What do you know about pregnancy from what pregnant
women, their partners, and their families have told you?
What helped them in pregnancy?
What hindered them in pregnancy?
What does ideal prenatal care involve?
WOMEN TEACH US
Ask open-ended questions, such as: “What has pregnancy
been like for you?”
Pregnancy is a time of health protection and health
promotion. Most women are not sick. But, without
CARE they and their babies can become sick. With
CARE, they thrive—this is a time of maximum growth
Your role involves NURTURING NURTURANCE!
At least two intertwined lives are involved. Protecting
promoting maternal/child health affects future
NO OTHER time in human life is growth and
development so rapid and transformative.
Pregnancy. Non-mother to mother involves a
profound shift in identity and responsibility
and in her anatomy and physiology!
Fetal development. From less than a gram to
6-8 pounds in 40 weeks!
Infant development. Doubling weight in 6
months, tripling in 12!
And such times of creation touches the spiritual.
Nurturing birth, like humanizing the ebbing of life in palliative
care, are times where we –if we allow ourselves -- touch
deeply within the human condition.
Profound call for ETHICS, including the ethics of
NURSES ARE CALLED
Safe, compassionate, competent care
Promotion of Health and Well-being
Promoting and Respecting INFORMED
decision-making. (INFORMED based on the
best science available!)
Privacy and Confidentiality (with caveats if
child abuse or neglect is involved)
ALL documented philosophies of nursing, from Nightingale
onwards, have called for nursing to be HOLISTIC.
(Yet our health care system is ever so fragmented and
compartmentalized), creating a paradox for practice.
CARE ATTENDS TO
The rapidly-transitioning PHYSICAL
The tumultuous EMOTIONAL
The profoundly SPIRITUAL involved in the
creation of life
The ENVIRONMENT which supports or fails to
support mothers and children.
What does such “care” involve?
--practically and materially in terms of the environment?
PRENATAL CARE AND
Medical prenatal care
Group pregnancy care www.centeringpregnancy.org
Self-education (books, films…)
Informal sharing of information
Formal prenatal classes, private or public
WHAT DO PREGNANT
WOMEN WANT FROM
Novick, G. (2009).
of prenatal care: An
Journal of Midwifery
and Women’s Health,
No barriers. No access to transportation
and “too many other problems” were cited
as reasons for non-attendance. Women
also backed away from prenatal care that
involved long waits, perceptions of poor
treatment, and fear of examinations.
Relaxed, interactive, informal settings; staff
who tolerated children. Unhurried visits.
Continuity. Women who saw the same care provider over
time were more likely satisfied with care than those who saw
Comprehensiveness. Access to non-medical services such
as drug treatment, psychological and support services,
childbirth education, and peer support in addition to
“medical” prenatal care.
Control. A say. Decision-making power about own care.
Relationships with clinicians that spoke a comprehensible
language, conveyed respect, individualized care, were caring
and put women at ease, and who communicated information
Information about the following:
what to expect in pregnancy
labor and birth
dealing with stress and conflict
DEVELOPMENT OF A BABY
LMP – 3 months + 7
days = EDB
(But remember you
have a range of
normalcy that is 38 –
AND DATE OF BIRTH
Has been around for decades upon decades.
First day of woman’s last menstrual period (LMP) – 3 months
+ 7 days = EDB (expected date of birth)
Excellent, time-tried approach to calculating gestation, if…
Woman has regular q 28 d cycles
That LMP was a normal period
Woman actually remembers when her period happened.
You are an outport nurse in Nunavut and you do the
prenatal care in your community, referring problems to
a doctor who flies in for 3 days a month, or flying
patients out if there are medical problems. More
commonly, problems relate to social and economic
Etukelu tells you she thinks she is pregnant, no period
for “awhile” and sore breasts. As you explore, she tells
you her last period was the first day of the first
snowstorm in late October, and she is sure, and yes,
she menstruates regularly every month. You check the
calendar and see that the snowstorm was October 21st.
When can Etukelu expect to give birth?
Oct 21 + 7 = Oct 28
Go back three months
Sept… Aug… July
Etukelu can expect to
give birth July 28 …
+/- 2 weeks!
EDB is simply a midpoint of an entire
month that babies are normally and
physiologically considered TERM!
