The Pregnant Woman Chapter 29 Elsevier items and

The Pregnant Woman Chapter 29 Elsevier items and

The Pregnant Woman Chapter 29 Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 29: The Pregnant Woman Structure and Function Pregnancy and the endocrine placenta First day of menses is day 1 of menstrual cycle For first 14 days of cycle, one or more follicles in ovary develops and matures One follicle grows faster than others, and on day 14 of cycle this dominant follicle ruptures and ovulation occurs If ovum meets viable sperm, fertilization occurs somewhere in oviduct (fallopian tube) Remaining cells in follicle form corpus luteum, or yellow body, which makes important hormones

Chief among these is progesterone, which prevents sloughing of endometrial wall, ensuring a rich vascular network into which fertilized ovum will implant Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-2 Chapter 29: The Pregnant Woman Structure and Function (cont.) Pregnancy and the endocrine placenta (cont.) Blastocyst, or fertilized ovum, continues to divide, differentiate, and grow rapidly Specialized cells in blastocyst produce human chorionic gonadotropin (hCG), which stimulates corpus luteum to continue making progesterone Between days 20 and 24, blastocyst implants into wall of uterus, and may cause small amount of vaginal bleeding

Specialized layer of cells around blastocyst becomes placenta Placenta starts to produce progesterone to support pregnancy at 7 weeks and takes over this function completely from corpus luteum at about 10 weeks Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-3 Chapter 29: The Pregnant Woman Structure and Function (cont.) Pregnancy and the endocrine placenta (cont.) Placenta functions as an endocrine organ and produces several hormones These hormones help growth and maintenance of fetus, and direct changes in womans body to prepare for birth and lactation The hCG stimulates rise in progesterone during pregnancy

Progesterone maintains endometrium around fetus, increases alveoli in breast, and keeps uterus in a quiescent state Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-4 Chapter 29: The Pregnant Woman Structure and Function (cont.) Pregnancy and the endocrine placenta (cont.) Estrogen stimulates duct formation in breast Also increases weight of uterus and increases certain receptors in uterus that are important at birth

Average length of pregnancy is 280 days from first day of last menstrual period (LMP), which is equal to: 40 weeks 10 lunar months 9 calendar months Note that this includes 2 weeks when follicle was maturing but before conception actually occurred Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-5 Chapter 29: The Pregnant Woman Structure and Function (cont.) Pregnancy and the endocrine placenta (cont.)

Pregnancy is divided into three trimesters First trimester is the first 12 weeks Second trimester is from 13 to 27 weeks Third trimester is from 28 weeks to delivery Woman pregnant for first time called primigravida After she delivers, she is called a primipara Multigravida: pregnant woman who has previously carried a fetus to the point of viability Any pregnant woman might be called a gravida Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-6 Chapter 29: The Pregnant Woman Structure and Function (cont.) Pregnancy and the endocrine placenta (cont.)

Commonly used terminology is G, gravida P, para T, term PT, preterm deliveries A, abortionincluding missed, therapeutic, or voluntary L, living children It may be written as G5 T3 PT0 A2 L3 Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-7 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy Pregnancy is diagnosed by three types of signs and symptoms Presumptive signs are those woman experiences, such as amenorrhea, breast tenderness, nausea, fatigue, and

increased urinary frequency Probable signs are those detected by examiner, such as an enlarged uterus Positive signs of pregnancy are those that are direct evidence of fetus, such as auscultation of fetal heart tones (FHTs) or positive cardiac activity on ultrasound (US) Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-8 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: first trimester Conception occurs on approximately 14th day of menstrual cycle Blastocyst, which is the developing fertilized ovum,

implants in uterus 6 to 10 days after conception, sometimes accompanied by small amount of painless bleeding Serum hCG becomes positive after implantation when it is first detectable in maternal serum at approximately 8 to 11 days after conception Following menstrual period is missed Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-9 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: first trimester (cont.) At time of missed menses, hCG can be detected in urine Breast tingling and tenderness begin as rising estrogen

levels promote mammary growth and development of ductal system; progesterone stimulates alveolar system as well as the mammary growth Chorionic somatomammotropin (also called human placental lactogen or hPL), which is also produced by placenta, stimulates breast growth and exerts lactogenic properties Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-10 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: first trimester (cont.) More than half of all pregnant women have nausea and vomiting Cause is unclear but may involve hormonal changes of

pregnancy, low blood sugar, gastric overloading, slowed peristalsis, an enlarging uterus, and emotional factors Fatigue is common and may be related to initial fall in metabolic rate that occurs in early pregnancy Estrogen, and possibly progesterone, cause hypertrophy of uterine muscle cells and uterine blood vessels, and lymphatics enlarge Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-11 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: first trimester (cont.) Uterus becomes globular in shape, softens, and flexes easily over cervix (Hegars sign) This causes compression of bladder, which results in

urinary frequency Increased vascularity, congestion, and edema cause cervix to soften (Goodells sign) and become bluish purple (Chadwicks sign) Early first-trimester blood pressures (BPs) reflect prepregnancy values Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-12 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: first trimester (cont.) In 7th gestational week BP begins to drop until midpregnancy as a result of

falling peripheral vascular resistance Systemic vascular resistance decreases from vasodilatory effect of progesterone and prostaglandins At end of 9 weeks, embryonic period ends and fetal period begins, at which time major structures are present FHTs can be heard by Doppler US between 9 and 12 weeks Uterus may be palpated at about 12 weeks Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-13 Chapter 29: The Pregnant Woman Height of Fundus at Weeks of Gestation Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-14

Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: second trimester By weeks 12 to 16 Nausea, vomiting, fatigue, and urinary frequency of first trimester improve 18 to 20 weeks woman recognizes fetal movement (quickening) As breast enlargement continues, the veins of breast enlarge and are more visible through skin of lightly pigmented women Colostrum, precursor of milk, may be expressed from nipples Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-15

Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: second trimester (cont.) Colostrum Yellow in color, contains more minerals and protein but less sugar and fat than mature milk Also contains antibodies, which are protective for newborn during its first days of life until mature milk production begins Areola and nipples darken, it is thought, because estrogen and progesterone have a melanocyte-stimulating effect, and melanocyte-stimulating hormone levels escalate from second month of pregnancy until delivery Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-16

Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: second trimester (cont.) For same reason, midline of abdominal skin becomes pigmented, called linea nigra You may note striae gravidarum (stretch marks) on breast, abdomen, and areas of weight gain Systolic BP may be 2 to 8 mm Hg lower and diastolic BP 5 to 15 mm Hg lower than prepregnancy levels Drop most pronounced at 20 weeks and may cause symptoms of dizziness and faintness, particularly after rising quickly Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-17 Chapter 29: The Pregnant Woman

Structure and Function (cont.) Changes during normal pregnancy: second trimester (cont.) Stomach displacement from enlarging uterus and altered esophageal sphincter and gastric tone as a result of progesterone predispose woman to heartburn Intestines are also displaced by growing uterus, and tone and motility are decreased because of action of progesterone, often causing constipation Gallbladder, possibly resulting from action of progesterone on its smooth muscle, empties sluggishly and may become distended Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-18 Chapter 29: The Pregnant Woman Structure and Function (cont.)

