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FINAL BLUEPRINT EXAM HOORAH!!!!!!!!Chapter 13 , 14 – Psychological responses Reproductive system Uterus ● Growth o Occurs due to hyperplasia and hypertrophy; pear-shaped o First trimester: growth caused by hyperplasia, which is caused by stimulation of estrogen and growth factors o Second and third ...

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FINAL BLUEPRINT EXAM HOORAH!!!!!!!! Chapter 13 , 14 – Psychological responses Reproductive system Uterus ● Growth o Occurs due to hyperplasia and hypertrophy; pear-shaped o First trimester: growth caused by hyperplasia, which is caused by stimulation of estrogen and growth factors o Second and third trimester: growth by hypertrophy and hyperplasia, as muscle fibers stretch o Third trimester: uterine muscles are thin, fetus can be palpated through the abdominal wall. Intestines are displaced (upward and lateral) due to movement of uterus into abdominal cavity and rotated to the right ● Pattern o Enlargement of uterus can confirm estimated delivery date o 12 weeks: fundus can be palpated above symphysis pubis o 16 weeks: fundus is between symphysis and umbilicus o 20 weeks: the fundus is at umbilicus o 36 weeks: xiphoid process o 40 weeks: Lightening – descent of fetal head → reduces pressure on diaphragm making breathing easier

Braxton Hicks contractions: irregular contractions → False Labor Blood flow Uterus sz increases = blood flow increases Blood flow to uterus and placenta reache 1200 mL/min

Cervix ● Estrogen → hyperemia(congestion w/blood) → Chadwick’s sign → bluish purple color that extends to include the vagina and labia ● ***Chadwick’s sign = earliest sign of pregnancy ● Mucous plugs cervical canal and blocks bacteria from the vagina into uterus during pregnancy. → The cervical glands proliferate during pregnancy, and the endocervical tissue resembles a honeycomb that fills with mucus. o Basically mucus is blocking the bacteria ● Connective tissue decreases = softer cervix (Goodell’s sign) o Before pregnancy, feels like tip of nose o After conception, cervix feels more like lips or ear lobe ● “Bloody show” = earliest signs of labor o consists of mucous plug w/ small amount of blood. This bleeding occurs from the disruption of the cervical capillaries as the mucus plug is dislodged when the cervix begins to thin and dilate. Vagina and Vulva ● Vascularity → bluish color change of vagina ● Loosening of the abundant connective tissue allows the vagina to distend during childbirth. The vaginal mucosa thickens, and the vaginal rugae (folds) become very prominent. ● Cells have an increased amount of glycogen → vaginal discharge o discharge is acidic d/t lactic acid production from Lactobacillis acidophilus o Acidity helps prevent bacteria, BUT favors growth of yeast infections ● Congestion of pelvis → heightened sexual interest, increased orgasms ● Ovaries o Major function: secrete progesterone from the corpus luteum for the first 6 to 7 weeks of pregnancy. o Progesterone is the hormone of pregnancy. o Corpus luteum secretes progesterone until placenta is fully developed (first 67w) o Ovulation ends during pregnancy d/t progesterone and estrogen → inhibits LH and FSH (needed for ovulation) ● Breast o Striae gravidarum: Lineal tears in connective tissue (stretch mark) o Estrogen stimulates the growth of mammary ductal tissue, and progesterone promotes the growth of lobes, lobules, and alveoli o Breasts highly vascular o Nipples: darker and more erect o Tubercles of Montgomery ▪ Lubricate the nipples

