Antepartal Nursing Care

Lunar month- 4 weeks, 28 days

OB Terminology • Pregnancy – divided into 3 trimesters 13 weeks each• EDC - estimated date of confinement• EDB - estimated date of birth *same thing• Gestation - number of weeks since first day of last menstrual period• Abortion - birth that occurs before end of 20 weeks gestation

• Preterm 20 - 37 weeks• Term 38 - 40 wks • Postterm after 42 weeks

• Gravida -any pregnancy (any: when preg lasts 4, 5, 6wks or to term)• Para - birth after 20 weeks gestation multiples count as one• Stillborn - born dead after 20 weeks • Primigravida - first time pregnancy• Multigravida - second or any subsequent pregnancy

Essential Components of a Prenatal History

• Basis of prenatal care- reevaluated and updated throughout the pregnancy.

• Obstetric history – pertaining to pregnancy current and past• Gynecologic history- …how long pt has had menses.• Medical history - Current and past• Family medical history including Father’s health history• Religious, spiritual, and cultural history• Occupational history• Personal information about woman• Comprehensive psychosocial assessment

Comprehensive OB History Acronym

• TPAL– T - term births, twins or more count as one

• 38 weeks– P - birth from 20 - 37 weeks– A - spontaneous or therapeutic abortion– L - living children- multiples count here

Practice• Cindy is currently 34 weeks gestation and in labor

with her first baby.• Gravida 1 Para 0• After delivery - G 1 P 1• More detail:

– Gravida 1– Term 0– Preterm 1– Abortions 0– Living 1

Practice• Mary is currently 26 weeks gestation and she has a 4

year old daughter that was born at 38 weeks gestation.

• G 2 P 1• More detail:

– G 2– T 1– PT 0– AB 0– L 1

Practice• Ms Johnson is pregnant for the 4th time. She had one

abortion at 8 wks gestation. She has a daughter who was born at 40 wks gestation and a son born at 34 weeks gestation.

• G 4 P 2• More detail:

– G 4– T 1– PT 1– AB 1– L 2

More Practice• Ms T, at 27 weeks gestation, comes to the clinic for a routine

prenatal visit. This is her 4th pregnancy. She has three children at home. One child was born at 34 wks gestation and the other two were 40 wks gestation.

• G 4 P 3• More Detail:

– G 4– T 2– PT 1– AB 0– L 3

One More Practice • Sharon is 22 wks pregnant. She has a 2 year old and a 4 year

old that were born at 39 wks. She lost 4 pregnancies at 12 wks and she has 10 year old twin boys that were born at 33 wks gestation.

• G 8 P 3• More detail:

– G 8– T 2– PT 1– AB 4– L 4

Determination of Due Date

• Nagele’s Rule- one method of determining the EDB. Fairly accurate method to use if woman’s cycle is every 28

days. – First day of LMP – Subtract 3 months – Add 7 days– EDB

Nagele’s Rule Example

• LMP April 6• Subtract 3 months - 3 months• Jan 6• Add 7 days +_7 days• EDB Jan 13

Another Option of Nagele’s Rule

• Just change the month to number• December 10 becomes 12-10• Subtract 3 months -_3___• 9 -10• Add 7 days __+_7• EDB Sept 17

Other Indicators of EDB

• Fundal Height – correlates with weeks gestation (top of a pregnant woman's uterus (fundus) to her pubic bone)

• Quickening - fetal movement felt be the mom (~16-22wks, not very accurate)

• Fetal heartbeat - Doppler 10-12 wks and 17-20 wks with fetoscope.

• Ultrasound - most accurate

Initial Physical Assessment

• Head to toe physical assessment • 8-12 wks gestation• Starts with VS and ends with pelvic exam.

Pregnancy Physical Assessment

• Blood pressure - trimester specific changes (1st tri = BP drops and will rise towards the 3rd)

• Weight - sudden wt gain • Skin - pigmentation • ENT - nosebleeds and swollen gums, dental

infection preterm labor• Breast – enlarge, colostrum 12 wks• Abdomen - becomes larger, measured each visit

(Fundal Height Measurement)

Fundal Height Measurement

• Measure in centimeters from the top of the symphysis pubis to the top of the uterine fundus.

• 22 - 34 weeks - fundal height correlate with weeks of gestation

• Too small or too large - needs to be evaluated.

Figure 8–3 A cross-sectional view of fetal position when McDonald’s method is used to assess fundal height.

Fundal Height Assessment

• 10-12 wks - fundus slightly above symphysis pubis• 16 wks - fundus halfway between symphysis and

umbilicus• 20-22 wks - fundus at umbilicus• 28 weeks - fundus three finger breadths above

umbilicus• 36 wks - fundus just below ensiform cartilage

Abdominal Assessment

• Fetal movement felt by examiner -18 weeks• Ballotment - Fetus floating in amniotic fluid• Fetal heart tones - 110-160 BPM

– Doppler 10-12wks – Fetoscope 17-20 wks

Physical Assessment cont

• Extremities - edema of hands and feet in later pregnancy

• Reflexes - hyperactivity or clonus associated with preeclampsia

• Pelvic - Pelvic measurement assessed for shape and size; dilatation and effacement

• Rectum - hemorrhoids (if already present, give advice about incr fiber and fluids)

Initial Laboratory Evaluation and Screening

• CBC (Anemia give more iron)• ABO and Rh typing, Antibody Screen, Blood type• Serolgy (RPR tests for syphilis)• Rubella• Hepatitis• HIV• PAP smear• STD screen• Urinalysis – C&S; drug screen, can have a UTI that is

asymptomatic• Thyroid panel- because of chance of cretinism

Subsequent Prenatal Visit Routines

• Every 4 weeks until 28 wks• Every 2 wks until 36 wks• Every wk until delivery• Visits include teaching and assessment of

maternal/fetal well-being.

