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Metro Community College NURS 1400 Family Nursing I Unit 1. CONCEPTION. Fertilization Implantation. DEVELOPMENTAL CHARACTERISTICS & FUNCTION. Placenta Umbilical cord Fetus Fetal circulation. Pregnancy. Psychosocial Effects of Pregnancy. Presumptive Signs of Pregnancy. Amenorrhea

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metro community college nurs 1400 family nursing i unit 1
Metro Community College

NURS 1400 Family Nursing I

Unit 1

conception
CONCEPTION
  • Fertilization
  • Implantation
developmental characteristics function
DEVELOPMENTAL CHARACTERISTICS & FUNCTION
  • Placenta
  • Umbilical cord
  • Fetus
  • Fetal circulation
presumptive signs of pregnancy
Presumptive Signs of Pregnancy
  • Amenorrhea
  • Nausea and vomiting
  • Fatigue
  • Urinary frequency
  • Breast enlargement and tenderness
  • Quickening
probable signs of pregnancy
Probable Signs of Pregnancy
  • Goodell’s sign (softening of the cervix)
  • Chadwick’s sign (bluish vaginal tissue)
  • Hegar’s sign (softening of the cervix)
  • Ballottement
  • Positive pregnancy test

Ballottement

slide9
Figure 14–4 Hegar’s sign, a softening of the isthmus of the uterus, can be determined by the examiner during a vaginal examination.
slide10

Figure 14–5 Early uterine changes of pregnancy. A, Ladin’s sign, a soft spot anteriorly in the middle of the uterus near the junction of the body of the uterus and the cervix. B, Braun von Fernwald’s sign, irregular softening and enlargement at the site of implantation. C, Piskacek’s sign, a tumorlike, asymmetric enlargement.

slide11

Figure 14–5 (continued) Early uterine changes of pregnancy. A, Ladin’s sign, a soft spot anteriorly in the middle of the uterus near the junction of the body of the uterus and the cervix. B, Braun von Fernwald’s sign, irregular softening and enlargement at the site of implantation. C, Piskacek’s sign, a tumorlike, asymmetric enlargement.

slide12

Figure 14–5 (continued) Early uterine changes of pregnancy. A, Ladin’s sign, a soft spot anteriorly in the middle of the uterus near the junction of the body of the uterus and the cervix. B, Braun von Fernwald’s sign, irregular softening and enlargement at the site of implantation. C, Piskacek’s sign, a tumorlike, asymmetric enlargement.

positive signs of pregnancy
Positive Signs of Pregnancy
  • Fetal heart tones
  • Fetal movement
  • Ultrasound

