NORMAL PREGNANCY AND ITS MANAGEMENT
a) Preconception care:
Definition:
Preconception care is defined as the necessary care a woman receives before becoming pregnant, which involves the identification of problems and risk factors that may affect the health of the mother and child, and measures to reduce these risk factors (birth). Such steps are also involved.
“Preconception care is defined as a set of interventions aimed at identifying and modifying biomedical behavioral and social risks to a woman’s health or pregnancy outcome through prevention and management”.
Preconception care involves the involvement of biomedical, behavioral, and social health interventions for women and couples before pregnancy.
When a couple is seen and counseling is provided about pregnancy, providing information about its course and outcome before the time of actual conception is called pre-conception counseling.
Preconception Care Aims:
To improve their health conditions and reduce behavioral, personal and environmental factors that contribute to poor maternal and child health outcomes.
To improve maternal and child health, both short term and long term.
Opportunities to prevent and control disease in multiple stages of life; Strong public health programs that use a life-course perspective from infancy to childhood and adolescence to adulthood are essential.
To improve maternal and child health, it provides health benefits to adolescents, women and men, regardless of their plans to become parents.
Ensuring optimal health and nutritional condition in both parents can reduce not only the chances of conception but also the chances of prenatal death and many congenital anomalies.
To ensure that the woman and her partner are in an optimal stage of physical and emotional health in the early stages of pregnancy.
To achieve normal health in child bearing women.
To promote prenatal health which involves developing positive attitudes about sexuality, womanhood and childbearing.
Purpose of Preconception Care:
To establish lifestyle behaviors that lead to optimal health maintenance.
For early identification of risk (eg, medical condition, substance abuse etc.).
To conceive a pregnancy without any risk factor.
To prepare people psychologically for pregnancy and to prepare them for the responsibilities of parenthood. What is preconception care for?
To reduce maternal and child mortality rate.
To reduce unintended pregnancy.
To reduce complications during pregnancy and delivery.
To reduce the rate of still birth, pre-term birth and low birth weight.
To reduce birth defects in the child.
To prevent neonatal infections.
To prevent underweight and stunting in children.
To reduce the risk of childhood cancer.
To reduce the risk of type 2 diabetes mellitus and cardiovascular disease during the later years of life. Steps and Preconception Planning:
1) Communication Skill,
2) Maternal age,
3) Menstrual history,
4) Personal medical history,
5) Obstetric history,
6) Risk to Health/ Personal History,
7) Over the counter drugs,
8) Environmental exposure,
9) Psychological History,
10) Family history.
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1) Communication Skill:
Preconception care is ideally based on an interview. To make the interview productive, it requires patience, interest, thoughtfulness, understanding of the client’s comfort and concerns for privacy.
No one interview approach works well with all women. This is especially true when it comes to asking questions about sensitive subjects, social support, substance abuse, domestic violence, sexual abuse, emotional problems, mental illness, and so on. It is as important as medical and obstetric factors.
2) Maternal age:
Pregnancy, labor and birth are the safest for women between the ages of 20 and 34 when they give birth. Teenage mothers have an increased risk of premature delivery and intrauterine growth-retarded (IUGR) babies.
Whereas, women with age 35 or older face chronic illness, chromosomal abnormalities, or medical complications at delivery. Therefore, this age group needs genetic counselling. This should include the range of options for diagnostic testing, as well as the timing of tests and procedures, although the spectrum of chromosomal abnormalities and their phenotypes should be thoroughly discussed.
Discussion should cover trisomy 21, 18 and 13 as well as sex aneuploidies of 47, xxx and 46, xxy.
In addition, older gravida women are more likely to have medical problems such as spontaneous abortion, premature separation of placenta, intrauterine growth restriction, pre-eclampsia, macrosomia (abnormally large baby) and stillbirth.
3) Menstrual History:
Menstrual history is an important part of the preconception interview because it provides information for ovulation to occur.
A normal menstrual cycle ranges from 18 to 40 days in two-thirds (2/3) of women, with menstruation occurring on day 28. The interval may be plus or minus 3 days.
A woman whose menstrual cycle is abnormal should ask questions about the following conditions, such as:
Pubertal Mildstone,
diet,
employment,
Excise Habit,
Use of Medication and Drugs,
Environmental exposure,
psychological stress,
Family history of amenorrhea and genetic abnormality etc….
To refer clients who have irregularity in menstrual cycle and want to carry pregnancy to specialty.
4) Personal Medical History:
Personal medical history is related to the following medical history.
a) Organic Disease:
Certain types of medical conditions can affect both the mother and the baby, some of which are more common, such as seizure disorders, diabetes mellitus, hypertension, cancer, autoimmune diseases, heart diseases, hematological disorders and HIV diseases, etc.
b) Seizure disorder:
In most of the cases, the seizure has no effect on the pregnancy, but in about 1/3 of the cases, the seizure activity during pregnancy may increase due to pregnancy.
Women with epilepsy need 4 mg of folic acid daily instead of 0.4 mg (400) Any woman with epilepsy should consult a physician before conception.
c) Insulin Dependent Diabetes Mellitus:
Severe hypertension in women who have insulin dependent diabetes mellitus,
Conditions like pre-eclampsia, ketoacidosis, excessive amniotic fluid and blindness and renal failure can occur.
Congenital anomalies may also occur to the fetus. Also, the baby can be large (macrosomic) or small i.e. intrauterine growth retardation (IUGR).
If the baby is macrosomic, vaginal delivery can be traumatic for both mother and baby, and the condition of postpartum hemorrhage (PPH) can also occur.
Women with type II DM (diabetes mellitus) should be followed by an obstetrician or perinatologist whenever possible.
d) Hypertension:
Most women with stage I and II chronic hypertension (systolic blood pressure 140/179 mm hg or diastolic BP 90/109 mm hg) are at low risk for cardiovascular complications during pregnancy and most if normal renal function is present. There will be good maternal and neonatal outcome.
Serum creatinine is a marker of renal function and if the creatinine level at conception is above 1.4 mg/dl, fetal loss may occur and the risk of maternal disease progression increases.
Even with chronic hypertension, pre-eclampsia significantly increases the incidence of fetal growth restriction and placental abruption. Additionally, ultrasound examinations during pregnancy are important to monitor fetal growth.
E) Cancer:
Although spontaneous abortions are increased in cancer survivors, the risk of cancer in their offspring is not increased unless the parents carry the cancer carrier gene.
F) Autoimmune disorders:
In autoimmune disorders, the immune system turns against itself, causing severe illness.
Antiphospholipid syndrome and systemic lupus erythematosus (SLE) are two examples of this disorder.
Autoantibodies during pregnancy can cause thrombosis and stroke, conditions such as pre-eclampsia and fetal death.
G) Tuberculosis:
It is a serious and potentially debilitating disease.
H) Thyroid Diseases:
Fatigue and menstrual irregularity occur in both hypothyroidism and hyperthyroidism.
Weight gain, cold intolerance are both symptoms of hypothyroidism and weight loss and hot intolerance are both symptoms of hyperthyroidism.
Testing for thyroid disease is important because both hypothyroidism and hyperthyroidism can cause problems for women and their babies.
The risk of conditions such as low birth weight and still babies may increase in pregnant women who do not get proper treatment of thyroid disease.
Hypothyroidism is a rare problem during pregnancy as long as the woman continues to take thyroid medication (levothyroxine) as long as she has hypothyroidism.
Women with hyperthyroidism are at increased risk of pre-eclampsia and heart failure. Their children may develop neonatal thyrotoxicosis and may die in utero.
I) Heart Diseases:
A pre-conception evaluation can identify any cardiovascular disease.
A client with cardiovascular disease should be referred to a specialist.
Because pregnancy is contraindicated in some cardiac diseases.
J) Haematological Disorders:
Some anemias affect the health of both the mother and the baby.
E.g. Some thalassemias are associated with:
i Pre-term labour
ii. IUGR
iii Increase fital loss.
Babies can have pernicious anemia.
Sickle trait can cause urinary tract infection in pregnant women.
Women who have hematological problems need consultation with a perinatologist.
Testing is often done to identify the nature and extent of risk to the father of the child before making a final decision about whether to attempt pregnancy.
K) Sexually Transmitted Infections:
Perinatal outcome can be influenced by various sexually transmitted diseases. Infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae can lead to PI. D (Pelvic Inflammatory Disease), Infertility and Ectopic Pregnancy, Salpingitis Sequelae of this infection may increase the risk of infertility and ectopic pregnancy.
A single incidence of PID increases the chances of an ectopic pregnancy in a woman.
If the mother has the condition of gonorrhea and her child is born through vaginal delivery, the risk of blindness in the child increases.
If left untreated, chlamydia can cause both conjunctivitis and pneumonia.
A woman with herpes infection has a 40% chance of developing neonatal herpes infection.
The AIDS epidemic has not bypassed pregnant women, women are 8 times more likely than men to come into contact with HIV during intercourse.
Decision-making about pregnancy in HIV-positive women is highly personal and complex.
5) Obstetric History:
Information about previous pregnancies should be obtained to identify complications that recur in subsequent pregnancies.
The information gained often provides an opportunity to discuss fears or concerns about the new pregnancy, as well as emotional responses and reproductive problems. In which the following information is collected.
such as:
Birth date, miscarriage, gestational age, type of delivery, length of labor to identify prolonged labor, birth weight, sex of children, any complications during pregnancy, current health status of the child, whether the child is alive Discussion is done about.
6) Risk to Health/ Personal History:
a) Smoking
b) Alcohol
C) Illegal drugs
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a)Smoking:
If the mother smokes half a pack of cigarettes a day while the baby is in the uterine cavity, it may decrease the uteroplacental perfusion in the child and the child’s weight may also decrease from its normal weight.
Babies born in homes where people smoke have long-term effects, including sudden infant death syndrome (SIDS), meningococcal disease, pneumonia, asthma, bronchitis, colds and ear infections.
Women who smoke and are considering conception should stop smoking before conception.
b) Alcohol:
Pregnant women who have at least one or more drinks per day have a two-fold increase in spontaneous abortions.
Women who drink during pregnancy are also at risk of developing the following in their children:
a) Fetal alcohol syndrome
b) A syndrome of abnormal facial features
c) Behavioral problem
d) Intellectual handicaps
Preconception counseling helps the client to quit this habit.
To identify barriers to smoking cessation such as living with a smoker. Offer them a treatment plan and provide psychological support and reassurance.
C) Illegal drugs:
Medicines used in pregnancy can cause problems during pregnancy, birth and childhood. All women should be asked about past and present use of medications. Ask specifically about marijuana use.
7) Over the Counter Drugs:
Most of the pregnant women are aware that certain types of medication are harmful to the growing baby.
Fewer women are concerned about the teratogenic effects of over-the-counter drugs and herbs.
For example, many women do not know that vitamin A is consumed in amounts greater than 10,000 IU per day. Contributes to cranial neural crest defects when taken in the first 7 weeks of pregnancy. The effectiveness and safety of most herbal products are unknown.
8) Environmental Exposure:
Exposure to toxic elements in the environment can occur at work, at home or at play.
Women should receive proper information about whether they are exposed to any product such as:
•Carbon Monoxide,
Volatine organic compounds (VOC) from furniture paint carpets and office equipment;
9) Psychological History:
Preconception counseling is used to identify stressors and support sources such as
poverty,
Inadequate housing,
problem in relationship,
A history of abuse,
depression,
Poor self-esteem,
Low level of education,
High level of stress etc.
10) Family History:
Collecting family history can identify the risk of birth defects in the child and the risk of any inherited disorders that may appear later in life.
Race/ethnicity, medical and obstetrical problems can be identified in the family history.
If risk factors are identified, refer them for referral and genetic counselling.
Preconception care is important for maternal and child health.
b) Genetic counselling:
Genetics:
The science dealing with heredity and variation is called genetics and the science of studying the structure and behavior of genes is called genetics.
Genetic counseling
Genetic counseling is a process carried out by medical experts in which genetic tests are done and family history is taken and medical records are reviewed by experts with the aim of preventing parents from having any type of genetic disorder in their child. A disorder can be identified whether or not there is a possibility of passing.
Genetic counseling provides education to parents about genetic disorders.
as well as psychological to them
Support is provided and information on support groups and services is provided.
Genetic counseling is clinical genetic services that include the provision of genetic information, education, and support to individuals and families with genetic health concerns and problems.
The term ‘genetic counselling’ was first used by ‘Sheldon Reed’ in 1947.
According to American Society of Human Genetics (1975):
Genetic counseling is one such communication process. It is associated with human problems. One or more trained persons help the individual and family in this process:
Understand the medical facts including diagnosis, probable course of the disorder and available management.
Appreciating the ways in which heredity contributes to the disorder and the risk of recurrence in certain relatives.
Understanding alternatives in specific relative risk of recurrence.
Making the best possible adjustment in the affected family members. Genetic counseling is a screening procedure to identify high-risk individuals and their children for genetic abnormalities. The main purpose of genetic counseling is to help the patient and her husband make informed decisions about the future management of the pregnancy. Its objectives are to provide information, provide assistance in counseling and help the couple to adjust to the problem. Thus reducing the chances of birth of genetically defective babies. Benefits of Genetic Counseling
•For pregnancy planning.
Having interest in prenatal diagnosis.
Concerned about the results of the first and second trimester screening.
Pregnant and will be 35 years or older at the time of delivery. Implications of genetic counselling
Have had a previous miscarriage or pregnancy loss.
Having previously had a child with birth defects, genetic disorders, and mental retardation.
A woman may have been exposed to some type of medication or drugs, radiation and infection during her pregnancy. Common Genetic Conditions: Genetic disorders arise due to abnormalities in a person’s genetic materials. Mainly genetic disorders are differentiated into four types:
such as,
1) Changes in a single gene
2) Changes in multiple genes
3) Chromosomal changes:
Entire areas of chromosomes are missing or misplaced.
4) Mitochondrial:
Maternal genetic materials in mitochondria can also be mutated.
Common disorders are as follows:
1) Cystic fibrosis,
2) Down Syndrome,
3) Fragile-X syndrome,
4) Inherited clotting problem,
5) Familial combined hyperlipidemia and familial hypercholesterolemia,
6) Huntington’s Disease,
7) Muscular dystrophies
8) Sickle cell anemia,
9) Thalassemia,
10) Mutation affecting biochemical pathway,
11) Turner syndrome,
12) Alpha 1 antitrypsin deficiency,
13) Myotonic dystrophy,
14) Parkinson’s Disease,
15) Alzheimer’s Disease,
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1) Cystic fibrosis:
Cystic fibrosis is a common inherited disease in Caucasians and is caused by a deficiency of a protein that controls the chloride balance in the body.
This results in breathing difficulties and frequent lung infections. It involves problems in digestion and reproduction. Symptoms range from mild to severe.
Both parents must be carriers for the child to be affected. Each child thereafter has a 25% (1 in 4) chance of being affected
2) Down Syndrome:
Down syndrome is a common chromosomal abnormality in which an extra copy of a gene is located on chromosome 21.
Down syndrome affects about 1 in 800 to 1000 newborn babies. It can be detected through prenatal testing.
It consists of a pattern of symptoms that appear immediately after birth, such as,
•Facial characteristic,
•Decreases muscle tone,
Defects in heart and digestive system,
Down syndrome can range from mild, moderate and severe and is associated with increasing maternal age.
3)Fragile-X Syndrome:
Fragile-X syndrome is the most common type of inherited developmental delay and associated mental retardation. They have developmental delays and cognitive difficulties ranging from mild to severe and can sometimes be associated with autism.
About 1/1500 males and 1/2500 females have fragile X-syndrome, a fragment of the X chromosome may break. A region on the X-chromosome that causes frailty
It can be repeated on chromosomes – the higher the number of repeated areas, the
More frailty and more serious syndromes are seen.
4) Inherited clotting problem:
The process of blood clotting is one of the more complicated biochemical pathways in the body and a different inherited clotting problem.
This clotting problem can result in heavy bleeding and abnormal clotting throughout the body, usually in the veins.
The most common factor V Leiden abnormality occurs especially during pregnancy which can lead to pre-eclampsia, small for gestational age, still birth and placental problems.
Other inherited clotting problems also involve prothrombin deficiency, protein S deficiency, protein C deficiency and antithrombin III deficiency.
Hemophilia is a benign clotting disorder. The most common types are hemophilia A (which is caused by a deficiency of clotting factor 7) and hemophilia B (which is caused by a deficiency of clotting factor 9).
Its symptoms include excessive bleeding in the gums, nose, gastrointestinal system, and joints.
Abnormal menstrual bleeding occurs.
Excessive bruising and skin rashes also occur.
