Care of the Woman During Pregnancy

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR Care DISTRIBUTION of the WomanNOT FOR SALE OR DISTRIBUTION During Pregnancy © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlettrenatal Learning, care provides LLC an opportunity to deliver© Jonesmeaningful & Bartlett health care Learning, at a LLC NOT FOR PSALEtransformative OR DISTRIBUTION time in a woman’s life within NOTthe context FOR SALEof a continuing OR DISTRIBUTION and nurturing relationship.

As midwives, we are privileged to witness and support the growth and development of mother and fetus during pregnancy.© Jones Prenatal & Bartlett care is aLearning, comprehensive LLC ongoing program of care ©that Jones & Bartlett Learning, LLC addresses the biophysical,NOT psychosocial,FOR SALE and OR educational DISTRIBUTION needs of the pregnant woman NOTand FOR SALE OR DISTRIBUTION her family. The purpose of prenatal care is to provide primary preventive health care to preg- nant women and to facilitate women’s acquisition of knowledge regarding health behaviors that promote optimal pregnancy and birth outcomes. Additionally, risk assessment is done at each visit to identify deviations from the wide range of normal that may affect maternal © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC or fetal well-being. For women with conditions that fall outside of normal variations of preg- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nancy, the midwife can consult with, collaborate with, or refer to an appropriate clinician. For the pregnant woman, an obstetrician or a perinatologist is the most common consultant needed. Of course, pregnant women are susceptible to all the same ills and injuries as anyone else, and so the services of other healthcare professionals, such as a dermatologist, endocri- © Jones &nologist, Bartlett psychologist, Learning, or LLCphysical therapist, may also be© Jonesrequired. & Bartlett Learning, LLC NOT FOR SALE Provision OR ofDISTRIBUTION the basic components of prenatal care NOTis included FOR in SALE the core OR competencies DISTRIBUTION of midwifery practice. For further information, the midwife is encouraged to compare the standards for basic midwifery practice that have been developed by the American College of Nurse-Midwives (ACNM), the Midwives Alliance of North America (MANA), and the Inter- national Confederation© Jonesof Midwives & Bartlett (ICM). By Learning, reviewing the LLC core documents produced© by Jones & Bartlett Learning, LLC these organizations (allNOT available FOR onlineSALE by OR accessing DISTRIBUTION the respective organizations’ websites),NOT FOR SALE OR DISTRIBUTION one can gain an understanding of the expected standards for midwifery practice in the United States and globally. Additionally, each midwife’s perinatal practice is shaped by state and local regulations, resources, and standards of practice. Midwives© Jones are & concerned Bartlett withLearning, the structure, LLC process, and outcomes ©of Jonesprenatal &care Bartlett and the Learning, LLC intrinsicNOT characteristics FOR SALE ofOR the DISTRIBUTION women they serve. All of these componentsNOT are FOR important SALE in OR DISTRIBUTION developing a model of care and service delivery that is responsive to women’s needs and that ensures assessment of quality and fosters improvement. The ongoing nature of providing pre- natal care facilitates the development of a therapeutic working relationship between woman © Jones &and Bartlett midwife, Learning, making it an LLC ideal opportunity to improve© healthJones behaviors & Bartlett and lifestyle Learning, choices LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 49 20/04/16 3:56 pm © Jones50 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

during pregnancy and beyond through active listening, any expenses that may be incurred. A standardized format ­respectful dialogue, and tangible and emotional support. to clearly document the woman’s decision to accept, de- The content and structure© Jones of prenatal & Bartlett care follow Learning, a cline, LLC or refuse an offered or recommended© Jones &test Bartlett or proce -Learning, LLC ­typical pattern of scheduledNOT visits, FOR health SALE education OR topics,DISTRIBUTION dure is an essential mechanism NOTto have FOR in place. SALE OR DISTRIBUTION and tests, and this standard package of care is easily modi- Many of the women midwives see are unfamiliar with fied to meet the needs and preferences of the individual the range and expectations of the healthcare system and women we serve. The traditional schedule of prenatal care can benefit from guidance to navigate the system and nego- rendered ©by Jonesa provider & or Bartlett group of Learning,providers is structured LLC tiate for care that© Jonesis appropriate & Bartlett to their needs.Learning, Each midLLC- in 12–14 NOTvisits scheduledFOR SALE every OR 4 weeks DISTRIBUTION until the 28th wife is responsibleNOT for FOR outlining SALE to the OR pregnant DISTRIBUTION woman the week of pregnancy, every 2 weeks until the 36th week of scope of her or his practice and the usual parameters for pregnancy, and then weekly until birth (Klima, 2014). A prenatal, labor and birth, and postpartum care services, as reduced visit schedule may also be well suited for low-risk well as describing how the continuum of perinatal services © Joneswomen & Bartlett (Krans & Learning,Davis, 2012). LLC Another model proposed is ©are Jones accessed & Bartlettwhen needed. Learning, When the LLC midwife functions as NOT FORthat of SALE increased OR visits DISTRIBUTION in early pregnancy based on individ- NOTa member FOR of SALE the perinatal OR DISTRIBUTION team, she or he can continue to ual risk and specific disease states (Nicolaides, 2011). In provide support, continuity of care, and advocacy for the this approach, women with high-risk conditions, charac- woman, providing a common thread and source of comfort teristics, and history have an increased number of prenatal and safety should specialty care become necessary. visits early in pregnancy in an effort to address issues and Building a warm, caring, and professional relationship © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC intervene early to reduce potential adverse outcome. allows for mutual trust to develop. Trust, in turn, fosters NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The Centering Pregnancy model of group prenatal women’s active participation in healthcare decisions. The care has become popular in recent years. In this model, woman who trusts her midwife is more likely to accept groups of 8–12 women of similar gestational ages meet the recommendations of the midwife when challenges in 10 sessions throughout pregnancy for health assess- or complications arise. The midwife’s ethical obligation, ment, education,© Jones and & support. Bartlett This Learning, format capitalizes LLC then, is to behave© Jones in a trustworthy & Bartlett manner Learning, by providing LLC on pregnantNOT women’s FOR needSALE to shareOR DISTRIBUTIONtheir concerns, reac- care during pregnancyNOT FOR that isSALE respectful OR ofDISTRIBUTION each woman’s tions, and experiences with others, and on their openness individual desires and preferences. These may range from to learning about childbirth. In the group prenatal care the preferred type of healthcare provider and approach to ­approach, the midwife’s role shifts from authority figure care, the amount of her active participation in her own © Jonesto group & Bartlett facilitator Learning,. As a group, LLC the women influence the ©care Jones and care& Bartlett planning, Learning, the planned LLCand preferred loca- NOT FORtopics SALE addressed OR at DISTRIBUTION each visit, participate in physical NOTtion forFOR her SALE labor and OR birth, DISTRIBUTION and the methods to access ad- assessments, share self-care strategies, and provide social ditional medical services should they be needed. support to one another. Research has demonstrated im- Maternal participation in prenatal care encourages self- proved perinatal health outcomes including reduced rates determination and can enhance a woman’s confidence in of preterm birth (PTB) and© depression, Jones & decreasedBartlett stress,Learning, her LLC ability to labor and give birth© in Jones a manner & Bartlettthat helps Learning, LLC and increased satisfaction NOTwith care FOR using SALE this modelOR DISTRIBUTION of her to feel safe and successful. IncreasedNOT FOR levels SALE of con- OR DISTRIBUTION prenatal care (Ickovics et al., 2007; Picklesimer, Billings, fidence about the ability to give birth is associated with Hale, ­Blackhurst, & Covington-Kolb, 2012). improved perinatal health outcomes and childbirth sat- The number and types of screening and diagnostic tests isfaction (Attanasio, McPherson, & Kozhimannil, 2014). performed© duringJones pregnancy & Bartlett are determined Learning, by LLCindica- Thoughtful, deliberate© Jones attention & Bartlett to factors Learning, promoting LLC tions for NOTtesting FOR or evaluation, SALE currentOR DISTRIBUTION recommendations birth confidenceNOT during FOR the SALEprenatal OR care DISTRIBUTION period can help for practice, and discussion with the woman regarding the create circumstances amenable to enhancing the quality benefits, potential harms, and alternatives to testing, such of maternity care and improving outcomes for mothers as informed refusal of testing, and associated evaluation and infants. The process of mutual participation during © Jonesprocesses. & Bartlett It is important Learning, to share LLC information regarding ©prenatal Jones care & Bartlett builds trust Learning, and fosters LLC resilience in the face NOT FORthe costs SALE of tests OR and DISTRIBUTION procedures so the woman is aware of NOTof unexpected FOR SALE or unfortunate OR DISTRIBUTION events. Sharing information

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9781284083415_CH02_Pass03.indd 50 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,Diagnosis LLC of Pregnancy 51 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

on developing situations, reviewing the options that are History and Chart Review: Components possible during childbirth, and encouraging strength and of the History to Consider flexibility on the part© of Jones both the & mother-to-be Bartlett Learning, and the LLC(Jordan, Engstrom, Marfell,© &Jones Farley, &2014) Bartlett Learning, LLC midwife when addressingNOT whatever FOR SALE circumstances OR DISTRIBUTION come NOT FOR SALE OR DISTRIBUTION their way is an important part of prenatal care. •• Reproductive history Every woman has unique, yet universal, needs during ■■ Gravidity, parity (GP TPAL) pregnancy. This period is a time of many changes and ■■ Menstrual history ­adjustments© Jones of &a physical, Bartlett psychological, Learning, andLLC social ◆◆ ©Usual Jones menstrual & Bartlett patterns Learning, LLC nature.NOT Caring FOR for SALE a woman OR during DISTRIBUTION this time of transi- ◆◆ NOTLast menstrualFOR SALE period OR (LMP) DISTRIBUTION tion can foster her individual feelings of autonomy and ◆◆ Known or suspected date of conception enhance her self-care practices. As such, prenatal care has ■■ Method of birth control the potential to enhance each woman’s ability to care for ■■ Planned or unintended pregnancy © Jones &her Bartlett child and Learning, to develop herLLC strengths as a woman and© a Jones &■■ BartlettConception Learning, issues LLC NOT FOR motherSALE andOR thereby DISTRIBUTION improve family health. NOT FOR SALE◆◆ Interconception OR DISTRIBUTION interval ◆◆ History of primary or secondary infertility ◆◆ Assisted reproductive technologies or DIAGNOSIS OF PREGNANCY treatments ■■ Early signs and symptoms of pregnancy © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Key Clinical Information ◆◆ Breast tenderness NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The diagnosis of pregnancy should be entertained when ◆◆ Fatigue caring for any woman of childbearing age. Pregnancy ◆◆ Fetal movement is the most common cause of secondary amenorrhea in ◆◆ Nausea and/or vomiting women in this life stage. Early-gestation pregnancy can be ◆◆ Urinary frequency discovered© Jones by the & Bartlettclinician as Learning, an incidental LLC finding during ■■ Birth© Jones history & Bartlett Learning, LLC a reproductiveNOT FOR health SALE or primaryOR DISTRIBUTION care visit. ◆◆ NOTDates FOR of prior SALE births OR DISTRIBUTION Pregnancy signs and symptoms are classified as follows: ◆◆ Pain relief measures used during labor and presumptive, meaning those changes that the mother birth can perceive; probable, meaning those changes that ◆◆ Routes of prior births © Jones &can Bartlett be detected Learning, by the examiner; LLC and positive, meaning© Jones & Bartlett◆◆ Pregnancy, Learning, birth, or LLCpostpartum problems NOT FOR thoseSALE changes OR DISTRIBUTION that can be directly attributed to the fetusNOT FOR SALE◆◆ Babies’ OR weights DISTRIBUTION and health (­Engstrom & Cappiello, 2014). Women frequently make ◆◆ Infant feeding method the diagnosis of pregnancy themselves with affordable and ➤➤ Length of breastfeeding if chosen easy urine-based home pregnancy tests. •• Interval history since LMP The diagnosis of pregnancy© Jones may & Bartlettbe a welcome Learning, event or LLC ■■ Pain or cramping © Jones & Bartlett Learning, LLC devastating news. ManyNOT women FOR have SALE mixed OR feelings DISTRIBUTION about ■■ Vaginal bleeding NOT FOR SALE OR DISTRIBUTION the changes that pregnancy will bring to their lives. Am- ■■ Illness or fever bivalence is normal as the newly pregnant woman adjusts ■■ Occupational or environmental substance her self-image to include a baby that is more an abstrac- exposures tion© than Jones a reality & Bartlett in the early Learning, days of pregnancy. LLC The ■■ Use© ofJones herbs or& supplementsBartlett Learning, LLC diagnosisNOT ofFOR pregnancy SALE should OR DISTRIBUTION be shared and explored in a ■■ IngestionNOT FOR of alcohol, SALE medications, OR DISTRIBUTION or drugs private setting in a straightforward and kind manner. This ■■ Significant family, social, or lifestyle changes openness allows the woman to express a wide range of •• Relevant social history emotions and describe how she sees this pregnancy in the ■■ The woman’s feelings and intentions about © Jones &context Bartlett of her Learning, life. The midwife LLC can then take her cues© for Jones & Bartlettpregnancy Learning, LLC NOT FOR nextSALE steps OR from DISTRIBUTION the woman’s response. NOT FOR■■ SALELiving situation:OR DISTRIBUTION housing, people sharing the space

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9781284083415_CH02_Pass03.indd 51 20/04/16 3:56 pm © Jones52 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ ■■ Partner situation Cervix ◆◆ Partner gender ◆◆ Color, size, appearance of os ◆◆ Marital or commitment© Jones status & Bartlett Learning, LLC◆◆ Length and dilatation© Jones & Bartlett Learning, LLC ◆◆ Partner’s feelingsNOT regarding FOR pregnancy SALE OR DISTRIBUTION◆◆ Consistency and positionNOT FOR SALE OR DISTRIBUTION ◆◆ Partner’s intent to co-parent this child ◆◆ Cervical motion tenderness ■■ ■■ Information about the father of the baby Vaginal or cervical discharge ■■ ■■ History of emotional, physical, or sexual abuse Adnexal tenderness, enlargement •• Other physical exam components as indicated by history ■■ Support© Jones systems & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ EmploymentNOT FOR situation SALE and OR occupational DISTRIBUTION NOT FOR SALE OR DISTRIBUTION environment Clinical Impression: Differential Diagnoses to Consider ■■ Socioeconomic status •• Relevant medical/surgical history (ICD10Data.com, 2015) ■■ Allergies © Jones & Bartlett Learning, LLC ©• Jones• Pregnancy, & Bartlett intrauterine Learning, LLC ■■ Medications NOT FOR SALE OR DISTRIBUTION NOT•• Also FOR consider SALE the OR following: DISTRIBUTION ■■ Medical conditions ■■ Ectopic pregnancy ■■ Surgeries ■■ Problems related to unwanted pregnancy (see ■■ Sexually transmitted infections (STIs) Care of the Woman with Unintended Pregnancy in •• Review of systems (ROS) © Jones & Bartlett Learning, LLCChapter 6) © Jones & Bartlett Learning, LLC Physical Examination: ComponentsNOT FOR SALEof the OR DISTRIBUTION■■ Threatened abortion NOT FOR SALE OR DISTRIBUTION Physical Exam to Consider ■■ Molar pregnancy ■■ Blighted ovum •• Vital signs, weight, height, and body mass •• Secondary amenorrhea (see Care of the Woman with index (BMI) Amenorrhea in Chapter 7) •• Skin changes© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ HyperpigmentationNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Screening and Diagnosis: Tests and ◆◆ Melasma Procedures to Consider ◆◆ Linea nigra ◆◆ Areolar darkening •• Urine or serum human chorionic gonadotropin (hCG) © Jones &■■ BartlettVascular spiders Learning, LLC ©• Jones• Quantitative & Bartlett β-hCG Learning, LLC NOT FOR■■ SALEPalmar OR erythema DISTRIBUTION NOT•• Abdominal FOR SALE or vaginal OR DISTRIBUTION ultrasound, depending on most ■■ Striae likely gestational age •• Breast changes Providing Treatment: Therapeutic Measures ■■ Enlargement to Consider ■■ Increased nodularity© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Increased vascularityNOT FOR SALE OR DISTRIBUTION•• Prenatal or other vitamin supplementNOT FOR with SALE OR DISTRIBUTION ■■ Increased tenderness ■■ Folic acid •• Abdominal examination and gestational age ■■ Iron assessment ■■ ω-3 Fatty acids docosahexaenoic acid (DHA) and ■■ Fetal© Jones heart tones & Bartlett Learning, LLC eicosapentaenoic© Jones acid & Bartlett (EPA) Learning, LLC ■■ FundalNOT height FOR SALE OR DISTRIBUTION •• Treatment NOTof any FORunderlying SALE condition OR DISTRIBUTION as indicated ■■ Palpable fetal parts, position, and movement ■■ Abdominal tenderness and consistency Providing Treatment: Integrative Therapies •• Pelvic evaluation and gestational age assessment to Consider © Jones &■■ BartlettBimanual uterineLearning, sizing LLC ©• Jones• High-folate & Bartlett foods Learning, LLC NOT FOR■■ SALEConsistency OR DISTRIBUTION and position of uterus and cervix NOT•• Red FOR raspberry SALE leaf OR tea DISTRIBUTION

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9781284083415_CH02_Pass03.indd 52 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC © JonesInitial & Bartlett Assessment Learning, of the Pregnant Woman LLC 53 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Providing Support: Education and Support ■■ Pregnancy verification statement for various agencies: Measures to Consider ◆◆ Women, infants, and children (WIC) program •• Pregnancy options© counselingJones & asBartlett indicated Learning, LLC ◆◆ Medicaid © Jones & Bartlett Learning, LLC •• Preliminary nutritionNOT and FOR social SALE assessments OR DISTRIBUTION and ■■ Other programs basedNOT on FORhistory SALE and preferences, OR DISTRIBUTION counseling such as •• Tobacco, alcohol, and substance avoidance ◆◆ Substance use treatment •• Review prenatal care options and expectations ◆◆ Smoking cessation ◆◆ Counseling or mental health services ©■■ JonesPrenatal & testing Bartlett as indicated Learning, LLC © Jones & Bartlett Learning, LLC ◆◆ Women’s shelter/safe house NOT■■ Family FOR involvement SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Provide or suggest readings to increase •• For diagnosis or treatment outside the midwife’s scope knowledge of pregnancy care and birth choices of practice •• Practice information INITIAL ASSESSMENT OF THE © Jones & Bartlett■■ Philosophy Learning, of care LLC © Jones & Bartlett Learning, LLC PREGNANT WOMAN NOT FOR SALE■■ ORWomen’s DISTRIBUTION rights and responsibilities NOT FOR SALE OR DISTRIBUTION ■■ Prenatal and birth care providers ■■ Birth location options Key Clinical Information ■■ Medical and hospital affiliations The initial assessment of the pregnant woman provides ■■ Billing arrangements© Jones & Bartlett Learning, LLCthe basis for ongoing prenatal© Jones care. Careful & Bartlett attention Learning, to LLC NOT FOR SALE OR DISTRIBUTION­behaviors and communication,NOT the FOR woman’s SALE personal OR healthDISTRIBUTION Follow-up Care: Follow-up Measures to Consider history, family history, and physical examination allows the midwife to develop a comprehensive, yet dynamic, mid- •• Document and discuss wifery plan of care with the woman and alerts the midwife ■■ Gestational age and expected due date (EDD) to sensitive concerns that may require further investigation © Jonesor estimated & Bartlett date of birth Learning, (EDB) LLC © Jones & Bartlett Learning, LLC or follow-up over time. Gentle touch, coupled with an orga- NOT■■ Relevant FOR reproductive,SALE OR DISTRIBUTIONmedical, and NOT FOR SALE OR DISTRIBUTION nized, systematic, yet unhurried, manner is ideal during the social history first visit. Providing respectful care that promotes a sense ■■ Clinical findings of safety and connection with the woman and her unique ■■ Woman’s preferences for pregnancy and care experience is particularly important during the pregnancy ■■ Midwifery plan of care © Jones & Bartlett Learning, LLC © Jonesand &birth Bartlett (see Appendix Learning, C). This LLC encounter builds on the •• Return for continued care NOT FOR SALE OR DISTRIBUTION NOT FORinformation SALE obtained OR DISTRIBUTION during the office visit at which the ■■ Between 6 and 12 weeks’ gestation for initial pregnancy was diagnosed. The first prenatal care encounter ­prenatal visit is a time-intensive visit, but it is well worth the investment ■■ As soon as possible when >12 weeks’ gestation of time and energy to establish a good rapport with the ■■ Prenatal testing as indicated and desired © Jones & Bartlett Learning, LLCpregnant woman and her family© Jones and to &co-create Bartlett an optimalLearning, LLC NOT FOR SALE OR DISTRIBUTIONplan of care for the individualNOT woman FOR and SALE her baby. OR DISTRIBUTION Interdisciplinary Practice: Consider Consultation, Collaboration, or Referral History and Chart Review: Components •• Maternity care services of the History to Consider ©■■ JonesGenetic &counseling Bartlett Learning, LLC (Jordan et© al., Jones 2014) & Bartlett Learning, LLC NOT■■ Genetic FOR diagnostic SALE OR testing DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Adoption services •• Age, cultural and demographic information ■■ Abortion services •• Maternity history ■■ ■■ Specialty perinatal care Present pregnancy history

