NURSING CARE DURING PRENATAL PERIOD 60 days / 7 = 8 weeks and 4

days (AOG)
I. ASSESSMENT

A. Nursing Health History  Mc Donald’s Rule

1. Estimation of EDC, AOG, LMP, FH, • Formula: AOG (months)= Fundic height
Naegele’s Rule, Weight (in cm)÷ 4

Determining the Last Menstual Period (LMP) E.g. FH of 24 cm

 First day of last menstruation = 24 ÷ 4
= 6 months (24 weeks)
Example: Last menstruation=
June 14-18, 2008 ***For 20 weeks AOG and above:
FUNDIC HEIGHT (CM) = AOG (WEEKS)
AOG Anatomical Landmark:
12 weeks Slightly above the symphysis pubis
20 weeks Level of the umbilicus
36 weeks Below the xiphoid process
32 and 40 weeks Same level due to lightening on the
40th week
LMP: June 14, 2008 **For below 20 weeks AOG:
= FH (CM) x 8 / 7
Determining the Expected date of delivery (EDC) = AOG in weeks
A. Naegele’s Rule
 Bartholomew’s Rule – estimates AOG by
 For LMP between April to December: the relative position of the uterus in the
- 3 (months) +7 (days) +1 (Year) abdominal cavity

 For LMP betwen January to March:

+ 9 (months) +7 (days) 2. OB Classification: Gravida; Para;
Full term; Abortion
Examples:
1. LMP : January 15, 2005 Obstetrical Scoring (GP TPALM)
01 15 2005  Gravida- number of pregnancy (including
+ 9 +7 present pregnancy)
__________________
 Parity- number of viable pregnancies who
10 22 2005 (October 22, 2005)
are previously born/ number of viable
deliveries
2. LMP : December 16 2004
 Term- number of children born between
37- 42 weeks AOG
12 16 2004
-03 +7 +1  Preterm- number of children born before
__________________ the 37th week of gestation
09 23 2005  Abortion- pregnancy that did not reach the
(September 23, 2005) age of viability (> 20 weeks AOG or <
400g)
Determining the Age of Gestation (AOG)  Living- number of CURRENTLY living
 Number of days since LMP to the present children
day divided by 7  Multiple Pregnancies- (i.e. twins, triplets
are counted as one)
Example:
A pregnant woman comes to the clinic for an B. Physical Assessment
initial prenatal check up. Her LMP was 1. Leopold’s Maneuver
December 16, 2004. Present day is February Purpose: to estimate fetal size, locate fetal parts
14, 2005. and determine presentation, position, engagement
and attitude
December - 15 (31 days – 16 days) LM1: fetal presentation
January - 31 LM2: fetal position
February - 14 LM3: fetal engagement
______________________ LM4: fetal attitude
 1. Drink 1- 1.5 quart of water 2 hours
Position: dorsal recumbent position before the procedure

Preparation: 1. The client must empty her bladder 2. Instruct the client not to void
30 minutes before examination; 2. Place a small • Rationale: Fills the urinary bladder and
pillow underneath the client’s hips. moves it upward and away from the
uterus; when the bladder is full, the
2. Vital signs (BP)/ Weight examiner can assess other structures,
3. Fetal assessment: FHR; Fetal Movement especially the vagina, cervix, in relation
Normal Fetal Heart Tone: 120-160 BPM to the bladder
Number of Fetal movement every 10 minutes:
2 for every 10 minutes 3. Position: Supine
Number of Fetal movement every hour: • If the client complains of dizziness or
10-12 per hour shortness of breath:
A. Place the patient on side lying
*DIAGNOSIS OF PREGNANCY position with towel under hip
B. Elevate the patient’s upper body
STAGE PRESUMPTIVE PROBABLE POSITIVE during the test to PREVENT
COMPRESSION OF VENA CAVA
First Amenorrhea Chadwick’s Ultrasound
Trimester Morning signs evidence Amniocentesis
sickness Goodell’s sign
Breast changes Hegar’s sign  It is a procedure used to obtain amniotic
Fatigue Positive HCG fluid for testing
Urinary (pregnancy
frequency test)  The physician scans the uterus using
Enlarging uterus Elevation of
ultrasound to identify the fetal and placental
BBT
positions to identify adequate amount of
Second Quickening Enlarged Fetal heart tone amniotic fluids.
trimester Increased skin abdomen Fetal movement
pigmentation; Braxton Hicks felt by the  The skin is cleaned with betadine; local
(chloasma and Contraction examiner anesthesia at the needle insertion is
linea nigra) Ballotement Fetal outline on X-ray optional; gauge 22 needle is then inserted
Striae into the uterine cavity and amniotic fluid is
gravidarum
withdrawn.

