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Prenatal Care


hearing the fetal heart with a stethoscope or a Doppler ... if fetal heart cannot be auscultated or detected with Doppler, fetal death is likely ... – PowerPoint PPT presentation

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Title: Prenatal Care

Prenatal Care
  • Anna Mae Smith, MPAS, PA-C

Signs of Fetal Life
  • hearing the fetal heart with a stethoscope or a
  • visualizing the fetal heart with real-time
  • palpating fetal movements

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Diagnosis of Fetal Death
  • early in pregnancy
  • initially accompanied by failure of uterine
  • regression of many signs of pregnancy
  • placenta may continue to produce HCG for several
    weeks after embryonic or fetal death, so positive
    endocrine tests do not indicate viable pregnancy
  • ultrasound is primary method for establishing
    fetal death

  • later in pregancy
  • failure to feel fetal movement
  • if fetal heart cannot be auscultated or detected
    with Doppler, fetal death is likely
  • ultrasound is best method for confirming the
    diagnosis of fetal demise
  • two independent observers should document lack of
    fetal cardiac activity
  • with fetal death
  • maternal weight gain ceases
  • breast changes regress

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  • if U/S not available, x-ray films can be used
  • use only if pregnancy has progressed to the point
    at which fetus is visible on x-ray and fetal
    death has occurred at least a few days earlier
  • three principal radiographic signs of fetal
  • overlapping of the fetal cranium (Spalding sign)
    - follows liquefaction of the fetal brain
  • exaggerated curvature of the fetal spine because
    of deterioration of the spinous ligaments
  • presence of gas in the fetal abdomen (Robert sign)

Estimation of the Duration of Pregnancy
  • mean duration of pregnancy is 266 days from
  • average duration of pregnancy from the first day
    of LMP to range between 279-282 days
  • Naegle Rule
  • EDC 1st day of LMP 7 days, - 3 months, 1
    year (ex., LMP May 5, 1992 EDC February 12,
  • based on premise ovulation occurs on day 14 of 28
    day cycle

  • timing from quickening
  • height of the fundus
  • fundus felt above pubic symphysis 12 wks after
  • at 16 wks, halfway between symphysis and the
  • at 20 wks, at umbilicus
  • by 36th wk, the fundus is just below the ensiform

  • the height of the fundus, measured in cm from the
    symphysis, is equal to the wks of gestation
    between 20 31 weeks
  • fundus smaller than expected
  • earlier gestation
  • oligohydramnios
  • fundus larger than expected
  • later gestation
  • polyhydramnios
  • twins
  • uterus fails to grow as expected
  • IUGR should be considered
  • U/S at 20 wks

Initial Prenatal Visit
  • Confirmation of pregnancy
  • History
  • medical history
  • psychosocial history
  • family history
  • surgical history
  • genetic-familial history of both patient and
  • reproductive history
  • menstrual history
  • contraceptive history
  • gynecologic history
  • obstetrical history
  • sexual history
  • medications/exposures since LMP
  • alcohol
  • smoking
  • social drugs
  • medications

  • Perform physical examination
  • vital signs
  • head-to-toe exam
  • pelvimetry
  • measurement of the diagonal conjugate from the
    posterior inferior edge of the symphysis pubis to
    the sacral promontory - normally 12.5 cm
    estimates the inlet
  • the transverse diameter of the midpelvis includes
    evaluation of the ischial spines (sharp or blunt
    and degree of prominence) and of the
    anteroposterior diameter by the shape of the
    sacrum (curved or flat). The ischial
    tuberosities should be 8 cm apart.

  • Laboratory tests
  • Pap smear
  • GC screening
  • chlamydia screening
  • HIV screening
  • syphilis screening
  • hepatitis screening (HBV)
  • rubella antibody titer
  • complete CBC with indices
  • ABO blood group/Rh factor/antibody screen
  • urinalysis

  • Other laboratory tests which may be performed on
    the basis of patients history
  • alpha fetoprotein
  • blood chemistry
  • cytomegalovirus titer
  • fifth disease titer
  • glucose tolerance tests
  • Group beta strep culture
  • hemoglobin A1C
  • hemoglobin electrophoresis
  • herpes culture
  • serum iron studies

