Establishing Pregnancy

 Pregnancy may be assumed based on the

presence of certain signs and symptoms
Trimesters of Pregnancy
 Presumptive signs are subjective and recorded Normally, pregnancy continues for 40 weeks or 280 days
under the history of present illness
1st Trimester—conception until 12 weeks gestation
 Probable and positive signs of pregnancy are
2nd Trimester—13 weeks until 27 week’s gestation
objective and recorded as physical assessment
3rd Trimester—28 weeks until 40 week’s gestation
findings
Presumptive Probable Positive
Amenorrhea -Positive pregnancy -Fetal Heart Schedule of Prenatal Visits (low-risk pregnancy)
Breast test Beat  Monthly until 28 weeks gestation
Tenderness -Uterine enlargement auscultated  Biweekly from 28 weeks until 36 weeks
Quickening -Hegar’s sign -Fetal  Weekly from 36 weeks until delivery
Nausea/ (softening of the lower movement
PRENATAL HEALTH HISTORY
Vomiting uterine segment) palpated per
Urinary -Goodell’s sign practitioner Performing a thorough health history in the prenatal
Frequency (softening of cervix) -Ultrasound of period is essential to planning nursing care and
-Chadwick’s sign gestation identifying high risk women.
(bluish hue to  Medical History:
cervix/vagina) - Chronic illness
-Braxton hicks - Current and recent medication
contraction - Recent acute illness
- Childhood illness
Urine Pregnancy Test  Surgical History:
 Reacts with human chorionic gonadotropin - Problems with anesthesia
(hCG) - Previous surgeries
 Performed on first voided urine sample of the - Uterine/Cervical Surgeries
day; positive results possible before the first day  Obstetrical history:
of a missed menstrual period - Type of deliveries: vagina/cesarean
Serum Pregnancy Test - Complications with past pregnancy
 Useful in monitoring expected pattern of - Infertility
progression of hCG; detects hCG as early as 9 - Documentation of obstetrical history
days post conception
GRAVIDA (G)—number of pregnancies
Ultrasound TERM (T)—number of deliveries after 27 weeks
 Confirms presence of gestational sac, fetal pole,
and fetal cardiac activity PRETERM (P)—number of deliveries after 20 weeks
 Validates location of pregnancy but before 38 weeks
ABORTION (A)—number of delivery before 20
Estimated Date of Delivery weeks, either spontaneous or induced
 Establishing an accurate date of delivery is LIVING (L)—number of living children
important to:
 Determine timing of antenatal screening
 Monitor growth of the fetus Documentation Example 1: the prenatal client states
 Scrutinize timing of delivery having three children at home. She reports that her son
 Common abbreviations denoting delivery date was born on his due date, but her daughters were both a
are: month early. She States that she lost a baby in her second
 EDD—estimated date of delivery month.
 EDC—estimated date of confinement G: 5= currently pregnancy, 3 children at home, one
 EDB—estimated date of birth abortion)
T: 1= her son was born on his due date
Naegele’s Rule P: 2= her daughters were born a month early
Formula used to estimate date of delivery. A: 1= she lost a pregnancy at approximately 8 weeks
Count back 3 months and add 7 days to the last normal L: 3= reports three children at home
menstrual period (LNMP) reported by the patient. DOCUMENT AS G5-1213
Example: The patient states that her LNMP was
April 20th Documentation Example 2: the same prenatal client may
April is the 4th month 20th day also be described as G5 (5pregnancies) P3 (number of
—3 months + 7days live births); pregnancies ended before 20 weeks are not
1st month 27th day counted as “P” in this method.
 The baby is estimated to be due on January 27th  Sexual History
of the following year - Number of sexual partners
- Sexually transmitted infections
- Sexual abuse

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 - Methods of contraceptions  Auscultate fetal heart tones
- Condom Use  Measure fundal height in centimeters from
 Social History symphysis pubis to the fundus
- Use of recreational Drugs - Uterine size increases in pregnancy in a
- Smoking predictable pattern and is measured to
- Domestic abuse gauge fetal growth
- Educational level/ability to read - Fundal height that is lagging or greater than
- Economic status expected should be further investigated
- Type of health insurance Week’s Gestation Fundal Height
- Need for community referrals 12 Just above symphysis pubis
 Transportation Halfway between
 Nutrition 16 symphysis pubis and the
 Medications umbilicus
Physiologic Changes in Pregnancy 20 At the umbilicus
Fundal height generally
matches weeks gestation
21-36 in centimeters
EXAMPLE: Fundal height at
28 weeks should be
approximately 28 cm

