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CHAPTER 25 HEALTH PROMOTION and PREGNANCY

Fertilization sperm carried in males ejaculatory semen enters female vagina and sperm travel through mucous of cervical canal by flagellation and enter uterine chamber and move to ampulla outer third of fallopian tube and there is where fertilization of ovum/sperm takes place C ONCEPTION requires 24 hrs. once fertilization occurs union of two creates a new cell called ZYGOTE cell contains 46 chromosomes sex is determined at this union with all genetic characteristics and do not change IMPLANTATION zygote moves through uterine tube by ciliary action and some peristalsic activity takes 3-4 days to enter uterine cavity during this time ZYGOTE is in phase of rapid cell division called MITOSIS changes result in formation of MORULA (development stage of fertilized ovum in which there is a SOLID MASS of cells) then develops into a BLASTOCYST (embryonic form, spherical mass of cells having central fluid filled cavity surrounded by two layers of cells) stem cells are derived from inner cell mass of blastocyst after blastocyst is free in the uterine cavity for 1-2 days, exposed cell walls of blastocyst (NOW CALLED TROPHOBLAST) secrete enzymes that are able to break down protein and penetrate cell membranes allow the blastocyst to enter endometrium and implant (action of enzymes normally stops short of myometrium b ut may cause slight bleeding in some women) called implantation bleeding Condition of uterus critical for IMPLANTATION of the zygote during secretory phase of menstrual cycle, endometrium has enriched vascular bed with enlarged blood vessels and increased store of glycogen this will support development of embryo if implantation occurs implantation occurs in FUNDUS of uterus either on anterior/posterior surfaces it uterine conditions are not suitable, implantation is unlikely to occur spontaneous abortion will occur ECTOPIC PREGNANCY-where implantation occurs outside uterine cavity During first weeks after implantation, primary villi appear use maternal blood vessels as a source of nourishment and O2 for developing embryo villi nourish the embryo from time of implantation (about 2 wks after conception) until seventh/eighth week also going on is the first stages of the CHORIONIC VILLI (tiny vascular protrusions on chorionic surface that project into maternal blood sinuses of uterus and help form placenta) occur the C. villi secrete human chorionic gonadotrophin (HCG) a hormone that stimulates the continued production of progesterone/estrogen by corpus luteum that is why menstruation and ovulation cannot occur in pregnancy 0 the primary villi will also synthesize protein/glucose for about 12 weeks until fetus is adequately developed to meet its own needs chorionic villi become fetal portion of placenta EMBRYONIC and FETAL DEVELOPMENT until time of implantation, cell mass is called a zygote the fertilized ovum develops from two original cells into a many celled organism and the zygote develops two separate and distinct cavities amniotic cavity and yolk sac amniotic cavity has walls lined with ectoderm (outer layer of embryonic tissue giving rise to skin, nails, hair) and is filled with amniotic fluid yolk sace is lined with endoderm (innermost layer of cells develops into lining of cavities and passages

of body and covering of most internal organs) the YOLK sac supplies nourishment until implantation a third layer of cells (MESODERM) gives rise to all types of muscles, connective tissue, bone marrow, blood, lymphoid tissue and epithelial tissue) located between the two cavities embryo develops at the point at which three layers meet called TRLAMINAR EMBRYONIC DISK Embryonic stages conception to end of 8 weeks the three layers of cells differentiate into tissue an dlayers, which forms the placenta, embryonic structures and embryo itself cell growth rapid simple heart begins beating and rudimentary (basic) forms of all major organs/systems develop by end of the stage embryo has acquired a human appearance FETAL STAGE _ from 9th week until delivery embryo is now a FETUS During early weeks of pregnancy threat of teratogenic agents (drug, virus, irradiation that can cause malformation of fetus) can cause serious hardm (ie-RUBELLA) Rubella can cause serious anomalies in fetus in all stages of pregnancy-that is why a rubella titer is done early in pregnancy EMBRYONIC/FETAL PHYSIOLOGY Placenta disklike organ made up of about 20 sections called cotyledons unique structure only present during pregnancy develops rapidly bulk of placenta is fetal in origin side attached to uterine wall (Dirty Duncan)appears dark red and has rough surface and cotyledons are apparent and distint lobes with clefts/divisions between each lobe Duncan presentation is associated with blood expulsion with palcenta FETAL SIDE is smooth and shiny (shiny schultze) consists of membranes of amniotic sac that encases fetus small gush of blood precedes the placenta when Schulze side is presenting on delivery assess placenta and determine the presenting side then examine placenta for intactness Placenta-functions as endocrine gland secreting HCG and steroidal hormones estrogen/progesteronewhich maintain pregnancy placenta is also site of exchange of nutrients, oxygen, and waste products between fetus and maternal circulation placenta allows transfer of oxygen and nutrients thru such processes of diffusion and active transport and also blocks transfer of certain substances (placental barrier)-some virus are able to cross over but most bacteria are too large some drugs do not cross over placenta but most due and cause serious harm to growing embryo or fetus placenta no longer useful after delivery and is expelled**MUST KNOW FETAL MEMBRANES-umbilical cord joins embryo to placenta originates in the fetal portion of the placenta and is normally attached near center = cord is typically 20-22 inches long and less than 1 wide at time of delivery major part of cord is pale white, gelatinous mucoid substance called WHARTONS JELLY-gelatinous tissue that remains when embryonic body stalk blends with yolk sac within umbilical cord) it prevents compression of blood vessels there are TWO ARTERIES and ONE VEIN in the umbilical cord giving it a ropelike appearance VEIN carries oxygenated blood to the fetus; the ARTERIES carry deoxygenated blood back to the placenta. Cord has no pain receptors, so cutting at time of delivery does not cause pain