5) Familial combined hyperlipidemia and familial hypercholesterolemia:
This is an inherited disorder in which the amount of lipids and cholesterol in the blood increases.
6) Huntington’s Disease:
This is an inherited disorder in which certain nerve cells of the brain and central nervous system degenerate. Among its symptoms,
behavioral changes,
Unusual Snake Like Movement (Korea),
uncontrolled movement,
walking difficulty,
loss of memory,
Changes in speech and cognitive function,
Difficulty in swallowing.
Huntington’s disease is an autosomal dominant disorder, meaning that if one parent has Huntington’s disease, the offspring has a 50% chance of developing the disease.
7) Muscular dystrophies:
Muscular dystrophy is an inherited disorder characterized by weakness in the muscles.
a) Baker muscular dystrophy:
In Becker muscular dystrophy, symptoms are similar to Duchenne muscular dystrophy but are slower to appear and are also slower to worsen. Those features involve:
i ) Feeling tired
ii) Possible mental retardation
iii )Muscle weakness starts from the leg.
Muscle weakness in the upper body is not as severe as in Duchenne. Again, boys are more likely to develop this disorder and are confined to wheelchairs by the age of 25-30.
b) Duchenne muscular dystrophy:
Here, symptoms usually appear before the age of 6 and may appear even earlier.
In its symptoms
feel tired,
Mental retardation,
Muscle weakness starts from the leg and radiates to the upper body.
heart problem,
Respiratory problems, etc…
8) Sickle Cell Anemia:
“Sickle cell anemia” is a severe hemolytic anemia and a hereditary and genetic blood disorder that usually affects red blood cells in which the red blood cells have an abnormal sickle cell. In this disease, red blood cells are rigid, sticky and abnormal crescent and sickle sep. The abnormal shape of these red blood cells blocks blood flow, which increases pain, organ damage, and the risk of infection. The capacity is also decreased.
Because of that
Due to genetic mutation.
Due to hereditary condition.
Having a family history of sickle cell disease.
Symptoms like,
mild jaundice,
fever,
headache,
feel tired,
weakness,
Paleness of skin, conjunctiva and mucous membrane,
Shortness of breathing,
dizziness,
Vision problems,
Leg ulcers,
Absence of speech,
Having pain episodes,
headache,
Rapid and irregular heartbeat,
Cold hands and feet.
Nails become brittle.
Poor concentration.
Cognitive difficulties.
Growth and development will be delayed.
Loss of appetite.
Dizziness.
tachypnea.
Tachycardia.
Palpitation.
Diarrhea and vomiting.
Cardiac enlargement with murmur sound.
Jaundice, petechiae and ecchymosis are also present in some cases.
Hepatomegaly.
Irritability.
Tiredness.
Pneumonia.
Symptoms like traumatic rupture of enlarged spleen etc. are seen.
9) Thalassemia:
Thalassemia is a group of hereditary hemolytic anemias. which is an autosomal recessive genetic disorder in which the synthesis of hemoglobin is reduced/inadequate amount of production. Thalassemia is a genetic blood disorder in which the body does not produce sufficient amount of hemoglobin (protein in red blood cells that carry oxygen into the body). These red blood cells are destroyed in large amounts due to which the condition of anemia arises.
Finally there are mainly two types of semiana.
Causes of Thalassemia:
Due to genetic mutation,
Due to impairment in alpha globin and beta globin.
Being a family history.
Its signs and symptoms like,
feel tired,
Pale skin, conjunctiva and mucous membrane.
Shortness of breath,
Spleen and liver enlargement (hepatosplenomegaly),
jaundice,
Growth and development are delayed,
Bone abnormalities,
heart problem,
Endocrine complications,
Getting infected.
Loss of appetite (anorexia),
Poor feeding habit,
Abdomen is distended,
Failure to Thrive,
Facial Features – Upper maxilla hypertrophoid, exposing of upper teeth, depressed nasal bridge,
mal occlusion of teeth,
lymphadenopathy or hypogonadism,
Osteoporosis of
Metacarpals and Metatarsals.
Recurrent respiratory infection,
lymph node enlargement,
Poor nutritional status.
10) Mutations Affecting Biochemical Pathways:
Phenylketonuria (PKU)
Phenylketonuria (PKU) results from a deficiency of the liver enzyme required to convert the amino acid phenylalanine to another amino acid tyrosine. If it goes undetected, early, insufficient, high levels of phenylalanine accumulate and cause mental retardation, brain damage and seizures.
Treatment consists of a phenylalanine-restricted food and the use of a cofactor—tetrahydrobiopterin (BH₄)—to reduce the amount of phenylalanine in the blood.
11) Turner Syndrome:
Turner syndrome is a chromosomal condition that affects female development.
Women with this condition are smaller than normal and usually unable to conceive a child (infertile) due to the absence of ovarian function.
A chromosomal disorder in which women are born with only one X chromosome. Turner syndrome results from a missing or incomplete sex chromosome, consisting of the absence of an X chromosome.
In its symptoms,
Extra skin is seen on the neck area,
Swelling of the hands and feet (lymphedema).
Skeletal abnormalities
Heart defect
Kidney problem
Developmental delay
Learning Disability
Symptoms such as behavioral problems are seen. 12) Alpha 1 Antitrypsin Deficiency: Alpha-1: Antitrypsin deficiency describes a decrease in the amount of alpha-1 antitrypsin in the lungs and blood. This results in lung diseases like emphysema. Its early symptoms include:
Shortness of breathing.
•Whizzing
Frequent respiratory infections
feeling tired
Symptoms like rapid heart beat etc. are seen. 13) Myotonic dystrophy: Myotonic dystrophy is an inherited disorder of muscles and other body systems.
This is the most common muscular dystrophy seen in adults
There are two types of muscular dystrophy as follows:
1) Myotonic dystrophy type-1
2) Myotonic dystrophy type-2
It has the following symptoms like,
Progressive muscle wasting and weakness is seen especially in lower leg, head and neck and face.
•Clouding of the lens of ice.
Heart abnormality etc. 14) Parkinson’s disease: Parkinson’s disorder is a chronic, progressive, neurological disorder in which muscle control, movement and balance are disturbed. Parkinson’s disease is a slowly, progressive neurological movement disorder that also results in disability.
Parkinson’s disease is a type of movement disorder. In which a person’s muscle movement is altered.
Parkinson’s disease was first described in 1817 by London surgeon James Parkinson.
Parkinson’s disease
3 main cardinal signs are observed.
1) Tremor:= Trembling,
2) Muscle Rigidity:
3) Bradykinesia
1) Tremor:= Trembling,
Voluntary movement is seen in fingers, hands, feet, pads etc. Tremors are mainly seen when the person is in the resting stage, but not when the person is on task. Tremors occur when a person is excited, tired and stressed.
2) Muscle Rigidity:
Stiffness occurs in limbs and trunk. This stiffness increases during movement. Rigidity causes pain and ache in the muscles.
3) Bradykinesia
Bradykinesia is a slowness of voluntary movement. Sometimes there is difficulty in movement due to stiffness in the facial muscles in bradykinesia.
A “mask like” appearance is observed.
His symptoms
tremors,
muscle stiffness,
bradykinesia,
Postural instability,
Difficulty in speech and swallowing.
Sleep disturbance.
Mood and cognitive changes.
Constipation.
Memory loss.
Difficulty in swallowing.
Having problems in speech.
Depression.
Anxiety.
Getting stressed.
Confusion.
Memory loss.
Dementia.
Sense of smell is deminized.
Sweating will increase.
Skin problem.
Impairment in speech.
Urinary frequency and urgency.
Loss of spontaneous movement.
Symptoms like etc. are seen
15) Alzheimer’s disease
Alzheimer’s disease is a progressive neurological disorder.Alzheimer’s disease is also called senile dementia of Alzheimer type (SDAT).
Alzheimer’s is the most common form of dementia (a loss of memory for anything, whether short-term or long-term).
Alzheimer’s disease shows impairment in a person’s memory, judgment, language, cognitive function, and daily living activities. In Alzheimer’s dementia, brain cells are destroyed first, due to which mental disorders are seen.
Alzheimer’s disease primarily affects older adults. This includes impairment in a person’s memory, cognitive function, behavior, and daily routine activities. In these diseases, mainly due to the accumulation of proteins in the brain, the first brain cells are destroyed, due to which the neural pathways break down and mental disorders are observed in the person.
In its symptoms,
Memory loss.
Difficulty in solving tasks.
Confusion.
Disorientation in time, place and person.
Changes in mood and behavior.
A language problem occurs. Judgment to be decreed.
Impairment in solving tasks.
Memory loss.
Confusion.
Having problems in daily living activities.
Problems in dressing and eating.
Symptoms like changes in personality are seen.
Nursing Activity in Genetic Counselling:
The nurse refers the patient to a genetic specialist and participates in genetic counseling.
Collects family history, prenatal and health history
Assessment of genetic condition of family members.
Helps explain genetic conditions to family members.
Refers clients for genetic evaluation and counseling when needed.
Forms care plans with family members and coordinates with other health care professionals.
Provides education about the benefits and risks of genetic testing and available testing to families.
Maintains privacy and confidentiality of family records and information.
Provides information on early child stimulation programs, genetic resources, and support groups to families.
Provides follow-up care and support throughout the child’s life.
Provides support to the patient and family in the genetic counseling process.
Provides related health care by integrating genetics through national support resources for relevant communities.
C) Physiological changes in pregnancy
Pregnancy is a condition from the time of conception to the time of delivery. Physiological changes are observed in the mother’s body during pregnancy due to certain types of specific hormones. These changes occur to develop the fetus, prepare the mother’s body for labor, and produce the best milk during the periperium period.
1) Changes in reproductive system
A)Vulva:=
The vulva becomes more edematous and vacuolar.
Superficial varicosities (varicose vein := vein enlarged and swollen, usually seen in leg and also in pelvic area during pregnancy period) are also seen in multipara and labia minora becomes pigmented and its hypertrophy ( Organ size increases).
B)Vajaina:=
Vaginal wall is hypertrophoid,
becomes edematous and hypervascular.
Bluish discoloration of the vaginal mucosa due to increased venous blood supply to the vaginal wall is called “Jacquemeier’s sign”.
The length of the interior wall increases.
Vaginal secretions are highly acidic, thin and curdy white.
The acidic pH of vaginal secretions inhibits the multiplication of pathogenic microorganisms.
(C) Uterus:=
During pregnancy, the uterus grows more. During pregnancy, the weight of the uterus and its length also increases.
Weight of Uterus:
In the non-pregnant state, the weight of the uterus is about 60 gm, which increases to 900-1000 gm during pregnancy.
Length, Width and Thickness of Uterus:
of the uterus in the non-pregnant state,
Length := 7.5 cm,
Width:=5 cm and thickness:=2.5 cm.
When during pregnancy (at term) of the uterus
Length := 30-35 cm,
Height:= 22.5 cm and
Thickness: = 20 cm.
Volume of uterine cavity:
In the non-pregnant state, the volume of the uterus is 10 ml, which increases to 5 liters during pregnancy (at term).
Body of Uterus:
Growth and enlargement of the body of the uterus.
Muscles
1) Outer:= longitudinal layer
2) Middle:= vascular layer
3) Inner:=circular layer
Hypertrophy (increase in size) and hyperplasia (increase in number) are seen in muscles.
After 20 weeks of pregnancy, the length of the uterine muscle fibers increases and the uterine wall becomes thinner due to which the uterus becomes softer and more elastic in the pregnant condition than in the non-pregnant condition.
Vascular System:
Blood supply begins to increase from 20 weeks onwards due to vasodilatation due to estradiol and progesterone.
The diameter of uterine artery doubles and blood flow increases and veins dilate.
During pregnancy the endometrium of the uterus is called decidua.
Braxton Hicks contractions:
Spontaneous contractions of the uterus early in pregnancy are irregular, infrequent, spasmodic and painless due to no effect on cervical dilatation until near term (37-42 weeks) they increase and finally merge with painful labor contractions. is
D) Isthmus:=
During pregnancy the lower segment of the uterus forms an isthmus.
The length of the isthmus in the nonpregnant state is 0.5 cm, which increases in length during pregnancy to a maximum of 7.5 cm-10 cm.
The muscle fibers of the isthmus are arranged circularly in the lower segment and form a sphincter-like structure, which helps the fetus to stay in the uterus during early pregnancy. If this sphincter is incompetent, abortion can also occur.
E)Cervix:=
During pregnancy the cervix becomes vascular, oedematous and hypertrophoid and hyperplastic.
Cervix that becomes soft is called “Goodell’s sign”.
The length of the cervix doubles and its volume also increases.
F) Fallopian tubes:=
The length of the fallopian tubes is slightly increased. The tube becomes congested. Muscles hypertrophy and epithelium flattens.
G)overy:=
Ovulation remains at a standstill during pregnancy. Ovaries are hypertrophied and vascular.
In the usual menstrual cycle, the corpus luteum remains constant and enlarges by two 2.5 cm until the 8th week.
Colloid degeneration occurs and the uterus becomes calcified.Estrogen and progesterone hormones are produced by the corpus luteum and provide an environment to maintain the ovum until placental action begins.
H) Breast:=
Breast size, nodularity, and sensitivity increase with increased vascularity of the breast throughout pregnancy due to the effects of estrogen and progesterone.
The nipple becomes enlarged, dark and erectile.
Hypertrophy of 5 to 15 sebaceous glands that are invisible in the non-pregnant state is seen.
” Montgomery
They are called tubercles. They are located around the nipple and their secretion keeps the nipple and areola moist and healthy.
Areola that becomes dark and pigmented is called primary areola.
In the second trimester, another pigmented zone called the secondary areola forms around the primary areola.
In the first three months, the growth of the ductal system in the breast increases as the pregnancy progresses, its alveolar cells become secretory.
The total weight of the breast is 0.4 kg.
The cyst enlarges due to alveolar proliferation and fat deposition and clear sticky fluid can be squeezed from the cyst at about 12 weeks.
At 16 weeks this clear sticky fluid becomes thick and yellow called colostrum which is an important sign of pregnancy.
Changes in other systems of the body.
1) Skin Changes:=
A) Face:
Pigmentation occurs around the cheeks, forehead, and eyelids called “gravidarum in close” or “pregnancy mask” which disappears on its own after delivery.
B) Breast:
Visible pigmentation changes occur in the breast.
C) Abdomen:
Laina nigra
Melanocyte stimulating hormone causes a brownish black line visible in the midline from the xiphisternum to the symphysis pubis called the linea nigra.
stria gravidarum
Abdominal wall below the umbilicus and sometimes on the chest and breast is a depressed linear mask that is initially pink but turns glistening white after delivery called stria albicans or stria gravidarum.
Vacuolar spindle and palmar erythema are seen with high estrogen levels.Skin
Mild degree of hirsutism (excess hair) is seen and excess amount of hair is lost during purperium period.
2) Weight gain
Weight loss occurs during the early weeks of pregnancy due to nausea and vomiting. Weight gain remains progressive from the following months.
A healthy woman gains an average of 11 kg (24 lbs) of weight during pregnancy.
During 1st trimester: 1kg,
2nd trimester
During: 5kg,
During 3rd trimester: 5kg,
As the weight increases.
A) Reproductive weight gain
1) Weight of Fits: 3.3kg,
2)Weight of placenta: 0.6kg,
3)Weight of Liker: 0.8kg,
4) Weight of Uterus: 0.9kg,
5) Weight of breast: 0.4kg.
B) net maternal weight gain
1) Increase blood volume:=1.3kg,
2) Increase extracellular fluid:=1.2kg,
3) Fat and Protein:=3.5kg.
3) Cardio vascular system
A) Heart has to work more during pregnancy.
Cardiac volume increases by 10% but there is no change in ECG.
Cardiac output also increases due to increased heart rate and stroke volume.
Pulse rate also increases.
Platelets count is slightly decreased as the concentration rate increases from 40 to 45 mm.
B) Blood Pressure and Blood Volume:
Blood pressure remains within normal limits In some women, diastolic pressure drops by 5 to 10 mm during mid-pregnancy.
C) Venus pressor:
Femoral venous pressure increases by 10 cm due to the pressure of gravid uterus on the pelvic vein, then the blood volume also increases, the volume of red blood cells and plasma volume also increases in many parts of the body like uterus, pulmonary, renal, skin. , and blood flow to the mucosa increases.
4) Respiratory system
Hyperemia (increased blood flow) and congestion are seen in the upper respiratory mucosa.
Increased inspiration also increases oxygen intake and oxygen supply to the fetus.