 Obtain 15-20 cc of amniotic fluid for

C. Laboratory tests examination
Urine
Heat acetic- ALBUMINURIA  Should not be done until at least 16 weeks
Benedict’s tests- GLYCOSURIA of gestation
Urinalysis- UTI
 A. Diagnostic Uses: Provides information on
Blood 1. Fetal Health
CBC (Hgb, Hct)- ANEMIA • Assesses appropriate levels of:
Blood typing a. Alpha- fetoprotein (AFP)
VDRL- SYPHILIS b. Human chorionic gonadotropin
(HCG)
4. Diagnostic Tests c. Unconjugated estriol (UE)
• Necessary for detection of DOWN
Ultrasound SYNDROME (TRISOMY 21),
TRISOMY 18, and NEURAL TUBE
 Intermittent ultrasonic waves are transmitted DEFECT
by an alternating current to a transducer,
which is applied to the women’s abdomen 2. Fetal lung maturity
• Assesses for:
 Two types: a. Lecithin/ Sphingomyelin (L/S)
A. Transabdominal ratio-surfactant
B. Transvaginal
**By 35 weeks AOG, the normal
 Nursing Responsibilities: L/S ratio= 2:1; decrease risk of
 acquiring Respiratory Distress
Syndrome
b. Phosphatidylglycerol (PG)-
phospholipid in surfactant
**Appears when fetal lung maturity
has been attained at about 35
weeks AOG, must be present to
prevent RDS
3. Genetic disorders
 Nursing Responsibilities:
1. Monitor for the side effects:
• Unusual fetal hyperactivity or lack of
movement
• Clear vaginal discharge/ Bleeding
• Uterine contraction or abdominal pain
• Fever or chills
2. Instruct to engage to LIGHT ACTIVITY
24 HOURS after the test
• Rationale: to decrease uterine irritability
3. Increase fluid intake
• Rationale: to increase utero-placental
circulation and replace amniotic fluid
Contraction Stress Test (CST)
 Means of evaluating the respiratory function
(oxygen and carbon dioxide exchange) of
the placenta
 Identifies the fetus at risk for intrauterine
asphyxia by observing the response of the
FHR to the stress of uterine contractions
(spontaneous or induced)
 Procedure
1. The critical component of CST is the
presence of uterine contractions.
They may occur spontaneously or may
be induced with oxytocin administered
via IV (also known as oxytocin
challenge test). The natural way of
obtaining oxytocin is through nipple
stimulation.
2. An electronic fetal monitor is used to
provide continuous data about the fetal
heart rate and uterine contractions.
3. After 15 minutes of baseline recording
of uterine activity and FHR, the tracing
is evaluated for presence of
spontaneous contractions. If 3
spontaneous contractions of good
quality and lasting 40-60 seconds occur
in a 10 minute window, the results are
evaluated. If no contractions occur or
they are insufficient for interpretation,
oxytocin is administered via IV or the
breasts are stimulated.
 Interpretation
1. Negative (normal/ desired result)
• 3 contractions of good quality lasting
40 seconds or more in 10 minutes
without evidence of late
decelerations
• Implies that the fetus can handle the
hypoxic stress of uterine
contractions
2. Positive (Abnormal result)
• Repetitive late decelerations with
more than 50% of the contractions
• Implies that the hypoxic stress of
contraction causes a slowing of the
FHR
3. Equivocal/ Suspicious
• Non-persistent late decelerations or
decelerations associated with
hyper-stimulation (contractions
frequency every 2 minutes or
duration of longer than 90 seconds
Nonstress Test
 measures the response of the fetal heart
rate to fetal movement
 Instruct the mother to push the button
attached to uterine contraction monitor if
she feels the fetus moves
 Usually done for 10-20 minutes
 What happens to the FHT if fetal movement
occurs?
As the fetus moves, there is an
INCREASE in FHT (15 beats per minute)
and remains elevated for 15 seconds
 Results and Interpretation:
A. Reactive
If two accelerations of FHR (15 beats or
more) lasting for 15 seconds occur after
fetal movement
B. Non reactive
If no acceleration occurs with fetal
movement or no fetal movement
Biophysical Profile (BPP)
 Comprehensive assessment of five
biophysical variables:
1. fetal breathing movement
2. fetal movements of body or limbs
3. fetal tone (extension or flexion of
extremities)
 4. amniotic fluid volume (visualized as  Can be performed either transabdominally
pockets of fluids around the fetus) or transcervically
5. reactive FHR with activity (reactive
NST)  Performed between 10 and 12 weeks; thus
it can not detect neural tube defect
 The first 4 variables are assessed by UTZ
scanning. FHR reactivity is assessed with  Risk of CVS include:
the NST. 6. Failure to obtain tissue
 Determines the compromised fetus or 7. Rupture of membranes
confirms the healthy fetus 8. Leakage of amniotic fluid
9. Bleeding
(Criteria for BPP Scoring) 10. Intrauterine infection
Component Normal (score= 2) Abnormal (score= 0) 11. Maternal tissue contamination of the
Fetal breathing ≥ 1 episode of ≤ 30 seconds of specimen
rhythmic breathing breathing in 30 12. Rh alloimmunization
movement lasting ≥ 30 seconds minutes
within 30 minutes
13. Spontaneous abortion
Fetal ≥ 3 discrete body or ≤ 2 movements in 30
limb movements in minutes
movements of 30 minutes (episodes
body or limbs of active continuous
movement
considered as single
movement)
Fetal tone ≥ 1 episode of No movements or
extension of a fetal extension/flexion
extremity with return
to flexion, or opening
or closing of hand
Amniotic fluid ≥ 2 accelerations of ≥ 0-1 acceleration in 20
15 beats/min for ≥ 15 minutes
volume seconds in 20
minutes
Non stress Test Single vertical pocket Largest single vertical
> 2 cm pocket ≤ 2 cm