Abdominal ultrasound

Transvaginal probe

estimation of due date
Estimation of Due Date
  • Naegele’s rule
  • Uterine size
  • Ultrasound
n egle s rule
Näegle’s Rule
  • First day of last menstrual period – 3 months + 7 days = EDB
expected date of delivery
Expected Date of Delivery
  • Other indicators of gestational age
    • FHT with doppler at 10–12 weeks
    • Fetal movement felt at about 20 weeks
    • Fundal height correlation with gestational age
  • Ultrasound
reproductive system
Reproductive System
  • Uterus
    • Enlarges to hold a volume of 15–20 liters
    • At 12 weeks rises out of the pelvis
    • Walls thin, but strengthened with fibrous tissue
reproductive system continued
Reproductive System (continued)
  • Uterus (continued)
    • 20–25% of cardiac output goes to uterus
    • Braxton Hicks contractions occur throughout pregnancy
  • Cervix
    • Softens and becomes bluish in color
    • Mucous plug forms to protect the fetus
reproductive system continued21
Reproductive System (continued)
  • Vagina, perineum, and vulva
    • Increased vascularity
    • Increased vaginal discharge
      • Acidic environment prevents bacterial infection
      • Yeast infection (candida) common during pregnancy
reproductive system continued22
Reproductive System (continued)
  • Ovaries
    • Normal function ceases
    • Corpus luteum secretes progesterone
    • Placenta produces progesterone by six to seven weeks and corpus luteum regresses
reproductive system continued23
Reproductive System (continued)
  • Breasts
    • Enlarge and become tender
    • Increased alveoli
    • Areola darken
    • Tubercles of Montgomery enlarge and secrete a substance to maintain areolar suppleness
    • Colostrum may leak from the breast
hematologic system
Hematologic System
  • Blood volume
    • Increases by 40–50%
    • Plasma volume increases by 1,200–1,600 ml
    • Red blood cells increase by 450 ml
    • Physiologic anemia results
      • Hemoglobin drops up to 2 mg/dl
      • Iron deficiency anemia considered when hemoglobin drops to 10.5 mg/dl or less
hematologic system continued
Hematologic System (continued)
  • Blood coagulation
    • Increase in clotting factors and risk of thrombus
cardiovascular system
Cardiovascular System
  • Heart
    • Displaced up and to the left
    • Heart enlarges
    • Systolic murmurs common
cardiovascular system continued
Cardiovascular System (continued)
  • Cardiac output
    • Increases by 10 weeks, peaks at 24 weeks
    • Heart rate increases by 20 beats/minute
  • Blood pressure
    • Decreases in first trimester
    • Returns to normal reading by term
  • Systemic vascular resistance
    • Decreases during pregnancy
cardiovascular system continued28
Effect of positioning during pregnancy

Supine hypotension

Cardiovascular System (continued)

Inferior

vena cava

Descending aorta

A. Supine position

B. Right lateral position

respiratory system
Respiratory System
  • Changes in mechanical function
    • Diaphragm rises 4 cm
    • Chest circumference increases 5 to 7 cm
  • Progesterone
    • Causes increase in tidal volume (30–40%) and decrease in Pco2 (compensated respiratory alkalosis)
  • Rate does not change
  • Changes facilitate removal of carbon dioxide from fetus
gastrointestinal system
Gastrointestinal System
  • Mouth
    • Gums become soft and edematous
    • Ptyalism may develop
    • Benign tumors may appear
  • Esophagus
    • Progesterone relaxes cardiac sphincter
    • Pyrosis or heartburn develops from acid reflux
gastrointestinal system continued
Gastrointestinal System (continued)
  • Stomach and intestine
    • Delayed stomach emptying
    • Constipation common
  • Gallbladder
    • Predisposed to stone formation
gastrointestinal system continued32
Gastrointestinal System (continued)
  • Liver
    • Spider angioma
    • Palmar erythema
    • Albumin decreased, alkaline phosphatase increased, cholesterol increased

Stomach compressed

Liver

pushed up

Bladder largely in pelvis therefore frequent urination

endocrine system
Endocrine System
  • Thyroid
    • Enlarges, euthyroid state maintained
    • Increase in BMR by 25%
  • Parathyroid
    • Increased secretion of parathyroid hormone to meet calcium needs of the fetus
  • Pituitary
    • FSH, LH suppressed
    • Prolactin increased
    • Oxytocin for contractions and lactation
endocrine system continued
Endocrine System (continued)
  • Adrenal glands
    • Cortisol
      • Activates gluconeogenesis
      • Increases blood glucose levels
    • Aldosterone
      • Increases
      • Protects the woman from sodium loss
  • Pancreas
    • Beta cells increase in number and size
endocrine system continued35
Endocrine System (continued)
  • Placenta
    • hCG
      • Confirms pregnancy
      • Maintains corpus luteum
    • Human placental lactogen (HPL)
      • Produces insulin resistance
      • Makes adequate glucose available to fetus
endocrine system continued36
Endocrine System (continued)
  • Placenta (continued)
    • Estrogen
      • Vasodilation, softens cervix, breast development
    • Progesterone
      • Relaxes smooth muscle of uterus, GI tract, GU tract, and aids breast development
endocrine system continued37
Endocrine System (continued)
  • Changes in metabolism
    • Fetus has constant need for glucose
    • In fasting state ketosis develops rapidly
    • Maternal insulin resistance develops
    • Diabetogenic effect of pregnancy
    • Increased need for iron
    • Water retention
    • Dependent edema common in late pregnancy
weight gain in pregnancy
Weight Gain in Pregnancy
  • Individualized by pre-pregnancy weight
  • Average weight gain is 27.5 lbs.
    • 27.5–39.6 lb for underweight women
    • 25.3–35.2 lb for normal weight women
    • 15.4–25 lb for overweight women
urinary system
Urinary System
  • Anatomic changes
    • Kidneys and ureters enlarge
    • Ureters compressed at pelvic brim
    • Increased incidence of pyelonephritis
    • Urinary frequency and incontinence common
    • Bladder tone relaxed and capacity and pressure increase
    • UTIs common in pregnancy
urinary system continued
Urinary System (continued)
  • Physiologic changes
    • Increased blood flow by 35–60%
    • Increase in GFR
      • Increased urine flow and volume
      • Decreased BUN, creatinine, uric acid
      • Increased filtration of solutes
        • Glucose
        • Protein
      • Altered excretion of drugs (increased)
integumentary system
Spider angiomas and palmar erythema

