NSG210 Exam 2 Reading Outline - Durham Ch. 4: Physiological Aspects of Pregnancy

Source: Durham & Chapman, Davis Advantage for Maternal-Newborn Nursing, Chapter 4 (~/Documents/texts/nursing/NSG210/exam02/DURHAM_OB_CH04.pdf). Part of nsg210-exam-2-readings-outline.

Learning Outcomes

1. Identify the major components of preconception health care.
2. Describe methods to diagnose pregnancy and determine the estimated date of delivery (EDD).
3. Explain the progression of anatomical and physiological changes during pregnancy.
4. Link those changes to the signs, symptoms, and common discomforts of pregnancy.
5. Discuss interventions to relieve common discomforts.
6. Compare assessment and nursing care at initial and subsequent prenatal visits.
7. Outline patient education and anticipatory guidance for each trimester.

I. Physiological Progression of Pregnancy

Every body system adapts to protect the woman and fetus, maintain the pregnancy, support fetal development, and prepare for labor and birth. Understanding normal change is what lets the nurse spot abnormal change.

A. Reproductive System

1. Breasts (estrogen, progesterone, prolactin)
   • Tenderness, fullness, tingling; breast weight increases about 400 g
   • Enlargement of breasts, nipples, areola, and Montgomery follicles (small glands on the areola)
   • Darkening of areola and nipple; striae; prominent veins (blood flow doubles)
   • Growth of mammary glands, lactiferous ducts, and alveoli
   • Colostrum (yellow, antibody-rich) can be produced as early as 16 weeks
2. Uterus - three parts: fundus (upper), isthmus (lower segment), cervix (neck; the os dilates in labor)
   • Pre-pregnancy: small pear, 40-70 g, capacity about 10 mL
   • At term: 1,100-1,200 g, capacity about 5,000 mL, about 20 times nonpregnant size
   • Wall thins as the uterus expands; fundus reaches the umbilicus at mid-pregnancy (about 20 weeks)
   • Uterine blood flow at term: 500-600 mL/min
   • Braxton-Hicks contractions: intermittent, painless, irregular; begin in the second trimester, often not felt until the third
3. Cervix
   • Goodell’s sign - softening of the cervix
   • Mucus plug forms from hypertrophied cervical glands - protective barrier between uterus and vagina
4. Vagina
   • Increased vascularity; Chadwick’s sign (bluish color of cervix, vagina, vulva)
   • Leukorrhea - increased discharge from estrogen-driven gland hypertrophy
   • Relaxation of vaginal wall and perineal body for birth
   • Acidic pH - inhibits bacteria but allows Candida albicans overgrowth, raising risk of yeast infection
5. Ovaries
   • hCG maintains the corpus luteum, which produces progesterone to maintain the endometrium in early pregnancy
   • Ovulation and menstruation stop
   • By 6-7 weeks the placenta takes over progesterone production and the corpus luteum degenerates

B. Cardiovascular System

Changes begin early; blood volume rises fastest in the second trimester and peaks in the final weeks. The changes support the fetus and protect against the blood loss of birth.

• Blood volume increases 30-50% (about 1,200-1,600 mL) - hypervolemia of pregnancy
• Plasma volume increases 40-60%, peaking at 32-34 weeks
• RBC count increases about 30%; RBC volume up 20-30% with iron supplementation (about 18% without)
• Physiological anemia (pseudoanemia) of pregnancy - plasma rises more than RBCs, so hemoglobin and hematocrit fall (hemodilution); lower viscosity eases cardiac work and helps placental perfusion
• Iron-deficiency anemia - hemoglobin under 11 g/dL, hematocrit under 33%
• Cardiac output increases 30-50%, peaking at 25-30 weeks
• Resting heart rate increases 10-20 bpm; stroke volume up 25-30%
• Basal metabolic rate up 10-20% by the third trimester
• WBC count up to 16,000/mm3 without infection (hormonally induced)
• Hypercoagulability - plasma fibrin up 40%, fibrinogen up 50%, clotting inhibitors down; protects against postpartum hemorrhage but raises thrombosis risk
• Heart enlarges slightly and shifts upward and laterally
• Systolic murmur or S3 may be heard by mid-pregnancy (normal)
• BP falls in the first trimester (lower peripheral vascular resistance) and returns to baseline by term
• Increased venous pressure below the uterus - dependent edema, varicosities of legs and vulva, hemorrhoids
• Supine hypotensive syndrome (Critical Component) - in mid to late pregnancy, lying supine lets the uterus compress the inferior vena cava, dropping venous return, cardiac output, and BP; woman feels dizzy and faint. Position on side.

