Day 2 Review DME 11 - Midwives Revision

Day 2 - Normal Pregnancy | Nurses Revision Uganda

DAY 2 📅 Nov 11 (Mon)

🤰 Normal Pregnancy

DME 111: Physiology & Minor Disorders

Physiological Changes (Cardiac, Respiratory, Renal)
Minor Disorders (Nausea, Varicose veins, Backache)
Management & Health Education

💓 REMEMBER: Cardiac output ↑ by 40-50%! Blood volume ↑ by 40-50%!

🎯 KEY POINT: Reassure! Nausea = small frequent meals. Varicose veins = elevation!

"Pregnancy is miraculous. Understand the changes, support the mother!"

"You knitted me together in my mother's womb." - Psalm 139:13

1. INTRODUCTION TO PREGNANCY PHYSIOLOGY

Pregnancy is a physiological state (not pathological) that causes adaptive changes in all body systems to support fetal growth and prepare for labor. These changes are HORMONE-DRIVEN.

🧠 MNEMONIC: Remember the BIG 3 Hormones!
📌 Progesterone - Relaxes smooth muscle
📌 Estrogen - Grows fetal organs & maternal tissues
📌 HCG - Prevents menstruation (pregnancy hormone)

⚠️ DIPLOMA LEVEL TIP: Examiners love asking about WHY changes happen (hormonal cause). Always link the change to progesterone or estrogen!

2. CARDIOVASCULAR SYSTEM CHANGES

🔴 Key Changes:

Cardiac Output ↑ by 40-50% (peaks at 24-28 weeks) - Due to ↑ heart rate and stroke volume
Blood Volume ↑ by 40-50% (1500-1600ml increase) - For placenta and fetal needs
Plasma Volume ↑ > RBC Volume → Physiological Anemia (hemodilution)
Heart enlarges & shifts left - May hear systolic murmurs (normal!)
Blood Pressure: Slight ↓ in 2nd trimester, returns to normal in 3rd
↑ Fibrinogen (200→600 mg/dL) - Body prepares for blood loss → ↑ Risk of DVT!

🚨 CLINICAL ALERT: Pregnant women are HYPERCOAGULABLE! Watch for leg swelling, pain, redness - could be DVT. In Uganda's long travel distances, advise frequent movement!

❤️ MNEMONIC: HEART in Pregnancy
Higher output (40-50%)
Enlarged heart
Anemia (physiological)
Risk of DVT ↑
Time: BP drops in 2nd trimester

3. RESPIRATORY SYSTEM CHANGES

🫁 Key Changes:

↑ Oxygen needs by 15-20% - For mother and fetus
↑ Respiratory rate - Slight increase
Tidal Volume ↑ (more air per breath)
Respiratory Alkalosis (MILD) - Due to ↑ ventilation
↑ BMR (Basal Metabolic Rate)
Women feel breathless on exertion - Normal in 2nd/3rd trimester!

🇺🇬 UGANDAN CONTEXT: In high-altitude areas (Kigezi, Mt. Elgon), breathlessness may be more pronounced. Advise women to avoid heavy farm work in late pregnancy!

🫁 MNEMONIC: BREATHE
Breathlessness normal
Respiratory rate up
Energy needs up (BMR)
Alkalosis mild
Tidal volume increased
Hyperventilation occurs
Exertion = dyspnea

4. RENAL SYSTEM CHANGES

🚽 Key Changes:

↑ Kidney size & GFR by 50% - Filter more waste
↑ Urge, Frequency & Nocturia - Especially in 1st & 3rd trimesters
Progesterone relaxes uterine smooth muscle → ↑ RISK OF UTIs!
↑ Risk of pyelonephritis - Due to urinary stasis

💡 EXAM TIP: Always screen urine for protein and glucose at ANC visits! Preeclampsia and gestational diabetes are common exam topics!

🚽 MNEMONIC: PEE MORE
Provider checks urine
Every ANC visit
Enlarged kidneys
More GFR (50% up)
Often UTIs
Repeated nocturia
Extra fluids needed

5. GASTROINTESTINAL SYSTEM CHANGES

🍽️ Effects of Progesterone:

Lower Esophageal Sphincter (LES) relaxes → Reflux & Heartburn (Pyrosis)
↓ Gastrointestinal motility → Constipation & Hemorrhoids
Displacement of stomach by enlarging uterus (2nd/3rd trimester)
Pica may occur - Craving non-foods (ice, clay, starch)

🇺🇬 UGANDAN NOTE: Pica is common! Women may crave soil (ejumbwe), raw rice, or starch. Counsel about iron deficiency and dangers of soil (tapeworms, bacteria)!

