Normal Antepartum

Pregnancy and Trimester Pregnancy: period between conception through complete birth of the products of
conception
Divided into three trimesters:
 1st Trimester: 1-12 weeks
 2nd Trimester: 12-24 weeks
 3rd Trimester: 24-40 weeks
We don’t talk in months – we talk in weeks/trimesters
**Cannot induce labor until 39 weeks

The nurse must be aware of:

 Physical, emotional, and physiological changes
 Discomforts that accompany each trimester
 Danger or warning signs that need medical referral
Key Words Gestation: in mammals, the length of time from conception to birth; the average
gestation time is a species-specific trait; in humans, the average length, as calculated
from the first day of the last normal menstrual period, is 280 days, with a normal range
of 259-287 days; infants born prior to the 37 th week are considered premature and those
born after the 41st week, postmature

Term: 39-40 weeks – normal duration of pregnancy

Preterm: any labor 38 weeks or less
Post-term: after 42 weeks

Antepartum: from conception to the onset of labor

Intrapartum: during labor and delivery and delivering of the placenta
Postpartum: after the delivery

Gravida: the number of times the woman has been pregnant

Nulligravida: woman who has never been pregnant
Primigravida: woman who is pregnant for the first time
Multigravida: woman who has been pregnant multiple times

Abortion: before the end of 20 weeks (baby is less than 500g)

Stillbirth: birth of a dead fetus after 20 weeks

Gravida and Parity  Gravida refers to the number of times a woman has been pregnant
o “How many times have you been pregnant?” – includes living and
aborted pregnancies
 Para refers to the number of births 20 or more weeks of gestation
 FPAL/TPAL [full-term (39 weeks)/term, pre-term (38 weeks), abortion (20
weeks), and living]
o How many of each did the patient have?
o Determines the level of risk the patient is – allows for reference to
appropriate doctors/facilities
Hospitals:
Level 3: take care of all babies (including babies less than 1000g)
Level 2: only take care of babies over 1000g
DISCLAIMER: This document was compiled utilizing the note-takers’ interpretations of the lectures. It is up to the reader
to verify that the information provided in this document is accurate.
- LL
 Level 1: only take care of normal babies
Maternal Nutrition  A pregnant woman needs an additional 300 kcal/day
Basic Four Food Groups  Protein
 Carbohydrate
 Dairy
 Fruit and vegetables

Education
 Prenatal vitamins – high levels of folic acid, calcium and iron; take at night before
bed – prevents it from being thrown back up
o Folic acid – 400 mcg/day
 Prevents spina bifida
o Calcium – 1000 mg/day

Iron Deficiency Anemia

 RDA for iron is 27 mg/dL
 Iron supplements must be given to most women (ferrous sulfate or ferrous
sequels)
 Take with orange juice
 Normal Value: Hct = 37-47% Hemoglobin = 12-16
 What are some food sources of iron?
o Kale, liver, red beans, red meats, lentils, anything green
o Understand the patient’s culture and what that indicates for their diet
 PICA: eating substances that have no nutritional value
o Usually occurs because of anemia
o The substances are toxic to the fetus – need to fix this issue
o People who are anemic chew on ice
o Fix anemia and remove the substance they’re chewing on
Weight Gain in Pregnancy  Normal weight gain based on BMI is 25-35 lbs.
 If the woman is overweight before pregnancy:
o Gain only 15-25 lbs. during pregnancy
 If the woman is underweight before pregnancy:
o Gain 28-40 lbs. during pregnancy
***should consider exercising and being on folic acid prior to pregnancy if planning to
become pregnant
Prenatal Care – Normal  The goal of prenatal care is to monitor the progress of a pregnancy and to
identify potential problems
o Weeks 4-28: 1 visit per month (every 4 weeks)
o Weeks 28-36: 2 visits per month (every 2-3 weeks)
 Urine, weight, vaginal exams begin at 36 weeks
o Weeks 36-birth: 1 visit per week
Hormones in Pregnancy  Progesterone
 Estrogen
 HCG (human chorionic gonadotropin): elevated during pregnancy; this is what
pregnancy tests detect
 HPL (human placental lactogen)
 Relaxin: sometimes leads to breakage of symphysis pubis muscle; reason for
change in gait
DISCLAIMER: This document was compiled utilizing the note-takers’ interpretations of the lectures. It is up to the reader
to verify that the information provided in this document is accurate.
- LL

