Prepared by: ROSELYN S.

PACARDO, MAN, MM,RN, RM

Preconception Care

Immunization status Underlying medical conditions Reproductive health care practices Sexuality and sexual practices Nutrition Lifestyle practices Psychosocial issues Medication and drug use Support system

1st Prenatal Visit

 Establishment of trusting relationship  Focus on education for overall wellness  Detection and prevention of potential problems  Comprehensive health history, physical examination, and laboratory tests

Comprehensive Health History

 Reason for seeking care - Suspicion of pregnancy - Date of last menstrual period - Signs and symptoms of pregnancy

Presumptive

Probable

Positive

Breast changes Morning sickness Amenorrhea Frequent urination Fatigue Uterine enlargement Quickening Linea nigra Melasma/Chloasma Striae Gravidarum

Positive pregnancy test Chadwicks sign Goodells sign Hegars sign Sonographic evidence of gestational sac Ballotement Braxton Hicks contractions Fetal outline felt by examiner

Sonographic evidence of fetal outline Fetal heart audible Fetal movement felt by examiner

- Urine or blood test for hCG  Past medical, surgical, and personal history  Womans reproductive history: menstrual, obstetric and gynecologic history

Menstrual History
 Menstrual cycle Age at menarche Days in cycle Flow characteristics Discomforts Use of contraception

 Date

of last menstrual period (LMP)

Calculation of estimated or expected date of birth (EDB) or delivery (EDD) - Nageles rule Use first day of LNMP 11/21/09 Subtract 3 months 8/21/09 Add 7 days 8/28/09 Add 1 year 8/28/10 = EDB - Gestational or birth calculator or wheel (see Fig.)

Ultrasound

Obstetric History
Gravida: a pregnant woman - Gravida I (primigravida): first pregnancy - Gravida II (secundigravida): second pregnancy, etc. Para: a woman who has produced one or more viable offspring carrying a pregnancy 20 weeks or more - Primapara: one birth after a pregnancy of at least 20 weeks (primip) - Multipara: two or more pregnancies resulting in viable offspring (multip) - Nullipara: no viable offspring; para 0

Terminology G (gravida): the current pregnancy T (term births): the number of pregnancies ending >37 weeks gestation, at term P (preterm births): the number of preterm pregnancies ending >20 weeks or viability but before completion of 37 weeks A (abortions): the number of pregnancies ending before 20 weeks or viability L (living children): number of children currently living M multiple gestation

Physical Examination

Vital signs Head-to-toe assessment - Head and neck - Chest - Abdomen, including fundal height if appropriate - Extremities

 Pelvic examination - Examination of external and internal genitalia - Bimanual examination

- Pelvic shape: gynecoid, android, anthropoid, platypelloid - Pelvic measurements: diagonal conjugate, true (obstetric) conjugate and ischial tuberosity
Solid line diagonal Conjugate Dotted line true conjugate

Pelvic Measurements a. Diagonal Conjugate

Distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphisis pubis Anteroposterior diameter of the pelvic inlet Measurement - 12.5 cm
Measurement between the anterior surface of the sacral prominence and the posterior surface of the inferior margin of the symphisis pubis Measurement 10.5 to 11 cm Distance between the ischial tuberosities Transverse diameter of the outlet Measurement 11 cm

b. True conjugate or Conjugate vera

c. Ischial tuberosity

Note: Heads diameter is 9 cm to be able to pass through the pelvis

Measurement of ischial tuberosity

Laboratory Tests
Urinalysis Complete blood count Blood typing Rh factor Rubella titer Hepatitis B surface antigen HIV, VDRL, and RPR (rapid plasma reagin) testing Cervical smears Ultrasound

Follow-up Visits
Visit

schedule:

- Every 4 weeks up to 28 weeks - Every 2 weeks from 29 to 36 weeks - Every week from 37 weeks to birth

 Assessments - Weight & BP compared to baseline values - Urine testing for protein, glucose, ketones, and nitrites

- Fundal Height a. McDonalds Method Measure from the top of the symphisis pubis to the top of the uterus(in cm) then divide by 4

b. Bartholomews Rule Determines the relative position of the uterus in the abdominal cavity