In Eurocentric clock-centered cultures, we
try to schedule everything, try to make
things fit into compartments to make our
worklife easier. But scheduling
physiological birth, like scheduling
physiological death, doesn’t fit so nicely
into a schedule.
Canadian Perinatal Health Report (2008):
Term gestation: b/w 38 – 42 weeks
i.e. : b/w 259 – 294 days.
There ARE concerns with true preterm and true postterm, but
normal, healthy physiological term gestation has a span of 35
Today is January 11th. You are the community health nurse in
a fly-in community in Nunavut, and there are no doctors.
How many weeks gestation is Etukelu’s baby?
AT 12 WEEKS…
In ideal situations, how much weight
should Etukelu have gained?
How big would her uterus be now?
Would the fetal heart be audible with a
What are some common discomforts,and
how can these be managed?
You test her urine for glucose, ketones, and
protein. Why? Would you expect positive
or negative findings?
THE FIRST PRENATAL
Trust-building and assessment.
Health and illness history.
Screening for safety: relationships, employment, lifestyle,
availability of basic food, water, shelter requirements
Physical exam. System-by-system, with focus on
ABO Blood group with Rh factor
Pap smear, STD screen
Offer: screening for chromosomal anomalies
You are a prenatal clinic nurse. Cindy, age
34, G5P2A2, presents saying she had a
positive at-home pregnancy test, and her
LMP was November 15. Cindy says she is
worried as “I’m older now than with my
other babies” and tells you that her cousin
had a baby with Down Syndrome; she
doesn’t know what to do. On the one hand,
she says she would not choose to abort
anyway. On the other hand, she is
wondering if she should get tested “just to
know”. She asks, “How do they test?” “Are
the tests accurate?” What would you tell
If Cindy’s LMP was November 15, 2010, what is her “due
What is the range of physiological normalcy for term
gestation with that due date?
Ask: Was it a normal period?
Are you reasonably sure of that date?
And then, if yes, calculate:
Nov 15 + 7 d = Nov 22
Nov 22 – 3 months = August 22, 2011
+ / - 2 weeks = Aug 8 – Sept 5, 2011
What is Cindy’s baby’s gestational age today (Jan 12, 2011)?
b/w 8-9 weeks.
What is her primary concern today?
Maternal serum AFP tests obtained
between 15-16 weeks of pregnancy. These
are SCREENING tests only.
High levels may indicate open neural tube
defect (e.g. spina bifida). Low levels may
indicate Down Syndrome.
BUT levels are affected by gestational age,
rage, glucose levels and are NOT definitive.
Identifying a higher risk leads to more
diagnostic options such as amniocentesis,
which has a 1:200 risk of losing a
CANADIAN medical guidelines for prenatal screening. See
following references (avail on-line at www.sogc.org website
of the Society of Obstetricians and Gynecologists of Canada)
Summers, A.M. et al (2007). Prenatal screening for fetal
aneuploidy. JOGC, 187, 146-160.
Cindy says that she has heard that she is three times more
likely to have a baby with Down Syndrome now that she is in
What is Cindy’s age-related risk for Down Syndrome?
DIFFERENT WAYS OF
“At age 34, Cindy, you have a 499/500 chance of having a
baby who does not have Down Syndrome”
Cindy is G5P2A2.
What does that mean?
G Gravida. The lifetime number of pregnancies that a woman
P Para. The lifetime number of delivered pregnancies that
A Abortions. The lifetime number of spontaneous
(miscarriage) or induced abortions a woman has had.
G5 P2 A2
Means that Cindy is pregnant for the fifth time. She had two
pregnancies that reached viability (at least 20 weeks
gestation). She also had two abortions (spontaneous
abortions or ‘miscarriages’ or induced/clinical abortions).
G TPAL SYSTEM
Another system. G TPAL
T Number of Term pregnancies
P Number of Premature births
A Number of Abortions, spontaneous or induced
L Living children
Harriet presents to your clinic. She says this is her 4th
pregnancy. She has two children home, one born at term
gestation, the other at 28 weeks gestation. She also had an
abortion when she was a teenager.
Harriet is G4 P2 A1 acc to GPA system
Harriet is G4 T1P1A1L2 acc to GTPAL system.
Sally is pregnant a third time. She has twins born
prematurely at home now aged 4 years, a daughter born at
Sally is G? P? A?
