1. Women’s health encompasses breast care, GYN exams, and assessments. Be comfortable with the parameters of education for Self breast exams, and what is normal for a woman to note when doing breast exam. Know normal menstrual cycle – what is the most common complaint with the menstrual cycle, and complications; (dysmenorrhea) Know STI’s and risks. a. The most common compliant women have with menstrual cycle is abnormal bleeding, painful menses (dysmenorrhea), treatment is heating pad and NSAIDs. Other OBGYN complaints are fibroids, ovarian cysts, and endometriosis. Self-breasts exams monthly 7- 10 days after the cycle. Two hormones with women’s health are Estrogen(growth hormone makes everything bigger), Progesterone(slows things down, makes lining thicker, the pregnancy will not survive without enough of this hormone) 2. If a patient finds a breast lump how will you advise her? a. It’s never normal to feel a lump, make sure you follow up and have other testing, discharge is not normal unless it’s a milk discharge after pregnancy b. web-x all women should be doing breast exams once they start menses (10 days after) c. if a lump is found make an appointment d. ultrasound, mammography e. breast cancer at all ages 3. What is your role in the GYN exam a. Our role in the GYN exam assisting the physician and the patient, explain to her what is happening so she is not nervous, pap smears are never down in the E 4. Contraception – Forms of birth control – good subject for your postpartum patients as well – know them, know the risks and some of the educational points to share with them regarding each type. Remember birth control choice should be based on a patient’s lifestyle – if she cannot swallow pills do not offer oral contraception – right? Etc… a. Types of birth control- diaphragm, IUD, the pill, condoms, depo shot(12 week injection), patches, sponge, cervical cap, nuva ring, rod in arm, abstinence, withdrawal, sterilization b. web-x c. patient education: does not prevent std d. same-time everyday e. for depo take ca because it depletes mineralization of bones f. based on lifestyle g. IF BREAST FEEDING DO NOT TAKE ANYTHING ESTROGEN BASED BC IT WILL IMPEDED THE BREAST MILK. The prolactin will be affected by the estrogen because they work against each other h. When the estrogen levels are high. The prolactin is depleted and vice-vers 5. Emergency contraception – know education. a. Plan B used as soon as possible up to 72 hours, doesn’t cause abortion, if your pregnant it won’t hurt the baby, high dose birth control, bad side effects-N/V, headache. b. web-x does not cause abortions-spotting n/v c. does not protect from sti d. follow- up for cultures for sti e. messes with menstrual cycle f. OTC 6. Preconceptual care is provided for a means to identify risks and provide nutrition – not to establish who should become pregnant. a. Identify risk factors, is it safe for them to become pregnant. Healthy nutrition and lifestyle. Weight and folic acid. Immunizations. Are they smoking or drinking? b. web-x genetics/ genetic counseling c. starting prenatal vitamins d. community referrals 7. Pregnancy – understand the structure and function of the external and internal genitalia. Know the purpose of each in the process of pregnancy. You must understand the changes that occur to each system – a. Uterus has two functions that are to house the baby and expel it (menses). Vagina is a collapsible tube that stretches to deliver baby. Cervix is usually closed but will thin and open to 10cm to allow baby to come out. b. Ovaries are egg storage, you start with all the eggs you have, and you don’t make new ones. If the Bladder is inflamed, or UTI can cause preterm labor. Bowel, if you have diarrhea, if you use enema or laxative, can start preterm labor. Illegal drugs can also can use preterm labor. Three things uterus needs are food, fluids and rest if it doesn’t have these things if can cause muscle irritation and preterm labor. c. web-x d. ovaries house eggs & produce hormones: estrogen- growth hormone and progesteroneacquiescent/quieting hormone e. Progesterone better than estrogen because it progestation/ pro-life hormone. without, it many women have multiple loses f. synthetic progesterone to maintain pregnancy g. Fallopian tubes transport. Gets the egg from one place to the other h. Egg & sperm fertilized in the ampula of the tube. largest, most distal part of the tube- goes through tube and ends up in the endometrial lining i. Bladder if the bladder is infected, spasming, or is distended can cause a lot of problems with pregnancy. If we see issues with preterm labor, or with bleeding, n/v, prone to uti. uti can cause problems. 