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HEALTHIER PREGNANCY:
PATIENT SAFETY GOALS
JASSIN M. JOURIA, MD
DR. JASSIN M. JOURIA IS A MEDICAL DOCTOR,
PROFESSOR OF ACADEMIC MEDICINE, AND MEDICAL
AUTHOR. HE GRADUATED FROM ROSS UNIVERSITY
SCHOOL OF MEDICINE AND HAS COMPLETED HIS
CLINICAL CLERKSHIP TRAINING IN VARIOUS TEACHING
HOSPITALS THROUGHOUT NEW YORK, INCLUDING
KING’S COUNTY HOSPITAL CENTER AND BROOKDALE
MEDICAL CENTER, AMONG OTHERS. DR. JOURIA HAS
PASSED ALL USMLE MEDICAL BOARD EXAMS, AND HAS
SERVED AS A TEST PREP TUTOR AND INSTRUCTOR FOR
KAPLAN. HE HAS DEVELOPED SEVERAL MEDICAL
COURSES AND CURRICULA FOR A VARIETY OF EDUCATIONAL INSTITUTIONS. DR. JOURIA HAS ALSO
SERVED ON MULTIPLE LEVELS IN THE ACADEMIC FIELD INCLUDING FACULTY MEMBER AND
DEPARTMENT CHAIR. DR. JOURIA CONTINUES TO SERVES AS A SUBJECT MATTER EXPERT FOR
SEVERAL CONTINUING EDUCATION ORGANIZATIONS COVERING MULTIPLE BASIC MEDICAL
SCIENCES. HE HAS ALSO DEVELOPED SEVERAL CONTINUING MEDICAL EDUCATION COURSES
COVERING VARIOUS TOPICS IN CLINICAL MEDICINE. RECENTLY, DR. JOURIA HAS BEEN
CONTRACTED BY THE UNIVERSITY OF MIAMI/JACKSON MEMORIAL HOSPITAL’S DEPARTMENT OF
SURGERY TO DEVELOP AN E-MODULE TRAINING SERIES FOR TRAUMA PATIENT MANAGEMENT. DR.
JOURIA IS CURRENTLY AUTHORING AN ACADEMIC TEXTBOOK ON HUMAN ANATOMY & PHYSIOLOGY.
Abstract
Preparing women early on in a pregnancy to follow a plan for routine
prenatal care has been shown to promote healthy outcomes for expectant
mothers and the developing baby during all phases of pregnancy. Proper
nutrition and prevention should be reviewed at the first prenatal visit and for
every visit throughout the pregnancy. To ensure that best care practices are
followed and that promotion of maternal and infant health is of top priority,
all health professionals should understand patient safety goals and standards
of practice. The health team should understand the importance of working in
unison not only with other clinicians and associates, but also with patients
and their families.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 5 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Pharmacy content is 0.5 hours (30 minutes).
Statement of Learning Need
Clinicians need to understand the components involved in the initial prenatal
assessment including assessing for pre-existing hypertension, glucose in the
urine, and sexually transmitted diseases. Additionally, identifying existing
risks at the first prenatal appointment through open communication
regarding unhealthy lifestyle choices can make a profound difference in the
health outcomes of the expectant mother and baby.
Course Purpose
To provide nurses with the fundamental skills and elements involved in
managing healthy pregnancies, as well as basic concepts, which should be
well understood by healthcare clinicians at all levels of patient care.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. Using the Estimated Date of Delivery (EDD) method, the care
provider will always _____________________ from the first
day of a woman’s last menstrual period.
a.
b.
c.
d.
count
count
count
count
forward 266 days
backward 266 days
forward 280 days
backward three months
2. ______________ of women deliver on their actual Estimated
Date of Delivery (EDD).
a.
b.
c.
d.
One half
One-third
Twenty percent
Four percent
3. True or False: Properly determining a woman’s due date is
nominally important because the patient’s contractions will
provide enough notice.
a. True
b. False
4. Which pregnancy due date method or rule involves counting
backwards three months from the first day of the last missed
period and then subsequently adding 7 days?
a.
b.
c.
d.
Naegele’s rule
The hCG test
The menstrual cycle method
EDD method
5. Using the Estimated Date of Delivery (EDD) method, the care
provider will always count forward 266 days from the date of
conception if
a.
b.
c.
d.
the woman took a home pregnancy test.
the woman recorded the first day of her menstrual period.
the exact date of conception is known.
if the date is confirmed through urinalysis.
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Introduction
Having a child is a deeply personal and challenging experience even for the
parents who have previously had a child. All health professionals providing
care to expectant mothers and their families should promote feelings of
confidence in them that pregnancy safety goals are a high priority of the
health team. To ensure that best care practices are followed and that
promotion of maternal and infant health is of top priority, all health
professionals need to understand patient safety goals and standards of
practice. The health team that works in unison not only with other clinicians
and associates, but also with patients and their families, will be better able
to develop detailed, open communication with a focus on building strong and
long-term relationships. When working collaboratively, health professionals
and patients can promote a positive pregnancy outcome of healthy mothers
and babies.
Planning The Prenatal Visit
The initial prenatal visit is an emotionally charged event for most women.
During this time there are a variety of competing factors related to
physiological and environmental changes an expectant mother may be
experiencing; her body is changing in ways she cannot control, her family
will have begun anticipating big changes in their lives, and she is likely
anxious about the health care. The pregnant woman and her family will want
reassurance that they are safe and in good hands.
Health clinicians working with pregnant women will need to understand their
underlying feelings of becoming a mother; whether they are thrilled with
being pregnant, terrified of the process, or unsure or even remorseful
regarding their pregnancy. At the initial visit, all members of the health team
should help the expectant mother through all of her emotions as well as
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those of her family. Patient engagement and healthy responses to teaching
during all aspects of the pregnancy is promoted through the initial encounter
of building a warm and trusting atmosphere, and the use of compassionate
and therapeutic communication.
During the initial prenatal visit, the health clinician will determine the
expected date of delivery, perform a physical assessment of the mother and
fetus, identify any underlying risks to a successful pregnancy, and
understand how the mother and other members of her family are adapting
to the pregnancy.
Assessing The Estimated Delivery Date
This section discusses the various and common strategies used in identifying
a pregnant woman’s expected delivery date. Properly determining a
woman’s due date is of utmost importance, because the more accurate the
prediction of the due date, the less likely complications related to
unnecessary medical interventions will arise.1
Evaluation of Gestational Age and Expected Date of Delivery
The estimated date of delivery (EDD) method2 has been the principal
method in determining a pregnant woman’s due date for more than 200
years. On top of using paper wheels or charts, some clinicians will use EDD
calculators online based on the 280-day rule. The clinician must always
count forward 280 days from the first day of a woman’s last menstrual
period, or forward 266 days from the date of conception if this exact date is
known, which is usually in cases of in vitro fertilization.
The EDD method assumes that a woman’s ovulation occurs on day 14 of her
cycle but this is untrue for many women, especially those with irregular
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cycles. There are limitations of using the EDD method in evaluating
gestational age.2 Only 4% of women deliver on their actual EDD because of
natural biological variations in gestation and hormonal cycles. EDD is based
on a 28-day menstrual cycle and does not account for women with varying
period lengths or those with alternate fertile days due to changes in episodes
of heightened luteinizing hormone (LH), the chemical signal responsible for
the release of an ovum.
Occasionally, the first day of the last menstrual cycle is unknown, either
because the mother has irregular periods or because she has simply
forgotten. In these cases, Human Chorionic Gonadotropin (hCG) levels
should be drawn and an ultrasound scheduled depending on the findings
revealed in the hCG results.3 Currently, Naegele’s rule is the most common
technique of pregnancy dating. This rule involves counting backwards three
months from the first day of the last missed period and then subsequently
adding 7 days. Like the previous method, this rule considers a woman’s
menstrual cycle to be 28-days long and an ovulation that occurs on the 14th
day of the cycle. Because a woman is fertile for a few days before, during
and after ovulation, the 14th day is not necessarily the most likely date of
conception.3
As previously discussed, some women have cycles of varying lengths. A
typical menstrual cycle can be anywhere from 21 to 35 days in length. If the
expectant mother states that her last menstrual period was October 27th, to
determine this patient’s expected due date, the clinician will first subtract
three months, putting the date at July 27th. Next, the clinician will add seven
days to this date, ending up with an expected due date of August 3rd.
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When a woman believes she is
pregnant, either because of a missed
period or a positive pregnancy test, she
Case Scenario:
Rose is a 30-year-old
experiencing her first pregnancy.
will likely make an appointment with
She calls her family physician’s
her health clinician to be assessed. The
office and reports that the first
clinician will confirm pregnancy with a
day of her last period was May
urine sample in the office or sometimes
with an ordered laboratory blood
sample. The clinician will generally
5th. Using Naegele’s rule, the
clinician anticipates that her
estimated due date will fall on
which date?
gather the date of the patient’s last
missed period and inquire about any signs or symptoms.
The primary clinician will perform various physical assessments including
checking the cervix to ensure that it is closed and to check its color. The
clinician will note whether or not the cervix has taken on a blue or purplish
tint due to the increased blood flow to the cervix, which is known as
Chadwick’s sign.3 During the primary clinical assessment, the uterine size
will also be palpated. In the early stages of pregnancy, before 6 weeks, the
uterine fundus may not be felt, or will be only mildly noticeable. Between 6
and 8 weeks, the uterus should be soft, globular in shape and about the size
of a plum.
The clinician would likely order blood tests to determine current hCG levels
and schedule a future ultrasound to verify the gestational age of the fetus.
Women’s hCG levels fluctuate throughout their pregnancy but are always
more reliable early on. Results on hCG lab tests may be expected during the
following time periods:3

4 weeks: 1,000-30,000 mIU/mL

5 weeks: 3,500-115,000 mIU/mL
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
6 - 8 weeks: 12,000-270,000 mIU/mL
It is expected that a pregnant woman’s hCG level will double about every 2
to 3 days during the first trimester and will plateau or fluctuate after
approximately twenty weeks. This varies greatly for each mother and may
result in the need for fetal health confirmation by ultrasonography.
Ultrasounds are performed at various periods during a woman’s pregnancy;
the first usually between 6 and 10 weeks. These initial ultrasounds are the
most accurate measurement tools for determining gestational age of an
embryo or fetus.7 This accuracy decreases with time because biological
differences found within the fetus’ DNA take effect as the fetus grows in
utero. Also, fetuses grow at different rates and fetal physical measurements
obtained by ultrasound will vary for fetuses the same gestational age.
One study found that birth transpired within 7 days of the due date
determined by the use of ultrasound technology alone. This study also
showed a reduction of the possible risky process of labor induction for postterm pregnancies. First trimester ultrasounds are generally performed
transvaginally using a probe inserted into the mother’s vaginal canal. Early
ultrasounds performed around 4.5 to 5 weeks will show a gestational sac,
which will grow by about 1 mm in diameter per day. Crown to Rump Length
(CRL) is more accurate than measuring the gestational sac alone. This
measurement is generally performed between 7.5 and 10 weeks. Most
mother’s wonder when they can expect to see or hear an infant’s heartbeat.
Health clinicians should inform them that cardiac activity might be visible
after 5.5 or 6 weeks gestation.7
Like the other tests, ultrasounds have their limitations. The accuracy of
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sonography in assessing gestational age decreases after 10 weeks and
continues to decrease as the pregnancy progresses. As indicated above, this
is the result of biological differences in parents and fetal growth rates and
sizes. Before six weeks, locating the fetus in utero may be difficult even
transvaginally. This can cause unnecessary anxiety and stress for the
pregnant woman and her family.
Some women find the transvaginal ultrasound probe to be uncomfortable or
even traumatizing, especially if these women have been victims of sexual
abuse. The health team must be sensitive to these patients and understand
their special needs. New best practices suggest that women able to insert
the probe themselves, rather than having the ultrasound technician begin
the procedure, feel less discomfort overall. Drawbacks to the use of an early
term ultrasound exam, specifically the anxiety some women feel towards the
discomfort the procedure can cause, raises the question of whether this
procedure is necessary. The need to perform an ultrasound exam will be
determined between the primary physician and the expectant mother.
To return to the above case scenario of Rose who reported her last
menstrual cycle as starting May 5th, using Naegele’s rule the clinician would
be correct in identifying Rose’s expected due date as February 12th. This
number is found by subtracting three months from the first day of Rose’s
last menstrual period and then adding seven days: May 5th – 3 months =
February 5th; February 5th + 7 Days = February 12th.
History And Physical At The First Prenatal Visit
Prenatal care that is provided by a well-coordinated and cohesive team has
major advantages. This method of care, when coinciding with evidencebased practice, results in a decrease in prenatal admissions, superior
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prenatal education, and a higher level of overall patient care.5 For most
patients, prenatal care begins with healthy care planning. Next is the
physical assessment of both the pregnant mother and the fetus depending
on gestational age. Combined, these initial practices are the cornerstone for
a successful long-term health care relationship between the clinical team and
the expectant mother and her family.
Once the initial prenatal history and physical are completed the clinician will
be better able to plan the overall goal of care for the pregnant patient; and,
the team as a whole will be able to coordinate care to protect the health and
wellbeing of the mother. A thorough history and physical will ultimately help
to create a successful plan of care for the delivery of a healthy infant.
Case Scenario:
A patient has just arrived for her initial physical examination of her new
pregnancy. She received a positive pregnancy test 2 days prior and is 3
days late for her period. She asks about the following tests and
procedures and wondering when they will be performed. Her health
clinician would be correct in explaining which of the following
assessments will likely not be performed at this time:
a) Calculation of body mass index.
b) Evaluation of areas prone to edema, such as hands, face and
ankles.
c) Fetal Doppler assessment.
d) Pelvic examination.
Body Mass Index
At the initial prenatal visit, the clinician will first take a weight and height
measurement of the patient in order to determine the current body mass
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index (BMI). Studies have shown that having a BMI considered above
normal before the start of pregnancy correlates positively with pregnancyrelated hypertension, edema and gestational diabetes.4 Understanding a
woman’s current BMI will allow the clinician to know whether or not she is at
a higher risk of developing these issues among many others.
Patients commonly ask their physician, midwife, or nurse, how much weight
they should gain during pregnancy. If a patient asks this question, the
clinician should remind the patient that healthy BMIs tend to vary, and that
recommendations are not always based on large scale or absolutely accurate
studies. Nonetheless, the American College of Obstetricians and
Gynecologists suggests the following criteria:4,5

Women with BMIs below 18.5 are considered underweight and should
plan to gain between 28 and 40 pounds.

Women with BMIs that are thought to be in the normal range, between
18.5 and 24.9, should gain 25 to 35 pounds.

Women with BMIs above 24.9, a plan may be set to gain 15-20
pounds.

Obese women who have BMIs at 30 or greater may be recommended
to not gain weight at all if possible or to limit their weight gain to
between 11 and 20 pounds.
Weight is a sensitive subject for most patients and should be discussed
openly, kindly, and with plenty of compassion for the expectant mother.
Women with abnormal BMIs should be provided with information on dietary
modifications and may need a referral to a registered dietician. When dealing
with patients in this position, the clinician should show patience while
recommending dietary and lifestyle changes. Such changes may take time
and lots of encouraging reminders from a supportive health team.
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Urinalysis
The prenatal patient will often be asked to provide a urine sample during the
initial prenatal visit. This involves asking the patient to urinate into a
provided specimen container prior to seeing her physician so that there will
be results from an initial urine test before a scheduled physical exam.
The results being explored in the initial urinalysis include hCG indicating
whether there is a true positive pregnancy test.4,5 While it is very rare for a
woman to receive a false positive pregnancy test, it can occur. Clinicians
should double check a prenatal patient’s at-home test results. While tests
obtained by the patient at home checks for the presence of hCG, it does not
check for the precise hCG levels. To get an accurate measurement of hCG
levels, a blood test will need to be performed.
Chlamydia and gonorrhea also need to be tested, as these sexually
transmitted infections are especially known for their negative effects on a
developing fetus. Bacteria or blood cells may indicate a urinary or bladder
infection that may not have been felt by the mother. Ketones, proteins or
sugars may show a problem with the kidneys or undiagnosed diabetes. While
the results of sexually transmitted infection tests may take a week or so to
come back, it will be possible to see the presence of hCG, ketones, protein,
blood cells or bacteria during this initial appointment.
Urine Test Protocol
Before having a patient offer a urine sample, she should be provided with a
specimen cup, two prepackaged wipes, and education on how to privately
obtain the proper “clean catch” urine sample. Education on how to
accurately obtain this sample should be given in a private area before the
prenatal patient enters the restroom alone.6,9
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For women, the procedure starts by instructing them to wash their hands.
The next step requires that the woman sit down on the toilet and use two
fingers from their non-dominant hand to separate their labia. The clinician
should provide the client with two cleansing wipes. Using the first wipe, she
will use her dominant hand to clean the inner labial folds from front to back,
then discarding it with the same hand. Once the patient has the second
wipe, she must clean her urethra. Some patients may not know exactly
where this is located and will require teaching. Explain that the urethra is the
opening just above the vagina from where the urine exits. After cleaning this
area they may discard the second wipe. While keeping the labial folds spread
open, the patient should urinate a small amount into the toilet and then stop
the flow. At this point, the patient should now urinate into the specimen cup
until it is about half full. The process is finished once the sample is adequate
and the patient may be advised to complete urination into the toilet.
Obtaining the Patient History
Either through completion of a form or by discussion with her health
clinician, an expectant mother must have the opportunity to discuss her
previous and present medical conditions, family history of diseases, past
surgical and obstetrical history, personal and demographic history.7 The
patient’s name, date of birth and current living address should be obtained.
The clinician should also inquire into current medications including vitamins,
over-the-counter herbal supplements, and prescriptions, which are reviewed
in the section below.8,10,11,13
Herbal Supplements
Herbal supplements are an especially pressing matter to discuss with
prenatal clients as they are often seen as “natural” and therefore not
harmful. However, this is not always the case. St. John’s Wort is an herbal
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medicine used by pregnant women suffering from depression who may be
afraid to take pharmaceutical medications during their pregnancy. However,
because the effects of this herbal supplement on a developing fetus are
unknown, physicians believe that taking heavily studied selective serotonin
reuptake inhibitors (SSRIs) such as fluoxetine are less dangerous. Untreated
depression can be harmful to both the mother and fetus, a subject touched
upon later on.
Supplements to Avoid during Pregnancy
Aloe Vera taken orally should be noted and the patient informed that
ingesting aloe vera might have uterine stimulation and abortifacient
properties.
Gaurana is a supplement frequently added to energy drinks, which people
drink in order to increase their energy. Pregnant women should be advised
to avoid gaurana because it has been shown to lead to the birth of babies
prematurely, infants of low birth weight, and possible birth defects.
Wild cherry extract is often used to stave off colds or coughs, but it is
considered a teratogenic product; that is, it may disturb fetal development.
A pregnant woman should never take wild cherry extract. Health staff should
inform patients of the potential for increased birth defects in infants born to
mothers who consume this supplement during pregnancy.
Catnip or Nepeta Cataria is commonly taken in adult humans for sleep
induction. While acting as a stimulant in cats, catnip made into an extract,
tea, or supplement is quite frequently believed to be safe because of its
natural status. However, this herbal supplement is not recommended in
pregnant women as it has the ability to stimulate uterine activity and induce
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labor prematurely possibly leading to abortion.
Echinacea, taken in an attempt to improve the immune system, has a weak
oxytocic effect on the pregnant uterus.
Valerian root like catnip is an herbal supplement often purchased over-thecounter to combat insomnia. Health clinicians should advise prenatal
patients to avoid this drug as it can stimulate uterine contractions.
Ginseng is a tempting herbal supplement for pregnant and lactating women
experiencing “mommy brain” or frequent forgetfulness. Promoted as a
memory and concentration promoter, ginseng is not considered a safe
supplement to take during pregnancy or while breastfeeding. One study
found that a woman who had consumed this supplement while breastfeeding
gave birth to an infant with pubic hair, forehead hair, swollen testicles and
red swollen nipples. Once the infant was switched to formula, the infant lost
its pubic hair and the hair covering his forehead.
Uva Ursi has astringent and anti-inflammatory properties and is often used
to treat or prevent urinary tract infections or cystitis. Many women see an
increase in urinary tract infections during pregnancy. There is also an
increase in pyelonephritis, a kidney infection, during pregnancy. Treatment
of these conditions is very important. While prenatal patients may be
reluctant to use pharmaceutical antibiotics in order to treat their infections,
they should be discouraged from using uva ursi. In addition, this herbal
supplement can cause liver damage, especially if taken for more than 5 days
in a row. For this reason, uva ursi is a dangerous medication for pregnant
women.
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Melatonin, another common herbal sleep aid, is not recommended during
pregnancy, primarily due to the lack of studies surrounding the subject,
although it may correlate positively with developmental disorders. What is
known for certain about this herbal supplement is that it is an ovarian
suppressant and decreases sexual libido, both of which can be troublesome
for women planning to become pregnant.
Ginkgo Biloba is taken primarily to aid with memory function, depression,
and even breast tenderness. Still, this herbal medication should be avoided
during pregnancy and is especially discouraged around the end of
pregnancy, near labor. Antiplatelet properties in gingko may prolong
bleeding, increasing the potential for hemorrhage.
Past Obstetrical or Prenatal History
When discussing past obstetrical or prenatal history, the patient should be
asked about each completed pregnancy, any pregnancy complications, or
inherited diseases, and the sex and date of birth of any prior child or
children. Also, the events of labor (vaginal, cesarean, prolonged, or
precipitous labor) should be assessed. The mother’s psychosocial needs and
whether she has experienced postpartum depression in the past should also
be noted.