  • toxoplasmosis titer
  • thyroid studies
  • urine culture
  • Perform risk assessment
  • Advocate health promotion activities
  • counseling on nutrition, diet
  • smoking cessation
  • avoidance of teratogens
  • exercise
  • sleep
  • bowel habits
  • sexual relations
  • medication usage

  • Facilitate patient education
  • give handouts
  • answer questions
  • instruct about danger signals
  • vaginal bleeding
  • persistent vomiting
  • chills or fever
  • dysuria
  • abdominal pain or uterine cramping
  • swelling of the face or fingers
  • cerebral or visual disturbances
  • dizziness
  • mental confusion
  • spots before the eyes

  • headaches that do not respond to simple remedies
  • oliguria
  • leakage of fluid from the vagina
  • marked decrease in intensity or frequency of
    fetal movements
  • signs of preterm labor
  • uterine contractions
  • pelvic pressure
  • change in vaginal discharge
  • information about prenatal classes
  • choices in infant feeding
  • Schedule follow-up visits
  • discuss importance of prenatal care
  • discuss schedule of follow-up visits

Physiological Changes in Pregnancy That Influence
Couple Concerns Regarding Sexuality During
  • fear of causing miscarriage or harm to the
    developing fetus
  • need for modification in positioning for coitus
    with advancing gestation
  • fluctuating libido by both partners and the
    resulting effect on coital desire
  • the womans perceived loss of attractiveness to
    her sexual partner
  • misinformation and misconception regarding
    sexuality, safety the impact of religious
  • a declining desire for intimacy as the woman
    withdraws or focuses on infant preparation

Contraindications to Sexual Intercourse
  • history of repeated miscarriage
  • history of cerival incompetence, without
  • current possibility of threatened abortion
  • placenta previa
  • undiagnosed vaginal bleeding
  • premature rupture of membranes, preterm labor
  • severe vulvar varicosities

Subsequent Prenatal Visits
  • measure
  • weight
  • BP
  • evaluate urine for
  • blood
  • protein
  • ketones
  • nitrites
  • glucose
  • assess fetal movement
  • determine fundal height
  • assess fetal heart tones
  • assess fetal position
  • evaluate any patient complaints
  • answer questions appropriately

  • schedule of prenatal visits
  • Q 4 weeks through week 28
  • Q 2 weeks for weeks 28-36
  • Q week for weeks 36 until delivery
  • 2x per weeks for postdates 42 weeks
  • 12 weeks
  • review prenatal laboratory tests
  • assess FHT with Doppler
  • 14-16 weeks
  • assess growth
  • order indicated genetic tests
  • determine maternal serum alpha-fetoprotein (AFP)
  • perform amniocentesis

  • 20 weeks
  • auscultate fetal heart with fetoscope
  • reassess gestational age if clinical dates not
  • consider ultrasound examination
  • 24 weeks
  • begin maternal education for birthing
  • 28 weeks
  • repeat antibody screens when indicated
  • administer Rh immune globulin when indicated
  • perform glucose screen for women older than 26
    yrs of age

  • retest Hgb and Hct
  • evaluate for risk of preterm labor
  • perform cervical assessment including
  • cervical position
  • consistency
  • length
  • dilation
  • discuss daily FMC
  • 32 -36 weeks
  • reassess for risk of preterm labor
  • assess the cervix as indicated
  • review signs and symptoms of labor

  • 36-40 weeks
  • assess fetal position and presentation
  • forward copy of patients prenatal records to
  • document choice of pediatrician
  • initiate fetal surveillance as indicated
  • cervical exam each visit
  • 40 weeks and beyond
  • perform cervical assessment
  • institute fetal surveillance
  • NST, BPP
  • biweekly office visits

Weight Gain During Pregnancy
  • total weight gain of
  • 24-28 lb for women at ideal weight
  • 15-20 lb for women 20 over ideal weight
  • 30-35 lb for women 10 under ideal weight
  • 2-5 lb weight gain during 1st trimester
  • 2/3 lb - 1 lb weight gain per week after 1st
  • depends upon initial weight of mother
  • weight loss during pregnancy not advised
  • 2nd trimester weight gain reflects maternal
  • 3rd trimester weight gain reflects growth of
    intrauterine contents

Tobacco and Pregnancy
  • Smoking is related to
  • bleeding
  • preterm rupture of membranes
  • premature birth
  • low birthweight
  • congenital anomalies
  • lags in developmental milestones
  • low IQ in the child
  • Adverse effects increase with
  • of cigarettes smoked
  • years patient has smoked

