Chapter Obstetrics and Gynaecological Nursing

Antenatal care
Objectives:

By the end of the lecture, the student will be able to:

 Mention the components of antenatal care.

 Obtain complete history from the pregnant woman during antenatal visits.
 Perform general and abdominal examination.
 Auscultate FHR and identify its abnormalities.
 Follow ethical issues while examining the pregnant woman.

Aims of antenatal care:

• To screen the high-risk cases

• To prevent or detect or treat at the earliest complication.
• To ensure continued medical surveillance and prophylaxis
• To educate the mother about the physiology of pregnancy and labour by
demonstrations, charts, and diagrams so that fear is removed, and
psychology is improved.
• To discuss with the couple about the place, time, and mode of the delivery,
provisionally and care of the newborn
• To motivate the couple about the need of family planning
• To advice the mother about breast-feeding, post-natal care, and
immunization

Schedule for antenatal visits:

• Monthly up to 28 weeks
• Two weeks between 28 and 36 weeks

• Weekly 36 weeks onwards. (This equals about 15 visits)

 High-risk cases need more frequent visits.

Components of antenatal care:

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• Careful antenatal assessment (history taking and examination and

investigation).
• Advice given to the pregnant woman.

Antenatal assessment include:

Antenatal
Assessment

History taking Physical

Investigations
examination
Personal history. General examination Routine tests

Present pregnancy Abdominal Optional tests

history. examination

Past history (medical - Inspection

and surgical).
- Palpation (Fundal
height- leopold’s
Obstetric history maneuver)

- FHR auscultation.
Menstrual history

Family history Vaginal examination

History taking include:

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 Personal history which includes name, age, education, occupation, address,

marital status and duration of marriage.
 Present pregnancy history of any complaint as: nausea & vomiting,
increased frequency of micturition, constipation, heaviness of breast, rise of
temperature, oedema, pain in the abdomen, backache, and vaginal bleeding.
 Past medical history: which include any medical disorder as hypertension,
DM, renal, hepatic, cardiac or psychiatric disease.
If the woman is taking any drugs as antihypertensives, hypoglycemics,
antidepressants, corticosteroids, and anticoagulants. Allergy to certain foods
.or drugs are also considered
 Obstetrical history which includes details related to:
Gravidity: number of pregnancies, any complications encountered during
.previous pregnancy, onset of pregnancy (spontaneous, induced or ART)
Parity: number of deliveries, onset of labor (spontaneous, induced), mode of
delivery(NVD or CS), GA at the onset of labor( preterm, full term or
postdate), any complications encountered during labor or postpartum, sex of
.children
.Abortion: number, GA at the onset of abortion and management techniques
 Menstrual History: age of menarche, duration of menstrual period, LMP to
calculate EDD.
 Family history of HTN, DM, renal, hepatic, or cardiac diseases, multiple
pregnancy or pregnancy complications.

Physical examination:

 General examination: include vital signs, breast, heart sound, lungs,

appearance, height of patient, weight of patient, pallor, jaundice, edema and
cyanosis.

 Abdominal examination:

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Inspection of the shape of the uterus, striae gravidarum, linea nigra and scar
marks.

Palpation

 Assessment of fundal height

 Loepold’s maneuver:

Fundal grip:

• While facing the woman, palpate the woman's upper abdomen with both
hands.
• Often determine the size, consistency, shape, and mobility of the form that is
felt.
• The fetal head is hard,, round, and moves independently of the trunk.
• The buttocks feels softer, is symmetric, and has small bony prominences; it
moves with the trunk.

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Umbalical (Lateral grip):

• The maneuver attempts to determine the location of the fetal back.

• Facing the woman, the health care provider palpates each side of the
abdomen with gentle but deep pressure using the tips of his or her hands.
• The fetal back is firm and smooth, hard, resistant surface.
• Fetal extremities feels like small irregularities and protrusions.

Pelvic grip:

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To determine which part of the fetus, occupy the lower uterine segment

Pawlick grip:

 Done at 36 weeks to determine engagement of the fetal head.

 Determine what fetal part is lying above the inlet, or lower abdomen.
 The individual performing the maneuver first grasps the lower portion of the
abdomen just above the symphysis pubis with the thumb and fingers of the
right hand.

