There are 65 questions on this last test. Here is the break down:
Antepartum: 10 questions. Know about TPAL, Nagel‟s rule, signs of pregnancy, toxoplasmosis, exercise, cultural considerations, warning signs in the first trimester, quickening, measuring fundal height, beginning signs of labor.
Common complaints of pregnancy (you know all those reasons women get pregnant!!): 4 questions. Know about N &V, constipation, leg cramps and heartburn
Nutrition (eating for two): 9 questions. Know how to assess for nutritional intake, absorption of iron, fluid intake, weight gain and calorie intake in pregnancy, protein intake and pica.
Screening tests: 5 questions. Know when to do the screening tests for NTD and Down‟s, how and when to screen for diabetes, (3 questions) and insulin changes in
Testing fetuses: 3 questions: NSTs, amniotic fluid volume, and amniocentesis
High Risk antepartum: 12 questions. Know about hyperemesis gravidarum,, risk factors for PTL, what tocolytics are used and how, major risk factor for a preterm infant, BP changes in pregnancy.
Bad stuff that happens earlier in the pregnancy: 6 questions. Know about hydatiform moles, the LMP question!, ectopic pregnancy, treatment options for ectopic, kinds of miscarriages.
Domestic violence: 4 questions: the effects abuse can have on a pregnancy, asking a question that facilitates disclosure of DV, our role in documenting. (I know we haven‟t covered this yet, but the questions are basic)
Contraception: 6 questions. What to do if a woman misses 3 birth control pills, emergency contraception timing, IUD risks, basal body temperature method, and general things you want to ask a woman when counseling her on a type of contraceptive (only 1 question).
STIs: 6 questions. Risk factors for STIs, complications of GC in pregnancy, most common bacterial and viral STIs, the STI health care providers are most at risk for getting (NOT a personal question!!), treatment for PID in pregnancy.
There are 65 questions on this last test. Here is the break down:
Antepartum: 10 questions.
Know about TPAL,
Gravida-pregnant woman; Para- number of pregnancies where the fetus reached 20 wks, or that have, “reached 20 weeks.” To say a woman is gravida 1, para 1, means she‟s
either had one kid or maybe triplets b/c you‟re counting pregnancies. Only says you carried a kid (or several at once) past 20 weeks.
What do the terms: G, T, P, A and L mean?
GTPAL= gravidity, term births; preterm births; abortions/miscarriage; living children
？ Gravidity: number of times pregnant, including a current pregnancy, no matter
what the outcome
？ Term: term births: with kids that cooked until 38-42 weeks gestation
？ Parity- number of pregnancies where the fetus or fetuses reached 20 weeks or
beyond. Outcome also doesn‟t matter here—if the kid was born term, preterm,
still born, etc. But if you had an abortion before 20 weeks, that wouldn‟t count in
the parity section. However, you can distinguish preterm births if you account for
all these numbers. When you start using GTPAL, it seems that “P” really means
？ Abortions/Miscarriages: whether intentional or not.
？ Living: kids still alive.
What would it mean if a woman was 3-0-2-0-3?
？ 3 pregnancies-0 term births-2 preemies-0 abortions-3 living children
Nagele‟s rule stHow long are ya pregnant? 280 days, 38-42 weeks, etc. Count from 1 day of LMP-
which is also ridiculous.
Describe Nagele‟s Rule. st？ Nagele‟s rule- from the 1 day of LMP subtract 3 calendar months, add 7 days
and 1 year OR add 7 days to LMP & count forward 9 months (assuming that she
has 28 day cycle)
If a woman‟s LMP was 10/23/07 what is her EDC, EDB or EDD?
？ LMP (last menstrual period): 10/23/07 (-3+7+01)
？ EDC (estimated date of confinement: means delivery date)
？ EDB/ EDD (estimated date of birth/ delivery) 07/30/08
Only 5% of women deliver on their Nagele‟s date.
Signs of pregnancy
How soon can an hCG be positive? What can interfere with the results?
？ hCG is: Human chorionic gonadotropin, begins secretion at conception, reaching
detectable levels by day 7-10.