Subsequent Prenatal Assessments• Vital signs• Weight - 1st trimester > 3.5 – 5lbs• 2nd and 3rd trimester > 12 -15lbs, then a lb per wk• Monitor for Edema• Uterine size and uterine activity• FHT’s and fetal movement• Urine screen for protein, glucose and ketones• Lab

– CBC at 7 months – AFP at 15-20 wks– Indirect coombs for Rh negative moms at 28 wks– Glucose screen 28 wks – GBS vag culture 36 wks, “Group B Strept”- Carriers must understand the

dangers for the baby.

• Define: AFP- Alpha Fetal Protein, measurements in amniotic fluid are used for early diagnosis of fetal neural tube defects– High = Neural Tube defect (ex: spina bifida)– Low = Down’s Syndrome

Danger Signs in Pregnancy• Vaginal bleeding (Any bright red bleeding call phys)• Nausea and vomiting that last over 24hrs

– Dehydration leads to preterm labor• Fever -100.4• Dizziness - sudden and extreme, associated with pelvic or uterine pain• True Labor- Lower back pain to the front• False labor- Abd pain only• Preterm labor symptoms• Leaking of fluid from vagina• Preeclampsia symptoms - edema, rapid wt gain, headaches, visual

disturbances, vomiting, epigastric pain, irritability, scanty urine output (usually won’t see till after 20wks)

• Decreased fetal movement• Symptoms of UTI - dysuria, severe backache, fever

1st Trimester Discomforts and Measures to Alleviate

• Nausea (due to HcG levels) and vomiting - avoid odors, eat small frequent meals, crackers, avoid spicy or greasy foods– HcG- a hormone produced by the placenta about 10 days after

fertilization. Its detection is the basis for most pregnancy tests.• Urinary frequency - void when needed; increase fluids in day and

slow down at night• Fatigue - plan rest periods, get help from support system• Breast tenderness - wear good supportive bra• Increased vaginal discharge - frequent bathing, cotton underwear• Nasal stuffiness & epistaxis - cool mist, avoid nasal decongestants

and sprays• Ptyalism – “excessive saliva/bad taste in mouth” treat w/

mouthwash, chewing gum, candy

2nd and 3rd Trimester Discomforts and Measures to Alleviate

• Pyrosis – “hrt burn” treat w/ small frequent meals, avoid spicy or greasy meals, sit or stand after meal

• Ankle edema - rest frequently, elevate legs when resting, avoid garters

• Varicose veins - elevate legs, wear support hose, avoid crossing legs, avoid constrictive bands

• Flatulence - avoid constipation and gas producing foods• Hemorrhoids - avoid constipation• Constipation - increase fluids and fiber in diet, exercise, stool

softeners as ordered by physician– Make sure softeners are okay’d by phys first.

2nd and 3rd Trimester Discomforts and Measures to Alleviate cont

• Backache - proper body mechanics; avoid high heels, practice pelvic tilt exercise

• Leg cramps - dorsiflexing foot• Faintness - rise slowly from sitting or lying, evaluate hematocrit

and hemoglobin• Shortness of breath - eat small frequent meals• Difficulty sleeping - prop with pillows, use side-lying position

– Lt Side is better for baby• Round ligament pain - position change, heating pad• Carpal tunnel syndrome - avoid repetitive movements of hands

Promotion of Self Care During Pregnancy

• Fetal activity monitoring - after 28 wks • Breast care and preparation for breastfeeding • Prenatal classes and exercises• Clothing• Bathing• Employment• Travel- wear safety belts, travel only if you have no

problems, stop every 2 hrs, stay hydrated

• Activity

Promotion of Self Care During Pregnancy cont • Dental Care

• Immunizations • Complementary and alternative therapy

– Before anything over the counter they need to talk to their phys• Tertatogens

– Medications• Categories A – X, pg. 247 – 249; Cat. A is safe during Preg. No to Accutane!!

– Tobacco- IUGR Growth retardation, Tobacco vasocontricts!– Alcohol– Caffeine- limit intake– Street drugs– Flu Vaccine is okay, just not live ones.– Dental care > important, poor dental hygiene associated with preterm

labor

Concerns About Sexual Activity

• Safety for fetus• Contraindications

– PROM “Premature rupture of membranes” (water-break), preterm labor, vag bleeding Changes in sexual desire and response

– pregnant woman– partner

Nursing Care of the Pregnant Woman’s Family

• Father – involved, participation• Siblings – regression, rivalry• Grandparents – involvement, conflicts