Signs of Pregnancy

Signs of Pregnancy: 1.​ Presumptive a.​ Symptoms that the woman feels (subjective) i.​ Amenorrhea (no menstruation) ii.​ fatigue/nausea iii.​ Breast changes iv.​ Quickening (fluttering movements of the fetus felt by client) v.​ Uterine enlargement 2.​ Probable a.​ Abdominal enlargement b.​ Hegar's sign (softening of lower uterus) c.​ Chadwick’s sign (color change) d.​ Goodwill’s sign (softening of cervical tip) e.​ Positive pregnancy test f.​ Ballottement g.​ Braxton Hicks Contractions 3.​ Positive a.​ Fetal movement (palpated by experienced examiner) b.​ Fetal heart sounds c.​ Visualization of fetus by ultrasound Methods for Calculating EDC (Estimated Date of Confinement): 1.​ Naegle’s Rule a.​ Take the first date of the woman’s last menstrual period (ex: June 10) b.​ Subtract 3 months (March 10) c.​ Add 7 days (March 17) i.​ Add a year ahead for future due date 2.​ McDonald’s Rule a.​ Measure the woman’s fundal height i.​ Each centimeter measured indicates the patient’s gestational week 1.​ Is not a valid method for calculating after 36 weeks gestation since the fundus drops as the time gets closer to birth Prenatal Nursing Teaching: 1.​ Prenatal Visits a.​ Every 4 weeks for the first 28 weeks i.​ First Visit 1.​ Determine EDC, history, social reports, physical assessment of weight, vital signs, labs! b.​ Every 2 weeks from 28 weeks to 36 weeks c.​ After 36 weeks, weekly visits (if no complications are present) i.​ If complications are present, pre doctor’s request for multiple visits throughout the week 2.​ Teachings for Possible Complications a.​ Vaginal bleeding; NO SPOTTING OR BLEEDING b.​ Persistent emesis/vomiting c.​ Persistent chills/fever with urination d.​ Sudden escape of clear fluid from the vagina e.​ Abdominal/chest pains f.​ Gestational hypertension g.​ Noticeable decreased fetal movement (potentially increased movement as well) h.​ Uterine contractions before 37 weeks Prenatal Tests: 1.​ 1st Trimester (0-12 weeks) **Gather history data of pt!!** a.​ IF pregnancy is high risk, Glucose Tolerance Test end of 1st trimester!! i.​ Results that are greater than 140 mg/dL, follow-up is required with 3 hour glucose test (4 total values) 1.​ If 2 or more glucose readings are elevated, diagnosis of gestational diabetes is given b.​ 1st Ultrasound i.​ One sign of the three for true proof for pregnancy! 1.​ Fetal movement 2.​ Fetal heartbeat 3.​ Visualization of fetus c.​ Screening for STDs (HIV) d.​ Urine analysis e.​ HbA1c i.​ No diabetes is indicated for a result of < 5.9% ii.​ 6.5% to 8% indicates diabetes f.​ Drug screening g.​ Blood testing i.​ Genetic testing ii.​ Type screening iii.​ Titers (Rubella) iv.​ Nuchal Translucency test w/ ultrasound 1.​ Trisomy 13 (Patau Syndrome), 18 (Edwards Syndrome), 21 (Down Syndrome) a.​ IF the fetus does come back positive for this test, pregnancy does become a high risk!! v.​ Blood type testing 1.​ ABO Incompatibility a.​ Type O mother with fetus that has type A or B blood type (less severe) 2.​ Rh (D) Incompatibility a.​ Rh- mother with fetus that is Rh+ (fatal) i.​ RhoGAM given at 28 weeks (for safety of the remaining duration of pregnancy) or 72 hours post abortion (in case mom becomes pregnant again, this is a preventative measure) 2.​ 2nd Trimester (13-24 weeks) a.​ Glucose tolerance test (24-28 weeks if NOT high risk) b.​ 2nd Ultrasound i.​ Organ structures ii.​ Sex of baby (18-20) c.​ Repeat Hct to check for anemia i.