Preterm Birth

"Mommy I'm not yet ready"

A case study about Maternal and Child Health with emphasis on Preterm Birth

Description

• Refers to the birth of a neonate before the end of 37th week of gestation;
• Associated with numerous problems
• All body systems are immature;
• The extent of immaturity depends on gestational age and level of development at delivery;
• Preterm neonates between 28 and 37 weeks of gestation have the best chance of survival.

What happened?

• Preterm birth may occur because of maternal disease that necessitates delivery of the neonate for the health of the mother - example, preeclampsia (gestational hypertension);
• Preterm birth may also be a direct result of preterm labor.

Assessment findings

• Inspection findings
• Low birth weight
• Minimal subcutaneous fat deposits;
• Proportionally large head in relation to body;
• Wrinkled features;
• Thin, smooth, shiny skin that is almost translucent;
• Veins clearly visible under the thin, transparent epidermis;
• Lanugo hair over the body;
• Sparse, fine, fuzzy hair on the head;
• Soft, pliable ear cartilage; the ear may fold easily;
• Minimal creases in the soles and palms;
• Prominent eyes, possibly closed;
• Few scrotal rugae (males);
• Undescended testes (males);
• Prominent labia and clitoris (females)
• Neurologic examination findings
• Inactivity (although may be unsually active immediately after birth);
• Extension of extremeties
• Absence of sucking reflex;
• Weak swallow, gag, and cough reflex;
• Weak grasp reflex;
• Ability to bring neonate's elbow across the chest when eliciting the scarf sign;
• Ability to easily bring the neonate's heel to his ear
• Additional findings
• Inability to maintain body temperature;
• Limited ability to excrete solutes in the urine;
• Increased susceptibility to infection, hyperbilirubinemia, and hypoglycemia;
• Periodic breathing, hypoventilation, and periods of apnea.

Treatments

• Cardiac and respiratory assessment and assistance;
• Resuscitation if necessary;
• Maintenance of fluid and electrolyte balance;
• Nutritional support;
• Prevention of infection;
• Assessment of neurologic status;
• Maintenance of body temperature and neutral thermal environment;
• Monitoring of renal fuction;
• Emotional support to parents;
• Assessment of glucose and bilirubin levels

Interventions

• Closely assess all body systems;
• Anticipate the need for endotracheal intubation and mechanical ventilation;
• Administer oxygen as needed, avoiding concentrations that are too high;
• Monitor transcutaneous oxygen levels or pulse oximetry reading;
• Have emergency resuscitation equipment readily available.
• Administer medications to support cardiac and respiratory function;
• Institute measures to maintain a neutral thermal environment; anticipate the need for incubator or radiant warmer;
• Avoid vigorous stroking or rubbing; use firm but gentle touch when handling a neonate;
• Support the head and maintain extremeties close to the body during position changes;
• Monitor fluid and electrolyte balance, assess intake and output and administer intravenouos fluids as ordered;
• Provide emotional support, education and guidance to the mother and family;
• Explain the procedures and treatments to the parents, allow parents to verbalize their concerns, correct any misconceptions or  erroneous information;
• Assist with referrals for supportive services.

Human Immunodeficiency Virus Infection

AIDS Symbol - The Red Ribbon

The Wrath of AIDS

Definition

• HIV is the causative agent for acquired immunodeficiency syndrome (AIDS)
• Considered as an STD, it can have serious implications for the pregnant mother and her fetus.

The story behind it

• HIV infection is caused by a retrovirus that targets the helper T-lymphocytes that contain the CD4+ antigen.
• The virus integrates itself into the cell's genetic makeup, ultimately causing cellular dysfunction;
• The cells can no longer function in mounting an appropriate immune response, leaving the person vulnerable to opportunistic infections.
• The virus may be contracted through sexual intercourse, exposure to infected blood, vertical transmission across the placenta to the fetus during pregnancy, labor and delivery birth, or by breast milk to the neonate.

The clinical manifestations

• Lymphadenopathy
• Bacterial pneumonia
• Fever
• Night sweats
• Weight loss
• Dermatologic problems
• Thrush
• Thrombocytopenia;
• Diarrhea
• Severe vaginal yeast infection that is difficult to treat
• Abnormal pap smear result
• Frequent HPV infections, frequent and recurrent bacterial vaginosis, trichomonas, and genital herpes infections.

The test for AIDS

• Two positive enzyme-linked immunosorbent assays confirmed with the western blot test identifies the person as being positive for HIV
• CD4+ T-lymphocyte count is less than 200 cells/ul

How is it managed?

• Combination antiretroviral therapy in an attempt to reduce the mother's viral load and thus minimize the risk of vertical transmission of the infection to the fetus
• Supportive care

How is it intervened?

• Institute standard precautions when caring for the mother throughout the pregnancy and after delivery and when caring for the neonate;
• Teach the pregnant mother about the measures to minimize the risk of virus transmissions;
• Provide emotioanl support and guidance for the infected individual who is HIV positive and considering pregnancy;
• Allow the pregnant mother who is discovered to be HIV positive to verbalize her feelings and provide support for her;
• Monitor CD4+ T-lymphocyte counts and viral loads as indicated;
• Assess the infected individual for signs and symptoms of opportunistic infections;
• Encourage them to maintain prenatal follow-up to evauluate the status of pregnancy;
• Administer antiretroviral therapy as indicated:
• Teach the pregnanat mother how to administer the therapy;
• Assist with scheduling medications;
• Evaluate the mother for compliance on return visits
• Institute measures during labor and delivery to minimize the fetus's risk of exposure to maternal blood or body fluids;
• Avoid the use of internal fetal monitors, scalp blood sampling, forceps, and vacuum extraction to prevent the creation of an open lesion on the fetal scalp;
• Advise the mother that breast-feeding is not recommended because of the risk of possible virus transmission;
• Withhold blood sampling and injections on the neonate until maternal blood has been removed with the first bath;
• Educate the mother about the mode of HIV transmission and safer sex practices.

Barrier Method: Cervical Cap

Cervical Cap

Cervical Cap

Description

• A barrier-type method of contraception, similar to the diaphragm but smaller;
• A thimble-shape, soft rubber cup that the patient places over the cervix;
• Held in place by suction;
• The addition of a spermicide creates and additional chemical barrier;
• Persons who are not suited for diaphragms may use a cervical cap; failure of the cervical cap is commonly due to failure to use the device or inappropriate use of the device.

Advantages

• The cap requires less spermicide;
• It has an efficacy rate of 85% for nulliparous women and 70% for parous women when used correctly and consistently;
• It does not alter hormone levels;
• It can be inserted up to 8 hourse before intercourse;
• It does not require reapplication of spermicide before before repeated intecourse;
• It can remain in place longer than diaphragms because it does not exert pressure on the vaginal walls or urethra.

Disadvantages

• It requires possible reffiting after weight gain or loss of 15 lb *6.8 kg) or more, recent pregnancy, recent pelvic surgery, or cap slippage.
• It is more likely to become dislodged during intercourse;
• It may be difficult to insert or remove;
• It may cause an allergic reaction or vaginal lacerations and thickening of the vaginal mucosa;
• It may cause a foul odor of left in place for more than 36 hours;
• It can't be used during mesntruation or during the first 6 post-partum weeks;
• It should not be left in place longer than 24 hours;
• It is contraindicated in people with a history of toxic shock syndrome (TSS), a previously abnormal Pap test, allergy to latex or spermicide, an abnormally short or long cervix, history of pelvic inflammatory diseases (PID), cervicitis, papillomavirus infection, cervical cancer, or undiagnosed vaginal bleeding.

Implications

• Make sure that the person is properly fitted with the cap;
• The gap os space between the base of the cervix and the inside of the cervicl cap ring should be 1 to 2 mm (to reduce the possibility of dislodgement);
• The rim should fill the cervicovaginal fornix;
• If the cap is too small, the rim leaves a gap where the cervix remained exposed; if the cap is too large, it is not snug against the cervic and is more easily dislodged;
• Instruct the person on how to insert the cap properly;
• Re mind the person that the cap needs refitting after weight gain or loss of 15 lb or more, recent pregnancy, recent pelvic surgery or cap slippage.

Barrier Method: Diaphragm

Diaphragm and Spermicide

Diaphragm

Description

• A barrier-type contraceptive that mechanically blocks sperm from entering the cervix;
• Composed of a soft, latex dome that is supported by a round, metal spring on the outside;
• A diaphragm can be inserted up to 2 hours before intercourse;
• Optimum effectiveness is achieved by using it in combination with spermicidal jelly that is applied to ring of the diaphragm before it is inserted;
• Diaphragms are available in various sizes and must be fitted to the individual.

Advantages

• It is a good choice for people who choose not to use hormonal contraceptives or don't feel that they can be accurate in using natural family planning methods;
• When combined with spermicidal jelly, its effectiveness ranges from 80% to 90% for new users and increases to 97% for long term users;
• It causes few adverse reactions;
• It can help protect against STDs when used with spermicide;
• It does not alter the body's metabolic or physiologic process;
• It can be inserted up to 2 hours before intercourse;
• Providing it is correctly fitted and inserted, neither the partner can feel it during intercourse.

Disadvantages

• Some people dislike using a diaphragm because it must be inserted before intercourse;
• Although the diaphragm can be left in place for up to 24 hours, if intercourse is repeated before 6 hours (which is how long the diaphragm must be left in place after intercourse) more spermicidal gel must be inserted;
• The diaphragm can't be removed and replaced because this could cause sperm to bypass the spermicidal gel and fertilization could occur;
• It may cause more upper urinary tract infections (UITs) due to the pressure of the diaphragm on the urethra;
• The diaphragm must be refitted after birth, cervical surgery, miscarriage, dilatation and curettage (D&C), therapeutic abortion, or wieght gain or loss of more than 15 lb (6.8kg) because of cervical shape changes;
• It is contraindicated in people who have a history of cystocele, rectocele, uterine retroversion, proplapse, retroflexion, or anteflexion because the cervix position may be displaced, making insertion and proper fit questionable;
• It is contraindicated in people with a history of toxic shock syndrome (TSS) or repeated UTIs, vaginal stenosis, pelvic abnormalities, allergy to spermicidal jellies or rubber. It is also contraindicated in people who show an unwillingness to learn proper techniques for diaphragm care and insertion;
• it can't be used in the first 6 post-partum weeks.

Implications

• Intruct the person in proper insertion technique;
• Urge the person never to leave the diaphragm in place for longer than 24 hours;
• Instruct the individual to leave the diaphragm in place for about 6 hours after the intercourse;
• Advise the individual to use additional spermicide for additional intercourse;
• Urge the person to adhere to medical follow-up and to have the diaphragm refitted after birth, cervical surgery, miscarriage, D&C, therapuetic abortion, or weight gain or weight loss.

Barrier Methods: Condoms

Male Condoms

Male Condom

Description

• A latex or synthetic sheath that's placed over the erect penis before intercourse;
• Prevents pregnancy by collecting spermatozoa in the tip of the condom, preventing them from entering the vagina.

