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he Healthy Pregnancy: An Overview

The Healthy Pregnancy: An Overview

This course has been awarded Four (4.0) contact hours.

This course expires on January 22, 2015.

Copyright © 2010 by RN.com. All Rights Reserved. Reproduction and distribution

of these materials are prohibited without the express written authorization of RN.com.

First Published: January 23, 2012

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Disclaimer RN.com strives to keep its content fair and unbiased. The author(s), planning committee, and reviewers have no conflicts of interest in relation to this course. Conflict of Interest is defined as circumstances a conflict of interest that an individual may have, which could possibly affect Education content about products or services of a commercial interest with which he/she has a financial relationship.

There is no commercial support being used for this course. Participants are advised that the accredited status of RN.com does not imply endorsement by the provider or ANCC of any commercial products mentioned in this course. There is no "off label" usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com. The use of trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents described in the course. Note: All dosages given are for adults unless otherwise stated. The information on medications contained in this course is not meant to be prescriptive or all-encompassing. You are encouraged to consult with physicians and pharmacists about all medication issues for your patients.

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RN.com acknowledges the valuable contributions of… …The National Women’s Health Information Center (www.4women.gov). This agency is part of the U.S. Department of Health and Human Services and provides valuable information on health issues pertinent to women. …Nadine Salmon, RN, BSN, IBCLC is the Clinical content Specialist for RN.com. Nadine earned her BSN from the University of the Witwatersrand, Johannesburg, South Africa. She worked as a midwife in Labor and Delivery, an RN in Postpartum units and Antenatal units, before moving to the United Kingdom, where she worked as a Medical Surgical Nurse. After coming to the US in 1997, Nadine worked in obstetrics and became a Board Certified Lactation Consultant. Nadine was the Clinical Pre Placement Manager for the International Nurse Staffing division before joining RN.com. Nadine is currently pursuing her master’s degree in Nursing Leadership. …Karen Siroky, RN, MSN, is the previous Director of Education for RN.com. Karen received her BSN from the University of Arizona and her MSN from San Diego State University. Her nursing experience includes ICU, transplant coordination, recruitment, quality improvement, information, and education. She has previously published articles on Quality Improvement and Cardiac Transplantation.

Acknowledgements

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1. Define the time frame and developmental milestones of each trimester.

2. Review various diagnostic tests performed during pregnancy.

3. Describe common complications of pregnancy.

4. Identify specific areas where a pregnant woman can impact her health and the health of the fetus.

5. Describe the early signs of labor.

After successful completion of this course, you will be able to:

The purpose of The Healthy Pregnancy is to provide the learner with an overview of the stages of pregnancy and normal changes in the mother and the development of the fetus.

Purpose and Objectives

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This course provides an overview of normal physiological changes that women can expect to experience during an average non-complicated pregnancy. The course is divided into sections that discuss pregnancy changes and fetal development as they occur in each trimester. Although the trimesters are approximately the same length, the events that can occur in each one can vary greatly as the fetus grows and develops. The normal growth and development of the fetus can impact the pregnant woman differently during each phase. Some effects may be noticeable only to the pregnant woman, some are noticeable to others, and some may not be discovered except through blood tests or special examinations. Each stage of fetal growth and development will have an impact on the pregnant woman and the health and maturation of the fetus.

Introduction

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Most healthcare providers will refer to the pregnancy by the age of the fetus in weeks. The first trimester of pregnancy is defined as the time period that begins with the last menstrual period and extends through the 12th week of pregnancy. In these early weeks, many of the changes beginning in a woman’s body are subtle and noticeable only to the pregnant woman. The woman’s body will undergo physiologic changes that will help to maintain and support the fetus over the next nine months.

Pregnancy typically lasts 40 weeks, counting from the first day of the last menstrual period, and can be divided into three trimesters:

• The first trimester lasting 12 weeks.

• The second trimester extends from 13 to the end of 27 weeks.

• The third trimester extends from 28 to 40 weeks.

The first trimester is critical as the fetus begins to grow and develop.

The First Trimester

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During the first 3 months of pregnancy, the pregnant woman’s body is undergoing many changes. As the body adjusts to the growing baby, there may be nausea, fatigue, backaches, mood swings, and stress. These symptoms are normal during pregnancy as the body changes. Most of these discomforts will go away as the pregnancy progresses. There may be different symptoms associated with each pregnancy. Just as each woman is different, so is each pregnancy. And, as the body changes, the pregnant woman might need to make changes to her normal, everyday routine.

Changes in the Pregnant Woman’s Body

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During pregnancy, a woman might feel tired even though she has slept well. Many women find they're exhausted during the first trimester. This is common and quite normal. This is the body's way of indicating that more rest is needed. The pregnant body is using energy to develop the fetus. Fatigue will pass over time and is usually replaced with a feeling of well being and more energy. Encourage your patient to rest when tired. She should try to get eight hours of sleep every night and a nap during the day if possible. She may want to start sleeping on her left side, if it is more comfortable. This will relieve pressure on major blood vessels that supply oxygen and nutrients to the fetus. If your patient has high blood pressure during pregnancy, it is even more important to rest on the left side when she is lying down.

Fatigue

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Usually called "morning sickness," nausea and vomiting are common during early pregnancy. For many women, though, morning sickness isn't limited to just the morning. Although it can seem like it will last forever, nausea and vomiting will usually go away after the first trimester. Provide your patients with some of these tips to help decrease nausea:

• Eat frequent, small meals (6 to 8 small meals a day, rather than 3 large meals).

• Avoid fatty, fried, or spicy foods.

• Try eating starchy foods such as toast, saltine crackers, or dry cereals. Instruct her to keep some of these foods by the bed and eat them before getting out of bed in the morning and in the middle of the night if nausea persists. Many women find it helpful to keep a few starchy snacks with them at all times to relieve nausea that may occur.

Nausea and Vomiting

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If a pregnant woman suffers from excessive nausea and vomiting she can become dehydrated. Monitor her closely for signs of dehydration that include; poor skin , dry mucous membranes or orthostatic hypotension. As the nausea and vomiting begins to resolve, your pregnant patient should resume a healthy eating plan and continue to take prenatal vitamins.

Nausea and Vomiting

• Drinking carbonated drinks such as ginger ale or seltzer in between meals will help decrease nausea.

• Check with your patient’s healthcare provider (HCP) to see if she can stop taking prenatal vitamins for a short period of time if the vitamins add to morning sickness.

• Check with the HCP to see if your patient should take vitamin B6 treatments for severe nausea and vomiting that doesn't get better with the dietary changes listed above.

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Frequent urination is common during pregnancy. Early in pregnancy the growing uterus presses on the bladder. If there is pain, burning, pus, or blood in the urine, your patient should see her HCP right away. These signs can indicate a possible urinary tract infection that needs treatment. As the uterus begins to expand, constipation can occur. To prevent constipation your patient should adjust her diet to include fresh or dried fruit, raw vegetables, and whole grain cereals or breads every day. Also, encourage her to try to drink at least eight to ten glasses of water every day. Some of these servings can be substituted with fruit or vegetable juice. She should try to avoid caffeinated drinks (coffee, tea, colas, and some other sodas), since caffeine makes the body lose fluid and won't help with constipation.