Gotta have my cigarette!
Alcohol and Pregnancy
  • Alcohol is associated with
  • low birthweight
  • fetal alcohol syndrome
  • as little as 1 oz of alcohol per day (one beer or
    glass of wine or one shot of liquor) has been
  • best advice complete abstinence from alcohol

Caffeine and Pregnancy
  • Implicated as a teratogen in some animal studies
  • The half-life of caffeine triples during the last
    trimester and it passes eadily through the
    placenta to the fetus
  • Ideally, no caffeine during pregnancy but risks
    not as obvious as smoking and alcohol.

Genetic Screening
  • family pedigree
  • alpha-fetoprotein
  • levels in maternal serum or amniotic fluid
    reflective of
  • gestational age
  • maternal age
  • weight
  • race
  • presence of diabetes
  • previous history of neural tube defects

  • high levels indicative of
  • neural tube defects
  • spina bifida
  • anencephaly
  • multiple gestation
  • certain fetal abnormalities
  • gastroschisis
  • congenital nephrosis
  • cystic hygroma
  • low levels indicative of
  • chromosomal disorder
  • trisomy 21
  • AFP alone detects 20 Downs syndrome
  • AFP hCG estriol detects 60 Downs syndrome

  • amniocentesis
  • fetal loss after amniocentesis 0.5 or 1 in 200
  • tests possible on amniotic fluid
  • chromosome analysis
  • karyotype
  • alpha-fetoprotein
  • DNA markers
  • viral studies
  • bichemical linkage assays
  • inborn errors of metabolism
  • side-effects/complications
  • vaginal spotting or amniotic fluid leakage in
  • symptomatic amnionitis in less than 1 of 1000
  • serious maternal bowel or vascular injuries
    extremely rare

  • chorionic villus sampling
  • fetal loss after CVS 0.8
  • same tests as amniocentesis, except AFP
  • routes
  • transcervical - 9-12 wks gestation
  • transabdominal - anytime during gestation
  • transvaginal
  • side-effects/complications
  • transcervical
  • greater frequency of bleding or leakage of fluid

  • more uterine manipulation
  • greater risk of infection (not born out in
  • greater level of maternal cell contamination
  • transabdominal
  • increased incidents of limb anomalies in very
    early CVS

  • confined placental mosaicism (CPM)
  • 2 of 1st trimester CVS
  • discrepancy between cytogenetic anaylsis of the
    placenta and that of the fetus
  • 2nd invasive procedure usually required
  • amniocentesis
  • fetal blood sampling
  • may be at risk for
  • spontaneous abortion
  • perinatal loss
  • IUGR
  • reported rates of loss 3.6-16.7
  • level 2 ultrasound/fetal scan
  • fetoscopy

Work Conditions Which Increase Risk of Low
Birthweight, and Preterm Labor Delivery
  • physically intensive employment
  • standing for long periods of time
  • increased pulling, pushing, or lifting of more
    than 10-25 pounds
  • decreased rest periods

Recommended Favorable Working Conditions for
Pregnant Women
  • Work only 8-hour shifts.
  • no more than 48 hours per week
  • ideally less than 40 hours per week
  • Limit hours of work to between 6 am and
  • Take at least two 10-minute rest periods and one
    nutrition break per shift, with adequate rest
    facilities available.

  • Avoid occupations that involve heavy lifting,
    hard physical labor, continuous standing, or
    constant moving about.
  • Do not work in places where a good sense of
    balance is required for job safety, or where
    there is exposure to toxic substances.
  • Be aware that substances permissible by state
    codes for a nonpregnant individual may be unsafe
    for a pregnant woman and a developing fetus.
    OSHA can answer questions about specific
    substances and situations.

Factors That Prohibit Work
  • hypertension
  • retinopathy greater than stage 1
  • severe anemia
  • herpes gestationis if the pain is severe
  • diabetes
  • renal disease
  • severe disorders requiring medication
  • asthma
  • disk or back problems
  • incompetent cervix
  • history of fetal loss
  • cervical cerclage
  • heart disease classification greater than II (no
    symtoms at rest but minor limitations of physical
    activity due to fatigue, palpitations, or
  • uterine abnormalities
  • Marfans syndrome
  • hemoglobinopathies

Exercise ProgramsDuring Pregnancy
  • Should exercise 3-4 x per week, not
  • Should drink water before, during , and after
    exercise to replace what is lost during
  • Should not exercise in hot, humid conditions or
    when feeling ill.

