ASSESSING FETAL AND MATERNAL HEALTH  Menstrual history – menarche (onset,

regularity, duration, frequency, character)

Health Promotion During Pregnancy
 LMP, sexual hx, methods of contraception
Purposes of prenatal care:  PMP – menstrual period before the LMP
 Conduct of Initial Visit
 Establish a baseline of present health
 Determine gestational age of the fetus Medical and surgical history
 Monitor fetal development and maternal
 Past illnesses and surgical procedures, current
wellbeing
drugs used
 Identify women @ risk for complications
 Minimize the risk of possible complications by Family history
anticipating and preventing probs before they
 To detect illnesses or conditions that are
occur
transmittable
 Provide time for education about pregnancy,
lactation and newborn care Current problems
Prenatal Management  ADL, discomforts, danger signs
1st prenatal visit Initial & Subsequent Visits Our Evolution
 As soon as mother missed a menstrual period  Vital signs
when pregnancy is suspected • Temperature
 Major causes of death for pregnancy: • ❤rate: plus 10 – 15 bpm
 Ectopic pregnancy, HPN, hemorrhage, • RR: tend to be rapid and deep
embolism, anesthesia-related complications (16/min)
(intrapartum cardiac arrest) • BP: tends to be hypotensive w/
supine position
Support Persons
 Elevated BP = PIH
 Include support people in a prenatal visit so  Do roll-over test in 1st
that visits are family centered. trimester – for early detection
 Here a husband, wife, and child are included in of developing PIH by 20 – 24
the initial prenatal interview, making all feel a weeks
part of the pregnancy.  Roll-Over Test
 Procedure:
Screening for Danger Signs Include:
o Place mother on LLR
 Extensive health history o Check BP until stable, may take 10 –
 Complete physical examination 15 mins
 Including pelvic examination o Roll to supine
 Laboratory works: o Check BP right away
 Blood and urine specimen o Wait for 5 mins
 Manual Pelvic measurements can be taken to o Check BP again. Compare w/ 2nd
determine pelvic adequacy. diastolic reading
 Interpretation:
Schedule for Prenatal Visits
o Positive: ↑ in diastolic pressure greater
 Once a month: up to 1st 32 weeks than 20 mm HG; woman @ risk
 2 x a month or q 2 weeks: 32 – 36 weeks o Negative: ↑ in diastolic pressure less than
 4x a month or q week: 36 – 40 weeks 20 mm HG
 Presence of danger signals of pregnancy –  Weight
mother should be instructed to report o Checked in q visit
promptly for evaluation o 1st trimester: 1 lb/ mo (3 – 4 lb total)
o 2nd trimester: 0.9 – 1 lb/week to
Conduct of Initial Visit
about 10 -12 lb
Baseline data collection o 3rd trimester: 0.5 – 1 lb/week 8 – 11
lb*
 Basis for comparison
o Weight is a measure of health of a
 To screen for high-risk factors
mother

 Urine testing for albumin and sugar

OB history o Sugar – ideally not more than 1+
 o Albumin – negative; nephritis  Includes internal gynecologic and bimanual
 Fetal growth and development assessment examinations
o Fundal height  Internal examination (IE)
o FHT/FHR o Detects early signs of pregnancy
o Abdominal palpation • Chadwick’s, Goodell’s, and Hegar’s
o Quickening – 1st plus subsequent signs
movements • Preparations for IE
 OB history  Explanation
o 4-Point system: past pregnancies and  Void before
perinatal outcomes (FPAL)  Proper positioning:
o 5-Point System: GFPAL  Draping
 Estimates in Pregnancy  Instructions:
 EDC/EDD  DON’Ts:
o Naegele’s Rule • Important Concerns of PE:
o Mittendorf’s Rule  Breasts: look for changes,
adequacy of breasts for
o Date of Quickening
breastfeeding, abnormal signs
o Fundic Height
 Abdomen: Fundic height;
 AOG
Leopold’s
o McDonald’s Rule (2nd and 3rd
 Pelvic measurements: done in
trimester)
the 3rd trimester to
o Bartholomew’s Rule of Fours
determine CPD (cephalo-
 Estimated fetal weight (EFW)
pelvic disproportions)
• Johnson’s Rule
• Extremities:
 Estimated fetal height in cm (EFL)  Discomforts: leg cramps,
• Haase’s Rule varicosities, pedal edema
 Para  Danger signs: + Homan’s sign
• # of pregnancies that have reached = thrombophlebitis
viability, regardless of whether born
alive Estimating Pelvic Size
• 24 weeks, or 601 g
 Estimating pelvic size
 Gravida- is or has been pregnant
 Type
 Primigravida- Pregnant for the 1st time
• Measurements
 Primipara- Has given birth to 1 child past age  Diagonal conjugate
of viability  True conjugate or conjugate
 Multigravida- Has been pregnant previously vera
 Multipara- Has carried 2 or more pregnancies  Ischial tuberosity diameter
to viability
 Nulligravida- Has never been and is not Pelvic Measurements
currently pregnant