Carbon dioxide is released due to increased exhalation, so the transfer of carbon dioxide from the fetus to the mother’s blood can be easily done due to low maternal carbon dioxide.
In the last weeks of pregnancy, due to the pressure of the gravid uterus on the diaphragm, there is a complaint of breathing difficulty which is relieved by lightening.
5) Digestive system
Due to the effect of progesterone, the muscle tone of the gastrointestinal system is reduced.
Relaxation of cardiac sphincter leads to regurgitation of stomach contents and heartburn.
As the gastric size decreases, it slowly empties and is continuous even in labor.
In many women, the gums become spongy and vascular and may bleed during brushing.
A decrease in the size of the intestine leads to better absorption of food and causes constipation.
6) Nervous system
Mood changes during pregnancy and periperium period are due to psychological conditions such as nausea, vomiting, mental irritability and sleeplessness.
Depression or psychosis may also develop in women.
Compression of the median nerve in the wrist leads to pain and paresthesia (tingling) in the hands and arms, which is called carpal tunnel syndrome and is seen in the last month of pregnancy as well as sensory loss due to compression of the cutaneous nerve.
7) Urinary track
Frequent micturition is commonly seen in early and late pregnancy.
Stress incontinence can also occur.
Due to continuous dilatation of uterus and pelvis from early pregnancy to mid pregnancy, urinary stasis occurs and infection can also occur. Renal function also increases in pregnancy.
8) Locomotor system
Backache is common during pregnancy due to relaxation of lordosis and joints due to relaxin hormone.
Due to weight gain in sacral and lumbar plexus, leg cramps remain and difficulty in walking also occurs.
Thus, physiological changes are observed in women during pregnancy.
Uterine Fundal Height at Different Weeks During Pregnancy:
Non-pregnant uterus pyri shape (pear-like) Uterus becomes globular shape during 12 weeks of pregnancy.
The uterus enlarges again and forms pyri foam at 28 weeks.
And after 36 weeks of pregnancy the spherical shape is formed.
•> At 12 Weeks of Pregnancy:
During 12 weeks of pregnancy the uterus is not more anteverted and antiflexed than the fundus is palpated abdominally over the symphysis pubis.
•> At 16 Weeks of Pregnancy:
During 16 weeks of pregnancy, the uterus is ovoid in shape. The uterus is between the symphysis pubis and the umbilicus.
•> At 20 Weeks of Pregnancy:
During the 20th week of pregnancy, the fundus part of the uterus is about two fingers below the umbilicus.
•> At 24 Weeks of Pregnancy:
During the 24th week of pregnancy, the fundus part of the uterus is at the level of the umbilicus and one finger below it.
•> At 30 Weeks of Pregnancy:
At 30 weeks of pregnancy, the fundal part of the uterine cavity lies between the umbilicus and the zygosternum
•> At 36 Weeks of Pregnancy:
During the 36th week of pregnancy, the fundal part of the uterine cavity is at its highest level i.e. up to the zephysternum.
•> At 38 Weeks of Pregnancy:
During 38 of pregnancy the fundus part of uterine cavity descends and reaches the level of 34 is called lightening.
•> At 40 Weeks of Pregnancy:
During 40 weeks of pregnancy, the fundus part of the uterine cavity reaches the level of 32 weeks and then the lower uterine segment relaxes and stretches while service becomes soft and short and the uterus prepares for labor.
d) Diagnosis of pregnancy:
Introduction:
Maternal ability to reproduce starts at menarche and ends with menopause. Reproductive age normally ranges from 13 years to 45 years of age.
Gestational Age:
The normal average duration of pregnancy starts from the first day of a woman’s last menstrual period (LMP) and has a duration of 9 months and 7 days i.e. 280 days or 40 weeks.
True Gestational Age:
Fertilization occurs 14 days before the expected missed period. Thus, the correct duration of pregnancy is calculated by subtracting 14 days from 280 days, ie. There are 266 days. These ages are called fertilization age and ovulatory age.
A woman’s antenatal period usually starts from the first day of the last menstrual period (LMP) until true labor starts.
The total duration of pregnancy is 38 – 40 weeks which is divided into three trimesters. It involves about 13 weeks or 3 months in one trimester.
No pregnancy
First Trimester Ma := First 12 Weeks,
In Second Trimester := 13 to 28 Weeks,
And in the third trimester := 29 to 40 weeks is involved.
•> Objective and subjective signs of pregnancy:
First Trimester (1- 12(1-3 months) week):
Subjective Symptoms:
amenorrhea,
morning sickness,
Frequency of micturition,
breast discomfort,
fatigue
Amenorrhea:
Amenorrhoea in healthy married women during the reproductive period from 6 weeks after the last menstrual period is mostly due to pregnancy.
Morning sickness:
Most of the time the mother gets nausea and vomiting.
Frequency of Micturation:
In 8 to 12 weeks of pregnancy frequency of micturition is seen due to the pressure of the bulging uterus on the bladder.
Breast Discomfort:
Discomfort due to sensation of fullness in breast during 6 to 8 weeks.
Fatigue (feeling tired):
These symptoms are seen during early pregnancy and are experienced by many pregnant women.
Objective Sign:
breast changes,
Abdomen and Pelvic Changes on Changes,
Immunological test
Breast Changes:
Breast changes occur more clearly in primigravida.
These best changes happen during 6 to 8 weeks.
A delicate vein is visible under the skin and the breast is enlarged.
The nipple and primary areola are heavily pigmented.
Montgomery tubercle appears prominent.
And from 12 weeks of pregnancy, yellow secretion (colestrum) can be expressed.
On Abdominal Changes and Pelvic Changes:
On the abdomen:
The uterus is a pelvic organ up to 12 weeks’ gestation and then the abdomen is felt as the suprapubic bulge (upper part) over the uterus.
Pelvic Changes:
These changes are varied and appear in different periods.
1) Jacquesmeier sign, Chadwick sign,
2) Vaginal sign (Ossander sign),
3) Cervical sign
(Goodell’s sign),
4) Uterine sign (Picksack sign),
5) Hagar sign,
6) Palmer’s sign..
1) Jackmier’s Sign:
The vaginal wall becomes hypertrophoid, edematous, and highly vascular.
Bluish discoloration of the vaginal mucosa due to increased venous blood supply to the vaginal wall is called Jacquemeier’s sign.
•> Chadwick Sign:
This sign is seen during the 8th week of pregnancy. Bluish discoloration of cervix, vagina and labia minora is seen due to local vascular changes. This is called “Chadwick’s sign”.
2) Vaginal sign (Ossander sign):
There is bluish discoloration of the anterior vaginal wall, anterior vaginal wall tenderness, and non-irritating mucoid discharge at 6 weeks.
It also has a palpation fill through the lateral fornix during 8 wks called “Ossander’s sign”.
3) Cervical sign
(Goodell Sign):
Cervical sign is seen during 6 weeks of pregnancy.
In which cervix is vacuolar, oedematous and hyperthyroid and hyperplasia.
Where the cervix becomes soft is called “Goodell’s sign”.
4) Uterine sign:
Size, Sap and Consistency:
6 The uterus is as large as a hen’s egg,
8 wickets equal to a cricket ball,
And 12 wicks are equal to the head of a fettle.
The pyriform sap in the nonpregnant stage of the uterus becomes globular during 12 weeks. The uterus becomes soft and elastic.
Piscak Sign:
If lateral implantation occurs in the uterus, symmetrical enlargement of the uterus may occur. This is called the “piscsec sign”, where one half is firmer (stronger) than the other.
5) Hagar Sign:
Hagar sign a
Seen during 6- 10 wks.
In which the upper body part of the uterus is enlarged due to growing fitters.
Lower segment of uterus becomes soft due to increased vascularity.
It causes cyanosis and softening of the cervix called “Hagar’s sign”.
6) Palmer Sign:
Palmer’s sign consists of regular and rhythmic contractions of the uterus on bimanual examination of the uterus from 4 to 8 weeks. It is called “Palmer’s sign”.
Immunological Test for Diagnosis of Pregnancy:
A pregnancy test depends on the presence of antigen (HCG) in maternal urine or serum.
Ex: Agglutination inhibition test
One drop of urine is mixed with one drop of human chorionic gonadotropin (HCG) antibody solution.
If human chorionic gonadotrophin is not present in the urine (the woman is not pregnant), the antibody will be free.
Now taking one drop solution containing latex particles coated with human chorionic gonadotrophin,
If agglutination occurs, the pregnancy test is negative.
Human chorionic gonadotrophin (HCG) binds to available antibodies when present in urine. Now administration of one drop solution containing latex particles coated with human chorionic gonadotropin trophin does not cause second agglutination as it binds the available antibody hence the pregnancy test is positive.
Ultrasonography:
Fetal viability and gestational age are determined by transvaginal sonography.
Second Trimester (13 to 28 weeks (4-7 months)):
Subjective Symptoms:
Nausea, vomiting and frequency of micturition are common and amenorrhea is continuous.
New features appear such as quickening (women’s active fetal movements are felt around 16 weeks in multipara).
It fills most often at 18 weeks in Primipara, allowing for accuracy in calculating the expected date of delivery.
A progressive enlargement of the lower utrust takes place.
Objective Symptoms:
1) General Examination,
2) Abdominal examination,
3) Vaginal examination,
4) Investigations.
1) General Examination:
a) In the clause:
24th week A pigmentation appears on the face, forehead and cheeks.
b) Breast Changes:
Breast enlargement with prominent veins.
Secondary areola appears during 20th week.
16 th wk colostrum is thick and yellowish.
Striae are seen in varying degrees with advanced wicks.
2) Abdominal Examination:
a) Inspection,
b) Palpation,
c) Auscultation,
a) Inspection:
Linea nigra (brownish color pigmented line appears from symphysis pubis to nciform cartilage) from 20th week.
The stria gravidarum is seen on the lower abdomen.
b) Palpation:
Fundal height increases,
16 th week is the height of the uterus between the symphysis pubis and the umbilical.
20th week is about 2.5 cm below the umbilicus.
At 24th wick is at umbilical level.
The uterus feels soft and elastic.
At the 28th week – at the junction of the lower third and upper two-thirds of the distance between the umbilicus and ensiform cartilage.
Uterus becomes ovoid shape.
Breakstone Hicks contractions (irregular, infrequent, spasmodic, and painless uterine contractions) fill.
Women do not feel contractions at this time but can be felt when the palm is placed on the uterus.
Active fetal movement is felt from 20th week.
External balloting takes place from 20 th vic.
c) Auscultation:
18-20 wk fetal heart sound is heard with ordinary stethoscope. Its sound is like the tick of a watch, its location is according to the position of the fit, the rate is 110 – 160 / minute.
Vaginal Examination:
Bluish discoloration of the vulva, vagina and cervix occurs and the cervix is soft.
Internal balloting takes place during 16 to 18 weeks.
Uterine Souffle:
This sound is from dilated uterine vessels, a soft blowing sound heard during auscultation and synchronized with the mother’s pulse.
Phynic or Fittal Success:
This sound is the blood rush of the umbilical artery synchronized with the fetal hard sound.
Investigations:
Sonography:
Routine sonography is performed between 18 and 20 weeks to assess fetal anatomy, placental site, and cervical canal integrity.
Radiography:
Radiography is done during the 16 th week in which the fetal skeletal shadow is visible.
Last/Third Trimester (29-40 Weeks/7-9 Months):
Subjective Symptoms:
amenorrhea,
feel tired,
Litigation (ie descent of the presenting part of the fetus into the lower uterine segment).
Resumption of frequency of micturition.
Increased fetal movement.
Objective symptoms:
Cutaneous changes become more prominent with increased pigmentation and striae i.e. lina nigra, stria gravidarum dermis and closes.
Uterine sap changes from cylindrical to spherical after 36th week.
Fittal movement is easily filled.
Fundal height is as follows:
1) At 32nd wick:
Fundal height at 32 weeks is seen up to the junction of the upper and middle thirds.
2)At 36th wick:
The fundal height reaches the encysted cartilage.
3) At 40 th wick:
Due to the engagement of the fitus, the fundal height comes up to a fundal height of 32 weeks.
Braxton Hicks contractions are more pronounced during the last two weeks of pregnancy and become more regular during that time.
The lie, presentation and position of the fetus can be determined by palpation of the fetal parts.
A fetal heart sound is audible.
Sonography can assess the growth of the fitus.
Assessment of amniotic fluid volume.
Fittal movement fills more.
Signs of Pregnancy:
After combining the three trimesters, the main three signs of pregnancy are seen as follows.
1) Presumptive sign,
2) Probable sign,
3) Positive sign.
1) Presumptive sign
Mostly subjective i.e. the mother herself feels that she is pregnant while it may be due to other illnesses as well.
Appearance of Montgomery tubercles in the breast.
Expressing colostrum from the nipple.
2) Probable sign:
A probable sign is maternal physiological changes that can be detected during examination.
It cannot be called an objective but definite conformation of pregnancy.
Enlargement of the abdomen. Abdominal palpation can detect the signs of pregnancy.
Changes in the size and shape of the uterus and enlargement of the uterus.
External Ballotment and Internal Ballotment.
A positive pregnancy test means detection of human chorionic gonadotrophin (HCG) hormone in urine. It has the following signs:
Jacquier’s sign or Chadwick’s sign may be seen.
This sign appears during 8 weeks of pregnancy, the bluish discoloration of the vulva, vagina and cervix is called Chadwick’s sign, while the bluish discoloration of the vagina is called Jacques’s sign.
Hataman sign is seen
This sign is seen between 1-3 months of pregnancy and involves slight bleeding when the fertilized egg implants in the uterine cavity.
Palmer’s sign is seen
This sign is seen during 4-8 weeks of pregnancy. In this sign, regular and rhythmic contractions of the uterus occur when bimanual examination is performed.
Goodell sign
. Goodell’s sign is a softening of the lower part of the cervix seen up to 6 weeks.
Hagar sign
This sign is seen during 6 to 10 weeks in which the upper part of the uterus i.e. the body part of the uterus enlarges with the growing of fits and the lower part of the uterus becomes soft. Hagar’s sign involves cyanosis and softening of the cervix
Piscak sign
This sign is observed during the 6-8 weeks in which the uterus implants in the uterus and enlarges asymmetrically.
Ossiander sign
This sign is seen during 6-8 weeks. In this sign, pulsations are felt at the lateral fornix in the vaginal area.
Braxton Hicks contractions
Early in pregnancy, the uterus undergoes spontaneous contractions, which are regular, infrequent, spasmodic, painless, without any effect on dilatation of the cervix, increasing near term and finally merging with painful labor contractions. Ballotment of Fits in which,
Internal Ballotment and External Ballotment are:
Internal Ballotment: After the sixteenth week, vaginal examination reveals the presence of a body that moves on tapping and later returns to its place with chills.
External belotment: Around 20 weeks of pregnancy, the belotment fills the uterus under the hand palpating the uterus with the hand. This is known as External Ballotment.
3) Positive sign. Conformation of pregnancy takes place in positive sign. In which the examiner detects the fits and documents them.
Visualization of Fetus by Ultra Sound: This test confirms the pregnancy and also assesses the position of the fetus, presentation, fetal heart sound, location of the placenta, amount and distribution of amniotic fluid and internal os. Fetus abnormalities like encephaly, spina bifida, myelomeningocele, etc., and uterine and ovarian abnormalities are detected by this method.
A scan is routinely recommended during the mid-trimester before the 20th week of pregnancy. In cases of serious abnormalities of the fetus, the patient may be advised to undergo pregnancy termination.
Pregcolor and pregcolor-card test: These are mostly used as home-kits to confirm pregnancy. This color-change-card-test is simple and women can do it themselves. The presence of 2 lines in the Kada test on the 5th day after a missed period confirms pregnancy.
Auscultation of fetal heart sound: Fetal heart sound is heard after 20 wks in Phytoscope. • Fetal movements: Fetal movements are felt at 22 weeks. • Palpation of fetal parts: Fetal parts are palpable after 24 weeks.
Radiography: It is not usually advocated in pre-send day practice.
Radiographic pelvimetry is rarely indicated in selected cases of suspected cephalopelvic disproportion.
Radioimmunoassay: This is a very sensitive method and can be used to detect the presence of hCG in maternal serum and urine 7-8 days after ovulation or at the time of implantation.
It confirms the presence of pregnancy after 3 weeks of conception. The concentration of hCG in the mother’s serum doubles every 2-3 days until it reaches a peak value 2-3 months after conception (Black-Burn 2007).
Ultrasonography shows embryos up to 6 weeks followed by fetuses.
Radiological appearance of the skeletal system of Fittus.
Visualization of fetal skeleton in X-ray.
Visualization of fetal movement in late pregnancy.