  • Exercise program
  • Should make a 5-10 min warmup of stretching
    exercises routine.
  • HR is kept under 140 bpm during intense portion
    of exercise, which should last no more than 15-20
  • after 5-10 min cool-down period of stretching, HR
    should be under 100 bpm
  • total program lasts 30-60 min
  • beginners start with shorter program
  • length and intensity of the program are built

  • should exercise on a floor that absorbs impact ,
    e.g. rug-covered or wooden floor
  • wear clothes that are loose or stretch and a
    well-fitting support bra
  • sneakers are supportive and absorb impact
  • avoid (may injure joints or cause cramps)
  • deep knee bends
  • pointing toes
  • full situps
  • double leg raises
  • straight toe touches

  • rise slowly following exercise to avoid
  • avoid
  • high-impact exercises (jumping, jerking, rapid
    direction changes)
  • exercises that may force air ito the vagina
    (upside-down bicycles)
  • exercises that stretch the adductor muscles of
    the legs (putting soles of feet together and
    pushing down or bouncing legs)
  • exercises that require uncomfortable positions
  • exercises that exaggerate the normal curvature of
    the spine

  • after 20 weeks of pregnancy, should not lie on
    back for more than a few minutes at a time
  • should modify the exercise program as the
    physical load of pregnancy increases
  • should stop exercising and contact a health care
    provider if any of the following occur
  • pain
  • bleeding
  • dizziness that does not resolve quickly after

  • SOB (unable to talk comfortably)
  • palpitations
  • faintness
  • tachycardia
  • back pain
  • pelvic pain or pressure
  • difficulty walking

Prohibited Sports
  • snow or water skiing
  • surfing
  • diving
  • scuba diving
  • ice or roller skating
  • sprinting
  • any sport performed at altitudes higher than
    10,000 ft

Pregnancy Complications Which May Prohibit
  • premature labor
  • placental abruption or previa
  • threatened abortion
  • history of 3 or more spontaneous abortions
  • history of stillbirth
  • incompetent cervix
  • medical diseases

Saunas, Hot Tubs, and Whirlpools
  • advise not to use while pregnant
  • could raise body temperature 1.5 to 20 above
    normal, which is not considered normal
  • syncope can also result due to shunting of blood
    to skin and heart has difficulty maintaining

  • Travel is best undertaken during 2nd trimester
    when risk of complications is low and patient is
    feeling her best.
  • Check with health care provider prior to
  • Travel may be contraindicated with certain
  • risk for preterm labor
  • repeated spontaneous abortions
  • pregnancy-induced hypertension
  • bleeding
  • medical condition, e.g., cardiac disease
  • should travel with copy of prenatal record in
    case of unexpected complications

  • if planning to fly, should check with the airline
    about its regulations concerning pregnancy.
  • should not fly in unpressurized planes flying
    above 7,000-9,000 ft.
  • should walk for 5-10 min q1-2 hrs while
  • if driving, plan to make stops
  • if flying or traveling by train or bus, should
    arrange for an aisle seat
  • should drink adequate fluids and urinate q 2 hrs
    to increase comfort
  • light snacks may help reduce nausea
  • should not take medication for motion sickness or
    constipation without first consulting a health
    care provider

Common Pregnancy Complaints
  • First Trimester
  • Nausea and Vomiting
  • higher incidence associated with
  • multiple gestation
  • molar pregnancy
  • 60-80 experience
  • generally lasts 14-16 weeks into pregnancy
  • associated with positive pregnancy outcome
  • Objective data
  • PE and VS WNL

  • significant negatives
  • absence of signs of dehydration (urine ketone,
    specific gravity)
  • absence of vaginal bleeding
  • weight changes
  • depend upon severity of vomiting
  • 5 total body weight lost suspect hyperemesis
  • Medications
  • Vitamin B6 50 mg po tid - qid
  • Phosporated carbohydrate solution (Emetrol) 1-2
    tbsp q15 min up to 5x until NV are relieved
  • contraindicationsDM or hereditary fructose

