HEALTHIER : PATIENT SAFETY GOALS

JASSIN M. JOURIA, MD

DR. JASSIN M. JOURIA IS A MEDICAL DOCTOR, PROFESSOR OF ACADEMIC MEDICINE, AND MEDICAL AUTHOR. HE GRADUATED FROM ROSS UNIVERSITY SCHOOL OF MEDICINE AND HAS COMPLETED HIS CLINICAL CLERKSHIP TRAINING IN VARIOUS TEACHING HOSPITALS THROUGHOUT NEW YORK, INCLUDING KING’S COUNTY HOSPITAL CENTER AND BROOKDALE MEDICAL CENTER, AMONG OTHERS. DR. JOURIA HAS PASSED ALL USMLE MEDICAL BOARD EXAMS, AND HAS SERVED AS A TEST PREP TUTOR AND INSTRUCTOR FOR KAPLAN. HE HAS DEVELOPED SEVERAL MEDICAL COURSES AND CURRICULA FOR A VARIETY OF EDUCATIONAL INSTITUTIONS. DR. JOURIA HAS ALSO SERVED ON MULTIPLE LEVELS IN THE ACADEMIC FIELD INCLUDING FACULTY MEMBER AND DEPARTMENT CHAIR. DR. JOURIA CONTINUES TO SERVES AS A SUBJECT MATTER EXPERT FOR SEVERAL CONTINUING EDUCATION ORGANIZATIONS COVERING MULTIPLE BASIC MEDICAL SCIENCES. HE HAS ALSO DEVELOPED SEVERAL CONTINUING MEDICAL EDUCATION COURSES COVERING VARIOUS TOPICS IN CLINICAL MEDICINE. RECENTLY, DR. JOURIA HAS BEEN CONTRACTED BY THE UNIVERSITY OF MIAMI/JACKSON MEMORIAL HOSPITAL’S DEPARTMENT OF SURGERY TO DEVELOP AN E-MODULE TRAINING SERIES FOR TRAUMA PATIENT MANAGEMENT. DR. JOURIA IS CURRENTLY AUTHORING AN ACADEMIC TEXTBOOK ON HUMAN ANATOMY & PHYSIOLOGY.

Abstract

Preparing women early on in a pregnancy to follow a plan for routine has been shown to promote healthy outcomes for expectant mothers and the developing baby during all phases of pregnancy. Proper nutrition and prevention should be reviewed at the first prenatal visit and for every visit throughout the pregnancy. To ensure that best care practices are followed and that promotion of maternal and health is of top priority, all health professionals should understand patient safety goals and standards of practice. The health team should understand the importance of working in unison not only with other clinicians and associates, but also with patients and their families. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacy content is 0.5 hours (30 minutes).

Statement of Learning Need

Clinicians need to understand the components involved in the initial prenatal assessment including assessing for pre-existing , glucose in the urine, and sexually transmitted . Additionally, identifying existing risks at the first prenatal appointment through open communication regarding unhealthy lifestyle choices can make a profound difference in the health outcomes of the expectant mother and baby.

Course Purpose

To provide nurses with the fundamental skills and elements involved in managing healthy , as well as basic concepts, which should be well understood by healthcare clinicians at all levels of patient care.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience

Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. Using the Estimated Date of Delivery (EDD) method, the care provider will always ______from the first day of a woman’s last menstrual period.

a. count forward 266 days b. count backward 266 days c. count forward 280 days d. count backward three months

2. ______of women deliver on their actual Estimated Date of Delivery (EDD).

a. One half b. One-third c. Twenty percent d. Four percent

3. True or False: Properly determining a woman’s due date is nominally important because the patient’s contractions will provide enough notice.

a. True b. False

4. Which pregnancy due date method or rule involves counting backwards three months from the first day of the last missed period and then subsequently adding 7 days?

a. Naegele’s rule b. The hCG test c. The menstrual cycle method d. EDD method

5. Using the Estimated Date of Delivery (EDD) method, the care provider will always count forward 266 days from the date of conception if

a. the woman took a home . b. the woman recorded the first day of her menstrual period. c. the exact date of conception is known. d. if the date is confirmed through urinalysis.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction

Having a child is a deeply personal and challenging experience even for the parents who have previously had a child. All health professionals providing care to expectant mothers and their families should promote feelings of confidence in them that pregnancy safety goals are a high priority of the health team. To ensure that best care practices are followed and that promotion of maternal and infant health is of top priority, all health professionals need to understand patient safety goals and standards of practice. The health team that works in unison not only with other clinicians and associates, but also with patients and their families, will be better able to develop detailed, open communication with a focus on building strong and long-term relationships. When working collaboratively, health professionals and patients can promote a positive pregnancy outcome of healthy mothers and babies.

Planning The Prenatal Visit

The initial prenatal visit is an emotionally charged event for most women. During this time there are a variety of competing factors related to physiological and environmental changes an expectant mother may be experiencing; her body is changing in ways she cannot control, her family will have begun anticipating big changes in their lives, and she is likely anxious about the health care. The pregnant woman and her family will want reassurance that they are safe and in good hands.

Health clinicians working with pregnant women will need to understand their underlying feelings of becoming a mother; whether they are thrilled with being pregnant, terrified of the process, or unsure or even remorseful regarding their pregnancy. At the initial visit, all members of the health team should help the expectant mother through all of her emotions as well as

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 those of her family. Patient engagement and healthy responses to teaching during all aspects of the pregnancy is promoted through the initial encounter of building a warm and trusting atmosphere, and the use of compassionate and therapeutic communication.

During the initial prenatal visit, the health clinician will determine the expected date of delivery, perform a physical assessment of the mother and , identify any underlying risks to a successful pregnancy, and understand how the mother and other members of her family are adapting to the pregnancy.

Assessing The Estimated Delivery Date

This section discusses the various and common strategies used in identifying a pregnant woman’s expected delivery date. Properly determining a woman’s due date is of utmost importance, because the more accurate the prediction of the due date, the less likely complications related to unnecessary medical interventions will arise.1

Evaluation of and Expected Date of Delivery

The estimated date of delivery (EDD) method2 has been the principal method in determining a pregnant woman’s due date for more than 200 years. On top of using paper wheels or charts, some clinicians will use EDD calculators online based on the 280-day rule. The clinician must always count forward 280 days from the first day of a woman’s last menstrual period, or forward 266 days from the date of conception if this exact date is known, which is usually in cases of in vitro fertilization.

The EDD method assumes that a woman’s ovulation occurs on day 14 of her cycle but this is untrue for many women, especially those with irregular

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 cycles. There are limitations of using the EDD method in evaluating gestational age.2 Only 4% of women deliver on their actual EDD because of natural biological variations in and hormonal cycles. EDD is based on a 28-day menstrual cycle and does not account for women with varying period lengths or those with alternate fertile days due to changes in episodes of heightened luteinizing hormone (LH), the chemical signal responsible for the release of an ovum.

Occasionally, the first day of the last menstrual cycle is unknown, either because the mother has irregular periods or because she has simply forgotten. In these cases, Human Chorionic Gonadotropin (hCG) levels should be drawn and an ultrasound scheduled depending on the findings revealed in the hCG results.3 Currently, Naegele’s rule is the most common technique of pregnancy dating. This rule involves counting backwards three months from the first day of the last missed period and then subsequently adding 7 days. Like the previous method, this rule considers a woman’s menstrual cycle to be 28-days long and an ovulation that occurs on the 14th day of the cycle. Because a woman is fertile for a few days before, during and after ovulation, the 14th day is not necessarily the most likely date of conception.3

As previously discussed, some women have cycles of varying lengths. A typical menstrual cycle can be anywhere from 21 to 35 days in length. If the expectant mother states that her last menstrual period was October 27th, to determine this patient’s expected due date, the clinician will first subtract three months, putting the date at July 27th. Next, the clinician will add seven days to this date, ending up with an expected due date of August 3rd.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 When a woman believes she is Case Scenario: pregnant, either because of a missed Rose is a 30-year-old period or a positive pregnancy test, she experiencing her first pregnancy. will likely make an appointment with She calls her family physician’s her health clinician to be assessed. The office and reports that the first clinician will confirm pregnancy with a day of her last period was May 5th. Using Naegele’s rule, the urine sample in the office or sometimes clinician anticipates that her with an ordered laboratory blood estimated due date will fall on sample. The clinician will generally which date? gather the date of the patient’s last missed period and inquire about any signs or symptoms.

The primary clinician will perform various physical assessments including checking the cervix to ensure that it is closed and to check its color. The clinician will note whether or not the cervix has taken on a blue or purplish tint due to the increased blood flow to the cervix, which is known as Chadwick’s sign.3 During the primary clinical assessment, the uterine size will also be palpated. In the early stages of pregnancy, before 6 weeks, the uterine fundus may not be felt, or will be only mildly noticeable. Between 6 and 8 weeks, the uterus should be soft, globular in shape and about the size of a plum.

The clinician would likely order blood tests to determine current hCG levels and schedule a future ultrasound to verify the gestational age of the fetus. Women’s hCG levels fluctuate throughout their pregnancy but are always more reliable early on. Results on hCG lab tests may be expected during the following time periods:3

• 4 weeks: 1,000-30,000 mIU/mL • 5 weeks: 3,500-115,000 mIU/mL

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 • 6 - 8 weeks: 12,000-270,000 mIU/mL

It is expected that a pregnant woman’s hCG level will double about every 2 to 3 days during the first trimester and will plateau or fluctuate after approximately twenty weeks. This varies greatly for each mother and may result in the need for fetal health confirmation by ultrasonography.

Ultrasounds are performed at various periods during a woman’s pregnancy; the first usually between 6 and 10 weeks. These initial ultrasounds are the most accurate measurement tools for determining gestational age of an or fetus.7 This accuracy decreases with time because biological differences found within the fetus’ DNA take effect as the fetus grows in utero. Also, grow at different rates and fetal physical measurements obtained by ultrasound will vary for fetuses the same gestational age.

One study found that birth transpired within 7 days of the due date determined by the use of ultrasound technology alone. This study also showed a reduction of the possible risky process of labor induction for post- term pregnancies. First trimester ultrasounds are generally performed transvaginally using a probe inserted into the mother’s vaginal canal. Early ultrasounds performed around 4.5 to 5 weeks will show a gestational sac, which will grow by about 1 mm in diameter per day. Crown to Rump Length (CRL) is more accurate than measuring the gestational sac alone. This measurement is generally performed between 7.5 and 10 weeks. Most mother’s wonder when they can expect to see or hear an infant’s heartbeat. Health clinicians should inform them that cardiac activity might be visible after 5.5 or 6 weeks gestation.7

Like the other tests, ultrasounds have their limitations. The accuracy of

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 sonography in assessing gestational age decreases after 10 weeks and continues to decrease as the pregnancy progresses. As indicated above, this is the result of biological differences in parents and fetal growth rates and sizes. Before six weeks, locating the fetus in utero may be difficult even transvaginally. This can cause unnecessary anxiety and stress for the pregnant woman and her family.

Some women find the transvaginal ultrasound probe to be uncomfortable or even traumatizing, especially if these women have been victims of sexual abuse. The health team must be sensitive to these patients and understand their special needs. New best practices suggest that women able to insert the probe themselves, rather than having the ultrasound technician begin the procedure, feel less discomfort overall. Drawbacks to the use of an early term ultrasound exam, specifically the anxiety some women feel towards the discomfort the procedure can cause, raises the question of whether this procedure is necessary. The need to perform an ultrasound exam will be determined between the primary physician and the expectant mother.

To return to the above case scenario of Rose who reported her last menstrual cycle as starting May 5th, using Naegele’s rule the clinician would be correct in identifying Rose’s expected due date as February 12th. This number is found by subtracting three months from the first day of Rose’s last menstrual period and then adding seven days: May 5th – 3 months = February 5th; February 5th + 7 Days = February 12th.

History And Physical At The First Prenatal Visit

Prenatal care that is provided by a well-coordinated and cohesive team has major advantages. This method of care, when coinciding with evidence- based practice, results in a decrease in prenatal admissions, superior

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 prenatal education, and a higher level of overall patient care.5 For most patients, prenatal care begins with healthy care planning. Next is the physical assessment of both the pregnant mother and the fetus depending on gestational age. Combined, these initial practices are the cornerstone for a successful long-term health care relationship between the clinical team and the expectant mother and her family.

Once the initial prenatal history and physical are completed the clinician will be better able to plan the overall goal of care for the pregnant patient; and, the team as a whole will be able to coordinate care to protect the health and wellbeing of the mother. A thorough history and physical will ultimately help to create a successful plan of care for the delivery of a healthy infant.

Case Scenario:

A patient has just arrived for her initial physical examination of her new pregnancy. She received a positive pregnancy test 2 days prior and is 3 days late for her period. She asks about the following tests and procedures and wondering when they will be performed. Her health clinician would be correct in explaining which of the following assessments will likely not be performed at this time:

a) Calculation of . b) Evaluation of areas prone to edema, such as hands, face and ankles. c) Fetal Doppler assessment. d) Pelvic examination.

Body Mass Index

At the initial prenatal visit, the clinician will first take a weight and height measurement of the patient in order to determine the current body mass

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 index (BMI). Studies have shown that having a BMI considered above normal before the start of pregnancy correlates positively with pregnancy- related hypertension, edema and gestational .4 Understanding a woman’s current BMI will allow the clinician to know whether or not she is at a higher risk of developing these issues among many others.

Patients commonly ask their physician, , or nurse, how much weight they should gain during pregnancy. If a patient asks this question, the clinician should remind the patient that healthy BMIs tend to vary, and that recommendations are not always based on large scale or absolutely accurate studies. Nonetheless, the American College of Obstetricians and Gynecologists suggests the following criteria:4,5

• Women with BMIs below 18.5 are considered and should plan to gain between 28 and 40 pounds. • Women with BMIs that are thought to be in the normal range, between 18.5 and 24.9, should gain 25 to 35 pounds. • Women with BMIs above 24.9, a plan may be set to gain 15-20 pounds. • Obese women who have BMIs at 30 or greater may be recommended to not gain weight at all if possible or to limit their weight gain to between 11 and 20 pounds.

Weight is a sensitive subject for most patients and should be discussed openly, kindly, and with plenty of compassion for the expectant mother. Women with abnormal BMIs should be provided with information on dietary modifications and may need a referral to a registered dietician. When dealing with patients in this , the clinician should show patience while recommending dietary and lifestyle changes. Such changes may take time and lots of encouraging reminders from a supportive health team.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 Urinalysis

The prenatal patient will often be asked to provide a urine sample during the initial prenatal visit. This involves asking the patient to urinate into a provided specimen container prior to seeing her physician so that there will be results from an initial urine test before a scheduled physical exam.

The results being explored in the initial urinalysis include hCG indicating whether there is a true positive pregnancy test.4,5 While it is very rare for a woman to receive a false positive pregnancy test, it can occur. Clinicians should double check a prenatal patient’s at-home test results. While tests obtained by the patient at home checks for the presence of hCG, it does not check for the precise hCG levels. To get an accurate measurement of hCG levels, a blood test will need to be performed.

Chlamydia and gonorrhea also need to be tested, as these sexually transmitted infections are especially known for their negative effects on a developing fetus. Bacteria or blood cells may indicate a urinary or bladder infection that may not have been felt by the mother. Ketones, proteins or sugars may show a problem with the kidneys or undiagnosed diabetes. While the results of sexually transmitted infection tests may take a week or so to come back, it will be possible to see the presence of hCG, ketones, protein, blood cells or bacteria during this initial appointment.

Urine Test Protocol

Before having a patient offer a urine sample, she should be provided with a specimen cup, two prepackaged wipes, and education on how to privately obtain the proper “clean catch” urine sample. Education on how to accurately obtain this sample should be given in a private area before the prenatal patient enters the restroom alone.6,9

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 For women, the procedure starts by instructing them to wash their hands. The next step requires that the woman sit down on the toilet and use two fingers from their non-dominant hand to separate their labia. The clinician should provide the client with two cleansing wipes. Using the first wipe, she will use her dominant hand to clean the inner labial folds from front to back, then discarding it with the same hand. Once the patient has the second wipe, she must clean her urethra. Some patients may not know exactly where this is located and will require teaching. Explain that the urethra is the opening just above the vagina from where the urine exits. After cleaning this area they may discard the second wipe. While keeping the labial folds spread open, the patient should urinate a small amount into the toilet and then stop the flow. At this point, the patient should now urinate into the specimen cup until it is about half full. The process is finished once the sample is adequate and the patient may be advised to complete urination into the toilet.

Obtaining the Patient History

Either through completion of a form or by discussion with her health clinician, an expectant mother must have the opportunity to discuss her previous and present medical conditions, family history of diseases, past surgical and obstetrical history, personal and demographic history.7 The patient’s name, date of birth and current living address should be obtained. The clinician should also inquire into current medications including vitamins, over-the-counter herbal supplements, and prescriptions, which are reviewed in the section below.8,10,11,13

Herbal Supplements

Herbal supplements are an especially pressing matter to discuss with prenatal clients as they are often seen as “natural” and therefore not harmful. However, this is not always the case. St. John’s Wort is an herbal

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 medicine used by pregnant women suffering from depression who may be afraid to take pharmaceutical medications during their pregnancy. However, because the effects of this herbal supplement on a developing fetus are unknown, physicians believe that taking heavily studied selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine are less dangerous. Untreated depression can be harmful to both the mother and fetus, a subject touched upon later on.

Supplements to Avoid during Pregnancy

Aloe Vera taken orally should be noted and the patient informed that ingesting aloe vera might have uterine stimulation and abortifacient properties.

Gaurana is a supplement frequently added to energy drinks, which people drink in order to increase their energy. Pregnant women should be advised to avoid gaurana because it has been shown to lead to the birth of babies prematurely, of low , and possible birth defects.

Wild cherry extract is often used to stave off colds or coughs, but it is considered a teratogenic product; that is, it may disturb fetal development. A pregnant woman should never take wild cherry extract. Health staff should inform patients of the potential for increased birth defects in infants born to mothers who consume this supplement during pregnancy.

Catnip or Nepeta Cataria is commonly taken in adult humans for sleep induction. While acting as a stimulant in cats, catnip made into an extract, tea, or supplement is quite frequently believed to be safe because of its natural status. However, this herbal supplement is not recommended in pregnant women as it has the ability to stimulate uterine activity and induce

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 labor prematurely possibly leading to .

Echinacea, taken in an attempt to improve the immune system, has a weak oxytocic effect on the pregnant uterus.

Valerian root like catnip is an herbal supplement often purchased over-the- counter to combat insomnia. Health clinicians should advise prenatal patients to avoid this drug as it can stimulate uterine contractions.

Ginseng is a tempting herbal supplement for pregnant and lactating women experiencing “mommy brain” or frequent forgetfulness. Promoted as a memory and concentration promoter, ginseng is not considered a safe supplement to take during pregnancy or while breastfeeding. One study found that a woman who had consumed this supplement while breastfeeding gave birth to an infant with pubic hair, forehead hair, swollen testicles and red swollen nipples. Once the infant was switched to formula, the infant lost its pubic hair and the hair covering his forehead.

Uva Ursi has astringent and anti-inflammatory properties and is often used to treat or prevent urinary tract infections or cystitis. Many women see an increase in urinary tract infections during pregnancy. There is also an increase in pyelonephritis, a kidney infection, during pregnancy. Treatment of these conditions is very important. While prenatal patients may be reluctant to use pharmaceutical antibiotics in order to treat their infections, they should be discouraged from using uva ursi. In addition, this herbal supplement can cause liver damage, especially if taken for more than 5 days in a row. For this reason, uva ursi is a dangerous medication for pregnant women.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 Melatonin, another common herbal sleep aid, is not recommended during pregnancy, primarily due to the lack of studies surrounding the subject, although it may correlate positively with developmental disorders. What is known for certain about this herbal supplement is that it is an ovarian suppressant and decreases sexual libido, both of which can be troublesome for women planning to become pregnant.

Ginkgo Biloba is taken primarily to aid with memory function, depression, and even breast tenderness. Still, this herbal medication should be avoided during pregnancy and is especially discouraged around the end of pregnancy, near labor. Antiplatelet properties in gingko may prolong bleeding, increasing the potential for hemorrhage.

Past Obstetrical or Prenatal History

When discussing past obstetrical or prenatal history, the patient should be asked about each completed pregnancy, any pregnancy complications, or inherited diseases, and the sex and date of birth of any prior child or children. Also, the events of labor (vaginal, cesarean, prolonged, or precipitous labor) should be assessed. The mother’s psychosocial needs and whether she has experienced postpartum depression in the past should also be noted.

Past number of pregnancies should be included in the patient’s history taking. The number of pregnancies a woman has is described as follows: • Nulligravida - a woman who has never been pregnant • Primigravida - a woman who is pregnant for the first time or has been pregnant once before • Multigravida - refers to a woman who has been pregnant more than once

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 There are many other terminologies used in questions regarding a woman’s obstetrical history including full-term, preterm, miscarriage, elective abortion, and multiples.12 A full-term is an infant born after 39 weeks of gestation,12 while preterm births occur before 36 weeks gestation. A miscarriage, or spontaneous abortion, is the expulsion of the fetus or embryo from the uterus before 20 weeks gestation. The majority of miscarriages occur between 4 and 12 weeks gestation. Elective are the number of pregnancies purposefully terminated either chemically through the use of a prescribed pill or through a dilation and curettage procedure. Twins or multiples refer to a mother who has carried more than one fetus in utero at the same time. Prenatal patients with multiples will need specialized care and may be required to see high-risk obstetricians.

Patient Demographics and Risk of Domestic Violence

Marital status is a frequently asked question, but it is just as important to investigate the circumstances surrounding the mother and her support system. The American College of Obstetricians and Gynecologists (ACOG) recommends that all pregnant women be assessed for abuse during each prenatal visit because pregnancy increases a woman’s risk of falling victim to domestic violence.14 Women are at an even higher risk of falling victim to violence if they are under 20 years old. Pregnant women are at a two to four times greater risk if their pregnancy was unplanned.

Signs of abuse may be late initiation of prenatal care, unexplained or poorly explained injury or bruising, as well as depression. Careful observance for domestic violence in prenatal clients is especially important for a number of reasons. Homicide is the second most common injury-related cause of death in pregnant women (the first being car accidents) and pregnancy-related complications like bleeding and infants of low-birth weight are more common

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 in victims of abuse. Domestic violence victims are likely to engage in poor prenatal care and continue use of tobacco, alcohol and other drugs.

Religion is important to review with the patient, especially if she is a member of a religion that prohibits blood transfusions. The clinician should be familiar with religions that have medical treatment prohibitions. In such circumstances, it is important to ask the patient whether or not she is willing to get a blood transfusion should she hemorrhage during or after labor. Other social questions may include family support, financial standing and living situation.

Therapeutic Communication

Raising questions with a pregnant woman related to her social circumstances may seem difficult but are a necessary part of the patient history to develop a plan of care, including protecting the safety of both the mother and infant throughout the entire pregnancy and postpartum. During this time, health professionals should use therapeutic communication techniques to promote patient engagement and to understand a woman’s untold needs.

Therapeutic communication includes restating and seeking clarification, using broad openings, focusing, and making observations.

Restating and seeking clarification involves the health professional restating what the patient said and asking questions to be sure what she was trying to say was understood. This technique is useful to prevent miscommunication and to help the patient identify her true needs or feelings. The following examples include types of therapeutic communication the clinician may use.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 Example 1:

A patient expresses: “I’m sometimes afraid my husband doesn’t want this baby. I am happy to be pregnant, but whenever I bring it up, he seems to change the subject.”

The clinician should respond: “You’re scared that your husband is not as happy about the pregnancy as you are. Is that right?” This opens the opportunity for the patient to confirm: “Yes, I’m wondering if I’ll have to take care of this baby by myself. If he doesn’t care about the pregnancy now, how could he care about the baby?”

Example 2:

Using broad openings is a therapeutic technique performed by asking a general open-ended question to encourage the patient to discuss personal fears, concerns, or issues surrounding a pregnancy. The clinician may ask, “What would you like to ask me about today?”

If the patient responds: “Oh, hmmm, I guess I am a little worried about some discharge I’ve been having,” the clinician can ask to hear more about the discharge.

Example 3:

Focusing involves bringing a patient back to a subject touched upon earlier. The patient may say, “I try to eat healthy, but it can be hard because I don’t have a lot of money. I have other children so I want to make sure they eat first. But, I’m trying to exercise and I’ve stopped drinking alcohol and smoking cigarettes.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 The clinician responds positively to the cessation of alcohol and cigarettes by saying, “I’m glad to hear that you aren’t smoking or drinking alcohol. I’d like to go back a bit, however, and discuss what you said about feeding your children first. Could you tell me more about that?” The patient may respond, “Well, I just don’t have enough money to buy food to feed myself as much as I’d like. I have a feeling I’m not eating enough.”

Example 4:

Making observations involves stating what the clinician observes or perceives. It helps to prevent the clinician from making generalizations or assumptions. The clinician may say, “You are shaking, are you feeling nervous about something?”

The patient may respond by saying “No, not at all! I suddenly got hungry in the waiting room and am worried that I’m having a bit of a sugar crash!” The clinician can now make the patient feel less shaky as well as educate her: “Sometimes pregnancy alters your hunger patterns. Let me grab you some graham crackers and a juice for you!”