C. Respiratory System

• Oxygen consumption up 20-40%; metabolic rate up about 15%
• Minute ventilation up 30-50%, mostly from tidal volume (up 30-40%), not respiratory rate
• Slight respiratory alkalosis - lower PCO2 raises pH and lowers bicarbonate; this helps move CO2 away from the fetus
• Estrogen, progesterone, and prostaglandins cause vascular engorgement: nasal and sinus congestion, epistaxis, dyspnea
• Anatomical: diaphragm displaced up about 4 cm; chest circumference up about 6 cm; costal angle over 90 degrees; shift from abdominal to thoracic breathing
• Physiological dyspnea is common; pulmonary function is not compromised in normal pregnancy

D. Renal System

• Renal plasma flow increases (60-80% in the first trimester, then decreases); GFR and tubular reabsorption increase
• Small amounts of glucosuria and proteinuria can be normal (reabsorption threshold exceeded) but must be monitored for pathology
• RAAS and ADH regulation shift to handle increased fluid needs
• Position matters: supine and upright positions pool blood in the lower body, lowering cardiac output, GFR, and urine output. Left lateral recumbent maximizes cardiac output, renal perfusion, and urine output, and minimizes edema.
• Anatomical: renal pelvis dilates; ureters become elongated, tortuous, and dilated (progesterone relaxes smooth muscle); bladder compressed by the uterus
• Urinary stasis raises risk of UTI and pyelonephritis; UTIs are common and may be asymptomatic; untreated UTI can lead to pyelonephritis or preterm labor; treated with 7-10 days of anti-infectives
• Frequency, urgency, nocturia; incontinence in about 20% in the first trimester and at least 40% in the third

E. Gastrointestinal System

• Nausea and vomiting of pregnancy (NVP) - hCG and altered carbohydrate metabolism; most women have some; about a third have significant distress; usually improves by 16 weeks
• Appetite changes, cravings, food aversions
• Pica - craving and eating nonfood substances (clay, starch); risk of toxicity or malnutrition
• Uterus displaces stomach, liver, and intestines; by term the appendix is high and to the right near the costal margin (relevant to appendicitis assessment)
• Progesterone slows GI motility - heartburn (lower esophageal sphincter relaxes), bloating, constipation
• Hemorrhoids in 30-40%, worsened by constipation
• Gallbladder empties slowly - bile stasis and gallstones; abdominal pruritus may be an early sign of cholestasis
• Ptyalism (excess salivation)
• Gingivitis, bleeding gums, periodontal disease (estrogen-driven vascular congestion)

F. Musculoskeletal System

• Progesterone and relaxin soften ligaments and loosen the sacroiliac joints and symphysis pubis - “waddle” gait
• Center of gravity shifts forward; lordosis increases; higher fall risk
• Low back pain and pelvic discomfort
• Round ligament spasm - stretching of round ligaments causes pain
• Diastasis recti - separation of the rectus abdominis in the midline, benign, third trimester
• Maintaining normal weight and exercising reduces discomforts

G. Integumentary System

• Hyperpigmentation (estrogen and progesterone increase melanin):
  • Linea nigra - dark midline line of the abdomen
  • Melasma (chloasma, “mask of pregnancy”) - brown patches on cheeks, nose, forehead; 50-70% of pregnant women; after 16 weeks; worse with sun
  • Darker nipples, areola, vulva, scars, moles
• Striae gravidarum (stretch marks) - breasts, abdomen, hips, buttocks
• Vascular changes: varicosities, spider nevi (angiomas), palmar erythema
• Hot flashes, flushing, sweating (increased BMR, progesterone-raised temperature)
• Oily skin and acne (androgens)
• None are pathological; most resolve or fade after pregnancy

