VII.

PRENATAL MANAGEMENT

A. FIRST VISIT: as soon as the mother missed a menstrual period when pregnancy is
suspected.

B. SCHEDULE OF VISITS

1. Once a month up to first 32 weeks

2. Twice a month (every 2 weeks) from 32 to 36 weeks

3. Four times a month (every week) from 36 to 40 weeks

C. CONDUCT OF INITIAL VISIT

1. Baseline Data Connection

a. To serve as basis for comparison with information gathered on
subsequent visits
b. To screen for high factors

ROLL-OVER TEST
I. PROCEDURE
A. Place mother on left-side lying position (left lateral recumbent, LLR).
B. Check BP until stable, may take 10 to 15 minutes.
C. Roll to supine.
D. Check BP right away.
E. Wait for 5 minutes.
F. Check BP again. Compare the first with the second diastolic reading.
II. INTERPRETATION
A. Positive Result – An increase in the diastolic pressure of values greater
than 20 mm of mercury; woman at risk
B. Negative Result – An increase in the diastolic pressure of values less than
20 mm of mercury

2. Obstetrical History
a. Menstrual history – menarche (onset, regularity, duration, frequency,
character)
b. Last menstrual period (LMP), sexual history, methods of contraception
c. Past menstrual period (PMP): menstrual period before the last

3. Medical and Surgical History – past illnesses and surgical procedures,

current drugs used

4. Family History to detect illnesses or conditions that are transmittable

5. Current Problems – activities of daily living, discomforts, danger signs

6. Initial and Subsequent Visits

a. Vital signs
 Temperature: slight rise because of increased progesterone and
activity of the thyroid gland; not to reach 38°C.
 CR: Plus 10 to 15BPM
 RR: May tend to be rapid and deep (16/min, deeper) because of
progesterone’s influence on the respiratory center. Maximum increase
under normal conditions: 24/min at rest.
 BP: Tends to be hypotensive with supine position: vena caval
syndrome.

 Prevention: LLR. BP lowest in the 2nd trimester. Elevated BP reading,

may indicate pregnancy-induced hypertension (PIH)
 The roll-over test can be done in the first trimester for early
detection of developing pregnancy-induced hypertension by 20 to
24 weeks.
b. Weight is checked in every visit.
 Total weight gain: 20 to 25 lb., with average of 24 lb., upper limit: 25 to
35 lb.
 First trimester: 1 lb. per month, which is 3 to 4 lb. total
 Second trimester: 0.9 lb. to 1 lb. per week or about 8 to 11 lb.
 The patterns of weight gain are more important than the amount of
weight gain.
 Normal weight gain patterns contribute to health of mother and fetus.
 Failure to gain weight is an ominous sign.
 Weight is therefore a measure of health of a pregnant mother.
c. Urine testing for albumin and sugar
 Sugar – ideally not more than 1+
 Albumin – negative
d. Fetal growth and development assessment
 Fundal height
 Requires emptying of the bladder for accurate results
 Fetal heart tones/fetal heart rate
 Abdominal palpitation –Leopold’s maneuver
Quickening – first fetal movement, plus subsequent mobility

7. Obstetrical History
a. Preceding pregnancies and perinatal outcomes:
 4-Point System: Past pregnancies and perinatal outcomes (FPAL)

F: number of full term births

 P: number of premature births
A: number of abortions
L: number of currently living children

 5-Point System: the total number pregnancies (G) is the first number
(GFPAL)

G: total number of pregnancies

F: number of full term births
P: number of premature births
A: number of abortions
L: number of currently living children

b. Gravida: number of pregnancies regardless of duration and outcomes,

including the present pregnancy
 Gravida 1 (G) –pregnant for the first time; a primigravida had one
pregnancy
 Multigravida – with two or more pregnancies
 Nulligravida – woman who is not pregnant now and has never been
pregnant.
c. Parity: number of pregnancies carried to period of viability whether born
dead or alive at birth (twins considered as one parity)
 Primipara: a woman who has once delivered a fetus or fetuses who
reached the stage of viability. Therefore, the completion or pregnancy
beyond the period of abortion means one parity. It also means,
therefore, that any abortion is not included in the counting.
 Multipara: a woman who has completed two or more pregnancies to
the stage of viability.