Frequent Urination and Constipation

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Dizziness, feeling light-headed and even fainting can happen at any stage of pregnancy. This can occur due to the extra volume of blood circulating toward the uterus and legs. These symptoms can often be relieved by lying down on the left side; however, the woman should alert her healthcare provider if any of these problems occur.

Dizziness

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During pregnancy, pressure on the large veins behind the uterus causes the blood to slow in its return to the heart. This can lead to varicose veins in the legs and hemorrhoids. As blood is pumped back to the heart, veins act as one-way valves to prevent the blood from flowing backwards. If the one-way valve becomes weak, some of the blood can leak back into the vein, collect there, and then become congested or clogged. This congestion will cause the vein to abnormally enlarge. These enlarged veins can be either varicose veins, hemorrhoids, or spider veins. Varicose veins look like swollen veins raised above the surface of the skin. They can be twisted or bulging, and tend to be dark purple or blue in color. They are found most often on the backs of the calves or on the inside of the leg, anywhere from the groin to the ankle. Varicose veins can be prevented during pregnancy by:

• Avoiding tight knee-highs or garters.

• Sitting with the legs and feet raised when possible. If working at a desk, prop the feet up on a footstool, box or several books. When relaxing at home, keep the feet up on a footstool, some pillows on the couch, or another chair.

During pregnancy, varicose veins called hemorrhoids can form in the vagina or around the anus. Hemorrhoids will be discussed further in the course section outlining the third trimester.

Varicose Veins and Hemorrhoids

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Leg and foot cramps can be relieved by gently stretching these muscles. If your patient has a sudden leg cramp, have her flex her foot towards her body. If the foot is pointed to stretch the leg, the cramp could worsen. Wrapping a warm heating pad or warm, moist towel around the muscle also can help the muscles to relax.

At different times during pregnancy, cramps in the legs or feet may occur. This is due to a change in the way the body metabolizes calcium. One way to prevent these cramps is to ensure that the pregnant woman gets enough calcium through nonfat or low fat milk and calcium-rich foods. There is also some calcium in prenatal vitamins, but some women need to take a calcium supplement if they don't get enough through their diet. Encourage patients to talk with their healthcare provider before taking calcium supplements.

Leg Cramps

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Any nasal stuffiness that occurs during pregnancy can be decreased by drinking extra water, or by using a cool mist humidifier while sleeping. Encourage patients to talk with their healthcare provider before taking any over-the-counter or prescription medicines for colds or nasal stuffiness. Bleeding gums can be decreased by brushing with a soft-bristled toothbrush and flossing daily.

Nosebleeds, nasal stuffiness, or bleeding gums during pregnancy are often the result of hormonal effects on the tissues of the throat, mouth, and nose. They usually are not serious, and many women might not even notice them. Your patient should see her healthcare provider if she has nosebleeds that do not stop in a few minutes or happen often.

Nosebleeds, Nasal Stuffiness, Bleeding Gums

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Image courtesy of guimi.net. The fetus is 13 weeks gestation.

The sperm and egg unite in one of the fallopian tubes to form a single-celled zygote. If more than one egg is released and fertilized, multiple zygotes may result. Each zygote has 46 chromosomes; 23 from each partner. These chromosomes will determine the physical and mental characteristics. Soon after fertilization, the zygote travels down the fallopian tube toward the uterus. At the same time, it will begin dividing rapidly to form a cluster of cells. The inner group of cells will become the embryo. The outer group of cells will become the membranes that nourish and protect it. During the fourth week, the rapidly dividing ball of cells, now known as a blastocyst, implants itself into the uterine wall for nourishment, and the placenta develops. During the next several weeks, the fetal brain, spinal cord, and internal organs begin to form. During week 6, the neural tube closes, basic facial features form and limb buds arise. Facial features develop, including eyelids for protection of the developing eyes. The genitals form around week 11. By the end of the first trimester, the baby is about three inches long and weighs about half an ounce. The eyes move closer together and the ears also are also visible. The liver is producing bile and the kidneys are secreting urine into the bladder. Although the pregnant woman can't feel the baby move yet, the baby will move inside the uterus in response to pushing on the abdomen.

Fetal Development In The First Trimester

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During the first prenatal visit, the provider will discuss important aspects of the pregnant woman’s health history that may have some impact on the pregnancy. This includes diseases, operations, and other pregnancies. There also will be questions about family health history. She will have a complete physical exam, lab tests, and a Pap test. Blood pressure, urine, and weight will be checked at every visit. Additional lab testing is done throughout the pregnancy to monitor the health and well being of mother and the fetus. Blood and urine testing, vaginal cultures and ultrasound exams are performed routinely.

During pregnancy, ongoing evaluations with a healthcare provider are very important. The provider will schedule regular check-ups throughout the nine months to monitor the mother and baby’s health and to avoid or minimize problems during the pregnancy. Encourage patients to become a partner with their healthcare provider to manage their care. Keep all appointments - every one is important!

Prenatal Care

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It is important for the healthcare professional to accurately document the pregnant woman's obstetrical history in a standardized format. This format is commonly referred to as the gravida / para (GP) or gravida / para / abortus (GPA) score, which is essentially just a shorthand notation for a woman's obstetric history.

• Gravida: Indicates the number of times the mother has been pregnant, regardless of whether these pregnancies were carried to term. A current pregnancy, if any, is included in this count.

• Parity: Indicates the number of viable (>20 wks) births. Pregnancies consisting of multiples, such as twins or triplets, count as ONE birth for the purpose of this notation.

• Abortus: Is the number of pregnancies that were lost for any reason, including induced abortions or miscarriages. The term is usually dropped when no pregnancies have been lost.

Therefore, the history of a woman who has had two pregnancies (both of which resulted in live births) would be noted as G2P2. The obstetrical history of a woman who has had four pregnancies, one of which was a miscarriage before 20 weeks, would be noted as G4P3A1. This notation system is often confused with the TPAL system, which provides additional information about the number of miscarriages, preterm births, and live births by dropping the "A" and including four separate numbers after the "P", as in G5P3113. This indicates 5 pregnancies, with 3 term births, 1 preterm birth, 1 induced abortion or miscarriage, and 3 live births (but does not denote whether the children are currently living). TPAL is one of the methods to provide a quick overview of a female's obstetric history (Hatfield & Klossner, 2006). In TPAL:

• T refers to term births (after 37 weeks gestation)

• P refers to premature births

• A refers to abortions

• L refers to living children The TPAL is described by numbers separated by hyphens. Multiple births (twins, triplets and higher multiples) count as one birth. For example, a pregnant woman who carried one pregnancy to term with a

surviving infant; carried one pregnancy to 35 weeks with surviving twins; carried one pregnancy to 9 weeks as an ectopic (tubal) pregnancy; and has 3 living children would have a TPAL annotation of T1, P1, A1, L3. This could also be written as 1-1-1-3.