Advantages

• Many people favor the male condom because it puts the responsibility of birth control on the male;
• No health care visit is needed;
• Available over-the-counter in pharmacies and grocery stores;
• Easy to carry;
• Prevents the spread of STD.

Disadvantages

• A condom must be applied before any vulvar penile contact takes place because preejaculation fluid may contain sperm;
• It may cause an allergic reaction if the product contains latex and the male individual or his partner is allergic;
• It may break during use if it is used incorrectly or is of poor quality;
• It can't be reused;
• Sexual pleasure may be affected.

Implications

• Remind the male individual and his partner that the condom must be positioned so that it is loose enough at the penis tip to collect ejaculatory but not so loose that it comes off the penis;
• Reinforce that the penis must be withdrawn before it becomes flaccid after ejeculation, otherwise sperm may escape from the condom into the vagina.

Barrier Method: Female Condom

Female Condom

Female Condom

Description

• A vaginal sheath made of polyurethant and lubricated with monoxyl 9;
• The inner ring (closed end) covers the cervix. The outer ring (open end) rests against the vaginal opening;
• It is intended for one-time use and should not be used in combination with male condom.

Advantages

• It is 95% effective;
• It helps prevent the spread of STDs;
• It can be purchased over-the-counter.

Disadvantages

• The feale condom is more expensive than the male condom;
• It can be difficult to use and has not gained as much acceptance as a male condom;
• Pregnancy can occur as a result of failure to use or incorrect use;
• It may break or become dislodged;
• It is contraindicated in individuals or partners with latex allergies.

Implications

• Instruct the individual on how to insert the female condom;
• Advise the person that the condom may be inserted for up to 8 hours before intercourse;
• Reinforce that the female condom is for one-time use only and must be discarded after use.

Nutritional Guidelines for Pregnant Woman

U.S. Department Of Agriculture Food Pyramid

Food Group Recommendations

Because not all foods in a food group are created equal, the U.S. Department of Agriculture makes the following recommendations for choosing foods within a food group.

Grains

• Make half your grains whole. Eat at least 3 oz of whole-grain cereals, breads, crackers, rice, or pasta every day;
• 1 oz is about 1 slice of bread, about 1 cup of breakfast cereal, or 1/2 cup of cooked rice, cereal, or pasta.

Vegetables

• Vary your veggies;
• Eat more dark-green veggies like broccoli, spinach, and other dark leafy greens;
• Eat more orange veggies, like carrots and sweet potatoes;
• Eat more dry beans and peas like pinto beans, kidney beans, and lentils.

Fruits

• Focus on fruits;
• Eat a variety of fruit;
• Choose fresh, frozen, canned, or dried fruit;
• Go easy on fruit juices.

Milk

• Consume calcium-rich foods;
• Go low-fat or fat-free when you choose milk, yogurt, and other milk products;
• If you don't or can't consume milk, choose lactose-free products or other calciums sources, such as fortified foods and beverages.

Meats and Beans

• Go lean with protein;
• Choose low-fat or lean meats and poultry;
• Bake it, broil it, or grill it.
• Vary your protein routine; choose more fish, beans, nuts, and seeds

For a 2,000 calorie diet, you need the amounts below from each food group:

Grains:                   Eat 6 oz every day
Veggies:                 Eat 2 1/2 cups every day
Fruits:                    Eat 2 cups every day
Milk:                      Get 3 cups every day; for kids ages 2 to 8 years, 2 cups
Meats and Leans:   Eat 5 1/2 oz every day

Find you balance between food and physical activity

• Be sure to stay within your daily calorie needs;
• Be physically active for at elast 30 minutes most days of the week;
• About 60 minutes a day of physical activity may be needed to prevent weight gain;
• For sustaining weight loss, at least 60 to 90 minutes a day of physical activity may be required;
• Children and teenagers should be physically active for 60 minutes every day, or most days.

Know the limits on fats, sugars, and salt (sodium)

• Make the most of your fat sources from fish, nuts, and vegetable oils;
• Limit solid fats like butter, stick margarine, shortening, and lard, as well as foods that contain these;
• Check the Nutritional Facts label to keep saturated fats, trans fats, and sodium low;
• Choose food and beverages low in added sugars. Added sugars contribute calories with few, if any, nutrients.

Health Nutrition for Pregnant Mother

Healthy Mother

Nutrition During Pregnancy

Calories

• Requirement exceeds pre-pregnancy needs by 300 calories per day (from 2,200 kcal/day to 2,500 kcal/day)
• To support maternal-fetal tissue synthesis;
• To meet increased basal metabolic needs;
• To provide optimal use of protein and tissue growth

Proteins

• Requirement exceeds pre-pregnancy needs by 14 to 16 grams per day (from 44 to 46 g/day to 60 g/day)
• For expansion of blood volume;
• For tissue growth'
• For adequate amino acid intake for fetal development

Fats

• 20% to 35% of woman's daily calorie intake
• Linoleic acid
• Essential for new cell growth;
• Must be supplied by the diet;
• Found in vegetable oils, such as corn, olive, peanut, and safflower oils.

Vitamins

• Intake of all vitamins should be increased
• Necessary for tissue synthesis and energy production;
• Requirements for fat and water soluble vitamins increase
• Intake of varied, healthy diet usually supplies the requirement for all of the vitamins except folic acid;
• Folic acid is particularly important;
• Promotes fetal growth and prevents anemia;
• Intake should be increased from 400 to 800 mcg/day;
• Sources include green, leafy vegetables, eggs, milk, and whole-grain bread.