Hx of Previous Pregnancies- determine woman’s

status

 GTPAL/GTPALM Classification

T: # of Full-term infants born (born @ 37 weeks or

after)

P: # of Preterm infants born (born before 37 weeks

A: # of therapeutic miscarriage or spontaneous Laboratory Tests Our Evolution

abortion
 Blood studies
L: #of Living children  Complete blood count (CBC)
o Hgb: 12 – 16g/dL
M: Multiple pregnancies
o Hct: 37 – 47%
o Leucocytosis – elevated WBC; normal
 Pregnancy: 5,500
-11,500/mm3
Complete Physical Examination  Labor: 20,000/mm3
 Postpartum:25,000/mm3
  Blood typing and Rh determination
 According to institution protocol,
Serology for:
 Syphylis (VDRL)
 Rubella antibody titer
 HIV
 Alpha-fetoprotein (AFP)
screening @ 16 – 18 weeks’
gestation to rule out neural
defects
 Urine Test
o Tested for sugar
o Bacteria – asymptomatic bacteriuria
w/c can result in abortion in early
pregnancy, and premature labor, late
in pregnancy
 Pelvic Lab tests
 Collection of pelvic cultures
o Pap test, culture for gonorrhea and
Chlamydia
 Bimanual examination -Usually, last part of the
initial PE
o To identify cervical and uterine
changes
o Detect uterine size
o Assess for deviation in expected shape
and size
 In all the necessary lab tests, prepare the
client thru the ff steps:
o Providing an explanation of the
procedure
o Physical prep specific to procedure
o Provision of support to client and
spouse; encouraging verbalization of
concerns
o Monitoring of client and fetus after
procedure
o Documentation prn
PROMOTING FETAL AND MATERNAL HEALTH-Health
promotion during pregnancy begins with reviewing
self-care.
SELF-CARE NEEDS
 Because pregnancy is not an illness, few
special care measures other than common
sense about self-care are required
 Average woman needs some help separating
fact from fiction so that she can enjoy her
pregnancy unhampered by unnecessary
restrictions
 Be alert to the common misunderstandings,
misconceptions, or inappropriate information
of pregnancy
BATHING
Misconceptions:
 Tub baths restricted @ one time – water
would enter the vagina and cervix and
contaminate the uterine contents
 Hot water touching the abdomen might
initiate labor
Truths:
 Normally vagina is in a closed position –
danger of tub bath entering the cervix is
minimal
 Water temperature has no documented
effect on initiating labor
 During pregnancy, sweating tends to ↑
because woman excretes waste products for
herself and the fetus
 Vaginal discharge ↑ed
BOTH Daily baths and showers are now
recommended
 As pregnancy advances – woman may have
difficulty maintaining her balance when
getting in and out of a bathtub
o change to showering or sponge
bathing for her owN safety
 If membranes rupture or vaginal bleeding
present
• tub baths contraindicated because of
danger of contamination of uterine
contents
 During last month of pregnancy, when
uterine cervix may begin to dilate
• some health care providers restrict
tub bathing
BREAST CARE
 Woman should wear a firm, supportive bra
w/ wide straps to spread weight across the
shoulders
 May need to buy a larger bra halfway
through pregnancy – to accommodate ↑ed
breast size
 If plans to breastfeed – choose bras suitable
for breast-feeding so she can continue to use
them after baby’s birth
 16th week of pregnancy – colostrum
secretion begins in the breast
• Sensation of a fluid discharge can be
frightening unless woman is warned
that this is a possibility
• Instruct to wash her breasts w/ clear
tap water daily (no soap coz it could
 be drying) – to remove colostrum and
reduce risk of infection
• Dry her nipples well by patting them
• If colostrum secretion is profuse need to
place gauze or breast pads inside her bra,
change frequently – to maintain dryness
o -constant moisture next to nipple can
cause excoriation, pain, and fissuring
DENTAL CARE
• Gingival tissue tends to hypertrophy during
pregnancy
o Unless woman brushes well, pockets
of plaque form readily bet. enlarged
gum line and teeth
o Encourage to see dentist regularly for
routine examination and cleaning
 9 months is a fairly long time
to be w/o preventive
• Woman should question the need for x-rays
during pregnancy – if necessary, abdomen
should be shielded w/ a lead apron