Documentation of Obstetric History

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Encourage pregnant patients not to drink alcohol and provide them with information about the effects of alcohol on fetal development. The amount of alcohol required to cause problems in a baby is not known; however drinking every day or intermittent drinking that involves large amounts of alcohol has been shown to have harmful effects. Pregnant women should also tell their healthcare provider if they are taking any medications or drugs since some can be harmful to the baby's development. Pregnant women should only take drugs or medicines prescribed or approved by her healthcare provider; they should never take illegal or illicit drugs such as marijuana, cocaine, heroin, speed (amphetamines), barbiturates, LSD, or others. Encourage your patient to talk with her HCP if she needs help with smoking cessation, drinking, or if she has a drug habit.

By practicing healthy habits during pregnancy, the soon-to-be-mother is also caring for the new life within her. If a pregnant woman smokes, she should be encouraged to quit smoking and be provided with smoking cessation materials. Smoking during pregnancy passes nicotine and cancer-causing drugs to the fetus. Smoke also keeps the baby from obtaining needed nourishment while in the uterus, and raises the risk of fetal death and premature birth.

Smoking, Alcohol & Drugs

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Nutrition & Weight Gain

The type of food a pregnant woman eats is not only important for her health, but for the current and future health of her baby. A balanced diet that includes a variety of healthy foods is the building blocks for a growing baby since pregnancy is a complex time of developing new tissues and organs. Throughout pregnancy, encourage health conscious food choices with your patient. Consuming foods high in sugar and fat during pregnancy can lead to excessive weight gain and obesity without meeting the increased need for nutrients. During the first trimester, it is normal to gain only a small amount of weight, about one pound per month. According to the American College of Obstetricians and Gynecologists (ACOG), if underweight before becoming pregnant, a woman should gain between 28 and 40 pounds; if the woman is overweight prior to pregnancy, between 15 and 25 pounds. Recent research shows that women who gain more than the recommended amount during pregnancy and who fail to lose this weight within six months after giving birth are at much higher risk of being obese nearly 10 years later. In general, pregnant women gain weight more rapidly towards the end of the pregnancy, and normal weight gain in the third trimester is about one pound per week, or three to four pounds per month. By the end of the pregnancy the average weight gain will usually be about 25 to 30 pounds. Approximately 7 1/2 pounds of that weight is usually the baby.

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Folic Acid

Folic acid is one of the most vital nutrients pregnant women need. Folic acid is a B vitamin that helps prevent neural tube defects and other birth defects such as cleft lip and congenital heart disease. By making sure she consumes at least 0.4 milligrams of folic acid every day before getting pregnant and during the first three months of pregnancy, women can help reduce the risk of these defects. Folic acid is found in dark-green leafy vegetables (like spinach or kale), beans and citrus fruits, and in fortified cereals and bread. But to make sure she consumes enough folic acid, it is best to take a daily vitamin that contains it.

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Iron

Iron is needed to fuel hemoglobin production for mother and baby. Iron also helps build bones and teeth. A shortage of iron can also cause anemia. Most women do not have symptoms of anemia, but some may experience extreme fatigue. Anemia is determined through the routine blood tests that are obtained during different stages of pregnancy. If a pregnant woman has anemia, her provider will usually give her iron supplements to take once or twice a day. Anemia can be prevented by eating more iron-rich foods like potatoes, raisins, broccoli, leafy green vegetables, whole-grain breads, and iron-fortified cereals.

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During pregnancy, a woman should be eating to nourish her baby with a variety of foods from the daily Food Guide Pyramid. Women who are pregnant or breastfeeding should have at least three servings of milk, yogurt, or cheese per day to meet their calcium needs.

Pregnant women should also increase their intake of breads and cereals, fruits, vegetables, meat and meat alternatives - up to a total of 2,200 or 2,800 calories. They should try to have three meals every day or six smaller meals if there are problems with nausea or heartburn.

• Protein-rich foods build muscle, tissue, enzymes, hormones, and antibodies for mother and baby. They also have B vitamins and iron, which is important for making red blood cells.

• Carbohydrates (breads and cereals) provide energy, iron, B vitamins, some protein, and other minerals. Encourage whole grains (like whole wheat bread) because they contain more vitamins and fiber.

• Milk and other dairy products contain calcium, which mother and baby need for strong bones and teeth. Milk and diary products also have vitamin A and D, protein, and B vitamins. Vitamin A helps growth, resistance to infection, and vision. Pregnant women need 1200 to 1500 milligrams of calcium each day. She should try to have nonfat milk and milk products to lower her fat intake. Other sources of calcium include dark green leafy vegetables, dried beans and peas, nuts and seeds, salmon and sardines (with bones), and tofu.

• Fruits and vegetables with vitamin C help mother and baby to have healthy gums and other tissues. They also help heal wounds and to absorb iron. Examples of fruits and vegetables with vitamin C include strawberries, melons, oranges, papaya, tomatoes, peppers, greens, cabbage, and broccoli. A variety of fruits and vegetables also add fiber and other minerals to a diet, and help provide energy. Dark green vegetables also have vitamin A, iron, and folic acid.

Key Food Groups

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Water intake plays a key role during pregnancy. Water carries the nutrients from foods consumed by the mother to the baby, and also helps prevent constipation, hemorrhoids, and urinary tract or bladder infections. Most importantly, drinking enough water, especially in the last trimester, prevents dehydration which can lead to contractions and premature labor. Pregnant women should drink at least six to eight 8oz. glasses of water per day, and another glass for each hour of activity. Juices provide fluid, but they also have a lot of calories and can cause extra weight gain. Coffee, soft drinks, and teas that have caffeine actually reduce the amount of fluid in the body, so they should not count towards the total daily amount of fluid needed.

Water

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Because connective tissues stretch much more easily during pregnancy, high impact or high resistance exercises that involve a lot of bouncing and extreme muscle stretching can increase the risk of joint injury. One type of exercise that can help muscles prepare for delivery, help support the uterus during pregnancy, and help prevent urinary incontinence is pelvic floor exercises (also called Kegel exercises). Pelvic muscles are the same ones used to stop and start the flow of urine. This exercise can be done standing, sitting, or lying down. To do this exercise, tighten the pelvic floor muscles for five seconds and then relax. Repeat 10 times.

Exercise

If there are no medical problems with a pregnancy, regular physical activity (30 minutes per day, most days of the week) can help a woman have a more comfortable pregnancy and labor. It helps lower the risk of high blood pressure and gestational diabetes. The new mother who exercises will have an easier time getting back into a healthy body shape and weight after the birth. Normal, low-impact activities, like walking and swimming, that don't involve a lot of bouncing, stretching muscles, or deeply bending joints, are healthy choices for the pregnant woman.

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Bathing

Baths and showers are fine to take during pregnancy, but very hot baths, hot tubs, and saunas can be harmful to the fetus, and can cause fainting. The pregnant woman might also want to avoid taking frequent bubble baths or baths with perfumed products that might irritate her vaginal area and increase the risk of a urinary tract infection or yeast infection. Douches are generally discouraged. Although vaginal discharge tends to be heavier during pregnancy, the pregnant woman should see her healthcare provider if she has vaginal itching, burning, or a heavy discharge. She could have a urinary tract infection, yeast infection, or a viral or bacterial infection.