AMNIOTIC FLUID: acts as cushion against mechanical injury, helps regulate fetal temp, and allows developing fetus or embryo room for growth. Amount of fluid changes from about 30 ml at 10 wks to as much as 1L at delivery contains albumin, urea, uric acid, creatinine, bilirubin, lecithin (phospholipid for fat metabolism), sphingomyelin (compound of lipids and spingosine, found in high concentrations in brain and other tissues of nervous system), fructose, fat, leukocytes, proteins, epithelial cells, enzymes, and strands of lanugo (downy fine hair characteristic of fetus between 20 wk and birth) amniocentesis can be done in later stages of pregnancy to help determine development, maturity, health and sex of fetus Important weeks of development Week 5 - heart starts pumping blood, limb buds appear; major divisions of brain can now be discerned Week 8 the embryo is now a little more than 1 inch long and resembles a baby Week 9 genitalia now well defined baby s sex can be determined eyelids finish forming and seal shut embryo has become a fetus Week 10 some women describe sensation of first movements as if something were blowing bubbles through straw in their stomachs Week 16 fetal heartbeat can now be heard with amplified stethoscope placenta begins production of hormone estrogen

Note; maternal antibodies against measles, mumps, rubella, whooping cough, and scarlet fever are transferred to baby, providing protection for about 6 mths until infants own immune system can take over if mother hasnt made antibodies, baby wont get protection Benefits of breastfeeding allergies, extra nutrition Fetal Well-Being Assessing Fetal Heart tones shows activity by seventh week of gestation can auscultate fetal heart tones between 10-12 weeks by using Doppler play Doppler in midline, just above symphysis pubis, and apply firm pressure Assessing fundal height during second trimester, uterus becomes an abdominal organ fundal height is one way of determining fetal growth measurement also provides estimate of duration of pregnancyduring second/third trimesters, (18-30 wks) height of fundus in centimeters is approximately the same as the number of weeks of gestation, if the womans bladder is empty at time of measurement-in adiditon, measurement of fundal height may aid in ID of high risk factors stable or decreased fundal height may indicate intrauterine growth restriction; an excessive increase may indicate multiple gestation or hydramnios

