Assessing fetal and maternal health: prenatal care

- Essential for ensuring overall health of mom and baby

- Major strategy to reduce complications
- Begins during Mom’s Childhood!
o Balanced nutrition w/ adequate intake of
calcium and vitamin D – prevent rickets that
can distort pelvic size
o Adequate immunizations – protection against
viral diseases such as rubella during pregnancy
o Maintenance of overall healthy lifestyle
 Positive attitude: sexuality,
womanhood, childbearing
- Lack of Prenatal Care: birth of preterm infants &
various complications such as hypertension
- PURPOSE:
o Establish Present Health Baseline
o Determine Gestational Age of Fetus
o Monitor Fetal Development and Maternal
Wellbeing
o Identify and Minimize Risks
o Provide Time for Education
- Includes both Preconceptual and Pregnancy Timeframes

HEALTH PROMOTION DURING PREGNANCY

 Preconceptual Visit
o Schedule an appointment w/ Physician / nurse-midwife before pregnancy
 However, most of the time moms that have their first prenatal visit does not have
a recent health care appointment oriented this way (lol)
o Thorough Health History and Physical and Pelvic Examinations
o Hemoglobin Level & Blood Type + Rh Factor
o Papanicolaou (Pap) Test
 Minor vaginal infections such as Candida / Chlamydia be corrected to ensure
fertility
 Choosing HCP for Pregnancy and Childbirth
o Regardless of the ff it needs to be initiated early and continued throughout pregnancy

 Prenatal clinic  Certified nurse-midwife

 Health Maintenance  Obstetrician
Organization (HMO)  Family Practitioner
 Preferred Provider
(PPO)
o Nurse Contribution: 3 Nursing Area Expertise
 Listening
 Counseling
  Teaching
 Educational seminar is usually led by nurse / nurse practitioner

HEALTH ASSESSMENT DURING FIRST PRENATAL VISIT

- Screening to identify danger signs that may reveal symptoms for Major Causes of Death:
o Ectopic Pregnancy
o Hypertension
o Hemorrhage
o Embolism
o Infection
o Anesthesia-related Complications
 Intrapartum Cardia Arrest
- Screening includes:
o Extensive Health History
o Complete Physical Examination
o Pelvic Examination
o Blood and Urine Specimens
o Manual Pelvic Measurements – determine pelvic adequacy

Initial interview
- Often time-consuming: form completion
- Good Interviewing Technique is important to obtain thorough and meaningful health histories
(establish rapport)
o Interviewing expectant women often elicits contradictory information
- Outside Pressures can limit length of interview
o Late Pregnancy: feel uncomfortable when sitting for too long
o Helpful if the person scheduling the appointment informs that patient in advance that the
first visit may be lengthy
- Be certain to ask what name a woman wants to use for calling her
- PURPOSE:
o Establishing Rapport
o Gaining Information: Physical and Psychosocial Health
o Obtaining basis for anticipatory guidance
o When subsequent symptoms occurred, used to verify that new symptom

Components of healthy history

1. DEMOGRAPHIC DATA
a. Name
b. Age
c. Address
d. Telephone Number
e. Email
f. Religion
g. Health Insurance Information
2. CHIEF CONCERN
 a.Reason
b.Inquire about date of last menstrual period
c.Had a pregnancy kit / home test kit
d.Signs of Early Pregnancy: Nausea, Vomiting, Breast Changes / Fatigue
e.Discomforts: Constipation / Backache / Frequent Urination
f.Danger Signs: Bleeding / Continuous Headache / Visual Disturbances / Swelling of
Hands or Face
g. Document if Pregnancy was Planned
i. If not Planned: ask if they will continue the pregnancy
3. FAMILY PROFILE
4. HISTORY OF PAST ILLNESSES
5. HISTORY OF FAMILY ILLNESSES
a. Frequently occurring among family
b. Cardiovascular / Renal Disease
c. Cognitive Impairment
d. Blood Disorders
e. Any known genetically inherited disease / Congenital Anomalies
6. DAY HISTORY / SOCIAL PROFILE
7. GYNECOLOGIC HISTORY
8. OBSTETRIC HISTORY
9. REVIEW OF SYSTEMS
10. CONCLUSION
a. Ask if there is something you have not covered that mom wants to discuss
b. More chances to ask any questions

