The Pregnant Woman. Chapter 29. Structure and Function. Pregnancy and the endocrine placenta First day of menses is day 1 of menstrual cycle For first 14 days of cycle, one or more follicles in ovary develops and matures
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Changes during normal pregnancy: second trimester (cont.)
Yellow in color, contains more minerals and protein but less sugar and fat than mature milk
Also contains antibodies, which are protective for newborn during its first days of life until mature milk production begins
Areola and nipples darken, it is thought, because estrogen and progesterone have a melanocyte-stimulating effect, and melanocyte-stimulating hormone levels escalate from second month of pregnancy until delivery
Changes during normal pregnancy: third trimester (cont.)
Slumping of shoulders and anterior flexion of neck from increasing weight of breasts may cause aching and numbness of arms and hands as a result of compression of median and ulnar nerves in arm, commonly referred to as carpal tunnel syndrome
Approximately 2 weeks before going into labor, primigravida experiences engagement, also called “lightening” or “dropping,” when fetal head moves down into pelvis
Other risks for pregnant adolescents are largely psychosocial
This young woman is at risk for downward cycle of poverty beginning with an incomplete education, failure to limit family size, and continuing with failure to establish a vocation and become independent
She may be unprepared emotionally to be a mother
Her social situation may be stressful
She may not have the support of her family, her partner, or his family
Other risks for pregnant adolescent are largely psychosocial (cont.)
Medical risks for pregnant adolescent are generally related to poverty, inadequate nutrition, substance abuse, and sometimes sexually transmitted infections (STIs), poor health before pregnancy, and emotional and physical abuse from her partner
Adolescents, for social reasons, seek health care later when early prenatal care provides optimal management
In developing countries, maternal mortality for pregnant teenagers is major concern because of hypertension, embolism, ectopic pregnancy, and complications from pregnancy termination where abortion is illegal
Due in part to a decrease in number and health of eggs to be ovulated, a decrease in ovulation, endometriosis, and early onset of menopause
According to the American Society for Reproductive Medicine there is an unrealistic expectation that medical science can undo effects of aging when women delay childbearing; therefore, more women of advanced maternal age are choosing to use donor eggs from younger women
The age of egg is important factor, not age of uterus
Prenatal screening involves a fetal anatomy ultrasound (US) scan and serum screening
There are two US scans used in genetic screening
Nuchal translucency (NT) done between gestational weeks 11 and 14, which measures a collection of fluid at nape of fetal neck
Detailed anatomy scan done between gestational weeks 18 and 20
Some facilities continue to use Integrated Prenatal Risk Profile (IPRP), which uses a first trimester US between 10 and 12 weeks to measure NT and maternal serum analysis and a second maternal serum blood draw in the second trimester; results are only received after second maternal blood draw
There are two US scans used in genetic screening (cont.)
Because integrated screen requires a waiting period, the sequential screen was developed
Similar to IPRP, except that those whose risk for Down syndrome is increased after first blood draw are given an earlier option for prenatal diagnostic testing
Women of advanced maternal age (over 35 years old) experience increased risk of prenatal and neonatal deaths, pregnancy-induced hypertension, preterm delivery, small for gestational age (SGA), and large for gestational age (LGA) neonates, gestational diabetes, severe preeclampsia, anal sphincter tears, and cesarean deliveries
In earlier pregnancies, did you have any history of hypertension, preeclampsia, eclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, diabetes, hemolytic Streptococcus infection, intrauterine growth restriction, congenital anomalies, premature labor, postpartum hemorrhage, or postpartum depression?
How did you experience previous pregnancies and deliveries?
Have you ever had a cesarean section? If so, what was the indication? At how many centimeters of dilation, if any, was the surgery performed? What type of uterine incision was made? (Confirming records of this surgery must be obtained.) Have you ever had a vaginal birth after a cesarean section (VBAC)?
How many times have you been pregnant? Number of term or preterm deliveries? Number of spontaneous miscarriages, elective abortions, or ectopic pregnancies? Any fetal or neonatal deaths?
Are you experiencing any visual changes, such as the new onset of blurred vision or spots before your eyes?
Are you experiencing any edema? Where and under what circumstances does it occur?
Do you have any frequency or burning with urination? Is there any blood in your urine? Do you void in small amounts? Do you have a history of urinary tract infections, pyelonephritis, or kidney stones?
Do you have any vaginal burning or itching? Do you have any foul-smelling or colored discharge?
Spontaneous accelerations of FHTs indicate fetal well-being
Differentiate FHTs from slower rate of maternal pulse and uterine souffle (the soft, swishing sound of the placenta receiving the pulse of maternal arterial blood) by palpating the mother’s pulse while you listen
Also, distinguish FHTs from funic souffle (blood rushing through umbilical arteries at same rate as FHTs)
FHTs are a double sound, like tick-tock of a clock under a pillow, whereas funic souffle is sharp, whistling sound heard only 15% of time
When examining vagina, you may see Chadwick’s sign, the bluish-purplish discoloration and congested look of vaginal wall and cervix from increased vascularity and engorgement
Note vaginal discharge; discharge in pregnancy may be heavier in amount but should be similar in description to woman’s nonpregnant discharge and should not be associated with itching, burning, or an unusual odor (except that, occasionally, chapping of vaginal area may be seen due to excessive moisture)
Perform a wet mount or culture of discharge when you are uncertain of its normalcy
Note whether cervix appears open
Note whether it is smooth, round cervix with a dotlike external os of nulliparous woman or irregular multiparous cervix with an external os that appears more like a crooked line, result of cervical dilation and possibly lacerations in a previous pregnancy
When examining cervix, note its position (anterior, midposition, or posterior), degree of effacement (or thinning, expressed in percentages assuming a 2-cm long cervix initially), dilation (opening, expressed in centimeters), consistency (soft or firm), and station of presenting part (centimeters above or below ischial plane)
Dimensions may indicate favorableness of bony structure for vaginal delivery
However, relaxation of pelvic joints, widening of pelvis in squatting position, and capacity of fetal head to mold to shape of pelvis may enable a vaginal birth despite seemingly unfavorable measurements
To aid in visualizing pelvis, imagine three planes:
Pelvic inlet, from sacral promontory to upper edge of pubis
Midpelvis, and pelvic outlet, from coccyx to lower edge of pubis