USound-high frequency sound waves to visualizefetus - can determine gestational age, monitor fetal growth, determine the number of fetuses and location of the placenta, estimate volume of amniotic fluid, and detect anomalies many nurses perform U/S scans and biophysical profiles Maternal Serum Alph-Fetoprotein Screening (AFP)-used to identify certain birth defects and chromosomal anomalies should be done between 16-18 wks elevated levels indicate neural tube defects whereas low levels may suggest fetus with Downs Syndrome ** Chorionic Villus Screening (CVS)-new test to detect genetic disorders of fetus usually performed at 812 weeks of gestation and requires aspiration of sm amt of tissue from chorion of placenta Amniocentesis-involves removing small amt of amniotic fluid by passing a needle through abdominal wall done in conjunction of U/S so that dr can visualize location of fetus, placenta, and pocket of amniotic fluid test can reveal genetic factors such as sex and chromosomal abnormalities, health status, and maturity of fetus early amniocentesis is performed at 16th week and used to detect biochemical or chromosomal abnormalities testing allows mother to consider termination of pregnancy before legal point of viability (22 weeks)** fetuss ability to survive outside womb is known as VIABILITY has decreased from 28 weeks to 20 weeks later in pregnancy used to determine fetal lung maturity sometimes done to determine intrauterine infection ro fetal diseases NONSTRESS test done to evaluate how fetal heart rate responds to periods of fetal movement indicated where there is a risk of placental insufficiency (pregnancy induced hypertension, diabetes, postmaturity, maternal smoking, or inadequate maternal nutrition) baseline of fetal heart rate of 120160 bpm, fetal heart rate normally accelerates at least 15 bmps for at least 15 seconds with fetal movement done using fetal monitor with tocotransducer recording fetal movement and U/S transducer recording fetal heart rate reaction means healthy fetus nonreactive NST may indicate a compromised fetal and requires further evaluation with another NST , BPP or contraction stress test done after 27th week Nursemust explain test to patient, assuring pt has no discomfort is associated with NST, encouraging pt to express fears, having patient east before test to evaluate serum glucose levels, having pt empty bladder and then assume Sims position, applying external fetal monitors to pts abdomen, observing for increase in fetal heart rate with movement, and stimulating fetal activity by external methods if fetus remains quiet for more than 20minutes Contraction Stress Test used external fetal monitoring and stimulation of contractions to evaluate how fetal heart rate responds to decreased oxygen supply during uterine contractions desire response is no change in fetal heart rate, resulting in negative test positive test indicates placental insufficiency and fetal hypoxia as evidenced by late decelerations fetus may be at risk during labor and require delivery by C section testing done after 32 weeks uterine contractions are stimulated by nipple massage or IV infusion of oxytocin

MRI provides excellent pictures of soft tissues does not use ionizing radiation like CT scan, vascular structures can be evaluated without injecting iodine dye noninvasive and provides images in multiple planes, butinterference from skeletal, fatty, or gas filled structures is not a problem does not depend on full bladder Biophysical Profile BPP assesses fetal status by evaluating several factors NST, fetal breathing movements, fetal muscle tone, fetal movements, amniotic fluid volume each given a score of 0-2, total score of 8 reassuring MATERNAL PHYSIOLOGY Hormonal changes estrogen/progesterone levels remain evaluated for first 8-10 weeks as result of HCG, which supports corpus luteum, structure that grows on surface of ovary within ruptured ovarian follicle after ovulation during pregnancy, it secretes progesterone after this time, placenta takes over production and maintains necessary levels as long as levels are high, FSH, LH, and ovulation are suppressed, as is menstruation UTERUS enlarges during pregnancy s result of hormonal stimulus, increased vascularity, hyperplasia (new muscle fiber and tissue) and hypertrophy (enlargement of existing fiber and tissue) nonpregnant womans uterus is pear shaped and weighs about 2 oz by third trimester it is egg shaped and has increased in wt to 2.2 lbs can hold a fetus, placenta, amniotic fluid totaling about 8-1/2 lbs Changes in cervis and fundus along with altered position of in pelvis, are early signs of pregnancy uterus, rises to base of ribcage superiod aspect of uterus (fundus) is located at level of xiphoid process by end of third trimester Breasts changes include hypertrophy of mammary glandular tissue and increased vascularization, pigmentation, size, and prominence of nipples and areolae caused by hormonal stimulation MATERNITY CYCLE three distinct periods first one ANTEPARTAL period or prenatal period begins with conception and ends with onset of labor; INTRAPARTAL period begins with onset of labor and ends with delivery of placenta sometimes called perinatal period; last period is POSTPARTAL period starts with delivery of placenta and lasts appx. 6 weeks or until reproductive organs return to prepregnancy state pregnancy lasts 9 mths, appx 40 weeks also divided into 3 month periods TRIMESTERS first trimester 1-13 weeks; second trimester 14-26 weeks and third trimester 27-through birth (38-40 wks) ANTEPARTAL ASSESSMENT General physical assessment prenatal care should commence as soon as menstrual period is missed many do not obtain routine health care due to cost first visit involves obtaining demographic (statistical and quantitative study of characteristics of human population)age, occupation, martial status, insurance inf. helps dr identify potential area of concern, -obtain complete family and personal medical hx dr must be aware of genetic diseases in either mothers or fathers side - includes any