​ Hgb < 10.5 mg/dL (2nd Trimester) – NOT GOOD ii.​ Hct < 33% – NOT GOOD 1.​ Hct is how packed the blood is with RBC’s 3.​ 3rd Trimester (25-40 weeks) a.​ GBS Swab Test (35-37 weeks) b.​ Repeat HIV screening if high risk or concerned c.​ CBC if anemic in the past i.​ Hgb < 11mg/dL (1st and 3rd Trimester) ii.​ Hct < 33% Maternal Nutrition: ❖​ Underweight BMI: < 18.5 ➢​ 28 - 40 lb weight gain ❖​ Normal BMI: 18.5 - 24.9 ➢​ 25 - 35 lb weight gain ■​ 1st trimester – 1.5 lb/0.8 kg per month ■​ 2nd trimester – 1 lb/0.4kg per week ❖​ Overweight BMI: 25 - 29.9 ➢​ 15 - 25 lb weight gain ❖​ Obese BMI: > 30 ➢​ 11 - 20 lb weight gain ❖​ PICA ➢​ Patient craves ice/chalk, substances that have no nutritional value ■​ Refer to the primary care provider for iron-deficiency anemia!! ❖​ Constipation ➢​ Uptake Fiber!! ❖​ Calorie Intake ➢​ Increase 340 calories a day (2nd Trimester) ➢​ Increase 452 calories a day (3rd Trimester) ➢​ Increase 450 to 500 a day (Breastfeeding moms) ❖​ Fluids ➢​ 8 to 10 glasses (no more than 3 L) ❖​ Caffeine ➢​ No more than 300 mg daily ❖​ Folic Acid ➢​ 400-600 mcg ❖​ Protein ➢​ Uptake to 71g of protein during 2nd and 3rd trimester Stages of Labor: 1.​ First Stage of Labor (care begins when there is contraction strength/frequency and/or there is SROM (spontaneous rupture of membranes)) a.​ lasts from beginning of dilation to when the cervix is fully dilated and 100% effaced b.​ Three phases of the first stage of labor include: i.​ Latent Phase: cervix dilated up to 3 cm (~12 hrs) 1.​ Electronic FHM occurs every 30 minutes during this stage 2.​ contractions last 20-40 seconds ii.​ Active Phase: cervix dilated 4-7 cm 1.​ cervical dilation happens more rapidly; rupture of membranes are more likely to occur if they haven’t already 2.​ Electronic FHM occurs every 15 minutes 3.​ contractions last 40-60 seconds every 3-5 minutes iii.​ Transition Phase: cervix dilated 8-10 cm 1.​ multipara pt will progress more rapidly than nullipara 2.​ pt may have nausea, anxiety, and panic 3.​ contractions are every 60-70 seconds every 2 to 3 minutes 2.​ Second Stage of Labor a.​ lasts from full dilation to birthday of infant (pushing stage) i.​ Cervix is completely dilated (10cm) and completely effaced (100%) ii.​ pushing begins 1.​ second stage ends when baby is delivered iii.​ Crowning occurs when fetal head is showing in the vagina iv.​ Electronic FHM occurs every 5 minutes 3.​ Third Stage of Labor a.​ lasts from the infant's birth to the expulsion of the placenta 4.​ Fourth Stage of Labor a.​ first 2 hours after birth (recovery) Complications of Pregnancy and Labor & Delivery: -​ Placenta Previa (placenta blocking the cervical os, either through detachment or placenta was attached low within the uterine to begin with) -​ Complete/Total blockage of os -​ Results in C/S -​ Incomplete/partial cervical os -​ Results in C/S -​ Marginal/Low Lying = placenta is attached low within the uterus -​ Can be done vaginally depending on how the placenta’s position is at the time of labor -​ Expected Findings: -​ Bright red (painless) Vaginal bleeding during 2nd and 3rd trimester -​ -​ -​ -​ -​ Soft uterus -​ Fetal presentation breech, oblique, and transverse -​ Nursing Care: -​ Corticosteroids betamethasone Abruptio Placentae (premature separation of the placenta from the uterine lining after 20 weeks gestation) -​ Can be complete or partial separation that occurs due to a coagulation defect. -​ Expected Findings: -​ Dark red vaginal bleeding (with pain) -​ Nursing Care:​ -​ Get mom ready for birth and get ready for immediate birth -​ Manage mom’s vital signs by infusing fluids and oxygen Preterm Labor (20 - 36 weeks gestation) -​ Types of Preterm: -​ Very preterm labor (before 32 weeks gestation) -​ Moderate Preterm Labor (32 to 34 weeks gestation) -​ Late Preterm Labor (34 - 36 weeks gestation) -​ Expected Findings: -​ Uterine contractions -​ Persistent low backache -​ Vaginal discharge -​ PROM -​ Nursing Care: -​ Activity Restriction -​ If vaginal discharge is present, screen for infection and treat -​ Medications (tocolytics → toco/contraction & lytic/to stop: -​ Nifedipine (stops muscle contractions) -​ Contraindication is hypotension -​ Magnesium Sulfate (relaxes smooth muscles) -​ Watch for toxicity -​ Lethargy -​ Flushing -​ Edema -​ Loss of tendon reflexes (low numbers such as 0 and +1) -​ Terbutaline (inhibits uterine activity) Shoulder Dystocia (during vaginal delivery when baby’s head is out, but one or both of baby’s shoulders are stuck behind the pelvic bone) -​ Risk Factors: -​ Fetal Macrosomia (big baby, usually in diabetic patients) -​ Maternal obesity -​ Evident through prolonged second stage of labor -​ Baby’s clavicle can become fractured or baby can have Erb’s palsy -​ DO McRoberts Maneuver (placing woman’s legs by hyperflexing towards the abdomen) Gestational HTN -​ After 20 week gestation, when pt has two blood pressure readings (4 hours apart) that are greater or equal to 140/90 -​ NO proteinuria -​ BP should return to normal 12 weeks PP -​ Preeclampsia -​ GH w/ proteinuria 1+ -​ Report headaches -​ Present edema -​ Severe Preeclampsia -​ Proteinuria 3+ -​ BP is 160/110 or greater -​ Headaches AND blurred vision -​ Hypereflexia (check reflex points) -​ Extensive edema -​ Eclampsia -​ Severe preeclampsia WITH onset seizure activity or coma HELLP Syndrome: H - Hemolysis (anemia and jaundice) E - Elevated L - Liver enzymes (higher levels of AST, nausea and vomiting) L - Low P - platelet count (less than 100,000, abnormal bleeding, petechiae) ●​ complication of preeclampsia Gestational Diabetes: -​ Lab Tests: -​ 1-hr Glucose Test (Screening) -​ Done at 24 to 28 weeks gestation → 50g oral glucose, no fasting, positive test is 130-140 mg/dL or more -​ OGTT (3 hr) -​ 12 hr fasting is required, no caffeine → 100g oral glucose, glucose levels are determined at 1, 2, and 3 hourly -​ If 2 out of 3 results are high, pt is positive for gestational diabetes -​ Higher risk of infection of diabetes Fetal Heart Monitoring Categories: -​ Category 1 -​ Fetal heart rate is within normal limits (110-160 bpm) -​ Moderate variability -​ Accelerations: present or absent -​ Early decelerations: present or absent -​ Variable or late decelerations: absent -​ Category 2 -​ Baseline rate not normal (bradycardia or tachycardia) -​ Variability: minimal, absent, or marked variability -​ Some decelerations may occur, but they are NOT persistent -​ Category 3 -​ Bradycardia/Tachycardia -​ Absence of variability -​ Recurrent variable or late decelerations -​ Late and variable decelerations Maternal-Fetal Circulation: -​ aVa -​ Arteries: Take away deoxygenated blood from the fetal heart -​ Vein: brings oxygenated blood to the fetal heart -​ A baby's blood is never exchanged/mixed/shared with mom’s blood. -​ Connects to the chorionic villi in the placenta -​ Has wharton’s jelly = soft, gelatinous connective tissue that surrounds the umbilical cord, protecting the blood vessels