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LIU.

MAKAti
Maternal& ChildHealthNursing:
NursingCarein the Antepartalperiod

DIAGNOSIS
OF PREGNANCY
PresumptiveSigns

- lessindicativeof pregnancy
- takenassingleentities
- couldeasityindicateotherconditions
- largetySUBJECTTVE

Probable Signs

- canbe documented by the examiner
- atthoughmorereliabtethanthe presumptive
signs,
they are still not positive or true diagnostic
of pregnancy

Positive Signs Serumlab.tests
Breastchanges
- there are onty three positive signs: Morningsickness
- fetal hearth tones Amenorrhea
- fetal movement felt by the examiner Urinaryfrequen-
- ultrasound evidence of the fetus cy
Chadwick'ssign
Goodeltlssign
Hegar'ssign
Sonographic
evidence of
gestationaI
5ac

Sonographic
evidence of
fetal out-
line
Fetal heart
audibte
Fatigue
Entarging
uterus
Batlotement
Quickening
Fetalmove-
mentfett
by examiner
BraxtonHicks

MarlonBernardo,RN
Matemal& ChildHealthNursing:
NursingCarein the AntepartalPeriod

b. Constipation andflatulenceare dueto disptace-
mentof stomachandintestines,thusslowing d. Heart burn, especially in the last trimester, is due
peristalsisandgastricemptyingtime; mayatsodue to.increased progesterone which decreased gastric
to increased progesteronewhichinhibitsgastric motitity, thereby causingreverse peristaltic waves.
motitity. This leads to regurgitation of acid in the stomach
> Increasedfluids and roughagein the diet. into the esophagus,causingirritation.
> Establlsheliminationtime. > Avoid fried or fatty foods.
> Avoid enemas- may lead to habit forming. > Sips of milk at frequent intervals.
> Alineraloil shouldnot be taken becauieit > Small frequent meals taken slowly.
interferes with the absorptionof fat-soluble > Bend at the knees, not at th€ waist.
vitamins(ADEK), > Take antacids. NEVERsodium bicarbonate
(alkaseltzer or baking soda becau5e they
c. Hemorrhoids are dueto pressureof entargeduterus promote fl uid retention),
on the intestine.
> Coldcompress(promotesyasoconstriction).

4. Urinqry
3. Respiratory
a. Urinaryfrequenryis seenduringthe 1rt and3rd
a. Shortnessof breath due to: trimesters.
- increasedO, consumptionand production of - 1sttri is dueto increasedbloodsupplyin the
CO2by the product of conception during the btood.
first trimester.
- 3d tri is dueto pressureof entargeduteruson
- increased uterine size causesthe diaphragm to btadderespeciatty duringtigthening.
be pushedor displaced, thus crowding the
chest cavity, b. Decreasedrenal treshold for stgar becauseof the
> Lateral expansion of the chest to compensate
increasedproduction of glucocorticoidsthat cause
for shortness of breathing increases O, supply lactose and dextrose to spi[[ into the urine of
and vital lung capacity. pregnant women (glycosuria).
' Since alt pregnant women have sugar in their
urine, it woutd be difficutt to diagnosediabeteg
mettitus in pregnancybasedon the urine sampte
atone.

> Frequent rest periods with legs elevated.
5. llusculoskeletal > Increase calcium intake-
> Do not massage legs.
a. Because of the woman'sattemptto changeher > Press knob of the affected leg and dorslflex
center of gravity,shemakesambutationeasierby foot.
standingmorestraightandtatler (LORDOS|S/ PRIDE
OFPREGMNCY). Dueto productionof relaxin, Temperature
petvicbonesbecomemoremovable,increasing the
incidence of accidental falts due to the whobty Slightincreasein basalbodytemperaturedueto
> Adviseto use low-heeled shoes increasedprogesterone,but the bodyadaptsafter the
4h monthof pregnanry.
b. L€g cramps are causedby:
- increasedpressureof the graviduteruson the 7. Endocrine
lowersxtremities. a. Ptacentaproduces hCG,HLBestrogen,and
- fatigueandmuscletenseness. progesterone.
- tow catciumtevel in the body. b. ,{oderateentargement of the thyroidglanddue
to hyperptasia
of the grandulartissuesand
increasedvascutarity.