Past number of pregnancies should be included in the patient’s history
taking. The number of pregnancies a woman has is described as follows:

Nulligravida - a woman who has never been pregnant

Primigravida - a woman who is pregnant for the first time or has been
pregnant once before

Multigravida - refers to a woman who has been pregnant more than
once
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There are many other terminologies used in questions regarding a woman’s
obstetrical history including full-term, preterm, miscarriage, elective
abortion, and multiples.12 A full-term is an infant born after 39 weeks of
gestation,12 while preterm births occur before 36 weeks gestation. A
miscarriage, or spontaneous abortion, is the expulsion of the fetus or
embryo from the uterus before 20 weeks gestation. The majority of
miscarriages occur between 4 and 12 weeks gestation. Elective abortions are
the number of pregnancies purposefully terminated either chemically
through the use of a prescribed pill or through a dilation and curettage
procedure. Twins or multiples refer to a mother who has carried more than
one fetus in utero at the same time. Prenatal patients with multiples will
need specialized care and may be required to see high-risk obstetricians.
Patient Demographics and Risk of Domestic Violence
Marital status is a frequently asked question, but it is just as important to
investigate the circumstances surrounding the mother and her support
system. The American College of Obstetricians and Gynecologists (ACOG)
recommends that all pregnant women be assessed for abuse during each
prenatal visit because pregnancy increases a woman’s risk of falling victim to
domestic violence.14 Women are at an even higher risk of falling victim to
violence if they are under 20 years old. Pregnant women are at a two to four
times greater risk if their pregnancy was unplanned.
Signs of abuse may be late initiation of prenatal care, unexplained or poorly
explained injury or bruising, as well as depression. Careful observance for
domestic violence in prenatal clients is especially important for a number of
reasons. Homicide is the second most common injury-related cause of death
in pregnant women (the first being car accidents) and pregnancy-related
complications like bleeding and infants of low-birth weight are more common
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in victims of abuse. Domestic violence victims are likely to engage in poor
prenatal care and continue use of tobacco, alcohol and other drugs.
Religion is important to review with the patient, especially if she is a
member of a religion that prohibits blood transfusions. The clinician should
be familiar with religions that have medical treatment prohibitions. In such
circumstances, it is important to ask the patient whether or not she is willing
to get a blood transfusion should she hemorrhage during or after labor.
Other social questions may include family support, financial standing and
living situation.
Therapeutic Communication
Raising questions with a pregnant woman related to her social circumstances
may seem difficult but are a necessary part of the patient history to develop
a plan of care, including protecting the safety of both the mother and infant
throughout the entire pregnancy and postpartum. During this time, health
professionals should use therapeutic communication techniques to promote
patient engagement and to understand a woman’s untold needs.
Therapeutic communication includes restating and seeking clarification,
using broad openings, focusing, and making observations.
Restating and seeking clarification involves the health professional restating
what the patient said and asking questions to be sure what she was trying to
say was understood. This technique is useful to prevent miscommunication
and to help the patient identify her true needs or feelings. The following
examples include types of therapeutic communication the clinician may use.
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Example 1:
A patient expresses: “I’m sometimes afraid my husband doesn’t want this
baby. I am happy to be pregnant, but whenever I bring it up, he seems to
change the subject.”
The clinician should respond: “You’re scared that your husband is not as
happy about the pregnancy as you are. Is that right?” This opens the
opportunity for the patient to confirm: “Yes, I’m wondering if I’ll have to
take care of this baby by myself. If he doesn’t care about the pregnancy
now, how could he care about the baby?”
Example 2:
Using broad openings is a therapeutic technique performed by asking a
general open-ended question to encourage the patient to discuss personal
fears, concerns, or issues surrounding a pregnancy. The clinician may ask,
“What would you like to ask me about today?”
If the patient responds: “Oh, hmmm, I guess I am a little worried about
some discharge I’ve been having,” the clinician can ask to hear more about
the discharge.
Example 3:
Focusing involves bringing a patient back to a subject touched upon earlier.
The patient may say, “I try to eat healthy, but it can be hard because I don’t
have a lot of money. I have other children so I want to make sure they eat
first. But, I’m trying to exercise and I’ve stopped drinking alcohol and
smoking cigarettes.”
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The clinician responds positively to the cessation of alcohol and cigarettes by
saying, “I’m glad to hear that you aren’t smoking or drinking alcohol. I’d like
to go back a bit, however, and discuss what you said about feeding your
children first. Could you tell me more about that?” The patient may respond,
“Well, I just don’t have enough money to buy food to feed myself as much
as I’d like. I have a feeling I’m not eating enough.”
Example 4:
Making observations involves stating what the clinician observes or
perceives. It helps to prevent the clinician from making generalizations or
assumptions. The clinician may say, “You are shaking, are you feeling
nervous about something?”
The patient may respond by saying “No, not at all! I suddenly got hungry in
the waiting room and am worried that I’m having a bit of a sugar crash!”
The clinician can now make the patient feel less shaky as well as educate
her: “Sometimes pregnancy alters your hunger patterns. Let me grab you
some graham crackers and a juice for you!”
Acknowledging the Patient’s Feelings
Perhaps one of the most important communication techniques involves
acknowledging the patient’s feelings. Sometimes complicated situations
become simpler to both the patient and clinician once the patient feels
empathy from the clinician.
Acknowledging the patient’s feelings involve listening, showing
understanding, and acknowledging the patient’s frustration. For example, a
prenatal client may state, “I’m sick of being treated like I’m so fragile. My
husband is so critical and afraid that everything I do could hurt the baby.”
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An appropriate response from the clinician might include, “That must be very
difficult to feel judged for your actions.” Empathy and the acknowledgment
of the patient’s distress help the patient feel relaxed and understood, and
help promote a trusting relationship between the patient and her health
clinician.
Using Silence
Using silence to keep a conversation flowing is an oft forgotten therapeutic
communication technique. Frequently, in the midst of a stressful
conversation, a member of the health team and a prenatal patient may
neglect to sit back and just listen to what the other person is saying. Letting
the patient communicate, then sitting back and listening attentively, may
slow the patient down and give her time to think and refocus.
Anxiety is not uncommon in the pregnant woman and this anxiety often
leads to distorted thinking. For example, a pregnant mother may be likely to
say something along the lines of, “I can’t go through labor. I just can’t. I’m
not strong enough.” To combat these distorted thoughts, the clinician may
try expressing doubt at beliefs that are likely untrue. In the aforementioned
statement, a clinician may respond with, “Do you really believe you can’t go
through labor? What about the thousands of women who deliver babies each
year? What about the women who’ve been giving birth since the dawn of
time?” Labor especially can seem daunting to many women, especially those
who have never experienced it. A reminder that it is a natural, human
process can help ease the patient’s stress and help her correct or control her
thoughts.
A clinician may learn what the expectant mother is feeling through these
communication skills; such as that the mother is fearful about her support
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system at home, that she is not receiving adequate nutrition or that she is
experiencing changes in appetite. Learning to dig deeper and discover the
unspoken needs of a woman during her pregnancy is a skill that takes time
and practice to learn but ultimately improves the quality of a clinician’s
practice. Therapeutic communication can also be used to identify possible
psychiatric issues that may prevent the mother’s pregnancy from ending
successfully. In fact, research suggests that anxiety, depression and chronic
mental strain result in more cases of preterm birth, low birth weight and
adverse fetal neurodevelopment.13
Before moving on to the physical assessment portion of the initial prenatal
visit, the clinician should discuss other possible health hazards; for example,
exposure to viral infections not transmitted sexually, such as toxoplasmosis.
Toxoplasmosis is carried by cats, chickens and rodents, and is found in their
feces. Pregnant women should be taught to avoid cleaning litter boxes.
Potential dangers related to toxoplasmosis infection may cause
malformations of the neonate’s head, still birth, or spontaneous abortion.
The clinician should discuss travel history with patient. Here, assessment is
made for possible travel related illnesses, including serious diseases carried
by mosquitos, such as the Zika virus or malaria. Zika virus is an emerging
disease spread through the bites of female mosquitos. It may also be
transmitted sexually. While the potential dangers of infection of the Zika
virus are not known with absolute certainty, Brazil has seen a rise in
microcephaly in neonates whose mothers were infected with the disorder.
Other brain abnormalities are also noted including severe mental
retardation.15 Malaria, another disease transmitted via mosquito bites,
causes intrauterine fetal death, premature birth, low-birth weight infants,
and an increase in neonatal death.16,17
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To prevent infection of these diseases in pregnant women, the clinician
should encourage the use of mosquito repellent containing 10% deet,16 the
wearing of long sleeves, pants, and clothing with hoods (to help protect the
back of the neck). Pregnant mothers should know the peak hours for
mosquitos (dawn and dusk), and always pay strict attention to the Center
for Disease Control’s travel warnings and advisories.
The Initial Physical Examination
The first physical assessment will occur much like the prenatal examinations
that will follow. After the expectant mother’s weight is recorded, the clinician
will take her vital signs. This includes blood pressure, heart rate and
temperature. The clinician will also assess for respiratory rate, lung sounds
and bowel activity. Any signs or symptoms leading to discomfort in the
prenatal patient’s pregnancy will also be recorded and reevaluated on followup visits.
The health clinician will need to check for any swelling in the hands, feet,
ankles, or face. This is performed in order to monitor symptoms of beginning
high blood pressure or hypervolemia. Palpation of the woman’s abdomen
should involve searching for the top of the fundus. In the early weeks of
pregnancy, the uterine fundus may not be felt, or will be only mildly
noticeable. Between 6 and 8 weeks, the uterus will be soft and the globular
will be about the size of a plum. If the woman is between 10 and 12 weeks
gestation, the clinician may search for fetal heart tones using a fetal doppler.
Before this time, it is unlikely that they will be able to hear cardiac activity
without the use of a transvaginal ultrasound. At the initial visit, fetal
assessment is limited to the doppler, uterine measurements, and the status
of maternal health in the first trimester.
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The clinician will also perform a pelvic examination at this time,18 checking
the cervix for thickness, opening and length. If an opening or thinned cervix
is found then there is cause for concern of a spontaneous abortion. Some
women with what is known as cervical insufficiency,19 or recurrent cervical
dilation especially in the second trimester, will undergo a procedure known
as transvaginal cervical cerclage.20 This procedure is performed in varying
manners, but ends the same − with a closed cervix. At 37 weeks gestation,
the cerclage is removed allowing labor to proceed naturally.20
During the pelvic exam, the physician will use his/her fingers to manipulate
around the uterus to measure its approximate size and position in relation to
the pelvic bones. The physician may also check for sexually transmitted
diseases with the use of a speculum to open the vagina and swabbing with a
long cotton tip. The results to this test generally take about a week to
return. At the end of the physical exam, the physician will likely order
multiple tests. Testing for hCG levels will ensure clinicians that the findings
are expected with the embryonic or fetal gestational age. Expected findings
have been previously discussed in regards to the confirmation of pregnancy
and the determination of estimated date of delivery.
The Rhesus type and antibody screen is designed to detect possible antibody
related complications that could cause hemolytic disease of the newborn.21
Women who are found to be Rh(D) negative may need anti-D
immunoglobulin therapy throughout their pregnancies. In traditional
management, the identification of the fetal blood type must be determined.
This is accomplished by first checking the blood type of the fetus’s biological
father. If the father is Rh(D) negative like the mother, then the infant will
also be Rh(D) negative. However, if the father is Rh(D) positive, further
testing will be necessary. DNA testing of maternal circulating blood may
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reveal the infant’s blood type; however, this test is known for false positive
results and is not available at all clinics. When this is the case, an
amniocentesis will be performed in order to confirm the severity of Rh(D)
incompatibility. Because this procedure is invasive and does not come
without the possibility of serious complications, it is only performed when
blood tests indicate high maternal anti-D titers.
Hemoglobin and hematocrit and Mean Corpuscular Volume (MCV) testing will
check for warning signs of hemoglobinopathy, anemia, and thalassemia that
may affect a woman’s pregnancy and her newborn.22 A decrease in
hemoglobin and hematocrit levels is expected during pregnancy. Normal
hemoglobin in the first trimester should be 11.6 to 13.9 g/dL, hematocrit
between 116 to 139 g/dL, and MCV levels of 85 to 97.8 fl.
Immunity to rubella23 is important because a rubella infection, also known as
German Measles, can cause miscarriage, stillbirth, and congenital risks such
as intrauterine growth restriction, hydrocephaly and other abnormalities. If
not immune and exposed to infection, women may need to be counseled on
early pregnancy termination to prevent stillbirth or catastrophic
abnormalities in the fetus. While there is a vaccine available for this disease,
it is a live-attenuated vaccine and thus should not be given during
pregnancy. The delivery of this vaccine in pregnancy may result in the
transmission of the virus to the fetus prenatally.
Testing for varicella immunity24 is necessary because, while uncommon, fetal
effects of varicella-zoster infection can result in fetal scaring, microcephaly,
mental retardation, optic nerve atrophy, limb abnormalities, and low birth
weight. Congenital abnormalities result in a 30% mortality rate in the child’s
first four years of life. The best way to prevent this disorder is to receive the
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varicella vaccine before becoming pregnant. Much like the German Measles
vaccine, pregnant women should not receive this vaccine while pregnant.
Screening for Human Immunodeficiency Virus (HIV) is done to give the
mother an opportunity to decide whether or not to continue the pregnancy
and to help physicians control delivery to reduce the risk of transmission to
the fetus. If the mother tests positive for HIV, the clinician should help her
adjust to an appropriate antiretroviral treatment plan. Her infant will then be
tested 14 to 21 days post birth and again 1 to 2 months later. Infants whose
mother received treatment during pregnancy are at a lower risk of
contracting the disease during pregnancy and birth. HIV positive mothers
should not be encouraged to breastfeed.
Syphilis Testing25 is appropriate because a mother systemically infected by
the causative spirochete Treponem pallidum can cause perinatal death, low
birth weight, premature birth, congenital anomalies as well as active
congenital syphilis in the neonate. Other long-term sequelae include
deafness and neurological retardation.
The American College of Obstetrics and Gynecologists recommends that all
women be tested for Hepatitis B Antigen26 to prevent perinatal transmission.
Hepatitis infection can cause cirrhosis and hepatocellular carcinoma. If a
mother does test positive for hepatitis B while pregnant, her health team will
need to weigh the pros and cons of treatment, primarily in the third
trimester. The higher the viral load in the circulating blood, the more likely
the mother will need pharmaceutical treatment of hepatitis B. Medications
that suppress this viral load will lower the risk of mother to fetus
transmission. As with HIV, mothers with hepatitis B should not be
encouraged to breastfeed their neonates.26
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The health clinician will also need to refer the prenatal woman to a dentist to
care for her oral health. There is no evidence that dental health care such as
tooth extraction, cavity filling and root canals should be delayed because of
pregnancy.27 If anything, there is evidence endorsing the idea that dental
care during pregnancy promotes better maternal and fetal health.27
Depending on the information collected during the patient’s history, some
patients may require a referral to genetic specialists, psychiatrists, or a
social assistance program. During the first visit, the clinician will get an idea
of the prenatal patient’s estimated due date, calculate BMI, and provide
counseling should her BMI be over or under the expected normal weight.
The patient will also have labs performed, usually both blood and urine
testing, to check for hCG levels, signs of underlying health problems, or
infectious disease. Clinicians will also ask the mother about her health
history including past obstetrical and gynecological care as well as personal
illness.
Once the history-gathering portion of the appointment is completed, a
general physical assessment followed by a pelvic exam will be done. At the
end of this initial appointment, the clinician may refer the patient to a
dentist to continue oral healthcare began before pregnancy, an ultrasound
technician to verify fetal health and the estimated due date, and/or a genetic
specialist, social worker, or other health clinician dependent upon the data
collected. Between 8 and 10 weeks, an ultrasound is ordered to confirm the
estimated date of delivery through measurement of fetal crown to rump
length as well as verify the pelvic health and shape determined at the first
clinical pelvic exam.
This section has discussed what a woman can expect during the history and
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physical portion of her first prenatal clinic appointment. Using the
information gained through the history and physical, how would the clinician
respond to the following case scenario?
A patient has just arrived for her initial physical examination of her new
pregnancy. She received a positive pregnancy test two days ago and is 3
days late for her period. She asks about the following tests and
procedures, wondering when they will be performed. As her primary
clinician, you would be correct in explaining that which assessment will
likely not be performed at this time:
a) Calculation of body mass index.
b) Evaluation of areas prone to edema, i.e., hands, face and ankles.
c) Fetal Doppler assessment.
d) Pelvic examination.
Choice C is correct. The clinician would explain that because she is likely
between 4 and 5 weeks pregnant, a fetal doppler assessment would not be
performed at this time. A fetal Doppler will likely be able to pick up fetal
heart tones between 10 and 12 weeks gestation.
Identifying Existing Risks In The Pregnant Mother
Ideally, women would all start out their pregnancy completely healthy and
without known health risks. Unfortunately, no life event is perfect and that
includes pregnancy. For many women, existing health risks must be
identified and managed from the start of their pregnancy to promote the
best outcome for their unborn child, as well as their own health. The clinical
team’s task is to take note of these existing health risks at the initial
prenatal visit and to create a therapeutic plan to manage health concerns.
All prenatal care is aimed at helping the mother have a healthy, full-term
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pregnancy and an equally healthy newborn.
Preexisting Hypertension in Pregnancy
During all prenatal visits, a blood pressure will be taken in order to track
how a woman is adapting to her pregnancy and to identify underlying
hypertension. Tracking blood pressure is important during pregnancy since
expectant mothers tend to have lower blood pressures during their first
trimester. While it is always important to record vital signs throughout a
woman’s pregnancy, the first few readings are the most important because
these evaluations help clinicians establish a baseline blood pressure.
This makes differentiating between preeclampsia and preexisting
hypertension possible.29
Preeclampsia
Preeclampsia is a systemic condition where a woman develops high blood
pressure later in her pregnancy, or after 20 weeks. It can cause excessive
bleeding due to thrombocytopenia, or a low blood platelet count, visual or
mental changes, edema, renal abnormalities, end-organ damage, and
pulmonary congestion.
Preeclampsia sometimes results in seizures in the mother, a subsequent
issue that increases the risk for prenatal injury as well as delayed
oxygenation and potential risks to the developing fetus. To differentiate
between preeclampsia and preexisting hypertension, clinicians need to look
at the patient’s previous health history, such as whether she has had
charted evidence of high blood pressure before. If the pregnant woman has
had evidence of previously charted high blood pressure, it is likely that she is
not experiencing preeclampsia as a result of her pregnancy.30
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Preeclampsia develops after 20 weeks gestation and is characterized by the
finding of large amounts of protein in the mother’s urine and a high blood
pressure.30 The pregnant woman’s blood pressure is usually defined as being
high when it reads over 140 systolic and 90 diastolic for two readings
separated by a few hours. Normally, protein does not pass into the urine,
but with enough force behind it, blood pushes proteins through the kidney’s
filtering systems, allowing protein to spill into the urine and later be detected
upon urinalysis. Long-term high blood pressure can lead to kidney damage,
as well as problems with fetal oxygenation and health. For this reason, most
women with preeclampsia will have a scheduled cesarean section before
their due date.
Screening for preeclampsia with a urinalysis looks for [+1] result of protein
in the urine. This result is indicative of about 30 to 100 mg/dL of protein in
the urine. False positives of proteinuria do occur, especially in the presence
of alkaline urine, or urine with a pH over 7.0, gross hematuria, or semen.
False negative occurs most commonly in circumstances involving
dehydration with hyponatremia, acidic urine, or urine with a low specific
gravity.30
HELLP Syndrome
HELLP syndrome refers to Hemolysis of the red blood cells, Elevated Liver
enzymes, and Low Platelets, all of which are grave consequences of longterm or suddenly worsened preeclampsia. In most cases, delivering the fetus
as soon as possible prevents complications from the disorder. Unfortunately,
this may in some cases mean preterm delivery of the infant. Until delivery
occurs, the health clinician will treat the prenatal client with intravenous
magnesium sulfate to prevent seizures and corticosteroid medications to
increase fetal lung development should the infant need to be delivered early.
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Preterm delivery occurs before 36 weeks gestation. A premature infant is at
an increased risk of SIDS, respiratory complications, and may require a stay
in the neonatal intensive care unit. HELLP syndrome is managed in hospital
and varies depending on the fetus’s estimated gestational age.
Best practice standards indicate that there is little risk of an adverse
outcome if this condition is treated conservatively when the fetus is
premature and less than 37 weeks estimated gestational age. In order to
preserve maternal health, a cesarean section will likely be performed once a
woman with HELLP syndrome shows signs of worsening condition and poor
lab result findings. Delivery by cesarean section increases for infants whose
mother has either type 1 or type 2 diabetes.
Vaginal birth is generally the preferred method of delivery as it comes with
fewer complications to both the mother and neonate. However, as previously
mentioned, in circumstances such as the development of HELLP syndrome,
cesarean section may be preferable.31,32
Pharmaceutical Therapy in Hypertension
Pharmaceutical therapy is recommended for all patients with severe
hypertension (systolic blood pressure equal to or greater than 160 mmHg
and diastolic blood pressure at or above 110 mmHg). Combatting mild to
moderately high blood pressure is done through careful monitoring of the
mother’s vital signs while also watching for the addition of signs and
symptoms of increased pressures like blurred vision, swelling and headache.
If these appear alongside high blood pressure, drug therapy is likely needed.
Medications considered in the treatment of prenatal high blood pressure
include methyldopa, labetalol, nifedipine, and hydralazine.31,32
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Methyldopa
Methyldopa works to treat high blood pressure by relaxing and dilating the
blood vessels. In terms of safety, this medication’s effects on fetal
development are not alarming and are thus considered safe. The downside
to this medication is that some women feel it has a sedating effect while it
only acts as a mild antihypertensive with a slow onset of action.
Labetalol
Labetalol is a beta-blocker that acts on both alpha and beta adrenergic
receptors, creating a stronger antihypertensive impact than more traditional
beta-blockers. The downside to this medication is that liver damage,
premature labor, neonatal apnea, bradycardia, and fetal growth restriction
have all been reported as possible side effects to this medication. Still, this
drug continues to be employed as an effective blood pressure-lowering agent
when use of less controversial drugs has not proved effective.
Nifedipine
Nifedipine is a calcium channel blocker used widely in pregnancy with little
report of major adverse outcomes. Other calcium channel blockers may also
work in the same fashion but have not been studied as often as nifedipine.