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Every expectant mother should have a complete oral exam prior to or very early in pregnancy. All needed dental work should be managed early, because having urgent treatment during pregnancy, while possible, can present risks. Interventions can be started to control risks for gum inflammation and disease. This also is the best time to change habits that may affect the health of teeth and gums, and the health of the baby. Encourage patients to brush with a soft toothbrush and floss gently at least twice a day.

Oral Care

A pregnant woman's teeth and gums need special care. Research indicates that pregnant women with gum disease are more likely to have premature babies with low-birth weight. This may result from the transfer of bacterial microbes in the mother's mouth to the baby during the third trimester of pregnancy. The microbes can reach the baby through the placenta, the amniotic fluid, and the layer of tissues in the mother's stomach.

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Sexual Relations

In most cases, intercourse is safe throughout an uncomplicated, low risk pregnancy.

Some women who have had miscarriages are advised to avoid sexual intercourse during the first three months. Pregnant women should contact their HCP if they have any of the following symptoms during sexual intercourse:

• Pain in the vagina or abdomen

• Bleeding from the vagina

• Leaking of water (amniotic fluid) from the vagina

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The first prenatal appointment should be scheduled as soon as possible after the pregnancy is confirmed.

Medical History

The nurse should begin with a detailed Medical history, including documentation of menstrual cycle, use of contraceptives, past pregnancies, and allergies or other medical conditions. Identify any current medications and ask about any family history of congenital abnormalities or genetic diseases. Be sure to mention even sensitive issues, such as abortion or past drug use.

Calculation of Due Date

To estimate the due date, count 40 weeks from the start of the last menstrual period, or add seven days to the first day of the last period and subtract three months. If there's any question about your due date, an early ultrasound can be used to confirm dates.

Physical exam

Record weight, height and blood pressure. Perform a full physical assessment, including cardiovascular and pulmonary assessment. A baseline pap test is usually performed to screen for cervical cancer. An examination of the vagina and cervix is performed to observe for any infections or structural abnormalities. Changes in the cervix and the size of the uterus can confirm the stage of pregnancy.

The First Prenatal Visit

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Maternal blood tests are routinely performed between 10-14 weeks to measure levels of hCG (a hormone secreted by the placenta) and progesterone (the hormone responsible for maintaining the pregnancy).

Other baseline lab tests include:

• Blood type, including Rh (rhesus) factor.

• Anemia screen.

• Check for immunity to rubella.

• Test for hepatitis B, syphilis, and HIV.

• Tests for exposure to varicella (chickenpox virus) or toxoplasmosis may be

performed as well.

Depending on racial, ethnic, or family background, additional testing and genetic counseling may be offered to assess risks for diseases such as Tay-Sachs, cystic fibrosis, and sickle cell anemia. A combination of screening tests using ultrasound and blood analysis may be done in the first trimester to look for Down syndrome. The integrated test uses an ultrasound measurement of the thickness of the skin at the back of the baby's neck (nuchal translucency) and the blood levels of free beta-HCG and a protein called pregnancy-associated plasma protein A (PAPP-A) to check for abnormalities.

In addition, urine analysis is performed to detect infection, proteinuria or glucose, which may indicate gestational diabetes or kidney disease.

Lab Investigations

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An ultrasound can be performed as early as the fifth week of pregnancy (WebMD,

2011).

In addition to the ultrasound performed during the integrated test, first trimester fetal ultrasound may be performed to:

• Determine the number of fetuses and ensure the fetus is developing.

• Estimate the age of the fetus (gestational age).

• Check for other birth defects that affect the brain or spinal cord. Note that transvaginal (rather than transabdominal) ultrasound may be performed in early pregnancy to determine fetal age or to detect a suspected ectopic pregnancy.

Ultrasound Performed During The First Trimester

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Chorionic villus sampling provides detailed information about the fetal genetic makeup, and is offered when test results may have a significant impact on the management of the pregnancy. It is usually done between the 10th and 12th weeks of pregnancy, following abnormal results from a prenatal screening test, such as the first trimester screen , or in cases where there has been a chromosomal abnormality in a previous pregnancy. Other indications are advanced maternal age (over 35), or a family history of a specific genetic disorder. In addition to identifying Down syndrome, chorionic villus sampling can be used to diagnose many other genetic disorders, such as Tay-Sachs disease and cystic fibrosis. This requires specialized testing of the chorionic villi, however, so there must be a reason to test for these conditions. Chorionic villus sampling cannot detect neural tube defects, such as spina bifida. If neural tube defects are a concern, an ultrasound or genetic amniocentesis may be recommended instead. Before chorionic villus sampling, the patient can remain on unrestricted foods and fluid. A full bladder is sometimes needed for the procedure, depending on the placental position. Informed consent must be obtained prior to the procedure. Ultrasound imaging is used as a guide and tissue samples can be taken through the cervix (transcervical) or the abdominal wall (transabdominal), depending on the position of the placenta. If the placenta isn't clearly accessible through the cervix or there is an active cervical infection, transabominal sampling is preferred.

Chorionic Villi Sampling

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Chorionic villus sampling carries various risks, including:

• Miscarriage. Overall, chorionic villus sampling carries a 1 in 100 risk of miscarriage. The risk of miscarriage appears to be slightly higher when the tissue sample is taken through the cervix (transcervical) rather than the abdominal wall (transabdominal). The risk of miscarriage also increases if the baby is smaller than normal for his or her gestational age.

• Cramping and vaginal bleeding during and after the test.

• Rh sensitization. Chorionic villus sampling may cause some of the fetal blood cells to enter the maternal bloodstream. Rh negative patients are routinely given Rh immunoglobulin after the test to prevent antibodies formation.

• Rarely, chorionic villus sampling may trigger a uterine infection.

• Some older studies suggested that chorionic villus sampling may cause defects in a baby's fingers or toes. However, the risk appears to be a concern only if the procedure is done before the ninth week of pregnancy.

Risks of Chorionic Villus Sampling

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Subsequent prenatal visits, scheduled every four to six weeks during the first

trimester, will be shorter than the first, and will include assessment of:

• Weight and blood pressure.

• Urinalysis.

• Review of any presenting signs and symptoms.

• Abdominal palpation. Assess and record abdominal girth.

• Near the end of the first trimester, a doppler can be used to listen to the fetal

heartbeat.

The prenatal appointments are an ideal time to discuss any questions or concerns

and provide patient support and education.

Other First Trimester Visits

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Assessment of gestational size and age by fundal assessment is done by either using ‘landmarks’ such as the umbilicus or xiphisternum, or by measuring the fundal height with a tape measure. Both methods have limitations such as positioning of the fetus, amniotic fluid volume, and the size and shape of the woman. All these factors should be taken into account when measuring fundal height and clinical judgement is used to determine if the gestational size and growth of the fetus is appropriate. Fundal height is performed in order to:

• Evaluate the fetus's gestational age.