8. Estimates in Pregnancy
a. EDC/EDD: expected data of confinement/expected date of delivery
 Naegele’s Rule Formula:
Add 7 days to the first day of the last menstrual period (LMP), subtract
3 calendar months then add 1 year

Given LMP: May 20, 2008

5 20 2008
- 3 + 7 + 1
2 27 200
EDD: February 27, 2009
  Mittendorf’s Rule Formula:
First, identify the LMP woman’s race (Caucasian/white or non-
Caucasian), and gravidity [primigravida (G₁) or multigravida (G₂) above]

 Formula for Caucasian/white woman, first time pregnant (G₁):

EDD = [LMP + 15 days] – 3 months
 Formula for non-Caucasian/non-white, multigravida:
EDD = [LMP + 10 days] – 3 months

 Date of Quickening
Primigravida: Date of Q + 4 months and 20 days = EDC
Multigravida: Date of Q + 5 months and 4 days = EDC

 Fundic height can also help estimate EDC. To get accurate results,
instruct the mother to first VOID.
 At symphysis pubis: 12 weeks
 At umbilicus: 20 to 22 weeks
 At xiphoid process: 36 weeks

b. Age of Gestation: clinicians use the gestational age or menstrual age

calculated from the first day of the last menstrual period, to identify
temporal events in pregnancy. Reproductive biologists and embryologist
often use the terms ovulatory age or fertilization age which are
calculated from the time of ovulation or fertilization; both are 2 weeks
shorter (Cunningham, et al., 1989).

 McDonald’s Rule (used in second and third trimesters)

 First take the fundic height (FH) in centimeter using a tape
measure. Measure the distance from the top of the symphysis
pubis over the curve of the abdomen to the top of the uterine
fundus using a tape measure.
 Formula for estimating age of gestation in lunar months:
FH X 2
7
 Formula for estimating age of gestation in lunar weeks:
FH X 8
7
 Fundic height correlates well with weeks of gestation between 20
and 31 weeks. For example, at 26 weeks gestation, fundal height is
 probably 26 cm; at 20 weeks gestation, the fundus is about 20 cm
and at the level of the umbilicus in an average female (Olds,
London & Ladewig, 1988).

MEASURES OF AGE OF GESTATION (AOG)

A. LMP: last menstrual period
B. Fundic height
C. McDonald’s Rule: requires fundic height measurement in cm
 AOG in weeks: FH in cm X 8 ÷ 7
 AOG in months: FH in cm X 2 ÷ 7
D. Ultrasonography: measures biparietal diameter
 A biparietal diameter of 9.5 cm = mature fetus: usually attained at 36 weeks of
gestation
E. X-ray: after 15 weeks to be safe
 Identification of distal femoral ossification = 36 weeks
 Identification of proximotibial ossification = mature
F. Date of Quickening: at 20 weeks
G. Identification of FHT: at 12 weeks by Doppler ultrasound

 Bartholomew’s Rule of Fours – measures age of gestation by

determining the position of the fundus in the abdominal cavity.

c. EFW: estimated fetal weight

 Johnson’s Rule: needs fundic height measure in cm
 If unengaged: EFW in g = [FH - 11] X 155
 If engaged: EFW in g = [FH - 12] X 155

d. EFL: estimated fetal length in cm; Haase’s Rule

 First five months of pregnancy: square the month.
To square the month is to multiply it by itself:
Example: How long is a 3 month old fetus?
3 X 3 = 9 cm
 For the second half of pregnancy: Multiply month by 5.
Example: How long is a 7 month old fetus?
7 X 5 = 35 cm

9. Complete Physical Examination: includes internal gynecologic examination

and bimanual examinations.
a. Internal Examination (IE): detects early sign of pregnancy: Chadwick’s
sign, Goodell’s and Hegar’s sign. The following are the preparation for IE:
 Explanation
  Void before IE.
 Proper positioning: Lithomy
 Equal height of padded stirrups
 Simultaneous placing of legs on stirrups
 No pressure on the popliteal region
 Draping
 Instruction: position hands across the chest; correct breathing, slo,
chest breaths
 DON’TS:
 Any activity that can increase intra-abdominal pressure (i.e.,
squeezing of nurse’s hands, breath holding)
 Distracting woman’s attention from focused breathing/relaxation
techniques.
 Any impediment to communication

b. Important concerns of physical examinations

 Breasts – look for breast changes, adequacy of breasts for
breastfeeding, any abnormal signs.
 Abdomen
 Fundic height
 Leopold’s maneuvers: systematic abdominal palpitation to estimate
fetal size, locate fetal back and parts and determine fetal position
and representation.
Preparations for Leopold’s Maneuvers are as follows:
 Explain the procedure and the need for it.
 Ensure proper position: dorsal recumbent with knees slightly
flexed to relax abdominal muscles.
 Drape accordingly.
 Nurse’s hands should be warm to prevent contracting mother’s
abdominal muscles resulting in difficult palpation.
 Apply gentle, firm palpations using the palm of the hands.