■■ ◆◆ LMP, interval, and flow © Jones & BartlettNutritional Learning, services LLC © Jones & Bartlett Learning, LLC ◆◆ Signs and symptoms NOT FOR •SALE• Social OR services DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 53 20/04/16 3:56 pm © Jones54 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ GP TPAL, prior pregnancy information, •• Genitourinary system ­interventions and complications ■■ External genitalia •• Reproductive health history© Jones & Bartlett Learning, LLC◆◆ Vulvar varicosities © Jones & Bartlett Learning, LLC ■■ Gynecologic disorders,NOT problems, FOR SALE or treatment, OR DISTRIBUTION ◆◆ Scars, lesions, piercingsNOT FOR SALE OR DISTRIBUTION such as ◆◆ Discharge ◆◆ Sexually transmitted infections ■■ Speculum examination ◆◆ Cervical cryotherapy ◆◆ Vagina ◆◆ ©Loop Jones electrosurgical & Bartlett excision Learning, procedure LLC ◆◆ Cervix© Jones & Bartlett Learning, LLC •• ContraceptiveNOT FOR history SALE OR DISTRIBUTION ◆◆ CollectionNOT FORof laboratory SALE specimens OR DISTRIBUTION •• Sexual history ■■ Bimanual examination and assessment of •• Interval history since LMP ­gestational age ■■ Drugs, supplements, or herbs taken ◆◆ Uterine size, contour, position © Jones &■■ BartlettIllness or feverLearning, LLC © Jones◆◆ &Tenderness Bartlett Learning, LLC ■■ NOT FOR SALEOccupational OR DISTRIBUTION or environmental substance exposures NOT FOR◆◆ Clinical SALE pelvimetryOR DISTRIBUTION assessment ■■ Significant family, social, or lifestyle changes ■■ Rectal examination as indicated •• Maternity risk assessment (see Assessment of Health ◆◆ Presence of hemorrhoids Risks and Protective Factors in the Pregnant Woman •• Musculoskeletal system in Chapter 2) ■■ Symmetry and ease of movement © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Medical, surgical, and mental health history •• Extremities NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Vaccination history (Centers for Disease ■■ Varicosities ­Control and Prevention [CDC], 2014a) ■■ Needle track marks •• Social history ■■ Signs of infestations ■■ History of emotional, physical, sexual abuse ■■ Bruising ■■ Family© Jones history & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ OccupationalNOT FOR history SALE OR DISTRIBUTION Clinical Impression:NOT FORDifferential SALE Diagnoses OR DISTRIBUTION to Consider ■■ Tobacco, alcohol, or substance use (ICD10Data.com, 2015) ■■ Usual nutrition patterns and preferences •• Pregnancy, normal •• Review of systems •• High-risk pregnancy © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Secondary diagnoses related to other findings as NOT FORPhysical SALE Examination: OR DISTRIBUTION Components of the NOT FOR SALE OR DISTRIBUTION Physical Exam to Consider ­indicated by ■■ History •• Vital signs ■■ Physical examination •• Observation of general appearance and affect ■■ Diagnostic testing •• Head, eyes, ears, nose,© and Jones throat &(HEENT) Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Skin NOT FOR SALE OR DISTRIBUTIONScreening and Diagnosis: TestsNOT and FOR SALE OR DISTRIBUTION ■■ Striae Procedures to Consider ■■ Scars, tracks, or bruises (Berghella, 2012; Jordan et al., 2014) ■■ Body art, piercings, or tattoos •• Cardiopulmonary© Jones & system Bartlett Learning, LLC •• Pregnancy ©testing Jones if needed & Bartlett Learning, LLC •• BreastsNOT and FORaxilla SALE OR DISTRIBUTION ■■ Urine orNOT serum FOR SALE OR DISTRIBUTION •• Abdominal examination and assessment of gestational age ■■ Quantitative β-human chorionic gonadotropin ■■ Fundal height (β-hCG) ■■ Fetal heart rate (FHR) •• Routine prenatal sexually transmitted infection (STI) © Jones &■■ BartlettFetal lie and Learning, position LLC © Jonestesting & (universal Bartlett approach) Learning, LLC NOT FOR■■ SALEGastrointestinal OR DISTRIBUTION system NOT ■■ FORChlamydia SALE and OR gonorrhea DISTRIBUTION

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■■ Venereal Disease Research Laboratory (VDRL) or ◆◆ Nuchal translucency done between 10 and 13 rapid plasma reagin (RPR) completed weeks’ gestation ■■ Human immunodeficiency© Jones & virus Bartlett (HIV) Learning,using opt-out­ LLC ◆◆ Detects Down syndrome© Jones and & NTDBartlett Learning, LLC approach NOT FOR SALE OR DISTRIBUTION ◆◆ Highest sensitivityNOT (95%) FOR with SALE lowest OR false- DISTRIBUTION ■■ Hepatitis B surface antigen positive rate (2%) •• Cervical cytology with reflex human papillomavirus ■■ Cystic fibrosis screening offered to all couples re- (HPV) testing if due gardless of ethnicity •• Hematology© Jones & evaluation Bartlett and Learning, titers LLC •• Ultrasound,© Jones transvaginal & Bartlett or abdominal Learning, LLC NOT■■ Complete FOR SALEblood count OR (CBC)DISTRIBUTION with platelet count ■■ EstablishNOT FOR or confirm SALE dates OR DISTRIBUTION ■■ Blood type, Rh factor, and antibody screen ◆◆ Optimal pregnancy dating is first ­trimester up to ■■ Rubella titer 13 6/7 weeks’ gestation (American Congress of ■■ Varicella antibody screen Obstetricians and Gynecologists [ACOG], 2010) © Jones & Bartlett■■ Drug Learning, screen offered LLC © Jones &■■ BartlettPregnancy Learning, location and LLCfetal viability ■■ NOT FOR •SALE• Fetal OR and DISTRIBUTIONgenetic screening and testing offered NOT FOR SALEFetal anatomical OR DISTRIBUTION survey, with informed consent ■■ All genetic screening is offered with full informed ◆◆ First trimester—nuchal translucency consent ◆◆ Second trimester—after 18 weeks’ gestation ■■ The option of no genetic screening is offered as an ■■ Benefits, risks, and limitations of ultrasound equal consideration should be discussed with all pregnant women © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ First-trimester screening options (ACOG, 2009) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ◆◆ Serum screen done between 9 and 13 weeks’ •• Urinalysis with culture gestation •• Group B Streptococcus culture at 35–37 weeks’ gesta- ◆◆ Nuchal translucency done at 10–13 completed tion (CDC, 2014b) weeks’ gestation ■■ Swab lower vaginal vault and rectum © Jones➤➤ Screens & Bartlett for Down Learning, syndrome LLC ◆◆ ©Self Jones or provider & Bartlett swab Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ➤➤ Does not detect neural tube defect (NTD) •• For selected high-risk populations or individuals, ◆◆ Noninvasive prenatal testing (NIPT) consider ➤➤ Done between 10 and 12 weeks’ ■■ Amniocentesis or chorionic villus sampling gestation ■■ Cytomegalovirus (CMV) © Jones & Bartlett➤ Learning,➤ Analyzes placental LLC DNA © Jones &■■ BartlettHepatitis CLearning, serology LLC NOT FOR SALE OR➤➤ DISTRIBUTIONOffered to women with genetic high- NOT FOR■■ SALEThyroid-stimulating OR DISTRIBUTION hormone (TSH) risk indications (American College of ■■ Carrier screening for select populations ­Obstetricians and Gynecologists [ACOG], ◆◆ Tay–Sachs disease—Ashkenazi Jewish, 2015) Cajun, and French Canadian ➤➤ Detects© Down Jones syndrome, & Bartlett Edwards Learning, LLC ◆◆ Sickle cell screen© orJones hemoglobin & Bartlett Learning, LLC ­syndrome,NOT Patau FOR syndrome, SALE ORsex DISTRIBUTION electrophoresis—AfricanNOT FOR American SALE and OR DISTRIBUTION ­chromosomal abnormalities African descent ■■ Second-trimester screening options ◆◆ Thalassemia—Southeast Asian, ◆◆ Quad serum screen Mediterranean, and Hispanic © Jones➤➤ Done & Bartlett between Learning,15 and 22 weeks’ LLC gestation ■■ Blood© Jones lead screening & Bartlett Learning, LLC NOT FOR➤➤ Measures SALE fourOR specificDISTRIBUTION substances: ■■ One-hourNOT FOR glucose SALE challenge OR DISTRIBUTIONtest or other diabetes α fetoprotein (AFP), hCG, estriol, and screening inhibin-A ■■ For suspicion of bacterial vaginosis, candidiasis, ➤➤ Screens for Down syndrome and NTD and trichomoniasis © Jones & Bartlett■■ Integrated Learning, screening LLC © Jones & Bartlett◆◆ Wet prep Learning, microscopic LLC examination NOT FOR SALE◆ ◆ORFirst- DISTRIBUTION and second-trimester serum markers NOT FOR SALE◆◆ Commercial OR DISTRIBUTION testing such as BD Affirm VPIII

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9781284083415_CH02_Pass03.indd 55 20/04/16 3:56 pm © Jones56 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ Tuberculosis testing: purified protein derivative (PPD) ■■ How to access care providers ◆◆ History of positive PPD or bacillus Calmette- ■■ Typical return visit schedule Guérin (BCG) vaccine,© Jones consider & Bartlett chest x-ray Learning, LLC■■ Recommended prenatal ©visits Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION■■ Recommended pregnancy,NOT childbirth, FOR SALEand OR DISTRIBUTION Providing Treatment: Therapeutic Measures ­parenting classes to Consider ■■ Recommended and optional prenatal testing •• Pharmacotherapy ■■ Birth options ■■ Prenatal© Jones vitamins & Bartlett with folic Learning, acid, iron, and LLC ω-3 ◆◆ Location© Jones of birth & (see Bartlett Box 2-1 Learning,) LLC fattyNOT acids FOR docosahexaenoic SALE OR acidDISTRIBUTION (DHA) and ◆◆ WaterNOT birth/hydrotherapy FOR SALE ORavailability DISTRIBUTION eicosapentaenoic acid (EPA) ◆◆ Vaginal birth after cesarean (VBAC) counseling ■■ Seasonal influenza vaccination (CDC, 2014c) as needed •• Lifestyle recommendations ■■ Interdisciplinary healthcare team and providers ■■ Regular mild to moderate exercise © Jones & Bartlett Learning, LLC ©Follow-up Jones & Care:Bartlett Follow-up Learning, Measures LLC to Consider NOT FOR■■ SALEAdequate OR rest DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Stress management techniques •• Document and discuss ■■ ■■ Social support networks Pregnancy status ■■ ■■ Dietary sources of nutrients: Woman’s expressed preferences ◆◆ Folate ■■ Risk assessment with plan for care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ◆◆ Iron ■■ Information provided and discussions NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ◆◆ Calcium ■■ Informed consent for care ◆◆ ω-3 Fatty acids DHA and EPA •• Schedule return for prenatal visits ◆◆ Vitamin D ■■ Every 4–6 weeks through 28–32 weeks’ gestation ◆◆ Fiber ■■ Every 2–3 weeks through 32–36 weeks’ gestation © Jones & Bartlett Learning, LLC ■■ © Jones & Bartlett Learning, LLC ◆◆ Protein Weekly from 36 weeks’ gestation to onset of labor NOT FOR SALE OR DISTRIBUTION ■■ NOT FOR SALE OR DISTRIBUTION ■■ Whole unprocessed grains, complex carbohydrates More or less frequent visits based on risk assess- ■■ Organic food when possible ment (see Assessment of Health Risks and Protec- •• Continue or modify treatment of existing conditions in tive Factors in the Pregnant Woman in Chapter 2) light of pregnancy diagnosis as indicated ■■ Centering Pregnancy group starting in second trimester © Jones & Bartlett Learning, LLC ©• Jones• VBAC & or Bartlett planned repeat Learning, cesarean LLC NOT FORProviding SALE Treatment: OR DISTRIBUTION Integrative Therapies NOT ■■ FORObtain SALE and reviewOR DISTRIBUTION operative notes to verify type of to Consider uterine incision These measures are intended to supplement—not ■■ Surgical and anesthesia consultation ­replace—regular prenatal care: Interdisciplinary Practice: Consider Consultation, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Prenatal yoga Collaboration, or Referral NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Meditation and relaxation therapies •• Obstetric services •• Pregnancy massage therapy ■■ Per practice standards •• Childbirth education classes ■■ Genetic or other counseling •• Prenatal exercise classes •• Other perinatal or medical subspecialty as indicated by © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC secondary diagnoses or findings NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Providing Support: Education and Support •• Social services, such as Measures to Consider ■■ WIC program •• Discuss the following topics: ■■ Medicaid ■■ Diet and exercise recommendations •• Dietary or nutrition counseling © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Lifestyle modification recommendations •• For diagnosis or treatment outside the midwife’s scope NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Danger signs and when to call of practice

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9781284083415_CH02_Pass03.indd 56 20/04/16 3:56 pm © Jones & Bartlett Learning, LLCAssessment of Health Risks© Jonesand Protective & Bartlett Factors Learning, in the Pregnant Woman LLC 57 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

BOX 2-1 BIRTH AT HOME OR IN A FREESTANDING BIRTH CENTER

Out-of-hospital birth—either© Jones in& the Bartlett home or Learning, in a freestanding LLC birth center setting—is a© safe Jones option & for Bartlett women whoLearning, LLC meet and maintainNOT the criteria FOR ofSALE low risk OR during DISTRIBUTION pregnancy and who arrange care withNOT a skilled FOR provider SALE (Cheyney OR DISTRIBUTION et al., 2014; Elder, 2014; Olsen & Clausen, 2012). The prevalence of out-of-hospital births in the United States has increased by 56% from 2004 to 2012, and this trend is expected to continue (MacDorman, Mathews, & Declerq, 2014). There are no universally endorsed selection criteria for home birth candidates in the United States although guidelines for maternal transfer from home to the hospital have been jointly developed by several expert groups (Vedam© Jones et al., & 2014) Bartlett. The Learning, information LLC presented here is a brief overview© Jones of considerations & Bartlett Learning,for labor and LLC birth for theNOT woman FOR who SALE chooses OR an DISTRIBUTIONout-of-hospital birth. NOT FOR SALE OR DISTRIBUTION The woman should have a strong preference for birth in an out-of-hospital setting and demonstrate the following characteristics: •• Presence of protective factors for normal birth and healthy baby

© Jones & Bartlett■■ Low Learning, risk for perinatal LLC complications © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Commitment to healthy pregnancy and physiologic birth

■■ Flexible approach to addressing issues that arise •• Strong sense of self-determination for life choices ■■ Maintenance© of Jones positive &health Bartlett habits Learning,and prenatal LLCcare © Jones & Bartlett Learning, LLC ■■ Preparation ofNOT birthing FOR environment SALE OR and DISTRIBUTION supportive others NOT FOR SALE OR DISTRIBUTION ■■ Willingness to transfer during labor or postpartum when indicated •• Plans in place for urgent or emergency transfer of care to a hospital setting •• Spontaneous progressive labor The© Joneswoman should& Bartlett also have Learning, the following LLC psychosocial attributes: © Jones & Bartlett Learning, LLC •NOT• Understand FOR SALEand ackno ORwledge DISTRIBUTION the shared responsibility for care andNOT outcome FOR SALE OR DISTRIBUTION •• Have adequate social support for her choice •• Have a strong commitment to labor and birth without medications © Jones & Bartlett•• Agree toLearning, assessment LLCusing screening criteria for the© specificJones out-of-hospital& Bartlett Learning, practice LLC NOT FOR SALE•• Hav ORe open DISTRIBUTION and clear communication with the midwifeNOT FOR SALE OR DISTRIBUTION The interested reader is encouraged to access American College of Nurse-Midwives (ACNM), Midwives Alliance of North America (MANA), and American Association of Birth Centers (AABC) documents regarding the safe provision of out-of-hospital care. American Association of Birth Centers: http://www.birthcenters.org/ American College of Nurse-Midwives:© Jones & http://www.midwife.org/ Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Midwives Alliance of NorthNOT America: FOR http://mana.org/ SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

ASSESSMENT OF HEALTH RISKS physiologic or psychological stresses arise, while nega- AND© Jones PROTECTIVE & Bartlett FACTORS Learning, LLC tive factors© Jonescan increase & Bartlett a woman’s Learning, risk of complications. LLC IN THE PREGNANT WOMANNOT FOR SALE OR DISTRIBUTION Many riskNOT factors FOR can SALEbe modified OR orDISTRIBUTION diminished through timely assessment, diagnosis, and intervention or treat- Key Clinical Information ment. Health and psychosocial risks have the potential One of the important elements of prenatal care is the to affect the health of the mother, the fetus, or her newly © Jones &identification Bartlett Learning, of health factors LLC that can affect pregnancy.© Jones born & infant. Bartlett These Learning, risks can be LLC related to lifestyle, diet, NOT FOR ProtectiveSALE OR factors DISTRIBUTION result in greater resiliency when NOT FORsubstance SALE use, OR social DISTRIBUTION circumstances, genetic heritage,

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9781284083415_CH02_Pass03.indd 57 20/04/16 3:56 pm © Jones58 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

environmental exposures, ability to access prenatal care, ■■ Use of integrative therapies, such as and cultural or ethnic background and practices. Prenatal ◆◆ Herbs assessment and identification© Jones of health & risksBartlett offer theLearning, op- LLC◆◆ Homeopathy © Jones & Bartlett Learning, LLC portunity to diagnose or treatNOT actual FOR or SALEpotential OR condi- DISTRIBUTION◆◆ Acupuncture NOT FOR SALE OR DISTRIBUTION tions or to provide parents with information and support •• Maternity and reproductive health history to help them cope with unexpected outcomes. ■■ Prior pregnancy conditions or complications Many risk factors for pregnant women are associated ◆◆ Prior pregnancy losses with habitual© Jones or addictive & Bartlett behaviors, Learning, such as dietary LLC hab- ◆◆ Birth© defects Jones & Bartlett Learning, LLC its and smoking.NOT FOR The midwife SALE canOR begin DISTRIBUTION to address these ◆◆ InfertilityNOT FOR SALE OR DISTRIBUTION modifiable behaviors with the woman by assessing her ◆◆ Prior physical or psychological birth trauma readiness to change. For those women testing positive for ■■ Sexually transmitted infections (STIs) substance use, or with other lifestyle behaviors associated ■■ Previous gynecologic procedures, such as © Joneswith & negative Bartlett health Learning, effects, using LLC a direct and woman- © Jones◆◆ &Loop Bartlett electrosurgical Learning, excision LLC procedure NOT FORcentered SALE counseling OR DISTRIBUTION style, assessing the woman’s readi- NOT FOR◆◆ Myomectomy SALE OR DISTRIBUTION ness to change, and demonstrating empathy and reflective ◆◆ Hysterosalpingogram listening can significantly modify behavior (Copeland, •• Family medical history McNamara, Kelson, & Simpson, 2015). Motivational ■■ Ethnic heritage interviewing principles should be used during healthcare ■■ Hereditary or genetic health conditions © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC encounters that cover lifestyle issues to facilitate behavior ■■ Cultural health habits or conditions NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION change and positive outcomes (Rubak, Sandbaek, Laurit- •• Pregnancy-related risk factors zen, & Christensen, 2005). ■■ Signs or symptoms of concern ■■ Adverse lifestyle and health habits History and Chart Review: Components ■■ Tobacco, e-cigarette use, alcohol, and/or illicit or of the History© Jones to Consider & Bartlett Learning, LLC prescription© Jones drug use & Bartlett Learning, LLC •• MaternalNOT demographic FOR SALE information OR DISTRIBUTION ■■ ObesityNOT FOR SALE OR DISTRIBUTION ■■ Age ■■ Multifetal gestation ■■ Partner status ■■ Sociodemographic factors, such as ■■ Education ◆◆ Intimate partner violence © Jones &■■ BartlettSocioeconomic Learning, status LLC © Jones◆◆ &Unstable Bartlett housing Learning, or relationships LLC NOT FOR■■ SALE Ethnic/racial OR DISTRIBUTION background NOT•• Nutritional FOR SALE assessment OR DISTRIBUTION ■■ Employment status and type ■■ Focused food and fluid intake history ■■ Religious preference ◆◆ 24-hour food recall ■■ Sexual orientation and gender ◆◆ Typical day’s diet identification © Jones & Bartlett Learning, LLC■■ Caffeine use © Jones & Bartlett Learning, LLC •• Medical and mental healthNOT history FOR SALE OR DISTRIBUTION◆◆ 200 mg or less per dayNOT recommended FOR SALE (March OR of DISTRIBUTION ■■ Diseases or health disorders, such as Dimes, 2012) ◆◆ Hypertension •• Physical activity patterns ◆◆ Diabetes •• Review of environmental exposures (Arnesen, 2006) ◆◆©Kidney Jones disease & Bartlett Learning, LLC ■■ Cats in ©household Jones and& Bartlett ingestion Learning,of raw or rare LLC ◆◆NOTAutoimmune FOR SALE disease OR DISTRIBUTION meat (toxoplasmosis)NOT FOR SALE OR DISTRIBUTION ◆◆ Thyroid disease ■■ Paint and pipes in older homes and various house- ◆◆ Mental illness hold items (lead) ■■ Medication use patterns: over the counter (OTC) ■■ Regular high-mercury fish consumption (mercury) © Jones & Bartlettand prescription Learning, LLC © Jones◆◆ &Shark, Bartlett swordfish, Learning, king mackerel, LLC and tilefish NOT FOR■■ SALESurgeries OR DISTRIBUTION NOT ■■ FORSoft SALEcheeses, OR packaged DISTRIBUTION meats (listeriosis)

