CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107

CHAPTER 1: COMPUTING THE EDD, AOG, GTPAL

DEFINITION OF TERMS and that ovulation and conception occurs on day 14 of the
• Gravida cycle.
o A pregnant woman. • Use of the LMP to establish the due date may overestimate
o This refers to any pregnancy regardless of duration. the duration of the pregnancy and can be subject to an error of
• Para more than 2 weeks.
o A woman who has delivered a viable young (not
necessarily living at birth).
o Para is used with numerals to designate the number of
pregnancies that have resulted in the birth of a viable
offspring.
• Nulligravida
o A woman who has never been pregnant.
• Nullipara
o A woman who has not delivered a child who reached
viability.
• Primigravida
o A woman pregnant for the first time.
• Primipara
o A woman who has delivered one child after the age of
viability.
• Multigravida
o A woman who has been pregnant more than once.
• Multipara
o A woman who has delivered two or more fetuses past the
age of viability.
o It does not matter whether they are born dead or alive.
• Grandmultipara
o A woman who has had six or more births past the age of
viability.
• Viability
o Refers to the capability of a fetus to survive outside the
uterus after the earliest gestational age (approximately 24
weeks gestation).
• In utero •
o Refers to within the uterus.
HEALTH ASSESSMENT DURING PRENATAL VISITS
• Schedule of Prenatal Visits:
o Up to 28th week of pregnancy
- Every 4 weeks
o 28th – 36th week of pregnancy
- Every 2 weeks •
o 36th week until Birth
- Every week
METHODS OF ESTIMATING EDD AND AOG
1. Naegel’s Method
• LMP – 3 months + 7 days + 1 year
•
3. Some women have cycles that are consistently longer than
the average 28-day cycle. In these cases, a pregnancy wheel
can still be used, but some simple calculations are
necessary
• The second half of a woman’s menstrual cycle always lasts for
• 14 days. This is the time from ovulation to the next menstrual
2. Another method is by Adding 9 months and 7 days (LMP period.
from Jan – Mar only) to the first day of the last menstrual • If your cycle is 35 days long, for example, then you probably
period (LMP) ovulated on day 21 (35 – 14 = 21)
• This is the method used by "pregnancy wheels".
• The accuracy of the EDD derived by this method depends on
accurate recall by the mother, assumes regular 2-day cycles,
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 1: COMPUTING THE EDD, AOG, GTPAL

4. Once you have a general idea of when you ovulated, you 2. If LMP was March 21, 2023, determine the AOG until Sept.
can use an adjusted LMP to find your due date with a 22, 2023
pregnancy wheel
• For example, if your menstrual cycle is usually 35 days long and
the first day of your LMP was November 1:
o Add 21 days (November 22).
o Subtract 14 days to find your adjusted LMP date
(November 8).
o After you calculate your adjusted LMP date, simply mark it
on the pregnancy wheel and then look at the date where
the line crosses. That is your estimated due date. •
5. McDonald’s Rule (Fundal Height Measurement)
• If LMP is not known.
• Palpate the fundus and relate height of fundus with abdominal
landmarks.
• After week 24 of pregnancy, the fundal height for a normally
growing baby will match the number of weeks of pregnancy — •
plus or minus 2 centimeters. OBSTETRIC HISTORY
o For example: Fundal height 27 cm. = 27 weeks pregnant • Comprehensive system of classifying pregnancy status.
• Height of fundus (cm) ÷ 3.5 = age of pregnancy in lunar o G (gravida) – total # of pregnancies
months. o P (para) - number of deliveries that reached viability,
• Typically, tape measurement from the notch of the symphysis regardless of whether the infant was born alive.
pubis to over the top of the uterine fundus as a woman lies ▪ Para broken down into:
supine is equal to the week of gestation in centimeters A. T = # of full-term infants born at 37 weeks or
between the 20th and 31st weeks of pregnancy (e.g., in a after
pregnancy of 24 weeks, the fundal height should be 24 cm). B. P = # of preterm infants born before 37 weeks
BARTHOLOMEW RULE OF 4THS C. A = # of spontaneous or induced abortions
• Bartholomew's rule of fourths does not use a numerical height D. L = # of living children
value to compute gestational age, but landmarks. E. M = # of multiple pregnancies
GTPAL PRACTICE QUESTIONS
QUESTION 1
• A 26-year-old female is currently26weekspregnant. She had a
miscarriage at 10weeksgestation five years ago. She has a three-
year-old who was born at 39 weeks. What is her GTPAL?
o Answer:
▪ G=3
▪ T=1
▪ P=0
▪ A=1
▪ L=1
QUESTION 2
• A 35-year-old female is currently pregnant with twins. She has
10-year-old triplets who were born at 32 weeks gestation, and a
AOG 16-year-old who was born at 41-week gestation. Twelve years
1. If LMP was Feb. 20, 2023, compute the AOG in weeks until ago, she had a miscarriage at 8 weeks gestation. What is her
Sept. 23, 2023 GTPAL?
o Answer:
▪ G=4
▪ T=1
▪ P=1
▪ A=1
▪ L=4
QUESTION 3
• A woman with a history of 5 pregnancies: 2 births at 39 and 40
•
weeks, and 3 miscarriages before 20 weeks.
o Answer:
▪ G=5
▪ T=2
▪ P=0
•
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 1: COMPUTING THE EDD, AOG, GTPAL