8. Please identify pregnancy history – G, F, P, A, L – know how to complete this given each women’s obstetrical history. a. Only for delivery, doesn’t matter how many times went into labor even if went into labor. doesn’t matter if pre/post term if baby survived, or didn’t survive b. Gravida- Number of pregnancies c. Full term pregnancies- Live or dead 37-40 weeks d. Pre term pregnancies-Live or dead 20-37 weeks e. Abortion/Miscarriages- Prior to 20 weeks f. Living- children that are living g. Twins are one pregnancy 9. What is fetal well- being and how do we measure it. Can you date a pregnancy using Naegele’s Rule? Can you measure fundal height? Know the normal parameters of fetal growth. When are fetal heart tones audible with a Doppler? What are the parameters and what does it mean if the fetus falls outside those parameters? a. Naegele’s Rule is first day of last missed period subtract 3 months add 7 days and add one year b. Fetal well-being is fetal movement, fetal heart tones and fundal height. All moms can feel the baby movement first between 16-20 weeks, primigravida feel it first at 18-20 weeks, it is a butterfly feeling low in the abdomen. Multigravida is 16-18 weeks. c. web-x d. Fetal well-being e. 3 assessment fx to complete a fetal assessment (since we cannot see the baby) f. 1. fundal height- 1st palpate of the uterus- uterus becomes an abdominal organ by 12-14 weeks g. 2. Fetal heart rate. h. 3. fetal movement-not position in 16-20 weeks i. We can identify fetal hr. in 10-12 weeks. We can hear heart tones with Doppler’s. j. -we can see baby heartbeat much earlier on the ultrasound k. First pregnancy can feel babies in 18 weeks, if you had a baby b4 you feel the baby much earlier in like 16 weeks when you feel the butterflies. l. someone on the outside trying to feel the baby- doesn’t feel until 24-26 weeks m. primigravida- mom can feel baby within 18-20 weeks n. multiparish- 16-18 weeks o. at 20 weeks we can find the baby at the umbilicus p. entire parameter is 16-20 weeks q. if a mom comes and says i am 7 mts pregnant, how many weeks pregnant is she? 28 weeks fundal- height 28 cm r. we place the tape measure: 0 goes at the symphysis, and pull tape measure to the top of the fundus s. When can we hear fetal heart tones with a Doppler? By 12 weeks because the uterus is coming outside of the pelvis at this time. t. With the Doppler stethoscope, FHT may be auscultated by 10 to 12 weeks able to hear heart tones or by 17 to 19 weeks with the fetal stethoscope. u. Fundal height starts at 14 weeks, it grows with the weeks’ gestation, we don’t use cm till after 20 weeks, if a mommy is 16 weeks where would we see fundal height? Halfway between the symphysis pubis and the umbilicus, 20 weeks is the umbilicus and 12-14 weeks is the symphysis pubis. We start at the symphysis pubis and measure cm to the top of the uterus. Give or take 2 cm. So if its 28 weeks it could be 26 or 30. If the measure is wrong by more than 2cm the date could be wrong or twins or something else is growing in the uterus. If it is less than 2 cm the date could be wrong, the baby isn’t growing. v. The fetal heart rate (FHR) is heard most clearly directly over the fetal upper back (the maternal right or left lower abdominal quadrants) in a vertex presentation. The intensity of the fetal heart tones (FHT) varies according to the fetal position (Fig. 9-7). With a breech presentation, the fetal heart tones may be best heard in the patient’s right or left upper abdominal quadrants w. The normal heart rate for a fetus is approximately 110 to 160 beats per minute (bpm). x. even after the baby is born it is 110-160 10. Fetal development from the conception through the embryonic (critical) period, to the placental development and beyond. – It is all about the placenta. What risk factors will impede placental perfusion to