding meconium-stained amniotic fluid?
•Document color and consistency
•Notify neonatal resuscitation team to be present at birth
•Gather equipment needed for neonatal resuscitation
What respiratory interventions would the nurse implement upon delivering a baby with GOOD respirations, muscle tone, and HR who had meconium-stained amniotic fluid?
Follow designated suction protocol
-Assess neonate's respiratory efforts, muscle tone, HR.
-Suction mouth and nose using bulb syringe if respiratory efforts strong, muscle tone good, and HR > 100/min.
What respiratory interventions would the nurse implement upon delivering a baby with POOR respirations, muscle tone, and HR who had meconium-stained amniotic fluid?
Suction below the vocal cords using an endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and heart rate < 100/min.
What is Shoulder Dystocia
A condition in which the head is born, but the anterior shoulder cannot pass under the pubic arch.
Signs that indicate:
-slowing of the progress of the second stage
-THe nurse should observe for retraction of the fetal head against the perineum immediately following its emergence (TURTLE SIGN)
USE THE McROBERTS Maneuver.
- womens legs are flexed apart with her knees on her abdomen
-This manuever causes the sacrum to straighten and the symphysis pubis to rotate towards the mothers head. The angle of pelvic inclination is decreased which frees the shoulder.
NEVER USE FUNDAL PRESSURE - associated with neurologic complications.
Prolapsed umbilical cord
When the umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix.
A. Occult prolaspe of cord: hidden rather than visible
B. Complete prolapse of cord
C. Cord presenting in front of the fetal head may be seen in vagina
Results in cord compression and compromised fetal circulation.
Client reports that she feels something coming through her vagina.
note the pressure of presenting part on umbilical cord, which endangers fetal circulation
•Visualization/palpation of the umbilical cord protruding.
•FHR monitoring show variable or prolonged deceleration
•Excessive fetal activity followed by cessation of movement; suggestive of severe fetal hypoxia
Emergency : Prolapsed Umbilical cord
What are the priority actions of the nurse if a prolapsed cord is assessed?
Variable or prolonged deceleration during uterine contractions
-Woman reports feeling the cord after membranes rupture
-Cord is seen or felt in or protruding from the vagina
Call for assistance immediately
•Notify the provider
•Use sterile-gloved hand, insert two fingers, apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. DO NOT MOVE YOUR HAND. ANOTHER person may place a role towel under the woman right or left hip
•Reposition client: knee-chest, ExtreemTrendelenburg, or a (either) side-lying position with rolled towel under hip to relieve pressure on the cord.
•Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow. DO NOT TRY TO ATTEMPT TO REPLACE CORD INTO CERVIX
•Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia.
•Administer oxygen at 8-10 L/min via a face mask to improve fetal oxygenation.
•Initiate IV access, administer IV fluid bolus.
•Prepare for a cesarean birth if other measures fail.
•Inform and educate the client and her partner about the interventions.
Nursing assessment and interventions
-Prepare for birth
-Observe for turtle sign
- summon help
-Mac Roberts position
Presence of deep prolonged decel
-Check for visible or palpable cord in vagina
-Prepare for immediate delivery
Follow standards of care
Documentation is timely and according to facility and association standards
Client safety is always paramount!
Never leave your client in a crisis!
Chapter 16: Labor and Child birth process.p. 367
What impacts Progress of labor?
At least 5 factors affect the process of labor and birth. these are known as the 5P's:
1.Passenger (fetus and placenta)
4.Position (of the mother)
1.Passenger (fetus and placenta)
4.Position (of the mother)
1.Passenger: or fetus moves through the birth canal is determined by:
A.Size of fetal head
B.Fetal Presentation: part of the fetus that enters the pelvic first
-Cephalic: HEAD FIRST
-Breech: BUTTOCKS, FEET or BOTH FIRST
-Shoulder: Shoulder first
-Fetal Lie: relation of the long axis of the fetus (spine) to the mother's long axis (spine)
C.Fetal Attitude: is the reaction of fetal body parts to one another
they should be General flexion
D.Fetal position:relationship of a specific reference point on the PRESENTING PART to the 4 quadrants of the mother's pelvis
(Described by 3 numbers )
4.Position (of the mother)
Fetal Position explained
A.1st letter of abbreviation denotes THE LOCATION of the presenting part in the RIGHT or LEFT side. of the mother pelvis.