Changes during normal pregnancy: second trimester (cont.) Stasis of bile, together with increased cholesterol saturation of pregnancy, predisposes some women to gallstone formation Progesterone and, to lesser degree, estrogen cause increased respiratory effort during pregnancy by increasing tidal volume Hemoglobin, and therefore oxygen-carrying capacity, also increases Increased tidal volume causes slight drop in partial pressure of arterial carbon dioxide (PaCO2), causing woman to occasionally have dyspnea Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-19 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: second

trimester (cont.) Cutaneous blood flow augmented during pregnancy caused by decreased vascular resistance, presumably helping to dissipate heat generated by increased metabolism Gums may hypertrophy and bleed easily; condition is called gingivitis or epulis of pregnancy For same reason, nosebleeds may occur more frequently Pregnant women with periodontal disease, a chronic local oral infection, are at risk for preterm delivery Untreated, this may lead to systemic infection that affects maternal levels of prostaglandin E2 (PGE-2) Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-20 Chapter 29: The Pregnant Woman Structure and Function (cont.)

Changes during normal pregnancy: second trimester (cont.) 17 to 19 weeks FHTs are audible by fetoscope, as opposed to Doppler imaging Fetal outline palpable through abdominal wall at approximately 20 weeks Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-21 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: third trimester Blood volume, which increased rapidly during second

trimester, peaks in middle of third trimester at approximately 45% greater than prepregnancy level and plateaus thereafter This volume is greater in multiple gestations Erythrocyte mass increases by 20% to 30%, caused by an increase in erythropoiesis, mediated by progesterone, estrogen, and placental chorionic somatomammotropin However, plasma volume increases slightly more, causing slight hemodilution and small drop in hematocrit Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-22 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: third trimester (cont.) BP slowly rises again to approximately prepregnant level Uterine enlargement causes diaphragm to rise and

shape of rib cage to widen at base Decreased space for lung expansion may cause a sense of shortness of breath Rising diaphragm displaces heart up and to left Cardiac output, stroke volume, and force of contraction are increased Pulse rate rises 15 to 20 beats per minute Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-23 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: third trimester (cont.) Because of increase in blood volume, a functional

systolic murmur, grade ii/iv or less, can be heard in more than 95% of pregnant women (Creasy and Resnick, 2004) Edema of lower extremities may occur as result of enlarging fetus impeding venous return, and from lower colloid osmotic pressure; worsens with dependency, such as prolonged standing Varicosities, which have a familial tendency, may form or enlarge from progesterone-induced vascular relaxation Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-24 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: third trimester (cont.) Also causing varicosities is engorgement caused by weight of full uterus compressing inferior vena cava and vessels of pelvic area, resulting in venous congestion in

legs, vulva, and rectum Hemorrhoids are varicosities of rectum that are worsened by constipation, which occurs from relaxation of large bowel by progesterone Progressive lordosis, an inward curvature of lumbar spine, occurs to compensate for shifting center of balance caused by anteriorly enlarging uterus, predisposing woman to backaches Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-25 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: third trimester (cont.) Slumping of shoulders and anterior flexion of neck from increasing weight of breasts may cause aching and numbness of arms and hands as a result of compression of median and ulnar nerves in arm, commonly referred to as carpal tunnel syndrome

Approximately 2 weeks before going into labor, primigravida experiences engagement, also called lightening or dropping, when fetal head moves down into pelvis Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-26 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: third trimester (cont.) Symptoms include lower-appearing and smaller-measuring fundus, urinary frequency, increased vaginal secretions from increased pelvic congestion, and increased lung capacity In multigravida, fetus may move down at any time in late pregnancy or often not until labor Cervix, in preparation for labor, begins to thin (efface) and open (dilate)

Thick mucous plug, formed in cervix as a mechanical barrier during pregnancy, is expelled at variable times before or during labor Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-27 Chapter 29: The Pregnant Woman Structure and Function (cont.) Changes during normal pregnancy: third trimester (cont.) Between 37 and 42 weeks Pregnancy is considered term After 42 weeks, pregnancy is considered postdated Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-28

Chapter 29: The Pregnant Woman Structure and Function (cont.) Determining weeks of gestation Expected date of delivery, or EDD 280 days from first day of LMP, may be calculated by using Ngeles rule Determine first day of last normal menstrual period Using first day of LMP, add 7 days and subtract 3 months This is the EDD that can then be used with a pregnancy wheel, on which EDD arrow is set, and then present date will be pointing to present weeks gestation Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-29 Chapter 29: The Pregnant Woman

Structure and Function (cont.) Determining weeks of gestation (cont.) Expected date of delivery, or EDD (cont.) Number of weeks of gestation also can be estimated by Physical examination (bimanual and pelvic exam) Measurement of maternal serum hCG Ultrasound Signs such as first perceived fetal movement Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-30 Chapter 29: The Pregnant Woman

Structure and Function (cont.) Weight gain in pregnancy Amount of weight gained by term Represents a baby, amniotic fluid, placenta, increased uterine size, increased blood volume, increased extravascular fluid, maternal fat stores, and increased breast size Weight gain during pregnancy reflects both mother and fetus and is approximately 62% water gain, 30% fat gain, and 8% protein Approximately 25% of the total gain is attributed to the fetus, 11% to placenta and amniotic fluid, and remainder to mother Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-31 Chapter 29: The Pregnant Woman

Structure and Function (cont.) Weight gain in pregnancy (cont.) The American College of Obstetricians and Gynecologists recommends following weight gain during pregnancy 28 to 40 lb for underweight women 25 to 35 lb for normal-weight women 15 to 25 lb for overweight women 35 to 45 lb for twin gestation A healthy outcome may be expected within a great range of weight gain Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-32 Chapter 29: The Pregnant Woman