Support Person’s role

PHYSICAL EXAMINATION

SIGNS INDICATING COMPLICATIONS OF

PERGNANCY:
 Most signs occur toward the end of pregnancy, however they need to know it from the beginning!
 When Teaching: Assure the she is going to have a normal / uncomplicated pregnancy’ no reason
to think that she is going to experience any serious problem
 If signs to occur, report immediately to hcp: give both contact number and an alternative contract
number if hc facility is closed.
 EMPHASIZE that signs occurring serve merely as a signal of possibility and not that something
has already happened!
VAGINAL BLEEDING
- Report immediately despite the amount
- Serious Bleeding usually begins with slight spotting! Need further evaluation
 - Ask how it was discovered
o Hemorrhoid - toilet Paper following a bowel movement

PERSISTENT VOMITING
- Normal: Once / Twice Daily DURING 1st Trimester
- Abnormal: Persistent, Frequent / Extended past 12th week
- Depletes nutritional supply available for fetus
CHILLS AND FEVER
- Symptoms of relatively benign gastroenteritis
- Indicate an intrauterine infection (complication for both mom and baby)
- Further evaluation necessary
SUDDEN ESCAPE OF CLEAR FLUIF FROM VAGINA
- Means that membranes have ruptured
o Occasionally: confuses stress incontinence (loss of urine on coughing / sneezing / lifting
heavy objects) and upon vaginal examination the membranes are still intact
- Mom and Baby threatened since uterine cavity is no longer sealed against infection
- Fetus Small: head does not fit snugly into the cervix = umbilical cord may prolapse following
membrane rupture
o If cord is compressed by fetal head = oxygenation is compromised (immediate and grave
danger to baby)
- Alert hcp is crucial so a safe and controlled birth can be planned
ABDOMINAL / CHEST PAIN
- Signal that something is abnormal therefore there is a need to report immediately
- REMEMBER! Pregnant uterus normally expands PAINLESSLY
- Chest Pain may indicate Pulmonary Embolus that can follow Thrombophlebitis
- Sign of other problems:
o Tubal (Ectopic) Pregnancy
o Separation of Placenta
o Preterm Labor
o Appendicitis
o Ulcer
o Pancreatitis

PREGNANCY-INDUCED HYPERTENSION (PIH)

- Potentially severe and even fatal elevation of blood pressure that occurs during pregnancy
- Several Symptoms
o Rapid Weight Gain (over 2 lb per week in 2nd trimester / 1 lb per week in 3rd trimester)
o Swelling of Face (eyelids) / Fingers
 Edema of Ankles is NORMAL!
 For the hands, ask if she has tight rings!
o Flashes of Light / Dots before the eyes
o Dimness / Blurring Vision
 o Sever Continuous Headache
 Signal cerebral edema / acuter hypertension
o Decreased Urine Output
o NOTE! Ask if she have the symptoms before pregnancy, if yes, it is better to seen an
ophthalmologist rather than her obstetrician for help
INCREASE / DECREASE IN FETAL MOVEMENT
- Normal: moves more / less the same amount everyday
- Fetus Response for a need of oxygen
- Ask Mom if there is a change in usual pace / typical movements = further test / follow up