genetic problems, if known, if serious genetic problems areknown, many couples seek genetic counseling before they consider having children GENETIC COUNSELING assessment begins with good medical hx and review of systems discuss chronic disease such as cardiac problems, hypertension, DM, infectious disease (rubella, acquired immunodeficiency syndrome, or STI) document hx of accidents/past surgeries assess lifestyle patterns, (activity, nutrition, drugs, alcohol, tobacco and work exposure to hazardous conditions) early detection and correction of problem can reducehazard to woman and prevent detrimental effects on fetus OBSTETRIC ASSESSMENT obtain information on patients gynecologic, menstrual, and obstetric hx (use of contraception in past, regularity of menses, any surgeries, any vaginal discharge, herpes infection) exposure to diethylstilbestrol (DES) daughters of women who took DES during pregnenacy have increased risk of spontaneous abortion caused by incompetent cervis. Discuss number of past pregnancies and outcomes GYNECOLOGICAL EXAM nurse prepares equipment needed for exam palpation and auscultation of abdomen, visualization of cervix/vagina, evaluation of bony pelvis, palpation of uterus externally and bimanually, exam of vulva, perineum, anus, rectum, possibly a pap smear will be performed DETERMINATION OF PREGNANC Y PRESUMPTIVE SIGNS indicators that woman may be pregnant, but that be signs of something other than this: Amenorrhea, N&V, frequent urination, breast changes, changes in shape of abdomen, quickening (usually felt 16-18 weeks in pregnancy), skin changes (pigment changes), Chadwicks sign (vagina, cervix, and vulva may have purplish discoloration PROBABLE SIGNS indicate high likelihood that woman is pregnant : change in reproductive organs (enlargement of uterus, softening of this segment (consistency ofisthmus of uterus segment between fundus and cervix), softening or increased pliability of cervix (Goodells sign), Ballottement 16-18 weeks technique that involves palpating the uterus in such a way the dr feels rebound of floating fetus); positive pregnancy tests(urine or blood test to measure level of HCG)-best one is one done by dr. if testing is positive but dr may suspect comploicaitons such as ectopic pregnancy, pregnancy or hydatidiform mole (abnormal growth of fertilized ovum in which large vascular mass, but no fetus, develops); =this mole frequently results in high reactive pregnancy test and may continue even if mass is removed POSITIVE SIGNS-signs that ONLY occur if pregnant visualization (fetal skeleton seen on xray, U/S of fetus); fetal movement (may be detected by trained observer or dr), ausculatation of fetal heart rate (can be detected by U/S at 6 weeks; tones heard by Doppler at 10-17 weeks and by stethoscope at 17-19 weeks

DETERMINATION OF EDD: 280 days, or 40 weeks, 1 0 lunar mths of 28 days each, or slightly more than 9 consecutive mths most common method to compute is the Nageles rule start with first day oflast period, count back three mths, then add 7 days if pt is unaware of last period, dr. will have to determine based on signs of quickening, estimation of fetal size by palpation, U/S tests, and other testing OBSTETRIC TERMINOLOGY : Gravida indicates a pregnant woman and number of pregnancies-pregnant woman primigravida (first pregnancy); nulligravida (never pregnant), multigravida (multiple prior births) Para number of births: Primipara (one birth); nullipara (no births), multipara (multiple births) May be done by Five digit system: GTPAL : G(gravidity), T (term births), P (preterm births), A (abortions), L (living children) or Four digit system: TPAL: T (term births), P (preterm births), A (abortions) and L (living children) Abortion loss of fetus before the age of viability (20 weeks) Antepartal care Health promotion pregnancy is the one time in life when most women see importance of medical supervision and willing to make changes in their habits thinking of their baby and what to do for best of baby ck list on 788 for trimester chlist Once pregnancy is determined prenatal care is commenced must develop good general health practices-pap smear, BSE, routine care starts with first visit for nurse/dr to obtain full history appts are monthly for first 7 mths, then every 2 weeks for the next month, then once every week untilbaby is born scheduling may be altered in cases of multiple births of other conditions dental work can continue during pregnancy, but any major dental work held off until after deliveyr Smoking dangerous to mother/baby oxygen deprivation can lead to intrauterine growth decrease, and low birth weight drinking alcohol alsocontraindicated especially 1st trimester Do not take any meds during pregnancy until prescribed by Dr or OK by dr.-drugs can cross placenta and transmitted to fetus Embryonic and fetal development is vulnerable to env. Teratogens harmful chemicals, cleaning products, paints, sprays, herbicides and pesticides)woman needs to read labels on potential hazardous items DANGER SIGNS DURING PREGNANCY: 1) Visual disturbances, diplopia (double vision), blurring or spots 2) Headaches, severe, sudden or continuous 3) Edema- swelling of face, presacral area, fingers