Differential diagnosis:
Whenever positive signs of pregnancy are not clinically evident, the diagnosis of pregnancy can sometimes be problematic. Differential diagnosis for presumptive and probable signs.
are as follows:
Presumptive sign:= Differential diagnosis
1) Amenorrhea: Due to emotional stress, illness and hormonal imbalance.
2) Breast changes : Due to contraceptive pills.
3) Nausea and vomiting: due to gastro-interstitial disorder or cerebral irritation.
4)Frequency of Micturation, Bladder Irritability:= Due to Urinary Tract Infection or Pelvic Tumor
5) Quickening:= due to interstitial movement
Probable Sign:= Differential Diagnosis
HCG in urine:= due to choriocarcinoma.
HCG in blood:= due to hydatidiform mole.
Uterine growth:= due to tumors.
Ocender’s sign, Hegar’s sign, Chadwick’s sign:= due to pelvic congestion.
Uterine Sulph: Increases blood flow to uterus (ovarian tumor)
Important Note:
There is no alternative diagnosis for a positive sign of pregnancy.
Conformometry Test:
A) Urinary Immunological Test –
Urinary immunological tests include latex agglutination slide test and immunochromatographic test.
•Immunochromatographic test- This test is available as precolor card or ascutest hCG etc. This test is more sensitive than the previous test and comes positive after one week of missed menstruation.
•ELISA or Radioimmunoassay (RIA)-
This test is particularly indicated for patients with trophoblastic disease. It can detect hCG on day 8 of fertilization, before menses are missed.
B)Ultrasonography-
Abdominal ultrasonography can diagnose the following:
5th week:
Spherical gestational shake is visible.
Transvaginal ultrasonography:
Transvaginal ultrasonography can make an earlier diagnosis than abdominal sonography.
In 4 weeks:
Visualization of jstational shake is done.
In 5th week:
Assessment of yolk sac and fetal cardiac motion can be done.
Antenatal care
Definition:
Antenatal care is also called prenatal care in which comprehensive health care is provided to the pregnant woman from conception to childbirth.
This period is a crucial time for monitoring the mother and the developing fetus. Because if there are any potential health complications to the mother and the developing fetus, they can be managed by early identification. And the mother can be physically and emotionally prepared for childbirth and the postpartum period.
Systemic supervision (examination or advice) of women during pregnancy which is regular and periodic is called “antenatal or prenatal care”. Antenatal care starts from the beginning of pregnancy and ends when the baby is delivered.
Aim and Objectives of Antenatal Care:
Aim of antenatal care:
The aim of antenatal care is to improve the overall health of the fetus and the mother and to improve the well-being of the mother and the fetus and to prevent complications.
1) Monitoring maternal health
Regular health checkups can monitor the mother’s overall health, such as blood pressure, weight gain, and overall well-being, etc., so that early identification of any complications can be done. And by treating it early, it can be prevented from happening further.
2) Monitoring fetal health
In antenatal care, assessment of the fetus including ultrasound scan, fetal heartbeat monitoring, and other tests can be done properly due to which the growth and development of the fetus can take place properly. If the child has any abnormality, it can be detected early and properly managed.
3) Health Education
Antenatal care provides an opportunity for appropriate education to expectant mothers, including pregnancy, child birth, breastfeeding, nutrition and parenting. This education can be helpful to the antenatal mother in making proper decisions.
4) Early detection of pregnancy related complications for proper management.
By visiting antenatal care, early detection of pregnancy related complications can be done and their timely management can be done. such as,
gestational diabetes,
Preeclampsia, infection and other pregnancy related risks that can affect the pregnancy.
gestational diabetes,
Preeclampsia, infection and other pregnancy related risks that can affect the pregnancy.
5) Preparation for Childbirth
Birth planning, preparation for labor, and delivery options are discussed in antenatal care sessions. By having this discussion, the mother and her family members can mentally and practically prepare for child birth.
6) Psychological support
Emotional and psychological changes are seen due to pregnancy. Antenatal care provides a supportive environment in which the expectant mother can discuss her anxiety, fear and doubts and clear them and reduce her anxiety and fear and feel emotionally well-being.
7) Prevention and Management of Maternal and Infant Complications
Antenatal care interventions include immunization, iron and folic acid supplementation, and preventive treatment provided to prevent pregnancy and childbirth related risks and complications.
8) Promotion of healthy behavior
Antenatal care provides education to promote behaviors such as smoking cessation, alcohol and drug avoidance, maintaining a balanced diet, and being physically active, which are important for healthy pregnancy outcomes.
9) Postpartum planning
Post-partum care is also discussed in antenatal care in which, post-partum care,
Breast feeding support and family planning options are discussed.
The objectives of overall antenatal care are to have a healthy pregnancy, properly manage any risks and complications, prepare the mother for child birth, and properly maintain the health of the mother and fetus during the throwout pregnancy.
Objectives:
The main objective is to deliver a healthy baby by a healthy mother with a normal pregnancy.
The first visit must be before the second missed period.
To assess the health status of mother and fetus.
To formulate a plan for further management.
To promote, protect and maintain good physical and mental health of the mother during pregnancy. •> Components of Antenatal Care: 1) Initial Assessment:
The first antenatal visit should be done early in pregnancy, ideally within the first 8 to 12 weeks of the last menstrual period.
During this assessment the health care providers properly assess the woman in which the woman’s
Medical History, incl
previous pregnancy,
Medical condition, medication, and relevant family history are fully assessed.
This information is collected so that potential risk factors of the mother can be identified and appropriate care can be provided to the mother. 2) Physical Examination: A physical assessment of the mother is done to assess the health status of the mother and the fetus during the throw out pregnancy period.
In this examination the mother’s blood pressure,
Weight, and urine tests are done due to which the mother can be identified early if she has the condition of gestational diabetes and preeclampsia.
Mother’s blood test is also done due to which mother’s hemoglobin level, blood group is done.
The mother is also screened for hepatitis and HIV infection. 3) Fetal Monitoring: Growth and development of the fetus is also monitored in antenatal care.
It involves assessment of the fetus through different methods such as ultrasound: Ultrasound is used to confirm pregnancy, to assess gestational age, to assess fetal growth and also if the fetus has any structural problems i.e. malformations. Made to be identifiable. Fetal Doppler: Fetal heart rate is monitored by fetal doppler. Kick Counting:
Advising the mother to feel fetal movement and counting the number of fetal kicks throughout the day can monitor fetal well-being. 4) Nutritional guidance: Proper nutrition is important for providing support to maternal health and fit development.
Antenatal health care providers provide guidance to the mother on a balanced diet along with proper weight maintenance and adequate amounts of vitamins and minerals.
Education is provided to pregnant women regarding the importance of taking (Ex: Iron and Folic Acid). And education is also provided to women that congenital birth defects in fetuses and anemia conditions in pregnant women can be prevented by taking adequate diet. 5) Health Education and Counselling: In antenatal care education is provided to the pregnant woman about pregnancy related topics like,
1) Exercise:
Safe physical activity and exercise are important for maintaining the health of mother and fetus.
2) Labor and Birth Preparation
Mothers are provided with information about the stages of labor as well as education about pain relief strategies and birth plans.
3) Breast feeding:
Providing education to mothers about the techniques, benefits of breast feeding.
4) Emotional and Mental Health:
To properly assess the emotional and mental health of the mother and to provide adequate education and psychological support to the mother to relieve her fear and anxiety and to clear all the doubts of the mother.
6) Screening and Test:
Proper genetic testing during the antenatal period of the mother so that any genetic complications can be identified. Genetic Screening:
In this, mother’s ultrasound and blood test are done due to which genetic disorder can be identified if there is a risk. (Ex: Ultrasound). Screening for Infection:
The mother is screened to identify any sexually transmitted diseases and any other infections that may affect the pregnancy. Glucose Tolerance Test:
A glucose test is done to identify whether the mother has any gestational diabetes condition or not.
7) Preparation for Labor and Birth:
Antenatal care includes discussions about birth preferences, options for management of labor pain, and preparation for potential complications.
8) Postpartum Planning:
Antenatal care also includes planning for post partum care including breastfeeding support, education of the mother about newborn care. Thus, antenatal care is important for maintaining the health condition of the mother, for proper growth and development of the fetus and for early identification and management of potential risk factors.
Generally an antenatal mother should visit the antenatal clinic once a month for the first five months of pregnancy, then twice a month from 6 months to 9 months and then weekly antenatal clinic visits after nine months. .
A large number of mothers in India come from families with low socio-economic status and the majority of women are working women.
Thus, women who come from a family with low socioeconomic status and are working women and find it difficult to attend the clinic during pregnancy are required to have a minimum of 4 antenatal visits during the entire pregnancy.
such as,
(WHO) recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care.
First visit as soon as pregnancy is suspected;
The second visit should be scheduled between 4-6 months (about 24-28 weeks).
3 Third visit at 8th month (around 32 weeks) and
4th visit to be done during 9th month (36-40 weeks). Thus, it is important for pregnant women to have at least 4 antenatal visits.
Antenatal Assessment:
In antenatal assessment, an essential assessment of the health level of the pregnant woman is done, in which the woman’s history is collected in detail, a proper physical examination is done, antenatal assessment is done by abdominal examination and screening test.
The aim of antenatal assessment is to assess blood pressure, urinalysis, blood volume, uterine growth and recording of fetal development which can serve as a standard for comparison with advanced pregnancy.
Taking the past and present health status of the pregnant woman, and obstetrical history, medical history, family history and personal history in accurate detail so that risk factors can be identified early. An initial assessment with a pregnant woman provides an opportunity to build a trusting relationship with the woman so that the woman can be properly cared for during the pregnancy period.
A woman’s first visit involves her general health history, obstetric history, physical and pelvic examination and laboratory investigations.
Objectives:
To assess the health status of mother and fetus.
To assess the fittal jstational age.
To conduct a baseline investigation.
To provide continuous obstetrical care
To screen high risk cases.
History Taking:
Pregnant pregnant women in history taking
1) Name
2) Date of Examination
3) Address
4) Edge
If a woman’s first pregnancy is at the age of 30 years or more than 35 years, it is called elderly primi gravida.
Extremes of age i.e. teenage pregnancy and elderly pregnancy are obstetrical risk factors.
5) Gravida
6) Mercury
7) Religion
8) Duration of Marriage
(It helps to note fertility and fecundity)
9) Occupation
(It helps in interpreting symptoms due to fatigue or occupational hazards).
10) Occupation of Husband
(To assess the socio economic status of the family).
11) Period of Gestation (POG).
(Pregnancy is known by how many weeks have been completed which is counted from the first day of the last menstrual period. The most reliable method is ultra sonography.
12) GPTPAL Score
in which,
G: Gravida
P: Mercury
T: Term Delivery
P: Pre Term
A: Abortion
L: Live birth.
Information about is written.
13) Complain
Ask about sleep patterns, appetite, bowel habits and urination etc.
History of Present Illness
In it, the history of the chief complaint and its onset, duration, severity, progress, medication etc. should be collected.
History of present pregnancy
To note if there are different complications in different trimesters of pregnancy.
such as hyperemesis gravidarum in the first trimester,
Threatened abortion in the second trimester and pyelitis (infection and inflammation of the renal pelvis, which is the part of the kidney where urine collects before passing into the ureters, is called pyelitis).
And asking about last trimester anemia, preeclampsia and antepartum hemorrhage (APH).
Previus antenatal visit status to check immunization status, medical or radiation exposure in early pregnancy and medical surgical events.
Health History:
Finding out medical conditions that affect pregnancy can range from common urinary tract infections to severe cardiac conditions. Certain medical conditions require special care.
such as,
urinary tract infection,
Women with a history of thrombosis,
hypertension,
Other conditions including asthma, epilepsy, generalized infection,
psychiatric disorders,
diabetes,
And cardiac condition requires the support of medical specialists.
Obstetrical History:
The midwife asks the pregnant woman for information in a friendly and sympathetic approach; Like, Age, Last Menstruation Period etc.
The midwife calculates the expected date of delivery, from the last menstrual period, and records the present and past pregnancies and other information related to the pregnancy in a history sheet.
such as,
1) Age of woman should be less than 18 years or more than 40 years.
2)Having the condition of Grand Multipara i.e. having births above 5.
3) Vaginal bleeding anytime during pregnancy.
To collect history about miscarriage and medical termination of pregnancy (MTP).
Menstrual History:
It collects the history about the age of women’s minarchy.
In it, the frequency, duration and amount of menstrual blood flow are assessed.
A history of first day of last menstrual period (LMP) is also collected.
EDD (Expected Date of Delivery) is calculated by Nigel’s formula.
Collect history about dysfunction uterine bleeding like,
Eg: menorrhagia, metrorrhagia, and intermenstrual spotting…
Past Medical History:
Collect information about any medical history in the past eg tuberculosis.
Past Surgical History:
Primarily to collect information about history of general and gynecological surgery.
Family History:
Collect information about whether any person in the family members has a history of genetic diseases or not.
Collecting information about certain types of genetics found in family members like DCs like hypertension, diabetes, tuberculosis and family history of twins pregnancy.
Personal History:
Collect history of contraceptive practice, smoking or alcohol habit, blood transfusion, corticosteroid therapy, drug allergies, immunization, anti-D and immunoglobulin etc. before pregnancy.
Post Obstetrical History:
In the post-obstetrical history,
steel berth,
Neonatal Death,
Having a baby smaller than the gestational age,
postmature baby,
congenital defect,
Rhesus Iso Immunization,
Especially having a history of abortion, miscarriage and termination.
Usually having preterm labor.
Having prior caesarean section and uterine surgery.
Having history of antepartum and postpartum.
Multiple pregnancy and
Collect information about whether there is a history of precipitate labor.
Thus, an antenatal history is collected from the mother and the general health of the mother is assessed. And if any complication is likely to arise, its early identification can be done
Gravida:
Gravida means “pregnant woman” and refers to the number of times a woman has been pregnant, regardless of the outcome. This does not mean how many children are born from the pregnancy but it is the total number of pregnancies that counts and not the number of children.
Gravida means pregnant state in past and present which can be any station period. Overall gravida means the number of total pregnancies of a woman is called gravida.
Women pregnant for the first time are called primigravida.
Or
A woman who is pregnant for the first time is called a primi gravida.
A woman who is pregnant more than once, regardless of the outcome of the pregnancy, is called multigravida.
A woman who becomes pregnant five or more times is called grand multigravida.
A woman who has never become pregnant is called nulligravida.
Mercury:
It includes the number of times a woman has given birth to a child that survived to the period of viability (28 weeks), whether it was a live birth or a stillbirth (stillborn), excluding abortions.
Parity means the status of pregnancy after the period of viability (28 days).
Pregnancy complete till the period of viability
Absence or pre-abortion or none at all is called nulliparous.
•Primipara:
A primipara means that if one viable child has been delivered, it is called a primipara. Parity does not increase if the fetuses are more than one at the same time.
Ex:=Twins, triplets do not grow.
Ex:=Twins, triplets do not grow.
One or more pregnancies complete to the stage of viability or longer are called multipara.
Calculation of Expected Expected Date of Delivery (EDD)
To calculate the Expected Date of Delivery (EDD), one should first know about the normal duration of pregnancy.
•> Normal duration of pregnancy is 9 months + 7 days, 40 weeks or 280 days.
Now, for the woman to calculate the Expected Date of Delivery (EDD).
1) Ask 1st day of Last Menstrual Period (LMP).
And
2) Asking the length of menstruation cycle.
The length of a normal menstruation cycle is 28 days.
1) If a woman’s menstrual cycle is 28 days, the Expected Date of Delivery (EDD) is calculated by Nagels formula.
such as,
Expected Date of Delivery (EDD) := In this +9 months +7 days are added to the first day (1st day) of the woman’s last menstruation period (LMP).
EX:= 1st day of Last Menstruation Period (LMP)
3 is March 2022.
EDD:= 3 March 2022
↓ ↓
7 Days 9 Months Expected Date of Delivery (EDD):= 10 December 2022
2) If the woman states that her menstrual cycle is less than 28 days or more than 28 days then Expected Date of Delivery (EDD) can be obtained using modified Nigel’s formula.
••> First using Nigel’s formula in modified Nigel’s formula to derive Approximate Expected Date of Delivery (EDD).
••>★ If the menstrual cycle is less than 28 days
EX:= If 24 days menstrual cycle and Medwell EDD by Nigels formula is: 10 December 2022.
So:
28 days – cycle length = X
28 – 24 = 4 days
Correct EDD = Approximate Obtained EDD –” X “
EDD = 10 December 2022 — 4 days
EDD= 6 December 2022 will happen.