B.Middle letter stands for: SPECIFIC PRESENTING PART of the FETUS :
C. The final letter stands for the LOCATION of the presenting part in relation to the Anterior (A), Posterior (P), Transverse(T) portion r/t the maternal pelvis.
Example: ROA Means that the OCCIPUT is the presenting part and is located in the Right Anterior Quadrant of the maternal pelvis
-LSP- The SACRUM is the presenting part and is located in the LEFT POSTERIOR quadrant of the maternal pelvis
Stations p. 370
What relationship does this examine?
How are these measured?
What anatomical features is used to examine this?
is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines and is a MEASURE OF THE DEGREE OF DECENT OF THE PRESENTING PART OF THE FETUS THROUGH THE BIRTH CANAL.
- Placement part is measured in CM above or below the Ischial spine
A.When the PRESENTING PART IS 1 CM ABOVE THE SPINES, it is noted as MINUS (-) 1.
B. At the level of the of the Spines the station is said to be 0
C. When the presenting part is 1 cm BELOW the SPINES, the station is said to be PLUS (+) 1
note : birth is imminent when the presenting part is at +4 or +5.
The station of the presenting part should be determined when labor begins so that the rate of decent of the fetus during labor can be determined accurately .
A.Passageway (Pelvic) inlet
Fetus must successfully accommodate self to the rigid passageway.
The true pelvis, the part involved in birth is decided into 3 planes: The inlet or brim; the mid pelvis (Cavity); and the outlet
A. Pelvic Inlet is the UPPER BORDER of the true pelvis
B. The Pelvic outlet: is the LOWER BORDER of the true pelvis
What are the 4 basic types of pelvis:
1. Gynecoid (The classic female type)
2. Android (Resembling the male pelvis)
3. Anthropoid (Oval Shaped, with a wider Anterioposterior diameter
4. Platypelloid (The flat pelvis)
note: Even precise measurements do no always predict a woman ability to give birth vaginally because of the many ways the fetus can negotiate the pelvis and the accommodation of maternal soft tissues . There for pelvimetry wrestles would rarely contraindicate a trial of labor,
Powers of labor p. 373
note: Contractions are described by
Involuntary and voluntary powers combine to expel the fetus and the placenta from the uterus.
Involuntary uterine contractions , called PRIMARY POWERS SIGNALS THE BEGINNING OF LABOR
Once the cervix has dilated, voluntary bearing down effort by the woman, called the SECONDARY POWERS , argument the force of involuntary contractions.
1.Primary powers of labor:(Effacement,Dilation,Decent)
note the primary powers are responsible for
a. Effacement(Shortening/thining of cervix)
note: when this is complete only a thin edge of the cervix can be palpated
b. Dilation(Widening of Cervical opening)
-the diameter of the cervix increases from being fully closed to full dilation (10cm) to allow birth of term fetus
-When the cervix is fully dilated (n retracted) it can no longer be palpated
-Full cervical dilation marks the end of the first stage of labor
C. initiate decent
-so primary powers Dilate and efface the cervix and initiate descent
B. Voluntary powers:
1.Bearing down: aids in expulsion of the fetus as she contracts her diaphragm and abdominal muscles and pushes.
2.Augment the force of the primary contractions
3. Involuntary urge to bear down (Ferguson reflex)
-Stretch receptors cause release of endogenous oxytocin that triggers the maternal urge to bear down or the FERGUSON REFLEX.