Sally is G? T? P? A? L?
High dose ionizing radiation: e.g. X-Rays
Certain chemicals, including certain medications, alcohol,
and organic solvents
Certain infections: Toxoplasmosis, Rubella,
Cytomegalovirus, Herpes, parvovirus B19, varicella.
Cytomegalovirus. Found in the urine of
children and immunocompromised adults.
Careful handwashing; pregnant nurses
attending to universal precautions.
Toxoplasmosis. Found in manure and cat
litter. Wash produce well before eating. Wear
gloves when doing barn work or cleaning kitty
Rubella and Varicella. Two common childhood
illness which can have devastating
consequences in pregnancy. Immunization of
all non-exposed women recommended as
Teratogens can cause:
Alterations in structure/function
Interferences with growth and development
Angie, G1P0, age 29 comes to your clinic. She said she had
been at a party two weeks ago, before she knew she was
pregant, and drank half a bottle of wine. Her LMP was 3
weeks ago,and she has had a positive pregnany test with a
home-kit she bought at the drug store. She is concerned
about fetal alcohol effect. What will you tell her?
It is during the second to eighth week of development after
conception—the embryonic period—that most structural
Teratogenicity is on a dose-response basis. Generally, the
higher the dose and/or the longer the exposure, the more
You are a nurse on an orthopedic unit. Helga was admitted
last night with a fractured femur. She is also 30 weeks
pregnant. The doctor has ordered Demerol (Meperidine) for
pain relief. Helga is in pain, but also worried about the effect
of Demerol for her baby. What do you do? Where do you
Drug manuals generally provide a risk profile during
pregnancy and lactation.
Most drugs cross placental barrier but their molecular weight
determines at what rate.
Placental transfer also is affect by the relative water/lipid
solubility of the drug.
Once across the placental barrier, the drug may be benign,
beneficial, or harmful.
You look up Meperidine and see that it is
Risk Factor B* (*D if used for prolonged periods or high
doses at term).
What do the terms B and D mean?
Mei works in a dry-cleaning plant. She has just learned she
is pregnant. Is her workplace safe?
Sara pumps gas on the weekends. She is 8 weeks pregnant.
Is her workplace safe?
A safe, harms seem remote. (Vitamin C)
B tested; no evidence of harm. (Ampicillin)
C don’t know. (Clarithromycin, Echinacea)
D evidence of harm, but benefits in some situations may
outweigh harms. (Dilantin)
X harms clearly outweigh possible benefits. (Accutane)
NEW CLASS WED JAN
19 STARTS HERE
Write down one question you have about pregnancy, fetal
development, prenatal care, nursing roles/responsibilities…
How does a woman know that she is pregnant?
Amenorrhea (no menses)
Breast changes/ tenderness
Quickening (sensation of fetal movement)
Sometimes, women report an intuitive sensation: something
PROBABLE SIGNS OF
Goodell sign (softening of cervix)
Chadwick sign (deepened red color of cervix and vagina
because of increased blood flow)
Hegar sign (softening of lower uterine segment and
anteflexion of uterus)
Positive pregnancy test (urine or serum)
Braxton Hicks contractions
Detection of fetal heart tones by doppler (possible as early
as 8 weeks)
Fetal movements palpated by examiner
Visualization of fetus by ultrasound (possible at 5-6 weeks)
Theodora, G3 T2 P0 A0 L2, age 30, 8 weeks
gestation, comes to your clinic. She owns
and manages a small restaurant business
but says she is “going crazy with the food
smells at work” and is “nauseated all the
time”. “But I can’t stay home; I own the
business. And even at home, I’m
nauseated all the time. I throw up maybe
two or three times a day, and I’m making
sure I keep some toast and stuff down, but
I’m miserable, I’m not fun to be around, and
I HATE being pregnant! What can I do?”
E.G. NAUSEA AND
Three in ten women have n&v severe enough
to affect their daily lives. Occurs at any time of
Only a few are nausea-free.
Related, at least in part, to rising pregnancy
hormone levels (hCG).