••> ★ If menstrual cycle is more than 28 days
EX:= If 31 days menstrual cycle and Medwell EDD by Nigels formula is: 10 December 2022.
So:
Cycle length — 28 days = Y
31 – 28 = 3 days
Correct EDD = Approximate Derived EDD + ” Y “
EDD = 10 December 2022 + 3 days
EDD= will be 13 December 2022.
3) If the length of a woman’s menstrual cycle is a variable,
Measuring the approximate cycle length of the next three-month menstrual cycle includes:
C1+C2+C3
——————- = Avg
3 Menstruation
Bicycle
Now, asking what was the first day of a woman’s last menstrual cycle.
If the average menstrual cycle is 28 days, then calculate the Expected Date of Delivery (EDD) using Nigel’s formula.
And if the length of the average menstrual cycle is less than 28 days or more than 28 days, then use the modified Nigels formula to count the expected delivery.
4) Alternatively to calculate the Expected Date of Delivery (EDD) by going back three months from the first day of the Last Menstrual Period (LMP) and adding 7 days and 1 year to it. Due to which Expected Date of Delivery can be found.
EX:= 1st day of Last Menstruation Period (LMP)
3 is March 2022.
EDD=
3 March 2022 — 3 months
= 3 December 2021.
EDD:
= 3 December 2021
↓ ↓
EDD:
= 10 December 2022
Thus, the EDD (Expected Date of Delivery) for the pregnancy can be obtained as follows.
Physical Examination:
A physical examination is usually done to find out any disease or abnormality in the mother and fetus during the early antenatal period.
Before starting the initial antenatal examination, take the woman’s consent and provide her with a comfortable position.
Examination of body systems through observation, inspection, auscultation and measurement techniques. Attend the woman gently and respectfully and perform her physical examination in a properly organized manner. Properly maintain woman’s privacy during entire physical examination.
Antenatal examination is usually performed in two parts such as:
1) General Examination
2) Obstetrical Examination
•> General Physical Examination:
1) Build:
Assess whether the mother is obese, average and thin.
2) Nutritional status of mother:
To assess whether it is good, average, or poor.
3)Height:
A woman’s height is usually measured only when a woman comes for the first antenatal visit. If the woman is short, there are chances of having a small pelvis.
5 feet in western countries and 4′.7″ in India are considered to be short stature. And most of them have small pelvis. So it is important for every woman to get height measurement during her antenatal visit.
4) Weight:
Weighing the mother by the same weight machine during every antenatal visit and measuring her accurately.
An average woman usually gains about 11 kg of weight during her pregnancy.
If the mother has a condition of obesity, it can usually be due to gestational diabetes, pregnancy induced hypertension (PIH) and shoulder distortion. Risk increases during pregnancy due to obesity. If the mother has OBCD, she has difficulty in palpating the fetal parts and assessing the presentation of fits, position and engagement of the presenting part.
5) Paler:
Lower palpebral conjunctiva, dorsum of tongue and nail bed 52 pallor.
6) Jaundice:
Assess the condition of jaundice on sclera, conjunctiva, underside of tongue, hard palate and skin.
7) Ice:
Inspect for anemia and jaundice condition.
8) Years:
Assess for ear pain, any discharge, and tinnitus in the ears.
9) Tongue, Teeth, Gums and Tonsils:
Assess whether there is a condition of malnutrition Assess whether there is a condition of glossitis and stomatitis.
10) Neck:
Look for neck vein, thyroid gland, and lymph gland abnormalities.
In up to 50% of cases of pregnancy, the condition of slightly enlargement of the thyroid gland may occur.
11) Edema of Legs:
Look for edema on medial malleolus and 1/3 rd anterior surface of tibia in both legs by pressing the area with thumb for 5 seconds and assess for condition of leg varicosities.
Causes of edema include pre-eclampsia, cardiac failure, and nephrotic syndrome.
12) Heart, Lungs, Spleen, and Liver:
Assess the patient for cardiomegaly, splenomegaly, liver enlargement, and lung abnormalities.
13) Blood Pressure:
It is checked to ascertain normality and provide baseline information for comparison during the throwout pregnancy period. A blood pressure greater than 126/94 is indicative of an alarming situation. In the prenatal period, special care and rest are mandatory to maintain normal blood pressure and placental perfusion.
14) Breast:
Breast examination is used not only to identify the presence of pregnancy but also to assess the skin condition of the nipple and areola.
Breast examination can identify any normality or difficulty due to which difficulties occurring at the time of best fitting can be prevented.
15) Urine Analysis:
Urinalysis is usually done during the first visit of pregnancy and further during pregnancy to assess the condition of proteinuria, ketone bodies in urine and glycosuria.
When there is a condition of vomiting, hyper emesis, starvation and exercise conditions, adequate amounts of fat are used for energy as per the demand of the fetus and ketone bodies are found in the urine.
Higher circulating blood levels, reduced renal threshold, or increased amounts of glucose in the urine due to renal disease.
The amount of protein in the urine is also seen due to the condition of pre-eclampsia or infection.
Blood test during antenatal examination:
A blood test is used in antenatal examination to assess a woman’s hemoglobin level, hematocrit level, ABO blood group, Rhesus (Rh) factor and VDRL (Venereal Diseases Research Laboratory Test), HIV (Human Immunodeficiency Virus Test), Rubella immune status. .
ABO Blood Group and Rhesus (Rh) Factor:
Blood analysis is usually done to find out the ABO blood group and Rhesus (Rh) factor. Blood analysis is performed to identify the status and presence of antibodies in red blood cells to prevent hemolysis in the newborn baby.
A rising titer indicates an antibody response, so frequent, blood assessments are performed in Rh-ve women. Antigamma globulin should be administered with a blood titration during the 28th and 34th weeks of gestation.
To prevent hemolytic disease in newborn babies in conditions like threatened abortion, amniocentesis, trauma, provide an additional dose of anti-gamma globulin within a few days of this event.
Hemoglobin and Hematocrit:
Estimation of hemoglobin is done to assess whether iron is in adequate amount. This is important because if the mother is anemic, her need for iron intake (dietary or supplement) increases.
Red blood cell count is important to provide adequate amount of oxygen to the mother and her growing fetus.
Repeat it at 28th week of pregnancy, as the physiological effect of hemodilation becomes apparent, and at 36th week to assess the Hb level and if the Hb level is below the normal range then properly before delivery. Assay the level of hemoglobin to treat accordingly. Along with giving advice to the mother to take iron supplementation, folic acid and foods that are rich in iron.
Venereal Diseases Research Laboratory Test (VDRL):
This test is usually performed to identify the presence of syphilis in women. If syphilis is detected early, transmission of this disease to the fetus can be prevented. Not all positive results indicate the presence of active syphilis in a woman.
Human Immunodeficiency Virus (HIV) Test:
Obtaining informed consent and proceeding with screening HIV tests to prevent active transmission of infection to fetuses and counseling couples as soon as possible if results are unsatisfactory.
Rubella Immune Status:
This is done by measuring the rubella antibody titer. Exposure to rubella infection during pregnancy can cause deformities of the fetus, so if a woman tests positive for rubella, advise her to terminate the pregnancy.
The woman is then advised to take live vaccination during periperiod period and to avoid pregnancy till the next three months.
Other investigations involve investigation for Hepatitis B, C and Chlamydia based on history of contracting disease/infection in the first trimester.
According to this blood test is done or education is provided about it to the mother during pregnancy.
Obstetrical Examination of Pregnant Women:
Abdominal examination and vaginal examination are involved in obstetrical examination.
The midwife examines the woman after obtaining her consent. Advise the mother to properly evacuate her bowels before performing the obstetrical examination. After that, providing a dorsal position to the mother, flexing her knee (knee) and providing a comfortable position, the obstetrical examination of the woman is done. The examination is performed after exposing the abdomen of the woman as required and the examiner should stand on the right side of the mother while performing the examination.
The midwife should maintain rapport with the mother throughout the procedure by inquiring about the health of the pregnant woman, the investigations performed and the breastfeeding of the newborn baby.
Abdominal examination can usually be performed by an obstetrician after 12 weeks but for best assessment of fetal growth an obstetrical examination can be done after 25 weeks of gestation for best assessment of fetal growth.
Assessment of fetal growth is not properly done by abdominal palpation before 25 weeks.
Physical examination and abdominal assessment can be beneficial as follows:
1) The midwife can assess the wick of gestation and the growth pattern of fits by observing the size of uterus, sep, abdominal counter, scars, injury marks, linea nigra and striagravidarum etc.
2) By assessing the lie, presentation, position and engagement of the fetal head of the growing fit, the wellbeing of the fit and any deviation from the normal condition can be detected.
3) By measuring the fundal height and abdominal girth of the pregnant woman, palpating the fetal position, auscultating the fetal heart sound, the midwife can minimize the risk of pregnancy and labor.
★ Inspection:
Preliminaries:
To properly prepare the woman for the examination of the woman, advise her to lie down in a properly flat position, then advise her to keep her arms at her side, and advise her to relax her abdominal muscles.
Expose only that area of the abdomen that needs to be examined and keep the remaining area properly covered.
Before doing the abdominal examination, make sure that the woman empties the bladder properly, because a full bladder can make the examination uncomfortable and difficult to fill. Discuss with the mother about her investigating report and maintain proper reports.
Inspection:
The size and shape of the uterus can be assessed by inspection. Also the movement of the fetus can be observed and in multiparous women, a pendulous abdomen can be noted, in which the uterus tilts forward. The condition of the skin and any incisional scars and herniations present are noted.
Distended colon and OBCD provide a false impression If there is polyhydroamnios or multiple pregnancy due to which both the length and width of the uterus increases, if there is a large baby then the length of the uterus also increases due to this.
of the umbilicus in the occipito-posterior position
A depression of the saucer-shaped abdomen can be seen below.
On abdominal inspection, a brownish-black line is visible in the midline from the zephysternum to the symphysis pubis due to melanocyte stimulating hormone called the linea nigra.
Abdominal wall below the umbilicus and sometimes on the breast are depressed marks that are initially pink but turn to a glistening silvery white color after delivery called stria albicans or stria gravidarum.
The fundus part of the uterus is palpated just above the symphysis pubis during the 12th week of gestation.
On inspection inspect whether the uterus is ovoid longitudinally, transversely, or obliquely.
To assess whether the shape of the uterus, its fundal notch and anterior wall is convex or flat and whether its shape is cylindrical or spherical.
Inspect the uterus for enlargement.
Palpation: (Leopold Maneuver)
Wash the hands properly before palpating the abdomen to dry it. The left hand evokes a sense of touch but does not induce premature contractions. Midwife should keep her hands properly relaxed while doing palpation. Use handpad instead of finger tips for proper palpation. Avoid induction of contraction by using rough method of palpation.
Measurement of fundal height:
The midwife places the ulnar border of her left hand below the xiphosternum to find the fundal height. Gradually, he moves his hand downwards to the abdomen, feels the flexion at the upper border of the fundus and places the ulnar border of his hand between the fundus and the xiphosternum to detect the wick of pregnancy. Fundal height can be measured using a tape measure. Fundal height is measured from the top of the pubic bone (symphysis pubis) to the top level of the uterus (fundus). Thus, the measurement between the fundal border and the symphysis pubis is called the symphysis fundal height (SFH). ) is called This measurement roughly corresponds to the number of weeks of pregnancy.
Recording: Measurement of fundal height is recorded in centimeters (Cm). For example, if the fundal height is 28 cm, it usually indicates that the pregnancy will be approximately 28 weeks.
•> Uterine fundal height at different weeks during pregnancy:
Non-pregnant uterus pyri shape (pear-like) Uterus becomes globular shape during 12 weeks of pregnancy.
Uterus re-enlarges to form pyri foam during 28 weeks and spherical shape after 36 weeks of pregnancy.
•> At 12 Weeks of Pregnancy:
During 12 weeks of pregnancy the uterus is not more anteverted and antiflexed than the fundus is palpated abdominally over the symphysis pubis.
•> At 16 Weeks of Pregnancy:
During 16 weeks of pregnancy, the uterus is ovoid in shape. The uterus is between the symphysis pubis and the umbilicus.
•> At 20 Weeks of Pregnancy:
During the 20th week of pregnancy, the fundus part of the uterus is about two fingers below the umbilicus.
•> At 24 Weeks of Pregnancy:
During the 24th week of pregnancy, the fundus part of the uterus is at the level of the umbilicus and one finger below it.
•> At 30 Weeks of Pregnancy:
At 30 weeks of pregnancy, the fundal part of the uterine cavity lies between the umbilicus and the zygosternum.
•> At 36 Weeks of Pregnancy:
During the 36th week of pregnancy, the fundal part of the uterine cavity is at the highest level i.e. up to the zephysternum.
•> At 38 Weeks of Pregnancy:
During 38 of pregnancy the fundus part of uterine cavity descends and reaches the level of 34 is called lightening.
•> At 40 Weeks of Pregnancy:
During 40 weeks of pregnancy, the fundus part of the uterine cavity reaches the level of 32 weeks and then the lower uterine segment relaxes and stretches while service becomes soft and short and the uterus prepares for labor.
Lie, presentation, attitude and position of the fetus can be known through Leopold Maneuver. Leopold has given mainly 4 manoeuvres.
1) Fundal palpation
(Fundal Grip/First Leopold/First Maneuver):
Fundal palpation (fundal grip) assesses which part of the fetus is present at the fundus site, i.e. head is present or buttocks (breech).
In fundal palpation palpate with the examiner facing the patient’s face.
Then place both hands on the fundus of the woman and slightly curve the fingers around the top part of the fundus.
Then gently palpate to palpate the vital parts.
If palpating the fundus part,
a) A broad, soft and irregular mass indicates that part of the buttocks of the fitus is present at the fundus site.
b) If smooth hard and globular mass like structure fills it indicates fitus no head no part is present on fund side.
C) No part of the fetus is palpated at the fundus site in transverse lie.
2) Lateral palpation
(Umbilical Grip/Second Leopold/Second Maneuver):
Through this maneuver, the position of the back and lims of the fitus is assessed, due to which the position of the fitus in the uterus can be assessed.
Palpate in this maneuver keeping the face next to the patient’s face.
Then place both hands directly on either side of the umbilicus.
Then provide support to the fundus with one hand and palpate the fundus with the other hand. Palpate alternately on both sides of the umbilicus in this manner.
It involves palpating the back parts of the fitus, the limbus and the anterior shoulder.
If a smooth covered shape part of the fetus and a resistant feel is felt on palpation, then it can be said that the part of the back is present.
If an irregular mass is felt on palpation that is more movable than palpated, it suggests that a limb (extremity) of fitus is present.
3) Pavlik Grip/Third Leopold/Third Manuer):
Through this maneuver, the size, flexion and mobility of the head can be assessed and it can also be known whether the presenting part is engaged.
In this manuever, do the examination by keeping the face towards the face of the patient. Then advise the patient to bend the knee so that the abdomen can relax.
Then place the thumb and four fingers of the examiner’s stretched hand on the lower pole of the uterus and place the ulnar border of the palm on the symphysis pubis and grasp the presenting part of the fetus properly when the fingers and thumb are almost equal.
If the presenting part of the fitus is not engaged then a movable mass is felt and if the presenting part is engaged then the part of the fitus felt by examination is not movable.
4) Pelvic Grip/ Fourth Leopold/ Fourth Maneuver):
Assessment of head presentation, head flexion, and head balloting can be done through this maneuver.
This maneuver involves examining the patient’s face toward the leg and asking the woman to bend the knee.
Then place the four fingers of both hands on the midline on both sides in the lower pole of the uterus and parallel to the inguinal ligament.
Then press the fingers downwards and backwards to palpate which part of the fitus is present in the lower pole of the uterus.
Keep moving the hand towards the pelvic inlet. If those hands separate i.e. do not overlap each other, it shows that the presenting part is engaged. If the hands are overlapping, it indicates that the head is not engaged.
If a firm mass with a definite round shape and smooth surface is felt on palpation, it indicates the head as the presenting part.
The sinciput will be felt on the opposite side of the occiput and if higher than the occiput – indicates a well-flexed head.
If the prominences – synciput and occiput at the same level – indicate a deflected head.
If the excess part of the head is on the same side of the back, it indicates an extended head.
ASKULSTATION:
A midwife uses a Pinada Phytoscope to auscultate fetal heart sounds.
Using a Pinard fetal stethoscope, the examiner can listen to the fetal heart sounds. It is placed on the abdomen of the mother, at right angles to the back of the fitus. Without touching the phytoscope, the ear is placed in firm contact with the phytoscope. The phytoscope is moved to the point of maximum intensity of the voice and the F.H.S is heard.
Auscultation not only diagnoses live baby from fetal hard sound but also gives an idea of its presentation through maximum intensity of its location.
a) FHS can be heard well from back side of fitus in vertex and breech presentation.
Because the convex portion of the back of the fetus comes in contact with the uterine wall.
b) Heart sound can be heard well from the chest of a fitus in face presentation.
According to the rules, maximum intensity of fetal heart sound (FHS) is heard below the umbilicus in cephalic presentation and fetal heart sound (FHS) is heard around the umbilicus in breech presentation.
In occipito lateral, FSH is heard laterally and in occipito posterior position it is heard towards the flanks.
In left occipito posterior position, F.H.S is difficult to find.
The fetal hard sound (FHS) is heard at different places depending on the presentation and position of the fetal such as,
Cephalic: It is heard between the umbilicus and the anterior superior spine.
Breach: At or above the level of the umbilicus.
Anterior: Near the abdominal midline.
Transverse: in the lateral side of the abdominal area
Posterior: In the flank area or near the abdominal midline.
Accordingly, the fetal heart sound (FHS) can be heard at different places depending on the presentation and position of the fitus.
Vaginal Examination:
A vaginal examination is done when a woman comes for a checkup at an antenatal clinic.
If there is a history of previous abortion or occasional bleeding in the present pregnancy, vaginal examination is omitted and ultrasound examination is performed.
Steps of Vaginal Examination:
Vaginal examination is done in the antenatal clinic.
Then provide dorsal position to the patient to flex his hips and advise to keep the buttocks on the foot end of the table.
After washing hands properly wear gloves on examining hand Wear gloves mostly on right hand.
Inspection:
Separate the labia with thumb and index finger to look for vaginal discharge, cystocele, rectocele, or uterine prolapse.
Speculum Examination:
Speculum examination should be done before bimanual examination and take cervical smear and vaginal swab using bivalve speculum.
Bimanual Examination:
Separate the labia with the left hand and introduce two fingers (index and middle finger) of the right hand into the vagina. Place the left hand suprapubically. Perform a slow systemic examination noting the following:
1) Cervix: Consistency, direction, and pathology
2) Uterus: Size, shape, position and consistency
3) Adnexai: Note if any mass is felt.
If the introitus is narrow, a finger can be introduced for examination. No attempt should be made to assess the pelvis during this stage.
Purpose of Vaginal Examination:
To observe the findings as follows:
Observation of the labia for any sign of varicositis, edema or vulvar warts or sores.
To observe if there are scars from previous ter or episiotomy.
Properly note any bleeding from the vaginal orifice.
Assess color and order of amniotic fluid if membranes are ruptured (eg, offensive amniotic fluid-infection. Green amniotic fluid-due to presence of meconium).
Playing:
A warm, moist vagina with a small soft distensible vaginal wall is good for delivery.
Hot and dry contractions are a sign of obstructed labor.
Cervix:
Long and titily close services indicate that the labor process has not yet started.
The cervix should normally be soft and elastic, if tight and rigid then labor may be protracted.
Uterine OS:
Dilatation of the external os is assessed in centimetres, usually the cervix is dilated by 10 cm with one finger = 2 cm dilated.
Forewater:
Filling whether the membrane is an intake by dilating OS.
Station of Presenting Part:
Estimating the relationship of the maternal ischial spines to the presenting part and evaluating the descent of the fitus during labor. The distance of the presenting part above or below is expressed in centimetres.
Presentation:
Filling sutures in the hard bone and fontanelles and vertex of the vault of the skull bone.
Special Investigations:
Biochemical and biophysical methods are used for diagnosis along with clinical evaluation to find the cause of congenital malformation, chromosomal abnormalities, first trimester spontaneous abortion and still born infant etc. and to prevent fetal death and unnecessary treatment in late pregnancy.
1) Serological test:
Serological tests are performed to identify rubella, hepatitis B, and HIV infections.
2) Maternal Serum Alpha Phyto Protein (MSAFP) Estimation:
Maternal serum alpha phytoprotein (MSAFP) estimation or triple test at 16-18 weeks is done for mothers who are at risk of carrying a fetus with neural tube defects, Down’s syndrome or other chromosomal abnormalities.
3) Blood test:
Blood test is done to detect and condition of thalassemia and sickle cell anemia due to which early detection and appropriate measures can be taken.
4) Ultrasound Examination:
Ultra sound examination is done in first trimester transabdominal sonography (TAS) transvaginal (TVS).
from that
Ultrasound examination is usually performed during 18 – 20 weeks.
Bi Parietal Diameter (BPD),
Abdominal Circumference ( AC ),
Head Circumference(HC),
Femur Length (FL)
And the diagnosis of intrauterine growth retardation (IUGR) can also be made by serial measurement of amniotic fluid volume.
5) Repeat Investigations:
During the 28th week and 36th week of pregnancy, the hemoglobin level of the mother is repeatedly tested.
A urine test is done during every antenatal visit to check the amount of protein and sugar present in the urine.
Screening and Assessment for High Risk:
A pregnancy that has a risk of serious complications is considered a high risk pregnancy.
All pregnancies are evaluated to identify potential risk factors. By classifying pregnancies as high risk, if they require extra attention, they can be provided in an adequate amount.
Screening options are available to assess the risk for specific congenital anomalies during pregnancy and do not involve the risk of miscarriage.
If evaluation of high-risk women is done early, those high-risk pregnant women can be referred to a perinatal center before delivery, thereby reducing neonatal morbidity and mortality rates.
The most common reason for referral is preterm delivery, usually due to premature rupture of membranes.
A major benefit of screening and assessment of high-risk mothers is that early detection of any complications or problems in the mother and baby can lead to better outcomes in the health status of the mother and baby. And the mother can give birth to a healthy baby.
High risk cases like,
Obstetrical History:
privys steel berth,
Previous Neonatal Death,
Previous premature infant,
History of recurrent abortion.
Medical history of mother viz.
Maternal Illness,
chronic hypertension,
Abnormal PAP smear test,
insulin dependent diabetes,
renal diseases,
Rh- isoimmunization,
Maternal physical risk factors,
Incompetent cervix,
Uterine Malformation.
Risk factors of current pregnancy,
Moderate to severe preeclampsia (eg, hypertension, edema (weight gain), proteinuria (protein in urine), and albuminuria),
Polyhydroamnios (i.e. when the amniotic fluid amount exceeds 2000 ml),
Oligo hydroamnios (When the amount of fluid at term is less than 200 ml, it is called oligohydroamnios.),
Placenta previa (When the placenta partially or completely implants near or above the internal os of the uterus, it is called placenta previa).
Multiple pregnancy (when more than one fetus develops in the uterus simultaneously and at the same time, it is called multiple pregnancy).
Abruptio placenta (Abruptio placenta is a form of antepartum hemorrhage (APH) in which the normally situated placenta prematurely separates from the uterine wall and causes bleeding, called abruptio placenta.)
Other High Risk Pregnancies:
Abnormal fetal position,
vaginal bleeding,
malpresentation,
Fits are smaller than gestational age,
Hb level should be less than 10 g/dl,
Poor weight gain,
proteinuria,
glycosuria,
Systolic BP. Being greater than 155 mm of Hg.
Vaginal infection. etc.
Things to consider during early pregnancy are —
Blood testing in which mother’s hemoglobin level, ABO and Rh group and blood sugar level are monitored.
Excessive weight gain in the mother is usually due to fluid retention. And if the weight is decreasing in the mother, there is also a risk of developing the condition of intrauterine growth retardation (IUGR).
A previous history of hypertension or pregnancy induced hypertension (PIH) may be a risk factor in the mother as well as the fetus.
If the amount of amniotic fluid is high or if the amount of amniotic fluid is low, these are also called risk factors.
Another approach to be followed for high risk cases is as follows:
Maternal Serum Alpha Phyto Protein (MSAFP):
Alpha phytoprotein (AFP) is an onco-fetal protein and is produced in the yolk sac and fetal liver.
Peak levels in fetal serum and amniotic fluid occur around 13 weeks and in maternal serum around 32 weeks.
Maternal serum and amniotic fluid are tested for alpha phytoprotein (AFP). This is usually done when there is a risk of neural tube defects and other congenital defects in the fetus. If the level of Alpha Phyto Protein (AFP) is high then it indicates fitus pathology, open neural tube defect and if the level of Alpha Phyto Protein (AFP) is low then it suggests the condition of Down Syndrome and Gestational Trophoblastic Disease.
The amount of maternal serum alpha phytoprotein (MSAFP) is increased in some cases such as multiple pregnancy, open neural tube defect, renal anomaly, Rh isoimmunization, IUFD (intrauterine fetal death), anterior abdominal wall defect etc.
This test is done between 15 to 18 weeks.
Chorionic villus sampling (CVS):
For prenatal diagnosis of genetic disorders, chorionic villus sampling is taken transcervically at 10 – 12 weeks and transabdominally at 10 weeks under ultrasound guidance.
A small amount of fluid can be collected from the chorion frondosum, transcervically (a catheter is introduced through the cervix), or transabdominally (by inserting a needle through the uterine wall of the maternal abdomen into the placental tissue). Diagnosis is obtained within 24 hours.
The positive aspect of this test is that the results are obtained early, and if termination is required, it can be done only in the first trimester. This test is also associated with fetal loss, limb deformities and vaginal bleeding etc. In addition to miscarriage, there is a risk of infection and amniotic fluid leakage.
As a result amniotic fluid can leak which can develop into a condition known as oligohydramnios which is a low amniotic fluid level.
Timing of Test – After 10 weeks.
Cordosynthesis (percutaneous umbilical blood sampling):
In this test, blood sample of the fetus is collected during pregnancy and then any chromosomal abnormality or blood disorder is diagnosed. In it, under the guidance of ultrasound, the umbilical vein is punctured and the needle is inserted. And then 0.5 to 2 ml of fetal blood is collected. Preterm labor, abortion or intrauterine fetal death can be caused due to this test.
The time to do this test is after 18 weeks.
Triple Test:
In this test, a combination of three tests is done in which,
Maternal serum alpha-fetoprotein (MSAFP), human chorionic gonadotrophin (HCG), and unconjugated estrol (UE) are involved.
This test is used to detect Down syndrome.
If pregnancy is affected, maternal serum alpha phytoprotein (MSAFP) and estrogen levels are low and human chorionic gonadotrophin (HCG) levels are high.
Amniocentesis:
This is an invasive procedure usually performed at 16 – 18 weeks under ultrasonography guidance for cytogenetic analysis of fetal cells DNA analysis and biochemical tests of fluid.
In this procedure, a fine needle is inserted transabdominally into the amniotic cavity and aspiration of amniotic fluid is performed.
Procedure –
Before the actual procedure, a local anesthetic is given to relieve pain during the needle insertion used to withdraw the amniotic fluid.
Needle insertion is done through the abdominal wall of the mother and into the amniotic sac through the wall of the uterus.
Using ultrasound-guidance, the needle is guided to an area of the sac that is away from the fetus and approximately 20 ml of amniotic fluid is withdrawn for testing. Amniotic fluid contains cells that are shed by the developing fetus.
Cells are checked for the number and size of chromosomes (karyotype) to see if there are any problems that put the baby at risk for certain conditions. After the amniotic fluid is removed, the cells of the fetus are separated from it.
Cells are grown in culture medium, then fixed and stained.
Chromosomes are examined for abnormalities under a microscope.
This test detects most common abnormalities including mostly chromosomal disorders like Down syndrome, Edward syndrome (trisomy 18) and Turner syndrome, neural tube defects like spina bifida and anencephaly.
Hundreds of genetic disorders can be identified through this test.
Amniocentesis can also detect whether the mother or baby is Rh-negative and whether the baby’s lungs are mature enough for birth if immediate termination is needed. Amniosynthesis cannot detect every type of abnormality – for example, it cannot tell whether a baby has a cleft lip or a cleft palate.
Amniocentesis is performed during pregnancy when:
It is done to determine if a woman has previously had a chromosomally affected pregnancy or genetic disorder, has Down syndrome and other defects.
Chromosomal abnormalities detected by ultrasound examination may indicate an increased risk of developing chromosomal abnormalities.
When parents have a history of any genetic disorder or birth defect in the family.
In women who are older than 35 years.
Due to the request of a woman who is concerned about a chromosomal abnormality in her child.
Risks Associated with Amniocentesis:
Maternal and fetal haemorrhage,
infection,
fital injury,
Miscarriage.
During late pregnancy:
Biophysical
Biophysical investigations like fetal movement count, cardiotocography, non-stress test, fetal bio physical profile (BPP), Doppler ultrasound, contraction stress test (CST), amniotic fluid volume etc. are done for uteroplacental insufficiency.
Fittal Movement Count:
Cardiff Count 10 Formula:
In this, the patient starts counting the fetal movements from 9.am and stops when 10 movements are done, he is asked to inform the doctor if he does not have less than 10 movements within 12 hours in two consecutive days or no movement in one day.
Daily Fatal Movement Count (DFMC):
In this test, counting three counts in each period of morning, afternoon and evening and multiplying it by four, if it is more than 10 in 12 hours or less than three fetal movements in each period, then it is indicated that there is a problem with the fetus.
Diagnosis Modalities Invasive and Noninvasive:
Different invasive and non-invasive methods are used for prenatal screening and diagnosis.
•> In which non-invasive method (a method that does not require any instrument to open and insert inside the body),
•> Invasive method (a medical procedure that invades (enters) the body, usually by cutting or puncturing the skin or inserting an instrument into the body)
such as,
An ultrasound scan is generally a safe, non-invasive, accurate and cost-effective investigation. In an ultrasound scan, high frequency sound waves are transmitted into the uterus. In ultrasound, the baby’s bouncing off and returning echoes are translated by a computer into an image on a screen that shows the baby’s position and movements. Hard tissues such as bone reflect the greatest echoes and are white in the image, and smooth tissues appear gray and mottled. Fluid (such as the amniotic fluid that contains the baby) does not reflect any echoes and therefore appears black.
It is the difference between these different shades of white, gray and black that allows the sonographer to interpret the image.When scanning the abdomen in early pregnancy, the procedure often requires a full bladder.
•> Use of Ultrasound:
Fitus’ heart beats can be checked by ultrasound.
Usually before 14 weeks of pregnancy, when a woman is pregnant with a baby, ultrasound scanning is used to check if the fetus is live and if it is a single fetus or one of twins or triplets. is
It is used to detect any abnormality, such as a condition of ectopic pregnancy, in which the fetus implants outside the uterine cavity, mainly in the fallopian tube. .
Doppler ultrasonography measures the speed at which RBCs travel in the blood vessels of the uterus and fetus. This is helpful in determining whether vascular resistance is present in women with diabetes or gestational hypertension and consequent placental insufficiency.
Placental grading usually depends on the amount of calcium deposited in the placenta. Grading can be provided as
Amniotic fluid volume assessment
If the fetus is stressed in utero as the amniotic fluid decreases, the fetus is placed at risk of umbilical cord compression and thus interferes with its nutritional level.
At less than 20 wk, the uterus divides into two vertical lines along the midpoint (line nigra). The vertical diameter of the largest pocket of amniotic fluid present on each side is measured in centimeters (cm). The amniotic fluid index (AFI) is the sum of the two.
After 20 wk, the uterus is divided into four parts and the sum of four is taken. Average AFI: 12-15 cm (28-40 wicks); 5-6 (oligohydramnios), 20-24 (polyhydramnios).
Ultrasound helps the mother find the cause of any bleeding. In cases of vaginal bleeding, the viability of the placenta is measured by ultrasound.
Visible heart beats can be seen and detected by pulse Doppler ultrasound at about 6 wk and are usually clearly depictable (pictured) at 7 wk.
The exact date of pregnancy can also be known by measuring the baby. For patients with uncertainty of the last menstrual cycle, such measurements must be done as early as possible in pregnancy to arrive at a suitable dating. Measurements made are:
a) Crown-rump length (CRL):
This measurement can be done between 7 and 13 weeks and gives a very accurate estimate of gestation.
b) Biparietal diameter (BPD)
Diameter between 2 sides of head.
This is measured after 13 weeks. It went from about 2.4 cm at 13 wks to about 9.5 cm at term. increases up to
c) Femur Length (FL)
Measures the longest bone in the body and reflects the longitudinal growth of the fitus. Its utility is similar to that of BPD. It grows from about 1.5 cm at 14 wk to about 7.8 cm at term.
d) The Abdominal Circumference ( AC )
It is the single most important measurement to make in late pregnancy.
It reflects the size and weight of the fit more than the edge.