4.Endogenous oxytocin release
-Closed Versus open glottis pushing
NO CLOSED GLOTTIS PUSHING!
note: Secodary powers have NO EFFECT ON CERVICAL DILATION, but are important of the expulsion of the infant from the uterus
Chapter 19Nursing Care of Family during Labor and birth
-We are analyzing
A. Pushing during Second stage of labor
B. Positioning during labor p.449
A. Pushing during second stage of labor
-When coaching women to push, encourage them to push as they feel like pushing (Instinctive , Spontaneous pushing) rather than to give a prolonged push on command (Directed closed glottis pushing)
NO CLOSED GLOTTIS PUSHING!
note: do not teach pt to hold their breath ad push, because this triggers the Valsalva Maneuver which occurs when the women closes her glottis.
-This REDUCES CARDIAC OUPUT and Decrease Perfusion of the uterus and placenta
-Tell her take deep breathes before and after each contraction
-Bearing down while exhaling (open glottis pushing) GOOD and taking breaths between bearing down effort help to maintain adequate oxygen levels for mother and fetus
-Every effort should be made to ensure that women use non directed spontaneous pushing to conserve energy
B. Positioning during labor:
-Squating is highly effective in facilitating the descent and birth of fetus. It is one of the best and most natural positions for second stage labor and has been associated with the same benefits as
Position of the laboring women
B.Hands and knees or squat for back labor
-Squatting or kneeling is best
-Lateral may help rotate OP presentation
-Usually see lithotomy
Woman needs power of positive thinking
Continuation of Chp 16:
Stages of Labor p. 376
Onset of labor (regular uterine contractions) to full effacement and dilation of the cervix.
Three stages: Latent,Active,Transition
1.Latent: progress of effacement(0%-100%)
2.ACTIVE ( approx. 3cm -10cm)
Note: during the active and transition phase there is more rapid dilation of cervix n increased rate of decent
B.Second stage (2 phases): Lasts from the time the CERVIX is fully DILATED to the birth of the fetus. has 2 phases
1..Latent (natural decent and rotation of fetus )
2. Active pushing phase (strong expulsive urge)
Birth of fetus to delivery of placenta
Delivery of placenta to 1-2 hours p birth
Note: during this stage is the time to recover so it is important to observe for complications such as abnormal bleeding (Chp 33)
Box 16-1 Signs Preceding labor
return of urinary frequency
Stronger braxton Hicks Contractions
Weight loss of 0.5 to 1.5 kg (Approximately 1 to 3 1/2 pounds)
Surge of energy
Increased vaginal discharge;blood show
Possible rupture of membranes
Adaptations in labor
FETUS p. 379
A. Fetal Heart Rate (FHR)
-Average at TERM is 140bpm
-Norm is 110-160bpm
note: Acelerations or decelerations in FHR can be due to movement, vaginal examination, fundal pressure, uterine contractions
B Fetal Circulation:
-Affected by maternal position, uterine contractions, BP,n Umbilical cord flow
note: Uterine Contractions during labor tend to decrease circulation
-Most fetuses compensate for this stress and exposure while passivly moving
C. Fetal Respiration:
-Certain changes are done to prepare the fetus for initiating respirations immediately after birth
-Clearing of lung fluid
-Fetal Po2 decreases
-Fetal Pco2 increases
-Fetal arterial pH decreases
-Fetal bicarb decreases
-Fetal respiratory movements decrease during labor.
box 16-2 Maternal Physiologic changes during labor
-cardiac output increases 10 to 15% in first stage 30% to 50% in second stage
-HR increases slightly in first and second stages
-Blood pressure (Both S/D) increases during contractions n returns to baseline levels between contractions.
-WBC count increases
-Respiratory Rate increases (Hyperventilation=Greater oxygen consumption may cause respiratory alkalosis and INCREASE IN PH
-Temperature may be slightly elevated
-Proteinuria may occur
- (GI) Gastric motility and absorption of solid food are decreased;N and V may occur
-Blood glucose level decrease
-Difficulty with urination
When in Labor the nurse should discourage the woman from using the ?