Hyperpigmentation

Linea nigra

Chloasma

Striae gravidarum

Integumentary System
musculoskeletal system
Musculoskeletal System
  • Lordosis develops
    • Back pain common during pregnancy
  • Ligaments soften due to relaxin
    • Pelvic discomfort
    • Unsteady gait
eye cognitive and metabolic changes
Eye, Cognitive, and Metabolic Changes
  • Decreased intraocular pressure
  • Thickening of cornea
  • Reports of decreased attention, concentration, and memory
  • Extra stored water, fat, and protein are stored
  • Fats more completely absorbed
nausea and vomiting
Nausea and Vomiting
  • Probably caused by hormones
  • Client education
    • Plenty of fluids, avoid caffeine and carbonation
    • Frequent, small meals, high protein, and carbohydrates
    • Eat crackers to avoid an empty stomach
    • Avoid noxious odors
    • Limit stress
nausea and vomiting continued
Nausea and Vomiting (continued)
  • Hyperemesis gravidarum–severe vomiting requiring medical intervention
heartburn
Heartburn
  • Caused by reflux
  • Client education
    • Monitor for foods that cause symptoms
    • Spread liquids throughout the day
    • Stay upright after meals
    • Don’t eat close to bedtime, extra pillows
    • Bend at waist
    • OTC calcium containing antacids
heartburn continued
Heartburn (continued)
  • Epigastric pain can also be associated with hypertension in pregnancy
constipation
Constipation
  • Caused by progesterone’s effect on GI tract
  • Aggravated by iron supplementation
  • Client education
    • Increase fiber
    • Increase fluids
    • Regular exercise
    • Regular time for bowel movements
fatigue
Fatigue
  • More common early in pregnancy
  • Client education
    • Meditation may be helpful
    • Rest when tired
    • Alleviate stress
    • Reassurance that the fatigue lessens after the first trimester
frequent urination
Frequent Urination
  • Most common early in pregnancy
  • Client education
    • Notify HCP if pain or burning occur
    • Kegel exercises
varicosities
Varicosities
  • Can occur in the legs, vulva, and rectum
  • Client education
    • Support hose
    • Avoid long standing, sitting, leg crossing
    • Elevate legs when sitting
    • Loose clothing and avoid knee-high hose
other discomforts in pregnancy
Other Discomforts in Pregnancy
  • Hemorrhoids
    • Client education
      • Maintain healthy and regular bowel habits
      • Sitz bath
      • Compresses soaked with witch hazel
      • Reduce external hemorroids if possible
  • Back pain
    • Good body mechanics
slide53

Figure 14–1 Vena caval syndrome. The gravid uterus compresses the vena cava when the woman is supine. This reduces the blood flow returning to the heart and may cause maternal hypotension.

