NORMAL OB by Gasco

Broad Ligaments wing like from lateral margins of uterus & pelvic walls divides the pelvic cavity into anterior & posterior compartments envelops the fallopian tube, ovaries, renal & ovarian ligaments Round Ligaments holds fundus forward attached either sides of fundus below the fallopian tube Uterosacral Ligaments cordlike structures, extends from posterior cervical portion to the sacrum aids in supporting the cervix Cardinal Ligaments

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materials move from the embryo- process called as anabolism & catabolism serves as the fetal lungs, kidneys, GIT & as a separate endocrine organ throughout pregnancy maternal blood reaches the intervillous spaces through coiled or spiral endometrial uterine arteries the rate of uteroplacental blood flow in pregnancy increases from about 50ml/min @ 0wks to 500600ml/min @ term by the 3rd wk O2 & other nutrients e.g. glucose, amino acids, fatty acids, minerals & vitamins diffuse the maternal blood through the cell laters of the chorionic villi to the villi capillaries mature placenta has: o 30 cotyledons- @ maternal side o looks rough & uneven o fetal side- steel blue covered adherent amion.

united to the supravaginal portion of the cervix connected to the lateral margins of uterus & encloses uterine vessels Fetal Circulation Placenta Umbilical Veins Liver, sinusoids, Hepatic veins Inferior Vena Cava Ductus Venosus Superior Vena Cava atrium Right atrium Right ventricle atrium Lungs Pulmonary Artery Ductus Arteriosus Aorta Hypogastric Arteries 2 umbilical arteries Placenta Note: Patent ductus arteriosus produces machinery like sound Decidua (3 Separate Areas) 1. Decidua Basalis- part lying directly under the embryo or the portion where the trophoblast cells are lysing maternal blood vessels 2. Decidua Capsularis- portion that stretches or encapsulates the surface of the trophoblast 3. Decidua Vera- remaining portion of uterine lining Chorionic Villi Right Foramen ovale Left Left ventricle

Endocrine Functions of the Placenta 1. HCG a glycoprotein, solely of placental origin, it is produced in the Syncytial layer & Langhans layer of the chorionic villi

placent @ 40th -100th day of pregnancy

Purpose: pregnancy testing acts as a fast safe measure to insure that the corpus luteum of the ovary continues to produce a sufficient quantity of progesterone. 2. Estrogen produced by the Syncytial cells of the placenta it contributes to the mammary gland development in preparation for lactation & stimulates the uterus to grow to accommodate the developing fetus. it is excreted by the mother in uterine estriol test of fetal welfare because the immediate precursor of estrogen synthesis by the placenta is as steroid produced by the fetal adrenal gland. when a fetus is I difficulty of breathing the fetal adrenal steroid is decreased then estriol is decreased 3. Progesterone necessary to maintain the endothelial lining of the uterus induction of quiescence of the uterine musculature during pregnancy w/c prevents premature labor this quiescence is produced by a change in electrolytes w/c decreases the contraction potential of the uterus urine formed- Pregnanediol. 4. Chorionic Somatomamotropin it fnx to promote mammary gland growth in preparation for lactation in the mother 5. Relaxin softens cartilage in the pelvic joints & symphysis pubis promotes relaxation of pelvic ligaments & connective tissues Umbilical Cord the chorionic villi joins together into larger & larger veins & arteries till they form the umbilical cord 21in in length; 2cm thick 1 vein & 2 arteries no nerve supply bulk of the cord is genlatinous substance- whartons jelly smooth muscle is abundant in the arteries of the cord; the constriction of these circular muscles after birth & the presence of prostaglandins contributes to hemostasis & helps prevent hemorrhage of th newborn through the cord rate of blood flow=100-130mg/kg of body wt/min Membranes & Amniotic Fluid 1. the amniotic fluid is produced from the cells of the amniotic membrane at a rate of about 500ml/24hrs

forms on the 11th or 12th day. 200 chorionic villi formed at term. have a central core w/c contains fetal capillaries Syncytial layer- outer covering- instrumental in the production of various placental hormones Langhans layer- inner layer- the cells protect the growing embryo & fetus from certain infectious organisms e.g. syphilis.

Placenta 1. transport mechanism between embryo & mother through w/c nutrients pass to the embryo & waste

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the fetus swallows the fluid at a rapid rate & it is absorbed across the fetal intestine into the blood stream & exchanged across the placenta if the fetus is unable to swallow (as in atresia, anencephaly) hydramios results (1,500ml)

Placental Transfer is Affceted by 5 Principal Mechanism 1. Diffusion- e.g. as across a membrane, allows passage of O2 CO2 anesthetic gases, water, electrolytes & other substances of low molecular wt. 2. Selective Transfer- often by enzymes action results in the passage of glucose, amino acids, calcium, iron & other substances of molecular wt. the concentration of material on the maternal side is than that of the fetal side. Transfer is w/o the use of energy. this mechanism is carrier mediated (transferred by cellular elements through the membranes). 3. Pinocytosis- mechanism by w/c minute particles may be engulfed & carried across the cell including fats & protein. 4. Leakage- as a result of small defects in the trophoblastic surface allows slight mixing of maternal or fetal blood cells & plasma. this process is responsible for sensitization of Rh(-) woman carrying Rh(+) fetus 5. Bulk Flow- involves the transfer of substances by hydrostatic or osmotic gradients through micropores in the membrane. this mechanism is important in maintaining maternal- fetal exchange of water & dissolved elecrolytes.

actively formed on the 3rd & 4th wk of life while nerve tissues is developing rapidly, the embryo requires a vast quantity of glucose. accrdg to one theory, this is why morning sickness occurs. the embryo takes glucose from the maternal blood stream, leaving the mother w/ a mild hypoglycemia of w/c nausea is one manifestation GIT

6wks- abdomen is too small to conatin the intestine, & a portion of the intestine enters the base of the umbilical cord. if the intestinal cord remains outside the abdomen- omphalocele develops meconium forms 5-8thwks.

Skeletal System 3rd wk- ossification of bone continues all throughout life. tissue begins. it

Genital System 6wks gonad form Respiratory System

3rd wk of life- the respiratory & digestive tract exist as a single tube 4th wk- the septum begins to divide the two systems. lung buds appear on the trachea 6th wk- lung buds may extend down into the abdomen reentering the chest, only as the chests longitudinal dimension increases & the diaphragm becomes complete (end of 7th wk) diaphragmatic hernia results if the diaphragm fails to close. (Sx: stomach flat, chest bulges) alveoli begin to form between the 26th-28th wks. both alveoli must be developed before gas exchange can occur in the fetal lungs. that is why 28wks is a practical lower limit of prematurity on the earliest gestation age at w/c a fetus can survive in an extra uterine environment 6th month- alveoli secretes surfactant. lack of surfactant results to hyaline membrane disease. surfactant (lipoprotein) act as wetting agents that prevent alveolar walls from sticking together. Lecithin lubricates alveolar surfaces so that they can remain open on expiration following birth. Lecithin is compared to powdering rubber gloves so that they do not stick together

FETAL PHYSIOLOGY Primary Germ Layers 1. Ectoderm germ layer that lines the wall of the amniotic cavity develops into the nervous system, skin, hair, nails, sense organ, anus, mouth, mucous membranes 2. Entoderm

layer of cells that line the yolk sac. in human reproduction the yolk sac appears to supply nourishment only until implantation. it then provides a source of RBC the embryos hematopoietic system mature enough to provide fnx. develops into lining of the GIT, respiratory tract, tonsils, parathyroid, thyroid, thymus gland & bladder & urethra Zygote morula blastocyte fetus 1-2days3-4days 6-8days 2mos-birth embryo 2nd-8wk

Urinary System

12wks- urine is formed & excreted on the 4th month fetal urine is excreted at a rate of 500ml day on the placenta Hepatic Fnx

Liver Fnx- begins on the 4th wk after conception

Hematopoiesis starts on the 6th wk of intrauterine life. this activity is primarily responsible for rapid growth & relatively large size of the liver during the 2nd month of gestation production of fetal liver enzyme is limited Reproductive System

3. Mesoderm responsible for formation of the supporting structures of the body (connective tissue, bones, cartilage, muscles, tendons, upper portion of the urinary system, kidneys, ureters, the reproductive system, heart, circulatory & blood cells) Cardiovascular System Heart

12th wk external genitals are well developed it is the high level of maternal estrogen that stimulates the fetal endometrium the rapid drop in maternal estrogen in fetal circulation is followed by withdrawal bleeding

begins to form- 16th day of life begins to beat- 24th day septum that divides the heart into chambers develops during 6th 7th wks. heart valves- 7th wk.