PREGNANCY DIAGNOSIS:
- Date of Birth
- Prediction of high risk status
- If a woman does not want: therapeutic termination of pregnancy carried out at the earliest stage
for safest outcome
- SCENARIO: Any scheduled diagnostic test, make sure to have a rapid serum pregnancy test first
to avoid exposing the fetus to radiation
- Pregnancy is officially diagnosed on basis of symptoms
3 Classification of Symptoms
1.) Presumptive / Subjective
o Least indicative and taken as single entities
o Experienced but cant be documented by an examiner
2.) Probable / Objective
o documented by an examiner
o Reliable but are not positive / true diagnostic findings
o Laboratory Tests:
 Detection of hCG via urine / blood test
 Performed by Radioimmunoassay (RIA), Enzyme-linked immunosorbent assay
(ELISA), Radioreceptor assay (RRA) techniques
 hCG measured in international units
 Nonpregnant: no units detectable because there are no trophoblast cells
 Pregnant: 24-48 hrs after implantation; measurable levels (50mlU/mL) 7-9 days
after conception and 100mL on 60th-80th day of gestation and then declines
o Home Pregnancy Tests:
 Convenient to use and can detect as little as 35mL of hCG
 If negative but still experiencing amenorrhea, repeat after 1 week and if still
negative but still experiences it, it is advised to see a doctor for ovarian tumor
check
 FALSE POSITIVES:
 Psychotropic Drugs (antianxiety agents)
 Oral Contraceptives (should be discontinued 5 days prior to test)
 Proteinuria - many amount of protein in urine
 Postmenopausal
  Hyperthyroid
3.) Positive / Documented
o Demonstration of Fetal Heart
 Ultrasound (6th - 7th Week)
 Doppler Technique: Ultrasonic frequencies to Audible Frequencies (10th - 12th
week)
 Echocardiography: heartbeat demonstration (5 weeks)
 NOTE! Fetal Heart is beating since the 24th day after conception, audible by
abdominal auscultation (18-20 weeks) Can be hard to hear when fat > amniotic
fluid
 Heard best when position of the fetus determine by palpation and stethoscope is
placed over fetus’ back
 Normal HR: 120-160 bpm
o Fetal Movements
 16th - 20th weeks
 More valid when felt by a examiner (20th - 24th week) than the woman herself;
may mistake for intestinal gas movement
o Fetus Visualization by Ultrasound
 High frequency sound waves projected toward abdomen
 Indication of Gestational Sac: Oscilloscope Screen (4th - 6th week)
 Gives information of Site Implantation and whether Multiple Pregnancy
Exist
 8th week: fetal outline can be seen
o Crown-to-Rump Length can be measured = gestational age
 LABOR PREPARATION:
 LIGHTENING
o Settling of fetal head into the inlet of true pelvis
o Primiparas: 2 weeks before
o Multiparas: unpredictable
o Abdominal contour changed
o Frequent urination when standing
o Lowered Fetal Position brings sciatic pain
 SHOW
o Common term for release of cervical plug / operculum
o Mucous + blood-streaked vaginal discharge
o Indicates beginning of cervical dilation
 RUPTURE OF MEMBRANES
o Sudden gush of clear amniotic fluid from vagina
o Call hcp immediately
o Risk of cord prolapse / uterine infection
 EXCESS ENERGY
o Body’s physiologic preparation for labor
o Recognize so that energy can be conserved for actual labor
 UTERINE CONTRACTIONS
o True Contractions – from back to abdomen in a forward manner that gradually increase
in frequency and intensity
o Call hcp asap and inform her at what point in labor

BIRTH SETTING:

ALTERNATIVE BIRTH METHODS:

 LEBOYER METHOD
o Frederick Leboyer – French obstretician
 Major Shock for Newborns movement to
 Noisy Environment
 Air-filled
 Brightly Lit
o Darkened and Warm Birthing Room
o Soft Music Played
o Infant Handle Gently

OTHERS: CRITICISMS:
Cord Cut Late Excess Blood Viscosity
Placed Immediately to Warm Bath Reduce Spontaneous Respiration
 Risk of High Level Acidosis

 HYDROTHERAPHY & WATERBIRTH

o Reclining / Sitting in Warm Water
o To feel weightlessness and reduce discomfort
o Born underwater then immediately brought to surface for first breath
o Potential Difficulty: Contamination of Bath Water due to feces expelled
 Mom: Uterine Infection and Maternal Chilling (when leaving the water)
 Child: Aspiration = Pneumonia