 A score of 2 is assigned to each normal II. Diagnosis

finding and 0 to each abnormal one, for a Wellness diagnosis
maximum score of 10. Knowledge Deficit
 Score of 8 (with normal amniotic fluid) and Altered Health Maintenance
10 are considered normal. Nutrition, less than required
 Indication of BPP: (at risk of placental
insufficiency or fetal compromise because III. Planning/ Implementation/ Evaluation
of the following:
4. Intrauterine growth restriction (IUGR) A. Nutrition – most important aspect
5. Maternal DM *Nutritional assessment is
6. Maternal heart disease based on
7. Maternal chronic HPN/ Preeclampsia/ taking a diet history first:
eclampsia 1. food preferences/ eating
8. Maternal sickle cell anemia habits
9. Suspected fetal post maturity 2. cultural/religious
10. History of previous still births influences
11. Rh sensitization 3. occupation/educational
12. Abnormal estriol excretion level
13. Hypeethyroidism
14. Renal disease B. Prenatal Exercises
15. Nonreactive NST 1. Tailor sitting
-stretches and strengthen perineal muscles;
Chorionic Villi Sampling increase circulation in the perineum; make
 Involves obtaining a small sample of pelvic joints more pliable
chorionic villi from the developing placenta
2. Pelvic rock
st
 For 1 trimester diagnosis of genetic, -maintains good posture; relieves abdominal
metabolic, and DNA studies pressure and low backache; strengthens
abdominal muscles following delivery
3. Squatting 1. Women with history of abortion
-stretches the pelvic floor muscle; should be 2. Rupture membrane
done15 minutes daily 3. Vaginal spotting

4. Pelvic Floor Contraction (Kegel’s) I. Prenatal visit

-promotes perineal healing; relieves Start of pregnancy – 32 weeks
congestion and discomfort in pelvic region; Every month
tones up pelvic floor muscles `
On 32-36 weeks AOG
5. Abdominal Contractions Every 2 weeks/twice a month
-strengthens abdominal muscle during
pregnancy and prevents constipation On 36 weeks AOG
in the postpartal period Every week until labor pains set in

Walking is the best exercise during

pregnancy

Jogging is questionable because of the

strain of extra weight of pregnancy placed
on the knees

C. Hygiene
If membranes rupture or vaginal bleeding is
present or during the last month of
pregnancy, tub baths are contraindicated.

D. Travel
Advise a woman who is taking a long trip by
automobile to plan for frequent rest or
stretch period

At least every 2 hours, she should get out of

the car and walk a short distance

Use of seat belt is advised (shoulder

harness and lap belts)

Infant car seat should be purchased

Traveling by plane is not contraindicated as

long as plane is pressurized. If more than 7
months, traveling by plane is not
recommended.

F. Immunization –Tetanus Toxoid

G. Nutritional Supplement
1. Folic acid
2. Iron

H. Managing Discomforts of Pregnancy

G. Clothing
Use of abdominal support such as light
maternity girdle for support not to compress
and constrict the abdomen

Avoid knee high stockings

H. Sexual Activity
Contraindicated:
3. Squatting 1. Women with history of abortion
-stretches the pelvic floor muscle; should be 2. Rupture membrane
done15 minutes daily 3. Vaginal spotting

4. Pelvic Floor Contraction (Kegel’s) I. Prenatal visit

-promotes perineal healing; relieves Start of pregnancy – 32 weeks
congestion and discomfort in pelvic region; Every month
tones up pelvic floor muscles `
On 32-36 weeks AOG
5. Abdominal Contractions Every 2 weeks/twice a month
-strengthens abdominal muscle during
pregnancy and prevents constipation On 36 weeks AOG
in the postpartal period Every week until labor pains set in

Walking is the best exercise during

pregnancy

Jogging is questionable because of the

strain of extra weight of pregnancy placed
on the knees

C. Hygiene
If membranes rupture or vaginal bleeding is
present or during the last month of
pregnancy, tub baths are contraindicated.

D. Travel
Advise a woman who is taking a long trip by
automobile to plan for frequent rest or
stretch period

At least every 2 hours, she should get out of

the car and walk a short distance

Use of seat belt is advised (shoulder

harness and lap belts)

Infant car seat should be purchased

Traveling by plane is not contraindicated as

long as plane is pressurized. If more than 7
months, traveling by plane is not
recommended.

F. Immunization –Tetanus Toxoid

G. Nutritional Supplement
1. Folic acid
2. Iron

H. Managing Discomforts of Pregnancy

G. Clothing
Use of abdominal support such as light
maternity girdle for support not to compress
and constrict the abdomen

Avoid knee high stockings

H. Sexual Activity
Contraindicated: