WEBVTT 00:00:07.880 --> 00:00:10.759 You're in the bay. Once you get over to the bed, 00:00:10.919 --> 00:00:13.560 we'll give you the story. Everything's going 00:00:13.560 --> 00:00:17.339 to happen super fast. Welcome to the emergency 00:00:17.339 --> 00:00:44.539 room. Imagine pouring like an extra liter and 00:00:44.539 --> 00:00:47.280 a half of fluid directly into someone's circulatory 00:00:47.280 --> 00:00:50.200 system. Right, just straight in. Yeah. And then 00:00:50.200 --> 00:00:53.520 you force their kidneys to filter blood 50 % 00:00:53.520 --> 00:00:57.310 faster than normal. On top of that, you deliberately 00:00:57.310 --> 00:00:59.670 alter their endocrine system to make their cells 00:00:59.670 --> 00:01:03.109 completely resistant to their own insulin, and 00:01:03.109 --> 00:01:05.290 you suppress their immune system. I mean, if 00:01:05.290 --> 00:01:08.250 a non -pregnant patient presented to the ER with 00:01:08.250 --> 00:01:11.370 that exact clinical picture, you'd be initiating 00:01:11.370 --> 00:01:13.590 rapid response protocols. Exactly. They would 00:01:13.590 --> 00:01:15.930 be going straight to the ICU. But in the world 00:01:15.930 --> 00:01:18.030 of obstetrics, we just call that a healthy second 00:01:18.030 --> 00:01:20.909 trimester. It's just absolute systemic upheaval. 00:01:21.069 --> 00:01:23.569 And if you're listening to this deep dive right 00:01:23.569 --> 00:01:25.650 now, you're probably staring down the barrel 00:01:25.650 --> 00:01:29.260 of a massive OB nursing exam. or prepping for 00:01:29.260 --> 00:01:31.799 a really high stakes clinical rotation. Right. 00:01:31.799 --> 00:01:34.079 You've got hundreds of pages of textbook material 00:01:34.079 --> 00:01:36.480 on maternal adaptations, and it feels completely 00:01:36.480 --> 00:01:38.780 overwhelming. It is a mountain of information. 00:01:38.859 --> 00:01:41.620 But that is exactly why we are putting on our 00:01:41.620 --> 00:01:43.900 clinical educator hats today. Yes, our elite 00:01:43.900 --> 00:01:48.359 mentor hats. Exactly. We are aggressively applying 00:01:48.359 --> 00:01:50.579 the Pareto principle to your study materials. 00:01:50.739 --> 00:01:53.400 We've sifted through all those texts to extract 00:01:53.400 --> 00:01:57.430 that high yield, top 20 % of core concepts. to 00:01:57.430 --> 00:02:00.150 give you 80 % of the value on your exam. Exactly. 00:02:00.250 --> 00:02:02.549 We are skipping the fluff. We are hunting for 00:02:02.549 --> 00:02:05.930 the exam traps, the vital sign red flags, and 00:02:05.930 --> 00:02:09.610 the absolute priority safety interventions. Because 00:02:09.610 --> 00:02:12.169 understanding the underlying physics and chemistry 00:02:12.169 --> 00:02:14.349 of these changes isn't just about passing a test. 00:02:14.370 --> 00:02:16.590 No, not at all. It's about building the clinical 00:02:16.590 --> 00:02:19.150 judgment that makes you a safe, effective nurse. 00:02:19.650 --> 00:02:21.949 So let's build that foundation. Everything in 00:02:21.949 --> 00:02:24.830 OB starts with confirming the patient is actually 00:02:24.830 --> 00:02:27.330 pregnant. Which sounds incredibly straightforward, 00:02:27.750 --> 00:02:30.009 but it is one of the most common areas where 00:02:30.009 --> 00:02:32.569 nursing students lose easy points. Really? Oh 00:02:32.569 --> 00:02:35.310 yeah. The texts divide the signs of pregnancy 00:02:35.310 --> 00:02:38.110 into three buckets, presumptive, probable, and 00:02:38.110 --> 00:02:40.189 positive. OK, let me think through this clinically. 00:02:41.310 --> 00:02:43.889 A patient walks into the clinic. She tells me 00:02:43.889 --> 00:02:47.009 she missed her period. She has amenorrhea. She 00:02:47.009 --> 00:02:49.090 says her breasts are tender, she's exhausted, 00:02:49.189 --> 00:02:51.090 and she's been throwing up every morning. Right. 00:02:51.229 --> 00:02:53.689 She might even say she feels quickening, you 00:02:53.689 --> 00:02:55.889 know, that little flutter of fetal movement you 00:02:55.889 --> 00:02:58.870 supposedly feel around 18 to 20 weeks. That is 00:02:58.870 --> 00:03:01.370 a lot of evidence. It is a lot of evidence, but 00:03:01.370 --> 00:03:03.909 every single thing you just listed is merely 00:03:03.909 --> 00:03:06.629 a presumptive sign. Because it's entirely subjective. 00:03:06.969 --> 00:03:09.229 Like, it's just what the patient is perceiving. 00:03:09.530 --> 00:03:12.539 Precisely. From a clinical safety standpoint, 00:03:12.840 --> 00:03:15.719 you cannot diagnose a medical condition based 00:03:15.719 --> 00:03:18.039 solely on subjective perception. So she could 00:03:18.039 --> 00:03:20.400 just be feeling something else entirely. Exactly. 00:03:20.719 --> 00:03:24.180 A patient might interpret... gas bubbles or like 00:03:24.180 --> 00:03:27.099 normal intestinal peristalsis as fetal movement. 00:03:27.159 --> 00:03:30.139 Oh, wow. And relying on amenorrhea or fatigue 00:03:30.139 --> 00:03:32.300 is dangerous because those symptoms could be 00:03:32.300 --> 00:03:35.199 caused by severe stress, an endocrine disorder, 00:03:35.800 --> 00:03:38.180 extreme exercise, or just an underlying illness. 00:03:38.379 --> 00:03:41.520 Right. So presumptive is just the patient's experience, 00:03:41.520 --> 00:03:44.819 which brings us to the objective data, the probable 00:03:44.819 --> 00:03:47.099 signs. And this is where the biggest exam trap 00:03:47.099 --> 00:03:49.479 lives, right? Instructors absolutely love to 00:03:49.479 --> 00:03:51.879 test this. No, they do. The patient says, look, 00:03:52.039 --> 00:03:54.400 I took a home pregnancy test and the two pink 00:03:54.400 --> 00:03:57.139 lines popped up. It's positive. That has to be 00:03:57.139 --> 00:03:59.800 a positive sign of pregnancy. It is a trap. A 00:03:59.800 --> 00:04:02.419 positive home pregnancy test is a probable sign. 00:04:02.460 --> 00:04:04.759 It is not a positive sign of pregnancy. See, 00:04:04.759 --> 00:04:06.740 I have to push back on this because it defies 00:04:06.740 --> 00:04:11.400 common sense. The test is looking for HCG human 00:04:11.400 --> 00:04:14.300 chorionic gonadotropin. Right. We literally call 00:04:14.300 --> 00:04:16.899 it the pregnancy hormone. It's an objective biochemical 00:04:16.899 --> 00:04:19.879 marker. If the hormone is there, how is that 00:04:19.879 --> 00:04:22.339 not a definitive positive of confirmation of 00:04:22.339 --> 00:04:24.319 a baby. Because as a clinician, you always have 00:04:24.319 --> 00:04:27.060 to ask why that specific hormone is elevated. 00:04:27.259 --> 00:04:29.959 OK. While a healthy viable fetus is the most 00:04:29.959 --> 00:04:32.560 common reason for an HCG spike, it is not the 00:04:32.560 --> 00:04:35.800 only reason. HCG can also be secreted by tumors. 00:04:36.579 --> 00:04:39.000 Wait, really? Yes. We're talking about ovarian 00:04:39.000 --> 00:04:41.519 cancer or a condition called choreocarcinoma. 00:04:41.639 --> 00:04:43.779 Break that down for me. Choreocarcinoma. It's 00:04:43.779 --> 00:04:45.620 a fast growing cancer that occurs in a woman's 00:04:45.620 --> 00:04:48.579 uterus. The abnormal cells start in the tissue 00:04:48.579 --> 00:04:51.040 that would normally become the placenta. Oh, 00:04:51.120 --> 00:04:55.180 wow. That's awful. It is. Another cause is a 00:04:55.180 --> 00:04:58.839 hydatidiform mole, which is essentially an abnormal 00:04:58.839 --> 00:05:01.860 growth of trophoblastic tissue inside the uterus. 00:05:02.079 --> 00:05:04.879 So it's not a fetus at all? No, it's a mass of 00:05:04.879 --> 00:05:07.779 cysts that looks like a cluster of grapes. It 00:05:07.779 --> 00:05:10.620 produces massive amounts of HCG, so the patient 00:05:10.620 --> 00:05:13.620 will have raging positive pregnancy tests, severe 00:05:13.620 --> 00:05:17.139 nausea, and expanding uterus. But there is no 00:05:17.139 --> 00:05:20.240 viable fetus. Exactly. That is terrifying, but 00:05:20.240 --> 00:05:22.879 it perfectly explains the rationale for the exam. 00:05:23.620 --> 00:05:26.220 Let me try an analogy to lock this in. Go for 00:05:26.220 --> 00:05:27.939 it. Let's say we're trying to determine if there 00:05:27.939 --> 00:05:31.220 is a fire in a building. A presumptive sign is 00:05:31.220 --> 00:05:33.620 me standing outside saying, hey, I think I smell 00:05:33.620 --> 00:05:36.100 smoke. Right. It's just your perception. Exactly. 00:05:36.360 --> 00:05:38.779 A probable sign is the smoke alarm in the hallway 00:05:38.779 --> 00:05:41.079 actually going off. That's our HCG test. Yes. 00:05:41.279 --> 00:05:43.540 It is objective. It is loud. And it usually means 00:05:43.540 --> 00:05:47.069 fire. But a faulty wire. or a blast of steam 00:05:47.069 --> 00:05:48.930 from a shower could also trigger that alarm. 00:05:49.050 --> 00:05:51.709 That is brilliant. Yes. So what is the positive 00:05:51.709 --> 00:05:53.949 sign in your analogy? The positive sign is the 00:05:53.949 --> 00:05:55.769 firefighter kicking down the door and physically 00:05:55.769 --> 00:05:58.279 seeing the flames with their own eyes. You nailed 00:05:58.279 --> 00:06:00.540 it. To see the flames in obstetrics, the clinical 00:06:00.540 --> 00:06:03.819 finding must be directly, irrefutably attributed 00:06:03.819 --> 00:06:07.759 to a fetus. So like an ultrasound? Yes. Visualizing 00:06:07.759 --> 00:06:10.459 the embryo via ultrasound, hearing the fetal 00:06:10.459 --> 00:06:12.959 heart tones with the Doppler, or having fetal 00:06:12.959 --> 00:06:15.399 movement palpated by an experienced health care 00:06:15.399 --> 00:06:18.680 provider, nothing else