- Leopolds Maneuver

- Fetal Heart Rate

- Quickening/Fetal Movement a.Cardiff Technique or Count to Ten Method record time interval that mother feels ten fetal movements; interval is usually 60 minutes b.Sadovsky Technique- fetus usually moves twice every 10 minutes or average of 10 to 12 times an hour

- Teach: Danger Signals

First Trimester
Second Trimester Third Trimester

Spotting or bleeding(miscarriage) Painful urination (infection) Severe persistent vomiting (Hyperemesis gravidarum) Fever higher than 100 F (infection) Lower abdominal pain with dizziness and shoulder pain (ruptured ectopic pregnancy)

Regular uterine contractions (preterm labor) Pain in calf often increased with foot flexion (blood clot in deep vein) sudden gush or leakage of fluid from vagina (PROM) Absence of fetal movement for more than 24 hours (possible fetal distress or demise)

Sudden weight gain Periorbital or facial edema, severe abdominal pain, or headache with visual changes (PIH) Decrease in fetal daily movement for more than 24 hours (possible demise) Plus any danger signal Of the first and second trimester

 Ultrasonography

Assessment of Fetal Well-Being

Use of intermittent high frequency sound waves by applying an alternating current to a transducer made of piezoelectric material

Doppler Flow Studies

- Measure the velocity of diastolic blood flow within the umbilical vessels via ultrasound

Alpha-fetoprotein analysis

-substance produced by the liver between 13 and 20 weeks of gestation

Marker screening tests

-a. Triple markers AFP, unconjugated estriol, and hCG done at 16 18 weeks; detects Downs syndrome - b. Four markers -3 markers +inhibin A; done at 14 to 22 weeks; detects Downs syndrome and neural tube defects

 Amniocentesis

Done at 14 16 weeks

Chorionic Villus Sampling (CVS)

Percutaneous Umbilical Blood Sampling (PUBS)

Nonstress test;

Test results of the NST: Test results of the NST may be: reactive (normal) - two or more fetal heart rate increases in the testing period (usually 20 minutes). nonreactive - there is no change in the fetal heart rate when the fetus moves. This may indicate a problem that requires further testing.

Contraction Stress Test/Oxytocin Challenge Test

External fetal heart rate monitoring

Newest Trend: Nipple Stimulation

- Contraction stress test

Normal:

Normal test results are called negative. Your baby's heart rate does not get lower (decelerate) and stay low after the contraction (late decelerations). Note: There may be a few times during the test when your baby's heart rate decelerates, but it doesn't stay low so it is not a problem. If three contractions occur during a 10-minute period of nipple stimulation or oxytocin infusion and there are no late decelerations in your baby's heart rate, your baby is expected to be able to tolerate the stress of labor.

Abnormal:

Abnormal test results are called positive. A slower heart rate (late decelerations) that stays low after the contraction may mean that your baby will have problems during normal labor. It may also mean that your baby will develop problems if delivery is delayed. Contractions that last longer than 90 seconds and occur every few minutes are present. This is called hyperstimulation.

- Biophysical Profile
a. Fetal Breathing 30 sec of sustained breathing within 30 min b. Fetal Movement at least 3 separate episodes of fetal limb or movement within a 30 min observation c. trunk

Fetal Tone must extend then flex extremities or spine at least once in 30 min

d. Amniotic Fluid Volume a pocket of amniotic fluid measuring more than 1 cm in vertical diameter must be present e. Fetal Heart Reactivity 2 or more HR accelerations of 15 beats/min above baseline and of 15 sec duration occur with fetal movement over a 20-min period Scoring System Score of 2 for each item; 10 highest score

First-Trimester Discomforts
Urinary frequency or incontinence Increased blood supply and pressure on the bladder  Kegels Exercise  Empty bladder when feeling a full sensation  Avoid caffeinated drinks  Reduce fluid intake after dinner  Increase fluid intake  Use cool mist humidifier at night  Blow nostril gently, one at a time  Avoid nasal decongestants and sprays  Good oral hygiene, use soft-bristled tooth brush, and floss daily  Manage nose bleeding  Keep perineal area clean and dry  Wash with mild soap and water  Avoid wearing pantyhose and tight- fitting nylon clothes; avoid douches & tampons  Use cotton underwear; use nightgown

Nasal stuffiness, bleeding gums, epistaxis Increased level of estrogen causing edema and hyperemia of mucous membranes

eukorr ea High levels of estrogen which caused increased vascularity and hypertrophy of cervical glands and vaginal cells

Fatigue
Increased O2 consumption; Increased levels of progesterone and relaxin; increased metabolic changes; psychosocial changes, etc.