？ It is the earliest biomarker for pregnancy
？ Detected as early as 7-10 days after conception; increases & peaks at 60-70 days
then declines at 80 days, remaining stabl until 30 weeks and then increases till
？ Higher levels: mean twins, abnormalities [like Downs‟ sydrome]
？ Low or decreasing levels may mean ectopic pregnancy, impending miscarriage.
？ Best urine collection: first of the morning.
Interference: doing the test too early; substance abuse or medications-
anticonvulsants & tranquillizers cause false-positive results, diuretics &
promethazine can cause false-negative results; Improper collection of specimen;
hormone producing tumors & laboratory errors= false results
3. What are presumptive and probable indicators of pregnancy? (I don‟t know why anyone cares with hCG tests being so accurate, but it is one of those old procedures that refuses to die. Kinda like clinical pelvimetry!) p 336- table 14.2
？ Presumptive indicator- changes felt by the woman- amenorrhea, fatigue, n/v,
breasts, peeing all the time, fatigue. Quickening [fetal movements].
o Other things: objective signs like abd enlargment, changes in vagina, striae
gravidarum, dark areola, linea nigra, chloasma [pregnancy mask].
？ Probable indicators- observed by examiner- still aren’t perfect positives [like a
pregnancy test isn‟t always right]
o uterine enlargement
o Pregnancy test (Hcg)
o BH ctx
o Uterine soufflé: sounds like a murmur in your uterus on ascultation, from
increased blood flow.
o Ballottement (A method of diagnosing pregnancy, in which the uterus is
pushed with a finger to feel whether a foetus moves away and returns
o Goodell Sign: softening of cervical tip @ 6wks in normal unscarred cervix;
from increased vascularity, slight hypertrophy & hyperplasia= loose,
edematous, elastic, increase in volume & looks velvety
o Chadwick Sign: @ 6-8 wks- increased vascularity gives violet-bluish color
of cervix & vaginal mucosa
o Hegar sign @ 6 wks softening & compressibility of uterine isthmus=
exaggerated uterine anteflexion= gotta pee q 15”
Positive indicators- presence of fetal signs- heartbeat, palpating or seeing fetal movement, US images
Why isn‟t Hcg a positive sign of pregnancy? It‟s not perfect, and it can indicate a molar pregnancy.
What‟s a TORCH screen?
TORCH infections can affect a pregnant woman and her fetus. Toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes form a collection of organisms capable
of crossing the placenta and adversely affecting fetal development, are teratogenic, and/or could cause miscarriage. Generally, all these organisms produce flu-like
symptoms in the mother, but more severe fetal and neonatal effects.
？ Toxoplasmosis: protozoal infection associated with the ingestion of infested raw or undercooked meat and with poor hand washing after handling infected cat litter, also loves infecting pregnant women. Miscarriage may occur. Treatment with
medications are potentially harmful to the fetus, but worth the risk. ？ JK From lecture: toxoplasmosis lives in cat feces—it‟s a virus (she‟s wrong),
it survives cat guts. Prenatal teaching is good here, you don‟t want mom stgetting the virus for the 1 time during pregnancy (probably also wrong)—stcauses CNS/learning, hearing, visual disabilities. If you get infected in 1 tri, rd30% of babies are affected, but in 3 tri 60% affect, so that‟s backwards from
the norm. Most people are already immune to it. It‟s airborne after about 3
days in feces, so don‟t inhale. Also wear gloves when gardening.
？ Other: Hepatitis, GBS, Varicella, and HIV (text). gon, syph, chicken pox, heb b, HIV, 5ths disease (lecture).
？ GBS: common vag flora, causes neonatal pneumonia,
？ Gonorrhea: blindness in kiddo
？ Chlamydia: causes blindness in neonate just like gonorrhea, in pregnancy
infection is assoc with miscarriage, stillbirth, PTL, PP endometritis.
？ Syphilis: Can cross placenta or transmit by lesion on vagina during
delivery. Results in stillbirth, infected babes will have neuro problems just
symtpoms may appear at birth, or like tertiary syphilis, and lesions etc—
within 2 year of life…some not until they are 20 yrs old! We test people stin 1 tri and high-risk people later on too. Need to treat and follow w/
serial syphilis tests if mom‟s got it.