  • Diphenhydramine 25-50 mg po q4-6 hrs, not to
    exceed 400 mg per day
  • Side-effects drowsiness
  • Contraindications Asthma, emphysema, chronic
    pulmonary disease, or a sensitivity to
  • Lifestyle changes
  • rest when nausea occurs
  • avoid stress
  • avoid sights and smells that trigger nausea
  • refrain from wearing tight, constricting clothing
    about abdomen
  • reduce work loads
  • Dietary interventions
  • eat small, frequent meals
  • high-carbohydrate or high-protein meals and
  • sip carbonated drinks

  • eat crackers on arising
  • drink fluids between meals rather than with
  • avoid foods that may irritate the stomach spicy
    or fatty
  • include foods that tend to neutralize stomach
    acid apples, milk, bread, potatoes, calcium
    carbonate tablets
  • sipping lukewarm fluids every 5 minutes is
    tolerated better than drinking an entire glass of
    fluid at one time
  • Constipation
  • Medications
  • Bulk-forming, nonnutritive laxatives (Metamucil
    or Fibercon)
  • Contraindication fecal impaction or intestinal
  • Drink 8 oz water with each dose.
  • May need to continue treatment for 2-3 days
    before maximum effect noted.

  • Docusate sodium (Colace), a stool softener
  • 50-200 mg per day
  • Side-effects bitter taste, throat irritation,
  • Contraindications sensitivity to docusate
  • Take with milk or juice to mask bitter taste.
  • Lifestyle changes
  • exercise regularly
  • establish a time of day to defecate
  • avoid prolonged attempts to defecate
  • elevate her feet on a stool while defecating to
    avoid straining
  • Dietary changes
  • eat foods high in fiber (fresh fruits and
    vegetables, whole-grain breads and cereals)
  • drink fluids 6-8 glasses of water per day above
    that drunk with meals
  • drink warm fluids on arising to stimulate bowel

  • Hemorrhoids
  • Medications
  • Topical Anesthetics (Preparation H, Anusol)
  • Cream or suppositories up to 3-5 x daily, in
    morning, at night, and after each bowel movement
  • Side-effects occasional burning of irritated
  • Contraindications sensitivity to componenets of
    medication. Heart disease, thyroid disease, and
    DM are contraindications to suppository use
  • Lifestyle changes
  • Follow same measures as for constipation.
  • warm or cool sitz baths (Epsom salts may be
  • witch hazel pads (Tucks)
  • ice packs or cold compresses
  • apply petroleum jelly around anus before
    defecating to help reduce pain and bleeding
  • sleep and rest on her side
  • Kegels exercises to reduce circulation 50-100 x
    per day

  • Flatulence
  • Lifestyle changes
  • avoid constipation
  • avoid hyperventilation or air swallowing
  • avoid gum chewing, large meals, and smoking
  • Dietary interventions
  • limit gas-forming foods
  • carbonated beverages
  • cruciferous vegetables
  • baking soda
  • cheese
  • beans
  • bananas
  • peanuts
  • calcium carbonate supplements

  • Fatigue
  • Medication
  • supplemental iron if anemic
  • no sleeping medications
  • Lifestyle changes
  • encourage adequate sleep and rest periods
  • encourage good posture, wearing of low-heeled
    shoes, and pelvic rock exercises to reduce
  • place pillows behind back or raising head of bed
    up on blocks to increase comfort and reduce
  • avoid exercise 2 hours prior to sleep
  • recommend exercise for sedentary patients
  • relaxation techniques
  • Dietary changes
  • correct nutritional inadequacies
  • avoid caffeine and heavy meals at the end of the
  • warm milk may help induce sleep

  • Urinary Frequency or Incontinence
  • Differentiate from ROM
  • ROM may be described as
  • fluid from vagina tht cannot be controlled with
    Kegel exercises
  • does not smell of urine
  • may increase while lying down
  • may decrease after standing
  • lab tests indicated
  • UA, urine CS
  • nitrazine test (pH 3.5-5 nl vaginal d/c, pH 7
    amniotic fluid)
  • fern test
  • Lifestyle changes
  • resting and sleeping in lateral recumbent
    position enhances kidney function
  • Kegel exercises increase perineal muscle tone

