Cultural Considerations in Preconception Care

lesson one is titled before conception student objectives for lesson one include number one explain cultural considerations when working with a client and how to provide culturally competent care number two students should be able to determine how a client's preconception age health history and health status can affect pregnancy and birth number three document the components of ob gyn health history including gtpal gp and calculate estimated dates of delivery using nagel's rule number four explain the function of key female reproductive hormones in the phases of the reproductive cycle and five students should examine the different ways of confirming pregnancy and distinguish between presumptive probable and positive signs of pregnancy let's look at the context of culture and what that includes if you were to give me some examples of culture in health care you might give me examples of maybe jewish cultures catholics muslims a lot of those cultures that may be religious based but just know culture includes religion language it can be a profession culture can include age gender identity disabilities sexual orientation beliefs and traditions the book uses the example of jehovah's witnesses who do not practice receiving blood donations and that certainly is a culture this may be the client's faith however keep in mind that there are still individual preferences even though they follow their faith this individual may not have that preference to not receive blood products even though they're jehovah's witness they may still in a health care situation want to have a blood donation if needed so keep that in mind that you don't stereotype when it comes to culture there are jewish cultures that avoid certain diets they believe in a kosher diet they have rabbis that perform circumcision on infants rather than doctors catholics i was a religion that i mentioned earlier that certainly can be identified as a culture in the muslim faith which could also be a culture um there are no men allowed in the delivery rooms um so therefore physicians who are female or sought after or nurse female nurse midwives in that culture men predominantly there are the decision makers hispanic cultures those are family oriented cultures usually the matriarch of the family is the decision maker in the hispanic culture a lot of times too if we're talking about different things that occur in certain cultures they may bottle feed until the breast milk comes in that's just something that i've noticed in taking care of hispanic clients in the ob setting chinese cultures they tend to take care of each other in an extended family fashion um you might see parents go to work right after having a baby and then the grandparents come in to care and nurture that infant through the growth they also believe in something called yin and yang where certain foods are necessary for illnesses whether it's hot or cold foods the vietnamese these individuals practice herbal remedies um they also believe in non-traditional healers like sean's so that's something to keep in mind whenever caring for clients that are vietnamese especially with the herbal remedies because what you probably learned in your assessment class is that when you're taking a health history on medications if they take herbs of any kind that might might interfere with whatever medications are being prescribed so just know that the key to cultural competence is good communication and keeping an open mind we as nurses should not make assumptions that simply because a client identifies with a culture such as religion that the patient will identify with it and always follow it like i said with the jehovah's witness in the blood products so on the other end there is an importance of respecting patient values and incorporating into the client's care if there are resources that can provide to assist incorporating culture the nurse should do so so for example providing a female doctor for a muslim patient coming into the ob setting or maybe calling upon a dietitian for a client who um only um consumes a vegan diet or a kosher diet for the jo or the jewish culture um because there's other ways to get in protein and and we if we could help them along by providing a dietitian to help them get the right food during their pregnancy that's the most important thing to do and still allow them to respect their culture now not all diets or cultural diets are bad for the clients so just know that those adjustments can be made another example is calling in a pharmacist to discuss the impact of her remedies of herbal remedies on on pregnancy that would be another example when we discuss cultural context on this slide especially i want you to focus on cultural competence cultural competence is recognizing and respecting culture and integrating aspects important to that individual's culture so here it discusses that it's effectively in integrating elements of culture whether that being vocabulary values attitudes or rules are in norms so it's just putting that knowledge of culture into action because as i said before one of our greatest pitfalls in nursing is stereotyping we need to avoid unintentionally stereotyping um this is just our own misconceptions or our opinions or our beliefs about some aspect of an individual or a group of people so to prevent better to provide care it's important to assess the client's cultural needs and i did and identify your ability as a nurse to address them so it's involving the client and representing their culture within their birth plan and facilitating um that culture practice and to that plan of care so just remember it's ultimately the decision of the client um you will have a cultural diversity assignment where in clinical you'll be presenting on this you'll pick a culture and you'll present on birth practices to become more culturally competent so for example in the past some of these cultures that were chosen were sweden germany india russia spain italy australia iran let's see japan china taiwan the philippines korea vietnamese there's just a vast number of cultural variations and where you'll discuss religion language family structure birth practices all of that's going to vary so it might be beneficial to your research to already know what topic you want to choose and then support uh your presentation on that culture with evidence-based references um you'll turn in your chosen culture to your clinical instructor as soon as you know what it's going to be or whatever you've chosen and it's best to do that early before someone else picks the culture you want and then you'll present and we'll learn a little something so let's practice a question to see what you have learned a student nurse is concerned about learning enough about different cultures to deliver competent care the preceptor responds by saying a responding effectively to different cultures means always using an interpreter to communicate b you will never know everything so focus on cultural sensitivity for people born in other countries or c you will never know everything but keep an open mind and communicating effectively will help or d you only need to be concerned about knowing about the main cultures in our community take a minute decide your answer and we'll review in the next slide the correct answer is c you will never know everything but keep an open mind and communicating effectively will help communicating effectively and keeping open mind will help the nurse better understand the patient's perspectives and needs providing culturally competent care is more than using an interpreter attempts to better understand the patient's perspective should be made with all patients not just specific cultural groups so communication barriers will happen in certain facilities they do have paid interpreters for those that are do not such as southeast health they have approved interpreters by phone they have a 1 800 number where you call and you have standby interpreters that can translate the language of choice we never use family members or small children or maybe the hispanic gsr that comes by getting orders for the trace um because we don't know really what they're telling them and certain languages do have different dialects so client family and friends do do not qualify as a source of interpretation they could be monopolizing the client or may not understand the medical terminology so it's best to provide the appropriate interpreter that the facility uses or maybe even the phone system but in this case yes you will never know everything and as we discussed we need to keep an open mind now we're going to focus on preconception age so the first few weeks of pregnancy is the most critical due to what's called organogenesis this is the formation of fetal organs and occurs in weeks three to ten gestation so early education and interventions are critical um it's best to be planning to get pregnant and and having discussed this with a client rather than them finding out they've been pregnant for quite a while so that you can provide them with the right amount of education and interventions and it's important to obtain a health history and identify the clients for risk factors to help promote those healthy behaviors so the average maternal age at the time of first birth is usually around 26.3 years so we're looking at healthy pregnancies between the ages maternal ages of 20 to 34 years and those are are the age ranges that are not as considered high risk pregnancies after the age of 35 and over are considered high risk this is because there is diminished egg quality after certain age and increased risk of pregnancy-related complications and there is also an increased risk of pre-existing health conditions so just fyi pregnancies in women age 35 and over are more likely to end in an abortion than any other group and i'm not talking elective abortion i'm talking spontaneous so adolescence um under the age of 20 they tend to seek like health care and pregnancy maybe it's more of their they're hiding it they're scared or maybe they are just um in denial but a lot of adolescents are abandoned by their partner and they struggle to even complete education if you're familiar with erickson's developmental task they fail to go forward here in that sense of self there are usually sometimes no support system such as family that are helpful and they tend to not know where to seek assistance through certain social programs so keep in mind that there are estate laws regarding disclosure of adolescent health care information so once adolescents come in and have experienced sexual behavior including they maybe want to obtain contraception or maybe they're seeking health care for an sti or sexually transmitted infection or they're seeking an abortion or pregnancy results there are state laws that require us not to disclose this information to anyone for that reason but it's best to just to encourage discussions with the parents or guardians and there is also a legal duty for the nurse to report teen abuse even if it's a minor so in this case just know that these laws protect these teens you can't necessarily disclose any of this health information to the parents or the guardians but we can disclose it to the adolescent and encourage them to talk to their parent our guardian however we we can also report if we think there is abuse so just like any client sinking healthcare ob gyn client will also seek health care and receive a health history so we're looking at that holistic interview we're wanting to know their sexual history we have questions about their self-care behaviors we review all the body systems we're looking at that biographic data their date of birth their weight all of that information allergies if they have them what their diet their sleeping patterns are what immunizations they've had and still need and then workplace and environmental habits their nutrition or eating habits and their family history it's it's pretty uh basic but it's important that we optimize health in a current pregnancy by understanding a woman's gynecologic and her obstetric history so for example if a woman has previously delivered a back or stomach or large infant in a previous pregnancy the provider now can look at this health history and encourage a diet change and monitor that patient closely for something called gestational diabetes so we review um sexual history so in review that's the number maybe a partners that they've had self-care practices that could be their health lifestyle of diet and exercise systems in the body that's their respiratory their cardiac or gi gu um what is going on in those systems maybe they have a history of murmurs maybe gi they're experiencing some nausea right now because of the pregnancy or gu could be urinary frequency that biographical data the name the address the date of birth marital status allergies penicillin that's a big one if this patient ends up positive or something called group beta strep if they're allergic to penicillin we'll have to treat that client with a different type of antibiotic instead of penicillin diet for example women of childbearing age wishing to become pregnant they need to be consuming 400 to 800 of folic acid a day this helps prevent birth defects so this helps that baby's brain and spinal cord in development look at sleep something else we need to look at is immunizations