So, welcome to our anapartum assessment 5 mini lecture. Um, if that looks familiar, it should. We had an

intrapartum assessment 5 and those are the same categories we're going to be talking about for anopartum. Uh, the

difference being that our normal or abnormal interpretation of these categories is slightly different based

on the gestation of the pregnancy. So, we're going to talk about how that looks different in the anopartum period.

So, we still have our vital signs that we're going to do on all of our assessments. And we still have our same

five categories, our pain, contractions, leaking, bleeding, and fetal movement. Uh, so same categories as intraartum,

but again, what we deem as normal or abnormal varies slightly depending on gestation. So, if we look at our vital

signs assessment, all of our normal ranges for vital signs are the same as they were for the intraartum period. Um,

so same range for blood pressure, any temperature over 100.4 or is still a fever, etc. Um, but we know that our

vital signs might fluctuate from the patient's baseline throughout the pregnancy. However, those those

fluctuations are going to be still within those normal ranges. So, let's say a patient's um baseline blood

pressure in the first trimester is 120s over 70s. Uh, and in the second trimester, we see a dip, which is kind

of common, a slightly lower blood pressure in the second trimester due to anatomical changes. um that their

baseline or their new blood pressure is now 110s over 60s and then it goes back up closer to that 120s over 70s or maybe

slightly elevated or slightly below that for the third trimester. We see those fluctuations and and we note that they

occur. Uh but all of those findings are still going to be within the normal ranges. It's just a change from

baseline, not a change in what we deem normal or abnormal. Um, one of the main reasons we monitor vital signs

throughout the pregnancy is that we can watch trends or if we see abnormal findings, uh, we can tie those to

underlying complications or problems. Uh, the general rule is any abnormal findings prior to 20 weeks of pregnancy,

so in the first half of pregnancy, are typically related to chronic issues that either we knew were there or that the

patient just had not been diagnosed with. Um, and we are catching it during pregnancy. um mostly because we see

pregnant patients so much more frequently than a normal adult seeks medical care. And then any abnormal

finding after 20 weeks gestation or in the second half of pregnancy are typically related to pregnancy induced

issues or complications. Um and the difference in those being that after pregnancy chronic issues are typically

still an issue and pregnancy induced issues usually eventually go away. Um, and you notice I'm not saying always or

never because we don't like absolutes and there's exceptions to every rule. Um, but for the most part, those those

statements are true. So, pain throughout the pregnancy, uh, again, never assume it to just be

normal. Um, but we still anytime we ask a patient if they're in pain and they report that they're in pain, we want to

know where the pain is, what kind of pain, what that description is. Um, a scale of 0 to 10. A lot of the um pain

and or discomforts throughout pregnancy have to do with the anatomical changes that occur within the body as the

pregnancy progresses. So one of the things that becomes really important during pregnancy is if a patient has a

pain ID identifying what stage they're at in that pregnancy, what gestational age, what trimester, and whether that

pain can be explained by one of those anatomical changes or not. Um, not to say that we ever just blow it off as

like not significant or even if we know it is caused by an anatomical change that we don't still address it and try

to make the patient more comfortable. Um, but for example, a low back ache at 34 weeks gestation. The lordosis of the

spine, the extra weight in the abdomen that is pulling on the spine and causing that extra curvature can absolutely

cause low back discomfort. We know that. Um, however, the same low back pain at 10 weeks gestation could indicate

uterine cramping or a threatened abortion or that something is um underliningly wrong. So, that's just an

example of how the same complaint could be viewed as normal or abnormal based on the gestation of pregnancy.

Contractions. So, um in the first trimester, cramping is never to be assumed normal. um there are not great

enough changes anatomically to cause what we would cause or call that un that discomfort kind of feeling due to those

changes in the pelvis or the abdomen. Um in the second and third trimesters it's really important to differentiate

between Braxton Hicks those practice contractions and actual uterine contractions. Um we always want to make

sure especially in the later half of the second um trimester and the third trimester that if the patient is having

any type of contractions that if they are painful, if they are rhythmic, they're coming closer together um or

they're persistent that we rule out that they are not experiencing preterm labor because preterm birth is a true risk

that carries a lot of potential uh detrimental uh complications and consequences. So we always want to rule

out that that is not the case if they are complaining of contractions that again are painful, rhythmic, closer

together, becoming stronger, don't go away when they lay down, drink some water, take a rest, etc.

Leaking of fluid during the anopartum period. We do not just consider this normal pretty much ever um unless the

patient is fullterm and we are expecting rupture of membranes has occurred and then we're anticipating labor um in the

near future. uh if we have leaking of fluid earlier in the anopartum period anytime it's preterm uh we don't assume

it is normal we absolutely want the patient to be evaluated we can have what we call prime premature prolonged

rupture of membranes so meaning that that rupture membrane occurs prior to the 37 weeks sometimes way way earlier

than that um and if it happens previability so viability date is generally accepted to be around 23 weeks

gestation meaning that um once a pregnancy reach reaches that gestation, we have interventions and medical care

that we can attempt to provide to keep baby alive on the outside of mom after birth. Um, prior to that there is uh

developmentally not enough body systems functioning adequately for us to keep a

baby alive is generally kind of how that's explained. Um but we know that PROM or that premature prolonged rupture

uh previability even if we can maintain the pregnancy to a viability point often leads to respiratory failure um because

of the lack of development of the lung tissue resulting from the lack of amniotic fluid.