？ Varicella; less of this lately, but in tri 1 can cause fetal demise, also IUGR,
limb and eye and neuro abnormalities.
？ Hep B: liver thing, pretty much vaccinating all kids for it. Doesn‟t cause
malformations or stillbirth, but does cause PTL/PTB.
？ HIV: in pregnancy: can get passed to the baby and they can die. Rapid
HIV screen is being used when admitted to L&D. Mom has to be treated
during pregnancy b/c it passes the placenta—this treatment works really
well. Most cases occur at or near time of delivery—C/S for women off
meds helps decrease transmission. Also transmitted through lactation.
You get little kids w/ HIV and opportunistic infections, etc.
？ 5ths: parvo-virus, carried in daycare by children, get generalized rashes, or
the bitch-slap rash on the face. Causes trouble before 18 weeks.
？ Rubella: transmitted by droplets. Rash, muscle aches, joint pain, and mild lymphedema. Miscarriage, congenital anomalies, and death occur in fetus.
Vaccination of a pregnant woman is contraindicated due to live vaccine. Postpartum vaccine is given with instructions to use contraception for at least 1 month after.
？ CMV: similar to mono, transmitted by close contact or body fluids and placental tissues. 60% of pop is immune to it already. Fetal infection can cause microcephaly, IUGR, eye, ear, and dental defects, and mental retardation and a crazy purple spot rash. No treatment is available during pregnancy.
？ Herpes simplex. 2 kinds, 1 and 2, used to say 1 was above the waist, but now we
know that‟s really not true. H1 is not as bad as H2 for fetus or grownups—I call
HSV2 “herpes not-so-simplex. Primary herpes is bad for fetus, is the first infection, stusually a systemic infection: if 1 tri, the baby will die. If after tri 1, she‟s at risk for
SGA and preterm labor, can have encephalitis. For women who have secondary
infection, at about 36 weeks we recommend women will use prophylactic antivirals to
prevent shedding so she doesn‟t have a lesion at delivery. Some hospitals will cut a
CS if she‟s got an outbreak, others will deliver vaginally and treat baby with IV anti
Kegels are good for strengthening pelvic floor, improves stretching and contraction at time of delivery. Also helps prevent PP urinary incontinence and improves sexual gratification. Deliberate contraction & relaxation of pubococcygeus muscle: strengthens muscles of pelvic floor: vagina & urethra
Physical activity promotes circulation, relaxation, counteracts boredom, helps w/ low back pain esp in 2tri. Weight bearing exercise isn‟t so good, but swimming, cycling, and stretching, and walking are best. Exercise a little every day to create stamina—30 mins.
Don‟t push it—decrease your activity as pregnancy progresses. Lay on your side for 10 mins to relax after workout. Other stretches to prepare for delivery include squatting stretches.
Cultural stuff on exercise: different groups have different ideas: Filipinos encourage women to do nothing but incubate the kid, some asian and native Americans keep her at work until near delivery. In Japan, I understand women are not allowed even near sewing machines and often live at mom‟s during pregnancy doing little activity.
Prenatal care as we know it is a US phenomena that is radically foreign to many moms. Some women are more modest—and need female care providers. Some think doctors are
for sick people, not pregnant people.
Each culture has its prescriptions and proscriptions about prenatal care—you should
know them for your clients. These include diet, sex, exercise, etc.
Food: You can gain the same amount of weight in pregnancy eating good foods or bad foods—one mom will be healthier. The kid gets what you give it.
The Hispanic paradox: Latina women tend to fall in lower SES, but their pregnancy outcomes are often as good or better than Caucasian women‟s. There‟s something about the diet that really works. Unless we‟re talking Latina women who are DM. It‟s also strdndoften 1 generation Latinas and 3 gen Latinas that do well, but the 2 gen are into
McDonald‟s and stuff.
Warning signs in the first trimester
Common discomforts of pregnancy: think about these and then look for some w/
pathological [bad] reason that‟s causing them.