other discomforts in pregnancy continued
Other Discomforts in Pregnancy (continued)
  • Leg cramps
    • Adequate calcium
    • Stretching exercises
signs of potential problems
Signs of Potential Problems
  • Persistent vomiting
  • Vaginal bleeding
  • Edema of face/hands
  • Temperature >101°F
  • Persistent abdominal pain, epigastric pain
  • Dysuria
health promotion
Health Promotion
  • Employment
  • Travel
  • Smoking
  • Alcohol use
  • Drug use
  • Medication use
psychological response to pregnancy
Psychological Response to Pregnancy
  • Acceptance of pregnancy
  • Time for reflection
  • Body image changes
  • Becoming a mother
  • Development of the maternal role
    • Mimicry, role play, fantasy, role fit
maternal tasks
Maternal Tasks
  • Safe passage
  • Acceptance by others
  • Binding in to the child
  • Giving of oneself
  • Conflicting developmental tasks
paternal tasks
Paternal Tasks
  • Transition to fatherhood
  • Stress of the paternal role
  • Bonding between father and infant
family response to pregnancy
Family Response to Pregnancy
  • Siblings:
    • Rivalry
    • Fear of changing parent relationships
  • Grandparents:
    • Closer relationship with expectant couple
    • Increasing support of couple
nursing process
Nursing Process
  • Assessment
  • Nursing diagnosis
  • Planning
  • Intervention
  • Evaluation
the initial prenatal visit
The Initial Prenatal Visit
  • Medical history
  • Physical exam
  • Diagnostic tests
  • Assess risk factors
  • Education
nutrition
Nutrition
  • Avoidance of potential teratogens
  • Folic acid supplementation
  • Prenatal vitamin and mineral supplements
  • Weight gain
    • Individualized according to pre-pregnancy weight
    • Weight assessed at every visit
    • Weight loss is never normal
    • Excessive weight gain requires evaluation
harmful substances in pregnancy
Harmful Substances in Pregnancy
  • Alcohol
  • Caffeine
  • Artificial sweeteners
  • Herbal supplements
  • Medications
  • Pica
gravidity and parity
Gravidity and Parity
  • Gravida–number of pregnancies
  • Para–number of births after 20 weeks
  • Five-digit system
    • G–total number of pregnancies
    • T–full-term pregnancies (37–40 weeks)
    • P–preterm deliveries (20–36 weeks)
    • A–abortions and miscarriages (before 20 weeks)
    • L–living children
slide67
Figure 15–1 The TPAL approach provides more detailed information about the woman’s pregnancy history.
important demographic data
Important Demographic Data
  • Age
  • Occupation
  • Education
  • Residence
  • Ethnicity
  • Race
  • Religion
  • Pets
medical and family history
Medical and Family History
  • Includes client and her partner
  • Information to obtain
    • Prior or current health issues
    • Medications and allergies
    • Possible inherited diseases in the families
    • Significant health issues in family members
    • Use of tobacco, alcohol, street drugs
critical pathway for prenatal care
Critical Pathway for Prenatal Care
  • Physical exam
  • Lab work and testing
  • Nutrition
  • Elimination
  • Rest/activity
  • Comfort
critical pathway for prenatal care continued
Critical Pathway for Prenatal Care (continued)
  • Psychosocial/family
  • Developmental/pregnancy progress
  • Spiritual
  • Risk assessment
  • Medications
assessment of pelvic adequacy
Assessment of Pelvic Adequacy
  • Pelvic inlet
  • Midpelvis
  • Pelvic outlet
slide73
Figure 15–6 Anteroposterior diameters of the pelvic inlet and their relationship to the pelvic planes.
slide74

Figure 15–7 Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.

slide75

Figure 15–7 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.

slide76

Figure 15–7 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.

slide77

Figure 15–8 Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal knuckles. If they do not, they can use a measuring device.

slide78

Figure 15–9 Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.

slide79

Figure 15–9 (continued) Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.

slide80

Figure 15–9 (continued) Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.

slide81

Figure 15–9 (continued) Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.

laboratory analysis and testing in pregnancy
Blood Work

Blood type and Rh status

Antibody screen (Coombs’ test)