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■■ Household cleaning chemicals Clinical Impression: Differential Diagnoses to Consider ■■ Household pesticides (ICD10Data.com, 2015) ■■ Occupational© exposures Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Review of social NOTsituation FOR and SALEsupport OR DISTRIBUTION•• Pregnancy, normal NOT FOR SALE OR DISTRIBUTION ■■ Presence of caring partner or supportive •• Pregnancy at risk, secondary to others ■■ Health habits, specify ■■ ■■ Number and relationship of people in the home Genetic disorders ■■ Maternal age ©■■ Jones Anticipated & Bartlett cultural Learning, practices during LLC © Jones & Bartlett Learning, LLC ■■ Fetal conditions, specify NOTpregnancy FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ ■■ Economic situation and resources Maternal health conditions, specify ■■ ■■ Food purchase and storage resources Prior uterine or cervical surgery ■■ ■■ Intimate partner violence screening Infection ■■ ■■ Barriers to regular prenatal care Abuse © Jones & Bartlett Learning, LLC © Jones & Bartlett◆◆ Physical Learning, LLC NOT FOR •SALE• Psychosocial OR DISTRIBUTION evaluation NOT FOR SALE OR DISTRIBUTION •• Depression screening ◆◆ Sexual •• Review of systems ◆◆ Emotional ■■ Substance abuse ■■ Poor social support Physical Examination: Components of the © Jones & Bartlett Learning, LLC ■■ Occupational hazards© Jones & Bartlett Learning, LLC Physical Exam to Consider NOT FOR SALE OR DISTRIBUTION•• Nonadherence to recommendedNOT FOR care SALE related OR to the DISTRIBUTION •• Physical assessment ­following issues: ■■ Vital signs, including blood pressure (BP), weight, ■■ Communication barriers height, and body mass index (BMI) calculation ■■ Transportation barriers •• © Evaluate Jones for & evidence Bartlett of theLearning, following: LLC ■■ Limited© Jones financial & Bartlett or social resourcesLearning, LLC ■■ NOTIllness FOR SALE OR DISTRIBUTION ■■ PsychologicalNOT FOR or SALE mental OR health DISTRIBUTION issues ■■ Malnutrition ■■ Self-determination or cultural factors ◆◆ Undernutrition ■■ Knowledge or learning deficits ◆◆ Overnutrition •• Other diagnoses as noted ■■ Fatigue, exhaustion © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Physical and/or emotional abuse or trauma Screening and Diagnosis: Tests and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Brief examination of the oral and nasal cavities Procedures to Consider ■■ Gingivitis •• Drug screening (informed consent requirements vary ■■ General dentition by state) ■■ Condition of mucous membranes •• HIV testing using opt-out approach © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Skin examination •• Hepatitis B and C testing NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Integrity and turgor •• Screening for hemoglobinopathies ■■ Needle tracks •• Serum screening for neural tube defect (NTD) and/or ■■ Bruising aneuploidy ■■ Burns •• Group B Streptococcus testing ©■■ JonesScars & Bartlett Learning, LLC •• STI testing© Jones & Bartlett Learning, LLC NOT■■ Petechia FOR SALE OR DISTRIBUTION •• UltrasoundNOT FOR SALE OR DISTRIBUTION ■■ Lesions ■■ Fetal anatomy •• Olfactory evidence ■■ Nuchal translucency ■■ Tobacco or alcohol use •• Amniocentesis © Jones & Bartlett■■ Ketosis Learning, LLC © Jones•• Chorionic& Bartlett villus Learning, sampling LLC NOT FOR SALE■■ General OR DISTRIBUTION hygiene NOT FOR•• Other SALE testing OR as DISTRIBUTION indicated

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9781284083415_CH02_Pass03.indd 59 20/04/16 3:56 pm © Jones60 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Providing Treatment: Therapeutic Measures to Consider Follow-up Care: Follow-up Measures to Consider •• Prenatal or multivitamin with folic acid, iron, and •• Document and discuss identified concerns, risks, and ω-3 fatty acids docosahexaenoic© Jones acid & Bartlett(DHA) and Learning, LLChealth conditions © Jones & Bartlett Learning, LLC eicosapentaenoic acid NOT(EPA) FOR SALE OR DISTRIBUTION•• Recommended schedule of returnNOT FORvisits SALE OR DISTRIBUTION •• Behavioral interventions to promote optimal health ■■ Factors determining frequency behaviors ◆◆ Gestational age •• Assess readiness to change problem behaviors ◆◆ Individual maternal and/or fetal health •• Smoking© Jones cessation & Bartlett counseling Learning, (American LLC Congress condition(s)© Jones & Bartlett Learning, LLC of ObstetriciansNOT FOR and SALE Gynecologists OR DISTRIBUTION [ACOG], 2009) ◆◆ MaternalNOT or FOR fetal SALEevaluation OR or DISTRIBUTIONmonitoring ■■ “Five A’s” of smoking cessation: ask, advise, assess, intervals assist, arrange ■■ Allow adequate time ■■ “Five R’s” of smoking reduction for those who ◆◆ Develop a cooperative and trusting relationship © Jones & Bartlett­continue smoking: Learning, relevance, LLC risk, rewards, © Jones◆◆ &Observe Bartlett for risk-relatedLearning, behaviors LLC NOT FOR SALE­roadblocks, OR DISTRIBUTIONrepetition NOT ■■ FORSerial SALE drug or OR STI DISTRIBUTION testing as indicated •• Nicotine replacement therapies, bupropion, and vare- nicline to be avoided during pregnancy (ACOG, 2009) Interdisciplinary Practice: Consider Consultation, •• Other medications, interventions, or treatments based Collaboration, or Referral on diagnosis © Jones & Bartlett Learning,•• LLC Subspecialty maternity care ©services Jones & Bartlett Learning, LLC ■■ Genetic counseling and testing Providing Treatment: IntegrativeNOT FOR Therapies SALE to OR Consider DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Nutritional counseling •• Nutritional support, based on condition ■■ Nuchal translucency, amniocentesis, or chorionic •• Strategies to support change in health habits villus sampling

■■ Hypnosis ■■ © Jones & Bartlett Learning, LLC Obstetric© orJones perinatal & Bartlettphysician consultation,Learning, LLC ■■ Acupuncture NOT FOR SALE OR DISTRIBUTION ­collaboration,NOT FORor referral SALE per indicationOR DISTRIBUTION ■■ Interdisciplinary integrative team-based care •• Medical services ■■ Social support and support groups ■■ As indicated for medical or specialty care •• Other therapies based on risk assessment or diagnosis •• Social services ■■ As indicated by lifestyle and social indicators Providing Support: Education and Support © Jones & Bartlett Learning, LLC © Jones■■ Inpatient & Bartlett or outpatient Learning, substance LLC use treatment Measures to Consider NOT FOR SALE OR DISTRIBUTION NOT FORprogram SALE OR DISTRIBUTION •• Provide information about ■■ Counseling or therapy ■■ Identified concerns, risks, and health conditions ■■ Women’s shelter/safe house ■■ Risks and/or benefits •• Midwifery leadership: Participation in collaborative ◆◆ Current lifestyle© behaviors Jones & Bartlett Learning, LLCinterdisciplinary care enhances© Jones health outcomes & Bartlett and Learning, LLC ◆◆ Prenatal tests andNOT other FOR offered SALE tests OR DISTRIBUTIONexperiences NOT FOR SALE OR DISTRIBUTION ◆◆ Genetic screening and testing options •• For diagnosis or treatment outside the midwife’s scope ◆◆ Treatment options of practice ■■ Genetic counseling •• Review© drugJones and &alcohol Bartlett screening Learning, policy LLC © Jones & Bartlett Learning, LLC ONGOING CARE OF THE PREGNANT •• AllowNOT private FOR time SALEto encourage OR DISTRIBUTIONdisclosure NOT FOR SALE OR DISTRIBUTION •• Develop plan for safety as indicated by history WOMAN •• Social support services •• Cultural support services Key Clinical Information © Jones &■■ BartlettTranslation Learning, services LLC ©The Jones “routine” & Bartlett prenatal Learning,visit is anything LLC but routine NOT FOR•• Diagnosis-related SALE OR DISTRIBUTION information and support groups NOTfor most FOR pregnant SALE women. OR DISTRIBUTION This visit is each woman’s

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opportunity to have her needs met and her concerns ad- ■■ Presence of common discomforts dressed while the well-being of herself and her child is ◆◆ Relief measures used and effectiveness evaluated. Prenatal care© Jones provides & an Bartlett opportunity Learning, to look LLC ■■ Signs or symptoms© Jones of & Bartlett Learning, LLC for subtle signs or symptomsNOT FOR that SALEcan indicate OR DISTRIBUTIONdevelop- ◆◆ Preterm labor NOT FOR SALE OR DISTRIBUTION ment of a deviation from normal. Time spent during ◆◆ Pregnancy-induced hypertension prenatal care also facilitates the creation of a caring, ◆◆ Urinary tract infection respectful, and therapeutic relationship conducive to ◆◆ Vaginal bleeding or discharge ­optimal© Jones pregnancy & Bartlett care and outcomesLearning, (Jordan LLC et al., 2014; ◆◆ ©Exposure Jones to& infectiousBartlett diseaseLearning, LLC Sandall,NOT Soltani, FOR SALEGates, Shennan, OR DISTRIBUTION & Devane, 2013). ◆◆ NOTEnvironmental FOR SALE exposure OR DISTRIBUTION Prenatal care began in the early 1900s as a method ◆◆ Developing deviations from normal to screen for signs and symptoms of preeclampsia. Over ■■ Fetal movement the years, it has evolved into a platform for teaching and ■■ Maternal concerns © Jones &testing. Bartlett Follow-up Learning, activities LLC by the midwife allow women© Jones & Bartlett◆◆ Questions Learning, LLC NOT FOR toSALE fully realizeOR DISTRIBUTION the benefits of prenatal care and fosterNOT FOR SALE◆◆ Plans OR related DISTRIBUTION to pregnancy, labor, an ongoing interaction that builds trust and understand- and birth ing between the woman and the midwife. Follow-up on laboratory and test results, on behavioral changes, and Physical Examination: Components of the on teaching highlights the value placed on these mea- Physical Exam to Consider © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC sures. The group prenatal care model capitalizes on the NOT FOR SALE OR DISTRIBUTION•• Blood pressure (BP), otherNOT vital FOR signs SALE as indicated OR DISTRIBUTION social support and compassion provided by a cohort of •• Interval weight gain or loss peers—women from diverse backgrounds meeting on •• Assessment of general well-being the common ground of the pregnancy and childbearing •• Abdominal examination and gestational age experience. The overarching goal of prenatal care is a © Jones & Bartlett Learning, LLC assessment© Jones & Bartlett Learning, LLC safe and emotionally satisfying pregnancy, increased em- ■■ Fundal height NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION powerment and self-efficacy regarding the woman’s own ■■ Fetal heart tones health behaviors, and optimal outcomes given the unique ■■ Estimated fetal weight circumstances of the mother’s life and health during her ■■ Fetal lie, presentation, position, and variety pregnancy. •• Costovertebral angle (CVA) tenderness © Jones & Bartlett Learning, LLC © Jones•• Examination& Bartlett ofLearning, extremities LLC NOT FOR HistorySALE ORand DISTRIBUTIONChart Review: Components NOT FOR■■ SALEEdema OR DISTRIBUTION of the History to Consider ■■ Varicosities, phlebitis (Jordan et al., 2014) ■■ Reflexes •• Additional components as indicated by history •• Review relevant aspects© Jones of chart & Bartlett before the Learning, care visit LLC © Jones & Bartlett Learning, LLC •• Interval history sinceNOT last FOR visit SALE OR DISTRIBUTIONClinical Impression: DifferentialNOT FOR Diagnoses SALE OR DISTRIBUTION ■■ Gestational age to Consider ■■ Maternal well-being (ICD10Data.com, 2015) ◆◆ Nutrition and weight gain © Jones◆◆ Sleep & and Bartlett rest patterns Learning, LLC •• Pregnancy© Jones & Bartlett Learning, LLC NOT◆◆ FORActivity SALE and exercise OR DISTRIBUTION ■■ LowNOT risk FOR SALE OR DISTRIBUTION ◆◆ Bowel and bladder function ■■ At risk—specify ◆◆ Adaptation to pregnancy •• Additional diagnoses based on ➤➤ Maternal role development ■■ History © Jones & Bartlett➤ Learning,➤ Partner and LLC family adaptation to pregnancy© Jones &■■ BartlettPhysical examination Learning, LLC NOT FOR SALE◆ ◆OROccupational DISTRIBUTION issues NOT FOR■■ SALEDiagnostic OR testingDISTRIBUTION

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Screening and Diagnosis: Tests and ◆◆ Ideal time frame is first trimester up to Procedures to Consider 13 6/7 weeks’ gestation (American Congress •• Dip urinalysis: routine© or Jonesfor women & Bartlettwith signs Learning,or LLC of Obstetricians and ©Gynecologists Jones & Bartlett Learning, LLC symptoms of the following:NOT FOR SALE OR DISTRIBUTION[ACOG], 2010) NOT FOR SALE OR DISTRIBUTION ■■ ■■ Hypertension Genetic evaluation/amniocentesis ■■ ■■ Rapid weight gain Fetal growth and development ■■ ■■ Preeclampsia Placental location ■■ Biophysical profile ■■ Gestational© Jones diabetes & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Amniotic fluid index ■■ UrinaryNOT frequencyFOR SALE or urgency OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Urine culture ■■ Cervical length measurement ■■ History of asymptomatic bacteriuria •• Additional testing as indicated ■■ ■■ Sickle cell trait Repeat sexually transmitted infection (STI) testing ■■ Repeat wet preparation for micropscopy © Jones &■■ BartlettHistory of Learning,pyelonephritis LLC © Jones & Bartlett Learning, LLC ■■ Complete blood count (CBC) with reticulocytes, NOT FOR■■ SALEUrinary OR symptoms DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Positive dip urinalysis total iron-binding capacity (TIBC), serum iron, ◆◆ Many bacteria serum ferritin ■■ ◆◆ Positive nitrite with positive leukocytes TSH, free T4, thyroid antibodies ■■ Three-hour glucose tolerance testing •• Glucose challenge test© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Fetal fibronectin ■■ First trimester NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ ◆◆ Obesity CBC with differential, renal and liver function ◆◆ Gestational diabetes mellitus (GDM) in previ- studies, serum uric acid, 24-hour urine ous pregnancy for protein ■■ ◆◆ Women at high risk for GDM (see Care of the Dental evaluation for periodontal disease © Jones & Bartlett Learning, LLC ■■ Other tests© Jones as indicated & Bartlett by findings Learning, LLC NOTPregnant FOR Woman SALE with OR Gestational DISTRIBUTION Diabetes in NOT FOR SALE OR DISTRIBUTION Chapter 3) ■■ 24–28 weeks’ gestation Providing Treatment: Therapeutic Measures ◆◆ Selective or universal screening protocol to Consider for GDM •• Encourage appropriate weight gain (Institute of © Jones & Bartlett◆◆ Repeat Learning,testing in women LLC at high risk for GDM © Jones­Medicine & Bartlett [IOM], 2009) Learning, (see Appendix LLC B) NOT FOR SALEwith OR prior DISTRIBUTION negative screen NOT ■■ FORBody SALE mass index OR (BMI)DISTRIBUTION < 18.5: gain 28–40 lb •• Blood type and antibody screen ■■ BMI = 18.5–24.9: gain 25–35 lb ■■ Included in initial prenatal labs ■■ BMI = 25–29.9: gain 15–25 lb ■■ 24–28 weeks’ gestation for Rh-negative ■■ BMI ≥ 30: gain 11–20 lb mothers © Jones & Bartlett Learning,•• LLC Eat regular meals that include© Jonesa variety &of Bartlettfoods Learning, LLC •• Hematocrit and hemoglobinNOT FOR SALE OR DISTRIBUTION■■ Organic foods when possibleNOT FOR SALE OR DISTRIBUTION ■■ Included in initial prenatal labs ■■ Whole, nonprocessed foods ■■ 24–28 weeks’ gestation as needed •• Prenatal vitamins with folic acid ■■ Every 4–6 weeks to evaluate for women on iron •• Adequate ω-3s: docosahexaenoic acid (DHA) and ­replacement© Jones therapy& Bartlett Learning, LLC eicosapentaenoic© Jones acid &(EPA) Bartlett (Jordan, Learning, 2010) LLC •• GroupNOT B Streptococcus FOR SALE testing OR (CentersDISTRIBUTION for Disease ■■ Two cold-waterNOT FOR fish meals/weekSALE OR for DISTRIBUTION DHA and EPA Control and Prevention [CDC], 2014a) ◆◆ Low-mercury fish choices ■■ 35–37 weeks’ gestation ➤➤ Avoid tilefish, shark, swordfish, and king ■■ Signs or symptoms of preterm labor mackerel © Jones•• Ultrasound& Bartlett evaluation Learning, as indicated LLC © Jones◆◆ &Purified Bartlett fish Learning,oil supplements LLC if fish not eaten NOT FOR■■ SALEPregnancy OR dating DISTRIBUTION NOT FOR➤ SALE➤ Barleans OR liquid DISTRIBUTION or tablets: 200–300 mg/day

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9781284083415_CH02_Pass03.indd 62 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC © Jones &Ongoing Bartlett Care Learning, of the Pregnant LLC Woman 63 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

•• Iron from dietary sources (see Appendix B) with ■■ Primrose oil gelcaps 500–1,000 mg BID after ­supplementation as needed 37 weeks, PO or intravaginally ■■ Ferro-sequels© 1–2 Jones PO daily & Bartlett Learning, LLC•• As indicated by symptom© Jonesor condition & Bartlett Learning, LLC ■■ Floridix 10 mLNOT PO BIDFOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Niferex 150 mg 1–2 PO daily Providing Support: Education and Support ■■ Ferrous gluconate 1–2 PO daily Measures to Consider ■■ Other supplement of choice •• Expectations related to care •• Calcium from dietary sources (see Appendix B) © Jones & Bartlett Learning, LLC ■■ Woman/family© Jones & expectations Bartlett Learning, LLC with supplements as needed NOT FOR SALE OR DISTRIBUTION ■■ Midwife/practiceNOT FOR SALE expectations OR DISTRIBUTION ■■ Citracal: 200–400 PO mg BID •• Anticipatory guidance ■■ Tums: 500 mg, 1–2 PO daily ■■ Expected physical and emotional changes over next ■■ Os-cal: one tablet, 1–2 PO daily visit interval •• Probiotic supplement for women with © Jones & Bartlett Learning, LLC © Jones &■■ BartlettTesting indications Learning, with LLCtiming and cost information allergies NOT FOR SALE OR DISTRIBUTION NOT FOR■■ SALESuggested OR activity DISTRIBUTION additions or modifications as ■■ Reduce incidence of atopic diseases in offspring needed (Cuello-Garcia et al., 2015) •• Health education •• Vaccinations in pregnancy ■■ Importance of the following issues: ■■ Influenza vaccine in the fall and winter months © Jones & Bartlett Learning, LLC ◆◆ Fetal movement© pattern Jones awareness & Bartlett Learning, LLC (CDC, 2014c) NOT FOR SALE OR DISTRIBUTION ◆◆ Nutrition and appropriateNOT FOR weight SALE gain OR for DISTRIBUTIONBMI ■■ Tetanus, diphtheria, and pertussis (Tdap) ideally ◆◆ Regular daily activity and exercise between 6 and 37 weeks’ gestation ■■ Management of common discomforts ■■ Immunization update if at significant risk or ■■ Feelings about pregnancy, birth, and family ­traveling abroad ◆◆ Relationship changes •• © Preterm Jones birth & (PTB)Bartlett prevention Learning, for women LLC with risk © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ◆◆ NOTSexual FOR relations SALE in pregnancy OR DISTRIBUTION of PTB ◆◆ Social services available ■■ Weekly intramuscular (IM) progesterone (17p) ◆◆ Labor and birth discussion beginning at 16–20 weeks until 36 weeks (ACOG, ■■ Preterm labor symptom education until 37 weeks Committee on Practice Bulletins: Obstetrics, 2012) ■■ Planned location of birth ■■ Consider serial cervical length measurement © Jones & Bartlett Learning, LLC © Jones &■■ BartlettPreparation Learning, for labor LLC ■■ NOT FOR SALETreatment OR DISTRIBUTION of significant periodontal disease mayNOT FOR SALE◆◆ Options OR DISTRIBUTIONfor childbirth education classes reduce PTB risk (Jeffcoat, Jeffcoat, Tanna, & ◆◆ Resources for physiologic birth Parry, 2014) ◆◆ Developing a birth plan Providing Treatment: Integrative Therapies ➤➤ Opportunity for dialogue © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to Consider ➤➤ Based on pregnancy status and expectations NOT FOR SALE OR DISTRIBUTION ➤➤ Includes preferencesNOT FOR for careSALE during OR vaginal DISTRIBUTION (Romm, 2010; Walls, 2009) birth and cesarean •• Pregnant belly massage ■■ Signs and symptoms of labor ■■ Jojoba oil ■■ Anticipated labor care and birth options ©■■ JonesShea or &cocoa Bartlett butter Learning, LLC ◆◆©Labor Jones support & Bartlett plans Learning, LLC NOT■■ Calendula FOR SALE infusion OR DISTRIBUTION ◆◆NOTPain FORrelief SALE OR DISTRIBUTION •• Third-trimester herbal support ➤➤ Hydrotherapy/water birth ■■ Red raspberry leaf ➤➤ Birth ball ■■ Chamomile ➤➤ Music therapy © Jones & Bartlett■■ Nettle Learning, LLC © Jones & Bartlett➤➤ Heated Learning, rice packs LLC NOT FOR SALE■■ Cranberry OR DISTRIBUTION NOT FOR SALE➤➤ ORMassage DISTRIBUTION

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9781284083415_CH02_Pass03.indd 63 20/04/16 3:56 pm © Jones64 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