Acknowledging the Patient’s Feelings

Perhaps one of the most important communication techniques involves acknowledging the patient’s feelings. Sometimes complicated situations become simpler to both the patient and clinician once the patient feels empathy from the clinician.

Acknowledging the patient’s feelings involve listening, showing understanding, and acknowledging the patient’s frustration. For example, a prenatal client may state, “I’m sick of being treated like I’m so fragile. My husband is so critical and afraid that everything I do could hurt the baby.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 An appropriate response from the clinician might include, “That must be very difficult to feel judged for your actions.” Empathy and the acknowledgment of the patient’s distress help the patient feel relaxed and understood, and help promote a trusting relationship between the patient and her health clinician.

Using Silence

Using silence to keep a conversation flowing is an oft forgotten therapeutic communication technique. Frequently, in the midst of a stressful conversation, a member of the health team and a prenatal patient may neglect to sit back and just listen to what the other person is saying. Letting the patient communicate, then sitting back and listening attentively, may slow the patient down and give her time to think and refocus.

Anxiety is not uncommon in the pregnant woman and this anxiety often leads to distorted thinking. For example, a pregnant mother may be likely to say something along the lines of, “I can’t go through labor. I just can’t. I’m not strong enough.” To combat these distorted thoughts, the clinician may try expressing doubt at beliefs that are likely untrue. In the aforementioned statement, a clinician may respond with, “Do you really believe you can’t go through labor? What about the thousands of women who deliver babies each year? What about the women who’ve been giving birth since the dawn of time?” Labor especially can seem daunting to many women, especially those who have never experienced it. A reminder that it is a natural, human process can help ease the patient’s stress and help her correct or control her thoughts.

A clinician may learn what the expectant mother is feeling through these communication skills; such as that the mother is fearful about her support

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 system at home, that she is not receiving adequate nutrition or that she is experiencing changes in appetite. Learning to dig deeper and discover the unspoken needs of a woman during her pregnancy is a skill that takes time and practice to learn but ultimately improves the quality of a clinician’s practice. Therapeutic communication can also be used to identify possible psychiatric issues that may prevent the mother’s pregnancy from ending successfully. In fact, research suggests that anxiety, depression and chronic mental strain result in more cases of preterm birth, low birth weight and adverse fetal neurodevelopment.13

Before moving on to the physical assessment portion of the initial prenatal visit, the clinician should discuss other possible health hazards; for example, exposure to viral infections not transmitted sexually, such as toxoplasmosis. Toxoplasmosis is carried by cats, chickens and rodents, and is found in their feces. Pregnant women should be taught to avoid cleaning litter boxes. Potential dangers related to toxoplasmosis infection may cause malformations of the neonate’s head, still birth, or spontaneous abortion.

The clinician should discuss travel history with patient. Here, assessment is made for possible travel related illnesses, including serious diseases carried by mosquitos, such as the Zika virus or malaria. Zika virus is an emerging spread through the bites of female mosquitos. It may also be transmitted sexually. While the potential dangers of infection of the Zika virus are not known with absolute certainty, Brazil has seen a rise in microcephaly in neonates whose mothers were infected with the disorder. Other brain abnormalities are also noted including severe mental retardation.15 Malaria, another disease transmitted via mosquito bites, causes intrauterine fetal death, premature birth, low-birth weight infants, and an increase in neonatal death.16,17

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 To prevent infection of these diseases in pregnant women, the clinician should encourage the use of mosquito repellent containing 10% deet,16 the wearing of long sleeves, pants, and clothing with hoods (to help protect the back of the neck). Pregnant mothers should know the peak hours for mosquitos (dawn and dusk), and always pay strict attention to the Center for Disease Control’s travel warnings and advisories.

The Initial Physical Examination

The first physical assessment will occur much like the prenatal examinations that will follow. After the expectant mother’s weight is recorded, the clinician will take her vital signs. This includes blood pressure, heart rate and temperature. The clinician will also assess for respiratory rate, lung sounds and bowel activity. Any signs or symptoms leading to discomfort in the prenatal patient’s pregnancy will also be recorded and reevaluated on follow- up visits.

The health clinician will need to check for any swelling in the hands, feet, ankles, or face. This is performed in order to monitor symptoms of beginning high blood pressure or hypervolemia. Palpation of the woman’s abdomen should involve searching for the top of the fundus. In the early weeks of pregnancy, the uterine fundus may not be felt, or will be only mildly noticeable. Between 6 and 8 weeks, the uterus will be soft and the globular will be about the size of a plum. If the woman is between 10 and 12 weeks gestation, the clinician may search for fetal heart tones using a fetal doppler. Before this time, it is unlikely that they will be able to hear cardiac activity without the use of a transvaginal ultrasound. At the initial visit, fetal assessment is limited to the doppler, uterine measurements, and the status of maternal health in the first trimester.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 The clinician will also perform a pelvic examination at this time,18 checking the cervix for thickness, opening and length. If an opening or thinned cervix is found then there is cause for concern of a spontaneous abortion. Some women with what is known as cervical insufficiency,19 or recurrent especially in the second trimester, will undergo a procedure known as transvaginal cervical cerclage.20 This procedure is performed in varying manners, but ends the same − with a closed cervix. At 37 weeks gestation, the cerclage is removed allowing labor to proceed naturally.20

During the pelvic exam, the physician will use his/her fingers to manipulate around the uterus to measure its approximate size and position in relation to the pelvic bones. The physician may also check for sexually transmitted diseases with the use of a speculum to open the vagina and swabbing with a long cotton tip. The results to this test generally take about a week to return. At the end of the physical exam, the physician will likely order multiple tests. Testing for hCG levels will ensure clinicians that the findings are expected with the embryonic or fetal gestational age. Expected findings have been previously discussed in regards to the confirmation of pregnancy and the determination of estimated date of delivery.

The Rhesus type and antibody screen is designed to detect possible antibody related complications that could cause hemolytic disease of the newborn.21 Women who are found to be Rh(D) negative may need anti-D immunoglobulin therapy throughout their pregnancies. In traditional management, the identification of the fetal blood type must be determined. This is accomplished by first checking the blood type of the fetus’s biological father. If the father is Rh(D) negative like the mother, then the infant will also be Rh(D) negative. However, if the father is Rh(D) positive, further testing will be necessary. DNA testing of maternal circulating blood may

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 reveal the infant’s blood type; however, this test is known for false positive results and is not available at all clinics. When this is the case, an will be performed in order to confirm the severity of Rh(D) incompatibility. Because this procedure is invasive and does not come without the possibility of serious complications, it is only performed when blood tests indicate high maternal anti-D titers.

Hemoglobin and hematocrit and Mean Corpuscular Volume (MCV) testing will check for warning signs of hemoglobinopathy, anemia, and thalassemia that may affect a woman’s pregnancy and her newborn.22 A decrease in hemoglobin and hematocrit levels is expected during pregnancy. Normal hemoglobin in the first trimester should be 11.6 to 13.9 g/dL, hematocrit between 116 to 139 g/dL, and MCV levels of 85 to 97.8 fl.

Immunity to rubella23 is important because a rubella infection, also known as German Measles, can cause miscarriage, stillbirth, and congenital risks such as intrauterine growth restriction, hydrocephaly and other abnormalities. If not immune and exposed to infection, women may need to be counseled on early pregnancy termination to prevent stillbirth or catastrophic abnormalities in the fetus. While there is a vaccine available for this disease, it is a live-attenuated vaccine and thus should not be given during pregnancy. The delivery of this vaccine in pregnancy may result in the transmission of the virus to the fetus prenatally.

Testing for varicella immunity24 is necessary because, while uncommon, fetal effects of varicella-zoster infection can result in fetal scaring, microcephaly, mental retardation, optic nerve atrophy, limb abnormalities, and low birth weight. Congenital abnormalities result in a 30% in the child’s first four years of life. The best way to prevent this disorder is to receive the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 varicella vaccine before becoming pregnant. Much like the German Measles vaccine, pregnant women should not receive this vaccine while pregnant.

Screening for Human Immunodeficiency Virus (HIV) is done to give the mother an opportunity to decide whether or not to continue the pregnancy and to help physicians control delivery to reduce the risk of transmission to the fetus. If the mother tests positive for HIV, the clinician should help her adjust to an appropriate antiretroviral treatment plan. Her infant will then be tested 14 to 21 days post birth and again 1 to 2 months later. Infants whose mother received treatment during pregnancy are at a lower risk of contracting the disease during pregnancy and birth. HIV positive mothers should not be encouraged to breastfeed.

Syphilis Testing25 is appropriate because a mother systemically infected by the causative spirochete Treponem pallidum can cause perinatal death, low birth weight, premature birth, congenital anomalies as well as active congenital syphilis in the neonate. Other long-term sequelae include deafness and neurological retardation.

The American College of and Gynecologists recommends that all women be tested for Hepatitis B Antigen26 to prevent perinatal transmission. Hepatitis infection can cause cirrhosis and hepatocellular carcinoma. If a mother does test positive for hepatitis B while pregnant, her health team will need to weigh the pros and cons of treatment, primarily in the third trimester. The higher the viral load in the circulating blood, the more likely the mother will need pharmaceutical treatment of hepatitis B. Medications that suppress this viral load will lower the risk of mother to fetus transmission. As with HIV, mothers with hepatitis B should not be encouraged to breastfeed their neonates.26

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 The health clinician will also need to refer the prenatal woman to a dentist to care for her oral health. There is no evidence that dental health care such as tooth extraction, cavity filling and root canals should be delayed because of pregnancy.27 If anything, there is evidence endorsing the idea that dental care during pregnancy promotes better maternal and fetal health.27

Depending on the information collected during the patient’s history, some patients may require a referral to genetic specialists, psychiatrists, or a social assistance program. During the first visit, the clinician will get an idea of the prenatal patient’s estimated due date, calculate BMI, and provide counseling should her BMI be over or under the expected normal weight. The patient will also have labs performed, usually both blood and urine testing, to check for hCG levels, signs of underlying health problems, or infectious disease. Clinicians will also ask the mother about her health history including past obstetrical and gynecological care as well as personal illness.

Once the history-gathering portion of the appointment is completed, a general physical assessment followed by a pelvic exam will be done. At the end of this initial appointment, the clinician may refer the patient to a dentist to continue oral healthcare began before pregnancy, an ultrasound technician to verify fetal health and the estimated due date, and/or a genetic specialist, social worker, or other health clinician dependent upon the data collected. Between 8 and 10 weeks, an ultrasound is ordered to confirm the estimated date of delivery through measurement of fetal crown to rump length as well as verify the pelvic health and shape determined at the first clinical pelvic exam.

This section has discussed what a woman can expect during the history and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 physical portion of her first prenatal clinic appointment. Using the information gained through the history and physical, how would the clinician respond to the following case scenario?

A patient has just arrived for her initial physical examination of her new pregnancy. She received a positive pregnancy test two days ago and is 3 days late for her period. She asks about the following tests and procedures, wondering when they will be performed. As her primary clinician, you would be correct in explaining that which assessment will likely not be performed at this time: a) Calculation of body mass index. b) Evaluation of areas prone to edema, i.e., hands, face and ankles. c) Fetal Doppler assessment. d) Pelvic examination.

Choice C is correct. The clinician would explain that because she is likely between 4 and 5 weeks pregnant, a fetal doppler assessment would not be performed at this time. A fetal Doppler will likely be able to pick up fetal heart tones between 10 and 12 weeks gestation.

Identifying Existing Risks In The Pregnant Mother

Ideally, women would all start out their pregnancy completely healthy and without known health risks. Unfortunately, no life event is perfect and that includes pregnancy. For many women, existing health risks must be identified and managed from the start of their pregnancy to promote the best outcome for their unborn child, as well as their own health. The clinical team’s task is to take note of these existing health risks at the initial prenatal visit and to create a therapeutic plan to manage health concerns. All prenatal care is aimed at helping the mother have a healthy, full-term

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 pregnancy and an equally healthy newborn.

Preexisting Hypertension in Pregnancy

During all prenatal visits, a blood pressure will be taken in order to track how a woman is adapting to her pregnancy and to identify underlying hypertension. Tracking blood pressure is important during pregnancy since expectant mothers tend to have lower blood pressures during their first trimester. While it is always important to record vital signs throughout a woman’s pregnancy, the first few readings are the most important because these evaluations help clinicians establish a baseline blood pressure. This makes differentiating between preeclampsia and preexisting hypertension possible.29

Preeclampsia

Preeclampsia is a systemic condition where a woman develops high blood pressure later in her pregnancy, or after 20 weeks. It can cause excessive bleeding due to thrombocytopenia, or a low blood platelet count, visual or mental changes, edema, renal abnormalities, end-organ damage, and pulmonary congestion.

Preeclampsia sometimes results in seizures in the mother, a subsequent issue that increases the risk for prenatal injury as well as delayed oxygenation and potential risks to the developing fetus. To differentiate between preeclampsia and preexisting hypertension, clinicians need to look at the patient’s previous health history, such as whether she has had charted evidence of high blood pressure before. If the pregnant woman has had evidence of previously charted high blood pressure, it is likely that she is not experiencing preeclampsia as a result of her pregnancy.30

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 Preeclampsia develops after 20 weeks gestation and is characterized by the finding of large amounts of protein in the mother’s urine and a high blood pressure.30 The pregnant woman’s blood pressure is usually defined as being high when it reads over 140 systolic and 90 diastolic for two readings separated by a few hours. Normally, protein does not pass into the urine, but with enough force behind it, blood pushes proteins through the kidney’s filtering systems, allowing protein to spill into the urine and later be detected upon urinalysis. Long-term high blood pressure can lead to kidney damage, as well as problems with fetal oxygenation and health. For this reason, most women with preeclampsia will have a scheduled cesarean section before their due date.

Screening for preeclampsia with a urinalysis looks for [+1] result of protein in the urine. This result is indicative of about 30 to 100 mg/dL of protein in the urine. False positives of proteinuria do occur, especially in the presence of alkaline urine, or urine with a pH over 7.0, gross hematuria, or semen. False negative occurs most commonly in circumstances involving dehydration with hyponatremia, acidic urine, or urine with a low specific gravity.30

HELLP Syndrome

HELLP syndrome refers to Hemolysis of the red blood cells, Elevated Liver enzymes, and Low Platelets, all of which are grave consequences of long- term or suddenly worsened preeclampsia. In most cases, delivering the fetus as soon as possible prevents complications from the disorder. Unfortunately, this may in some cases mean preterm delivery of the infant. Until delivery occurs, the health clinician will treat the prenatal client with intravenous magnesium sulfate to prevent seizures and corticosteroid medications to increase fetal lung development should the infant need to be delivered early.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 Preterm delivery occurs before 36 weeks gestation. A premature infant is at an increased risk of SIDS, respiratory complications, and may require a stay in the neonatal intensive care unit. HELLP syndrome is managed in hospital and varies depending on the fetus’s estimated gestational age.

Best practice standards indicate that there is little risk of an adverse outcome if this condition is treated conservatively when the fetus is premature and less than 37 weeks estimated gestational age. In order to preserve maternal health, a cesarean section will likely be performed once a woman with HELLP syndrome shows signs of worsening condition and poor lab result findings. Delivery by cesarean section increases for infants whose mother has either type 1 or .

Vaginal birth is generally the preferred method of delivery as it comes with fewer complications to both the mother and neonate. However, as previously mentioned, in circumstances such as the development of HELLP syndrome, cesarean section may be preferable.31,32

Pharmaceutical Therapy in Hypertension

Pharmaceutical therapy is recommended for all patients with severe hypertension (systolic blood pressure equal to or greater than 160 mmHg and diastolic blood pressure at or above 110 mmHg). Combatting mild to moderately high blood pressure is done through careful monitoring of the mother’s vital signs while also watching for the addition of signs and symptoms of increased pressures like blurred vision, swelling and headache. If these appear alongside high blood pressure, drug therapy is likely needed. Medications considered in the treatment of prenatal high blood pressure include methyldopa, labetalol, nifedipine, and hydralazine.31,32

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 Methyldopa

Methyldopa works to treat high blood pressure by relaxing and dilating the blood vessels. In terms of safety, this medication’s effects on fetal development are not alarming and are thus considered safe. The downside to this medication is that some women feel it has a sedating effect while it only acts as a mild antihypertensive with a slow onset of action.

Labetalol

Labetalol is a beta-blocker that acts on both alpha and beta adrenergic receptors, creating a stronger antihypertensive impact than more traditional beta-blockers. The downside to this medication is that liver damage, premature labor, neonatal apnea, bradycardia, and fetal growth restriction have all been reported as possible side effects to this medication. Still, this drug continues to be employed as an effective blood pressure-lowering agent when use of less controversial drugs has not proved effective.

Nifedipine

Nifedipine is a calcium channel blocker used widely in pregnancy with little report of major adverse outcomes. Other calcium channel blockers may also work in the same fashion but have not been studied as often as nifedipine.

Hydralazine

Hydralazine can be given intravenously or orally and is used widely to treat preeclampsia. A small increase in adverse effects have been noted in the use of hydralazine over labetalol, but not a large enough of an increase to justify its discontinuation. Nursing considerations for the use of this medication includes watching closely for an unpredictable hypotensive response, reflex tachycardia and fluid retention.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 While bed rest is not advised for women with preexisting hypertension, there are no large studies on whether exercising or a change in activity level should be implemented in order to improve blood pressure. The clinician should make these decisions on a patient-by-patient basis, taking into account the severity of the mother’s hypertension and whether or not she is symptomatic.

A dietary reduction of salt should be part of the management of a pregnant patient who is found to have preexisting hypertension on her initial prenatal visit. Foods to avoid should be discussed including canned, processed, or prepackaged foods, as these tend to be sodium rich. The use of fresh herbs and spices to enhance flavor should be encouraged rather than adding extra salt to food at meal times. For women finding it difficult to reduce sodium intake, a referral to a registered dietician may be in order.

Acquired Heart Disease During Pregnancy

Valvular heart disease is most easily understood as a cardiac disease caused by lesions on the valves of the heart. These lesions are generally the result of congenital abnormalities or acquired diseases like rheumatic fever.33 Clinicians need to know about these valvular heart diseases, like mitral valve stenosis, aortic stenosis, or mitral regurgitation as soon as possible, so that they can create an appropriate plan of care. To assess for these risks, cardiac auscultation should be performed with a stethoscope near the mid to lower left sternal border to help identify an underlying mitral valve issue.

Women should be asked about their history of rheumatic fever, past heart problems, or current use of anticoagulant therapy to prevent blood clots. If identified, a patient with valvular heart disease will need to seek a referral to a cardiologist and will need to see this physician in conjunction with a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 primary OB/GYN physician throughout her pregnancy.

Cardiomyopathy is flawed ventricular function that can occur as a result of HIV infection, Parvovirus or Fifth disease, Enterovirus infection, Lyme disease, or Staphylococcus aureus infection of the blood. A woman with cardiomyopathy should have an echocardiogram after a confirmed pregnancy to evaluate the current state of her heart’s function. Symptoms of cardiomyopathy include pulmonary congestion heard when auscultating the lungs, edema, chronic fatigue, and jugular vein distention, depending on the respective type of cardiomyopathy. Any patient suspected of having cardiomyopathy should be referred to a cardiologist.34

Infective endocarditis usually occurs with intravenous drug use or an identified underlying condition. Infective endocarditis occurs when the endocardium becomes infected, usually by a fungus or streptococcal or staphylococcal bacterial colony. Studies are limited but both fetal and maternal death may occur in between 20-25% of cases. To assess for prenatal risk of infective endocarditis at the initial visit, therapeutic communication techniques should be used to inquire about possible intravenous drug use and previous cardiac conditions should be explored.35

Coronary artery disease can be identified easily in pregnant women who have had previous myocardial infarctions or percutaneous coronary interventions and coronary artery bypass surgery. There is no strict protocol for the management of in pregnant women but with the mean age of first-time mothers increasing as well as the incidence of mothers becoming pregnant at an advanced maternal age, it is important to ask women about their cardiac history during the initial visit.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 Arrhythmias are easily identified through cardiac auscultation and an accurate gathering of a patient’s medical history. Management of cardiac arrhythmias in pregnant women can be a difficult balance as medications intended to treat these maladies are considered to be category C medications, thus prenatal harm to the fetus cannot be ruled out. Still the risk to the mother’s cardiac health may require continuation of antiarrhythmic drugs taken before conception.36,37

Patients with arrhythmias should be evaluated for a past history of blood clots or management of their disease with anticoagulant medications. Warfarin will likely be withheld during pregnancy and instead prenatal patients will be given once or twice a day injections of low molecular weight heparin. Because of the increase in risk of hemorrhage during labor, most women should discontinue anticoagulation therapy in the few weeks preceding delivery. As with the other cardiac complications, prenatal patients with suspected arrhythmias should have an echocardiogram performed and be referred to a cardiologist.38

Heart transplant recipients can be identified through physical examination of the sternum where a large scar will indicate heart surgery. It will be likely that the heart transplant recipient will have had preconception counseling and discussed the ethical considerations to both mother and fetal health before pregnancy. This discussion should again occur at the first prenatal appointment after an investigation into the mother’s current health and ability to tolerate pregnancy safely.39,40

Diabetes During Pregnancy

Both type 1 and type 2 diabetes pose similar risks to pregnancy. Type 1 diabetes involves the inability of the pancreas to produce insulin, while type

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 2 diabetes involves resistance to insulin developed in a person’s body over an extended period of time. Diabetic women should be identified through gathering a thorough patient history. Women with diabetes should be counseled about their condition.

To identify type 2 diabetes, the clinician should look for risk factors.41 Women who are over the age of 45 are considered at risk for preexisting type 2 diabetes and are also considered to be of advanced maternal age (any pregnant woman over 35 years old). This categorization places the mother at a greater risk for preeclampsia, of delivering an infant who is large for gestational age, a higher incidence of cesarean section and, worst of all, women over the age of 35 are more likely to deliver a stillborn infant. Newly pregnant women who are or obese are more likely to develop type 2 diabetes before 20 weeks gestation and/or have preexisting insulin resistance before pregnancy. Overweight and obese women should be referred to a dietician who specializes in promoting healthy eating habits and the prevention or management of gestational diabetes.

According to the National Institute of Health, physical inactivity strongly correlates with the development of type 2 diabetes before pregnancy. Clinicians working with women planning on becoming pregnant should encourage a healthy lifestyle that incorporates extra physical activity and exercise whenever possible. The clinician can suggest simple ways to increase cardio-based exercise such as parking further away from a store’s entrance, using electronic fitness trackers to keep an eye on the number of steps per day, or joining a stress relieving exercise class at a local gym such as dancing or swimming.

Racial origin seems to play an important role in the development of type 2

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 diabetes during and before pregnancy. Whether this is due to , cultural variations in , or an environmental cause, the teaching is the same; some races must be more cognizant of certain dietary factors than others. African Americans, Hispanics, Polynesians, and women of Native American heritage are more likely than other races to develop insulin resistance.

Type 2 diabetes involves excess glucose circulating the blood stream and this extra sugar crosses the . Once in the fetal bloodstream, this glucose stimulates insulin production, which encourages rapid growth. Previous delivery of a large infant, or one over 9 pounds is an existing risk factor for type 2 diabetes. While previously mentioned, it should be restated that there is a genetic component to diabetes that cannot be denied.41 There exists a strong correlation between having a woman with a family history of type 2 diabetes, especially a parent or sibling, and the woman developing the disease at some point during her lifetime.

Type 2 diabetes may be identified in the clinic setting if the patient presents with glucose in the urine as well as a random blood glucose level of 200 mg/dL. These findings will need to be verified with an in-lab blood draw of fasting blood glucose and A1c levels.42 The guidelines to obtain a fasting glucose level is further discussed below.42,43

Fasting blood glucose levels should be taken after the pregnant mother has fasted for 12 hours. Most healthcare providers will ask that the mother go to bed, and not eat or drink sugary fluids until the blood draw scheduled for the following morning. A1c levels measure long-term blood glucose control. If drawing strictly for A1c levels, patients will not need to fast before this procedure. However, since fasting blood glucose and A1c are often tested at

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38 the same time in order to confirm gestational diabetes or type 2 diabetes in prenatal clients, the prescribing physician may require fasting. Since A1c measures long-term blood sugar levels, fasting will not alter the results of this specific test. To confirm type 2 diabetes after receiving a positive urine glucose test, clinicians should expect to find a fasting blood glucose of 126 mg/dL or higher and A1c level of 6.5 or higher as well.

Whether she is suffering from type 1 or type 2 diabetes, the diabetic mother is at an increased risk for the development of many serious pregnancy complications. As mentioned previously, prenatal hypertension is an existing condition where the mother has preexisting high blood pressure or high blood pressure that develops in the first 20 weeks of her pregnancy. Dietary changes will certainly be in order. This includes a lowered salt intake and a focus on water and healthy fiber rich vegetables. A registered dietician will best be able to determine how to help the patient coordinate achievable dietary modification goals for comorbid diabetes and hypertension. At subsequent prenatal visits, chart information sent over from the registered dietician should be reviewed and the potential successes and barriers to effective dietary and lifestyle changes discussed with the patient.

Diabetic mothers are at a higher risk for miscarriage and perinatal death. Miscarriage generally occurs between 4 and 12 weeks, but all fetal deaths occurring before 20 weeks are considered a miscarriage. Perinatal death occurs after 20 weeks gestation. The emotional state of the mother and her family should be monitored and discussed post-miscarriage or perinatal death. A referral to a social worker or other therapist may be in order.