Valsalva manever (Holdings ones breath and tightening abdominal muscles for PUSHING during the second stage.
-This activity increases intrathoracic pressure, reduces venous return and increases venous pressure.
-During Valsalva maneuver fetal hypoxia may occur . This is reversed when the woman takes a breath.
Your client is in 2nd stage of labor c/o severe back pain. What nursing interventions will facilitate rotation and decent of the fetus?
A. counter pressure to her lower back
B. assist client to change position side to side to push
C. assist client to squatting position for pushing
D. assist client to push steadily by counting to 10
E. Assist client to breath through her contractions
The cardinal movements of he mechanism of labor are
Expulsion of infant
Chapter 32 Labor and Birth Complications p.759
Preterm birth vs. LBW
A.Preterm birth is any birth that occurs between 20 0/7 and 36 6/7 weeks of gestation.
-Describes the length of gestation
Categorys: Very preterm, Moderately preterm , Late preterm
Very Preterm: <32 weeks of gestation
Moderately Preterm: 32-34 wks of gestation
Late Preterm: 34 to 36 wks
B.Low birth weight describes only weight at time of birth.
-Low birth weight <2500 gm (5 ½ lb)
Preterm birth is MORE dangerous health condition for an infant because less time in the uterus correlates with immaturity
Note: Low birthweight can be caused by conditions such as:
IUGR (Intrauterine Growth Restriction)- a condition of inadequate fetal growth.
-Usually related to poor placental perfusion
Risk for Preterm LABOR p.760
History of previous spontaneous PT Birth
Genital tract colonization & infection
2nd trimester bleeding
Low prepregnancy weight(box 32-1 p760)
Box 32-2 Common causes of Indicated Preterm Birth
Preexisting or gestational diabetes
Obsterical disorders or risk factors in previous pregnacy
Previous cesarean birth
Maternal HIV or active herpes infection
Advanced maternal age
IUGR or Abnormal NST or BPP
Excessive or inadequte amount of amniotic fluid
Congenital fetal abnormalities
Fetal Fibronectin Test
a diagnostic tool for preterm labor
-note: fFN is a glycoprotein "Glue" found in plasma an
-Test is performed by collecting fluid from the womens vagina using a swab during a speculum exam
- the presence of fFN alone is Not a sensitive predictor or preterm birth
- test is often USED TO PREDICT WHO WILL NOT GO INTO PRETERM LABOR
NEGATIVE TEST=predictive of continued pregnancy
Predicting Preterm birth p. 761
It is best to use a combined approach
-Combining evaulation of fFN levels and ultrasound measurement of cervical length was found to increase the ability to identify those at risk for Preterm labor
Nursing Care management
Educate pregnant women due to
-not only in pregnancy but also in the preconception period.
Box 32-3 Signs and symptoms of Preterm Labor
Because more than half of preterm births occur in women without obvious risk factors , it is essential that all pregnant women are taught the symptoms of preterm labor
a. Uterine Activity (Regular contractions)
- Uterine contractions occurring more frequently than every 10 min persisting for 1 hour or more
-Uterine contractions may be painful or painless.
b.Discomfort( Pelvic Pressure)
-Lower abdominal cramping similar to gas pains;may be accompanied by diarrhrea
-Dull, intermittent low back pain
-Painful, menstrual-like cramps
-Suprapubic pain or pressure
-Pelvic pressure or heaviness; feeling that baby is pushing down
C. Vaginal Discharge
- Change in character or amount of usual discharge:
thicker (Mucoid) or thinner (watery, bloody, brown or colorless, increased amount, odor
-Rupture of amniotic membranes (WATER BREAKS)
Teaching for Self Management
What to do if symptoms of preterm labor occur?