Structure and Function Developmental Competence Each year in U.S., almost one million teenage women become pregnant 78% are unplanned Many pose serious medical risks for both mother and fetus, such as toxemia, anemia, prematurity, low birth weight infants, prolonged labor, and postpartum complications Some teen pregnancies are planned and due in part to maladaptive attempts to solve social issues within home environment or manipulation of a boyfriend with promise of a prolonged relationship Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-33 Chapter 29: The Pregnant Woman

Structure and Function Developmental Competence (cont.) Each year in the U.S., almost one million teenage women become pregnant (cont.) Either attempt can bring bitterness from family and friends leading to cycle of poor reproductive and social choices It is important for those teens wishing to continue a pregnancy to seek early prenatal care because they are at risk for maternal/fetal morbidity and mortality Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-34 Chapter 29: The Pregnant Woman Structure and Function Developmental Competence

(cont.) Other risks for pregnant adolescents are largely psychosocial This young woman is at risk for downward cycle of poverty beginning with an incomplete education, failure to limit family size, and continuing with failure to establish a vocation and become independent She may be unprepared emotionally to be a mother Her social situation may be stressful She may not have the support of her family, her partner, or his family Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-35 Chapter 29: The Pregnant Woman Structure and Function Developmental Competence

(cont.) Other risks for pregnant adolescent are largely psychosocial (cont.) Medical risks for pregnant adolescent are generally related to poverty, inadequate nutrition, substance abuse, and sometimes sexually transmitted infections (STIs), poor health before pregnancy, and emotional and physical abuse from her partner Adolescents, for social reasons, seek health care later when early prenatal care provides optimal management In developing countries, maternal mortality for pregnant teenagers is major concern because of hypertension, embolism, ectopic pregnancy, and complications from pregnancy termination where abortion is illegal Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-36 Chapter 29: The Pregnant Woman Structure and Function

Developmental Competence (cont.) Fertility Declines with advancing maternal age Due in part to a decrease in number and health of eggs to be ovulated, a decrease in ovulation, endometriosis, and early onset of menopause According to the American Society for Reproductive Medicine there is an unrealistic expectation that medical science can undo effects of aging when women delay childbearing; therefore, more women of advanced maternal age are choosing to use donor eggs from younger women The age of egg is important factor, not age of uterus Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-37

Chapter 29: The Pregnant Woman Structure and Function Developmental Competence (cont.) As we come to end of baby boomers fertility, many women of advanced maternal age (40s and 50s) are choosing to become pregnant with assisted fertility With this comes concern not only for physical and emotional well-being of mother, but of psychological challenges that child growing up with parents of advanced age will face Women age 35 and older experience an increased risk of intrauterine fetal death, pregnancy induced hypertension, gestational diabetes, and delivery by cesarean Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Slide 29-38 Chapter 29: The Pregnant Woman Structure and Function Developmental Competence (cont.) Risk of Down syndrome increases with maternal age 1 in 1,250 at age 25 1 in 1,000 at age 30 1 in 400 at age 35 1 in 100 at age 40 1 in 30 at age 45 Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-39 Chapter 29: The Pregnant Woman

Structure and Function Developmental Competence (cont.) Women age 35 years or older or who have a history of a genetic abnormality are offered genetic counseling, and the options of both prenatal diagnostic screening tests Two prenatal diagnostic options are: Chorionic villi sampling (CVS) performed between gestational weeks 11 and 13 in which small sample of chorionic villi is removed to analyze genetic makeup Amniocentesis, which is performed between gestational weeks 15 and 20 in which a small amount of amniotic fluid is removed to analyze genetic makeup Both associated with small risk of complications and miscarriage Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-40

Chapter 29: The Pregnant Woman Structure and Function Developmental Competence (cont.) Prenatal screening involves a fetal anatomy ultrasound (US) scan and serum screening There are two US scans used in genetic screening Nuchal translucency (NT) done between gestational weeks 11 and 14, which measures a collection of fluid at nape of fetal neck Detailed anatomy scan done between gestational weeks 18 and 20 Some facilities continue to use Integrated Prenatal Risk Profile (IPRP), which uses a first trimester US between 10 and 12 weeks to measure NT and maternal serum analysis and a second maternal serum blood draw in the second trimester; results are only received after second maternal blood draw

Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-41 Chapter 29: The Pregnant Woman Structure and Function Developmental Competence (cont.) There are two US scans used in genetic screening (cont.) Because integrated screen requires a waiting period, the sequential screen was developed Similar to IPRP, except that those whose risk for Down syndrome is increased after first blood draw are given an earlier option for prenatal diagnostic testing Women of advanced maternal age (over 35 years old)

experience increased risk of prenatal and neonatal deaths, pregnancy-induced hypertension, preterm delivery, small for gestational age (SGA), and large for gestational age (LGA) neonates, gestational diabetes, severe preeclampsia, anal sphincter tears, and cesarean deliveries Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-42 Chapter 29: The Pregnant Woman Structure and Function Cultural Competence Over 30 million women worldwide have undergone female genital cutting, or female circumcision Due to large racial demographic in U.S., more with this condition are seen in current clinical setting

These women are at an increased risk of perineal tears, wound infections, separation of episiotomies, postpartum hemorrhage and sepsis Every minute, another woman dies in pregnancy or childbirth leaving children without a mother and families shattered struggling to care for those left behind Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-43 Chapter 29: The Pregnant Woman Structure and Function Cultural Competence (cont.) Over 500,000 women die in childbirth each year According to United Nations Populations Fund,

this number remains globally high in an age where these deaths are preventable 90% of these maternal deaths occur in Africa and Asia, and they occur from severe bleeding, sepsis, eclampsia, obstructed labor, and unsafe abortions Many women who survive pregnancy and childbirth may suffer lifetime of physical and emotional complications such as vaginal or rectal fistula Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-44 Chapter 29: The Pregnant Woman Structure and Function Cultural Competence (cont.) Hispanic population within U.S. between 1990 and 2000 grew by more than 40%