Hemorrhage secondary to diabetes occurs during labor and birth primarily because of high blood pressure. Clinicians will need to make preparations for

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 management of hemorrhage, should it occur. Knowing the pregnant woman’s blood type and having an intravenous line started will expedite blood replacement if necessary.

Pregnant mothers with diabetes are at risk for delivering an infant both large and small for gestational age. This variation in infant size is based on two different pathological systems. Babies are born large for gestational age because of insulin production created by their pancreases in response to the excess amount of sugar crossing over from the placenta and into their blood stream. Insulin stimulates cells to grow and expand, creating larger for gestational age infants. Diabetic mothers who give birth to infants who are small for gestational age may also be experiencing high blood pressure, which causes low levels of hypoxemia to the infant, restricting fetal growth.

The infant of a diabetic mother is at risk for prematurity, persistent hyperinsulinemic hypoglycemia of infancy, respiratory distress, congenital anomalies, hypocalcemia, hyperbilirubinemia, and cardiomyopathy. Infants may be born prematurely, or before 36 weeks gestation, because of a lack of intrauterine growth or development, high blood pressure, severe preeclampsia, or HELLP syndrome. Pre-term delivery may occur spontaneously or through induction by the healthcare provider in order to prevent maternal or infant injury.

While in utero, fetuses of a diabetic mother are receiving excess glucose through the umbilical cord and thus producing plenty of insulin to keep their own blood sugar levels in check. Once separated from the mother’s placenta, the neonate may continue to produce insulin. Known as persistent hyperinsulinemic hypoglycemia of infancy, this hypoglycemia is very dangerous and will need strict monitoring and management. Signs and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 symptoms of hypoglycemia in the neonate of a diabetic mother include lethargy with hypotonia, tremors, pallor, tachycardia, cyanosis, apnea, seizures, and congestive heart failure.41

Respiratory distress is recognized in infants who are apneic, gasping to catch their breath while maintaining low oxygen saturation levels, and appear cyanotic. Respiratory distress is more likely to occur when the diabetic mother delivers prematurely, leaving the infant with little to no surfactant in the pulmonary alveoli and limiting the ability to exchange oxygen and carbon dioxide. Infants in respiratory distress will need admittance to the neonatal intensive care unit and given a manufactured surfactant via an endotracheal tube alongside the provision of oxygen via a continuous positive airway pressure machine.44

Maternal diabetes is coupled with depleted fetal iron stores. This complication is related to the mother’s blood sugar control prenatally rather than the mother’s iron stores.45

Congenital anomalies occur more frequently in the infant of a diabetic mother with an increase in that frequency for mothers who are insulin dependent. The exact pathophysiology behind the teratogenicity of maternal diabetes is still unknown.46

Low calcium in circulation, or hypocalcemia, occurs in the infant of the diabetic mother because of lowered production of the parathyroid hormone.47

Hyperbilirubinemia occurs when red blood cells are broken down rapidly, leaving the infant jaundiced or yellow in coloration. It can also cause

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41 lethargy and impaired feeding in the neonate. In infants of the diabetic mother, hyperbilirubinemia likely occurs as a result of polycythemia or ineffective red blood cell production.48

Cardiomyopathy in the neonate is generally caused because of thickening of the heart walls, hypertrophy, and from excess insulin production. In most circumstances, this condition resolves itself within a few months after birth.34

Clinicians who detect diabetes in the newly pregnant mother should make certain that she is referred to a dietician who specializes in controlling diabetes. As noted in many of the previous complications, well controlled blood glucose levels during pregnancy is a defining factor in the avoidance of dangerous diabetic-complications in the neonate. Pregnant mothers with diabetes should be told to check their blood glucose between 2 and 4 times daily depending on the severity of their illness.

Depression During Pregnancy

Depression is an extremely common condition occurring in about 18% of Americans.49 Screening for depression is very important at the first prenatal appointment. Treating depression in the pregnant mother is considered a necessary part of prenatal care because untreated depression in pregnancy may contribute to non-adherence to prenatal care recommendations, substance use (specifically alcohol and tobacco), fetal growth restriction, and preterm birth.49 The methods of action behind some of these adverse outcomes are unknown, but the correlation between them and lacking prenatal mental health treatment is undeniable.

Screening for depression should begin by looking for risk factors, life stress

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 42 including emotional and socioeconomic strain, and lack of social support within the prenatal client’s friends and family. Domestic violence increases in frequency while a woman is pregnant. It is not difficult to understand how this stressor could lead to chronic unipolar depression.50

Warning signs of depression include51 dysphoria, or a general feeling of discomfort and agitation, paired with a loss of interest in activities that are normally enjoyable. Women may also report changes in appetite, sleeping habits, or focus and concentration. Depression may affect a woman’s neurological function, which can slow the woman’s movements and her ability to make rapid judgments. Suicidal ideation is a serious indicator of depression and one of the riskiest outcomes of depression.

The use of selective serotonin reuptake inhibitors (SSRIs) to treat depression has been studied in pregnant women with little to no risk found of spontaneous abortion, hypertension, or perinatal death. Clinicians must weigh the pros and cons of using antidepressants to treat depressed pregnant mothers. Some common SSRIs given during pregnancy include fluoxetine, citalopram, and sertraline.52

Many pharmaceutical agents have been proven safe through long-term studies. Decisions on whether or not to treat depression pharmaceutically will need to be made carefully by the clinician and the prenatal client.

Genetic Conditions Affecting Pregnancy

Screening for genetic conditions aids the clinician in developing an appropriate plan of care beginning at the initial prenatal appointment.53 These tests may be performed at the first prenatal exam or during the second trimester, depending on the risks found when gathering the patient’s

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 43 history. These tests address the risk that an infant will be born with an inherited or genetic disorder. Screening tests are comprised of blood tests that measure the level of certain substances in the mother’s blood usually paired with an ultrasound exam. These assessments determine the risk that a baby will have Down syndrome or other trisomies, as well as neural tube defects or inherited diseases that may lead to death or mental abnormalities.

Carrier tests are a type of screening test that can show if a person carries a gene for an inherited disorder. Carrier testing often is recommended for people with a family history of a genetic disorder or people from certain races or ethnicities. Cystic fibrosis carrier screening is offered to all women of reproductive age because it is one of the most common genetic disorders.

Cystic fibrosis is an illness that causes abnormal mucous and sweat formation. It affects the pancreas and thus how food is broken down after meals. In turn, digestion is also altered causing constipation, foul-smelling stool, , and failure to gain weight. Cystic fibrosis also causes excessively thick mucus to build up in the lungs often causing fatigue, wheezing, and a wet cough. If the infant with cystic fibrosis lives past childhood, they face an average life expectancy of 37 years.54 Since cystic fibrosis is an inherited disorder known as an autosomal recessive disorder it only appears in an infant when both parents have the mutated gene without necessarily showing signs of the disease.55

Testing for the gene that carries Huntington’s disease is done when there is a history of this disorder in the family. Huntington’s disease is a major degenerative brain disorder. It is incurable and the patient with Huntington’s disease will eventually be unable to think clearly, will have personality

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 44 changes, and difficulty controlling movements. Being a dominant disorder, if a pregnant patient has this gene, there is a 50% chance her child will develop this devastating neuromuscular disorder. How would the clinician best address concern of cystic fibrosis in the following scenario? What information about this genetic condition should the health clinician share with the patient?

Case Scenario:

Kelly is a 31-year-old woman pregnant for her second time. Her first child is 4-years-old, was born vaginally and is considered to be a healthy preschooler. During her initial prenatal visit, Kelly explains that she’s worried that her newborn child will be born with cystic fibrosis because her sister’s daughter has it. What information about this genetic condition should the healthcare provider share with Kelly?

In the above scenario, the clinician would best address the patient’s concerns by discussing the genetics behind cystic fibrosis. In order for a child to develop cystic fibrosis, both parents must have the gene for this disorder. In the case of Kelly’s sister, both she and the father of their child had to have been carriers of the gene. Since Kelly has had a healthy child with her spouse, it is unlikely that they are both carriers of the gene. Still, the clinician may recommend that both she and her unborn child’s father be tested genetically to see if they are carriers of the gene. This will calm their fears or help them prepare in the event that they are both indeed carriers.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 45 Health Conditions And Pregnancy Outcomes

There are well-researched health risks that can occur during pregnancy. Medical researchers have suggested that identifying health risks early in the pregnancy during the initial prenatal visits improve the health outcomes of the expectant mother and baby. Some women are at greater risk of a pregnancy complication than others, depending on their socioeconomic conditions and depending on a pregnant woman’s history. This section discusses areas of major concern that can place a woman and her unborn baby at risk of poor pregnancy outcomes.

Sexually Transmitted Diseases

Complications associated with various sexually transmitted diseases are discussed here. HIV, syphilis, hepatitis B, chlamydia, and gonorrhea are common sexually transmitted infections that may impact maternal, fetal, and neonatal health.

Pregnant women are at an increased risk of carrying a sexually transmitted disease if they are or have been sex workers, have had a new sexual partner in the last 60 days, multiple sex partners or concurrent sexual partners, history of previous sexually transmitted diseases, use illicit drugs, are of low socioeconomic status, or are unmarried.56 The clinician should use compassionate and therapeutic communication when initially screening prenatal clients for sexually transmitted diseases and when explaining possible risk factors.

Alcohol and Tobacco Use

Several screening tools, such as CAGE, TWEAK, or AUDIT-C, exist for assessing a newly pregnant woman’s alcohol use. Whichever screening tool

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 46 the clinician uses, it is also important to approach the subject of alcohol use sensitively and to formulate a plan to stop drinking that the patient and fetus can tolerate.58 The patient needs to be educated that alcohol use is very harmful to developing fetuses and should be stopped completely during pregnancy. Fetal development is at high risk during the first trimester.57

According to the American College of Obstetrics and Gynecology, all women should be screened for tobacco use at their initial prenatal appointment.59 Women should be asked if they have ever smoked cigarettes, the last time they smoked cigarettes, and if they currently smoke. Many women are afraid to report their tobacco use and they should be informed of the risks associated with smoking while pregnant whether they report they are smokers or not. Risks to the mother include poor weight gain and preeclampsia.60 The fetus is put at major risk; an expectant mother that smokes is more likely to have a fetus with congenital malformations and acquired growth restriction, as well as be born prematurely, suffer from sudden infant death syndrome (SIDS), or display long-term behavioral problems in childhood.

Quitting smoking often causes withdrawal symptoms whether the person is pregnant or not. Pregnant women may find these symptoms extra uncomfortable, especially if they are already experiencing discomfort related to their pregnancy. Common nicotine withdrawal symptoms include tremors, irritability, headaches, fatigue, stomach discomfort, and restlessness. To deal with symptoms, patients should be encouraged to take walks, rest when tired, and to drink plenty of water.60

Inadequate Nutrition

Poor nutrition or malnutrition in pregnancy is a serious problem, which needs

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 47 to be screened for and addressed at the initial prenatal appointment and followed up should another assessment be indicated. Malnutrition can occur because the patient has an eating disorder, lacks the funds to purchase enough food for herself, or eats meals that contain little to no nutritional value.

The clinician should evaluate the prenatal patient’s eating habits by discussing how many meals she eats in a day. If she states that she is eating less than two meals a day, the clinician should consider this to be a warning sign. The patient should be asked what her typical day is like in terms of meal preparation and nutritional intake. The clinician should evaluate how many servings of vegetables, fruits and protein sources the patient typically eats as well as food or beverages with added sugar.61

The patient’s health history should be discussed prior to the time she becomes pregnant. The clinician should review the patient’s health history extensively, and enquire: Does she have diabetes? Has she ever had gestational diabetes? Has she ever suffered from an eating disorder such as bulimia or anorexia? The clinician should engage with the patient compassionately to learn about her social situation. Does she have enough money to purchase the healthy foods that she needs? Is she drinking alcohol or smoking cigarettes?

Pregnant patients should be educated on the risks of poor nutrition, including delivering a baby of low birth weight and pre-term, or having a newborn with congenital malformations. Women who are considered high risk in terms of poor nutrition should be referred to a registered dietician and/or a social worker to help them get on a healthy and full diet to support their pregnancy.61

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 48 Unhealthy Weight Issues

A healthy pregnancy is partially achieved by beginning the pregnancy at a healthy weight and a healthy physical activity level. Being either overweight or underweight can cause problems during gestation and lead to an increased risk of complications prenatally as well as after delivery.

Underweight women with a BMI below 18.5 should be advised to meet with a registered dietician and attempt to gain 28 to 40 pounds over the course of their 9-month-long pregnancy. Women starting their pregnancies with BMIs considered underweight are at increased risk of miscarriage, delivery before 37 weeks gestation, and delivering a neonate who is of low weight for its gestational age. Their infant is subsequently at greater risk for infant mortality and childhood later in life.62

Women who are overweight or obese are advised to gain less weight, usually under twenty pounds. Just as with women who are underweight, overweight women should seek education from a registered dietician in order to learn how to avoid excessive weight gain during pregnancy and associated risks. Overweight or obese pregnant women are at an increased risk for pregnancy induced hypertension, preeclampsia, and, worst of all, HELLP syndrome.

Prenatal Morbidity and Mortality of Overweight Mothers

Cardiomyopathy, or the inability of the heart to properly pump blood throughout the body, is seen more commonly in pregnant women with high body mass index. The development of gestational diabetes occurs most frequently in women with high body mass index.

Infants born from mothers who have high body mass index are more likely to be born prematurely. Perinatal mortality, or death in the womb, is a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 49 greater risk among fetuses of overweight mothers.62 These infants also have an increased occurrence of SIDS. While it seems contradictory, women who are overweight are likely to deliver infants both small for gestational age and large for gestational age infants. This may have to do with a hyper-insulin response or existing high blood pressure.

A clinician must know how to differentiate between preexisting hypertension and the development of preeclampsia in pregnancy. Mothers who develop high blood pressure before 20 weeks gestation have likely been suffering from preexisting hypertension, while pregnant women who develop hypertension after 20 weeks gestation are likely dealing with preeclampsia.

In cases of severe preexisting hypertension, there are prescriptive options to manage high blood pressure such as using labetalol, calcium channel blockers, methyldopa and hydralazine. A clinician must also know how to identify cardiac issues that could have an impact on pregnancy and when the case should be referred to a cardiologist.

Adapting To Pregnancy: Physical, Emotional And Social Considerations

For first time mothers and experienced mothers alike, to describe the adaptation to pregnancy as being a challenging process is an understatement. From the moment of conception, a woman’s body begins a tumultuous transition, yet the emotional and social implications of pregnancy also affect how clinicians should care for the pregnant woman. Changes in friendships and social standings are not unlikely to occur in the life of a new mother, and suggestions and referrals will need to be made to manage the challenges appropriately.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 50 The husband and child or children of a newly pregnant woman should also have their needs and their emotional resilience addressed. The clinician should evaluate whether the expectant mother has a strong family support system; strong family support is associated with decreased risk of developing post-partum depression.63 During the first prenatal visit, careful questioning, mindfulness teaching, and empathetic care provided by a unified health team effectively promote physical, emotional and social wellness in the entire family.64

The First Trimester

During the first trimester the hormone relaxin begins flooding the body, causing the mother’s uterine ligaments to loosen and prepare for the inevitable housing of a full-term sized infant. Human chorionic gonadotropin influences breast development and causes growth and changes to the uterus that help maintain the pregnancy. At the implantation and thus hatching of the blastocyst in the uterine lining, the cells of the uterine lining are stimulated with a fresh supply of glucose, which creates the potential for syncytiotrophoblast epithelia development. This releases steroids and other hormones used to regulate fetal and maternal systems. Insulin-like growth factors begin acting to influence embryonic and fetal growth.65

There are many hormones involved in the transformation of a woman’s body during pregnancy. Many are responsible for the uncomfortable parts of pregnancy such as nausea and fatigue. Other physical changes in the pregnant mother include full, growing breasts from increased blood to the organs, in order to prepare them for milk production expected to occur months down the road. Side effects from the hormone relaxin that are common during the first trimester include heartburn, constipation, nausea, and a generally slowed digestion.66

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 51 Pregnancy glow is a real occurrence and the result of an increase in the production of melanin. This increase creates a literal change in a woman’s skin color, bronzing and darkening it to a glowing shade, even in her first trimester. An increase in hair growth, on the scalp, body, and even occasionally the face may be expected during pregnancy. Enhanced nail growth is also common and usually a welcome change for pregnant women.67

Blood cell mass and plasma volume increases as soon as 4 weeks gestation and begins contributing to edema and nausea in pregnancy.68 The respiratory center of the brain is stimulated early on in pregnancy, a result of an increase in the hormone progesterone. Nasal discomfort also presents itself as a result of glandular hyperactivity and subsequent congestion.69 This process occurs similarly in the breasts.

Due to a change in several endocrine systems, the pregnant woman’s renal glomerular filtration rate is increased and thus urinary frequency occurs. The bladder fills more quickly and, because of the release of the hormone relaxin, a loose pelvic floor increases urinary urgency as well.70 Slowed digestion as a result of relaxin causes heartburn; and, constipation and nausea are common in the early stages of pregnancy. Later on, an increase in physical pressure from the fetus on the abdominal cavity increases the gastrointestinal discomfort as well as gastric reflux.71

Women often notice joint looseness and sometimes an increased flexibility during pregnancy, occasionally putting them at risk for musculoskeletal injury and lower back pain.72

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 52 Emotional and Social Changes in Early Pregnancy

Emotional and social changes are highly connected to pregnancy. Changes in body image, comfort levels, and lifestyles all contribute to mood changes. Hormones, such as progesterone and estrogen, are to blame for mood swings in pregnant women, and women are able to tolerate these hormones in varying degrees. Fatigue also contributes to emotional challenges as well as a woman’s ability to participate in normal social activities. This decrease in ability to tolerate activity and engage with peers often leads to the woman’s feelings of isolation and a decrease in her overall support system.

To combat fatigue, pregnant women should be advised to drink plenty of water and eat nourishing, energizing foods throughout the day. Nuts, avocados, and foods with healthy fats and complex B vitamins elevate mood and provide sustaining energy throughout the day. The prenatal patient should be encouraged to incorporate these foods into each of their small meals. Also, at least eight hours of sleep daily, with naps during the day when possible, should be recommended.

Lifestyle changes can hugely impact a woman’s stress level and her ability to cope with pregnancy. For example, the family may need to buy a larger vehicle to accommodate another child, or be the first member among a circle of friends to have a child. Whatever the lifestyle changes, the clinician should discuss these with the patient and her family, as well as consider the prenatal client’s support system for common stressors such as lack of friends with children, a non-supportive workplace, or limited finances to maintain an accustomed lifestyle.

Prenatal clinicians should keep plenty of pamphlets, flyers and other resources on hand to direct women to pregnancy support groups, infant

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 53 playgroups and social workers, when applicable. Women should be reminded to practice self-care and to continue to do things they enjoy. This may mean managing feeling tired to be able to continue social interactions with friends by, for example, planning to return home from outings earlier than usual. While habits may change, it is good to continue doing the activities of enjoyment unrelated to pregnancy.

At the initial visit, the newly pregnant woman and her prenatal health team should work together to brainstorm and come up with solutions for actual or potential emotional, financial, or support stressors.73 As her body changes, there will likely be accompanying feelings of nervousness surrounding the impact of pregnancy on the body and her associated body image. The clinician should identify body image issues that may create anxiety in the newly pregnant woman and provide recommendations based on her needs for support. Some women may need therapeutic counseling or nutritional counseling from a registered dietician. Other women may only need reassurance from the health team that their weight gain will be normal and that they can have a happy and healthy pregnancy.73

The Family’s Adaptation to Pregnancy

Family members of a newly pregnant woman will go through changes as well. These changes may not be physical in nature but they are still drastic. Whether first-time partners learning how to cope with their partner’s new emotional and physical state or children trying to understand what the addition of another sibling will mean for their lives, the family of the pregnant woman is an important consideration in prenatal care. Health clinicians should take careful histories of their patient’s support system and listen carefully for signs and symptoms of abuse or poor support systems. Such issues, previously discussed, should be managed appropriately.74

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 54 Newly expectant fathers or partners will likely feel some anxiety and frustration. They may worry about their ability to care for their new child or to provide financially for changes in lifestyle, which come with prenatal care, birth costs and infancy. Another common anxiety is the health of their partner or unborn child. They may also feel frustration over the inability to relieve all symptoms of discomfort in their pregnant partner. All fathers or partners will adapt to the pregnancy of their partner differently. Health staff can help them best by listening to their needs carefully, suggesting support groups, therapy, or open communication between the mother and partner.

Any concerns of an expectant mother’s children should also be addressed at the initial prenatal appointment. Children may take the news of their mother’s pregnancy differently, contingent upon their age, maturity level and individual personality. While most children are adaptable and understanding, some children may experience uncomfortable feelings such as they may fear change and the unpredictable, may worry about their mother’s health, and may be nervous about their care after the baby is born. The clinician must be prepared to evaluate the levels of adaptation in the patient’s children, discuss with her any concerns for her children and suggest mindful, compassionate ways to discuss the pregnancy with her children, and refer the family to a therapist or social worker if necessary.74

There is no protocol set in place for When it comes to telling children discussing pregnancy and, in some about a woman’s pregnancy or cases, pregnancy loss with children. It pregnancy loss, it is the is the health clinician’s job to support healthcare team’s job to support the family’s decisions regarding these the family’s choices regarding the choice of how to discuss the choices and to provide information news with their children. where applicable. Health staff should

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 55 never push their clients into making a decision they aren’t comfortable with. It’s important for families to come to conclusions about their family dynamics on their own with the full support of their health team.

Medication Safety And Pregnancy

Many pregnant women will inquire about medication safety at their initial prenatal check-up. Common medications taken outside of pregnancy, such as ibuprofen or aspirin, may not be recommended or safe to take while pregnant. Firstly, all prenatal clients should be taught to report any medications they are taking to their health clinician. Pregnant clients should also ask their prescribers about the safety of any medication they would like to take whether it is prescribed or purchased over the counter.

From 1979 until 2015, the Food and Drug Administration (FDA) created pregnancy risk categories for medication labeling, in order to simply identify the risks behind specific medications. While this method is being phased out in favor of a more specific standard package, the category labeling method is still taught and found in medication packaging today. These categories include those outlined below.75

Pregnancy Category A

Pregnancy Category A medications have been studied to show that no fetal abnormalities were reported in human studies. Medications commonly considered pregnancy Category A include levothyroxine and most multivitamins. Medications in this category are considered the safest and have only remote possibilities of risk to the fetus.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 56 Pregnancy Category B Medications

Pregnancy Category B medications are taken when the benefit of the medication outweighs any purported risks. There are usually no good studies in humans; however, animal studies show little to no fetal abnormalities. Pregnancy Category B medications may also include pharmaceuticals that have shown some issues in animals but when used by pregnant women have not led to any malformations. Most insulins used to treat diabetes and amoxicillin used to combat bacterial infections are in this category. As with all medications taken while pregnant, the benefit of these Category B medications should outweigh the risk of harm to the fetus.

Pregnancy Category C Medications

Pregnancy Category C medications are always first looked at in terms of a cost-benefit analysis. This is because little studies will have been performed to show the risks involved with taking medications in this category. Category C medications generally have no good studies done in pregnant humans, while animal studies are either lacking or showing some potential for fetal harm. Low-dose fluconazole is used to treat vaginal yeast infections and falls into this category. Most SSRIs such as Zoloft of Celexa fall into this category.

While risks are not well known or controlled when taking these medications, the possible problems associated with untreated depression may outweigh the risks. For example, women with untreated depression are less likely to practice self-care, adhere to prenatal care, and refrain from harmful substances like tobacco and alcohol. Infants born to mothers with untreated depression are likely to suffer from low birth weight.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 57 Pregnancy Category D Medications

Pregnancy Category D medications have shown that infants exposed to this drug have had issues directly correlated to exposure. Still, in some circumstances, use of this medication may outweigh the risks, especially in cases where the mother is being treated for seizures with phenytoin or with some chemotherapeutic agents for cancer. Other Category D medications include Paxil and Lithium.

Pregnancy Category X Medications

Pregnancy Category X medications are considered the most teratogenic of medications. There are no situations in which the taking of these medications outweigh the risks to the fetus. Studies on both humans and animals show that pregnancy Category X medications result in direct fetal abnormalities, usually severe enough to cause death in utero or after birth. Such medications include Accutane, which is used to treat severe cystic acne, and warfarin used to prevent deep vein thrombosis or stroke.

New Model for Medication Classification

The new model for medication classification uses a more inclusive labeling system with information related to pregnancy, lactation, and to men and women of reproductive age. The FDA made this switch in order to help women and men of reproductive age fully understand the implications of their medications without having to understand a letter-style grading system.75 Instead, the sections are broken up into easy to read, detailed explanations of potential risks.