Auscultation of FHR:

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 Explain the procedure to the woman.

 Assist the woman to a supine position.
 By palpation, determine the following fetal position , fetal presentation and
fetal lie
 Place the head of the fetoscope on the woman’s
abdomen where you are most likely to find fetal heart
tones.
 In cephalic presentation, FHR is auscultated below the umbilicus on the side
of the fetal back.
 In breech presentation, FHR is auscultated above the umbilicus on the side
of the feta back.
 Normal FHR is 120-160 b/m, foetal tachycardia (>160 b/m), foetal
bradycardia (<120 b/m).
 Then note any irregularity of heart rhythm or of heart sounds , loudness of
the heart tones relative to the position of the fetus
 Document findings and compare with earlier recordings.

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Investigations:

Name First done Repeated Interpretation

1. Hb Booking Once every <10 g/dL or < 11 g/dL
trimester (WHO) consider as
anemia
2. Blood group & Booking --- If Rh –ve, husband’s
Rh typing group & ICT
4. Urine routine Booking Every visit Pus cells> 5, do a
examination culture

Alb+ or >, consider pre-

eclampsia
5. GCT 24-48 weeks --- 130 mg/dL or more, do
a GTT

6- culture swabs if infection is

from vagina and suspected
cervix

Ultrasound: Benefits:

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• Determine gestational age

• Detect multiple pregnancies
• Help with later screening for Down's syndrome.
• Determine the amount of amniotic fluid (average, oligohydramnios,
polyhydramnios).
• Localize site of the placenta and evaluation of the retro placental space.
• Determine fetal sex.
• Determine fetal viability.
• Identify fetal presentation, position, lie and attitude.
• Localize fibroid with pregnancy.
• Diagnosis of cervical incompetence by vaginal ultrasonography.

Optional tests:

 Amniocentesis
 Alpha fetoprotein to screen for birth defects.
 Non stress test.
 Screening for syphilis.

In subsequent visits:

• Patient complains
• General examination
• Gestational age to be calculated
• Identification of problem
• Foetal movement
• Health education
• Prophylaxis & treatment of anemia
• Developing individualized birth plan

Antenatal advice:

Following advice are to be given:

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1- Diet should be nutritious, balanced, light, easily digestible, rich in protein,

mineral and vitamin and with woman’s choice. The woman needs extra
300kcal/day from 2nd trimester onwards, Calcium: 1.5 g daily, Vit. C, folic
acid, Vit. B12.
2- Rest and sleep: 8-hour sleep at night, at least 2-hour sleep after mid-day
meal. Hard strenuous work should be avoided in first trimester and last 4
weeks.
3- Bowel: Regular bowel movement may be facilitated by regulation of diet,
taking plenty fluid, vegetable, and milk.
4- Coitus: should be avoided in 1st trimester and in the last 6 weeks.
5- Travelling: should be avoided in 1st trimester and in the last 6 weeks. Air
travelling is contraindicated in placenta praevia, preeclampsia, severe
anemia and history of abortion and preterm labor.

Immunization: Indicated TT, HAV, HBV and Rabies.

Contraindicated immunizations are live virus vaccine (rubella measles, mumps,

varicella).

Warning signals of pregnancy!!!

• Bleeding p/v at any time in pregnancy

• Headache, blurring vision, epigastric pain & oliguria.
• oedema, severe, not subsiding with rest, or on face & hands.
• Decrease/ loss of fetal movements.
• Abdominal pain
• Urinary infection with vulvovaginitis
• Clear fluid p/v (PROM).

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Minor Complaints During Pregnancy

Objectives:
By the end of the lecture, the student will be able to:

 Identify several minor ailments that the woman may experience during
pregnancy.
 Mention the causes of each ailment or discomfort.
 Determine the relief measures of each discomfort.

(1) Backache:

Causes:

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 Lumbar lordosis.
 Relaxation of ligaments and intervertebral joints by progesterone effect.

Relief measures:

 Adequate rest and support the back when sitting in a chair with a pillow.
 Avoid wearing high heeled shoes.

(2) Nausea and vomiting:

It is called morning sickness.

 Having vomiting and nausea and feeling tired are normal during pregnancy
due to the adjustment of your body’s hormone level.
 This usually all happens in early pregnancy from 4-12 wks.