Usually a first trimester discomfort and
If severe, can lead to dehydration and weight
loss—sometimes requiring hospitalization and
eat small meals instead of large ones
hi-carb food may help: toast, potatoes
avoiding greasy foods
avoid dehydration. Sip frequently
Ginger ales, teas, cookies, breads and capsules (up to
250 mg qid have been tested (Vutyavanich et al, 2001)
and appear to be safe (SOCG, 2006). Larger doses
Rx: Diclectin (a mixture of Vitamin B6 and an
Pressure of the gravid uterus decreases bladder capacity.
Frequent urination and urination at night are discomforting
or annoying to many women.
ALSO must r/o urinary infections (these can precipitate
WHY ALL THIS?
hCG. HUMAN CHORIONIC GONATOTROPIN
Biologically similar to LH, maintains corpus
luteum in early pregnancy
Suppresses maternal lymphocyte responses to
prevent “rejection” of “foreign protein” of the
Promotes differentiation of the tiny conceptus
into placentation and early zygotic
And contributes to gestational nausea!
PROGESTERONE (think “pro-gestation”)
Secreted at first by the corpus luteum, and then by the
placenta, it is a major hormone in maintaining pregnancy.
Relaxes smoothe muscle and prevents excessive uterine
… and of the smoothe muscle of the g-i tract (causing
heartburn and other g-i symptoms) and urinary systems.
Progesterone also inhibits prolactin
secretion… so while mom will produce
colostrum by mid-pregnancy the amounts
of it are minute…. TILL after the placenta is
expelled in childbirth and another phase of
Continues to inhibit immunological
responses that could cause ‘rejection’ of
baby. (Women with MS and allergies feel
ESTROGEN enhances development of uterus and of the
ductal system of the breasts.
Estrogen also affects skin, hair, and secretory
Hyperpigmentation of freckles, linea nigra forms…
Connective tissue changes such as striae gravidarum
Increased sebaceous gland activity, increased vaginal
HUMAN PLACENTAL LACTOGEN (aka
human chorionic somatomammotropin or
chorionic growth hormone)
A growth hormone for the baby, it promotes
fetal growth. Its primary role is regulating
glucose availability for the fetus.
Insulin antagonist… so glucose is
consistently available to the baby
And it can impact on maternal “appetite” and maternal
Affecting insulin use, insulin stores.
Pregestational diabetic women require modifications in
insulin use. Some women develop gestational diabetes.
Nutrition in pregnancy is crucial!
Ideally needs to be addressed on each prenatal visit.
Access to food (Ask: “Do you have enough money for
food” “Do you have a working stove and fridge”)
Giselle, age 30, G1P0, tells you that she has always had a
“weight problem”, weighing more than 250 lbs ever since she
was a teenager. She tells you that she has had nausea and
vomiting for several weeks, and for the first time in her life
has “no appetite”. She says she may even try to lose some
weight, that the baby has “plenty to grow on” given her size.
What would your reaction be?
Guidelines for gestational weight gain ranges, singleton
pregnancy, Health Canada, 2008:
BMI <20: 12.5 -18 kg or 28-40 lbs
BMI 20-27: 11.5 – 16 kg or 25-35 lbs
BMI >27: 7 – 11.5 kg or 15-25 lbs
?Eating for two?
No. Women do not require double-the-calories! But they do
require protein-rich and vitamin/mineral-rich foods.
Supplements? Health Canada recommends 0.4 mg folic acid
and 16-20 mg iron in a multivitamin.
During pregnancy, the RDA for caloric intake
increases only slightly, and requires only a 300
kcal/day increase from prepregnancy
requirements. (add 1 milk, 1 fruit/veg, 1 grain
and DON’T add empty calories!)
In the first trimester, an average maternal
weight gain of 1-2.5 kg over 13 weeks is ideal.
Thereafter, the recommended weight gain is
0.3 kg/week for overweight women; 0.4
kg/week for women of normal BMI, and
0.5kg/week for underweight women.
Problems with undernutrition in pregnancy?
Fetal malnourishment, SGA babies
Certain birth defects (e.g NTD if low folacin)
Problems with overnutrition in pregnancy?
LGA babies and birth trauma
Supporting the “developmental tasks” of
Companionship and woman-to-woman and
Screening for safety in relationships
(Ask: “Do you feel safe at
Screening for depression
WOMEN AND FAMILIES
Developmental tasks of the mother’s own
lifespan stage: teens? 20s? 30s? 40s?