• Monitor the gestation and growth of the fetus.

• Identify multiple pregnancies and complications of pregnancy e.g. amniotic fluid disorders, hydatidiform mole, and fetal growth disturbances.

Fundal height is measured from the top of the symphysis pubis to the top of the fundus. Height is assessed in centimeters. To Measure Fundal Height :

• Place the pregnant women in a comfortable position with the lower back supported by a wedge.

• Place the end of the tape measure at the level of the symphysis pubis.

• Stretch the tape to the top of the uterine fundus.

• Record / document the measurement.

Measuring Fundal Height

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The second trimester is defined as the time period between the 13th to 27th weeks of pregnancy. During this time the pregnant woman’s body is changing significantly as the fetus grows and develops. Most women find the second trimester of pregnancy to be easier than the first trimester since symptoms like nausea and fatigue often resolve; however, there will be new, more noticeable changes in the pregnant woman’s body. Her abdomen will expand as she gains weight and the baby continues to grow. Before this trimester is over, she will feel the baby beginning to move. Many of the other symptoms that occurred in the first trimester might also continue, such as constipation or leg cramps, so it is important to continue the successful practices that helped prevent or treat those symptoms.

The Second Trimester

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Aches & Pains & Shortness of Breath

As the uterus and abdomen expand, there may be pain or discomfort in the abdomen, groin area, or thighs. The pregnant woman may experience backaches or aching near her pelvic bone from the pressure of the baby's head, increased weight, and the loosening joints in these areas. Lying down, resting, or applying heat can help resolve some of these aches and pains. If pains do not resolve after rest, the woman should be advised to contact her healthcare provider. As the baby increases in size, there will be increased pressure on all of the pregnant woman’s organs, including the lungs. She might begin to notice that she is short of breath or might not be able to catch her breath. Encourage her to take deep, long breaths, and maintain good posture so that her lungs have room to expand. She might be able to breathe more easily at night by using an extra pillow or by sleeping on her side. If the pregnant woman sleeps on her left side, she will relieve pressure on major blood vessels that supply oxygen and nutrients to the fetus. If she has high blood pressure, it is even more important to lie on the left side when lying down.

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Stretch marks are red, pink, or purple streaks in the skin, usually over the thighs, buttocks, abdomen, and breasts. They are scars caused by the stretching of the skin, and usually appear in the second half of pregnancy. Only about half of all pregnant women get stretch marks. They can start out as pink, reddish brown, or dark brown streaks, depending on skin color. While creams and lotions can keep skin well moisturized, they do not prevent stretch marks from forming. Most stretch marks fade after delivery to very light lines.

Example of linea nigra

Besides stretch marks, there are other skin changes in the second half of pregnancy. The pregnant woman may notice that her nipples are darker than before becoming pregnant, or that she has a dark line on her skin that runs down the abdomen from the belly button to the pubic hairline, called the linea nigra. There may also be blotchy brown pigmentations on the forehead, nose, or cheeks. These skin changes are called melasma or chloasma. They are more common in darker-skinned women. The hormones of pregnancy cause these skin changes, and most of them will fade or disappear after delivery.

Stretch Marks and Skin Changes

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Pruritic urticarial papules and plaques of pregnancy (PUPPP), is a chronic hives like rash

that some women experience during pregnancy.

Tingling & Itching

Tingling and numbness of the fingers and a feeling of swelling in the hands are common during pregnancy. These symptoms are due to swelling of tissues in the narrow passages in the wrists, and they should disappear after the baby is delivered. It also is common to feel itchy as pregnancy progresses. Pregnancy hormones and the stretching skin, especially over the abdomen, probably are to blame for most of this discomfort. About 20 percent of all pregnant women have some kind of itching. And many pregnant women also get red and itchy palms and soles of their feet. Only in rare cases do pregnant women develop a condition called cholestasis of pregnancy, a serious liver problem. The symptoms of this condition include itching, nausea, loss of appetite, vomiting, jaundice, and fatigue. In general, most itching usually goes away after delivery. In the meantime, itching can be relieved with moisturizers. Encourage your patient to use only gentle soaps, and avoid hot showers or baths that can dry her skin. She should try not to get over-heated since heat rash can make the itching worse.

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Early in the second trimester, a greasy, cheese-like coating called vernix caseosa begins to cover the fetus to protect the skin from exposure to amniotic fluid. The fetus also begins to move, and the first movements felt by the mother are referred to as quickening. The fetal activity increases throughout the trimester and the fetus develops the ability to swallow.

After 20 weeks gestation, lanugo (fine, down-like hair ) forms to hold the vernix caseosa on the skin. Fingerprints and footprints form, and rapid eye movements (REM) occur. In males, the testes descend from the abdomen, and the uterus and ovaries are completely formed in females. Fingernails develop. The lungs begin to produce surfactant (the substance that allows the air sacs in the lungs to inflate) and the nervous system continues to mature. The crown-to-rump length may triple since the 12-week mark. By the 26th week, the fetus will weigh about 1 ¾ pounds and be about 13 inches long.

Fetal Development In The Second Trimester

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During the second trimester, prenatal care includes the routine monitoring of blood pressure and weight gain, as well as auscultation of fetal heart rate, usually with a doppler. Education is provided regarding awareness of fetal movement, referred to as flutter-kicks. These are usually felt at 20 weeks gestation . Abdominal girth and fundal height are measured and documented and urinalysis performed to identify high levels of protein or glucose. At 16 weeks, the fundus can be found halfway between the symphysis pubis and the umbilicus. At 20 - 22 weeks, the fundus will be at the level of the umbilicus. Psychological support is an integral part of care, and the pregnant woman should be encouraged to express fears. Discussions regarding the onset of labor and delivery options should also be reviewed in depth.

Prenatal Care During The Second Trimester

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The second trimester is an opportune time to teach the signs of pre-term or premature labor. Premature labor occurs when labor begins before the 37th week of pregnancy, or three weeks or more before the due date. If the pregnant woman develops any symptoms of pre-term labor, and recognizes them, there is a better chance of stopping the labor. If symptoms are not treated, they can progress to repeated contractions that might cause the cervix to dilate and precipitate a premature delivery. Any woman can have pre-term labor, but some women have a higher risk because of problems with the uterus or placenta, or because of having had a pre-term birth with another pregnancy. Encourage your patient to drink plenty of water to keep from becoming dehydrated, especially in warm weather, since dehydration can cause pre-term labor. Pregnant women should call their healthcare provider right away if they have any of the following symptoms of pre-term labor:

• Contractions — these may occur with or without pain, but the abdomen will become very hard (a feeling like it is tightening) and then relax, on and off.

• Menstrual-like cramping — these may or may not be uncomfortable, but they feel like the cramps that occur before or when starting a menstrual period.

• Gas-type pains — feels like sharp pains in the stomach, or like a stomach virus. She could also have diarrhea or nausea.

• Low pelvic pressure — feels like the baby is putting a lot of heavy pressure very low inside the pelvis.

