CARE OF THE WOMAN DURING

PREGNANCY

PRENATAL CARE
ANTENATAL CARE

OBJECTIVES
• Give a definition of antenatal
• Identify the aims of Antenatal care
• Describe the initial assessment of a pregnant
woman
Prenatal care

• Also known as antenatal care

• refers to the care that is given to a pregnant
woman from the time that conception is
confirmed until beginning of labor.
Prenatal care

• Is a type of preventive healthcare.

• Goal: To provide regular check- ups that allow
doctors, nurses and midwives to treat and
prevent potential health problems throughout
the course of pregnancy and to promote
healthy lifestyle s that benefit both the
mother and the child.
Schedule of Clinic Visit

• Prenatal visit should begin as soon as possible after

the first missed period.
• Subsequent clinic visits for normal pregnancy are
scheduled as follows:
From first visit to 32 weeks – every 4 weeks
From 32 weeks to 36 weeks- every 2 weeks
From 36 weeks until delivery every week
Components of Prenatal Care:

1. History taking
2. Physical examination
3. Treatment of Disease
4. TT immunization
5. Iron supplementation
6. Health education
7. Laboratory Exam
8. Oral Dental Exam
9. Referral when necessary
The initial assessment

Objectives for initial assessment;

• To assess levels of health by taking a detailed
history and to offer appropriate screening tests.

• To ascertain baseline recordings of blood

pressure, urinalysis, blood values, uterine
growth and fetal development to be used as a
standard for the comparison as pregnancy
progresses.
Objectives of initial assessment

• To identify risk factors by taking accurate details of

past and present obstetric, medical, family and
person history.

• To provide an opportunity for the woman and her

family to express and discuss any concerns they might
have about the current pregnancy loss, labour ,birth
and puerperium.

• To give health advice and that pertaining to pregnancy

in order to maintain the health of the mother and
health of the developing fetus.
 GYNECOLOGIC HISTORY

ief complaint • Perimenopause/menopause

tory of present illness • Bleeding pattern
nstrual history
Age at menarche • Vasomotor symptoms
Last menstrual period
Menstrual pattern • Hormone replacement therapy
Cycle length
Duration of flow
Amount of flow
Abdominal symptoms?
Associated pain
intermenstrual bleeding
Contraception
Current method; satisfied with method?
Previous methods, including complications, reasons discontinued
Cervical and vaginal cytology
Most recent Pap smear result
History of abnormal Pap smears? If so, nature of diagnosis, treatment,
and follow-up
Infection
History of sexually transmitted infections
Fertility/infertility
Desire for future fertility
Any difficulty conceiving in past? If so, prior evaluation and treatments
Sexual history
Type
Concerns about libido, dyspareunia, or orgasm?
History of sexual abuse or sexual assault?

Obstetric history
Describe each pregnancy and the outcome. 
 Describe any maternal, fetal, or neonatal complications
Past medical history
Current or past illnesses
Hospitalizations
 Past surgical history
Past gynecologic surgeries
Past nongynecologic surgeries

Medications and allergies

Prescribed medications
Over-the-counter medications
Herbal preparations
Allergies to medications and nature of reactions

Family history Significant illnesses of family members

Known hereditary conditions in family

Social history, Marital or relationship status

Level of education
Occupation
Review of systems Abdomino-pelvic
Gynecologic
Urinary
Gastrointestinal
Breast
Other
Health maintenance, Tobacco, alcohol, illicit drug use
Diet
Calcium and folate intake
Exercise
Use of seatbelts, helmets, sunscreen, smoke detectors
Firearms in the home?
Dates and results of screening tests such as mammography, sigmoidoscopy
or colonoscopy, bone densitometry, lipid analysis, glucose and thyroid testing

• Immunizations and dates administered

OBSTETRIC HISTORY

Current pregnancy details

Past obstetric History ( details of all previous
pregnancy, miscarriages and termination, length of
gestation, date and place of delivery, onset of labor
Past gynecological history
Past medical and surgical history
Drug hx and allergies
Family hx- esp. multiple pregnancy
Diabetes, hpn,chromosome or congenital malformation
Social hx
History of systemic review
Things to ask.