▪ A=3 3) VIBROACOUSTIC STIMULATION

▪ L=2
METHODS IN ASSESSING THE FETAL WELL-BEING
A. FETAL MOVEMENT (Kick counts)
• Quickening – begins at 18 – 20 wks. AOG; peaks at 28 – 38 wks.
AOG
• Average fetal movement = 10 – 12x/ day.
• Decreased fetal movement = placental insufficiency.
• SANDOVSKY METHOD
o Counting & recording the number of fetal movements in
an hour after meal (mother in left recumbent position).
o Normal: 2x/ 10 min. or 10 – 12x/ hr.
o Needs Referral: 10 fetal movements in 2 hours.
• CARDIFF METHOD (Count-to-Ten)
o Recording the time interval it takes for the pregnant
woman to feel the fetal movement.
o Normal: 10 fetal movements/ hr.
B. FETAL HEART RATE
• As early as the 10th – 11th wk. AOG by Doppler
• Normal: 120 – 160 beats/ min.
1) RHYTHM STRIP TESTING • Purposes:
- Determine the presence of good baseline rate, long
& short-term variability by the use of external fetal
heart rate & uterine contraction monitors for 20 min.
- Position: SEMI – FOWLERS
- SHORT-TERM VARIABILITY – small changes in FHB
from second to second.
- LONG-TERM VARIABILITY – differences in FHR that
occur over 20 min. period.
• Preparation for Ultrasound:
1)
2)
3)
- -
2) NONSTRESS TESTING
- Response of FHR to fetal movement in which the FHR 4)
and Uterine Contraction Monitors are attached.
- Position: SEMI-FOWLERS/ LEFT LATERAL
- Normal: REACTIVE NONSTRESS TEST; 2 – 4 FHR
accelerations in 10min.
- Abnormal: NON-REACTIVE NONSTRESS TEST; No
accelerations with the fetal movements
- Test used to stimulate fetal movement by the use of
acoustic stimulator especially if a spontaneous
acceleration has not occurred within 20min. during
NONSTRESS TEST.
4) CONTRACTION STRESS TESTING
- Assessing FHR response to uterine contractions
- Purpose: to assess the fetal ability to tolerate the
stress of labor.
- Position: LEFT LATERAL/SEMI-FOWLERS
- Normal result: NEGATIVE; No late FHR decelerations
present by 3 contractions in 10 min. period
- Abnormal: POSITIVE; Presence of late FHR
decelerations by 50% or more of uterine
contractions.
- Contraindication:
✓ Placenta previa
✓ Multifetal pregnancy
✓ Incompetent cervix
✓ Rupture of membranes
C. ULTRASONOGRAPHY
1) To diagnose pregnancy as early as 6 wks.
2) To confirm the size, presence, & location of placenta &
amniotic fluid
3) To establish that a fetus is growing and has no gross
anomalies.
4) To establish sex of the fetus.
5) To establish the presentation and position of the fetus.
6) To predict the maturity of the fetus.
7) To discover complications of pregnancy.
1) Explain the procedure.
2) Encourage to have a full bladder at the time of procedure
(drink a full glass of water every 15 min. beginning 90 min.
before the procedure).
3) Position patient in supine.
4) Place a rolled towel or blanket under the right buttock
(prevent supine hypotension syndrome).
5) The gel must be at room temp. or slightly warm before
applying on the abdomen.
BIPARIETAL DIAMETER
- 8.5 cm. = 40 wks. of fetal age
DOPPLER UMBILICAL VELOCIMETRY
- Measures the velocity at which RBCs in the uterine and
fetal vessels and traveling.
- Low velocity = Poor neonatal outcome.
PLACENTAL GRADING
- Grade 0 = 12 – 24 wks. AOG
- Grade 1 = 30 – 32 wks.
Grade 2 = 36 wks.
- Grade 3 = 38 wks.
AMNIOTIC FLUID VOLUME ASSESSMENT
- The sum of the largest pocket measurements of amniotic
fluid.
- Average fluid index = 12 – 15 cm bet. 28–40wks.
- Abnormal Finding:
✓ Hydramnios = > 20-24 cm fluid index
✓ Oligohydramnios = < 5 – 6 cm fluid index
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 1: COMPUTING THE EDD, AOG, GTPAL

