Maternal and Child Health Nursing

Juvy G. Reyes MAN, RN

Care of the Mother and the Fetus during the Perinatal Period

1. Prenatal Care
2. Health assessment during the first Prenatal visit
3. Components of the Health history
4. Physical examination
 Objectives:

1. Describe the areas of health assessment

commonly included in prenatal visits

2. Assess the readiness for parenthood and the

health status of a pregnant woman and her
family

3. Identify expected outcomes to help ensure a

safe pregnancy as well as manage seamless
transitions across health care settings.
Care of the Mother and the Fetus during the Prenatal Period

Prenatal Care

▪ is essential for ensuring the overall health of

newborns and their mothers

▪ A major strategy for helping mothers to reduce

complications of pregnancy such as the
number of preterm or low-birth weight
babies born each year
Purpose of Prenatal care:

1. Establish a baseline of present health.

2. Determine the gestational age of the fetus.
3. Monitor fetal development and maternal well-being.
4. Identify women at risk for complications.
5. Minimize the risk of possible complications.
6. Provide education about pregnancy, lactation, and newborn care.
 Health Assessment during the first Prenatal visit
First Prenatal Visit

• First visit – as soon as they suspect they are pregnant

• Every 4 wks. through - 28 th wk. of pregnancy
• Every 2 wks. through - 36th wk. and then every wk. until birth.
 Role of the Nurse in Prenatal Care:

1. Established baseline data relevant to a woman’s health and identify

health promotion strategies.
2. Teaching women and their families about safe pregnancy lifestyle.
3. Obtained a detailed health and sexual history including screening
for the risk of teratogen exposure as well as any concern about
the woman pregnancy.
4. Urging the client to continue prenatal care because lack of prenatal
care is associated with pregnancy complications.
5. Be certain to reserve sufficient time a prenatal visit, so care can be
thorough and there is enough time to set realistic goals and
expected outcomes with both a woman and her partner
 Screening on the first Prenatal visit:

1. Health history
2. Complete physical examination (Pelvic examination)
3. Blood and urine specimen for laboratory analysis
4. Manual pelvic measurement to determine pelvic adequacy
 Components of Health history

1. Demographic Data – name, age, address, religion, place of

employment, ethnicity

2. Chief concern
a. Document the date of LMP
b. Signs of early pregnancy
c. Discomfort of pregnancy
d. Danger signs (bleeding, abdominal pain, continuous
headache, visual disturbances)
 Components of Health history
3. Family profile

• Marital status and support people available

• Educational level of her and her partner
• Occupation
• Size and structure of the house
• Lifestyle – smoke, drink alcohol, use recreational drugs
• Lifestyle changes - change in status, Chronic illnesses, Death or loss of a significant
person, geographic move, financial hardship, lack of support people
Components of Health history

4. History of Past Illnesses - past condition can become active

during or immediately following pregnancy

• Diseases that have potential difficulty during pregnancy –

(Kidney and heart disease, Hypertension, STI, gallbladder
disease, UTI)
• Childhood diseases – varicella, mumps, measles, poliomyelitis
• Immunization
Components of Health history

4. History of Past Illnesses

• Allergies including drug sensitivities
• Surgical procedures - adhesion resulting from past
abdominal surgery (Cesarian Section)

5. History of Family Illnesses

• Cardiovascular and renal disease
• Blood disorders
• Cognitive impairment
Components of Health history
5. History of Family Illnesses

• Genetically inherited diseases or congenital

anomalies
Components of Health history
6. Day History/ Social Profile

• Nutrition, elimination, sleep, recreation and

interpersonal interactions

• Exercise, - type, amount, and frequency

• Hobbies - lead-based glaze and ceramics need

to be identified because lead is a known
teratogen
Components of Health history

6. Day History/ Social Profile

Tobacco, alcohol and drug consumption:

• Poor nutrition
• Intrauterine growth restriction
• Preterm birth
• Fetal alcohol sequence disorder for excessive
alcohol intake
 Components of Health history

6. Day History/ Social Profile

• Medication and Herbal therapy
Tetracycline – antibiotic causes long bone
defects in fetus

• Herbal supplement -stimulate uterine

contraction and interfere with fetal health

• Intimate Partner Violence – need to be

identified the amount and severity of
violence
 Components of Health history

7. Gynecologic History

a. Menstrual History – (Menarche, cycle, interval, duration, amount of

menstrual flow, any discomfort)
(Document when the discomfort occurs, how long it lasts, and what she
does to relieve)