Gravida: number of times the patient has

conceived/got pregnant irrespective of outcome
Note!
1. Twins counted as 1
2. outcome is not important
Nulligravid – Never been pregnant ;
Primigravid – 1st time ;
Multigravid – been pregnant for many times
•Parity : Number of births/completed pregnancies reaching 20
weeks
Note!
1. Not increased if multiples are delivered in a given pregnancy (count
multiples (twins) as 1 parity, but TPAL is affected)
2. Not decreased by stillbirths (count as still births)
3. Twin abortion is counted as 1 in A of TPAL
Nullipara – Never completed pregnancy at 20 weeks or greater
; Primipara –Completed pregnancy at 20 wks or greater (ONCE )
; Multipara – Completed pregnancy at 20 wks or greater (MANY times)
 GTPAL
• Is an acronym used to understand more detail about a
woman’s obstetrical history.
G- Gravida( any pregnancy regardless of duration)
T- Term (baby born anytime from 37 wks to 42 wks)
P- Preterm births( number of preterm infants born after
20weeks and before 37 weeks)
A- Abortion( is the ending of pregnancy by removal or
expulsion of a fetus before it can survive outside the uterus)
L- Living(living children)
Let’s Practice
Determine the GP (TPAL)
Pregnant for 3 times, 1 birth at 39 weeks, another birth at 35 weeks and
present pregnancy is 18 weeks
G 3 P 2 (T1P1A0L2) Multigravid, Multipara
Pregnant with twins at 30 weeks, first time pregnancy
G 1 P0 (since the pregnancy is not yet completed)
Primigravid, Nullipara
Pregnant with twins at 32 weeks, delivered at 37 weeks
G 1 P1 Primigravid, Primipara (2002)
Pregnant for the first time, baby was spontaneously aborted at 16 weeks
G 1 P0 (0010) Primigravid, Nullipara
Pregnant for the 2nd time, delivered a healthy boy at 36 weeks, current
pregnancy was aborted at 24 weeks
G 2 P2 (0111) Multigravid, Multipara
Expected Date of Delivery (EDD)

Calculation of EDD/EDC
• Know the last menstrual period (LMP)
• Add 7 days to the date.
• Subtract 3 months from the month if the
month is above March.
• Add 9 month to the month if the month is
below April.
• Add 1 to year if its above April
Example

• LMP is June 22, 2019

• EDD is _________
6 22 2019
-3 +7 + 1
3 29 2020 (March 29, 2020)

LMP is January 15, 2020

EDD is
1 15 2020
+9____+7________
10 22 2020 (October 22, 2020)
Let’s Practice

Compute for the EDD

LMP is February 14, 2020
2 14 2020
+9 +7____________
11 21 2020 (November 21, 2020)
LMP is September 20, 2018
9 20 2018
-3 +7 +1
6 27 2019 (June 27, 2019)
LMP is April 16, 2021
4 16 2021
-3 +7 +1
1 23 2022 (January 23, 2022)
Age of Gestation ( AOG)

• Is the common term used during pregnancy to

describe how far along the pregnancy is.
• It is measured in weeks , from the first day of the
woman’s last menstrual period cycle to the current
date.
• A normal pregnancy can range from 38-42 weeks .
Infants born before 37 weeks are considered
premature.
Medical history

Medical conditions may affect both the

mother and the fetus during pregnancy.
The conditions include;
• Urinary stasis and reflux occur during
pregnancy. Urinary Tract Infection (UTI)
can easily develop into pyelonephritis,
if untreated may lead to kidney damage
and cause preterm labour.
Obstetric history…………….