 Pelvic measurements: done in the third trimester to determine CPD

(cephalo-pelvic disproportions).
 Extremities
 Discomforts: leg cramps, varicosities, pedal edema
 Danger sign: + Homan’s sign (Pain in the calf upon dorsiflexion
of the toes; a sign of thrombophlebitis)
c. Laboratory Tests
 Blood Studies
 Complete blood count
 Hemoglobin (12 to 16gdL) and haematocrit (37% to 47%);
decreased in pregnancy
 Leucocytosis is NOT a sign of infection in pregnancy because
the WBC count is usually elevated: Pregnancy: 5,500 to
11,500/mm³; labor: 20,000/mm³; and postpartum: 25,000 /mm³
 Blood typing and Rh determination. If the mother is Rh negative,
the first thing to be done is to determine paternal Rh; and if the
result is Rh positive, cord blood will be obtained at birth to
determine Rh of the baby’s blood.
 According to institution protocol, Serology for:
 Syphilis (VDRL). If the mother is found positive for syphilis,
she must be treated early. There is a placental barrier to
syphilis in the first 16 weeks.
 Rubella antibody titer determination. Results: If the ratio is
1:8 or less, there is a risk; the mother should be immunized
in the postpartum confinement. If the ratio is greater than
1:8, the immunity is present and thus, there is; no need for
immunization.
 Human Immunodeficiency Virus (HIV)
 Hepatitis screening as indicated
 Alpha-fetoprotein screening (AFP) at 16 to 18 weeks’ gestation to
rule out neural defects.
 Screening for sickle cell trait (if of Black race).

 Urine Test: In addition to testing for sugar (Normal finding in

pregnancy +1), urine may also be tested for bacteria for there is
asymptomatic bacteriuria which can result in abortion in early
pregnancy, and premature labor in late pregnancy.
 Pelvic Lab Tests: collection of pelvic cultures (Pap test, culture for
gonorrhoea and Chlamydia) and the performance of bimanual
examination, usually the last part of the initial physical examination
(Littleton & Engebreston, 2006).
 to identify cervical and uterine changes in pregnancy
 to detect uterine size
 to assess for deviation in expected size and shape
  In all the necessary testing, prepare the client through the following
steps:
 providing an explanation of the procedure
 physical preparations specific to the procedure
 provisions of support to patient and spouse; encouraging
verbalization of concerns
 monitoring of patient and fetus after procedure
 documentation as necessary

VIII. MAJOR GOALS OF COMPREHENSIVE PRENATAL ASSESSMENT AND

EVALUATION:

A. Define the health status of the mother and fetus.

B. Determine gestational age of the fetus: estimate date of confinement.
C. Initiate a nursing care plan for continuing maternity care of both mother and fetus.
D. Detect early any high-risk condition.

IX. HYGIENE OF PREGNANCY

A. NUTRITION
1. Always start with diet history when it comes to giving nutritional instruction to
the mother.

2. Nutritional Profile should include the following:

a. Pre-pregnant and current nutritional status
b. Dietary habits: junk, empty-caloric foods, regularity of meals, peer pressure,
adequacy of food/available finances, cultural and religious restrictions
c. Pica: persistent ingestion of inedible substances (e.g. clay, dirt, starch,
chalk), and/or substances of little nutritional value; a psychobehavioral
disorder (Rainville, 1998). Effects are displacement of nutritious foods,
interference with nutrient absorption and anemia.
d. Mothers knowledge of nutritional needs and the daily recommended
allowances
e. Physical findings indicative of poor nutritional status such as:
 anemia, underweight/overweight
 dull hair
 dry/scaly skin
 pale/dull mucus membrane/conjunctiva
f. Factors/conditions requiring special attention such as:
 young, adolescent mother
  primigravidity
 low pre-pregnant weight
 obesity
 low socioeconomic status/ economic deprivation
 pre-pregnant debilitating conditions
 vegetarians – lack essential protein and minerals; may need vitamin B12
supplement
 successive pregnancies; short interval between pregnancies
 education – not so much what they know (may receive nutritional
teaching) but how much they earn (spells adequate finances) to buy
essential foods.