H. Endocrine System

• hCG - produced by fertilized ovum and chorionic villi; maintains the corpus luteum until the placenta takes over
• Progesterone - relaxes smooth muscle, decreasing uterine activity (lowers spontaneous abortion risk); slows GI motility
• Estrogen - uterine and breast development, vascularity, hyperpigmentation, fluid and metabolic changes
• Prolactin - lactation
• Oxytocin - uterine contractions and milk let-down
• Human placental lactogen (hPL, human chorionic somatomammotropin) - breast development; acts as an insulin antagonist, shifting maternal metabolism to favor fetal growth
• Thyroid - hyperplasia, enlargement, heat intolerance, fatigue
• Pancreas and glucose - maternal glucose stores depleted by the fetus (hypoglycemia risk), increased insulin production, increased cortisol and insulin resistance (hyperglycemia risk)
• Decreased FSH - amenorrhea

I. Immune System

• Maternal immune system adapts to tolerate the “foreign” fetus while still protecting against infection; not fully understood

J. Patient Education on Normal Changes

• Supportive bra; colostrum leaking is normal
• Braxton-Hicks patterns and which to report
• Causes and prevention of supine and orthostatic hypotension
• Iron-rich foods and supplements
• Edema and varicosity prevention; stand, stretch, deep breaths periodically
• Reasons for urinary frequency in the first and third trimesters; UTI signs and prevention (void often, wipe front to back, void before and after intercourse, at least 8 glasses of fluid)
• Kegel exercises
• NVP is normal and self-limiting
• Oral hygiene and dental care
• High-fiber diet, fluids, activity for constipation and hemorrhoids
• Back and ligament pain relief; gentle abdominal strengthening
• Skin changes and striae are normal; limit sun, use sunscreen

II. Preconception Health Care

Preconception care identifies and manages social, behavioral, environmental, and biomedical risks before conception to improve the chance of a healthy baby. It is a process across the reproductive years, not a single visit, and applies to men and women. Almost half of US pregnancies are unintended, so every visit is an opportunity.

A. Routine Physical Examination and Screening

• Height, weight, BMI; comprehensive physical with breast and pelvic exam
• Labs: blood type and Rh, CBC, cholesterol, glucose, rubella IgG, HIV, syphilis, urinalysis, STI cultures, Pap smear, tuberculin skin test

B. Health History and Risk Assessment (Table 4-2)

• Demographics, health promotion (vaccines, folic acid, reproductive life plan), medical and surgical history, medications, allergies
• Family and genetic history
• Reproductive history - menstrual, obstetric (prior preterm or cesarean births), gynecological, contraceptive, sexual, abuse history
• Self-care and lifestyle - sleep, stress, nutrition, BMI, exercise, safety (seat belts, smoke and CO detectors, guns), tobacco, alcohol, drugs, caffeine
• Psychosocial - mental health, depression, IPV, support
• Cultural - beliefs, practices, language (interpreters)
• Environmental and occupational exposures
• Financial - food, housing, insurance

C. Zika Virus (Critical Component)

• Spread by mosquitoes and sexually; causes microcephaly, impaired growth, vision and hearing deficits
• No vaccine; symptoms mild (fever, rash, joint pain, conjunctivitis)
• Wait at least 8 weeks after symptoms before conceiving; if the partner is exposed, avoid pregnancy for at least 3 months
• Pregnant women should avoid travel to active-transmission areas

D. Nutrition and Weight

• WHO BMI categories: underweight under 18.5; normal 18.5-24.9; pre-obesity 25-29.9; obesity class I 30-34.9, class II 35-39.9, class III 40 or more
• Obesity risks: spontaneous abortion, congenital anomalies, GDM, macrosomia, fetal growth restriction, preterm birth, failed labor, cesarean, shoulder dystocia; postpartum endometritis, wound problems, VTE, hemorrhage; childhood obesity and metabolic disease in offspring
• Underweight or inadequate gain: poor fetal growth, low birth weight
• IOM recommends reaching a normal BMI before conception
• Avoid: high-mercury fish, undercooked meat, fish, eggs, unpasteurized dairy and juice, unwashed produce, alcohol (no safe amount), most herbal supplements; ginger 1-1.5 g/day helps nausea