• Menarche – first menstrual period

• Dysmenorrhea – painful menstruation
Components of Health history
7. Gynecologic History

b. Perineal and breast self-examination

• Perineal self-examination – inspecting external
genitalia monthly for signs of infections or
lesions

• Breast self-examination – normal breast changes

during pregnancy
• Having mammograms when they reach 40years old,
a yearly breast examination by health care
provider.
Components of Health history

8. Past Surgery – any type of past surgery on the

reproductive tract is documented
because it can influence the ability to
conceive and give birth

• Tubal surgery following an ectopic pregnancy

 Components of Health history
8. Past Surgery
• Frequent Dilatation and curettage
• Cervical biopsies
Components of Health history

9. Reproductive Planning – ask about

reproductive planning method and if
pregnancy is confirmed it should be
discontinued.
 Components of Health history

10. Sexual history

a. History includes number of sexual partners
b. The use of safer sex practices, to establish a woman’s risk for
contacting sexually transmitted infection (Herpes or hepatitis C)

11. Stress Incontinence – assess for the possibility of incontinence of

urine on laughing, coughing, deep inspiration, jogging or running.
Components of Health history

12. Obstetric History – determining gravidity and Parity

Principles in identifying Parity:

▪ The number of pregnancies is counted and not the
number of fetuses.

▪ Multiple pregnancies do not increase Parity.

Twins and triplets would only be considered as one
delivery and thus, one parity

Parity or Para – the number of births after 20 weeks,

whether live births or stillbirths
Components of Health history

12. Obstetric History – determining gravity and parity

Principles in identifying Parity:

▪ Abortion is not included in parity count, because in
abortion, the fetus is delivered before the age
of viability (before 20 weeks)

▪ Live birth or stillbirth is counted in Parity count,

whether the fetus is born alive or stillbirth

▪ Stillbirth - is the delivery after the 20th week of

pregnancy, of a baby who has died.
Components of Health history
12. Obstetric History – determining gravity and parity

Gravida- number of pregnancies regardless of duration or outcomes

(Total Pregnancy)
A gravida (G) is a woman who:
• Is pregnant (present) now
• Has been pregnant (past), irrespective of the outcome of pregnancy

A nulligravida (G) is a woman who:

• Is not pregnant now
• Has never been pregnant
 Components of Health history

12. Obstetric History – determining gravity and parity

Gravida - number of pregnancies regardless of duration or outcomes (Total Pregnancy)
▪ A primigravida – is a woman who is pregnant for the first time (G1)

▪ A multigravida – is a woman who has been pregnant previously (G2 and more)
▪ A grand multigravida – is a woman who has had six or more pregnancies
(G6 and more)
 Components of Health history

12. Obstetric History – determining gravity and parity

Parity or Para – refers to the total number of pregnancies in which the fetus has
reached the age of viability and subsequently delivered whether dead
or alive at birth

▪ A primipara – is a woman who has given birth to one child past age of viability
▪ A multipara – is a woman who has carried two or more pregnancies to
viability (before 20 weeks)

▪ A grand multipara – is a woman who has had 6 or more viable deliveries,

whether the fetuses were alive or dead
 Components of Health history

Coding Results of Previous Pregnancies

• Obstetrical Scoring – a comprehensive system for classifying

pregnancy status

• During the initial prenatal visit, it is essential that a thorough

obstetrical history of a client be taken to come up with the
obstetrical scoring and coding of the results of previous
pregnancies.

• The previous miscarriages or therapeutic abortion is also included

in the obstetrical history.
 Coding Results of Previous Pregnancies

• One method to provide greater detail on a woman’s pregnancy history involves the
use of:
• (GTPAL) or (GTPALM) – by this system the gravid classification remains the same,
but Para is broken down as follows:

o G - number of pregnancies regardless of duration or outcomes

o T - the number of full-term infants born (infants born at 37 weeks or after)
o P – the number of preterm infants born (infants born before 37 weeks)
o A – the number of spontaneous miscarriages or therapeutic abortions
o L – the number of living children
o M – multiple pregnancies
 Sample Obstetrical Scoring using GTPALM

Mrs. Villa is 32 weeks pregnant, her first child baby boy delivered
at 38 wks. alive and normal, her second baby, a girl 36 wks.
alive and normal and the youngest child a twin baby boy
36 wks. alive and normal

Question: What is the GTPALM of Mrs. Villa?