• Deep vein thrombosis and thus pulmonary

embolism, women at risk are those with
increased age parity and obese.
• Essential hypertension predisposes to
Pregnancy Induced Hypertension (PIH)
which has many effects.
• Other conditions include asthma, epilepsy,
infections and psychiatric disorders
Family history

• Certain conditions are genetic in origin, others are

familial or related to ethnicity and some are
associated with physical or social environment in
which the family lives.
• Genetic disease in the baby is much more likely to
occur if his biological parents are close relatives
such first cousins.
• Diabetes leads to a predisposition in other family
members , hypertension has a familial component
and multiple pregnancy has a higher incidence in
certain families
Factors requiring additional
surveillance or advice

Initial assessment

• Age less than 18 years or over 35 years.

• Grande multipara (more than four previous
births)
• Vaginal bleeding at any time during pregnancy.
• Unknown or uncertain expected date or
delivery
• Past obstetric history.
• Baby small or large for gestational age.
• Congenital abnormality
• Rhesus isoimmunisation.
• Pregnancy – induced hypertension
• Two or more termination of pregnancy.
• Two or more spontaneous abortions
• Previous preterm labour.
• Cervical cerclage in the past or present
pregnancy
• Antepartum or postpartum haemorrhage.
• Precipitate labour.
• Multiple pregnancy.
 Maternal health
• Previous history of deep vein thrombosis
or pulmonary embolism.
• Chronic illness.
• Hypertension.
• History of infertility.
• Uterine anomaly including fibroids.
• Smoking.
• Family history of diabetes
• Alcohol or drug taking.
• Psychological or psychiatric disorders.
 Examination at the initial assessment.
• Blood pressure 140/90 or above.
• Maternal obesity or underweight according
to the BMI
• Maternal height of 150cm (5 feet) or less.
• Cardiac murmur detected.
• Rhesus negative blood group
• Blood disorders
Danger Signs of Pregnancy

1.Vaginal bleeding
2.Persistent vomiting
3.Chills and fever
4.Sudden escape of fluid from the vagina
5.Swelling of face and fingers
6.Visual disturbance( blurring of vision, spots before
the eyes)
7.Painful urination/ dysuria
8.Abdominal pain
9.Severe or continuous headache
Physical examination

The woman’s consent and comfort are of primary

consideration. Assess the woman holistically
looking at her and her family in order to assess
fetal growth development.

• Weight;
All women should be weighed or asked for a pre-
pregnant weight at booking. Over weight or under
weight should be carefully monitored.
Physical examination………

• Blood pressure;
Blood pressure is taken in order to ascertain
normality and provide a baseline reading for
comparison throughout pregnancy. The woman
should be relaxed and comfortable.
Physical examination………

• Urinalysis;
Urinalysis is performed at every visit to exclude
abnormality.
• Midstream urine for culture and
sensitivity to exclude asymptomatic
bacteria
• Ketones due to fat breakdown to
provide glucose caused by unmet
fetal
Physical examination

demands that may be due to vomiting ,

hypermeresis starvation or excessive
exercise.
• Glucose caused by higher circulating blood
levels reduced renal threshold or disease.
• Protein due to contamination by vaginal
leucorrhoea, or disease such as urinary
tract infection or hypertensive disorders of
pregnancy
Physical examination………….

Blood test in pregnancy

• ABO blood group and rhesus (Rh) factor.
Rhesus negative women who have
threatened miscarriage or any other trauma
should be given anti-D gammaglobulin
within a few days of the event and close a
follow up for Rh – ve mothers.
• Full blood count
• If facilities allow otherwise Haemoglobin
(Hb) is done on every visit
Physical examination…………..

• Veneral Disease Research Laboratory (VDRL)

This test is performed for syphilis.
• HIV antibodies
• Rubella- (Germany measles)
• Sickle cell when necessary
• Hepatitis B
• Screening for cytomegalovirus and
toxoplasmosis
Examination………

• Abdominal examination
This should be performed at each visit. Initially
we will observe for signs of pregnancy
edema
This is not likely to be in evidence during the
initial assessment, may occur as the pregnancy
progresses. It may be physiological edema or
pathological.
 Varicosities
• Occurs during pregnancy and are a
predisposing cause of deep vein thrombosis.
Check for pain in the legs, reddened areas on
the calf or whitish appearance, this should be
reported.
Abdominal examination

This is done to establish and affirm that

fetal growth is consistent with gestational
age during the progression. The aims are to;
• Observe the signs of pregnancy.
• Assess fetal size and growth
• Auscultate the fetal heart.
• Locate fetal parts.
• Detect any deviation form normal
Abdominal examination…….