D. MATERNAL SERUM ALPHA-FETOPROTEIN • INDICATIONS:

• Alpha-fetoprotein (AFP) 1) Maternal age of 35 yrs. or older
o A substance produced by the fetal liver that is present in 2) Previous child with chromosomal abnormalities
amniotic fluid and maternal serum. 3) Parent with chromosomal abnormalities
o High MSAFP = spina bifida 4) Familial history of neural tube defects
o An AFP multiple of the median (MoM) <2.5 is reported as 5) Fetal abnormalities per ultrasound
screen negative. AFP MoMs > or =2.5 (singleton and twin 6) Assessment of fetal pulmonary maturity
pregnancies) are reported as screen positive. 7) Evaluate alpha-fetal protein (AFP)
o Low MSAFP = down syndrome 8) Diagnosis of fetal hemolytic disease
E. TRIPLE SCREENING • COLOR OF AMNIOTIC FLUID:
o NORMAL:
• An analysis of 3 indicators:
▪ Clear, slightly yellow tinge during late pregnancy
1) MSAFP
o ABNORMAL:
2) Unconjugated estriol
▪ Strong yellow (blood incompatibility)
3) hCG
▪ Green color (meconium staining)
F. CHORIONIC VILLI SAMPLING • Amniocentesis can provide the following information:
• A biopsy & chromosomal or DNA analysis of chorionic villi 1) L/S (Lecithin/sphingomyelin ratio)
done at 10 – 12 wks. AOG. - These are the protein components of the lung
• An invasive procedure, Ultasonography is used to direct the enzyme surfactant that the alveoli begin to format
procedure. about 22nd–24th wks. Pregnancy.
• COMPLICATIONS: - Surfactant
1) Infection - A substance composed of lipoprotein that is
2) Bleeding secreted by the alveolar cells of the lung and
3) Threatened miscarriage serves to maintain the stability of pulmonary
tissue by reducing the surface tension of fluids
that coat the lung.
- NORMAL:
- 2:1 (fetal lung maturity)
2) Phosphatidyl Glycerol (PG)
- Precursor of surfactant; presence in amniotic fluid of
the NB indicates lung maturity.
- Helps confirm fetal maturity.
3) Bilirubin level
- Indicates blood incompatibility or the degree of
destruction of fetal RBCs in an RH sensitized woman.
- 1 – 4 mg/100 ml
G. AMNIOCENTESIS
- If elevated:
• An invasive procedure that involves withdrawal of amniotic - Reflects release of bilirubin as excessive RBC
fluid through the abdominal wall at 14th–16th wk. of begin their breakdown.
pregnancy. - Bilirubin:
• Women with Rh – blood type need Rh immune globulin adm. - A byproduct of RBC breakdown
after the procedure to protect fetus from isoimmunization 4) Creatinine
• Ultrasonography is used to direct the procedure. - Level of < 1.8 mg/dl demonstrates maturing kidney
• PURPOSE: function of fetus.
o To evaluate fetal status (maturity, congenital anomalies) 5) Alpha-Fetoprotein
- High indicates NEURAL TUBE DEFECT.
- Low indicates DOWN’S SYNDROME.
6) Chromosome analysis
- Skin cells in the amniotic fluid may be cultured and
stained for karyotyping.
7) Fetal Fibronectin
- A glycoprotein that helps placenta attach to the
uterine decidua.
- Found abundantly in the amniotic fluid.
- Can be found in the woman’s cervical mucus early in
pregnancy (fades after 20 wks. AOG).
- Detection of this in the amniotic fluid or in the
mother’s vagina indicates that preterm labor may
begin.
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 1: COMPUTING THE EDD, AOG, GTPAL