3. Nutrient Needs should include the following:

a. Calories
 Non-pregnant requirement: 1,800 to 2,200 Kcal/day
 Additional caloric requirement per day: 300 Kcal/day
 Usual daily caloric need in pregnancy: 2,100 - 2,500; never less than
1,800 Kcal/day
 Avoid “empty” calories like soft drinks.
b. Protein: body-building food: additional 30 g/day to ensure 74 to 76g/day.
Rich food sources include: milk, meat, fish, poultry and eggs.
c. Carbohydrates: sufficient intake is necessary for added energy needs; avoid
“empty” calories like soft drinks
d. Fiber: taken from fruits and vegetables to prevent constipation
e. Fats: high-energy foods for absorption of vitamins A, D, E, and K. Avoid too
much fat to prevent vomiting and heartburn.
f. Essential Minerals and Vitamins
 Iron: Most important mineral that must be taken in supplementary amount
 18 mg/day in non-pregnant state: supplementary in pregnancy: 30 to
60 mg/day
 Source: liver (best source) and other red meats, green leafy
vegetables, egg yolk, cereals, dried fruits, and nuts
 Needed to increase maternal RBC mass and for fetal liver storage in
the third trimester.
 Intake of iron-fortified multivitamins to ensure essential levels.
 best absorbed in acidic medium: take between meals and with
vitamin C – rich juice
 may cause constipation: so there is also a need for increased fluid
intake, fibers/roughage; regular ambulation
 will darken stools: explain this to the patient; can be used in
evaluating compliance

 Calcium
 Needed for maternal calcium and phosphorous metabolism and fetal
bone and skeletal growth
  1,200 mg/day, equivalent to 1 quart of milk a day (4 glasses)
 Sources: milk and milk products and broccoli (which carries the same
amount of calcium as milk)
 Sodium: most abundant cation in extracellular fluid
 Needed in pregnancy for tissue growth and development
 Contained in most kinds of foods
 Should not be restricted without serious indications

 Folic Acid
 Needed to meet increased metabolic demands in pregnancy and for
productions of blood products
 Deficiency may cause fetal anomalies/neural defect and bleeding
complications
 Sources: liver, dark green leafy vegetables

 Vitamins: water-soluble vitamins (C and B) and fat-soluble vitamins (A, D,

E, and K)
Major Food Sources
 Vitamin C: citrus fruits and vegetables like broccoli, bell peppers, and
tomatoes
 Vitamin B Group: legumes, beans, nuts, whole grain, oatmeal, pork,
beef, fish, liver, organ meats, eggs, and green leafy vegetables
 Vitamin A: milk and dairy products; dark green and dark yellow fruits
and vegetables; eggs and liver
 Vitamin D: milk and foods fortified with vitamin D; egg yolk; fish
 Vitamin E: nuts, seeds, wheat germ, whole grain products, green leafy
vegetables, vegetable oils
 Vitamin K: meats, liver, cheese, tomatoes, peas, and egg yolk

4. Daily Food Needs/Servings

Food Number of Servings
Milk and milk products 1 quart a day (4 glasses/day)
Meat and meat products 3-4 servings
Cereals/grain products 4-5 servings
Fruit/fruit juices 3-4 servings (one serving of vitamin C-
rich fruit/juice included)
Vegetables/vegetable juices 3-4 servings (included is 1 serving of
dark green or yellow vegetable)
Fluids 4-6 glasses of water plus other fluids
to equal 8 (8-10) cups/day

B. BATH
1. Daily bath if desired.

2. Avoid soaps on nipples: with drying effect.

 3. Towel-dry breasts: increases integrity/toughness of nipples.

4. Tub bath: may cause injuries from accidental slipping as pregnant women have
difficulty maintaining balance
a. Usually contraindicated except when there is care in getting into and out of
bathtub; non-skid rubber mat on bathtub floor helps to prevent falls.

5. Douching: not needed to manage vaginal discharge (Leucorrhea is estrogen-

induced.); daily bath will suffice.