Hydralazine
Hydralazine can be given intravenously or orally and is used widely to treat
preeclampsia. A small increase in adverse effects have been noted in the use
of hydralazine over labetalol, but not a large enough of an increase to justify
its discontinuation. Nursing considerations for the use of this medication
includes watching closely for an unpredictable hypotensive response, reflex
tachycardia and fluid retention.
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While bed rest is not advised for women with preexisting hypertension, there
are no large studies on whether exercising or a change in activity level
should be implemented in order to improve blood pressure. The clinician
should make these decisions on a patient-by-patient basis, taking into
account the severity of the mother’s hypertension and whether or not she is
symptomatic.
A dietary reduction of salt should be part of the management of a pregnant
patient who is found to have preexisting hypertension on her initial prenatal
visit. Foods to avoid should be discussed including canned, processed, or
prepackaged foods, as these tend to be sodium rich. The use of fresh herbs
and spices to enhance flavor should be encouraged rather than adding extra
salt to food at meal times. For women finding it difficult to reduce sodium
intake, a referral to a registered dietician may be in order.
Acquired Heart Disease During Pregnancy
Valvular heart disease is most easily understood as a cardiac disease caused
by lesions on the valves of the heart. These lesions are generally the result
of congenital abnormalities or acquired diseases like rheumatic fever.33
Clinicians need to know about these valvular heart diseases, like mitral valve
stenosis, aortic stenosis, or mitral regurgitation as soon as possible, so that
they can create an appropriate plan of care. To assess for these risks,
cardiac auscultation should be performed with a stethoscope near the mid to
lower left sternal border to help identify an underlying mitral valve issue.
Women should be asked about their history of rheumatic fever, past heart
problems, or current use of anticoagulant therapy to prevent blood clots. If
identified, a patient with valvular heart disease will need to seek a referral to
a cardiologist and will need to see this physician in conjunction with a
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primary OB/GYN physician throughout her pregnancy.
Cardiomyopathy is flawed ventricular function that can occur as a result of
HIV infection, Parvovirus or Fifth disease, Enterovirus infection, Lyme
disease, or Staphylococcus aureus infection of the blood. A woman with
cardiomyopathy should have an echocardiogram after a confirmed
pregnancy to evaluate the current state of her heart’s function. Symptoms of
cardiomyopathy include pulmonary congestion heard when auscultating the
lungs, edema, chronic fatigue, and jugular vein distention, depending on the
respective type of cardiomyopathy. Any patient suspected of having
cardiomyopathy should be referred to a cardiologist.34
Infective endocarditis usually occurs with intravenous drug use or an
identified underlying condition. Infective endocarditis occurs when the
endocardium becomes infected, usually by a fungus or streptococcal or
staphylococcal bacterial colony. Studies are limited but both fetal and
maternal death may occur in between 20-25% of cases. To assess for
prenatal risk of infective endocarditis at the initial visit, therapeutic
communication techniques should be used to inquire about possible
intravenous drug use and previous cardiac conditions should be explored.35
Coronary artery disease can be identified easily in pregnant women who
have had previous myocardial infarctions or percutaneous coronary
interventions and coronary artery bypass surgery. There is no strict protocol
for the management of coronary artery disease in pregnant women but with
the mean age of first-time mothers increasing as well as the incidence of
mothers becoming pregnant at an advanced maternal age, it is important to
ask women about their cardiac history during the initial visit.
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Arrhythmias are easily identified through cardiac auscultation and an
accurate gathering of a patient’s medical history. Management of cardiac
arrhythmias in pregnant women can be a difficult balance as medications
intended to treat these maladies are considered to be category C
medications, thus prenatal harm to the fetus cannot be ruled out. Still the
risk to the mother’s cardiac health may require continuation of
antiarrhythmic drugs taken before conception.36,37
Patients with arrhythmias should be evaluated for a past history of blood
clots or management of their disease with anticoagulant medications.
Warfarin will likely be withheld during pregnancy and instead prenatal
patients will be given once or twice a day injections of low molecular weight
heparin. Because of the increase in risk of hemorrhage during labor, most
women should discontinue anticoagulation therapy in the few weeks
preceding delivery. As with the other cardiac complications, prenatal patients
with suspected arrhythmias should have an echocardiogram performed and
be referred to a cardiologist.38
Heart transplant recipients can be identified through physical examination of
the sternum where a large scar will indicate heart surgery. It will be likely
that the heart transplant recipient will have had preconception counseling
and discussed the ethical considerations to both mother and fetal health
before pregnancy. This discussion should again occur at the first prenatal
appointment after an investigation into the mother’s current health and
ability to tolerate pregnancy safely.39,40
Diabetes During Pregnancy
Both type 1 and type 2 diabetes pose similar risks to pregnancy. Type 1
diabetes involves the inability of the pancreas to produce insulin, while type
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2 diabetes involves resistance to insulin developed in a person’s body over
an extended period of time. Diabetic women should be identified through
gathering a thorough patient history. Women with diabetes should be
counseled about their condition.
To identify type 2 diabetes, the clinician should look for risk factors.41
Women who are over the age of 45 are considered at risk for preexisting
type 2 diabetes and are also considered to be of advanced maternal age
(any pregnant woman over 35 years old). This categorization places the
mother at a greater risk for preeclampsia, of delivering an infant who is
large for gestational age, a higher incidence of cesarean section and, worst
of all, women over the age of 35 are more likely to deliver a stillborn infant.
Newly pregnant women who are overweight or obese are more likely to
develop type 2 diabetes before 20 weeks gestation and/or have preexisting
insulin resistance before pregnancy. Overweight and obese women should be
referred to a dietician who specializes in promoting healthy eating habits and
the prevention or management of gestational diabetes.
According to the National Institute of Health, physical inactivity strongly
correlates with the development of type 2 diabetes before pregnancy.
Clinicians working with women planning on becoming pregnant should
encourage a healthy lifestyle that incorporates extra physical activity and
exercise whenever possible. The clinician can suggest simple ways to
increase cardio-based exercise such as parking further away from a store’s
entrance, using electronic fitness trackers to keep an eye on the number of
steps per day, or joining a stress relieving exercise class at a local gym such
as dancing or swimming.
Racial origin seems to play an important role in the development of type 2
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diabetes during and before pregnancy. Whether this is due to genetics,
cultural variations in diet, or an environmental cause, the teaching is the
same; some races must be more cognizant of certain dietary factors than
others. African Americans, Hispanics, Polynesians, and women of Native
American heritage are more likely than other races to develop insulin
resistance.
Type 2 diabetes involves excess glucose circulating the blood stream and
this extra sugar crosses the placenta. Once in the fetal bloodstream, this
glucose stimulates insulin production, which encourages rapid growth.
Previous delivery of a large infant, or one over 9 pounds is an existing risk
factor for type 2 diabetes. While previously mentioned, it should be restated
that there is a genetic component to diabetes that cannot be denied.41 There
exists a strong correlation between having a woman with a family history of
type 2 diabetes, especially a parent or sibling, and the woman developing
the disease at some point during her lifetime.
Type 2 diabetes may be identified in the clinic setting if the patient presents
with glucose in the urine as well as a random blood glucose level of 200
mg/dL. These findings will need to be verified with an in-lab blood draw of
fasting blood glucose and A1c levels.42 The guidelines to obtain a fasting
glucose level is further discussed below.42,43
Fasting blood glucose levels should be taken after the pregnant mother has
fasted for 12 hours. Most healthcare providers will ask that the mother go to
bed, and not eat or drink sugary fluids until the blood draw scheduled for the
following morning. A1c levels measure long-term blood glucose control. If
drawing strictly for A1c levels, patients will not need to fast before this
procedure. However, since fasting blood glucose and A1c are often tested at
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the same time in order to confirm gestational diabetes or type 2 diabetes in
prenatal clients, the prescribing physician may require fasting. Since A1c
measures long-term blood sugar levels, fasting will not alter the results of
this specific test. To confirm type 2 diabetes after receiving a positive urine
glucose test, clinicians should expect to find a fasting blood glucose of 126
mg/dL or higher and A1c level of 6.5 or higher as well.
Whether she is suffering from type 1 or type 2 diabetes, the diabetic mother
is at an increased risk for the development of many serious pregnancy
complications. As mentioned previously, prenatal hypertension is an existing
condition where the mother has preexisting high blood pressure or high
blood pressure that develops in the first 20 weeks of her pregnancy. Dietary
changes will certainly be in order. This includes a lowered salt intake and a
focus on water and healthy fiber rich vegetables. A registered dietician will
best be able to determine how to help the patient coordinate achievable
dietary modification goals for comorbid diabetes and hypertension. At
subsequent prenatal visits, chart information sent over from the registered
dietician should be reviewed and the potential successes and barriers to
effective dietary and lifestyle changes discussed with the patient.
Diabetic mothers are at a higher risk for miscarriage and perinatal death.
Miscarriage generally occurs between 4 and 12 weeks, but all fetal deaths
occurring before 20 weeks are considered a miscarriage. Perinatal death
occurs after 20 weeks gestation. The emotional state of the mother and her
family should be monitored and discussed post-miscarriage or perinatal
death. A referral to a social worker or other therapist may be in order.
Hemorrhage secondary to diabetes occurs during labor and birth primarily
because of high blood pressure. Clinicians will need to make preparations for
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management of hemorrhage, should it occur. Knowing the pregnant
woman’s blood type and having an intravenous line started will expedite
blood replacement if necessary.
Pregnant mothers with diabetes are at risk for delivering an infant both large
and small for gestational age. This variation in infant size is based on two
different pathological systems. Babies are born large for gestational age
because of insulin production created by their pancreases in response to the
excess amount of sugar crossing over from the placenta and into their blood
stream. Insulin stimulates cells to grow and expand, creating larger for
gestational age infants. Diabetic mothers who give birth to infants who are
small for gestational age may also be experiencing high blood pressure,
which causes low levels of hypoxemia to the infant, restricting fetal growth.
The infant of a diabetic mother is at risk for prematurity, persistent
hyperinsulinemic hypoglycemia of infancy, respiratory distress, congenital
anomalies, hypocalcemia, hyperbilirubinemia, and cardiomyopathy.
Infants may be born prematurely, or before 36 weeks gestation, because of
a lack of intrauterine growth or development, high blood pressure, severe
preeclampsia, or HELLP syndrome. Pre-term delivery may occur
spontaneously or through induction by the healthcare provider in order to
prevent maternal or infant injury.
While in utero, fetuses of a diabetic mother are receiving excess glucose
through the umbilical cord and thus producing plenty of insulin to keep their
own blood sugar levels in check. Once separated from the mother’s placenta,
the neonate may continue to produce insulin. Known as persistent
hyperinsulinemic hypoglycemia of infancy, this hypoglycemia is very
dangerous and will need strict monitoring and management. Signs and
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symptoms of hypoglycemia in the neonate of a diabetic mother include
lethargy with hypotonia, tremors, pallor, tachycardia, cyanosis, apnea,
seizures, and congestive heart failure.41
Respiratory distress is recognized in infants who are apneic, gasping to catch
their breath while maintaining low oxygen saturation levels, and appear
cyanotic. Respiratory distress is more likely to occur when the diabetic
mother delivers prematurely, leaving the infant with little to no surfactant in
the pulmonary alveoli and limiting the ability to exchange oxygen and
carbon dioxide. Infants in respiratory distress will need admittance to the
neonatal intensive care unit and given a manufactured surfactant via an
endotracheal tube alongside the provision of oxygen via a continuous
positive airway pressure machine.44
Maternal diabetes is coupled with depleted fetal iron stores. This
complication is related to the mother’s blood sugar control prenatally rather
than the mother’s iron stores.45
Congenital anomalies occur more frequently in the infant of a diabetic
mother with an increase in that frequency for mothers who are insulin
dependent. The exact pathophysiology behind the teratogenicity of maternal
diabetes is still unknown.46
Low calcium in circulation, or hypocalcemia, occurs in the infant of the
diabetic mother because of lowered production of the parathyroid
hormone.47
Hyperbilirubinemia occurs when red blood cells are broken down rapidly,
leaving the infant jaundiced or yellow in coloration. It can also cause
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lethargy and impaired feeding in the neonate. In infants of the diabetic
mother, hyperbilirubinemia likely occurs as a result of polycythemia or
ineffective red blood cell production.48
Cardiomyopathy in the neonate is generally caused because of thickening of
the heart walls, hypertrophy, and from excess insulin production. In most
circumstances, this condition resolves itself within a few months after
birth.34
Clinicians who detect diabetes in the newly pregnant mother should make
certain that she is referred to a dietician who specializes in controlling
diabetes. As noted in many of the previous complications, well controlled
blood glucose levels during pregnancy is a defining factor in the avoidance of
dangerous diabetic-complications in the neonate. Pregnant mothers with
diabetes should be told to check their blood glucose between 2 and 4 times
daily depending on the severity of their illness.
Depression During Pregnancy
Depression is an extremely common condition occurring in about 18% of
Americans.49 Screening for depression is very important at the first prenatal
appointment. Treating depression in the pregnant mother is considered a
necessary part of prenatal care because untreated depression in pregnancy
may contribute to non-adherence to prenatal care recommendations,
substance use (specifically alcohol and tobacco), fetal growth restriction, and
preterm birth.49 The methods of action behind some of these adverse
outcomes are unknown, but the correlation between them and lacking
prenatal mental health treatment is undeniable.
Screening for depression should begin by looking for risk factors, life stress
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including emotional and socioeconomic strain, and lack of social support
within the prenatal client’s friends and family. Domestic violence increases in
frequency while a woman is pregnant. It is not difficult to understand how
this stressor could lead to chronic unipolar depression.50
Warning signs of depression include51 dysphoria, or a general feeling of
discomfort and agitation, paired with a loss of interest in activities that are
normally enjoyable. Women may also report changes in appetite, sleeping
habits, or focus and concentration. Depression may affect a woman’s
neurological function, which can slow the woman’s movements and her
ability to make rapid judgments. Suicidal ideation is a serious indicator of
depression and one of the riskiest outcomes of depression.
The use of selective serotonin reuptake inhibitors (SSRIs) to treat depression
has been studied in pregnant women with little to no risk found of
spontaneous abortion, hypertension, or perinatal death. Clinicians must
weigh the pros and cons of using antidepressants to treat depressed
pregnant mothers. Some common SSRIs given during pregnancy include
fluoxetine, citalopram, and sertraline.52
Many pharmaceutical agents have been proven safe through long-term
studies. Decisions on whether or not to treat depression pharmaceutically
will need to be made carefully by the clinician and the prenatal client.
Genetic Conditions Affecting Pregnancy
Screening for genetic conditions aids the clinician in developing an
appropriate plan of care beginning at the initial prenatal appointment.53
These tests may be performed at the first prenatal exam or during the
second trimester, depending on the risks found when gathering the patient’s
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history. These tests address the risk that an infant will be born with an
inherited birth defect or genetic disorder. Screening tests are comprised of
blood tests that measure the level of certain substances in the mother’s
blood usually paired with an ultrasound exam. These assessments determine
the risk that a baby will have Down syndrome or other trisomies, as well as
neural tube defects or inherited diseases that may lead to death or mental
abnormalities.
Carrier tests are a type of screening test that can show if a person carries a
gene for an inherited disorder. Carrier testing often is recommended for
people with a family history of a genetic disorder or people from certain
races or ethnicities. Cystic fibrosis carrier screening is offered to all women
of reproductive age because it is one of the most common genetic disorders.
Cystic fibrosis is an illness that causes abnormal mucous and sweat
formation. It affects the pancreas and thus how food is broken down after
meals. In turn, digestion is also altered causing constipation, foul-smelling
stool, weight loss, and failure to gain weight. Cystic fibrosis also causes
excessively thick mucus to build up in the lungs often causing fatigue,
wheezing, and a wet cough. If the infant with cystic fibrosis lives past
childhood, they face an average life expectancy of 37 years.54 Since cystic
fibrosis is an inherited disorder known as an autosomal recessive disorder it
only appears in an infant when both parents have the mutated gene without
necessarily showing signs of the disease.55
Testing for the gene that carries Huntington’s disease is done when there is
a history of this disorder in the family. Huntington’s disease is a major
degenerative brain disorder. It is incurable and the patient with Huntington’s
disease will eventually be unable to think clearly, will have personality
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changes, and difficulty controlling movements. Being a dominant disorder, if
a pregnant patient has this gene, there is a 50% chance her child will
develop this devastating neuromuscular disorder. How would the clinician
best address concern of cystic fibrosis in the following scenario? What
information about this genetic condition should the health clinician share
with the patient?
Case Scenario:
Kelly is a 31-year-old woman pregnant for her second time. Her first
child is 4-years-old, was born vaginally and is considered to be a healthy
preschooler. During her initial prenatal visit, Kelly explains that she’s
worried that her newborn child will be born with cystic fibrosis because
her sister’s daughter has it. What information about this genetic
condition should the healthcare provider share with Kelly?
In the above scenario, the clinician would best address the patient’s
concerns by discussing the genetics behind cystic fibrosis. In order for a
child to develop cystic fibrosis, both parents must have the gene for this
disorder. In the case of Kelly’s sister, both she and the father of their child
had to have been carriers of the gene. Since Kelly has had a healthy child
with her spouse, it is unlikely that they are both carriers of the gene. Still,
the clinician may recommend that both she and her unborn child’s father be
tested genetically to see if they are carriers of the gene. This will calm their
fears or help them prepare in the event that they are both indeed carriers.
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Health Conditions And Pregnancy Outcomes
There are well-researched health risks that can occur during pregnancy.
Medical researchers have suggested that identifying health risks early in the
pregnancy during the initial prenatal visits improve the health outcomes of
the expectant mother and baby. Some women are at greater risk of a
pregnancy complication than others, depending on their socioeconomic
conditions and depending on a pregnant woman’s history. This section
discusses areas of major concern that can place a woman and her unborn
baby at risk of poor pregnancy outcomes.
Sexually Transmitted Diseases
Complications associated with various sexually transmitted diseases are
discussed here. HIV, syphilis, hepatitis B, chlamydia, and gonorrhea are
common sexually transmitted infections that may impact maternal, fetal,
and neonatal health.
Pregnant women are at an increased risk of carrying a sexually transmitted
disease if they are or have been sex workers, have had a new sexual partner
in the last 60 days, multiple sex partners or concurrent sexual partners,
history of previous sexually transmitted diseases, use illicit drugs, are of low
socioeconomic status, or are unmarried.56 The clinician should use
compassionate and therapeutic communication when initially screening
prenatal clients for sexually transmitted diseases and when explaining
possible risk factors.
Alcohol and Tobacco Use
Several screening tools, such as CAGE, TWEAK, or AUDIT-C, exist for
assessing a newly pregnant woman’s alcohol use. Whichever screening tool
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the clinician uses, it is also important to approach the subject of alcohol use
sensitively and to formulate a plan to stop drinking that the patient and
fetus can tolerate.58 The patient needs to be educated that alcohol use is
very harmful to developing fetuses and should be stopped completely during
pregnancy. Fetal development is at high risk during the first trimester.57
According to the American College of Obstetrics and Gynecology, all women
should be screened for tobacco use at their initial prenatal appointment.59
Women should be asked if they have ever smoked cigarettes, the last time
they smoked cigarettes, and if they currently smoke. Many women are afraid
to report their tobacco use and they should be informed of the risks
associated with smoking while pregnant whether they report they are
smokers or not. Risks to the mother include poor weight gain and
preeclampsia.60 The fetus is put at major risk; an expectant mother that
smokes is more likely to have a fetus with congenital malformations and
acquired growth restriction, as well as be born prematurely, suffer from
sudden infant death syndrome (SIDS), or display long-term behavioral
problems in childhood.
Quitting smoking often causes withdrawal symptoms whether the person is
pregnant or not. Pregnant women may find these symptoms extra
uncomfortable, especially if they are already experiencing discomfort related
to their pregnancy. Common nicotine withdrawal symptoms include tremors,
irritability, headaches, fatigue, stomach discomfort, and restlessness. To
deal with symptoms, patients should be encouraged to take walks, rest
when tired, and to drink plenty of water.60
Inadequate Nutrition
Poor nutrition or malnutrition in pregnancy is a serious problem, which needs
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to be screened for and addressed at the initial prenatal appointment and
followed up should another assessment be indicated. Malnutrition can occur
because the patient has an eating disorder, lacks the funds to purchase
enough food for herself, or eats meals that contain little to no nutritional
value.
The clinician should evaluate the prenatal patient’s eating habits by
discussing how many meals she eats in a day. If she states that she is
eating less than two meals a day, the clinician should consider this to be a
warning sign. The patient should be asked what her typical day is like in
terms of meal preparation and nutritional intake. The clinician should
evaluate how many servings of vegetables, fruits and protein sources the
patient typically eats as well as food or beverages with added sugar.61
The patient’s health history should be discussed prior to the time she
becomes pregnant. The clinician should review the patient’s health history
extensively, and enquire: Does she have diabetes? Has she ever had
gestational diabetes? Has she ever suffered from an eating disorder such as
bulimia or anorexia? The clinician should engage with the patient
compassionately to learn about her social situation. Does she have enough
money to purchase the healthy foods that she needs? Is she drinking alcohol
or smoking cigarettes?
Pregnant patients should be educated on the risks of poor nutrition,
including delivering a baby of low birth weight and pre-term, or having a
newborn with congenital malformations. Women who are considered high
risk in terms of poor nutrition should be referred to a registered dietician
and/or a social worker to help them get on a healthy and full diet to support
their pregnancy.61
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Unhealthy Weight Issues
A healthy pregnancy is partially achieved by beginning the pregnancy at a
healthy weight and a healthy physical activity level. Being either overweight
or underweight can cause problems during gestation and lead to an
increased risk of complications prenatally as well as after delivery.