🍽️ MNEMONIC: GUT PREGNANT
Gastric reflux (heartburn)
Uterus displaces stomach
Time to eat small meals
Progestrone slows motility
Reflux common
Eat fiber for constipation
GNausea early pregnancy
Avoid spicy foods
Need for antacids
Tell provider about pica

6. MUSCULOSKELETAL SYSTEM CHANGES

🦴 Key Changes:

Lordosis - Center of gravity shifts forward → lower back pain
Relaxin & Progesterone loosen joints → ↑ Risk of falls!
Carpal Tunnel Syndrome - Due to fluid retention
Calf Cramps - Especially at night

🦴 MNEMONIC: BACK ACHES
Back pain common
Add support belt
Center of gravity shifts
Keep good posture
Avoid high heels
Cramps in calves
Heat helps pain
Elevate legs
Slow down activity

7. OTHER SYSTEM CHANGES

🎨 Skin Changes:

Striae gravidarum (stretch marks) - Abdomen, breasts, hips
Chloasma ("mask of pregnancy") - Brownish facial hyperpigmentation
Linea nigra - Dark line from pubis to umbilicus
Montgomery glands - Nipple tubercles become prominent

🩸 Hematological Changes:

↑ White blood cells - Normal in pregnancy
↓ Platelets - Slight decrease
Physiological anemia - Due to hemodilution
Iron needs ↑ - For fetal blood production

🧠 Pituitary & Thyroid:

FSH/LH suppressed (no ovulation)
Prolactin ↑ - Prepares breasts for milk
Thyroid enlarges - May develop goiter
↑ Metabolism & appetite

8. MINOR DISORDERS OF PREGNANCY

🎯 EXAM STRATEGY: For each disorder, know: CAUSE → CLINICAL FEATURES → MANAGEMENT → HEALTH EDUCATION. Examiners ask in this order!

🤰 MNEMONIC: 5 MINOR NIGGLES
Nausea & Vomiting
Indigestion/Heartburn
Gut problems (Constipation)
Groin pain (Backache)
Leg problems (Varicose veins, cramps)
Edema & Breathing difficulty
Supine Hypotension

8A. NAUSEA & VOMITING (Morning Sickness)

🤢 Causes:

↑ hCG levels (peak at 8-12 weeks)
↑ Progesterone → ↓ gastric motility
Psychological factors - Anxiety, stress
Vitamin B6 deficiency

📋 Clinical Features:

Nausea with/without vomiting, worse in morning
Usually starts 6-8 weeks, peaks 8-12 weeks, resolves by 16-20 weeks
Common in first pregnancy and multiple pregnancy

💊 Management:

🎯 MANAGEMENT MNEUMONIC: FREQUENT SMALL BITES
Frequent small meals
Rise slowly from bed
Eat dry crackers before rising
Quit strong smells
Use ginger tea (local remedy!)
Ensure hydration (sip water)
No fatty/spicy foods
Take vitamin B6 if severe

Health Education:

Reassure: Normal in early pregnancy!
Eat small, frequent meals (6/day)
Avoid triggers: Strong smells, fatty foods
Take fluids between meals, not with meals
Dry biscuits before getting out of bed
Tailor-sitting exercises help
Refer if: Persistent vomiting, weight loss, dehydration (Hyperemesis Gravidarum!)

🇺🇬 LOCAL REMEDIES: Ginger tea, lemon water, and avoiding strong-smelling foods like fish are culturally acceptable. Support from co-wives and mothers helps psychologically!

8B. HEARTBURN (PYROSIS)

🔥 Causes:

↑ Progesterone → LES (Lower Esophageal Sphincter) relaxes
↓ Gastrointestinal motility
Displacement of stomach by enlarging uterus (2nd/3rd trimester)
Pressure from uterus pushes stomach contents up

📋 Clinical Features:

Burning sensation behind sternum (chest)
Occurs in 2nd & 3rd trimesters
Worse after meals, when bending, or lying flat
May have right quadrant pain

💊 Management:

🔥 MNEMONIC: CALM the BURN
Consult about antacids (safe ones)
Avoid fatty & spicy foods
Lie propped up (45° angle)
Milk between meals helps
Bend at knees, not waist
Upright for 30 min after meals
Refrain from large meals
No lying flat after food

Health Education:

Eat small, frequent meals (5-6/day)
Sit upright for 30 minutes after eating
Drink milk between meals (neutralizes acid)
Avoid fatty, spicy, acidic foods
Tailor-sitting exercises reduce pressure
Sleep propped up with pillows
Bend at knees, not waist
Consult before antacids: Avoid sodium bicarbonate (causes fluid retention). Use calcium carbonate instead!

