What does preconception counseling involve (6)?
Promotion of healthy lifestyle including:
1. Well-balanced nutrition including 400 micrograms of Folic acid to prevent neural tube defects
2. No ETOH or drugs, review of meds
3. Immunizations- Rubella, Varicella, Tdap
4. Exercise, Ht/Wt ratios, med hx- genetics
5. A wanted baby, parents emotional health?
6. Enviornmental concerns- violence, teratogens (anything in enviornment that can negatively affect fetus)
What are prenatal care goals (6)?
1. Monitor mom and baby for progression of pregnancy and their response
2. Screen for complications and minimize
3. Provide support and education for mother and family; Smoking cessation
4. Identify high risk situations and provide appropriate referrals
5. Goals for each visit during all 3 trimesters
6. Can not promise a healthy baby
What happens the 1st prenatal visit (6)?
1. Best if in 1st trimester, but better late than never
2. If later attempt to 'catch up' the pt. with care (labs, US, pt support/education)
3. Confirm pregnancy
4. complete hx and PE
5. What you don't ask- you don't know
6. Homicide is the leading cause of death in pregnancy
What are the 5 critical questions to ask regarding social support?
1. Who helps you get the day to day things you need in life?
2. If you had an emergency, who would you call on for help?
3. Who would lend you money or keep your child(ren) if you needed it?
4. Who gives you advice that is useful?
5. Who understands your private worries and feelings?
What are some labs drawn during the 1st prenatal visit (8)?
1. CBC
2. blood type and antibody screen
3. STD screening: VDRL or RPR, HIV w/consent
4. HBsAg
5. Rubella Titer- poss Varicella titer, possibly also a 1 hr glucose tolerance test if high risk for gestation diabetes
6. UDS w/ consent
7. UA/culture
8. Pelvic exam: STD screening/ pap smear
What is nuchal transluceny?
1st trimester screening for anomalies
Use US to see behind neck for luceny at 10.5-14 wks gestational age- very specific window of time for accuracy
Associated w/ multiple congenital anomalies
Cardiac, Diaphragmatic hernia, Ompalocele, Increased risk for IUFD
>95th centile will find babies w/ trisomy 21,18, 13
How do we confirm pregnancy and determine EDC (5)?
1. 1st day of LNMP (last normal menstrual period)
2. Nagele's rule- subtract 3 mons/add 7 days from 1st day of LNMP and correct the year PRN
3. Symptoms of pregnancy
4. urine or blood for HCG
5. If pt. does not know LNMP expect US to be ordered and pt to do within next 2 weeks
What is the 1st trimester psychosocial task (4)?
1. Accept pregnancy
2. Ambivalence is normal
3. Take cues from your pts verbal and non-verbal communication
4. Abortion? Adoption?
What is involved in the STD/STI Screening (6)?
1. Never assume a pts risk
2. Visual inspection/cultures/blood work
3. Chlamydia fasting growing STD. often no s/s. txt=antibiotics
4. Gonorrhea- need cervical culture to dx
5. Syphillis VDRL, RPR- blood test
6. Trichomonas- wet prep slide of vag d/c
What is herpes (6)?
1. Herpes blister like lesion in perineal area
2. Be alert- if hx of herpes on chart- its a lifelong dx that is active/dormant in the dorsal horn of the specific nerve ganglion
3. Active herpes C/S very dangerous to baby
4. Virus shed 24 hrs before lesion
5. Stress brings outbreaks
6. Pt. may have prodromal symptoms
What is HPV (9)?
1. Human Papillomavirus
2. Many different serotypes
3. venereal warts (small or resemble cauliflower)
4. common sites are vagina, labia, cervix
5. associated w/cervical cancer, Increases risk of cervical dysplasia
6. tx: remove warts
7. No current therapy cures
8. HPV vaccine- CDC reccommends ages 9-26 contraindicated when pregnant
9. Current anti-viral therapies decrease the viral load and the 'mass of lesions'
What are some danger signs during the 1st trimester (4)?
1. Vaginal bleeding is never normal
2. N/V that won't stop
3. Adb. pain
4. Syncope
What are some additional issues during the 1st trimester?
HCG: fatigue, uterus bigger, cx bluish, soft
N/V: small, frequent meals, low fat, not spicy, if s/s of dehydration call MD
Sexual desires may change- WNL, sex ok during pregnancy unless MD forbids
At 11-13 wks FHT audible Doppler
Urinary frequency WNL
Calculate BMI
What are some weight gain goals during pregnancy?
Ideal wt (BMI 18.5-24.9) 25-35 lbs
Underweight (BMI <18.5) 28-40 lbs
Overweight (BMI 25-29.9) 15-25 lbs
Obese (BMI >30) 11-20 lbs
1st trimester- 0-4 lbs
2nd and 3rd- 3/4-1 lb per week
Evaluated each visit
What is a 24 hour diet recall?
Written or verbal
Taking prenatal vitamins?
If in doubt send pt home w/ 'form'
Give mom a copy of recommened daily intake
What is the recommeneded daily intake?