• Low backache — can be a strong or a dull ache.

• Blood from the vagina — can be either light spotting or more blood like during a menstrual period. Blood can be red or brown in color.

• Increased discharge from the vagina — more discharge than usual during this pregnancy. Can even be a sudden gush of a lot of water, or a small trickle or leak of water that is continuous. Discharge can be watery, pinkish, or brownish in color.

Prenatal Education: Pre-Term Labor

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The quad marker screen, similar to the triple marker screen, is a blood test that screens for open neural tube defects, and must be performed between 15 and 20 weeks of pregnancy . This screen can predict approximately 75-80% of open neural tube defects in women under age 35 and over 80% of Down syndrome cases in women age 35 years and older (WebMD, 2011).

The blood sample is tested for the presence of the following four substances, which are normally found in the baby's blood, brain, spinal fluid, and amniotic fluid:

• Alpha-fetoprotein (AFP): A protein produced by the baby's liver.

• Unconjugated Estriol (UE): A protein produced in the placenta and in the baby's

liver.

• Human Chorionic Gonadotropin (hCG): A hormone produced by the placenta.

• Inhibin-A: A hormone produced by the placenta.

The expected amount of these substances normally found in the mother's bloodstream changes each week of pregnancy, so it is important to accurately determine the stage of pregnancy.

High AFP levels may indicate that the baby has an open neural tube defect, or indicate that the fetus is older than was initially thought or that the woman is expecting twins. Lower than normal AFP levels could indicate that a woman is at higher risk for having a baby with Down syndrome.

Levels of hCG and Inhibin-A are higher than normal when a woman has an increased risk of having a baby with Down syndrome. Lower than normal levels of Estriol may also indicate that a woman is at high risk for having a baby with Down syndrome.

Normal levels of AFP, estriol, hCG, and Inhibin-A strongly indicate a healthy pregnancy and fetus. In over 98% of pregnancies, normal quad marker screen results predict healthy babies and births without major complications. However, there are no prenatal tests that can guarantee that the fetus will be completely healthy or without complications.

The quad marker screen is used for screening only, if abnormal results are found, further tests such as an ultrasound or amniocentesis may be necessary.

Out of 1,000 pregnant women, approximately 50 will have quad marker screen results that indicate an increased risk for having a baby with a birth defect. Of those

50 women, only one or two will actually have a baby with an open neural tube defect (WebMD, 2011).

Lab Testing: The Quad Marker Screen

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The glucose challenge test is a basic screen for gestational diabetes, and is usually performed between weeks 24 and 28 of pregnancy, although it can be done earlier if there is a risk of gestational diabetes based on family history or other factors. During the challenge, the pregnant woman is given oral glucose to drink, and intermittent blood glucose levels are drawn for testing. If the test is positive, additional testing is needed to confirm the diagnosis. Results of the glucose challenge test are given in milligrams per deciliter (mg/dL) or millimoles per liter (mmol/L). One hour after drinking the glucose solution:

• A blood sugar level below 140 mg/dL (7.8 mmol/L) is usually considered normal.

• A blood sugar level of 140 mg/dL (7.8 mmol/L) or higher may indicate gestational diabetes.

Some labs use a lower threshold of 130 mg/dL (7.2 mmol/L) when screening for gestational diabetes (Mayo Clinic, 2011). If the results of the glucose challenge test indicate the possibility of gestational diabetes, a glucose tolerance test is usually ordered, which is done over the course of two to three hours.

The glucose challenge test is a modified version of the glucose tolerance test, a similar test used to screen for type 2 diabetes.

Lab Testing: Glucose Challenge

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Second trimester fetal ultrasound is done to:

• Confirm the age of the fetus (gestational age).

• Examine the size and position of the fetus, placenta, and amniotic fluid.

• Determine the position of the fetus, umbilical cord, and the placenta during a procedure, such as an amniocentesis or umbilical cord blood sampling.

• Detect major birth defects, such as a neural tube defect or heart problems.

Ultrasound Performed During The Second Trimester

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If there are any indications in the medical history or findings on physical examination that warrant further investigation, an amniocentesis may be peformed. During this procedure, a sample of amniotic fluid is withdrawn from the mother's abdomen with an ultrasound-guided needle, usually after week 15 of pregnancy. This procedure can identify some chromosomal or genetic conditions, as well as neural tube defects. The risk of miscarriage following amniocentesis is between 1 in 300 and 1 in 500 (WebMD, 2011).

Additional Testing: Amniocentesis

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Cordocentesis (also known as percutaneous umbilical blood sampling, or PUBS) is the removal of a small sample of blood from the umbilical cord, through an ultrasound-guided needle inserted in the mother's abdomen. This test can identify chromosomal conditions, blood disorders, infections and restricted growth, and has about a 2 in 100 risk of miscarriage (WebMD, 2011).

Cordocentesis

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The third trimester takes place from the 28th week of pregnancy until birth. It is an exciting time for the pregnant woman as she prepares for the new baby. However, there are still many changes occurring in both the mother and baby during this trimester.

The Third Trimester

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The pregnant woman could still be having some of the same discomforts she had in her second trimester, but now she may notice frequent urination or that she finds it harder to breathe, as the fetus enlarges and places more pressure on internal organs.

Heartburn As the baby continues to grow in size, the uterus pushes on the stomach and can cause heartburn, especially before bedtime or right after eating. The pregnant woman should continue to adhere to a healthy diet and eat six to eight smaller meals instead of large meals. She also can take small sips of milk or eat small pieces of chipped ice. If her heartburn is severe and doesn't improve with these tips, she should discuss this with her healthcare provider. Also check with her healthcare provider before recommending an antacid medication.

Water Retention As she nears the end of her pregnancy, the pregnant woman may notice more water retention than she had before, especially in the ankles, fingers, and face. She needs to continue to drink lots of fluids (water is best) and rest when she can with her feet elevated. If she notices sudden, extreme swelling in any of these areas, or has a rapid significant weight gain, she should call her healthcare provider immediately. This could be a sign of pre-eclampsia or toxemia.

Third Trimester Changes

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Third Trimester Changes (cont).

Hemorrhoids Pregnant women often experience discomfort from hemorrhoids in the third trimester from the increased pressure of her growing baby on the veins in the rectum. They will often experience constipation as well. This can increase the discomfort associated with hemorrhoids related to straining for a bowel movement. Your patient can avoid or decrease the likelihood of hemorrhoids by drinking lots of fluids and eating plenty of whole grains, raw or cooked leafy green vegetables, and fruits. Encourage your patients not to strain for bowel movements, and refer them to their healthcare provider for safe medication choices if she needs to take a laxative.