MarlonBernardo,RN
CEU-Makati Matemal& ChildHealthNursing:
NursingCarein the AntepartalPeriod

b. Constipation andftatulenceare dueto disptace-
mentof stomachandintestines,thusslowing d. Heart burn, especially in the last trimestet is due
peristalsisandgastricemptyingtime; mayatsodue to.increased progesterone which decreased gastric
to increased progesteronewhichinhibitsgastric motitity, thereby causingreverse peristaltic waves.
motility. This leads to regurgitation of acid in the stomach
> Increasedfluids and roughagein the diet. into the esophagus,causingirritation.
> Establlsheliminationtime. > Avoid fried or fatty foods.
> Avoid enemas- may lead to habit forming. > Sips of milk at frequent intervals.
> Alineraloil shouldnot be taken becauieit > Small frequent meals taken slowly.
interferes with the absorptionof fat-soluble > Bend at the knees, not at the waist.
vitamins(ADEK). > Take antacids. NEVERsodium bicarbonate
(alkaseltz€r or baking soda becau5e they
c. Hemorrhoids are dueto pressureof entargeduterus promote fl uid retention),
on the intestine.
> Coldcompress(promotesvasoconstriction).

4. Urinqry
3. Respiratory
a. Urinaryfrequenryis seenduringthe 1rt and3rd
a. Shortnessof breath due to: trimesters.
- increasedO, consumptionand production of - 1sttri is dueto increasedbloodsupplyin the
COzby the product of conception during the btood.
first trimester.
- 3d tri is dueto pressureof entargeduteruson
- increased uterine size causesthe diaphragm to btadderespeciatty duringtigthening.
be pushedor disptaced, thus crowding the
chest cavity. b. Decreasedrenal treshold for sugar becauseof the
> Lateral expansion of the chest to compensate
increased production of glucocorticoids that cause
for shortness of breathing increases O, supply lactose and dextrose to spi[[ into the urine of
and vital lung capacity. pregnant women (glycosuria).
' Since all pregnant women have sugar in their
urine, it woutd be difficutt to diagnosediabeteg
mettitus in pregnancybasedon the urine sampte
a{one.

> Frequent rest periods with legs elevated.
5. llusculoskeletal > Increase calcium intake-
> Do not massage legs.
a. Because of the woman'sattemptto changeher > Press knob of the affected leg and dorslflex
center of gravity,shemakesambutationeasierby foot.
standingmorestraightandtatler (LORDOS|S/ PRIDE
OFPREGMNCY). Dueto productionof relaxin, Temperature
petvicbonesbecomemoremovable,increasing the
incidence of accidental fatts due to the whobty Slightincreasein basalbodytemperaturedueto
> Adviseto use low-heeled shoes increasedprogesterone,but the bodyadaptsafter the
4h monthof pregnanry.
b. L€g cramps are causedby:
- increasedpressureof the graviduteruson the 7. Endocrine
lowersxtremities. a. Ptacentaproduces hCG,HLBestrogen,and
- fatigueandmuscletenseness. progesterone,
- tow catciumtevel in the body. b. i{oderateentargement of the thyroidglanddue
to hyperptasiaof the grandutartissuesand
increasedvascutarity.

MarlonBernardo,RN
cEU-Makati Maternal& ChildHeahhNursing:
NursingCarein the Antepartalperiod

Weight LocalChanges
a. Averageweight gain is 24-30 pounds, comprised of: 1. Uterus
- Fetus: 7 lbs
- Amniotic ftuid: 2 lbs a. Changein shape pear like to ovoid.
- Placenta and membranes: 1 14lbs b, Changein consistencyof lower uterine segment
- Uterus: 2 ,,1lbs causes extreme softening known as Hegar's sign,
- Breast: 3 lbs seen at about 6 weeks gestation.
- Increasedblood volume: 2-4 lbs c. Mucusptugs in the cervix, catted operculum, are
- Extravascularftuid and fat: 4-9 tbs. produced to seal out the bacteria.
d. CeMx becomesmore vascutarand edematous
b. Water retention, about 7 titers, commontyoccurs resembtingthe consistencyof the eartobe known
during pregnancy. as Goodel's sign.
- Fetus, placenta and amniotic fluid: 3,5 liters e. Eraxton Hick's contractions (painless
- Increasedblood volume, interstitiat fluid, and contractions) occur intermittentty throughout
hypertrophi€d maternal organs: 3.5 liters pregnancy,and can be fett by the mother by the
4B month.