Underweight women with a BMI below 18.5 should be advised to meet with
a registered dietician and attempt to gain 28 to 40 pounds over the course
of their 9-month-long pregnancy. Women starting their pregnancies with
BMIs considered underweight are at increased risk of miscarriage, delivery
before 37 weeks gestation, and delivering a neonate who is of low weight for
its gestational age. Their infant is subsequently at greater risk for infant
mortality and childhood obesity later in life.62
Women who are overweight or obese are advised to gain less weight, usually
under twenty pounds. Just as with women who are underweight, overweight
women should seek education from a registered dietician in order to learn
how to avoid excessive weight gain during pregnancy and associated risks.
Overweight or obese pregnant women are at an increased risk for pregnancy
induced hypertension, preeclampsia, and, worst of all, HELLP syndrome.
Prenatal Morbidity and Mortality of Overweight Mothers
Cardiomyopathy, or the inability of the heart to properly pump blood
throughout the body, is seen more commonly in pregnant women with high
body mass index. The development of gestational diabetes occurs most
frequently in women with high body mass index.
Infants born from mothers who have high body mass index are more likely
to be born prematurely. Perinatal mortality, or death in the womb, is a
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greater risk among fetuses of overweight mothers.62 These infants also have
an increased occurrence of SIDS. While it seems contradictory, women who
are overweight are likely to deliver infants both small for gestational age and
large for gestational age infants. This may have to do with a hyper-insulin
response or existing high blood pressure.
A clinician must know how to differentiate between preexisting hypertension
and the development of preeclampsia in pregnancy. Mothers who develop
high blood pressure before 20 weeks gestation have likely been suffering
from preexisting hypertension, while pregnant women who develop
hypertension after 20 weeks gestation are likely dealing with preeclampsia.
In cases of severe preexisting hypertension, there are prescriptive options to
manage high blood pressure such as using labetalol, calcium channel
blockers, methyldopa and hydralazine. A clinician must also know how to
identify cardiac issues that could have an impact on pregnancy and when the
case should be referred to a cardiologist.
Adapting To Pregnancy:
Physical, Emotional And Social Considerations
For first time mothers and experienced mothers alike, to describe the
adaptation to pregnancy as being a challenging process is an
understatement. From the moment of conception, a woman’s body begins a
tumultuous transition, yet the emotional and social implications of pregnancy
also affect how clinicians should care for the pregnant woman. Changes in
friendships and social standings are not unlikely to occur in the life of a new
mother, and suggestions and referrals will need to be made to manage the
challenges appropriately.
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The husband and child or children of a newly pregnant woman should also
have their needs and their emotional resilience addressed. The clinician
should evaluate whether the expectant mother has a strong family support
system; strong family support is associated with decreased risk of
developing post-partum depression.63 During the first prenatal visit, careful
questioning, mindfulness teaching, and empathetic care provided by a
unified health team effectively promote physical, emotional and social
wellness in the entire family.64
The First Trimester
During the first trimester the hormone relaxin begins flooding the body,
causing the mother’s uterine ligaments to loosen and prepare for the
inevitable housing of a full-term sized infant. Human chorionic gonadotropin
influences breast development and causes growth and changes to the uterus
that help maintain the pregnancy. At the implantation and thus hatching of
the blastocyst in the uterine lining, the cells of the uterine lining are
stimulated with a fresh supply of glucose, which creates the potential for
syncytiotrophoblast epithelia development. This releases steroids and other
hormones used to regulate fetal and maternal systems. Insulin-like growth
factors begin acting to influence embryonic and fetal growth.65
There are many hormones involved in the transformation of a woman’s body
during pregnancy. Many are responsible for the uncomfortable parts of
pregnancy such as nausea and fatigue. Other physical changes in the
pregnant mother include full, growing breasts from increased blood to the
organs, in order to prepare them for milk production expected to occur
months down the road. Side effects from the hormone relaxin that are
common during the first trimester include heartburn, constipation, nausea,
and a generally slowed digestion.66
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Pregnancy glow is a real occurrence and the result of an increase in the
production of melanin. This increase creates a literal change in a woman’s
skin color, bronzing and darkening it to a glowing shade, even in her first
trimester. An increase in hair growth, on the scalp, body, and even
occasionally the face may be expected during pregnancy. Enhanced nail
growth is also common and usually a welcome change for pregnant
women.67
Blood cell mass and plasma volume increases as soon as 4 weeks gestation
and begins contributing to edema and nausea in pregnancy.68 The
respiratory center of the brain is stimulated early on in pregnancy, a result
of an increase in the hormone progesterone. Nasal discomfort also presents
itself as a result of glandular hyperactivity and subsequent congestion.69 This
process occurs similarly in the breasts.
Due to a change in several endocrine systems, the pregnant woman’s renal
glomerular filtration rate is increased and thus urinary frequency occurs. The
bladder fills more quickly and, because of the release of the hormone
relaxin, a loose pelvic floor increases urinary urgency as well.70 Slowed
digestion as a result of relaxin causes heartburn; and, constipation and
nausea are common in the early stages of pregnancy. Later on, an increase
in physical pressure from the fetus on the abdominal cavity increases the
gastrointestinal discomfort as well as gastric reflux.71
Women often notice joint looseness and sometimes an increased flexibility
during pregnancy, occasionally putting them at risk for musculoskeletal
injury and lower back pain.72
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Emotional and Social Changes in Early Pregnancy
Emotional and social changes are highly connected to pregnancy. Changes in
body image, comfort levels, and lifestyles all contribute to mood changes.
Hormones, such as progesterone and estrogen, are to blame for mood
swings in pregnant women, and women are able to tolerate these hormones
in varying degrees. Fatigue also contributes to emotional challenges as well
as a woman’s ability to participate in normal social activities. This decrease
in ability to tolerate activity and engage with peers often leads to the
woman’s feelings of isolation and a decrease in her overall support system.
To combat fatigue, pregnant women should be advised to drink plenty of
water and eat nourishing, energizing foods throughout the day. Nuts,
avocados, and foods with healthy fats and complex B vitamins elevate mood
and provide sustaining energy throughout the day. The prenatal patient
should be encouraged to incorporate these foods into each of their small
meals. Also, at least eight hours of sleep daily, with naps during the day
when possible, should be recommended.
Lifestyle changes can hugely impact a woman’s stress level and her ability to
cope with pregnancy. For example, the family may need to buy a larger
vehicle to accommodate another child, or be the first member among a circle
of friends to have a child. Whatever the lifestyle changes, the clinician
should discuss these with the patient and her family, as well as consider the
prenatal client’s support system for common stressors such as lack of friends
with children, a non-supportive workplace, or limited finances to maintain an
accustomed lifestyle.
Prenatal clinicians should keep plenty of pamphlets, flyers and other
resources on hand to direct women to pregnancy support groups, infant
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playgroups and social workers, when applicable. Women should be reminded
to practice self-care and to continue to do things they enjoy. This may mean
managing feeling tired to be able to continue social interactions with friends
by, for example, planning to return home from outings earlier than usual.
While habits may change, it is good to continue doing the activities of
enjoyment unrelated to pregnancy.
At the initial visit, the newly pregnant woman and her prenatal health team
should work together to brainstorm and come up with solutions for actual or
potential emotional, financial, or support stressors.73 As her body changes,
there will likely be accompanying feelings of nervousness surrounding the
impact of pregnancy on the body and her associated body image. The
clinician should identify body image issues that may create anxiety in the
newly pregnant woman and provide recommendations based on her needs
for support. Some women may need therapeutic counseling or nutritional
counseling from a registered dietician. Other women may only need
reassurance from the health team that their weight gain will be normal and
that they can have a happy and healthy pregnancy.73
The Family’s Adaptation to Pregnancy
Family members of a newly pregnant woman will go through changes as
well. These changes may not be physical in nature but they are still drastic.
Whether first-time partners learning how to cope with their partner’s new
emotional and physical state or children trying to understand what the
addition of another sibling will mean for their lives, the family of the
pregnant woman is an important consideration in prenatal care. Health
clinicians should take careful histories of their patient’s support system and
listen carefully for signs and symptoms of abuse or poor support systems.
Such issues, previously discussed, should be managed appropriately.74
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Newly expectant fathers or partners will likely feel some anxiety and
frustration. They may worry about their ability to care for their new child or
to provide financially for changes in lifestyle, which come with prenatal care,
birth costs and infancy. Another common anxiety is the health of their
partner or unborn child. They may also feel frustration over the inability to
relieve all symptoms of discomfort in their pregnant partner. All fathers or
partners will adapt to the pregnancy of their partner differently. Health staff
can help them best by listening to their needs carefully, suggesting support
groups, therapy, or open communication between the mother and partner.
Any concerns of an expectant mother’s children should also be addressed at
the initial prenatal appointment. Children may take the news of their
mother’s pregnancy differently, contingent upon their age, maturity level
and individual personality. While most children are adaptable and
understanding, some children may experience uncomfortable feelings such
as they may fear change and the unpredictable, may worry about their
mother’s health, and may be nervous about their care after the baby is born.
The clinician must be prepared to evaluate the levels of adaptation in the
patient’s children, discuss with her any concerns for her children and suggest
mindful, compassionate ways to discuss the pregnancy with her children,
and refer the family to a therapist or social worker if necessary.74
There is no protocol set in place for
discussing pregnancy and, in some
When it comes to telling children
about a woman’s pregnancy or
cases, pregnancy loss with children. It
pregnancy loss, it is the
is the health clinician’s job to support
healthcare team’s job to support
the family’s decisions regarding these
the family’s choices regarding
choices and to provide information
where applicable. Health staff should
the choice of how to discuss the
news with their children.
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never push their clients into making a decision they aren’t comfortable with.
It’s important for families to come to conclusions about their family
dynamics on their own with the full support of their health team.
Medication Safety And Pregnancy
Many pregnant women will inquire about medication safety at their initial
prenatal check-up. Common medications taken outside of pregnancy, such
as ibuprofen or aspirin, may not be recommended or safe to take while
pregnant. Firstly, all prenatal clients should be taught to report any
medications they are taking to their health clinician. Pregnant clients should
also ask their prescribers about the safety of any medication they would like
to take whether it is prescribed or purchased over the counter.
From 1979 until 2015, the Food and Drug Administration (FDA) created
pregnancy risk categories for medication labeling, in order to simply identify
the risks behind specific medications. While this method is being phased out
in favor of a more specific standard package, the category labeling method is
still taught and found in medication packaging today. These categories
include those outlined below.75
Pregnancy Category A
Pregnancy Category A medications have been studied to show that no fetal
abnormalities were reported in human studies. Medications commonly
considered pregnancy Category A include levothyroxine and most
multivitamins. Medications in this category are considered the safest and
have only remote possibilities of risk to the fetus.
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Pregnancy Category B Medications
Pregnancy Category B medications are taken when the benefit of the
medication outweighs any purported risks. There are usually no good studies
in humans; however, animal studies show little to no fetal abnormalities.
Pregnancy Category B medications may also include pharmaceuticals that
have shown some issues in animals but when used by pregnant women have
not led to any malformations. Most insulins used to treat diabetes and
amoxicillin used to combat bacterial infections are in this category. As with
all medications taken while pregnant, the benefit of these Category B
medications should outweigh the risk of harm to the fetus.
Pregnancy Category C Medications
Pregnancy Category C medications are always first looked at in terms of a
cost-benefit analysis. This is because little studies will have been performed
to show the risks involved with taking medications in this category. Category
C medications generally have no good studies done in pregnant humans,
while animal studies are either lacking or showing some potential for fetal
harm. Low-dose fluconazole is used to treat vaginal yeast infections and falls
into this category. Most SSRIs such as Zoloft of Celexa fall into this
category.
While risks are not well known or controlled when taking these medications,
the possible problems associated with untreated depression may outweigh
the risks. For example, women with untreated depression are less likely to
practice self-care, adhere to prenatal care, and refrain from harmful
substances like tobacco and alcohol. Infants born to mothers with untreated
depression are likely to suffer from low birth weight.
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Pregnancy Category D Medications
Pregnancy Category D medications have shown that infants exposed to this
drug have had issues directly correlated to exposure. Still, in some
circumstances, use of this medication may outweigh the risks, especially in
cases where the mother is being treated for seizures with phenytoin or with
some chemotherapeutic agents for cancer. Other Category D medications
include Paxil and Lithium.
Pregnancy Category X Medications
Pregnancy Category X medications are considered the most teratogenic of
medications. There are no situations in which the taking of these
medications outweigh the risks to the fetus. Studies on both humans and
animals show that pregnancy Category X medications result in direct fetal
abnormalities, usually severe enough to cause death in utero or after birth.
Such medications include Accutane, which is used to treat severe cystic
acne, and warfarin used to prevent deep vein thrombosis or stroke.
New Model for Medication Classification
The new model for medication classification uses a more inclusive labeling
system with information related to pregnancy, lactation, and to men and
women of reproductive age. The FDA made this switch in order to help
women and men of reproductive age fully understand the implications of
their medications without having to understand a letter-style grading
system.75 Instead, the sections are broken up into easy to read, detailed
explanations of potential risks.
The Pregnancy labeling comprises both labor and delivery along with the
nine months of gestation. A risk summary, clinical considerations, like a
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cost-benefit analysis, and available data are reviewed. There is also a
section focused on lactation and that provides information on the safety of
using the drug while breastfeeding, the amount of the drug that passes into
the breast milk, and the potential effect on the infant receiving the
medication through the mother’s breast milk.76
In particular, the new FDA labeling system covers females and males of
reproductive potential. The information provided discusses the need for
pregnancy testing, contraceptive concerns, and data on how fertility may be
affected by the medication. Health clinicians should be familiar with both
systems of drug labeling in order to prepare prenatal clients on both systems
of medication labeling. It deserves restating that, when in doubt, pregnant
mothers should be advised to contact their clinician’s office when they are
unsure about the safety of a medication.
Diet And Exercise During Pregnancy
It is vital that the clinician discusses healthy diet and exercise with the
pregnant patient. Many patients will fear that they will gain weight and they
need to be reassured that this is normal and necessary for the health of the
mother and the developing fetus.
The normal caloric needs of the non-pregnant woman should first be
discussed. There are a variety of variables to consider, such as age, height,
physical activity, and if the woman needs to gain, lose, or maintain weight.
Most women need approximately 1,600 calories to 2,400 calories per day.
The higher range of calories needed on a daily basis are higher for active
women and the lower number of calories are necessary for sedentary
women. As basil metabolism slows in aging women, they need fewer
calories.77 As previously discussed, if a patient has a normal BMI, she should
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gain between 25 and 25 pounds during a healthy pregnancy. Underweight
women and women with a multiple pregnancy will need to gain between 35
and 45 pounds, while overweight women only need to gain 10 to 25 pounds.
Calories should be obtained through nutrient-rich foods that are low in fat
and sugar and high in protein.78
Babies need plenty of calcium to promote healthy growth, especially for
bone growth. Iron is necessary for a healthy blood supply for the fetus and
to prevent anemia in the mother. Folic acid is also important in a healthy
diet to lower the risk of spina bifida in the baby, which is an underdeveloped
closing of the spinal column. The baby is also at risk for anencephaly (major
part of the brain, skull and scalp have not developed). A clinician should
instruct a mother that a diet rich in iron would also prevent a number of
other birth defects.
If a woman is not taking enough minerals or vitamins, the developing fetus
will use up most of the necessary nutrients, leaving less for her to use.
Between 9 and 11 daily servings of pasta, cereal, rice, and bread are needed
to give a mother the carbohydrates that will be needed to provide energy for
the baby’s growth and for the woman’s health. Fortified foods, such as
cereal, and whole-grains provide the necessary folic acid and iron.
The clinician should talk to the mother about the necessity of regular
consumption of fruits and vegetables. She should eat 3-4 servings of fruit to
give her vitamins A and C, fiber, and potassium. Foods like citrus fruits,
melons, and berries are high in vitamin C. Fresh fruits and fruit juices are
ideal; canned or frozen fruits are not as good sources of nutrition. Between 4
and 5 servings of vegetables everyday are optimal, providing vitamins A and
C, folic acid, magnesium, and iron. Again, the mother should aim to gain
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these from fresh vegetables. She ought to eat at least two servings from
leafy greens.
Milk, cheese, and eggs are excellent sources of calcium, phosphorous, and
magnesium. Clinicians should teach the mother to eat 3 servings a day. If
the mother needs to limit caloric intake, she should choose nonfat options.
Iron, protein, and zinc and vitamin B are found largely in nuts, poultry,
meat, eggs, and dry beans. The pregnant patient should be assured that fats
and oils are important. This is especially relevant to note if a mother is
hesitant to gain weight. Fats aid in the fetus’ brain development and are
necessary for growth.
The clinician needs to ask about special diets. Women who are vegetarians,
vegans, lactose-free, or eat a gluten-free diet need to make sure to plan
their meals carefully so that they consume nutrients that are necessary for a
healthy pregnancy and their baby’s development.
The clinician should discuss with the patient the importance of taking
appropriate amounts of fluids and vitamin supplements. Women should
avoid caffeine and sugar and should consult their clinician regarding how
much of these drinks are safe to consume. Most mothers need to take
prenatal vitamins for folic acid, iron, and other vitamins and minerals.
Vitamins can be prescription or purchased over-the-counter. Some health
insurance plans do not cover prenatal vitamins, so options should be
discussed with the patient.
It is not completely understood why some women experience strong
cravings for certain foods. These usually pass after the first trimester.
Women can satisfy these cravings as long as they talk about them with their
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clinician and are eating healthy foods. Sometimes pregnant women crave
things like laundry detergent, dirt, clay, and ice chips; the term for this
condition is pica. At the first office visit, the patient should be advised to
inform the clinician if she experiences pica. This may be a result of low iron
and she may be at a higher risk for anemia. The woman should be assured
this condition is common and nothing to be embarrassed about. If she
expresses these urges, discuss strategies to avoid non-foods.
Pregnant women need approximately 1,800 calories during the first
trimester. In the first trimester, the expectant mother should consume about
2,200 calories, and while in the second trimester she will need about 2,200.
In the final three months of pregnancy, she should eat around 2,400
calories. The patient should be asked about eating disorders prior to
pregnancy. She should be monitored throughout pregnancy and the clinician
should discuss the benefit of regular therapy to prevent eating disorders.
Even if the patient does not have a history of disordered eating, she is still at
risk for an unhealthy body image as she gains weight.
Meal planning should be discussed and the patient offered suggestions to
help the mother consistently eat healthily. For breakfast she could eat 2-3
servings of carbohydrates, a serving of protein, fat, and as many servings of
vegetables as she would like. For example, an omelet with her choice of
protein and plenty of leafy greens, and a side of whole grain toast with
peanut butter, with a cup of fresh fruit and yogurt. If she is a vegan or
vegetarian, healthy alternatives should be raised such as tofu, proteinpacked grains, and fermented soybeans instead of meat. Plants, nuts, and
beans are also filled with protein.
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An example of a healthy lunch could be a tuna or egg salad sandwich on
whole grain bread for protein and carbohydrates, an apple, yogurt (fortified
almond or soy for vegans), and a generous serving of carrots and other raw
vegetables of her choice. At dinner the mother should include 3-4 servings of
carbohydrates as well as protein, vegetables and healthy fats. This might
look like an entrée of whole grain pasta with a tomato-based sauce, chicken
or tofu, sautéed vegetables, and a small amount of olive oil with a side of
brown rice. Cheesy broccoli and cauliflower make a great side dish, as does
a generous portion of a salad with lots of leafy greens. A serving of fruit
provides a sweet, healthy dessert.
It is also important for the pregnant mother to eat snacks throughout the
day to control blood glucose, maintain energy, and curb nausea. Suggest
snacks that include healthy carbohydrates, protein, fat, and vegetables.
Slices of peppers, a handful of nuts or soybeans, pumpkin seeds, yogurt,
cottage cheese, premade leafy green salad, string cheese, and strips of bell
peppers are all excellent examples of healthy snacks.
Food-Borne Infections
The top five food-borne pathogens that will put the mother and baby at risk
are Campylobacter, E. coli, Listeria, Salmonella, and Toxoplasma gondii.79
These are briefly reviewed below.
Campylobacter infections can cause miscarriages and premature birth in the
first trimester. They do not usually harm the mother or child but can induce
severe diarrhea in the mother.
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Dehydration is likely to result if the mother is infected with E. coli. Rarely,
more serious complications arise and the mother should take great care to
prevent E. coli infection.
Pregnant women are 10 times more likely than the general population to
become infected with Listeria. Listeria puts the fetus in danger because it
can cause listeriosis, which increases the chance of miscarriages, premature
labor, low-birth-weight infants, or even infant death. Even if the mother
shows no sign of infection, the fetus may become infected. This can cause
problems for the baby later in life, such as blindness, intellectual disability,
seizures, paralysis, and impairments of the brain, heart, or kidney failure.
Salmonella, like E. coli, can lead to serious dehydration in the mother. It
may also cause bacteremia (bacteria in the blood) which may cause
meningitis. If Salmonella passes to the baby during pregnancy, he or she
may develop meningitis, diarrhea, and fever after birth.
Taxoplasma gondii is a food-borne pathogen that can be passed on to the
fetus even though the mother shows no signs of infection. If this happens,
babies can develop hearing loss, blindness, and intellectual disability. The
baby may also experience brain or eye problems after birth.
Safe and Unsafe Foods While Pregnant
The clinician should educate the pregnant patient about safe and unsafe
foods while pregnant, including caffeine.81,82 These are reviewed here.
Unpasteurized juices and cider often contain E. coli and should be avoided at
all times. Instead, the pregnant woman should choose pasteurized juice or
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boil unpasteurized drinks before consumption. Raw sprouts may also contain
E. coli.
Unpasteurized milk and soft cheeses can be detrimental for both the mother
and fetus because they may cause E. coli, Campylobacter, Listeria,
Salmonella, or even Tuberculosis. Cheeses like Brie, Feta, Camembert,
Queso Fresco, and Roquefort are often made from unpasteurized milk and
are not part of a healthy diet during pregnancy.
Undercooked poultry and meat are very dangerous because they have
potential to infect the mother and fetus with E. coli, Salmonella,
Campylobacter, and Toxoplasma gondii.
Clinicians should advise pregnant patients to avoid uncooked eggs, as they
are often a major cause of Salmonella. Foods such as tiramisu, cookie
batter, and eggs benedict contain uncooked eggs.