 Sample Obstetrical Scoring using GTPALM

Mrs. Villa is 32 weeks pregnant, her first child baby boy

delivered at 38 wks. alive and normal, her second baby,
a girl 36 wks. alive and normal and the youngest child a
twin baby boy 36 wks. alive and normal

Question: What is the GTPALM of Mrs. Villa?

G T P A L M
↓ ↓ ↓ ↓ ↓ ↓
4 1 2 0 4 1
 Determination of Estimated Date of Delivery (EDD) or Estimated Date of
Birth (EDB)

▪ The ability to detect the date of confinement or delivery is an

essential nursing competency needed in dealing with
maternity clients

1. Naegele’s Rule - is the standard method used to predict the length of

pregnancy. To calculate the date of birth by this rule count backward 3
calendar months from the first day of a woman’s last menstrual period
and add 7 days.
2. Mc Donald rule
3. Bartholomew rule
1. Naegele’s Rule Formula:
For the first three months of the year, add 12 to the numerical value then
subtract 3 months and add 7 days to the first day of the LMP
January: 1 + 12 = 13
February: 2 + 12 = 14
March: 3 + 12 = 15

Sample Problem: LMP is February 5, 2021. The numerical value of

February is
14 5
- 3
_______
11 5
+ 7
_____________
11 12 = EDD Nov. 12, 2021
1. Naegele’s Rule Formula:
For the first three months of the year, add 9 months and add 7 days to the
first day of the LMP
January: 1 + 9 = 10
February: 2 + 9 = 11
March: 3 + 9 = 12

Sample Problem: LMP is February 5, 2021. The numerical value of

February is
Feb 2 + 9 = 11

11 5
+ 7
_____________
11 12 = EDD Nov. 12, 2021
1. Naegele’s Rule Formula:
Subtract 3 months and add 7 days to the first day of the last menstrual
period (LMP) + 1 year

April: 4–3= 1
May: 5–3= 2
June: 6–3= 3
Dec: 12 – 3 = 9

Sample Problem: LMP is May 5, 2021. The numerical value of May is

(May) 5 - 3 = 2

2 5
+ 7
_____________
2 12 = EDD Feb. 12, 2022
 Determination of Estimated Date of Delivery (EDD) or Estimated Date of Birth (EDB)

2. Mc Donald’s Rule - helps in estimating fetal gestational age

using fundic height.

• Measure the fundic height (FH) from the symphysis pubis to

the top of the fundus
• Formula: AOG in months and Weeks

Computing in Lunar months, multiply the fundic height by

2, then divide by 7
FH (in cm.) x 2
________________ = Gestational age in Lunar months
7
 2. Mc Donald’s Rule

Sample: AOG in months

Problem: What is the estimated Gestational age in months if the

fundic height is 31.5 cm.?
2. Mc Donald’s Rule

Sample: AOG in months

Problem: What is the Estimated Gestational age

in months if the fundic height is 31.5 cm.?

31. 5 x 2 = 64
_________ ____ = 9 months
7 7
 2. Mc Donald’s Rule

Formula: AOG in weeks

Computing in weeks, multiply the fundic height by 8, then

divide by 7.
FH (in cm.) x 8
_________________ = Gestational age in Weeks
7
 2. Mc Donald’s Rule

Sample: AOG in weeks

Problem: What is the Estimated Gestational age in weeks if

the fundic height is 31.5 cm.?
 2. Mc Donald’s Rule

Sample: AOG in weeks

Problem:
What is the estimated gestational age in weeks if the fundic height is
31.5 cm.?
31.5 x 8 = 252
____ = 36 weeks
7
 14. Measurement of Fundal height and Fetal Heart Sounds

3. Bartholomew’s rule – measures AOG by

determining the position of the
uterus in the abdominal cavity
 14. Measurement of Fundal height and Fetal Heart Sounds

▪ 12 – 14 weeks – the uterus becomes palpable as a firm

globular sphere showing over the symphysis pubis

▪ 20th or 22nd weeks – palpable at the level of the umbilicus

▪ 36th week – touches the xiphoid process

▪ 38th week – 2 weeks before term for primigravida the fetal

head settles into the pelvis and the uterus returns to the
height it was at 36 weeks
 Leopold’s Maneuver - are systematic abdominal palpation to determine the
position and presentation of the fetus. They are done at about 32
weeks and over.