Fetal Development Milestones End of 1st Lunar length= 0.25-1cm ; wt= 400mg heart is prominent with tail arms & legs are bud like structure rudimentary eyes, ears, nose are discernible 2nd month

Nervous system

length= 2.5cm; wt= 20g organogenesis is complete heart has a septum & valves; beating legs, arms, finger, toes, elbows, bones, have been developed external genitals are present 3rd month nail beds are forming; wt= 45g babinski reflex is present kidney secretion has begun 4th month length= 10-17cm; wt= 55- 120g FHB can be heard lanugo is formed active swallowing reflex End of 5th month quickening- 25cm in length; wt= 223g FHB can be heard w/ stethoscope capable of antibody production; lanugo prominent

1. Uterine changes 2. Fetal outline- a tumor w/ calcium deposits may occasionally stimulate fetal outline 3. Braxton Hicks contraction- it may be caused by any growing mass in the uterus

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Pregnancy test- not absolute (+) sign in H-mole a. Ascheim-zondek test (mice) b. Friedmans test (rabbit) c. Frog test (frog) 5. Goodells sign 6. Enlargement of abdomen- could be due to obesity, tumor 7. Ladins sign- anterior uterine softening @ midline

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Mcdonalds sign- flexibility of uterus where uterus & cervix join 9. Piskaceks sign- softening over implantation site. III.positive sign a. FHT b. Fetal movement c. x-ray outline of skeleton Emotional & Psychosocial Changes 1. Ambivalence initially even if pregnancy is planned, there is an element of surprise there is a feeling that timing was wrong & pregnancy is desirable some day but not now the reasons: a. long-term plans b. job commitments c. financial stress d. needs of another child Ambivalence may also be related to: a. need to modify career plans b. fear on assuming a new role c. unresolved emotional conflicts w/ ones own mother d. fears about pregnancy, labor & delivery Ambivalence may be expressed as: a. denial or rejection of pregnancy b. depression c. nausea & vomiting d. somatic complaints

End of 6th month length= 28-36cm; wt= 560g passive antibody transfer IgG; eyebrows & lashes are present vernix caseosa forms End of 7th month length= 35cm; wt= 1200g lung alveoli begin to appear; surfactant production has begun eyes can open & pupils are capable of reacting to light

vessel of the retina are highly susceptible to concentration of O2 skin covered w/ vernix caseosa End of 8th month length= 43cm; wt+ 1.6kg subcutaneous aft begins to be deposited aware of sounds active moro reflex o stores mineral o iron End of 9th month lanugo diminish body store of glycogen, iron, CHO, Ca vernix caseosa End of 10th month lightening, kicks actively Diagnosis of Pregnancy I.presumptive signs- can be caused by other conditions & therefore are inconclusive & not diagnostic of pregnancy 1. Amenorrhea- it is presumptive bcoz menstruation may be delayed bcoz of changes in climate, worry, chronic illness, severe anemia, stress 2. Fatigue- it can be due to illness, overexertion & depression 3. Nausea & Vomiting- it can be due to GI d/o, emotional stress, infection 4. Frequent Micturation / urination- it can be caused by UTI, emotional tension, pelvic tumor 5. Breast changes- not significant in multipara

during the early stage the pregnant woman may seriously consider the possibility of abortion in unwanted pregnancy

2. Introversion turning in ones self outgoing woman may lose interest in going out & be more concerned w/ need for rest & time alone

this concentration of attention permits the woman to adjust, plan, adapt, build, & draw strength in preparation for her childs birth

3. Emotional Lability characterized by mood swings- great joy to deep despair may cry w/o reason- this is unsettling for the husband causing him to feel confused & inadequate bcoz the husband may feel unable to handle his wifes tears. he often reacts by withdrawing & ignoring the problem