Listeria is found in raw fish such as sushi, sashimi, ceviche, and raw oysters,
clams, and scallops. Women should avoid these foods while pregnant.
Refrigerated seafood with labels like Lox, Nova-style, jerky, kippered, or
smoked also pose a threat for Listeria. Patients may consume seafood if it is
canned, shelf-stable, or if it has been cooked at 165 degrees or higher prior
to eating.
Seafood contains many necessary nutrients for pregnant woman because of
its protein, omega-3 fatty acids, minerals, and low levels of saturated fat.
Mothers should not avoid fish and seafood altogether. Crab, salmon, cod,
light tuna, shrimp, pollock, pangasius, clams, crab, and tilapia generally
have low levels of mercury and should be encouraged as part of a nutrient-
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rich diet. While pregnant women can consume albacore tuna and tuna
steaks, they should limit their tuna intake to 6 ounces a week. This is
because some testing has shown that tuna can have high mercury levels
that could lead to poor fetal development.
Studies have linked caffeine consumption to miscarriage. Clinicians often
limit patients to 200 grams of caffeine daily. Patients should be reminded to
discuss safe caffeine consumption with their clinician during the course of
their pregnancy. Most people know that caffeine is present in tea, coffee,
and soda. Patients should also be informed that caffeine is found in foods
like chocolate and instant oatmeal, and that labels should be checked on
foods to avoid hidden caffeine content.
Exercise for a Healthy Pregnancy
Exercise plays a vital role in a healthy pregnancy. It promotes healthy
weight gain, restful sleep, and overall health of the mother by strengthening
the heart and blood vessels. Regular exercise can also ease or prevent back
pain, constipation, varicose veins, and mood swings. It reduces the risk for
preeclampsia, gestational diabetes, and the need for a caesarian section.81
Exercise also prepares the mother for labor and delivery.
The mother should aim for at least 2.5 hours of exercise per week. The
amount of time spent exercising can be divided into ten-minute intervals
throughout the day. Exercise should be moderate intensity aerobic, which
means that she is sweating and raising her heart rate, but she is not so out
of breath that she cannot talk. Brisk walking, stationary bicycling, modified
yoga and Pilates, and gentle water aerobics are all superb ways to exercise
while pregnant.
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“Hot” yoga, skydiving, and scuba diving should be avoided. Patients should
also avoid contact sports and sports that pose a risk for being hit in the
abdomen, such as volleyball, water polo, and tennis. Workouts that increase
the likelihood of falling like gymnastics, climbing trees, and horseback riding
are prohibited.
The mother’s breathing, balance, and joints will be affected throughout
pregnancy. Her body’s hormones cause her joints to become more relaxed
so that they’re mobile and she has less risk for injury. Because of this, she
should avoid high impact exercises like jumping rope. As her belly and the
fetus grow, her sense of balance will shift. Because of this, she is more likely
to fall or lose her balance. She needs to adapt exercise for each trimester.
Throughout her pregnancy, the mother will need more and more oxygen.
Due to pressure from the uterus on the diaphragm, she will likely need to
reduce the intensity of workouts as her pregnancy progresses. If the patient
was sedentary prior to pregnancy, she needs to be counseled to develop a
plan to help her gradually ease into a healthy workout plan. Women should
be monitored who are very active to ensure they are gaining enough weight.
They may need to increase calorie intake for healthy weight gain.
The patient should be advised to stop exercising immediately and to notify
her obstetrician’s office if she experiences headache, chest pain, shortness
of breath prior to exercising, feeling faint or dizzy, swelling of the calves, or
painful contractions of the uterus. Blood or fluid coming out from the vagina
also signals the need to stop and contact her obstetrician.
Establishing an exercise workout routine lays the groundwork for exercising
after the baby is born, which is vital for losing extra weight and preventing
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the risk of deep vein thrombosis (DVT), which is the formation of a blood
clot in a leg vein or vein in another part of the body. Exercise also helps with
postpartum depression and reduces the stress that inevitably comes from
caring for an infant.
Clinicians must be aware of contraindications of exercise during pregnancy.
They include prior or current complications, certain types of heart and lung
disease, preterm ruptured membranes, sickle cell anemia, being pregnant
with multiples, and preeclampsia. The pregnant woman also may not
exercise if she has cervical insufficiency or cerclage. Cervical insufficiency
occurs when the cervix is unable to retain a pregnancy in the second
trimester. Cerclage, or the procedure in which a physician stitches together
the cervical opening to prevent preterm birth, also contraindicates exercise.
Kegel exercises strengthen the pelvic floor and are just as important as
aerobic exercises. The pelvic floor muscles hold up the rectum, vagina, and
urethra. Strengthening these muscles is extraordinarily beneficial because
they help the mother to push during delivery. Regular Kegel exercises help
the mother to recover sooner after birth, lowers her risk for hemorrhoids,
and helps prevent leaks from the bladder.
To perform a Kegel exercise, the woman will tighten her pelvic floor muscles
(the same ones used to control urination) for a count of three, and then
relax for a count of three. She should do the Kegel exercises 10 to 15
repetitions three times a day. It is easiest to perform Kegel exercises in the
supine position. As her pelvic floor strengthens, she can do them when
standing or sitting down. If the patient is unsure as to whether or not she is
performing them correctly, she can squeeze the muscles during urination as
a test. If she stops her flow of urine, she is doing them correctly. She may
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also put a finger into her vagina and clench her muscles; pressure on her
finger indicates that she is doing the exercises correctly. Pelvic muscles are
the same ones used to stop the flow of urine. Still, it can be hard to find the
right muscles to squeeze. The woman can be sure she is exercising the right
muscles if when squeezing them she stops urinating. Putting a finger into
the vagina and squeezing to feel pressure around the finger helps to know
the pelvic floor muscles are found. In the process of performing Kegel
exercises, the woman should be advised to avoid tightening the stomach,
legs, or other muscles.
Exercise will need to change as the patient transitions from one trimester to
the next. In the first trimester, she needs to be especially carefully to avoid
overheating. Before starting an exercise regimen, the patient must have it
cleared with her obstetrician, and should not alter exercises before medical
consultation.
Plan Of Care And Follow-up Prenatal Visits
The initial prenatal visit is important because of its role in developing a plan
of care for the continued care of the pregnant woman and her follow up
visits. The results from lab tests, the initial ultrasound, and answers to the
pregnant woman’s history will help shape the subsequent visits and the goal
of delivering a baby at term and keeping the mother as healthy as possible
during and after the pregnancy. It is common practice for health clinicians to
see a pregnant woman monthly, and until her last month when weekly visits
are generally scheduled.82 Studies have shown little risk in reducing the
number of prenatal visits, however, mothers tend to prefer the standard
schedule with more appointments.83
The purpose of follow-up prenatal visits is to ensure that the pregnancy is
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progressing as expected, manage maternal discomfort or unspoken issues,
such as inadvertent malnutrition or lack of a strong support system, and to
plan for a successful delivery. All prenatal visits will include obtaining a
weight for assessment, and taking vital signs such as blood pressure and
heart rate.
3rd Month of Pregnancy
The third month of pregnancy is often a prenatal client’s second in-office
visit. At this time, the clinical staff will likely have the results of the first visit
urinalysis, laboratory blood draws, and 8 to 10-week ultrasound. The
clinician is then able to confirm findings, whether the findings are expected
or unexpected, with the 12-week clinic visit.
It is standard to assess a mother’s vital signs during each visit. Health
clinicians should address any symptoms of discomfort related to the
pregnancy that the mother may be experiencing such as nausea,
constipation, or headaches. For general pregnancy pain and discomfort, the
prenatal client may ask what medications are safe for her to take. Nonsteroidal anti-inflammatory drugs (NSAIDS)84 are often taken over the
counter for headaches, joint pain and fevers. Prenatal patients should be
encouraged to rest and drink plenty of water to manage such issues. If not
relieved, patients may take acetaminophen and should be asked to avoid
ibuprofen and aspirin.
For nausea and vomiting, plenty of fluids and small servings of salty foods
should be encouraged. This prevents dehydration and dizziness, one of the
main triggers of nausea.85 The patient should be asked regarding other
possible triggers of nausea including strong smelling foods, rich fatty foods,
or strong perfumes. If these are present, the clinician should discuss with
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the mother ways to avoid these triggers.
There are many natural treatment options. Acupuncture and pressure point
wristbands, commonly sold as treatment for seasickness in many
pharmacies, are frequently tested as interventions for cases of nausea and
vomiting. While not necessarily dangerous to the prenatal client, these
interventions have not been shown to be any more effective than placebos in
randomized trials. Nzu is a traditional African remedy for morning sickness
and may be called calabar stone, argile, la craie, calabash clay, or mabele.86
The FDA has advised against this traditional medicine over worries of
possible lead and arsenic poisoning. Ginger has been used for thousands of
years in order to treat nausea. Given in the form of teas, chews, flavored
popsicles, sodas, and even straight ginger itself, ginger is effective in
reducing episodes of nausea, but may not reduce vomiting.87
If nausea and vomiting persist despite less invasive measures, a healthcare
provider may prescribe a pharmaceutical intervention to prevent weight loss
and/or treat hyperemesis gravidarum. Doxylamine, an antihistamine, works
by blocking receptors in the stomach, reducing nausea and vomiting. It has
been shown to have a protective effect against malformations when fetuses
were exposed to antihistamines during the first trimester.88
Dopamine antagonists are considered second line therapy because of a small
study showing a small increase in birth defects after use. Large studies have
not revealed such findings. Serotonin antagonists like ondansetron are
another option. This medication can prolong the QT interval, especially in
patients with cardiac arrhythmias. Prolonged Q-T intervals can cause
fainting, cardiac arrest, or even sudden death. These patients will need
constant monitoring until their hyperemesis gravidarum has been relieved.89
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Studies on infant outcomes are mixed, mostly showing that while an
increase of physical abnormalities is not as common, there is an increase in
cardiac dysfunction. Health clinicians will need to carefully weigh the pros
and cons of prescribing this medication to their prenatal clients.90
Clinicians will need to perform fetal assessments. Fetal heart tones will be
checked at the 3rd month prenatal visit. Healthcare providers will expect the
heart rate to be around 160 beats per minute. The clinician will palpate the
uterus, expecting to find that it is beginning to grow above the pelvis. About
the size of a grapefruit, the uterine fundus should be firm and easily
palpable.91
4th Month of Pregnancy
During the 4th month of pregnancy the clinician should discuss morning
sickness and whether or not it has improved since onset. If not, investigate
methods related to the management of morning sickness that may have
been started in the 3rd month. It may be that the mother needs medical
intervention especially if she is losing weight or unable to perform her
activities of daily living (ADL).
By the 4th month, the fetal weight will begin impacting the mother’s
circulation when she lays supine or on her back. Encourage women in their
4th month of gestation to lie on their left side when possible. This will
prevent any decrease in blood flow to the mother and subsequently the
fetus.
During the second trimester of pregnancy, women are more likely to develop
vaginal yeast infections. This irritating condition can cause itching, soreness,
and general discomfort of the vagina. Caused by a disturbance in vaginal pH,
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a possible result of increased estrogen levels, vaginal yeast infections do not
pose a risk to the fetus but can be very frustrating, painful and difficult to
treat during pregnancy.92 Women experiencing symptoms of a vaginal yeast
infection should be encouraged to see their physician in order to rule out
other infections and to monitor treatment.
Vaginal yeast infections are treated either through administration of a topical
ointment to the vagina or by taking an oral medication. Topical options
include clotrimazole, miconazole, and terconazole. These medications are
delivered through a vaginal suppository, cream filled tubes inserted into the
vagina much like a tampon, and by external application to the labia. These
medications are prescribed or instructed to be given anywhere from one to
seven days and are often purchased over the counter.93 These creams are
generally effective; however, some women experience discomfort and
burning during and after application.
For some women, these topical creams are ineffective or cause more
discomfort than they solve. In these circumstances, clinicians may consider
prescribing an oral treatment of fluconazole for one day. In severe cases,
fluconazole may be given twice over three days.
The evidence regarding the safety of fluconazole has gone through many
stages as researchers completed studies on this subject. More recent
findings suggest that fluconazole given in larger doses such as 400 to 800
mg per day increases the risk of birth defects in the neonate, especially
when exposure to this medication occurred during the first trimester. This
does not seem to be the case for low dose treatments of fluconazole 150
mg. High doses of fluconazole are considered to be Pregnancy Category D
medications while a low-dose treatment for vaginal yeast infection remains
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at Pregnancy Category C.94
To prevent yeast infections, patients should refrain from eating sugary,
simple carbohydrate heavy foods. Instead, prenatal women should be
educated on the benefits of probiotic foods such as kim chee and yogurt.
Prenatal clients with frequent recurring yeast infections may also want to
avoid tight fitting clothing.
Urinary tract infections are also more common during pregnancy. Incidence
of this infection increases because of a variety of factors, primarily the extra
weight of the uterus. As the uterus grows in size, drainage of urine from the
bladder may be impacted leading to the retention of urine and sometimes
urinary reflux. This failure to expel urine causes bacteria to pool in the
bladder and along the urinary tract, causing urinary discomfort, increased
urinary frequency, abdominal pain, and often hematuria, or bloody urine.
Because urinary tract infections can lead to a more severe infection of the
kidneys known as pyelonephritis, treatment of urinary tract infections should
not be avoided. Kidney infections may lead to low birth weight, preterm
labor, or miscarriage.95
To treat urinary tract infections, clinicians will prescribe a three to seven-day
course of antibiotics to the mother. Prescribers will need to evaluate the
patient for possible allergies to specific antibiotics and choose the medication
based on level of pregnancy safety.
While UTIs are sometimes unavoidable, there are some tips health staff can
teach their pregnant clients to try and prevent these infections. This includes
ensuring they completely empty their bladder each time they urinate, drink
plenty of water, avoid foods that irritate the urinary tract such as chocolates,
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sugars, and caffeine, and be sure to urinate before and after sexual
intercourse. Prenatal clients should be taught to avoid wearing tight fitting
pants and pantyhose and make sure they are wearing loose fitting clothing
with cotton underwear.
For the fetal assessments, the clinician will once again palpate the pregnant
woman’s abdomen, expecting the uterus to be the size of a grapefruit. This
will place the fundal height about midway between the pubic symphysis and
the mother’s navel.96 The healthcare professional will measure the prenatal
client’s fundus by feeling for the top of her uterus and then measuring from
this spot to the symphysis pubis.
The “multiple marker screening,” also known as the quad screening, is a test
that evaluates the mother’s blood for fetal abnormalities. This test checks for
serum markers which may indicate neural tube defects and aneuploidies, or
disorders where there is an abnormal number of chromosomes in the cells.
Some alterations looked for in the multiple marker screening include Down
syndrome, spina bifida, and trisomy.
Down syndrome is a genetic disorder caused by a defect in the number of
copies of the 21st chromosome. Typically, those with Down syndrome have
slowed mental development, a delay in physical development, and
sometimes problems with cardiovascular function and bone malformation.97
The average adult with Down syndrome has an IQ equivalent to an eightyear-old. Small or missing nasal bones found on an ultrasound are an
indication of the possible presence of this disorder.98
Spina bifida is a neural tube defect where the spinal tube fails to close
properly resulting in malformation of the vertebral column and brain.99
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Those affected by spina bifida will be paralyzed completely and unable to
control their bowels and bladder in 97% of cases. Hydrocephaly, often
referred to as “water on the brain,” is present in many with spina bifida and
is the leading cause of death in those affected by the condition.
Trisomy 18 and 13, known as Edwards’s syndrome and Patau syndrome,
occur when there are extra chromosomes on the 18th or 13th chromosome.
Most infants with this condition will live to term, but will have shorter than
average life expectancies.
If any markers return positive, the health clinician will likely order an
ultrasound or amniocentesis to verify the findings. Clinicians may also
suggest genetic counseling. At this point, depending on the results, a woman
may choose to terminate her pregnancy, especially if the results indicate
that her baby will not survive birth or will not live very long after delivery.
The fetal doppler will again be used to detect fetal heart tones. A normal
fetal heart rate at 4 months gestation is between 120 and 160 beats per
minute.100
5th Month of Pregnancy
During the 5th month appointment, the clinician will continue to monitor the
mother’s weight gain and will keep a close eye on the mother’s blood
pressure. Providers will continue to assess for edema and signs of high blood
pressure. After 20 weeks gestation the development of high blood pressure
is considered to be a sign of poor adaptation to the pregnancy and may lead
to preeclampsia.
The clinician will also check for proteins, sugars and infections in the urine to
ensure that gestational diabetes is not developing and that there is no
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ongoing urinary tract infection in the mother. At the end of the 5th month
prenatal visit, the clinician will schedule an ultrasound to assess placental
placement and the health of her developing fetus. The clinician may also
suggest that the pregnant woman schedule a prenatal labor preparation
class with her labor coach or partner.
Between the 5th and 6th month of pregnancy, a pregnant mother will likely
feel her fetus begin kicking, known as “quickening.” Sometimes this feels
like bubbles in her uterus, easily mistaken for gas, while other times it feels
like electric shocks. As the baby grows, these kicks will become more
forceful and sometimes uncomfortable.
The health clinician will schedule the pregnant mother for a fetal ultrasound
to be performed by an ultrasound technician. The results will be read by a
radiologist101 and delivered back to the healthcare provider.
The ultrasound technician will take readings of the amniotic fluid present in
the uterus, the size, shape and location of the placenta. Specific facts
considered in regards to the placenta besides simple measurements include
blood flow to the maternal fetal organ.
The ultrasound will ensure that the umbilical cord connecting the fetus to the
placenta has two umbilical arteries and one vein. The technicians will
evaluate the flow through this vascular system to ensure that the fetus is
receiving proper nutrition and oxygenation.102 Ultrasound technicians will
also measure the fetus from crown to rump, and analyze its organs as well
as their function. They will also monitor blood flow to and from the fetus,
verifying the function of the fetal arterial and venous system. Identifying the
sex of the fetus is also done at this appointment, if the parents would like
this service to be provided. Fetal heart rate should be about 140 beats per
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minute at 5 months pregnancy.
6th Month of Pregnancy
Discussions between the health clinician and the pregnant mother should
focus on potential problems such as possible hemorrhoid formation and its
management, weight gain, back pain and therapeutic interventions, as well
as any other reports of physical discomfort. The clinician will assess for signs
of developing high blood pressure and symptoms of preeclampsia such as
swelling of ankles or feet, accompanied by headaches, visual changes, or
abdominal pain.
Glucose testing is generally performed at 6 months’ gestation to determine
whether or not a mother has or is at risk of developing gestational
diabetes.103 Testing can be performed in a two-step approach or one-step
approach. The two-step approach is the commonly used methodology for
identifying pregnant women with gestational diabetes in the United States.
The first step is a glucose challenge test in which the mother will drink
anywhere from 50-grams to 75-grams of sweetened liquid after fasting all
morning. Positive patients will continue on to the second step, a 100-gram,
three-hour oral glucose tolerance test (GTT), which is the diagnostic test for
gestational diabetes. The one-step approach forgoes the screening test and
shortens diagnostic testing by performing only a 75-gram, 2-hour oral GTT.
Relationship and social considerations should be taken into account during
this check-up, especially in regards to the pregnant mother’s sexual health.
Because the fetal weight and maternal weight gain is generally noticeably
significant by the 6th month of gestation, pregnant women and their partners
often complain of sexual dysfunction or discomfort at this point. Some
women may be reluctant to discuss such issues, however, clinicians should
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present the topic to their patients in private, and in a matter of fact, easy
going manner.
Many women are concerned that as their pregnancy progresses, sex with
their partner will cause preterm labor. Women with low-risk, single
pregnancies should be informed that large studies have shown no increase in
premature birth in mothers who engage in sexual activity while pregnant.104
Pregnant women at risk for pre-term labor after sexual intercourse are
women carrying more than one fetus, women with cervical incompetency, or
women with pelvic inflammatory disease (PID).
While many women report an increase in their sexual desire during
pregnancy, others may experience an aversion to intercourse. For women
feeling uninterested by sexual intercourse or sexual touch, mothers and
partners should both be reminded that such occurrences are not abnormal
and usually pass with time. Couples should be encouraged to spend time
together participating in non-sexual activities that foster intimacy, such as
cooking a new meal, going on special dates, or taking a weekend trip
somewhere relaxing.
Pregnant mothers who report instances of sexual discomfort may benefit
from counseling. Some women experience vaginal dryness during
pregnancy. Discuss the use of a water-based personal lubricant to relieve
dryness and to help resolve the discomfort or soreness experienced during
sex.
Sexual positions are another area of frequent grief for pregnant women and
their partners. As the mother’s abdomen and weight increases, sexual
positions that were once easy or comfortable may become difficult or
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awkward. Mothers interested in learning about alternative positions during
intercourse should be given information on specific strategies to obtain
sexual satisfaction. One study performed in Taiwan found that women with
the highest sexual satisfaction practiced positions where the pregnant
mother was on top, where the couple was face to face, or positions where
the abdomen was supported by pillows or their partner’s body.105
Fundal height of the fetus will be measured at every appointment. At 6
months’ gestation the fundal height should be at the navel.125 The
development of fetal growth restriction is often looked for at this point of
gestation. Suspicion of fetal growth restriction begins when fundal height
measurement is not in agreement with the expected size for gestational age.
The most used standard is a fundal height in centimeters, which is three
centimeters or greater below the gestational age in weeks.106
Fetal assessment during the 6th month of pregnancy begins again by
palpation. The clinician will feel for the fetus through the abdominal wall to
check its position. The clinician will ask the mother about fetal movement
and encourage her to stay alert for a decrease or cessation of fetal
movements throughout the second and third trimester. This practice is
known as monitoring “fetal kick counts.”
Health clinicians should encourage their prenatal clients who are concerned
about fetal activity to lie down on their left side and focus on counting their
fetus’s kicks and movement. If the prenatal client counts 10 fetal
movements in 2 hours, they can rest easily knowing that their fetus has met
the threshold for reassured fetal movement.107 Once again, the clinician will
need to check for fetal heart tones and rate. At 6 months gestation, the
fetus should have an average of 140 beats per minute; however, it can vary
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between 110 and 160 beats per minute.