because there are vaccinations that may be administered during pregnancy and there are some that we don't want our clients to receive during pregnancy we won the non-live vaccines for our pregnant patients so non-live vaccines can be the annual flu vaccine the tdap um for pregnancy and we give that usually between 27 and 37 weeks of pregnancy and then hepatitis b vaccine can also be administered it is not a lie viruses virus vaccines that should be administered preconception or postpartum this means not during pregnancy would be that of measles mumps and rubella tigers can be drawn for this to see if they need to be administered prior to conception varicella virus or chickenpox vaccine hepatitis a pneumococcal virus poliovirus human papillomavirus those are all live that we would not want our patients to receive during pregnancy we'll discuss exposure to environmental toxins um with the health history so we're looking at uh teratogens t-e-r-a-t-o-g-e-n-s is how that's spelled um these can cause birth defects uh childhood cancers they can impair brain development they can cause miscarriage and stillbirth so exposures to large amounts of ocean fish or fish high in mercury this can cause birth defects or damage to the central nervous system pesticides would be a teratogen solvents some some dietary animal fats a bpa containing plastics would be another example processed foods like deli meats these are uncooked uh foods especially that can expose the mom and fetus to something like listeria um fruits and vegetables that aren't washed thoroughly would be also another type of environmental toxin i think your book also mentions the zikr zika virus because it's kind of a new and out there kind of thing and it causes neurological effects on on the fetus eating habits patients are strongly encouraged to reach and maintain a goal weight and that bmi would be of 18.5 and 30 and this is just prior to seeking pregnancy obesity and pregnancy that can be associated with birth defects like infertility gestational diabetes and other complications so a maternal bmi below 18.5 is correlated with a low birth weight and preterm birth so we like to keep that 18.5 between 18.5 and 30 as bmi for pregnancy so when obtaining a health history of a client we also want to know their gynecological history um so we ask questions that like the age of their men are or their first menses for some it could be 12 13 14 or it could be later on they could be um 18 or 19. um so the first menses is important because both early and late menarche may be associated with certain physical conditions um it can also be associated with socio-economic correlations um we'll ask the client their date of last menstrual period or lmp that is actually the first day of the most recent menses or most recent period it's referred to as the lnp this date helps us predict when a woman may be most likely ready to conceive so lmp then we ask questions like the length of their cycle or their period their regularity is it every 28 days we ask them about sexually transmitted infections or stis you might have heard this also called stds but your book discusses them as stis some examples of those would be gonorrhea and chlamydia those cause permanent damage to the fallopian tubes they can impair a woman for fertility hiv it's important to know of their hiv status because we can treat hiv during pregnancy to prevent transmission to the newborn genital herpes a big one it must be treated immediately before and during delivery to prevent transmission to the fetus if there's an active genital herpes lesion in the vagina during delivery um we need to know about it so that we could maybe take that baby via caesarean section so it doesn't have to pass through the birth canal hepatitis b measures can be taken after birth to prevent the neonate from contracting that that disease and then hepatitis c this can be passed this infection can be passed on to the child as well when you know their history of gynecological surgeries um certain surgeries may make pregnancy or labor more challenging for example the cervix may be less likely to dilate surgery on the uterus maybe like a previous c-section but may make it more likely to rupture during labor surgery for a woman with endometriosis may improve her chances for even getting pregnant um surgeries that's important to know chronological conditions that would include say for instance endometriosis this endometriosis this thickened lining this can make it very difficult to get pregnant because the embryo cannot attach to the uterine wall as easily it may be that the client has a malformed uterus and may make it less likely that pregnancy can be successful successfully carried to term so those are some things to keep in mind also something else to keep in mind is the medications that patients might be on those can be teratogens as well the food and drug administration or fda it requires specific labeling of medications to reflect the risk in pregnancy they categorize medications a b c d or x and this just informs that broad nature of risk of medication to pregnancy a lot of psychological medications can be harmful in pregnancy an obstetric health history includes dates of prior delivery so a delivery within the prior year may increase a female's chances of pregnancy complications so we need to know how close they were gestational agent delivery this is a significant risk for preterm births especially if the female has had a prior preterm birth so and it's the same even with post term but we need to know what gestation the last delivery occurred was it earlier late mode of delivery um a pasty serum section or c-section may make um a future vaginal birth less likely just because there's at risk for tearing that uterine wall anesthesia that's good to know because previous surgeries or births with complications due to anesthesia would have to be carefully recorded so that we can make adjustments for the next delivery pregnancy outcomes this could be captured on our records of gtal which we're going to discuss but we need to need to know the outcomes of pregnancy you know how many pregnancies a woman has carried a term for example how many pregnancies had total has she had any abortions how many does she have that are living and that is something we're going to discuss uh coming up the sex of the child this just informs the healthcare providers that the family views and what is preferred for the family with children is identified and that some chromosomal defects may be revealed within a family so we just need to know the sex of the child or children that they've had length of labor timing of the past experiences with labor may indicate the length of future labors and this assists with planning so um if she's had really fast deliveries and maybe didn't make it for the physician to even attend maybe they will do a different type of plan so that she doesn't have a precipitous delivery the next time around birth weight and percentile we look at past small for gestational age or large for gestational age infants and we just highlight those complications that they've had with those pregnancies it could be that maybe there was some malnutrition or hypertension or if it's you know large for gestational babies maybe there was some gestational diabetes and that baby was swimming around and sugar getting nice and chunky um but it is good to know um the birth weight and percentile other things we look at is controlled hypertension because hypertension puts moms at risk for stroke arrhythmias growth restricted infants it also affects maternal mortality and then also predisposes infants to preterm births hemorrhage this is just a lot of bleeding so with previous pregnancies this can cause reoccurrence with future pregnancies things like placental abruption this is where placenta detaches from the wall of the uterus this could happen especially with placenta previa where the placenta is coming first instead of the baby the placenta just fyi it attaches to a new location in the uterine wall each pregnancy so percents placenta abruption is something that is flagged when we're doing a health history for sure diabetes this if a patient has diabetes this can cause preeclampsia it predisposes that pregnancy for c-section birth because it may be a large for gestational age infant now that's not to say they couldn't have an sga baby as small for gestation we have to be concerned with what's going to happen to the baby for neonatal hypoglycemia after it's born will it be able to sustain sugars or will it drop them we look at congenital abnormalities so that's why we also look at maternal bmi we need that maternal bmi to be in that range of 18.5 and 30. we look at length of labor the timing of the past experiences may indicate the length of future labor um and then pregnancy complications that's just problems whether it be pre-eclampsia or fetal complications maybe there's inner uterine growth restriction maybe the baby was born with neonatal complications like respiratory distress syndrome all of that has to be carefully recorded so for a health history um we need to keep in mind the definition of term pregnancies especially if we're asking about previous pregnancies and how far they carried the baby but just for your knowledge an early term pregnancy is 37 through 38 and 6 7 weeks full term is 39 through 40 and 6 7's weeks late turn pregnancy is 41 through 41 and 6 7 week and then a post-term pregnancy would be 42 weeks and beyond when obtaining a woman's health history it is important that we have an understanding of the number of times she's been pregnant how many living children she has and how many non-viable pregnancies there are there's a way to do this and that is to obtain a gtpal and we also get what's called a gp now i want you to understand something the p in both of these means something different the p in gtpal is the number of pre-term pregnancies the p in gp is the number of viable pregnancies regarding the outcome greater than 20 weeks so let's let's discuss this okay we look at g in gtpal g is the gravida that is the number of times or number of pregnancies a woman has had in her lifetime regardless of how it ended so the number of times a woman has been pregnant regardless of how it ended t in gdpal stands for term births so the term births or pregnancies at 37 weeks regardless the outcome regardless if they were born alive or not so here keep in mind you need to account the number of pregnancies not the number of infants born the number of term births at 37 weeks regardless of the outcome now p like i said this means something different in each of these realms p here is the number of pre-term and pre-term is designated 20 to 37 weeks and six days regardless of the outcome so it could be that the baby was born and maybe lived for for six days so the number of pregnancies or the number of preterm pregnancies 20 to 37 weeks in six days regardless the outcome as with the term in this case for example a twin pregnancy that would still be counted as one not two just so we have that understanding a here is abortion this can be elective or spontaneous abortion before 20 weeks this is regardless the number of fetuses included in the pregnancy so again as before with a twin pregnancy ending prior to 20 weeks this would still be counted as one all right and as you look here on this slide the table in your book doesn't always spell this out but it does within your text so read your book so you can get an understanding of this it also says here with a abortion and i know i said this could be elected they chose to have an abortion or it could be spontaneous and they had a miscarriage but if you note here on this table it says a patient with a pregnancy history including a spontaneous abortion and one elected abortion might have a one-to-one ratio if you want to write it like that that's fine sometimes i see students add this together as long as they're noted that's all i'm really looking for but the elective one might come before the spontaneous one and they might note that as one one so if she's had an elective um meaning she had an abortion and then um a spontaneous that would be labeled one slash one depending on the on the system that's used that's usually how sometimes we see it but like i said i've seen students add them together and i'm okay with that l stands for living all right this accounts for the children alive at the time of the recording so the number of living children that they have all right let's look at gp this gravida still means the same as it does in gtpal g here means the number of pregnancy a woman has had in her lifetime so that's still the same but p in this realm is different p is the number of viable pregnancies regardless the outcome greater than 20 weeks and i believe your book gives a range of like 20 to 24 weeks okay so just keep in mind that the piece means something different between gtpal and gp okay i'm going to use a highlighter here to help explain the difference between gtpal and gp so we're going to go through this slide together we're going to read the first sample here this is a sample of stress history of a client so our client is pregnant for the first time so under our gravity the number of times a woman has been pregnant we have her down for one okay so this since this is her first pregnancy she does not have any term children already or any term