⚠️ RED FLAGS: If heartburn severe, persistent, or associated with vomiting blood → REFER! Could be peptic ulcer disease.

8C. CONSTIPATION & HEMORRHOIDS

💩 Causes:

↑ Progesterone → ↓ gut motility (slow peristalsis)
Pressure of uterus on intestines
↓ Physical activity in late pregnancy
Iron supplements (side effect)
↓ Fluid intake (due to nausea or frequent urination)

📋 Clinical Features:

Infrequent, hard stools
Straining during bowel movement
Hemorrhoids: Painful, swollen veins in rectum/anal area
May have bleeding per rectum

💊 Management:

💩 MNEMONIC: FIBER & FLUIDS
Fruits & vegetables daily (mangoes, pawpaw, dodo)
Increase water intake (3L/day)
Brown posho & whole grains
Exercise regularly (walk 30 min/day)
Respond to call to stool (don't delay!)
&
Fluid, fluid, fluid!
Laxatives only if prescribed
Use stool softeners (if needed)
Iron with vitamin C (im absorption)
Don't strain (use footstool)
Sit on toilet <5 minutes

Health Education:

Diet high in fiber: Matooke, sweet potatoes, vegetables (dodo, nakati), fruits (mangoes, pineapple)
Drink 8-10 glasses water/day (3 liters)
Regular exercise: Walking, tailor-sitting exercises
Iron tablets with vitamin C (orange juice)
Warm fluids in morning (herbal tea, water with lemon)
Don't ignore urge to defecate!
For hemorrhoids: Warm sitz baths, apply ice, witch hazel pads
Refer if: Severe pain, heavy bleeding, prolapsed hemorrhoids

🇺🇬 DIETARY TIPS: Recommend local high-fiber foods: cassava with fiber, millet, groundnut sauce with vegetables. Avoid recommending expensive imported fiber supplements!

8D. VARICOSE VEINS & LEG CRAMPS

🦵 Causes:

↑ Blood volume
Progesterone → venous dilatation
Pressure of uterus on pelvic veins → ↓ venous return
↓ Physical activity
Hereditary factors

📋 Clinical Features:

Visible, tortuous veins on legs (saphenous)
Aching, heaviness in legs
Worse at end of day
Cramps: Painful muscle spasms, often at night

💊 Management:

🦵 MNEMONIC: ELEVATE & MOVE
Elevate legs above heart level (3x/day, 15 min)
Lie on left side (improves circulation)
Exercise: Rotate ankles, walk regularly
Vavoid tight clothing
Avoid standing long periods
Take breaks to sit down
Elevate foot of bed at night
&
Massage gently (towards heart)
Over time, may need support stockings
Vitamin supplements (calcium, magnesium) for cramps
Ensure hydration

8E. EDEMA (Swelling)

💧 Causes:

↑ Blood volume & plasma volume
↓ Albumin → fluid leaks into tissues
Pressure of uterus on veins
Standing long hours

💊 Management:

DIFFERENTIAL: Physiological vs Pathological (Preeclampsia!)
Physiologic: Bilateral ankle edema, worse in evening, no hypertension/proteinuria
Management: Rest, elevate legs, left side lying, avoid tight socks

🚨 RED FLAGS FOR PREECLAMPSIA: Facial edema, sudden swelling, edema with headache/visual changes, high BP, protein in urine → REFER IMMEDIATELY!

8F. BACKACHE

🤕 Causes:

Lordosis - Increased curvature of spine
Relaxin & progesterone - Loosen joints & ligaments
Weight gain
Poor posture
Previous back problems

💊 Management:

🤕 MNEMONIC: POSTURE
Proper posture when sitting/standing
Orthopedic support belt (if severe)
Sleep on firm mattress
Tailor-sitting exercises
Use warm compresses
Rest periods during day
Exercise: Pelvic tilts, gentle stretching

8G. SUPINE HYPOTENSION SYNDROME

🛌 Cause:

In supine position (lying on back), uterus compresses inferior vena cava
↓ Venous return → ↓ Cardiac output → ↓ Blood pressure
↓ Blood flow to placenta → Fetal distress!