  • Dietary interventions
  • maintain adequate fluid intake (6-8 glasses per
    day) to decrease incidence of UTIs
  • decrease water intake 2-3 hours before bedtime
  • discontinue beverages that contain alcohol or
  • Varicosities of Vulva and Legs
  • Lifestyle changes
  • support hose and compression stockings
  • put on before arises in morning
  • leave on until she goes to bed at night
  • avoid crossing legs
  • not to wear knee-high stockings or a
    constricitive band around the legs
  • change position gradually to avoid dizziness
  • elevate legs above the level of the heart at
    least twice daily
  • wear comfortable shoes

  • avoid prolonged standing or sitting
  • alter position frequently
  • use perineal pads with a sanitary belt to
    compress vulvar varicosities
  • avoid leg injury, as hemorrhage may result
  • Dietary interventions
  • avoid excess weight gain during pregnancy
  • encourage weight loss during the post-partum
  • Headache
  • women who had HAs prior to pregnancy
  • 60 improve
  • 13 worsen
  • 27 no change
  • Medication
  • Acetaminophen 325 - 650 mg q4hrs prn

  • Lifestyle changes
  • avoid activities and situations that may trigger
  • stress
  • smoking
  • smoke-filled rooms
  • blinking lights
  • sleeping late
  • get adequate sleep
  • have her neck and shoulders massaged with heat or
    coolness applied
  • practice relaxation exercises
  • Dietary interventions
  • eat regular, balanced diet
  • avoid intake of food that triggers headaches
  • caffeine
  • chocolate

  • nitrites
  • hard aged cheese
  • alcohol, especially red wine
  • Breast Pain, Enlargement, and Changes in
  • Lifestyle Changes
  • examine breasts in the same way as before
    pregnancy, except that no special time of the
    month is indicated
  • may need to constantly wear supportive bra
  • may be more comfortable wearing bra while
  • Dietary interventions
  • avoid the use of caffeine
  • Menstrual-like Cramping

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  • Second Trimester
  • Backache
  • Medications
  • Acetaminophen 325 - 650 mg q4hrs prn
  • Lifestyle changes
  • instruct in pelvic tilt exercise and proper body
    mechanics, particularly when lifting something
  • avoid excessive twisting, bending, and
  • encourage exercise program
  • avoid excessive walking or standing
  • firm, supportive mattress may be helpful
  • use lateral recumbent position while sleeping,
    with pillows supporting the back and legs
  • with upper back pain wear good, supportive bra
  • with lower back pain wear maternity support

  • warm tub baths
  • massage and relaxation techniques
  • use of heating pad for short periods, but not
    during sleep
  • Dietary interventions
  • avoid gaining excessive weight
  • Syncope
  • Lifestyle changes
  • rest in lateral recumbent position
  • change position gradually, holding on to
    something when rising
  • lower head below the level of the heart if
    feeling faint
  • apply compression stockings before getting out of
  • perform leg pumping exercises (flexing and
    extending the ankle several times)
  • if being in crowd induces symptoms, move to an
    open window or go outside and loosen or remove
    layers of clothing

  • Dietary interventions
  • eat regularly throughout the day
  • assess diet for adequate calorie and fluid
  • Leukorrhea
  • Objective data
  • KOH/wet prep
  • Pap smear
  • nitrazine
  • fern test
  • Lifestyle changes
  • keep vulva clean and dry
  • avoid pantyhose and other tight or layered
  • wear cotton underwear
  • wear a nightgown without underwear at night
  • if using panty liners, use unscented/nondeodorant
    ones, changing them frequently

  • avoid douching
  • avoid tampon use
  • Dietary changes
  • recurrent monilia during pregnancy
  • avoid large amounts of simple sugar in diet
  • eat yogurt with activfe cultures
  • add lactobacillus in tablet or granular form
  • Epistaxis and Epulis
  • Objective data
  • CBC
  • Lifestyle changes
  • when nosebleeds occur
  • loosen clothing around the neck
  • sit with head tilted forward
  • pinch nostrils for 10-15 min
  • apply ice packs to nose

  • light packing of the nose with sterile gauze may
  • apply petroleum jelly to the nostrils will
    lubricate and protect the mucosa
  • avoid overheated air, excessive exertion, and
    nasal sprays
  • reduced air pressure at high altitudes may
    precipitate nosebleeds
  • blow nose gently, one nostril a t a time
  • not to pick at her nose
  • with epulis
  • practice good oral hygience
  • use soft toothbrush
  • floss regularly and gently
  • have regular dental care
  • warm saline mouthwashes relieve discomfort
  • Dietary interventions
  • maintain healthy diet