births um that's births at 37 weeks or greater regardless the outcome and then remember in gtpal the p stands for the number of pre-term um 20 to 37 weeks regardless the outcome so at this point in time she has no pre-terms so she's at a zero and a stands for abortions whether that's elective or spontaneous well this is her first time being pregnant she's at zero and zero she has no living children yet this is just her first pregnancy so if we look at gp remember g stands for the same thing here that's the um number of times a woman has been pregnant and she's pregnant currently so she's at a gravito one now for gp the p means something different the p here is the number of viable pregnancies regardless the outcome greater than 20 weeks well she has none at this point time so she is a a pair of zero okay so the client's pregnancy ends within electro abortion so that means she chose to have an abortion well she still has been pregnant one time so she has a gravido one t stands for term this pregnancy did not go to terms she electively had an abortion so she is a t zero p here stands for pre-term um she did not have a preterm infant because more than likely this elective abortion occurred before 20 weeks so that would be a pre-term of zero a for abortion here she's zero when it comes to um the spontaneous abortion but she chose to have an elective abortion so that makes her an a1 okay and then living she has no living so she's a zero so with gp remember g is the same thing the number of times a woman's been pregnant so she's um a gravida 1 and p here does not stand for preterm but p stands for the number of viable pregnancies regardless the outcome greater than 20 weeks she does not have a viable pregnancy so she's a para zero okay now our client is pregnant for the second time but she chose or she did not choose she had a spontaneous abortion so she's now a gravida ii she's on her second pregnancy she has not had any term births at 37 weeks regardless of the outcome so she is a term zero or t zero piece here stands for pre-term she's not had any um pre-term births regardless the outcome between 20 and 37 weeks so she is a pre-term zero now if we look look at abortions she had that elective abortion so that was at one but now this is a spontaneous abortion so she's a a1 and 1. still she has no living children however when we look at gp she still is a gravida 2 meaning she has been pregnant two times and then when we look at p here this is for the number of viable pregnancy regardless the outcome greater than 20 weeks she still has no had no viable pregnancies so she is a g2 para zero okay now the client has been pregnant uh for a third time and she is with twins and she delivers those twins at 30 weeks okay so now we have to really pay attention so if we look at gravida the number of times she's been pregnant even though this is a set of twins we count this as one pregnancy so where she's had two previous pregnancies and then this pregnancy with twins she's actually a gravida three in pregnancies she's been pregnant three times okay has she had any term children yet no so she's still at a zero here we're looking at the number of pre-term births um that's pre-term 20 to 37 weeks regardless the outcome well she delivers at 30 weeks she delivers twins at 30 weeks so if we're looking at pre-term births between 20 and 37 weeks regardless the outcome she's had one pre-term birth and that's with the twins even though she had two babies it's still one preterm birth okay now we look at her elective and spontaneous abortion she had one elective and one spontaneous so she's in a one in one now how many living children has she had well so far she had had the elective and spontaneous abortion she was at a zero but now she's delivered twins at 30 weeks so she now has two living children okay so let's assess her gravita pera here not gravity pre-term gravity para so gravitas still means the same thing that's the number of times she's been pregnant even though this is twins this is really her third time being pregnant so she's a gravida three she had the elective the spontaneous and pregnant the twin pregnancy so she did gravita3 now p does not stand for preterm here remember p is the number of viable pregnancies regardless the outcome greater than 20 weeks well she's had this one viable pregnancy with the twins and she delivered it delivered these twins at 30 weeks so that's greater than the 20 week mark off or time period so she's now a g 3 pair of one follow me all right let's move on to the next now our client is pregnant again and she delivers a stillborn infant at 30 weeks gestation okay so when we look at gravida here the number time she's been pregnant she's had an elective abortion that's one a spontaneous abortion that's two pregnancies she's had a pregnancy with twins at 30 weeks so that's three pregnancies and now she's had a stillborn infant at 38 weeks that is four pregnancies total now t stands for term how many um term deliveries had she had now regardless of the outcome term births are 37 weeks regardless of the outcome well we can only count the 38 weeks stillborn infant as a term pregnancy because 38 weeks is term and regardless of the outcome this baby didn't make it but it's still term okay so she is a t one p here stands for preterm okay and preterm is the number of preterm pregnancies between 20 and 37 weeks regardless the outcome well she had 30 week twins so that pregnancy is a one okay so she's a p pre-term one she still had one elective and one spontaneous abortion but now how many living children does she have well so far she's only had abortions and a still birth but the only living one she's had was those 30 week twins so those count as two living children okay so again she's been pregnant four times but p in the gp realm of things peace here stands for the number of viable pregnancies regardless the outcome greater than 20 weeks okay so our p here would mean her number of viable pregnancies would be two she's had the the 30-week pregnancy with twins and then the 38 week stillborn infants because it's regardless the outcome so she is a para two okay the client is pregnant for the final time she delivers a viable infant at 40 weeks gestation okay so she's had an elective a spontaneous a twin pregnancy is stillborn and now a 40 weaker that's five pregnancies if you add that up so she's a gravitative five now how many term children does she have well she did she had twins but they weren't term at 30 weeks okay and this is regardless of the outcome so when we look at her 38 week delivery of a stillborn infant that one counts even though regardless the outcome that baby didn't make it it still counts as a term pregnancy and now this 40-week baby counts as a term pregnancy so she's a t2 now p here is the number of pre-term between 20 and 37 weeks regardless of the outcome so she had a pre-term birth at 30 weeks of twins and that counts as one pre-term pregnancy okay now we remember her abortions here she had the one elective and the one spontaneous so she's an a one in one now how many living children does she have she had the two abortions and she had the stillbirth but she had successfully delivered living twins and now this 40 weaker so if we count those number of children she has three living children okay gravida number gravity of five pregnancies total um and then if we look at para here this is the number of viable pregnancies regardless the outcome greater than 20 weeks okay so the 38 weaker counts here the 40 weaker counts here and then the twin pregnancy counts here so she's a pair of three gravita five pair of three okay when obtaining a health history we may need to calculate a woman's estimated uh due date okay and to do this we use what's called niggles rule nagel's rule is used for estimating an expected due date based on a woman's last menstrual period or lmp um this calculation is based upon a woman having a regular cycle a 28-day menstrual cycle um and a gestational period of 280 days or 40 weeks again this it varies slightly um it might vary for mothers that are first-time moms because they tend to have slightly longer pregnancies um but nagel's rule it's just a calculation it's an estimation so um it's always a given if we look at our months that there are various number of days within each month like for example february is 28 days regardless of the leap year just to keep things simple um so you need to know which months have 30 days versus 31 and and i can tell you september april june and november have 30 days but if you need to pull out your mnemonic or your little saying that you were taught as a child it goes 30 days has september april june and november all the rest have 31 except for february alone which has but 28 days clear and 29 in each leap year okay so according to this slide there are two different ways to calculate nagel's rule you can subtract three months from the last known menstrual period date and add seven days to that lmp and add one year this calculation is usually used for a woman whose last metro period falls between the months of april through december or you can do it this way you can add seven days and add nine months or vice versa and that calculation usually falls for a woman who has a last menstrual period between the month of january through march okay so let's do this example down here if you want to do the first one at the top where you subtract three months add seven days and then add a year if a woman came in and said hey and i don't have a year on here you can do that yourself if you want um but if it's if she says hey my last menstrual period was um june 6 of 2019 you would subtract three months from june and that will give you the month of march so you just say okay march 6th at this point you would add seven days to march 6 so 7 7 8 9 10 11 12 13 takes you to march 13th and if she said the year was 2019 you're just going to add a year that would make it march 13 2020 okay or if you wanted to try the one below where you add nine months and seven days so say um your patient gives you a last menstrual period of january 5th 2017. so if you add say um seven days to that so fifth six seven eight nine ten eleven twelve would give you the twelve and then you add uh nine months to january um that would put you october 12 2017 okay so there there's a few that you can you can practice you can create some dates and try to do those in your head if you want to and see how close you are but i would certainly practice that before the exam and if you have any questions please come see me or mrs hubbard i included a link here and you can copy and paste that in your web browser and watch it it's just the fertilization of an egg after ovulation ova or that's what they're called or they're viable for fertilization that usually is between 6 and 24 hours not a very big marginal window there so sperm are capable of fertilizing that egg for up as long up to as long as five days okay fertilization here generally occurs in the fallopian tube which you can see in this video when that sperm fertilizes the egg additional sperm become blocked from that penetration it's it's a cortical reaction is what it's called that then becomes conception so after conception the 23 chromosomes of the sperm unite with the 23 remaining chromosomes of the ovum or the egg and they kind of create a diploid zygote with 46 chromosomes if you remember back to your science classes and then um implantation happens within the wall of the uterus and everything just has to be the right medium for that especially when we talk about the phases um like the peripheration phase and that's all coming up but this might be an interesting little video to kind of just kind of have a view of how that fertilization happens this is just another video that you can copy and paste this link in your browser and watch if you want to about conception and birth i think it may even play to music okay i had mentioned previously that a typical cycle for female menstruation or period is a 28-day cycle um within that cycle hormones such as estrogen progesterone a luteinizing hormone otherwise known as lh hormone luteinizing is spelled l-u-t-e-i-n-i-z-i-n-g or a follicle stimulating hormone fsh those hormones are responsible for signaling the maternal anterior pituitary um and once that's signaled for hormone release that assists in ovulation so there's a lot of interactions that have to occur between the ovaries that anterior pituitary and the hypothalamus to regulate a female reproductive cycle okay so this is just a slide kind of um showing you um that reproductive cycle and when the egg is released it does have on here the fsh the lh and when that all kind of occurs you can see the lh is identified as the dashed line and the estrogen is the solid purple the progesterone is that little solid blue green and then that follicle stimulating hormone is that kind of light blue dash line and then you can see the days of the cycle under there and when most likely that egg is released and so we're going to talk about these hormones um the fs h hormone the follicle stimulating hormone that is responsible for the maturation of the follicle of the ovary where that egg is released so that follicle gets mature the egg starts to release that's what that fsh hormone is for the luteinizing hormone the lh hormone that is responsible for that actual egg release from the