E. Prenatal Vitamins

• Folic acid 0.4 mg daily for all women who could become pregnant - prevents neural tube defects; the neural tube closes before many women know they are pregnant
• High-risk for NTD: 1-4 mg daily starting 1-3 months before conception through the first trimester, then 0.4 mg
• Calcium, magnesium, vitamin D for bone health; iron especially with short interpregnancy intervals
• Avoid megadoses (possible fetal toxicity)

F. Exercise

• Regular activity is safe in a normal pregnancy; ideally started before conception
• Good choices: walking, swimming, stationary bike, stretching, strength work
• Avoid: prolonged supine yoga poses, hot yoga, contact sports, scuba, skydiving, fall-risk activities (horseback riding, downhill skiing)
• Contraindications: significant heart or lung disease; preeclampsia, placenta previa, anemia, morbid obesity, fetal growth restriction, poorly controlled diabetes; preterm labor risk (multiples, PROM, cerclage)
• Stop and call the provider for (Critical Component): abdominal pain, calf pain or swelling, chest pain, dizziness or syncope, headache, muscle weakness affecting balance, new dyspnea before exercise, regular painful contractions, vaginal bleeding or fluid leakage

G. Self-Care, Contraception Cessation, Timing

• Avoid drugs, cannabis, alcohol, tobacco (including secondhand), excess caffeine, contraindicated medications, environmental toxins (lead, mercury, pesticides, solvents)
• Safe sex, seat belts, sunscreen, sleep, dental care; discuss complementary therapies with the provider
• Ideally two or three normal periods before conception; switch from hormonal to barrier methods; Depo-Provera can delay conception by months to over a year; IUD must be removed
• Teach cycle, ovulation signs, and timing of intercourse

H. Preconception Care for Men and Access to Care

• Men: evaluate and manage chronic disease, healthy behaviors, avoid tobacco and toxins
• Nurses reduce disparities: interpreters and teach-back, shared decision-making, implicit-bias training, tracking quality data by race and language, promoting equitable care

III. Diagnosis of Pregnancy

A. Presumptive Signs (subjective - reported by the woman; not diagnostic)

• Amenorrhea
• Nausea and vomiting (weeks 2-12)
• Breast changes (from 2-3 weeks)
• Fatigue (first trimester)
• Urinary frequency
• Quickening - first felt fetal movement; 18-20 weeks in primigravidas, 14-16 weeks in multigravidas

B. Probable Signs (objective - observed by the examiner; could have other causes)

• Chadwick’s sign - bluish-purple vagina, cervix, vulva at 6-8 weeks
• Goodell’s sign - softening of the cervix at 8 weeks
• Hegar’s sign - softening of the lower uterine segment at 6 weeks
• Uterine and abdominal growth
• Skin hyperpigmentation (melasma, linea nigra, darker areola)
• Ballottement - tap on the cervix makes the fetus rise and rebound, 16-18 weeks
• Positive pregnancy test - detects hCG; considered probable because false positives and negatives occur
  • Blood test detects hCG before a missed period
  • Urine best with first morning specimen

C. Positive Signs (objective - can only be caused by the fetus)

• Fetal heart heard by Doppler at 10-12 weeks
• Fetal movement palpated by examiner after about 20 weeks
• Ultrasound visualization of the fetus; cardiac movement at 4-8 weeks
• Transvaginal ultrasound: gestational sac by 4.5-5 weeks
• Early ultrasound indications: first-trimester pain or bleeding, prior loss or ectopic, uncertain LMP, size-dates discrepancy