counts as positive. OK. 00:06:18.879 --> 00:06:22.040 That is permanently anchored in my brain. Before 00:06:22.040 --> 00:06:24.160 we move into the physiological changes, there 00:06:24.160 --> 00:06:27.540 are a few other Probable signs, right? Yes, those 00:06:27.540 --> 00:06:29.939 physical changes to the reproductive organs that 00:06:29.939 --> 00:06:32.060 providers find during an exam. They have these 00:06:32.060 --> 00:06:35.319 classic eponymous names that always show up on 00:06:35.319 --> 00:06:37.839 multiple -choice questions. Chadwick's sign, 00:06:38.040 --> 00:06:40.379 Goodell's sign, and Hagar's sign. And you really 00:06:40.379 --> 00:06:42.160 need memory hooks for these because they blur 00:06:42.160 --> 00:06:45.000 together. Start with Chadwick. Okay. Think C 00:06:45.000 --> 00:06:47.879 for Chadwick and C for color. This is the bluish 00:06:47.879 --> 00:06:50.620 -purple cyanotic coloration of the vaginal mucosa 00:06:50.620 --> 00:06:53.620 and cervix. Why does it turn blue? It happens 00:06:53.620 --> 00:06:56.079 because the body is suddenly sending a massive 00:06:56.079 --> 00:06:58.560 increase of blood flow to the pelvic region. 00:06:58.839 --> 00:07:01.259 C is for color, Chadwick. Got it. What about 00:07:01.259 --> 00:07:04.459 Goodell? Think G for Goodell and G for gooey. 00:07:04.860 --> 00:07:06.819 It is the profound softening of the cervical 00:07:06.819 --> 00:07:10.379 tip. Gooey Goodell. Nice. And Hagar. Hagar's 00:07:10.379 --> 00:07:12.800 line is the softening and compressibility of 00:07:12.800 --> 00:07:15.360 the lower uterine segment. OK. Chadwick is color, 00:07:15.620 --> 00:07:18.259 Gadil is gooey, Hagar is the lower segment. Perfect. 00:07:18.480 --> 00:07:20.560 And quickly, on the psychosocial side, during 00:07:20.560 --> 00:07:23.399 this first trimester when all this is happening. 00:07:25.420 --> 00:07:28.199 Ambivalence is the expected finding. Completely 00:07:28.199 --> 00:07:30.819 expected. Even if it was planned. Even if a patient 00:07:30.819 --> 00:07:34.339 spent years doing IVF, going through incredible 00:07:34.339 --> 00:07:37.160 expense and emotional toll to get pregnant, feeling 00:07:37.160 --> 00:07:40.360 terrified, doubtful, or having conflicting feelings 00:07:40.360 --> 00:07:43.040 once it actually happens, is a normal psychological 00:07:43.040 --> 00:07:46.379 adaptation. Good to know. Yeah. Do not flag ambivalence 00:07:46.379 --> 00:07:49.000 in the first trimester as a pathological psychiatric 00:07:49.000 --> 00:07:51.560 issue. So once she gets past that initial shock, 00:07:52.180 --> 00:07:54.370 the body really steps on the gas pedal. Let's 00:07:54.370 --> 00:07:56.269 look at the hemodynamic overhaul because the 00:07:56.269 --> 00:07:59.250 cardiovascular and renal changes are just staggering. 00:07:59.610 --> 00:08:01.750 They really are. The texts state that maternal 00:08:01.750 --> 00:08:05.269 blood volume increases by 30 to 50 percent. It 00:08:05.269 --> 00:08:09.370 peaks right around weeks 30 to 34. We are talking 00:08:09.370 --> 00:08:13.290 about adding 1100 to 1600 milliliters of blood 00:08:13.290 --> 00:08:16.550 to her circulatory system. That is so much fluid. 00:08:16.730 --> 00:08:18.769 And think about the mechanical domino effect 00:08:18.769 --> 00:08:21.550 of that. All that extra fluid has to be filtered, 00:08:21.610 --> 00:08:24.350 so the kidneys have to work overtime. Oh. The 00:08:24.350 --> 00:08:27.670 renal glomerular filtration rate, the GFR, shoots 00:08:27.670 --> 00:08:30.610 up by as much as 50%. Hold on. Let me think about 00:08:30.610 --> 00:08:32.669 the physics of that for a nurse administering 00:08:32.669 --> 00:08:35.250 medications. OK. If the kidneys are essentially 00:08:35.250 --> 00:08:38.519 a biological filter, and we just... crank the 00:08:38.519 --> 00:08:40.919 fluid running through that filter up by 50%. 00:08:40.919 --> 00:08:43.039 Does that mean she is flushing out her medications 00:08:43.039 --> 00:08:45.799 way faster? That is exactly what it means, and 00:08:45.799 --> 00:08:49.480 it is a massive safety priority. Drugs that are 00:08:49.480 --> 00:08:51.620 excreted by the kidneys are cleared from her 00:08:51.620 --> 00:08:55.059 body much quicker. As a nurse, you must anticipate 00:08:55.059 --> 00:08:57.519 that therapeutic medication dosing will likely 00:08:57.519 --> 00:09:00.299 need to be increased. Or maybe given more frequently. 00:09:00.460 --> 00:09:03.340 Yes, just to maintain a steady level in her blood. 00:09:03.580 --> 00:09:05.620 What worked perfectly for her before she got 00:09:05.620 --> 00:09:08.259 pregnant might be totally subtherapeutic now. 00:09:08.500 --> 00:09:11.100 That is such a high -yield clinical connection. 00:09:11.500 --> 00:09:13.360 But wait, I have a basic plumbing question. Shoot. 