 Get

a full nights sleep.  Eat a healthy balanced diet.  Schedule a nap early in the afternoon daily.  When tired, get rest.

Nausea and vomiting

High levels of estrogen, progesterone, hCG, and vitamnin B6 deficiency; Increased acidity, emotional factors, and altered glucose Metabolism * Couvade Syndrome

 Avoid an empty stomach at all times  Eat dry crackers or toast before arising in AM  Drink fluids between meals  Avoid greasy, fried foods or ones with strong odor  Avoid spicy foods  Avoid stress

Breast tenderness
Increased estrogen and Progesterone levels

 Wear

a well supportive bra even while sleeping

Constipation
Increased progesterone leads to decreased contractility of the GIT causing water absorption; Dietary factors; compression on colon by uterus; iron and calcium

 Increase fluid intake  High fiber diet  Exercise  Reduce cheese  Eat meals at regular interval  Decrease sugary sodas  Drink warm fluids on arising

Cravings
Increased hormone levels * Pica * Leg Cramps

 Instruct on importance of a healthy and balanced diet

Second-Trimester Discomforts  Proper posture with head up and Backache shoulders back
Shift in the center of gravity; high level of progesterone softens joints and cartilage; upper back pain due to increased breast size Varicosities of the vulva and legs Increased venous stasis due to pressure of the gravid uterus on thepelvic vessels; vasodilation caused by increased progesterone levels
Hemorrhoids Caused by progesterone- induced vasodilation Flatulence with bloating Increased progesterone level causes relaxation of GIT & dilatation * SUPINE HYPOTENSION  Apply body mechanics  When sitting, use foot supports and pillows behind the back  Pelvic tilt or rocking exercises to strengthen the back  Walk daily  Elevate both legs above heart level  Avoid prolonged standing  Avoid constrictive clothing  Avoid crossing legs  Wear support stockings  Vulva: elevate hips; knee-chest  Regular bowel elimination  Prevent straining  Warm sitz  Avoid gas-forming foods & foods with high sugar  Avoid chewing gum or smoking

Third-Trimester Discomforts
Return of first-trimester discomforts: fatigue, urinary Frequency, and leukorrhea Shortness of breath and dyspnea
Limited space for expansion of the diaphragm  Proper posture  Avoid large meals  Raising the head part or use pillows  Avoid exercises precipitating dyspnea  Avoid spicy or greasy foods  Sleep using several pillows  Avoid lying down for at least 2 hours after meals ; drink sips of water  Elevate feet and legs  Change position frequently  Avoid foods rich in sodium  Change position  Engage in mild exercise  Increase fluid intake

Heartburn and indigestion

High progesterone levels causes relaxation of the cardiac sphincter Dependent edema Due to elevated hormone levels and Increased blood volume Braxton Hicks contractions Irregular, painless uterine contractions

Nursing Management to Promote Self-Care

Personal hygiene Avoidance of saunas and hot tubs Perineal care Dental care Breast care Clothing Exercise

Sleep and rest Sexual activity and sexuality Employment Travel Immunizations and medications

Preparation for Labor, Birth, and Parenthood

Perinatal education Childbirth education Lamaze (psychoprophylactic) method: focus on breathing and relaxation techniques Bradley (partner-coached childbirth) method: focus on exercises and slow, controlled abdominal breathing Dick-Read (natural childbirth) method: focus on fear reduction via knowledge and abdominal breathing techniques

 Options for birth setting - Hospitals: delivery room, birthing suite - Birth centers - Home birth Options for care providers - Obstetrician - Midwife -Doula