8) Inborn Errors of Metabolism J. FETOSCOPY

- Examples: • Visual inspection of the fetus through a fetoscope that is
✓ Cystinosis inserted by amniocentesis technique in assessing fetal well-
- Characterized by cystinuria (characterized being.
by stone formation in the urinary tract) • PURPOSES:
✓ Maple syrup urine disease (amino acid 1) To confirm intactness of the spinal column.
disorders) 2) Obtain biopsy sample of fetal tissue and fetal blood
- Characterized by: samples.
▪ Vomiting 3) Perform elemental surgery, such as:
▪ Hypertonicity ✓ Inserting polyethylene shunt into the fetal ventricles
▪ Severe mental retardation to relieve hydrocephalus, or
▪ Seizures ✓ Into the bladder to relieve stenosed urethra
✓ Phenylketonuria • COMPLICATION:
- Enzyme deficiency resulting in 1) Premature labor
accumulation of phenylalanine (an 2) Amnionitis
essential amino acid) & its metabolites in
K. BIOPHYSICAL PROFILE
the blood causing severe mental
retardation. • 5 parameters:
1) Fetal heart reactivity
• THERAPEUTIC NURSING MANAGEMENT
- 2 or more accelerations of at least 15 bpm for 15 sec.
1) Assist with procedure, monitor for sterility.
2) Determine whether the client is to empty her bladder prior over a period of 20 min.
2) Fetal breathing movements
to procedure (empty the bladder to prevent inadvertent
- 1 episode of 30 sec. of sustained fetal breathing
puncture).
movement within 30 min. of observation.
3) Position client in left lateral.
3) Fetal body movements
4) Provide emotional support.
- 3 separate episodes of fetal limb or trunk
5) Refer client for genetic counseling when indicated.
movements within 30 min.
6) Women who are Rh negative receive Rho(D)
4) Fetal tone
immuneglobulin (RhIG; RhoGAM) after the procedure to
- Fetus extends then flexes extremities or spine of at
prevent fetal isoimmunization (development of antibodies
in response to antigen from another individual of the same least once in 30 min.
5) Amniotic volume
specie).
- Pocket of amniotic fluid measuring 1 cm in vertical
7) Secure an informed consent form, including a clear
diameter.
explanation of risks of the procedure before the procedure
is done. • Score:
8) Use universal precautions during the procedure. 1) 8 – 10 - fetus is doing well; healthy fetus.
2) 6 - suspicious; requires determination of the need for
• COMPLICATIONS:
immediate delivery of the fetus, considering maturity of
1) Needle puncture of the fetus
the fetal lungs.
2) Bleeding
3) 4 - fetus in jeopardy.
3) Loss of amniotic fluid
4) Infection
5) Premature labor
6) Spontaneous abortion
7) Fetal distress
H. PERCUTANEOUS UMBILICAL BLOOD SAMPLING
(PUBS/CORDOCENTESIS OR FUNICENTESIS)
• Removal of blood from the fetal umbilical cord (vein) at about
17 wks.
• Blood studies:
1) CBC
2) Direct Coomb’s test (agglutination test used to detect
proteins esp. antibodies on the surface of RBC.
3) Blood gases
4) Karyotyping (chromosomal characteristics)
I. AMNIOSCOPY
• Visual inspection of the amniotic fluid through the cervix and
membranes with an amnioscope.
• PURPOSE:
o To detect meconium staining
• COMPLICATION:
o Rupture of membrane