00:09:13.960 --> 00:09:17.120 If her blood volume increases by 50%, why doesn't 00:09:17.120 --> 00:09:19.279 her blood pressure go through the roof? Like, 00:09:19.480 --> 00:09:22.899 if I force 50 % more water into a closed water 00:09:22.899 --> 00:09:25.340 balloon, the pressure against the rubber stretches 00:09:25.340 --> 00:09:29.039 tight. The pressure has to spike. It would if 00:09:29.039 --> 00:09:32.330 the blood vessels were rigid pipes. But the body 00:09:32.330 --> 00:09:34.929 has a chemical pressure release valve progesterone. 00:09:35.070 --> 00:09:37.870 Oh, progesterone. Progesterone is the great relaxer 00:09:37.870 --> 00:09:41.070 of pregnancy. It causes profound, smooth muscle 00:09:41.070 --> 00:09:43.929 relaxation all over the body. So her blood vessels 00:09:43.929 --> 00:09:46.809 actually undergo peripheral vasodilation. So 00:09:46.809 --> 00:09:49.350 the pipes get bigger. The pipes literally widen 00:09:49.350 --> 00:09:51.870 and become floppy to accommodate that massive 00:09:51.870 --> 00:09:54.850 new volume of blood. So her blood pressure should 00:09:54.850 --> 00:09:57.149 actually stay stable. Not just stable, it often 00:09:57.149 --> 00:09:59.389 drops slightly in the second trimester before 00:09:59.389 --> 00:10:01.289 returning to her baseline by the end of the pregnancy. 00:10:01.389 --> 00:10:04.009 Which means? And let me deduce the exam trap 00:10:04.009 --> 00:10:06.490 here. If I am taking vital signs on a pregnant 00:10:06.490 --> 00:10:08.970 patient and her blood pressure is significantly 00:10:08.970 --> 00:10:11.669 elevated, that is not just a little anomaly. 00:10:11.769 --> 00:10:15.009 No. That is a blaring siren. It is a massive 00:10:15.009 --> 00:10:18.429 red flag. If she has all this progesterone naturally 00:10:18.429 --> 00:10:21.429 forcing her vessels open, a high blood pressure 00:10:21.429 --> 00:10:24.110 reading means that natural safety system is failing. 00:10:24.330 --> 00:10:27.090 So we're thinking preeclampsia. It points straight 00:10:27.090 --> 00:10:30.129 toward gestational hypertension or preeclampsia. 00:10:30.490 --> 00:10:33.990 Any significant rise in BP must be reported to 00:10:33.990 --> 00:10:36.429 the provider and investigated immediately. It 00:10:36.429 --> 00:10:38.690 is never an, oh, she's just stressed finding. 00:10:39.129 --> 00:10:42.370 OK, another hemodynamic puzzle. With all that 00:10:42.370 --> 00:10:45.049 extra blood volume, I'd assume her lab work looks 00:10:45.049 --> 00:10:48.000 chaotic. Will she look anemic on Poper? She will. 00:10:48.379 --> 00:10:50.360 And you have to differentiate between what is 00:10:50.360 --> 00:10:53.019 an expected adaptation and what is a dangerous 00:10:53.019 --> 00:10:56.200 complication. Physiologic anemia of pregnancy 00:10:56.200 --> 00:10:59.159 is expected. How does that work? Here is the 00:10:59.159 --> 00:11:01.740 mechanism. Her body produces more red blood cells, 00:11:01.820 --> 00:11:04.539 yes, but her plasma volume, the liquid part of 00:11:04.539 --> 00:11:06.799 the blood, increases significantly more than 00:11:06.799 --> 00:11:09.139 the red cells do. Oh, it's hemodilution, like 00:11:09.139 --> 00:11:11.679 pouring a large glass of water into a bowl of 00:11:11.679 --> 00:11:13.980 chicken noodle soup. Uh -huh, exactly. The soup 00:11:13.980 --> 00:11:15.700 suddenly looks much thinner, the noodles are 00:11:15.700 --> 00:11:17.940 spaced further apart, but all the original ingredients 00:11:17.940 --> 00:11:20.399 are still in the bowl. Exactly. The concentration 00:11:20.399 --> 00:11:23.639 drops, but the actual oxygen -carrying capacity 00:11:23.639 --> 00:11:26.360 is still there. But while she looks anemic, the 00:11:26.360 --> 00:11:28.840 truly concerning shift is that she is simultaneously 00:11:28.970 --> 00:11:31.870 in a hypercoagulable state. Her blood is prone 00:11:31.870 --> 00:11:34.289 to clotting. Why would her body do that? Because 00:11:34.289 --> 00:11:37.169 childbirth is inherently a massive bleeding event. 00:11:37.690 --> 00:11:40.289 The placenta detaching from the uterine wall 00:11:40.289 --> 00:11:43.509 leaves a huge wound. Of course. To survive that, 00:11:43.649 --> 00:11:46.509 the body preemptively increases fibrin, plasma 00:11:46.509 --> 00:11:49.450 fibrinogen, and various clotting factors. The 00:11:49.450 --> 00:11:51.570 evolutionary goal is to prevent the mother from 00:11:51.570 --> 00:11:54.460 bleeding to death during delivery. But the dangerous 00:11:54.460 --> 00:11:56.879 trade -off is that it makes her a walking risk 00:11:56.879 --> 00:12:00.000 for a deep vein thrombosis. Yes. You combine 00:12:00.000 --> 00:12:02.600 hypercoagulable blood with the stasis of blood 00:12:02.600 --> 00:12:04.539 pooling in her legs because the heavy uterus 00:12:04.539 --> 00:12:06.799 is pressing on her pelvic veins, and you have 00:12:06.799 --> 00:12:09.559 a perfect recipe for a DVT. So what's the nursing 00:12:09.559 --> 00:12:12.120 priority there? Your priority assessment is monitoring 00:12:12.120 --> 00:12:14.779 for unilateral leg pain, redness, or swelling. 