Hormonal Changes In Pregnancy

 Provide appropriate education for gestational

age
 Discuss procedure for lab testing
Common Laboratory Expected Finding In
Tests Pregnancy
HIV *check state laws Negative
regarding HIV testing in
pregnancy
Blood type A,B,AB,O
Rh factor Negative/Positive
Antibody screen Negative
Hemoglobin >11.5 mg/dL
Hematocrit >33%
Nursing Care with First Prenatal Visit Platelets 150,00—400,000 mm(3)
WBC 5,00—12,00 mm(3)
 Determine EDD based on LNMP RPR Negative
 Document current gestational age (gestational Hepatitis B antigen Negative
wheel is a tool for quick reference to current Rubella Titer 1:8 Immune
gestational age) Hemoglobin AA, unaffected
 Document baseline vital signs electrophoresis
 Document height, weight, and body mass index Chlamydia culture Negative
(BMI) Gonorrhea culture Negative
 Obtain urine specimen and test for presence of: Pap smear Normal cytology
Substance Expected Finding
Glucose Negative/Trace
Protein Negative/Trace

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Diagnostic Testing In Early Pregnancy Education in the Early Prenatal Period
Diagnostic Test:  Elevated estrogen and progesterone levels in
 Ultrasound perform throughout pregnancy early pregnancy generate changes in the body,
Clinical Applications: causing pregnancy associated discomforts
 Confirm and date pregnancy  Offer suggestion to lessen discomforts
 Verify pregnancy location  Teach patient to report symptoms that may
 Detect fetal cardiac activity indicate a potential complications
 Measure fetal growth Discomfort Patient Education
 Detect fetal anomalies Urinary frequency Related to uterine position/weight.
 Measure amniotic fluid index Encourage frequent emptying of
 Determine fetal position bladder.
 Determine placental position Discourage limiting oral fluids.
 Measure cervical length Report burning or pain with urination.
 Adjunct to invasive procedures Nausea and Related to elevated hormone levels
Nursing Consideration vomiting Encourage small, fequejnt meals
 Position to avoid supine hypotension; folded Eat crackers before rising
towel under right hip if supine Avoid pungent odors, spicy, or
greasy foods
Chorionic villi sampling (CVS)—performed at 10-12 weeks Discuss limited time frame for nausea
Clinical Application—chromosomal analysis (subsides around 12 weeks
Amniocentesis—performed throughout pregnancy gestation)
Report excessive vomiting
Clinical Applications: Emotional Lability Related to hormone changes.
 Chromosomal analysis is desired Discuss normalcy of emotional
 Measure AFP changes with patients and partner.
 Measure bilirubin level Ambivalence normal in first trimester
 Determine lung maturity Report constant crying, inability to
- Lecithin/ sphingomyelin ratio (L/S Ratio) care for self, suicidal thoughs
- Phosphatidyglycerols (PG) Leukorrhea Related to vasocongestation of
- L/S Ration of 2:1 and positive PG indicative of mucos membrane
fetal lung maturity Avoid tampon use and douching
Nursing Consideration: Wear peri-pad to absorb discharge
 Review blood type, rH and antibody status Encourage cotton underwear.
 Administer Rh (D) immune globulin if indicated Report vaginal discharge with an
 Monitor patient for post procedure cramping or odor or color, vaginal bleeding or
bleeding leaking of amniotic fluid.
 Monitor fetal heart beat Breast discomfort Hormone related breast
Maternal Serum Triple Screen (test maternal development often first presumptive
serum for AFP, hCG, and estriol) sign of pregnancy.
NOTE: this is a screening method only. A positive result Wear a supportive bra
suggests the need for further testing Colostrum may be expressed in
Diagnostic Test Nursing Consideration pregnancy.
Performed at 15-18 weeks Result adjusted Introduce the value of
Clinical Applications: according to breastfeeding.
 Serum screen for neural documented Introduce/reinforce breast self-exam
tube defects/down gestational age, Repost any breast lump or unusual;
syndrome maternal age, race, discharge.
and weight, presence Fatigue Related to rapid hemodynamic and
Interpretations of Result
of diabetes/ multiple metabolic changes in the first
Defect AFP hCG Estriol
gestation; the nurse trimester.
Risk for
must accurately Encourage naps during the day.
open WNL WNL
document these Encourage prenatal vitamins.
neural
variables on the Encourage healthy diet.
tube
laboratory requisition. Report syncope and vertigo.
Risk for Nasal stuffiness/ Related to vasocongestion of musoc
down epistaxis membranes.
syndrome Increased humidity in home may
help.
= elevated = decreased Warm compresses to sinus area
WNL = within normal limits Avoid over the counter (OTC) cold
remedies
Report fever, green/yellow nasal
discharge or frequent nosebleed.