Minerals

• Intake of all minerals should be increased, including iodine, calcium, phosphorus, and zinc;
• Drinking fluoridated water is important to aid in tooth formation; if fluoridated water is unavaiblable, a fluoride supplement should be prescribed;
• The average American diet does not provide enough iron to prevent iron deficiency anemia; recommended supplemental iron intake is 30 to 60 mg per day.
• Sodium restrictions is no longer advocated because it has been associated with hormonal and biochemical changes;
• The National Research Council (NRC) recommends an increase in daily sodium intake of 69 mg over the normal dietary requirment of 2,400 mg;
• Excessive sodium may lead to hypertension by altering fluid and electrolyte balance.

Developmental Tasks of Pregnancy

Acceptance of Pregnancy

General Characteristics

Depending on the woman's age, tasks may include acceptance and comfort with body image, development, of a personal value system, adjustment to an adult identity, and internalization of sexual role and identity. Other tasks include acceptance of pregnancy's termination at the time of the delivery and the maternal role, and resolution of fears about childbirth and bonding. The woman's partner also achieves these same developmental tasks.

First trimester: Acceptance of the Pregnancy

• Pregnancy confirmation may leave some couples with disbelief, shick, or amazement;
• The woman and her partner must learn to accept the reality of the pregnancy;
• Most couples experience some degree of ambivalence;
• Feeling the fetus move or seeing the fetus on an ultrasound can help the couple achieve acceptance; and
• In accepting the pregnancy, the partner also accepts the woma as she undergoes he changes associated with pregnancy.

Second Trimester: Acceptance of the Baby

• The woman and her partner work to accept the baby;
• Acceptance of the baby refers to acknowledgement that the fetus is a distinct individual, separate from another;
• Feeling the fetus move or hearing its heart beat demonstrates that the fetus is an active being;
• Anticipatory role playing, for example with the woman or partner imagining the type of parent she or he will be, may occur;
• The woman and her partner begin active preparations for the baby; and
• The partner may feel left out with all the information being focused on the woman and fetus; time is needed to ensure that the partner is given the information and support required.

Third Trimester: Preparation for Parenthood

• The couple work on preparing to become parents;
• The couple begin to demonstrate "nesting" behavior, such as preparing the baby's room, shopping for necessary baby items, and discussing names;
• The couple may attend the childbirth education classes; and
• The couple may review relationships with their own parents and engage in role-playing and fantasizing about being a parent.

Common Discomforts During the Second and Third Trimester

Second and Third Trimester Discomforts

The Second and Third Trimester

Heartburn

Causes

• Relaxation of the cardiac sphincter;
• Decreased GI Motility;
• Increased production of progesterone; and
• Gastric displacement

Interventions

• Encourage the woman to eat small, frequent meals spaced throughout the day;
• Caution her to avoid fatty and fried foods and caffeine products;
• Suggest that she remain upright for at least 1 hour after eating; and
• Encourage her to check with her health care provider before using an over-the-counter antacid.

Constipation

Causes

• Oral iron supplements;
• Displacement of the intestines caused by the fetus; and
• Bowel sluggishness caused by increases progesterone and steroid metabolism.

Interventions

• Encourage the woman to engage in moderate daily exercise;
• Advise the increased intake of fluids and foods high in fiber;
• Urge the woman to maintain regular elimination patterns and avoid ignoring the urge to defecate; and
• Caution the woman to avoid the use of mineral oil, which can deplete her level of fat-soluble vitamins.

Hemorrhoids

Causes

• Pressure on the pelvic veins by the enlarging uterus, which interferes with venous circulation; and
• Increased pressure secondary to constipation.

Interventions

• Describe ways to avoid constipation;
• Caution the woman against prolonged standing and wearing constrictive clothing;
• Suggest the use of a topical ointment or anesthetic if allowed;
• Encourage the use of witch hazel compresses;
• Teach the woman how to perform sitz baths or apply warm soaks; and
• Encourage the woman to lie on her left side with her feet slightly elevated.

Backache

Causes

• Postural adjustments of pregnancy secondary to curvature of the lumbosacral vertebrae that increases with uterine enlargement.

Interventions

• Teach the woman  how to use proper body mechanics;
• Encourage the woman to maintain good posture;
• Suggest that she wear low to mid heel shoes;
• Recommend that the woman walk with her pelvis tilted forward;
• Advise the woman to apply local heat to the back if necessary;
• Suggest sleeping on a firmer mattress or using a board under the current mattress to add firmness; and
• Teach the woman how to do pelvic rocking or tilting exercises.

Leg Cramps

Causes

• Pressure from the enlarging uterus;
• Poor blood circulation;
• Fatigue; and
• Balance in the calcium-phosphorus ratio

Interventions

• If necessary, assist the woman with measures to alter calcium and phophorus intake;
• Encourage frequent rest periods with the elgs slightly elevated;
• Encourage her to wear warm clothing; and
• Teach her what to do during a leg cramps by pulling the toes upward the leg while pressing down on the knee.

Shortness of Breath

Causes

• Pressure of the uterus on the diaphram

Interventions

• Encourage the woman to maintain proper posture, especially when standing;
• Suggest that the woman use semi-Fowleer's position when sleeping and use additional pillows for support; and
• Encourage a balance of activity and rest.

Ankle Edema

Causes

• Poor venous return from the lower extremities; aggravated by prolonged sitting or standing and by warm weather; and
• Fluid retention

Interventions

• Recommend that the woman lie on her side in bed to enhance glomerular filtration rate of the kidneys;
• Encourage the woman to avoid wearing tight, constrictive clothing;
• Advise her to elevate her legs during the rest periods;
• Urge her to dorsiflex her feet when standing or sitting for prolonged periods; and
• Suggest that she get up and move every 1 to 2 hours when sitting for long periods.