At 11-14 weeks the presence of Down syndrome can be detected by measuring fluid from the back of the child’s neck (called a nuchal translucency scan).
Some major abnormalities can also be detected in this stage. At 11 to 14 weeks, a measurement of the thickness of the skin on the back of the neck (known as a nuchal translucency measurement) can be used to measure the risk of a fetus having a chromosomal abnormality.
Some tests to assess the well-being of the fetus, such as CVS or amniocentesis, are performed safely with the help of ultrasound to show the position of the baby and the placenta.
After 18 weeks it is possible to examine the fetus in more detail. Examination of most organ systems can be performed to ensure that the development of the fetus appears to be occurring normally.
such as spina bifida. Many structural abnormalities in the fetus can be reliably diagnosed by ultrasound scan, and this can usually be done before 20 weeks.
Liker i.e. high or low amount of amniotic fluid can be clearly detected by ultrasound and both these conditions can adversely affect the fetus.
Ultrasonography is also important to detect the location of the placenta. Due to which any abnormal site of the placenta can be detected early such as placenta previa.
a) When intrauterine death is a conforming requirement.
b) To check fetal presentation in certain cases.
C) When there is a need to evaluate fetal movement, tone and breathing in the biophysical profile.
d) To diagnose uterine and pelvic abnormalities during pregnancy.
Ex: Fibromyomata, Ovarian cyst.
•> Ultrasound scan can be done both vaginally and abdominally
•Vaginal scan
A vaginal scan is only done during the first 12 – 14 weeks of pregnancy. Because the fit is very small at this stage, vaginal scan provides a better view compared to abdominal scan. In vaginal scan, the mother is asked to lie down on her back and then a lubricated sensor is inserted into the vagina. The sensor is usually covered by a condom.
•Abdominal scan
An abdominal scan is usually used after 12 to 14 weeks of pregnancy. In an abdominal scan, the mother is asked to lie on her back. A gel is applied to her skin over her lower abdomen. The gel allows the sensor to slide smoothly over the skin and helps produce clear images. The sensor is held firmly against his skin and moved over the abdominal surface.
•Doppler ultrasound
Doppler ultrasound is currently most widely used to detect fetal cardiac pulsations and pulsations in various blood vessels of the fetus. Further developments in Doppler ultrasound technology in recent years have enabled a great expansion in its application in obstetrics, particularly Assessment and monitoring of well-being of Curry Fits in keeping area,
Diagnosis of its progression is intrauterine growth restriction and cardiac malformation.
Karma ma faces.
Cardiotocography (CTG):
Cardiotocography (CTG) graphically records the fetal heart beat and uterine contractions.
It is generally done during the third trimester. The machine used for monitoring is called a cardiotocograph and is also known as an electronic fetal monitor (EFM) or external fetal monitor (EFM).
Two transducers are used externally by strapping to the abdominal wall. One measures the heart rate of the fetus and the other measures the contractions of the uterus.
Internal measurement can also be done. It requires a certain degree of cervical dilatation, as it involves inserting a pressure catheter into the uterine cavity and attaching a scalp electrode to the head of the fetus to adequately measure the pulse. It is preferred when there is a possibility of complicated birth. is Cardiotocography is also used to perform a non-stress test (NST) as well as a contraction stress test (CST).
Non Stress Test (NST):
Fetal well-being is evaluated by monitoring fetal heart rate (FHR) in response to fetal movement in the non-stress test (NST). Doing this test does not put any special stress on the fetus.
In the non-stress test, a belt is attached around the mother’s abdomen to monitor the fetus’s heart rate and uterine contractions.
Nonstress is a common prenatal procedure that is usually performed during the third trimester to assess fetal health.
The heart rate is recorded for about 20-30 minutes, during which time the mother indicates whether she feels any movement of fits. Short-term variation from baseline should be between 10 and 15 bpm. And if the variation with other abnormalities cannot be reduced for a long time, there may be fitous distress.
Purpose:
The primary goal of the NST (Non Stress Test) is to monitor the baby’s heart rate and assess how the fetal heart rate (FHR) responds to movement. It helps evaluate the well-being of the fetus and can provide insight into the baby’s oxygen levels and overall health. NST is usually used in cases where there are concerns about the health of the fetus or when there is a risk for complications.
Position and Preparation of Mother:
Non-Stress Stress (NST) is usually performed by providing the mother in a properly comfortable position. While performing this test, the fetus should not be in sleeping condition as it may lead to variation in fetal heart rate i.e. in fetal heart rate. A decrease may be observed. Fits are elicited by abdominal palpation or buzzing. Advise the woman to press the button when she feels fetal movement and monitor the fetal heart rate (FHR).
Advantages:
It is inexpensive and less time consuming.
Interpretation of Test:
Reactive Test (Normal Stress Test (NST)):
The test is considered reactive when the fetal heart rate (FHR) accelerates to 15 beats/min above baseline for 15-30 seconds in relation to fetal movement.
When there are two or more such events in a 10-minute period or five or more accelerations in a 20-minute period, the test is considered normal.
Non Reactive Test (Abnormal Non Stress Test):
A non-reactive test is performed when the fetal heart rate is absent in response to fetal movements.
When the fetal heart rate is less than 15 beats/min in response to fetal movement and lasts for less than 15 seconds, the test is called abnormal.
Suspicious non-stress test
These include an acceleration of the heart rate of the fit in relation to the movement of the fit, but the number of beats above baseline, or the length of the duration, does not meet the criteria for being reactive or non-reactive.
Indication of Non Stress Test (NST):
Women who have any pre-existing medical conditions like diabetes or conditions that arose during pregnancy like,
Have a condition of hyper tension.
When a pregnant woman reports that the fetal movement is less than usual.
Intra-Uterine Growth Retardation (IUGR) A condition in which a child does not grow properly at its normal age.
When the amount of amniotic fluid is too high or the amount of amniotic fluid is reduced.
In the condition that a woman has lost her baby in a previous pregnancy.
This test is performed to check the babbling of the baby in the condition that the pregnancy of the woman is continuous even after 40 weeks of pregnancy.
After a woman undergoes a procedure such as an external cephalic version (to turn a breech baby) or an amniocentesis in the third trimester (to determine whether the baby’s lungs are mature enough for birth or to rule out an infection of the uterus), the health care practitioner may A non stress test (NST) is done to ensure that the baby is well-being.
Contraction Stress Test (CST):
Contraction stress test
(CST) is used to assess the condition of the health of the fetus and the condition of the fetal heart rate (FHR) in women when the oxygen level of the fetus is reduced during uterine contractions. In this test, the fetal heart rate response to uterine contractions induced by oxytocin is assessed. External heart monitoring is done in this test. During uterine contractions, the blood and oxygen supply to the fetus drops for a short period of time. This condition is not a problem for most babies, but in some babies, their heart rate slows down. These changes in heart rate are monitored on an external fetal monitoring device. This test is usually performed when a woman is 34 weeks or more weeks pregnant.
Preparation of Mother:
In this, semirecumbent position, lateral tilt position, and properly comfortable position are provided to women. Uterine contractions are then recorded for 20 to 30 minutes. If the uterine contractions are three or more than three in 10 minutes and their duration is usually longer than 40 seconds, no stimulation is needed. If spontaneous stimulation is absent, stimulation is induced by providing oxytocin.
In the oxytocin challenge test, a diluted oxytocin solution is administered intravenously. Then increase the infusion rate at small intervals until three or more than three uterine contractions in 10 minutes are observed for more than 30 minutes, then stop the oxytocin infusion after recording.
Contraction stress test is done to check the condition of the following such as,
It is used to assess fetal welling and fetal heart rate (FHR) during the process of labor or during uterine contractions when the amount of oxygen is low.
Contraindications
If a woman has the condition of placenta previa,
Women have the condition of Antepartum Haemorrhage (APH),
Privus classic caesarean section is performed,
Clients who are at high risk of preterm labor
Risk
Labor can usually start early after the expected date of delivery.
Prolonged contractions can cause problems in the baby.
Interpretation:
The contraction stress test (CST) is used to assess the health status of the fetus due to reduced blood and oxygen supply to the fetus for a short period of time when the woman is in labor. is
Normal Contraction Stress Test (CST)
The result of a normal test is called negative. In which the baby’s heart rate is not low (decelerate). But after contraction (late decelerate) it is low.
Abnormal Contraction Stress Test (CST)
A positive result of abnormal contraction stress test (CST) in which the heart rate of the fetus slows down and remains continuously slow even after the contractions, means that problems can arise during normal labor in the fetus. It can also mean that
If there is a delay during the delivery time, the baby may have a problem.
Hyperstimulation
Contractions in hyperstimulation last 90 seconds or longer.
Suspicious
There is a late declaration of the fetal heart rate, but this is not repetitive and does not occur with continuous contractions.
Unsatisfactory
The quality of this recording is not that good.
Antenatal Health Education:
Antenatal education is provided to pregnant women during pregnancy.
Principals:
Health education is provided to the mother during pregnancy as follows:
1) A diet that also involves supplemental therapy
2) Antenatal hygiene
3) Rest and Sleep
4) Travel
5) Comfort measure
6) Coitus
7) Smoking and Alcohol
8) Avoidance of drugs
9) Immunization
10) Preparation for confinement
11) Child Care
12) General advice
13) Antenatal Exercise
Antenatal Diet:
Providing an adequate amount of diet to the mother during pregnancy maintains good maternal health and optimal fetal growth. Good food and optimum maternal nutrition are important for pregnant women. The first three months of pregnancy are very important as most of the baby’s physical and mental growth takes place during this time. Nutrition plays a very important role in maintaining a healthy pregnancy. Pregnancy is one of the most demanding periods for a woman, therefore, having a balanced diet becomes even more important. Adequate amount of nutrition provides strength required during labor and successful lactation. Adequate amount of dietary intake by the mother during pregnancy can reduce spontaneous abortion, still birth, and neonatal death as well as promote fetal growth.
Adequate antenatal diet is essential due to the following factors:
•Helps develop and maintain the strength and vitality required during labour.
During pregnancy time
Basal Metabolic Rate (BMR) increases due to increase in growth of maternal tissues, fetus and placenta due to which caloric requirement increases by 2500 kcal. A pregnant woman normally gains about 11 kg of weight during pregnancy.
Carbohydrate and Fat
Carbohydrates are essential for producing energy in the body. Adequate amount of carbohydrate intake is necessary during pregnancy. If carbohydrate intake is not done in adequate amount, the mother’s weight is not properly maintained, due to which complications may occur to the mother and the fetus.
Carbohydrate rich foods like rice, wheat, potatoes, sugar, fruits, etc. Fatty foods like butter, ghee, vegetables, oil milk, meat and eggs are included.
protein
A mother should eat a variety of protein-rich foods, as her needs increase during pregnancy. Vitamin B6 is essential for proper protein utilization. Fish, meat, nuts, peas, beans and dairy foods such as milk and eggs all provide protein. The daily requirement of protein in a pregnant woman is about 60 grams.
Minerals
Calcium, phosphorus, iron, zinc, sodium and iodine should be taken during pregnancy. Deficiency of these minerals can lead to complications and adversely affect the mother and fetus.
Important minerals such as calcium and iron are discussed below:
Iron:
Iron helps build bones and teeth and is responsible for the production of hemoglobin. Iron deficiency can cause the condition of anemia. In this case, iron supplements have to be taken once or twice a day. Eat more potatoes, raisins, dates, broccoli, leafy green vegetables, whole grain bread and iron rich foods. Iron-fortified cereals can prevent anemia.
Calcium:
The need for calcium is double its normal need during pregnancy. This is important for the healthy development of the baby’s bones and teeth, which begin to form at around 8 weeks. Milk, eggs, cheese, green vegetables are good sources of calcium. The recommended daily amount of calcium increases significantly from 800-1200 mg during pregnancy and breastfeeding.
Folic Acid:
Folic acid is one of the most important nutrients required during pregnancy. This is essential for the development of the baby’s nervous system, especially in the first few weeks. Folic acid helps prevent neural tube defects (defects of the spine, brain or their covering) and other congenital defects such as cleft lip and congenital heart disease. Folic acid supplements can be taken during pregnancy. Folic acid is found in dark green leafy vegetables (such as spinach or kale), liver, yeast, beans and citrus fruits, and fortified cereals and breads. Folic acid is easily lost during cooking; As seen after green vegetables are steamed or boiled.
The daily requirement of folic acid is about 400 micrograms.
Vitamins have a special role in the physiological state of the mother and fetus. So its daily intake should be increased.
Important vitamins in pregnancy are A, B, C, and D. So giving advice to women to intake vitamin rich diet.
Vitamin A
It improves vision and cell integrity which is obtained from vegetables, liver, and fruits.
Vitamin B
Vitamin B prevents the condition of anemia.
It is found in yeast, seeds, beans, nuts, dairy foods, and whole grains.
Vitamin C
Vitamin C is necessary for the structure of the placenta, it is also necessary to fight infection and is also useful in the absorption of iron. Its requirement is 70 mg/day. Its rich sources include citrus fruits, and vegetables.
Vitamin D
An important vitamin for maternal calcium absorption and calcium metabolism of the infant.
Vitamin E
It is used to prevent abortion.
Vitamin K
Prevents neonatal hemorrhage.
Fiber
Constipation is relieved by taking fiber in the daily diet.
Fruits, vegetables, brown rice, nuts,
Found in cereals, oats, beans, and pulses.
Antenatal hygiene
Daily Bathing:
Advise pregnant women to take daily bath to maintain personal hygiene but take proper care not to fall down due to imbalance while taking daily bath.
Dental Care:
Advise pregnant women to maintain good dental care and oral health and consult a dentist when necessary.
Breast care
Advising pregnant women on proper best care during the antenatal period so that breastfeeding can be promoted and lactase can be properly maintained during the postpartum period.
Rest and sleep
Usual activities can be done throughout the pregnancy but strenuous work should be avoided especially in the first and last trimester. A pregnant woman should sleep for a total of 10 hours including eight hours at night and two hours in the afternoon.
Advise the mother not to stay in one position continuously for long periods of time and advise her to keep her legs elevated while taking rest to relieve leg-to-heel pain. Advise the mother to sleep on the left side as far as possible due to which better blood circulation can occur.
traveling
Pregnant women should be advised that heavy and jerky traveling should be avoided in the first trimester and in the last trimester. Because chances of miscarriage are high during this time. Advise the woman to avoid traveling especially if there is a high risk of pregnancy.
Advising the mother to avoid air traveling after 32 weeks of gestation because the membrane of the uterus may be damaged due to air traveling and it may prove to be dangerous.
Advise women to avoid air travel in cases of placenta previa, severe anemia, and sickle cell disease.
Comfort measures
Advising pregnant women to wear loose clothes to relieve discomfort and provide a comfortable environment and advising women to avoid wearing high-heeled shoes.
coitus
Advising the pregnant woman to avoid sexual activity especially in the first and third trimesters because mostly there are chances of abortion in the first trimester and there are chances of infection in the third trimester so giving advice to the pregnant women to avoid coitus activity.
Smoking and Alcohol
Advise the mother that smoking is injurious to health, so smoking should be avoided during pregnancy because, if a heavy smoker, there are chances of the baby being small and there are chances of abortion as well if the mother is an alcoholic. In case of intake, advice should be given to avoid it as it can cause fetal maldevelopment and growth restriction. Thus, smoking and alcohol are harmful to health, so advice should be given to stop them.
Avoidance of drug
Drug intake should be done keeping in mind the possibility of reproductive asthma pregnancy as most drugs can cross the placenta to reach the fetus and many of the drugs have teratogenic effects which can harm the fetus. And women should also avoid intake of over the counter drugs.
During pregnancy, the mother should be advised to take folic acid tablets as prescribed.
radiation
Advise the mother to avoid abdominal X Ray during pregnancy as it increases the chances of developing leukemia or cancer in the fetus.
Family planning
Only when the mother is pregnant should she be educated and brought up to have small family names and a period between two children.
Immunization
Immunization of the mother for tetanus during pregnancy not only protects the mother but also the fetus.
Pregnant women should usually be given two doses of tetanus.
In which 1st dose is 0.5 ml.Intramuscular. Upper arm should be provided early in pregnancy.
2nd dose should be provided 1 month after vaccination of 1st dose of tetanus toxoid.
If the pregnant woman has been vaccinated with tetanus toxoid in the last three years of pregnancy, a booster dose of tetanus toxoid should be provided to the pregnant woman.
Live virus vaccines (rubella, measles, mumps and yellow fever) cannot be given to pregnant women, and rabies, hepatitis A & B, and toxoid can be given as in the non-pregnant state.
Preparation for Confinement
This includes properly collecting articles for mother and baby.