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since the pregnant woman needs love & affecting she may perceive her husband as unloving & unsupporting Distorted Body Image- picture of our own body w/c form in our mind Acceptance- eager for the pregnancy to end makes final preparation for the body & spends long periods selecting names for the child, at this time woman feels vulnerable to rejection, loss & insult

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Vaginal Changes- may be present in a rapidly growing uterine tumor. (Chadwicks sign) Skin changes- it may occur in a rapidly expanding abdominal mass Quickening- movement of gas in the intestine may stimulate such sensation

Stages of Cancer stage 1- cancer confined to the cervix stage 2- cancer extends beyond the cervix into the vagina

II.probable signs- more reliable indication & more diagnostic however their presence does not offer a differential diagnosis of pregnancy

stage 3- cancer extends to the pelvic wall stage 4- cancer extends beyond the pelvic wall into the bladder & rectum

Posture realaxation of the sacrococcygeal & sacroiliac joints & the symphysis pubis creates a certain amount of pelvic instability , producing additional strain on the back muscles & thighs >waddling gait in late pregnancy or early postpartal period when a pregnant woman stands, the major part of her uterus rests against the anterior abdominal wall & alters her center of gravity to compensate for the pressure on her abdomen, the woman walks w/ her head & shoulders thrust backwards & / her chest producingpride of pregnancy Abdominal muscles striae gravidarum- due to the stretching rupture & atrophy of the deep connective tissue of the skin

Physiological Changes in Normal Pregnancy Uterus in size to accommodate the growing fetus in length from 6.5cm-32cm 2.5 to 22cm in depth 50-1000g in wt 4-24cm in width hypertrophy of the uterus is due to stimulating action of estrogen on muscle fibers- 17 to 40x mymetrial cells 5th 6th month of pregnancy the uterus is at the level of the umbilicus 9th month- the uterus at the level of the xyphoid process 2wks before term the fetal hed settles into the pelvis preparatory to delivery- lightening position is antiflexion uterine contractions are measured in Montevideo units; 80-120 montevideo units during labor hegars sign- soften of the lower uterine segment contraction can be felt through the abdominal all soon after the 4th month & are called Braxton hicks contraction.- due to amounts of estrogen & distention of uterus Purpose: to facilitate the return of venous blood to the placenta & to aid in the oxygenation of fetal blood 1. Funic Souffle- sound of blood as it courses through the umbilical arteries. 2. rate of blood flow- 500ml/min 3. O2 consumption- 25ml/min

when the abdominal wall is unable to withstand the tension created by the enlarging uterus, the recti muscles become separated in the median line- diastasis recti

Integumentary Changes

extra pigmentation due to MSH- by pituitary linea negra- umbilicus to symphysis pubis chloasma( mask of pregnancy)- darkened brown areas on the face, cheeks, & across the nose activity of sweat glands vascular spiders on the skin of pregnant omen due to level of estrogen

Breast Changes feeling of fullness or tingling is experienced due to the stimulation of estrogen in the body breast size bcoz of hyperplasia & hypertrophy of the mammary alveoli & fat deposits in preparation for lactation

Factors that contribute to the enlargement of the uterus 1. Action of the endocrine system 2. Augmentation of the uterine musculature 3. Development of the deciduas 4. Hypertrophy & hyperplasia of the connective tissues 5. In vascularity of the pre-existing fibers 6. formation of new muscle cells Cervix softening- due to vascualrity, slight hypertrophy & hyperplasia of the muscles & connective tissue, glands & edema. they are estrogen induced

Vascularity- blue veins may become prominent over the surface sebaceous glands of the Montgomery glands enlarged & become protuberant coloctrum- thin, watery, CHON, antibody rich, less sugar & fat nipples are more erectile & pigmentation more prominent

Respiratory System

glands undergo hyperplasia, secretes thick tenacious mucus known as the mucus plugs or obliterates the cervical canal- operculum- seals out bacteria during pregnancy & helps prevent infection in the fetus & membranes mucus plug is expelled hen cervical dilation begins secretions also give rise to vaginal discharges throughout pregnancy