2. Yagina Treatment:
' Ftagyl(metronidazote) or vaginatsupptement of
a. Increasedvasarlarity causeschange cotor from trichomonicidatcompounds (ex. Tricofuron,
tight pink to deep purpte or violet known as Vagisoc,andDevogan).
Chadwick's sign.
> Treatmalepartneraswe[[,
> Avoidintercoursetd preventreinfection.
b. pH of the vagina changesfrom acidic to alkaline
becauseof estrogen. lt protects the vaginal lvlONlLfASlS causedby fungusCondidaalbicans. Also
environmentfrom bacteria,but favorsthe cattedCANDIDIASIS.
of trichomonas- a protozoaor flagettate.tt witt S/S: - white, patchy,cheeze-tike partictesthat
TCSUIItO TRICHOAAONAS VAGINALISOr
adhereto vaginalwatts.
TRICHOI,IONAS VAGlNlTlSor TRtCHOilONtAStS. - irritatinglyitchy,andfoul smetlingdischarges.
S/5: - frothy, cream-colored, irritatingty itchy Treatment:
and foul smetling discharge.
> /r4ycostatin/l,lystatin
> Ayoidintercourse.
- vulvutar edema and hyperemia secondary . Monitiasis
to irritation from discharges. is seenasoral thrushin the newborn
whentransmittedduringdeliverythroughthe
birth canalof the infectedmother.

3. Ovories 5. Skin
Do not produce ova during pregnancy. a. Lineanigra- brownline runningfrom the
umbiticusto the symphysis pubis. '
4. Ahdonpn b. Chloasma - extrapigmentation of the cheeksand
acrossthe nosedue to increasedproductionof
a. Striae gravidarum - increaseduterine size metanoqftes by the pituitarygland. lGrownasthe
results in rupture and atrophy of connective MASKOFPREGMNCY.
tissue layers, seen as pink or reddish streaks.
b. Umbilicusis pushedout. 6. Ereast

a. Estrogencontributesin the deve{opment
of the
breastin preparationfor [actation.
b. Nipptesare moreere€t,areotabecomes darker
andlarge6andcolostrumis formed.

MarlonBernardo,RN
CEU-Makati Maternal& ChildHealthNursing:
NursingCarein the Antepartalperiod

PSYCHOLOGICALTASKS
OF
PREGNANCY kcond Trimester (Accepting the Baby)

Fetus is perceived as a separate entity. Fantasized
First Trimeiter (Accepting the Pregnancy)
the appearanceof the baby. Irlother accepts pregnancy.
The fetus is an unidentified concept with a great Third Trimester (Preparing for Parenthood)
future imptications but without tangibte evidence of
reality. Somedegree of rejection and disbetief, deniat
Has personal identification with a real baby about to
and depression. lilother is ambivalent.
be born and reatistic plans for future child care
> When giving health teachings, emphasize the
responsibilities. This is the best time to tatk about
bodily changes in pregnancy. infant feeding method. Fear of death is prominent.
> Let the woman listen to the fetal heart sound.

1. HistoryToking
THEPRENATAL
VISIT
a. Personat Data
The provision of.prenatal care is the b- ObstetricalData GP(IPAL)
primary focus in the improvement of Gravida- numberof pregnancies a womanhas
Para- numberof viabtepregnancyregardtessof
matemal and infant morbidity and mortatity
numberandoutcome.
rateg. To ensurethe successof prenatal care TPALscore- numberof fu[[ Termbabies,
programs,it shoutdbe rememberedthat the Prematuredeliveries,Abortions,Livingchildren.
client's understandingof the modatities of Ti infantsbornat 37 weeksor after
care is basic to cooperative action among P: infantsbornbefore37weeks
health professionalsand pregnant woman A: spontaneous or inducedabortions
and her famity. L: tivingchitdren
* ln USsetting,lt (muttiptepregnancies)
is alsotaken
aspart of the obstetricaldata - GP(TPALM).