Acceptance of the pregnancy
Acceptance of this child or these
Reordering relationships with partner,
children, family of origin, friendships,
* Seeking “safe passage” through pregnancy,
labor, and birth
Reordering of sexuality, body image, communication styles,
each partners needs.
Concerns about abuse, which often begins or escalates in
Addressing issues of sadness, anxiety, and
Reflection and intensifying sensitivities.
Need for closeness and connections.
Need for relaxation and recreation
endometrial lining is shed
involving a surge in LH from pituary
post-ovulatory transformation of Graafian
follicle into a hormone-secreting corpus
OVULATION occurs 1-2 days after the onset of
the LH surge mid-cycle as the Graafian follicle
This includes a localized inflammatory
response with hyperemia and a characteristic
slight rise in basal body temperature.
By keeping records of basal body temperature
for a few physiologic uterine cycles, women
can determine the precise day of ovulation.
And, for about 48 hours after ovulation, the
woman is FERTILE.
Cervical mucus is like eggwhite and
plentiful (spinnbarkeit) so to make the
journey for the sperm easier.
From an evolutionary standpoint, most
women are biologically predestined for
fertility… from the mid-teens through
thirties (and a few beyond)
WEEKS POST LMP…
If no conception occurs, and no implantation happens, about
14 days later, menstruation happens.
If conception occurs, the fertilized egg undergoes a series of
changes preparing for implantation.
MOST of the time.
But at least 10-12% of clinically diagnosed pregnancies are
lost in these early weeks because of problems with
differentiation and implantation. Among spontaneous
abortions (SA or ‘miscarriage’) 90% occur in the first eight
weeks of pregnancy. (Perry et al text, USA data)
The mother will see a growth in her abdomen to correspond
to expected fetal growth.
Measured from symphisis pubis to top of uterus, or the
12 weeks. Level of symphysis pubis
20 weeks. At umbilicus, +/- 1 cm
28 weeks. One-third of way between
umbilicus and xyphoid process
32 weeks. Two-thirds of way between umbilicus
and xyphoid process
36 weeks. At the xyphoid process
40 weeks. 3-4 cms below xyphoid process
One element of prenatal care is to monitor the congruency of
fundal growth with expected gestational age.
It is important for RNs to understand the chronology of
Allison, G1P0, arrives. No prenatal care to date. Fundal
height at umbilicus, quickening felt 2 weeks ago. An
ultrasound can be done, but what would you estimate
Allison’s gestation to be?
Gloria is 12 weeks pregnant according to certain menstrual
dating, history of regular periods. Her fundal height
measures 3 cms. below the umbilicus. What could explain
Woman usually realizes she is pregnant. Ideally presents
now for prenatal care and screening.
Usually AMBIVALENT about being pregnant. … mixed
emotions and emotional lability are common.
The first 14 days is the PRE-EMBRYONIC PERIOD (aka
Zygote is protected by the ZONA PELLUCIDA and not yet
Exposure to teratogens during this period is “All or Nothing”,
either conceptus is aborted or there is no effect.
MORULA: a ball of 12 or more cells
BLASTOCYST: shortly after the morula enters the uterus,
about 4 days post-fertilization, differentiation of cells into two
parts occurs: trophoblast and embryoblast. This tiny
organism is termed a blastocyst,
Loss of the zona pellucida, followed by rapid
differentiation of cells as the blastocyst forms
Adherence of the blastocyst to the endometrial
Erosion of the endometrial surface and
burrowing of the blastocyst beneath the
Blastocyst implantation is complete about 10 days after
At this point, it begins to secrete HUMAN CHORIONIC
GONADOTROPIN, or hCG, the hormone that is detected in
Generally implantation is on the anterior or
posterior upper wall of the uterus.
Implantations near the lower end of the uterus
can be problematic as the placenta grows too
low, and there is risk of PLACENTA PREVIA.
Implantations outside of the uterus can also
occur and are known as ECTOPIC
EMBRYO 3 WEEKS
15-60 days post-conception is the PERIOD OF
ORGANOGENESIS, a period of extreme sensitivity to
teratogens, nutritional deficiencies.
EMBRYO 4 WEEKS
EMBRYO 5 WEEKS
EMBRYO 6 WEEKS
EMBRYO 7 WEEKS
At 8 weeks, the developing baby is called a FETUS, and
begins to look more human in form.