The Pregnancy labeling comprises both labor and delivery along with the nine months of gestation. A risk summary, clinical considerations, like a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 58 cost-benefit analysis, and available data are reviewed. There is also a section focused on lactation and that provides information on the safety of using the drug while breastfeeding, the amount of the drug that passes into the breast milk, and the potential effect on the infant receiving the medication through the mother’s breast milk.76

In particular, the new FDA labeling system covers females and males of reproductive potential. The information provided discusses the need for pregnancy testing, contraceptive concerns, and data on how fertility may be affected by the medication. Health clinicians should be familiar with both systems of drug labeling in order to prepare prenatal clients on both systems of medication labeling. It deserves restating that, when in doubt, pregnant mothers should be advised to contact their clinician’s office when they are unsure about the safety of a medication.

Diet And Exercise During Pregnancy

It is vital that the clinician discusses and exercise with the pregnant patient. Many patients will fear that they will gain weight and they need to be reassured that this is normal and necessary for the health of the mother and the developing fetus.

The normal caloric needs of the non-pregnant woman should first be discussed. There are a variety of variables to consider, such as age, height, physical activity, and if the woman needs to gain, lose, or maintain weight. Most women need approximately 1,600 calories to 2,400 calories per day. The higher range of calories needed on a daily basis are higher for active women and the lower number of calories are necessary for sedentary women. As basil metabolism slows in aging women, they need fewer calories.77 As previously discussed, if a patient has a normal BMI, she should

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 59 gain between 25 and 25 pounds during a healthy pregnancy. Underweight women and women with a multiple pregnancy will need to gain between 35 and 45 pounds, while overweight women only need to gain 10 to 25 pounds. Calories should be obtained through nutrient-rich foods that are low in fat and sugar and high in protein.78

Babies need plenty of calcium to promote healthy growth, especially for bone growth. Iron is necessary for a healthy blood supply for the fetus and to prevent anemia in the mother. Folic acid is also important in a healthy diet to lower the risk of spina bifida in the baby, which is an underdeveloped closing of the spinal column. The baby is also at risk for anencephaly (major part of the brain, skull and scalp have not developed). A clinician should instruct a mother that a diet rich in iron would also prevent a number of other birth defects.

If a woman is not taking enough minerals or vitamins, the developing fetus will use up most of the necessary nutrients, leaving less for her to use. Between 9 and 11 daily servings of pasta, cereal, rice, and bread are needed to give a mother the that will be needed to provide energy for the baby’s growth and for the woman’s health. Fortified foods, such as cereal, and whole-grains provide the necessary folic acid and iron.

The clinician should talk to the mother about the necessity of regular consumption of fruits and vegetables. She should eat 3-4 servings of fruit to give her vitamins A and C, fiber, and potassium. Foods like citrus fruits, melons, and berries are high in vitamin C. Fresh fruits and fruit juices are ideal; canned or frozen fruits are not as good sources of nutrition. Between 4 and 5 servings of vegetables everyday are optimal, providing vitamins A and C, folic acid, magnesium, and iron. Again, the mother should aim to gain

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 60 these from fresh vegetables. She ought to eat at least two servings from leafy greens.

Milk, cheese, and eggs are excellent sources of calcium, phosphorous, and magnesium. Clinicians should teach the mother to eat 3 servings a day. If the mother needs to limit caloric intake, she should choose nonfat options. Iron, protein, and zinc and vitamin B are found largely in nuts, poultry, meat, eggs, and dry beans. The pregnant patient should be assured that fats and oils are important. This is especially relevant to note if a mother is hesitant to gain weight. Fats aid in the fetus’ brain development and are necessary for growth.

The clinician needs to ask about special diets. Women who are vegetarians, vegans, lactose-free, or eat a gluten-free diet need to make sure to plan their meals carefully so that they consume nutrients that are necessary for a healthy pregnancy and their baby’s development.

The clinician should discuss with the patient the importance of taking appropriate amounts of fluids and vitamin supplements. Women should avoid caffeine and sugar and should consult their clinician regarding how much of these drinks are safe to consume. Most mothers need to take prenatal vitamins for folic acid, iron, and other vitamins and minerals. Vitamins can be prescription or purchased over-the-counter. Some health insurance plans do not cover prenatal vitamins, so options should be discussed with the patient.

It is not completely understood why some women experience strong cravings for certain foods. These usually pass after the first trimester. Women can satisfy these cravings as long as they talk about them with their

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 61 clinician and are eating healthy foods. Sometimes pregnant women crave things like laundry detergent, dirt, clay, and ice chips; the term for this condition is pica. At the first office visit, the patient should be advised to inform the clinician if she experiences pica. This may be a result of low iron and she may be at a higher risk for anemia. The woman should be assured this condition is common and nothing to be embarrassed about. If she expresses these urges, discuss strategies to avoid non-foods.

Pregnant women need approximately 1,800 calories during the first trimester. In the first trimester, the expectant mother should consume about 2,200 calories, and while in the second trimester she will need about 2,200. In the final three months of pregnancy, she should eat around 2,400 calories. The patient should be asked about eating disorders prior to pregnancy. She should be monitored throughout pregnancy and the clinician should discuss the benefit of regular therapy to prevent eating disorders. Even if the patient does not have a history of disordered eating, she is still at risk for an unhealthy body image as she gains weight.

Meal planning should be discussed and the patient offered suggestions to help the mother consistently eat healthily. For breakfast she could eat 2-3 servings of carbohydrates, a serving of protein, fat, and as many servings of vegetables as she would like. For example, an omelet with her choice of protein and plenty of leafy greens, and a side of toast with peanut butter, with a cup of fresh fruit and yogurt. If she is a vegan or vegetarian, healthy alternatives should be raised such as tofu, protein- packed grains, and fermented soybeans instead of meat. Plants, nuts, and beans are also filled with protein.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 62 An example of a healthy lunch could be a tuna or egg salad sandwich on whole grain bread for protein and carbohydrates, an apple, yogurt (fortified almond or soy for vegans), and a generous serving of carrots and other raw vegetables of her choice. At dinner the mother should include 3-4 servings of carbohydrates as well as protein, vegetables and healthy fats. This might look like an entrée of whole grain pasta with a tomato-based sauce, chicken or tofu, sautéed vegetables, and a small amount of olive oil with a side of brown rice. Cheesy broccoli and cauliflower make a great side dish, as does a generous portion of a salad with lots of leafy greens. A serving of fruit provides a sweet, healthy dessert.

It is also important for the pregnant mother to eat snacks throughout the day to control blood glucose, maintain energy, and curb nausea. Suggest snacks that include healthy carbohydrates, protein, fat, and vegetables. Slices of peppers, a handful of nuts or soybeans, pumpkin seeds, yogurt, cottage cheese, premade leafy green salad, string cheese, and strips of bell peppers are all excellent examples of healthy snacks.

Food-Borne Infections

The top five food-borne pathogens that will put the mother and baby at risk are Campylobacter, E. coli, Listeria, Salmonella, and Toxoplasma gondii.79 These are briefly reviewed below.

Campylobacter infections can cause miscarriages and premature birth in the first trimester. They do not usually harm the mother or child but can induce severe diarrhea in the mother.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 63 Dehydration is likely to result if the mother is infected with E. coli. Rarely, more serious complications arise and the mother should take great care to prevent E. coli infection.

Pregnant women are 10 times more likely than the general population to become infected with Listeria. Listeria puts the fetus in danger because it can cause listeriosis, which increases the chance of miscarriages, premature labor, low-birth-weight infants, or even infant death. Even if the mother shows no sign of infection, the fetus may become infected. This can cause problems for the baby later in life, such as blindness, intellectual disability, seizures, paralysis, and impairments of the brain, heart, or kidney failure.

Salmonella, like E. coli, can lead to serious dehydration in the mother. It may also cause bacteremia (bacteria in the blood) which may cause meningitis. If Salmonella passes to the baby during pregnancy, he or she may develop meningitis, diarrhea, and fever after birth.

Taxoplasma gondii is a food-borne pathogen that can be passed on to the fetus even though the mother shows no signs of infection. If this happens, babies can develop hearing loss, blindness, and intellectual disability. The baby may also experience brain or eye problems after birth.

Safe and Unsafe Foods While Pregnant

The clinician should educate the pregnant patient about safe and unsafe foods while pregnant, including caffeine.81,82 These are reviewed here.

Unpasteurized juices and cider often contain E. coli and should be avoided at all times. Instead, the pregnant woman should choose pasteurized juice or

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 64 boil unpasteurized drinks before consumption. Raw sprouts may also contain E. coli.

Unpasteurized milk and soft cheeses can be detrimental for both the mother and fetus because they may cause E. coli, Campylobacter, Listeria, Salmonella, or even Tuberculosis. Cheeses like Brie, Feta, Camembert, Queso Fresco, and Roquefort are often made from unpasteurized milk and are not part of a healthy diet during pregnancy.

Undercooked poultry and meat are very dangerous because they have potential to infect the mother and fetus with E. coli, Salmonella, Campylobacter, and Toxoplasma gondii.

Clinicians should advise pregnant patients to avoid uncooked eggs, as they are often a major cause of Salmonella. Foods such as tiramisu, cookie batter, and eggs benedict contain uncooked eggs.

Listeria is found in raw fish such as sushi, sashimi, ceviche, and raw oysters, clams, and scallops. Women should avoid these foods while pregnant. Refrigerated seafood with labels like Lox, Nova-style, jerky, kippered, or smoked also pose a threat for Listeria. Patients may consume seafood if it is canned, shelf-stable, or if it has been cooked at 165 degrees or higher prior to eating.

Seafood contains many necessary nutrients for pregnant woman because of its protein, omega-3 fatty acids, minerals, and low levels of saturated fat. Mothers should not avoid fish and seafood altogether. Crab, salmon, cod, light tuna, shrimp, pollock, pangasius, clams, crab, and tilapia generally have low levels of mercury and should be encouraged as part of a nutrient-

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 65 rich diet. While pregnant women can consume albacore tuna and tuna steaks, they should limit their tuna intake to 6 ounces a week. This is because some testing has shown that tuna can have high mercury levels that could lead to poor fetal development.

Studies have linked caffeine consumption to miscarriage. Clinicians often limit patients to 200 grams of caffeine daily. Patients should be reminded to discuss safe caffeine consumption with their clinician during the course of their pregnancy. Most people know that caffeine is present in tea, coffee, and soda. Patients should also be informed that caffeine is found in foods like chocolate and instant oatmeal, and that labels should be checked on foods to avoid hidden caffeine content.

Exercise for a Healthy Pregnancy

Exercise plays a vital role in a healthy pregnancy. It promotes healthy weight gain, restful sleep, and overall health of the mother by strengthening the heart and blood vessels. Regular exercise can also ease or prevent back pain, constipation, varicose veins, and mood swings. It reduces the risk for preeclampsia, gestational diabetes, and the need for a caesarian section.81 Exercise also prepares the mother for labor and delivery.

The mother should aim for at least 2.5 hours of exercise per week. The amount of time spent exercising can be divided into ten-minute intervals throughout the day. Exercise should be moderate intensity aerobic, which means that she is sweating and raising her heart rate, but she is not so out of breath that she cannot talk. Brisk walking, stationary bicycling, modified yoga and Pilates, and gentle water aerobics are all superb ways to exercise while pregnant.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 66 “Hot” yoga, skydiving, and scuba diving should be avoided. Patients should also avoid contact sports and sports that pose a risk for being hit in the abdomen, such as volleyball, water polo, and tennis. Workouts that increase the likelihood of falling like gymnastics, climbing trees, and horseback riding are prohibited.

The mother’s breathing, balance, and joints will be affected throughout pregnancy. Her body’s hormones cause her joints to become more relaxed so that they’re mobile and she has less risk for injury. Because of this, she should avoid high impact exercises like jumping rope. As her belly and the fetus grow, her sense of balance will shift. Because of this, she is more likely to fall or lose her balance. She needs to adapt exercise for each trimester.

Throughout her pregnancy, the mother will need more and more oxygen. Due to pressure from the uterus on the diaphragm, she will likely need to reduce the intensity of workouts as her pregnancy progresses. If the patient was sedentary prior to pregnancy, she needs to be counseled to develop a plan to help her gradually ease into a healthy workout plan. Women should be monitored who are very active to ensure they are gaining enough weight. They may need to increase calorie intake for healthy weight gain.

The patient should be advised to stop exercising immediately and to notify her obstetrician’s office if she experiences headache, chest pain, shortness of breath prior to exercising, feeling faint or dizzy, swelling of the calves, or painful contractions of the uterus. Blood or fluid coming out from the vagina also signals the need to stop and contact her obstetrician.

Establishing an exercise workout routine lays the groundwork for exercising after the baby is born, which is vital for losing extra weight and preventing

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 67 the risk of deep vein thrombosis (DVT), which is the formation of a blood clot in a leg vein or vein in another part of the body. Exercise also helps with postpartum depression and reduces the stress that inevitably comes from caring for an infant.

Clinicians must be aware of contraindications of exercise during pregnancy. They include prior or current complications, certain types of heart and lung disease, preterm ruptured membranes, sickle cell anemia, being pregnant with multiples, and preeclampsia. The pregnant woman also may not exercise if she has cervical insufficiency or cerclage. Cervical insufficiency occurs when the cervix is unable to retain a pregnancy in the second trimester. Cerclage, or the procedure in which a physician stitches together the cervical opening to prevent preterm birth, also contraindicates exercise.

Kegel exercises strengthen the pelvic floor and are just as important as aerobic exercises. The pelvic floor muscles hold up the rectum, vagina, and urethra. Strengthening these muscles is extraordinarily beneficial because they help the mother to push during delivery. Regular Kegel exercises help the mother to recover sooner after birth, lowers her risk for hemorrhoids, and helps prevent leaks from the bladder.

To perform a Kegel exercise, the woman will tighten her pelvic floor muscles (the same ones used to control urination) for a count of three, and then relax for a count of three. She should do the Kegel exercises 10 to 15 repetitions three times a day. It is easiest to perform Kegel exercises in the supine position. As her pelvic floor strengthens, she can do them when standing or sitting down. If the patient is unsure as to whether or not she is performing them correctly, she can squeeze the muscles during urination as a test. If she stops her flow of urine, she is doing them correctly. She may

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 68 also put a finger into her vagina and clench her muscles; pressure on her finger indicates that she is doing the exercises correctly. Pelvic muscles are the same ones used to stop the flow of urine. Still, it can be hard to find the right muscles to squeeze. The woman can be sure she is exercising the right muscles if when squeezing them she stops urinating. Putting a finger into the vagina and squeezing to feel pressure around the finger helps to know the pelvic floor muscles are found. In the process of performing Kegel exercises, the woman should be advised to avoid tightening the stomach, legs, or other muscles.

Exercise will need to change as the patient transitions from one trimester to the next. In the first trimester, she needs to be especially carefully to avoid overheating. Before starting an exercise regimen, the patient must have it cleared with her obstetrician, and should not alter exercises before medical consultation.

Plan Of Care And Follow-up Prenatal Visits

The initial prenatal visit is important because of its role in developing a plan of care for the continued care of the pregnant woman and her follow up visits. The results from lab tests, the initial ultrasound, and answers to the pregnant woman’s history will help shape the subsequent visits and the goal of delivering a baby at term and keeping the mother as healthy as possible during and after the pregnancy. It is common practice for health clinicians to see a pregnant woman monthly, and until her last month when weekly visits are generally scheduled.82 Studies have shown little risk in reducing the number of prenatal visits, however, mothers tend to prefer the standard schedule with more appointments.83

The purpose of follow-up prenatal visits is to ensure that the pregnancy is

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 69 progressing as expected, manage maternal discomfort or unspoken issues, such as inadvertent malnutrition or lack of a strong support system, and to plan for a successful delivery. All prenatal visits will include obtaining a weight for assessment, and taking vital signs such as blood pressure and heart rate.

3rd Month of Pregnancy

The third month of pregnancy is often a prenatal client’s second in-office visit. At this time, the clinical staff will likely have the results of the first visit urinalysis, laboratory blood draws, and 8 to 10-week ultrasound. The clinician is then able to confirm findings, whether the findings are expected or unexpected, with the 12-week clinic visit.

It is standard to assess a mother’s vital signs during each visit. Health clinicians should address any symptoms of discomfort related to the pregnancy that the mother may be experiencing such as nausea, constipation, or headaches. For general pregnancy pain and discomfort, the prenatal client may ask what medications are safe for her to take. Non- steroidal anti-inflammatory drugs (NSAIDS)84 are often taken over the counter for headaches, joint pain and fevers. Prenatal patients should be encouraged to rest and drink plenty of water to manage such issues. If not relieved, patients may take acetaminophen and should be asked to avoid ibuprofen and aspirin.

For nausea and vomiting, plenty of fluids and small servings of salty foods should be encouraged. This prevents dehydration and dizziness, one of the main triggers of nausea.85 The patient should be asked regarding other possible triggers of nausea including strong smelling foods, rich fatty foods, or strong perfumes. If these are present, the clinician should discuss with

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 70 the mother ways to avoid these triggers.

There are many natural treatment options. Acupuncture and pressure point wristbands, commonly sold as treatment for seasickness in many pharmacies, are frequently tested as interventions for cases of nausea and vomiting. While not necessarily dangerous to the prenatal client, these interventions have not been shown to be any more effective than placebos in randomized trials. Nzu is a traditional African remedy for morning sickness and may be called calabar stone, argile, la craie, calabash clay, or mabele.86 The FDA has advised against this traditional medicine over worries of possible lead and arsenic poisoning. Ginger has been used for thousands of years in order to treat nausea. Given in the form of teas, chews, flavored popsicles, sodas, and even straight ginger itself, ginger is effective in reducing episodes of nausea, but may not reduce vomiting.87

If nausea and vomiting persist despite less invasive measures, a healthcare provider may prescribe a pharmaceutical intervention to prevent weight loss and/or treat hyperemesis gravidarum. Doxylamine, an antihistamine, works by blocking receptors in the stomach, reducing nausea and vomiting. It has been shown to have a protective effect against malformations when fetuses were exposed to antihistamines during the first trimester.88

Dopamine antagonists are considered second line therapy because of a small study showing a small increase in birth defects after use. Large studies have not revealed such findings. Serotonin antagonists like ondansetron are another option. This medication can prolong the QT interval, especially in patients with cardiac arrhythmias. Prolonged Q-T intervals can cause fainting, cardiac arrest, or even sudden death. These patients will need constant monitoring until their hyperemesis gravidarum has been relieved.89

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 71 Studies on infant outcomes are mixed, mostly showing that while an increase of physical abnormalities is not as common, there is an increase in cardiac dysfunction. Health clinicians will need to carefully weigh the pros and cons of prescribing this medication to their prenatal clients.90

Clinicians will need to perform fetal assessments. Fetal heart tones will be checked at the 3rd month prenatal visit. Healthcare providers will expect the heart rate to be around 160 beats per minute. The clinician will palpate the uterus, expecting to find that it is beginning to grow above the pelvis. About the size of a grapefruit, the uterine fundus should be firm and easily palpable.91

4th Month of Pregnancy

During the 4th month of pregnancy the clinician should discuss morning sickness and whether or not it has improved since onset. If not, investigate methods related to the management of morning sickness that may have been started in the 3rd month. It may be that the mother needs medical intervention especially if she is losing weight or unable to perform her activities of daily living (ADL).

By the 4th month, the fetal weight will begin impacting the mother’s circulation when she lays supine or on her back. Encourage women in their 4th month of gestation to lie on their left side when possible. This will prevent any decrease in blood flow to the mother and subsequently the fetus.

During the second trimester of pregnancy, women are more likely to develop vaginal yeast infections. This irritating condition can cause itching, soreness, and general discomfort of the vagina. Caused by a disturbance in vaginal pH,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 72 a possible result of increased estrogen levels, vaginal yeast infections do not pose a risk to the fetus but can be very frustrating, painful and difficult to treat during pregnancy.92 Women experiencing symptoms of a vaginal yeast infection should be encouraged to see their physician in order to rule out other infections and to monitor treatment.

Vaginal yeast infections are treated either through administration of a topical ointment to the vagina or by taking an oral medication. Topical options include clotrimazole, miconazole, and terconazole. These medications are delivered through a vaginal suppository, cream filled tubes inserted into the vagina much like a tampon, and by external application to the labia. These medications are prescribed or instructed to be given anywhere from one to seven days and are often purchased over the counter.93 These creams are generally effective; however, some women experience discomfort and burning during and after application.

For some women, these topical creams are ineffective or cause more discomfort than they solve. In these circumstances, clinicians may consider prescribing an oral treatment of fluconazole for one day. In severe cases, fluconazole may be given twice over three days.

The evidence regarding the safety of fluconazole has gone through many stages as researchers completed studies on this subject. More recent findings suggest that fluconazole given in larger doses such as 400 to 800 mg per day increases the risk of birth defects in the neonate, especially when exposure to this medication occurred during the first trimester. This does not seem to be the case for low dose treatments of fluconazole 150 mg. High doses of fluconazole are considered to be Pregnancy Category D medications while a low-dose treatment for vaginal yeast infection remains

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 73 at Pregnancy Category C.94

To prevent yeast infections, patients should refrain from eating sugary, simple heavy foods. Instead, prenatal women should be educated on the benefits of probiotic foods such as kim chee and yogurt. Prenatal clients with frequent recurring yeast infections may also want to avoid tight fitting clothing.

Urinary tract infections are also more common during pregnancy. Incidence of this infection increases because of a variety of factors, primarily the extra weight of the uterus. As the uterus grows in size, drainage of urine from the bladder may be impacted leading to the retention of urine and sometimes urinary reflux. This failure to expel urine causes bacteria to pool in the bladder and along the urinary tract, causing urinary discomfort, increased urinary frequency, abdominal pain, and often hematuria, or bloody urine. Because urinary tract infections can lead to a more severe infection of the kidneys known as pyelonephritis, treatment of urinary tract infections should not be avoided. Kidney infections may lead to low birth weight, preterm labor, or miscarriage.95

To treat urinary tract infections, clinicians will prescribe a three to seven-day course of antibiotics to the mother. Prescribers will need to evaluate the patient for possible allergies to specific antibiotics and choose the medication based on level of pregnancy safety.

While UTIs are sometimes unavoidable, there are some tips health staff can teach their pregnant clients to try and prevent these infections. This includes ensuring they completely empty their bladder each time they urinate, drink plenty of water, avoid foods that irritate the urinary tract such as chocolates,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 74 sugars, and caffeine, and be sure to urinate before and after sexual intercourse. Prenatal clients should be taught to avoid wearing tight fitting pants and pantyhose and make sure they are wearing loose fitting clothing with cotton underwear.

For the fetal assessments, the clinician will once again palpate the pregnant woman’s abdomen, expecting the uterus to be the size of a grapefruit. This will place the about midway between the pubic symphysis and the mother’s navel.96 The healthcare professional will measure the prenatal client’s fundus by feeling for the top of her uterus and then measuring from this spot to the symphysis pubis.

The “multiple marker screening,” also known as the quad screening, is a test that evaluates the mother’s blood for fetal abnormalities. This test checks for serum markers which may indicate neural tube defects and aneuploidies, or disorders where there is an abnormal number of chromosomes in the cells. Some alterations looked for in the multiple marker screening include Down syndrome, spina bifida, and trisomy.

Down syndrome is a genetic disorder caused by a defect in the number of copies of the 21st chromosome. Typically, those with Down syndrome have slowed mental development, a delay in physical development, and sometimes problems with cardiovascular function and bone malformation.97 The average adult with Down syndrome has an IQ equivalent to an eight- year-old. Small or missing nasal bones found on an ultrasound are an indication of the possible presence of this disorder.98

Spina bifida is a neural tube defect where the spinal tube fails to close properly resulting in malformation of the vertebral column and brain.99

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 75 Those affected by spina bifida will be paralyzed completely and unable to control their bowels and bladder in 97% of cases. Hydrocephaly, often referred to as “water on the brain,” is present in many with spina bifida and is the leading cause of death in those affected by the condition.

Trisomy 18 and 13, known as Edwards’s syndrome and Patau syndrome, occur when there are extra chromosomes on the 18th or 13th chromosome. Most infants with this condition will live to term, but will have shorter than average life expectancies.

If any markers return positive, the health clinician will likely order an ultrasound or amniocentesis to verify the findings. Clinicians may also suggest genetic counseling. At this point, depending on the results, a woman may choose to terminate her pregnancy, especially if the results indicate that her baby will not survive birth or will not live very long after delivery. The fetal doppler will again be used to detect fetal heart tones. A normal fetal heart rate at 4 months gestation is between 120 and 160 beats per minute.100

5th Month of Pregnancy

During the 5th month appointment, the clinician will continue to monitor the mother’s weight gain and will keep a close eye on the mother’s blood pressure. Providers will continue to assess for edema and signs of high blood pressure. After 20 weeks gestation the development of high blood pressure is considered to be a sign of poor adaptation to the pregnancy and may lead to preeclampsia.

The clinician will also check for proteins, sugars and infections in the urine to ensure that gestational diabetes is not developing and that there is no

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 76 ongoing urinary tract infection in the mother. At the end of the 5th month prenatal visit, the clinician will schedule an ultrasound to assess placental placement and the health of her developing fetus. The clinician may also suggest that the pregnant woman schedule a prenatal labor preparation class with her labor coach or partner.

Between the 5th and 6th month of pregnancy, a pregnant mother will likely feel her fetus begin kicking, known as “.” Sometimes this feels like bubbles in her uterus, easily mistaken for gas, while other times it feels like electric shocks. As the baby grows, these kicks will become more forceful and sometimes uncomfortable.