Abortion is the medical term for any pregnancy
terminated before the age of viabitity.
'Age of viability - the earliest age at which fetuses Mrs. Bemardois pregnantfor the sixth time.
coutd survive if they were born at that time, Sheis seenfor her first prenatal check-up.
generallyacceptedas 24weeks,or fetusesweighi Shereported that she has a girl born at 35
morethan400g. weeks; 2 boys, both born at 39 weeks; and a
' Today'spracticeaccepts20 weeksas the ageof twin born at 37 weeks, Shealso noted that
viabitity. she had one miscarriageat 18 weeks. Using
the GP(TPAL) systemto describeMrs.
Terms related to preqndnc'r status:
Bernardo's,current obstetrica[ history the
Primigrovida - pregnant for the first time
Primipara - has given birth to one chitd past age of nursewoutd record:
viabitity
Itultigravida - has been pregnant previousty G6P4(3-1,1
-5)
llultipara - has caried two or more pregnanciesto
viabitity
Nulligravida - never been and is not currenttv
pregnant

MarlonBernardo,RN
CEU-Makati Maternal& ChildHealthNursing:
llursingCarein the AntepartalPeriod

\
A pregnantwomanis seenfor her Zndprenatat Awoman is pregnantfor the secondtime. Her
check-up. Sheretated that she has4 first pregnancyendedin a spontaneous
children, Shehas a boy born at 35 week, a abortion at 12 weeks. The correct term to
girl born at 37 weeks, and a fratemat twin
useto describethis woman'sobstetrical
bom at 40 week. Sheaddedthat she had a historywoutd be:
miscarriageat 12 weeks. Usingthe
GP(TPALM) system,the nursewould record:

Multigravida,nutlipara
G5P3Q-1-1-4-1)

Aside from the GP (TPAL),the nurse shoutd also ask fo
Past preenancies 2. Assessment
- method of delivery?
- where? a. PhysicalExam
- risk invotved? Reviorof systemii indicated,inctuding
Present pregnan(t! inspectionof teeth becausethey are commonfoci
- chief concern infection.
Dancer Sienak
- yaginal bteeding no matter how stight b. Petvic Exam (Cardinal rule: Empty bladder firstt)
- swetting of face and fingers - Internal Exam (lE) to determine Chadwicks,
- severe and continuous headache Goodett'sand Hegar'ssigns.
- dimnessor bturring of vision ' Ballotement - fetus will bounce when tower
- flashing of light or dots before the eyes uterine segment is tapped on the 5s month.
- persistent vomiting, chitts, and fever
- suddenescape of ftuid from the vagina - Pap Smear (PapanicotauSmear)- cytotogical
- absenceof fetal heart soundsafter they have been study to diagnosecervical carcinoma.
auscuttated on the 4s and 56 month.
Medicat Data

- C[assificationof findings in Pap Smear: - Petvic measurementsare done after the 56
Ctass1 - absenceof abnormal celts month through X-ray pelvimetry, This
Class2 - presenceof atypical cytotogy, but no preferabty done 2 weeks before EDBto
evidence of matignancy determine CPD(cephato-petvicdisproportion).
Class3 - q/totogy suggestiveof malignahcy
Ctass4 - cytotogy strongty suggestive of - Leopold's }lan€uver - done to estimate fetal
matignancy size, [ocate fetal parts, and determine
Ctas 5 - cytology conctusiveof ma[ignancy presentation, position, engagement, and
attitude.
- Clinicol Stqq*: reftects {ocalization or spread of
malignant cervical changes
Stage 1 - CA confined in the cervix
Stage2 - CAextends into vagina, but not in the
petvic walt
Stage3 - metastasisin the petvic wall
Stage 4 - metastasis beyond petvic wa[[ into
bladder and rectum

MarlonBernardo,RN
CEU-Makati Maternal& ChildHealthNursing:
NursingCarein the Antepartalperiod