C. CLOTHING
1. Loose, comfortable clothes, of cotton material for more comfort

2. No constrictions around breasts, abdomen, legs; no round garters

3. Flat-heeled shoes for comfort and balance

4. Support panty hose for varicosities (avoid knee-length stockings).

5. Supportive, cotton-lined brassiere

6. Maternity girdle as necessary

D. SLEEP AND REST

1. Assess activities to identify need for rest and sleep.

2. Average number of hours of sleep is 8 hours; may need 1 to 2 hours of afternoon

nap. In the second half of pregnancy, advise to avoid the supine position in bed.

3. Plan rest time during the day.

4. At work, get to stand and walk about for few minutes at last once in every 2 hours
(if task requires prolong standing, there should be time to walk about and sit at
intervals).

E. TRAVELING
1. Long distance travel by land needs stop-overs so pregnant women can get out of
the car and walk. Seatbelts are needed.

2. Traveling by air requires pressurized planes; in late pregnancy, airlines will

require a medical certificate indicating fitness to travel by air.

3. Best time to travel is during the second trimester because:

a. the pregnant woman is most comfortable.
 b. the danger of abortion is not great.
c. the threat of premature labor is at a minimum.

4. Journeys close to term are discouraged.

F. EXERCISES
1. Cleansing Breathing: deep relaxed breath, like a sigh. Can be practiced in
pregnancy; used in labor to signal the beginning of uterine contractions.

2. Pelvic Rock: The most important exercise for comfort during pregnancy.
Purposes:
a. increases flexibility of the lower back
b. strengthens the abdominal muscles
c. shifts center of gravity back to uterine spine
d. relieves backache, improves posture and appearance in late pregnancy

3. Squatting/Tailor-sitting: strengthens perineal muscles; makes pelvic joints

more pliable.

4. Abdominal Breathing: utilizes the diaphragm primarily and not the chest
muscles; helpful during the first half of labor, and, when used together with total
relaxation, can carry women through most of the first stage.

5. Kegel: improves the tone of pubococcygeal, perineal, vaginal and pelvic floor
muscles. In uterine prolapse, cystocele and rectocele, this can be done every
hour.

6. Panting: best for crowning period and actual delivery of the baby leaving the
work to be accomplished by the uterus. Only by panting can the mother be kept
from pushing in the transition phase of labor; pushing should be in the second
stage of labor EXCEPT during CROWNING.

7. Nursing Considerations Related to Exercises in Pregnancy

a. Regular exercises are needed.
b. Not necessary to limit maternal exercises provided they are:
 Usual, customary: no new exercise should be started in pregnancy.
 Do not cause maternal fatigue. Evidences support women who are used
to aerobic exercises before pregnancy should continue them during
pregnancy provided fatigue is avoided.
 With no risk for maternal and fetal injury.
c. Literature reports that regular exercise in pregnant women results to lower CS
Rate and length of hospitalization.
d. Exercise in standing position (not supine) to prevent pressure on the interior
vena and against the diaphragm.
 e. Avoid excessive and strenuous exercise.
 Excessive exercises cause increased blood flow to muscles and bones,
diminishing blood flow to uterus, placenta and therefore, fetus. This
implies the possibility of fetal distress in severe exercise.
 Excessive exercises can cause increased body temperature; elevated
temperature is theoretically teratogenic.

G. MARITAL RELATIONS/COITUS
1. Changes in normal sexual response are related to the physiologic changes of
pregnancy (Alteneder & Hartzell, 1997):
a. First Trimester: less interest in sex due to fatigue, nausea, or adaptation to
pregnancy.
b. Second Trimester: interest in sex may increase as this trimester is the most
comfortable period.
c. Third Trimester: near term: less interest due to discomforts brought about by
positional difficulty and abdominal size.

2. Generally no contraindications except in the presence of:

a. premature rupture of membranes
b. premature labor
c. history of abortion, bleeding
d. deeply engaged head in late pregnancy
e. incompetent cervix

3. In healthy, pregnant women, sexual intercourse usually does no harm.

a. Like any other activity, avoid fatigue; exercise moderation and hygiene.
b. Couple may need counselling regarding more comfortable positions. The
traditional man-on-top position is uncomfortable for many couples.
c. Suggested positions: side lying and the woman-on-top position.

H. EMPLOYMENT
The pregnant woman may continue working provided the work, work area, and work
conditions do not pose hazards to the health of the mother and fetus.
1. Safety and rest are the two most important considerations in deciding whether or
not the pregnant woman should continue working.

2. Whether standing or sitting at work, the pregnant woman should be advised to

stop and walk about every few hours to improve circulation of blood.