Preparation
• The woman should be lying comfortably with
her arms by her side to relax her abdominal
muscles. The bladder should be empty.
Method:
Inspection
- The size of the uterus is assessed
approximately by observation.
Inspection…………..……….

- Shape of uterus is observed, when the

fetus is longitudinal uterus is longer than its
broad, if it is transverse the uterus is low
and broad.
- Its possible to see the shape of the fetal
back or limbs. If the fetus is in an occipital
posterior position a saucer-like depression
may be seen at or below the umbilicus.
- Fetal movements may be observed
Inspection…………………….

- Lax abdominal muscles in multiparous woman,

the uterus sags forwards the it is known as
pendulous abdomen or anterior obliquity of
the uterus.
Palpation

• Hands should be clean and

warm, arms and hands should be
relaxed and the pads, not tips of
the fingers used, move smoothly
over the abdomen in a stroking
motion.
Palpation………………………

Height of the fundus

• The nurse places her hand just below the
xiphisternum and pressing gently she moves her
hands down the abdomen until she feels the
curved upper border of the fundus noting the
number of fingerbreadths that can be
accommodated between two.

• Alternatively the distance between the fundus

and the symphysis pubis can be determined by a
tape measure.
Palpation………………….

• The height of the fundus correlates well

with gestational age during earlier weeks.
The size may be affected with other
condition in late pregnancy.

Pelvic palpation
• Pelvic palpation will identify the pole of the
fetus in the pelvis, done before lateral or
fundal palpation as it can cause contractions
Palpation………………….

• The woman bends her knees slightly in

order to relax the abdominal muscles
and suggest to breath steadily and sigh
out slowly. The sides of the uterus just
below the umbilicus level are grasped
snugly between the palms of the hands
with the hands held together and
pointing downwards and inwards.
• Pawlik’s manoevre is sometimes used.
Palpation……………………….

Lateral palpation
 It is used to locate the fetal back in order to
determine position.
 The hands are placed on either side of the uterus at
the level of the umbilicus. Gentle pressure is applied
with alternate hands in order to detect which side of
the uterus offers greater resistance.
 Walking the fingertips of both hands over the
abdomen from one side to the other is an excellent
method of locating the back.
Palpation……………………….

Fundal palpation

 This determines the presence of the breech or

the head.
 This information will help to diagnose the lie and
the presentation of the fetus.
 The midwife lays both hands on the sides of the
fundus, fingers held close together and curving
round the upper boarder of the uterus, gentle
yet deliberate pressure is applied using the
palmer surface of the fingers.
Auscultation.……………….

 Listening to the fetal heart is an important

process.
 A fetal stethoscope is used, it is placed on
the mother’s abdomen at right angles to it
over the fetal back.
 Do not touch while listening
 Distinguish from maternal pulse by listening
to the fetal heart at the same time.
 Gestational age
• Is the duration of pregnancy from
conception until the time of
assessment. In early pregnancy it is
reliable while in late pregnancy it is less
reliable. The fetus sinks down into the
lower pole of the uterus in the last
month, this is termed as lightening.
 Lie
• The lie of the fetus is the relationship
between the long axis of the fetus and the
long axis of the uterus.
• Majority of cases the lie is longitudinal owing to
the ovoid shape of the uterus.
• Oblique lie is when the fetus lie diagonally
across the axis of the uterus.
• Transverse lie is when the fetus lies at right
angles across the long axis of the uterus
 Attitude
• Attitude is the relationship of the fetal
head and the limbs to its trunk.
• The attitude should be one of the
flexion.
• The fetus is curled up with chin on the
chest, arms and legs flexed, forming a
snug, compact mass.
• Presentation
• Presentation refers to the part of the fetus
that lies at the pelvic brim or in the lower
pole of the uterus.
• Presentation can be vertex, breech,
shoulder, face or brow.
• When the head is flexed the vertex present
when is fully extended the face presents
and when partially the brow presents.
 Denominator