o Colostrum present during 12-16 weeks -- - Can be expressed from the breasts by the third trimester o Milk is suppressed from high levels estrogen/progesterone Cardiovascular system Heart ● Size/Position/Sound o Pushed up & left (mainly 3rd trimester) --upward and laterally o Enlarges due to workload ------- if you remember ch 12, the workload of R atrium increases and that’s why a shunt is created ;) o Changes are first heard between 12 to 20 weeks and regress during the first week after childbirth o Splitting of 1st/3rd heart sound is most common o Systolic murmur found in 95% prego women Blood Volume ● Total volume o Contains plasma, RBC, WBC, and platelets o Increases 45% ● Plasma volume o Increases 40-60% (1200-1600mL) o Increases from 6 to 8 weeks of gestation until approximately 32 weeks o Increase related to vasodilation from nitric oxide and form estrogen and progesterone stimulation of the renin-angiotensin aldosterone system, which stimulates sodium and water retention o Needed for ▪ Transportation of nutrients/oxygen to placenta ▪ Meet demands of expanded maternal tissue ▪ Reserve for AE of blood loss during birth ● RBC mass *** 1st/3rd trimester: o Dilution causes decrease in Hgb/ Hct - Hgb: less than 11 ▪ Named pseudo anemia or - Hct: less than 33% pseudoanemia of pregnancy ***2nd trimester: o Dilution d/t expanded plasma volume & NOT - Hgb: less than 10.5 - Hct: less than 32% decrease in RBC → does not indicate true anemia o Dilution → obstruct blood vessels causing serious complications o Even though blood volume increase, BP is not elevated Cardiac Output ● Based on stroke volume and heart rate ● Increases by 50% in first 8w (CO: amount of blood ejected each minute) ● HR increases approximately 15 to 20 beats per minute

● Most efficient in lateral position, Least efficient supine BP ● Effect on position o Sitting/standing ▪ systolic is unchanged, diastolic decreases by 10mm o Left Lateral ▪ systolic decreases 5-10mm, diastolic decreases 10-15mm ● Supine hypotension syndrome o Weight of gravid uterus occludes vena cava and aorta o s/s: Faintness, lightheaded, dizzy, nausea, agitation, syncope, lapse in consciousness o Blood flow through the placenta also decreases if the woman remains in the supine position for a prolonged period, which could cause fetal hypoxia o Treatment: Lateral recumbent position o Wedge or pillow can be used under hip to help decrease syndrome if required to be supine o Figure 13.4

Blood flow ● Altered to include uteroplacental unit ● More blood circulates kidneys to remove wastes ● Blood flow to breasts increase ● Skin requires increased circulation to decrease heat caused by increased metabolism ● Inferior vena cava & iliac veins obstructs blood (b/c of weight of uterus) to return to veins in legs→ varicose veins, or hemorrhoids Blood components

● Need iron supplementation ● Leukocytes increase o During pregnancy: 5,000-12,000 or 15,000 cells/mm Thrombus: causes blood clots o Postpartum: 25,000-30,000 ● Fibrinolytic activity decreases (break down clots) ● Changes can protect hemorrhage during childbirth but also increase thrombus formation ● Woman must stand or sit for prolonged periods, causing stasis of blood in the veins of the legs Respiratory system ● Oxygen consumption o Increases by 20% o To compensate for increased need of oxygen, hyperventilation occurs ▪ Breathe more deeply, rr does not change ▪ Promotes transfer of oxygen away from fetus and to maternal blood o Tidal volume increased (vol. of gas each breath, in/out) ● Hormonal factors o Progesterone ▪ Decreases airway resistance ▪ Raise sensitivity of medulla oblongata to CO2 → increase minute ventilation o Estrogen ▪ Increases vascularity of mucous membranes ▪ May result in nasal and sinus stuffiness, epistaxis (nosebleed), and deepening of the voice. Sense of fullness in the ears or earaches. ● Physical change o Total lung capacity is decreased o Diaphragm is elevated o Ribs flare, substernal angle widen, thoracic circumference increases o Breathing is more thoracic than abdominal → dyspnea GI system Mouth ● Hyperemia can occur → gingivitis/ bleeding gums ● Ptyalism (excessive salivation) o Caused by ingestion of starch o Treat: small, frequent meals, gum chewing, and oral lozenges ● Periodontal disease exacerbated Esophagus ● Sphincter tone decreases ● Reflux can occur causing pyrosis (heartburn)

PROGESTERONE = relaxes smooth musle !!!