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 Pregnancy Classification of Medications
Nursing Care For Return Prenatal visits
Sexuality in Pregnancy
 Sexy not restricted in pregnancy unless risk factors
exist for bleeding or preterm labor
 Discuss extended changes in sexuality
- Change in libido
- Body image changes
- Braxton-hicks contraction with orgasm
- Comfortable positioning for intercourse
 Measure pulse and blood pressure (BP)
 Compare BP to initial reading (measure in the
same position at each visit)
 Measure weight and compare to last reading
 Note total weight gain

Nutrition 

Note pattern of weight gain
Obtain urine specimen and test for protein and
 Inquire about dietary practices glucose
 Gather 24 hours diet recall  Measure fundal height.
 Suggest an addition of 300 healthy calories per
day
Determine Fetal position
o Perform leopold’s maneuver
 Encourage daily prenatal vitamin with 400 ug
- Palpate for fetal body part in fundus (A)
folic acid
- Palpate for fetal back (B)
 Suggest 6-8 glasses of water daily
- Palpate for presenting part (C)
 Encourage to follow food pyramid in daily
- Palpate for attitude of presenting part (D)
choices.
Weight Gain in Pregnancy

Exercise in Pregnancy
Place Doppler on maternal abdomen over fetal back to
monitor fetal heart tones (FHT)

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  Record presence of fetal movement -teach oatient to
 Assess for presence of edema/deep tendon differentiate between true
reflexes and false labor
 Record symptoms since last visit -REPORT SIGNS OF PRETERM
 Discuss procedure for diagnostic testing LABOR
 Provide patient education appropriate for Ankle edema -Related to decreased
gestational age venous return due to
Education in the second and third pressure of the gravid
uterus
trimester -rest in lateral recumbent
 Teach patient to count fetal movement and position
report change in fetal movement pattern to -elevate legs when sitting
primary health-care provider immediately -continue with 6-8 glasses
 Discuss fetal growth and development water daily
 Demonstrate palpating for contractions -REPORT GENERALIZED
 Discuss symptoms of preterm labor EDEMA
 Lower backache Varicose vein -caused by increased
 Increased vaginal discharge venous stasis related to
 Bloody show pressure from the gravid
 Leaking amniotic fluid uterus
 Contractions -wear pregnancy support
 Pelvic pressure hose
 Differentiate between true and false labor -avoid lengthy standing
True Labor False Labor -change positions
frequently
Cervix dilates Cervix unchanged
-REPORT PAIN, REDNESS,
Contraction increase in Contractions irregular and
LOCALIZED HEAT TO LEGS
intensity and frequency decrease with change of
Faintness -Related to hemodynamic
position/activity
changes
Leaking amniotic fluid, No evidence of change in
-avoid sudden position
bloody show vaginal discharge
change
 Encourage childbirth preparation class
-Avoid long periods without
 Discuss options for pain control in labor
eating
 Cesarean preparations class, if indicated
-Avoid lying supine
 Epidural anesthesia class, if indicated
-REPORT LOSS OF
 Explore preparing for the newborn
CONSCIOUSNESS
 Breastfeeding
Heartburn -related to increased
 Circumcision
pressure on abdominal
 Choosing a pediatrician
organs and sphincter
 Car seat safety
relaxations
 Discuss the discomforts associated with late
-encourage small, frequent
pregnancy and teach reportable symptoms
meals.
Discomforts Patient education -avoid spicy foods
Changes in pigmentation -Related to hormone -sit up after meals
1. Linea nigra changes in pregnancy; -REPORT PERSISTENT
(pigmented line fade after pregnancy SYMPTOMS
from umbilicus to -moisturizers decrease Backache Related to shift in posture
pubic bones) itching, but will not prevent due to gravid uterus
2. Chloasma (deeper striae -encourage low-heated
facial pigment) -REPORT BODY RASHES shoes
3. Striae (stretch -avoid standing for long
marks) periods
Round ligament pain -Related to round ligament -teach pelvic tilt exercise
(occasional, sharp lower stretching as uterus grows -REPORT CONTANT OR
abdominal pain) -change positions slowly RHYTHMIC BACKACHE
-encourage good body Shortness of breath Related to upward
mechanics diaphragmatic pressure
-REPORT ABDOMINAL exerted by the gravid
CRAMPING, CONSTANT uterus
PAIN, OR BLEEDING -allow more time for
Braxton-Hicks contractions -Instruct patient how to strenuous activities
(false labor contraction) palpate contractions -eat small, frequent meals
-labor should occur after 38 -lightening will lessen
weeks gestation symptoms
-REPORT DYSPNEA WITH

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 REST
Insomia -related to fetal
movement, nocturia
-teach relaxations
techniques
-encourage side-lying
position with pillow support
-warm milk/shower before
sleep
Leg cramps -related to uterine pressure
on the pelvic nerves or
calcium imbalance
-review daily calcium
intake
-teach signs of deep vein
thrombosis
-REPORT PAIN, REDNESS,
LOCALIZED HEAT
Constipations Hemorrhoids -related to decreased
gastric motility; iron
supplement may worsen
constipation
-increase dietary fiber and
water intake
-encourage exercise
-discourage enemas and
laxatives
-REPORT PAINFUL OR
BLEEDING HEMORRHOIDS

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