It is projected that between 2000 and 2010 that will increase by another 34% Hispanics had highest birth rate in 2003 with 82.2 births per 1,000 teen females aged 15 to 19 Still there are disparities in adequate access to preventative, prenatal, and dental care with these cultural groups along with Asian/Pacific islander, American Indian, and Alaskan Native populations Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-45 Chapter 29: The Pregnant Woman Structure and Function Cultural Competence (cont.) Pregnancy is not only a medical event, but also one with profound psychological and social meaning for woman and for her family and community All cultures recognize pregnancy as a unique period in a womans life that surrounds special customs and beliefs that have been developed throughout the ages Spiritual practices and beliefs either provide her with or

without support Understanding what role these beliefs and practices play in womans pregnancy helps health care provider to acknowledge cultural differences Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-46 Chapter 29: The Pregnant Woman Structure and Function Cultural Competence (cont.) Pregnancy is intensely personal and involves such charged issues as sexuality, relationships, contraception, nutritional practices, maternal weight gain, and abortion You must be sensitive to these issues

You may begin by inquiring whether woman or her significant others have any special requests This communicates your intention to respect cultural differences and preferences Continuing rapport will help enable woman to bring up issues as they develop A womans resistance to an action or a suggestion by clinician may represent a cultural issue Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-47 Chapter 29: The Pregnant Woman Structure and Function Cultural Competence (cont.) Such issues may also be held differently by woman and one or more of her significant others, and such situations must be handled with care Examples of culturally-charged issues are:

Dietary practices Sexuality during and after pregnancy Preference for gender of care provider Preference for gender of infant Contraceptive usage Use your skill to understand such preferences within a cultural context and accept rather than judge the person Whenever safe and possible, respect such wishes; this enhances success of birth in psychosocial dimensions Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-48 Chapter 29: The Pregnant Woman Subjective Data

Menstrual history Gynecologic history Obstetric history Current pregnancy Medical history Family history Review of systems Nutritional history Environment/hazard Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-49 Chapter 29: The Pregnant Woman Subjective Data (cont.)

Menstrual history When was the first day of your last menstrual period that was normal in timing? Describe premenstrual symptoms, length, amount of flow, cramping. Number of days in cycle? Age at menarche? Gynecologic history Have you ever had surgery of the cervix or uterus? Do you have any known history of or exposure to genital herpes? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Slide 29-50 Chapter 29: The Pregnant Woman Subjective Data (cont.) Gynecologic history (cont.) When your mother was pregnant with you, did she ever take a drug called diethylstilbestrol (DES)? DES was a synthetic nonsteroidal estrogen given to pregnant women between 1948 and 1971 in an attempt to prevent various pregnancy-related complications Pap smears: When was your last one? Any history of abnormal results? If so, when? Have you ever had a colposcopy? Do you have any history of infertility, fibroids, or

uterine abnormalities? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-51 Chapter 29: The Pregnant Woman Subjective Data (cont.) Gynecologic history (cont.) Any history of gonorrhea, chlamydia, syphilis, trichomoniasis, or pelvic inflammatory disease (PID)? Do you or your partner have more than one sexual partner? Were you a preterm infant? Have you had a mammogram, breast biopsy,

breast implants, lumpectomy, or mastectomy? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-52 Chapter 29: The Pregnant Woman Subjective Data (cont.) Obstetric history In earlier pregnancies, did you have any history of hypertension, preeclampsia, eclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, diabetes, hemolytic Streptococcus infection, intrauterine growth restriction, congenital anomalies, premature labor, postpartum hemorrhage, or postpartum depression? How did you experience previous pregnancies and

deliveries? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-53 Chapter 29: The Pregnant Woman Subjective Data (cont.) Obstetric history (cont.) Have you ever had a cesarean section? If so, what was the indication? At how many centimeters of dilation, if any, was the surgery performed? What type of uterine incision was made? (Confirming records of this surgery must be obtained.) Have you ever had a vaginal birth after a cesarean section (VBAC)? How many times have you been pregnant? Number of term or preterm deliveries? Number of spontaneous

miscarriages, elective abortions, or ectopic pregnancies? Any fetal or neonatal deaths? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-54 Chapter 29: The Pregnant Woman Subjective Data (cont.) Obstetric history (cont.) Any history of infertility? Have you used assisted reproductive technology? Any history of preterm labor or preterm rupture of membranes? Have you been told you have cervical insufficiency

or incompetency? Have you had a cervical cerclage placed in previous pregnancies? What were the gestational ages and weights of your infants at birth? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-55 Chapter 29: The Pregnant Woman Subjective Data (cont.) Obstetric history (cont.) Did you breastfeed the previously born infants? How was that experience for you? Any history of mastitis?

Present pregnancy Having calculated current number of weeks of gestation, you can reassess probable accuracy of that date when eliciting the following history What method of contraceptive did you use most recently, and when did you discontinue it? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-56 Chapter 29: The Pregnant Woman Subjective Data (cont.) Present pregnancy

Was the pregnancy planned? How do you feel about it? How does the babys father feel about the pregnancy? How do other family members feel? Have you experienced any vaginal bleeding? When? How much? What color was it? Was it accompanied by any pain? Are you experiencing any nausea or vomiting? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-57 Chapter 29: The Pregnant Woman Subjective Data (cont.) Present pregnancy (cont.)

Have you experienced abdominal pain? When? Where in your abdomen? Was it accompanied by vaginal bleeding? Have you experienced any illnesses since becoming pregnant? Have you had any recent fevers, unexplained rashes, or infections? Have you had any x-rays? Have you taken any medications? Have you used any recreational drugs or alcohol? Do you smoke cigarettes? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-58 Chapter 29: The Pregnant Woman Subjective Data (cont.) Present pregnancy (cont.)

Are you experiencing any visual changes, such as the new onset of blurred vision or spots before your eyes? Are you experiencing any edema? Where and under what circumstances does it occur? Do you have any frequency or burning with urination? Is there any blood in your urine? Do you void in small amounts? Do you have a history of urinary tract infections, pyelonephritis, or kidney stones? Do you have any vaginal burning or itching? Do you have any foul-smelling or colored discharge? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-59 Chapter 29: The Pregnant Woman Subjective Data (cont.)

Present pregnancy (cont.) What date did you first feel the fetus move? How does the fetus move on a daily basis? Do you have cats in the home? Do you plan to breastfeed this infant? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-60 Chapter 29: The Pregnant Woman Subjective Data (cont.) Medical history

Do you have allergies to medications or foods? If so, what type of reaction? Any personal or family history of cancer? Do you have a history of asthma? If yes, have you ever been intubated? Have you ever had German measles (rubella)? Have you ever had chickenpox? Have you had an injury to your back or another weight-bearing part? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-61 Chapter 29: The Pregnant Woman Subjective Data (cont.)