Physiologic Changes Cardiovascular System:
*Everything except for GI
increases
 Prostaglandins
 Physiologic anemia: normal drop in H&H during 2 nd trimester
o Occurs because fluids are increasing quicker than the proteins
(hemoglobin)
o Volume is increased  drop in Hct
o Should go back to normal by the third trimester
 Supine hypotension/venocaval syndrome/aortocaval compression
o Women should sleep on their left side (preferably) – NOT on their back
o Tip: answer is always LEFT side
 Increased cardiac load and pulse
 Blood pressure decreases during second trimester
 Decreased blood flow causes edema and varicosities
o Swelling and varicose veins

Respiratory System:
 Breathing changes from abdominal to thoracic
 Hyperventilation
o History of asthma – hyperventilation is worse
 Shortness of breath
 Nasal stuffiness and epistaxis (nosebleed)

Renal System:
 Bladder – urinary frequency
o Determine if it’s normal or UTI
 Increased risk for UTIs – don’t always fully empty urethra when
urinating
 Contractions may be caused by UTI or dehydration
 Give antibiotics
 Ureter: urinary stasis and pyelonephritis ( UTI)
 Urethra: poor emptying
 Glomerular filtration rate increases

Gastrointestinal System:
 Heartburn and acid reflux
 Constipation and flatulence
 Gum tissue softened and bleeds
 Nausea and vomiting/morning sickness
o During the first trimester, it is normal to have morning sickness –
afterwards, there’s a problem
o Tell patient not to keep her stomach empty
 Hyperptyalism (too much saliva): goes away when pregnancy is over

Integumentary System:
 Chloasma/melisma: large brown patches on the skin, especially on the face
 Linea negra: black line that forms along the midline of the abdomen
 Striae gravidarum (stretch marks)

DISCLAIMER: This document was compiled utilizing the note-takers’ interpretations of the lectures. It is up to the reader
to verify that the information provided in this document is accurate.
- LL
 Musculoskeletal System:
 Relaxation of pelvis joints  waddling gait
o Caused by relaxin
 Changed center of gravity
 Lordosis
 Diastasis recti
o 4-6 weeks after birth, workout core to close-up diastasis rectus
Postural changes during pregnancy:
20 weeks: the top of fundus can be palpated as firm at the umbilicus
By week 40, the belly drops (getting ready for birth)

Endocrine System:
 Thyroid: enlargement causes increased BMI
 Parathyroid: allows for better use of calcium and vitamin D
 Pancreas: in the first trimester, there is decreased insulin production that allows
for more glucose availability for fetal growth
o If uncontrolled, baby comes out really big; need to control their sugars
o Gestational diabetes – test for 24-28 weeks
o Strict diet and insulin
 Pituitary: produce hormones that support pregnancy such as prolactin, oxytocin,
and vasopressin
o Normally, brain sends oxytocin to the uterus to contract when the baby
suckles for the first time  birth of the placenta
 Adrenal: increased glandular activity

Uterus:
 Increases in size
 Lightening: the descent of the presenting part of the fetus into the pelvis; this
often occurs 2-3 weeks before the first stage of labor begins; it may not occur in
multiparas until the active labor begins
 Hegar’s Sign: softening of the lower uterine segment upon palpation
 Braxton Hicks Contractions: false labor; contractions aren’t causing any cervical
changes; problem occurs when cervical changes happen; sometimes goes away
with contractions

Cervical:
 Goodell’s Sign: softening of the cervix; probable sign of pregnancy
 Operculum/Mucus Plug: created in the cervix during pregnancy; probable sign
of pregnancy

Vaginal:
 Chadwick’s Sign: blue discoloration of cervix; probable sign of pregnancy
 Vaginal secretions are increased (leukorrhea)