Stomach ● Upward displacement Large/small intestines ● Emptying time is increased, more time for nutrient absorption ● Vitamin B absorption decreased ● Decreased motility → increased absorption BUT causes constipation Liver/gallbladder ● Emptying time is prolonged in gallbladder → thicker bile due to progesterone ● Reduced gallbladder tone ( tendency to retain bile salts) → pruritis (itch) ● 3rd trimester: liver pushed up and back ● serum albumin = decreased ● alkaline phosphatase increases Urinary system Bladder ● frequent urination ● nocturia ● stress/urge incontinence ● base of bladder is pushed up and forward ● Bladder mucosa becomes congested with blood, and the bladder walls become hypertrophied as a result of stimulation from estrogen. ● Decreased drainage of the blood from the base of the bladder makes the tissues edematous and susceptible to trauma Kidney and ureters ● Changes in size and shape o dilation of renal pelvis, calyces, ureters ▪ caused by: progesterone (causes ureters to become longer and more distensible) and compression of ureters o flow of urine in ureters is partially obstructed → stasis of urine → increased UTI ● Functional changes o Increased renal plasma o Increased GFR ▪ Substances exceed ability to reabsorb nutrients → spills into urine → increased UTI ▪ Glycosuria ▪ Mild proteinuria ▪ Blood urea nitrogen, serum creatine decrease Integumentary system Skin ● Increased pigmentation from elevated estrogen, progesterone, and melanocytestimulating hormone may begin as early as the 8th week

● Hyperpigmentation and vascular changes in the skin o Women with dark hair present more than those with light

o Areas include melasma/ chloasma/ mask of pregnancy (brownish patches) ▪ Can occur in ppl take OC ▪ Increases with the exposure of sunlight o Linea alba darkens and becomes Linea niagra (longitudinal line) ● Cutaneous vascular changes ESTROGEN: dilates/ o Spider angiomas -- appear as tiny red elevations that proliferates blood branch in all directions vessels!!!!! o Palmar erythema -- redness of the palms or soles of *normal: can cause the feet epistaxis – nose bleed Connective tissue ● Striae gravidarum o Fades to white or silver o Believe that oil/lotion helps prevent Hair ● Hair grows more rapidly, less hair falls out during pregnancy ● After childbirth o Concerned about rate of hair loss from 2-4months pp ▪ Reassure that hair growth returns normal and excessive hair loss won’t continue o Hair growth becomes normal 6-12months pp Musculoskeletal system Calcium storage ● Fetal demands of calcium increase ● Absorption of calcium increases in 1st trimester, & then calcium is stored ● **No loss of maternal bone density Postural changes ● 28-30 weeks pelvic symphysis separates ● wide stance, waddling gait ● progressive lordosis, curvature of the lower spine, may lead to backache Abdominal Wall ● During the third trimester, the abdominal muscles may become so stretched that the rectus abdominis muscles separate (diastasis recti)

● Can be severe -- large portion of the uterine wall is covered only by the peritoneum, fascia, and skin Endocrine Pituitary gland ● prolactin: breast milk ● oxytocin: contraction of uterus, contraction of breast for breast milk to nipple Thyroid gland ● thyroid hormones important in developing fetal brain ● BMR increases 25% ● Thyroid gland enlarges Parathyroid gland ● Parathyroid hormone decreases 1st trimester, decreases throughout pregnancy ● Important for calcium homeostasis Pancreas ● Hypoglycemia occurs between meals and at night ● Insulin begins to decline second half of pregnancy ● Mom uses FAT for energy Adrenal gland ● Cortisol o Metabolically active form elevated o Regulates carbohydrate and protein metabolism o Stimulates glucogenesis ● Aldosterone o Increased o Helps maintain necessary level of sodium Changes caused by placental hormones ● HCG o Causes positive pregnancy result ● Estrogen o Stimulates uterine growth, increases blood supply o Aids in developing ductal system of breasts to prepare for lactation o Hyperpigmentation, vascular changes in skin, increase salivary glands, hyperemia of gums ● Progesterone o Maintain endometrial layer for implantation o Prevent random abortion → relax/dilation smooth muscles o Stimulate lobes and lobules in breast o Facilitate fat stores (reserves energy) o Increase sensitivity to CO2 → ventilation