00:12:14.940 --> 00:12:17.100 And speaking of that heavy uterus pressing on 00:12:17.100 --> 00:12:20.039 veins, we have to talk about supine hypotensive 00:12:20.039 --> 00:12:23.460 syndrome. This is universally tested. It is the 00:12:23.460 --> 00:12:27.100 classic positional error. As the pregnancy progresses, 00:12:27.580 --> 00:12:30.240 the gravid uterus becomes essentially a heavy 00:12:30.240 --> 00:12:33.120 internal boulder. If a pregnant patient lies 00:12:33.120 --> 00:12:35.779 flat on her back, the supine position that heavy 00:12:35.779 --> 00:12:38.399 uterus falls backward and physically crushes 00:12:38.399 --> 00:12:41.159 the inferior vena cava against her spine. And 00:12:41.159 --> 00:12:44.279 the inferior vena cava is the massive vein responsible 00:12:44.279 --> 00:12:47.120 for bringing all the deoxygenated blood from 00:12:47.120 --> 00:12:49.299 the lower half of the body back up to the heart. 00:12:49.600 --> 00:12:52.480 Exactly. So it's essentially like resting a 15 00:12:52.480 --> 00:12:55.159 -pound bowling ball directly on top of a garden 00:12:55.159 --> 00:12:57.240 hose. That is exactly what happens. The hose 00:12:57.240 --> 00:12:59.919 is pinched shut, venous return to the heart suddenly 00:12:59.919 --> 00:13:02.779 drops. Because less blood is entering the heart, 00:13:03.259 --> 00:13:05.679 cardiac output plummets. So she's not getting 00:13:05.679 --> 00:13:07.799 blood to her brain. Right. Less blood is pumped 00:13:07.799 --> 00:13:09.980 out to the brain and the body. The patient will 00:13:09.980 --> 00:13:12.480 suddenly get very dizzy, light -headed, pale, 00:13:12.600 --> 00:13:15.159 and clammy. Her blood pressure tanks. If you 00:13:15.159 --> 00:13:17.080 walk into a patient's room and they're laying 00:13:17.080 --> 00:13:19.019 flat on their back complaining of dizziness, 00:13:19.639 --> 00:13:22.019 You don't even need to think. Your absolute first 00:13:22.019 --> 00:13:24.500 reflex as a nurse has to be rolling them onto 00:13:24.500 --> 00:13:26.960 their left side. The left lateral side lying 00:13:26.960 --> 00:13:30.100 position. The moment you roll her over, the bowling 00:13:30.100 --> 00:13:32.820 ball rolls off the garden hose. Immediate fix. 00:13:33.120 --> 00:13:35.580 Blood flow is instantly restored and the hypotension 00:13:35.580 --> 00:13:38.480 resolves. Left lateral is the magic position 00:13:38.480 --> 00:13:40.720 in obstetrics. Incredible. So we've got the extra 00:13:40.720 --> 00:13:42.559 blood flowing. Where is it all going? It's going 00:13:42.559 --> 00:13:45.740 to the placenta. which leads to this fascinating 00:13:45.740 --> 00:13:49.039 metabolic tug of war between the mother and the 00:13:49.039 --> 00:13:51.620 fetus. It really is a battle for resources. During 00:13:51.620 --> 00:13:53.720 the first half of pregnancy, maternal glucose 00:13:53.720 --> 00:13:56.159 is actively diverted to the fetus. Makes sense. 00:13:56.419 --> 00:13:58.799 But as we get into the second half, the fetus 00:13:58.799 --> 00:14:01.980 is growing rapidly and demands more fuel. So 00:14:01.980 --> 00:14:04.940 the placenta actually steps up and starts acting 00:14:04.940 --> 00:14:07.259 like an independent endocrine gland. What does 00:14:07.259 --> 00:14:11.220 it do? It begins secreting human chorionic somatomamotropin, 00:14:11.299 --> 00:14:14.309 often called HPL, along with maternal cortisol. 00:14:14.649 --> 00:14:17.149 OK, if the placenta is releasing hormones into 00:14:17.149 --> 00:14:20.450 the mother's system, it must be trying to manipulate 00:14:20.450 --> 00:14:23.309 her metabolism to favor the baby. What do those 00:14:23.309 --> 00:14:26.090 hormones do? They are insulin antagonists. They 00:14:26.090 --> 00:14:28.470 deliberately create maternal insulin resistance. 00:14:28.990 --> 00:14:32.429 Whoa. The placenta intentionally makes the mother's 00:14:32.429 --> 00:14:35.710 cells reject her own insulin. That sounds parasitic. 