7th Month of Pregnancy
The extra weight from amniotic fluid and the fetus itself may be causing the
mother musculoskeletal discomfort as well as fatigue. Mothers should be
encouraged to rest frequently and to take acetaminophen as needed to
resolve the pain. For women experiencing shortness of breath, remind them
to lie on their left side and take frequent breaks during exercise or work.108
If the lab test has not yet been performed, the mother will be tested for Rh
negativity at this time and given Rho(D) immunoglobulin injection at this
time.109
During the 7th month of gestation, the fetal fundal height should be about 4
fingers above the navel and can vary between patients.110 More importantly,
the clinician will ensure that the fundal height is growing continuously with
each prenatal checkup. Fetal heart rate will be evaluated to ensure that it
has continued to stay between 110 and 160 beats per minutes.
The clinician will also palpate the maternal abdomen to assess fetal position
within the abdomen. Around 30 weeks gestation, the baby should be head
down. If not, the clinician will need to keep a close watch on the positioning
of the infant to prepare for a breech delivery or caesarean section. Vaginal
breech deliveries are on the decline. The practice of delivering a baby breech
is a learned skill that many believe needs to be kept in practice. However,
risks and worries over liabilities contribute to the decline of this skill.111,112
8th Month of Pregnancy
At 8 months gestation, many health clinicians will begin seeing their patients
biweekly. Continued assessment of swelling and symptoms that may indicate
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pregnancy-induced hypertension will be conducted.
The Group B Streptococcus exam113 is performed around 8 months
gestation, and involves screening for the colonization of the aforementioned
bacteria. An active infection of group B strep in the mother puts the newborn
at risk for the development of a blood infection (sepsis), bacterial pneumonia
and meningitis. In neonates, all three conditions are life threatening.
Mothers who test positive for group B strep will be treated before birth with
intravenous antibiotics during labor and/or oral antibiotics prior to labor.114
During this time, the clinician will also check for cervical dilation. It will not
be expected to find any dilation, especially in a first-time mother.
Continued monitoring of the fetal heart rate occurs through the 8th month of
gestation. By this point in fetal development, the heart rate should be
plateaued around 140 beats per minute. Again, fetal position will be
assessed in the hope of finding the baby in the anterior cephalic position. If
the baby is not in this position, the physician may perform an external
cephalic version in the 9th month of gestation.115 An external cephalic
version (ECV) is the process of rotating a breech baby by manipulating the
fetus through the mother’s abdominal wall.
Women where ECV was attempted had their risk of a cesarean section
reduced by half.116 It did not, however, reduce cesarean sections in
subsequent deliveries.
A factor that positively influences the effectiveness of ECV includes116 having
a posteriorly located placenta, meaning the placenta lies against the
mother’s spine rather than on the side nearest the abdominal wall. A fetus in
an oblique or transverse lie helps with fetal manipulation during an external
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cephalic version as does having an amniotic fluid index under 10. For
whatever reason, pregnant women of black heritage are more likely to have
successful ECV procedures.
Factors that negatively influence ECV effectiveness include having an
overweight or obese mother, an anterior positioned placenta, tense uterus,
and/or a breech fetus that has already descended into the pelvis. If the
mother has already had her membranes rupture or a low amniotic fluid
volume, it is also unlikely that the external cephalic version will be
successful. Although infrequent, there are risks associated with external
cephalic version. Some of these risks include a placental abruption, ruptured
membranes, vaginal bleeding, cord prolapsed and, most critical, perinatal
death or stillbirth.
9th Month of Pregnancy
At 9 months’ gestation, many health clinicians begin seeing their prenatal
patients weekly. While this may not change the outcome of the pregnancy,
recent studies show that most women prefer this standard method of
prenatal scheduling.
The clinician will continue diligent monitoring of the mother’s vital signs and
symptoms of developing high blood pressure such as swelling, dizziness, or
blurred vision. It is necessary to check cervical dilation and record findings.
Cervical dilation is noted from “closed” to 1 to 10 cm. At 3 cm, most women
are considered to be in “active labor.” The clinician will also look for
effacement, or the thinning of the cervix in preparation for labor,
engagement of the fetus into the birth canal, and fetus positioning.
The prenatal patient’s understanding of labor should be assessed, including
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when it is most appropriate to come to her place of delivery or call her
midwife. The patient should also be informed about what labor looks like in
the early stages, or before 3 cm dilation. Contractions will be mild but
frequent and not relieved by walking. They will also occur every 5 to 30
minutes, lasting about thirty seconds each time.117 Contractions generally
feel like menstrual cramps in the beginning and may radiate to the lower
back. Prenatal patients should be told to note the color and time their water
breaks, if this occurs at home.
Pregnant mothers should be encouraged to call their midwife or head to the
hospital when they are in “active labor.” They will need to watch for signs
that the time is approaching to deliver their baby. During active labor,
contractions will be more intense and last up to a minute long with only 3 to
5 minutes of rest in between. If a mother waits too long to get to her
birthing center or to call her midwife, she risks entering the “transition
phase” where the cervix dilates from 8 cm to 10 cm. During this phase the
pregnant mother will feel the most intense pressure during her contractions.
Contractions may overlap and last up to a minute and a half. It is good to let
a woman know that while this may be the most difficult portion of labor, it is
the shortest portion.
When discussing birth with pregnant patients, especially first-time mothers,
it is important to discuss the birth process and to recommend a birthing
course if they have not yet attended one. Discussing postpartum care
including vaginal bleeding is necessary. After delivery, postpartum patients
will have lochia, or vaginal bleeding, for three to six weeks. Bleeding will
begin like a very heavy period and become light to clear during the last
week.118 Mothers planning to breastfeed should be encouraged to attend a
breastfeeding course led by a breastfeeding peer counselor or lactation
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consultant.
As with the 8th month, fetal position will be verified. Once the fetus is
considered term, 37 weeks, the clinician may perform an ECV for the breech
fetus. Fundal height will also be determined and is expected to be positioned
just at or below the xiphoid process. Evaluation of the mother’s
understanding of fetal movement is needed, and the mother should be
informed that fetal movements might reduce as the onset of labor draws
closer. Beats per minute will again be assessed, expecting the fetal heart
tones to move closer to 120 beats per minute as the fetus nears delivery.
Occasionally, a clinician may require an assessment known as a non-stress
test to be performed. A non-stress test is used to ensure that a fetus is
healthy despite possible extraneous circumstances. The test measures
contractions, heart rate and fetal movement. A few reasons a non-stress test
may be performed is in circumstances where the infant is post-term and the
clinician and mother are hoping to let birth occur without the use of labor
induction medications.119
A non-stress test will also be used for a mother with hypertension or
gestational diabetes. If the mother’s fetus is growing slowly or plateauing in
growth, a non-stress test will confirm the health of the fetus and help
determine a plan of care for the prenatal patient. A non-stress test will also
be performed before and often after an external cephalic version to ensure
there are no existing fetal abnormalities present.120 If an ultrasound test
shows that the prenatal patient has too little or too much amniotic fluid. A
non-stress test is performed very frequently and is considered the most
common cardiotocographic technique for fetal assessment. Many clinicians
prefer it because it is non-invasive and easy to set up in the clinical setting.
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When a fetus is believed to be at risk of perinatal death after 26 or 28 weeks
gestation, a non-stress test may be performed on a daily to weekly basis
until delivery. This exam is looking for signs of fetal hypoxemia and results
are categorized as reassuring and non-reassuring. Health staff needs to
know that reassuring findings are indicative of current positive fetal
oxygenation. This result does not mean that further non-stress tests are
unnecessary; rather continued tests will be needed as long as the other risk
factors mentioned above (maternal hypertension, low amniotic fluid volume,
gestational diabetes, etc.) are present.120
A non-reassuring stress test indicates fetal hypoxemia and may require a
repeat test to rule out a falsely positive result. If tests continue to present as
non-reactive, also known as non-reassuring, the clinician should suggest
hospitalization. This hospitalization will include continuous monitoring as well
as the possibility of induction or caesarean section, dependent upon the fetal
gestational age, severity of the non-reassuring results and maternal
comorbidities.
Multiple Births
Patients who are pregnant with multiples will likely experience anxiety and
experience mixed emotions, especially when they first discover that they are
carrying more than one child. The mother should be assured that while care
for women pregnant with two or more babies needs to be more highly
specialized, it is common and the outcome of most multiple births is
generally positive. The clinician should be aware that mothers pregnant with
multiples are considered at an increased risk for complications.121
Gestational diabetes is more likely to occur in patients carrying multiples.
The patient should be advised that a healthy lifestyle, including sound diet
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and exercise practices, greatly reduces the risk for developing gestational
diabetes. Even while exercising and following nutritional guidelines, the
mother may need to take insulin pills or shots to keep her blood sugar levels
in check. Preeclampsia is 2-3 times more likely to present in cases of
multiple births. Preeclampsia can damage organs, placenta, and may put the
patient’s life at risk. Early detection is vital in prevention.
Another complication, while rare, is twin-to-twin transfusion syndrome,
which occurs in identical rather than fraternal twins. Laser surgery may be
necessary to prevent connection between the babies’ blood vessels. About
10-15% of identical twins have this syndrome.
Placental abruption takes place when the placenta disconnects from the
uterine wall prior to delivery. Still birth, preterm birth, and developmental
problems may result and can occur anytime during the second half of the
pregnancy. Abruption may occur after the first infant is born vaginally,
causing the need for a caesarian section.
Low-birth weight will likely occur, with the likelihood increasing for each
additional multiple. The average birth weight for singles is 7 pounds, while
twins usually weigh at about 5.5 pounds, triplets at 4, and quadruplets at 3
pounds. Babies who weigh less than 5.5 pounds are considered to have a
low-birth weight.
Low-birth weight typically causes health issues like difficulty to breathe on
their own, to gain weight, fight against infection, and to control body
temperature. The majority of low-birth weight infants spend time in the
neonatal intensive care unit before going home with their parents.
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Clinicians may place mothers on bed rest prior to labor, especially if any of
these complications arise. The clinician must be prepared to discuss each
patient’s individual situation when them and to prescribe bed rest if needed.
This generally begins in the third trimester.
In the case of multiple births, the mother may lose one or more of the
babies. A “vanishing twin” occurs when one baby in a set of two miscarries
early in the pregnancy while the other one remains intact. This occurs in
about 20% of twin cases and in about 40% of triplets. Miscarriages such as
these often go undetected before an ultrasound. The only symptom is
vaginal bleeding.
Death of a fetus after 20 weeks, or a stillbirth, is more common in multiple
pregnancies. About 0.5% of single pregnancies result in in stillbirths. About
1-2% of twins and triplets are stillbirths. A still-born multiple can be expelled
many weeks before the surviving twin, but most are delivered alongside the
surviving baby. The odds are in the surviving baby’s favor when the baby
has its own placenta, though the baby is still at great risk for survival. If
surviving baby or babies look unhealthy, labor may be induced.
The earlier the mother goes into the labor, the more likely it is that her
babies will experience complications. Usually, premature babies are fairly
healthy if born between 35 and 37 weeks. Risk increases the earlier the
babies are born and babies born under 28 weeks will especially need
intensive care.
Health clinicians will probably attempt to delay labor if the patient goes into
labor before 34 weeks. The patient will need to be prepared that the baby
may receive magnesium sulfate to reduce the risk of developing cerebral
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palsy. The extra time provided by delaying labor allows clinicians to use
corticosteroids to assist the development of the baby’s lungs and other
organs. This will increase the likelihood of survival.121
The initial prenatal has been discussed here in terms of developing a plan of
care for the rest of the mother’s pregnancy. Each month of gestation has its
own set of maternal and fetal assessments, while all appointments look at
the standard vital signs, fundal height and fetal heart tones. Other tests will
determine gestational diabetes, immunity to Rho(D) and breech positioning.
Treatment of these conditions as well as the risks involved with treatment
itself has also been reviewed. External cephalic version is one such
procedure used in an attempt to correct a breech baby.
Popular use of non-stress tests to evaluate for fetal hypoxemia as well as
non-reassuring results indicating little fetal reactivity and fetal hypoxemia
were discussed as well. Women whose fetus fails these screenings may be
hospitalized, induced, or scheduled for a caesarean section. As always, it is
the health professional’s job to evaluate the prenatal patient’s knowledge of
labor and delivery, their emotional state and their risk for malnutrition.
While this was likely evaluated at their initial prenatal appointment, these
needs should be addressed at each appointment.
During the 4th month of pregnancy, a test known as the ‘multiple
marker screening’ or ‘Quad screening’ is performed via a blood draw in
a laboratory or clinic. Which of the following disorders is not routinely
screened for with this specific test?
a) Down syndrome
b) Cystic fibrosis
c) Spina bifida
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d) Aneuploidy
Cystic fibrosis is not routinely screened for during the ‘multiple marker
screening.’ Rather, this test looks for trisomy abnormalities as well as neural
tube defects.
Birth Plan: Obstetrical Care And Birth Setting
Planning the manner in which a mother would like to give birth is a personal
decision made for the promotion of comfort and feelings of personal safety.
Some pregnant women make their birth plan based on deeply intimate and
spiritual feelings. Health professionals should always work towards balancing
respect for their prenatal client’s birth plan preferences by promoting the
health of the mother and her infant in the process. This means
understanding whether a mother wants pain medication to relieve pain
during contractions, a doula or birth coach in the room, her entire family
present, or to give birth nearly alone. As with the beginnings of prenatal
care, a highly supportive health team is very beneficial during labor. Women
who feel adequately supported during their labor experience and throughout
the birth of their infant reported higher satisfaction of care and less pain
during the event.122
In the U.S., choosing an obstetric care provider is varied but limited. A
woman’s health clinician will be highly dependent on certain factors, such as
where she would like to give birth, whether her pregnancy is considered high
or low risk, and whether or not she will have a planned cesarean section.
The elements involved in making these decisions vary greatly from woman
to woman and deserve careful consideration and deference when the health
clinician weighs in with his or her opinion on how to best accommodate the
mother’s labor and birth experience.
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Choosing An Obstetrician
An obstetrician is the most common medical clinician attending a woman
during labor and birth in the United States. These are medical physicians
who have spent their residencies specializing in obstetrical care and are
knowledgeable of the varied abnormal deliveries that need special attention.
Most hospitals have protocols in place allowing only board-certified
obstetricians to deliver infants by caesarean section. Obstetricians are
uniquely qualified to deliver high risk infants such as those being born preterm, with known congenital abnormalities, and in some hospitals, breech
babies. A hospital or physician may require an obstetrician perform a
delivery because a mother has preexisting medical conditions, Rho(D) nonimmunity, or preeclampsia. Specific policies regarding when an obstetrician
is appropriate vary hospital to hospital.
Family practitioners are specialized in all areas of general medicine including
prenatal care. They deliver infants whose mothers are at a low-risk for
complications during labor and birth. The major benefit of using a family
practitioner during pregnancy, labor and delivery is the continuity of care.
Family practitioners are able to see a mother pre-pregnancy, during her
pregnancy, and her entire family afterwards as well. While many hospitals
do not permit family care physicians to deliver high-risk pregnancies, studies
have shown that both obstetrician and family care practitioners provide
comparable care even for high-risk pregnancies.
Midwives vary from state to state and their scope of practice ranges greatly.
There are nurse midwives who have gone to school for midwifery on top of
getting their four-year nursing degree and direct-entry midwives, whose
training can vary from shadowing a midwife to taking courses designed for
the trade. Their care is very personal and effective, offering compassionate
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care to mother’s with low-risk pregnancies.
Birth Settings
Home birth has been the most common form of birth throughout world
history. Many women turn to home birth with a midwife because they feel
most comfortable in their home environment and they have a strong belief
in their ability to give birth without medical intervention.123 Having a home
birth requires that the mother and family research their chosen midwife
carefully, know the signs if her pregnancy changes from a low-risk
pregnancy to a high-risk pregnancy, and have a plan in place, should she
need to transfer to the hospital. A competent midwife will be skilled enough
to know any potential warning signs before delivery and request hospital
transfer. Fortunately, the vast majority of home births does not require
transfers and are successfully achieved. A recent study found that nearly
90% of planned home births were safely completed as planned.124
Birthing centers began in the 1970s and provided women with a great
intermediate between having a baby at home and having a child in a
hospital. Birthing centers have fewer restrictions than hospitals and allow for
greater freedom of movement for the laboring mother. Generally, they have
warm atmospheres made to make the mother feel as if she were at home.
Nurse practitioners and midwives most frequently perform deliveries at
birthing centers.124
Many birthing centers also offer the mother and her family the option of
delivering her infant by a water birth. A water birth is simply the practice of
giving birth while in a tub of warm water. Many people believe this practice
helps the baby transition from womb to the outside world in a gentler and
more familiar manner. Water birthing is also often more comfortable for the
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mother, providing her relief from some discomfort and pressure during
labor. Submersion in water also decreases blood pressure, relaxes, and
provides the mother with more energy. Water may also relax and loosen the
perineum, helping it stretch for the passage of the fetus’ head and
shoulders.
Typically, water births are performed in water pools either provided by the
birthing center or personally purchased or rented if the woman plans to
deliver her infant at home.125 These baths are about 18” to 22” deep and
anywhere from 45” to 65” long.
As labor starts, fill the birthing pool with warm water, between 99 and 100
degrees Fahrenheit. Some women like their water a bit hotter, but pregnant
clients should be advised to use a thermometer and check that the tub never
goes above 101 degrees Fahrenheit. Most women find an upright, semireclined position to be the most comfortable while pushing during
contractions. The patient should be encouraged to discover which position
feels best. Depending on the patient’s birth plan, it will be the midwife,
partner, or other health clinician that will be in the tub with the mother as
she pushes during labor. This will help bring the infant up to the surface
after the final push. Since babies have a natural instinct to hold their breath
while under water, breathing in or swallowing watering is generally not a
concern.127
Fetal health seems to have little impact as a result of a water birth. While
theoretically possible for the water to ease infant stress upon birth, some
physicians believe there is also the possible risk of the fetus swallowing air
and suffering from an air embolism upon birth. There are no studies
supporting this theory and the British Medical Journal who reported this
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potential risk is 95% certain that water births are safe. It is known that there
are situations where water births should not be practiced. One example is
when the mother is afflicted by genital herpes. Herpes easily spreads
through water and the infant is at risk while being born through the birth
canal. C-sections are often the primary option for delivery when the mother
has an active outbreak of genital herpes.
If heavy meconium, or the infant’s first stool made up of amniotic fluid and
mucous is present, the mother should exit the tub and birth her infant
elsewhere to prevent the newborn from breathing in this stool. All
pregnancies considered high risk or marked by preexisting medical
conditions in the mother should be evaluated closely to understand the best
birthing option. Every pregnancy and birth is unique and deserves as unique
a birthing option whether that occurs within a birthing center or at home.
Women are prime candidates to deliver at birthing centers if they would like
a drug-free labor, non-augmented by medications like Pitocin (a medication
which helps stimulate uterine contractions), and a home-like delivery with
the comfort of knowing they are surrounded by trained health clinicians in
emergency care should that be necessary.126 If a prenatal patient’s
pregnancy is deemed high-risk, she may not be able to deliver at a birthing
center.
Hospitals are the most frequented birthing locations in the United States.
Hospitals tend to be a bit more invasive in their care, frequently monitoring
the laboring mother and restricting freedom of movement. New guidelines in
the U.K., have proposed that 45% of women who are at an extremely low
risk of experiencing complications should consider giving birth outside of the
hospital. Still, if the mother is high-risk, the hospital is the best option for
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the mother and infant’s health as well. The decision of what is best for the
mother should be a team decision made with the health staff, the family and
the pregnant mother.
Comfort Techniques During Labor
There are many terms used to describe the sensations during labor, such as
pressure, pain, aching, cramping; however, one thing is certain, labor is
certainly uncomfortable in many ways. In early labor, pains begin as mild
cramping. Prenatal patients should be education on how to manage this type
of discomfort before labor begins, as they will likely be at home for much of
this period of labor. Women should use distraction as a primary mode of
relief during early labor. Going for slow, relaxing walks, listening to calming
music, watching comedy television, and even going out to eat for a small,
comforting meal can help women move through contractions and conserve
energy for the upcoming labor and delivery.
As labor grows more intense, women benefit from showers, lukewarm baths,
and finding positions to take pressure off the most intense areas of
discomfort. Women experiencing back labor, or labor pains that are
increasingly felt in the lower back during contractions, will benefit from
different laboring positions than women not enduring back pain. Some of
these positions include sitting on a birthing ball, rocking back and forth on all
fours, standing with their head on the partner’s shoulder with his or her
hands on the small of her back, and kneeling in front of a chair with her
head resting on the seat.
Many women find lying on their side to be a very comfortable position. The
fetus also benefits from this position, as left side-lying generally promotes
optimal oxygenation of the fetus by taking pressure off their cord. Women
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also find that this position helps them rest between contractions and support
their abdomen nicely. Partners should be encouraged to help make the
laboring mother more comfortable by arranging pillows behind her back,
between and around her legs, underneath her stomach, and underneath her
head and neck. This energy saving position is especially nice in the early
stage of labor as contractions begin to grow closer together.
Oddly enough, the least helpful birthing and laboring position is the one we
see time and time again in films and sometimes even on the hospital floor;
laying back with legs in the air is a potentially damaging position in that it
relieves very little pain, it works against gravity thus making the baby and
the mother’s body work harder to push the infant out, and actually makes
the pelvic outlet smaller. This classic flat-lying birthing position also
increases the likelihood that the mother will need an episiotomy or an
assisted vaginal delivery through the use of forceps or a vacuum. Mother’s
feeling drawn to this position should try semi-sitting, side lying, or kneeling
forward onto a chair. These positions will work with gravity yet also relieve
pain and save maternal energy.
There are also non-positional comfort techniques to use while aiding a
laboring prenatal client. Unfortunately, what works for one mother may
make another mother feel wholly uncomfortable. While a room fan may
make one mother calm and less hot, another mother may feel totally
disturbed by feeling the blowing air on her skin. Still, helping a prenatal
patient is often about testing out things that have worked for others while
being adaptable.