Medical history (cont.) Have you been tested for HIV? When? What was the result? Have you ever had a blood transfusion? Have you used intravenous drugs? Have you had a sexual partner who had any HIV risk factors? Do you smoke cigarettes? How many? For how many years? Have you ever tried to quit? Do you drink any alcohol? How many times per week? Do you use any street drugs? Do you take any prescribed, over-the-counter, or herbal medications? Do you have regular exercise program? What type? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-62

Chapter 29: The Pregnant Woman Subjective Data (cont.) Family history Does anyone in your family have hypertension? Does anyone in your family have diabetes? If so, is it of juvenile or adult onset? Is he or she insulin dependent? Do you have a family history of mental illness? Do you have a family history of kidney disease? Do you have a family history of fraternal twins? Has anyone in your family, or in the family of the babys father, had congenital anomalies? Is your racial descent Mediterranean? Black? Ashkenazi Jewish? Irish?

Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-63 Chapter 29: The Pregnant Woman Subjective Data (cont.) Review of systems What was your weight before pregnancy? Do you wear glasses? When did you last see the dentist? Did you need any dental work? Have you been exposed to tuberculosis (TB) or had a positive PPD or chest x-ray?

Any cardiovascular disease, such as vascular disease, or disease of a heart valve? Any anemia? What kind? When? Was it treated? How? Did it improve? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-64 Chapter 29: The Pregnant Woman Subjective Data (cont.) Review of systems (cont.) Have you had thrombophlebitis, pulmonary embolus (PE), or deep venous thrombosis (DVT)?

Have you had hypertension or kidney disease? Have you any history of hepatitis B or C? Have you any history of thyroid disease? Have you any history of seizures? Have you had any urinary tract infections? Have you had depression or any other mental illness? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-65 Chapter 29: The Pregnant Woman Subjective Data (cont.) Review of systems (cont.) Do you feel safe in your relationship or home environment?

Are you in a relationship with someone who physically or emotionally abuses or threatens you? Has anyone forced you to do sexual activities against your will? Do you have diabetes? Did you have diabetes during a previous pregnancy? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-66 Chapter 29: The Pregnant Woman Subjective Data (cont.) Nutritional history Do you follow a special diet?

Do you have any food intolerance? Do you crave nonfoods such as ice, paint chips, dirt, or clay? Environment/hazards What is your occupation? What are the physical demands of the work? Are you exposed to any strong odors, chemicals, radiation, or other harmful substances? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-67 Chapter 29: The Pregnant Woman Subjective Data (cont.) Environment/hazards (cont.)

Do you consider your food and housing adequate? How do you wear your seat belt when driving? Do you have any other questions or concerns? Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-68 Chapter 29: The Pregnant Woman Objective Data Preparation Initial examination for pregnancy is often first pelvic examination, and many women extremely anxious Alternatively, woman may not know for certain whether she is pregnant, and may be anxious about findings Verbally prepare woman for what will happen during examination before touching her

Save pelvic examination for last, as woman will be more comfortable with your gentle, informing manner Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-69 Chapter 29: The Pregnant Woman Objective Data (cont.) Preparation (cont.) Communicate all findings as you go along to demonstrate respect for her control and responsibility in her own health and her child Ask the woman to empty her bladder before examination, reserving specimen Before examination, ask her to weigh herself on office scale Provide woman with a chaperone, if desired Some clinics require an escort or chaperone during

examinations Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-70 Chapter 29: The Pregnant Woman Objective Data (cont.) Preparation (cont.) Give woman a gown and drape Begin examination with woman sitting on examination table, wearing gown, her lap covered by drape During breast examination, help her to lie down

She remains recumbent for abdominal and extremity examination Use lithotomy position for pelvic examination Help her to a seated position to check her BP Recheck after examination if BP is elevated Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-71 Chapter 29: The Pregnant Woman Objective Data (cont.) Equipment needed

Stethoscope BP cuff Centimeter measuring tape Fetoscope and Doppler sonometer Reflex hammer Urine collection containers Chemostix for checking urine for glucose and protein Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-72 Chapter 29: The Pregnant Woman Objective Data (cont.) General survey Observe womans state of nourishment, and her

grooming, posture, mood, and affect, which reflect her mental state Throughout examination, observe her maturity and ability to attend and learn to plan your teaching of information needed to successfully complete healthy pregnancy Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-73 Chapter 29: The Pregnant Woman Objective Data (cont.) Skin Note any scars, particularly those of previous cesarean delivery Many women have skin changes during pregnancy that may spontaneously resolve after pregnancy, such as acne or skin tags

Vascular spiders may be present on upper body Some women have chloasma, known as mask of pregnancy, which is a butterfly-shaped pigmentation of face Note presence of linea nigra, a hyperpigmented line that begins at sternal notch and extends down abdomen through umbilicus to pubis Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-74 Chapter 29: The Pregnant Woman Objective Data (cont.) Skin (cont.) Note striae, or stretch marks, in areas of weight gain, particularly on abdomen and breasts of multiparous women These marks are bright red when they first form, but will shrink and lighten to silvery color after pregnancy in

lightly pigmented woman Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-75 Chapter 29: The Pregnant Woman Objective Data (cont.) Mouth Mucous membranes should be red and moist Gum hypertrophy, surface looks smooth and stippling disappears, may occur normally during pregnancy (pregnancy gingivitis) Bleeding gums may be from estrogen stimulation, which causes increased vascularity and fragility Neck

Thyroid may be palpable and may feel full but smooth during normal pregnancy of euthyroid woman Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-76 Chapter 29: The Pregnant Woman Objective Data (cont.) Breasts Breasts are enlarged, perhaps with striae, and are very tender Areolae and nipples enlarge and darken in pigmentation, nipples become more erect, and secondary areolae, mottling around areolae, may develop Blood vessels of breast enlarge and may shine blue through more translucent chest wall