• Tooth decay occurs from the action of
bacteria on sugar =lowers pH of the mouth,
creating an acid medium → etching or
destruction of the enamel of teeth
o Encourage to snack on nutritious
foods – fresh fruits and vegetables
(apples, carrots) to avoid sugar
coming in contact w/ teeth
o If w/ trouble avoiding sweet snacks –
suggest those that dissolve easily
(chocolate bar) to minimize the level
of sugar in the mouth
PERINEAL HYGIENE
• Douching is contraindicated force of irrigating
fluid could enter cervix and lead to infection
EXERCISES
• Douching alters pH of the vagina = ↑ed risk
of bacterial growth
MARKET SEGMENTATION
• Garters
• extremely firm girdles w/ panty legs
• knee-high stockings
• Suggest: shoes w/ moderate to low heel – to
minimize pelvic tilt and backache
May impede lower extremity circulation
SEXUAL ACTIVITY
• Many need information to refute some myths
about sexual relations in pregnancy that still
exists, such as:
o Coitus on expected date of period will
initiate labor
o Orgasm will initiate labor; sexual
relations w/o
o orgasm will not cause labor
o Coitus during fertile days of a cycle
will cause a 2nd
o pregnancy or twins
o Coitus might cause rupture of
membranes
• Asking a woman @ a prenatal if she has any
questions about sexual activity – allows her
to voice concerns; nurse can help dispel
myths
• Coitus is contraindicated in the ff. conditions:
o Hx of spontaneous miscarriage
o Ruptured membranes
o Vaginal spotting
o Deeply engaged presenting part
• Advise caution about male oral – female
genital contact= accidental air embolism has
been reported from this act during pregnancy
• Couple should be advised to find a
comfortable position for intercourse
• w/ non-monogamous sexual partner –
partner needs to use a condom to prevent
STIs during pregnancy
• women may use female condom throughout
pregnancy
• Sex in moderation is permitted but not during
the last 6 weeks of pregnancy
o increase incidence of postpartum
infection in women who engage in
sex during the last 6 weeks
• Important during pregnancy to prevent
circulatory stasis in the lower extremities
• to strengthen the muscles used in labor and
delivery
• it also offers a general feeling of well-being
• Should be done in moderation
• Exercise Programs:
o Exercises that target large muscle
groups rhythmically –e.g. walking, are
best
o Intensity of exercise program
depends on the woman’s
cardiopulmonary fitness
o Before any exercise program –
woman must consult her physician or
nurse-midwife
 o If any complication of pregnancy
occurs – e.g. bleeding or PIH –
discontinue until she rechecks w/
primary health care provider about
continuing
• Exercise should be individualized – according
to age; physical condition; customary amount
of exercise (e.g. swimming, tennis), not C/I
unless done the first time; stage of pregnancy
• Swimming may help relieve backache
o Membranes should be intact
• Walking – best exercise
• Should be encouraged to take daily walks
• unless:
o bad weather,
o many levels of stairs or
o unsafe neighborhood will not permit
SLEEP
• The optimal condition for body growth occurs
when growth hormone secretion is @ its
highest level – that is, during
o sleep
• This, plus overall increased metabolic demand
of pregnancy – appears to be the physiologic
reason pregnant women need an ↑ed amount
of sleep or @ least rest to build new body cells
during pregnancy
• Pregnant women rarely have difficulty falling
asleep @ night
o Trouble falling asleep – drink a glass of
warm milk may help
o Relaxation techniques :
• lying quietly,
• systematically relaxing neck
muscles, shoulder muscles, arm
muscles, and so on = may also be
effective
• Late in pregnancy – awakening @ short,
frequent intervals by the activity of the fetus
o Leads to loss of REM sleep
o On rising, may feel anxious or not
well-rested
• May also awaken w/ pyrosis or dyspnea, if she
has been lying flat – sleeping on 2 pillows or
on a couch w/ an armrest may be helpful
• Rest period during the afternoon and full night
of sleep – needed to obtain enough sleep and
rest during pregnancy
• Modified Sim’s position w/ top leg forward
o good resting or sleeping position
o Puts weight of the fetus on the bed,