Box pg 399 says panic if:
Tri 1; severe n/v [hyperemesis grav], chills/fever and or diarrhea [infection], burning on peeing [UTI], abd cramps/vag bleedeing [miscarriage, ectopic pregnancy]. I add heartburn b/c of HELLP.
？ Other times to panic: vag bleeding, alteration in fetal movements, symptoms of
What is quickening?
？ First recognition of fetal movement “feeling life”; multi- 14-16 wks; nulli- 18 +
wks. multips feel it at 14-16 weeks, primips 16-20 weeks. If no quickening by 22
weeks there‟s a problem.
Measuring fundal height
4. How is fundal height measured (also called McDonald‟s measurement)? P398
？ Uterine enlargement- to estimate duration of pregnancy; w/ paper tape, have her
empty her bladder, upper border of symphysis pubis to upper border of fundus w/
tape measure held in contact with the skin
6. About how many weeks pregnant is a woman if her uterus is at her umbilicus (considering she only has one fetus and everything is normal)?
？ @ 22-24 wks (text pg 336)
9. If a woman is 28 weeks pg, what will her fundal height be (check out ATI and p. 398 in text!)?
？ 28 cm @ 28 weeks. From 18-32 weeks, the fundus is at the same height in cm
as the woman is in weeks!
At 15 weeks pregnant: somewhere between symphysis pubis and umbilicus
20-22 weeks fundus is at umbilicus (picture)
Beginning signs of labor.
(signs of preterm labor pg 416): tightening of the fundus that can be felt with a hand on the abd., see if ctx continue while laying down over 1 hr to r/o Braxton-hicks ctx—not
normals to have ctx 1-10 mins apart for an hour pre-term, that‟s when you should call.
Sign of preterm labor: “Do you have a „balling up‟ feeling in your lower abd?” That‟s
a really predictive question/sensation for preterm
？ Signs preceeding labor [pg 459]: lightening, low backache, brax-hix ctx that are
strong but irregular, bloody show, PROM, weight loss of 1 kg caused by water loss
and peeing like crazy, surge of energy [and corresponding nesting], 5. What is lightening?
？ Btwn 38 & 40 wks, fundal height drops as fetus begins to descend & engage
(nullipara 2 wks before onset of labor; multip- lightens at the start of labor).
Called lightening because you have more room to breathe [literally.] 8. When do Braxton-Hicks contractions commonly occur? (p337)
？ After 4 mos- ctx are felt in abdominal wall. Good b/c: they assist uterine blood
flow thru intervillous spaces of placenta & oxygenates fetus; usually stop with
exercise/walking; mistaken for true labor (but they don‟t increase in intensity or
frequency or cause cervical dilation). Not painful, not regular.
Common complaints of pregnancy (you know all those reasons women get pregnant!!): 4 questions. Know about N &V, constipation, leg cramps and heartburn
N/V: all of these on pages 412-415 in a nice table!
？ Happens in 50-75% of women esp in tri 1. Cause unknown, may be from hormones
or HcG. Could lead to alkalosis. Old wives‟ tale says it‟s from ambivalence about
？ Whaddydo for a mom w/ n/v in tri1: peppermint, ginger, acupressure bracelets, salty stcrackers esp when you 1 wake up. Graze and eat small meals. Try not to eat and
drink at the same time. Call MD if it‟s really really bad.
Heartburn: Heartburn is d/t a lack of room, but it could indicate HELLP.
18. Why do pregnant women get heartburn (other than HELLP!!)
？ Incr progesterone causes less tone & motility of smooth muscles = esophageal
regurgitation, slower emptying time of stomach & reverse peristalsis = acid strdindigestion/ heartburn/pyrosis. Starts at 1 trim & intensifies through 3. Let‟s
hear it for Jessica Ezra, my dear friend who‟s pregnant and whose heartburn
started early and still has not let up.
？ Why does progesterone do that? It relaxes all smooth muscles and aids in
？ Good news: More estrogen production causes less hydrochloric acid secretion=
no more peptic ulcer formation or flare up—these women often get relief from
symptoms during their pregnancies.