In early embryonic life, most mammals look the same… and
indeed we share MUCH of our DNA with other animals,
particularly other mammals, and primates in particular.
FETUS 8 WEEKS
A neural tube or early anatomical CNS has
A primitive cardiovascular system has formed
and there is rhythmic movement of cardiac
cells (“a beating heart”) at 22 days
Coelum or body cavities are forming
Beginning limb buds by 26-28 days
Internal genitalia have differentiated
Primitive fetoplacental circulation is
FETUS 9 WEEKS
FETUS 10 WEEKS
FETUS 12 WEEKS
At 12 weeks, the uterus fills the pelvic cavity
and the fundus is felt level with or just above
the upper margins of the symphisis pubis.
The uterus has now grown from being about
the size of a pear, to being the size of a small
grapefruit with a baby inside!
Heartbeat can usually now be heard with a
Weeks 13 – 27
Woman usually feels well in this trimester. Heightened
awareness of and sometimes joy and excitement in being
The nausea has generally subsided, the baby now feels real,
and the awkward largess of late pregnancy is not here yet.
FETUS 14 WEEKS
FETUS 16 WEEKS
Somewhere b/w 16 and 18 weeks, women
feel the first real unmistable sensations of
the baby alive and moving inside them.
Very exciting. Also – for many dads, the
pregnancy becomes emotionally “real” for
the first time.
This is called “quickening” and is useful to
questimate or affirm gestational dating.
FETUS 18 WEEKS
FETUS 20 WEEKS
“HALFWAY TO BIRTH”
The fetus weighs about 300 grams (“a little over a pound”)
and is 25 cms long.
Maternal fundal height is at the level of the umbilicus.
FETUS 22 WEEKS
FETUS 24 WEEKS
Baby is now about 1100 grams and could potentially survive
if born now…
FETUS 26 WEEKS
Weeks 28 – birth
Progressive growth in fetal size and maternal discomforts
such as leg cramps, back pain.
Increased uterine irritability particularly near term, in
preparation for birth.
Movement becomes more awkward and rest now become
Increased sodium and water reabsorption contributes to mild
(NOT SEVERE) fluid retention … and swollen ankles, fingers,
carpal tunnel symptoms.
Pressure on legs causing cramps and varicosities
Pressure on bottom causing hemorrhoids
…as the mom’s body readies for birthing.
FETUS 28 WEEKS
FETUS 32 WEEKS
FETUS 34 WEEKS
FETUS 36 WEEKS
FETUS 40 WEEKS
PRENATAL CARE ON
EACH VISIT INCLUDES
FETAL HEART TONES
120-160, up to 180 in early gestation.
If any concerns: “nonstress test”: Reactive if heart rate
accelerates by at least 15 bpm above baseline, for at least 15
seconds, with at least 3 accelerations in a 20-minute period
Ultrasounds (PRN for dating and if there are
any discrepancies or questionable findings in
Urinalysis including PRN cultures. Urinary
infections can increase risk for preterm labor
Maternal blood pressure with each prenatal
Glucose tolerance in pregnancy (GTT screen)
“So how does the baby eat and breathe in there?”
What would you say to the 4-year-old sibling?
Hormone production and secretion
Remember…. Very early on, the blastocyst involved
differentiation b/w the TROPHOBLAST and the actual zygote
that will grow to be a baby.
The TROPHOBLAST becomes the supportive structures of
placenta, membranes, and cord…
An amazing organ….this placenta is!
During gestation, under the influence of the hormones of
pregnancy, there will be a 50-fold increase of blood flow to
This involves a doubling of maternal cardiac output, and a
40% increase in maternal blood volume.
OXYGENATION. Maternal and fetal bloods do not actually
mix. Instead, there is transfer of oxygen across thin
placental membrane. (Remember how in extrauterine
circulation, oxygen is absorbed at the level of tiny pulmonary
NUTRIENT (and toxin) exchange and ELIMINATION OF FETAL
WASTE occurs in much the same way.
At the anatomic level of the tiny fingerlike projections calles
Throughout gestation, the placenta will grow to be about 1/7
to 1/5 the size of the baby.
A very vascular organ, structured into a group of
COTYLEDONS, with the fetal surface involving connections
to the PLACENTAL MEMBRANES, the AMNION and CHORION
that enclose the baby.