00:14:35.809 --> 00:14:38.210 From a biological perspective, it's a brilliant 00:14:38.210 --> 00:14:41.460 survival mechanism. Think of HPL as a bouncer 00:14:41.460 --> 00:14:44.379 at a nightclub. OK, I like this. The mother's 00:14:44.379 --> 00:14:46.500 cells are trying to consume the glucose in her 00:14:46.500 --> 00:14:49.500 bloodstream, but the placental hormones act as 00:14:49.500 --> 00:14:52.000 bouncers, blocking the doors to the mother's 00:14:52.000 --> 00:14:55.580 cells. This forces the glucose to remain circulating 00:14:55.580 --> 00:14:58.500 in her bloodstream for much longer, ensuring 00:14:58.500 --> 00:15:01.899 there is a massive, steady buffet of sugar available 00:15:01.899 --> 00:15:04.799 to cross the placenta and feed the fetus. So 00:15:04.799 --> 00:15:06.740 the mother's pancreas realizes her blood sugar 00:15:06.740 --> 00:15:09.120 is staying high. And it has to work overtime, 00:15:09.240 --> 00:15:11.679 pumping out extra insulin just to overpower those 00:15:11.679 --> 00:15:13.840 bouncers and get some of that glucose into her 00:15:13.840 --> 00:15:16.379 own tissues. Exactly. And what happens if her 00:15:16.379 --> 00:15:18.559 pancreas simply cannot keep up with the demand? 00:15:18.700 --> 00:15:21.000 Then the blood sugar stays chronically elevated 00:15:21.000 --> 00:15:23.519 and she develops gestational diabetes. You've 00:15:23.519 --> 00:15:25.779 got it. Gestational diabetes isn't just, you 00:15:25.779 --> 00:15:27.700 know, eating too much sugar during pregnancy. 00:15:27.940 --> 00:15:30.600 It is an exaggerated physiological failure of 00:15:30.600 --> 00:15:33.460 the pancreas to overcome the placenta's aggressive 00:15:33.460 --> 00:15:36.080 insulin resistance. That completely reframes 00:15:36.080 --> 00:15:38.529 how I'll look at that diagnosis. Right. Now, 00:15:38.529 --> 00:15:40.610 earlier you mentioned progesterone relaxes smooth 00:15:40.610 --> 00:15:42.830 muscle to keep blood pressure down. Right. But 00:15:42.830 --> 00:15:44.669 the blood vessels aren't the only smooth muscle 00:15:44.669 --> 00:15:47.690 in the body. The entire gastrointestinal tract 00:15:47.690 --> 00:15:50.990 is a giant tube of smooth muscle. And it suffers 00:15:50.990 --> 00:15:53.750 the consequences of all that relaxation. Because 00:15:53.750 --> 00:15:57.129 of progesterone, gastric motility and peristalsis 00:15:57.129 --> 00:16:00.049 slow to a crawl. So everything just stops moving. 00:16:00.360 --> 00:16:04.100 Pretty much. The expected normal findings are 00:16:04.100 --> 00:16:06.720 delayed gastric emptying, bloating, and severe 00:16:06.720 --> 00:16:09.360 constipation. Even the cardiac sphincter at the 00:16:09.360 --> 00:16:11.240 top of the stomach becomes sloppy. Which means 00:16:11.240 --> 00:16:13.120 stomach acid splashes up into the esophagus. 00:16:13.320 --> 00:16:16.039 Exactly, causing brutal heartburn. The sources 00:16:16.039 --> 00:16:18.799 also list TDMLism excessive saliva production 00:16:18.799 --> 00:16:21.120 as an expected finding. Why does that happen? 00:16:21.440 --> 00:16:24.029 It's twofold. Hormones stimulate the salivary 00:16:24.029 --> 00:16:26.590 glands, but more importantly, women who are experiencing 00:16:26.590 --> 00:16:29.590 severe morning sickness naturally swallow less 00:16:29.590 --> 00:16:31.909 frequently because it triggers their gag reflex. 00:16:32.210 --> 00:16:34.090 Oh, that sounds miserable. So the saliva just 00:16:34.090 --> 00:16:35.830 pools in the mouth. It's miserable, but it's 00:16:35.830 --> 00:16:39.570 an expected harmless adaptation. But there is 00:16:39.570 --> 00:16:42.990 a GI finding that is not harmless, and it is 00:16:42.990 --> 00:16:47.750 a major exam trap pica. The intense, compulsive 00:16:47.750 --> 00:16:51.110 craving for non -food items. Yes. The text highlight 00:16:51.110 --> 00:16:54.570 geophagia, which is eating soil or clay, pagovagia, 00:16:54.669 --> 00:16:57.269 which is eating ice, and craving laundry starch. 00:16:57.610 --> 00:16:59.629 I feel like pop culture has done a disservice 00:16:59.629 --> 00:17:02.789 here by treating bizarre pregnancy cravings as 00:17:02.789 --> 00:17:04.549 a quirky joke. Like, oh, look, she's chewing 00:17:04.549 --> 00:17:07.029 on a cup of ice chips. How funny. It's not a 00:17:07.029 --> 00:17:09.509 joke. If a patient casually mentions she's been 00:17:09.509 --> 00:17:12.009 eating dirt or compulsively chewing on the frost 00:17:12.009 --> 00:17:14.769 from her freezer, I know from my general nursing 00:17:14.769 --> 00:17:17.230 knowledge that pica is deeply tied to nutritional 00:17:17.230 --> 00:17:20.410 deficits. It is highly correlated with severe 00:17:20.410 --> 00:17:23.069 iron deficiency anemia. If you hear about pica, 00:17:23.190 --> 00:17:25.710 your immediate clinical reflex must be to assess 00:17:25.710 --> 00:17:28.089 that patient's hemoglobin and iron levels. The 00:17:28.089 --> 00:17:30.230 body is essentially short -circuiting, trying 00:17:30.230 --> 00:17:32.710 to find minerals wherever it can. Exactly. Which 00:17:32.710 --> 00:17:35.069 bridges us perfectly to our final major topic, 00:17:35.250 --> 00:17:37.789 high -risk nutrition and the immune system. Because 00:17:37.789 --> 00:17:40.390 the GI tract is moving so slowly and the immune 00:17:40.390 --> 00:17:42.769 system is altered, what the patient eats becomes 00:17:42.769 --> 00:17:45.109 a critical safety issue. Let's talk about the 00:17:45.109 --> 00:17:48.089 immune system shift. It's a dual mechanism. The 00:17:48.089 --> 00:17:50.809 maternal immune system undergoes a general enhancement 00:17:50.809 --> 00:17:52.990 of its innate immunity. That's the immediate 00:17:53.210 --> 00:17:55.950 generalized inflammatory response, right? Exactly. 