When auscultating, flow through these blood vessels can be heard and may be mistaken for a cardiac murmur Sound is called mammary souffle Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-77 Chapter 29: The Pregnant Woman Objective Data (cont.) Breasts (cont.) Montgomerys tubercles, located around areola and responsible for skin integrity of areola, enlarge Colostrum, a thick yellow fluid, may be expressed from nipples Breast tissue feels nodular as mammary alveoli hypertrophy Take this opportunity to teach or reinforce breast selfexamination (BSE) Woman should expect changes in breast tissue during

pregnancy Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-78 Chapter 29: The Pregnant Woman Objective Data (cont.) Breasts (cont.) Because of lack of menses, instruct woman to perform BSE according to calendar on a monthly basis Recall that some women have an embryologic remnant called a supernumerary nipple, which may or may not have breast tissue beneath it Possibly mistaken previously for a mole, these occur under arm or in line directly underneath each nipple on abdominal wall This nipple and breast tissue may show same changes

during pregnancy Instruct woman to check these areas as well during BSE Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-79 Chapter 29: The Pregnant Woman Objective Data (cont.) Heart Pregnant woman often has functional, soft, blowing, systolic murmur as result of increased volume Murmur requires no treatment and will resolve after pregnancy Lungs

Lungs are clear bilaterally to auscultation with no crackles or wheezing Shortness of breath common in third trimester from pressure on diaphragm from enlarged uterus Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-80 Chapter 29: The Pregnant Woman Objective Data (cont.) Peripheral vasculature Legs may show diffuse, bilateral pitting edema, particularly if examination occurs later in day when woman has been on her feet and in third trimester

Varicose veins in the legs are common in third trimester Homans sign is negative Neurologic Using the reflex hammer, check biceps, patellar, and ankle deep tendon reflexes Normally these are 1+ to 2+ and are equal bilaterally Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-81 Chapter 29: The Pregnant Woman Objective Data Inspect and palpate the abdomen Observe shape and contours of abdomen to

discern signs of fetal position As the woman lifts her head, you may see diastasis recti, separation of abdominal muscles, which occurs during pregnancy, with muscles returning together after pregnancy with abdominal exercise When palpating, note abdominal muscle tone, which grows more relaxed with each subsequent pregnancy Note any tenderness; uterus is normally nontender Fundus should be palpable abdominally from 12 weeks of gestation on Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-82 Chapter 29: The Pregnant Woman Objective Data (cont.) Inspect and palpate the abdomen (cont.) Use side of hand and begin palpating centrally on

abdomen higher than you expect uterus to be Palpate down until you feel fundus (top of uterus) Alternatively, stand at womans right side facing her head Place palm of your right hand on curve of uterus in left lower quadrant and your left palm on curve of uterus in right lower quadrant Moving from hand to hand, allowing curve of uterus to guide you, walk your hands to where they meet centrally at fundus Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-83 Chapter 29: The Pregnant Woman Objective Data (cont.) Inspect and palpate the abdomen (cont.) Note fundal location by landmarks More accurate to use centimeter measuring tape and

measure height of fundus in centimeters from superior border of symphysis to fundus After 20 weeks, number of centimeters should approximate number of weeks of gestation Beginning at 20 weeks, you may feel fetal movement, and fetuss head can be ballotted Gentle, quick palpation with fingertips can locate head that is not only hard when you push it away, but hard as it bobs or bounces back against your fingers Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-84 Chapter 29: The Pregnant Woman Objective Data (cont.) Inspect and palpate the abdomen (cont.) If you suspect woman to be in labor, palpate for uterine contractions

Palpate uterus over its entire surface to familiarize yourself with its indentability Then rest your hand lightly on uterus with fingers opened When uterus contracts, it rises and pulls together, drawing your fingers closer together During contraction, notice that uterus is less indentable When uterus relaxes, your fingers relax open again Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-85 Chapter 29: The Pregnant Woman Objective Data (cont.) Inspect and palpate the abdomen (cont.)

In this way, contractions can be monitored for frequency, length, and quality Mild contraction feels like firmness of tip of your nose Moderate contraction feels like your chin Hard contraction feels like a forehead Make allowance for the amount of soft tissue between your fingers and the uterus Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-86 Chapter 29: The Pregnant Woman Objective Data (cont.) Leopolds maneuvers In third trimester, perform Leopolds maneuvers to

determine fetal: Lie Presentation Attitude Position Variety Engagement Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-87 Chapter 29: The Pregnant Woman Objective Data (cont.) Leopolds maneuvers (cont.) Fetal lie: orientation of fetal spine to maternal spine;

may be longitudinal, transverse, or oblique Presentation: describes part of fetus entering pelvis first Attitude: position of fetal parts in relation to each other, and may be flexed, military (straight), or extended Position: designates location of fetal part to right or left of maternal pelvis Variety: location of fetal back to anterior, lateral, or posterior part of the maternal pelvis Engagement: when widest diameter of presenting part has descended into pelvic inlet; specifically, to imagined plane at level of ischial spines Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-88 Chapter 29: The Pregnant Woman Objective Data (cont.) Leopolds maneuvers: first maneuver

Performed by facing gravidas head and placing your fingertips around top of fundus Note its size, consistency, and shape Imagine what fetal part is in fundus Breech feels large and firm because it is attached to fetus at waist In contrast, fetal head feels large, round, and hard When ballotted, it feels hard as you push it away and hard again as it bobs back against your fingers Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-89 Chapter 29: The Pregnant Woman Objective Data (cont.) Leopolds maneuvers: first maneuver (cont.)

Note that bobbing or ballotting sensation of movement occurs because head attached at neck and moves easily If there is no part in fundus, fetus is in the transverse lie Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-90 Chapter 29: The Pregnant Woman Objective Data (cont.) Leopolds maneuvers: second maneuver Move your hands to sides of uterus Note whether small parts or a long, firm surface palpable on womans left or right side Long, firm surface is the back Note whether back is anterior, lateral, or out of reach (posterior)

Small parts, or limbs, indicate a posterior position when they are palpable all over abdomen Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-91 Chapter 29: The Pregnant Woman Objective Data (cont.) Leopolds maneuvers: third maneuver Also called Pawliks maneuver, requires woman to bend her knees up slightly Grasp lower abdomen just above symphysis pubis between thumb and fingers of one hand and, as you did at fundus during first maneuver, to determine what part of fetus is there If presenting part is beginning to engage, it will feel fixed With this maneuver alone, it may be difficult to

differentiate shoulder from vertex Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-92 Chapter 29: The Pregnant Woman Objective Data (cont.) Leopolds maneuvers: fourth maneuver Assists in determining engagement and, in vertex presentation, to differentiate shoulder from vertex Womans knees are still bent Facing her feet, place your palms, with fingers pointing toward feet, on either side of lower abdomen Pressing your fingers firmly, move slowly down toward pelvic inlet If your fingers meet, presenting part is not engaged If your fingers diverge at pelvic rim meeting a hard prominence on one side, this prominence is the occiput

Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-93 Chapter 29: The Pregnant Woman Objective Data (cont.) Leopolds maneuvers: fourth maneuver (cont.) This indicates vertex is presenting with a deflexed head, the face presenting If your fingers meet hard prominences on both sides, vertex is engaged in either a military or a flexed position If your fingers come to pelvic brim diverged but with no prominences palpable, vertex is dipping into pelvis, or is engaged In this case, firm object felt above symphysis pubis in the third maneuver is shoulder

Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-94 Chapter 29: The Pregnant Woman Objective Data (cont.) Auscultate the fetal heart tones FHTs are positive sign of pregnancy They can be heard by Doppler US at 8 to 10 weeks gestation and with a fetoscope at 20 weeks gestation This use of fetoscope assists in dating pregnancy FHTs are auscultated best over shoulder of fetus After identifying position of fetus, use heart tones to

confirm your findings Count FHTs for 15 seconds and multiply by four to obtain the rate Normal rate is between 120 and 160 beats per minute Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-95 Chapter 29: The Pregnant Woman Objective Data (cont.) Auscultate the fetal heart tones (cont.) Spontaneous accelerations of FHTs indicate fetal well-being Differentiate FHTs from slower rate of maternal pulse and uterine souffle (the soft, swishing sound of the placenta receiving the pulse of maternal arterial blood) by palpating the mothers pulse while you listen Also, distinguish FHTs from funic souffle (blood rushing

through umbilical arteries at same rate as FHTs) FHTs are a double sound, like tick-tock of a clock under a pillow, whereas funic souffle is sharp, whistling sound heard only 15% of time Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-96 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvic examination Genitalia Use procedure for pelvic examination described in

Chapter 26 Note following characteristics Enlargement of labia minora common in multiparous women Labial varicosities may be present Perineum may be scarred from a previous episiotomy or from lacerations Note presence of any hemorrhoids of rectum Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-97 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvic examination (cont.) Speculum examination When examining vagina, you may see Chadwicks sign,

the bluish-purplish discoloration and congested look of vaginal wall and cervix from increased vascularity and engorgement Note vaginal discharge; discharge in pregnancy may be heavier in amount but should be similar in description to womans nonpregnant discharge and should not be associated with itching, burning, or an unusual odor (except that, occasionally, chapping of vaginal area may be seen due to excessive moisture) Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-98 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvic examination (cont.) Speculum examination (cont.) Perform a wet mount or culture of discharge when you

are uncertain of its normalcy Note whether cervix appears open Note whether it is smooth, round cervix with a dotlike external os of nulliparous woman or irregular multiparous cervix with an external os that appears more like a crooked line, result of cervical dilation and possibly lacerations in a previous pregnancy Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-99 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvic examination (cont.) Bimanual examination Palpate the uterus between your internal and external hands; note its position Pregnant uterus may be rotated toward right side as it

rises out of pelvis because of presence of descending colon on left This is called dextrorotation; irregular enlargement of uterus may be noted at 8 to 10 weeks of gestation and occurs when implantation occurs close to a cornual area of uterus This is called Piskacek sign Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-100 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvic examination (cont.) Bimanual examination (cont.) May also note Hegars sign, when enlarged uterus bends

forward on its softened isthmus between 4th and 6th weeks of pregnancy Note size and consistency of uterus 6-week gestation uterus may seem only slightly enlarged and softened 8-week gestation uterus is approximately size of an avocado, approximately 7 to 8 cm across fundus 10-week gestation uterus about size of grapefruit and may reach to pelvic brim, but is narrow and does not fill pelvis from side to side Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-101 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvic examination (cont.)

Bimanual examination (cont.) 12-week gestation uterus will fill pelvis After 12 weeks, uterus is sized from abdomen Softening of cervix is called Goodells sign When examining cervix, note its position (anterior, midposition, or posterior), degree of effacement (or thinning, expressed in percentages assuming a 2-cm long cervix initially), dilation (opening, expressed in centimeters), consistency (soft or firm), and station of presenting part (centimeters above or below ischial plane) Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-102 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvic examination (cont.)

Bimanual examination (cont.) Ovaries rise with growing uterus; always examine adnexae to rule out presence of a mass, such as an ectopic pregnancy To determine tone, ask woman to squeeze your fingers as they rest in vagina Take this opportunity to teach Kegel exercise, squeezing of vagina, which woman can do to prepare for and to recover from birth Woman can also identify exercise of these muscles by stopping flow of urine midstream, although she should only do this once, and should usually let urine flow freely Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-103 Chapter 29: The Pregnant Woman Objective Data (cont.)

Pelvic examination (cont.) Bimanual examination (cont.) Direct woman to squeeze slowly to a peak at count of eight and then release slowly to count of eight You can prescribe this exercise to be performed 50 to 100 times a day Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-104 Chapter 29: The Pregnant Woman Objective Data (cont.)

Pelvimetry Assess bones of the pelvis for shape and size Dimensions may indicate favorableness of bony structure for vaginal delivery However, relaxation of pelvic joints, widening of pelvis in squatting position, and capacity of fetal head to mold to shape of pelvis may enable a vaginal birth despite seemingly unfavorable measurements To aid in visualizing pelvis, imagine three planes: Pelvic inlet, from sacral promontory to upper edge of pubis Midpelvis, and pelvic outlet, from coccyx to lower edge of pubis Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-105 Chapter 29: The Pregnant Woman

Objective Data (cont.) Pelvimetry (cont.) Assessment of each of these pelvic planes allows you to estimate adequacy of pelvis for vaginal delivery There are four general types of pelves: gynecoid, anthropoid, android, and platypelloid You may postpone examination of bony pelvis until third trimester when vagina is more distensible With your two fingers still in the vagina, note shape and width of pubic arch (a 90-degree arch, or 2 fingerbreadths, is desirable) Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-106

Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvimetry (cont.) If you are right-handed, move your hand to right side of womans pelvis If you are left-handed, move it to left side of womans pelvis Assess the inclination and curve of side walls and prominence of ischial spine Move your fingers back and forth between spines to get an impression of transverse diameter; 10 cm is desirable Sweep your fingers down sacrum, noting its shape and inclination (hollow, J-shaped, or straight) Assess coccyx for prominence and mobility

Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-107 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvimetry (cont.) From sacrum, locate sacrospinous ligament Assess length of the ligament; 2 to 3 fingerbreadths is adequate Assess shape and width of sacrospinous notch Shift to other side of pelvis and assess it for similarity to the first The pelvic inlet cannot be reached by clinical examination, but you can estimate it by measure of diagonal conjugate, which indicates anteroposterior diameter of pelvic inlet

Having measured length of second and third fingers of your examining hand, with your fingers still in vagina, point these fingers toward sacral promontory Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-108 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvimetry (cont.) If you cannot reach promontory, note measurement as being greater than centimeters of length of your examining fingers; measurement of 11.5 to 12.0 cm is desirable

Remove your fingers from vagina Having previously measured width of your own hand across knuckles, form your hand into a closed fist and place it across perineum between ischial tuberosities. Estimate this diameter, which is bi-ischial diameter (also known as the intertubous diameter and transverse diameter of pelvic outlet) Measurement greater than 8 cm is generally adequate Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-109 Chapter 29: The Pregnant Woman Objective Data (cont.) Pelvimetry (cont.) When describing pelvimetry, note all above measurements and state pelvic type Pelvis may be described as being proven to number of

pounds of largest vaginally-born infant Alternatively, to describe a small pelvis, you may make assessment, for example, adequate for a 7-lb infant Blood pressure After examination, take blood pressure when woman is most relaxed, in semi-Fowlers or upright position Recheck an elevated pressure Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-110 Chapter 29: The Pregnant Woman Objective Data (cont.) Routine laboratory and radiologic imaging studies

At onset of pregnancy, order routine prenatal panel Usually includes complete blood cell count, serology, rubella antibodies, hepatitis B screening, blood type and Rhesus factor, and an antibody screening Some providers screen for herpes simplex virus I and II Sickle cell screening may be indicated For some populations, a PPD/TINE test may be indicated to rule out active or exposure to tuberculosis Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-111 Chapter 29: The Pregnant Woman Objective Data (cont.) Routine laboratory and radiologic imaging studies (cont.)

Offer woman HIV screening and cystic fibrosis screening Obtain Papanicolaou smear at initial visit along with cervical cultures Collect a clean-catch urinalysis at initial prenatal visit to rule out cystitis At each prenatal visit, check urine for protein and glucose Clean-catch specimen ideal for this dip because a random specimen may include vaginal secretions, which contain protein, skewing results Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-112 Chapter 29: The Pregnant Woman Objective Data (cont.) Routine laboratory and radiologic imaging

studies (cont.) Each agency has policy regarding frequency of US exam Some providers prefer to do US for dating at time of maternal serum alpha-fetoprotein or quad screening is drawn because accurate dating is essential Others will do it later (11 to 14 weeks of gestation), when measuring for fetal nuchal translucency (another fetal risk screening tool), which is best done at this gestation Some providers use US only with a medical indication Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-113 Chapter 29: The Pregnant Woman Objective Data (cont.) Routine laboratory and radiologic imaging studies (cont.) Others routinely order US to confirm dates and fetal normalcy (insofar as US is able to determine normalcy) and for any specific medical indication, such as fundus

measuring small or large for dates US shows placental and fetal location and fetal gender Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-114 Chapter 29: The Pregnant Woman Sample charting Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-115 Chapter 29: The Pregnant Woman Sample charting (cont.) Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-116 Chapter 29: The Pregnant Woman

Sample charting (cont.) Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-117 Chapter 29: The Pregnant Woman Sample charting (cont.) Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-118 Chapter 29: The Pregnant Woman Abnormal Findings: Fetal Size Inconsistent with Dates Size small for dates

Inaccuracy of dates Premature labor Intrauterine growth restriction (IUGR) or fetal growth restriction Fetal position Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-119 Chapter 29: The Pregnant Woman Abnormal Findings: Fetal Size Inconsistent with Dates (cont.) Size large for dates

Inaccuracy of dates Multiple fetuses Polyhydramnios Fetal macrosomia Leiomyoma (myoma or fibroids) Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-120 Chapter 29: The Pregnant Woman Abnormal Findings: Disorders of Pregnancy

Preeclampsia Vaginal bleeding Incompetent cervix Hyperemesis Preterm labor Decreased fetal movement Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Slide 29-121

Recently Viewed Presentations

  • Diapositiva 1 - Weebly

    Diapositiva 1 - Weebly

    the origins of rome. the people who lived on the italian peninsula during this period came from different origins. the . etruscans. lived in the north and centre of italy. the. latins . lived in central italy, where they founded...
  • Find it and Fix it Henry VII was

    Find it and Fix it Henry VII was

    The Truce of Ayton came after Warbeck's execution and saw was sealed by the marriage of James to Margaret (daughter) Whilst Phillip of Burgundy was stranded in England, the Treaty of Etaples and Intercursus Magus were made During the Cornish...
  • Type Title Here

    Type Title Here

    Amendment to the U.S. Lacey Act: Implications for Forest Products Manufacturers, Exporters and Importers Beijing, June 18-19, 2008 R. Juge Gregg
  • An Algorithmic Approach to Learning Markov Random Fields

    An Algorithmic Approach to Learning Markov Random Fields

    Set Then New formulation Max-likelihood value of G is just sum of weights of cliques it contains So, given weights on cliques of size up to k+1, want to find a hypertree (triangulated graph of treewidth at most k) containing...
  • Revolutions in Networks and Grids for HEP and Global Science

    Revolutions in Networks and Grids for HEP and Global Science

    Internet Performance for Africa and the rest of the World Prepared by: Les CottrellSLAC, Umar KalimSEECS,NUST/SLAC International Centre for Theoretical Physics,
  • What is biofouling  The growth of organisms (both

    What is biofouling The growth of organisms (both

    A vessel undertaking regular maintenance is a key factor influencing the risk it could introduce or spread a harmful aquatic organism. It is not enough for a vessel to simply apply an anti-fouling system and do no other maintenance until...
  • 1-d Kinematics - Chemeketa Community College

    1-d Kinematics - Chemeketa Community College

    1-d Kinematics 1-d Kinematics Which position-versus-time graph represents the motion shown in the motion diagram? Which position-versus-time graph represents the motion shown in the motion diagram? Which velocity-versus-time graph goes with this position-versus-time graph on the left?
  • Javascript/HTML - eecs.yorku.ca

    Javascript/HTML - eecs.yorku.ca

    WIMP Elements GUI goo