Common Discomforts During the First Trimester

Discomforts during the First 3 months of Pregnancy

The First Trimester

Nausea and Vomiting

• Called as morning sickness, but it may occur anytime during the day.

Causes

• Hormonal changes;
• Fatigue;
• Emotional factors; and
• Changes in carbohydrates metabolism

Interventions

• Instruct the mother to avoid greasy, highly seasoned foods;
• Encourage her to eat small frequent meals;
• Advise her to eat dry toast or crackers before getting out of bed in the morning; and
• Suggest intake of complex carbohydrates with the onset of nausea.

Nasal Stuffiness, Discharge, or Obstruction

Causes

• Edema of the nasal mucosa from elevated estrogen levels

Interventions

• Encourage the use of a cool-moist humidifier;
• Suggest the use of normal saline nose drops or nasal spray; and
• Advise the mother to apply cool compress to the nasal area.

Breast Enlargement and Tenderness

Causes

• Increased estrogen and progesterone level

Interventions

• Encourage the use of a well-fitting bra with wide shoulder straps for support;
• Reinforce the need for maintaining good posture; and
• Advise the mother to wash her breast and nipple area with water only.

Urinary Frequency and Urgency

Causes

• Pressure of the enlarging uterus on the bladder
• Around the 12th week the  uterus rises into the abdominal cavity, causing symptoms to disappear; and
• Symptoms recur in the thir trimester as the uterus again presses on the bladder.

Interventions

• Suggest to the mother that she decrease her fluid intake in the evening to minimize nocturia (urinary frequency at night times);
• Encourage her to limit the intake of caffeinated beverages;
• Reinforce the need to promptly respond to the urge to void in order to prevent bladder distention and urinary stasis;
• Teach her how to perform Kegel's Exercises; and
• Teach her the signs and symptoms of urinary tract infection and instruct her to promptly report any she experiences.

Increased Leukorrhea (vaginal discharges)

Causes

• Hyperplasia of vaginal mucosa; and
• Increased mucus production by the endocervical glands.

Interventions

• Encourage the mother to bathe daily and avoid using soap on the vulvar area;
• Reinforce the need to wipe from front to back;
• Urger her to wear loose, absorbent cotton underwear and to avoid tight pants and pantyhose;
• Suggest the use of panty liners or perineal pads and frequent changing if discharges is bothersome;
• Caution her to avoid douching; and
• Instruct her to notify the health care provider immediately if the discharge changes in color or odor.

Increased Fatigue

Causes

• The increased effort of the body to manufacture the placenta; and
• The need to adjust to the many other physical and emotional demands of pregnancy.

Interventions

• Encourage frequent rest periods as much as possible;
• Offer suggestions to obtain rest during the day at home or at work;
• Encourage intake of a balanced diet with iron supplements;
• Suggest the use of warm milk or warm shower or bath before going to bed at night to aid in relaxation; and
• Advise engaging in moderate regular exercise.

Normal Signs of Pregnancy

Signs and Symptoms of Pregnancy

Signs and Symptoms of Pregnancy

Presumptive

• Amenorrhes (in about 80% of patients) or slight, painless spotting of unknown cause in early gestation (in about 20% of patients);
• Nausea and vomiting;
• Urinary frequency and urgency;
• Breast enlargement and tenderness;
• Fatigue;
• Quickening (partial fetal movement);
• Thinning and softening of the fingernails; and

Intensified skin pigmentation.

Probable

• Uterine enlargement;
• Goodell's sign (softening of the cervix);

Chadwick's Sign

• Chadwick's sign (bluish mucous membranes of the vagina, cervix and vulva);
• Braxton Hicks contractions (painless uterine contraction that recur throughout pregnancy);
• Ballottement (passive fetal movement in response to tapping of the lower portion of the uterus or cervix);
• Laboratory test results indicating pregnancy;
• Sonogram results showing the characteristics ring of the gestational sac (visible as early as 4 to 6 weeks of gestation); and
• Palpable fetal outline.

Positive

• Fetal heartbeat detected by 17 to 20 weeks of gestation;
• Ultrasonography results as early as 6 weeks of gestation;
• Fetal movements felt by examiner after 16 weeks of gestation; and
• Visualization of fetus and fetal outline.

Normal Pregnancy

Pregnant Mother

Overview of the trimesters of pregnancy

First Trimester (1st - 3rd month)

• Lasts from weeks 1 through 12 and is a critical time in the pregnancy;
• Rapid cell differentiation makes the developing embryo or fetus highly susceptible to the teratogenic effects of viruses, alcohol, cigarettes, caffeine, and other drugs;
• The woman usally experiences physical changes, such as amenorrhes (absence of menstruation), urinary frequency, nausea and vomiting (more severe in the morning or when the stomach is empty), breast swelling and tenderness, fatigue, increased vaginal secretions, and constipation;
• 7 to 10 days after conception, a serum pregnancy test can usaully detect the presence of human chorionic gonadotropin (hCG);
• A pelvic examination, performed 6 to 8 weeks later, shows uterine enlargement, Chadwick's sign, and Hegar's sign.

Second Trimester (4th - 6th month)

• Lasts from weeks 13 through 27;
• Uterine and fetal size increase substantially;
• The woman gains weight, the waistline thickens, and the abdomen enlarges;
• Reddish streaks (striations) may become apparent as abdominal skin stretches;
• Pigment changes may cause skin alterations, such as linea nigra, melasma (mask of pregnancy) and a darkening of the areola of the nipples;
• Other physical changes include diaphoresis (massive perspiration), increased salivation, indigestion, continuing constipation, hemorrhoids, nosebleeds, and some dependent edema;
• The breast become larger and heavier, and about 19 weeks after the last menses they may secrete colostrum.
• By week 20, the fetus is large enough for the mother to feel its movement (quickening).