➤➤ Maternal positioning ◆◆ Planned help at home, resources ➤➤ Acupressure ◆◆ Postpartum method of birth control ➤➤ Rebozo © Jones & Bartlett Learning, LLC■■ Anticipated visits for follow-up© Jones care & Bartlett Learning, LLC ➤➤ Medication NOToptions FOR SALE OR DISTRIBUTION◆◆ Home visits NOT FOR SALE OR DISTRIBUTION ◆◆ Perineal support (see Care of the Woman in ◆◆ Mother postpartum visits Second-Stage Labor in Chapter 4) ◆◆ Infant evaluation ◆◆ Prebirth collection of drops of colostrum in late Follow-up Care: Follow-up Measures to Consider ©third Jones trimester & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT➤➤ For FOR use inSALE special OR neonatal DISTRIBUTION and postpartum •• Review withNOT the woman FOR SALE OR DISTRIBUTION circumstances ■■ Previously performed laboratory results ◆◆ Indications and preventive measures for inter- ■■ Health education and attention to expressed needs ventions, such as ■■ Behavioral and lifestyle changes initiated © Jones & Bartlett➤➤ Episiotomy Learning, LLC © Jones■■ Healthy & Bartlett lifestyle Learning, maintenance LLC or improvement NOT FOR SALE➤➤ TransportOR DISTRIBUTION NOT FOR◆◆ Diet, SALE nutritional OR DISTRIBUTION needs and weight gain ➤➤ Consult ◆◆ Exercise, activity, and rest ➤➤ Cesarean ◆◆ Stress management ■■ Access to obstetrician/gynecologist (OB/GYN) or •• Midwifery plan of care physician coverage for needed care or emergencies ■■ Alternate (covering) providers and/or location for © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Anticipated infant care birth NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ◆◆ At-birth infant physiologic adaptation and ■■ Risk factors and anticipated management stabilization ■■ Preferred newborn care provider(s) or practice ➤➤ Infant to mother for warmth and comfort ■■ Anticipated return visit schedule and to foster attachment ◆◆ Every 4–6 weeks until 28–32 weeks’ gestation ©➤ Jones➤ Delayed & timing Bartlett of cord Learning, clamping unlessLLC in- ◆◆ Every© 2–3Jones weeks & from Bartlett 30 to 36Learning, weeks’ gestation LLC NOTdications FOR SALE for immediate OR DISTRIBUTION clamping present ◆◆ WeeklyNOT from FOR 36 weeks’ SALE gestation OR DISTRIBUTION until birth occurs ◗◗ Physiologic ◆◆ Centering Pregnancy groups meet a total of ★★ Cord clamped after birth of pla- 10 sessions centa, maximizes stem cell trans- ◆◆ Various scheduling as needed; specify indication © Jones & Bartlett Learning,fer (­Sanberg, LLC Divers, Mehindru, © Jones■■ Informed & Bartlett consent Learning, or consultation, LLC as indicated NOT FOR SALE OR DISTRIBUTION­Mehindru, & Borlongan, 2014) NOT FOR◆◆ Planned SALE out-of-hospitalOR DISTRIBUTION birth ◗◗ Delayed ◆◆ Vaginal birth after cesarean ★★ Cord clamped 1–5 minutes after birth ◆◆ Cesarean of infant, enhances cardiopulmonary ◆◆ Postpartum tubal ligation transition,© Jones BP and & neonatal Bartlett iron Learning, stores •• LLC Document and discuss © Jones & Bartlett Learning, LLC (MercerNOT & Erickson- FOR SALE­Owens, OR 2012) DISTRIBUTION■■ Findings and updated riskNOT assessment FOR SALE OR DISTRIBUTION ➤➤ Early breastmilk feeding to maintain blood ■■ Discussions with woman/family glucose levels ■■ Woman’s preferences for labor and birth ◆◆ Vitamin K options ■■ Plan for continued care ◆◆©Ophthalmic Jones & prophylaxisBartlett Learning, LLC ■■ Informed© consentJones forms& Bartlett Learning, LLC ◆◆NOTPlanned FOR method SALE of infantOR DISTRIBUTION feeding NOT FOR SALE OR DISTRIBUTION ◆◆ Transport indicators Interdisciplinary Practice: Consider Consultation, ◆◆ Circumcision options Collaboration, or Referral ◆◆ Newborn evaluation •• Midwifery leadership © Jones &■■ BartlettAnticipated Learning, postpartum LLCcare © Jones■■ Providing & Bartlett woman-centered, Learning, relationship-based LLC pre- NOT FOR SALE◆◆ Based OR on DISTRIBUTION location of birth NOT FORnatal SALE care that OR is responsiveDISTRIBUTION to women’s needs and ◆◆ Cultural practices after birth results in optimal health outcomes

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9781284083415_CH02_Pass03.indd 64 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC © JonesCare of& theBartlett Pregnant Learning, Woman LLCwith Backache 65 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ Promoting womens’ self-knowledge during or gallbladder. Additionally, back pathology, such as disc prenatal care disease or muscle strain, is included in the differential ■■ Providing evidence© Jones informed & Bartlett childbirth Learning, informa- LLCdiagnosis when pain is severe© Jones or not ameliorated& Bartlett by Learning, typical LLC tion to promoteNOT individual FOR SALEchoice andOR decision DISTRIBUTION treatments. NOT FOR SALE OR DISTRIBUTION making •• Health education History and Chart Review: Components ■■ Pregnancy and/or childbirth education classes of the History to Consider ©■■ JonesPregnancy & Bartlettyoga or exercise Learning, program LLC •• Gestational© Jones age & Bartlett Learning, LLC NOT■■ Registered FOR SALE dietitian OR or nutritionalDISTRIBUTION professional •• Onset,NOT duration, FOR severity, SALE and OR location DISTRIBUTION of backache ◆◆ Pregnant women with diabetes or gestational •• History of backache diabetes ■■ Precipitating event, if any ◆◆ Pregnant women with a low or elevated BMI ■■ Timing © Jones & Bartlett◆◆ Pregnant Learning, women LLC with history of eating © Jones &■■ BartlettActivities thatLearning, exacerbate LLC backache ■■ NOT FOR SALE ORdisorders DISTRIBUTION NOT FOR SALEMedications OR DISTRIBUTION or self-help measures used and relief •• Social services, as indicated obtained •• Physician consultation, collaboration, or referral •• Presence of other associated symptoms ■■ Complications or problems during pregnancy ■■ Presence or absence of contractions or pelvic ■■ Surgical consultation pressure © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Anesthesia services ■■ Urinary symptoms NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ◆◆ Preoperative evaluation ◆◆ Frequency, urgency •• For diagnosis or treatment outside the midwife’s scope ◆◆ Flank pain of practice ■■ Presence of neurologic signs or symptoms ◆◆ Numbness in legs or feet CARE© Jones OF THE & PREGNANTBartlett Learning, WOMAN LLC ◆◆ ©Sciatica Jones & Bartlett Learning, LLC WITH BACKACHENOT FOR SALE OR DISTRIBUTION •• MedicalNOT history FOR SALE OR DISTRIBUTION ■■ Back injury or disease Key Clinical Information ■■ Kidney stones or pyelonephritis Backache is pain in the upper or lower back. It affects •• Potential contributing factors © Jones &most Bartlett pregnant Learning, women to LLCsome degree, with approxi- © Jones &■■ BartlettBody mechanics Learning, LLC NOT FOR matelySALE two OR thirds DISTRIBUTION of pregnant women experiencing lowNOT FOR■■ SALEComputer OR work DISTRIBUTION back pain (­Pennick & Liddle, 2013). As pregnancy pro- ■■ High-heeled shoes gresses, a woman’s center of gravity shifts and postural ■■ Lifting at work or home compensations are made for this change. Kyphosis of the ■■ Physical activity cervical spine accommodates© Jones the & growth Bartlett and Learning,weight of LLC ■■ Physical abuse, trauma,© Jones or injury & Bartlett Learning, LLC the breasts, while lordosisNOT ofFOR the lumbarSALE spineOR DISTRIBUTIONaccommo- NOT FOR SALE OR DISTRIBUTION dates the distention of the abdomen. These changes com- Physical Examination: Components of the bine with hormonal influences that loosen ligaments and Physical Exam to Consider joints and lead to backache for many pregnant women. •• Vital signs, including weight Posture,© Jones body mechanics,& Bartlett and Learning, muscle tone LLC all influence •• Abdominal© Jones examination & Bartlett Learning, LLC theNOT amount FOR of strain SALE on theOR back DISTRIBUTION from the pregnant wom- ■■ AbdominalNOT FOR muscle SALE tone OR DISTRIBUTION an’s growing uterus. ■■ Uterine size Other potential causes of backache during pregnancy ■■ Suprapubic tenderness deserve thoughtful consideration and inclusion in the ■■ Upper abdominal tenderness © Jones &woman’s Bartlett evaluation, Learning, as this LLC general symptom is frequently© Jones •• Back& Bartlett examination Learning, LLC NOT FOR theSALE only ORindication DISTRIBUTION of preterm labor, pyelonephritis, orNOT FOR■■ SALEMobility OR DISTRIBUTION renal calculi, or can represent referred pain from the liver ◆◆ Ease of movement, symmetry

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9781284083415_CH02_Pass03.indd 65 20/04/16 3:56 pm © Jones66 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ Point tenderness Providing Treatment: Therapeutic Measures ■■ Posture, presence of lordosis, kyphosis, or scoliosis to Consider ■■ Costovertebral angle© (CVA)Jones tenderness & Bartlett Learning,•• LLC Abdominal binder designed ©for Jones pregnancy & Bartlett Learning, LLC ■■ Presence of muscleNOT spasm FOR SALE OR DISTRIBUTION•• Heat application NOT FOR SALE OR DISTRIBUTION •• Pelvic evaluation ■■ Hot compresses or packs ■■ Backache accompanied by contractions or pressure ■■ Warm bath with Epsom salts ■■ History suggestive of preterm labor •• Pain relief (Brucker & King, 2017) ■■ Evaluation of cervical status © Jones & Bartlett Learning, LLC ■■ Acetaminophen© Jones (Tylenol) & Bartlett Learning, LLC •• Evaluation of neurologic status NOT FOR SALE OR DISTRIBUTION ◆◆ 325–975NOT mg FOR PO qSALE 4–6 h OR DISTRIBUTION ■■ Muscle tone ◆◆ Maximum dose is 4 g daily ■■ Strength ◆◆ Best choice for pain relief during pregnancy ■■ Coordination ■■ Naproxen (Aleve, others) ■■ Reflexes © Jones & Bartlett Learning, LLC © Jones◆◆ &200–800 Bartlett mg Learning, PO q 4–12 h LLC •• Signs of physical abuse NOT FOR SALE OR DISTRIBUTION NOT FOR◆◆ Avoid SALE in firstOR andDISTRIBUTION last trimester ■■ Bruising ◆◆ Increase in miscarriage risk in early pregnancy ■■ Burns (Verma et al., 2012) ■■ Partner: presence for entire visit, responds for the ■■ Ibuprofen (Advil, Motrin, others) woman © Jones & Bartlett Learning, LLC◆◆ 400, 600, or 800 mg ©PO Jones TID & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION◆◆ Avoid in late pregnancyNOT FOR SALE OR DISTRIBUTION Clinical Impression: Differential Diagnoses ■■ TENS (transcutaneous electrical nerve to Consider ­stimulation) unit (ICD10Data.com, 2015) •• Muscle spasm ■■ Flexeril 5–10 mg PO BID •• Backache© Jones of pregnancy & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• As appropriate for other confirmed diagnosis •• Dorsalgia,NOT unspecified FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Also consider the following: Providing Treatment: Integrative Therapies to Consider ■■ Pyelonephritis (Romm, 2010; Walls, 2009) ■■ Renal calculi © Jones &■■ BartlettHerniated Learning,disc LLC ©• Jones• Professional & Bartlett massage Learning, LLC NOT FOR■■ SALEIrritable OR bowel DISTRIBUTION syndrome NOT ■■ FORPrenatal SALE massage OR DISTRIBUTION ■■ Rheumatoid arthritis ■■ Craniosacral therapy ■■ Pregnancy-induced hypertension •• Massage affected area ■■ Gallbladder disease ■■ Arnica-infused oil ■■ © Jones & Bartlett Learning, LLCPeppermint-infused oil © Jones & Bartlett Learning, LLC ■■ Capsaicin salve or ointment Screening and Diagnosis:NOT Tests FOR and SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Procedures to Consider •• Adequate calcium and magnesium intake •• Herbals •• Urinalysis ■■ Chamomile tea •• Urine culture ■■ Cramp bark tincture •• Fetal/uterine© Jones monitoring & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• UltrasoundNOT FOR SALE OR DISTRIBUTION Providing Support:NOT FOREducation SALE and OR Support DISTRIBUTION ■■ Kidneys if renal calculi suspected Measures to Consider ■■ Upper abdomen if gallbladder disease suspected (Pennick & Liddle, 2013) •• Hypertensive disorders of pregnancy screening © Jones (see Care& Bartlett of the Learning, Pregnant Woman LLC with Hypertensive ©• Jones• Use of & good Bartlett body mechanics Learning, LLC NOT FORDisorders SALE inOR Chapter DISTRIBUTION 3) NOT ■■ FORLow-heeled SALE shoesOR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 66 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC © CareJones of the& Bartlett Pregnant Learning, Woman with Constipation LLC 67 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ Posture to minimize lordosis ■■ For exercise training ■■ Bend knees to lift using leg muscles ■■ For mobility aids ■■ Avoid lifting using© Jones back muscles & Bartlett Learning, LLC•• Physician consultation,© collaboration, Jones & Bartlett or referral Learning, LLC ■■ Avoid bendingNOT or turning FOR from SALE waist OR DISTRIBUTION■■ Persistent backacheNOT FOR SALE OR DISTRIBUTION •• Planned back care program ■■ Persistent backache with preterm contractions ■■ Pelvic tilt ■■ Development of fever and chills ■■ Stretching ■■ Positive testing for kidney involvement ©■■ JonesSwimming & Bartlett Learning, LLC ■■ Presence© Jones of neurologic & Bartlett symptoms Learning, LLC NOT■■ Yoga FOR SALE OR DISTRIBUTION •• SocialNOT services FOR SALE OR DISTRIBUTION •• Supportive sleep environment ■■ Indicators of domestic violence ■■ Firm mattress •• For diagnosis or treatment outside the midwife’s scope ■■ Pillows between knees of practice © Jones &• •Bartlett Ergonomic Learning, adjustments LLC of work and home © Jones & Bartlett Learning, LLC NOT FOR SALEenvironments OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Mechanical support measures CARE OF THE PREGNANT WOMAN ■■ Well-fitting supportive bra WITH CONSTIPATION ■■ Prenatal abdominal cradle ■■ Lumbar support in chair/car Key Clinical Information © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Footstool to raise knees above hips Constipation represents a change in a person’s normal NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Postural suggestions bowel patterns to less frequent or more difficult defeca- tion. Constipation can occur or be exacerbated in preg- Follow-up Care: Follow-up Measures to Consider nant women because of the decreased bowel motility and increased water reabsorption in the intestine as well as •• Document and discuss © Jones & Bartlett Learning, LLC pressure ©from Jones the enlarged & Bartlett uterus; Learning, this condition LLC affects ■■ Physical findings NOT FOR SALE OR DISTRIBUTION approximatelyNOT 25% FOR of womenSALE duringOR DISTRIBUTION pregnancy (Bradley, ■■ Treatment recommendations Kennedy, Turcea, Rao, & Nygaard, 2007). Prevention of ■■ Warning signs constipation requires adequate intake of fluid and fiber, ■■ When to return for care accompanied by physical activity to stimulate the bowels. •• Return for care © Jones & Bartlett Learning, LLC © JonesDetermining & Bartlett acceptable Learning, daily dietary LLC sources of fiber for ■■ As scheduled for gestation NOT FOR SALE OR DISTRIBUTION NOT FOReach womanSALE isOR essential. DISTRIBUTION Candid discussion regarding fre- ■■ With worsening symptoms quency and consistency of bowel movements is an integral ◆◆ Pain part of evaluation for this common malady. ◆◆ Numbness or tingling ◆◆ Signs of preterm labor © Jones & Bartlett Learning, LLCHistory and Chart Review:© Jones Components & Bartlett Learning, LLC ◆◆ Urinary symptoms NOT FOR SALE OR DISTRIBUTIONof the History to ConsiderNOT FOR SALE OR DISTRIBUTION •• Gestational age Interdisciplinary Practice: Consider Consultation, •• Onset of problem Collaboration, or Referral •• Bowel habits •• © Acupuncture/acupressure Jones & Bartlett Learning, therapist (Pennick LLC & ■■ Elimination© Jones patterns & Bartlett and routines Learning, LLC NOTLiddle, FOR 2013) SALE OR DISTRIBUTION ■■ FrequencyNOT FOR and SALEconsistency OR ofDISTRIBUTION bowel movements •• Prenatal massage therapist ■■ Straining or difficulty with evacuation •• Craniosacral massage therapist ■■ Remedies used and efficacy •• Physical or occupational therapist •• Dietary habits © Jones & Bartlett■■ For evaluation Learning, LLC © Jones &■■ BartlettUsual dietary Learning, patterns and LLC preferences NOT FOR SALE■■ For OR symptom DISTRIBUTION management NOT FOR■■ SALEProcessed OR and DISTRIBUTION fast foods

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9781284083415_CH02_Pass03.indd 67 20/04/16 3:56 pm © Jones68 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ Fiber-rich foods or supplements •• Irritable bowel syndrome ■■ Fluid intake •• Fecal impaction or obstipation •• Other associated symptoms© Jones & Bartlett Learning,•• LLC Diverticulitis © Jones & Bartlett Learning, LLC ■■ Abdominal crampingNOT with FOR bowel SALE movement OR DISTRIBUTION•• Preterm labor NOT FOR SALE OR DISTRIBUTION ◆◆ Nature of abdominal discomfort ◆◆ Location, severity Diagnostic Testing: Diagnostic Tests and ◆◆ Backache Procedures to Consider ◆◆ ©Uterine Jones contractions & Bartlett Learning, LLC •• Urine for specific© Jones gravity & Bartlett Learning, LLC ■■ PresenceNOT FOR of blood SALE in the OR stool DISTRIBUTION •• Complete bloodNOT count FOR (CBC) SALE with OR differential DISTRIBUTION ■■ Pain with stool passage •• Pelvic ultrasound •• Potential contributing factors •• Anoscopy ■■ Iron therapy © Jones &■■ BartlettPhysical inactivity Learning, LLC ©Providing Jones & Treatment: Bartlett Learning, Therapeutic LLC Measures ■■ NOT FOR SALEInadequate OR fluidDISTRIBUTION intake NOTto Consider FOR SALE OR DISTRIBUTION ■■ Inadequate fiber intake •• Increase fiber in diet ■■ Narcotic use ■■ Dried fruits, prunes, prune juice ■■ History of sexual abuse ■■ Whole grains, bran cereals, foods with •• Medical history © Jones & Bartlett Learning, LLCwheat bran © Jones & Bartlett Learning, LLC ■■ Abdominal surgeries (adhesions) NOT FOR SALE OR DISTRIBUTION■■ Vegetables NOT FOR SALE OR DISTRIBUTION ■■ Pelvic inflammatory disease (PID) ■■ Nuts and seeds ■■ Bowel disorders, such as diverticular disease ■■ See Appendix B-4 ■■ Status of appendix •• Fiber therapy ■■ Citrucel: 1 Tbs in 8 oz fluid, 1–3 times PO daily Physical ©Examination: Jones & Bartlett Components Learning, of the LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ■■ Metamucil:NOT 1 tspFOR in 8SALE oz fluid, OR 1–3 DISTRIBUTION times PO daily Physical Exam to Consider ■■ Psyllium capsules: 1–2 PO daily •• Vital signs, including temperature •• Stool softeners •• Abdominal examination ■■ Docusate sodium: 50–100 mg 1 PO QD or BID ■■ Auscultate bowel sounds in all four quadrants ■■ Docusate calcium: 240 mg 1 PO QD © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Palpate for presence of abdominal pain •• Bowel stimulants NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ◆◆ Location ■■ Senokot: 1 tablet PO at bedtime ◆◆ Rebound ■■ Milk of magnesia: tablet, capsule, or ◆◆ Guarding liquid form ◆◆ Masses •• Rectal treatments ■■ Bloating or distention© Jones & Bartlett Learning, LLC■■ Glycerin suppositories © Jones & Bartlett Learning, LLC •• Pelvic examination NOT FOR SALE OR DISTRIBUTION■■ Fleet enema if stool impactedNOT FOR SALE OR DISTRIBUTION ■■ Palpate for hard stool in rectum ■■ Cervical evaluation if cramping present Providing Treatment: Integrative Therapies •• Rectal examination as needed to Consider © Jones & Bartlett Learning, LLC (Romm, 2010)© Jones & Bartlett Learning, LLC Clinical NOTImpression: FOR SALEDifferential OR DISTRIBUTION Diagnoses NOT FOR SALE OR DISTRIBUTION to Consider •• Herbal support ■■ Senna leaf tea (ICD10Data.com, 2015) ■■ Licorice (Blumenthal, Goldberg, & © Jones•• Constipation& Bartlett Learning, LLC © Jones­Brinckmann, & Bartlett 2000) Learning, LLC NOT FOR•• Appendicitis SALE OR DISTRIBUTION NOT FOR◆◆ Use SALE no more OR thanDISTRIBUTION a week in modest doses

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9781284083415_CH02_Pass03.indd 68 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC © JonesCare & of Bartlett the Pregnant Learning, Woman LLC with Dyspnea 69 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

◆◆ Women with hypertension should not use •• Warning signs of ◆◆ DGL (deglycyrrhizinated licorice) form is safer ■■ Preterm labor ■■ Psyllium or Chia© Jones seed 1 tsp& BartlettTID in liquid Learning, LLC ■■ Acute abdomen © Jones & Bartlett Learning, LLC ■■ Flaxseed meal,NOT 2 Tbs FOR daily SALEadded to OR cereal DISTRIBUTION or yo- NOT FOR SALE OR DISTRIBUTION gurt, or mixed with water Follow-up Care: Follow-up Measures to Consider •• Increase fluid intake •• Document and discuss ■■ 8 cups per day ■■ Physical findings ■■ © JonesHot liquid & inBartlett morning Learning, LLC ■■ Treatment© Jones recommendations & Bartlett Learning, LLC ◆◆ Herbal teas NOT FOR SALE OR DISTRIBUTION ■■ WarningNOT FORsigns andSALE concerns OR DISTRIBUTION ◆◆ Hot prune juice ■■ Recommendations •• Increase physical activity •• Return for care ■■ Stimulates peristalsis and stool movement through ■■ As scheduled for gestation intestines © Jones & Bartlett Learning, LLC © Jones &■■ BartlettReturn sooner Learning, if symptoms LLC persist or worsen NOT FOR •SALE• Bowel OR retraining DISTRIBUTION NOT FOR•• For SALE emergency OR careDISTRIBUTION ■■ Allow regular time and privacy for toileting ■■ Symptoms of acute abdomen ■■ Follow natural urges ■■ Obstipation ■■ Symptoms of preterm labor Providing Support: Education and Support Measures to Consider© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONInterdisciplinary Practice:NOT Consider FOR SALE Consultation, OR DISTRIBUTION •• Walking: helps stimulate natural peristalsis Collaboration, or Referral •• Fiber •• Maternity care physician services ■■ Women need 25 mg dietary fiber daily ■■ Threatened preterm labor ■■ Helps to keep stool soft ■■ Positive occult blood in stool ©■■ JonesMust be & used Bartlett in conjunction Learning, with adequateLLC fluid © Jones & Bartlett Learning, LLC ■■ Severe or persistent abdominal pain NOTintake FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION accompanied by •• Stool softeners ◆◆ Fever ■■ Bring fluid to the stool to soften it ◆◆ Abdominal rigidity or guarding ■■ Coat stool with surfactant to help move it ◆◆ Obstipation © Jones &• •Bartlett Bowel stimulants Learning, LLC © Jones & Bartlett Learning, LLC •• For diagnosis or treatment outside the midwife’s scope NOT FOR SALE■■ Stimulate OR DISTRIBUTION peristalsis NOT FOR SALE OR DISTRIBUTION of practice ■■ Should be used sparingly and with caution during pregnancy ■■ Can cause cramping CARE OF THE PREGNANT WOMAN •• Suppositories © Jones & Bartlett Learning, LLCWITH DYSPNEA © Jones & Bartlett Learning, LLC ■■ Stimulate evacuationNOT FOR of lower SALE bowel OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Can cause cramping Key Clinical Information •• Enemas Dyspnea is an unpleasant sense of labored breathing, a ■■ Flush the lower bowel heightened awareness of respiratory discomfort, or short- ©■■ JonesCan cause & Bartlettcramping Learning, LLC ness of breath.© Jones It affects & Bartlett many pregnant Learning, women LLC especially •• NOT Lifestyle FOR recommendations SALE OR DISTRIBUTION in the firstNOT and FORthird trimester. SALE OR Physiologic DISTRIBUTION shortness of ■■ Increase dietary fiber and fluid breath occurs in early pregnancy as the body adjusts to ■■ Increase physical activity to stimulate bowels changes in carbon dioxide levels in the blood and its con- ■■ Hot drink in the morning may stimulate bowels comitant hyperventilation. Dyspnea again becomes com- © Jones & Bartlett■■ Establish Learning, regular timeLLC and privacy for toileting© Jonesmon & in Bartlett the later stagesLearning, of pregnancy LLC as the uterus pushes NOT FOR •SALE• Explore OR and DISTRIBUTION address contributing psychosocial issuesNOT FORagainst SALE the diaphragm, OR DISTRIBUTION reducing the functional residual