Some women enjoy aromatherapy while in labor. Their partner may take a
few drops of a relaxing essential oil, like lavender or rose oil, or something
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more energizing such as lemon or spearmint, and mix it into a base oil like
grapeseed or argan. A comforting massage on the back or even the hands
can help distract an uncomfortable mother and provide intermittent relief.
Cool compresses to the forehead are especially comforting to mothers who
tend to run hot during the birthing process. Make sure to have a few clean
washcloths around so that as one compress loses its chill, another can be
rotated out.
Breathing techniques have long been taught to prenatal patients in order to
prepare them for labor. This comfort technique does not relieve pain
completely, but it does ensure enough oxygen is available to the mother and
baby during labor and acts as a convenient distraction. Some breathing
techniques include abdominal breathing, patterned breathing, and natural
breathing with visualizations.128
Abdominal breathing, not to be confused with diaphragmatic breathing
practiced in patients with chronic obstructive pulmonary disease (COPD), is
practiced by teaching the prenatal patient to lay a hand on her abdomen and
take in air slowly, feeling the space around her abdomen fill all the way to
her diaphragm. On the exhale, have the mother breathe out slowly so that
this breath takes three times as long as the inhalation. This breathing
technique can be paired with relaxing visualizations that often help women
remain calm during contractions and periods of bodily stress.
To incorporate visualizations, women should be taught to imagine their
breath as a stream of lovely blue, green, or white air to represent healing
and calm. The prenatal patient should be instructed to imagine that this air
is replacing the stale air in the lungs and when exhaling, she is releasing
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pain, stress, and negative energy. She may imagine this exiting air to be red
or gray, like smoke from a chimney. This same breathing exercise works
while imagining the filling of a ships sails or waves rising and crashing in the
ocean.
Patterned breathing describes various ways for the mother to address her
breathing during different stages of labor. While in early labor the prenatal
patient may find deep, slowed breathing possible, and she may find this
same breathing practice difficult during the more active phase of labor when
the pain and pressure is the most intense. At this point she may benefit from
light rapid breathing; to perform this method, she should inhale slowly
through her nose and then exhale in quick short bursts at a rate of about
one breath per second. While trying the method of rapid breathing, she will
likely find the perfect rhythm to match her contractions and alleviate pain.
Careful attention should be paid to a mother’s breathing to prevent
hyperventilation, which can lead to dizziness and hypercapnia in the
bloodstream. Hyperventilation prevents full expulsion of carbon dioxide
during breathing and can be harmful to both mother and baby. Some women
will also need reminders to breathe normally and refrain from holding their
breath. Oftentimes, when pain is great, a woman may feel tempted to hold
her breath and clench down, a practice that deprives her and her baby of
oxygen and also wastes valuable energy.
Fetal Presentation Before And During Labor
Understanding fetal presentation and lie help manages discomfort during
labor and facilitates delivery of the neonate. While some positions facilitate
delivery, other positions make the voyage down the birth canal more
difficult. The most common position and the ideal lie for a fetus is head down
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facing the mother’s spine. This lie is known as “occiput anterior.” If this
position continues untill the time of delivery, it is known as the “cephalic
position,” or head down.
Other possible presentations include breech presentation. Breech
presentation is rare, happening in about 3% of births and may be a
complete breech, where the fetus presents bottom-first with legs and knees
flexed, frank breech, where the legs are straight against the chest, or with
one or both of the feet presenting first. Even more rare is transverse
presentation, a lie occurring when the arm, core, or shoulder presents before
the head or buttocks.
The Seven Cardinal Movements of Labor
The seven cardinal movements of labor describe the basic, but very
important, actions that are completed in order to deliver an infant vaginally.
It begins by the engagement of the fetus’ head into the pelvis. Once the
fetus is engaged, it may begin its descent into the birth canal, during labor
or while pushing to deliver the neonate.
Flexion occurs during descent. In this movement, the fetus tucks his head so
that his chin rests against his chest. This movement makes fitting through
the birth canal easier. Next, the fetus will complete internal rotation. This
movement involves the turning of the infant’s head so that the face is
towards the mother’s spine and moving past the pubic bone.
During extension, the baby moves the head once again, extending it back
around the pubic bone just when nearing the opening of the vagina. Finally,
as the fetal head is delivered, the head becomes aligned with the body.
Finally, during the expulsion stage, the top shoulder will also be delivered.
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Once the mother has passed the shoulders, delivering the rest of the infant
is not problematic.
Delivery Complications
While most pregnant women are able to deliver their infants without
complications, delivery complications are on the rise in the United States.
This may be related to the changes in the population of modern day
pregnant women; however, this has not been directly studied. Still, it is
known that more women are getting pregnant older than ever before, are
more likely to be obese that thirty years ago, and have reported health
conditions such as hypertension and diabetes.
Most common in women delivering their first infant, perineal lacerations are
a fairly frequent delivery complication. The lacerations are tears at the
perineum, the lower end of the vaginal opening. First-degree tears are
usually small and manageable in nature and do not generally require many,
if any, stiches. Second-degree tears are more serious and involve the
underlying muscular tissue of the perineum. These will require stiches and
more care postpartum. While rare, third and fourth degree tears are the
most severe and extend down into the anal sphincter.
Perineal massage is often initiated to reduce tearing during birth. Perineal
massage includes massaging the tissue on and around the perineum with
two to three fingers daily for the last several weeks of pregnancy. It also
involves stretching the outer portion of the vagina for one to three minutes
at a time. Perineal massage may also be performed during active labor and
especially helps when the prenatal client is encouraged to relax the muscles
in her vagina and perineal area.133 The effectiveness of perineal massage is
debated, but studies have shown that for every fifteen women performing
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these massages, one of them will avoid the need for an episiotomy or
tearing that will require stiches.134
Health clinicians can help prenatal patients avoid perineal damage by
1) providing frequent instruction on perineal massage, 2) applying warm
compresses to the perineum during labor, and 3) finding comfortable
positions to ease the passage of the fetus through the birth canal, especially
taking advantages of birthing positions which use gravity, such as standing
and semi-sitting. Preventing the use of forceps and vacuum-assisted delivery
can also lessen the risk of vaginal tearing. There are occasions, however, in
which the infant needs to be born as soon as possible to lessen the risk of
trauma.
An episiotomy is considered a minor surgery whereby the clinician
performing the delivery makes a small incision at the base of the vagina in
order to create a larger opening for the descending fetus. Once the mother
has delivered the placenta, the incision will be stitched closed. Episiotomies
do not prevent tearing and are, in fact, often more difficult to heal from than
natural tears. This is because the incision made during an episiotomy goes
through more layers of tissue on average than a natural tear.
Episiotomies often contribute to painful sexual intercourse in the mother for
a few months’ post-partum and occasionally, greater blood loss. The thought
of an episiotomy can be very scary to prenatal clients and they may be
curious as to what their steps are to avoid such a procedure. Much like
preventing tearing, pregnant women should be educated on the benefits of
perineal massage as well as performing Kegels exercises all throughout their
pregnancy.
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Forceps and vacuum devices are used in assisted vaginal delivery in
circumstances where the fetus is in distress, has not been delivered after the
second stage of labor, or if the mother is unable to safely continue pushing
due to exhaustion or preexisting medical conditions. Forceps can be painful
for the mother and often require anesthesia. Vacuum devices may be made
from metal or plastic cups, but each option has its own set of risks. For
example, while metal cups used in some vacuum assisted deliveries have
greater outcomes for vaginal delivery, they are also more likely to cause
fetal bruising, scalp harm, and cephalahematomas.135
Forceps are curved metal tongs used to cup the sides of the delivering fetus’
head and ultimately aid in delivering the baby by pulling down and out while
the mother pushes through a contraction. Like vacuum assisted delivery, the
use of forceps may cause some damage to the fetal scalp. All of the above
vaginal assisted deliveries may contribute to increased vaginal soreness
postpartum, prolonged issues with urinary continence, and, in rare cases,
weakened pelvic muscles leading to pelvic organ prolapse.
Cesarean Sections, commonly referred to as C-sections, are also on the rise
in the U.S., where nearly one-third of women delivering in the hospital will
undergo the serious surgery.136 A C-section is the best option when the
pregnant woman’s placenta is low-lying over the cervix, also known as
placenta previa. This condition obstructs the cervix, making attempted
vaginal delivery not only unlikely, but also dangerous. Occasionally, the
placenta will rupture from the side of the uterus prematurely, creating
another circumstance in which a C-section is necessary. Rarely, a woman
may experience a uterine rupture, requiring immediate delivery and medical
intervention through a Cesarean section.
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In most hospitals, infants in breech position are delivered via C-section
especially if there is evidence of a cord prolapse, or when the umbilical cord
exits the cervix before the infant, causing oxygen deprivation in the fetus.
Health clinicians may be confronted by many other circumstances which may
call for a C-section, including fetal distress usually related to oxygen
deprivation, failure to progress during labor, cephalopelvic disproportion (a
condition characterized by a fetal head too large to pass through the pelvis),
active genital herpes, and multiples infants.137
A Cesarean section requires the administration of epidural anesthesia to the
pregnant mother. After receiving this medication, the woman will be unable
to feel her lower body. The mother’s urine will be collected via a urinary
catheter. In a non-emergent C-section, the clinician, likely who is an
obstetrical-gynecology (OB-GYN) surgeon, will make a horizontal incision
below the navel at the bikini line. This allows for faster healing of the
abdominal wall and an easier to cover scar. In emergencies, a lateral incision
may be made in order to quickly deliver the fetus. Once the incision is made,
the surgeon will remove the amniotic fluid via suction and then deliver the
fetus, passing the infant to the mother if possible or to a team of assisting
health staff. Once the placenta is delivered, the surgeon will begin stitching
to close the incision.
Detailed after-care will need to be provided to the patient who has just
undergone a C-section, as this is a major surgery generally taking about six
weeks recovery time. Women who have undergone a C-section procedure
should be informed to call their health clinician if they experience any
redness or discharge at the site of the incision, an oral temperature greater
than 100.4 degrees Fahrenheit, or any evidence of non-adhesion at the site.
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While vaginal births continue to make up the majority of births around the
world, health clinicians should be familiar with the possible delivery
complications, which may arise throughout the labor and birthing process. A
well-educated team creates a safer birthing environment for both the mother
and her infant.
This section discussed different birthing options in terms of a pregnant
woman’s choice of a health clinician and the locations she can give birth. The
relative safety of each option, appropriate location for high-risk pregnancies
being the hospital, and possibility of home-birthing as suitable for very lowrisk pregnancies was discussed. A freestanding birth center might be the
best option for mothers who find themselves somewhere in the middle of
these two options.
Case Scenario:
A woman who would like freedom of movement and a drug free labor
and birth but is not comfortable with a home-birth should consider
having a birth at which of the following locations?
a) The nearest hospital to her home.
b) A birthing center.
c) She should continue with a home-birth anyway.
d) A clinician’s office.
A woman who would like freedom of movement and a drug-free birth
should consider: b) birthing center, if she is not comfortable with a
homebirth. A hospital will likely restrict her freedom of movement and
is thus not the best answer.
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Pain Medications During Labor
When comfort techniques fail to relieve stress or pain, some women turn to
pharmaceutical intervention not only to manage their discomfort but also to
prevent unfavorable results associated with excess pain. When undergoing
physical trauma, the human body undergoes a transition stemming from the
cerebral cortex in order to cope. It begins by the release of a floodgate of
acetylcholine compounds, thereby engaging the central nervous system.
Studies have found that these neurohumoral effects inhibit placental
perfusion and, therefore, fetal oxygenation. The more stress hormones (i.e.,
catecholamine) present in the blood steam, the more poorly perfused the
mother’s uterus.129 Maintaining optimal perfusion is very important during
labor not only to provide oxygen to the fetus but to provide the uterine
musculature with the necessities needed to produce forceful contractions.
Hyperventilation, as previously discussed, is another adverse outcome
related to pain. Women who hyperventilate while in pain have higher arterial
CO2 levels, creating maternal alkalosis and a shift of oxygen carrying red
bloods cells, thereby decreasing the amount of available oxygen for the
fetus. However, most women are able to self-regulate this breathing pattern
and the fetus generally tolerates the changes. However, high-risk
pregnancies, such as a woman delivering multiples or a fetus with
intrauterine growth restriction, may consider pain management a higher
priority in order to reduce the stress to the already taxed fetus.
It is not always the fetus that is at risk because of undertreated pain. In
fact, pain may create psychological problems in the postpartum period as a
direct result of previous trauma. One study found that women who
experienced unrelieved pain while in labor were more likely to suffer from
postpartum depression after the birth of their infant. This same study also
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found an increase in Post-Traumatic Stress Disorder (PTSD) in the group of
women with unrelieved pain.
Usually administered during the early stages of labor to reduce stress and
pain, narcotics, such as Stadol or butophanol, also provide mothers with the
ability to relax and conserve energy in preparation for the more intense
parts of labor. These medications do not take away pain completely but
rather lessen the intensity of the experience. Narcotics are generally given
by the intravenous route during the early stages of labor in order to prevent
or lessen the possibility of adverse effects to the fetus.130 Some of these side
effects include impaired respirations, central nervous system depression,
impaired early breastfeeding, and a lowered ability to regulate their own
body temperature following birth. Mothers are also at risk for lowered
respiratory function but most women complain of the dizziness, nausea, and
vomiting associated with taking opioid narcotics.
Nitrous oxide is seldom used in the U.S. during labor, but may be used in
Canada and the United Kingdom to soften the pain of labor. More a relaxing
distraction than true pain relief, nitrous oxide has little effect on the fetus
but may induce dizziness, sleepiness, nausea, and/or vomiting in the
mother.
Some women prefer more controlled pain management that does more than
simply “take the edge off.” The delivery of an epidural block is commonly
performed in the U.S. and may employ the use of varied medications, which
will provide pain relief and anesthesia to varying degrees. For women who
would like to continue to move throughout labor, a “walking epidural,” or
medication titrated to prevent total nerve blockage, can be delivered. Before
a Cesarean section or a vacuum-assisted delivery, a stronger epidural that
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numbs the entire lower body, usually by a spinal block, will be delivered.
Epidurals provide nearly complete pain relief while keeping the prenatal
patient awake and alert. However, epidurals may lower a woman’s blood
pressure, thereby contributing to lowered placental perfusion. Rarely,
women will have severe headaches for several days following this procedure.
For local pain relief during or just before the delivery of the fetus, a
pudendal block or local anesthetic injection may be used. A pudendal block
is a local nerve block, which takes between ten and twenty minutes to begin
working. It relieves vaginal pain for nearly an hour and helps the mother
manage the pain brought on by pushing. The local anesthetic block does not
help with labor pains but instead numbs the perineal area around the vaginal
opening and the anus. This is usually used before an episiotomy or before
the repair of a vaginal tear shortly after delivery of the placenta.
Summary
Being pregnant and delivering a child is a very intimate time in a family’s life
and can be experienced in innumerable ways. The health team providing
care to a pregnant woman should understand all aspects of a healthy
pregnancy to assist the woman and her family to be reassured of a healthy
pregnancy outcome. The expectant mother and her family should feel
confident that the prenatal health clinician has her best interest in mind. The
goal of prenatal care is to promote optimum maternal and infant health. To
ensure that best care practices are followed and that promotion of maternal
and infant health is of top priority, all health professionals need to
understand patient safety goals and standards of practice.
During initial prenatal visits the clinician will identify the expected date of
delivery and gather the patient history, including taking vital signs, height
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and weight, and laboratory testing urine for ketones, sugar, bacteria, and
blood. Existing risks are best identified during the first prenatal visit by using
open-ended questions to discuss possible drug use and testing for high risk
conditions potentially affecting the mother’s and fetus’ health. Identifying
signs and symptoms of depression, malnourishment, drug abuse, or lack of a
healthy support system are also an essential part of prenatal care all
throughout a woman’s pregnancy.
The clinician should express options that may be presented to the mother
relative to common birthing options and settings. The health team as a
whole working in unison with other clinicians and associates, and also with
patients and their families, will be better poised to support open
communication and strong, long-term relationships. When working
collaboratively, health professionals and their patients can promote a
positive pregnancy outcome of healthy mothers and babies.
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1. Using the Estimated Date of Delivery (EDD) method, the care
provider will count _____________________ from the first
day of a woman’s last menstrual period.
a.
b.
c.
d.
forward 266 days
backward 266 days
forward 280 days
backward three months
2. ______________ of women deliver on their actual Estimated
Date of Delivery (EDD).
a.
b.
c.
d.
One half
One-third
Twenty percent
Four percent
3. True or False: Properly determining a woman’s due date is
nominally important because the patient’s contractions will
provide enough notice.
a. True
b. False
4. Which pregnancy due date method or rule involves counting
backwards three months from the first day of the last missed
period and then subsequently adding 7 days?
a.
b.
c.
d.
Naegele’s rule
The hCG test
The menstrual cycle method
EDD method
5. Using the Estimated Date of Delivery (EDD) method, the care
provider will always count forward 266 days from the date of
conception if
a.
b.
c.
d.
the woman took a home pregnancy test.
the woman recorded the first day of her menstrual period.
the exact date of conception is known.
if the date is confirmed through urinalysis.
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6. Human Chorionic Gonadotropin (hCG) levels should be drawn
and an ultrasound scheduled (depending on the findings
revealed in the hCG results) when
a.
b.
c.
d.
the woman took a home pregnancy test.
the mother has irregular menstrual periods.
a urinalysis is not feasible.
the mother knows the first day of her last menstrual cycle.
7. A typical menstrual cycle is ______ days in length.
a.
b.
c.
d.
28
21 to 35
30
28 to 35
8. Using Naegele’s rule, if the first day of a mother’s last, missed
period was October 27th, her expected due date would be
a.
b.
c.
d.
August 3rd.
July 27th.
August 17th.
September 1st.
9. True or False: Naegele’s rule is the most common technique of
pregnancy dating.
a. True
b. False
10. A healthcare provider will confirm pregnancy with a urine
sample or laboratory blood sample
a.
b.
c.
d.
if the patient did not perform a home pregnancy test.
on a case-by-case basis.
in all cases.
if cervix has taken on a blue or purplish tint.
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11. A woman with an above normal __________________,
before the start of her pregnancy, is at a higher risk of
developing pregnancy-related hypertension, edema and
gestational diabetes.
a.
b.
c.
d.
menstruation
hCG levels
bacteria levels
body mass index (BMI)
12. Women’s Human Chorionic Gonadotropin (hCG) levels
fluctuate throughout their pregnancy but as far as verifying
the gestational age of the fetus, hCG levels are
a.
b.
c.
d.
always more reliable after the first trimester.
never reliable.
always more reliable early on.
more reliable during the second trimester.
13. The accuracy of ultrasounds ___________________ because
biological differences found within the fetus’ DNA take effect as the
fetus grows in the mother’s uterus.
a.
b.
c.
d.
decreases with time
increases with time
are the same throughout a pregnancy
is not known in the third trimester
14. Ultrasounds performed before six weeks are limited because
locating the fetus in utero
a.
b.
c.
d.
is difficult unless performed transvaginally.
if it is performed transvaginally.
is limited because of Chadwick’s sign.
may be difficult even transvaginally.
15. A care provider examining the cervix will look for Chadwick’s
sign, which refers whether or not the cervix
a.
b.
c.
d.
is closed.
has abortifacient properties.
has dilated.
has taken on a blue or purplish tint.
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16. Ingesting _________________ may have uterine stimulation
and abortifacient properties.
a.
b.
c.
d.
aloe vera
St. John’s Wort
fluoxetine
serotonin
17. True or False: To get an accurate measurement of hCG levels,
a urinalysis will need to be performed.
a. True
b. False
18. Herbal supplements are an especially pressing matter to
discuss with prenatal clients because
a.
b.
c.
d.
they are “natural” supplements for pharmaceuticals.
they may be harmful in some cases.
pregnant women cannot take prescription drugs.
they are harmful in all cases.
19. _________________ is often used to stave off colds or
coughs, but it is considered a teratogenic product and should
never be taken by a pregnant client.
a.
b.
c.
d.
Fluoxetine
Echinacea
Uva Ursi
Wild cherry extract
20. When an herbal supplement hastens or facilitates childbirth,
especially by stimulating contractions of the uterus in a
pregnant woman, it is said to
a.
b.
c.
d.
have an oxytocic effect.
have a teratogenic effect.
cause insomnia.
have an antidepressant effect.
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21. Because the effects of _____________ on a developing fetus
is unknown, doctors believe that taking heavily studied
selective serotonin reuptake inhibitors for depression are less
dangerous.
a.
b.
c.
d.
fluoxetine
valerian root
Nepeta Cataria
St. John’s Wort
22. _________________ is a supplement frequently added to
energy drinks in order to increase the drinker’s energy.
a.
b.
c.
d.
Nepeta Cataria
Gaurana
Fluoxetine
Valerian root
23. True or False: Pregnant women should be advised to avoid
gaurana because it has been shown to lead to the birth of
babies prematurely, infants of low birth weight, and possible
birth defects.
a. True
b. False
24. What herbal supplement taken for sleep induction is NOT
recommended in pregnant women as it has the ability to
stimulate uterine activity and induce labor prematurely,
possibly leading to abortion?
a.
b.
c.
d.
Uva Ursi
Melatonin
Catnip
Ginseng
25. ___________________, taken in an attempt to improve the
immune system, has a weak oxytocic effect on the pregnant
uterus.
a.
b.
c.
d.
Melatonin
Echinacea
Uva Ursi
Wild cherry extract
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26. One study found that a woman who had consumed
___________ while pregnant gave birth to an infant with
pubic hair, forehead hair, swollen testicles and red swollen
nipples.
a.
b.
c.
d.
Uva Ursi
Fluoxetine
Catnip
Ginseng
27. What herbal supplement, taken to treat urinary tract
infection, can cause liver damage, especially if taken for more
than 5 days in a row?
a.
b.
c.
d.