4) 5) 6) 7) 8) 9) 10) 11)

Rapid wt gain, in excess to normal gain for gestation Pain severe abdominal or epigastric pain Signs of infecciton fever chills, diarrhea, changes in vaginal dischg, pain/burning on urination Vaginal bleeding (no matter how slight) Vaginal drainage (aside normal mucous) Persistent vomiting Muscular irritability or convulsions Absence or decrease in fetal movement once felt

NUTRITIONAL and METABOLIC HEALTH PATTERN (in chapter 21) PICA craving and eating substances that are not normally considered edible reason unknown may include clay or laundry starch not toxic but may interfere with iron absorption, resulting in anemia lg amts of clay may also cause fetal impaction COMMON DISCOMFORTS 1) Gastrointestinal excessive salivation (ptyalism), in response to high levels of estrogen use astringent mouthwash, chew gum, or sucking on hard candy may help 2) Nausea common in early stages may be caused by increased HCG levels and changes in carb metabolism can be controlled by slowly eating a few soda crackers or dry toast before rising from bed eat smaller more frequent meals and avoid spicy or greasy foods usually subsides after fourth mth if longer than that dr should be contacted most severe form is HYPEREMESIS GRAVIDARUM cause unclear but if left untreated, can lead to dehydration, fluid and electrolyte imbalance, acid-base imbalance, altered kidney and cardiac function and even fetal death hospitalization may be required for supervision, including feeding 3) PYROSIS heartburn from gastric reflux into esophagus can be caused by increasing size offetus in abdominal cavity, which displaces stomach increased progesterone level, which can lead to relaxation of cardiac sphincter, and decreased gastric mobility delays stomachs emptying time eat smaller more frequent meals, decreased fat intake, low sodium antacids, and avoid lying down after meals SKIN CHANGES 1) Pigmentation due to increased amts of melanocyte-stimulating hormone changes may be seen in the areolae, nipples, vulva, perianal area, linea alba (midline of abdomen from pubis to umbilicus which darkens and is called a LINEA NIGRA 2) CHLOASMA mask of pregnancy irregular darkening of cheeks, forehead and nose changes more obvious in darker hair and skin tone and may worsen by sun exposure fades after delivery 3) STRIAE GRAVIDARUM-stretch marks, are reddish, wavy streaks that appear on thighs, abdomen and breasts more common with distention butmay occur even in relatively thin women usually fade after delivery

4) SPIDER NEVI (branched growth of dilated capillaries on skin) and PALMAR ERYTHEMA(reddened palms) caused by increased blood flow resulting from high estrogen levels disappear when pregnancy ends 5) Accelerated hair and nail growth with HIRSUTISM(excessive body hair in a masculine distribution pattern as result of heredity, hormonal dysfunction or medication) oily skin and acne may occur in some women some report clearing of skin 6) Occasionally, decreased emptying of gallbladder may result in subclinical jaundice causing pruritis CHANGES IN CARDIOVASCULAR SYSTEM 1) Episodes of orthostatic hypotension 2) Increase of platelets and fibrinogen increases womens risk of blood clots 3) Cardiovascular adaptations protect womens normal physiologic functioning, meet metabolic demands of pregnancy, and provide for fetal development and growth CHANGES IN RESPIRATORY SYSTEM 1) Structural and ventilator adaptations provide for maternal and fetal needs 2) Maternal oxygen requirements increase in response to accelerated metabolic rate and need to add to tissue mass in uterus and breasts fetus requires oxygen and way to eliminate carbon dioxide elevation of estrogen causes ligaments of ribcage to relax, permitting increased chest expansion CHANGES IN MUSCULOSKELETAL SYSTEM 1) Alteration in posture and way woman walks late in pregnancy 2) Abdominal distention that gives pelvis a forward tilt, decreased abdominal muscle tone, and increased wt bearing create realignment of spinal curvature womans center of gravity shifts forward 3) Increase in normal lumbosacral curve (lordosis) develops, and compensatory curvature in cervicodorsal region (exaggerated anterior flexion of head) develops to help maintain balance 4) Aching, numbness and weakness of upper extremities may result 5) Lg breasts and stoop shouldered stance further accentuate lumbar and dorsal curves 6) Ligamentous and muscular structures of middle and lower spine may be severely stressed 7) With large or multiple gestation pregnancies, overdistention may cause abdominal wall muscles to separate (DIASTASIS RECTI ABDOMINIS) 8) Slight relaxation and increased mobility of pelvic joints are normal result of exaggerated elasticity and softening of connective tissue caused by increased circulating steroid sex hormones, especially estrogen - RELAXIN, ovarian hormone, assists in relaxation and softeningthese permit enlargement of pelvic dimensions to facilitate in birth 9) Separation of symphysis pubis and instability of sacroiliac joints may cause pain and difficulty in walking (obesity/multifetal pregnancy tend to increase pelvic instability)