 Feeding choices - Breastfeeding: advantages and disadvantages - Bottle feeding: advantages and disadvantages -Teaching Final preparation for labor and birth

PSYCHOLOGICAL TASKS OF PREGNANCY

First Trimester Second Trimester

Accepting the Pregnancy

Accepting the Baby

Third Trimester

Preparing for the Baby and end of Pregnancy

16. r sum ti e si s re kno n to e caused conditions ot er t an re nancy. u jecti e and resum ti e manifestations reported y a oman ill include all of t e follo ing, except: . menorr ea B. ausea and vomiting in early . Breast changes . Hegars sign

16. Presumptive signs are known to be caused by conditions other than pregnancy. Subjective and presumptive manifestations reported by a woman will include all of the following, except: A. Amenorrhea B. Nausea and vomiting in early AM C. Breast changes D. Hegars sign ( increased vascularity and softening of the uterine isthmus) Source: Pillitteri p. 223

Hegars sign

17. The last menstrual period of KC was on Jan 18, 2010. Her estimated date of birth would be on: A. September 25, 2010 B. October 25, 2010 C. November 25, 2010 D. December 25, 2010

17. The last menstrual period of KC was on Jan 18. , 2010. Her estimated date of birth would be on: A. September 25, 2010 B. October 25, 2010 C. November 25, 2010 D. December 25, 2010 Ricci p. 259

18. This is the third pregnancy of KC. She had a miscarriage at 12 weeks and gave birth to a son, now 3 years old, at 32 weeks. She had no multiple gestation multiple gestation. Using the GTPALM system, the nurse would document this womans obstetric history as: A. 310211 B. 301110 C. 212120 D. 201111

18. This is the third pregnancy of KC. She had a miscarriage at 12 weeks and gave birth to a son, now 3 years old, at 32 weeks. She had no multiple gestation multiple gestation. Using the GTPALM system, the nurse would document this womans obstetric history as: A. 310211 B. 301110 C. 212120 D. 201111 The womans obstetric history would be documented as 301110: G (gravida) = 3 (current pregnancy), T (term pregnancies) = 0, P (number of preterm pregnancies) = 1, A (number of pregnancies ending before 20 weeks viability) = 1, L (number of living children) = 1, M (multiple gestation) = 0. Pillitteri pp 252 - 253

19. A nurse in the health care clinic is instructing KC on how to perform the kick counts. Which statement made by KC indicates a need for further education? A. I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks. B. I will record the number of fetal movements or kicks. C. I need to lie flat on my back to perform the procedure. D. A count of fewer than 3 fetal movements in 1 hour indicates the need to contact the physician.

19. A nurse in the health care clinic is instructing KC on how to perform the kick counts. Which statement made by KC indicates a need for further education? A. I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks. B. I will record the number of fetal movements or kicks. C. I need to lie flat on my back to perform the procedure. (Side-lying position or left lateral recumbent) D. A count of fewer than 3 fetal movements in 1 hour indicates the need to contact the physician. Sadovsky method the fetus moves twice every 10 minutes or an average of 10 to 12 times in an hour; Cardiff Method or Count to Ten feel at least 10 movements in an interval of 60 minutes Source: Ricci p. 266; Pillitteri p. 200

20. The nurse instructs KC that if she is already on her second trimester of pregnancy, she should return for a follow-up visit every: A. 4 weeks B. 3 weeks C. 2 weeks D.Week

20. The nurse instructs KC that if she is already on her second trimester of pregnancy, she should return for a follow-up visit every: A. 4 weeks B. 3 weeks C. 2 weeks D. Week The recommended follow-up schedule is every 4 weeks up to 28 weeks, every 2 weeks from 29 to 36 weeks, and then every week from 37 weeks to birth. Ricci p. 265

SITUATION E: Nena is a primigravid woman who experiences the common discomforts of pregnancy. She went to the health center and asks some recommendations on how to relieve the discomforts. 21. After teaching Nena about ways to minimize flatulence and bloating during pregnancy, which statement indicates the need for additional teaching? A. Ill try to drink more fluids to help move things along. B. Ill switch to chewing gum instead of using mints. C. Ill stay away from foods like cabbage and camote. D. Ill increase the time I spend walking each day.