follicle okay so the fsh is stimulating it the lh is causing that aid to be released um this lh level it peaks approximately and you can see on here uh 14 days all right um if so if you follow the lh line you can see it looks like the follicles release the egg um it's 14 days before menses to cause ovulation so this hormone guys this hormone initiates the menstrual cycle to occur all over again so each time you know a woman has a period it's this uh lh hormone that's initiating that cycle to curl again and again the body begins to prepare for ovulation here which could possibly be around day 14. so some women they start to if they're trying to get pregnant they start to take their temperature here because that's important to plan for this in order to get that best time to conceive okay now estrogen hormone that assists in what's called the proliferation or the growth of that endometrial lining after menstruation so that estrogen is responsible for that growth of that lining progesterone that helps maintain the uterine lining as well as relaxing the smooth muscle of the uterus it causes vasodilation to get good blood flow through the uterus and this is so important because that progesterone allows the uterus to support a pregnancy it supports implantation it is responsible progesterone is responsible for the rise in body temperature that lets us know that ovulation has occurred so when these women are checking their temperature it's that progesterone that's causing that body temp to rise and then they know okay ovulation has occurred i'm going to have to have intercourse in order to conceive it's when there is a drop in that temperature that means that there was no fertilization so a drop in progesterone there's no fertilization um when there is no fertilization menstruation occurs and the lining of the uterus sheds so we have that bleeding and again it's a 28 day cycle that lowering of the progesterone and estrogen that stimulates the hypothalamus to produce that gonadotropin releasing hormone it's otherwise abbreviated gnrh it just cues that anterior pituitary to produce fsh and that follicle stimulating hormone and lh that luteinizing hormone to start that whole thing all over again so there are three phases of the reproductive cycle we're going to talk about the proliferative phase the secretory phase and the ischemic phase okay as i said before regarding the menstrual cycle menstruation typically begins about 12 to 14 days after ovulation so many women find factors such as an illness or stress that might affect the timing of their menses so this can vary whereas others cycles they just remain consistent so menstrual flow if you are not familiar with menstrual flow consists of blood vaginal and cervical secretions some bacteria and just cellular debris a woman can lose around 10 to 80 milliliters of blood over two to seven days so menses may be red initially or brown depending on the duration of the time that that blood is pulled in the uterus older blood like the brown color um or maybe just the newer redder blood so it just depends so let's talk about these phases let's start with the pluriphorative phase during the proliferative phase the endometrium it thickens in response to that estrogen produced by the ovaries so close to ovulation the cervical mucus becomes particularly elastic inconsistency and egg white in nature like egg whites if you've ever you know had to stir egg whites this is when estrogen levels are the highest and stimulates proliferation or growth of cells and endometrium it's just preparing that uterus for the attachment of what hopes to be a fertilized egg so around day 14 is likely where we're going to see that egg release from the ovarian follicle it's just the best time for fertilization okay and you can see that perfective phase on this slide to the left if you want to look at the consistency on the right i've put the consistency of the mucus the secretory phase is usually after ovulation that endometrium is maintained by that progesterone there's increased blood flow and secretions um it's that smooth muscle relaxes so there's reduced contractility of the uterus it creates that hospital and hospital-like environment for implantation so fertilization occurs the process continues if it does not occur um that final phase of the menstrual cycle that ischemic phase begins so an ischemic phase and the corpus luteum begins to disintegrate um so there's that elimination that source progesterone so vascular changes that that starts to kind of i say dry up but um i don't want to say that either but it just leads to necrosis that breakdown of that endometrial lining which sheds and then menstruation really occurs so um eventually new endometrium will grow but this is where that bleeding that shedding occurs is that a skimming phase so let's discuss confirmation of pregnancy are presumptive symptoms of pregnancy which we presume we might be pregnant or probable signs that may kind of clue us in or actual positive factual signs of pregnancy okay so we're going to go through these women makes pre experience presumptive signs of pregnancy that could also be caused by something else for example amenorrhea that's just a lack of menses or period can be caused by stress or low body fat someone who exercises a lot may not have period for a long time so that can be a presumptive sign just because you have tender breasts can be a presumptive sign that doesn't necessarily mean that there is a pregnancy breast tenderness can be caused by a lot of things you could have a cyst or what have you nausea nausea can be caused by a lot of different things you could have gi upset it could be something you've ate that just maybe didn't agree with you those are presumptive symptoms of pregnancy now probable signs of pregnancy those include braxton hicks contractions these are contractions that are not consistent not regular they're usually alleviated by rest or hydration or fluids those are probable signs of pregnancy a positive pregnancy test is a probable signs especially a positive pregnancy urine test this could be because of a molar pregnancy which is just a growth of tissue causing that positive urine pregnancy um it may not always just be um a positive urine pregnancy test may not always mean pregnancy it could even be a cancer good else sign um good l sign is a softening of the cervix a lot of times it can be associated with pregnancy but it doesn't always mean it's a positive of pregnancy and then chadwick's sign is a bluish discoloration of the female genitalia in the cervix so that's usually a probable sign of pregnancy it doesn't mean there's a pregnancy but it's probable the positive signs for pregnancy include uh visual visualization of a pregnancy via ultrasound i mean that's positive you see a fetus there you see fetal movement so that can be visualized in the ultrasound as well um clinician can abdominally palpate fetal moment movement in around 20 weeks fetal heart tones auscultation of a fetal heartbeat or fetal heart tone can be heard as early as nine weeks and that's using a doppler ultrasound sometimes i do trans trans abdominal ultrasounds as well you just want to make sure you're hearing a fetal heartbeat and not hearing mom's heartbeat but it's almost certain by 12 weeks so positive signs are a fetal heartbeat and a visual visualization of the fetus and fetal movement in an ultrasound so positive signs are considered confirmation of pregnancy okay so here are some presumptive symptoms um this picture depe depicts breast tenderness this again can be because of hormones menstruation itself in a normal otherwise non-pregnant state it could be caused by cysts or stress amenorrhea as evidenced by this middle picture could be an extreme amount of exercise so excessive exercise can cause a lack of period or menses of course pregnancy could be a cause of amenorrhea medication or contraceptive use can cause amenorrhea stress hormones or poor nutrition or low body weight can cause amenorrhea the nausea vomit vomiting was another one we discussed this of course could be pregnancy but nausea involvement could be caused by other things food poisoning infection medications that we're taking pain stress motion sickness can cause nausea and vomiting and that's why this makes it presumptus signs or symptoms of pregnancy so one of the probable signs of pregnancy that we discussed was um a positive pregnancy test i want you to know that home pregnancy tests they are probable um they're used to detect the presence of human chorionic gonadotropin that's hcg in the urine so this is just the hormone that's produced during the time of implantation false negatives can occur that's what makes the test probable if a woman thinks she's pregnant but her urine test was negative she should repeat that test in three to seven days so a patient could get a false negative um if there's a possibility she's pregnant um there are also sometimes hcg secreting tumors that could give you a a false positive so false positive tests are usually caused by error um and sometimes it could just be reading the test late so if it sits too long before it's read you might see that extra line that indicates hcg but it could be caused by other issues such as a recent pregnancy loss and sometimes if a patient is on fertility treatments that might even give a false reading as well or false positive so hcg that amount of hormone doubles in early pregnancy approximately every 48 to 72 hours and it's it is detected in in urine now we also discussed um the chadwick sign in the good old sign as a probable um sign of pregnancy and i wanted to kind of discuss that here uh here at the top of this slide is a picture of the chadwick sign which is a blue violet discoloration of the cervix of the vagina in pregnancy so this is a normal exam finding especially if the client is pregnant just remember though that this um is a probable sign of pregnancy the good old sign is also a probable sign of pregnancy and that's that softening of the cervix itself there is also another sign called the hager sign and that's just the softening of the lower uterus segment so be familiar with those the hager sign when we say softening lower uterine segment that is the its mass of the lower portion of the uterus and usually around six to twelve weeks upon vaginal exam this can be noticed by the healthcare provider okay the good ol sign that softening of the cervix itself can be felt as early as five weeks in pregnancy by the healthcare provider and that's usually during a vaginal exam now the chadwick sign that blue bluing of the female genitalia also includes the labia the cervix that can be noted as early as six weeks and that can be seen with the vag speculum exam so they put the speculum in the vagina they can see it that way so confirmation of pregnancy remember that's noting fetal heart tone so you have to make sure you have to have the babies and not the moms and uh noticing fetal movement and a heartbeat so the way that this is done and best done is through a fetal ultrasound um you can try a fetoscope but a fetal ultrasound's the best and in early pregnancy this is done transvaginally so transvaginal ultrasound is a matter of placing a condom on the end of a probe and inserting it through the vagina and using that ultrasound technique to look around and usually you can see the old sac and the fetal pole and sometimes the fetal heartbeat depending on when you detect it you can confirm some fetal movement here and those are positive signs of pregnancy most likely fetal ultrasound especially transvaginal ultrasound is used to estimate due date when the last menstrual period date is unclear so here's a question for you to see what you've learned a patient complains of breast tenderness and about not getting her period which was due two days ago she states the pregnancy test she took in the morning was negative what's the best response by the nurse a if the pregnancy test was negative you're not pregnant b you should come to the clinic to get an early trimester of ultrasound c if you don't get your period take another pregnancy test in three days d you should come to the hospital to rule out an ectopic pregnancy take a minute and choose your answer if you answered c you got this correct because if you don't get your period take another pregnancy test in three days remember she was maybe only two days late with her period so if she still thinks that she may be pregnant after a negative pregnancy test she should take another test three to seven days because her first test may have been a false negative she does not need an ultrasound at this time it is too early to determine if she has an ectopic pregnancy signs of an ectopic pregnancy could include unilateral abdominal pain and vaginal bleeding