from compression Cerclage Use: -​ Surgical procedure since cervix is prematurely effaced (incompetent cervix during 2nd trimester;cervical insufficiency) -​ Either a band structure is placed or sutured -​ Other indications: previous cervical trauma (during previous births or any time), in utero exposure to -​ Usually removed at 36-37 weeks -​ Prematurely removed if there is infection or preterm labor Use of Magnesium Sulfate: -​ Used for HTN and preeclampsia; also anticonvulsant -​ Last resort after other HTN medications are not effective -​ Magnesium Sulfate Toxicity: -​ Flushing -​ Edema -​ Lethargy -​ Loss of deep tendon reflexes -​ Urine output less than 30 mL/hr -​ RR less than 12 -​ ANTIDOTE = CALCIUM GLUCONATE Signs of Labor: Feature Contractions True Labor Regular, stronger, closer together; increase with walking False Labor Irregular, do not increase in intensity Felt Lower back → radiates to abdomen Abdomen only Cervical change Progressive effacement/dilation No significant change Relief Not relieved by rest/hydration Relieved by rest, fluids, position change Week 1 Summary Notes: 1. Premonitory Signs of Labor (Signs Labor is Approaching) ●​ Backache: Low, dull back pain caused by pelvic relaxation. ●​ Weight loss: 1–3 lbs due to fluid shifts/electrolyte changes. ●​ Lightening: Fetus descends into pelvis, mother may breathe easier but experience more urinary frequency. ●​ Contractions: Become irregular, then progressively stronger/closer (esp. in true labor). ●​ Increased vaginal discharge/bloody show: Mucus plug expelled; pink/brown-tinged mucus. ●​ Energy burst ("nesting"): Surge of energy 24–48 hrs before labor. ●​ GI changes: Nausea, vomiting, diarrhea may occur. ●​ Rupture of membranes (ROM): May happen before or during labor; increases infection risk if >24 hrs before delivery. 3. Maternal Assessment Before/During Labor ●​ History: ○​ Obstetric hx (GTPAL, previous labor complications, C-section, preterm birth). ○​ Medical hx (HTN, diabetes, cardiac disease, infections). ○​ Prenatal labs (blood type, Rh, GBS, HIV, hepatitis B, rubella status). ●​ High-Risk Screening: ○​ Preeclampsia, gestational diabetes, placenta previa, placental abruption, multiples, advanced maternal age. ●​ Physical Factors: ○​ Pelvis adequacy, cervix dilation/effacement, fetal presentation/position. ●​ Psychological Factors: ○​ Anxiety, coping mechanisms, childbirth education, previous trauma. ●​ Social/Cultural Factors: ○​ Support system, birth plan, cultural beliefs/practices about birth, language needs. 4. Cardinal Movements of Labor (Mechanisms of Birth) The baby must maneuver through the pelvis by: 1.​ 2.​ 3.​ 4.​ 5.​ 6.​ 7.​ Engagement – head passes pelvic inlet (0 station). Descent – downward movement of fetus. Flexion – chin to chest, smallest diameter presents. Internal rotation – occiput rotates anteriorly to align with maternal pelvis. Extension – head extends as it passes under pubic symphysis. External rotation (restitution) – head rotates to align with shoulders. Expulsion – anterior then posterior shoulder, followed by body, delivered. 5. Maternal & Fetal Responses to Labor ●​ Maternal: ○​ ↑ HR, cardiac output, BP during contractions. ○​ ↑ WBC count. ○​ ↑ Respiration rate. ○​ ↓ GI motility → nausea, vomiting. ○​ Pain, anxiety, exhaustion. ●​ Fetal: ○​ Periodic FHR accelerations & decelerations (depending on labor phase). ○​ Fetal lung fluid absorption. ○​ Temporary oxygen decreases during contractions, usually tolerated if healthy. 