IV. Pregnancy Dating

• Antepartum (prenatal) period - from the first day of the LMP to the onset of labor; divided into trimesters of about 3 months
• Pregnancy lasts about 280 days (40 weeks) from the LMP
• Naegele’s rule: first day of LMP minus 3 months plus 7 days (example: LMP September 7 leads to EDD June 14); accuracy depends on regular 28-day cycles
• Other dating tools if LMP unknown: uterine size, first fetal heart tones, date of quickening, ultrasound, assisted reproduction dates
• Gestational wheel - quick but less reliable; use Naegele’s rule first
• Gestational age counts from the LMP; conceptual (embryological) age is about 2 weeks less
• Most births occur 3 weeks before to 2 weeks after the EDD
• Term classifications (Critical Component):
  • Early term: 37 0/7 to 38 6/7 weeks
  • Full term: 39 0/7 to 40 6/7 weeks
  • Late term: 41 0/7 to 41 6/7 weeks
  • Post term: 42 0/7 weeks and beyond

V. Prenatal Assessment Terminology

• Gravida - number of pregnancies, including the current one, regardless of outcome or number of fetuses
• Para - number of births after 20 weeks, live or stillborn; twins count as one
• Abortion - pregnancy ending before 20 weeks, spontaneous or induced
• GTPAL - Gravida, Term, Preterm, Abortions, Living children; GTPALM adds M for multiple gestations
• Nulligravida (never pregnant), primigravida (first pregnancy), multigravida (second or later)

VI. Prenatal Care

A. Purpose and Schedule

• Three components of adequate prenatal care: early and continuing risk assessment, health promotion, medical and psychosocial intervention with follow-up
• Goals: maternal-fetal health, accurate gestational age, ongoing risk assessment, rapport, referrals
• Visit schedule (AAP/ACOG): monthly to 28 weeks, every 2 weeks from 28-36 weeks, weekly from 36 weeks to delivery (twice weekly after 40 weeks)
• Every visit: maternal weight and BP; fetal heart rate, activity, growth, and amniotic fluid
• Healthy People 2030 target: 80.5% receiving early and adequate prenatal care (baseline 76.4%)
• Include the father’s health history (age, blood type and Rh, health, genetics)

B. Intimate Partner Violence (Critical Component)

• Physical, sexual, psychological, or emotional abuse by a current or former partner; affects all groups
• Pregnancy raises risk, especially unplanned pregnancy; highest in pregnant adolescents
• 20-30% of US women have experienced IPV
• USPSTF: screen all women of reproductive age; screen at each prenatal encounter, in private
• Tools: HARK, HITS, E-HITS, PVS, WAST
• Positive screen leads to risk assessment for serious harm and referral to support services

C. Nursing Actions at Prenatal Visits

• Privacy and therapeutic communication; ask sensitive questions (G/P, IPV) in private
• History (complete at first visit, interval history later), review of systems, vital signs, weight, BMI, edema check
• Assist with exams and specimens; dipstick urine for protein, glucose, ketones
• Teach procedures, warning signs, and when to call; document
• Cultural assessment - beliefs, language, religious preferences, expectations

D. First Trimester

Initial visit components:

• Current pregnancy history - LMP and certainty, cycle regularity, contraception, conception date, symptoms, intendedness, emotional response
• Obstetric history - GTPAL, type and dates of prior births, complications, neonatal outcomes, losses and grieving
• Physical and pelvic exams; bimanual exam estimates uterine size for dating; clinical pelvimetry not routine
• Ultrasound to confirm intrauterine pregnancy, viability, gestational age
• Fundal height from 10-12 weeks with tape from symphysis pubis to top of fundus; should roughly equal weeks gestation; have the woman empty her bladder first; used as a growth screen
• Fetal heart tones by Doppler at 10-12 weeks; normal FHR 110-160 bpm

Initial prenatal labs with rationale (Critical Component):

• ABO, Rh, and antibody screen - identify isoimmunization; Rh-negative women rescreened and given RhoGAM at 26-28 weeks and after delivery if baby is Rh-positive
• Hgb or Hct - anemia (usually iron deficiency; treat with iron in addition to prenatal vitamin)
• Rubella and varicella titers - if nonimmune, vaccinate postpartum (live vaccines)
• Syphilis (VDRL or RPR) - treat early to prevent congenital syphilis
• Gonorrhea and chlamydia
• Urinalysis and urine culture - asymptomatic bacteriuria carries a 25% risk of pyelonephritis if untreated
• Hepatitis B surface antigen - identify infants needing immunoprophylaxis
• HIV - antiretrovirals lower vertical transmission to under 2%
• Pap smear per age guidelines
• TB skin test for at-risk groups
• Offer genetic screening (10 0/7 to 13 6/7 weeks) - see Ch. 6