Factors that affect reliability of

findings:
a. Obesity
b. Polyhydramnios
c. Anterior placental location
Leopold’s Maneuver
Four Maneuvers:
1. Fundal Grip – palpate the upper abdomen to
detect what lies in the fundus of the uterus to
determine fetal presentation

▪ Cephalic presentation -- the buttocks

occupy the fundus and they are palpated as
a soft, globular and non-ballotable mass

▪ Breech presentation – if it is hard, round,

and ballotable mass, the head occupies the
fundus.
 Leopold’s Maneuver

Four Maneuvers:

2. Umbilical Grip – palpates the sides of the

abdomen to detect location of the fetal
back and fetal small parts.

▪ Fetal back– the palpation of a hard smooth and

resistant plane. The area of the fetal back is the best
site for FHT auscultation

▪ Fetal arms and legs – the palpation of numerous

small and irregular parts.
Leopold’s Maneuver

Four Maneuvers:

3. Pawlik’s Grip – palpates the lower abdomen just

above the symphysis pubis to detect what
occupies the pelvic inlet and whether or not it is
engaged. If the part easily moves, the
presenting part is not yet engaged.

▪ Cephalic – the head occupies the inlet and it is

palpated as a hard, round, and ballotable mass

▪ Breech – it is palpated as a soft, globular, non-

ballotable mass
 Leopold’s Maneuver

Four Maneuvers:

4. Pelvic Grip – the maneuver is only

done if the fetus is in cephalic
presentation to determine fetal
attitude and degree of fetal
extension into the pelvis
 14. Measurement of Fundal height and Fetal Heart Sounds

▪ Auscultate for FH sounds

Normal rate of - 120 to 160 bpm

▪ Palpate for fetal outline and

position after the 28th week as a
further estimation of fetal size and
growth
 Components of Health history

15. . Physical Examination – at a first prenatal visit includes inspection of the major body
systems, with emphasis on the changes that occur with pregnancy

▪ Baseline Height/ Weight and Vital Sign Measurement

a. Weight gain - 30-40 lbs. during pregnancy is healthy
b. Adolescent – need to gain 40 lbs. to help ensure a healthy fetus

▪ Vital signs:
a. Sudden increase in BP and sudden weight gain – are danger signs of gestational
hypertension
b. Sudden increase in Pulse, RR – suggest undetected bleeding
Nurse’s Role: Teach support person or the patient to continue monitoring BP at home.
 Components of Health history

15. Physical Examination

▪ Assessment of Body Systems
a. General appearance
(Head and scalp, eyes, nose, ears, sinuses, mouth, neck, lymph nodes)

b. Assessment of the heart, lungs, back, rectum, extremities and skin

c. Measurement of Fundal Height and fetal Heart sounds

 Assessment of Body System
a. General appearance
Eyes
Head and Scalp 1. Identified on ophthalmoscopic
examination
a. Edema of the eyelids combined
1. Examine the head for symmetry, with a swollen optic disk –
normal contour, and tenderness suggest edema from
Gestational hypertension
2. Assess hair for presence,
distribution, thickness, excessive a. Report seeing spots in their
dryness or oiliness, cleanliness, vision or diplopia (Double
and the use of hair dye vision)

3. Look for Choasma Nursing Intervention:

(extra pigment on the face, Teach the patient that symptoms of
forehead, nose) changing vision are prenatal danger
sign of pregnancy that need to be
A reported
d
Assessment of Body System Nose

1. Nasal congestion or appearance of swollen nasal

membranes – due to the increased level of
estrogen associated with pregnancy

Nursing Intervention:
a. General appearance 1. Advise to reduce the used of topical medicine,
such as nasal drops, nasal sprays.

2. Advise to avoid these medicine without primary

care provider’s knowledge and consent

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 Assessment of Body System
a. General appearance
Sinuses
Ears

1. Sinuses should feel nontender

1. Feeling of “fullness” in the ears or
dampening of sounds
during early pregnancy –
due to nasal stuffiness that
may blocked eustachian
tubes
▪ it is usually disappear as the body
adjust to a new estrogen level
▪ Lack of tenderness over sinuses
helps to determine that the
woman’s report of headache
during pregnancy (danger sign)
is probably not sinus related

2. Normal hearing level and normal

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tympanic landmarks should
be present
 Assessment of Body System
a. General appearance
Nursing Responsibilities:
Mouth, Teeth and throat
1. Assess cracked corners of the
mouth, a sign of vitamin A
1. Gingival (Gum) hypertrophy – is deficiency
a slightly swollen and tender to 2. Assess for pinpoint lesions with
touch that may result from an erythematous base on the lips
estrogen stimulation during – suggest a Herpes infection
pregnancy