Grains- 1/2 should be whole grains, 6-9 oz
Fruits- 2 cups
Vegetables- 2 1/2- 3 1/2 cups: 1 folic acid- bean, oranges, dark green leafy veggies, 1 Vit C- strawberries, kiwi, cabbage, 1 Vit A- deep yellow/dark green leafy, carrorts, yams, spinach
Meat and beans- 5 1/2- 61/2 oz
Dairy- 3 servings; 1 cup milk/yogurt, 2 cups cottage cheese, 1/3 cup hard cheese, frozen togurt, skim milk best
Caffeine- controversial, <300 mg/ 24 hrs
Nutrasweet, equal- ok unless have PKU
Fish- no shark, swordfish, king mackerel, tilefish. Only 12 oz/week
No blue cohosh, juniper, pennyroyal, rosemary, sage, raspberry, thuja
What is listeriosis?
Pregnant women 20x more at risk
Mom- sepsis, meningitis
Fetus- miscarriage, stillbirth, preterm delivery
Do not eat- Raw unpasteruized milk, raw or undercooked meat, poultry, eggs, fish, shellfish, refrigerated pates, soft cheeses like feta, brie, bleu, camembert, leftover food, NO hot dogs or deli meats unless heated until steaming hot
Prevention- clean kitchen, don't cross contaminate, throw out leftovers
1st Trimester development
Fertilized ovum- 'zygote' this occurs at about day 14 of the mothers cycle
Implantation- 6-10 days after conception zygote secretes HCG, spotting may occur
Embryo- 3-8 weeks organogeneisis- all major organ systems formed (most vunerable to teratogens)
3rd week- primitive heart begins to beat
4th week- limb buds appear, neural tube closes by 28 days
6th week- intestines are in the umbilical cord, blood is forming, teeth forming
10 weeks- intestines are back in the abd, toes are distinct, fingernails start, wt 14 grams, see movement on ultrasound
12 weeks- sucking reflex present, kidneys produce urine, wt 45 grams
9 weeks- 'young one', now has EEG waves, percieves touch, wt 5 grams
What are the 2nd trimester psychosocial tasks?
1. identifying w/ mother role- many women think about their relationship w/ own mother
2. recorder personal relationships- remind pt. to register for childbirth, breast feeding, infant care classes
Nipple Assessment
If mom wants to breastfeed...what are the conditions of her nipples? flat or inverted?
Shells may help 'pull out' the nipple to an everted position which aids in infant latch on
What are the 2nd trimester visit components?
Need to see pt. every 4 weeks if WNL
Wt check/nutrition review
Urine dipp for protein/sugar, UTI screen
B/P screen
FHT check
Fundal ht measurement 20 cm= 20 weeks
Pt. education, how is her life? concerns?
What is in the 2nd trimester 'timed' care?
15-20 weeks (maternal alpha fetoprotein) Triple/quad screen screening test- PT education first
Draw mothers blood to measure alpha fetoprotein, estriol, hCG, inhibin-A
Results indicate risk status for downs syndrome or open spinal bifida
Not a diagnostic test
What is the timed care for 16-20 weeks?
Quickening- fetal movement now felt by mother, confirms EDC, reinforces unique idenity of fetus
What is the timed care for 25-28 weeks?
Labs to r/o complications
1 gtt, CBC, Urine C&S
Others based on pt history/progress of pregnancy
Rhogam if mom is Rh-
2nd trimester fetal development
16 weeks- wt 200 grams (1/2 pound), pulmonary vascular system developing, fetus swallows amniotic fluid
20 weeks- wt 460 grams, surfactant production + myelination of nerves begins
24 weeks- wt 830 grams- viability, system continue to mature
What happens during the US exam?
16-20 weeks fetal survey
Can see sex of baby
Increase attachment
Impacts fathers a lot
What are some 2nd trimester danger signs?
Vaginal bleeding
SROM- spontaneous rupture of membranes
HA, edema, blurred vision
Loss of fetal movement
Flank pain, backache, fever, night sweats
Call MD stat
What happens during the 3rd trimester?
28- 40 weeks
Visits increase every 1-2 weeks if WNL
Components: B/P, UA; protein + sugar, fundal height, fetal movement, FHT, fetal position, wt gain evaluation
35-37 weeks GBS culture vag/rectum
Discuss birth plan
Psychosocial tasks- prep for birth and fantasy baby attachment
What are some 3rd trimester warning signs?
Contractions? stop til 35-36 weeks
HA that is not relieved by Tylonel -> PIH
Blurred vision, sudden edema -> PIH
Adb pain-> RUQ? (liver enlarged, risk for pre-ecamplsia)
Leaking fluid-> PROM
Fetal movement-> if decreased a sign of distress
3rd trimester pt. education
Review s/s of labor
True vs. false labor
True- longer, stronger, closer together even w/ movement, 'won't go away'
False- not regular, not intense, fade away esp. when walking
Go to hospital IF: ROM or suspect ROM, contractions q5min, vag bleeding, decreased FM