  • avoid decay-causing, sugary, starchy food
  • cut food that is difficult to chew into small
    pieces to reduce gum trauma
  • Muscle Cramps in the Calf, Thigh, or Buttocks
  • Lifestyle changes
  • advise the patient to
  • avoid stretching her legs
  • avoid pointing her toes
  • avoid walking excessively
  • avoid lying on her back
  • wear low-heeled shoes
  • instruct in calf stretching perform 10-12 x
    before bed
  • Dietary interventions
  • correct excessive or inadequate intake of dairy
    and calcium products

  • Round Ligament Pain
  • Lifestyle changes
  • avoid sudden, twisting movements
  • get out of bed by turning onto side and pushing
    up with arm to reduce abdominal muscle and back
  • may apply heat to the painful area
  • avoid excessive exercise, standing, or walking
  • Excessive Salivation and Bad Taste in Mouth
  • Lifestyle changes
  • maintain good oral hygiene
  • Dietary interventions
  • void excessive starch intake
  • maintain good diet and adequate hydration
  • sucking hard candy or breath mints or chewing gum
    may improve the tast in mouth

  • Pica and Change in Taste and Smell
  • Objective data
  • urine dipstick for ketones
  • CBC
  • Dietary interventions
  • evaluate diet for adequacy
  • Third Trimester
  • Braxton-Hicks Contractions
  • activity often decreases BH
  • no cervical changes
  • Lifestyle changes
  • empty bladder frequently
  • rest in lateral recumbent position
  • walking or exercising lightly may relieve
  • Lamaze type breathing

  • Dyspnea
  • Lifestyle changes
  • avoid exercise that precipitates dyspnea
  • rest after exercise
  • not to wear restrictive clothing
  • sitting up very straight or elevating her head
    with pillows may help relieve dyspnea
  • also lying in lateral recumbent position
  • Edema
  • Objective data
  • BP
  • urine dipstick for protein
  • Lifestyle changes
  • lie in lateral recumbent position for 1-2 hrs
    twice daily and to sleep in that position at night

  • avoid long periods of sitting or standing
  • if patient must sit for extended periods, should
    also stand - preferably walk - 10 min q1-2 hrs,
    or vice versa
  • not to wear constrictive bands on the legs and
  • may wear pantyhose if needed
  • raising arms and legs above the level of the
    heart for short periods and pumping hands and
    feet may decrease edema
  • advise not to curl hands under head or pillow at
    night if they are swollen or numb
  • use of wrist supports would decrease swelling and
  • Dietary interventions
  • eat adequate protein and calories
  • drink 6-8 glasses of water a day
  • avoid high intake of sugar and fats
  • moderate sodium intake

  • Dyspepsia
  • Medications
  • Actacids (Maalox, Mylanta)
  • take as directed
  • limit Mylanta to 24 tabs or tsp and Maalox to 16
    tabs per day
  • take iron and vitamin supplements at least 2 hrs
    before or after taking these antacids
  • advise patient not to take sodium bicarbonate
  • Calcium carbonate
  • Lifestyle changes
  • advise not to lie down, ben, or stoop for 2 hrs
    after eating
  • for sleeping, the head of the bed may be elevated
    6 inches
  • not to wear restrictive clothing around the
    abdomen or waist
  • flying exercises may help to reduce discomfort

  • Dietary interventions
  • avoid hot, spicy, fatty, gas-forming foods
  • avoid coffee
  • avoid alcohol
  • avoid gum chewing
  • eat small, frequent meals
  • chew slowly and thoroughly
  • avoid excessive weight gain
  • Joint Pain/Ache
  • Medication
  • Acetaminophen
  • Lifestyle changes
  • avoid excessive walking, high-heeled shoes,
    jarring movements, high-impact activities, or
    other movements which can cause pain

  • may apply heating pad or warm moist heat to
    painful area for 15-20 min
  • good posture is helpful
  • place pillows between the thighs and underneath
    her abdomen to support and aligh the back while
  • Emotional Lability
  • Dietary interventions
  • assess adequacy of diet
  • make sure caloric intake is spread throughout the

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