00:17:56.509 --> 00:17:59.690 But simultaneously, it causes a profound suppression 00:17:59.690 --> 00:18:02.150 of her adaptive immunity. Her adaptive immunity 00:18:02.150 --> 00:18:04.650 being her T cells, her targeted defense system. 00:18:05.210 --> 00:18:07.769 She's essentially lowering her shields. She is. 00:18:07.950 --> 00:18:10.250 We will get to the wild reason why she does that 00:18:10.250 --> 00:18:12.990 in a minute. But practically speaking, this suppressed 00:18:12.990 --> 00:18:16.089 immunity makes her a prime target for opportunistic 00:18:16.089 --> 00:18:18.599 infections. And this is where patient education 00:18:18.599 --> 00:18:20.940 becomes a life or death nursing intervention, 00:18:21.240 --> 00:18:24.839 particularly regarding foodborne illness. Listeriosis 00:18:24.839 --> 00:18:27.960 is the primary threat. Listeria. Yes, Listeria 00:18:27.960 --> 00:18:30.460 monocetogenes is a bacteria that might just give 00:18:30.460 --> 00:18:33.380 a healthy adult a mild stomach ache. But for 00:18:33.380 --> 00:18:35.700 a pregnant patient with suppressed adaptive immunity, 00:18:35.799 --> 00:18:38.259 it can cause severe maternal illness. And it 00:18:38.259 --> 00:18:40.359 affects the baby, too. It easily crosses the 00:18:40.359 --> 00:18:42.920 placenta and can be fatal to the fetus, causing 00:18:42.920 --> 00:18:45.579 miscarriage, stillbirth, or profound neonatal 00:18:45.579 --> 00:18:48.279 sepsis. So what are the hard and fast rules we 00:18:48.279 --> 00:18:50.440 have to teach? The patient cannot eat regular 00:18:50.440 --> 00:18:53.119 deli foods. They must avoid all soft cheeses, 00:18:53.339 --> 00:18:56.380 no feta, no brie, no blue cheese, no queso fresco. 00:18:56.140 --> 00:18:59.380 unless it explicitly says, made with pasteurized 00:18:59.380 --> 00:19:01.859 milk. No unpasteurized milk or juices either. 00:19:02.160 --> 00:19:04.660 Right. And the big one, do not eat hot dogs or 00:19:04.660 --> 00:19:06.839 deli luncheon meats unless they are reheated 00:19:06.839 --> 00:19:10.099 until they are literally steaming hot. Cold turkey 00:19:10.099 --> 00:19:13.079 from the deli counter is a massive risk. Steaming 00:19:13.079 --> 00:19:15.920 hot kills the listeria. Got it. And what about 00:19:15.920 --> 00:19:19.630 the mercury rules for seafood? Mercury is a severe 00:19:19.630 --> 00:19:22.410 neurotoxin to the developing fetal brain. The 00:19:22.410 --> 00:19:24.869 FDA rule is to avoid high mercury predatory fish 00:19:24.869 --> 00:19:26.970 entirely. Which ones are those? The big four 00:19:26.970 --> 00:19:30.029 to memorize are shark, swordfish, king mackerel, 00:19:30.329 --> 00:19:33.089 and pilefish. Okay, we know what to avoid. What 00:19:33.089 --> 00:19:35.029 are the absolute must -haves for supplements? 00:19:35.309 --> 00:19:37.730 Iron is non -negotiable to support that massive 00:19:37.730 --> 00:19:40.009 increase in blood volume we talked about and 00:19:40.009 --> 00:19:42.950 folic acid. Why folic acid? Adequate folic acid 00:19:42.950 --> 00:19:45.150 is the primary defense against fetal neural tube 00:19:45.150 --> 00:19:47.529 defects like spina bifida. The recommendation 00:19:47.529 --> 00:19:51.369 is 400 to 800 micrograms every single day. Let's 00:19:51.369 --> 00:19:54.130 wrap up nutrition with the weight gain math because 00:19:54.130 --> 00:19:57.589 I guarantee there will be a question asking us 00:19:57.589 --> 00:20:00.190 to calculate a patient's expected weight gain 00:20:00.190 --> 00:20:02.910 based on her pre -pregnancy body mass index. 00:20:03.029 --> 00:20:05.599 It's a standard calculation. Let's focus on the 00:20:05.599 --> 00:20:07.680 baseline, a patient who starts with a normal 00:20:07.680 --> 00:20:11.900 pre -pregnancy BMI, which is 18 .5 to 24 .9. 00:20:12.519 --> 00:20:14.819 The total expected weight gain for the entire 00:20:14.819 --> 00:20:18.099 pregnancy should be between 25 and 35 pounds. 00:20:18.359 --> 00:20:21.319 Here is the easiest mental math to remember how 00:20:21.319 --> 00:20:23.579 that actually breaks down across the nine months. 