SITUATION E: Nena is a primigravid woman who experiences the common discomforts of pregnancy. She went to the health center and asks some recommendations on how to relieve the discomforts. 21. After teaching Nena about ways to minimize flatulence and bloating during pregnancy, which statement indicates the need for additional teaching? A. Ill try to drink more fluids to help move things along. B. *Ill switch to chewing gum instead of using mints. C. Ill stay away from foods like cabbage and camote. D. Ill increase the time I spend walking each day. Eating mints can help reduce flatulence; chewing gum increases the amount of air that is swallowed, increasing gas build-up. Increasing fluid intake helps to reduce flatus. Gas-forming foods such as beans, cabbage, onions and camote should be avoided. Increasing physical exercise, such as walking, helps reduce flatus. Ricci pp. 286 - 287

22. Which of the following interventions would the nurse recommend to Nena who is experiencing a severe heartburn during her pregnancy? A. Eat several small meals daily B. Eat crackers on waking in the morning C. Lie down immediately after eating D. Drink orange juice frequently during the day

22. Which of the following interventions would the nurse recommend to Nena who is experiencing a severe heartburn during her pregnancy? A. Eat several small meals daily B. Eat crackers on waking in the morning for morning sickness C. Lie down immediately after eating (rest at least for 2 hours) D. Drink orange juice frequently during the day drink sips of water

Source: Pillitteri p. 315; Ricci p. 281

23. A nurse is providing instructions to Nena regarding measures that will assist in relieving backaches. Which statement made by the client indicates a need for further education? A. I need to try to maintain a good posture. B. I should do more vigorous exercise to strengthen my back muscles. C. I should sleep on a firm mattress. D. I should wear low-heeled shoes.

23. A nurse is providing instructions to Nena regarding measures that will assist in relieving backaches. Which statement made by the client indicates a need for further education? A. I need to try to maintain a good posture. B. I should do more vigorous exercise to strengthen my back muscles.(Moderate only; Pelvic Rocking) C. I should sleep on a firm mattress. D. I should wear low-heeled shoes.
Source: Pillitteri p. 276

Pelvic Rocking

24.Which of the following is the recommended weight gain per trimester of pregnancy that Nena should attain?
A. Three pounds for the first trimester, 12 pounds for the 2nd trimester, and 12 pounds for the last trimester of pregnancy B. One pound for the first trimester, 10 pounds for the 2nd trimester, 15 pounds for the last trimester of pregnancy C. Two pounds for the first trimester, 11 pounds for the 2nd trimester, and 13 pounds for the last trimester of pregnancy D. Four pounds for the first trimester, 13 pounds for the 2nd trimester, and 14 pounds for the last trimester of pregnancy

24.Which of the following is the recommended weight gain per trimester of pregnancy that Nena should attain? A. Three pounds for the first trimester, 12 pounds for the 2nd trimester, and 12 pounds for the last trimester of pregnancy (3-12-12) B. One pound for the first trimester, 10 pounds for the 2nd trimester, 15 pounds for the last trimester of pregnancy C. Two pounds for the first trimester, 11 pounds for the 2nd trimester, and 13 pounds for the last trimester of pregnancy D. Four pounds for the first trimester, 13 pounds for the 2nd trimester, and 14 pounds for the last trimester of pregnancy Source: Pillitteri p. 302

25. Anticipatory guidance during the first trimester of pregnancy is primarily directed toward increasing the pregnant womans knowledge of: A. Labor and delivery B. Signs of complications C. Role transition into parenthood D. Physical changes resulting from pregnancy

25. Anticipatory guidance during the first trimester of pregnancy is primarily directed toward increasing the pregnant womans knowledge of: A. Labor and delivery B. Signs of complications C. Role transition into parenthood Preparing for parenthood (Third trimester psychological task) D. Physical changes resulting from pregnancy Accepting the pregnancy (First trimester psychological task) Source: Pillitteri p. 215(Second trimester accepting the baby)