o Prevent rejection of fetus ● hCS (Human chorionic somatomammotropin) o aka hPL o increases availability of glucose to fetus ● Relaxin o Produced by corpus luteum, decidua, placenta o Inhibit uterine activity, soften tissue of cervix, lengthen pubic ligaments Changes in metabolism ● Weight gain o Encouraged 25-35 lbs ● Water metabolism o Body water increases 6.5-8.5L ● Dependent edema o Increases when weight of uterus compresses the veins of pelvis. This process delays venous return, causing the veins of the legs to become distended, and increases venous pressure, resulting in additional fluid shifts from the vascular compartment to the interstitial spaces ● Carpal tunnel syndrome o Fluid retention o s/s ▪ pain, burning, numbness or tingling of hand/wrist o splinting wrist necessary at night o resolves 3month pp ● Carbohydrate metabolism Sensory organs Eye ● Corneal edema causes thickening o ***instruct not to get new prescription lenses for several weeks after delivery ● Intraocular pressure decreases Ear ● Changes in mucous can cause mild temporary hearing loss Immune system ● Rheumatoid arthritis might improve during pregnancy Confirmation of pregnancy Presumptive indications of pregnancy (caused by conditions other than pregnancy) Table 13.2

Amenorrhea Nausea/Vomitting ● s/s begin 6-8 weeks Fatigue Urinary frequency ● 3rd trimester: fetus settles in pelvic cavity causing frequency and urgency to increase Breast skin changes Vaginal and cervical color changes ● Chadwick’s sign Fetal movement ● 2nd trimester ● quickening (16-20w) Probable indications of pregnancy ● Signs stronger indicator of pregnancy but cannot be dx d/t may be caused by something else Abdominal enlargement Cervical softening (Goodell’s sign)

Change in Uterus ● Uterine consistency o 6-8 weeks after last period the isthmus is able to be compressed to cervix o Softening (thin like paper), the uterus can be easily flexed against the cervix o ^ Hegar’s sign o Figure 13.7

● Ballottement o Tap on cervix can cause fetus to rise in amniotic fluid then return to position ● Braxton Hicks contraction o Irregular painless contractions ● Palpation of fetal outline ● Uterine soufflé o Soft blowing sound auscultated over uterus o Maternal pulse must be checked simultaneously Pregnancy tests ● Detect HcG for positive test ● Agglutination inhibition test o Uses antibodies to detect hCG o Quick, can be detect positivity early as 3-7 days after conception o At home or lab ● Radioreceptor assay

o Accurate 6-8 days after conception o Detects small amounts of hCG ● Radioimmunoassay o Only in laboratory o Accurate before the first missed period ● Inaccurate pregnancy test results o When test says negative, but she is preggo = false-negative o Hematuria or protein urea can cause false-positive ▪ When test indicates they are pregnant but they aren’t ▪ Some anticonvulsants, antiparkinsonian drugs, hypnotics, tranquilizers cause a false-positive result Positive indications of pregnancy Auscultation of fetal heart sounds ● Stethoscope: 16-20w ● Doppler: 9w ● Heartbeat can be seen on ultrasound: 8w Fetal movement felt by examiner Visualization of fetus ● Confirmation by 3 weeks: transvaginal ultrasonography Antepartum assessment and care Preconception and interconception care ● If not immune to rubella or varicella, vaccines can be given and time frame of 1 month should occur before conception Initial visit History ● Obstetric hx o Info about prior pregnancies to alert HCP about possible problems in present gravid o Primigravida: preggo first time o Multigravida: preggo 1< o Para: #of pregnancies ended at 20+weeks o Nullipara: never completed pregnancy past 20 weeks o Primipara: have delivered one pregnancy at 20+weeks o Multipara: more than one pregnancy at 20+weeks o **number of fetus does not change para o GTPAL ▪ Describe infants ▪ G: gravida ▪ T: term (38 and 42 weeks of gestation) ▪ P: preterm (births between the 20th and 38th week of gestation) ▪ A: abortions ▪ L: living children