3. Adequate periods of rest should be provided during the workday.

4. Women with previous complications that are likely to be repetitive like SGA,
premature labor, or abortions, probably should minimize physical work.
I. CARE OF THE TEETH
Regular examination of the teeth and gums should be part of the prenatal general
physical examination. Dental carries require prompt management in pregnancy, but
major dental surgeries should be postponed for the postpartal period.

1. Because of estrogen effect on vascularity, the gums of pregnant women are

painful and swollen. Instruct on the use of soft-bristled toothbrush and gentle
brushing.

2. The concept that dental carries are aggravated by pregnancy is not supported by
literature. There is no tooth loss secondary to pregnancy.

J. S-A-D HABITS OF PREGNANCY

1. Smoking. Pregnant women should not smoke. Women who smoke in pregnancy
have smaller infants (SGA) than those women who do not. The use of over five
cigarettes per day in pregnancy doubles a woman’s risk of delivering a low-birth
infant (Lieberman et al., 1994). Prenatal tobacco exposure causes learning and
attention problems in children but less consistently than does alcohol exposure
(Streissguth et al., 1997).
a. Effects of tobacco use (Lieberman et al., 1994):
 Increased risk of SGA
 Prematurity
 Infant mortality
 Spontaneous abortion
 Placenta previa/abruption placenta
 Premature rupture of membranes
b. Causes of adverse effects of smoking
 Nicotine, a vasoconstrictor, causes reduced placental perfusion.
 The increase of carbon monoxide causes functional inactivation of
maternal and fetal haemoglobin.
 Smokers have decreased plasma volume.
 Smokers have reduced appetite, resulting to decreased caloric intake.

2. Alcohol. Alcohol ingestion by pregnant women is likely to cause fetal

abnormalities. Alcohol is the leading known teratogen in the Western world.
a. Effects of chronic alcoholism: fetal alcohol syndrome (FAS). Heavy use of
alcohol (2 or more drinks/day) has 10% risk of producing FAS, characterized
by:
 retardation/delays: cognitive, motor, attention, and learning deficits
(Streissguth, Barr, Sampson, & Bookstein, 1997)
 Mental retardation: associated with microcephaly, and seizure disorders
(Littleton & Engebretson, 2006). Prenatal alcohol is the leading cause of
mental retardation, surpassing down syndrome (Streissguth et al., 1997).
  craniofacial defects (FAS facies): flat midface, wide nasal bridge, thin
upper lip
 cardiovascular defects
 limb defects
 impaired fine and gross motor function
b. Since modern science has not determined what level of alcohol is safe for
pregnant women, it is best that pregnant women abstain from alcohol
ingestion, including the so-called “social drinking”, as this can cause problems
that persist into the child’s teenage years and beyond (Streissguth et al.,
1997).

3. Caffeine: reduce intake of coffee, tea, colas, and cocoa to 300 mg of caffeine
per day or no more than 2 to 3 servings per day (US FDA).

4. Drugs should only be taken by pregnant women when prescribed by their

physicians. Drugs prescribed in pregnancy should have benefits or advantages
outweighing the risks. The best recommendation: no medication is taken
during pregnancy unless absolutely necessary and prescribed.
a. Intake of illicit drugs in the first trimester can cause the most adverse fetal
malformations because:
 Placental barrier is not yet fully developed; placenta is mature by 10 to 12
weeks of gestation.
 Rapid organogenesis takes place during this period and could therefore
be altered.
b. The so-called “hard” drugs may cause growth retardation and drug
withdrawal which is associated with increased which is associated with
increased neonatal mortality. The most common harmful effect of heroin on
the neonates is withdrawal (Richardson et al., 1996), or neonatal
abstinence syndrome giving rise to a group of signs that include:
 sneezing
 irritability
 vomiting and diarrhea
 seizures
c. Illegal drugs carry the risk of acquiring HIV and other STDs because women
may trade sex for drugs and may provide sexual favors for money needed to
acquire drugs (Henderson et al., 1994). (See pages 43 to 45).
d. Herbal Supplements. Herbs being natural are not always safe because of
lack of consistent potency in the active ingredient. For vomiting or morning
sickness, a gram of ginger is effective and safe, but 20 times the stomach-
settling dose can trigger menstruation (Littleton & Engebretson, 2006).
 General rule for natural herbs: must be approved and supervised by
health care provider.