Denominator means ‘to give a name to’; the

denominator is the name of the part of the
presentation which is used when referring to the
fetal position.
• In the vertex presentation it’s the occiput.
• In the breech presentation it’s the sacrum.
• In the face presentation it’s the mentum and in
shoulder presentation is the dorsum.
 Position
• The position is the relationship between
the denominator of the presentation
and six points on the pelvic brim.
• Anterior position are more favourable
than posterior positions. Also there is
more room in the anterior part of the
pelvic brim.
 Positions in the vertex presentation

• Left occipitoanterior (LOA). The occiput points the

left iliopectineal eminence; the sagittal suture is in
the right oblique diameter of the pelvis.

• Right occipitoanterior (ROA) .The occiput points to

the right iliopectineal eminence; the sagittal
suture is in the left oblique diameter of the pelvis.
Positions………

• Left occipitolateral (LOL) The occiput points to the

left iliopectineal line midway between the
iliopectineal eminence and the sacroiliac joint; the
sagittal suture is in the transverse diameter of the
pelvis.

• Right occipitolateror (ROL) The occiput points to the

right iliopectineal line midway between the
iliopectineal eminence and the sacroiliac joint; the
sagittal suture is in the transverse diameter of the
pelvis
Positions……………….

• Left occipoposterior (LOP) The occiput

points to the left sacroiliac joint; the
sagittal suture is in the left oblique
diameter of the pelvis.
• Right occipitoposterior (ROP) The
occiput points to the right sacroiliac
joint; the sagittal suture is in the right
oblique diameter of the pelvis.
Positions……………………

• Direct occipitoanterior (DOA) The occiput

points to the symphis pubis; the sagittal
suture is in the anteroposterior diameter of
the pelvis.

• Direct occipitoposterior (DOP) The occiput

points to the sacrum; the sagittal suture is in
the anteroposterior diameter of the pelvis.
Positions……………………….

In breech and face presentation the position

are described in the similar way using the
appropriate denominator.
 Engagement

 This is said to have occurred when the widest presentating

transverse diameter has passed through the brim of the
pelvis.
 In cephalic presentations this is the biparietal diameter
and in breech presentation the bitrochanteric diameter.
 When the vertex presents and the head is engaged the
following will be evident on the clinical examination
• Only 2/5 to 3/5 of the fetal head is palpable above the
pelvic brim.
• The head is not mobile.
 Assessment of the pelvic capacity.
• The size of the obstetric conjugate can be
estimated by measuring the diagonal
conjugate per vaginam. The assessment is of
the little use during antenatal period, until
when labour has commenced.
• Causes of non-engaged head at term are;
-occipitoposterior position
-full bladder
-wrongly calculated gestational age
-polyhydramnios
-placenta praevia or other space occupying lesion
-multiple pregnancy
-Abnormal pelvis
 Presenting part.
• The presenting part of the fetus is the part
that lies over the cervical os during labour on
which the caput succedaneum forms. It should
not be confused with presentation.
 Ongoing antenatal care.
The results of the assessment/findings will
determine the care and the future visits

Indicators of the fetal wellbeing:

• Increasing maternal weight in association
with the increasing uterine size comparable
with the gestational age of the fetus.
Indicators of fetal wellbeing….