Nutrition assessment and education:

• Obesity (BMI 30 or more) is the most prevalent medical condition in women of childbearing age; linked to loss, stillbirth, anomalies, preterm and post-term birth, GDM, hypertension, postpartum depression, VTE
• 24-hour diet recall; weight gain goals by BMI (Box 4-2):
  • Underweight: 28-40 lb
  • Normal: 25-35 lb (37-54 for twins)
  • Overweight: 15-25 lb (31-50 for twins)
  • Obese: 11-20 lb (25-42 for twins)
  • First trimester gain about 1-5 lb
• Weight gain distribution (Box 4-3): baby 7-8 lb, placenta 1.5 lb, amniotic fluid 2 lb, breasts 1-3 lb, uterus 2 lb, fluid 2-3 lb, blood 3-4 lb, fat stores 6-8 lb
• 8-10 glasses of fluid daily; caffeine limit 200 mg/day
• Avoid high-mercury fish (king mackerel, orange roughy, marlin, shark, swordfish, tilefish); albacore tuna limited to 6 oz/week
• Food safety: wash hands and produce, cook eggs and meats thoroughly, discard food left out over 2 hours
• Avoid unpasteurized juice and dairy, raw sprouts, soft cheeses (Brie, Camembert, feta), refrigerated smoked seafood, unheated deli meats and hot dogs, raw eggs, raw fish and shellfish, chamomile, peppermint, licorice, raspberry leaf teas

First trimester patient education:

• Discomforts and relief measures; fetal development (end of first trimester: 3 inches, 1-2 oz, all organ systems present, heartbeat audible by Doppler)
• Avoid tobacco, alcohol, drugs, teratogens; check with provider before medications and supplements
• Rest, hygiene, UTI and vaginal infection prevention (front to back, cotton underwear, hydration, void after intercourse, no douching), oral hygiene
• Exercise 30 minutes daily; Kegels; travel is safe in low-risk pregnancy with frequent stretch breaks
• Stress coping; sexuality changes

First trimester warning signs (Critical Component):

• Abdominal cramping or pain - threatened abortion, UTI, appendicitis
• Vaginal spotting or bleeding - threatened abortion
• Absent fetal heart tones - missed abortion
• Dysuria, frequency, urgency - UTI
• Fever or chills - infection
• Prolonged nausea and vomiting - hyperemesis gravidarum, dehydration

Migrant women: more likely to have late or inadequate prenatal care; need culturally respectful care and help navigating the health system.

E. Second Trimester

Assessment:

• Chart review and interval history
• Vital signs (slight BP decrease toward end of second trimester), weight gain by BMI
• Urine dipstick for glucose, albumin, ketones (mild proteinuria and glucosuria normal)
• FHR 110-160 by Doppler; fetal movement and quickening (about 18-20 weeks)
• Leopold’s maneuvers to identify fetal position
• Fundal height equals weeks of gestation
• Ultrasound around 20 weeks to confirm EDD and survey anatomy
• Edema: slight lower-body edema is normal; upper-body or facial edema is abnormal and needs evaluation

Labs and screening:

• Triple, quad, or penta screen at 15-20 weeks (NTD and trisomy 21) - see Ch. 6
• GDM screen: 1-hour glucose challenge test at 24-28 weeks; 3-hour GTT if elevated
• Hgb and Hct at 28-32 weeks - when values are lowest
• Antibody screen for Rh-negative women; RhoGAM at 28 weeks if antibody negative

RhoGAM - Rho(D) immune globulin (Understanding Medication):

• Indication: Rh-negative women at 26-28 weeks, within 72 hours after delivery of an Rh-positive infant, and after any likely exposure (pregnancy loss, amniocentesis, abdominal trauma)
• Action: prevents the mother from making anti-D antibodies, preventing hemolytic disease of the newborn (erythroblastosis fetalis) in future pregnancies
• Dose: 300 mcg IM; adverse effects are injection site pain and fever; use cautiously with ITP or anemia