6. Stages of Labor & Critical Events 1.​ First Stage: Onset → full dilation (10 cm). ○​ Latent: 0–3 cm (mild contractions). ○​ Active: 4–7 cm (stronger contractions). ○​ Transition: 8–10 cm (intense contractions, N/V, irritability). 2.​ Second Stage: Full dilation → birth of baby. ○​ Strong contractions, mother actively pushes. 3.​ Third Stage: Birth of baby → delivery of placenta. ○​ Placenta is usually expelled within 5–30 min. 4.​ Fourth Stage: 1–4 hrs postpartum. ○​ Maternal stabilization; monitor VS, bleeding, fundus firmness, bladder. 7. Normal Physiologic/Psychological Changes in Each Stage ●​ First Stage: ○​ Excitement, talkative, coping strategies used. ○​ Contractions increase in frequency/intensity. ●​ Second Stage: ○​ Urge to push, increased pressure. ○​ Relief after birth. ●​ Third Stage: ○​ Uterus contracts firmly. ○​ Joy, bonding, relief. ●​ Fourth Stage: ○​ Maternal chills, hunger, thirst. ○​ Emotional responses (excitement, fatigue, possible tearfulness). 8. Fetal Heart Rate Patterns ●​ Reassuring: ○​ Baseline 110–160 bpm. ○​ Moderate variability (6–25 bpm). ○​ Accelerations present. ●​ Non-Reassuring (Abnormal): ○​ Bradycardia <110 bpm or tachycardia >160 bpm. ○​ Minimal/absent variability. ○​ Repetitive late decelerations. ○​ Variable decelerations that persist. ●​ Nursing Interventions: ○​ Reposition mother (L side). ○​ O₂ 8–10 L via mask. ○​ IV fluids. ○​ Stop oxytocin. ○​ Notify the provider. 9. Nursing Responsibilities: Safe Medication Use in Labor ●​ Oxytocin (Pitocin): ○​ Administer via IV pump. ○​ Monitor FHR and contraction pattern q15 min. ○​ Stop if hyperstimulation (contractions <2 min apart, >90 sec, or late decels). ●​ Analgesia (opioids): ○​ Given during active labor, not transition. ○​ Monitor for maternal respiratory depression, neonatal depression. ○​ Have naloxone available. ●​ Regional anesthesia (epidural): ○​ Preload with IV fluids to prevent hypotension. ○​ Monitor BP, FHR. ○​ Watch for urinary retention. ●​ General anesthesia: ○​ Emergency C-sections only. ○​ Monitor airway, maternal/fetal depression. Week 2 Summary Notes: 1. Four Risk Factors Associated with Dystocia Dystocia is abnormal or difficult labor, often due to problems with one or more of the “4 Ps”: Powers, Passenger, Passageway, or Psyche. Risk factors include: 1.​ 2.​ 3.​ 4.​ Advanced maternal age – Less effective uterine contractions and increased risk of complications. Obesity – Associated with prolonged labor and increased risk of cesarean delivery. Abnormal fetal presentation or position – Breech, occiput posterior, or transverse lie. Uterine abnormalities or fibroids – Can impede fetal descent or effective contractions. 2. Four Major Abnormalities in Dysfunctional Labor Patterns Abnormality Description Example Hypotonic uterine dysfunction Contractions are too weak or Contractions <2 in 10 minutes; infrequent after labor is established minimal cervical change Hypertonic uterine dysfunction Ineffective, frequent contractions with high resting tone, often in latent phase Painful, frequent contractions with little progress Prolonged latent phase Latent phase >20 hrs in nullipara or >14 hrs in multipara Cervix dilates <4 cm after hours of regular contractions Arrest disorders No cervical dilation or descent of the fetus despite adequate contractions Arrest of dilation at 6 cm for >4 hrs with ruptured membranes 3. Nursing Management for Dysfunctional Labor (4 Ps) ●​ Powers (contractions): ○​ Monitor contraction pattern ○​ Administer oxytocin as ordered ○​ Provide rest and hydration if hypertonic pattern ●​ Passenger (fetal position/size): ○​ Perform Leopold’s maneuvers ○​ Encourage position changes to facilitate rotation ○​ Prepare for assisted delivery or cesarean if macrosomia or malpresentation ●​ Passageway (pelvis/soft tissues): ○​ Evaluate pelvic adequacy ○​ Monitor for signs of obstruction (caput, molding, slow descent) ●​ Psyche (emotional state): ○​ Provide emotional support and information ○​ Encourage relaxation techniques ○​ Offer pharmacologic pain relief if needed 4. Plan of Care for Specific Obstetric Conditions a. Preterm Labor ●​ ●​ ●​ ●​ Monitor uterine activity and fetal well-being Administer tocolytics (e.g., nifedipine, indomethacin) Give corticosteroids (e.g., betamethasone) for fetal lung maturity Provide emotional support and education b. Abruptio Placenta ●​ ●​ ●​ ●​ Monitor for signs of shock and fetal distress Initiate IV fluids and blood products Prepare for emergency delivery (often cesarean) Monitor closely postpartum for hemorrhage c. Prolapsed Cord ●​ ●​ ●​ ●​ Position in knee-chest or Trendelenburg Manually lift presenting part off the cord Administer oxygen, prepare for emergency cesarean Avoid handling the cord directly d. Shoulder Dystocia ●​ ●​ ●​ ●​ Call for help immediately Perform McRoberts maneuver and apply suprapubic pressure Do not apply fundal pressure Document time and interventions accurately e. Placenta Previa ●​ ●​ ●​ ●​ Monitor for painless vaginal bleeding Avoid vaginal exams Prepare for cesarean if complete previa Monitor fetal heart rate and maternal vitals 5. Nursing Assessment and Management for Prolonged Pregnancy ●​ Assessment: ○​ Evaluate fetal well-being via NST and BPP ○​ Monitor amniotic fluid volume ○​ Assess for signs of fetal distress or decreased movement ●​ Management: ○​ Induction of labor if indicated ○​ Frequent monitoring during labor ○​ Prepare for potential complications (e.g., meconium aspiration) 6. Four Obstetric Emergencies and Management Emergency Management Uterine rupture Emergency cesarean, monitor for shock, blood replacement Amniotic fluid embolism Call code, administer oxygen, CPR, prepare for ICU Cord prolapse Elevate presenting part, emergency cesarean, maternal positioning Shoulder dystocia McRoberts maneuver, suprapubic pressure, avoid fundal pressure 7. Compare & Contrast: Induction/Augmentation vs Forceps/Vacuum Aspect Induction/Augmentation Forceps/Vacuum Delivery Purpose Start or strengthen labor Assist with delivery of head Common Interventions Oxytocin, cervical ripening Episiotomy, traction Risks Uterine hyperstimulation, fetal distress Trauma to mother/fetus Nursing Role Monitor FHR/contractions, support Assist with positioning, support, monitor newborn 8. Plan of Care for Cesarean Birth Preoperative: ●​ ●​ ●​ ●​ Informed consent NPO status IV access and labs Fetal monitoring Intraoperative: ●​ Support person present ●​ Monitor vitals, fetal heart rate ●​ Assist with anesthesia Postoperative: ●​ ●​ ●​ ●​ Pain management Monitor for bleeding/infection Encourage bonding and breastfeeding Promote early ambulation 9. Key Areas for VBAC Care ●​ ●​ ●​ ●​ ●​ Informed consent: Discuss benefits and risks Continuous fetal monitoring: Early detection of uterine rupture Avoid routine induction (unless medically necessary) Immediate access to emergency cesarean if needed Support and reassurance throughout labor