> lnstruct to empty btadder. lit (Fundalgrip): Facingthe headpart, palpatefor
> The examiner, based on his/her dominant hand, fetal part in the fundus.
should position on that side of the mother (A
teft-hand dominant examiner shoutd oosition on 2d (Umbilicalgrip): Palpatesidesof the uterusto
the left side of the mother). determinelocationof fetal back.
> Ptacethe mother in dorsa( recumbent, to retax
the abdominaI muscles{knees stighttyftexed). 3rd(Pawlick'sgrip): Grasplowerportionof the
> Place a rolted towel or smatl pillow under the abdomenjust abovesymphysis pubisto
right side of the trunk to prevent supine determinedegreeof engagement.
hypotensive syndrome.
> Warm hands before palpating (cotd handscause 4tr: Facingthe feet part, crossfingersdownward
muscle tightening). on bothsidesof the uterusabovethe inguinal
> Use the finger pads in palpating. tigamentsto determineattitude,

c. Vital Signs ESTIMATES
OF PREGNANCY
TPRare important during the initiat visit. The 1. Nagele's Rule
most important are BPand weight to serve as
basetinedata during visits. calcutation of EDB(estimated date of birth) or
EDD(estimated date of detivery). Get the Wp
d. Urine Examination (first day of the last mestrual period), count back 3
months and add 7 days.
Albumineria - ideally negative. Presenceof this
must be reported becauseit is a sign of Z. AlcDonald's Rule
toxemia.
Pyuria - signsof UTl. UTI is the most common
cause of premature delivery.
Glycosuria - specimen shoutd be taken before
breakfast to avoid false positive resutts.

3. Bartholomew's Rule

estimates AOG (age of gestation) by the re{ative The first day of woman's last menstrual period
position of the uterus in the abdominal cavity was May 3, 2008 and it ended May 7. Using
Nagetek rule, this woman's estimated date of
3d month - fundus is stightty above the symphysispubis birth woutd be:
5b month - fundus is at the tevel.of umbilicus
9b month - fundus below the xyphoid process
86 and lOh monffis - same [eve[ because of t.igthening

4. Haase's Rule February10,2009

calcutation of the feta[ l'ength in cm. For the
first 5 months, square the month; 6 - 10 months,
muttipty by 5.
CEU-Makati Matemal& ChildHealthNursing:
NursingCarein the AntepartalPeriod

HEALTHPRO,TAOTION
ACTIVITIES
DURINGPREGNANCY
After measuringa woman'sfundus,a nllrse
usedMcDonatd's ruteto estimatethe a. Nutrition
gestationalageof the pregnancy in weeks.. - currentty recommended as an average
Sincethe woman'sfundatheightwas24 cm,
weight gain in pregnancyis 25 to 40 tbs.
the gestationat
ageof the pregnancy woutdbe
approximatetyhowmanyweeks? - Body massindex (BMl) is a more precise
\ estimation of adequate weight gain.
- Womenwho need speciat attention are
pregnant adolescent, underweight, obese,
low income, veg€tarians.

b. Bathing
Vitaminsand minerals: > daily tub baths or showers are recommended.
. Protein- for buitdingup of fetal tissue During pregnancy, sweating tends to increase
. Vit. C - for bloodctotting activity of the mother because the woman excretes waste products
for herself and the fetus.
andfetus,whichenhances the productionof
capittaries,therebyenhancing orygenation c. Dressing
necessaryfor tissuegrowthandwoundheating.
. .Catcium- necessary for lactation. > pregnantwoman should avoid garters, extre-
. lron-richfoodsare especiatty importantduringthe
mely firm $rdles with panty legs, and knee
lasttrimesterfor the fetusto haveenoughiron
high stockings because these may impede
storesto last him for 3 monthsof infancywhen
lower-extremity circutation.
intakeis main(ymilk (deficientin iron). > suggest wearing 3hoes wlth a moderate to low
heel to minimize pelvic titt and possibte
backache.

d. Steep f. Travel

> lf a woman has troubte steeping, drinking a - Earty in a normat pregnancy,there are no
glass of warm milk may help. Relaxatlon restrictions. Late in pregnancy, travel ptans
exercises also may be effective. shoutd take into consideration the possibility
> Avold restlng in a supine position to prevent of early labor.
supin6 hypotensive syndrome.
g. SexualActivity
e. Exercise
- sexual desires continue during pregnancybut
- Exerciseduring pregnancyis important to level changes.
prevent circulatory stasis in the tower ' 1it tri: decreased;woman is preoccupied
extremities. Also, to strengthen the muscle with the changesin her body.
used in tabor and delivery. ' 2d tri: increased; woman has adapted to
> Walking is the best exercise during pregnancy.
pregnancy, and women should be 3d tri: decreased;woman is afraid of hurting
encourag€d to tak6 a deily walk. the fetus.