• Fetal movements that follow a regular

pattern from the time when the first
movements are felt.
 Fetal heart rate that should be between
110 and 160 beats per minutes during
auscultation.
 Pattern's of the fetal movement are
reliable sign of the fetal well-being;
evidence of at least 10 movements a day
are considered usual.(12 hour period)
Risk factors that may raise
during pregnancy

- Fetal movement pattern reduced or changed

- Hb lower than 10g/dl
- Poor weight gain weight loss
- Proteinuria, glycosuria bacilluria
- BP systolic of or above 140mmHg, diastolic of
above 90mmHg or 15mmhg or more above
booking diastolic
- Uterus large or small for gestational age
Risk factors…………………….

- Excess or decreased liquor

- Malpresentation
- Head not engaged in primigravid woman at term
- Any vaginal, cervical or uterine bleeding
- Premature labour
- Infection
- Any Chronic or acute illness or disease in the
woman
- Relevant sociological or psychological factors
 Preparation for labour;
Final arrangements for birth are made;
- Whom to contact about commencement
of labour
- Discuss about the process of labour with
the woman and the family, normality is
priority but if there is a need to change
plans during labour, then women
 and their families should be
facilitated to ensure informed
choice.

- Parents wishes to be recorded

and any other care provided.
THE END

THANK YOU FOR LISTENING

• Multigravid Mrs. Lim has missed three menstrual
periods and thinks she might be pregnant. During her
first visit clinic, it is confirmed that she is pregnant.
If Mrs. Lim last menstrual period ( LMP) begun on
April 10, 2009, what is her estimated date of
confinement (EDC) according to Naegele’s rule?
JANUARY 17, 2010
The senior head- nursing student in the
maternity unit reviews with the junior students
ways of estimating the expected date of
delivery ( EDD) of pregnant clients. If the LMP
of Mrs. Juan , pregnant for the second time , is
May 5,2016 , what is her EDD?
February 12, 2017
Nurse Rose is collecting data during an admission
assessment on Mrs. Ruiz, a multigravida pregnant
with twins , Mrs. Ruiz also has a 5 -year old daughter
and a history o f abortion . The nurse would
document which gravida and para status on this
client?
Gravida 3, Para 1
When measuring the fundal height of a multigravida
client at 28 weeks gestation,the nurse would
anticipate locating the fundal height at which of the
following points ?
A. At about the level of client’s umbilicus.
B. Between the client’s symphisis pubis and
umbilicus.
C. Between the client’s umbilicus and xiphoid
process.
D. Near the client’s xiphoid process an
compressing the diaphragm
• During a prenatal visit the client tells you that her
last menstrual period was May 21, 2016 based on
the Naegele’s Rule when is the estimated due date
of her baby?
February 28, 2017
• During a prenatal visit the client tells you that her
last menstrual period was November 25, 2016 based
on the Naegele’s Rule when is the estimated due
date of her baby?
September 1, 2017
During a prenatal visit the client tells you that her last
menstrual period was January 20, 2019 based on the
Naegele’s Rule when is the estimated due date of her
baby?
October 27, 2019
Beth is 39 weeks pregnant with her third baby. She
has been pregnant 3 times. Her first pregnancy
resulted in a baby girl born at 39 weeks gestation. Her
second pregnancy resulted in a baby boy born at 38
weeks gestation. What is her GTPAL?
G3 T 2 P 0 A 0 L 2
During her initial visit to the prenatal clinic a client
states she 5-year-old triplets born at 36 weeks, a 2-
year-old son born at 38 weeks. How would the nurse
record this client's obstetric history?
G2 T1 P1 A0 L4
A nurse is obtaining a history from a pregnant client
making her first antepartum visit. The client has a 2-
year-old daughter born at 40 weeks, a 5-year-old son
born at 38 weeks,and 7-year-old twin daughters born
at 35 weeks. She had a spontaneous abortion 3 years
ago at 10 weeks. Using the GTPAL format, the nurse
identifies that the client is: ____________
G5 T2 P2 A1L4
LMP July 12, 1999
EDD________________ ?
LMP
Aug 8, 2018
December 4, 2019
October 9,2017
EDD
May 15,2019
September 11, 2020
July 16,2018
April 19, 2000