Hyperventilation- RR & tidal volume w/ shortness of breath- due to consumption, crowding of the chest cavity- until lightening relieves pressure estrogen & progesterone the pulmonary resistance, the progesterone helps to react the respiratory center in the brain

blood PCO2 & in the bicarbonated concentration take place

the consistency of a non-pregnant cervix may be compared to that of the nose consistency of the pregnant cervix- compared to that of the earlobe Vagina vasculrity- changes the color of the vagina from its normal light pink to deep violet

no respiratory alkalosis occurs during pregnancy bcoz of the PCO2 facilitates the in O2 consumption & O2 tension 6th month- pregnant woman breathes thoracically rather than abdominally Temperature Changes (slight) due to the activity of the corpus luteum (progesterone) Circulatory System blood volume is to at least 30%-50% to provide for an adequate amount of exchange of nutrient in the placenta

chadwicks sign- the result of hypertrophy engorgement of vessels is elow the growing fetus

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secretions- pH 4-5 bcoz of presence of doderlein bacilli (are resistant to bacterial invasion)

heart output to handle additional blood volume

 there is cardiac dilatation bcoz of blood volume & retained interstitial fluids

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concentration of hgb & erythrocyte may giving the woman psudoanemia

blood flow to the lower extremities is impaired by the pressure of the expanding uterus on veins & arteries w/c slows circulation- leading to edema, varicosities \of vulva, rectum & legs pulse rate (palpitation)- due to CNS stimulation

narcissism introversion decrease in decision making emotional lability changes in sexual desire vulnerability fear of death body image distorted

blood clotting factors the level of circulating fibrinogen during pregnancy due to the level of estrogen. pregnant women should not be massaged since blood clots can lead to thromboembolism nosebleed due to compression of nasopharynx GIT System increasing site of uterus- displace the stomach & intestines toward the back & sides of the abdomen at about the midpoint of pregnancy. the pressure may be sufficient to slow intestinal peristalsis & the emptying time of the stomach, leading to heartburn, constipation & flatulence Urinary System dilated kidney ureters bcoz: o pregnancy-enlarged pelvic blood vessels through w/c the ureters, pass in route to the bladder o influence tone of ureters- contributes to urinary stasis & vulnerable to UTI renal plasma flow by 50% bcoz of GFR- glucose may at times appear in the urine

Tasks of Pregnancy 1. accepting pregnancy 2. be aware of developmental task 3. preparation for motherhood Methods of Estimation For EDC 1. From Ovulation 9 lunar months 38wks or 265days 2. From last menstrual period 9 calendar months 10 lunar months 40wks or 280days 3. Hanses Rule length of the embryo in cm first 5 months of gestation- square the months=cm example. 4months x 4 =16cm 4. Nageles Rule count backwards 3months +7 calendar months from the first day of menstrual period & add 7days 5. Mcdonalds Rule height of fundus in cm divided by 4= duration of pregnancy - months height of fundus in cm x 8/7 = duration of pregnancy weeks 6. Bartholomews Rule 1. fundal height 2. 12-16wks- between the symphysis to the umbilicus 3. 20-22wks- level of the umbilicus 8th month @ the level of the xyphoid process Internal 1. Diagonal Conjugate- distance between the sacral prominence & the anterior margin of the sympyhsis pubis 12.5cm 2. True Conjugate or Conjugate Verameasurement between the posterior surface of the symphysis pubis & the anterior surface of the sacral prominence. the usual depth of the symphysis pubis is 1.5-2cm. if this distance is subtracted from the diagonal conjugate measurement, the distance remaining will be the true diagonal conjugate or the actual diameter of the pelvic inlet through w/c the fetal head must pass. 10.5-11cm 3. Ischial Tuberosity Diameter- measurement between the ischial tuberosities on the transverse diameter of the outlet is made at the medial & lower most aspect of the ischial tuberosity at the level of the anus. 11cm Do Pelvic Measurement to determine whether or not the normal vaginal route of delivery will be safe for both infant & mother External 1. Interdistal diameter distance between the middle points of the iliac crest diameter- 28cm 2. Interspinous diameter distance between the anterosuperior iliac spines average= 26cm 3. Intertrochanteric diameter