-Drink 2-3 glasses of water
-Lie on your side x 1hour
-Palpate your contractions
Note:If symptoms continue seek care
Immediately seek care for foul vaginal discharge, vaginal bleeding, fluid leaking
Preterm labor is based on 3 major diagnostic criteria
-Gestational age between 20 0/7 n 36 6/7 weeks
- uterine activity (regular contractions
- Progressive cerivical change (Effacement of 80% or cervical dilation of 2 cm or greater)
Nursing Care p. 765
If their is no cervical change then....
A.Lifestyle modification may be necessary:
-Restriction of sexual activity
-Home care: modify the women environment, keep essential items around her
Teaching for Self Management
Activities of Children of Women on Activity restriction
-schedule brief play periods through out day
-Keep a few toys in box or basket close to the bed or couch
-Read to the children
-Put puzzles together
-Play card board games
-Cut yt puc
Meds used p. 765-767)
Tocolytics are meds given to ARREST LABOR after uterine contractions and cervical change have occurred
- Drugs used for other purposes such as Anti inflammatory , are used on an "off-label" basis: drugs known to be effective for a specific purpose, to suppress labor
- These are given to DELAY BIRTH long enough to allow time for maternal transport
-Common one is Magnesium sulfate.
Antenatal glucocorticoid (p 769)
Box 32-4 Contraindication to Tocolysis
-Contraindications to specific tocolytic medications
-Lethal Fetal Anomaly
-Nonreassuring fetal status
-Preterm Premature rupture of Membranes (PROM
Box 32-5 Nursing Care of Women receiving Tocolytic therapy
-explain purpose and side effects
-Position on her side to enhance placental perfusion and reduce pressure on the cervix
-Monitor vital signs: lung sounds, respiratory effort, fetal heart rate and pattern and labor status
-Assess mother and the fetus for signs of adverse reactions r/t tocolytic meds
-Determine maternal fluid balance by measuring daily weight and intake and output
-Limit fluid intake to 2500 to 3000 ml/day
Safety alert for Mag sulfate
Because magnesium sulfate depresses the function of the central nervous system (CNS) , it is essential that the nurse frequetly assessed the women respiratory status, deep tendon reflexes and LOC to identify signs that the serum level of magnesium sulfate us reaching toxic levels
Antenatal glucocorticoid (p 769)
1.Terbutaline (Brethren : most commonly admin
-beta adrenergic agonist used for tocolysis,
-relaxes smooth muscle, inhibiting uterine activity and causing bronchodilation
- can be given to suppress uterine tachysystole and to suppress contractions prior to cesarean birth.
tx: does not last longer than 24 hrs
-Discontinue if Intolerable events occur
-Tachycardia greater than 130bpm
-bp less than 90/60
-should not be used in women with a hx of cardiac disease, pregestational or gestational diabetes , hypertension, preeclampsia or hyperthyroidism, significant hemorrhage
-SERIOUS FETAL OR NEONATAL side effects have cause major concerned
-Limiting use of INDOMETHACIN to a period of 48 hours or less in women with preterm labor at less than 32 weeks.
-use only if gestational age is less than 32 weeks
-Administer for 48 hours or less
-Do not use in women with renal or hepatic disease, PUD , hypertension, asthma, coagulation disorders
-Can mask maternal fever so, constant temperature checks
-Assess women and fetus
-Give food to minimize GI Distress
- Monitor signs of Postpartum hemorrhage
-Determine Amniotic fluid volume and function of fetal ductose arterioles before initiating therapy and within 48 hours of discontinuing therapy
3.Nifedipine (Adalat, Procardia)
- Relaxes smooth muscle by preventing calcium from entering smooth muscle
-Avoid concurrent use with magnesium sulfate because skeletal muscle blockade can result
-Can cause orthostatic hypotension and dizziness, so instruct women to slowly change positions
-Maintain adequate fluid balance to reduce the drop in blood pressure
-Should not be given simultaneously with or immediately after Tebutaline because of effects on heart rate and blood pressure
-Assess women and fetus
-Do not use sublingual route.