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 Assessment of Body System
a. General appearance

Mouth, Teeth and throat

Nursing Responsibilities:

3. Teach all women not to neglect their

dental hygiene or yearly dental
visits while pregnant

4. Dental caries should referred to a dental

health care provider in early
pregnancy

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 Assessment of Body System
a. General appearance
Nursing Responsibilities:
Neck

1. Slight Thyroid 1.Suggest to eat two servings of seafoods

hypertrophy (Goiter) –
large swelling at the (salmon, crab, or shrimp) once a week to
midline on the front supply enough iodine for increase
of the nek production of thyroxine to prevent
development of thyroid hypertrophy
▪ due to overall increased
of metabolic rate 2. Encourage the use of iodized salt

3. Avoid Albacore tuna, chunk white tuna,

Add Text Here tuna steak – high mercury content
 Assessment of Body System
a. General appearance

Lymph Nodes

1. On or more pea-sized “shotty” cervical

lymph nodes at the side of the
neck may be palpable

2. Increased upper respiratory infections

Cause :
a. Reduced immunologic resistance

b. Tooth abscess from bacterial growth

due to periodontal disease,
submaxillary lymph node
 Assessment of Body System
a. General appearance
Breast

Breast changes :
▪ Areola darken
▪ Secondary areola develop
▪ Montgomery tubercles (sebaceous glands
in the areola) become prominent
▪ Overall breast size increases
▪ Breast tenderness
▪ Blue streaking of veins becomes
prominent
▪ Colostrum may be expelled as early as
16th week of pregnancy
▪ Any supplementary nipples becomes
darker and enlarge in size
Assessment of Body System
a. General appearance

Heart Nursing Responsibilities:

HR ranges from 70-80 beats/min

▪ Heart murmur – occasionally heard on 1. Heart murmur

auscultation because of increased ▪ Further evaluation to ensure the
vascular volume crossing the heart murmur is only physiologic changes of
valves. pregnancy and not undetected heart
▪ Occasionally Palpitation when lying supine condition

2. Teach to rest or sleep on their left

side to keep their uterus from
compressing their vena cava
that can cause supine
hypotension syndrome
 Assessment of Body System
a. General appearance

Lungs

1. Assess RR and rhythm

▪ Slightly increase RR rate because lung
tissue assumes a more horizontal
position during pregnancy

▪ Diaphragmatic movement is lessened

because diaphragm cannot descend as
fully as usual because of distended
uterus
Assessment of Body System
a. General appearance

Back
Lumbar curve
• Increasingly deepens on standing to maintain
an upright body posture

• This posture can cause back pain

Nursing Responsibilities:
1. Assess a woman’s spine for any abnormal
curve – would suggest scoliosis
2. Assess the gait to be certain they don’t have
pain on walking

3. Referral to Orthopedist
Assessment of Body System
a. General appearance
Rectum
1. Assess the rectum for hemorrhoidal
tissue occurs from uterine
pressure on pelvic veins
Extremities and Skin
1. Assess the lower extremities for varicosities, filling
time of the toenails (should be under 5 seconds)
2. Assess the presence of edema caused by impaired
venous return from the lower extremities
because of uterine pressure
3. Assess in the development of Erythema or itching
of their palm in early pregnancy d high level of
estrogen
 15. Pelvic Examination - reveals information on the health of both internal
and external reproductive organs

• Internal genitalia – cervical infection, cervical

lesions, cervical polyps, carcinoma of the
cervix
• External genitalia - signs of inflammation,
infection, ulceration, lesions vaginal
discharge, or circumcision are noted
 15. Pelvic Examination

Papanicolaou Smear - is taken to be

certain a precancerous or
cancerous condition of the uterine
cervix, vulva or vagina is not
present

▪ Bethesda system – used in

interpretation of Pap Smear
15. Pelvic Examination
• Vaginal Inspection – a culture for
Trichomoniasis sample done at 34-36
wks. gestation may be taken
15. Pelvic Examination

Examination of Pelvic organ

• to assess the position, contour, consistency,

and tenderness of the pelvic organs

• to assess the ovaries, normally slightly tender

caused by pressure on palpation

• Abnormalities includes ovarian cyst, enlarged

fallopian tubes from pelvic
inflammatory disease
• Enlarge uterus (Hegar’s sign)
 15. Pelvic Examination

Rectovaginal Examination – the index finger

is reinserted into vagina and the
middle finger into the rectum to assess
the strength and irregularity of
posterior vaginal wall
Midterm wk. 1