The health clinician will schedule the pregnant mother for a fetal ultrasound to be performed by an ultrasound technician. The results will be read by a radiologist101 and delivered back to the healthcare provider. The ultrasound technician will take readings of the present in the uterus, the size, shape and location of the placenta. Specific facts considered in regards to the placenta besides simple measurements include blood flow to the maternal fetal organ.

The ultrasound will ensure that the umbilical cord connecting the fetus to the placenta has two umbilical arteries and one vein. The technicians will evaluate the flow through this vascular system to ensure that the fetus is receiving proper nutrition and oxygenation.102 Ultrasound technicians will also measure the fetus from crown to rump, and analyze its organs as well as their function. They will also monitor blood flow to and from the fetus, verifying the function of the fetal arterial and venous system. Identifying the sex of the fetus is also done at this appointment, if the parents would like this service to be provided. Fetal heart rate should be about 140 beats per

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 77 minute at 5 months pregnancy.

6th Month of Pregnancy

Discussions between the health clinician and the pregnant mother should focus on potential problems such as possible hemorrhoid formation and its management, weight gain, back pain and therapeutic interventions, as well as any other reports of physical discomfort. The clinician will assess for signs of developing high blood pressure and symptoms of preeclampsia such as swelling of ankles or feet, accompanied by headaches, visual changes, or abdominal pain.

Glucose testing is generally performed at 6 months’ gestation to determine whether or not a mother has or is at risk of developing gestational diabetes.103 Testing can be performed in a two-step approach or one-step approach. The two-step approach is the commonly used methodology for identifying pregnant women with gestational diabetes in the United States. The first step is a glucose challenge test in which the mother will drink anywhere from 50-grams to 75-grams of sweetened liquid after fasting all morning. Positive patients will continue on to the second step, a 100-gram, three-hour oral glucose tolerance test (GTT), which is the diagnostic test for gestational diabetes. The one-step approach forgoes the screening test and shortens diagnostic testing by performing only a 75-gram, 2-hour oral GTT.

Relationship and social considerations should be taken into account during this check-up, especially in regards to the pregnant mother’s sexual health. Because the fetal weight and maternal weight gain is generally noticeably significant by the 6th month of gestation, pregnant women and their partners often complain of sexual dysfunction or discomfort at this point. Some women may be reluctant to discuss such issues, however, clinicians should

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 78 present the topic to their patients in private, and in a matter of fact, easy going manner.

Many women are concerned that as their pregnancy progresses, sex with their partner will cause preterm labor. Women with low-risk, single pregnancies should be informed that large studies have shown no increase in premature birth in mothers who engage in sexual activity while pregnant.104 Pregnant women at risk for pre-term labor after sexual intercourse are women carrying more than one fetus, women with cervical incompetency, or women with pelvic inflammatory disease (PID).

While many women report an increase in their sexual desire during pregnancy, others may experience an aversion to intercourse. For women feeling uninterested by sexual intercourse or sexual touch, mothers and partners should both be reminded that such occurrences are not abnormal and usually pass with time. Couples should be encouraged to spend time together participating in non-sexual activities that foster intimacy, such as cooking a new meal, going on special dates, or taking a weekend trip somewhere relaxing.

Pregnant mothers who report instances of sexual discomfort may benefit from counseling. Some women experience vaginal dryness during pregnancy. Discuss the use of a water-based personal lubricant to relieve dryness and to help resolve the discomfort or soreness experienced during sex.

Sexual positions are another area of frequent grief for pregnant women and their partners. As the mother’s abdomen and weight increases, sexual positions that were once easy or comfortable may become difficult or

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 79 awkward. Mothers interested in learning about alternative positions during intercourse should be given information on specific strategies to obtain sexual satisfaction. One study performed in Taiwan found that women with the highest sexual satisfaction practiced positions where the pregnant mother was on top, where the couple was face to face, or positions where the abdomen was supported by pillows or their partner’s body.105

Fundal height of the fetus will be measured at every appointment. At 6 months’ gestation the fundal height should be at the navel.125 The development of fetal growth restriction is often looked for at this point of gestation. Suspicion of fetal growth restriction begins when fundal height measurement is not in agreement with the expected size for gestational age. The most used standard is a fundal height in centimeters, which is three centimeters or greater below the gestational age in weeks.106

Fetal assessment during the 6th month of pregnancy begins again by palpation. The clinician will feel for the fetus through the abdominal wall to check its position. The clinician will ask the mother about fetal movement and encourage her to stay alert for a decrease or cessation of fetal movements throughout the second and third trimester. This practice is known as monitoring “fetal kick counts.”

Health clinicians should encourage their prenatal clients who are concerned about fetal activity to lie down on their left side and focus on counting their fetus’s kicks and movement. If the prenatal client counts 10 fetal movements in 2 hours, they can rest easily knowing that their fetus has met the threshold for reassured fetal movement.107 Once again, the clinician will need to check for fetal heart tones and rate. At 6 months gestation, the fetus should have an average of 140 beats per minute; however, it can vary

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 80 between 110 and 160 beats per minute.

7th Month of Pregnancy

The extra weight from amniotic fluid and the fetus itself may be causing the mother musculoskeletal discomfort as well as fatigue. Mothers should be encouraged to rest frequently and to take acetaminophen as needed to resolve the pain. For women experiencing shortness of breath, remind them to lie on their left side and take frequent breaks during exercise or work.108 If the lab test has not yet been performed, the mother will be tested for Rh negativity at this time and given Rho(D) immunoglobulin injection at this time.109

During the 7th month of gestation, the fetal fundal height should be about 4 fingers above the navel and can vary between patients.110 More importantly, the clinician will ensure that the fundal height is growing continuously with each prenatal checkup. Fetal heart rate will be evaluated to ensure that it has continued to stay between 110 and 160 beats per minutes.

The clinician will also palpate the maternal abdomen to assess fetal position within the abdomen. Around 30 weeks gestation, the baby should be head down. If not, the clinician will need to keep a close watch on the positioning of the infant to prepare for a breech delivery or . Vaginal breech deliveries are on the decline. The practice of delivering a baby breech is a learned skill that many believe needs to be kept in practice. However, risks and worries over liabilities contribute to the decline of this skill.111,112

8th Month of Pregnancy

At 8 months gestation, many health clinicians will begin seeing their patients biweekly. Continued assessment of swelling and symptoms that may indicate

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 81 pregnancy-induced hypertension will be conducted.

The Group B Streptococcus exam113 is performed around 8 months gestation, and involves screening for the colonization of the aforementioned bacteria. An active infection of group B strep in the mother puts the newborn at risk for the development of a blood infection (sepsis), bacterial pneumonia and meningitis. In neonates, all three conditions are life threatening. Mothers who test positive for group B strep will be treated before birth with intravenous antibiotics during labor and/or oral antibiotics prior to labor.114 During this time, the clinician will also check for cervical dilation. It will not be expected to find any dilation, especially in a first-time mother.

Continued monitoring of the fetal heart rate occurs through the 8th month of gestation. By this point in fetal development, the heart rate should be plateaued around 140 beats per minute. Again, fetal position will be assessed in the hope of finding the baby in the anterior cephalic position. If the baby is not in this position, the physician may perform an external cephalic version in the 9th month of gestation.115 An external cephalic version (ECV) is the process of rotating a breech baby by manipulating the fetus through the mother’s abdominal wall.

Women where ECV was attempted had their risk of a cesarean section reduced by half.116 It did not, however, reduce cesarean sections in subsequent deliveries.

A factor that positively influences the effectiveness of ECV includes116 having a posteriorly located placenta, meaning the placenta lies against the mother’s spine rather than on the side nearest the abdominal wall. A fetus in an oblique or transverse lie helps with fetal manipulation during an external

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 82 cephalic version as does having an amniotic fluid index under 10. For whatever reason, pregnant women of black heritage are more likely to have successful ECV procedures.

Factors that negatively influence ECV effectiveness include having an overweight or obese mother, an anterior positioned placenta, tense uterus, and/or a breech fetus that has already descended into the pelvis. If the mother has already had her membranes rupture or a low amniotic fluid volume, it is also unlikely that the external cephalic version will be successful. Although infrequent, there are risks associated with external cephalic version. Some of these risks include a placental abruption, ruptured membranes, vaginal bleeding, cord prolapsed and, most critical, perinatal death or stillbirth.

9th Month of Pregnancy

At 9 months’ gestation, many health clinicians begin seeing their prenatal patients weekly. While this may not change the outcome of the pregnancy, recent studies show that most women prefer this standard method of prenatal scheduling.

The clinician will continue diligent monitoring of the mother’s vital signs and symptoms of developing high blood pressure such as swelling, dizziness, or blurred vision. It is necessary to check cervical dilation and record findings. Cervical dilation is noted from “closed” to 1 to 10 cm. At 3 cm, most women are considered to be in “active labor.” The clinician will also look for effacement, or the thinning of the cervix in preparation for labor, engagement of the fetus into the birth canal, and fetus positioning.

The prenatal patient’s understanding of labor should be assessed, including

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 83 when it is most appropriate to come to her place of delivery or call her midwife. The patient should also be informed about what labor looks like in the early stages, or before 3 cm dilation. Contractions will be mild but frequent and not relieved by walking. They will also occur every 5 to 30 minutes, lasting about thirty seconds each time.117 Contractions generally feel like menstrual cramps in the beginning and may radiate to the lower back. Prenatal patients should be told to note the color and time their water breaks, if this occurs at home.

Pregnant mothers should be encouraged to call their midwife or head to the hospital when they are in “active labor.” They will need to watch for signs that the time is approaching to deliver their baby. During active labor, contractions will be more intense and last up to a minute long with only 3 to 5 minutes of rest in between. If a mother waits too long to get to her birthing center or to call her midwife, she risks entering the “transition phase” where the cervix dilates from 8 cm to 10 cm. During this phase the pregnant mother will feel the most intense pressure during her contractions. Contractions may overlap and last up to a minute and a half. It is good to let a woman know that while this may be the most difficult portion of labor, it is the shortest portion.

When discussing birth with pregnant patients, especially first-time mothers, it is important to discuss the birth process and to recommend a birthing course if they have not yet attended one. Discussing including vaginal bleeding is necessary. After delivery, postpartum patients will have lochia, or vaginal bleeding, for three to six weeks. Bleeding will begin like a very heavy period and become light to clear during the last week.118 Mothers planning to breastfeed should be encouraged to attend a breastfeeding course led by a breastfeeding peer counselor or lactation

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 84 consultant.

As with the 8th month, fetal position will be verified. Once the fetus is considered term, 37 weeks, the clinician may perform an ECV for the breech fetus. Fundal height will also be determined and is expected to be positioned just at or below the xiphoid process. Evaluation of the mother’s understanding of fetal movement is needed, and the mother should be informed that fetal movements might reduce as the onset of labor draws closer. Beats per minute will again be assessed, expecting the fetal heart tones to move closer to 120 beats per minute as the fetus nears delivery.

Occasionally, a clinician may require an assessment known as a non-stress test to be performed. A non-stress test is used to ensure that a fetus is healthy despite possible extraneous circumstances. The test measures contractions, heart rate and fetal movement. A few reasons a non-stress test may be performed is in circumstances where the infant is post-term and the clinician and mother are hoping to let birth occur without the use of labor induction medications.119

A non-stress test will also be used for a mother with hypertension or gestational diabetes. If the mother’s fetus is growing slowly or plateauing in growth, a non-stress test will confirm the health of the fetus and help determine a plan of care for the prenatal patient. A non-stress test will also be performed before and often after an external cephalic version to ensure there are no existing fetal abnormalities present.120 If an ultrasound test shows that the prenatal patient has too little or too much amniotic fluid. A non-stress test is performed very frequently and is considered the most common cardiotocographic technique for fetal assessment. Many clinicians prefer it because it is non-invasive and easy to set up in the clinical setting.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 85 When a fetus is believed to be at risk of perinatal death after 26 or 28 weeks gestation, a non-stress test may be performed on a daily to weekly basis until delivery. This exam is looking for signs of fetal hypoxemia and results are categorized as reassuring and non-reassuring. Health staff needs to know that reassuring findings are indicative of current positive fetal oxygenation. This result does not mean that further non-stress tests are unnecessary; rather continued tests will be needed as long as the other risk factors mentioned above (maternal hypertension, low amniotic fluid volume, gestational diabetes, etc.) are present.120

A non-reassuring stress test indicates fetal hypoxemia and may require a repeat test to rule out a falsely positive result. If tests continue to present as non-reactive, also known as non-reassuring, the clinician should suggest hospitalization. This hospitalization will include continuous monitoring as well as the possibility of induction or caesarean section, dependent upon the fetal gestational age, severity of the non-reassuring results and maternal comorbidities.

Multiple Births

Patients who are pregnant with multiples will likely experience anxiety and experience mixed emotions, especially when they first discover that they are carrying more than one child. The mother should be assured that while care for women pregnant with two or more babies needs to be more highly specialized, it is common and the outcome of most multiple births is generally positive. The clinician should be aware that mothers pregnant with multiples are considered at an increased risk for complications.121

Gestational diabetes is more likely to occur in patients carrying multiples. The patient should be advised that a healthy lifestyle, including sound diet

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 86 and exercise practices, greatly reduces the risk for developing gestational diabetes. Even while exercising and following nutritional guidelines, the mother may need to take insulin pills or shots to keep her blood sugar levels in check. Preeclampsia is 2-3 times more likely to present in cases of multiple births. Preeclampsia can damage organs, placenta, and may put the patient’s life at risk. Early detection is vital in prevention. Another complication, while rare, is twin-to-twin transfusion syndrome, which occurs in identical rather than fraternal twins. Laser surgery may be necessary to prevent connection between the babies’ blood vessels. About 10-15% of identical twins have this syndrome.

Placental abruption takes place when the placenta disconnects from the uterine wall prior to delivery. Still birth, preterm birth, and developmental problems may result and can occur anytime during the second half of the pregnancy. Abruption may occur after the first infant is born vaginally, causing the need for a caesarian section.

Low-birth weight will likely occur, with the likelihood increasing for each additional multiple. The average birth weight for singles is 7 pounds, while twins usually weigh at about 5.5 pounds, triplets at 4, and quadruplets at 3 pounds. Babies who weigh less than 5.5 pounds are considered to have a low-birth weight.

Low-birth weight typically causes health issues like difficulty to breathe on their own, to gain weight, fight against infection, and to control body temperature. The majority of low-birth weight infants spend time in the neonatal intensive care unit before going home with their parents.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 87 Clinicians may place mothers on bed rest prior to labor, especially if any of these complications arise. The clinician must be prepared to discuss each patient’s individual situation when them and to prescribe bed rest if needed. This generally begins in the third trimester.

In the case of multiple births, the mother may lose one or more of the babies. A “vanishing twin” occurs when one baby in a set of two miscarries early in the pregnancy while the other one remains intact. This occurs in about 20% of twin cases and in about 40% of triplets. Miscarriages such as these often go undetected before an ultrasound. The only symptom is vaginal bleeding.

Death of a fetus after 20 weeks, or a stillbirth, is more common in multiple pregnancies. About 0.5% of single pregnancies result in in stillbirths. About 1-2% of twins and triplets are stillbirths. A still-born multiple can be expelled many weeks before the surviving twin, but most are delivered alongside the surviving baby. The odds are in the surviving baby’s favor when the baby has its own placenta, though the baby is still at great risk for survival. If surviving baby or babies look unhealthy, labor may be induced.

The earlier the mother goes into the labor, the more likely it is that her babies will experience complications. Usually, premature babies are fairly healthy if born between 35 and 37 weeks. Risk increases the earlier the babies are born and babies born under 28 weeks will especially need intensive care.

Health clinicians will probably attempt to delay labor if the patient goes into labor before 34 weeks. The patient will need to be prepared that the baby may receive magnesium sulfate to reduce the risk of developing cerebral

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 88 palsy. The extra time provided by delaying labor allows clinicians to use corticosteroids to assist the development of the baby’s lungs and other organs. This will increase the likelihood of survival.121

The initial prenatal has been discussed here in terms of developing a plan of care for the rest of the mother’s pregnancy. Each month of gestation has its own set of maternal and fetal assessments, while all appointments look at the standard vital signs, fundal height and fetal heart tones. Other tests will determine gestational diabetes, immunity to Rho(D) and breech positioning. Treatment of these conditions as well as the risks involved with treatment itself has also been reviewed. External cephalic version is one such procedure used in an attempt to correct a breech baby.

Popular use of non-stress tests to evaluate for fetal hypoxemia as well as non-reassuring results indicating little fetal reactivity and fetal hypoxemia were discussed as well. Women whose fetus fails these screenings may be hospitalized, induced, or scheduled for a caesarean section. As always, it is the health professional’s job to evaluate the prenatal patient’s knowledge of labor and delivery, their emotional state and their risk for malnutrition. While this was likely evaluated at their initial prenatal appointment, these needs should be addressed at each appointment.

During the 4th month of pregnancy, a test known as the ‘multiple marker screening’ or ‘Quad screening’ is performed via a blood draw in a laboratory or clinic. Which of the following disorders is not routinely screened for with this specific test? a) Down syndrome b) Cystic fibrosis c) Spina bifida

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 89 d) Aneuploidy

Cystic fibrosis is not routinely screened for during the ‘multiple marker screening.’ Rather, this test looks for trisomy abnormalities as well as neural tube defects.

Birth Plan: Obstetrical Care And Birth Setting

Planning the manner in which a mother would like to give birth is a personal decision made for the promotion of comfort and feelings of personal safety. Some pregnant women make their birth plan based on deeply intimate and spiritual feelings. Health professionals should always work towards balancing respect for their prenatal client’s birth plan preferences by promoting the health of the mother and her infant in the process. This means understanding whether a mother wants pain medication to relieve pain during contractions, a or birth coach in the room, her entire family present, or to give birth nearly alone. As with the beginnings of prenatal care, a highly supportive health team is very beneficial during labor. Women who feel adequately supported during their labor experience and throughout the birth of their infant reported higher satisfaction of care and less pain during the event.122

In the U.S., choosing an obstetric care provider is varied but limited. A woman’s health clinician will be highly dependent on certain factors, such as where she would like to give birth, whether her pregnancy is considered high or low risk, and whether or not she will have a planned cesarean section. The elements involved in making these decisions vary greatly from woman to woman and deserve careful consideration and deference when the health clinician weighs in with his or her opinion on how to best accommodate the mother’s labor and birth experience.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 90 Choosing An Obstetrician

An obstetrician is the most common medical clinician attending a woman during labor and birth in the United States. These are medical physicians who have spent their residencies specializing in obstetrical care and are knowledgeable of the varied abnormal deliveries that need special attention. Most hospitals have protocols in place allowing only board-certified obstetricians to deliver infants by caesarean section. Obstetricians are uniquely qualified to deliver high risk infants such as those being born pre- term, with known congenital abnormalities, and in some hospitals, breech babies. A hospital or physician may require an obstetrician perform a delivery because a mother has preexisting medical conditions, Rho(D) non- immunity, or preeclampsia. Specific policies regarding when an obstetrician is appropriate vary hospital to hospital.

Family practitioners are specialized in all areas of general medicine including prenatal care. They deliver infants whose mothers are at a low-risk for complications during labor and birth. The major benefit of using a family practitioner during pregnancy, labor and delivery is the continuity of care. Family practitioners are able to see a mother pre-pregnancy, during her pregnancy, and her entire family afterwards as well. While many hospitals do not permit family care physicians to deliver high-risk pregnancies, studies have shown that both obstetrician and family care practitioners provide comparable care even for high-risk pregnancies.

Midwives vary from state to state and their scope of practice ranges greatly. There are nurse who have gone to school for on top of getting their four-year nursing degree and direct-entry midwives, whose training can vary from shadowing a midwife to taking courses designed for the trade. Their care is very personal and effective, offering compassionate

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 91 care to mother’s with low-risk pregnancies.

Birth Settings

Home birth has been the most common form of birth throughout world history. Many women turn to with a midwife because they feel most comfortable in their home environment and they have a strong belief in their ability to give birth without medical intervention.123 Having a home birth requires that the mother and family research their chosen midwife carefully, know the signs if her pregnancy changes from a low-risk pregnancy to a high-risk pregnancy, and have a plan in place, should she need to transfer to the hospital. A competent midwife will be skilled enough to know any potential warning signs before delivery and request hospital transfer. Fortunately, the vast majority of home births does not require transfers and are successfully achieved. A recent study found that nearly 90% of planned home births were safely completed as planned.124

Birthing centers began in the 1970s and provided women with a great intermediate between having a baby at home and having a child in a hospital. Birthing centers have fewer restrictions than hospitals and allow for greater freedom of movement for the laboring mother. Generally, they have warm atmospheres made to make the mother feel as if she were at home. Nurse practitioners and midwives most frequently perform deliveries at birthing centers.124

Many birthing centers also offer the mother and her family the option of delivering her infant by a . A water birth is simply the practice of giving birth while in a tub of warm water. Many people believe this practice helps the baby transition from womb to the outside world in a gentler and more familiar manner. Water birthing is also often more comfortable for the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 92 mother, providing her relief from some discomfort and pressure during labor. Submersion in water also decreases blood pressure, relaxes, and provides the mother with more energy. Water may also relax and loosen the perineum, helping it stretch for the passage of the fetus’ head and shoulders.

Typically, water births are performed in water pools either provided by the birthing center or personally purchased or rented if the woman plans to deliver her infant at home.125 These baths are about 18” to 22” deep and anywhere from 45” to 65” long.

As labor starts, fill the birthing pool with warm water, between 99 and 100 degrees Fahrenheit. Some women like their water a bit hotter, but pregnant clients should be advised to use a thermometer and check that the tub never goes above 101 degrees Fahrenheit. Most women find an upright, semi- reclined position to be the most comfortable while pushing during contractions. The patient should be encouraged to discover which position feels best. Depending on the patient’s birth plan, it will be the midwife, partner, or other health clinician that will be in the tub with the mother as she pushes during labor. This will help bring the infant up to the surface after the final push. Since babies have a natural instinct to hold their breath while under water, breathing in or swallowing watering is generally not a concern.127

Fetal health seems to have little impact as a result of a water birth. While theoretically possible for the water to ease infant stress upon birth, some physicians believe there is also the possible risk of the fetus swallowing air and suffering from an air embolism upon birth. There are no studies supporting this theory and the British Medical Journal who reported this

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 93 potential risk is 95% certain that water births are safe. It is known that there are situations where water births should not be practiced. One example is when the mother is afflicted by genital herpes. Herpes easily spreads through water and the infant is at risk while being born through the birth canal. C-sections are often the primary option for delivery when the mother has an active outbreak of genital herpes.

If heavy meconium, or the infant’s first stool made up of amniotic fluid and mucous is present, the mother should exit the tub and birth her infant elsewhere to prevent the newborn from breathing in this stool. All pregnancies considered high risk or marked by preexisting medical conditions in the mother should be evaluated closely to understand the best birthing option. Every pregnancy and birth is unique and deserves as unique a birthing option whether that occurs within a birthing center or at home.

Women are prime candidates to deliver at birthing centers if they would like a drug-free labor, non-augmented by medications like Pitocin (a medication which helps stimulate uterine contractions), and a home-like delivery with the comfort of knowing they are surrounded by trained health clinicians in emergency care should that be necessary.126 If a prenatal patient’s pregnancy is deemed high-risk, she may not be able to deliver at a birthing center.

Hospitals are the most frequented birthing locations in the United States. Hospitals tend to be a bit more invasive in their care, frequently monitoring the laboring mother and restricting freedom of movement. New guidelines in the U.K., have proposed that 45% of women who are at an extremely low risk of experiencing complications should consider giving birth outside of the hospital. Still, if the mother is high-risk, the hospital is the best option for

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 94 the mother and infant’s health as well. The decision of what is best for the mother should be a team decision made with the health staff, the family and the pregnant mother.

Comfort Techniques During Labor

There are many terms used to describe the sensations during labor, such as pressure, pain, aching, cramping; however, one thing is certain, labor is certainly uncomfortable in many ways. In early labor, pains begin as mild cramping. Prenatal patients should be education on how to manage this type of discomfort before labor begins, as they will likely be at home for much of this period of labor. Women should use distraction as a primary mode of relief during early labor. Going for slow, relaxing walks, listening to calming music, watching comedy television, and even going out to eat for a small, comforting meal can help women move through contractions and conserve energy for the upcoming labor and delivery.

As labor grows more intense, women benefit from showers, lukewarm baths, and finding positions to take pressure off the most intense areas of discomfort. Women experiencing back labor, or labor pains that are increasingly felt in the lower back during contractions, will benefit from different laboring positions than women not enduring back pain. Some of these positions include sitting on a birthing ball, rocking back and forth on all fours, standing with their head on the partner’s shoulder with his or her hands on the small of her back, and kneeling in front of a chair with her head resting on the seat.

Many women find lying on their side to be a very comfortable position. The fetus also benefits from this position, as left side-lying generally promotes optimal oxygenation of the fetus by taking pressure off their cord. Women

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 95 also find that this position helps them rest between contractions and support their abdomen nicely. Partners should be encouraged to help make the laboring mother more comfortable by arranging pillows behind her back, between and around her legs, underneath her stomach, and underneath her head and neck. This energy saving position is especially nice in the early stage of labor as contractions begin to grow closer together.