Ovaries:
 Ovum production ceases
 Corpus luteum persists and secretes hormones until weeks 6-8

DISCLAIMER: This document was compiled utilizing the note-takers’ interpretations of the lectures. It is up to the reader
to verify that the information provided in this document is accurate.
- LL
 Breasts:
Psychological Tasks
Signs of Pregnancy
First Trimester
Discomforts
Second and Third
Trimester Discomforts
DISCLAIMER: This document was compiled utilizing the note-takers’ interpretations of the lectures. It is up to the reader
to verify that the information provided in this document is accurate.
- LL
 Fullness, tingling, or tenderness – usually first sign of pregnancy
 Darkened areola
 Prominent blue veins may be seen
 Secretion of colostrum by last trimester
 Acceptance of the pregnancy
o Often accompanied by feelings of ambivalence
 Acceptance of baby
o Feelings such as introversion
o Emotionally labile
o Couvade syndrome: when the dad gets the symptoms of pregnancy
 Preparation for baby – end of pregnancy (nesting)
 Presumptive (Subjective): what the patient is telling the doctor they’re
experiencing
o Amenorrhea
o N/V
o Excessive fatigue
o Breast changes
o Quickening: movement
o Urinary frequency
 Probable (Objective): what the doctor will see
o Pelvic Organ Changes: Goodell’s/Hegar’s/Chadwick’s signs
o Enlarged abdomen
o Uterine soufflé (“shhh” sound inside of belly; same heart rate as the
mother)
o Changes in pigmentation
o Ballottement
o Pregnancy tests
 Positive (Diagnostic)
o Fetal heart tones
o Fetal movement
o Ultrasound
 N/V (morning sickness)
 Fatigue
 Urinary frequency
 Breast tenderness
 Increased vaginal discharge
 Nasal stuffiness/epistaxis
 Hyperptyalism
 Backache – careful, could be back labor
 Shortness of breath
 Muscle cramps
 Carpel tunnel syndrome
o Due to relaxin
 Constipation
 Varicosities and hemorrhoids

Pregnancy Warning Signs
Things to Avoid During
Pregancy
**If patient wants to stimulate labor – tell them to have sex and go for a walk
The Obstetrical History
DISCLAIMER: This document was compiled utilizing the note-takers’ interpretations of the lectures. It is up to the reader
to verify that the information provided in this document is accurate.
- LL
 Heartburn
 Edema – a little is okay, a lot may be a problem
 Braxton Hicks contractions
 Insomnia
 Hypotension (don’t want too low)
 Palpitations
 Headaches – all the time is not good, could be related to blood pressure issues
 Vaginal bleeding
 Increased/decreased fetal movement
 Headaches or blurred vision
 Swelling of hands and/or feet
 Burning on urination (UTI)
 Abdominal or chest pains
 Chills or fever (infection)
 Persistent vomiting (hyperemesis – shouldn’t occur after first trimester)
o Alters electrolyte balance (particularly potassium)
 Increase in fluid from the vagina (STD)
 Alcohol – as healthcare professionals, NO amount of alcohol should be
permitted/suggested
 Smoking
 Marijuana
 Drugs and herbs
o Be very careful
o Ginger causes contractions
 Abuse
o Domestic violence occurs most frequently during pregnancy – the
woman is very vulnerable
o Rape – a 15/16 year-old girl with a 20 year old guy is considered rape;
17-18 years old gets a little fuzzy – ask social worker if unsure of what to
do
o Interview patient one-on-one with sensitive topics (abortion,
miscarriages, adoptions)
o Any abuse signs need to be reported to social worker on case and 1-800
number
 Hazardous substances
 Cleaning cat litter can cause toxoplasmosis
 Eating raw meat
 Mercury
 Stress
 Rodents
 Live vaccines
o Flu shot through nose is a live vaccine – the shot itself is okay
 Heat (environmental, hot tubs, saunas)
 X-rays – can only be done after 2nd trimesters with protector
 Current pregnancy
o Nagele’s Rule – only applies if woman has a 28-day cycle
 Method of determining estimated date of birth
 o Fundal height measurement
 At 20 weeks, the fundal height is at the umbilicus
 Around 40 weeks, the uterus is wider and lower
o Presence of discomforts
o Attitude towards pregnancy
 Past obstetrical history
o Gravida/Parity – FPAL
o Pregnancy history
o Perinatal status
 Gynecology History
o Last pap
o Prior infections
o Previous surgery
o Menarch
o Contraception
o Sexual history
 Current and past medical history
 Personal history
 Family medical history
 Partner’s medical and personal history