Relief measures:

 Add dry foods like crackers, cereal and toast before waking up from the
bed.
 Avoid fried and fatty foods.
 Eat small frequent meals.
 In case, your vomiting is constant and severe and to have anemia test,
consult your doctor.
(3) Gingivitis

Increased vascularity and hypertrophy of the interdental papillae. It is improved

usually after pregnancy termination.

Sequelae:

 Increased tendency for bleeding.

 Retention of food debris predisposes to sepsis and dental caries.

Relief measures:

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Proper dental hygiene.

(4) Ptyalism (Sialorrhoea)

Causes:

Increased salivation may occur early in pregnancy and subsides later . It is due to
failure of the patient to swallow the saliva rather than increase in its amount.

Relief measures:

 Care of dental hygiene.

 Discontinue smoking.
 Anticholinergic drugs as belladonna, which induce dryness of the mouth,
may be needed.
(5) Heartburn

Causes:

A common complaint caused by reflux of gastric contents into the lower

oesophagus due to mechanical relaxation of the cardiac sphincter caused by
upward displacement and compression of the stomach by the pregnant uterus, and
by the action of progesterone.

Relief measures:

 More frequent but smaller meals. Avoid salty and spicy foods.
 Avoidance of bending over or lying flat.
 Antacids containing aluminium hydroxide are preferable as they buffer the
gastric contents.

(6) Constipation
Causes

 Reduced intestinal motility by the action of progesterone.

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 Increased fluid resorption from the large bowel.

 Reduced exercise.
 Mechanical compression by the gravid uterus.

Relief measures:

 Evacuate the bowel at the same time every day. Increase fluid intake.
 Diet rich in green vegetables and fruits.
 Mild laxative as. Liquid paraffin interferes with absorption of fat soluble
vitamins, so better to be avoided.

(7) Hemorrhoids
Causes

 Laxity of the rectal veins by progesterone effect.

 Pressure by the gravid uterus.
 Tendency to constipation.

Relief measures:

 Avoid constipation.
 Soothing agents.
 Local anaesthetics.
 Surgical and local injection treatment have to be avoided.

(8) Varicosities
Causes:

 increased venous pressure in the lower limbs by compression with the

pregnant uterus.
 prolonged standing.

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 relaxation of veins walls by steroid hormones.

Relief measures:

 Avoid prolonged standing.

 Encourage active exercise.
 Elevate the legs in higher level than the body during sitting and sleeping.
 Elastic stocking are worn while the patient is lying down and veins are
empty.
 Surgical or injection treatment should be avoided during pregnancy.

(9) Dyspnoea:
Causes:

 It may occur early in pregnancy due to hyperventilation caused by

progesterone.
 Late in pregnancy, it occurs due to pressure on the diaphragm by the
pregnant uterus.

Relief measures:

 Avoid tight clothes around the chest.

 Sleeping in the semi- sitting position.
 Well ventilated areas.

(10) Dependent edema

Causes:

Shift of fluids from the intravascular compartment to the extravascular

compartment.

Relief measures:

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 Avoid standing for long periods.

 Elevate legs when laying or sitting.
 Avoid tight stockings.

(11) Faintness

Relief measures:

 Rise slowly from sitting to standing.

 Evaluate hemoglobin and hematocrit.
 Avoid hot environments

(12) Urinary symptoms

Frequency and stress incontinence may occur during pregnancy.

Causes

 Increased intra-abdominal pressure.

 Pressure on the bladder by the enlarging uterus reducing its capacity.

(13) Leucorrhoea
Causes:

Increased vaginal discharge is a common complaint during pregnancy due to

excess oestrogen production.

Relief measures:

No treatment is needed except if there is associated infection. Monilial infection

is common.

(14) Leg Cramps

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Sustained involuntary painful contractions, usually affecting the calf and peroneal
muscles may occur in the second half of pregnancy, particularly at night.

Causes

 Depletion of serum calcium as well as sodium and chloride due to excessive

vomiting, sweating or salt restriction.
 Local vascular insufficiency.

Relief measures:

 Massage of the contracted muscles and passive stretching.

 Calcium gluconate may be helpful.

(15) Paraethesia
Tingling sensation of the fingers and sometimes weakness of small muscles of the
hand caused by edema of the carpal tunnel.

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