Oddly enough, the least helpful birthing and laboring position is the one we see time and time again in films and sometimes even on the hospital floor; laying back with legs in the air is a potentially damaging position in that it relieves very little pain, it works against gravity thus making the baby and the mother’s body work harder to push the infant out, and actually makes the pelvic outlet smaller. This classic flat-lying birthing position also increases the likelihood that the mother will need an episiotomy or an assisted vaginal delivery through the use of forceps or a vacuum. Mother’s feeling drawn to this position should try semi-sitting, side lying, or kneeling forward onto a chair. These positions will work with gravity yet also relieve pain and save maternal energy.

There are also non-positional comfort techniques to use while aiding a laboring prenatal client. Unfortunately, what works for one mother may make another mother feel wholly uncomfortable. While a room fan may make one mother calm and less hot, another mother may feel totally disturbed by feeling the blowing air on her skin. Still, helping a prenatal patient is often about testing out things that have worked for others while being adaptable.

Some women enjoy aromatherapy while in labor. Their partner may take a few drops of a relaxing essential oil, like lavender or rose oil, or something

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 96 more energizing such as lemon or spearmint, and mix it into a base oil like grapeseed or argan. A comforting massage on the back or even the hands can help distract an uncomfortable mother and provide intermittent relief.

Cool compresses to the forehead are especially comforting to mothers who tend to run hot during the birthing process. Make sure to have a few clean washcloths around so that as one compress loses its chill, another can be rotated out.

Breathing techniques have long been taught to prenatal patients in order to prepare them for labor. This comfort technique does not relieve pain completely, but it does ensure enough oxygen is available to the mother and baby during labor and acts as a convenient distraction. Some breathing techniques include abdominal breathing, patterned breathing, and natural breathing with visualizations.128

Abdominal breathing, not to be confused with diaphragmatic breathing practiced in patients with chronic obstructive pulmonary disease (COPD), is practiced by teaching the prenatal patient to lay a hand on her abdomen and take in air slowly, feeling the space around her abdomen fill all the way to her diaphragm. On the exhale, have the mother breathe out slowly so that this breath takes three times as long as the inhalation. This breathing technique can be paired with relaxing visualizations that often help women remain calm during contractions and periods of bodily stress.

To incorporate visualizations, women should be taught to imagine their breath as a stream of lovely blue, green, or white air to represent healing and calm. The prenatal patient should be instructed to imagine that this air is replacing the stale air in the lungs and when exhaling, she is releasing

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 97 pain, stress, and negative energy. She may imagine this exiting air to be red or gray, like smoke from a chimney. This same breathing exercise works while imagining the filling of a ships sails or waves rising and crashing in the ocean.

Patterned breathing describes various ways for the mother to address her breathing during different stages of labor. While in early labor the prenatal patient may find deep, slowed breathing possible, and she may find this same breathing practice difficult during the more active phase of labor when the pain and pressure is the most intense. At this point she may benefit from light rapid breathing; to perform this method, she should inhale slowly through her nose and then exhale in quick short bursts at a rate of about one breath per second. While trying the method of rapid breathing, she will likely find the perfect rhythm to match her contractions and alleviate pain.

Careful attention should be paid to a mother’s breathing to prevent hyperventilation, which can lead to dizziness and hypercapnia in the bloodstream. Hyperventilation prevents full expulsion of carbon dioxide during breathing and can be harmful to both mother and baby. Some women will also need reminders to breathe normally and refrain from holding their breath. Oftentimes, when pain is great, a woman may feel tempted to hold her breath and clench down, a practice that deprives her and her baby of oxygen and also wastes valuable energy.

Fetal Presentation Before And During Labor

Understanding fetal presentation and lie help manages discomfort during labor and facilitates delivery of the neonate. While some positions facilitate delivery, other positions make the voyage down the birth canal more difficult. The most common position and the ideal lie for a fetus is head down

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 98 facing the mother’s spine. This lie is known as “occiput anterior.” If this position continues untill the time of delivery, it is known as the “cephalic position,” or head down.

Other possible presentations include breech presentation. Breech presentation is rare, happening in about 3% of births and may be a complete breech, where the fetus presents bottom-first with legs and knees flexed, frank breech, where the legs are straight against the chest, or with one or both of the feet presenting first. Even more rare is transverse presentation, a lie occurring when the arm, core, or shoulder presents before the head or buttocks.

The Seven Cardinal Movements of Labor

The seven cardinal movements of labor describe the basic, but very important, actions that are completed in order to deliver an infant vaginally. It begins by the engagement of the fetus’ head into the pelvis. Once the fetus is engaged, it may begin its descent into the birth canal, during labor or while pushing to deliver the neonate.

Flexion occurs during descent. In this movement, the fetus tucks his head so that his chin rests against his chest. This movement makes fitting through the birth canal easier. Next, the fetus will complete internal rotation. This movement involves the turning of the infant’s head so that the face is towards the mother’s spine and moving past the pubic bone.

During extension, the baby moves the head once again, extending it back around the pubic bone just when nearing the opening of the vagina. Finally, as the fetal head is delivered, the head becomes aligned with the body. Finally, during the expulsion stage, the top shoulder will also be delivered.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 99 Once the mother has passed the shoulders, delivering the rest of the infant is not problematic.

Delivery Complications

While most pregnant women are able to deliver their infants without complications, delivery complications are on the rise in the United States. This may be related to the changes in the population of modern day pregnant women; however, this has not been directly studied. Still, it is known that more women are getting pregnant older than ever before, are more likely to be obese that thirty years ago, and have reported health conditions such as hypertension and diabetes.

Most common in women delivering their first infant, perineal lacerations are a fairly frequent delivery complication. The lacerations are tears at the perineum, the lower end of the vaginal opening. First-degree tears are usually small and manageable in nature and do not generally require many, if any, stiches. Second-degree tears are more serious and involve the underlying muscular tissue of the perineum. These will require stiches and more care postpartum. While rare, third and fourth degree tears are the most severe and extend down into the anal sphincter.

Perineal massage is often initiated to reduce tearing during birth. Perineal massage includes massaging the tissue on and around the perineum with two to three fingers daily for the last several weeks of pregnancy. It also involves stretching the outer portion of the vagina for one to three minutes at a time. Perineal massage may also be performed during active labor and especially helps when the prenatal client is encouraged to relax the muscles in her vagina and perineal area.133 The effectiveness of perineal massage is debated, but studies have shown that for every fifteen women performing

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 100 these massages, one of them will avoid the need for an episiotomy or tearing that will require stiches.134

Health clinicians can help prenatal patients avoid perineal damage by 1) providing frequent instruction on perineal massage, 2) applying warm compresses to the perineum during labor, and 3) finding comfortable positions to ease the passage of the fetus through the birth canal, especially taking advantages of birthing positions which use gravity, such as standing and semi-sitting. Preventing the use of forceps and vacuum-assisted delivery can also lessen the risk of vaginal tearing. There are occasions, however, in which the infant needs to be born as soon as possible to lessen the risk of trauma.

An episiotomy is considered a minor surgery whereby the clinician performing the delivery makes a small incision at the base of the vagina in order to create a larger opening for the descending fetus. Once the mother has delivered the placenta, the incision will be stitched closed. Episiotomies do not prevent tearing and are, in fact, often more difficult to heal from than natural tears. This is because the incision made during an episiotomy goes through more layers of tissue on average than a natural tear.

Episiotomies often contribute to painful sexual intercourse in the mother for a few months’ post-partum and occasionally, greater blood loss. The thought of an episiotomy can be very scary to prenatal clients and they may be curious as to what their steps are to avoid such a procedure. Much like preventing tearing, pregnant women should be educated on the benefits of perineal massage as well as performing Kegels exercises all throughout their pregnancy.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 101 Forceps and vacuum devices are used in assisted vaginal delivery in circumstances where the fetus is in distress, has not been delivered after the second stage of labor, or if the mother is unable to safely continue pushing due to exhaustion or preexisting medical conditions. Forceps can be painful for the mother and often require anesthesia. Vacuum devices may be made from metal or plastic cups, but each option has its own set of risks. For example, while metal cups used in some vacuum assisted deliveries have greater outcomes for vaginal delivery, they are also more likely to cause fetal bruising, scalp harm, and cephalahematomas.135

Forceps are curved metal tongs used to cup the sides of the delivering fetus’ head and ultimately aid in delivering the baby by pulling down and out while the mother pushes through a contraction. Like vacuum assisted delivery, the use of forceps may cause some damage to the fetal scalp. All of the above vaginal assisted deliveries may contribute to increased vaginal soreness postpartum, prolonged issues with urinary continence, and, in rare cases, weakened pelvic muscles leading to pelvic organ prolapse.

Cesarean Sections, commonly referred to as C-sections, are also on the rise in the U.S., where nearly one-third of women delivering in the hospital will undergo the serious surgery.136 A C-section is the best option when the pregnant woman’s placenta is low-lying over the cervix, also known as placenta previa. This condition obstructs the cervix, making attempted vaginal delivery not only unlikely, but also dangerous. Occasionally, the placenta will rupture from the side of the uterus prematurely, creating another circumstance in which a C-section is necessary. Rarely, a woman may experience a uterine rupture, requiring immediate delivery and medical intervention through a Cesarean section.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 102 In most hospitals, infants in breech position are delivered via C-section especially if there is evidence of a cord prolapse, or when the umbilical cord exits the cervix before the infant, causing oxygen deprivation in the fetus. Health clinicians may be confronted by many other circumstances which may call for a C-section, including fetal distress usually related to oxygen deprivation, failure to progress during labor, cephalopelvic disproportion (a condition characterized by a fetal head too large to pass through the pelvis), active genital herpes, and multiples infants.137

A Cesarean section requires the administration of epidural anesthesia to the pregnant mother. After receiving this medication, the woman will be unable to feel her lower body. The mother’s urine will be collected via a urinary catheter. In a non-emergent C-section, the clinician, likely who is an obstetrical-gynecology (OB-GYN) surgeon, will make a horizontal incision below the navel at the bikini line. This allows for faster healing of the abdominal wall and an easier to cover scar. In emergencies, a lateral incision may be made in order to quickly deliver the fetus. Once the incision is made, the surgeon will remove the amniotic fluid via suction and then deliver the fetus, passing the infant to the mother if possible or to a team of assisting health staff. Once the placenta is delivered, the surgeon will begin stitching to close the incision.

Detailed after-care will need to be provided to the patient who has just undergone a C-section, as this is a major surgery generally taking about six weeks recovery time. Women who have undergone a C-section procedure should be informed to call their health clinician if they experience any redness or discharge at the site of the incision, an oral temperature greater than 100.4 degrees Fahrenheit, or any evidence of non-adhesion at the site.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 103 While vaginal births continue to make up the majority of births around the world, health clinicians should be familiar with the possible delivery complications, which may arise throughout the labor and birthing process. A well-educated team creates a safer birthing environment for both the mother and her infant.

This section discussed different birthing options in terms of a pregnant woman’s choice of a health clinician and the locations she can give birth. The relative safety of each option, appropriate location for high-risk pregnancies being the hospital, and possibility of home-birthing as suitable for very low- risk pregnancies was discussed. A freestanding birth center might be the best option for mothers who find themselves somewhere in the middle of these two options.

Case Scenario:

A woman who would like freedom of movement and a drug free labor and birth but is not comfortable with a home-birth should consider having a birth at which of the following locations? a) The nearest hospital to her home. b) A birthing center. c) She should continue with a home-birth anyway. d) A clinician’s office.

A woman who would like freedom of movement and a drug-free birth should consider: b) birthing center, if she is not comfortable with a homebirth. A hospital will likely restrict her freedom of movement and is thus not the best answer.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 104 Pain Medications During Labor

When comfort techniques fail to relieve stress or pain, some women turn to pharmaceutical intervention not only to manage their discomfort but also to prevent unfavorable results associated with excess pain. When undergoing physical trauma, the human body undergoes a transition stemming from the cerebral cortex in order to cope. It begins by the release of a floodgate of acetylcholine compounds, thereby engaging the central nervous system. Studies have found that these neurohumoral effects inhibit placental perfusion and, therefore, fetal oxygenation. The more stress hormones (i.e., catecholamine) present in the blood steam, the more poorly perfused the mother’s uterus.129 Maintaining optimal perfusion is very important during labor not only to provide oxygen to the fetus but to provide the uterine musculature with the necessities needed to produce forceful contractions.

Hyperventilation, as previously discussed, is another adverse outcome related to pain. Women who hyperventilate while in pain have higher arterial

CO2 levels, creating maternal alkalosis and a shift of oxygen carrying red bloods cells, thereby decreasing the amount of available oxygen for the fetus. However, most women are able to self-regulate this breathing pattern and the fetus generally tolerates the changes. However, high-risk pregnancies, such as a woman delivering multiples or a fetus with intrauterine growth restriction, may consider pain management a higher priority in order to reduce the stress to the already taxed fetus.

It is not always the fetus that is at risk because of undertreated pain. In fact, pain may create psychological problems in the as a direct result of previous trauma. One study found that women who experienced unrelieved pain while in labor were more likely to suffer from postpartum depression after the birth of their infant. This same study also

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 105 found an increase in Post-Traumatic Stress Disorder (PTSD) in the group of women with unrelieved pain.

Usually administered during the early stages of labor to reduce stress and pain, narcotics, such as Stadol or butophanol, also provide mothers with the ability to relax and conserve energy in preparation for the more intense parts of labor. These medications do not take away pain completely but rather lessen the intensity of the experience. Narcotics are generally given by the intravenous route during the early stages of labor in order to prevent or lessen the possibility of adverse effects to the fetus.130 Some of these side effects include impaired respirations, central nervous system depression, impaired early breastfeeding, and a lowered ability to regulate their own body temperature following birth. Mothers are also at risk for lowered respiratory function but most women complain of the dizziness, nausea, and vomiting associated with taking opioid narcotics.

Nitrous oxide is seldom used in the U.S. during labor, but may be used in Canada and the United Kingdom to soften the pain of labor. More a relaxing distraction than true pain relief, nitrous oxide has little effect on the fetus but may induce dizziness, sleepiness, nausea, and/or vomiting in the mother.

Some women prefer more controlled pain management that does more than simply “take the edge off.” The delivery of an epidural block is commonly performed in the U.S. and may employ the use of varied medications, which will provide pain relief and anesthesia to varying degrees. For women who would like to continue to move throughout labor, a “walking epidural,” or medication titrated to prevent total nerve blockage, can be delivered. Before a Cesarean section or a vacuum-assisted delivery, a stronger epidural that

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 106 numbs the entire lower body, usually by a spinal block, will be delivered. Epidurals provide nearly complete pain relief while keeping the prenatal patient awake and alert. However, epidurals may lower a woman’s blood pressure, thereby contributing to lowered placental perfusion. Rarely, women will have severe headaches for several days following this procedure.

For local pain relief during or just before the delivery of the fetus, a pudendal block or local anesthetic injection may be used. A pudendal block is a local nerve block, which takes between ten and twenty minutes to begin working. It relieves vaginal pain for nearly an hour and helps the mother manage the pain brought on by pushing. The local anesthetic block does not help with labor pains but instead numbs the perineal area around the vaginal opening and the anus. This is usually used before an episiotomy or before the repair of a vaginal tear shortly after delivery of the placenta.

Summary

Being pregnant and delivering a child is a very intimate time in a family’s life and can be experienced in innumerable ways. The health team providing care to a pregnant woman should understand all aspects of a healthy pregnancy to assist the woman and her family to be reassured of a healthy pregnancy outcome. The expectant mother and her family should feel confident that the prenatal health clinician has her best interest in mind. The goal of prenatal care is to promote optimum maternal and infant health. To ensure that best care practices are followed and that promotion of maternal and infant health is of top priority, all health professionals need to understand patient safety goals and standards of practice.

During initial prenatal visits the clinician will identify the expected date of delivery and gather the patient history, including taking vital signs, height

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 107 and weight, and laboratory testing urine for ketones, sugar, bacteria, and blood. Existing risks are best identified during the first prenatal visit by using open-ended questions to discuss possible drug use and testing for high risk conditions potentially affecting the mother’s and fetus’ health. Identifying signs and symptoms of depression, malnourishment, drug abuse, or lack of a healthy support system are also an essential part of prenatal care all throughout a woman’s pregnancy.

The clinician should express options that may be presented to the mother relative to common birthing options and settings. The health team as a whole working in unison with other clinicians and associates, and also with patients and their families, will be better poised to support open communication and strong, long-term relationships. When working collaboratively, health professionals and their patients can promote a positive pregnancy outcome of healthy mothers and babies.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 108 1. Using the Estimated Date of Delivery (EDD) method, the care provider will count ______from the first day of a woman’s last menstrual period.

a. forward 266 days b. backward 266 days c. forward 280 days d. backward three months

2. ______of women deliver on their actual Estimated Date of Delivery (EDD).

a. One half b. One-third c. Twenty percent d. Four percent

3. True or False: Properly determining a woman’s due date is nominally important because the patient’s contractions will provide enough notice.

a. True b. False

4. Which pregnancy due date method or rule involves counting backwards three months from the first day of the last missed period and then subsequently adding 7 days?

a. Naegele’s rule b. The hCG test c. The menstrual cycle method d. EDD method

5. Using the Estimated Date of Delivery (EDD) method, the care provider will always count forward 266 days from the date of conception if

a. the woman took a home pregnancy test. b. the woman recorded the first day of her menstrual period. c. the exact date of conception is known. d. if the date is confirmed through urinalysis.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 109 6. Human Chorionic Gonadotropin (hCG) levels should be drawn and an ultrasound scheduled (depending on the findings revealed in the hCG results) when

a. the woman took a home pregnancy test. b. the mother has irregular menstrual periods. c. a urinalysis is not feasible. d. the mother knows the first day of her last menstrual cycle.

7. A typical menstrual cycle is ______days in length.

a. 28 b. 21 to 35 c. 30 d. 28 to 35

8. Using Naegele’s rule, if the first day of a mother’s last, missed period was October 27th, her expected due date would be

a. August 3rd. b. July 27th. c. August 17th. d. September 1st.

9. True or False: Naegele’s rule is the most common technique of pregnancy dating.

a. True b. False

10. A healthcare provider will confirm pregnancy with a urine sample or laboratory blood sample

a. if the patient did not perform a home pregnancy test. b. on a case-by-case basis. c. in all cases. d. if cervix has taken on a blue or purplish tint.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 110 11. A woman with an above normal ______, before the start of her pregnancy, is at a higher risk of developing pregnancy-related hypertension, edema and gestational diabetes.

a. menstruation b. hCG levels c. bacteria levels d. body mass index (BMI)

12. Women’s Human Chorionic Gonadotropin (hCG) levels fluctuate throughout their pregnancy but as far as verifying the gestational age of the fetus, hCG levels are

a. always more reliable after the first trimester. b. never reliable. c. always more reliable early on. d. more reliable during the second trimester.

13. The accuracy of ultrasounds ______because biological differences found within the fetus’ DNA take effect as the fetus grows in the mother’s uterus.

a. decreases with time b. increases with time c. are the same throughout a pregnancy d. is not known in the third trimester

14. Ultrasounds performed before six weeks are limited because locating the fetus in utero

a. is difficult unless performed transvaginally. b. if it is performed transvaginally. c. is limited because of Chadwick’s sign. d. may be difficult even transvaginally.

15. A care provider examining the cervix will look for Chadwick’s sign, which refers whether or not the cervix

a. is closed. b. has abortifacient properties. c. has dilated. d. has taken on a blue or purplish tint.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 111 16. Ingesting ______may have uterine stimulation and abortifacient properties.

a. aloe vera b. St. John’s Wort c. fluoxetine d. serotonin

17. True or False: To get an accurate measurement of hCG levels, a urinalysis will need to be performed.

a. True b. False

18. Herbal supplements are an especially pressing matter to discuss with prenatal clients because

a. they are “natural” supplements for pharmaceuticals. b. they may be harmful in some cases. c. pregnant women cannot take prescription drugs. d. they are harmful in all cases.

19. ______is often used to stave off colds or coughs, but it is considered a teratogenic product and should never be taken by a pregnant client.

a. Fluoxetine b. Echinacea c. Uva Ursi d. Wild cherry extract

20. When an herbal supplement hastens or facilitates , especially by stimulating contractions of the uterus in a pregnant woman, it is said to

a. have an oxytocic effect. b. have a teratogenic effect. c. cause insomnia. d. have an antidepressant effect.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 112 21. Because the effects of ______on a developing fetus is unknown, doctors believe that taking heavily studied selective serotonin reuptake inhibitors for depression are less dangerous.

a. fluoxetine b. valerian root c. Nepeta Cataria d. St. John’s Wort

22. ______is a supplement frequently added to energy drinks in order to increase the drinker’s energy.

a. Nepeta Cataria b. Gaurana c. Fluoxetine d. Valerian root

23. True or False: Pregnant women should be advised to avoid gaurana because it has been shown to lead to the birth of babies prematurely, infants of low birth weight, and possible birth defects.

a. True b. False

24. What herbal supplement taken for sleep induction is NOT recommended in pregnant women as it has the ability to stimulate uterine activity and induce labor prematurely, possibly leading to abortion?

a. Uva Ursi b. Melatonin c. Catnip d. Ginseng

25. ______, taken in an attempt to improve the immune system, has a weak oxytocic effect on the pregnant uterus.

a. Melatonin b. Echinacea c. Uva Ursi d. Wild cherry extract

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 113 26. One study found that a woman who had consumed ______while pregnant gave birth to an infant with pubic hair, forehead hair, swollen testicles and red swollen nipples.

a. Uva Ursi b. Fluoxetine c. Catnip d. Ginseng

27. What herbal supplement, taken to treat urinary tract infection, can cause liver damage, especially if taken for more than 5 days in a row?

a. Uva Ursi b. Valerian root c. Nepeta Cataria d. Gaurana

28. Side effects from ingesting melatonin include(s):

a. It stimulates the ovaries b. It causes liver damage when taken 5 or more days in a row c. It decreases the libido d. All of the above

29. True or False: Ginseng IS considered a safe supplement to take during pregnancy or while breastfeeding.

a. True b. False

30. What herbal supplement taken as an herbal sleep aid, is not recommended during pregnancy because it is unstudied and may correlate positively with developmental disorders?

a. Uva Ursi b. Melatonin c. Catnip d. Ginkgo Biloba

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 114 31. Toxoplasmosis is a viral infection that may be contracted by

a. sexual contact. b. breastfeeding. c. contact with a cat’s litter box. d. by ingesting catnip.

32. Toxoplasmosis may be carried by ______, and toxoplasmosis is found in their feces.

a. cats b. chickens c. rodents d. All of the above

33. A woman who is trying to become pregnant for the FIRST time is described as

a. Nulligravida b. Primigravida c. Multigravida d. Uva Ursi

34. Side effects from Ginkgo Biloba include which of the following?

a. It causes breast tenderness b. It may prolong bleeding c. It may lead to urinary tract infection d. All of the above

35. True or False: Uva Ursi has astringent and anti-inflammatory properties and is often used to treat or prevent urinary tract infections or cystitis.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 115 36. During pregnancy, the issues associated with alcohol are best stated as follows:

a. each trimester is affected the same by alcohol consumption. b. alcohol consumption is safest during the first trimester. c. consuming alcohol only causes mild behavioral changes. d. there is no safe amount of alcohol.

37. Signs and symptoms of fetal alcohol syndrome in the neonate include:

a. heart defects. b. small and narrow eyes. c. smooth upper lip. d. All of the above.

38. Screening tools for alcohol use by a pregnant mother include:

a. Fetal Doppler assessment. b. Quad Screening. c. AUDIT-C. d. Multiple marker Screening.

39. True or False: Being overweight or underweight can cause problems during gestation and lead to an increased risk of complications prenatally as well as after delivery.

a. True b. False

40. Potential dangers related to toxoplasmosis infection may include

a. malformations of the neonate’s head. b. still birth c. spontaneous abortion d. All of the above

41. True or False: Pregnant women should be taught to avoid cleaning litter boxes.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 116 42. The fetus of a smoking mother is more likely to develop

a. congenital malformations. b. preeclampsia. c. diabetes. d. Chadwick’s sign.

43. A pregnant woman should be asked which of the following question(s) her tobacco use?

a. Have you ever smoked cigarettes? b. When was the last time you smoked cigarettes? c. Are you currently smoking? d. All of the above

44. True or False: According to the American College of Obstetrics and Gynecology, women should be screened for tobacco use at their initial prenatal appointment on a case-by-case basis.

a. True b. False

45. The use of selective serotonin reuptake inhibitors to treat depression has been studied in pregnant women and the studies found that there is

a. a great risk of perinatal death. b. a high risk of hypertension. c. little to no risk of spontaneous abortion. d. a moderate risk of preeclampsia.