Naegele’s Rule:
 Based on 280-day pregnancy
o 28-day cycle
o 40 weeks (38-42 is normal)
o Minus three months and plus 7 days to first day of the last menstrual
period (give or take 2 days)
Maternal Screening Blood Studies:
 Blood type
o Rh-negative: need to be given at 28 weeks, after any invasive
procedures, and again if the baby is Rh-positive; protects any
subsequent pregnancies
 If baby is Rh-positive, the mother will form antibodies against it
 Rhogam is a blood product that creates a barrier that doesn’t
allow for the antibodies to cross the placenta barrier; women
who don’t get it are at risk of having miscarriages when they get
pregnant again (because the body has developed antibodies)
o CBC
o VDRL – test for syphilis
o AFP (alpha fetal protein) determines if the baby has any genetic
abnormalities
 Done at 15-20 weeks
 If positive, need to do an amniocentesis (diagnostic)
o MSAFP
o HIV
 Not obligated to share partners’ names to report
 Test all women for HIV – if positive, can start AZT treatment; the
earlier it is started, the better chance the HIV will not be passed
DISCLAIMER: This document was compiled utilizing the note-takers’ interpretations of the lectures. It is up to the reader
to verify that the information provided in this document is accurate.
- LL
 on to the baby
 Patient has the right to refuse – asked antepartum and during
labor
 If positive during antepartum – given AZT orally ASAP
and during labor
 If positive during labor (buccal testing) – AZT started
during labor
o Hepatitis and Rubella
 Live vaccine is given postpartum and the patient is advised not
to get pregnant for 3 months
o Sickle Cell
o TORCH
o Glucose Testing: 24-28 weeks; determines if mom’s diabetic during
pregnancy
 Urinalysis and pap smear
 Cultures – GBS (Group Beta Strep) 35-37 weeks
o Swab between anus and vagina
o If positive, give antibiotics during labor – if baby goes through canal with
positive GBS  increased risk of respiratory issues
 TB – PPD
 Ultrasound – AFI (amniotic fluid index), placenta
TORCH Toxoplasmosis
Other infections
Rubella
Cytomegalovirus (CMV)
Herpes Simples
**If there is a herpes lesion – cannot deliver vaginally; have to do C-section (textbook –
in real life, C-section will always be done)
RH Incompatibility  Antigen-antibody reaction
 Mother is RH-negative and baby is Rh-positive
 Sensitization-maternal body forms antibodies when baby blood is mixed
 Screening
o Direct coombs test
o Indirect coombs test
 Prevention
o Good prenatal care
o RhoGAM (also needs to be given after an abortion – within 72 hours)
Adolescent Pregnancy  Nursing Management
o Confidentiality – once a girl under legal age is pregnant, she is
emancipated (does not need to call parents; applies to contraception)
o Develop a trusting relationship
o Promote self-esteem and physical health
o Education – regular prenatal visits, STDs, substance abuse, signs of
complications
 Risk Factors
o Preterm labor
o Cephalopelvic disproportion (CPD)
o Preeclampsia (HTN issues are increased)
DISCLAIMER: This document was compiled utilizing the note-takers’ interpretations of the lectures. It is up to the reader
to verify that the information provided in this document is accurate.
- LL
 o Iron deficiency anemia
o Low birth weight

DISCLAIMER: This document was compiled utilizing the note-takers’ interpretations of the lectures. It is up to the reader
to verify that the information provided in this document is accurate.
- LL