HYGIENE PRACTICE Bathing/showering should continue during pregnancy increased perspiration is normal and good hygiene is important to prevent body odor tub bathing may become difficult in later pregnancy because of changes in mobility and balance some dr may restrict baths in last month because cervix may have begun to dilate Dr usually advise against hot tubs, saunas, and spa because maternal hyperthermia during first trimester may result in CNS defects in fetus avoid hyperthermic baths Douching NOT recommended report any abnormal dischg to dr Make sure clothing is nonrestricting and comfortable ELIMINATION GI system slowing of intestinal peristalsis can result in abdominal distention, flatulence, constipation can be related to iron supplements Hemorrhoids can result from straining as result of constipation or caused by enlarged uterus putting pressure on pelvic blood vessels, slowing venous return from lower extremities Women with hx of cholelithiasis may experience problems with this as result of increased cholesterol level, common in pregnancy Adequate fluid intake, dietary roughage, and exercise will help reduce constipation Urinary system frequency of urination common mother must excrete not only her own waste products but those of fetus output increases, and specific gravity of urine decreases early in pregnancy the enlarging uterus puts pressure on bladder continues until uterus rises into abdominal cavity later in pregnancy, when presenting part descends into pelvis, pressure returns teach pt kegel exercises to help build perineal muscles and prevent stress incontinence ureter and kidneys may become dilated, particularly on right side, as result of placental progesterone and pressure from enlarging uterus restricted circulation in pelvis as uterus enlarges increases risk of bladder trauma and UTI ACTIVITY AND EXERCISE pts should continue normal activity throughout uncomplicated pregnancy discuss with dr Fatigue common problem woman must pace herself and not ovedo Changes in balance and posture occur as fetus increases in size may result in lower back pain wear low heels Leg cramps common related to pressure on pelvic blood vessels and nerves and altered calcium and phosphorus balance dorsiflexion of foot may help may need support hose if experiencing varicose veins or dependent edema

Round ligament pain or tenderness in lower abdomen is result of stretching of ligaments by enlarging utuerus no real way to prevent using good body mechanics Dyspnea may be experienced as uterus enlarges and pushes diaphragm upward decreasing size ofchest cavity avoid large meals and use good posture =exercise encouraged REST AND SLEEP supine position not recommended as woman approaches due date because enlarged uterus may place excessive pressure on aorta and vena cava can result in vena cava syndrome woman may experience syncope and vertigo-and may also result in decreased circulation to fetus side lying position is recommended encourage rest periods during day with feet elevated SEXUALITY AND REPRODUCTIVE SYSTEM Breast changes begin early in pregnancy c/o tingling and feeling of fullness increased sensitivity nipples and areolae darken colostrums may be secreted by nipples in late pregnancy SEXUAL ACTIVITY no physiological reason to limit sex during pregnancy may increase or decrease Increased vaginal secretions are common =LEUKORRHEA increase in vaginal mucus, results from hormonal changes if changes in color or odor, contact dr Contact dr with ANY vaginal bleeding noted Changes in roles, relationships, adaptation to expected delivery and new baby Cognitive and perceptual changes blurring and diplopia may indicate problems with gestational hypertension

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