Uva Ursi
Valerian root
Nepeta Cataria
Gaurana
28. Side effects from ingesting melatonin include(s):
a.
b.
c.
d.
It stimulates the ovaries
It causes liver damage when taken 5 or more days in a row
It decreases the libido
All of the above
29. True or False: Ginseng IS considered a safe supplement to
take during pregnancy or while breastfeeding.
a. True
b. False
30. What herbal supplement taken as an herbal sleep aid, is not
recommended during pregnancy because it is unstudied and
may correlate positively with developmental disorders?
a.
b.
c.
d.
Uva Ursi
Melatonin
Catnip
Ginkgo Biloba
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31. Toxoplasmosis is a viral infection that may be contracted by
a.
b.
c.
d.
sexual contact.
breastfeeding.
contact with a cat’s litter box.
by ingesting catnip.
32. Toxoplasmosis may be carried by ______, and toxoplasmosis
is found in their feces.
a.
b.
c.
d.
cats
chickens
rodents
All of the above
33. A woman who is trying to become pregnant for the FIRST
time is described as
a.
b.
c.
d.
Nulligravida
Primigravida
Multigravida
Uva Ursi
34. Side effects from Ginkgo Biloba include which of the
following?
a.
b.
c.
d.
It causes breast tenderness
It may prolong bleeding
It may lead to urinary tract infection
All of the above
35. True or False: Uva Ursi has astringent and anti-inflammatory
properties and is often used to treat or prevent urinary tract
infections or cystitis.
a. True
b. False
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36. During pregnancy, the issues associated with alcohol are best
stated as follows:
a.
b.
c.
d.
each trimester is affected the same by alcohol consumption.
alcohol consumption is safest during the first trimester.
consuming alcohol only causes mild behavioral changes.
there is no safe amount of alcohol.
37. Signs and symptoms of fetal alcohol syndrome in the neonate
include:
a.
b.
c.
d.
heart defects.
small and narrow eyes.
smooth upper lip.
All of the above.
38. Screening tools for alcohol use by a pregnant mother include:
a.
b.
c.
d.
Fetal Doppler assessment.
Quad Screening.
AUDIT-C.
Multiple marker Screening.
39. True or False: Being overweight or underweight can cause
problems during gestation and lead to an increased risk of
complications prenatally as well as after delivery.
a. True
b. False
40. Potential dangers related to toxoplasmosis infection may
include
a.
b.
c.
d.
malformations of the neonate’s head.
still birth
spontaneous abortion
All of the above
41. True or False: Pregnant women should be taught to avoid
cleaning litter boxes.
a. True
b. False
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42. The fetus of a smoking mother is more likely to develop
a.
b.
c.
d.
congenital malformations.
preeclampsia.
diabetes.
Chadwick’s sign.
43. A pregnant woman should be asked which of the following
question(s) her tobacco use?
a.
b.
c.
d.
Have you ever smoked cigarettes?
When was the last time you smoked cigarettes?
Are you currently smoking?
All of the above
44. True or False: According to the American College of Obstetrics
and Gynecology, women should be screened for tobacco use
at their initial prenatal appointment on a case-by-case basis.
a. True
b. False
45. The use of selective serotonin reuptake inhibitors to treat
depression has been studied in pregnant women and the
studies found that there is
a.
b.
c.
d.
a great risk of perinatal death.
a high risk of hypertension.
little to no risk of spontaneous abortion.
a moderate risk of preeclampsia.
46. Zika virus is an emerging disease spread through
a.
b.
c.
d.
the bite from a tick.
the bites of female mosquitoes.
food.
contact with a cat’s litter box.
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47. _________________________ may be one of the dangers of
the Zika virus.
a.
b.
c.
d.
Hydrocephalus in neonates
Severe mental retardation in neonates
Gestational diabetes
Rubella infection
48. Immunity to rubella is important because a rubella infection,
also known as _____________, can cause miscarriage,
stillbirth, and congenital risks such as intra-uterine growth
restriction, hydrocephaly and other abnormalities.
a.
b.
c.
d.
Rhesus disease
urinary tract infections
German Measles
cystitis
49. If a mother tests positive for HIV, her infant will be tested
a.
b.
c.
d.
14 to 21 days post birth.
1 to 2 months later post birth.
if the newborn shows symptoms of HIV.
Answers a., and b., above
50. True or False: If the mother tests positive for HIV, she should
not be encouraged to breastfeed.
a. True
b. False
51. Which of the following statements about pregnant women
is/are true related to domestic violence and pregnancy?
a.
b.
c.
d.
The risk is higher if they are over 20 years old.
The risk is 2 to 4 times greater if the pregnancy was unplanned.
They have a lower risk of suffering domestic violence.
All of the above
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52. Signs of abuse may include
a.
b.
c.
d.
injuries caused by falling.
tobacco use.
patient is over 35 years old.
late initiation of prenatal care.
53. A health clinician will check for any swelling in the hands,
feet, ankles, or face to monitor
a.
b.
c.
d.
HIV.
Zika virus.
high blood pressure or hypervolemia.
Rhesus disease.
54. Methyldopa’s (a drug used to treat high blood pressure)
effects on fetal development
a.
b.
c.
d.
are considered unsafe.
are not alarming and are thus considered safe.
result in adverse fetal neurodevelopment.
result in hypervolemia.
55. True or False: Research suggests that anxiety, depression and
chronic mental strain result in more cases of pre-term birth,
low birth weight and adverse fetal neurodevelopment.
a. True
b. False
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CORRECT ANSWERS:
1. Using the Estimated Date of Delivery (EDD) method, the care
provider will count _____________________ from the first
day of a woman’s last menstrual period.
c. forward 280 days
p. 6: “Clinicians may use a wheel to determine the EDD, but always
count forward 280 days from the first day of a woman’s last
menstrual period, or forward 266 days from the date of conception
if this exact date is known, usually in cases of in vitro fertilization.”
2. ______________ of women deliver on their actual Estimated
Date of Delivery (EDD).
d. Four percent
p. 7: “Only 4 percent of women deliver on their actual EDD because
of natural biological variations in gestation and hormonal cycles.”
3. True or False: Properly determining a woman’s due date is
nominally important because the patient’s contractions will
provide enough notice.
b. False
p. 6: “Properly determining a woman’s due date is of utmost
importance, because the more accurate the prediction of the due
date is, the less likely complications related to unnecessary medical
interventions will arise.”
4. Which pregnancy due date method or rule involves counting
backwards three months from the first day of the last missed
period and then subsequently adding 7 days?
a. Naegele’s rule
p. 7: “Currently, Naegele’s rule is the most common technique of
pregnancy dating. This rule involves counting backwards three
months from the first day of the last missed period and then
subsequently adding 7 days.”
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5. Using the Estimated Date of Delivery (EDD) method, the care
provider will always count forward 266 days from the date of
conception if
c. the exact date of conception is known.
p. 6: “Clinicians may use a wheel to determine the EDD, but always
count forward 280 days from the first day of a woman’s last
menstrual period, or forward 266 days from the date of conception
if this exact date is known, usually in cases of in vitro fertilization.”
6. Human Chorionic Gonadotropin (hCG) levels should be drawn
and an ultrasound scheduled (depending on the findings
revealed in the hCG results) when
b. the mother has irregular menstrual periods.
p. 7: “Occasionally, the first day of the last menstrual cycle is
unknown, either because the mother has irregular periods or
because she has simply forgotten. In these cases, Human Chorionic
Gonadotropin (hCG) levels should be drawn and an ultrasound
scheduled depending on the findings revealed in the hCG results.”
7. A typical menstrual cycle is ______ days in length.
b. 21 to 35
p. 7: “A typical menstrual cycle can be anywhere from 21 to 35
days in length.”
8. Using Naegele’s rule, if the first day of a mother’s last, missed
period was October 27th, her expected due date would be
a. August 3rd.
pp. 7-8: “Imagine that the client states that her last menstrual
period was October 27th. To determine this client’s expected due
date, the nurse will first subtract three months, putting the date at
July 27th. Next the nurse will add seven days to this date, ending up
with an expected due date of 3rd August.”
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9. True or False: Naegele’s rule is the most common technique of
pregnancy dating.
a. True
p. 7: “Currently, Naegele’s rule is the most common technique of
pregnancy dating.”
10. A healthcare provider will confirm pregnancy with a urine
sample or laboratory blood sample
c. in all cases.
p. 8: “In the office, the health care provider will confirm pregnancy
with a urine sample or sometimes with an ordered out of the office,
laboratory blood sample.”
11. A woman with an above normal __________________,
before the start of her pregnancy, is at a higher risk of
developing pregnancy-related hypertension, edema and
gestational diabetes.
d. body mass index (BMI)
p. 12: “Studies have shown that having a BMI considered above
normal before the start of pregnancy correlates positively with
pregnancy-related hypertension, edema and gestational diabetes.”
12. Women’s Human Chorionic Gonadotropin (hCG) levels
fluctuate throughout their pregnancy but as far as verifying
the gestational age of the fetus, hCG levels are
c. always more reliable early on.
p. 9: “Women’s hCG levels fluctuate throughout their pregnancy but
are always more reliable early on.”
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13. The accuracy of ultrasounds ___________________ because
biological differences found within the fetus’ DNA take effect
as the fetus grows in the mother’s uterus.
a. decreases with time
p. 9: “This accuracy decreases with time because biological
differences found within the fetus’ DNA take effect as the fetus
grows in the mother’s uterus; that is, fetuses grow at different
rates, and fetal, physical measurements taken in an ultrasound for
babies with the same gestational age will vary.”
14. Ultrasounds performed before six weeks are limited because
locating the fetus in utero
d. may be difficult even transvaginally.
p. 10: “Like the other methods, ultrasounds have their limitations….
Before six weeks, locating the fetus in utero may be difficult even
transvaginally. This can cause unnecessary anxiety and stress for
the pregnant mother and her partner.”
15. A care provider examining the cervix will look for Chadwick’s
sign, which refers whether or not the cervix
d. has taken on a blue or purplish tint.
p. 8: “Known as Chadwick’s sign, the care provider will note
whether or not the cervix has taken on a blue or purplish tint due to
the increased blood flow to the cervix.”
16. Ingesting _________________ may have uterine stimulation
and abortifacient properties.
a. aloe vera
p. 16: “Oral Aloe Vera is not frequently taken in the United States,
however it should be noted that ingesting aloe vera may have
uterine stimulation and abortifacient properties.”
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17. True or False: To get an accurate measurement of hCG levels,
a urinalysis will need to be performed.
b. False
pp. 13-14: “To get an accurate measurement of hCG levels, a blood
test will need to be performed.”
18. Herbal supplements are an especially pressing matter to
discuss with prenatal clients because
b. they may be harmful in some cases.
p. 15: “Herbal supplements are an especially pressing matter to
discuss with prenatal clients as they are often seen as ‘natural’ and
therefore not harmful. However, this is not always the case.”
19. _________________ is often used to stave off colds or
coughs, but it is considered a teratogenic product and should
never be taken by a pregnant client.
d. Wild cherry extract
p. 16: “Wild cherry extract is often used to stave off colds or
coughs, but it is considered a teratogenic product; that is, it may
disturb fetal development. As such, wild cherry extract should never
be taken by a pregnant woman. Healthcare staff should inform their
clients of the potential for increased birth defects in infants born to
mothers who consume this supplement during pregnancy.”
20. When an herbal supplement hastens or facilitates childbirth,
especially by stimulating contractions of the uterus in a
pregnant woman, it is said to
a. have an oxytocic effect.
p. 16: For example, “Echinacea, taken in an attempt to improve the
immune system has a weak oxytocic effect on the pregnant uterus.”
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21. Because the effects of _____________ on a developing fetus
is unknown, doctors believe that taking heavily studied
selective serotonin reuptake inhibitors for depression are less
dangerous.
d. St. John’s Wort
p. 15: “St. John’s Wort is a herbal medicine used by pregnant
women suffering from depression who may be afraid to take
pharmaceutical medications during their pregnancy. However,
because the effects of this herbal supplement on a developing fetus
is unknown, doctors believe that taking heavily studied selective
serotonin reuptake inhibitors such as fluoxetine are less
dangerous.”
22. _________________ is a supplement frequently added to
energy drinks in order to increase the drinker’s energy.
b. Gaurana
p. 16: “Gaurana is a supplement frequently added to energy drinks,
which people drink in order to increase their energy. Pregnant
women should be advised to avoid gaurana because it has been
shown to lead to the birth of babies prematurely, infants of low
birth weight, and possible birth defects.”
23. True or False: Pregnant women should be advised to avoid
gaurana because it has been shown to lead to the birth of
babies prematurely, infants of low birth weight, and possible
birth defects.
a. True
p. 16: “Gaurana is a supplement frequently added to energy drinks,
which people drink in order to increase their energy. Pregnant women
should be advised to avoid gaurana because it has been shown to lead to
the birth of babies prematurely, infants of low birth weight, and possible
birth defects.”
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24. What herbal supplement taken for sleep induction is NOT
recommended in pregnant women as it has the ability to
stimulate uterine activity and induce labor prematurely,
possibly leading to abortion?
c. Catnip
p. 16: “[Catnip] is not recommended in pregnant women as it has
the ability to stimulate uterine activity and induce labor prematurely
possibly leading to abortion.”
25. ___________________, taken in an attempt to improve the
immune system, has a weak oxytocic effect on the pregnant
uterus.
b. Echinacea
p. 16: “Echinacea, taken in an attempt to improve the immune
system has a weak oxytocic effect on the pregnant uterus.”
26. One study found that a woman who had consumed
___________ while pregnant gave birth to an infant with
pubic hair, forehead hair, swollen testicles and red swollen
nipples.
d. Ginseng
p. 17: “One study found that a woman who had consumed
[ginseng] while breastfeeding gave birth to an infant with pubic
hair, forehead hair, swollen testicles and red swollen nipples.”
27. What herbal supplement, taken to treat urinary tract
infection, can cause liver damage, especially if taken for more
than 5 days in a row?
a. Uva Ursi
p. 17: “[Uva ursi] can cause liver damage, especially if taken for
more than 5 days in a row. For this reason, uva ursi is a dangerous
medication for pregnant women.”
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28. Side effects from ingesting melatonin include(s):
c. It decreases the libido
p. 17: “What is known for certain about [melatonin] is that it’s an
ovarian suppressant and decreases sexual libido, both of which can
be troublesome for women planning to become pregnant.”
29. True or False: Ginseng IS considered a safe supplement to
take during pregnancy or while breastfeeding.
b. False
p. 17: “Promoted as a memory and concentration promoter,
ginseng is not considered a safe supplement to take during
pregnancy or while breastfeeding.”
30. What herbal supplement taken as an herbal sleep aid, is not
recommended during pregnancy because it is unstudied and
may correlate positively with developmental disorders?
b. Melatonin
p. 17: “Melatonin, another common herbal sleep aid, is not
recommended during pregnancy, primarily due to the lack of
studies surrounding the subject, although it may correlate positively
with developmental disorders.”
31. Toxoplasmosis is a viral infection that may be contracted by
c. contact with a cat’s litter box.
p. 23: “Toxoplasmosis is carried by cats, chickens and rodents, and
is found in their feces. Pregnant women should be taught to avoid
cleaning litter boxes.”
32. Toxoplasmosis may be carried by ______, and toxoplasmosis
is found in their feces.
d. All of the above
p. 23: “Toxoplasmosis is carried by cats, chickens and rodents, and
is found in their feces.”
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33. A woman who is trying to become pregnant for the FIRST
time is described as
a. Nulligravida
p. 18: “The number of pregnancies a woman has is described as
follows: “Nulligravida”, meaning a woman who has never been
pregnant, “Primigravida”, or a woman who is pregnant for the first
time or has been pregnant once before and “Multigravida”, which
refers to a woman who has been pregnant more than once.”
34. Side effects from Ginkgo Biloba include which of the
following?
b. It may prolong bleeding
p. 18: “Anti-platelet properties in gingko may prolong bleeding,
increasing the potential for haemorrhage.”
35. True or False: Uva Ursi has astringent and anti-inflammatory
properties and is often used to treat or prevent urinary tract
infections or cystitis.
a. True
p. 17: “Uva Ursi has astringent and anti-inflammatory properties
and is often used to treat or prevent urinary tract infections or
cystitis.”
36. During pregnancy, the issues associated with alcohol are best
stated as follows:
d. there is no safe amount of alcohol.
p. 46: “The patient needs to be educated that alcohol use is very
harmful to developing fetuses and should be stopped completely
during pregnancy.”
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37. Signs and symptoms of fetal alcohol syndrome in the neonate
include:
d. All of the above.
pp. 45-46: “Signs and symptoms of fetal alcohol syndrome in the
neonate include heart defects such as a ventricle septal defect or an
atrial septal defect. Infants with fetal alcohol syndrome tend to be
weak and have physical issues with the face. Facial features such as
small and narrow eyes with a small head and fine, smooth upper lip
are generally indicators of the disease.”
38. Screening tools for alcohol use by a pregnant mother include:
c. AUDIT-C.
p. 46: “Several screening tools, such as CAGE, TWEAK, or AUDIT-C,
exist for assessing a newly pregnant woman’s alcohol use.”
39. True or False: Being overweight or underweight can cause
problems during gestation and lead to an increased risk of
complications prenatally as well as after delivery.
a. True
p. 48: “Both being overweight or underweight can cause problems
during gestation and lead to an increased risk of complications
prenatally as well as after delivery.”
40. Potential dangers related to toxoplasmosis infection may
include
d. All of the above
p. 23: “Potential dangers related to toxoplasmosis infection may
cause malformations of the neonate’s head, still birth, or
spontaneous abortion.”
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41. True or False: Pregnant women should be taught to avoid
cleaning litter boxes.
a. True
p. 23: “Pregnant women should be taught to avoid cleaning litter
boxes.”
42. The fetus of a smoking mother is more likely to develop
a. congenital malformations.
p. 46: “The fetus is put at major risk; the fetus of a smoking
mother is more likely to develop congenital malformations, acquire
fetal growth restriction, be born prematurely, suffer from SIDS or
sudden infant death syndrome, or display long term behavioral
problems in childhood.”
43. A pregnant woman should be asked which of the following
question(s) her tobacco use?
d. All of the above
p. 46: “… all women should be screened for tobacco use at their
initial prenatal appointment.72 Women should be asked if they have
ever smoked cigarettes, the last time they smoked cigarettes, and
if they currently smoke.”
44. True or False: According to the American College of Obstetrics
and Gynecology, women should be screened for tobacco use
at their initial prenatal appointment on a case-by-case basis.
b. False
p. 46: “According to the American College of Obstetrics and
Gynecology, all women should be screened for tobacco use at their
initial prenatal appointment.”
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45. The use of selective serotonin reuptake inhibitors to treat
depression has been studied in pregnant women and the
studies found that there is
c. little to no risk of spontaneous abortion.
p. 43: “The use of selective serotonin reuptake inhibitors to treat
depression has been studied in pregnant women and have found
little to no risk of spontaneous abortion, hypertension, or perinatal
death.”
46. Zika virus is an emerging disease spread through
b. the bites of female mosquitoes.
p. 23: “Zika virus is an emerging disease spread through the bites
of female mosquitos.”
47. _________________________ may be one of the dangers of
the Zika virus.
b. Severe mental retardation in neonates
p. 23: “Other brain abnormalities [from Zika virus] are also noted
including severe mental retardation.”
48. Immunity to rubella is important because a rubella infection,
also known as _____________, can cause miscarriage,
stillbirth, and congenital risks such as intra-uterine growth
restriction, hydrocephaly and other abnormalities.
c. German Measles
p. 26: “Immunity to rubella is important because a rubella infection,
also known as German Measles, can cause miscarriage, stillbirth,
and congenital risks such as intra-uterine growth restriction,
hydrocephaly and other abnormalities.”
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49. If a mother tests positive for HIV, her infant will be tested
d. Answers a., and b., above
p. 27: “If the mother tests positive for HIV, her medical staff should
help her adjust to an appropriate antiretroviral treatment plan. Her
infant will then be tested 14 to 21 days post birth and again 1 to 2
months later.”
50. True or False: If the mother tests positive for HIV, she should
not be encouraged to breastfeed.
a. True
p. 27: “HIV positive mothers should not be encouraged to
breastfeed.”
51. Which of the following statements about pregnant women
is/are true related to domestic violence and pregnancy?
b. The risk is 2 to 4 times greater if the pregnancy was unplanned.
p. 19. “The American College of Obstetricians and Gynecologists
also recommends that all pregnant women are assessed for abuse
during each prenatal visit because pregnancy increases a woman’s
risk of falling victim to domestic violence. Women are at an even
higher risk of falling victim to violence if they are under 20 years
old. Pregnant women are also at a two to four times greater risk if
their pregnancy was unplanned.”
52. Signs of abuse may include
d. late initiation of prenatal care.
p. 19. “Signs of abuse may be late initiation of prenatal care,
unexplained or poorly explained injury or bruising, as well as
depression.”
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53. A health clinician will check for any swelling in the hands,
feet, ankles, or face to monitor
c. high blood pressure or hypervolemia.
p. 25: “The health clinician will need to check for any swelling in the
hands, feet, ankles, or face. This is performed in order to monitor
symptoms of beginning high blood pressure or hypervolemia.”
54. Methyldopa’s (a drug used to treat high blood pressure)
effects on fetal development
b. are not alarming and are thus considered safe.
p. 33: “Methyldopa works to treat high blood pressure by relaxing
and dilating the blood vessels. In terms of safety, this medication’s
effects on fetal development are not alarming and are thus
considered safe. The downside to this medication is that some
women feel it has a sedating effect while it only acts as a mild
antihypertensive with a slow onset of action.”
55. True or False: Research suggests that anxiety, depression and
chronic mental strain result in more cases of pre-term birth,
low birth weight and adverse fetal neurodevelopment.
a. True
p. 24: “In fact, research suggests that anxiety, depression and
chronic mental strain result in more cases of pre-term birth, low
birth weight and adverse fetal neurodevelopment.”
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References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
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8. Uva ursi. University of Maryland Medical Center. 2016. Available at:
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