CBC

Rubella titer

HIV

Hepatitis B

Syphilis

Sickle cell

Glucose screen

Triple screen

Cystic fibrosis

Varicella

Laboratory Analysis and Testingin Pregnancy
laboratory analysis and testing in pregnancy continued
Laboratory Analysis and Testingin Pregnancy (continued)
  • Other Testing
    • Ultrasound
    • Urinalysis
    • Pap smear
    • GC culture
    • Chlamydia culture
    • Group B streptococcus
    • PPD
first trimester ultrasound
First Trimester Ultrasound
  • Establish gestational age:
    • Crown to rump length
    • Most accurate between 6 and 10 weeks
  • Nuchal translucency testing:
    • Combined ultrasound and serum testing
    • Risk for chromosomal disorder
    • Screened between 11 weeks and 1 day and 16 weeks and 7 days
first trimester viability confirmation
First Trimester Viability Confirmation
  • Serial quantitative serum beta hCG testing
  • Progesterone
  • Ultrasound
second trimester ultrasound
Second Trimester Ultrasound
  • Fetal life
  • Fetal number
  • Fetal presentation
  • Fetal anatomy
  • Gestational age
  • Amniotic fluid index
fetal movement
Fetal Movement
  • Noninvasive
  • Cost-effective
  • Indirect measure of the fetal central nervous system (CNS)
  • Vigorous movement indicates fetal well-being
  • Decreased movement is associated with chronic oxygen compromise
nonstress test nst
Nonstress Test (NST)
  • Accelerations imply an intact CNS.
  • Acceleration patterns are affected by gestational age
  • Accelerations must be 15 beats/minute above baseline, lasting 15 seconds
  • Reactive—two or more accelerations within 20 minutes
  • Nonreactive—insufficient accelerations over 40 minutes
slide90

Figure 21–11 Example of a reactive nonstress test (NST). Accelerations of 15 bpm lasting 15 seconds with each fetal movement (FM). Top of strip shows fetal heart rate (FHR); bottom of strip shows uterine activity tracing. Note that FHR increases (above the baseline) at least 15 beats and remains at that rate for at least 15 seconds before returning to the former baseline.

slide91

Figure 21–12 Example of a nonreactive NST. There are no accelerations of FHR with fetal movement (FM). Baseline FHR is 130 bpm. The tracing of uterine activity is on the bottom of the strip.

vibroacoustic stimulation vas
Vibroacoustic Stimulation (VAS)
  • Application of sound and vibration to stimulate fetal movement
  • Used to facilitate NST
contraction stress test cst
Contraction Stress Test (CST)
  • Evaluates uteroplacental function
  • Identifies intrauterine hypoxia
  • Observes FHR response to contractions
  • If compromised, FHR will decrease
interpretation of cst
Interpretation of CST
  • Negative
  • Positive
  • Equivocal-suspicious
  • Equivocal-hyperstimulatory
  • Unsatisfactory
slide96

Figure 21–14 Example of a negative CST (and reactive NST). The baseline FHR is 130 bpm with acceleration of FHR of at least 15 bpm lasting 15 seconds with each fetal movement (FM). Uterine contractions recorded on the bottom half of the strip indicate three contractions in 8 minutes.

slide97

Figure 21–15 Example of a positive contraction stress test (CST). Repetitive late decelerations occur with each contraction. Note that there are no accelerations of FHR with three fetal movements (FM). The baseline FHR is 120 bpm. Uterine contractions (bottom half of strip) occurred four times in 12 minutes.