Tender Breasts A woman’s breasts usually increase in size and fullness as pregnancy advances. As she nears the end of her pregnancy, hormones in the body cause breasts to increase even more in size to prepare for breastfeeding. Breasts can feel full and heavy, and they might be tender or uncomfortable. Wearing a well-fitting maternity or nursing bra will help a pregnant woman to be more comfortable, because these types of bras offer extra support. Some pregnant women begin to leak colostrum in the third trimester. Colostrum is the first milk that breasts produce for the baby. It is a thick, yellowish fluid that contains antibodies that can help to protect new babies from infections. If leaking breasts become a problem, disposable or cloth nursing pads can be placed inside the woman’s bra to prevent milk from soaking through her clothing. Beginning now, and after delivery, it is a good idea to only wash the nipples with water instead of soap. Soap might cause the skin of the nipples to become dry, irritated and crack. If a pregnant woman does have skin cracks, which can be sore and painful, she should use a heavier cream that contains lanolin for extra moisture.

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By the third trimester, the fetal movements are frequent in occurrence, but since the space in the uterus is more confined, the pregnant woman might not feel the kicks and movements as much as she did in the second trimester.

From 37 weeks on, the fetus is considered full term. Forty weeks into the pregnancy, the fetus may be about 18 to 20 inches long and weigh 6 to 9 pounds, but a wide variation of height and height is normal.

As the body starts to prepare for the birth, the fetus will start to move into its birth position. The mother might notice the baby "dropping," or moving down lower in her abdomen. This can reduce the pressure on the woman’s lungs and rib cage, making it easier to breathe. As the expected due date approaches, the woman’s cervix becomes thinner and softer (called effacing). The healthcare provider can check how much she has effaced or dilated with a vaginal exam. Most healthcare providers increase the frequency of check ups the month before birth.

Fetal Development In The Third Trimester

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Prenatal Care During The Third Trimester

At third trimester visits, routine monitoring of maternal blood pressure, weight, fundal height and urine analysis will continue. A record is maintained to track frequency of fetal movement and fetal heartbeat. At 36 weeks, measurement of fundal height should reveal a fundus that is at the level of the xyphoid process. During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks plus or minus 2 centimeters. Note that maternal obesity has been shown to distort the accuracy of these measurements. Any discrepancies between expected fundal height and gestation should be investigated by checking for positioning of the fetus (oblique or transverse lie), expected date of delivery estimation, multiple pregnancy, molar pregnancy, polyhydramnios, oligohydramnios, small-for-gestational age or large-for-gestation age fetus. Towards the end of the third trimester, prenatal visits may include pelvic exams, to check fetal position. If the fetus is found to be in the breech position for an extended period of time, an external version may be considered. The cervix is also monitored for dilation and effacement (thinning out). Effacement is recorded in centimeters.

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Most pregnant women are screened for group B streptococcus (GBS) during the third trimester. GBS is a common bacterium often carried in the gastrointestinal tract or the lower genital tract in 10% to 30% of women (Lab Test Online, 2011). It is usually not a problem, except when it is present in the vagina during delivery. When the infant passes through the birth canal, the bacteria can be inhaled or ingested. Infected infants may display symptoms within 6 hours of birth or as late as 2 months of age. If untreated, the baby may become septic, develop pneumonia, suffer hearing or vision loss, or develop varying degrees of physical and learning disabilities(Lab Test Online, 2011). To best assess the risk of infecting the baby at delivery, the pregnant woman is screened for Group B strep between 35 and 37 weeks of gestation. Specimens from the mother’s vaginal and rectal areas are collected, and within 24 to 48 hours the laboratory can determine if Group B strep bacteria are present. If the bacteria are present, or if the woman goes into labor before testing can be completed, it is recommended that she receive antibiotics intravenously during labor. Treatment with oral antibiotics taken before labor has not proven to be effective in preventing Group B strep infections in the newborn. Group B strep is usually harmless in adults, but can rarely cause health problems during pregnancy, including:

• Urinary tract infections.

• Infection of the placenta and amniotic fluid (chorioamnionitis).

• Inflammation and infection of the membrane lining the uterus (endometritis).

• Sepsis and wound infection after a cesarean section. Risk factors for Group B strep include a previous delivery of an infant with a group B strep infection, or a urinary tract infection caused by group B strep during the current pregnancy.

Testing For Group B Strep

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Only five percent of babies are actually born on their expected due date; occasionally, labor will need to be induced if it does not begin on its own, one to two weeks after a woman's due date. Some women may need to have a cesarean section, a trial of labor or an induction of labor.

Options For Delivery

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Indications for induction of labor include:

• Chronic illness such as high blood pressure or diabetes that threatens the health of the baby.

• Failure to thrive.

• Prolonged rupture of membranes (PROM).

An induction can be preceded by stripping the membranes surrounding the fetus, or inserting a gel or suppository containing a hormone to stimulate contractions. Pitocin can also be given intravenously to start contractions.

Induction of Labor

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Despite the Healthy People 2010 national goal to reduce the cesarean delivery rate to 15 percent of births each year, this century has set record rates of cesarean deliveries (AHRQ, 2010). With almost 1.5 million cesarean surgeries performed every year, cesarean is the most common surgical procedure in the U.S. Vaginal birth after cesarean (VBAC) is a controversial option that is more widely practiced in certain areas of the United States. Antepartum factors that influence the decision to allow a VBAC or Trial of Labor (TOL) include:

• Prior vaginal delivery: A prior history of vaginal delivery was consistently reported to increase likelihood of a successful VBAC (AHRQ, 2010). Among women requiring induction of labor, limited evidence also suggests a higher rate of VBAC among those with prior vaginal delivery (AHRQ, 2010).

• Indication for prior cesarean: Women with prior cesarean delivery for malpresentation/breech were more likely to have a VBAC compared with women with prior cesarean delivery for fetal distress or failure to progress/cephalopelvic disproportion (AHRQ, 2010).

The maternal benefits of VBAC instead of elective cesarean section are:

• Decreased adhesions: Prior cesarean delivery is associated with a statistically significant increase in adhesions at subsequent cesarean and hysterectomy. Adhesions are associated with increased perioperative complications, time to delivery, and total operative time. It is unclear whether adhesions and complications increase with increasing number of prior cesareans.

• Protection of fertility: Two studies have shown impaired fertility following cesarean delivery (AHRQ, 2010). One study found a difference in the ability to conceive in subjects undergoing cesarean delivery compared with instrumented vaginal delivery. Another study found a history of cesarean delivery was associated with increased odds of taking greater than 1 year to conceive.

• Delayed menopause: Studies have found an increased risk of early menopause in women with multiple cesarean deliveries compared with no pelvic surgery.-

Risks of VBAC / TOL:

Although a TOL is considerably less risky than a cesarean section, there are inherent risks. These include:

• Complications during labor that result in a cesarean delivery. This occurs with about 20 to 40 out of 100 women who try VBAC.

• Rupture of the scar on the uterus, which is rare but can be fatal to the mother and baby. A vertical incision used in a past cesarean section, use of certain medicines to start (induce) labor, and many scars on the uterus from past cesarean sections or other surgeries are some risk factors that can increase the chance of a rupture.

• Infection. Women who have a trial of labor and end up having a cesarean section have a higher risk of infection. This means that the risk of infection is lower after vaginal births and after planned cesareans. (AHRQ, 2010).