46. Zika virus is an emerging disease spread through

a. the bite from a tick. b. the bites of female mosquitoes. c. food. d. contact with a cat’s litter box.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 117 47. ______may be one of the dangers of the Zika virus.

a. Hydrocephalus in neonates b. Severe mental retardation in neonates c. Gestational diabetes d. Rubella infection

48. Immunity to rubella is important because a rubella infection, also known as ______, can cause miscarriage, stillbirth, and congenital risks such as intra-uterine growth restriction, hydrocephaly and other abnormalities.

a. Rhesus disease b. urinary tract infections c. German Measles d. cystitis

49. If a mother tests positive for HIV, her infant will be tested

a. 14 to 21 days post birth. b. 1 to 2 months later post birth. c. if the newborn shows symptoms of HIV. d. Answers a., and b., above

50. True or False: If the mother tests positive for HIV, she should not be encouraged to breastfeed.

a. True b. False

51. Which of the following statements about pregnant women is/are true related to domestic violence and pregnancy?

a. The risk is higher if they are over 20 years old. b. The risk is 2 to 4 times greater if the pregnancy was unplanned. c. They have a lower risk of suffering domestic violence. d. All of the above

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 118 52. Signs of abuse may include

a. injuries caused by falling. b. tobacco use. c. patient is over 35 years old. d. late initiation of prenatal care.

53. A health clinician will check for any swelling in the hands, feet, ankles, or face to monitor

a. HIV. b. Zika virus. c. high blood pressure or hypervolemia. d. Rhesus disease.

54. Methyldopa’s (a drug used to treat high blood pressure) effects on fetal development

a. are considered unsafe. b. are not alarming and are thus considered safe. c. result in adverse fetal neurodevelopment. d. result in hypervolemia.

55. True or False: Research suggests that anxiety, depression and chronic mental strain result in more cases of pre-term birth, low birth weight and adverse fetal neurodevelopment.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 119 CORRECT ANSWERS:

1. Using the Estimated Date of Delivery (EDD) method, the care provider will count ______from the first day of a woman’s last menstrual period.

c. forward 280 days

p. 6: “Clinicians may use a wheel to determine the EDD, but always count forward 280 days from the first day of a woman’s last menstrual period, or forward 266 days from the date of conception if this exact date is known, usually in cases of in vitro fertilization.”

2. ______of women deliver on their actual Estimated Date of Delivery (EDD).

d. Four percent

p. 7: “Only 4 percent of women deliver on their actual EDD because of natural biological variations in gestation and hormonal cycles.”

3. True or False: Properly determining a woman’s due date is nominally important because the patient’s contractions will provide enough notice.

b. False

p. 6: “Properly determining a woman’s due date is of utmost importance, because the more accurate the prediction of the due date is, the less likely complications related to unnecessary medical interventions will arise.”

4. Which pregnancy due date method or rule involves counting backwards three months from the first day of the last missed period and then subsequently adding 7 days?

a. Naegele’s rule

p. 7: “Currently, Naegele’s rule is the most common technique of pregnancy dating. This rule involves counting backwards three months from the first day of the last missed period and then subsequently adding 7 days.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 120 5. Using the Estimated Date of Delivery (EDD) method, the care provider will always count forward 266 days from the date of conception if

c. the exact date of conception is known.

p. 6: “Clinicians may use a wheel to determine the EDD, but always count forward 280 days from the first day of a woman’s last menstrual period, or forward 266 days from the date of conception if this exact date is known, usually in cases of in vitro fertilization.”

6. Human Chorionic Gonadotropin (hCG) levels should be drawn and an ultrasound scheduled (depending on the findings revealed in the hCG results) when

b. the mother has irregular menstrual periods.

p. 7: “Occasionally, the first day of the last menstrual cycle is unknown, either because the mother has irregular periods or because she has simply forgotten. In these cases, Human Chorionic Gonadotropin (hCG) levels should be drawn and an ultrasound scheduled depending on the findings revealed in the hCG results.”

7. A typical menstrual cycle is ______days in length.

b. 21 to 35

p. 7: “A typical menstrual cycle can be anywhere from 21 to 35 days in length.”

8. Using Naegele’s rule, if the first day of a mother’s last, missed period was October 27th, her expected due date would be

a. August 3rd.

pp. 7-8: “Imagine that the client states that her last menstrual period was October 27th. To determine this client’s expected due date, the nurse will first subtract three months, putting the date at July 27th. Next the nurse will add seven days to this date, ending up with an expected due date of 3rd August.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 121 9. True or False: Naegele’s rule is the most common technique of pregnancy dating.

a. True

p. 7: “Currently, Naegele’s rule is the most common technique of pregnancy dating.”

10. A healthcare provider will confirm pregnancy with a urine sample or laboratory blood sample

c. in all cases.

p. 8: “In the office, the health care provider will confirm pregnancy with a urine sample or sometimes with an ordered out of the office, laboratory blood sample.”

11. A woman with an above normal ______, before the start of her pregnancy, is at a higher risk of developing pregnancy-related hypertension, edema and gestational diabetes.

d. body mass index (BMI)

p. 12: “Studies have shown that having a BMI considered above normal before the start of pregnancy correlates positively with pregnancy-related hypertension, edema and gestational diabetes.”

12. Women’s Human Chorionic Gonadotropin (hCG) levels fluctuate throughout their pregnancy but as far as verifying the gestational age of the fetus, hCG levels are

c. always more reliable early on.

p. 9: “Women’s hCG levels fluctuate throughout their pregnancy but are always more reliable early on.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 122 13. The accuracy of ultrasounds ______because biological differences found within the fetus’ DNA take effect as the fetus grows in the mother’s uterus.

a. decreases with time

p. 9: “This accuracy decreases with time because biological differences found within the fetus’ DNA take effect as the fetus grows in the mother’s uterus; that is, fetuses grow at different rates, and fetal, physical measurements taken in an ultrasound for babies with the same gestational age will vary.”

14. Ultrasounds performed before six weeks are limited because locating the fetus in utero

d. may be difficult even transvaginally.

p. 10: “Like the other methods, ultrasounds have their limitations…. Before six weeks, locating the fetus in utero may be difficult even transvaginally. This can cause unnecessary anxiety and stress for the pregnant mother and her partner.”

15. A care provider examining the cervix will look for Chadwick’s sign, which refers whether or not the cervix

d. has taken on a blue or purplish tint.

p. 8: “Known as Chadwick’s sign, the care provider will note whether or not the cervix has taken on a blue or purplish tint due to the increased blood flow to the cervix.”

16. Ingesting ______may have uterine stimulation and abortifacient properties.

a. aloe vera

p. 16: “Oral Aloe Vera is not frequently taken in the United States, however it should be noted that ingesting aloe vera may have uterine stimulation and abortifacient properties.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 123 17. True or False: To get an accurate measurement of hCG levels, a urinalysis will need to be performed.

b. False

pp. 13-14: “To get an accurate measurement of hCG levels, a blood test will need to be performed.”

18. Herbal supplements are an especially pressing matter to discuss with prenatal clients because

b. they may be harmful in some cases.

p. 15: “Herbal supplements are an especially pressing matter to discuss with prenatal clients as they are often seen as ‘natural’ and therefore not harmful. However, this is not always the case.”

19. ______is often used to stave off colds or coughs, but it is considered a teratogenic product and should never be taken by a pregnant client.

d. Wild cherry extract

p. 16: “Wild cherry extract is often used to stave off colds or coughs, but it is considered a teratogenic product; that is, it may disturb fetal development. As such, wild cherry extract should never be taken by a pregnant woman. Healthcare staff should inform their clients of the potential for increased birth defects in infants born to mothers who consume this supplement during pregnancy.”

20. When an herbal supplement hastens or facilitates childbirth, especially by stimulating contractions of the uterus in a pregnant woman, it is said to

a. have an oxytocic effect.

p. 16: For example, “Echinacea, taken in an attempt to improve the immune system has a weak oxytocic effect on the pregnant uterus.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 124 21. Because the effects of ______on a developing fetus is unknown, doctors believe that taking heavily studied selective serotonin reuptake inhibitors for depression are less dangerous.

d. St. John’s Wort

p. 15: “St. John’s Wort is a herbal medicine used by pregnant women suffering from depression who may be afraid to take pharmaceutical medications during their pregnancy. However, because the effects of this herbal supplement on a developing fetus is unknown, doctors believe that taking heavily studied selective serotonin reuptake inhibitors such as fluoxetine are less dangerous.”

22. ______is a supplement frequently added to energy drinks in order to increase the drinker’s energy.

b. Gaurana

p. 16: “Gaurana is a supplement frequently added to energy drinks, which people drink in order to increase their energy. Pregnant women should be advised to avoid gaurana because it has been shown to lead to the birth of babies prematurely, infants of low birth weight, and possible birth defects.”

23. True or False: Pregnant women should be advised to avoid gaurana because it has been shown to lead to the birth of babies prematurely, infants of low birth weight, and possible birth defects.

a. True

p. 16: “Gaurana is a supplement frequently added to energy drinks, which people drink in order to increase their energy. Pregnant women should be advised to avoid gaurana because it has been shown to lead to the birth of babies prematurely, infants of low birth weight, and possible birth defects.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 125 24. What herbal supplement taken for sleep induction is NOT recommended in pregnant women as it has the ability to stimulate uterine activity and induce labor prematurely, possibly leading to abortion?

c. Catnip

p. 16: “[Catnip] is not recommended in pregnant women as it has the ability to stimulate uterine activity and induce labor prematurely possibly leading to abortion.”

25. ______, taken in an attempt to improve the immune system, has a weak oxytocic effect on the pregnant uterus.

b. Echinacea

p. 16: “Echinacea, taken in an attempt to improve the immune system has a weak oxytocic effect on the pregnant uterus.”

26. One study found that a woman who had consumed ______while pregnant gave birth to an infant with pubic hair, forehead hair, swollen testicles and red swollen nipples.

d. Ginseng

p. 17: “One study found that a woman who had consumed [ginseng] while breastfeeding gave birth to an infant with pubic hair, forehead hair, swollen testicles and red swollen nipples.”

27. What herbal supplement, taken to treat urinary tract infection, can cause liver damage, especially if taken for more than 5 days in a row?

a. Uva Ursi

p. 17: “[Uva ursi] can cause liver damage, especially if taken for more than 5 days in a row. For this reason, uva ursi is a dangerous medication for pregnant women.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 126 28. Side effects from ingesting melatonin include(s):

c. It decreases the libido

p. 17: “What is known for certain about [melatonin] is that it’s an ovarian suppressant and decreases sexual libido, both of which can be troublesome for women planning to become pregnant.”

29. True or False: Ginseng IS considered a safe supplement to take during pregnancy or while breastfeeding.

b. False

p. 17: “Promoted as a memory and concentration promoter, ginseng is not considered a safe supplement to take during pregnancy or while breastfeeding.”

30. What herbal supplement taken as an herbal sleep aid, is not recommended during pregnancy because it is unstudied and may correlate positively with developmental disorders?

b. Melatonin

p. 17: “Melatonin, another common herbal sleep aid, is not recommended during pregnancy, primarily due to the lack of studies surrounding the subject, although it may correlate positively with developmental disorders.”

31. Toxoplasmosis is a viral infection that may be contracted by

c. contact with a cat’s litter box.

p. 23: “Toxoplasmosis is carried by cats, chickens and rodents, and is found in their feces. Pregnant women should be taught to avoid cleaning litter boxes.”

32. Toxoplasmosis may be carried by ______, and toxoplasmosis is found in their feces.

d. All of the above

p. 23: “Toxoplasmosis is carried by cats, chickens and rodents, and is found in their feces.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 127 33. A woman who is trying to become pregnant for the FIRST time is described as

a. Nulligravida

p. 18: “The number of pregnancies a woman has is described as follows: “Nulligravida”, meaning a woman who has never been pregnant, “Primigravida”, or a woman who is pregnant for the first time or has been pregnant once before and “Multigravida”, which refers to a woman who has been pregnant more than once.”

34. Side effects from Ginkgo Biloba include which of the following?

b. It may prolong bleeding

p. 18: “Anti-platelet properties in gingko may prolong bleeding, increasing the potential for haemorrhage.”

35. True or False: Uva Ursi has astringent and anti-inflammatory properties and is often used to treat or prevent urinary tract infections or cystitis.

a. True

p. 17: “Uva Ursi has astringent and anti-inflammatory properties and is often used to treat or prevent urinary tract infections or cystitis.”

36. During pregnancy, the issues associated with alcohol are best stated as follows:

d. there is no safe amount of alcohol.

p. 46: “The patient needs to be educated that alcohol use is very harmful to developing fetuses and should be stopped completely during pregnancy.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 128 37. Signs and symptoms of fetal alcohol syndrome in the neonate include:

d. All of the above.

pp. 45-46: “Signs and symptoms of fetal alcohol syndrome in the neonate include heart defects such as a ventricle septal defect or an atrial septal defect. Infants with fetal alcohol syndrome tend to be weak and have physical issues with the face. Facial features such as small and narrow eyes with a small head and fine, smooth upper lip are generally indicators of the disease.”

38. Screening tools for alcohol use by a pregnant mother include:

c. AUDIT-C.

p. 46: “Several screening tools, such as CAGE, TWEAK, or AUDIT-C, exist for assessing a newly pregnant woman’s alcohol use.”

39. True or False: Being overweight or underweight can cause problems during gestation and lead to an increased risk of complications prenatally as well as after delivery.

a. True

p. 48: “Both being overweight or underweight can cause problems during gestation and lead to an increased risk of complications prenatally as well as after delivery.”

40. Potential dangers related to toxoplasmosis infection may include

d. All of the above

p. 23: “Potential dangers related to toxoplasmosis infection may cause malformations of the neonate’s head, still birth, or spontaneous abortion.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 129 41. True or False: Pregnant women should be taught to avoid cleaning litter boxes.

a. True

p. 23: “Pregnant women should be taught to avoid cleaning litter boxes.”

42. The fetus of a smoking mother is more likely to develop

a. congenital malformations.

p. 46: “The fetus is put at major risk; the fetus of a smoking mother is more likely to develop congenital malformations, acquire fetal growth restriction, be born prematurely, suffer from SIDS or sudden infant death syndrome, or display long term behavioral problems in childhood.”

43. A pregnant woman should be asked which of the following question(s) her tobacco use?

d. All of the above

p. 46: “… all women should be screened for tobacco use at their initial prenatal appointment.72 Women should be asked if they have ever smoked cigarettes, the last time they smoked cigarettes, and if they currently smoke.”

44. True or False: According to the American College of Obstetrics and Gynecology, women should be screened for tobacco use at their initial prenatal appointment on a case-by-case basis.

b. False

p. 46: “According to the American College of Obstetrics and Gynecology, all women should be screened for tobacco use at their initial prenatal appointment.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 130 45. The use of selective serotonin reuptake inhibitors to treat depression has been studied in pregnant women and the studies found that there is

c. little to no risk of spontaneous abortion.

p. 43: “The use of selective serotonin reuptake inhibitors to treat depression has been studied in pregnant women and have found little to no risk of spontaneous abortion, hypertension, or perinatal death.”

46. Zika virus is an emerging disease spread through

b. the bites of female mosquitoes.

p. 23: “Zika virus is an emerging disease spread through the bites of female mosquitos.”

47. ______may be one of the dangers of the Zika virus.

b. Severe mental retardation in neonates

p. 23: “Other brain abnormalities [from Zika virus] are also noted including severe mental retardation.”

48. Immunity to rubella is important because a rubella infection, also known as ______, can cause miscarriage, stillbirth, and congenital risks such as intra-uterine growth restriction, hydrocephaly and other abnormalities.

c. German Measles

p. 26: “Immunity to rubella is important because a rubella infection, also known as German Measles, can cause miscarriage, stillbirth, and congenital risks such as intra-uterine growth restriction, hydrocephaly and other abnormalities.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 131 49. If a mother tests positive for HIV, her infant will be tested

d. Answers a., and b., above

p. 27: “If the mother tests positive for HIV, her medical staff should help her adjust to an appropriate antiretroviral treatment plan. Her infant will then be tested 14 to 21 days post birth and again 1 to 2 months later.”

50. True or False: If the mother tests positive for HIV, she should not be encouraged to breastfeed.

a. True

p. 27: “HIV positive mothers should not be encouraged to breastfeed.”

51. Which of the following statements about pregnant women is/are true related to domestic violence and pregnancy?

b. The risk is 2 to 4 times greater if the pregnancy was unplanned.

p. 19. “The American College of Obstetricians and Gynecologists also recommends that all pregnant women are assessed for abuse during each prenatal visit because pregnancy increases a woman’s risk of falling victim to domestic violence. Women are at an even higher risk of falling victim to violence if they are under 20 years old. Pregnant women are also at a two to four times greater risk if their pregnancy was unplanned.”

52. Signs of abuse may include

d. late initiation of prenatal care. p. 19. “Signs of abuse may be late initiation of prenatal care, unexplained or poorly explained injury or bruising, as well as depression.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 132 53. A health clinician will check for any swelling in the hands, feet, ankles, or face to monitor

c. high blood pressure or hypervolemia.

p. 25: “The health clinician will need to check for any swelling in the hands, feet, ankles, or face. This is performed in order to monitor symptoms of beginning high blood pressure or hypervolemia.”

54. Methyldopa’s (a drug used to treat high blood pressure) effects on fetal development

b. are not alarming and are thus considered safe.

p. 33: “Methyldopa works to treat high blood pressure by relaxing and dilating the blood vessels. In terms of safety, this medication’s effects on fetal development are not alarming and are thus considered safe. The downside to this medication is that some women feel it has a sedating effect while it only acts as a mild antihypertensive with a slow onset of action.”

55. True or False: Research suggests that anxiety, depression and chronic mental strain result in more cases of pre-term birth, low birth weight and adverse fetal neurodevelopment.

a. True

p. 24: “In fact, research suggests that anxiety, depression and chronic mental strain result in more cases of pre-term birth, low birth weight and adverse fetal neurodevelopment.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 133 References Section

The reference section of in-text citations include published works intended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text.

1. Whitworth M, Bricker L, Neilson JP, Dowswell T. Ultrasound for fetal assessment in early pregnancy. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD007058. 2. Sfakianaki, MD ACopel, MD J. Prenatal assessment of gestational age and estimated date of delivery. uptodatecom (2016). Available at: https://www.uptodate.com/contents/prenatal-assessment-of- gestational-age-and-estimated-date-of-delivery. Accessed July 5, 2016. 3. Goff, MD B. Human chorionic gonadotropin: Testing in pregnancy and gestational trophoblastic disease and causes of low persistent levels. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/human-chorionic- gonadotropin-testing-in-pregnancy-and-gestational-trophoblastic- disease-and-causes-of-low-persistent- levels?source=search_result&search=when+check+hcg&selectedTit le=1%7E150. Accessed July 5, 2016. 4. Liu L, Hong Z, Zhang L. Associations of prepregnancy body mass index and with pregnancy outcomes in nulliparous women delivering single live babies. Sci Rep. 2015;5:12863. doi:10.1038/srep12863. 5. Update on Prenatal Care (2016). American Family Physician. at: http://www.aafp.org/afp/2014/0201/p199.html#afp20140201p199 -b6. Accessed July 6, 2016. 6. Updated by: Linda J. Vorvick a. Clean catch urine sample: MedlinePlus Medical Encyclopedia. Nlmnihgov. 2016. Available at: https://www.nlm.nih.gov/medlineplus/ency/article/007487.htm. Accessed July 6, 2016. 7. Lockwood, MD, MHCM C. Initial prenatal assessment and first- trimester prenatal care. Uptodatecom. 2016. Available at: https://www.uptodate.com/contents/initial-prenatal-assessment- and-first-trimester-prenatal- care?source=search_result&search=first+trimester+pregnancy&sel ectedTitle=1%7E150. Accessed July 6, 2016.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 134 8. Uva ursi. University of Maryland Medical Center. 2016. Available at: http://umm.edu/health/medical/altmed/herb/uva-ursi. Accessed August 2, 2016. 9. Matuszkiewicz-Rowińska J, Małyszko J, Wieliczko M. State of the art paper Urinary tract infections in pregnancy: old and new unresolved diagnostic and therapeutic problems. Archives of Medical Science. 2015;1:67-77. doi:10.5114/aoms.2013.39202. 10. Melatonin (N-acetyl-5-methoxytryptamine) Safety - Mayo Clinic. Mayoclinicorg. 2016. Available at: http://www.mayoclinic.org/drugs- supplements/melatonin/safety/hrb-20059770. Accessed August 2, 2016. 11. Le Bars PKastelan J. Efficacy and safety of a Ginkgo biloba extract. Public Health Nutrition. 2000;3(4a). doi:10.1017/s1368980000000574. 12. Ob-Gyns Redefine Meaning of "Term Pregnancy" - ACOG. Acogorg. 2016. Available at: http://www.acog.org/About-ACOG/News- Room/News-Releases/2013/Ob-Gyns-Redefine-Meaning-of-Term- Pregnancy. Accessed July 6, 2016. 13. Dunkel Schetter CTanner L. Anxiety, depression and stress in pregnancy. Current Opinion in Psychiatry. 2012;25(2):141-148. doi:10.1097/yco.0b013e3283503680. 14. Pregnancy and Domestic Violence Facts. National Coalition Against Domestic Violence. 2016. Available at: http://www.uua.org/sites/live- new.uua.org/files/documents/ncadv/dv_pregnancy.pdf. Accessed August 2, 2016. 15. Question and Answers: Zika virus infection (Zika) and pregnancy | Zika virus | CDC. Cdcgov. 2016. Available at: http://www.cdc.gov/zika/pregnancy/question-answers.html. Accessed August 2, 2016. 16. Menéndez C, Ferenchick E, Roman E, Bardají A, Mangiaterra V. Malaria in pregnancy: challenges for control and the need for urgent action. The Lancet Global Health. 2015;3(8):e433-e434. doi:10.1016/s2214-109x(15)00041-8. 17. Tauxe G, MacWilliam D, Boyle S, Guda T, Ray A. Targeting a Dual Detector of Skin and CO2 to Modify Mosquito Host Seeking. Cell. 2013;155(6):1365-1379. doi:10.1016/j.cell.2013.11.013. 18. Carusi, MD, MSc D. The gynecologic history and pelvic exam. 2016. Available at: http://www.uptodate.com/contents/the-gynecologic- history-and-pelvic- examination?source=machineLearning&search=pelvic+exam&select edTitle=1%7E150§ionRank=1&anchor=H19#H19. Accessed July 6, 2016.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 135 19. Berghella, MD V. Cervical insufficiency. uptodatecom. 2016. Available at: http://www.uptodate.com. Accessed August 2, 2016. 20. Norwitz, MD, PhD, MBA E. Transvaginal cervical cerclage. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/transvaginal-cervical- cerclage?source=search_result&search=cercival+cerclage&selected Title=1%7E35#H11. Accessed August 2, 2016. 21. Moise Jr, MD K. Prevention of Rh(D) alloimmunization in pregnancy. Uptodatecom. 2016. Available at: https://www.uptodate.com/contents/prevention-of-rh-d- alloimmunization-in-pregnancy?source=see_link. Accessed July 7, 2016. 22. Yates, M.D. A. Prenatal Screening and testing for hemoglobinopathy. Uptodatecom. 2016. Available at: https://www.uptodate.com/contents/prenatal-screening-and- testing-for-hemoglobinopathy?source=see_link. Accessed July 7, 2016. 23. Riley, M.D. L. Rubella in pregnancy. Uptodatecmo. 2016. Available at: https://www.uptodate.com/contents/rubella-in- pregnancy?source=see_link. Accessed July 7, 2016. 24. Riley, M.D. L. Varicella-zoster infection in pregnancy. Uptodatecom. 2016. Available at: https://www.uptodate.com/contents/varicella- zoster-virus-infection-in-pregnancy?source=see_link. Accessed July 7, 2016. 25. Norwitz, MD, PhD, MBA EHicks, MD C. Syphilis in pregnancy. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/syphilis- inpregnancy?source=see_linkAccessed July 7, 2016. 26. Teo, MD ELok, MD A. , transmission, and prevention of hepatitis B virus infection. Uptodatecom. 2016. Available at: https://www.uptodate.com/contents/epidemiology-transmission- and-prevention-of-hepatitis-b-virus- infection?source=see_link§ionName=Mother-to- child+transmission&anchor=H4#H4. Accessed July 7, 2016 27. Oral Health Care During Pregnancy | OHRC. Mchoralhealthorg. 2016. Available at: http://mchoralhealth.org/materials/consensus_statement.php. Accessed July 7, 2016. 28. Tanya Wrzosek A. Dental care during pregnancy. Canadian Family Physician. 2009;55(6):598. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2694079/. Accessed August 2, 2016. 29. August, MD, MPH PSibai, MD B. Preeclampsia: Clinical features and diagnosis. Uptodatecom. 2016. Available at:

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 136 http://www.uptodate.com/contents/preeclampsia-clinical-features- anddiagnosis?source=see_link§ionName=Preexisting+hyperten sion+versus+preeclampsia&anchor=H15110283#H15110283. Accessed July 7, 2016. 30. Norwitz, MD, PhD, MBA E. Expectant management of preeclampsia with severe features. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/expectant-management-of- preeclampsia-with- severefeatures?source=machineLearning&search=fetal+risks+of+p reeclampsia&selectedTitle=5%7E150§ionRank=1&anchor=H59 80324#H5980324. Accessed July 7, 2016. 31. Management of hypertension in pregnant and postpartum women. uptodatecom. 2016. Available at: http://www.uptodate.com/contents/management-of-hypertension- in-pregnant-and-postpartum- women?source=machineLearning&search=management+of+preexi sting+hypertension+pregnancy&selectedTitle=1%7E150§ionRa nk=1&anchor=H15#H15. Accessed July 7, 2016. 32. Cockburn J, Ounsted M, Moar V, Redman C. FINAL REPORT OF STUDY ON HYPERTENSION DURING PREGNANCY: THE EFFECTS OF SPECIFIC TREATMENT ON THE GROWTH AND DEVELOPMENT OF THE CHILDREN. The Lancet. 1982;319(8273):647-649. doi:10.1016/s0140-6736(82)92202-4. 33. Waksmonski, MD C, LaSala, MD A, R Foley, MD M. Acquired heart disease and pregnancy. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/acquired-heart-disease-and- pregnancy?source=search_result&search=heart+disease+in+pregn ancy&selectedTitle=1%7E150. Accessed July 7, 2016. 34. Cooper Jr., MD L. Definition and classification of the cardiomyopathies. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/definition-and-classification-of- the- cardiomyopathies?source=machineLearning&search=cardiomyopath y&selectedTitle=1%7E150§ionRank=1&anchor=H5#H5. Accessed July 7, 2016. 35. Diagnosing and Treating Acute Infective Endocarditis. Virtual Mentor. 2010;12(10):796-799. doi:10.1001/virtualmentor.2010.12.10.cprl1-1010. 36. Burkart TConti J. Cardiac Arrhythmias During Pregnancy. Current Treatment Options in Cardiovascular Medicine. 2010;12(5):457- 471. doi:10.1007/s11936-010-0084-7. 37. Enriquez A, Economy K, Tedrow U. Contemporary Management of Arrhythmias During Pregnancy. Circulation: Arrhythmia and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 137 Electrophysiology. 2014;7(5):961-967. doi:10.1161/circep.114.001517. 38. How are blood clots treated during pregnancy? - Blood Clots. Blood Clots. 2016. Available at: https://www.stoptheclot.org/pregnancy/clot_treatment_pregnancy. htm. Accessed August 5, 2016. 39. Foley, MD M. Pregnancy after cardiac transplantation. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/pregnancy- after-cardiac-transplantation?source=see_link. Accessed July 8, 2016. 40. Ross L. Ethical Considerations Related to Pregnancy in Transplant Recipients. New England Journal of Medicine. 2006;354(12):1313- 1316. doi:10.1056/nejmsb041648. 41. Causes of Diabetes. Niddknihgov. 2016. Available at: https://www.niddk.nih.gov/health-information/health- topics/Diabetes/causes-diabetes/Pages/index.aspx. Accessed July 8, 2016. 42. Updated by: Walead Latif a. Glucose urine test: MedlinePlus Medical Encyclopedia. Nlmnihgov. 2016. Available at: https://www.nlm.nih.gov/medlineplus/ency/article/003581.htm. Accessed July 8, 2016. 43. Thadhani, MD, MPH RMaynard, MD S. Proteinuria in pregnancy: Evaluation and management. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/proteinuria-in-pregnancy- evaluation-and- management?source=search_result&search=protein+in+urine+leve ls&selectedTitle=6%7E150. Accessed August 8, 2016. 44. Kopelman, MD A. Respiratory Distress Syndrome. Merck Manuals Consumer Version. 2016. Available at: https://www.merckmanuals.com/home/children-s-health- issues/problems-in-newborns/respiratory-distress-syndrome. Accessed August 8, 2016. 45. Maria Verner A, Manderson J, Lappin T, McCance D, Halliday H, Sweet D. Influence of maternal diabetes mellitus on fetal iron status. Archives of Disease in Childhood - Fetal and Neonatal Edition. 2007;92(5):F399-F401. doi:10.1136/adc.2006.097279. 46. Mills J. Malformations in infants of diabetic mothers. Teratology. 2010;25(3):385-394. doi:10.1002/tera.1420250316. 47. Abrams, MD S. neonatal hypocalcemia. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/neonatal- hypocalcemia#H7. Accessed August 8, 2016. 48. Wong, BA RBhutani, MD, FAAP V. Pathogenesis and etiology of unconjuagated hyperbilirubinemia in the newborn. uptodatecom. 2016. Available at:

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 138 https://www.uptodate.com/contents/pathogenesis-and-etiology-of- unconjugated-hyperbilirubinemia-in-the- newborn?source=machineLearning&search=hyperbilirubinemia+ne wborn&selectedTitle=1%7E150§ionRank=1&anchor=H15#H15. Accessed August 8, 2016. 49. Facts & Statistics | Anxiety and Depression Association of America, ADAA. Adaaorg. 2016. Available at: http://www.adaa.org/about- adaa/press-room/facts-statistics. Accessed July 8, 2016. 50. Roy-Byrne, MD P. Unipolar major depression in pregnant women. Uptodatecom. 2016. Available at: https://www.uptodate.com/contents/unipolar-major-depression-in- pregnant-women-clinical-features-consequences-assessment-and- diagnosis?source=search_result&search=depression+in+pregnancy &selectedTitle=2%7E150. Accessed July 8, 2016. 51. Lyness, MD J. Unipolar Depression in Adults: Clinical features. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/unipolar-depression-in-adults- clinical-features?source=see_link. Accessed July 8, 2016. 52. Stewart, CM, MD, FRCPC DVigod, MD, MSc, FRCPC S. Risks of antidepressants during pregnancy: Selective serotonin reuptake inhibitors (SSRIs). uptodatecom. 2016. Available at: https://www.uptodate.com/contents/risks-of-antidepressants- during-pregnancy-selective-serotonin-reuptake-inhibitors- ssris?source=see_link. Accessed July 8, 2016. 53. FAQ Genetic Disorders. Acogorg. 2016. Available at: https://www.acog.org/-/media/For- Patients/faq094.pdf?dmc=1&ts=20160708T0710414094. Accessed July 8, 2016. 54. Cystic Fibrosis Life Expectancy. Cystic Fibrosis News Today. 2016. Available at: http://cysticfibrosisnewstoday.com/cystic-fibrosis-life- expectancy/. Accessed August 9, 2016. 55. Cystic fibrosis. Genetics Home Reference. 2016. Available at: https://ghr.nlm.nih.gov/condition/cystic-fibrosis#inheritance. Accessed July 8, 2016. 56. Ghanem, MD, PhD KTuddenham, MD, MPH S. Screening for sexually transmitted infections. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/screening-for-sexually- transmitted- infections?source=machineLearning&search=risk+for+sexually+tra nsmitted+diseases&selectedTitle=1%7E150§ionRank=1&ancho r=H602295897#H602295897. Accessed July 8, 2016. 57. Kaneshiro a. Fetal alcohol syndrome: MedlinePlus Medical Encyclopedia. Medlineplusgov. 2016. Available at:

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 139 https://medlineplus.gov/ency/article/000911.htm. Accessed August 9, 2016. 58. Chang, MD, MPH G. Alcohol intake and pregnancy. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/alcohol- intake-and-pregnancy?source=see_link. Accessed July 8, 2016. 59. Rodriguez-Thompson, MD, MPH D. Cigarette smoking: Impact on pregnancy and the neonate. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/cigarette-smoking-impact-on- pregnancy-and-the-neonate?source=see_link. Accessed July 8, 2016. 60. How to Quit Smoking: A Guide to Kicking the Habit for Good. Helpguideorg. 2016. Available at: http://www.helpguide.org/articles/addiction/how-to-quit- smoking.htm. Accessed August 9, 2016. 61. Prenatal Nutrition Screening. Glensfallshospitalorg. 2016. Available at: http://www.glensfallshospital.org/services/Nutrition- Center/prenatal-nutrition-screening.cfm. Accessed July 8, 2016. 62. FC Denison, P Norwood, S Bhattacharya, A Duffy, T Mahmood, C Morris, EA Raja, JE Norman, AJ Lee, G Scotland. Association between maternal body mass index during pregnancy, short-term morbidity, and increased health service costs: a population-based study. BJOG: An International Journal of Obstetrics & Gynaecology, 2013; DOI: 10.1111/1471- 0528.12443http://dx.doi.org/10.1111/1471-0528.12443 http://dx.doi.org/10.1111/1471-0528.12443 63. Wolpert A. Pregnant mothers with strong family support less likely to have postpartum depression. UCLA Newsroom. 2013. Available at: http://newsroom.ucla.edu/releases/stress-hormone-foreshadows- postpartum-243844. Accessed July 9, 2016. 64. Duncan LBardacke N. Mindfulness-Based Childbirth and Parenting Education: Promoting Family Mindfulness During the Perinatal Period. Journal of Child and Family Studies. 2009;19(2):190-202. doi:10.1007/s10826-009-9313-7. 65. Pregnancy hormones | NCT. Nctorguk. 2016. Available at: https://www.nct.org.uk/pregnancy/hormones- pregnancy#Conception%20and%20early%20pregnancy. Accessed July 10, 2016. 66. Russo, MD J. Breast Development and Morphology. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/breast- development-and- morphology?source=machineLearning&search=hormonal+change+f irst+trimester&selectedTitle=9%7E150§ionRank=1&anchor=H1 9#H11. Accessed July 10, 2016.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 140 67. Geraghty LPomeranz M. Physiologic changes and dermatoses of pregnancy. International Journal of Dermatology. 2011;50(7):771- 782. doi:10.1111/j.1365-4632.2010.04869.x. 68. Mahendru A, Everett T, McEniery C, Wilkinson I, Lees C. O12. Pre- pregnancy to early pregnancy changes in maternal cardiovascular physiology. Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health. 2011;1(3-4):262-263. doi:10.1016/j.preghy.2011.08.044. 69. Odedra K. Treatment of rhinitis in pregnancy. Nursing Standard. 2014;29(8):37-41. doi:10.7748/ns.29.8.37.e9089. 70. Sangsawang BSangsawang N. Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. International Urogynecology Journal. 2013;24(6):901-912. doi:10.1007/s00192-013-2061-7. 71. Bradley C, Kennedy C, Turcea A, Rao S, Nygaard I. Constipation in Pregnancy. Obstetrics & Gynecology. 2007;110(6):1351-1357. doi:10.1097/01.aog.0000295723.94624.b1. 72. Bermas, MD B. Musculoskeletal changes and pain during pregnancy and postpartum. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/musculoskeletal-changes-and- pain-during-pregnancy-and-postpartum?source=see_link. Accessed July 10, 2016. 73. Pięta B, Jurczyk M, Wszołek K, Opala T. Emotional changes occurring in women in pregnancy, parturition and lying-in period according to factors exerting an effect on a woman during the peripartum period. Annals of Agricultural and Environmental Medicine. 2014;21(3):661-665. doi:10.5604/12321966.1120621. 74. Welcome to Berkeley Parents Network | Berkeley Parents Network. Berkeleyparentsnetworkorg. 2016. Available at: https://www.berkeleyparentsnetwork.org. Accessed July 10, 2016. 75. Pregnancy and medicines fact sheet | womenshealth.gov. Womenshealthgov. 2016. Available at: http://womenshealth.gov/publications/our-publications/fact- sheet/pregnancy-medicines.html. Accessed September 21, 2016. 76. Pregnancy and Lactation Labeling (Drugs) Final Rule. Fdagov. 2016. Available at: http://www.fda.gov/Drugs/DevelopmentApprovalProcess/Developm entResources/Labeling/ucm093307.htm. Accessed September 21, 2016. 77. Appendix 2. Estimated Calorie Needs per Day, by Age, Sex, and Physical Activity Level - 2015-2020 Dietary Guidelines - health.gov. Healthgov. 2016. Available at: https://health.gov/dietaryguidelines/2015/guidelines/appendix-2/. Accessed September 17, 2016.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 141 78. Updated by: Cynthia D. White a. Eating right during pregnancy: MedlinePlus Medical Encyclopedia. Medlineplusgov. 2016. Available at: https://medlineplus.gov/ency/patientinstructions/000584.htm. Accessed September 17, 2016. 79. Food Safety for Pregnant Women | FoodSafety.gov. Foodsafetygov. 2016. Available at: https://www.foodsafety.gov/risk/pregnant/. Accessed September 18, 2016. 80. What can I do to promote a healthy pregnancy?. Nichdnihgov. 2016. Available at: https://www.nichd.nih.gov/health/topics/preconceptioncare/conditi oninfo/pages/healthy-pregnancy.aspx. Accessed September 18, 2016. 81. Exercise During Pregnancy - ACOG. Acogorg. 2016. Available at: http://www.acog.org/Patients/FAQs/Exercise-During-Pregnancy. Accessed September 18, 2016. 82. Staying healthy and safe | womenshealth.gov. Womenshealthgov. 2016. Available at: http://womenshealth.gov/pregnancy/you-are- pregnant/staying-healthy-safe.html#b. Accessed September 18, 2016. 83. Ayoola A. Reducing the number of antenatal care visits in low-risk pregnancies increases perinatal mortality in low- and middle-income countries; women in all settings prefer the standard visit schedule. Evidence-Based Nursing. 2011;14(2):55-56. doi:10.1136/ebn1136. 84. Bermas, MD B. Use of anti-inflammatory and immunosuppressive drugs in rheumatic diseases during pregnancy. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/use-of- antiinflammatory-and-immunosuppressive-drugs-in-rheumatic- diseases-during-pregnancy-and-lactation?source=see_link. Accessed July 11, 2016. 85. Matthews A, Dowswell T, Haas D, Doyle M, O'Mathúna D. Interventions for nausea and vomiting in early pregnancy. Sao Paulo Med J. 2011;129(1):55-55. doi:10.1590/s1516-31802011000100013. 86. Nzu, Traditional Remedy for Morning Sickness. Fdagov. 2016. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAle rtsforHumanMedicalProducts/ucm196045.htm. Accessed July 13, 2016. 87. Viljoen E, Visser J, Koen N, Musekiwa A. A systematic review and meta-analysis of the effect and safety of ginger in the treatment of pregnancy-associated nausea and vomiting. Nutrition Journal. 2014;13(1). doi:10.1186/1475-2891-13-20. 88. Seto A, Einarson T, Koren G. Pregnancy Outcome Following First Trimester Exposure to Antihistamines: Meta-Analysis. Amer J Perinatol. 1997;14(03):119-124. doi:10.1055/s-2007-994110.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 142 89. Dungan J. Promethazine Compared With Metoclopramide for Hyperemesis Gravidarum: A Randomized Controlled Trial. Yearbook of Obstetrics, Gynecology and Women's Health. 2011;2011:209- 211. doi:10.1016/j.yobg.2011.06.086. 90. Carstairs S. Ondansetron Use in Pregnancy and Birth Defects. Obstetrics & Gynecology. 2016;127(5):878-883. doi:10.1097/aog.0000000000001388. 91. Uterus Size During Pregnancy. American Pregnancy Association. 2013. Available at: http://americanpregnancy.org/while-pregnant/uterus- size-during-pregnancy/. Accessed July 11, 2016. 92. Yeast Infections During Pregnancy: Symptoms & Treatment. American Pregnancy Association. 2012. Available at: http://americanpregnancy.org/pregnancy-complications/yeast- infections-during-pregnancy/. Accessed September 19, 2016. 93. Yeast infection (vaginal) Treatments and drugs - Mayo Clinic. Mayoclinicorg. 2016. Available at: http://www.mayoclinic.org/diseases-conditions/yeast- infection/basics/treatment/con-20035129. Accessed September 21, 2016. 94. High-dose fluconazole becomes pregnancy category D. Reactions Weekly. 2011;&NA;(1364):3. doi:10.2165/00128415-201113640- 00005. 95. How to Prevent Urinary Tract Infections During Pregnancy. American Pregnancy Association. 2012. Available at: http://americanpregnancy.org/pregnancy-complications/urinary- tract-infections-during-pregnancy/. Accessed September 21, 2016. 96. Gardosi JFrancis A. Controlled trial of fundal height measurement plotted on customised antenatal growth charts. BJOG: An International Journal of Obstetrics and Gynaecology. 1999;106(4):309-317. doi:10.1111/j.1471-0528.1999.tb08267.x. 97. Messerlian, PhD GPalomaki, PhD G. Laboratory issues related to maternal serum screening for down syndrome. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/laboratory- issues-related-to-maternal-serum-screening-for-down- syndrome?source=see_link§ionName=Smith-Lemli- Opitz+syndrome&anchor=H28084478#H28084478. Accessed July 14, 2016. 98. Messerlian, PhD G, Farina, MD A, Palomaki G. First-trimester combined test and integrated tests for screening for Down syndrome and trisomy 18. Uptodatecom. 2016. Available at: https://www.uptodate.com/contents/first-trimester-combined-test- and-integrated-tests-for-screening-for-down-syndrome-and- trisomy-18?source=see_link. Accessed July 14, 2016.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 143 99. McLone, MD, PhD DM Bowman, MD R. Pathophysiology and clinical manifestations of myelomeningocele (spina bifida). uptodatecom. 2016. Available at: https://www.uptodate.com/contents/pathophysiology-and-clinical- manifestations-of-myelomeningocele-spina- bifida?source=search_result&search=spina+bifida&selectedTitle=2 %7E121#H14. Accessed August 10, 2016. 100. Weerakkody Y. Fetal heart rate | Radiology Reference Article | Radiopaedia.org. Radiopaediaorg. 2016. Available at: http://radiopaedia.org/articles/fetal-heart-rate. Accessed July 14, 2016. 101. Signore, MD, MPH CSpong, MD C. Overview of antepartum fetal surveillance. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/overview-of-antepartum-fetal- surveillance?source=machineLearning&search=fetal+doppler+heart +tones&selectedTitle=1%7E150§ionRank=1&anchor=H113011 2032#H1130112032. Accessed July 14, 2016. 102. Roberts, PhD VMyatt, PhD, FRCOG L. Placental development and physiology. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/placental-development-and- physiology?source=search_result&search=placenta&selectedTitle=2 %7E150#H175804821. Accessed August 10, 2016. 103. Diabetes mellitus in pregnancy: Screening and diagnosis. uptodatecom. 2016. Available at: http://www.uptodate.com/contents/diabetes-mellitus-in- pregnancy-screening-and- diagnosis?source=search_result&search=glucose+testing&selectedT itle=3%7E150#H11. Accessed July 15, 2016. 104. Jones C, Chan C, Farine D. Sex in pregnancy. Canadian Medical Association Journal. 2011;183(7):815-818. doi:10.1503/cmaj.091580. 105. Lee J, Lin C, Wan G, Liang C. Sexual Positions and Sexual Satisfaction of Pregnant Women. Journal of Sex & Marital Therapy. 2010;36(5):408-420. doi:10.1080/0092623x.2010.510776. 106. Divon, MD M. Fetal growth restriction: Diagnosis. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/fetal- growth-restriction- diagnosis?source=machineLearning&search=fundal+height&selecte dTitle=1%7E18§ionRank=1&anchor=H8#H8. Accessed July 15, 2016. 107. Fretts, MD, MPH R. Decreased fetal movement: Diagnosis, evaluation, and management. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/decreased-fetal-movement- diagnosis-evaluation-and-

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 144 management?source=search_result&search=fetal+kick+counts&sel ectedTitle=1%7E11. Accessed July 15, 2016. 108. Pregnancy Month by Month | Hunterdon Healthcare. Hunterdon Healthcare. 2016. Available at: http://www.hunterdonhealthcare.org/service/maternity/pregnancy- month-by-month/#seventh. Accessed July 15, 2016. 109. Rho(D) immune globulin: Drug information. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/rho-d-immune- globulin-drug- information?source=search_result&search=rhogam&selectedTitle=1 %7E83. Accessed July 15, 2016. 110. Antenatal Care Module: 10. Estimating Gestational Age from Fundal Height Measurement: View as single page. Openedu. 2016. Available at: http://www.open.edu/openlearnworks/mod/oucontent/view.php?id =40&printable=1. Accessed July 15, 2016. 111. Hofmeyr, MD G. Delivery of the fetus in breech presentation. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/delivery-of-the-fetus-in-breech- presentation?source=search_result&search=head+down+pregnanc y&selectedTitle=3%7E150. Accessed July 15, 2016. 112. Grens K. Most breech births are now by C-section: study. Reuters. 2016. Available at: http://www.reuters.com/article/us-breech- births-idUSBRE83G15Z20120417. Accessed August 10, 2016. 113. Group B Strep | GBS | Home | Streptococcus | CDC. Cdcgov. 2016. Available at: http://www.cdc.gov/groupbstrep/. Accessed July 15, 2016. 114. Treatment - Group B strep disease - Mayo Clinic. Mayoclinicorg. 2016. Available at: http://www.mayoclinic.org/diseases- conditions/group-b-strep/diagnosis-treatment/treatment/txc- 20200558. Accessed July 15, 2016. 115. Hofmeyr, MD G. External Cephalic Version. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/external- cephalic- version?source=search_result&search=external+cephalic+version& selectedTitle=1%7E150. Accessed July 17, 2016. 116. Harvey D. EXTERNAL CEPHALIC VERSION IN THE MANAGEMENT OF BREECH PRESENTATION. Developmental Medicine & Child Neurology. 2008;15(3):357-359. doi:10.1111/j.1469- 8749.1973.tb04893.x 117. Stages of Labor: Early, Active & Transition Stage. American Pregnancy Association. 2012. Available at: http://americanpregnancy.org/labor-and-birth/first-stage-of-labor/. Accessed August 10, 2016.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 145 118. Berens, MD P. Overview of postpartum care. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/overview-of- postpartum- care?source=machineLearning&search=lochia&selectedTitle=1%7E 6§ionRank=1&anchor=H629529854#H629529854. Accessed August 10, 2016. 119. Miller, MD D. Non stress and contraction test. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/nonstress-test- and-contraction-stress- test?source=machineLearning&search=non+stress+thttps://www.u ptodate.com/contents/nonstress-test-and-contraction-stress- test?source=machineLearning&search=non+stress+test&selectedTi tle=1%7E84§ionRank=1&anchor=H10#H10est&selectedTitle=1 %7E84§ionRank=1&anchor=H10#H10. Accessed August 11, 2016. 120. Silverman A. External Cephalic Version - American Family Physician. Aafporg. 2016. Available at: http://www.aafp.org/afp/1998/0901/p731.html. Accessed August 11, 2016. 121. More Multiples C. Pregnant with multiples: Potential complications | BabyCenter. BabyCenter. 2016. Available at: http://www.babycenter.com/0_pregnant-with-multiples-potential- complications_3584.bc?page=1. Accessed September 24, 2016. 122. Gjerdingen D, Froberg D, Fontaine P. The effects of social support on women's health during pregnancy, labor and delivery, and the postpartum period. National Institutes of Health. 2016;25(3):370- 5. Available at: http://www.ncbi.nlm.nih.gov/pubmed/1884933. Accessed August 11, 2016. 123. Birthing Choices - American Pregnancy Association. American Pregnancy Association. 2012. Available at: http://americanpregnancy.org/labor-and-birth/birthing-choices/. Accessed July 21, 2016. 124. Types of Doctors for Labor and Delivery. Healthline. 2016. Available at: http://www.healthline.com/health/pregnancy/intrapartum-care- physician#Familypractitioners2. Accessed July 21, 2016. 125. Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women's Health. 2014;59(1):17-27. doi:10.1111/jmwh.12172. 126. Birth Centers - American Pregnancy Association. American Pregnancy Association. 2012. Available at: http://americanpregnancy.org/labor-and-birth/birth-center/. Accessed July 21, 2016.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 146 127. Water Birth: Benefits and Potential Risks. American Pregnancy Association. 2012. Available at: http://americanpregnancy.org/labor-and-birth/water-birth/. Accessed September 23, 2016. 128. Patterned Breathing During Labor: Techniques and Benefits. American Pregnancy Association. 2012. Available at: http://americanpregnancy.org/labor-and-birth/patterned- breathing/. Accessed September 23, 2016. 129. KN U. The neurohumoral response to trauma. - PubMed - NCBI. Ncbinlmnihgov. 2016. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24354. Accessed September 24, 2016. 130. Grant, MD G. Pharmacologic management of pain during labor. uptodatecom. 2016. Available at: https://www.uptodate.com/contents/pharmacologic-management- of-pain-during-labor-and- delivery?source=machineLearning&search=labor+pain+manageme nt&selectedTitle=1%7E92&anchor=H3§ionRank=1#H3. Accessed September 24, 2016. 131. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I. Does pain relief during delivery decrease the risk of postnatal depression?. Acta Obstetricia et Gynecologica Scandinavica. 2004;83(3):257-261. doi:10.1111/j.0001-6349.2004.0302.x. 132. Burd I. Your baby in the birth canal: MedlinePlus Medical Encyclopedia. Medlineplusgov. 2016. Available at: https://medlineplus.gov/ency/article/002060.htm. Accessed September 133. Perineal Massage in Pregnancy. Journal of Midwifery & Women's Health. 2016;61(1):143-144. doi:10.1111/jmwh.12427. 134. Episiotomy: MedlinePlus Medical Encyclopedia. Medlineplusgov. 2016. Available at: https://medlineplus.gov/ency/patientinstructions/000482.htm. Accessed September 23, 2016. 135. Petruska SBohnert C. Forceps-Assisted Vaginal Delivery Objective Structured Clinical Skills Exam (OSCE). MedEdPORTAL Publications. 2011. doi:10.15766/mep_2374-8265.8562. 136. FastStats. Cdcgov. 2016. Available at: http://www.cdc.gov/nchs/fastats/delivery.htm. Accessed September 23, 2016. 137. Reasons for a Cesarean Birth: What You Should Know. American Pregnancy Association. 2012. Available at: http://americanpregnancy.org/labor-and-birth/reasons-for-a- cesarean/. Accessed September 23, 2016.

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