Second trimester education:

• Fetal development (20 weeks: about 8 inches, 1 lb, long and skinny)
• Nutrition (+340 kcal/day), discomforts, warning signs
• Preterm labor signs: rhythmic lower abdominal cramping, low backache, pelvic pressure, leaking fluid, increased discharge, spotting or bleeding
• Hypertensive disorder signs: severe headache unrelieved by usual measures, visual changes, facial or generalized edema
• Informed decision-making about tests and procedures

Second trimester warning signs (Critical Component):

• Abdominal or pelvic pain - PTL, UTI, pyelonephritis, appendicitis
• Absent fetal movement after daily movement had been felt - fetal distress or death
• Prolonged nausea and vomiting - hyperemesis gravidarum
• Fever and chills - infection
• Dysuria, frequency, urgency - UTI
• Vaginal bleeding - infection, friable cervix, placenta previa, abruption, PTL

F. Third Trimester

Assessment:

• Everything from the second trimester, plus pelvic exam for cervical change as indicated (cervical exam starting around 36 weeks)
• Leopold’s maneuvers to confirm fetal position
• Fetal movement (kick) counts - a maternal assessment to identify potentially hypoxic fetuses:
  • ACOG 2-hour approach: 10 distinct movements within 2 hours is reassuring; stop counting once reached
  • 1-hour approach: meets or exceeds the woman’s baseline; generally 4 movements in 1 hour is reassuring
  • Count at the same time daily, record the time needed; kicks, flutters, swishes, and rolls all count
  • Decreased movement is reported and followed up with NST or BPP
• Group B streptococcus (GBS): 25-33% of women colonized (usually asymptomatic); newborn GBS can be severe with neurologic sequelae; vaginal-rectal swab at 35-37 weeks to plan intrapartum antibiotics
• Labs: 1-hour glucose test if not done, H&H, repeat GC, chlamydia, RPR, HIV, HBsAg as indicated

Third trimester education:

• Fetal growth (term: 17-20 inches, 6-8 lb, more subcutaneous fat, sleep-wake cycles)
• Nutrition (+452 kcal/day), discomforts, warning signs
• Travel limits in the last month
• Childbirth classes, pain management choices, birth plan
• Signs of impending labor, true versus false labor, when to call and when to go to the birthing unit
• Parenting classes, feeding method, infant’s provider, sibling preparation

Third trimester warning signs (Critical Component):

• Abdominal or pelvic pain - PTL, UTI, pyelonephritis, appendicitis
• Decreased or absent fetal movement - fetal hypoxia or death
• Prolonged nausea and vomiting - dehydration, hyperemesis
• Fever, chills - infection
• Dysuria, frequency, urgency - UTI
• Vaginal bleeding - infection, friable cervix, placenta previa, abruption, PTL
• PTL signs and hypertensive disorder signs (as listed for the second trimester)

VII. Common Discomforts and Relief Measures (Table 4-4)

VIII. Care Plan Highlights (Constipation Concept Map)

• Altered elimination: assess prior bowel patterns, teach fiber, fluids, exercise, regular toileting time; discuss stool softeners with provider
• Altered fluid intake from NVP: small frequent meals, no fluids with meals, avoid fatty and spicy foods, vitamin B6 or ginger
• Decreased gastric motility: high-fiber foods (pears, apples, prunes, kiwi, dried fruit), bran cereal with at least 4-5 g fiber per serving, warm liquid on rising
• Hemorrhoid discomfort: avoid straining, witch hazel pads, stool softeners, footstool during bowel movements

Case Study Themes (Margarite Sanchez, G3 P1)

• 8 weeks: initial assessment, first-visit labs and rationale, first-trimester teaching and discomforts (fatigue, nausea, breast tenderness)
• 18 weeks: quickening, protein needs, second-trimester screening tests
• 34 weeks: leg edema, backache, insomnia, nocturia, third-trimester warning signs