Trial Of Labor (VBAC)

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Signs & Symptoms of Labor

Women nearing their expected due date will sometimes think they are in labor but they are not (called false labor). This happens to many women, so it is important to explain that there is nothing to be embarrassed about if she goes the hospital certain that she is in labor, only to be sent home. It is always best to be evaluated as soon as possible to determine if labor has begun. The signs of true labor include:

• Contractions at regular and increasingly shorter intervals which also become stronger in intensity.

• Lower back pain that doesn't go away. Pain that feels premenstrual and is cramplike in nature.

• Her water breaks (can be a large gush or a continuous trickle) and she has contractions.

• A bloody (brownish or blood-tinged) mucous discharge. This is the mucous plug that blocks the cervix. Labor could be at any time, or days away.

• The cervix is dilating and becoming thinner and softer.

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Third trimester fetal ultrasound may be performed to:

• Make sure that the fetus is alive and moving.

• Examine the size and position of the fetus, placenta, and amniotic fluid. Note that transvaginal (rather than transabdominal) ultrasound is occasionally performed late in pregnancy to determine the location of the placenta or in a high-risk pregnancy to monitor the length of the cervix.

Ultrasound Performed During The Third Trimester

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Normal pregnancy involves many physiologic events and changes in the pregnant woman’s body. Although there are variations of “normal”, this course provides an overview of baseline knowledge for the average pregnancy. If complications do arise, they will differ from the symptoms described in this course.

Conclusion

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At the time this course was constructed all URL's in the reference list were current and accessible. RN.com is committed to providing healthcare professionals with the most up to date information available.

March of Dimes www.marchofdimes.com The mission of the March of Dimes is to improve the health of babies by preventing birth defects and infant mortality. They carry out this mission through research, community service, education and advocacy to save the babies lives. March of Dimes researchers, volunteers, educators, outreach workers, and advocates work together to give all babies a fighting chance against the threats to their health: prematurity birth defects, low birth weight.

National Women's Health Information Center www.4women.gov This website and toll-free call center were created to provide FREE, reliable health information for women everywhere. Browse our database for great resources or take a look through our Special Sections on topic areas like heart disease, disabilities and pregnancy. There are a multitude of sites related to pregnancy on the internet. Many have biases or are sponsored by different agencies. At this time, RN.com chooses not to list them in their resources. Visit the internet to view these websites.

Resources

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• Agency for Healthcare Research & Quality [AHRQ], (2010). Evidence

Report/Technology Assessment Number 191. Vaginal Birth After Cesarean:

New Insights. Retrieved January 5, 2012 from:

http://www.ahrq.gov/downloads/pub/evidence/pdf/vbacup/vbacup.pdf

• Hatfield, N. & Klossner, N. (2006). Introductory maternity & pediatric nursing.

Hagerstown, MD: Lippincott Williams & Wilkins.

• Lab Test Online (2011). Third Trimester: Group B Streptococcus. Retrieved

December 19, 2011 from:

http://labtestsonline.org/understanding/wellness/pregnancy/third-strep/

• Mayo Clinic (2011). Chorionic Villus Sampling. Retrieved December 6, 2011

from: http://www.mayoclinic.com/health/chorionic-villus-sampling

• Mayo Clinic (2011). Fetal Development. Retrieved December 5, 2011 from:

http://www.mayoclinic.com/health/fetal-development

• Mayo Clinic (2011). Prenatal testing: Your guide to common tests. Retrieved

December 6, 2011 from: http://www.mayoclinic.com/health/prenatal-testing

• WebMD (2011). Pregnancy and the Quad Marker Screen. Retrieved


http://www.webmd.com/baby/guide/quad-marker-screen

• WomensHealth.gov (2007 & updated 2011). Pregnancy. Updated December

13, 2011 from: http://www.womenshealth.gov/pregnancy/

• WebMD (2011). Pregnancy and the Quad Marker Screen. Retrieved


http://www.webmd.com/baby/guide/quad-marker-screen

References

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Please Read: This publication is intended solely for the use of healthcare professionals taking this course, for credit, from RN.com. It is designed to assist healthcare professionals, including nurses, in addressing many issues associated with healthcare. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from RN.com.

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• Some Health Care Providers routinely recommend the Quad Marker Test, others screen only when one or more of the following indications are present:

•

• Maternal age of 35 or older when the baby is due.

• Family history of birth defects.

• A previous pregnancy that resulted in an infant born with a birth defect.

• Maternal type 1 diabetes prior to the pregnancy.

(WebMD, 2011).

During the first trimester women will often experience:

A. Nausea

B. Vomiting

C. Fatigue

D. All of the above

Over the counter or prescription medicines for colds or nasal stuffiness can be taken during pregnancy without a healthcare providers approval.

True

False

Dizziness occurs only during the third trimester.

True

False

During pregnancy consuming foods that are high in ____ and fat can lead to excessive weight gain.

A. Protein

B. Sugar

C. Magnesium

D. Potassium

Folic acid is found in fortified cereals, bread, and ____.

A. Beans

B. Oranges

C. Spinach

D. All of the above

During the first trimester, it is normal to gain only a small amount of weight, about one pound per month.

True

False

Pregnancy Gingivitis

Some pregnant women will get a type of gum disease called pregnancy gingivitis. It can be caused by poor oral hygiene and increased hormone levels during

pregnancy. Having this problem can cause discomfort when a pregnant woman brushes or flosses, but it’s important not to stop brushing and flossing regularly.

Pregnancy gingivitus increases the risk of developing a more serious type of gum disease.

Pigmentations of the skin that occur during pregnancy are usually permanent.

True

False

Breastfeeding Information

Best for Baby A mother's milk has just the right amount of fat, sugar, water, and protein that is needed for a baby's growth and development. Most babies find it easier to digest breast milk than they do formula. Breast milk has antibodies in it to help protect infants from bacteria and viruses and to help them fight off infection and disease. Human milk straight from the breast is always sterile.

Best for Mom Breastfeeding saves times and money. The new mother does not have to purchase, measure, and mix formula, and there are no bottles to warm in the middle of the night. Breastfeeding also helps a mother bond with her baby. Physical contact is important to newborns and can help them feel more secure, warm and comforted. Nursing uses up extra calories, making it easier to lose the pounds gained from pregnancy. It also helps the uterus to get back to its original size more quickly and lessens any bleeding a woman may have after giving birth. Breastfeeding also may lower the risk of breast and ovarian cancers.

The U.S. Surgeon General Recommends Breastfeeding The U.S. Surgeon General recommends that babies be fed with breast milk only — no formula — for the first 6 months of life. It is better to breastfeed for 6 months and best to breastfeed for 12 months, or for as long as the mother and baby wish. Solid foods can be introduced when the baby is 6 months old, while she continues to breastfeed (US Department of Health and Human Services, Office of Women’s Health, 2000).

Check out RN.com’s “Breastfeeding: the Basics” for helpful information on breastfeeding issues.

A medication that is sometimes administered to start contractions is:

A. Pitressin

B. Magnesium

C. Pitocin

D. Indocin

he healthy pregnancy: an overview · the healthy pregnancy: an overview frequent urination is...

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