trigone of the bladders is & posterior margin thickens

Skeleteal System lordosis is present there is gradual softening of the pelvic ligaments & joints bcoz of relaxin to allow for passage of the baby through the pelvis at the time of delivery leg cramps is present Endocrine Changes estrogen pituitary gland thyroid gland - BMR +20-25% parathyroid gland activity /c are necessary for the metabolism of calcium adrenal cortex hypertrophies- corticoid secretion w/c regulate CHO+CHON metabolism prolactin- responsible for initial lactation

insulin production

EXAMPLE A B C D E Final Judith is pregnant 1 0 0 0 0 G1P0 for the 1st time She carries the 1 1 0 0 1 G1P1 pregnancy to term & the child survives She is pregnant 2 1 0 0 1 G2P1 again Her 2nd pregnancy 2 1 0 1 1 G2P1 ends in abortion During her 3rd 3 2 0 1 3 G3P3 pregnancy she delivers viable twins A- times uterus has been pregnant (Gravity); B- # of deliveries (Parity); C- # of preterm deliveries; D- # of abortion; E- # of living children Weight Gain of 20-25lbs (9-11.25kg) ; 25-40lbs (11-16kg) fetus= 7lbs placenta= 1lb amniotic fluid= 1 1/2lb-2lbs weight of uterus= 2lbs blood volume= 2lbs breast weight= 1 -3lbs weight of additional fluid & fats= 2lbs Psychosocial Changes of Pregnancy

 distance between the trochanter of the femur= 31cm 4. Baudelocquez diameter

distance between the anterior aspect of the symphysis pubis & the depression below the spine of the 5th lumbar vertebra. 18-20cm CARE DURING PUERPERIUM

progesterone that occurs w/ the delivery of the placenta exhaustion being away from home physical discomfort tension engendered by assuming a new role. Bladder Fnx an overdistended bladder causes temporary displacement of the uterus, pushing it to either side & relaxing it w/ subsequent hemorrhage voiding maybe impossible after delivery bcoz of the ff reasons: anesthesia may affect the nerve supply to the bladder perineal injuries may delay the womans ability to relax the urethral sphincter the urethra or bladder wall may have been so traumatized during labor & delivery that she does not have the sensation of a full bladder & experience no discomforts

1. Perineal Comfort Analgesics to relieve perineal doscomforts

Perineal

exercises- contracting & relaxing the muscles of the perineum 5 times in succession. as if trying to stop voiding. this exercise improve circulation to the area & so helps decrease edema

Heat

lamps- increases circulation of the area & thereby reducing edema, promoting healing & improving providing comforts Sitz bath 2. After Pains during the process of involution the uterus does not remain contracted but relaxes at short intervals & gives the mother the sensation of cramp like pains Reasons: oxytoxic drugs where given to increase the contracted state of the muscle fiber the infants sucking stimulates the sympathetic nervous systems to release oxytocin w/c in turn stimulates uterine contraction muscles were subjected to too much distention such as occurs w/ multiparity or polyhydramnios Pains due to hemorrhoids pressure of the presenting part of the fetus traps blood in the rectal veins during the last wks of pregnancy, & the hemorrhoids commonly results from pressure & straining efforts during labor & delivery TX: sitz bath anesthetic sprays witch-hazel compress sims position to relieve pressure laxatives Pains due to breasts discomforts the formation of breast milk will be initiated in a mother whether or not she plans to breastfeed breast milk forms as a result of the fall of estrogen & progesterone level that follows delivery of the placenta Engorgement the feeling of tension in the breasts on the third or fourth day post partum TX: sucking of the infant- to prevent engorgement firm-fitting bra- to prevent sagging of breast hot or cold application- to prevent discomfort Post Partal Blues feelings of overwhelming sadness that they cant account for. they burst into tears easily & are irritable at trifles post partal blues are largely the result of: Let down feelings- after the prom feelings. the mother looked forward to the birth of the baby for so long that the actual event seems anticlimactic as compared w. her expectations results of hormonal changes, particularly the decrease in estrogen &