lesson one is titled before conception student objectives for lesson one include number one explain cultural considerations when working with a client and how to provide culturally competent care number two students should be able to determine how a client&#39;s preconception age health history and health status can affect pregnancy and birth number three document the components of ob gyn health history including gtpal gp and calculate estimated dates of delivery using nagel&#39;s rule number four explain the function of key female reproductive hormones in the phases of the reproductive cycle and five students should examine the different ways of confirming pregnancy and distinguish between presumptive probable and positive signs of pregnancy let&#39;s look at the context of culture and what that includes if you were to give me some examples of culture in health care you might give me examples of maybe jewish cultures catholics muslims a lot of those cultures that may be religious based but just know culture includes religion language it can be a profession culture can include age gender identity disabilities sexual orientation beliefs and traditions the book uses the example of jehovah&#39;s witnesses who do not practice receiving blood donations and that certainly is a culture this may be the client&#39;s faith however keep in mind that there are still individual preferences even though they follow their faith this individual may not have that preference to not receive blood products even though they&#39;re jehovah&#39;s witness they may still in a health care situation want to have a blood donation if needed so keep that in mind that you don&#39;t stereotype when it comes to culture there are jewish cultures that avoid certain diets they believe in a kosher diet they have rabbis that perform circumcision on infants rather than doctors catholics i was a religion that i mentioned earlier that certainly can be identified as a culture in the muslim faith which could also be a culture um there are no men allowed in the delivery rooms um so therefore physicians who are female or sought after or nurse female nurse midwives in that culture men predominantly there are the decision makers hispanic cultures those are family oriented cultures usually the matriarch of the family is the decision maker in the hispanic culture a lot of times too if we&#39;re talking about different things that occur in certain cultures they may bottle feed until the breast milk comes in that&#39;s just something that i&#39;ve noticed in taking care of hispanic clients in the ob setting chinese cultures they tend to take care of each other in an extended family fashion um you might see parents go to work right after having a baby and then the grandparents come in to care and nurture that infant through the growth they also believe in something called yin and yang where certain foods are necessary for illnesses whether it&#39;s hot or cold foods the vietnamese these individuals practice herbal remedies um they also believe in non-traditional healers like sean&#39;s so that&#39;s something to keep in mind whenever caring for clients that are vietnamese especially with the herbal remedies because what you probably learned in your assessment class is that when you&#39;re taking a health history on medications if they take herbs of any kind that might might interfere with whatever medications are being prescribed so just know that the key to cultural competence is good communication and keeping an open mind we as nurses should not make assumptions that simply because a client identifies with a culture such as religion that the patient will identify with it and always follow it like i said with the jehovah&#39;s witness in the blood products so on the other end there is an importance of respecting patient values and incorporating into the client&#39;s care if there are resources that can provide to assist incorporating culture the nurse should do so so for example providing a female doctor for a muslim patient coming into the ob setting or maybe calling upon a dietitian for a client who um only um consumes a vegan diet or a kosher diet for the jo or the jewish culture um because there&#39;s other ways to get in protein and and we if we could help them along by providing a dietitian to help them get the right food during their pregnancy that&#39;s the most important thing to do and still allow them to respect their culture now not all diets or cultural diets are bad for the clients so just know that those adjustments can be made another example is calling in a pharmacist to discuss the impact of her remedies of herbal remedies on on pregnancy that would be another example when we discuss cultural context on this slide especially i want you to focus on cultural competence cultural competence is recognizing and respecting culture and integrating aspects important to that individual&#39;s culture so here it discusses that it&#39;s effectively in integrating elements of culture whether that being vocabulary values attitudes or rules are in norms so it&#39;s just putting that knowledge of culture into action because as i said before one of our greatest pitfalls in nursing is stereotyping we need to avoid unintentionally stereotyping um this is just our own misconceptions or our opinions or our beliefs about some aspect of an individual or a group of people so to prevent better to provide care it&#39;s important to assess the client&#39;s cultural needs and i did and identify your ability as a nurse to address them so it&#39;s involving the client and representing their culture within their birth plan and facilitating um that culture practice and to that plan of care so just remember it&#39;s ultimately the decision of the client um you will have a cultural diversity assignment where in clinical you&#39;ll be presenting on this you&#39;ll pick a culture and you&#39;ll present on birth practices to become more culturally competent so for example in the past some of these cultures that were chosen were sweden germany india russia spain italy australia iran let&#39;s see japan china taiwan the philippines korea vietnamese there&#39;s just a vast number of cultural variations and where you&#39;ll discuss religion language family structure birth practices all of that&#39;s going to vary so it might be beneficial to your research to already know what topic you want to choose and then support uh your presentation on that culture with evidence-based references um you&#39;ll turn in your chosen culture to your clinical instructor as soon as you know what it&#39;s going to be or whatever you&#39;ve chosen and it&#39;s best to do that early before someone else picks the culture you want and then you&#39;ll present and we&#39;ll learn a little something so let&#39;s practice a question to see what you have learned a student nurse is concerned about learning enough about different cultures to deliver competent care the preceptor responds by saying a responding effectively to different cultures means always using an interpreter to communicate b you will never know everything so focus on cultural sensitivity for people born in other countries or c you will never know everything but keep an open mind and communicating effectively will help or d you only need to be concerned about knowing about the main cultures in our community take a minute decide your answer and we&#39;ll review in the next slide the correct answer is c you will never know everything but keep an open mind and communicating effectively will help communicating effectively and keeping open mind will help the nurse better understand the patient&#39;s perspectives and needs providing culturally competent care is more than using an interpreter attempts to better understand the patient&#39;s perspective should be made with all patients not just specific cultural groups so communication barriers will happen in certain facilities they do have paid interpreters for those that are do not such as southeast health they have approved interpreters by phone they have a 1 800 number where you call and you have standby interpreters that can translate the language of choice we never use family members or small children or maybe the hispanic gsr that comes by getting orders for the trace um because we don&#39;t know really what they&#39;re telling them and certain languages do have different dialects so client family and friends do do not qualify as a source of interpretation they could be monopolizing the client or may not understand the medical terminology so it&#39;s best to provide the appropriate interpreter that the facility uses or maybe even the phone system but in this case yes you will never know everything and as we discussed we need to keep an open mind now we&#39;re going to focus on preconception age so the first few weeks of pregnancy is the most critical due to what&#39;s called organogenesis this is the formation of fetal organs and occurs in weeks three to ten gestation so early education and interventions are critical um it&#39;s best to be planning to get pregnant and and having discussed this with a client rather than them finding out they&#39;ve been pregnant for quite a while so that you can provide them with the right amount of education and interventions and it&#39;s important to obtain a health history and identify the clients for risk factors to help promote those healthy behaviors so the average maternal age at the time of first birth is usually around 26.3 years so we&#39;re looking at healthy pregnancies between the ages maternal ages of 20 to 34 years and those are are the age ranges that are not as considered high risk pregnancies after the age of 35 and over are considered high risk this is because there is diminished egg quality after certain age and increased risk of pregnancy-related complications and there is also an increased risk of pre-existing health conditions so just fyi pregnancies in women age 35 and over are more likely to end in an abortion than any other group and i&#39;m not talking elective abortion i&#39;m talking spontaneous so adolescence um under the age of 20 they tend to seek like health care and pregnancy maybe it&#39;s more of their they&#39;re hiding it they&#39;re scared or maybe they are just um in denial but a lot of adolescents are abandoned by their partner and they struggle to even complete education if you&#39;re familiar with erickson&#39;s developmental task they fail to go forward here in that sense of self there are usually sometimes no support system such as family that are helpful and they tend to not know where to seek assistance through certain social programs so keep in mind that there are estate laws regarding disclosure of adolescent health care information so once adolescents come in and have experienced sexual behavior including they maybe want to obtain contraception or maybe they&#39;re seeking health care for an sti or sexually transmitted infection or they&#39;re seeking an abortion or pregnancy results there are state laws that require us not to disclose this information to anyone for that reason but it&#39;s best to just to encourage discussions with the parents or guardians and there is also a legal duty for the nurse to report teen abuse even if it&#39;s a minor so in this case just know that these laws protect these teens you can&#39;t necessarily disclose any of this health information to the parents or the guardians but we can disclose it to the adolescent and encourage them to talk to their parent our guardian however we we can also report if we think there is abuse so just like any client sinking healthcare ob gyn client will also seek health care and receive a health history so we&#39;re looking at that holistic interview we&#39;re wanting to know their sexual history we have questions about their self-care behaviors we review all the body systems we&#39;re looking at that biographic data their date of birth their weight all of that information allergies if they have them what their diet their sleeping patterns are what immunizations they&#39;ve had and still need and then workplace and environmental habits their nutrition or eating habits and their family history it&#39;s it&#39;s pretty uh basic but it&#39;s important that we optimize health in a current pregnancy by understanding a woman&#39;s gynecologic and her obstetric history so for example if a woman has previously delivered a back or stomach or large infant in a previous pregnancy the provider now can look at this health history and encourage a diet change and monitor that patient closely for something called gestational diabetes so we review um sexual history so in review that&#39;s the number maybe a partners that they&#39;ve had self-care practices that could be their health lifestyle of diet and exercise systems in the body that&#39;s their respiratory their cardiac or gi gu um what is going on in those systems maybe they have a history of murmurs maybe gi they&#39;re experiencing some nausea right now because of the pregnancy or gu could be urinary frequency that biographical data the name the address the date of birth marital status allergies penicillin that&#39;s a big one if this patient ends up positive or something called group beta strep if they&#39;re allergic to penicillin we&#39;ll have to treat that client with a different type of antibiotic instead of penicillin diet for example women of childbearing age wishing to become pregnant they need to be consuming 400 to 800 of folic acid a day this helps prevent birth defects so this helps that baby&#39;s brain and spinal cord in development look at sleep something else we need to look at is immunizations because there are vaccinations that may be administered during pregnancy and there are some that we don&#39;t want our clients to receive during pregnancy we won the non-live vaccines for our pregnant patients so non-live vaccines can be the annual flu vaccine the tdap um for pregnancy and we give that usually between 27 and 37 weeks of