CNsS Depressant relaxes smooth muscle
Respiratory rate fewer than 12 breaths/min
Extreme muscle weaknes
-Assess women and fetus to obtain baseline
-moniter serum magnesium levels
therapeutic range is :4 and 7.5
- Discontinue infusion and notify physcian if intolerable adverse effects occur
-Ensure that calcium gluconate or calcium chloride is available for emergency administration to reverse magnesium sulfate toxicity
-Total intake should be limited to 125ml/hr
4.Antenatal glucocorticoid (p 769)
-given as a IM to mom to accelerate fetal lung maturity by stimulating fetal surfactant production
two doses..24 hours apart
four douses 12 hour apart
-Give DEEP IM in Ventral gluteal or Vastus laterals muscle
-Assess maternal blood glucose levels. women with diabetes may require increased insulin doses for several days.
Safety Alert :CCB NIFEDIPINE
because using a CCB can result in ORTHOSTATIC HYPOTENSION and DIZZINESS
-it is essential to instruct women to slowly change position from supine to upright and then sit until any dizziness disappears before standing
-Maintain adequate fluid balance to reduce the drop in blood pressure that can occur with drug related vasodilation
all women between 24 and 24 weeks of gestation who are at risk for preterm birth within 7 days should receive treatment with a single coarse of antennal glucocorticoids
- because optimal benefit to the fetus begins 24 hours after the first injection
Management of Inevitable Pre term birth p.769
1.Admin Magnesium sulfate
-to prevent neurologic morbidity (Neuroprotective)
- given to women who are atleast >24 weeks but <32 weeks of gestation.
-Labor that has progressed to a Cervical dilatation of 4 cm or more birth is inevitable
-Prepare team to handle the emergency birth of preterm infant.
-If birth occurs in a hospital that is not prepared to provide continuing care for a preterm neonate, plans should be made to Mobilize transport to a higher level of care
Premature rupture of membranes
PROM: is the spontaneous rupture of the amniotic sac (SROM)and leakage of amniotic fluid beginning before the onset of labor and at any gestational age
P-PROM: Pre term premature rupture of membranes
-Prior to 37 weeks GA
Both is diagnosed after woman reports either a sudden gush of fluid or a slow leak of fluid from vagina.
Risk for Chorioamnionitis(Most common cause of PROM)
-Bacterial infection of the amniotic cavity .
Nursing Care Management
-Minimal invasive procedures
A.Close surveillance of maternal temperature
-Maternal hygiene: teach the how to keep her genital area clean and that nothing should be introduced in her vaginia
-Foul odor: she should be taught the s/sx of infection(Fever, foul-smelling discharge, maternal and fetal tachycardia)
B.Close surveillance of fetal Heart patterns (NSTs)/BPP
-Antenatal corticosteroids:decrease risk of several neonatal complications
-Antenatal antibiotics: to prolong the time between membrane rupture and birth, prevent sepsis , decrease maternal chorioaminitis
Tx womman DFMC(Daily fetal movement counts
-If Chorioamnitis develops Labor is induced
-If preterm labor occurs , tocolytic medications may be administered in an attempt to gain time for transport
-Usually diagnosed by the clinical finding of
Maternal and fetal tachycardia
foul odor of amniotic fluid
young maternal age
low socioeconomic status
preexisting infections of lower GI tract.
-To prevent maternal and neonatal complication, prompt tx with IV broad spectrum antibiotics and birth of fetus are necessary
-Ampicillin or penicillin
note: after cesarean birth , an antibiotic that provides coverage for anaerobic organisms such as Clindamycin (Cleocin) or Flagly
How much weight should an underweight woman gain?
when can a baby sit without support?
How many weeks is considered a 'preterm' baby
What are the psychological changes during pregnancy
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