Um so once we make it to term or close enough to term if we've had rupture of membranes uh we absolutely still want

the patient to be evaluated. we need to identify whether they're in labor or whether they need to be in labor. Um and

as we talked about in inpartum, the longer a patient has rupture of membranes occur, the increased risk for

infection that they have. So um never to be assumed normal, always needs evaluated. We still want to know what

color. We still want to know how long, what time it occurred, and how long it's been since. Um and then what we do about

that based on their gestation, we will talk more about in class. Vaginal bleeding also never to be assumed normal

during the pregnancy um regardless of gestation. But we know that we have different causes of vaginal bleeding

based on gestation. So we're going back to that 20 week mark that I said was kind of important um when we looked at

whether vital sign changes were pregnancy induced or chronic. Um so the 20we mark is also significant for

vaginal bleeding because we know that vaginal bleeding prior to 20 weeks is usually caused by um the following

causes like implantation bleeding that's usually really early on uh close to conception. Spontaneous abortion or

threatened abortion uh subcorionic hemorrhage which is a um little pool of blood that accumulates underneath the

placenta as it's developing and can cause some external bleeding and then a lot of times gets reabsorbed by the body

and doesn't become like a long-term issue. um ectopic pregnancy which is a medical emergency situation and then a

molar pregnancy um and we'll talk further about that in class that's a little more complicated. Um so those are

the things we tend to think of if a patient experiences vaginal bleeding in the first half of pregnancy. If we have

vaginal bleeding in the second half of pregnancy we usually um tie it to one of three causes. It's a placenta privia um

where the placenta is covering the cervical ass a placental abruption where you have that placenta placenta detach

prematurely from the uterine wall or a vasa prabia. So those two things we've we've hit on a little bit in intraartum

um and we will talk more about those three in class but those are the three most likely culprits of vaginal bleeding

in the second half of pregnancy. fetal movement um which we is our last category um still important uh still a

red flag at certain points if they don't report it uh but our 20we mark becomes significant once again so prior to 20

weeks if a patient doesn't feel um any fetal movement yet they don't report that they feel anything subjectively uh

we're not generally concerned um throughout that portion of the pregnancy the fetus is very small the uterus is

still very low in the pelvis um and as it grows they typically are able to feel things more um but prior prior to 20

weeks if a patient hasn't been experiencing fetal movement, we do not we do not get concerned yet. Um, usually

between 16 to 20 weeks is when patients do start to report fetal movement and um, a lot of times uh, they report it as

like a flutter kind of feeling. Uh, and that's called quickening. That's the first or earliest felt and reported

fetal movement um, that patients will will describe or report feeling. Um, after 20 weeks, so again the 20we cut

off being significant. After 20 weeks, we expect patients to report some level of fetal movement and then they learn

what that baseline or normal amount is for their fetus, for their body, what they feel. Um, and then we tell them to

pay attention to what that normal amount is and then they can identify if there are changes from that. uh special noted

that if a patient has an anterior anterior placenta meaning the placenta is in the front of their uterus, a lot

of times that can um increase or or not sorry increase influence how much a patient can feel fetal movement um

because that it's almost like a cushion between the baby and the uterus and the abdominal wall to where we feel a lot

more or a lot of that movement as the patient. Um so if they have an anterior placenta it is not uncommon that they

report um less fetal movement less noticing fetal movement overall because of that being there and that's an

important education point for um patients who have been diagnosed with an anterior placa. Um again our warning

signs in that second half of pregnancy follow just what they did in the intpartum. If we have decreased fetal

movement or lack of fetal movement that would be concerning. Um during the anopartum period we teach patients kick

counts. Um, so if they feel like baby isn't moving like normal, we tell them to drink a glass of water, lay down on

their side, and really just pay attention to baby. Um, four, I think it's four counts in an hour or 10 in 2

hours is what's considered um, reassuring. Um, but we tell them to pay attention to how often baby moves.

Sometimes that's a pretty good indicator of like, hey, you know what? Nope, I was right. Baby isn't moving as much as

possible or as much as normal and we need to go in to be evaluated. Um, sometimes because women get busy and are

working or taking care of other children or doing other activities, um, sometimes they'll feel like maybe they haven't

felt baby move as much, but if they then once they lay down and really pay attention and monitor how many movements

they feel, sometimes it's like, oh, okay, yeah, baby's moving enough. We're good. Um, if we have that decrease or

lack of fetal movement, we typically want patients to come in to be evaluated. Usually that looks like in an

ST, which is a a method of putting them on the electronic fetal monitor for a period of

time and looking at what we see um to identify whether we're reassured or not of baby status uh based on their

findings. And then um that may or may not be a part of what we call a BPP, a biohysical profile, which is an

ultrasound that looks at five different categories, one of those being the baby's NST. Um or a general ultrasound

um to monitor baby's movement, to monitor baby's size, to uh measure amniotic fluid, etc. Um so fetal

movement is still just just as important. We just know that prior to 20 weeks, we don't expect um a whole lot of

patients to report a lot of fetal movement. And then after 20 weeks, we really do. we have those normal uh

baseline interpretations. So that is the um anopartum assessment five. So same categories just what we

look at is uh normal and abnormal being slightly different based on gestational age. And we'll talk further through all

of those pieces in class when we get into our antiparton content.