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▪ **** ex: A woman is 6 month preggo. Previously had 1 abortion and 1 elective abortion in first trimester. She has son born at 40 weeks of gestation and a daughter born at 34 weeks gestation - GTPAL is 5-1-1-2-2…. Why? - Gravida: 5 (total 5 kids) - T: 1 (son born at 40 weeks) - P: 1 (daughter born at 34 weeks) ---- preterm because its before 38 weeks - A: 2 -- the two abortions are counted in the gravida but are not included in the para because they occured before 20 weeks. - L: 2 (son and daughter) Menstrual hx and EDD o Nagele’s rule ▪ Subtract 3 months ▪ Add 7 ▪ Change date ▪ **ex: LNMP is October 30, 2012 → Subtract 3 months ( July 2012) → Add 7 (August 6, 2013) o Sonogram confirms EDD Gynecologic and contraceptive hx Medical/ Surgical hx o Previous or current conditions Fam Health hx o Info on chronic diseases Partners health hx o Blood incompatibility can occur o Tobacco use by the father increases the risk of upper respiratory complications as a result of passive smoke to both the mother and the infant

Physical examination ● Vital signs o BP ▪ Taken sitting, arm horizontal at heart ▪ Korotkoff’s phase to measure BP ● Korotkoff’s fifth phase (disappearance of sound) is most often used because of the fourth phase (muffling) is not always identifiable ▪ 140/90 mm Hg may indicate preeclampsia o Pulse ▪ Normal 60-90 bpm. Tachy = anxiety, hyperthyroidism, infection o RR ▪ Normal : 16-24 breaths ▪ Tachypnea = respiratory or cardiac disease o Temp

▪ Normal: 97.8 F to 99.6 F (36.6 C – 37.6 C) ● CV system o Venous congestion: most common in legs and vulva (as varicosities), rectum (hemorrhoids) o Edema (may be a benign condition that reflects the pooling of the blood in the extremities) ● Musculoskeletal system o Gait o Height/weight ▪ Underweight= risk for LBW o Abdomen ▪ Fundal height should be measured if the fundus is palpable above the symphysis pubis ● Neurologic system o Deep tendon reflexes should be evaluated ● Integumentary system ● Endocrine system o Thyroid enlarges slightly during the second trimester ● GI system o Mouth o Intestine ▪ Bowel sounds may be diminished ● Urinary system o Protein ▪ Contamination by vaginal secretions, kidney disease, or preeclampsia o Glucose: may indicate spilling ▪ Normal finding, unless excessive amounts o Ketones: found after heavy exercise or inadequate intake of food and fluid ● Reproductive system o Breast o External reproductive organs ▪ Discharge from Bartholin’s glands or Skene’s glands may indicate gonorrheal or chlamydial infection o Internal reproductive organs ▪ Chadwick’s sign and Goodell’s sign are seen during pregnancy. ▪ The external cervical os is closed in primigravidas, but one fingertip may be admitted in multiparas

● Common Lab Test o Table 13.3

Subsequent assessment ● Conception – 28 w: q4 weeks ● 29-36 weeks: q2 weeks ● 37- birth: weekly ● “Counting Pregnancy” -- alternative method o Involves ten 1.5 to 2 hour sessions with small groups of women and healthcare providers beginning at 12 to 16 weeks of pregnancy and ending in early postpartum Vital Signs

● Same arm with the woman in the same position each time Weight ● A gain of 11.5 to 16 kg (25 to 35 lb) is recommended for the woman of normal prepregnancy weight ● Sudden, rapid weight gain may indicate excessive fluid retention Urinalysis ● Tested each visit for protein, glucose, protein ● + nitrate result = infection → use a dipstick Fundal height ● Empty bladder first ● Evaluate fetal growth and confirm gestation age ● 16-18 w is approximately equal to gestational age of fetus in weeks ● Top of the symphysis pubis, over the abdominal curve, to the top of the fundus o Figure 13.9

● Presence of leiomyomata (fibroids) or gestational trophoblastic disease (hydatidiform mole) will affect fundal height Leopold maneuver ● Provide systematic method for palpating fetus through abdominal wall ● Later part of pregnancy ● Location and presentation of the fetus Fetal Heart Rate ● 110 and 160 bpm Fetal Activity ● 16 to 20 weeks of gestation ● Kick counts Glucose screen

● Done 24-28 weeks by glucose challenge test o + = gestational diabetes o Not necessary in women younger than 2...