？ What to do: eat simple foods that aren‟t spicy or fatty, small meals, good posture,
sip milk, hot herb tea, maybe an antacid, do call MD to r/o HELLP. Leg cramps/gastrocnemius spasm
？ Due to compression of nerves supplying lower extremities b/c the big ol uterus is
sitting on them. Or low calcium b/c your fetus is eating all of it trying to build a
whole new skeleton. Or high phosphorus. Or poor circulation, or pointing toes when
stretching or walking, or from drinking more than 1 L of milk a day. What? ？ What to do: check homan‟s sign to r/o clots, then use massage and heat pad. Stand on
a cold floor? What? Oral supplementation of Ca+ per MD, get rid of excess
phosphorus by eating aluminum gel [that‟s weird].
？ Same thing as heartburn: ?constipation (hypoperistalsis) due to progesterone slowing
things down and relaxing smooth muscle, also mom eating iron supplements, etc.
Does make her absorb more water, but also makes hemorrhoids worse. ？ Do this: drink a ton of water, incr fiber, moderate exercise, make a regular schedule
for BM, relax. Call MD for laxitive, stool softener, enema, etc.
Nutrition (eating for two): 9 questions.
Why care about prenatal nutrition? LBW and preterm kids, and neural tube defects are really weird looking/lethal.
Why do you need so much of this stuff? The growing kid, placenta, boobies, uterus, incr blood volume w/ more plasma and RBC‟s, and women‟s metabolic rate is up by 20%.
Nutrient: Amount Source: Significance
46 g Amino acids are the building blocks; synthesis
?+25g Meats, eggs cheese, yogurt, of products of conception, growth of maternal Protein: (during legumes, nuts & grains tissue & expansion of blood volume, secretions
pregnancy) of milk protein during lactation
Milk, cheese, yogurt, sardines, deep Skeletal development & tooth formation; Calcium: 1300 <19yo green vegetables, tofu, baked beans, maintains material of bone & tooth (mg) 1000 19-50 tortillas mineralization
25-35% of Olive or flax oil, fresh nuts and To absorb fat soluble vitamins A,D,E,K Fat: (mg) caloric intake seeds, avocados Anti-oxidents, cellular protection
Folic Fortified cereals & grains, green Prevents neural tube defects- spina bifida &
acid: 600 leafy vegetables, oranges, broccoli, anecephaly; supports increased amount of
(mcg) asparagus, artichokes, liver maternal RBC formation
Iodine: Iodized salt, seafood, milk products, 220 Increased maternal metabolic rate (mcg) yeast breads, donuts
Iron: Liver, meats, whole grains, deep Maternal hemoglobin formation, fetal liver 30 (mg) green vegetables, legumes, dried fruit iron storage
Expands blood volume; Facilitates exchange
Water, beverages, frozen desserts, of nutrients & wastes; Milk secretion; Regular Fluids: 3 total; 2.3 fruit, fresh vegetables (especially bowel function; Substance of cells blood, (L) in beverages lettuce) lymph, amniotic fluid; Maintains body
1. What vitamin is crucial in the prevention of neural tube defects?
？ Folic acid- synthesized ~folate- found naturally in foods [liver, beans, dark green
veggies, wheat germ [whole wheat products] etc.
Know how to assess for nutritional intake
Lecture; How do you know if someone is eating well? You ask them what they ate in the last 24 hours. Ask her about water and protein. Ask her what she‟s allergic to and what she does and doesn‟t like to eat. You can‟t talk anyone into eating liver if they just don‟t like it. Also figure out how she gets to a decent market to get well priced food, how much she has to pay for food, what kind of shop n‟ robs are in her neighborhood and if they have produce. How many buses is she away from a Safeway?
Absorption of iron
Iron is best absorbed by the body in combination with Vitamin C—found in citrus,
strrawberries, melon, tomatoes. Heme Iron in meats is easy to absorb. Bran, tea, coffee, milk, egg yolk, oxylates [in spinach and swiss chard] decrease iron absorption—so don‟t eat them with your iron vitamin
Iron is best absorbed w/ empty stomach, so take it btwn meals. Bedtime works too if you get pukey btwn meals.
Don‟t double dose one day if you forgot to take it yesterday.
Might make your poop green or black, might make you constip. Eat your fiber!