amniotic fluid index afi
Amniotic Fluid Index (AFI)
  • Decreased uteroplacental perfusion results in oligohydramnios
  • AFI of five or less requires further evaluation
biophysical profile bpp
Biophysical Profile (BPP)
  • Fetal heart rate acceleration
  • Fetal breathing
  • Fetal movements
  • Fetal tone
  • Amniotic fluid volume
maternal serum alpha fetoprotein
Maternal Serum Alpha-Fetoprotein
  • Component of quadruple check
  • Screening test for:
    • Neural tube defects
    • Trisomy 21 (Down syndrome)
    • Trisomy 18
  • Performed between 15 and 22 weeks of gestation
amniocentesis
Amniocentesis
  • Used to detect genetic, metabolic, and DNA abnormalities
  • Can detect neural tube defects
  • Amniotic fluid obtained through needle aspiration
  • Complications include:
    • Vaginal spotting and cramping
    • Mild fluid leaking
slide102

Figure 21–19 Amniocentesis. The woman is usually scanned by ultrasound to determine the placental site and to locate a pocket of fluid. As the needle is inserted, three levels of resistance are felt when the needle penetrates the skin, fascia, and uterine wall. When the needle is placed within the amniotic cavity, amniotic fluid is withdrawn.

chorionic villus sampling cvs
Chorionic Villus Sampling (CVS)
  • Used to detect genetic, metabolic, and DNA abnormalities
  • Needle aspiration of chorionic villi from placenta
  • Earlier diagnosis than amniocentesis
  • Cannot detect neural tube defects
  • Pregnancy loss is twice as high as with amniocentesis
  • Potential for limb reduction
predictors of preterm labor
Predictors of Preterm Labor
  • Fetal fibronectin (fFN):
    • Presence between 20 and 34 weeks is predictor of preterm delivery
  • Cervical length and internal os:
    • Measured by ultrasound
    • Shortened cervix and dilated internal os can predict preterm birth
    • False-positive common
fetal lung maturity
Fetal Lung Maturity
  • Lecithin/sphingomyelin ratio:
    • Ratio of 2 to 1 indicates fetal lung maturity
  • Phosphatidylglycerol (PG):
    • Presence indicates fetal lung maturity
return visits in pregnancy
Return Visits in Pregnancy
  • Education
  • Blood pressure
  • Weight
  • Fundal height
  • Fetal heart tones
  • Presentation of the fetus
return visits in pregnancy continued
Return Visits in Pregnancy (continued)
  • Urine test for protein, glucose
  • Assessment for edema
  • Evaluation for developing complications
strategies for labor management
Strategies for Labor Management
  • Relaxation techniques
  • Paced breathing
  • Progressive muscle relaxation
  • Neuromuscular dissociation
  • Touch
  • Imagery
round ligament pain
Felt on one or both sides of the lower abdomen

Client teaching

Calcium supplementation

Good body mechanics

Reassurance

Round Ligament Pain
urinary frequency
Urinary Frequency
  • Etiology
    • Mechanical pressure on the bladder by the enlarging uterus
    • Increased fluid volume
  • Client teaching
    • Maintain adequate fluid intake
    • Report burning or pain with urination
nausea and vomiting112
Nausea and Vomiting
  • Etiology
    • Hormones of pregnancy
  • Client teaching
    • Dry diet
    • Avoidance of offending smells and foods
    • Ginger or peppermint tea
indigestion
Indigestion
  • Etiology
    • Hormones cause relaxation of the cardiac sphincter
  • Client teaching
    • Avoidance of offending foods
    • Extra pillows at night
    • Avoiding large meals close to bedtime
    • Antacids may be used, but avoid those with high sodium content
constipation and hemorrhoids
Constipation and Hemorrhoids
  • Etiology
    • Hormones of pregnancy slow GI motility
    • Sluggish venous return predisposes to hemorrhoids
  • Client teaching
    • Ample fluid intake
    • Diet high in fiber
    • Stool softeners
    • Exercise
edema
Edema
  • Etiology
    • Increased fluid volume
    • Sluggish venous return
  • Client teaching
    • Avoid long periods of standing
    • Elevate feet
    • Exercise
danger signs in pregnancy
Danger Signs in Pregnancy
  • Vaginal bleeding
  • Edema of the face and hands
  • Severe headache
  • Vision changes
  • Abdominal pain
  • Chills and fever
  • Persistent vomiting
  • Fluid from the vagina