not on the woman, and allows good
circulation in the
o lower extremities
• MODIFIED SIM’S POSITION
• Avoid resting in a supine position
o prevent supine hypotension syndrome
• Avoid resting w/ knees sharply bent either
when sitting or lying down
o minimize risk of venous stasis below
the knee
EMPLOYMENT
• Not C/I unless it entails:
o exposure to toxic substances
o lifting heavy objects
o other kinds of physical strains
o long periods of standing
o or having to maintain body balance
• Advise to walk about every few hours to break
long periods of standing or sitting to promote
circulation
TRAVEL
• Early in a normal pregnancy – no travel
restriction
o Susceptible to motion sickness –
should not take any medication unless
specifically prescribed or approved by
physician or nurse-midwife
• Late in pregnancy – travel plans shd take into
consideration the possibility of early labor,
requiring birth @ a strange setting where
woman’s health history will be unknown
• Advise a woman taking long trip by
automobile:
o Plan for frequent rest or stretch
periods q hour
o Q 2h, should get out of the car and
walk short distance – relieve stiffness
and muscle ache; improve lower
extremity circulation = preventing
varicosities, hemorrhoids and
thrombophlebitis
• Traveling by plane – not C/I; as long as plane
has a well-pressurized cabin
o Some airlines do not permit women
who are more than 7 months pregnant
o Others require written permission
from woman’s primary care provider
• Advise to inquire about these restrictions by
calling airline
 • Advise additional immunizations (cholera
vaccines) if traveling internationally
o All live virus vaccines (measles,
mumps, rubella, yellow fever) –
o C/I during pregnancy, and should not
be administered unless risk of disease
outweighs risk to the pregnancy
S-A-D HABITS OF PREGNANCY
• Smoking
o Pregnant women shd NOT smoke
o Smaller infants (SGA) than those who
do not
o 5 or more cigarettes/day = doubles
risk of delivering low-birth infant
(Lieberman et al., 1994)
o Prenatal tobacco exposure = learning
and attention probs in children but
less consistently than alcohol
(Streissguth et al., 1997)
EFFECTS OF TOBACCO USE (LIEBERMAN ET AL., 1994)
• Increased risk of SGA
• Prematurity
• Infant mortality
• Spontaneous abortion
• Placenta previa/abruptio placenta
• PROM
CAUSES OF ADVERSE EFFECTS OF SMOKING
• Nicotiene
o Vasoconstrictor – causes reduced
placental perfusion
• increase in carbon monoxide
o Causes fxnal inactivation of maternal
and fetal hemoglobin
• Smokers have decreased plasma volume
• Smokers have reduced appetite= decreased
caloric intake
A - ALCOHOL
• Ingestion of pregnant women likely to cause
fetal abnormalities
• Effects of chronic alcoholism:
o Fetal alcohol syndrome (FAS) –
o heavy use of alcohol (2 or more
drinks/day) – 10% risk of producing
FAS, characterized by:
 Retardation/delays –
cognitive, motor, and learning
deficits
 Mental retardation –
associated w/ microcephaly,
and seizure disorders
 Craniofacial defects (FAS
facies): flat midface, wide
nasal bridge, thin upper lip
 Cardiovascular defects
 Limb defects
 Impaired fine and gross motor
fxn
D - DRUGS
• Should only be taken when prescribed
• Drugs prescribed should have benefits or
advantages outweighing the risks
• Best recommendation:
o NO MEDICATION IS TAKEN DURING
PREGNANCY UNLESS ABSOLUTELY
NECESSARY AND PRESCRIBED
• Intake of illicit drugs in the 1st trimester can
cause most adverse fetal malformation
because:
o Placental barrier not yet fully
developed; placental mature by 10 –
12 weeks’ gestation
o Rapid organogenesis
• So-called “hard” drugs (heroine, cocaine) =
growth retardation and drug withdrawal w/c is
assoc. w/ ed neonatal mortality
• Illegal drugs carry risk of acquiring HIV and
other STIs
o May trade SEX for drugs and may
provide sexual favors for money
needed to acquire drugs (Henderson,
et al., 1994)
• HERBAL Supplements
o Being natural – not always safe – lack
of consistent potency in the active
ingredient
o General RULE: MUST BE APPROVED
AND SUPERVISED BY HEALTH CARE
PROVIDER
CAFFEINE
• Reduce intake of coffee, tea, coals, and cocoa
to 300 mg of caffeine/day or
• No more than 2 – 3 servings per day (US FDA)