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9781284083415_CH02_Pass03.indd 69 20/04/16 3:56 pm © Jones70 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

volume of the lungs. Anemia, cardiac arrhythmias, and Clinical Impression: Differential Diagnoses poor physical conditioning can also contribute to dyspnea to Consider during pregnancy. Additionally,© Jones anxiety & or Bartlett panic can Learning, (ICD10Data.com, LLC 2015) © Jones & Bartlett Learning, LLC precede or exacerbate a dyspneicNOT FOR episode. SALE Evaluation OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Physiologic shortness of breath of pregnancy of shortness of breath during pregnancy is necessary to •• Dyspnea related to the following: ­determine whether it is physiologic or pathologic. ■■ Exercise or exertion induced History and Chart Review: Components ■■ Upper respiratory infection © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC of the History to Consider ■■ Asthma NOT FOR SALE OR DISTRIBUTION ■■ AnemiaNOT FOR SALE OR DISTRIBUTION •• Gestational age ■■ Pulmonary embolism •• Timing of onset, duration, and severity of dyspnea ■■ Anxiety or panic disorder ■■ With activity or at rest ■■ Other cardiovascular diseases ■■ While supine or upright © Jones & Bartlett Learning, LLC © Jones■■ Other & Bartlett respiratory Learning, disorders LLC NOT FOR•• Self-help SALE measures OR DISTRIBUTION or medications used NOT FOR SALE OR DISTRIBUTION •• Other associated symptoms Screening and Diagnosis: Tests and ■■ Fever, chills Procedures to Consider ■■ Cough, dry or productive •• Complete blood count (CBC) with differential ■■ Syncope © Jones & Bartlett Learning,•• LLC Sputum cultures © Jones & Bartlett Learning, LLC ■■ Peripheral edema NOT FOR SALE OR DISTRIBUTION•• Tuberculosis testing NOT FOR SALE OR DISTRIBUTION ■■ Anxiety or panic symptoms •• Chest x-ray ■■ Palpitations •• Pulmonary function testing •• Cardiopulmonary history ■■ Asthma Providing Treatment: Therapeutic Measures ■■ Smoking© Jones tobacco & Bartlett or other substancesLearning, LLC to Consider © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Environmental exposure to allergens, smoke, •• Reassurance of normalcy and explanation of or fumes physiologic basis ■■ Cardiac disorders and/or symptoms ■■ Encourage calm, slow breathing •• History of anxiety or panic disorders ■■ Lean forward or lie down © Jones•• Review& Bartlett of systems Learning, LLC © Jones■■ Raise & Bartlettarms to shoulder Learning, level LLC NOT FOR SALE OR DISTRIBUTION NOT ■■ FORStretch SALE periodically OR DISTRIBUTION Physical Examination: Components of the ■■ Maintain good posture Physical Exam to Consider •• Otherwise as indicated by diagnosis (see Assessment of •• Vital signs the Woman with Respiratory Symptoms in Chapter 8) •• Observe for the following:© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Providing Treatment: Integrative Therapies to ■■ Color and tissue perfusionNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Signs of anxiety Consider ■■ Respiratory effort •• Mindful breathing practice ■■ Presence of cough, sputum ■■ Awareness of rhythm and sensations of breath ■■ Signs© Jones of respiratory & Bartlett distress Learning, LLC ■■ Calm focused© Jones demeanor & Bartlett Learning, LLC ■■ EdemaNOT of FOR the extremities SALE OR DISTRIBUTION •• Maintain slow-pacedNOT FOR steady SALE physical OR activityDISTRIBUTION •• Auscultation and percussion of the chest ■■ Walking ■■ Respiratory rate, depth, and volume ■■ Yoga ■■ Cardiac rate and rhythm ■■ Swimming © Jones &■■ BartlettLung fields Learning, LLC ©• Jones• Use pillows & Bartlett as needed Learning, for comfort LLC while at rest NOT FOR■■ SALEPresence OR of DISTRIBUTIONabnormal breath sounds NOT•• Maintain FOR SALE upright OR posture DISTRIBUTION to expand lung capacity

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Providing Support: Education and Support body parts, such as feet and ankles. Dependent edema Measures to Consider becomes more common as pregnancy progresses. Physi- •• Review © Jones & Bartlett Learning, LLCologic edema of pregnancy© occurs Jones secondary & Bartlett to fluid Learning, LLC ■■ Physiologic basisNOT of FORshortness SALE of breath OR DISTRIBUTIONretention as the body worksNOT to increase FOR SALE and maintain OR DISTRIBUTION ad- ■■ Deliberate intercostal breathing equate circulating fluid volume. Pressure of the pregnant •• Comfort measures uterus can cause venous stasis and force fluid out of the ■■ Loose-fitting clothes circulatory system and into the soft tissue. Edema can be associated with some hypertensive disorders of pregnancy ©■■ JonesRest periods & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC and should be evaluated with this in mind. NOT■■ Avoid FOR lying SALE flat OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Warning signs History and Chart Review: Components ■■ Flu-like symptoms of the History to Consider ■■ Productive cough •• Gestational age © Jones & Bartlett■■ Chest Learning, pain, shortness LLC of breath, diaphoresis © Jones & Bartlett Learning, LLC •• Diet history NOT FOR SALE■■ Anxiety OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ ■■ Palpitations Fluid intake ■■ Sodium in diet Follow-up Care: Follow-up Measures to Consider ■■ Calorie and protein intake •• Document and discuss •• Recent medications © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Physical findings •• Onset, location, duration, and severity of edema NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Treatment recommendations ■■ Precipitating factors •• Return for care ■■ Circadian variations in edema ■■ As scheduled for gestation ■■ Usual fluid intake and urination patterns ■■ Sooner in the following circumstances: ■■ Self-help measures used and their effects © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ◆◆ Presence of warning signs ■■ Other associated symptoms such as visual changes NOT◆◆ FORPersistence SALE or ORworsening DISTRIBUTION of symptoms •• SymptomsNOT of FOR preeclampsia SALE OR DISTRIBUTION ◆◆ As needed for support •• History of ■■ Preeclampsia or hypertensive disorders of Interdisciplinary Practice: Consider Consultation, pregnancy Collaboration, or Referral © Jones & Bartlett Learning, LLC © Jones &■■ BartlettEdema with Learning, pregnancy LLC NOT FOR •SALE• Medical OR service DISTRIBUTION NOT FOR■■ SALEVaricose OR veins DISTRIBUTION ■■ Evidence of respiratory or physiologic •• Review of systems decompensation ■■ History or symptoms of asthma Physical Examination: Components of the ■■ Evidence of respiratory© Jones infection & Bartlett or disorder Learning, LLCPhysical Exam to Consider© Jones & Bartlett Learning, LLC •• Mental health serviceNOT FOR SALE OR DISTRIBUTION•• Vital signs including weight,NOT bloodFOR pressureSALE OR(BP), DISTRIBUTION ■■ Anxiety or panic attacks pulse and respiration •• For diagnosis or treatment outside the midwife’s scope •• Note interval weight changes of practice •• Evaluation of cardiopulmonary status © Jones & Bartlett Learning, LLC ■■ Audible© Jones S3 or & S4 Bartlett heart sounds Learning, LLC CARE OF THE PREGNANT WOMAN ■■ NOT FOR SALE OR DISTRIBUTION LungNOT sounds, FOR such SALE as crackles, OR DISTRIBUTION rales WITH EDEMA •• Palpation for epigastric or right-upper-quadrant (RUQ) pain Key Clinical Information •• Note presence and pattern of edema © Jones &Edema Bartlett is abnormal Learning, accumulation LLC of excess fluid in the© Jones &■■ BartlettDiffuse, dependent Learning, or localized LLC NOT FOR intercellularSALE OR tissueDISTRIBUTION spaces, most commonly in dependentNOT FOR■■ SALEPresence OR of DISTRIBUTIONpitting edema; time to resolution

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9781284083415_CH02_Pass03.indd 71 20/04/16 3:56 pm © Jones72 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ Bilateral or unilateral ■■ Draw the alphabet with your feet ■■ Facial, periorbital •• Herbal support for fluid balance, two to three cups •• Examination of extremities© Jones & Bartlett Learning, LLCof tea per day (Walls, 2009)© Jones & Bartlett Learning, LLC ■■ Deep tendon reflexesNOT FOR SALE OR DISTRIBUTION■■ Parsley NOT FOR SALE OR DISTRIBUTION ■■ Measurement of leg circumference ■■ Dandelion leaf ■■ Varicosities ■■ Signs of phlebitis: redness, tenderness, warmth Providing Support: Education and Support

■■ Measures to Consider Signs© Jones of clothing & Bartlett constriction Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION •• Provide informationNOT FOR on theSALE following: OR DISTRIBUTION Clinical Impression: Differential Diagnoses to Consider ■■ Physiologic basis of edema in pregnancy (ICD10Data.com, 2015) ■■ Warning signs ◆◆ Preeclampsia •• Physiologic edema of pregnancy ◆◆ Phlebitis or DVT © Jones•• Edema& Bartlett related Learning, to the following LLC conditions: © Jones & Bartlett Learning, LLC ◆◆ Cardiopulmonary decompensation NOT FOR■■ SALEPreeclampsia OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Self-help measures ■■ Thrombophlebitis ■■ Continue gentle physical activity ■■ Cardiovascular diseases or dysfunction ■■ Rest, elevate extremities, pillow under right hip ■■ Renal disorders ■■ Increase fluids © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Add salt to diet to taste if very low salt intake Screening and Diagnosis:NOT Tests FOR and SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Decrease dietary salt if excessive salt diet intake Procedures to Consider •• Avoid •• Urinalysis ■■ Constrictive clothing ■■ Proteinuria ■■ Diuretic medications, foods (asparagus, Brussels ■■ Specific© Jones gravity & Bartlett Learning, LLC sprouts,© cabbage), Jones or& herbsBartlett (juniper Learning, berry) LLC •• PreeclampsiaNOT FOR laboratory SALE testing OR DISTRIBUTIONpanel (see Care of NOT FOR SALE OR DISTRIBUTION the Pregnant Woman with Hypertensive Disorders in Follow-up Care: Follow-up Measures to Consider Chapter 3) •• Document and discuss •• Deep vein thrombosis (DVT) evaluation: lower ■■ Physical findings © Jones ­extremity& Bartlett ultrasound Learning, LLC © Jones■■ Treatment & Bartlett recommendations Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT ■■ FORWarning SALE signs OR DISTRIBUTION Providing Treatment: Therapeutic Measures •• Return for care to Consider ■■ As scheduled for gestation •• Rest 1 hour BID with feet higher than heart ■■ For increasing edema ■■ Suggest elevating foot© Jones of bed for & gentleBartlett overnight Learning, LLC■■ Symptoms of preeclampsia,© phlebitis, Jones or& otherBartlett disorder Learning, LLC elevation NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Left lateral position to maximize venous return Interdisciplinary Practice: Consider Consultation, •• Prescription support hose Collaboration, or Referral ■■ Apply with legs elevated to maximize compression •• Maternity care services •• Water© immersion Jones & for Bartlett 20 minutes Learning, daily LLC ■■ Symptoms© Jones of severe & preeclampsia Bartlett Learning, LLC ■■ ProvidesNOT FORuniform SALE compression OR DISTRIBUTION ■■ Severe progressiveNOT FOR edema SALE OR DISTRIBUTION ■■ Severe varicosities Providing Treatment: Integrative Therapies ■■ Signs of phlebitis or thrombophlebitis to Consider ■■ Signs of cardiac decompensation or pulmonary edema © Jones•• Foot& Bartlett massage, Learning, reflexology LLC ©• Jones• For diagnosis & Bartlett or treatment Learning, outside LLC the midwife’s scope NOT FOR•• Foot SALE exercises OR DISTRIBUTION NOTof FOR practice SALE OR DISTRIBUTION

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CARE OF THE PREGNANT WOMAN ■■ Polyps or lesions WITH EPISTAXIS ■■ Trauma © Jones & Bartlett Learning, LLC ■■ Erosion © Jones & Bartlett Learning, LLC Key Clinical InformationNOT FOR SALE OR DISTRIBUTION■■ Inflammation NOT FOR SALE OR DISTRIBUTION Epistaxis is a nosebleed due to rupture of the nasal blood •• Observation for bruising vessels, which are richly supplied by the internal and Clinical Impression: Differential Diagnoses external carotid arteries. Frequency of epistaxis is dif- to Consider ficult© toJones determine & Bartlett because mostLearning, episodes LLC resolve with © Jones & Bartlett Learning, LLC (ICD10Data.com, 2015) self-treatmentNOT FOR and SALE are not OR reported, DISTRIBUTION though it is estimated NOT FOR SALE OR DISTRIBUTION that approximately 20% of pregnant women experience •• Epistaxis epistaxis (Namazy & Schatz, 2011), and it may be higher •• Epistaxis secondary to the following conditions: in women with seasonal allergies. Although nosebleeds are ■■ Hypertension © Jones &rarely Bartlett of a serious Learning, nature, LLC most women are anxious about© Jones &■■ BartlettNasal polyps Learning, LLC NOT FOR theSALE blood OR loss DISTRIBUTION and may require treatment if the bleedingNOT FOR■■ SALEInhalation OR drug DISTRIBUTION use does not stop promptly. Epistaxis can also be the present- ■■ Nasal trauma or injury ing symptom of labile hypertension. Inhaled drug use ■■ Coagulation defects can contribute to epistaxis and can rapidly elevate blood ■■ Seasonal allergies pressure (BP) and lead© Jonesto placental & Bartlett abruption Learning, or other LLC ■■ Upper respiratory tract© Jones infection & Bartlett Learning, LLC hypertension-relatedNOT complications FOR SALE of pregnancy. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Diagnostic Testing: Diagnostic Tests and Procedures to Consider History and Chart Review: Components of the History to Consider •• Hematocrit and hemoglobin ■■ Persistent, recurrent, copious flow •• © Gestational Jones &age Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Signs or symptoms of anemia •• NOT Onset, FOR frequency, SALE duration, OR DISTRIBUTION and severity of bleeding NOT FOR SALE OR DISTRIBUTION •• Serial BPs ■■ Precipitating factors or events •• Drug screen ◆◆ Allergies or upper respiratory tract infection ◆◆ Use of inhaled drugs (e.g., cocaine, glue) Providing Treatment: Therapeutic Measures © Jones & Bartlett◆◆ Use Learning, of anticoagulant LLC or other medications © Jonesto Consider & Bartlett Learning, LLC ◆◆ Trauma NOT FOR SALE OR DISTRIBUTION NOT FOR•• Normal SALE saline OR (NS)DISTRIBUTION nasal spray ■■ Self-help measures used and efficacy •• Pressure to nares to stop bleeding ■■ Typical nasal hygiene practices ■■ Ice with pressure to bridge of nose ■■ Associated signs and symptoms ■■ Pinch bridge of nose × 10–20 minutes •• Medical history © Jones & Bartlett Learning, LLC ■■ Nasal packing © Jones & Bartlett Learning, LLC ■■ Epistaxis NOT FOR SALE OR DISTRIBUTION•• Avoid nose-blowing forNOT 12 hours FOR SALE OR DISTRIBUTION ■■ Bleeding disorder ■■ Seasonal allergies Providing Treatment: Integrative Therapies •• Family history to Consider ■■ Bleeding disorder © Jones & Bartlett Learning, LLC •• Herbal© andJones dietary & supportBartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ■■ FoodsNOT rich FOR in vitamins SALE A,OR C, DISTRIBUTIONand E Physical Examination: Components of the ◆◆ Deep-green leafy vegetables Physical Exam to Consider ◆◆ Onions •• Vital signs, BP ◆◆ Parsley © Jones &• •Bartlett Examination Learning, of nares LLC © Jones & Bartlett◆◆ Nettle teaLearning, LLC NOT FOR SALE■■ Condition OR DISTRIBUTION of mucous membranes NOT FOR■■ SALEZinc OR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 73 20/04/16 3:56 pm © Jones74 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

•• Treatment the pregnancy hormone relaxin on the lower esophageal ■■ Cold compresses of comfrey, yarrow, and/or mullein sphincter is one contributor to the increased incidence of ■■ Plantain and yarrow© ointment Jones & Bartlett Learning,heartburn LLC noted in pregnancy. As© pregnancyJones & progresses, Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONsimple mechanical pressure alsoNOT contributes FOR SALEto heartburn. OR DISTRIBUTION Providing Support: Education and Support Women with a history of GERD may require treatment Measures to Consider during early pregnancy. Consumption of small meals and a •• Reassurance of normalcy bland diet are often helpful in minimizing this problem. •• Provide information on © Jones & Bartlett Learning, LLC History and Chart© Jones Review: & Bartlett Components Learning, LLC ■■ PhysiologicNOT FOR basis SALE for epistaxis OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Nasal hygiene of the History to Consider ◆◆ Gentle clearing of nasal debris after bath or •• Gestational age shower •• Onset, frequency, timing, duration, and severity of ■■ Self-help measures heartburn © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ◆◆ Avoid vigorous blowing or picking of nose ■■ Preexisting or new onset symptoms NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ◆◆ Use humidifier or vaporizer ■■ Precipitating factors or events ◆◆ High-fat or spicy foods Follow-up Care: Follow-up Measures to Consider ◆◆ Anxiety •• Document and discuss ◆◆ Positioning © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Physical findings ■■ Common symptoms ■■ Treatment recommendationsNOT FOR SALE OR DISTRIBUTION◆◆ Burning epigastric painNOT FOR SALE OR DISTRIBUTION •• Return for care ◆◆ Reflux ■■ As scheduled for gestation ◆◆ Belching, bloating ■■ For bleeding unresponsive to self-help measures ■■ Associated symptoms © Jones & Bartlett Learning, LLC ◆◆ Palpitations© Jones & Bartlett Learning, LLC Interdisciplinary Practice: Consider Consultation, NOT FOR SALE OR DISTRIBUTION ◆◆ DiaphoresisNOT FOR SALE OR DISTRIBUTION Collaboration, or Referral ◆◆ Vomiting •• Ear, nose, and throat (ENT) service •• Typical diet patterns ■■ Electrocautery of bleeding vessel •• Self-help measures and efficacy © Jones &■■ BartlettNasal polyps Learning, or lesions LLC © Jones & Bartlett Learning, LLC Physical Examination: Components of the NOT FOR•• Medical SALE services OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Suspected bleeding disorder Physical Exam to Consider •• For diagnosis or treatment outside the midwife’s scope •• Vital signs of practice •• Interval weight gain or loss © Jones & Bartlett Learning,•• LLC Abdominal palpation © Jones & Bartlett Learning, LLC CARE OF THE PREGNANTNOT FORWOMAN SALE OR DISTRIBUTION■■ Fundal height NOT FOR SALE OR DISTRIBUTION WITH HEARTBURN ■■ Right upper quadrant (RUQ) or epigastric pain

Key Clinical Information Clinical Impression: Differential Diagnoses to Consider Heartburn© isJones a sensation & Bartlett of burning Learning, behind the LLC breast- © Jones & Bartlett Learning, LLC (ICD10Data.com, 2015) bone, resultingNOT FORfrom the SALE backflow OR of DISTRIBUTION stomach contents NOT FOR SALE OR DISTRIBUTION into the esophagus. Heartburn or gastroesophageal reflux •• Physiologic heartburn of pregnancy disease (GERD) affects 30–50% of women at some point •• GERD in pregnancy and affects 25% of women daily in their •• Hiatal hernia © Jonesthird & trimester Bartlett (Dowswell Learning, & Neilson, LLC 2008; Zielinski, ©• Jones• Gastritis & Bartlett Learning, LLC NOT FORSearing, SALE & Deibel, OR DISTRIBUTION2015). The softening influence of NOT•• Gallbladder FOR SALE disease OR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 74 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC ©Care Jones of the & BartlettPregnant Learning,Woman with Hemorrhoids LLC 75 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Screening and Diagnosis: Tests and Providing Support: Education and Support Procedures to Consider Measures to Consider •• Consult or refer© theJones woman & Bartlettif Helicobacter Learning, pylori LLC•• Reassurance of normalcy© Jones & Bartlett Learning, LLC ­testing is indicated.NOT Both FOR noninvasive SALE andOR invasive DISTRIBUTION •• Provide information NOT FOR SALE OR DISTRIBUTION methods of testing are available. ■■ Physiologic basis of heartburn ■■ Warning signs Providing Treatment: Therapeutic Measures ■■ Comfort measures to Consider© Jones & Bartlett Learning, LLC ◆◆ ©Small, Jones frequent & Bartlett meals 5–6 Learning, times daily LLC (BruckerNOT & FOR King, SALE 2017) OR DISTRIBUTION ◆◆ NOTAvoid FOR caffeine, SALE spicy OR and DISTRIBUTIONfatty foods ◆◆ •• Antacid preparations: Maintain good posture ◆◆ Remain in upright position for an hour after eating ■■ Calcium carbonate (Tums) 1–2 tab PO q2h prn ◆◆ with full glass of water Take food and fluids separately © Jones & Bartlett■■ Magnesium/aluminum Learning, LLC combination (Mylanta, © Jones & Bartlett Learning, LLC Follow-up Care: Follow-up Measures to Consider NOT FOR SALE­Gelusil) OR DISTRIBUTION 2–4 tsp PO q4h prn NOT FOR SALE OR DISTRIBUTION •• Document and discuss ■■ Aluminum hydroxide (Amphojel) 600–1,200 mg ■■ PO between meals and after meals prn Physical findings ■■ •• Proton pump inhibitors Treatment recommendations •• Return for care ■■ Aciphex 20 mg© POJones QD & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• As scheduled for gestation ■■ Nexium 20 mgNOT PO QDFOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Persistent reflux or abdominal pain ■■ Prevacid 30 mg PO BID ■■ Indications for referral •H• 2 blockers ◆◆ Persistent severe reflux ■■ Axid 150 mg PO BID ◆◆ Abdominal pain ©■■ JonesPepcid 20 & mgBartlett PO BID Learning, LLC © Jones & Bartlett Learning, LLC ◆◆ Signs or symptoms of ulcer or perforation NOT■■ Tagamet FOR 300SALE mg POOR QID DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Zantac 150 mg PO BID Interdisciplinary Practice: Consider Consultation, Providing Treatment: Integrative Therapies Collaboration, or Referral to Consider •• Medical or gastroenterology services © Jones & Bartlett Learning, LLC © Jones &■■ Bartlett Learning, LLC (Romm, 2010) Severe symptoms unrelieved by treatment NOT FOR SALE OR DISTRIBUTION NOT FOR■■ SALEFor suspected OR DISTRIBUTION or documented •• Alginates—sea vegetable basis, such as Gaviscon ◆◆ H. pylori infection •• Slippery elm lozenges or tea ◆◆ Hiatal hernia •• Marshmallow root infusion ◆◆ GERD •• Raw almonds © Jones & Bartlett Learning, LLC ◆◆ Gastric ulcer or© perforation Jones & Bartlett Learning, LLC •• Ginger NOT FOR SALE OR DISTRIBUTION•• For diagnosis or treatmentNOT outside FOR the SALE midwife’ ORs scopeDISTRIBUTION •• Peppermint tea of practice •• Papaya chewable tablets •• Licorice (Blumenthal et al., 2000) ©■■ JonesUse no more& Bartlett than one Learning, week in modest LLC doses CARE OF© JonesTHE PREGNANT & Bartlett WOMAN Learning, LLC NOT■■ Women FOR with SALE hypertension OR DISTRIBUTION should not use WITH HEMORRHOIDSNOT FOR SALE OR DISTRIBUTION ■■ Deglycyrrhizinated licorice (DGL) form is safer •• If heartburn leads to insomnia, add nervines as a tea Key Clinical Information ■■ Chamomile Hemorrhoids are dilated veins of the hemorrhoidal plexus © Jones & Bartlett■■ Skullcap Learning, LLC © Jonesin the & lowerBartlett rectum. Learning, Hemorrhoids LLC are considered com- NOT FOR SALE■■ Passion OR DISTRIBUTION flower NOT FORmon inSALE pregnancy, OR DISTRIBUTIONbut their prevalence in pregnancy is

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9781284083415_CH02_Pass03.indd 75 20/04/16 3:56 pm © Jones76 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

unknown. Symptoms include rectal irritation, itching, •• Anal trauma pain, and bleeding. Hemorrhoids are internal when they •• Anal herpes occur inside the anal canal© and Jones external & Bartlettwhen they Learning,occur •• LLC Anal fistula © Jones & Bartlett Learning, LLC at the anal opening. InternalNOT hemorrhoids FOR SALE are usually OR DISTRIBUTION not •• Rectal polyp NOT FOR SALE OR DISTRIBUTION painful unless they become ulcerated, infected, or project •• Rectal malignancy outside through the anus. The pressure of the pregnant uterus on pelvic vessels and constipation both aggravate Screening and Diagnosis: Tests and Procedures to Consider hemorrhoids,© Jones causing & bleeding, Bartlett itching, Learning, and burning. LLC © Jones & Bartlett Learning, LLC ThrombosedNOT hemorrhoids FOR SALE are extremelyOR DISTRIBUTION painful and can •• Stool for occultNOT blood FOR SALE OR DISTRIBUTION require treatment with incision and drainage. •• Anoscopy

History and Chart Review: Components Providing Treatment: Therapeutic Measures of the History to Consider to Consider © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• GP TPAL NOT FOR SALE OR DISTRIBUTION NOT•• AnaMantle FOR SALE HC: OR topical DISTRIBUTION anesthetic and steroid •• Gestational age ■■ Apply BID for 7 days •• Prior history of hemorrhoids •• Anusol: topical pramoxine and zinc oxide •• Onset, duration, and severity of hemorrhoids ■■ Apply 2–4 times daily as needed ■■ Presence of bleeding, pain, and itching •• Anusol-HC: topical with added steroid © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Self-help measures used and their efficacy ■■ Apply 2–4 times daily as needed NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Contributing factors •• Desitin: topical zinc oxide ■■ Toileting habits ■■ Apply 2–4 times daily as needed ■■ Straining with defecation •• Manual reduction of hemorrhoids ■■ Low-fiber diet •• Stool softeners as needed ■■ Recurrent© Jones constipation & Bartlett or diarrheaLearning, LLC •• Ice packs prn© Jones & Bartlett Learning, LLC ■■ RegularNOT useFOR of certainSALE medications, OR DISTRIBUTION such as •• Bidet cleansingNOT and FOR air drying SALE OR DISTRIBUTION ◆◆ Iron supplements ◆◆ Stool softeners Herbal Suppository for Hemorrhoids (Romm, 2010) ◆◆ Enemas © Jones & Bartlett Learning, LLC © Jones4 oz. cocoa & Bartlett butter Learning, LLC Physical Examination: Components of the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Physical Exam to Consider 2 oz. each marshmallow root, white oak bark, ­goldenseal powders •• Examination and palpation of the rectum for 2 oz. calendula oil ■■ Presence of hemorrhoids Refrigerate in suppository mold ◆◆ External © Jones & Bartlett Learning,Insert LLC every evening, wear a pad© Jones to absorb & leakage Bartlett Learning, LLC ◆◆ Internal NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ◆◆ Strangulated Knee–chest position to promote drainage ◆◆ Thrombosed ■■ Anal lesions or masses Providing Treatment: Integrative Therapies ■■ Anal© Jonesfissures & Bartlett Learning, LLC to Consider © Jones & Bartlett Learning, LLC •• Herbal remedies (Romm, 2010) Clinical NOTImpression: FOR SALEDifferential OR DISTRIBUTION Diagnoses NOT FOR SALE OR DISTRIBUTION ■■ Bilberry tablets or capsules TID to Consider ■■ Horse chestnut tea, tincture, or capsules (ICD10Data.com, 2015) •• Herbal or warm water sitz baths © Jones•• Hemorrhoids& Bartlett Learning, LLC ©• Jones• Topical & applications Bartlett Learning, LLC NOT FOR•• Anal SALE fissures OR DISTRIBUTION NOT ■■ FORWitch SALE hazel 10–50%OR DISTRIBUTION compresses

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9781284083415_CH02_Pass03.indd 76 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC © JonesCare &of Bartlettthe Pregnant Learning, Woman LLC with Insomnia 77 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ Comfrey compresses wakefulness. Most women report alterations in their sleep ■■ Epsom salt compresses patterns during pregnancy (Facco, Kramer, Ho, Zee, & ■■ Plantain and ©yarrow Jones ointment & Bartlett Learning, LLCGroban, 2010). Mood changes© Jones during & pregnancy Bartlett can Learning, be LLC ■■ Goldenrod ointmentNOT FOR SALE OR DISTRIBUTIONa primary cause or a resultNOT of sleep FOR deprivation. SALE OR Chronic DISTRIBUTION or acute sleep deprivation can significantly impair the Providing Support: Education and Support pregnant woman’s ability to function and her body’s ability Measures to Consider to regenerate and recover from daily stressors. Insomnia •• Provide© Jones information & Bartlett on Learning, LLC and lack of© sleepJones can & cause Bartlett a stress-mediated Learning, physical LLC re- ■■ NOTPhysiologic FOR SALE basis forOR hemorrhoid DISTRIBUTION formation sponse andNOT can FORcontribute SALE to adverse OR DISTRIBUTION pregnancy outcomes ■■ Increasing fiber and fluids in diet such as hypertensive disorders, reduced fetal growth, and ■■ Topical medication use dysfunctional labor patterns (Palagini et al., 2014). Start- ■■ Signs and symptoms necessitating return for care ing labor with severe sleep deprivation can result in early •• Avoid © Jones & Bartlett Learning, LLC © Jonesmaternal & Bartlett exhaustion, Learning, leading to LLC inability to cope with ■■ Straining with defecation NOT FOR SALE OR DISTRIBUTION NOT FORlabor, SALEdysfunctional OR DISTRIBUTION labor, and breastfeeding difficulties ■■ Prolonged sitting on toilet (see Care of the Woman: Promoting Restorative Sleep in ■■ Constipation (see Care of the Pregnant Woman Chapter 8). with Constipation in Chapter 2) History and Chart Review: Components Follow-up Care: Follow-up© Jones Measures & Bartlett to Consider Learning, LLCof the History to Consider© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Document and discuss •• Gestational age ■■ Physical findings •• Onset, duration, and severity of symptoms ■■ Treatment recommendations ■■ Difficulty falling asleep •• Return for care ■■ Wakefulness ■■ © JonesAs scheduled & Bartlett for gestation Learning, LLC ■■ Fitful© Jones sleep & Bartlett Learning, LLC ■■ NOTAs soonFOR as SALE possible OR for DISTRIBUTIONthrombosed hemorrhoids ■■ InterruptionsNOT FOR SALE OR DISTRIBUTION ◆◆ Nocturia Interdisciplinary Practice: Consider Consultation, ◆◆ Pain or restless leg syndrome Collaboration, or Referral ◆◆ Caregiver responsibilities •• Maternity care or surgical services © Jones & Bartlett Learning, LLC © Jones & Bartlett◆◆ Partner/children Learning, sleep LLC habits ■■ Evaluation of severe, strangulated, or bleeding NOT FOR SALE OR DISTRIBUTION NOT FOR SALE◆◆ Pets OR nocturnal DISTRIBUTION behaviors hemorrhoids ◆◆ Environmental noise or disruption ■■ Blood in stool with no evidence of hemorrhoids or •• Sleep habits rectal fissure ■■ Sleep–wake patterns ■■ For incision and drainage of thrombosed © Jones & Bartlett Learning, LLC ◆◆ Bedtime © Jones & Bartlett Learning, LLC hemorrhoids NOT FOR SALE OR DISTRIBUTION ◆◆ Naps NOT FOR SALE OR DISTRIBUTION •• For diagnosis or treatment outside the midwife’s scope ■■ Sleep environment of practice ◆◆ Adequate bed and bedding ◆◆ Room situation, noise, and privacy CARE OF THE PREGNANT WOMAN © Jones & Bartlett Learning, LLC ◆◆©Sleep Jones partner(s) & Bartlett Learning, LLC WITH INSOMNIA NOT FOR SALE OR DISTRIBUTION NOT➤➤ Intimate FOR SALE partner OR DISTRIBUTION ➤➤ Children Key Clinical Information ➤➤ Roommates Insomnia is difficulty in initiating or maintaining sleep ➤➤ Pets © Jones &and Bartlett can include Learning, delays in LLC falling asleep, poor qual- © Jones & Bartlett◆◆ Infestations; Learning, bedbugs, LLC lice, rodents NOT FOR itySALE of sleep, OR frequent DISTRIBUTION awakening, and early-morning NOT FOR■■ SALETotal hours OR DISTRIBUTIONof sleep per 24 hours

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9781284083415_CH02_Pass03.indd 77 20/04/16 3:56 pm © Jones78 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

•• Social issues Providing Treatment: Therapeutic ■■ Home environment or living situation Measures to Consider ■■ Emotional response© to Jones sleep deprivation & Bartlett Learning,•• LLC Use pharmacotherapy only when© Jones necessary & Bartlett Learning, LLC ■■ Caffeine intake andNOT timing FOR SALE OR DISTRIBUTION•• For sleep (Brucker & King, 2017)NOT FOR SALE OR DISTRIBUTION ■■ Meal patterns and content ■■ Ambien 5 mg PO at bedtime ■■ Work hours ■■ Ambien CR 6.5 mg PO at bedtime ■■ Anxieties and concerns ■■ Lunesta 2 mg PO at bedtime ■■ Help and support © Jones & Bartlett Learning, LLC ■■ Benadryl© 25–50 Jones mg & PO Bartlett at bedtime Learning, LLC •• CurrentNOT or prior FOR history SALE of depressionOR DISTRIBUTION or other •• TherapeuticNOT sleep FORfor persistent SALE prodromalOR DISTRIBUTION labor mood disorders (see Care of the Woman with Prolonged Latent-Phase •• Other related symptoms ­Labor in Chapter 4) ■■ Morphine 15–20 mg intramuscularly (IM) Physical Examination: Components of the ■■ Ambien 5–10 mg PO © JonesPhysical Exam & Bartlett to Learning, Consider LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Assess the woman for the following Providing Treatment: Integrative Therapies to Consider conditions: (Sarris & Byrne, 2011) ■■ Nutrition and hydration status •• Sleep hygiene ■■ Evidence of sleep deprivation © Jones & Bartlett Learning, LLC■■ Same time to bed and arising© Jones in the &morning Bartlett Learning, LLC ◆◆ Decrease in alertness and attention NOT FOR SALE OR DISTRIBUTION■■ Avoid use of electronic devicesNOT FORor discussing SALE OR DISTRIBUTION ◆◆ Slowing in response time ­emotional issues before sleep ◆◆ Performance degradation ■■ Take some quiet time to relax before getting ■■ Physical causes of sleep deprivation, into bed such as nasal congestion ■■ Manage sleep environment ■■ Mood© Jones disorders & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ◆◆ DarkenedNOT areaFOR SALE OR DISTRIBUTION Clinical Impression: Differential Diagnoses ◆◆ Sound dampened to Consider ◆◆ Use of white noise (e.g., nature tapes, fan) •• Increase vitamin B intake (ICD10Data.com, 2015) •• l-Tryptophan 1 g PO before bedtime (University © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Insomnia, or secondary to the following: of Maryland, 2013) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Anxiety ■■ Raises serotonin levels ■■ Pregnancy discomforts ■■ Use with caution if taking selective serotonin •• Depression or mood disorder reuptake inhibitors (SSRIs) •• Substance use •• Herbal remedies (University of Maryland, 2013; © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Sleep disturbance unspecified Walls, 2009) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Adjustment insomnia ■■ Chamomile tea ■■ Valerian standardized extract 200–400 mg PO Screening and Diagnosis: Tests and Procedures at bedtime to Consider ■■ Hops tea or tincture (after 20 weeks’ gestation) •• Insomnia:© Jones diagnosed & Bartlett by Learning, LLC ■■ Lemon ©balm Jones tea & Bartlett Learning, LLC ■■ Self-reportNOT FOR SALE OR DISTRIBUTION •• Hydrotherapy,NOT warm FOR bath SALE with Epsom OR DISTRIBUTION salts ■■ Sleep studies •• Hypnotherapy •• Other testing: as indicated by symptoms (see Care •• Acupressure or acupuncture of the Woman: Promoting Restorative Sleep in •• Yoga or tai chi © Jones Chapter 8)& Bartlett Learning, LLC ©• Jones• Massage & Bartletttherapy Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 78 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC © JonesCare of &the Bartlett Pregnant Learning, Woman with Leg Cramps LLC 79 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

•• Mindful breathing practice •• Mental health services ■■ Awareness of rhythm and sensations of breath ■■ Depression © Jones & Bartlett Learning, LLC ■■ Anxiety © Jones & Bartlett Learning, LLC Providing Support: Education and Support NOT FOR SALE OR DISTRIBUTION■■ Substance use disorderNOT FOR SALE OR DISTRIBUTION Measures to Consider •• Social services, as indicated by living situation •• Reassurance of normalcy •• For diagnosis or treatment outside the •• Information related to the following topics: midwife’s scope of practice ■■ Physiologic basis of insomnia © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Management of personal factors that interfere NOT FOR SALE OR DISTRIBUTION CARE OFNOT THE FOR PREGNANT SALE OR WOMAN DISTRIBUTION with sleep, such as WITH LEG CRAMPS ◆◆ Stress ◆◆ Work hours Key Clinical Information ◆◆ Caregiver responsibilities © Jones & Bartlett Learning, LLC © JonesLeg &cramps Bartlett are intermittent, Learning, painfulLLC muscle spasms of ◆◆ Small children NOT FOR SALE OR DISTRIBUTION NOT FORthe lower SALE leg muscles.OR DISTRIBUTION A similar condition, known as ◆◆ Elderly or ill parents/family restless leg syndrome, is characterized by unpleasant ◆◆ Sleep environment sensations in the lower leg, ranging from twitching to ◆◆ Nighttime hunger •• Encourage a positive approach to this difficult problem burning to pain, accompanied by an urge to move the •• Self-help measures© Jones & Bartlett Learning, LLClegs when at rest. Leg cramps© Jones are estimated & Bartlett to affect Learning, LLC 30% of pregnant women, whereas restless leg syndrome ■■ Sleep hygieneNOT (see above) FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION is seen in 10–26% of pregnant women (Hensley, 2009; ■■ Nap during day to maintain rest Zhou, Xu, Li, & Zhang, 2013). Leg cramps are a com- ■■ Eat a carbohydrate snack prior to bed mon occurrence during pregnancy and can interfere with ■■ Regular daily physical activity a woman’s ability to sleep. They are more common dur- ©■■ JonesAdequate & nutrition Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ing nighttime. Cramping can be related to an imbalance NOT■■ Limit FOR fluids SALE 2 hours OR before DISTRIBUTION bedtime NOT FOR SALE OR DISTRIBUTION of calcium and magnesium, or it can reflect pressure of ■■ Avoid or minimize caffeine the enlarging uterus on pelvic blood vessels or on nerves ■■ Reinforce abstinence from alcohol supplying the lower leg. Other less common causes of ■■ Stress management techniques leg cramps are related to duration and type of physical © Jones & Bartlett■■ Welcoming Learning, sleep environmentLLC © Jones & Bartlett Learning, LLC activity, dehydration, and metabolic, vascular, or neuro- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Follow-up Care: Follow-up Measures to Consider logic disorders. •• Document and discuss ■■ Physical findings History and Chart Review: Components ■■ of the History to Consider Treatment recommendations© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Return for care NOT FOR SALE OR DISTRIBUTION(Hensley, 2009) NOT FOR SALE OR DISTRIBUTION ■■ As scheduled for gestation ■■ Increased visits as needed •• Gestational age ◆◆ Evaluation and monitoring of medication use •• Onset, frequency, duration, and severity ◆◆ Emotional support of cramps © Jones & Bartlett Learning, LLC ■■ Timing© Jones and severity & Bartlett of cramps Learning, LLC InterdisciplinaryNOT FOR SALE Practice: OR ConsiderDISTRIBUTION Consultation, ■■ Location;NOT FOR bilateral SALE or unilateral OR DISTRIBUTION pain Collaboration, or Referral ■■ Precipitating factors •• Sleep disorder professional ■■ Self-help measures used and efficacy •• OB/GYN or inpatient maternity care ■■ Physical activity level © Jones & Bartlett■■ Maternal Learning, exhaustion LLC © Jones•• Other& Bartlett associated Learning, symptoms LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 79 20/04/16 3:56 pm © Jones80 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

•• History ■■ Hamstring and calf stretching prior to bedtime ■■ Back or other musculoskeletal injury •• Magnesium supplement ■■ Thyroid disease © Jones & Bartlett Learning, LLC■■ 5 mmol PO in the morning,© Jones 10 mmol & POBartlett at night Learning, LLC ■■ Diabetes mellitus NOT FOR SALE OR DISTRIBUTION(Brucker & King, 2017) NOT FOR SALE OR DISTRIBUTION ■■ Magnesium bisglycinate chelate, 300 mg PO per Physical Examination: Components of the day (Supakatisant & Phupong, 2015) Physical Exam to Consider •• Sleep aids as needed (Hensley,© 2009) Jones & Bartlett Learning, LLC •• Iron supplementation© Jones (Hensley,& Bartlett 2009) Learning, LLC •• Vital signsNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Providing Treatment: Integrative Therapies •• Evaluate foot arch to Consider •• Evaluate extremities •• Dietary sources of calcium and magnesium ■■ Color (see ­Appendix B) © Jones &■■ BartlettClonus Learning, LLC © Jones & Bartlett Learning, LLC •• Warm bath with Epsom salts (MgSO ) NOT FOR■■ SALEMuscle OR spasm DISTRIBUTION NOT FOR SALE OR DISTRIBUTION4 •• Acupressure ■■ Varicosities ■■ Pressure to posterior mid-calf ■■ Calf circumference •• Herbal remedies ■■ Pulses ■■ Raspberry leaf ■■ Muscle strength © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Nettle ■■ Sensory integrity NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Dandelion Clinical Impression: Differential Diagnoses ■■ Crampbark tincture to Consider Providing Support: Education and Support (ICD10Data.com,© Jones 2015) & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Measures to Consider NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Physiologic leg cramps •• Reassurance of normalcy •• Varicose veins •• Provide information on •• Restless leg syndrome ■■ Physiologic nature of leg cramps in pregnancy •• Thrombophlebitis ■■ Increasing calcium and magnesium intake © Jones•• Deep& Bartlett vein thrombosis Learning, LLC © Jones(­Hensley & Bartlett, 2009) Learning, LLC NOT FOR•• Muscle SALE strain OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Regular daily activity ◆◆ Walking Screening and Diagnosis: Tests and Procedures ◆◆ Yoga to Consider ◆◆ Swimming (Hensley, 2009) © Jones & Bartlett Learning, LLC■■ Keep legs warm © Jones & Bartlett Learning, LLC •• Serial calf measurementsNOT FOR SALE OR DISTRIBUTION•• Warning signs NOT FOR SALE OR DISTRIBUTION •• Venous ultrasound ■■ Increasing muscle spasms •• Clotting studies ■■ Swelling, pain, or redness in leg •• Serum ferritin © Jones & Bartlett Learning, LLC Follow-up Care:© Jones Follow-up & Bartlett Measures Learning, to Consider LLC ProvidingNOT Treatment: FOR SALE Therapeutic OR DISTRIBUTION Measures •• Document NOTand discuss FOR SALE OR DISTRIBUTION to Consider ■■ Physical findings •• Physical manipulation ■■ Treatment recommendations ■■ Dorsiflexion of foot during cramp •• Return for care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 80 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC Care of© the Jones Pregnant & Bartlett Woman Learning,with Nausea LLC and Vomiting 81 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ As scheduled for gestation although symptoms can persist until 16 weeks’ gestation ■■ For persistent leg pain or warning signs or later. © Jones & Bartlett Learning, LLCWhile nausea and vomiting© Jones are considered & Bartlett classic Learning, LLC Interdisciplinary Practice:NOT FOR Consider SALE Consultation, OR DISTRIBUTION early-pregnancy symptoms,NOT they FORcan cause SALE significant OR DISTRIBUTION Collaboration, or Referral ­dehydration and metabolic imbalance and contribute to •• Medical services poor nutrition and weight loss. Approximately 35% of ■■ For non-pregnancy-related cause of leg pain, women who have nausea and vomiting related to preg- © Jonessuch as & Bartlett Learning, LLC nancy experience© Jones lost & time Bartlett at work Learning, or a negative LLC impact NOT◆◆ FORPhlebitis SALE OR DISTRIBUTION on familyNOT relationships FOR SALE (Niebyl, OR 2010). DISTRIBUTION In a small minor- ◆◆ Thrombophlebitis ity of women, nausea and vomiting continue throughout ◆◆ Deep vein thrombosis the pregnancy or develop into hyperemesis gravidarum, a •• For diagnosis or treatment outside the midwife’s scope condition characterized by persistent nausea and vomiting © Jones & Bartlettof practice Learning, LLC © Jonesassociated & Bartlett with ketosis Learning, and weight LLC loss of greater than 5% NOT FOR SALE OR DISTRIBUTION NOT FORfrom prepregnancySALE OR DISTRIBUTION weight. For most women, conservative treatment with lifestyle changes and OTC remedies pro- CARE OF THE PREGNANT WOMAN vides adequate relief; however, women with moderate to WITH NAUSEA AND VOMITING severe nausea and vomiting may require medication and intravenous hydration to obtain relief. Key Clinical Information© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Nausea is a subjective and unpleasant feeling associated History and Chart Review: Components with feeling ill and the urge to vomit. Vomiting is the of the History to Consider expulsion of the stomach contents through the mouth as •• Gestational age a result of involuntary muscle spasms. Nausea with or •• Assess onset, duration, and severity of nausea and without© Jones vomiting & isBartlett a common Learning, early-pregnancy LLC symptom, vomiting© Jones (see Table & Bartlett2-1) Learning, LLC experiencedNOT FOR to some SALE degree OR by DISTRIBUTION an estimated 70–85% of ■■ PresenceNOT FOR and frequency SALE OR of vomiting DISTRIBUTION pregnant women (Bottomley & Bourne, 2009). Onset ■■ Symptoms of dehydration is typically at 6–8 weeks’ gestation, and resolution is ■■ Other associated symptoms, such as ptyalism most common at approximately 12 weeks’ gestation, ■■ Self-help measures used and results © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Table 2-1 Pregnancy-Unique Quantification of Emesis (PUQE) Scale

Total Over the last 12 hours, . 6 h 4–6 h 2–3 h #1 h None how many hours have© Jones 5& pts Bartlett Learning,4 pts LLC 3 pts 2 pts © Jones 1& pt Bartlett Learning, LLC you felt nauseated? NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Over the last 12 hours, 7 or . 5–6 3–4 1–2 None how many times have 5 pts 4 pts 3 pts 2 pts 1 pt you vomited? Over the last 12 hours, 7 . 5–6 3–4 1–2 None how© manyJones times & have Bartlett Learning,5 pts LLC 4 pts 3 pts © Jones &2 pts Bartlett Learning,1 pt LLC youNOT had dryFOR heaves? SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Nausea & Vomiting Scoring: Mild # 6; Moderate 7–12; Severe ≥ 13 Adapted from Koren, G., Piwko, C., Ahn, E., Boskovic, R., Maltepe, C., Einarson, A., . . . Unger, W. (2005). Validation studies of the Pregnancy–Unique Quantification of Emesis (PUQE) scores. Journal of Obstetrics & Gynecology, 25(3), 241–244. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 81 20/04/16 3:56 pm © Jones82 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

•• Assess other factors •• Urinalysis ■■ Nutritional intake, solids and liquids •• Blood urea nitrogen, creatinine, serum ketones, ■■ Effect on activities ©of Jonesdaily living & Bartlett(ADL) Learning, LLCand electrolytes © Jones & Bartlett Learning, LLC ■■ Bowel and bladder NOTelimination FOR patterns SALE and OR changes DISTRIBUTION•• Thyroid evaluation: TSH, T3NOT, and TFOR4 SALE OR DISTRIBUTION •• Medical history •• Liver function testing and amylase ■■ Thyroid disorders •• Complete blood count (CBC) and white blood cell count ■■ Eating disorders •• Pelvic ultrasound •• Review© of Jones systems & Bartlett Learning, LLC •• Ultrasound© of Jonesthe gallbladder & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION •• H. pylori testingNOT FOR SALE OR DISTRIBUTION Physical Examination: Components of the Physical Exam to Consider Providing Treatment: Therapeutic Measures •• Vital signs to Consider © Jones•• Interval& Bartlett weight Learning, gain or loss LLC ©(Brucker Jones & King,Bartlett 2017; Learning, Jordan et al., LLC 2014) NOT FOR•• Usual SALE prenatal OR evaluation,DISTRIBUTION including examination NOT FOR SALE OR DISTRIBUTION of the following factors: •• Treat conservatively, progressing as indicated by ■■ Overall appearance ­symptoms (Table 2-2) ◆◆ Weight loss •• Initiate medications if relief not obtained from ­conservative measures or symptoms warrant ◆◆ Skin turgor, heart© Jonesrate, and & other Bartlett signs Learning, LLC © Jones & Bartlett Learning, LLC •• Doxylamine succinate and pyridoxine hydrochloride of dehydration NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ◆◆ Self-care and hygiene (Diclegis) ◆◆ Abdominal examination ■■ 2 tablets at bedtime •• Vitamin B6 (pyridoxine) Clinical Impression: Differential Diagnoses ■■ 25 mg TID or QID or 50 mg BID © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to Consider •• Ginger NOT FOR SALE OR DISTRIBUTION ■■ NOT FOR SALE OR DISTRIBUTION (ICD10Data.com, 2015) Up to 1 g total daily, in divided doses ■■ 250 mg QID in capsule form •• Physiologic nausea and vomiting of pregnancy ■■ 1 tsp grated fresh rhizome •• Also consider the following: ■■ 2 mL liquid extract © Jones &■■ BartlettHyperemesis Learning, gravidarum LLC © Jones■■ 2-inch & Bartlett piece of crystallizedLearning, ginger, LLC 0.25 mg NOT FOR■■ SALEHydatidiform OR DISTRIBUTION mole NOT FORthick SALE OR DISTRIBUTION ■■ Ectopic implantation ■■ 8 oz ginger ale or ginger beer (must contain real •• Mental health conditions ginger) ■■ Bulimia •• Thiamine supplement for women with protracted ■■ Anxiety © Jones & Bartlett Learning, LLCvomiting © Jones & Bartlett Learning, LLC ■■ Depression NOT FOR SALE OR DISTRIBUTION■■ 1.5 mg PO daily (Wegryzniak,NOT Repke, FOR &SALE OR DISTRIBUTION •• Other medical conditions Ural, 2012) ■■ Gallbladder disease •• Intravenous (IV) hydration when indicated ■■ Pyelonephritis ■■ Hydration alone may resolve symptoms ■■ Gastroenteritis© Jones & Bartlett Learning, LLC ■■ NS is the© fluidJones of choice & Bartlett to correct Learning, hyponatremia LLC ■■ HyperthyroidismNOT FOR SALE OR DISTRIBUTION ■■ 500 mLNOT bolus FORto start SALE OR DISTRIBUTION ■■ Thiamine 100 mg to first liter of IV fluid Screening and Diagnosis: Tests (­Wegryzniak et al., 2012) and Procedures to Consider ■■ Titrate to maintain urinary specific gravity within © Jones•• Urine& Bartlett dipstick Learning, for ketones andLLC glucose © Jonesthe & normal Bartlett range Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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9781284083415_CH02_Pass03.indd 82 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC Care of© the Jones Pregnant & Bartlett Woman Learning,with Nausea LLC and Vomiting 83 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Table 2-2 Common Medicinal Treatments for Nausea and Vomiting in Pregnancy

AGENT GENERIC © Jones & Bartlett Learning, LLC SAFETY © Jones & Bartlett Learning, LLC (BRAND) NOTORAL FOR DOSE SALE OR DISTRIBUTIONSIDE EFFECTS INFORMATIONNOT FOR COMMENTS SALE OR DISTRIBUTION First-Line Therapies Doxylamine (10 mg) 2 tabs at bedtime. Sedation Human data do not Titrate dosing for and pyridoxine (10 mg) If not enough relief, indicate fetal risk individual optimal relief. (Diclegis) add 1–2 tabs in the Take without food. Not © Jones & Bartlettmorning. Learning, Take up toLLC © Jones & Bartlett Learning,for use by woman LLC taking NOT FOR SALE OR4 tabs DISTRIBUTION daily NOT FOR SALE OR DISTRIBUTIONmonoamine oxidase (MAO) inhibitors

Pyridoxine 10–25 mg q8h Human data do not Vitamin B6 alone indicate fetal risk or B6–antihistamine combination advised © Jones & BartlettPyridoxine andLearning, LLCPyridoxine 10–25 mg Sedation© Jones & BartlettHuman Learning, data do not LLC Doxylamine (Unisom q8h, doxylamine 25 mg indicate fetal risk as first-line treatment. NOT FOR SALESleepTabs) OR combination DISTRIBUTIONat bedtime, 12.5 mg NOT FOR SALE OR DISTRIBUTIONCombination treatment in the a.m. prn, has same ingredients as and 12.5 mg in the Diclegis. Take without afternoon prn food. Available over the counter Ginger (considered a © Jones1 g daily & in Bartlett divided Learning,Reflux, heartburn LLC Generally recognized© Jones Wide & Bartlett variety of formsLearning, LLC food supplement) NOTdoses FOR SALE OR DISTRIBUTION as safe in pregnancyNOT FORavailable SALE (capsule, OR DISTRIBUTION in beverages, whole, candied). Available over the counter Secondary Therapies Dimenhydrinate© Jones & Bartlett50–100 Learning, mg q4–6h, LLC Dizziness, headache © JonesHuman data & Bartlettdo not Learning,Antihistamine LLC (Dramamine)NOT FOR SALE ORnot to DISTRIBUTION exceed 400 mg sedation NOTindicate FOR fetal SALE risk OR DISTRIBUTION daily; not to exceed 200 mg daily if also taking doxylamine Diphenhydramine 25–50 mg q8h Dizziness, headache Human data do not Antihistamine © Jones & Bartlett(Benadryl) Learning, LLC sedation© Jones & Bartlettindicate Learning, fetal risk LLC NOT FOR SALEHydroxyzine OR DISTRIBUTION(Vistaril) 50 mg q4–6h Dizziness,NOT headache FOR SALE Human OR DISTRIBUTIONdata do not Antihistamine. Can be sedation indicate fetal risk administered PO or IM Meclazine (Antivert) 25 mg q6h Dizziness, headache Human data do not Antihistamine sedation indicate fetal risk Prochlorperazine 5–10 mg q4–6h, not to Anticholinergic Animal studies indicate Phenothiazine. (Compazine) © Jonesexceed &40 Bartlettmg daily Learning,effects, dry LLC mouth, possible fetal risk,© JonesAvailable & Bartlett as buccal Learning, LLC NOT FOR SALE OR DISTRIBUTIONextrapyramidal but not establishedNOT or FORtablet. SALE Can be OR DISTRIBUTION symptoms, hypotension studied in humans administered PO, IM, IV Promethazine 12.5–25 mg q4–6h Sedation, Animal studies indicate Antihistamine. Can be (Phenergan) anticholinergic possible fetal risk, given PO, PR, IM, or effects, dry mouth, but not established or IV. Black box warning: © Jones & Bartlett Learning, LLC extrapyramidal © Jonesstudied in & humans Bartlett Learning,Possible severe LLC tissue NOT FOR SALE OR DISTRIBUTIONsymptoms NOT FOR SALE OR DISTRIBUTIONinjury with IV use Therapies for Refractory Nausea and Vomiting Metoclopramide 5–10 mg q8h Extrapyramidal Human data do not Dopamine antagonist. (Reglan) symptoms, agitation, indicate fetal risk Black box warning: anxiety, acute dystonic May cause long-term © Jones & Bartlett Learning, LLC reaction© Jones & Bartlett Learning, LLCtardive dyskinesia. Can NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTIONbe given PO, IM, or IV

(continues )

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9781284083415_CH02_Pass03.indd 83 20/04/16 3:56 pm © Jones84 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Table 2-2 Common Medicinal Treatments for Nausea and Vomiting in Pregnancy (Continued)

AGENT GENERIC © Jones & Bartlett Learning, LLC SAFETY © Jones & Bartlett Learning, LLC (BRAND) ORALNOT DOSE FOR SALE ORSIDE DISTRIBUTION EFFECTS INFORMATIONNOT COMMENTS FOR SALE OR DISTRIBUTION Ondansetron (Zofran) 4–8 mg q6h Headache, blurred Human data indicate Serotonin agonist. vision, diarrhea, possible increase in Use in pregnancy constipation, fatigue cardiac septal defects is off-label. Check compatibility © Jones & Bartlett Learning, LLC © Jones & Bartlettwith Learning, concurrent LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE medications.OR DISTRIBUTION Can be given PO, IM, or IV Methylprednisolone 16 mg q8h for 3 d, then Small increased risk of Animal studies indicate Glucocorticoid. (Medrol) taper down over 2 wk cleft lip if used prior to possible fetal risk, Use reserved 10 wk’s gestation but not established or for women with © Jones & Bartlett Learning, LLC © Jones & studiedBartlett in humans Learning, hyperemesisLLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALEAvoid use OR before DISTRIBUTION demonstrating weight 10 wk’s gestation loss and requiring parenteral nutrition.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Providing Treatment: Integrative Therapies •• Avoid dehydration to Consider ■■ Sip small amounts of fluid throughout the day •• Acupressure at Neiguan P6 point via wristbands ■■ Drink cold, clear, carbonated, flat, or sour fluids between meals •• Chamomile© Jones tea & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Peppermint tea ◆◆ Increase sleep, rest, and fresh air NOT FOR SALE OR DISTRIBUTION ◆◆ NOT FOR SALE OR DISTRIBUTION ■■ Not recommended for women with heartburn Avoid brushing teeth soon after meals or gastroesophageal reflux disease (GERD) ◆◆ Avoid triggers such as strong odors, fatigue, •• Foods rich in B vitamins, such as heat, and stuffy rooms ■■ Wheat germ •• Advise family of need for support © Jones &■■ BartlettMolasses Learning, LLC ©• Jones• Provide & reassuranceBartlett Learning, that symptoms LLC resolve around NOT FOR■■ SALEBrewer’s OR yeast DISTRIBUTION NOT12–16 FOR weeks’SALE gestation OR DISTRIBUTION for most women •• Hypnosis •• Review when to call •• Cola syrup ■■ ADL become significantly affected •• Sucking on hard candies ■■ Unable to keep down food or fluids for more than © Jones & Bartlett Learning, LLC12–24 hours © Jones & Bartlett Learning, LLC Providing Support: EducationNOT FORand Support SALE OR DISTRIBUTION■■ Signs and symptoms of dehydrationNOT FOR SALE OR DISTRIBUTION Measures to Consider ■■ Abdominal pain ■■ Weakness, lethargy, or confusion All women with nausea and/or vomiting should be ­encouraged to take the following steps: © Jones & Bartlett Learning, LLC Follow-up Care:© Jones Follow-up & Bartlett Measures Learning, to Consider LLC •• Take NOTprenatal FOR vitamins SALE at night OR orDISTRIBUTION discontinue until •• Document NOTand discuss FOR SALE OR DISTRIBUTION symptoms resolve ■■ Physical findings •• Eat small amounts of bland, dry, high-protein foods q2h ■■ Treatment recommendations ■■ Increase intake of protein and complex •• Return for care © Jones & Bartlettcarbohydrates Learning, LLC © Jones■■ As &scheduled Bartlett for Learning, gestation LLC NOT FOR■■ SALELimit dietary OR DISTRIBUTION fat NOT ■■ FORAs needed SALE for OR worsening DISTRIBUTION symptoms

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9781284083415_CH02_Pass03.indd 84 20/04/16 3:56 pm © Jones & Bartlett Learning, LLC © Jones &Care Bartlett of the PregnantLearning, Woman LLC with Pica 85 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ For outpatient or inpatient IV rehydration as History and Chart Review: Components needed of the History to Consider © Jones & Bartlett Learning, LLC(Ellis & Schnoes, 2006) © Jones & Bartlett Learning, LLC Interdisciplinary Practice: Consider Consultation, NOT FOR SALE OR DISTRIBUTION•• Maternal age NOT FOR SALE OR DISTRIBUTION Collaboration, or Referral ■■ More common in adolescents •• Healing arts therapist offering •• Gestational age ■■ Acupuncture therapy •• Identify ■■ © JonesHypnosis & therapy Bartlett Learning, LLC ■■ Nonfood© Jones substances & Bartlett craved Learning, or consumed LLC •• InpatientNOT FOR maternity SALE care OR services DISTRIBUTION ■■ FoodNOT cravings FOR that SALE may ORindicate DISTRIBUTION or contribute to ■■ Hyperemesis nutritional deficiencies ■■ Dehydration ■■ Social issues that may contribute to pica •• Medical or surgical services ◆◆ Inadequate diet © Jones & Bartlett■■ Gallbladder Learning, disease LLC © Jones & Bartlett◆◆ Food insecurity Learning, LLC NOT FOR •SALE• For diagnosis OR DISTRIBUTION or treatment outside the midwife’s NOT FOR SALE◆◆ Cultural OR DISTRIBUTIONexpectations scope of practice •• Evaluate ■■ Woman’s diet and nutritional resources CARE OF THE PREGNANT WOMAN ■■ Use of vitamin and mineral supplements WITH PICA © Jones & Bartlett Learning, LLC ■■ Previous hematocrit© and Jones hemoglobin & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION■■ History of anemia orNOT nutritional FOR SALEdeficiencies OR DISTRIBUTION Key Clinical Information •• Psychosocial status ■■ Cultural or ethnic expressions of pica Pica is defined as the craving and purposeful consump- ■■ Traumatic life events tion of nonnutritive substances for more than one month. Earth© Jones(geophagy), & Bartlettcorn or laundry Learning, starches LLC (amylophagy), © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Physical NOTExamination: FOR SALE Components OR DISTRIBUTION of the and ice (pagophagy) are the most commonly reported Physical Exam to Consider pica substances in the United States (Young, 2010). •• Vital signs including weight and pulse Hormonally mediated changes in sensory perception •• Interval weight gain or loss may affect craving intensity (Orloff & Hormes, 2014). •• Assess nutritional status © Jones &Pica Bartlett may be Learning, accepted in someLLC cultures and subcultures;© Jones & Bartlett Learning, LLC •• Evaluate for signs of anemia NOT FOR forSALE example, OR clayDISTRIBUTION eating and starch eating are seen in NOT FOR SALE OR DISTRIBUTION ■■ Color of mucous membranes the United States in some southern, rural, African ■■ Capillary refill American communities, primarily among women and ■■ Orthostatic hypotension children (Ellis & Schnoes, 2006). The prevalence of this ■■ Elevated heart rate practice is not known© because Jones pica & Bartlett is often undisclosed, Learning, LLC © Jones & Bartlett Learning, LLC unrecognized, and underreported.NOT FOR SALE It is thought OR DISTRIBUTION to occur Clinical Impression: DifferentialNOT FOR Diagnoses SALE OR DISTRIBUTION in approximately 1.6% of pregnant women, with as many to Consider as 20% of women with high-risk pregnancies (Orloff & (ICD10Data.com, 2015) Hormes, 2014). Whether pica is a contributing factor to pregnancy© Jones risk & Bartlettor a stress-related Learning, behavior LLC remains •• Pica © Jones & Bartlett Learning, LLC unclear.NOT The FOR nature SALE and amountOR DISTRIBUTION of ingested substances •• NutritionalNOT anemiaFOR SALE OR DISTRIBUTION determine the health consequences of this behavior. •• Lead toxicity Pica is associated with iron-deficiency anemia and low zinc levels, though it is still unclear if these deficits are Screening and Diagnosis: Tests and Procedures to Consider © Jones &a Bartlettcause or a Learning, result of pica LLC practices (Miao, Young, & © Jones & Bartlett Learning, LLC NOT FOR Golden,SALE OR2015). DISTRIBUTION NOT FOR•• Hematocrit SALE OR and DISTRIBUTION hemoglobin

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9781284083415_CH02_Pass03.indd 85 20/04/16 3:56 pm © Jones86 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

•• Lead screening Interdisciplinary Practice: Consider Consultation, •• Anemia workup (see Care of the Pregnant Woman Collaboration, or Referral with Anemia in Chapter© 3)Jones & Bartlett Learning,•• LLC Dietary counseling services © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION•• Social services NOT FOR SALE OR DISTRIBUTION Providing Treatment: Therapeutic Measures ■■ WIC program to Consider ■■ Food stamps •• Iron replacement therapy if anemia is present ■■ Food bank •• Multivitamin© Jones and & mineral Bartlett supplements Learning, LLC •• Maternity subspecialist© Jones & or Bartlett medical services Learning, LLC •• BehavioralNOT interventions FOR SALE OR DISTRIBUTION ■■ For severeNOT pica FOR accompanied SALE ORby anemia DISTRIBUTION ■■ ■■ Food diary and nutrition counseling For elevated lead levels ■■ Cognitive behavioral therapy •• For diagnosis or treatment outside the midwife’s •• Treatment of lead or other toxicity as indicated scope of practice © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORProviding SALE Treatment: OR DISTRIBUTION Integrative Therapies NOTCARE FOR OF SALETHE PREGNANT OR DISTRIBUTION WOMAN to Consider WITH ROUND LIGAMENT PAIN •• Iron-rich foods (see Appendix B) Key Clinical Information •• Sea vegetables high in iron and trace minerals, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC such as kelp, nori, and wakame Round ligament pain is an unpleasant sensation that NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Red raspberry leaf tea ranges from sharp knifelike pain to dull intermittent •• Yellow dock pain in the lower abdominal and inguinal areas of the pregnant woman. It is believed that virtually all pregnant women will experience this pain at some point, typically Providing Support: Education and Support © Jones & Bartlett Learning, LLC in the last weeks© ofJones the first & trimesterBartlett and Learning, into the early LLC Measures to Consider NOT FOR SALE OR DISTRIBUTION part of the secondNOT trimester, FOR SALE and so educationOR DISTRIBUTION and reassur- •• Explore concerns about pica with the woman in a ance are important (Jordan et al., 2014). It can mimic, or ­nonjudgmental manner mask, uncommon yet more serious conditions, such as ■■ Pica can interfere with good nutrition ­appendicitis or ovarian torsion. Round ligament varicosi- ■■ Provide or arrange for nutritional education and © Jones & Bartlett Learning, LLC ©ties Jones can occur & Bartlett in pregnancy Learning, and like LLCinguinal ­hernia, pres- support NOT FOR SALE OR DISTRIBUTION NOTent with FOR pain SALE and swelling OR DISTRIBUTION in the ­inguinal ­region (Ryu & ■■ Encourage avoidance of nonfood items Yoon, 2014). Round ligament pain can cause significant •• Try offering substitute items distress, especially in women who ­participate in sports ■■ Laundry starch, ice: frozen fruit pops such as jogging or tennis, and in women who have highly ■■ Clay: food-grade seaweed © Jones & Bartlett Learning,physical LLC jobs. An objective pain ©scale Jones is recommended & Bartlett to Learning, LLC ■■ Other acceptable nutritional items NOT FOR SALE OR DISTRIBUTIONassess and document the woman’sNOT pain FOR level. SALE OR DISTRIBUTION

Follow-up Care: Follow-up Measures History and Chart Review: Components to Consider of the History to Consider •• Document© Jones findings & Bartlettand discuss Learning, LLC •• Gestational© age Jones & Bartlett Learning, LLC ■■ PhysicalNOT FORfindings SALE OR DISTRIBUTION •• Evaluation NOTof the FORpain SALE OR DISTRIBUTION ■■ Treatment recommendations ■■ Onset, location, severity, and duration •• Return for care ■■ Quality of the pain ■■ As scheduled for gestation ◆◆ Intermittent or constant © Jones &■■ BartlettFor follow-up Learning, of laboratory LLC values as indicated © Jones◆◆ &Sharp Bartlett or dull Learning, LLC NOT FOR■■ SALETo assess OR continued DISTRIBUTION pica practices NOT FOR◆◆ Exacerbating SALE OR factorsDISTRIBUTION

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■■ Associated symptoms ■■ Inguinal hernia ◆◆ Cramping ■■ Acute abdomen secondary to the following ◆◆ Backache© Jones & Bartlett Learning, LLC conditions: © Jones & Bartlett Learning, LLC ◆◆ Nausea andNOT vomiting FOR SALE OR DISTRIBUTION ◆◆ Ovarian torsionNOT FOR SALE OR DISTRIBUTION ◆◆ Change in bowel or bladder function ◆◆ Renal calculi •• Relief measures used and efficacy ◆◆ Pyelonephritis •• Activities of daily living ◆◆ Appendicitis ©■■ JonesEmployment & Bartlett activities Learning, LLC ◆◆ ©Gallbladder Jones & disease Bartlett Learning, LLC NOT■■ Lifestyle FOR activities SALE OR DISTRIBUTION ◆◆ NOTPelvic FOR inflammatory SALE ORdisease DISTRIBUTION ■■ Limitations secondary to pain Screening and Diagnosis: Tests and Procedures Physical Examination: Components of the to Consider © Jones &Physical Exam Bartlett Learning, to Consider LLC © Jones•• Urinalysis& Bartlett Learning, LLC NOT FOR •SALE• Vital ORsigns DISTRIBUTION NOT FOR•• Complete SALE bloodOR DISTRIBUTION count (CBC) with differential •• Verify location of pain; observe and palpate •• Ultrasound evaluation the area ■■ Pelvis •• Note posture and overall appearance ◆◆ Uterus, ovaries, and tubes •• Abdominal and groin© Jones examination & Bartlett Learning, LLC ◆◆ Inguinal region© Jones & Bartlett Learning, LLC ■■ Palpate forNOT tenderness FOR SALE OR DISTRIBUTION ◆◆ Appendix NOT FOR SALE OR DISTRIBUTION ◆◆ Guarding ■■ Abdomen ◆◆ Rebound pain ◆◆ Kidneys, ureters, and bladder ◆◆ Referred pain ◆◆ Gallbladder ©■■ JonesInguinal & mass Bartlett or pain Learning, LLC © Jones & Bartlett Learning, LLC ■■ Uterine examination NOT FOR SALE OR DISTRIBUTION ProvidingNOT Treatment: FOR SALE Therapeutic OR DISTRIBUTION Measures ◆◆ Fundal height to Consider ◆◆ Fetal heart rate •• Maternity abdominal support or girdle ◆◆ Presence of contractions •• Instruction on slow movement and position ◆◆ Consistency and position of uterus change © Jones &• •Bartlett Pelvic examination Learning, as LLCindicated © Jones & Bartlett Learning, LLC •• Counterpressure NOT FOR SALE■■ Cervical OR DISTRIBUTION or vaginal discharge NOT FOR SALE OR DISTRIBUTION •• Pain relief (Brucker & King, 2017) ■■ Dilation and/or effacement ■■ Acetaminophen •• Evaluate for costovertebral angle (CVA) tenderness ◆◆ 325–975 mg PO q 4–6 h up to a maximum daily dose of 4,000 mg per day. Clinical Impression:© DifferentialJones & Bartlett Diagnoses Learning, LLC © Jones & Bartlett Learning, LLC to Consider NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Providing Treatment: Integrative Measures (ICD10Data.com, 2015) to Consider •• Physiologic round ligament pain •• Muscle strengthening and stretching •• © Also Jones consider & theBartlett following: Learning, LLC ■■ Yoga© Jones & Bartlett Learning, LLC NOT■■ Round FOR ligament SALE varicosities OR DISTRIBUTION ■■ SwimmingNOT FOR SALE OR DISTRIBUTION ■■ Urinary tract infection ■■ Prenatal exercise class ■■ Threatened abortion •• Reflexology to waist and pelvic points ■■ Ectopic pregnancy •• Herbal remedies © Jones & Bartlett■■ Preterm Learning, labor LLC © Jones &■■ BartlettRed raspberry Learning, leaf tea LLC NOT FOR SALE■■ Placental OR DISTRIBUTION abruption NOT FOR■■ SALEMassage OR with DISTRIBUTION arnica-infused massage oil

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9781284083415_CH02_Pass03.indd 87 20/04/16 3:56 pm © Jones88 & BartlettChapter Learning, 2 Care ofLLC the Woman During Pregnancy© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Providing Support: Education and Support •• For diagnosis or treatment outside the midwife’s scope Measures to Consider of practice •• Reassurance of normalcy© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •• Provide information onNOT physiologic FOR SALEcause of OR round DISTRIBUTION CARE OF THE PREGNANTNOT WOMAN FOR SALE OR DISTRIBUTION ligament pain WITH VARICOSE VEINS •• Self-help measures ■■ Pelvic tilt Key Clinical Information ■■ Arise slowly from bed; avoid sudden movement © Jones & Bartlett Learning, LLC Varicose veins are© Jones distended & veinsBartlett that resultLearning, in abnor- LLC from sitting to standing NOT FOR SALE OR DISTRIBUTION mal collectionsNOT of blood FOR caused SALE by weak OR venousDISTRIBUTION walls ■■ Warm baths or ­improperly functioning venous valves. Itching, swelling, ■■ Apply gentle heat to area or pain can accompany varicose veins, and they generally ■■ Positioning worsen as the pregnancy progresses and with each subse- ◆◆ Knees to abdomen © Jones & Bartlett Learning, LLC ©quent Jones pregnancy & Bartlett. Care Learning,must be taken LLC to avoid trauma to ◆◆ Bending toward pain to ease ligament tension NOT FOR SALE OR DISTRIBUTION NOTthese FOR vessels, SALE as even OR minor DISTRIBUTION trauma can result in hema- ◆◆ Side-lying with pillow under abdomen and toma formation, superficial phlebitis, or thrombophlebitis. ­between knees Frequent rest periods with the feet elevated higher than ■■ Limit lifting and twisting the heart are essential for women with ­varicose veins. ■■ Ask for help as needed © Jones & Bartlett Learning,High-quality LLC support hose are helpful© Jones in easing & Bartlett the Learning, LLC •• Warning signs NOT FOR SALE OR DISTRIBUTION­discomfort of significant lower-limbNOT varicosities. FOR SALE For OR DISTRIBUTION ■■ Onset of contractions women with vulvar varicosities, snug-fitting panties, ■■ Persistent abdominal or groin pain or swelling spandex bicycle shorts, or a girdle can be used to ­provide ■■ Fever counterpressure. The discomfort of varicose veins is ■■ Onset of nausea and vomiting © Jones & Bartlett Learning, LLC often described© as Jones fatigue, & heaviness, Bartlett or Learning, itching, which LLC ■■ Vaginal bleeding or discharge NOT FOR SALE OR DISTRIBUTION are ­exacerbatedNOT following FOR prolonged SALE ORstanding DISTRIBUTION and relieved ■■ Pain with intercourse or bowel movement by leg elevation. Follow-up Care: Follow-up Measures to Consider History and Chart Review: Components •• Document and discuss of the History to Consider © Jones &■■ BartlettPhysical findings Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR■■ SALETreatment OR recommendations DISTRIBUTION NOT•• GP FOR TPAL SALE OR DISTRIBUTION •• Return for care •• Gestational age ■■ As scheduled for gestation •• Onset and location of varicose veins ■■ ■■ As indicated by test results Changes with pregnancy ■■ ■■ With onset of warning© Jones signs & Bartlett Learning, LLCAssociated symptoms © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION◆◆ Pain NOT FOR SALE OR DISTRIBUTION Interdisciplinary Practice: Consider Consultation, ◆◆ Edema Collaboration, or Referral ◆◆ Redness or change in pigmentation •• Physical therapist for movement evaluation ◆◆ Sensation of leg heaviness •• Prenatal© Jones massage & therapist Bartlett Learning, LLC ◆◆ Other© symptomsJones & Bartlett Learning, LLC •• PhysicianNOT or FOR medical SALE services OR DISTRIBUTION ■■ CurrentNOT relief FORmeasures SALE and theirOR DISTRIBUTIONeffects ■■ ■■ Abdominal pain inconsistent with round Use of medications ligament pain ◆◆ Aspirin ◆◆ ■■ Abnormal test results or findings, such as Nonsteroidal anti-inflammatory drugs •• Medical history © Jones & Bartlett◆◆ Thrombosed Learning, round ligamentLLC varicosities © Jones & Bartlett Learning, LLC ■■ Varicose veins NOT FOR SALE◆◆ Inguinal OR DISTRIBUTIONhernia NOT FOR SALE OR DISTRIBUTION

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■■ Superficial phlebitis ■■ Prothrombin time (PT), partial thromboplastin ■■ Thrombophlebitis time (PTT) •• Activities of daily© living Jones & Bartlett Learning, LLC•• Ultrasound as indicated© toJones evaluate & forBartlett DVT Learning, LLC ■■ Employment NOTactivities FOR SALE OR DISTRIBUTION■■ Complete compressionNOT ultrasonography FOR SALE OR(CCU) DISTRIBUTION ◆◆ Long periods of standing increase risk for varicosities Providing Treatment: Therapeutic Measures ◆◆ Prolonged sitting to Consider ©■■ JonesRecent immobility& Bartlett Learning, LLC •• Support© Jonesgarments & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ■■ CompressionNOT FOR hosiery SALE OR DISTRIBUTION Physical Examination: Components of the ◆◆ Apply after elevating the legs for 10 minutes Physical Exam to Consider ◆◆ Wear daily •• Weight and body mass index (BMI) ■■ Foam pad to support vulvar varicosities: Use with © Jones & Bartlett■■ Obesity Learning, increases riskLLC for varicosities © Jones & Bartlettclose-fitting Learning, but nonconstricting LLC undergarment ■■ NOT FOR •SALE• Examination OR DISTRIBUTION of varicosities NOT FOR SALEMaternity OR abdominal DISTRIBUTION support to relieve pressure on ■■ Location(s) pelvic veins ■■ Number •• Thromboprophylaxis: Women with a history of ■■ Size thrombosis or thrombophilia may be candidates for

■■ prophylactic treatment with low-dose anticoagulants Severity © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC in pregnancy (American Congress of Obstetricians and •• Serial calf measurementsNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION •• Evaluate for symptoms of other conditions Gynecologists [ACOG], 2010) ■■ Superficial phlebitis Providing Treatment: Integrative Therapies to Consider ◆◆ Heat ◆◆ Redness or discoloration •• Increase intake of onions and garlic in the diet © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ◆◆ Tenderness •• Herbal remedies (Romm, 2010) NOT FOR SALE OR DISTRIBUTION ■■ NOT FOR SALE OR DISTRIBUTION ■■ Deep vein thrombosis Bilberry 120–360 mg tablets or capsules PO BID ◆◆ Pain and swelling or TID ◆◆ Positive Homans sign (low specificity) ◆◆ Strengthen capillaries ◆◆ Leg or vulvar edema ◆◆ Reduce platelet aggregation © Jones & Bartlett Learning, LLC © Jones &■■ BartlettHorse chestnut Learning, tea, tincture, LLC or capsule NOT FOR ClinicalSALE OR Impression: DISTRIBUTION Differential Diagnoses NOT FOR■■ SALENettle infusionOR DISTRIBUTION to Consider •• Vitamin C with bioflavonoids 500 mg PO BID (Romm, 2010) (ICD10Data.com, 2015) •• Positioning •• Varicose veins of ©the Jones lower extremities & Bartlett or vulvaLearning, LLC•• Leg elevation above the© heart Jones & Bartlett Learning, LLC •• Varicose veins complicatingNOT FOR pregnancy SALE OR DISTRIBUTION■■ Leg inversion (right-angleNOT FOR position) SALE OR DISTRIBUTION •• Superficial phlebitis and thrombophlebitis •• Deep vein thrombosis Providing Support: Education and Support Measures to Consider Screening© Jones and & Diagnosis: Bartlett Learning,Tests and LLC •• Provide© Jonesinformation & Bartlett regarding Learning,the physiologic LLC basis of ProceduresNOT FOR to ConsiderSALE OR DISTRIBUTION varicoseNOT veins FOR SALE OR DISTRIBUTION •• Serial calf measurements •• Encourage the following: •• Testing for bleeding or clotting disorders ■■ Use and application of support hose ■■ Coagulation factors ■■ Rest and sleep with legs elevated © Jones & Bartlett■■ Superficial Learning, phlebitis LLC © Jones &■■ BartlettRegular mild Learning, exercise, especially LLC walking or NOT FOR SALE■■ d-Dimer OR DISTRIBUTION NOT FOR SALEswimming OR DISTRIBUTION

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•• Avoidance of the following: ■■ Onset of warning signs ■■ Constrictive clothing ■■ Four to 7 days for suspected early superficial ■■ Long periods of standing© Jones or sitting & Bartlett Learning, LLCphlebitis © Jones & Bartlett Learning, LLC ■■ Crossing legs whileNOT sitting FOR SALE OR DISTRIBUTION■■ Evaluate closely in the earlyNOT postpartum FOR SALE period OR DISTRIBUTION ■■ Leg massage •• Vulvar varicosities •• Medication instructions ■■ Provide support during birth •• Warning signs ■■ Observe for hematoma formation after birth ■■ Persistent© Jones or worsening& Bartlett pain Learning, LLC © Jones & Bartlett Learning, LLC ■■ Interdisciplinary Practice: Consider Consultation, UnilateralNOT FOR edema SALE of extremity OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Localized redness, heat, or tenderness Collaboration, or Referral ■■ Fever •• Maternity subspecialist or medical services ■■ Thromboprophylaxis

Follow-up Care: Follow-up Measures to Consider ■■ © Jones & Bartlett Learning, LLC © JonesSevere & Bartlett vulvar varicosities Learning, LLC ■■ NOT FOR•• Document SALE OR and DISTRIBUTIONdiscuss NOT FORSuspected SALE or OR confirmed DISTRIBUTION ■■ Physical findings ◆◆ Phlebitis ■■ Treatment recommendations ◆◆ Thrombophlebitis •• Return for care •• For diagnosis or treatment outside the midwife’s scope ■■ As scheduled for gestation of practice © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

WEB RESOURCES FOR CLINICIANS RESOURCE URL © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The Rights of Childbearing Women http://www.childbirthconnection.org/article.asp?ck=10084 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Centering Pregnancy http://centeringhealthcare.org/pages/centering-model/pregnancy-overview.php Fetal positioning http://spinningbabies.com ACNM Healthy Birth Initiative http://www.midwife.org/ACNM-Healthy-Birth-Initiative Drugs in Pregnancy and Breastfeeding http://www.perinatology.com/exposures/druglist.htm © Jones & Bartlett Learning, LLC http://www.motherisk.org/women/drugs.jsp#bottom© Jones & Bartlett Learning, LLC NOT FORScreening SALE for substanceOR DISTRIBUTION use in pregnancy http://www.nnepqin.org/documentUpload/NNEPQIN_Guideline_for_Screening_NOT FOR SALE OR DISTRIBUTION for_Use_of_Alcohol_and_Drugs_Tobacco_and_Drugs_of_Abuse_in_Pregnancy._ March_2014_Revision.pdf Home birth summit http://www.homebirthsummit.org/ Physiologic birth © Jones & BartlettFor women: Learning, http://childbirthconnection.org/pdfs/CC.NPWF.Booklet.Pathway. LLC © Jones & Bartlett Learning, LLC NOT FOR SALEHealthyBirth.2015.pdf OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION For clinicians: http://childbirthconnection.org/pdfs/CC.NPWF.HPoC.Report.2015.pdf Smoking cessation tools for clinicians Informational handout for women: http://www.midwife.org/acnm/ and women files/ccLibraryFiles/Filename/000000004528/CDC-SC-ForWomen- NeedToKnowAndHowToQuit-101314.pdf © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC To develop clinical skills in facilitating smoking cessation: https://www NOT FOR SALE OR DISTRIBUTION.smokingcessationandpregnancy.org/NOT FOR SALE OR DISTRIBUTION Vaccines for pregnant women http://www.cdc.gov/vaccines/adults/rec-vac/pregnant.html

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REFERENCES of the Advisory Committee on Influenza Practices-United States, 2014–2015 Influenza Season. Retrieved from http:// American College of Obstetricians and Gynecologists. (2009; re- www.cdc.gov/flu/professionals/acip/index.htm affirmed 2013). Practice Bulletin No. 101: Ultrasonography © Jones & Bartlett Learning, LLCCheyney, M., Bovbjerg, ©M., Jones Everson, & BartlettC., Gordon, Learning, W., LLC in pregnancy. Obstetrics & Gynecology, 113, 451. NOT FOR SALE OR DISTRIBUTION­Hannibal, D., & Vedam,NOT S. (2014). FOR Outcomes SALE OR of care DISTRIBUTION for American College of Obstetricians and Gynecologists. (2010; reaf- 16,924 planned home births in the United States: The Mid- firmed 2014). Practice Bulletin No. 138: Inherited thrombo- wives Alliance of North America Statistics project, 2004 to philias in pregnancy. Obstetrics & Gynecology, 122, 706–717. 2009. Journal of Midwifery & Women’s Health, 59(1), 17–27. American College of Obstetricians and Gynecologists. (2013). Copeland, L., McNamara, R., Kelson, M., & Simpson, S. (2015). Committee opinion number 471: Smoking cessation during © Jones & Bartlett Learning, LLC Mechanisms© Jones of change & Bartlett within motivational Learning, interviewing LLC in pregnancy. Obstetrics & Gynecology, 166(5), 1241–1244. NOT FOR SALE OR DISTRIBUTION relationNOT to health FOR behaviors SALE outcomes:OR DISTRIBUTION A systematic review. American College of Obstetricians and Gynecologists. (2014). Patient Education and Counseling, 98(4), 401–411. Committee opinion number 471: Method for estimating due Cuello-Garcia, C. A., Broz. ek, J. L., Fiocchi, A., Pawankar, R., date. Retrieved from https://www.acog.org/-/media/Committee-­ Yepes-Nuñez, J. J., Terracciano, L., . . . Schünemann, H. J. Opinions/Committee-on-Obstetric-Practice/co611.pdf?dmc= (2015). Probiotics for the prevention of allergy: A systematic 1&ts=20141218T0646129888 © Jones & Bartlett Learning, LLC © Jones review& Bartlett and meta-analysis Learning, of randomized LLC controlled trials. The American College of Obstetricians and Gynecologists. (2015). NOT FOR SALE OR DISTRIBUTION NOT FORJournal SALE of Allergy OR DISTRIBUTIONand Clinical Immunology, 136(4), 952–961. Committee opinion number 464: Cell-free DNA screening Danielsson, B., Wikner, B. N., & Källén, B. (2014). Use of ondan- for fetal aneuploidy. Retrieved from http://www.acog.org/ setron during pregnancy and congenital malformations in the Resources-And-­Publications/Committee-Opinions/Committee- infant. Reproductive Toxicology, 50, 134–137. on-Genetics/Cell-free-DNA-Screening-for-Fetal-Aneuploidy Dowswell, T., & Neilson, J. (2008). Interventions for heartburn American College of Obstetricians© Jones and& BartlettGynecologists; Learning, Committee LLC © Jones & Bartlett Learning, LLC in pregnancy. 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