pregnancy and then hepatitis b vaccine can also be administered it is not a lie viruses virus vaccines that should be administered preconception or postpartum this means not during pregnancy would be that of measles mumps and rubella tigers can be drawn for this to see if they need to be administered prior to conception varicella virus or chickenpox vaccine hepatitis a pneumococcal virus poliovirus human papillomavirus those are all live that we would not want our patients to receive during pregnancy we&#39;ll discuss exposure to environmental toxins um with the health history so we&#39;re looking at uh teratogens t-e-r-a-t-o-g-e-n-s is how that&#39;s spelled um these can cause birth defects uh childhood cancers they can impair brain development they can cause miscarriage and stillbirth so exposures to large amounts of ocean fish or fish high in mercury this can cause birth defects or damage to the central nervous system pesticides would be a teratogen solvents some some dietary animal fats a bpa containing plastics would be another example processed foods like deli meats these are uncooked uh foods especially that can expose the mom and fetus to something like listeria um fruits and vegetables that aren&#39;t washed thoroughly would be also another type of environmental toxin i think your book also mentions the zikr zika virus because it&#39;s kind of a new and out there kind of thing and it causes neurological effects on on the fetus eating habits patients are strongly encouraged to reach and maintain a goal weight and that bmi would be of 18.5 and 30 and this is just prior to seeking pregnancy obesity and pregnancy that can be associated with birth defects like infertility gestational diabetes and other complications so a maternal bmi below 18.5 is correlated with a low birth weight and preterm birth so we like to keep that 18.5 between 18.5 and 30 as bmi for pregnancy so when obtaining a health history of a client we also want to know their gynecological history um so we ask questions that like the age of their men are or their first menses for some it could be 12 13 14 or it could be later on they could be um 18 or 19. um so the first menses is important because both early and late menarche may be associated with certain physical conditions um it can also be associated with socio-economic correlations um we&#39;ll ask the client their date of last menstrual period or lmp that is actually the first day of the most recent menses or most recent period it&#39;s referred to as the lnp this date helps us predict when a woman may be most likely ready to conceive so lmp then we ask questions like the length of their cycle or their period their regularity is it every 28 days we ask them about sexually transmitted infections or stis you might have heard this also called stds but your book discusses them as stis some examples of those would be gonorrhea and chlamydia those cause permanent damage to the fallopian tubes they can impair a woman for fertility hiv it&#39;s important to know of their hiv status because we can treat hiv during pregnancy to prevent transmission to the newborn genital herpes a big one it must be treated immediately before and during delivery to prevent transmission to the fetus if there&#39;s an active genital herpes lesion in the vagina during delivery um we need to know about it so that we could maybe take that baby via caesarean section so it doesn&#39;t have to pass through the birth canal hepatitis b measures can be taken after birth to prevent the neonate from contracting that that disease and then hepatitis c this can be passed this infection can be passed on to the child as well when you know their history of gynecological surgeries um certain surgeries may make pregnancy or labor more challenging for example the cervix may be less likely to dilate surgery on the uterus maybe like a previous c-section but may make it more likely to rupture during labor surgery for a woman with endometriosis may improve her chances for even getting pregnant um surgeries that&#39;s important to know chronological conditions that would include say for instance endometriosis this endometriosis this thickened lining this can make it very difficult to get pregnant because the embryo cannot attach to the uterine wall as easily it may be that the client has a malformed uterus and may make it less likely that pregnancy can be successful successfully carried to term so those are some things to keep in mind also something else to keep in mind is the medications that patients might be on those can be teratogens as well the food and drug administration or fda it requires specific labeling of medications to reflect the risk in pregnancy they categorize medications a b c d or x and this just informs that broad nature of risk of medication to pregnancy a lot of psychological medications can be harmful in pregnancy an obstetric health history includes dates of prior delivery so a delivery within the prior year may increase a female&#39;s chances of pregnancy complications so we need to know how close they were gestational agent delivery this is a significant risk for preterm births especially if the female has had a prior preterm birth so and it&#39;s the same even with post term but we need to know what gestation the last delivery occurred was it earlier late mode of delivery um a pasty serum section or c-section may make um a future vaginal birth less likely just because there&#39;s at risk for tearing that uterine wall anesthesia that&#39;s good to know because previous surgeries or births with complications due to anesthesia would have to be carefully recorded so that we can make adjustments for the next delivery pregnancy outcomes this could be captured on our records of gtal which we&#39;re going to discuss but we need to need to know the outcomes of pregnancy you know how many pregnancies a woman has carried a term for example how many pregnancies had total has she had any abortions how many does she have that are living and that is something we&#39;re going to discuss uh coming up the sex of the child this just informs the healthcare providers that the family views and what is preferred for the family with children is identified and that some chromosomal defects may be revealed within a family so we just need to know the sex of the child or children that they&#39;ve had length of labor timing of the past experiences with labor may indicate the length of future labors and this assists with planning so um if she&#39;s had really fast deliveries and maybe didn&#39;t make it for the physician to even attend maybe they will do a different type of plan so that she doesn&#39;t have a precipitous delivery the next time around birth weight and percentile we look at past small for gestational age or large for gestational age infants and we just highlight those complications that they&#39;ve had with those pregnancies it could be that maybe there was some malnutrition or hypertension or if it&#39;s you know large for gestational babies maybe there was some gestational diabetes and that baby was swimming around and sugar getting nice and chunky um but it is good to know um the birth weight and percentile other things we look at is controlled hypertension because hypertension puts moms at risk for stroke arrhythmias growth restricted infants it also affects maternal mortality and then also predisposes infants to preterm births hemorrhage this is just a lot of bleeding so with previous pregnancies this can cause reoccurrence with future pregnancies things like placental abruption this is where placenta detaches from the wall of the uterus this could happen especially with placenta previa where the placenta is coming first instead of the baby the placenta just fyi it attaches to a new location in the uterine wall each pregnancy so percents placenta abruption is something that is flagged when we&#39;re doing a health history for sure diabetes this if a patient has diabetes this can cause preeclampsia it predisposes that pregnancy for c-section birth because it may be a large for gestational age infant now that&#39;s not to say they couldn&#39;t have an sga baby as small for gestation we have to be concerned with what&#39;s going to happen to the baby for neonatal hypoglycemia after it&#39;s born will it be able to sustain sugars or will it drop them we look at congenital abnormalities so that&#39;s why we also look at maternal bmi we need that maternal bmi to be in that range of 18.5 and 30. we look at length of labor the timing of the past experiences may indicate the length of future labor um and then pregnancy complications that&#39;s just problems whether it be pre-eclampsia or fetal complications maybe there&#39;s inner uterine growth restriction maybe the baby was born with neonatal complications like respiratory distress syndrome all of that has to be carefully recorded so for a health history um we need to keep in mind the definition of term pregnancies especially if we&#39;re asking about previous pregnancies and how far they carried the baby but just for your knowledge an early term pregnancy is 37 through 38 and 6 7 weeks full term is 39 through 40 and 6 7&#39;s weeks late turn pregnancy is 41 through 41 and 6 7 week and then a post-term pregnancy would be 42 weeks and beyond when obtaining a woman&#39;s health history it is important that we have an understanding of the number of times she&#39;s been pregnant how many living children she has and how many non-viable pregnancies there are there&#39;s a way to do this and that is to obtain a gtpal and we also get what&#39;s called a gp now i want you to understand something the p in both of these means something different the p in gtpal is the number of pre-term pregnancies the p in gp is the number of viable pregnancies regarding the outcome greater than 20 weeks so let&#39;s let&#39;s discuss this okay we look at g in gtpal g is the gravida that is the number of times or number of pregnancies a woman has had in her lifetime regardless of how it ended so the number of times a woman has been pregnant regardless of how it ended t in gdpal stands for term births so the term births or pregnancies at 37 weeks regardless the outcome regardless if they were born alive or not so here keep in mind you need to account the number of pregnancies not the number of infants born the number of term births at 37 weeks regardless of the outcome now p like i said this means something different in each of these realms p here is the number of pre-term and pre-term is designated 20 to 37 weeks and six days regardless of the outcome so it could be that the baby was born and maybe lived for for six days so the number of pregnancies or the number of preterm pregnancies 20 to 37 weeks in six days regardless the outcome as with the term in this case for example a twin pregnancy that would still be counted as one not two just so we have that understanding a here is abortion this can be elective or spontaneous abortion before 20 weeks this is regardless the number of fetuses included in the pregnancy so again as before with a twin pregnancy ending prior to 20 weeks this would still be counted as one all right and as you look here on this slide the table in your book doesn&#39;t always spell this out but it does within your text so read your book so you can get an understanding of this it also says here with a abortion and i know i said this could be elected they chose to have an abortion or it could be spontaneous and they had a miscarriage but if you note here on this table it says a patient with a pregnancy history including a spontaneous abortion and one elected abortion might have a one-to-one ratio if you want to write it like that that&#39;s fine sometimes i see students add this together as long as they&#39;re noted that&#39;s all i&#39;m really looking for but the elective one might come before the spontaneous one and they might note that as one one so if she&#39;s had an elective um meaning she had an abortion and then um a spontaneous that would be labeled one slash one depending on the on the system that&#39;s used that&#39;s usually how sometimes we see it but like i said i&#39;ve seen students add them together and i&#39;m okay with that l stands for living all right this accounts for the children alive at the time of the recording so the number of living children that they have all right let&#39;s look at gp this gravida still means the same as it does in gtpal g here means the number of pregnancy a woman has had in her lifetime so that&#39;s still the same but p in this realm is different p is the number of viable pregnancies regardless the outcome greater than 20 weeks and i believe your book gives a range of like 20 to 24 weeks okay so just keep in mind that the piece means something different between gtpal and gp okay i&#39;m going to use a highlighter here to help explain the difference between gtpal and gp so we&#39;re going to go through this slide together we&#39;re going to read the first sample here this is a sample of stress history of a client so our client is pregnant for the first time so under our gravity the number of times a woman has been pregnant we have her down for one okay so this since this is her first pregnancy she does not have any term children already or any term births um that&#39;s births at 37 weeks or greater regardless the outcome and then remember in gtpal the p stands for the