Third Trimester (7th - 9th month)

• Lasts from weeks 28 through 40;
• The woman experiences Braxton Hicks contractions - sporadic episodes of painless uterine tightening - which help strengthen uterine muscles in preparation for labor;
• Increasing uterine size may displace pelvic and intestinal structures, causing indigestion, protrusion of the umbilicus, shortness of breath and insomnia;
• The woman's center of gravity changes; she may experience backaches beacuse she walks with a swaybacked posture to counteract the frontal weight.

STD: Condyloma Acuminata

STD:                                     Condyloma Acuminata
Causative Agent:                 Human Papillomavirus
Signs/Symptoms:

• Discrete papillary structures that spread, enlarge, and coalesce to form large lesions; increasing in size during pregnancy; and
• Possible secondary ulceration and infection with foul odor.

Treatment:

• Topical application of trichloroacetic acid or bichloroacetic acid to lesions.
• Lesions removal with laser therapy, cryocautery, or knife excision.

Special Considerations:

• Serious infections associated with the development of cervical cancer later in life;
• Lesions left in place during pregnancy unless bothersome and removed during the postpartum period.

STD: Gonorrhea

STD:                             Gonorrhea
Causative Agent:         Neisseria Gonorrhea
Signs/Symptoms:

• May not produce symptoms;
• Yellow-green vaginal discharges;
• Male partner who experience severe pain on urination and purulent yellow penile discharge; and
• Positive culture of vaginal, rectal, or urethral secretions.

Treatment:

• Cefixime (Suprax) as a one-time intramascular injection

Special Considerations:

• Associated with spontaneous abortion, preterm birth, and endometritis in the post-partum period;
• Treatment of sexual partners required to prevent reinfection;
• Major cause of pelvic infectious disease and infertility;
• Severe eye infection leading to blindness in the neonate (ophthalmia neonatorum) if infection is present at birth.

STD: Genital Herpes

STD:                         Genital Herpes
Causative Agent:     Herpes Simplex Virus, type 2
Signs/Symptoms:

• Painful, small vesicles with erythematous base on vulva or vagina rupturing within 1 to 8 days from ulcers;
• Low-grade fever;
• Dyspareunia (painful sex);
• Positive viral culture of vesicular fluid; and
• Positive enzyme linked immunosorbent assay.

Treatment:

• Acyclovir (Zovirax) orally or ointment form

Special Considerations:

• Reducation or suppression of symptoms, shedding or recurrent episodes only with drug therapy, not a cure for infection;
• Abstinence urged until vesicles completely heal;
• Primary infection transmission possible across the placenta, resulting in congenital infection in the neonate;
• Transmission to neonate is possible if active lesions are present in the vagina or on the vulva at birth, which can be fatal; and
• Cesarean delivery is recommended if patient has active lesions.

STD: Syphilis

STD:                         Syphilis
Causative Agent:    Treponema Pallidum
Signs/Symptoms:

• Painless ulcer on vulva or vagina (primary syphilis);
• Hepatic and splenic enlargement, headache, anorexia, and maculopapular rash on the palms of the hands abd soles of the feet (secondary syphilis; occuring about 2 months after initial infection;
• Cardiac, vascular, and central nervous system changes (tertiary syphilis; occuring after an undetermined latent phase);
• Positive venereal disease research laboratory serum test confirmed with positive rapid plasma reagin and fluorescent treponemal antibody absorption tests;
• Dark-field microscopy positive for spirochete.

Treatment:

• Penicillin G Benzathine (Bcillin L-A) Intramascular (single dose)

Special Considerations:

• Possible transmission across placenta after approximately 18 weeks of gestation, leading to spontaneous abortion, preterm labor, stillbirth, or congenital anomalies in the neonate;
• Standard screening for syphillis at the first prenatal visit, screening at 36 weeks of gestation for mother with multiple partners, and possible rescreening at beginning of labor, with neonates tested for congenital syphilis using a sample of cord blood;
• Jarisch-Herxheimer reaction (sudden hypotension, fever, tachycardia, and muscle aches) after medication administration, lasting for about 24 hours, and then fading becaus espirochetes are destroyed.

STD: Chlamydia

STD:                        Chlamydia
Causative Agent:    Chlamydia Tranchomatis
Signs/Symptoms:

• Commonly produces no symptoms, suspicion raised if partner treated for nongonococcal urethritis (inflammation of the urethra);
• Heavy, gray-white vaginal discharges;
• Painful urination; and
• Positive vaginal culture using special chlamydial test kit.

Treatment:

• Amoxicillin (Amoxil)

Special Considerations:

• Screening for infection at first prenatal visit because it is one of the most common types of vaginal infection seen during pregnancy;
• Repeated screening in the third trimester if the person has multiple sexual partners;
• Doxycycline (Vibramycin) - drug of choice for treatments if the patient is not pregnant - contraindicated during pregnancy because of association with fetal long bone deformities;
• Concomitant testing for gonorrhea because of high incidence of concurrent infection;
• Possible premature rupture of membrane, preterm labor, and endometritis (inflammation of the endometrium0 in the post-partum period resulting from infection; and
• Possible development of conjunctivitis or pneumonia in neonate born to mother with infection present in the vagina.