Perineal care- to prevent infection

catheritization is resorted id the patient will not void w/in 8hrs bcoz the perineum is usually edematous ff delivery. the vulva in post partum mothers appear out proportion & it is usually difficult to locate the urethra for catheritization

NSG Care: fluid intake

early ambulation perineal exercise catheterize aseptically

Bowel Fnx early ambulation good diet w/ adequate roughage adequate fluid intake Reasons: the mother is usually given an enema or suppository at the beginning of labor she may not have eaten for a number of hours less fluid is in the intestinal tract because of puerperal diuresis abdominal muscles are flaccid pressure exerted by the gravid uterus is withdrawn she may be apprehensive about tearing sutures if she has hemorrhoids, defecation maybe delayed bcoz of the discomforts involved Exercises Purpose: 1. to tone skeletal muscles especially those stretched during labor & delivery such as the abdomen & perineum 2. to improve physique 3. to reduce excessive fats 4. to improve tone of breasts muscles 5. to correct posture that was altered during pregnancy Early Ambulation gradual approach to full activity should be explained to the mother it improves bladder & bowel fnx & circulation especially in the lower extremities & reduces the tendency toward blood clot formation & thrombophlebitis Pyrosis or Heart burn (2nd trimester) regurgitation of gastric acid contents into the esophagus due to: diminished gastric motility reverse peristaltic waves progesterone induced TX:

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sips of H2O during heartburn MAALOX eat smaller, frequent meals keep head elevated when lying avoid spicy, fatty & fried foods

TX: o tepid bath w/ Na bicarbonate or oatmeat added H2O. Edema- due to lack of exercise, production of adrenal & placental hormones w/c tends to favor retention of Na & H2O, poor posture, prolonged standing w/c venous pressure in the lower extremities, use of circular garters w/c constricts circulation, CHON deficiency w/c cause nutritional edema, pressure exerted by gravity. Nasal Stuffiness TX: o fluid intake o massage sinuses o place moist towel in sinuses Ptyalism TX: o mouthwash o chewing gum Backache TX: o avoid prolonged standing & using high heeled shoes Flatulence TX: o avoid gas forming & fatty foods Breast Tenderness TX: o use supportive bra o caffeine intake

Gingivitis- caused by dietary deficiency, estrogen during pregnancy, changes in salivary pH TX: o vitamin C rich foods o soft toothbrush Constipation- due to activity, slow GI tract motility bcoz of progesterone, muscles lose tonicity bcoz of hormone relaxin, intestine compressed by enlarging uterus, pressure of the presenting part causes congestion of the lower bowel use of iron, vitamin preparation tend to aggravate constipation. TX: o avoid laxatives o avoid use of mineral oil o roughage, bulk, natural fiber o fuid intake o daily bowel habits, adequate exercise Fatigue- due to metabolic requirement Urinary frequency- due to pressure of gravid uterus on the bladder TX: o avoid caffeine, practice Kegel exercise Syncope- due to postural hypotension, changes in blood volume TX: o side lying position/ sims position o avoid crowds o move slowly Varicosities- due to poor circulation in the lower extremities (pressure of gravid uterus), relaxation of smooth muscle walls of veins bcoz of hormones causing congestion TX: o use elastic stockings o extend legs, avoid prolong standing o exercise o avoid use constrictive garter o no crossing legs Muscle cramps- due to in serum calcium levels, in serum phosphorus level, interference of circulation & pressure on nerves supplying the lower extremities bcoz of enlarging uterus. TX: o milk in diet o calcium sulfate o avoid ponting your toes o make pressure on the knees & straighten the leg & dorsiflex the foot Palpitation & dyspnea- due to flow of vital capacity, bcoz of circulatory adjustments necessary to accommodate the blood supply during pregnancy TX: o sleep propped up in bed Leukorrhea- whitish viscous vaginal discharges due to in estrogen levels & blood supply to the vaginal epithelium, hyperplasia of vaginal mucosa, X production of mucus by endocervical glands TX: o daily bathing o use absorbent cotton panties

Pruritus- due to stretching of abdominal wall, caused by liver dysfnx or by products of teal metabolism foreign to the maternal organisms