number of pre-term um 20 to 37 weeks regardless the outcome so at this point in time she has no pre-terms so she&#39;s at a zero and a stands for abortions whether that&#39;s elective or spontaneous well this is her first time being pregnant she&#39;s at zero and zero she has no living children yet this is just her first pregnancy so if we look at gp remember g stands for the same thing here that&#39;s the um number of times a woman has been pregnant and she&#39;s pregnant currently so she&#39;s at a gravito one now for gp the p means something different the p here is the number of viable pregnancies regardless the outcome greater than 20 weeks well she has none at this point time so she is a a pair of zero okay so the client&#39;s pregnancy ends within electro abortion so that means she chose to have an abortion well she still has been pregnant one time so she has a gravido one t stands for term this pregnancy did not go to terms she electively had an abortion so she is a t zero p here stands for pre-term um she did not have a preterm infant because more than likely this elective abortion occurred before 20 weeks so that would be a pre-term of zero a for abortion here she&#39;s zero when it comes to um the spontaneous abortion but she chose to have an elective abortion so that makes her an a1 okay and then living she has no living so she&#39;s a zero so with gp remember g is the same thing the number of times a woman&#39;s been pregnant so she&#39;s um a gravida 1 and p here does not stand for preterm but p stands for the number of viable pregnancies regardless the outcome greater than 20 weeks she does not have a viable pregnancy so she&#39;s a para zero okay now our client is pregnant for the second time but she chose or she did not choose she had a spontaneous abortion so she&#39;s now a gravida ii she&#39;s on her second pregnancy she has not had any term births at 37 weeks regardless of the outcome so she is a term zero or t zero piece here stands for pre-term she&#39;s not had any um pre-term births regardless the outcome between 20 and 37 weeks so she is a pre-term zero now if we look look at abortions she had that elective abortion so that was at one but now this is a spontaneous abortion so she&#39;s a a1 and 1. still she has no living children however when we look at gp she still is a gravida 2 meaning she has been pregnant two times and then when we look at p here this is for the number of viable pregnancy regardless the outcome greater than 20 weeks she still has no had no viable pregnancies so she is a g2 para zero okay now the client has been pregnant uh for a third time and she is with twins and she delivers those twins at 30 weeks okay so now we have to really pay attention so if we look at gravida the number of times she&#39;s been pregnant even though this is a set of twins we count this as one pregnancy so where she&#39;s had two previous pregnancies and then this pregnancy with twins she&#39;s actually a gravida three in pregnancies she&#39;s been pregnant three times okay has she had any term children yet no so she&#39;s still at a zero here we&#39;re looking at the number of pre-term births um that&#39;s pre-term 20 to 37 weeks regardless the outcome well she delivers at 30 weeks she delivers twins at 30 weeks so if we&#39;re looking at pre-term births between 20 and 37 weeks regardless the outcome she&#39;s had one pre-term birth and that&#39;s with the twins even though she had two babies it&#39;s still one preterm birth okay now we look at her elective and spontaneous abortion she had one elective and one spontaneous so she&#39;s in a one in one now how many living children has she had well so far she had had the elective and spontaneous abortion she was at a zero but now she&#39;s delivered twins at 30 weeks so she now has two living children okay so let&#39;s assess her gravita pera here not gravity pre-term gravity para so gravitas still means the same thing that&#39;s the number of times she&#39;s been pregnant even though this is twins this is really her third time being pregnant so she&#39;s a gravida three she had the elective the spontaneous and pregnant the twin pregnancy so she did gravita3 now p does not stand for preterm here remember p is the number of viable pregnancies regardless the outcome greater than 20 weeks well she&#39;s had this one viable pregnancy with the twins and she delivered it delivered these twins at 30 weeks so that&#39;s greater than the 20 week mark off or time period so she&#39;s now a g 3 pair of one follow me all right let&#39;s move on to the next now our client is pregnant again and she delivers a stillborn infant at 30 weeks gestation okay so when we look at gravida here the number time she&#39;s been pregnant she&#39;s had an elective abortion that&#39;s one a spontaneous abortion that&#39;s two pregnancies she&#39;s had a pregnancy with twins at 30 weeks so that&#39;s three pregnancies and now she&#39;s had a stillborn infant at 38 weeks that is four pregnancies total now t stands for term how many um term deliveries had she had now regardless of the outcome term births are 37 weeks regardless of the outcome well we can only count the 38 weeks stillborn infant as a term pregnancy because 38 weeks is term and regardless of the outcome this baby didn&#39;t make it but it&#39;s still term okay so she is a t one p here stands for preterm okay and preterm is the number of preterm pregnancies between 20 and 37 weeks regardless the outcome well she had 30 week twins so that pregnancy is a one okay so she&#39;s a p pre-term one she still had one elective and one spontaneous abortion but now how many living children does she have well so far she&#39;s only had abortions and a still birth but the only living one she&#39;s had was those 30 week twins so those count as two living children okay so again she&#39;s been pregnant four times but p in the gp realm of things peace here stands for the number of viable pregnancies regardless the outcome greater than 20 weeks okay so our p here would mean her number of viable pregnancies would be two she&#39;s had the the 30-week pregnancy with twins and then the 38 week stillborn infants because it&#39;s regardless the outcome so she is a para two okay the client is pregnant for the final time she delivers a viable infant at 40 weeks gestation okay so she&#39;s had an elective a spontaneous a twin pregnancy is stillborn and now a 40 weaker that&#39;s five pregnancies if you add that up so she&#39;s a gravitative five now how many term children does she have well she did she had twins but they weren&#39;t term at 30 weeks okay and this is regardless of the outcome so when we look at her 38 week delivery of a stillborn infant that one counts even though regardless the outcome that baby didn&#39;t make it it still counts as a term pregnancy and now this 40-week baby counts as a term pregnancy so she&#39;s a t2 now p here is the number of pre-term between 20 and 37 weeks regardless of the outcome so she had a pre-term birth at 30 weeks of twins and that counts as one pre-term pregnancy okay now we remember her abortions here she had the one elective and the one spontaneous so she&#39;s an a one in one now how many living children does she have she had the two abortions and she had the stillbirth but she had successfully delivered living twins and now this 40 weaker so if we count those number of children she has three living children okay gravida number gravity of five pregnancies total um and then if we look at para here this is the number of viable pregnancies regardless the outcome greater than 20 weeks okay so the 38 weaker counts here the 40 weaker counts here and then the twin pregnancy counts here so she&#39;s a pair of three gravita five pair of three okay when obtaining a health history we may need to calculate a woman&#39;s estimated uh due date okay and to do this we use what&#39;s called niggles rule nagel&#39;s rule is used for estimating an expected due date based on a woman&#39;s last menstrual period or lmp um this calculation is based upon a woman having a regular cycle a 28-day menstrual cycle um and a gestational period of 280 days or 40 weeks again this it varies slightly um it might vary for mothers that are first-time moms because they tend to have slightly longer pregnancies um but nagel&#39;s rule it&#39;s just a calculation it&#39;s an estimation so um it&#39;s always a given if we look at our months that there are various number of days within each month like for example february is 28 days regardless of the leap year just to keep things simple um so you need to know which months have 30 days versus 31 and and i can tell you september april june and november have 30 days but if you need to pull out your mnemonic or your little saying that you were taught as a child it goes 30 days has september april june and november all the rest have 31 except for february alone which has but 28 days clear and 29 in each leap year okay so according to this slide there are two different ways to calculate nagel&#39;s rule you can subtract three months from the last known menstrual period date and add seven days to that lmp and add one year this calculation is usually used for a woman whose last metro period falls between the months of april through december or you can do it this way you can add seven days and add nine months or vice versa and that calculation usually falls for a woman who has a last menstrual period between the month of january through march okay so let&#39;s do this example down here if you want to do the first one at the top where you subtract three months add seven days and then add a year if a woman came in and said hey and i don&#39;t have a year on here you can do that yourself if you want um but if it&#39;s if she says hey my last menstrual period was um june 6 of 2019 you would subtract three months from june and that will give you the month of march so you just say okay march 6th at this point you would add seven days to march 6 so 7 7 8 9 10 11 12 13 takes you to march 13th and if she said the year was 2019 you&#39;re just going to add a year that would make it march 13 2020 okay or if you wanted to try the one below where you add nine months and seven days so say um your patient gives you a last menstrual period of january 5th 2017. so if you add say um seven days to that so fifth six seven eight nine ten eleven twelve would give you the twelve and then you add uh nine months to january um that would put you october 12 2017 okay so there there&#39;s a few that you can you can practice you can create some dates and try to do those in your head if you want to and see how close you are but i would certainly practice that before the exam and if you have any questions please come see me or mrs hubbard i included a link here and you can copy and paste that in your web browser and watch it it&#39;s just the fertilization of an egg after ovulation ova or that&#39;s what they&#39;re called or they&#39;re viable for fertilization that usually is between 6 and 24 hours not a very big marginal window there so sperm are capable of fertilizing that egg for up as long up to as long as five days okay fertilization here generally occurs in the fallopian tube which you can see in this video when that sperm fertilizes the egg additional sperm become blocked from that penetration it&#39;s it&#39;s a cortical reaction is what it&#39;s called that then becomes conception so after conception the 23 chromosomes of the sperm unite with the 23 remaining chromosomes of the ovum or the egg and they kind of create a diploid zygote with 46 chromosomes if you remember back to your science classes and then um implantation happens within the wall of the uterus and everything just has to be the right medium for that especially when we talk about the phases um like the peripheration phase and that&#39;s all coming up but this might be an interesting little video to kind of just kind of have a view of how that fertilization happens this is just another video that you can copy and paste this link in your browser and watch if you want to about conception and birth i think it may even play to music okay i had mentioned previously that a typical cycle for female menstruation or period is a 28-day cycle um within that cycle hormones such as estrogen progesterone a luteinizing hormone otherwise known as lh hormone luteinizing is spelled l-u-t-e-i-n-i-z-i-n-g or a follicle stimulating hormone fsh those hormones are responsible for signaling the maternal anterior pituitary um and once that&#39;s signaled for hormone release that assists in ovulation so there&#39;s a lot of interactions that have to occur between the ovaries that anterior pituitary and the hypothalamus to regulate a female reproductive cycle okay so this is just a slide kind of um showing you um that reproductive cycle and when the egg is released it does have on here the fsh the lh and when that all kind of occurs you can see the lh is identified as the dashed line and the estrogen is the solid purple the progesterone is that little solid blue green and then that follicle stimulating hormone is that kind of light blue dash line and then you can see the days of the cycle under there and when most likely that egg is released and so we&#39;re going to talk about these hormones um the fs h hormone the follicle stimulating hormone that is responsible for the maturation of the follicle of