Liver, Iron: Maternal hemoglobin formation, 30 mg meats, (mg) fetal liver iron storage whole
4. Why is an adequate supply of iron such a big deal? (p362)
？ Required for expansion of maternal RBC mass & transfer of adequate iron to
？ 10% of nonpregnant women are iron deficient. Women w/ iron deficiency are
unable to handle hemorrhage at time of birth & are at risk of preterm birth &
LBW (most common problem in teenagers, black moms, & lower socioeconomic
？ Overdoing iron: puts women at risk of gest DM st？ Recommend 30 mg of iron after week 12 [most women have too much n/v in 1
tri] and plenty from food.
Which vitamins and mineral require the greatest increase in pregnancy? Any change in requirements on p. 356-357 that surprise you?
？ Iron, Zinc, folate, iodine, vit C, B Surprise was incr. in iodine otherwise not 6 .
really surprising at all.
？ 8-10 glasses/ day
？ keeps away constipation, helps exchange of wastes/nutrients
Water, Expands blood volume; Facilitates beverages, 8-10 exchange of nutrients & wastes; frozen glasses/ 3L Milk secretion; Regular bowel Fluids: desserts, total; 2.3 function; Substance of cells blood, (L) fruit, fresh in lymph, amniotic fluid; Maintains vegetables beverages body temperature. Prevents (especially cramping, ctx, and preterm labor lettuce)
weight gain and calorie intake in pregnancy
2. What is an adequate weight gain? What influences "adequate?"
？ It‟s not known precisely. Adequate weight gain is 11-14kg (25-35lbs); Adequate
nutrients & calories to avoid (SGA) & maternal/ fetal risks in pregnancy
？ better mom be nutritionally sound & neither over or underweight before
becoming pregnant. Bad things happen if you gain too much or too little weight
o Normal weight and skinny moms: risk for IUGR, SGA
o Overweight moms: risk for big kid and instrumental birth, PPH, gest DM,
2) The need for calories: Increases to an extra 340- 462 per day
a) How many calories does a pregnant woman need a day: At least 2,500 kcal. b) A pregnant woman should never eat less than _1,800_ calories a day. c) What is the current recommended weight gain during pregnancy?
For singleton pregnancies in normal mommy:
？ 25lbs (11.3kg)- 35lbs (15.9kg) overall. st？ 1 trimester, up to 4lb (1.8kg), ndrd？ 2 & 3 trimesters 1lb (0.5kg) per week
For singleton pregnancies in underweight mommy:
？ 12.5-18 kg (28-40 lbs)
For singleton pregnancies in fat mommy:
？ 7-11.5 kg (15-26 lbs)
For singleton pregnancies in adolescent mommy:
？ Gain close to 18 kg (40lbs) b/c teen’s growing body and growing baby
compete for food.
？ It is the nutritional element basic to growth of fetus, uterus, placenta, boobies, blood,
etc. Find it in animal products, legumes, grains, nuts. Most Americans overeat
protein and no increase is usually needed. Teens, underweight women, impoverished
women, and vegetarian/vegan/macrobiotic people need good education and resources.
Meats, Amino acids are the building eggs 46 g blocks; synthesis of products of cheese, ?+25g conception, growth of maternal Protein: yogurt, (during tissue & expansion of blood legumes, pregnancy) volume, secretions of milk protein nuts & during lactation grains
5. What is pica?
？ Cravings for non nutritional food substances or excessive amounts of crap.
7. What are some indications we get that women are not eating an adequate diet during pregnancy (this is a summary question... reflecting on what you gleaned from this chapter!)?
？ Optimal maternal nutrition = optimal foundation for supporting fetal G&D
？ Indicators of poor nutrition: anemia, N/V, pica, small for gestational age or
intrauterine growth restriction, preemie
Screening tests: 5 questions.
Know when to do the screening tests for NTD and Down‟s,
？ NTD is a: CNS anomaly d/t incomplete closure of the neural tube.
？ Causes: genes, ETOH, valproate [anti convulsant], methotrexate [chemo], mom is too
hot [like febrile, hot-tub,] folic acid deficit, 30% of folic-acid resistant pregnancies.