the baby? a. A baby is completely developed by 12 weeks, the embryonic/critical stage where you need to be the most cautious about what you put into your body. The pregnancy is tucked away in the pelvis for 12 weeks protecting the baby from trauma. b. web-x c. If something happens to the baby during the embryonic period, or if there is some kind of insult at any kind, you’re going to find anomalies (genetic insult, environment insult) because of infection, or moms lifestyle choices. we can pinpoint that to the weeks of gestation, so during the 1st 12 weeks the baby stays in the pelvic organ to try to protect it somewhat from trauma, after that once it becomes and abdominal organ it is cushioned by amniotic fluid: cushions the baby from injury, cushions the cord from being collapsed, or restricted, helps the lungs from sticking- temp control free movement, so the muscles can dev. so they can get stronger and when they are born have the ability suck/swallow/push/pull d. Oligohydramnios- too little fluid e. polyhydramnios- when the fluid is too much( diabetes in mom) f. oligo- look for renal issues in baby g. The placenta is the work organ of pregnancy, if something happens to the placenta it happens to the baby as well. IT’S ALL ABOUT PERFUSION. It’s all about the blood flow to and from the placenta. Baby’s blood does not come in contact with mother’s blood. A gas exchange takes place at the chorionic villi, where nutrients and oxygen are given to the baby then the baby gives back carbon dioxide. Carbon dioxide is given to the mother’s lungs to be expelled this makes the mother breathe a little bit faster/deeper. Mother needs more lung capacity, diaphragm pushes on the lungs, so she uses a lateral lung expansion (arches back to receive more lung capacity). h. The kidneys need to work harder because the filtration rate is greater because they can’t filter all the extra fluids/salts/proteins. i. PREGNANCY IS ALL ABOUT PERFUSION j. The placenta is a huge filtering organ and everything has to go placenta for the baby. Bad/good things go through the placenta 11. Know normal discomforts of pregnancy and what is not normal and how do nurses educate their patients on the difference. Look at each system. What a normal change means to her and what education you would give. a. Headaches in pregnancy are NOT normal. A lot of times it is preeclampsia. 12. What activity is appropriate for the pregnant patient? a. Walking is best to get heart rate up b. also swimming, bicycling c. as long as Heart rate doesn’t go up over 140 d. Don’t start a new exercise you didn’t do before pregnancy e. be careful with bending/ supine position because of blood flow- heavy uterus sits on superior vena cava and causes hypertension for mom and decrease blood flow to baby f. no pregnant woman should lay flat on their back- continue doing what you were doing before, as long as it doesn’t impede blood flow g. low impact, not high impact because joints become more flexible (Hormone called relaxin h. relaxin: helps the pelvic bone to separate just a little to help baby to snuggle before birth to expand i. also knees and elbows hyperextend- discourage high active sports with women who are pregnant- jet ski’s j. no alcohol 13. Placenta is the ‘work horse’ organ of pregnancy – what does it provide/what it doesn’t provide. a. Placenta has two sides the fetal side and maternal side. b. Maternal side (dirty dunkin) has 15-20 tissue pads called Catalina pads (where the gas exchange takes place), count and make sure they’re all there after birth. c. Fetal side is the Shiny Schultz side is translucent and you can see through it but you can’t break it without an sharp instrument. d. The placenta is made up of two layers of tissue the chorion and amnion. The chorion is on the outside of the balloon and the amnion is on the inside with the baby inside. e. The three vessels in the umbilical cord are two arteries (deoxygenated blood baby to mother) and a vein (take oxygenated blood mother to baby). The vessels wrap around each other, to keep the cord from being compressed is Wharton’s jelly. Inside the amnion sac is fluids. The reasons we have fluid are to protect the baby and cord, temperature control and free movement. f. Sugar, caffeine, Nicotine, Carbon monoxide and any drugs mom takes crosses the placental barrier, but heparin and insulin do not. 14. Amniotic fluid what is the purpose? What is the issue with oligohydramnios, and polyhydramnios. a. Purpose of amniotic fluid is protect fetus and cord from trauma and temperature control. b. Oligohydramnios is losing fluid or not enough fluid. PROM can result (premature rupture of membranes) c. Polyhydramnios is too much fluid.