📋 Clinical Features:

Dizziness, faintness when lying flat
Pallor, sweating
Nausea

💊 Management:

🚨 LIFE-SAVING ADVICE: NEVER lie flat on back after 20 weeks! Always SLEEP ON LEFT SIDE!

Avoid supine position after mid-pregnancy
Left lateral position is BEST (improves placental perfusion)
If dizzy, turn to left side immediately
Use pillows to support side-lying position

LIKELY EXAM QUESTIONS FOR DAY 2

1. FILL-IN-THE-BLANK (2 marks)

Cardiac output increases by ______% during pregnancy, peaking at ______ weeks.

ANSWER: 40-50%, 24-28 weeks

2. FILL-IN-THE-BLANK (2 marks)

The hormone ______ causes relaxation of the lower esophageal sphincter, leading to heartburn.

ANSWER: Progesterone

3. MULTIPLE CHOICE (3 marks)

Which position should a pregnant woman AVOID after 20 weeks gestation?
A) Left lateral position
B) Supine position ⭐ CORRECT
C) Right lateral position
D) Semi-sitting position

EXPLANATION: Supine position compresses inferior vena cava, causing hypotension and reduced placental blood flow.

4. SHORT ANSWER (5 marks)

Explain the management of constipation in pregnancy and why it's important.

ANSWER GUIDE: • Dietary fiber (fruits, vegetables, whole grains)
• Increase fluids (3L/day)
• Regular exercise (walking)
• Respond to urge immediately
• Iron with vitamin C
• Why important: Prevent hemorrhoids, reduce straining, improve comfort
• Uganda context: Use affordable foods like matooke, dodo, millet

5. PRACTICAL SCENARIO (10 marks)

A 25-year-old primigravida at 28 weeks complains of severe leg swelling by evening. Her BP is 140/90 mmHg and urine shows protein +2. How do you differentiate physiological from pathological edema? What actions do you take?

ANSWER GUIDE: • Physiological: Bilateral ankle, worse evening, NO hypertension/proteinuria
• Pathological: Facial edema, sudden onset, +BP +proteinuria = PREECLAMPSIA
• Actions: REFER IMMEDIATELY to hospital, do NOT manage at health centre!
• While waiting: Left side lying, calm environment, prepare for transport
• Document findings, inform senior midwife/doctor

6. LIST QUESTION (8 marks)

List four physiological changes in the cardiovascular system during pregnancy and their clinical implications.

ANSWER GUIDE: 1. ↑ Blood volume 40-50% → May hear systolic murmurs (normal)
2. ↑ Cardiac output → Palpitations common
3. Plasma > RBC → Physiological anemia (check Hb)
4. ↑ Fibrinogen → ↑ DVT risk (advise movement)
Each point needs implication for 2 marks!

📊 STATISTICS: This topic appears in 90% of midwifery exams! Master the physiology-because examiners ask "WHY" changes happen. Minor disorders are favorite for scenario questions!

📚 DAY 2 SUMMARY: KEY TAKEAWAYS

🎯 Remember the BIG 3 Hormones:

Progesterone = RELAXATION (smooth muscle, sphincters, veins)
Estrogen = GROWTH (uterus, breasts, blood vessels)
hCG = MAINTAINS pregnancy (supports corpus luteum)

🎯 For Every Minor Disorder: Remember 4 Steps:

REASSURE - Normal in pregnancy!
EXPLAIN CAUSE - Link to hormones
MANAGE CONSERVATIVELY - Diet, lifestyle first
REFER WHEN RED FLAGS - Know danger signs!

🎓 FINAL EXAM MNEMONIC: PREGNANCY CARE
Physiological changes affect ALL systems
Reassure mother about normal discomforts
Educate about diet, posture, exercise
Give practical tips (small meals, left side)
Normal vs abnormal - know the difference!
Always check BP & urine at every visit
No supine position after 20 weeks
Counsel on danger signs
Your role: Support, educate, refer!

✨ ENCOURAGEMENT: You are learning to support mothers through one of life's most beautiful journeys! Master this knowledge to provide safe, compassionate care.

"Children are a heritage from the Lord, offspring a reward from Him." - Psalm 127:3