Prenatal Care

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Prenatal Care

• Anna Mae Smith, MPAS, PA-C

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Signs of Fetal Life

• hearing the fetal heart with a stethoscope or a
  Doppler
  
• visualizing the fetal heart with real-time
  ultrasound
  
• palpating fetal movements

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Diagnosis of Fetal Death

• early in pregnancy
• initially accompanied by failure of uterine
  growth
  
• 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

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• 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
  death
  
• 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)

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Estimation of the Duration of Pregnancy

• mean duration of pregnancy is 266 days from
  conception
  
• 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,
  1993)
  
• based on premise ovulation occurs on day 14 of 28
  day cycle

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

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• 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

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Initial Prenatal Visit

• Confirmation of pregnancy
• History
• medical history
• psychosocial history
• family history
• surgical history
• genetic-familial history of both patient and
  spouse

• reproductive history
• menstrual history
• contraceptive history
• gynecologic history
• obstetrical history
• sexual history
• medications/exposures since LMP
• alcohol
• smoking
• social drugs
• medications

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• 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.

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• 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

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• 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

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• 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

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• 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

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• 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

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Physiological Changes in Pregnancy That Influence
Sexuality
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Couple Concerns Regarding Sexuality During
Pregnancy

• 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
  taboos
  
• a declining desire for intimacy as the woman
  withdraws or focuses on infant preparation

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Contraindications to Sexual Intercourse

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

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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

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• 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)
  level
  
• perform amniocentesis

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• 20 weeks
• auscultate fetal heart with fetoscope
• reassess gestational age if clinical dates not
  confirmed
  
• 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

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• 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

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• 36-40 weeks
• assess fetal position and presentation
• forward copy of patients prenatal records to
  LD
  
• 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

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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
  trimester
  
• depends upon initial weight of mother
• weight loss during pregnancy not advised
• 2nd trimester weight gain reflects maternal
  growth
  
• 3rd trimester weight gain reflects growth of
  intrauterine contents

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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

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Gotta have my cigarette!
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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
  implicated
  
• best advice complete abstinence from alcohol

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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.

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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

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• 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

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• 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
  1-2
  
• symptomatic amnionitis in less than 1 of 1000
• serious maternal bowel or vascular injuries
  extremely rare

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• 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
  studies)
  
• greater level of maternal cell contamination
• transabdominal
• increased incidents of limb anomalies in very
  early CVS

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• 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

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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

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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
  midnight.
  
• Take at least two 10-minute rest periods and one
  nutrition break per shift, with adequate rest
  facilities available.

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• 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.

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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
  dyspnea)
• uterine abnormalities
• Marfans syndrome
• hemoglobinopathies

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Exercise ProgramsDuring Pregnancy

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

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• 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
  min.
  
• 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
  gradually

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• 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

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• rise slowly following exercise to avoid
  dizziness
  
• 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

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• 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
  rising

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

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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

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Pregnancy Complications Which May Prohibit
Exercise

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

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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
  circulation

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Travel

• 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
  traveling.
  
• Travel may be contraindicated with certain
  complications
  
• 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

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• 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
  traveling
  
• 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

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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

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• 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
  gravidarum
  
• 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
  intolerance

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• 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
  diphenhydramine
  
• 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
  snacks
  
• sip carbonated drinks

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• eat crackers on arising
• drink fluids between meals rather than with
  meals
  
• 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
  obstruction
  
• Drink 8 oz water with each dose.
• May need to continue treatment for 2-3 days
  before maximum effect noted.

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• Docusate sodium (Colace), a stool softener
• 50-200 mg per day
• Side-effects bitter taste, throat irritation,
  nausea
  
• Contraindications sensitivity to docusate
  sodium
  
• 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
  motility

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• 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
  tissues
  
• 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
  added)
  
• 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

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• 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

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• 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
  backache
  
• place pillows behind back or raising head of bed
  up on blocks to increase comfort and reduce
  insomnia
  
• 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
  day
  
• warm milk may help induce sleep

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• 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

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• 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
  caffeine
  
• 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

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• 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
  period
  
• Headache
• women who had HAs prior to pregnancy
• 60 improve
• 13 worsen
• 27 no change
• Medication
• Acetaminophen 325 - 650 mg q4hrs prn

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• Lifestyle changes
• avoid activities and situations that may trigger
  HAs
  
• 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

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• nitrites
• hard aged cheese
• alcohol, especially red wine
• Breast Pain, Enlargement, and Changes in
  Pigmentation
  
• 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
  sleeping
  
• 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
  stretching
  
• 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
  girdle

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• 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
  bed
  
• 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

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• Dietary interventions
• eat regularly throughout the day
• assess diet for adequate calorie and fluid
  intake
  
• 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
  clothing
  
• wear cotton underwear
• wear a nightgown without underwear at night
• if using panty liners, use unscented/nondeodorant
  ones, changing them frequently

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• 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

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• light packing of the nose with sterile gauze may
  help
  
• 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

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• 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

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• 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
  strain
  
• 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

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• 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

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• 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

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• 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
  arms
  
• 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
  numbness
  
• 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

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• 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

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• 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

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• 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
  sleeping
  
• Emotional Lability
• Dietary interventions
• assess adequacy of diet
• make sure caloric intake is spread throughout the
  day

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