Providing education about signs for true labor to mothers.
Provide education to the mother about untoward symptoms and advise her to report immediately if any of these symptoms occur:
•Severe headache with disturbed sleep and restlessness.
Child care
Educating mothers on various aspects of child care like care during pregnancy, child bearing, best feeding, growth, development, immunization etc.
General advice
Advise the mother to come for proper checkup as per the schedule of prenatal visit, if excessive headache, dizziness, blurred vision, baby does not feel movement, sleep disturbance, restless ness, urinary problems, swelling on hands, feet and face. Inform health care personnel immediately if any symptoms occur.
Antenatal Exercise
Providing education to the mother to perform proper antenatal exercises as exercise strengthens the abdominal muscles and pelvic floor muscles due to which the labor process remains easy and exercise also helps in promoting recovery after child birth.
Antenatal Exercise
By doing antenatal exercises, the pregnant woman’s abdominal muscles and pelvic floor muscles are strengthened, due to which the labor process remains easy and the exercise helps in promoting recovery even after child birth. Being fit and healthy during pregnancy is important for the well-being of the mother and baby, which also means that the mother’s body should be properly prepared for labor, birth and the physical demands of the baby.
The benefits of exercise
•Increased endorphin hormone release leads to emotions.
Posture During Pregnancy:
Properly standing
Stand with weight spread evenly on both legs.
Keeping balance between heels and toes. When a mother has to stand in one place for a long time, she can put one leg forward and put all her weight on that leg for a few minutes. Then do the same with the other leg.
Sitting properly
Sit well in a chair with your back and thighs supported, legs slightly apart, feet flat on the floor. Use your leg muscles to lower and raise
Do not sit on the edge of the chair.
Picking up objects from the floor (Lichting) –
Move closer to the object. Sit down, bend your knees and keep your back straight. Hold the object in front of the body with elbows bent. Straighten slowly and smoothly into a standing position using the leg muscles. Bend the hips and knees, not the back.
Special Exercise
Walking
Walking is a good exercise and one of the best exercises for pregnant women as it does not put too much pressure on the knees and ankles. A pregnant woman can last up to nine months.
•> Abdominal exercises
This exercise helps strengthen the abdominal muscles, supports the back, and helps with pushing during childbirth.
Benefit:
Resisted knee to chest
Tell the woman to lie flat on your back, then keep your knees bent and your feet flat on the floor. Start with a pelvic tilt and then lift your head towards your chest and lift one knee towards your abdomen.Hold your leg below the knee using both hands. Using your leg muscles, try to push the knees toward your feet while your hands pull the knees toward your stomach. Hold for a count of 5, then release. Repeat on the opposite knee. Do these exercises first 5 times. And do up to 10 repetitions.
Timing for Resisted Knee to Chest Exercise:-
First trimester (1-3 months): This is usually a good time to do knee(s) to chest exercises if there are no complications.
Duration: – Generally safe till about 7th month of pregnancy After this, due to changes in your body and growing belly, consent of your healthcare provider should be taken for personal advice.
Straight curl-up exercise
Lie on your back with your knees bent and feet flat on the floor. Then keep your hands straight down slightly below the knees.
Exhaling, bring your chin to your chest and lean forward continuously for about 8″ (20 cm). Try to arch your back without raising your waist. Then roll back down.
Do this curl-up exercise first 5 times. Do it up to 10 repetitions. .
Time for Straight Curl-up Exercise:-
First trimester (1-3 months): Straight curl-up exercises are generally safe if you have no complications.
Duration:
Usually safe for about 5 months After this period, as your pregnancy progresses, straight curl-ups may become uncomfortable or impractical due to the growing belly (stomach) and changes in your body.
•> Pelvic Exercises:
Increases strength and elasticity which helps in bladder control and can also prevent the condition of urinary incontinence.
Pelvic tilt:
Advise women for the pelvic tilt exercise to be on your hands and knees with your head and back parallel to the floor. Tighten your stomach muscles and tuck your butt downwards to round out your lower back. Hold for a slow count of 5, then release. Don’t hold your breath. Repeat this pelvic tilt first 5 times. Then repeat 10 times.
Timing for Pelvic Tilt Exercise:-
Pelvic tilt exercises are usually done starting around the fourth month of pregnancy (16 weeks) and can be done safely up to the 7th month of pregnancy (28 weeks).
After this period, changes or alternative exercises may be necessary due to increased belly size and potential for discomfort.
Pelvic floor exercises
The pelvic floor muscles are under a lot of strain during labor and pregnancy. These muscle exercises help maintain muscle tone and quickly regain their previous strength after pregnancy. The main exercise performed here is the Kegel exercise
Kegel Exercise:
This exercise can be done anywhere, such as sitting, in the car, at someone’s desk, or standing in line at the store. This involves squeezing the urethral and vaginal openings, and tightening the pelvic floor muscles to prevent bowel movements. Similarly, the muscles are squeezed to prevent the flow of urine. These muscles are drawn into the muscle and this condition is maintained for a count of 10, then relaxed. It can be repeated up to 10 times.
Timing for Kegel Exercise:-
Kegel exercises can be started at any time during pregnancy, usually around the 4th month (16 weeks), and can be continued throughout the pregnancy, up to the 9th month (until delivery). These exercises help strengthen the pelvic floor muscles, which can provide benefits during labor, delivery and postpartum recovery.
•> Circulatory exercise
As we know venus return is less during pregnancy. Hence it can lead to varicose veins, edema etc. To prevent such complications, the following exercises are advised:
Foot and Leg Exercises:
Ask the mother to stay in sim sitting position and advise to support the legs. Bending and stretching of the ankles is done. After this the mother is asked to rotate both legs clockwise and counterclockwise. This exercise can be repeated many times.
Time for Circulatory Exercise:-
Circulatory exercises, such as leg and foot exercises, can ideally be started around the 4th month of pregnancy (16 weeks) and continued up to the 9th month of pregnancy (until delivery). These exercises are beneficial throughout pregnancy to improve blood circulation and reduce swelling.
Benefits
•> Breathing exercises
Knowing how to do deep breathing helps the mother during labor and also strengthens her abdomen.
Keeping the legs flat on the floor with the knees bent in a semi-sitting position, slowly breathing and contracting the abdominal muscles, then breathing out slowly and deeply relaxing the muscles, then doing natural breathing, repeating the deep breathing two to three times helps the mother in labor and the muscles. The strain also increases.
Time for Breathing Exercise:-
Breathing exercises can ideally be started around the fourth month of pregnancy (16 weeks) and practiced throughout the pregnancy, up to the 9th month (until delivery). These exercises help with relaxation, pain management and overall well-being during pregnancy and labor.
Benefits
•> Points to keep in mind while exercising:
Stop the exercise if you see the following signs like,
•Increased shortness of breath,
•Muscle weakness,
Pain and swelling in calf muscles,
Decreased fetal movement,
•Leakage of fluid from the vaginal area. etc..
Antenatal counselling
Antenatal counseling is an important part of antenatal care which starts from conception and continues till safe delivery with positive results without any complications. Antenatal counseling is the process of enabling the pregnant woman to know herself and her present condition and the possible changes during pregnancy so as to make a significant contribution to the solution of her own problem and to be able to make decisions for its solution.
Aim of Antenatal Counselling:
To bring about desire changes in the pregnant woman and her family for self-realization and to adjust in her physiology with the condition of pregnancy and adjust accordingly.
Providing assistance to solve problems through close personal relationships.
Objectives of Antenatal Counselling
Type of Counseling During Pregnancy:
follow up,
Appraisal Services,
Antinatal Care Important,
Immunization during antenatal,
Regular follow up visits,
Role of Mother During Pregnancy,
Importance of Institutional Delivery,
Incentives Available to Mother,
family planning,
Where to go for delivery,
Crisis Counseling
To promote family planning.
Provide information about the nearest Integrated Counseling Center and Health facilities and encourage her to join for Future Cervix.
By talking sympathetically to remove fear of the unknown and improve psychology by providing assistance in successfully passing the process of pregnancy and labour.
Counseling Process
Counseling involves personal interaction between the client with individual problems, which can be solved with help and education provided by the counselor. A counselor will help educate the situation and enable the pregnant woman to decide what is right for her in the current situation. Counselors do not suggest, command or force midwives to choose a specific course.
It provides education to women so that they can decide for themselves:
Counselors make rapport with pregnant women during home visits, antenatal clinics, immunization clinics or special contacts arranged for particular purposes.
Women should be advised to talk and express their feelings, fear and anxiety without any hesitation.
By encouraging the woman to analyze her motives, the midwife gains insight into her behavior.
Counseling is a very delicate undertaking that depends on personal feelings and private behavior, so the midwife would be wise to listen and observe carefully without interrupting.
A midwife should be friendly, intelligent and approachable. It should be neither critical nor judgmental.
The nurse explains different ways to problem solve or approach the midwife’s situation and helps the woman decide what is right for her and her unborn child.
Minor disorders of pregnancy and their management:
1) Digestive System:
Nausea and Vomiting:
Nausea and vomiting are very common in primigravida and especially in women when they wake up in the morning.
Hormones like HCG, Oestrogen, Progesterone are responsible for nausea and vomiting.
Nausea and vomiting are usually more common in primigravida and first trimester.
Management
Dietary changes
Advise the mother to take dry toast, biscuits, salty crackers and protein rich food when she wakes up in the morning.
Advising the mother to take food in small and frequent amounts.
Advising the mother to take low fat food.
Advise the mother to avoid fried food and spicy food.
Advise the mother to take proper antiemetic medication.
Constipation
Constipation is the most common problem in pregnancy. Constipation is mainly seen during the second and third trimester.
Constipation is due to the effects of progesterone, decreased bowel tone and mobility, decreased physical activity,
Due to intake of iron supplement,
Constipation occurs due to the pressure of gravid uterus on the colon.
Management
Advise the mother to take high fiber foods.
Advising mother to intake adequate amount of vegetables and fruits.
Advise the mother to intake 6-8 glasses of water throughout the day.
Advising the mother to fill a glass of water in the morning activates the bowel movement.
Advise the mother to take frequent, small, and low-fat meals.
Advising the mother to do regular exercise.
Advise mother to take milk of magnesia in small amount.
Acidity and heart burn
Acidity and heartburn are commonly seen during pregnancy due to relaxation of the esophageal sphincter.
It is usually more common in mothers during the second and third trimesters.
ACIDITY AND HEART BURN Mostly acidity and heart burn conditions are seen due to increase in progesterone level, decrease in size of intestine, and displacement of stomach due to enlarged uterus.
Management
Advising the mother to eat in small and frequent amounts.
Do not give advice or overeating to the mother.
Advise pregnant women not to sleep immediately after eating. Athletes should remain in a sitting upright position for 30 minutes after eating.
Giving advice to avoid fatty and spicy food.
Advise mother to sleep in reclining position with support of five to six pillows.
Advising the mother to perform tailor sitting exercises.
Advise mother to take antacid medication prescribed by health care personnel.
Bleeding from gums, glossitis and gingivitis.
Bleeding can occur due to increased blood supply due to high levels of progesterone during pregnancy.
Management
Advising the mother to use a soft toothbrush.
Advising the mother to maintain oral hygiene.
Advise the mother to take vitamin-B complex, green leafy vegetables, yeast, eggs and cheese.
2) Circulatory system
Dizziness and fainting
It is mainly caused by the relaxation of the muscles of the blood vessels due to the effect of progesterone.
It subsides due to increase in blood volume.
Later, the pressure of the gravid uterus on the inferior vena cava causes less blood supply to the heart.
Management
Advise the mother to sleep less on her back in the last month. And giving advice to the mother to avoid standing for a long time.
Giddiness (dizziness)
Dizziness can also occur during pregnancy and due to this, loss of balance and the possibility of falling are also more common.
It is usually due to cardiovascular changes during pregnancy and low blood sugar levels and can also be caused by anemia.
Management
Advise the mother to take adequate rest.
Advising the mother not to stay in standing position for long periods of time.
Varicose vein
The condition of varicose veins is usually more common during the second and third trimester of pregnancy.
Varicose veins mainly in the lower extremities and vulva develop during pregnancy and hemorrhoids in the rectum also occur due to obstruction of venous return by the pregnant uterus.
Management
Advise the mother to wear supportive shoes.
An elastic crepe bandage and elevating the limb while performing movement in the varicose vein provides release in the symtoms.
Giving advice to the mother not to stay in sitting and standing position for a long time.
After delivery, the condition of varicositis is relieved.
Complications like bleeding or prolapse are seen in hemorrhoids. Advise to use a small amount of laxatives to keep the bowels soft
Advise for local application of hydrocortisone ointment and replacement of prolapsed piles. Avoid surgical treatment as the condition reduces after delivery.
In ankle AD
Ankle AD usually occurs during the second and third trimesters.
It is usually vasodilatation,
Venous statis and uterine bellows are seen due to increased venous pressure.
Management
Properly marking the mother’s access to fluid is retention or how much weight is gained because fluid retention can also be caused by pregnancy induced hypertension (PIH).
Advise the mother to keep her legs elevated twice throughout the day.
Advising the mother to wear supporting stockings.
Advise the mother to avoid sitting and standing in one position for a long time.
As far as possible, pregnant women should not be given diuretics because the heel subsides on its own by resting and elevating the limbs.
Physiological ED or orthostatic ED does not require any treatment.
3) Musculo skeletal system
Becky
50% of the problem recurs during pregnancy.
Backache can occur during any stage of pregnancy but mostly occurs during the second and third trimester of pregnancy.
Backache occurs due to physiological changes such as joint ligaments laxity (relaxin and estrogen), weight gain, hyperlordosis, pelvis anterior tilt etc.
Another cause is faulty posture, high-heeled shoes, muscle spasm, constipation, and urinary infection etc.
Management
Advising the mother to take proper rest.
Advising mother to use correct body mechanism and improve body posture.
Advise the mother to keep the leg elevated while resting.
Advising the mother not to wear high heeled shoes.
Advise the mother to perform pelvic rocking and abdominal and breathing exercises.
A well-fitted pelvic girdle belt that corrects lumbar lordosis during walking.
Advising the mother to slip on a firm mattress.
Back muscle massage, analgesics and rest can reduce the pain caused by muscle spasm.
Leg cramps
Leg cramps usually occur during the second and third trimesters of pregnancy.
Leg cramps are usually caused by an altered calcium phosphorus balance.
And it can also be due to the pressure of the uterus.
Leg cramps may be more common at night.
Deficiency of calcium and vitamin B12 can also cause leg cramps.
Management
Giving advice to properly massage the legs.
Advise the mother to do regular exercise, specially advise to do walking.
Advising the mother to apply local hits where the leg is painful.
Advise for oral intake of vitamin B1 and calcium.
4) Genito-urinary system
Vaginal discharge
Vaginal discharge that occurs from the first trimester to the third trimester.
It is usually seen due to hyperplasia of the vaginal mucosa and increased mucus production.
Management
Advising the mother on proper cleansing and maintaining hygiene.
Advise the mother to wear cotton undergarments and to avoid tight undergarments.
If there is any condition of vaginal infection then apply vaginal application metronidazole and miconazole as per doctor’s advice.
Urinary urgency and frequency
During the 12th week of pregnancy due to the pressure of the uterus and during the 3rd trimester of pregnancy due to the pressure of the fetal head, the frequency of maturation is observed which is relieved after delivery.
Management
Advise mother to intake adequate amount of fluid during the day.
Advise the mother to have a limited amount of fluid intake in the evening time.
Advise the mother to void at regular intervals.
Advise mother to sleep in side lining position while sleeping at night.
Advise the mother to wear a perinatal pad if necessary.
Advising the mother to perform the eagle exercise.
5) Intangimetry system
Etching
Body itching due to stria gravidarum, poor personal hygiene, heat, race, minor skin diseases.
Management
Advising the mother for regular and daily bathing.
Advise the mother to apply calamine lotion.
Advise the application of talcum powder to provide a soothing effect to the mother’s skin.
Advising the mother to maintain proper hygiene condition.
6) Nervous system
Carpal tunnel syndrome
Fluid retention causes pressure in the ED and on the median nerve, leading to numbness in the mother and pins and needles sensation in the fingers and hands.
Management
Advising mother to increase salt intake in diet.
Advise the mother to keep her hand under the pillow.
Insomnia and headache
Insomnia and headaches are usually more common during the second and third trimesters.
Management
Bathing with warm water properly while sleeping at night.
Advise the mother to sleep in a total and well ventilated room.
Advise the mother to lie down in lateral position with the support of a pillow.
Advising the mother to share her anxiety and fear.
Thus, minor aliments and their management are as follows during pregnancy.