00:20:23.660 --> 00:20:26.700 Let's hear it. In the first trimester, the goal 00:20:26.700 --> 00:20:29.250 is to gain about one pound a month. So that's 00:20:29.250 --> 00:20:31.589 roughly three to five pounds total for the first 00:20:31.589 --> 00:20:34.349 trimester. Right. Then for the second and third 00:20:34.349 --> 00:20:37.210 trimesters, the mass shifts gain about one pound 00:20:37.210 --> 00:20:39.609 a week. A pound a month at the start, then a 00:20:39.609 --> 00:20:41.670 pound a week to the finish. It perfectly maps 00:20:41.670 --> 00:20:45.549 out to that 25 to 35 pound target. It's an elegant 00:20:45.549 --> 00:20:48.309 foolproof way to remember it for your exam. OK, 00:20:48.630 --> 00:20:51.470 we have covered a staggering amount of physiological 00:20:51.470 --> 00:20:54.009 ground. Let's solidify this. If our listener 00:20:54.009 --> 00:20:56.490 only takes five core concepts from this deep 00:20:56.490 --> 00:20:59.289 dive into their exam tomorrow, what are the absolute 00:20:59.289 --> 00:21:02.339 top five? Number one, seeing HCG on a pregnancy 00:21:02.339 --> 00:21:05.019 test is a probable sign, not a positive one, 00:21:05.059 --> 00:21:08.000 because of the risk of tumors or moles. Positive 00:21:08.000 --> 00:21:11.180 signs require direct clinical visualization or 00:21:11.180 --> 00:21:13.380 auscultation of the fetus. That's a huge one. 00:21:13.700 --> 00:21:15.980 Number two, the left lateral position is your 00:21:15.980 --> 00:21:18.799 immediate life -saving reflex for supine hypopensive 00:21:18.799 --> 00:21:21.339 syndrome to physically get the heavy uterus off 00:21:21.339 --> 00:21:24.420 the vena cava. Left lateral, always. Number three, 00:21:24.619 --> 00:21:27.200 physiologic anemia is expected because her plasma 00:21:27.200 --> 00:21:30.240 volume dilutes her red blood cells. But true 00:21:30.240 --> 00:21:33.000 iron deficiency often revealed by pica cravings 00:21:33.000 --> 00:21:35.700 for dirt or ice is a clinical red flag. Check 00:21:35.700 --> 00:21:38.440 the iron. Number four, placental hormones like 00:21:38.440 --> 00:21:41.559 HPL intentionally act as bouncers, causing maternal 00:21:41.559 --> 00:21:44.119 insulin resistance so the fetus gets priority 00:21:44.119 --> 00:21:46.779 access to circulating glucose. And number five. 00:21:47.200 --> 00:21:48.960 Because our adaptive immunity is suppressed, 00:21:49.339 --> 00:21:51.299 deli meats must be cooked until steaming hot 00:21:51.299 --> 00:21:53.880 to prevent listeriosis, and folic acid is non 00:21:53.880 --> 00:21:56.539 -negotiable to prevent neural tube defects. That 00:21:56.539 --> 00:21:59.019 is the highest year list you could possibly ask 00:21:59.019 --> 00:22:02.710 for. But before we sign off, I know you always 00:22:02.710 --> 00:22:04.890 like to leave us with a broader conceptual takeaway. 00:22:05.170 --> 00:22:07.690 I do, because we spend so much time looking at 00:22:07.690 --> 00:22:10.210 the mechanics, the expanding uterus, the blood 00:22:10.210 --> 00:22:13.069 volumes, the vital signs, but biologically, pregnancy 00:22:13.069 --> 00:22:15.950 is a masterclass and something much more profound. 00:22:16.369 --> 00:22:19.269 How so? Well, I mentioned earlier that the mother's 00:22:19.269 --> 00:22:21.730 body intentionally suppresses its own adaptive 00:22:21.730 --> 00:22:24.019 immune system. Think about the gravity of that. 00:22:24.200 --> 00:22:26.460 The fetus contains half of the partner's DNA. 00:22:27.339 --> 00:22:29.759 To the mother's immune system, the baby is technically 00:22:29.759 --> 00:22:32.700 a foreign invader. If her T cells were operating 00:22:32.700 --> 00:22:35.279 at full capacity, her body would relentlessly 00:22:35.279 --> 00:22:38.400 attack and reject the pregnancy. Oh, wow. So 00:22:38.400 --> 00:22:41.000 the maternal body intentionally dials back its 00:22:41.000 --> 00:22:43.720 own highly advanced defense mechanisms. The very 00:22:43.720 --> 00:22:46.019 systems evolved to keep her alive in a dangerous 00:22:46.019 --> 00:22:48.519 world just to harbor and protect this new foreign 00:22:48.519 --> 00:22:51.559 life. It is an immunological miracle of total 00:22:51.559 --> 00:22:54.000 self -sacrifice at the cellular level. That gives 00:22:54.000 --> 00:22:56.319 me chills. It's not just a list of uncomfortable 00:22:56.319 --> 00:22:59.160 symptoms or diagnostic muddy waters. It is a 00:22:59.160 --> 00:23:01.339 beautifully coordinated system of biological 00:23:01.339 --> 00:23:03.859 sacrifice. It really is. If you are prepping 00:23:03.859 --> 00:23:06.380 for your OB nursing exam, take a deep breath. 00:23:06.920 --> 00:23:08.779 You aren't just memorizing flashcards anymore. 00:23:09.240 --> 00:23:11.279 You understand the hidden physics of the blood 00:23:11.279 --> 00:23:14.220 vessels, the tug of war for glucose, and the 00:23:14.220 --> 00:23:16.799 profound why behind the symptoms. Absolutely. 00:23:16.960 --> 00:23:19.799 You know how to prioritize safety. Trust your 00:23:19.799 --> 00:23:21.559 clinical judgment and go ace that exam.