STD: Bacterial Vaginosis

STD:                           Bacterial Vaginosis
Causative Agent:        Gardnerella Vaginalis Infection
Signs/Symptoms:

• Thin, gray vaginal discharge with a fishlike odor;
• Intense pruritus;
• Wet mount slide positive for clue cells (epithelial cells with numerous bacilli clinging to the cells' surface)

Treatment:

• Topical vaginal metronidazole after the first trimester, usually late in pregnancy.

Special Considerations:

• Transmission is not always associated with sexual activity; however, sexual active patients have increased risk;
• Rapid growth and multiplication of organisms, replacing the normal lactobacilli organisms that are found in the healthy person's vagina;
• Treatment goal or reestablishing the normal balance of vaginal flora; and
• Untreated infections associated with amniotic fluid infections and, possibly, preterm labor and premature rupture of membrane.

Types of STD's

STD:                               Trichomoniasis
Causative Agent:            Single-cell protozoan infection
Signs/Symptoms:          

• Yellow-gray, frothy, odorous vaginal discharge;
• Vulvar itchingm edema and redness;
• Vaginal secretions on a wet slide treated with potassium hydroxide (+) for organism.

Treatment:

• Topical clotrimazole (Gyne-Lotrimin) instead of metronidazole (Flagyl) because of its possible teratogenic effects if used during the first trimester of pregnancy.

Special Considerations:

• Possibly associated with preterm labor, premature rupture of membranes, and post-ceasarean infection;
• Treatment of partner is required, even if asymptomatic.

Sexually Transmitted Disease

No entro mi puerta (Don't Enter My Door) pt.1

A case study of medical concern with emphasis on sexually transmitted diseases

Sexually transmitted diseases or sometimes known as STD is considered as one of the most threatening condition that can affect the pregnant mother and her unborn child. There are many complications that can occur once the baby was delivered normally. A pregnant mother who has STD must be carefully managed with medical intervention because there are certain drugs that can affect the growth and development process of the fetus.

Definition

• It is spread through sexual contacct with an infected partner;
• Although STDs can be serious, during pregnancy certain STDs place the mother at greater risk for problems because of theor potential effect on the pregnancy, fetus, or neonate.

The story behind it

• STDs can be caused by numerous organisms. These incliude:
• Fungi
• Bacteria
• Protozoa
• Parasites
• Viruses
• Regardless of the cause, the organism invades the body, placing the mother and fetus at risk for problem.

The clinical manifestations

• The signs and symptoms exhibited by the mother with STD typically involve some type of vaginal discharge or lesion;
• Vulvar or vaginal irritation, such as itching, commonly accompany the discharge or lesion.

Medical Management

• Pharmacological therapy with antifungal or antimicrobial;
• Safe-sex practices; and
• Treatment of partner

Implications

• Explain the mode of transmission of the STD and educate the people about measures to reduce the risk of transmission;
• Administer drug as indicated
• Instruct the mother in drug therapy regimens as appropriate;
• Advise the mother to comply with therapy, completing the entire course of drug therapy.
• Urge the mother to refrain from sexual intercourse until the active infection is completely gone;
• Instruct the mother to have her partner examined so that treatment can be initiated, thus preventing the risk of infection;
• Provide comfort measures for the mother to reduce vulvar and vaginal irritation;
• Encourage the mother to keep the vulvar area clean and dry;
• Advise her to avoid using strong soaps, creams, or ointments unless prescribed.
• Suggest the use of cool or tepid sitz baths to relieve itching;
• Encourage the mother to wear cotton underwear and avoid tight fighting clothing as much as possible;
• Instruct the mother is safe sex practices, including the use of condoms and spermicides such as nonoxynol 9;
• Encourage follow-up to ensure complete resolution of the infection (if possible)

Possible Complications

• Preterm labor
• Premature rupture of the membrane (PROM)
• Neonatal conjunctivitis (inflammation of the conjunctiva/sore eyes)
• Pneumonia
• Congenital herpes in the neonate
• Ophthalmia Neonatorum
• Respiratory distress syndrome

Cervical Mucus Method

Actual Cervical Mucus

The Power of Mucus

Description

• It is also known as the Billings Method.
• It predicts changes in cervical mucus during ovulation.
• Each month, before a woman's menses, the cervical mucus becomes thick and stretches when pulled between the thumb and forefinger.
• The normal stretchable amount of cervical mucus (also known as spinnbarkeit) is 8 to 10 cm.
• Just before ovulation, the cervical mucus becomes thin, watery, transparent, and copious.
• During the peak of ovulation, the cervical mucus becomes slippery and stretches at least 2.5 cm before the strand breaks.
• Breast tenderness and anterior tilt of the cervix also occur with ovulation.
• The fertile period consists of all the days that the cervical mucus is copious and the 3 days after the peak date.
• During these days, the woman and her partner should abstain from intercourse to avoid conception.

Advantages

• No drugs or devices are needed;
• It is free;
• It may be acceptable to members of religous groups that oppose birth control;
• It encourages couples to learn more about how female body functions;
• It encourages communication between partners;
• It can also be used to plan a pregnancy; and
• There are no contraindications.

Disadvantages

• It requires meticulous record keeping and an ability and willingness to monitor the woman's body changes;
• It restricts sexual spontaneity during the woman's fertile period;
• It requires extended periods of abstinence from intercourse;
• It is reliable only for woman with regular menses; and
• it may be unreliable during period of illness, infection, or stress.

Implications

• Remind the woman to check her cervical mucus every day to note changes in the consistency and amounts so that she can recognize the changes that signify ovulation.
• Advise them to avoid checking cervical mucus after intercourse, doing so is unreliable because seminal fluid has a watery, post-ovulatory consistency, which can be confused with ovulatory mucus.