MarlonBernardo,RN
CEU-Makati Maternal& child HeatthNursing:
NursingCarein the AntepartalPeriod

h. Work J. Breast Care

- Cautionwomanwhosejobs invotveexposure > Ageneral rule is to wear a firm, supportive
lifting heaw objects,
to toxic substances, bra with wide straps to spread welght across
otherkindsof excessive physicatstrain,long the shouldeF.
periodsof standing,or havingto maintain - Colostrum sxretion begins at about the 166
bodybalance. week of pregnancy. Instruct to wash her
breast with clear tap water daily to remove
l. DentalCare the colostrum, thus minimizing the rkk of
infection. Constant moisture next to the
- Gingivaltissuetendsto hypertrophy during breast nipple may cause nipple excoriation,
pregnancy (pocketsof ptaqueform readily pain, and lissurirg.
betweenthe entargedgumtineandteeth).
> Encouragesnakcingon nutritlous foods,
suchasfresh fruits and.vegetablesto avoid
sugarcomingin contactwlth teeth.

Marlon Bernardg,RN
CEU-Makati Maternal& ChildHealthNursing:
NursingCarein the AntepartalPeriod

LABORATORY
EXAMS
1. Urinary PregnancyTest 2. Progesterone Withdrawal Test

- presence of hCGin the urineis the basisfor - a contraceptive pitl is taken OD or TID x 3 days.
positiveresult. hCGis pr€Bentfrom 40s dayto the lf menstruation
occurwithin 10to I 5 days,the
100s day of pregnancy, reaching the peak levet on is not pregnant. lf pregnant, the corpus tuteum
60h day. hCG therefore is most correct 6 weeks after produces enough hormones to neutralize the effect of
LJ\{P.When cottecting urine for pregnancytest: withdrawn synthetic progesteroneand no bteeding
> NPOpost 8 pm to concentrate urine occurs.
> Flrst morning urine, midstream catch should be
collected.
> hCGis unstable under room temperature;
refrigerate prn.

CHANGES
OF PREGNANCY Consequences
of increasedcardiocvolume:

SystemicChanges - easyfatigabilityandshortnessof breathdueto
increasedcardiacworktoad
1. Cdrdiovascular or Circulatory - epistaxis/nosebteeding- dueto increased
of the nasopharynx
a. Beginningthe end of the 1't trimester, there is a
gradua[ increase of 30%-50%in total cardiac
volume reaching its peak during the 6s month of b. Patoitationsdueto increasedpressure
of uterus
pregnancy. This causesa drop in hemoglobin and againstthe diaphragmduringthe secondhalf of
hematocrit tevels (physiological anemia of pregnancy,
pregnanry or pseudoanemia).
c. Because of poorcirculationresuttingfrom pressure
the graviduteruson the btoodvessets of the tower
extremities:

- edema of the tower extremities occur
> Ralse legs above the hip level.
2. Gastrointestinal
" Edema of the lower extremities is NOT a sign of
toxemia.
a. Morning sickness(nauseaand vomiting during
- varicosities of the lower extremities can occur pregnancy) is due to increased hCG, increased
> Use/wear elastic stockings to promote varicose
production of gastric acid (heart burn) or due to
flow thus preyenting stasis in the lower ext.
emotionaI factors.
> Elastic bandage should start from the distal end
> Eat dry toast or crackers 30 mlnutes before
the extremityand work towardthe trunk to
arising In the moming.
congestionand impairedcirculationat the distal > Encourage to eat dry high carbohydrates, low
part.
> Avoid useof constricting garters. fat, and low spices in the diet.

d. Because of poorcircutationin the btoodvessels ' Flvperelnesis erovidorum - excessive nausea and
of vomiting which persists beyond 3 months may
genitatiadueto pressure of the graviduterus, result in dehydration, starvation and acidosis.
varicosities
of the vutvaandthe rectumappear.
> Side-lying position with hips elevated on

MarlonBernardo,RN