- cause shortness of breath and preterm labor 15. Nutrition is a key factor in pregnancy outcome – what is essential to include. What do most women need additional supplements for? Explore the vegetarian diet. Explore the problem of generalized nausea and vomiting – not severe – explore food fads. What are the risks to the fetus if mom does not gain weight or does not eat properly? And keep in mind the questions regarding the use of alcohol in pregnancy – it is never acceptable. a. Drink enough fluids(water) and fiber for constipation b. Vegetarian needs to increase protein, iron, folic acid, calcium c. IUGR- intrauterine growth restriction, baby doesn’t grow to normal weight during pregnancy. d. Mother is diabetic not taking care of herself eating a lot of sugar, baby will be macrosomia (baby grows too much in the trunk). These babies get stuck in the birth canal and causes fetal injuries. e. Alcohol is pregnancy is NEVER acceptable f. web-x g. be careful with vitamin d because it is a fat soluble vitamin and it is hard to excrete fast causing overdose h. calories should increase who are ideal/ underweight i. need to have 300cal a day j. 500c a day if you’re breastfeeding k. if someone is overweight we want to talk to them about improving there dietary intake to get rid of excess fat and sugars l. omega 3 for brain function be careful with fish because of mercury also sugar substitutes; lunch meats (packaged foods) because of listeria and sodium- don’t want to restrict sodium (Na), but we also retain lots of sodium 16. Prenatal testing – multiple tests are completed – recognize the difference between a screening exam and a diagnostic exam. Include diagnostic tests such as ultrasounds too. When do we provide them and why? Specifically the labs drawn in the early pregnancy – MSAFP – or the Triple screen when and why drawn, and we know Folic Acid is used to help prevent the development of the Neural Tube and the absence of openings, also the existence of some chromosomal abnormalities – ie: Down syndrome. a. RH factor, blood type, CBC, UA, Rubella, Hepatitis, Syphilis, Chlamydia and Gonorrhea cultures, HIV, Varicella titer, Pap smear. b. If she is between 15 and 20 weeks we do a Quad screen, this is for genetic testing like Down syndrome or looking for Neural tube defects like spina bifida. c. Glucose tolerance test is done between 24 and 28 weeks. d. At the end of pregnancy we do a group b strep swab both vagina and rectum (GBS) during labor. If mom is positive we need to treat her with antibiotics before the baby is born. CBC e. web-x f. starts in the initial visit in the 1st 12 weeks g. 8-12 weeks free DNA test starts (serum test) 17. Complications of pregnancy – bleeding can be normal or abnormal – what are the causes of both? Know the difference between placenta previa/ placental abruption. What are the risk factors for both? Ectopic pregnancy is another issue – know signs and symptoms, know management. a. Bleeding is not normal, always check b. Placenta previa is where the placenta is laying over the cervix (the cervix needs to open during labor to allow the baby to come through), so the placenta can come out first. If this happens the baby can die. This is very serious nothing in the vagina and most likely on bedrest. We need to do an ultrasound, no vaginal ultrasounds. The baby will have to be born by C-section. Placenta previa is PAINLESS bleeding. c. Placenta abruption is where the placenta tears away from the uterus which causes PAINFUL bleeding. This can happen because of a trauma like a car accident, cocaine or hypertensive crisis. If blood is filling up in the abdomen it becomes distended, rigid and hard. d. web-x e. serious s/e of pregnancy f. must report bleeding to physician g. pain/cramping h. RUPTURED MEMBRANES- WATER BREAKING report to hcp……..TO BE CONTINUED