Body Basal Temperature (BBT)

Graph and BBT Thermometer

Turn Me On When The Heat Goes Down

Description

-        This phenomenon is lower during the first 2 weeks of menstrual cycle, before ovulation;

-        It occurs immediately after ovulation, temperature begins to rise, continuing upward until it is time for the next menses;

o   The rise in the temperature indicates that progesterone (female hormone) has been released to the system.

o   It also means that the woman has ovulated.

-        Just before the day of ovulation, a woman’s BBT falls about one half degree; and

-        At the time of ovulation, the woman’s BBT rises a full degree because of progesterone influences.

How to use BBT Method?

-        To use the BBT method of contraception, a woman must take her temperature every morning before getting out of bed and beginning her morning activity;

-        By recording this daily temperature, she can see a slight dip and then an increase in body temperature. The increase in body temperature indicates ovulation;

-        With the temperature increases, intercourse is avoided for the next 3 days, which is the life of a discharged ovum (female egg cell); and

-        Because sperm can survive in the female reproductive tract for 4 days, BBT method of contraception is typically combined with the calendar method so that the couple can abstain from intercourse for a few days before ovulation as well.

Factors that can affect BBT Method

-        BBT Method can be affected by many variables, which may lead to mistaken interpretations of a fertile day as safe day and vice versa.

o   Forgetting to take the temperature or taking after arising may lead to a rise in temperature.

o   Illness also may cause temperature to rise.

o   Changes in daily routine or activities also could affect the temperature.

Advantages

-        It is relatively inexpensive. The woman only exposed in the cost of BBT Thermometer, which is calibrated in tenths of a degree.

-        No drugs are needed.

-        It may be acceptable to members of religious groups that oppose birth control.

-        It encourages couples to learn more about how female body functions.

-        It encourages communication between partners.

-        It can also be used to plan a pregnancy.

Disadvantages

-        It requires meticulous record keeping and an ability and willingness to monitor the woman’s body changes.

-        It restricts sexual spontaneity during the woman’s fertile period.

-        It requires extended periods of abstinence from intercourse.

-        It is reliable only for woman with regular menstrual cycles.

-        It may be unreliable during periods of illness, infection, or stress.

-        It is contraindicated to woman who has irregular menses.

Implications

-        Advise the woman that recording the BBT does not predict the exact day of ovulation. It just indicates that ovulation has occurred, allowing the woman to monitor her ovulatory pattern and giving her time frame for planning.

-        Advise the woman to record the days of menstrual flow on a temperature graph. Have her start with the first day of her menses (day 1) and then take her temperature each day after her menses ends.

-        Tell the woman to use a thermometer that measures tenths of a degree.

-        Instruct the woman to take her temperature as soon as she wakes up – before she gets out of the bed or does anything else. Tell the woman to do this at the same time each morning.

-        Instruct the woman to place a dot on the graph’s line that matches the temperature reading (Tell her not to be surprised if her waking temperature before ovulation is 96^o to 97^oF [35.6^o to 36.1^o C]).

-        If she forgets to take her temperature one day, instruct her to leave that day blank on the graph and not to connect the dots.

-        Instruct her to make notes on the graph if she misses taking her temperature, feels sick, can’t sleep, or wakes up at a different time.

-        Advise her also that if she is taking any medicine – even aspirin – to note this on the graph, because it may affect her temperature.

-        Remind her also to mark the dates when she had sexual relations.

Calendar Method: Natural Family Planning

Calendar Method or Rhythm Method

Natural Family Planning Method

Description

It is a form of contraceptive methods that don’t use chemical or foreign material or devices to prevent pregnancy. The religious beliefs may prevent some individuals from using hormonal or internal contraceptive devices. Others just prefer a more natural method of planning or preventing pregnancy. For most natural family planning methods, the individual’s fertile days must be calculated so that she can abstain from intercourse on those days.

·        Various methods are used to determine the individual’s fertile period.

·        The effectiveness of these methods depends on the person’s and person’s willingness to refrain from sex on the individual’s fertile days.

·        Failure rates vary from 10% to 20%.

Natural family planning methods include the rhythm, or calendar method.

Rhythm Method

-        It is also known as the calendar method;

-        Requires that the couple refrain from intercourse on these days the individual is most likely to conceive based on her menstrual cycle; and

-        This fertile period usually lasts from 3 to 4 days before until 3 to 4 days after ovulation.

Advantages

-        No drugs or devices needed;

-        It is free;

-        It may be acceptable to members of religious groups that oppose birth control;

-        It encourages couples to learn more about how the female body functions;

-        It encourage communication between partners; and

-        It can also be used to plan a pregnancy.

Disadvantages

-        It requires meticulous record keeping as well as ability and willingness for the individual to monitor her body changes;

-        It restricts sexual spontaneity during the person’s fertile period;

-        It requires extended periods of abstinence from intercourse;

-        It is reliable for individual with regular menstrual cycle; and

-        It may be unreliable during periods of illness, infection, or stress.

Implications

-        Teach the person to keep a diary of her menstrual cycle (for six consecutive cycles) to determine when ovulation is most likely to occur;

-        To calculate her safe periods, tell her to subtract 18 from the shortest cycle and 11 from the longest cycle that she has documented;

-        For instance, if she had 6 menstrual cycles that lasted 26 to 30 days, her fertile period would be from the 8^th day (26 minus 18) to the 19^th day (30 minus 11);

-        To ensure that pregnancy does not occur, she and her partner should abstain from intercourse during days 8 to 19 of her menstrual cycle; and

-        During those fertile days, she and her partner may also choose to use contraceptive foam.