the ovary where that egg is released so that follicle gets mature the egg starts to release that&#39;s what that fsh hormone is for the luteinizing hormone the lh hormone that is responsible for that actual egg release from the follicle okay so the fsh is stimulating it the lh is causing that aid to be released um this lh level it peaks approximately and you can see on here uh 14 days all right um if so if you follow the lh line you can see it looks like the follicles release the egg um it&#39;s 14 days before menses to cause ovulation so this hormone guys this hormone initiates the menstrual cycle to occur all over again so each time you know a woman has a period it&#39;s this uh lh hormone that&#39;s initiating that cycle to curl again and again the body begins to prepare for ovulation here which could possibly be around day 14. so some women they start to if they&#39;re trying to get pregnant they start to take their temperature here because that&#39;s important to plan for this in order to get that best time to conceive okay now estrogen hormone that assists in what&#39;s called the proliferation or the growth of that endometrial lining after menstruation so that estrogen is responsible for that growth of that lining progesterone that helps maintain the uterine lining as well as relaxing the smooth muscle of the uterus it causes vasodilation to get good blood flow through the uterus and this is so important because that progesterone allows the uterus to support a pregnancy it supports implantation it is responsible progesterone is responsible for the rise in body temperature that lets us know that ovulation has occurred so when these women are checking their temperature it&#39;s that progesterone that&#39;s causing that body temp to rise and then they know okay ovulation has occurred i&#39;m going to have to have intercourse in order to conceive it&#39;s when there is a drop in that temperature that means that there was no fertilization so a drop in progesterone there&#39;s no fertilization um when there is no fertilization menstruation occurs and the lining of the uterus sheds so we have that bleeding and again it&#39;s a 28 day cycle that lowering of the progesterone and estrogen that stimulates the hypothalamus to produce that gonadotropin releasing hormone it&#39;s otherwise abbreviated gnrh it just cues that anterior pituitary to produce fsh and that follicle stimulating hormone and lh that luteinizing hormone to start that whole thing all over again so there are three phases of the reproductive cycle we&#39;re going to talk about the proliferative phase the secretory phase and the ischemic phase okay as i said before regarding the menstrual cycle menstruation typically begins about 12 to 14 days after ovulation so many women find factors such as an illness or stress that might affect the timing of their menses so this can vary whereas others cycles they just remain consistent so menstrual flow if you are not familiar with menstrual flow consists of blood vaginal and cervical secretions some bacteria and just cellular debris a woman can lose around 10 to 80 milliliters of blood over two to seven days so menses may be red initially or brown depending on the duration of the time that that blood is pulled in the uterus older blood like the brown color um or maybe just the newer redder blood so it just depends so let&#39;s talk about these phases let&#39;s start with the pluriphorative phase during the proliferative phase the endometrium it thickens in response to that estrogen produced by the ovaries so close to ovulation the cervical mucus becomes particularly elastic inconsistency and egg white in nature like egg whites if you&#39;ve ever you know had to stir egg whites this is when estrogen levels are the highest and stimulates proliferation or growth of cells and endometrium it&#39;s just preparing that uterus for the attachment of what hopes to be a fertilized egg so around day 14 is likely where we&#39;re going to see that egg release from the ovarian follicle it&#39;s just the best time for fertilization okay and you can see that perfective phase on this slide to the left if you want to look at the consistency on the right i&#39;ve put the consistency of the mucus the secretory phase is usually after ovulation that endometrium is maintained by that progesterone there&#39;s increased blood flow and secretions um it&#39;s that smooth muscle relaxes so there&#39;s reduced contractility of the uterus it creates that hospital and hospital-like environment for implantation so fertilization occurs the process continues if it does not occur um that final phase of the menstrual cycle that ischemic phase begins so an ischemic phase and the corpus luteum begins to disintegrate um so there&#39;s that elimination that source progesterone so vascular changes that that starts to kind of i say dry up but um i don&#39;t want to say that either but it just leads to necrosis that breakdown of that endometrial lining which sheds and then menstruation really occurs so um eventually new endometrium will grow but this is where that bleeding that shedding occurs is that a skimming phase so let&#39;s discuss confirmation of pregnancy are presumptive symptoms of pregnancy which we presume we might be pregnant or probable signs that may kind of clue us in or actual positive factual signs of pregnancy okay so we&#39;re going to go through these women makes pre experience presumptive signs of pregnancy that could also be caused by something else for example amenorrhea that&#39;s just a lack of menses or period can be caused by stress or low body fat someone who exercises a lot may not have period for a long time so that can be a presumptive sign just because you have tender breasts can be a presumptive sign that doesn&#39;t necessarily mean that there is a pregnancy breast tenderness can be caused by a lot of things you could have a cyst or what have you nausea nausea can be caused by a lot of different things you could have gi upset it could be something you&#39;ve ate that just maybe didn&#39;t agree with you those are presumptive symptoms of pregnancy now probable signs of pregnancy those include braxton hicks contractions these are contractions that are not consistent not regular they&#39;re usually alleviated by rest or hydration or fluids those are probable signs of pregnancy a positive pregnancy test is a probable signs especially a positive pregnancy urine test this could be because of a molar pregnancy which is just a growth of tissue causing that positive urine pregnancy um it may not always just be um a positive urine pregnancy test may not always mean pregnancy it could even be a cancer good else sign um good l sign is a softening of the cervix a lot of times it can be associated with pregnancy but it doesn&#39;t always mean it&#39;s a positive of pregnancy and then chadwick&#39;s sign is a bluish discoloration of the female genitalia in the cervix so that&#39;s usually a probable sign of pregnancy it doesn&#39;t mean there&#39;s a pregnancy but it&#39;s probable the positive signs for pregnancy include uh visual visualization of a pregnancy via ultrasound i mean that&#39;s positive you see a fetus there you see fetal movement so that can be visualized in the ultrasound as well um clinician can abdominally palpate fetal moment movement in around 20 weeks fetal heart tones auscultation of a fetal heartbeat or fetal heart tone can be heard as early as nine weeks and that&#39;s using a doppler ultrasound sometimes i do trans trans abdominal ultrasounds as well you just want to make sure you&#39;re hearing a fetal heartbeat and not hearing mom&#39;s heartbeat but it&#39;s almost certain by 12 weeks so positive signs are a fetal heartbeat and a visual visualization of the fetus and fetal movement in an ultrasound so positive signs are considered confirmation of pregnancy okay so here are some presumptive symptoms um this picture depe depicts breast tenderness this again can be because of hormones menstruation itself in a normal otherwise non-pregnant state it could be caused by cysts or stress amenorrhea as evidenced by this middle picture could be an extreme amount of exercise so excessive exercise can cause a lack of period or menses of course pregnancy could be a cause of amenorrhea medication or contraceptive use can cause amenorrhea stress hormones or poor nutrition or low body weight can cause amenorrhea the nausea vomit vomiting was another one we discussed this of course could be pregnancy but nausea involvement could be caused by other things food poisoning infection medications that we&#39;re taking pain stress motion sickness can cause nausea and vomiting and that&#39;s why this makes it presumptus signs or symptoms of pregnancy so one of the probable signs of pregnancy that we discussed was um a positive pregnancy test i want you to know that home pregnancy tests they are probable um they&#39;re used to detect the presence of human chorionic gonadotropin that&#39;s hcg in the urine so this is just the hormone that&#39;s produced during the time of implantation false negatives can occur that&#39;s what makes the test probable if a woman thinks she&#39;s pregnant but her urine test was negative she should repeat that test in three to seven days so a patient could get a false negative um if there&#39;s a possibility she&#39;s pregnant um there are also sometimes hcg secreting tumors that could give you a a false positive so false positive tests are usually caused by error um and sometimes it could just be reading the test late so if it sits too long before it&#39;s read you might see that extra line that indicates hcg but it could be caused by other issues such as a recent pregnancy loss and sometimes if a patient is on fertility treatments that might even give a false reading as well or false positive so hcg that amount of hormone doubles in early pregnancy approximately every 48 to 72 hours and it&#39;s it is detected in in urine now we also discussed um the chadwick sign in the good old sign as a probable um sign of pregnancy and i wanted to kind of discuss that here uh here at the top of this slide is a picture of the chadwick sign which is a blue violet discoloration of the cervix of the vagina in pregnancy so this is a normal exam finding especially if the client is pregnant just remember though that this um is a probable sign of pregnancy the good old sign is also a probable sign of pregnancy and that&#39;s that softening of the cervix itself there is also another sign called the hager sign and that&#39;s just the softening of the lower uterus segment so be familiar with those the hager sign when we say softening lower uterine segment that is the its mass of the lower portion of the uterus and usually around six to twelve weeks upon vaginal exam this can be noticed by the healthcare provider okay the good ol sign that softening of the cervix itself can be felt as early as five weeks in pregnancy by the healthcare provider and that&#39;s usually during a vaginal exam now the chadwick sign that blue bluing of the female genitalia also includes the labia the cervix that can be noted as early as six weeks and that can be seen with the vag speculum exam so they put the speculum in the vagina they can see it that way so confirmation of pregnancy remember that&#39;s noting fetal heart tone so you have to make sure you have to have the babies and not the moms and uh noticing fetal movement and a heartbeat so the way that this is done and best done is through a fetal ultrasound um you can try a fetoscope but a fetal ultrasound&#39;s the best and in early pregnancy this is done transvaginally so transvaginal ultrasound is a matter of placing a condom on the end of a probe and inserting it through the vagina and using that ultrasound technique to look around and usually you can see the old sac and the fetal pole and sometimes the fetal heartbeat depending on when you detect it you can confirm some fetal movement here and those are positive signs of pregnancy most likely fetal ultrasound especially transvaginal ultrasound is used to estimate due date when the last menstrual period date is unclear so here&#39;s a question for you to see what you&#39;ve learned a patient complains of breast tenderness and about not getting her period which was due two days ago she states the pregnancy test she took in the morning was negative what&#39;s the best response by the nurse a if the pregnancy test was negative you&#39;re not pregnant b you should come to the clinic to get an early trimester of ultrasound c if you don&#39;t get your period take another pregnancy test in three days d you should come to the hospital to rule out an ectopic pregnancy take a minute and choose your answer if you answered c you got this correct because if you don&#39;t get your period take another pregnancy test in three days remember she was maybe only two days late with her period so if she still thinks that she may be pregnant after a negative pregnancy test she should take another test three to seven days because her first test may have been a false negative she does not need an ultrasound at this time it is too early to determine if she has an ectopic pregnancy signs of an ectopic pregnancy could include unilateral abdominal pain and vaginal bleeding

Transcript for:Cultural Considerations in Preconception Care

Transcript for:
Cultural Considerations in Preconception Care